Exploring kidney dialysis costs in the United States: a scoping review

AIMS

The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced.

METHODS

We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports).

RESULTS

Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs.

LIMITATIONS

Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult.

CONCLUSIONS

These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.

Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review

BACKGROUND

Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden.

METHODS

This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included.

RESULTS

133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare.

CONCLUSIONS

PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.

Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review

BACKGROUND: US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications. However, these reviews were conducted prior to contemporary benefit design and medication utilization. OBJECTIVE: To assess the relationship and factors associated with cost-sharing and (1) medication adherence, (2) clinical outcomes, (3) health care resource utilization (HRU), and (4) costs. METHODS: A systematic review of literature published between January 2010 and August 2020 was conducted to identify the relationship between cost-sharing and medication adherence, clinical outcomes, HRU, and health care costs. Data were extracted using a standardized template and were synthesized by key questions of interest. RESULTS: From 1,995 records screened, 79 articles were included. Most studies, 71 of 79 (90%), reported the relationship between cost-sharing and treatment adherence, persistence and/or discontinuation; 16 (20%) reported data on cost-sharing and HRU or medication initiation, 11 (14%) on costsharing and health care costs, and 6 (8%) on cost-sharing and clinical outcomes. The majority of publications found that, regardless of disease area, increased cost-sharing was associated with worse adherence, persistence, or discontinuation. The aggregate data suggested the greater the magnitude of cost-sharing, the worse the adherence. Among studies examining clinical outcomes, cost-sharing was associated with worse outcomes in 1 study and the remaining 3 found no significant differences. Regarding HRU, higher-cost-sharing trended toward decreased outpatient and increased inpatient utilization. The available evidence suggested higher cost-sharing has an overall neutral to negative impact on total costs. Studies evaluating elimination of copays found either decreased or no impact in total costs. CONCLUSIONS: The published literature shows consistent impacts of higher cost sharing on initiation and continuation of medications, and the greater the cost-sharing, the worse the medication adherence. The evidence is limited regarding the impact of cost-sharing on clinical outcomes, HRU, and costs. Limited evidence suggests increased cost-sharing is associated with more inpatient care and less outpatient care; however, a neutral to no difference was suggested for other outcomes. Although increased costsharing is intended to decrease total costs, studies evaluating reducing or eliminating cost-sharing found that total costs did not rise. Today's growing cost-containment environment should carefully consider the broader impact cost-sharing has on treatment adherence, clinical outcomes, resource use, and total costs. It may be that cost-sharing is a blunt, rather than precise, tool to curb health care costs, affecting both necessary and unnecessary health care use. DISCLOSURES: This study and the development of this article were funded by the National Pharmaceutical Council. Mr Sils is an employee of the National Pharmaceutical Council. Dr Graff is a former employee of the National Pharmaceutical Council. Drs Fusco and Kistler and Ms Ruiz are employees of Xcenda. Xcenda received funding to conduct the literature review.

1394. Impact of 7-Valent and 13-Valent Pneumococcal Conjugate Vaccines in the United States: A Systematic Literature Review

Background

The availability of 7-valent (PCV7) and 13-valent (PCV13) pneumococcal conjugate vaccines (PCVs) in the United States (US) since 2000 and 2010, respectively, has substantially reduced the occurrence, morbidity and mortality of pneumococcal disease. This systematic literature review aimed to assess the impact of the PCVs in reducing the pneumococcal disease burden since their introduction.

Methods

We searched Embase and Medline and disease-surveillance websites for observational studies of US participants < 19 years, published 1999–2019 and reporting incidence or prevalence of acute otitis media, invasive pneumococcal disease, meningitis, or pneumococcal disease-related morbidity, mortality, healthcare resource utilization (HCRU) or costs.

Results

Of 499 citations identified from the databases and other sources, 125 met inclusion criteria (Figure), all indicating clear reductions in multiple manifestations of pneumococcal disease with PCV7 and PCV13 use. However, variations across studies in outcomes reported, study years, and age strata, confounded assessment of vaccine impact on specific pneumococcal disease outcomes and key burden indicators, such as tympanostomy tube placement and antibiotic prescriptions.

Conclusion

PCVs have greatly decreased multiple manifestations of pneumococcal disease in the US. However, granular data on the frequency and morbidity associated with specific pneumococcal diseases and on associated HCRU are needed to quantify the public-health impact of these vaccines.

Disclosures

Kristin Kistler, PhD, Evidera, Inc. (Employee, Evidera, Inc. received the funding to conduct this study.) Evelyn F. Gomez-Espinosa, BSc, PhD, Evidera Inc (Employee, Scientific Research Study Investigator)Pfizer Inc (Consultant, Scientific Research Study Investigator) Kelly Sutton, PhD, Evidera (Other Financial or Material Support, Evidera, Inc. received the funding to conduct this study.) Ruth Chapman, MSc, PhD, Evidera, Inc, (Evidera, Inc. received the funding to conduct this study.) (Consultant) Desmond Dillon-Murphy, MSc, PhD, Evidera, Inc. (Evidera, Inc. received the funding to conduct this study.) (Consultant) Matthew Wasserman, MSc., Pfizer Inc. (Employee)

1706. Association between Cytomegalovirus Infection/Disease and Morbidity and Mortality in Kidney Transplantation: A Systematic Literature Review of Observational Studies

Background

Cytomegalovirus (CMV) is a common pathogen in kidney transplant recipients (KTRs). KTRs may develop CMV viremia that is asymptomatic (‘CMV infection’) or associated with clinical and laboratory findings (‘CMV disease’) such as fever, leukopenia/neutropenia, and malaise (‘CMV syndrome’), and/or evidence of specific organ(s) involvement (‘CMV end-organ disease’). The extent to which CMV affects morbidity such as acute rejection (AR), graft loss (GL), other opportunistic infections (OI), or mortality in KTRs has not been systematically evaluated recently. Therefore, we examined the association between CMV infection/disease and morbidity and mortality in KTRs using a systematic review of observational studies from the last decade.

Methods

MEDLINE and Embase were searched to identify observational studies published between January 2008 and November 2018 reporting outcomes of interest by CMV status. Meta-analysis was used to derive pooled odds ratio (pOR) with 95% confidence intervals(CIs) using the random-effects models and I² statistics to estimate heterogeneity between studies using R version 3.5.1.

Results

Of 1,860 retrieved citations, 23 studies with a total of 6,994 KTRs met inclusion criteria. The majority of studies were conducted in Europe (N=14) and included participants regardless of donor/recipient CMV serostatus (N=14). Included studies reported outcomes by different clinical manifestations of CMV. Overall, CMV infection/disease was associated with an increased odd of AR, with significant heterogeneity. CMV infection/disease was also associated with an increase in the odds of GL and mortality compared to no CMV infection/disease without heterogeneity (Figure 1). A higher rate of all-cause hospital readmission and a greater mean number of OI episodes were reported with CMV infection/disease in a single study.

Pooled Estimates on the Association between Outcomes and CMV Infection/Disease among Individuals undergoing Kidney Transplant

Conclusion

CMV infection/disease was associated with increased mortality and GL in adults with KT. The association between CMV and AR remained similar in direction with high heterogeneity limiting the robustness of the conclusion. Nonetheless, our analysis underscores the importance of interventions to reduce the incidence of CMV infection/disease to reduce mortality and GL in KTRs even in the current era.

Disclosures

Amit D. Raval, PhD, Merck and Co., Inc (Employee) Kristin Kistler, PhD, Evidera, Inc. (Employee, Evidera, Inc. received the funding to conduct this study.) Yuexin Tang, PhD, Merck and Co., Inc. (Employee) Yoshihiko Murata, MD, PhD, Merck and Co., Inc. (Employee) David R. Snydman, MD, Merck (Consultant)Merck (Advisor or Review Panel member)Pfizer (Consultant)Reviral, Anthrax Vaccine, Influenza Vaccine (Other Financial or Material Support, Data Safety Monitoring Board)Takeda/Shire (Advisor or Review Panel member)

Antiviral treatment approaches for cytomegalovirus prevention in kidney transplant recipients: A systematic review of randomized controlled trials

Various CMV anti-viral (AV) preventive strategies have been utilized in KTRs. We examined efficacy, safety and costs of CMV-AV prevention strategies in KTRs using a systematic literature review (SLR) of randomized controlled trials (RCTs) publications indexed in MEDLINE and Embase (from inception to November 2018). Thirty RCTs met inclusion criteria with 22 unique AV preventive strategies. Prophylaxis was associated with significantly lower rates of CMV infection/disease (CMVi/d) compared to no prophylaxis (pooled odds ratio, pOR with 95% confidence interval (CI): CMVi: 0.33; 0.19, 0.57; CMVd: 0.27; 0.19; 0.39). Preemptive therapy (PET) had lower rates of CMVd (0.29; 0.11, 0.77), and medical costs compared to no PET. Prophylaxis had significantly lower rates of early CMVi/d, and higher rates of late CMVi and hematological adverse events (leukopenia, 2.93; 1.22, 7.04), and similar overall medical costs compared to PET. Studies involving head-to-head comparison of different prophylaxis approaches showed mixed findings with respect to optimum dose, duration and route of administration on CMV outcomes. Although there was heterogeneity across populations and interventions, both prophylaxis and PET strategies reduced CMVi/d compared to no prophylaxis/PET and had differential safety profile in terms of hematological adverse events. For comprehensiveness we did not limit study inclusion based on date; the wide time-period may have contributed to the heterogeneity in prevention approaches which subsequently made pooling studies a challenge. Despite demonstrated efficacy of prophylaxis/PET, our findings highlight the potential need of a novel intervention with a better safety profile and perhaps improved outcomes.

2556. Retrospective Evaluation of Mismatch From Egg-Based Isolation of Influenza Strains Compared With Cell-Based Isolation and the Possible Implications for Vaccine Effectiveness

Background

Lower influenza vaccine effectiveness (VE) against circulating H3N2 strains compared with other influenza viruses is partly explained by antigenic mismatch between circulating strains and the vaccine strain (Belongia 2016). This mismatch has recently been linked to a new glycosylation site introduced in the egg-adaptation step (Zost 2017) and HA L194P substitution (Wu 2017) for H3N2. Vaccine manufactured using seed virus wholly grown in mammalian (e.g., Madin–Darby Canine Kidney—MDCK) cells, as with the NH17-18 version of Flucelvax®, avoids these mutations. Preliminary reports suggest that this cell-based vaccine showed greater VE than did similar egg-based vaccines [FDA Statement]. This study aimed to compile existing data on antigenic similarity to measure the degree of match with circulating wild-type isolates of egg- and MDCK-propagated versions of the vaccine H3N2 virus over multiple seasons.

Methods

Using publicly available reports from the Worldwide Influenza Centre, London (Crick), we compiled data on antigenic similarity, defined as H3N2 circulating wild-type virus isolates showing no more than a 4-fold reduction in titer to antisera raised against wholly MDCK- or egg-propagated versions of the vaccine H3N2 viruses. Titers were compared using hemagglutination inhibition (HI) assays and/or plaque reduction neutralization assays (PRNA).

Results

Data from Northern Hemisphere influenza seasons of 2011–2012 to 2017–2018 show a substantially higher proportion of tested circulating influenza H3N2 viruses matched the MDCK-propagated reference viruses than did corresponding egg-propagated reference vaccine viruses (Figures 1 and 2). In half of the seasons evaluated, there was little to no antigenic similarity between circulating viruses and the egg-based vaccine viral seed.

Conclusion

These data suggest higher levels of mismatch have occurred consistently with egg-propagated H3N2 reference viruses compared with MDCK-propagated reference viruses when measured against circulating wild-type isolates and may further explain the potential for lower VE observed against H3N2 historically. Furthermore, these data point to the importance of continuing to utilize cell-derived seeds in creating seasonal influenza vaccines for this strain.

Disclosures

S. Rajaram, Seqirus: Employee, Salary. J. Van Boxmeer, Seqirus: Employee, Salary. B. Leav, Seqirus: Employee and Shareholder, Salary. P. Suphaphiphat, Seqirus: Employee, Salary. I. Iheanacho, Seqirus: Consultant, Research support. K. Kistler, Seqirus: Consultant, Research support.

Evaluation of Flexible Tacrolimus Drug Concentration Monitoring Approach in Patients Receiving Extended-Release Once-Daily Tacrolimus Tablets

The majority of United States kidney transplant patients are treated with tacrolimus, a drug effective in preventing graft rejection, but with a narrow therapeutic range, necessitating close monitoring to avoid increased risks of transplant rejection or toxicity if the tacrolimus concentration is too low or too high, respectively. The trough drug concentration tests are time sensitive; patients treated on a twice-daily basis have blood draws exactly 12 hours after their previous dose. The schedule's rigidity causes problems for both patients and health care providers. Novel once-daily tacrolimus formulations such as LCPT (an extended-release tablet by Veloxis Pharmaceuticals, Inc., Cary, North Carolina) have allowed for blood draws on a once-daily basis; however, even that schedule can be restrictive. Results from tests taken either before or after that 24-hour target time may be discarded, or worse, may lead to inappropriate dose changes. Data from ASTCOFF, a phase 3B pharmacokinetic clinical trial (NCT02339246), demonstrated that the unique pharmacokinetic curve of LCPT may allow for a therapeutic monitoring window that extends for 3 hours before or after the 24-hour monitoring target. Furthermore, important tools to help clinicians interpret these levels, such as formulas to estimate the 24-hour trough level if an alternative monitoring time is used, were constructed from these data. These study results give treating clinicians access to data that allow them to safely use and monitor LCPT in their patients and expand the body of evidence surrounding differentiation and practical application of the novel LCPT tacrolimus formulation.

Characteristics and Medication Use of Psoriasis Patients Who May or May Not Qualify for Randomized Controlled Trials

BACKGROUND

Clinical trials impose exclusion criteria that may limit the generalizability of results.

OBJECTIVES

To (a) determine the percentage of real-world patients who would qualify for psoriasis randomized controlled trials; (b) ascertain differences between moderate-to-severe psoriasis patients who would be eligible, ineligible, or potentially eligible for clinical trials; and (c) compare their biologic treatment patterns.

METHODS

Moderate-to-severe psoriasis patients were identified from the U.S. Department of Defense health care database from January 1, 2008, to October 31, 2013. Eligibility classification for psoriasis trials was based on common trial exclusion criteria involving medical conditions and recent treatment history. Patient characteristics and treatment patterns of 4 biologics (adalimumab, etanercept, infliximab, and ustekinumab) were compared between groups. Adherence was measured by medication possession ratio and persistence as continuous time on drug with ≤ 90-day gap between supply times.

RESULTS

Among 16,284 qualifying psoriasis patients, 4,677 (28.7%) were medically ineligible, and 8,466 (52.0%) had ineligibility-related treatments that could be stopped prior to trial entry; the latter patients were considered potentially eligible for psoriasis trials. Common reasons for medical ineligibility included malignancies and hematologic disorders; treatment ineligibilities included use of topical corticosteroids and phototherapy. Medically ineligible patients were older and had more comorbidities, while potentially eligible patients were younger and healthier than trial-eligible patients. Most treatment patterns were similar across groups, except that, compared with the trial-eligible group, medically ineligible patients had greater adherence to infliximab and potentially trial-eligible patients had greater adherence and persistence to adalimumab.

CONCLUSIONS

This large real-world study found that patients who may be ineligible for psoriasis trials differ in important respects (e.g., comorbidities, prior treatments) from their trial-eligible counterparts. Regardless of their differences at baseline, adherence, persistence, and switching of biologic medications are largely similar, with few differences noted among groups.

DISCLOSURES

Financial support for this study was provided by Lilly USA. Wu has received research funding from AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Coherus Biosciences, Dermira, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Regeneron, Sandoz, and Sun Pharmaceutical Industries, and he is a consultant for AbbVie, Amgen, Celgene, Dermira, Eli Lilly, Pfizer, Regeneron, and Sun Pharmaceutical Industries. Malatestinic, Goldblum, Solotkin, Lin, Johnston, and Araujo are employees and/or stock owners of Lilly. Nordstrom, Kistler, and Fraeman are employees of Evidera, which received funding from Lilly to conduct this study. LCDR Hawley is a military service member. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that "copyright protection under this title is not available for any work of the United States Government." Title 17 U.S.C. 101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of that person's official duties. Research data were derived from an approved Naval Medical Center, Portsmouth, Virginia, institutional review board protocol. The views expressed in this work are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. Study concept and design were contributed by Malatestinic and Araujo, along with the other authors. Nordstrom, Kistler, Fraeman, and Sicignano collected the data, and data interpretation was performed by Wu, Lin, and Hawley, along with Malatestinic, Nordstrom, Solotkin, and Araujo. The manuscript was written by Johnston, Malatestinic, Kistler, Wu, and Araujo, along with Nordstrom, Goldblum, Solotkin, Hawley, and Sicignano, and revised by Goldblum, Solotkin, Malatestinic, and Araujo, along with Nordstrom, Wu, Fraeman, Johnston, Hawley, and Sicignano.

Use of TSH response to TRH as an independent variable

The thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH) was assessed in 35 consecutive male admissions. Patients with TSH blunting were identified; they were compared with patients without blunting and with normal subjects. Patients without TSH blunting were normal as regards all endocrine variables. Patients with TSH blunting showed reduced TSH (but normal prolactin) levels before and after TRH administration, although their thyroid hormone levels and cortisol levels were normal. Height, weight, and body surface were unrelated to TSH blunting. The test-retest reliability of a blunted TSH response was acceptable.