Real-world onabotulinumtoxinA treatment patterns in patients with overactive bladder

PURPOSE

Utilization patterns of third-line onabotulinumtoxinA for overactive bladder (OAB) symptoms-including discontinuation and use of other therapeutic options during or after treatment-are not well understood. This retrospective analysis of administrative claims was designed to characterize the unmet need for OAB treatment.

MATERIALS AND METHODS

A retrospective claims analysis of Optum's deidentified Clinformatics® Data Mart Database (2009-2021) was performed among patients with diagnosis of OAB newly starting onabotulinumtoxinA injection (2015-2017). Study measures were evaluated during an 18-month pretreatment baseline and over a minimum of 36 months of follow-up. These included number of injections, days between injections, other measures of onabotulinumtoxinA utilization, use of second-line pharmacologic treatments, use of device and surgical treatment options, and complications.

RESULTS

Of 2505 eligible patients, 535 (21.4%; 66.8 ± 13.3 y, 87.3% females) continued onabotulinumtoxinA throughout the study. The remaining 1970 (78.6%; 71.4 ± 11.6 y, 79.1% females) were considered discontinuers. Of continuers, 57% received ≥5 treatments. Of discontinuers, 84% received ≤2 treatments. Anticholinergics and β3-adrenoceptor agonist medication use declined in all patients from baseline to follow-up; however, the absolute reduction in the proportion with any medication fill was similar across continuers versus discontinuers (21% vs. 18%, p < 0.0001). Sacral neuromodulation was initiated by 15/535 (3%) of continuers and 137/1970 (7%) of discontinuers (p < 0.0001). No patients initiated percutaneous tibial neuromodulation.

CONCLUSIONS

Early discontinuation of onabotulinumtoxinA therapy for OAB is common and most discontinuers do not receive alternative treatments. Providers have the opportunity to educate OAB patients with un- or undertreated symptoms regarding alternative options.

Effect of Provider Specialty on Medical Resource Utilization and Costs in Chronic Spinal-Pain Management

BACKGROUND

Poorly managed chronic spinal pain encumbers medical resources and drives healthcare costs, suggesting a target for improvement.

OBJECTIVES

To determine how specialist-care pathways influence healthcare costs in the first year after a referral for chronic spine pain.

STUDY DESIGN

This was a retrospective cohort analysis of administrative claims from a large commercial health insurance provider, analyzing a 6-month baseline, a variable "pre-referral period," and a one-year period of specialist care.

SETTING

US patients covered by private commercial insurers.

METHODS

Adult patients diagnosed with chronic, spine-related pain between July 2016 and February 2018 and under the active care of a specialist were eligible. Patients with neurological deficits or cancer-related pain were excluded. Patients were categorized based on sequence-dependent exposure to a pain specialist, a surgeon, or both specialties. Key measures were pain-related and all-cause medical resource use and costs and opioid prescription fills.

RESULTS

Of 306,080 eligible patients (mean age 61.6; 61.5% women), 13% saw a pain specialist, 71% a surgeon, 7% a pain specialist then a surgeon, and 9% a surgeon then a pain specialist. Referral to a pain specialist alone was associated with lower resource use and per-patient adjusted cost savings of $3,311 (pain-related) and $6,447 (all-cause) compared to patients referred to a surgeon alone. The pain specialist pathway was associated with increased indicators of prescription opioid use.

LIMITATIONS

Cohort design constraints temper the results' generalizability, given the need to simultaneously examine specialty pathway and medical resource incurred over the same time period.

CONCLUSIONS

We observed meaningful savings in cost and resource use when chronic spine-pain patients were managed by pain specialists. Pain-management referrals should be an element of a thoughtfully designed care pathway.

Systemic Opioid Prescribing Patterns and Total Cost of Care in Patients Initiating Spinal Cord Stimulation Therapy: A Retrospective Analysis

BACKGROUND

Few studies have evaluated patterns of systemic opioid use among patients initiating spinal cord stimulation therapy for chronic pain. This study evaluated systemic opioid discontinuation and/or dose reduction and total health care cost after the start of spinal cord stimulation therapy.

METHODS

Using a commercial insurance claims database (2008-2017), we analyzed opioid utilization patterns in patients initiating spinal cord stimulation therapy over a 1-year baseline and 2-year follow-up. The primary end point was defined as either discontinuation (≥365-day gap between prescription fills or total days' supply in follow-up ≤30 days) or ≥50% reduction in average daily morphine milligram equivalent dose. "Costs" were defined as total payer plus patient out-of-pocket payments.

RESULTS

A total of 5,878 patients met the selection criteria. Of these, 152 (2.6%) showed no opioid prescription data at any point in the study period. Among patients with one or more prescriptions, 42.0% met the primary end point (22.0% discontinued, and 20.0% reduced their dose by 50% or more). Mean total adjusted costs were significantly reduced in years 1 and 2 of follow-up relative to baseline (excluding device insertion costs). The average time to breakeven when accounting for device trial and permanent insertion cost was 3.1 years among those who met the composite end point and 4.2 years among those who did not.

CONCLUSIONS

This analysis shows that among patients who continued spinal cord stimulation therapy for at least 2 years, a significant proportion were able to reduce and/or discontinue systemic opioid use, with costs after the start of therapy significantly reduced relative to baseline.

Abstract PD7-01: Interim analysis of multiplex gene panel testing for inherited susceptibility to breast cancer

Background: Emerging evidence demonstrates the effectiveness of targeted gene sequencing panels as a practical method for the diagnosis of inherited susceptibility to breast cancer. Sequencing of multiple high and moderate risk genes simultaneously accelerates the discovery of deleterious mutations (DM) or variants of unknown significance (VUS). However, a consequence of Multiplex Gene Panel (MGP) testing is the discovery of unexpected DMs in high or moderate risk genes other than BRCA1 or BRCA2 (BRCA1/2). The overall clinical utility and incremental gain of information conferred by MGP testing in hereditary cancer risk assessment is still unknown.

Methods: We are conducting a multicenter prospective cohort study of patients undergoing cancer-risk assessment using a 25 gene sequencing panel, which includes APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, and TP53. Patients were recruited from August 2014 to June 2015 at three medical centers. Patients are enrolled if they meet standard criteria for genetic testing or are predicted to have a ≥ 2.5% probability of inherited susceptibility to cancer calculated by validated risk prediction models. We present a planned interim analysis after enrolling 500 of 2000 total participants.

Results: HCP testing was performed for 332 patients referred for clinical suspicion of hereditary breast and ovarian cancer (HBOC). In this cohort, 96.7% were female (n=321) and the mean age was 50 years (standard deviation, SD=12.2); race/ethnicity was 43.1% Hispanic (n=143), 37% Non-Hispanic White (n=123), 4.2% Black (n=14), 10.5% Asian (n=35), and 1.8% other (n=6). Among this cohort, 37 tested positive for one deleterious mutation (DM) (11.1%: 95% confidence interval (CI), 8.2% to 15%) and 118 patients carried at least one variant of uncertain significance (VUS) (35.5%: 95% CI, 30.6% to 69%). Excluding BRCA1 or BRCA2, 14 patients (4.3%: 95% CI, 2.6% to 7.2%) have a DM in ATM (n=3), CHEK2 (n=2), MSH6 (n=1), MUTYH (n=3), PALB2 (n=1), PMS2 (n=1), RAD51C (n=2), and TP53 (n=2). In a patient with an unexpected PMS2 mutation, enhanced cancer surveillance based on Lynch Syndrome guidelines was recommended. Among 160 patients with a history of invasive breast cancer or breast DCIS, 19 patients carried a DM (11.8 %: 95 CI, 7.7% to 17.8%).

Conclusion: In this multicenter prospective cohort study among a diverse group of participants undergoing 25-gene MGP testing, 11.1% of participants tested positive for a DM. Among participants testing negative for BRCA1 and BRCA2, MGP testing identified DMs in 4.3% of participants prompting clinically appropriate risk reduction recommendations and enhanced cancer surveillance. Ongoing recruitment and long-term follow-up are in progress.

Citation Format: Idos GE, Kurian AW, Mcdonnell KJ, Ricker CN, Sturgeon DY, Culver JO, Lowstuter K, Hartman A-R, Allen B, Teeter C-R, Kingham KE, Koff R, Lebensohn A, Chun NM, Mills MA, Petrovchich I, Hong C, Ladabaum U, Ford JM, Gruber SB. Interim analysis of multiplex gene panel testing for inherited susceptibility to breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD7-01.