ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer

BACKGROUND

Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022.

METHODS

A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting.

RESULTS AND DISCUSSION

A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

Abstract PD7-01: Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients

Introduction: National Comprehensive Cancer Network (NCCN) guideline-based treatment is increasingly recognized as a marker of high quality care. Payers are progressively limiting reimbursement for non-guideline based care as they move towards value-based cancer care. However, the impact of treatment regimen concordance with NCCN guidelines on cost and health care utilization in early stage breast cancer is unclear.

Methods: This was a secondary analysis of Medicare administrative claims data from 2012-2015 for all women aged ≥65 with stage I-III breast cancer who received care within the University of Alabama at Birmingham Cancer Community Network. Concordance to NCCN Clinical Practice guidelines was assessed for treatment regimens including hormonal medications, chemotherapy, and/or HER2-targeted therapy. Costs to Medicare (reimbursements to providers for all care received) were averaged monthly from the start of cancer treatment until death or available follow-up. Health care utilization (emergency department [ED] visits and hospitalizations) was identified from the start of cancer treatment until death or available follow-up. Cost and adjusted monthly utilization rates per thousand observations and their corresponding 95% confidence intervals (CI) were estimated using linear mixed effect models and generalized linear models, respectively, using the negative binomial distribution and log link function.

Results: Of 1042 patients on treatment for early stage breast cancer, 82% received a guideline concordant treatment, with 79% receiving a “preferred” treatment and 3% receiving an “other” but still on-guideline treatment. Those receiving guideline concordant treatment were more likely to be white, treated at large volume centers, have an earlier stage cancer, ER/PR positive, and HER2 negative (p<0.05). Among patients receiving chemotherapy (N=496), 63% of patients received guideline concordant treatment (55% “preferred”, 8% “other”). After adjusting for age, race, treatment center volume, and stage, average monthly costs after initiation of treatment for guideline concordant patients were $1464 lower compared to guideline discordant patients (95% CI $1135-$1793, p<.001). For guideline concordant patients, adjusted rates of ED visits per thousand observations were 41% lower at 51.3 per month (95% CI 44.0-59.8) compared to 77.9 per month (95% CI 62.6-96.9) for guideline discordant patients. Adjusted rates of hospitalizations per thousand observations were also 41% lower for guideline concordant patients at 28.2 per month (95% CI 23.5-33.8) compared to 42.7 per month (95% CI 32.9-55.5) for guideline discordant patients.

Conclusions: Despite the majority of early stage breast cancer patients receiving guideline concordant care, almost one in five did not, with an even higher proportion of guideline discordance in those receiving chemotherapy. Guideline concordant treatment was significantly associated with lower costs and lower rates of health care utilization after adjusting for patient and center characteristics. The appropriateness of guideline deviation should be examined from both the patient and payer perspectives.

Citation Format: Williams CP, Azuero A, Pisu M, Halilova KI, Adewakun S, Yagnik SK, Goertz H-P, Rocque GB. Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-01.

Abstract P3-10-03: Effects of guideline-concordant treatment on ED visits, hospitalizations, and cost in metastatic breast cancer

Purpose: The National Comprehensive Cancer Network (NCCN) developed treatment guidelines that have directed care of patients with cancer for over 20 years. Receipt of treatment according to these guidelines is increasingly recognized as a marker of high quality care. A knowledge gap exists regarding concordance of treatment regimens for metastatic breast cancer with NCCN guidelines, as well as the potential impact of this concordance (or lack thereof) on resource utilization and costs – an issue that assumes significance in the new era of value-based healthcare.

Methods: From 2007-2013, women with de novo (n=988) or recurrent, treated metastatic breast cancer (n=5,651) were evaluated for concordance of first-line systemic therapy with NCCN guidelines within the SEER–Medicare linked database. Types of non-concordant treatments were reviewed and categorized. Outcomes include monthly rates of ED visits, monthly rates of hospital admissions, total overall and Medicare costs, and mortality. Specific (hospitalizations, antineoplastic agents, growth factor) and total costs to Medicare (excluding home health, hospice, skilled nursing facility) were calculated from initiation of treatment until death or available follow-up and examined by concordance status. Part D costs were excluded because costs are shared by Medicare, other payers, and patients. Cox regression was used to evaluate mortality risk. Student's t-tests, generalized linear models, and generalized mixed effects models were utilized to evaluate the relationship between concordance status and outcomes.

Results: We previously reported the prevalence of non-concordant first-line systemic therapy for de novo metastatic breast cancer (19%) and recurrent metastatic breast cancer (18%). The adjusted risk of mortality was comparable by concordance status. In the current analysis, non-concordant treatments were associated with a 9% increased rate of ED visits and a 7% increased rate of hospitalizations (p<.01). Total Medicare cost for patients receiving concordant and non-concordant treatments was $79,372 and $109,471, respectively (p<.001). Significant cost differences were found when comparing patients receiving concordant and non-concordant treatments by antineoplastic agents ($14,256 vs $24,817, p<.001) and growth factor ($1,754 vs $3,414, p<.001). A trend toward lower cost attributed to hospitalizations was observed for patients receiving concordant treatment compared to those receiving non-concordant treatment ($28,113 vs $34,134, p=.06). Overall, hospitalizations, antineoplastic agents, and growth factor accounted for 56% of total Medicare costs. Average monthly Medicare costs were higher for non-concordant patients by $1,761 (p<.01).

Conclusions: While not associated with increased overall mortality, non-concordant treatment is associated with higher health care utilization rates and cost. Increased costs attributed to non-concordant care were largely driven by antineoplastic agents and growth factor use. These findings may have policy implications for payment reform initiative, in particular pathway programs which aim to reduce variability in care and spending on medications.

Citation Format: Rocque GB, Williams CP, Jackson BE, Halilova KL, Adewakun SA, Pisu M, Forero A, Bhatia S. Effects of guideline-concordant treatment on ED visits, hospitalizations, and cost in metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-10-03.

Abstract P2-07-02: Concordance with National comprehensive cancer network (NCCN) metastatic breast cancer guidelines and impact on overall survival

Introduction:Payers are implementing reimbursement restrictions for non-guideline based care. Limited information exists regarding real-world concordance with guidelines for metastatic breast cancer (MBC) treatment. Further, the impact of non-concordance on mortality is unknown. We address these gaps by using the Surveillance, Epidemiology, and End Results (SEER) Program-linked Medicare database to evaluate national concordance with NCCN guidelines and the association between concordance and mortality.

Methods: From 2007 to 2013, women with de novo (n=988) or recurrent metastatic breast cancer (n=5651) were evaluated for concordance of first-line systemic therapy (hormonal therapy, chemotherapy, and Her2-targeted therapy) with NCCN guidelines. Concordance was defined as receipt of single agent or combination treatments listed on NCCN guidelines. Non-concordant treatments were grouped into 5 categories: single-agent HER2-targeted therapy (33%), adjuvant regimens used in the metastatic setting (12%), therapy mismatched with ER/HER2 status (12%), non-approved bevacizumab regimens (10%), and other miscellaneous reasons (33%). Multivariable logistic regression was used to identify predictors of non-concordance. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox regression to compare all-cause mortality associated with non-concordant vs. concordant treatment adjusted for receptor status, comorbidities, age, race, poverty level, entitlement reason, and treatment year.

Results: Mean age at MBC diagnosis was 69y; 77% were white. Median follow-up was 1.2 years. The prevalence of non-concordant first-line systemic therapy was 19% for de novo MBC and 18% for recurrent MBC. Younger age, hormone-receptor negative status, and Her2-positive status were associated with non-concordant treatments for Stage IV and recurrent MBC patients (p<0.001). Higher poverty by census tract was associated with non-concordance in recurrent MBC (p<0.05). The most frequent category of non-concordant treatment in de novo MBC was use of adjuvant regimens in Stage IV MBC (43%) and use of single-agent HER2-targeted therapy (31%) in recurrent MBCs. Adjusted overall survival was similar for patients with de novo MBC receiving concordant and non-concordant treatments (HR 0.88, CI 0.72-1.65). Mortality was modestly increased for patients with recurrent MBC receiving non-concordant care (HR 1.12, CI 1.02-1.22); however, substantial differences were noted by category of non-concordance. Compared to concordant treatment, single-agent HER2-targeted therapy was associated with decreased risk of mortality (HR 0.78, CI 0.68-0.91). Increased mortality was observed for non-approved bevacizumab use (HR 1.79, CI 1.44-2.22) and other miscellaneous regimens (HR 1.42, CI 1.26-1.60). Mortality for therapy mismatched with ER/HER2 status was similar to concordant treatment (HR 1.13, CI 0.88-1.44).

Conclusions: In the first-line setting, treatment inconsistent with NCCN guidelines remains common (18%). Overall mortality was not substantially higher among non-concordant patients. However, mortality risk varied (in both directions) by category of non-concordance. These findings may provide an opportunity for considering refinement of NCCN guidelines.

Citation Format: Rocque GB, Williams CP, Jackson BE, Halilova KI, Pisu M, Andres F, Smita B. Concordance with National comprehensive cancer network (NCCN) metastatic breast cancer guidelines and impact on overall survival [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-07-02.

Abstract P6-11-02: Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south

Background: Patient-centered strategies are needed to enhance the value of cancer care particularly at the end of life. Lay navigators (LN) can be trained to provide an extra layer of support for cancer patients from diagnosis through survivorship or end of life. We hypothesized that integrating LNs into the care team would reduce healthcare utilization and cost for patients with cancer, including those with breast cancer.

Methods: A prospective, observational study of Medicare claims data was conducted of beneficiaries ≥ 65 years old diagnosed with cancer after 2008 who received care within the UAB Health System Cancer Community Network (12 cancer centers of varying size located in AL, MS, TN, GA, and FL). The first breast cancer (BC) patient was enrolled in navigation in April 2013, and ∼18% of BC patients were navigated by the end of 2014. For this analysis, we report on the subset of patients with BC. The outcomes of interest were calculated per quarter from 2012-2014: (1) the proportion of patients with at least 1 hospitalization, (2) the proportion of the 492 deceased BC patients with a hospitalization in the last 30 and 14 days of life and (3) the Total costs for Medicare, excluding prescription drug costs. We used general linear models to evaluate changes in both health care utilization and cost over time, adjusting for age, sex, cancer stage, phase of care, and navigation group. Differential effects for navigated and non-navigated groups were tested with a group*time interaction. Healthcare utilization estimates are presented as Incidence Rate Ratios (IRR), and costs for Medicare as parameter estimates (β) in terms of dollar amounts.

Results: 4835 BC patients received care from 2012-2014: 622 received navigation services. 14.2 % of navigated BC patients were stage III/IV, compared to 9.33% of non-navigated patients. The proportion of hospitalizations trended downward from 7.9% in quarter 1 (Q1) 2012 to 5.7% in Q4 of 2014 (IRR 0.965, p =0.14), with similar decreases for navigated and non-navigated patients (IRR= 1.00, p > 0.05). Hospitalization in the last 30 days and last 14 days of life were 49.7% and 29.3%, respectively, with no between groups difference. Costs per beneficiary per quarter decreased overall from $4,161 in Q1 2012 to $3,010 in Q4 2014 (p <0.0001). In adjusted analysis, the navigated patients had an average $577 greater decline per quarter than the non-navigated patients (βNavigated=-$636; βnon-Navigated=-$59; p<0.0001).

Conclusions: Medicare costs declined during implementation of a lay navigation program, with greater reductions for navigated patients than non-navigated BC patients. Overall hospitalizations also declined, yet rates remain high for breast cancer patients at the end of life. Integration of LNs should be considered by health systems aiming to transition to value-based healthcare delivery.

The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Citation Format: Rocque GB, Kvale EA, Jackson BE, Kenzik K, Lisovicz N, Demark-Wahnefried W, Meneses KM, Taylor RA, Acemgil A, Chambless C, Li Y, Martin M, Fouad M, Pisu M, Partridge EE. Hospitalizations and costs during Implementation of a lay navigation program for older patients with breast cancer in the deep south. [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 P6-11-02.

Remarks on ISRU and ISFR Technologies for Manned Missions on Moon and Mars

Space colonization and exploitation of extra-terrestrial natural resources could help humanity in facing various Earth problems. In this regard, production of energy and materials starting from Moon and Mars natural resources as well as the transportation of humans in space could be considered the long term remedy to issues such as overpopulation, depletion of fossil fuels, climate change as well as reduction of available natural resources. Along theses lines, two recently filed patents related to use of novel technologies for the in situ exploitation of natural resources available on Moon and Mars have been developed.

Incidence and prevalence of epilepsy among older U.S. Medicare beneficiaries

OBJECTIVE

To determine the prevalence and incidence of epilepsy among U.S. Medicare beneficiaries aged 65 years old and over, and to compare rates across demographic groups.

METHODS

We performed a retrospective analysis of Medicare administrative claims for 2001-2005, defining prevalent cases as persons with ≥1 claim with diagnosis code 345.xx (epilepsy) or 2 or more with diagnosis code 780.3x (convulsion) ≥1 month apart, and incident cases as prevalent cases with 2 years immediately before diagnosis without such claims. Prevalence and incidence rates were calculated for the years 2003-2005 using denominators estimated from a 5% random sample of Medicare beneficiaries. Results were correlated with gender, age, and race.

RESULTS

We identified 282,661 per year on average during 2001-2005 (a total of 704,243 unique cases overall), and 62,182 incident cases per year on average during 2003-2005. Average annual prevalence and incidence rates were 10.8/1,000 and 2.4/1,000. Overall, rates were higher for black beneficiaries (prevalence 18.7/1,000, incidence 4.1/1,000), and lower for Asians (5.5/1,000, 1.6/1,000) and Native Americans (7.7/1,000, 1.1/1,000) than for white beneficiaries (10.2/1,000, 2.3/1,000). Incidence rates were slightly higher for women than for men, and increased with age for all gender and race groups.

CONCLUSIONS

Epilepsy is a significant public health problem among Medicare beneficiaries. Efforts are necessary to target groups at higher risk, such as minorities or the very old, and to provide the care necessary to reduce the negative effects of epilepsy on quality of life.

Experimental analysis and modelling of in vitro HUVECs proliferation in the presence of various types of drugs

OBJECTIVES

This study focuses on experimental analysis and corresponding mathematical simulation of in vitro HUVECs (human umbilical vein endothelial cells) proliferation in the presence of various types of drugs.

MATERIALS AND METHODS

HUVECs, once seeded in Petri dishes, were expanded to confluence. Temporal profiles of total count obtained by classic haemocytometry and cell size distribution measured using an electronic Coulter counter, are quantitatively simulated by a suitable model based on the population balance approach. Influence of drugs on cell proliferation is also properly simulated by accounting for suitable kinetic equations.

RESULTS AND DISCUSSION

The models' parameters have been determined by comparison with experimental data related to cell population expansion and cell size distribution in the absence of drugs. Inhibition constant for each type of drug has been estimated by comparing the experimental data with model results concerning temporal profiles of total cell count. The reliability of the model and its predictive capability have been tested by simulating cell size distribution for experiments performed in the presence of drugs. The proposed model will be useful in interpreting effects of selected drugs on expansion of readily available human cells.

Cost-effectiveness of multifaceted evidence implementation programs for the prevention of glucocorticoid-induced osteoporosis

SUMMARY

Using a computer simulation model, we determined that an intervention aimed at improving the management of glucocorticoid-induced osteoporosis is likely to be cost-effective to third-party health insurers only if it focuses on individuals with very high fracture risk and the proportion of prescriptions for generic bisphosphonates increases substantially.

INTRODUCTION

The purpose of this study is to determine whether an evidence implementation program (intervention) focused on increasing appropriate management of glucocorticoid-induced osteoporosis (GIOP) might be cost-effective compared with current practice (no intervention) from the perspective of a third-party health insurer.

METHODS

We developed a Markov microsimulation model to determine the cost-effectiveness of the intervention. The hypothetical patient cohort was of current chronic glucocorticoid users 50-65 years old and 70% female. Model parameters were derived from published literature, and sensitivity analyses were performed.

RESULTS

The intervention resulted in incremental cost-effectiveness ratios (ICERs) of $298,000 per quality adjusted life year (QALY) and $206,000 per hip fracture averted. If the cohort's baseline risk of fracture was increased by 50% (10-year cumulative incidence of hip fracture of 14%), the ICERs improved significantly: $105,000 per QALY and $137,000 per hip fracture averted. The ICERs improved significantly if the proportion of prescriptions for generic bisphosphonates was increased to 75%, with $113,000 per QALY and $77,900 per hip fracture averted.

CONCLUSIONS

Evidence implementation programs for the management of GIOP are likely to be cost-effective to third-party health insurers only if they are targeted at individuals with a very high risk of fracture and the proportion of prescriptions for less expensive generic bisphosphonates increases substantially.

In vitro ovine articular chondrocyte proliferation: experiments and modelling

This study focuses on analysis of in vitro cultures of chondrocytes from ovine articular cartilage. Isolated cells were seeded in Petri dishes, then expanded to confluence and phenotypically characterized by flow cytometry. The sigmoidal temporal profile of total counts was obtained by classic haemocytometry and corresponding cell size distributions were measured electronically using a Coulter Counter. A mathematical model recently proposed (1) was adopted for quantitative interpretation of these experimental data. The model is based on a 1-D (that is, mass-structured), single-staged population balance approach capable of taking into account contact inhibition at confluence. The model's parameters were determined by fitting measured total cell counts and size distributions. Model reliability was verified by predicting cell proliferation counts and corresponding size distributions at culture times longer than those used when tuning the model's parameters. It was found that adoption of cell mass as the intrinsic characteristic of a growing chondrocyte population enables sigmoidal temporal profiles of total counts in the Petri dish, as well as cell size distributions at 'balanced growth', to be adequately predicted.

Experimental analysis and modelling of in vitro proliferation of mesenchymal stem cells

OBJECTIVES

Stem cell therapies based on differentiation of adult or embryonic stem cells into specialized ones appear to be effective for treating several human diseases. This work addresses the mathematical simulation of proliferation kinetics of stem cells.

MATERIALS AND METHODS

Sheep bone marrow mesenchymal stem cells (phenotype characterized by flow cytometry analysis) seeded at different initial concentrations in Petri dishes were expanded to confluence. Sigmoid temporal profiles of total counts obtained through classic haemocytometry were quantitatively interpreted by both a phenomenological logistic equation and a novel model based on a one-dimensional, single-staged population balance approach capable of taking into account contact inhibition at confluence. The models' parameters were determined by comparison with experimental data on population expansion starting from single seeding concentration. Reliability of the models was tested by predicting cell proliferation carried out starting from different seeding concentrations.

RESULTS AND DISCUSSION

It was found that the proposed population balance modelling approach was successful in predicting the experimental data over the whole range of initial cell numbers investigated, while prediction capability of phenomenological logistic equation was more limited.

Cell proliferation, apoptosis and mitochondrial damage in rat B50 neuronal cells after cisplatin treatment

OBJECTIVES

Cisplatin (cisPt) is used as a chemotherapeutic agent for the treatment of a variety of human tumours; more recently, it has been demonstrated that tumour cell exposure to cisPt ultimately results in apoptosis, but the mechanism by which nuclear cisPt/DNA generates the cytoplasmic cascade of events involved has not been clarified. We have investigated the effects of cisPt on proliferation in the neuronal cell line B50, with particular attention being given to understand whether mitochondria are a target of cisPt and their involvement in the apoptotic process.

MATERIALS AND METHODS

Rat neuronal B50 cells were used to investigate the mechanisms of cisPt-induced cytotoxicity; this line has been used as a model system for neurotoxicity in vivo.

RESULTS

Changes in proliferation, induction of apoptosis, activation of caspase-3 and DNA fragmentation were observed in the cells, as well as morphological and biochemical alterations of mithocondria. Activation of caspase-9 confirmed that mitochondria are a target of cisPt.

CONCLUSION

CisPt exerts cytotoxic effects in the neuronal B50 cell line via a caspase-dependent pathway with mitochondria being central relay stations.

Mechanically induced self-propagating reactions: analysis of reactive substrates and degradation of aromatic sulfonic pollutants

Mechanochemical reactions have been identified as a valuable alternative to conventional methodologies for the degradation of toxic pollutants as well as for their abatement in contaminated matrices. This paper discusses the application of the mechanochemical technique to the degradation of sulfonic acids in a contaminated matrix. The degradation of the pollutant compound was carried out by taking advantage of combustive reactions on a suitable reactive system ignited under mechanical treatment conditions. Two systems have been investigated as possible reactive substrates. The first one was a Mg-SiO2 powder mixture while the second system was a Ca-SiO2 powder mixture. Milling trials performed under different mechanical processing conditions allowed one to characterise the reactivity of these chemical systems, which basically undergo a reduction/oxidation reaction involving the formation of MgO and Si phases when the Mg-SiO2 system is considered and CaO and Si phases when the Ca-SiO2 system is employed, respectively. The systematic change of the stoichiometric ratios Mg:SiO2 and Ca:SiO2 permitted to identify the minimum Mg or Ca content necessary for the ignition of the combustive reactions. The experimental runs performed with such systems have shown a greater effectiveness of the Mg-SiO2 because of less energy inputs required to ignite a combustion. For this reason the Mg-SiO2 has been considered as a reactive substrate in the following trials. Since the SiO2 amount in stoichiometric excess may be regarded as inert phase, it was substituted with a different phase consisting of the matrix contaminated by sulfonic acids. This aspect permitted to ignite a combustive reaction with the minimum possible content of Mg-SiO2 reacting mixture. The chemical analyses performed after the combustive reaction proved the complete removal of the sulfonic acid from the contaminated matrix.

Fracture Reduction Affects Medicare Economics (FRAME): impact of increased osteoporosis diagnosis and treatment

Osteoporosis is a common, debilitating disease affecting US Medicare beneficiaries, yet diagnosis and treatment lag behind medical advances. We estimated the cost of fractures to the Medicare program and the impact of increasing osteoporosis diagnosis and treatment. A Markov model was used to predict fracture incidence and costs in postmenopausal women aged 65 years and older, over 3 years (2001-2003). Only 1.80 million women were estimated to receive a Medicare-reimbursed bone mineral density (BMD) test in 2001. We evaluated the budget impact of testing an additional 1 million women from Medicare and patient perspectives. These women were stratified into high-risk (osteoporotic with prevalent vertebral fracture) and moderate-risk (without prevalent vertebral fracture) groups. During 2001-2003, an estimated 2.39 million fractures occurred among the 5.11 million women aged 65+ with osteoporosis, at a cost to Medicare of 12.96 billion dollars. We projected that BMD testing of an additional 1 million women in 2001 would result in treatment of 440,000 new patients with a bone-specific medication, preventing over 35,000 fractures over the 3 years. The decrease in fractures would produce a net discounted savings to the Medicare budget of 77.86 million dollars. Medicare's hospital inpatient cost would decrease by 115.41 million dollars and long-term care cost by 43.51 million dollars, more than offsetting incremental outpatient cost of 81.07 million dollars. Patients would benefit from fracture avoidance, but their out-of-pocket medical costs would increase by 63.49 million dollars during 2001-2003, or 1,771 dollars per fracture avoided. Sensitivity analyses showed that savings to the Medicare program varied in proportion to the unit cost of fractures, fracture risk of the populations tested, treatment rate, and adherence to therapy. Increased osteoporosis diagnosis may produce savings for the Medicare program if interventions are targeted to women at elevated risk for fracture and may be budget neutral if all older women are screened.

The cost of glucocorticoid-associated adverse events in rheumatoid arthritis

OBJECTIVE

To estimate the costs of glucocorticoid associated adverse events (GAEs) in patients with rheumatoid arthritis (RA).

METHODS

We conducted a literature review of studies reporting GAEs in RA patients, and developed a Markov model with the following GAEs: fractures (vertebral, hip, pelvic), hypertension, diabetes, gastrointestinal complications, pneumonia, urinary tract infection, cataract and, in an extended model, myocardial infarction (MI) and stroke. Two-year total costs were calculated using direct medical costs (2001 US dollars [USD]) and by running 10,000 Monte Carlo simulations with probability values randomly selected from the GAE literature.

RESULTS

On average, glucocorticoid users spent USD 445 more than non-users, or USD 0.46 for each dollar spent on purchasing the drug. When adding MI and stroke, users spent on average USD 430 more than non-users, or USD 0.44 for each dollar spent on purchasing the drug; this incremental cost ranged from USD 193 to USD 682 if MI and stroke were excluded, respectively. In 70% of the simulations there were more deaths among users than among non-users, in both the model with and without MI and stroke.

CONCLUSIONS

Although results varied depending on attributed GAEs, in general glucocorticoid users spent more than non-users on GAE treatment, and had higher mortality. Patients, providers and policy makers should consider these potential costs of GAEs when making treatment decisions.