Network meta-analysis of second line and beyond treatment options in metastatic clear cell renal cell carcinoma

INTRODUCTION

Deciding on the optimal second-line (2L) treatment for metastatic clear-cell renal cell carcinoma (ccRCC) remains challenging due to the limited information comparing each of the available options and the influence of the newly expanding first-line (1L) agents.

PATIENTS AND METHODS

We identified phase II/III randomized controlled trials (RCTs) evaluating 2L treatments in metastatic ccRCC. This Network Meta-analysis (NMA) evaluates the overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and severe adverse events (SAE). We used normal likelihood model to incorporate log hazard ratios (HRs), odds ratios (OR), and 95%-confidence-intervals (CI). Treatment p-scores were used for ranking. Data was analyzed in a fixed-effects model using the netmeta package in R v.1.5-0.

RESULTS

All therapies demonstrated some benefits over placebo. Lenvatinib + everolimus ranked first for OS (HR = 0.44; 95%CI = 0.24-0.82; p-score = 0.92), PFS (HR = 0.13; 95%CI = 0.07-0.24, p-score = 0.98), and ORR (OR = 35.95; 95%CI = 11.55-111.87; p-score = 0.93) compared to placebo, though with a higher SAE (OR = 5.27; p-score = 0.23). Cabozantinib ranked second for OS (HR = 0.57, p-score = 0.80), PFS (HR = 0.19; p-score = 0.86), and ORR (OR = 27.24, p-score = 0.84). Nivolumab was third for ORR (p-score = 0.79), fourth for OS (p-score = 0.69), fifth for PFS (p-score = 0.61), and last for SAE (p-score = 0.83). Lenvatinib monotherapy ranked worst SAE (OR = 5.89, p-score = 0.17) and third for OS and PFS. The latest drug, tivozanib, was sixth for PFS, OS, and ORR. The NMA matrix revealed no differential OS benefit between cabozantinib, lenvatinib + everolimus, and nivolumab. Other regimens had no significant OS benefit when compared to placebo.

CONCLUSION

Based on OS and PFS, the lenvtatinib + everolimus combination yielded superior, followed by cabozantinib and Lenvatinib monotherapies; all were limited by a worse SAE profile. Nivolumab and pazopanib had the lowest odds of SAEs.

Understanding faculty perceptions and experiences related to climate, diversity, equity, and inclusion at a college of pharmacy: A pilot study

INTRODUCTION

A climate survey was piloted to obtain an understanding of the perceptions and personal experiences of faculty for intentional planning of future meaningful, effective, and sustainable diversity, equity, and inclusion (DEI) efforts at a college of pharmacy.

METHODS

A 48-item, four section, online survey was developed and administered to 69 faculty between October and November 2021. Likert-like five-point scales and free-text items were included to determine an overall assessment of climate, as well as perceptions and/or personal experiences for each domain of DEI, and demographics.

RESULTS

Thirty-nine (57%) faculty completed the survey. For climate, every attribute had at least one respondent that observed someone make an insensitive or disparaging remark "rarely," "occasionally," and "frequently." The response pattern was similar for personal experience with insensitive remarks. For participation in diversity activities, "awareness without participation" was selected by 56% of respondents. For perceptions of diversity, "fairly" or "very" was selected by 38% to 54% of respondents. For equity, "attainable for some" to "not attainable" was identified for 15% to 26% of respondents.

CONCLUSIONS

These pilot climate survey results inform climate improvement as it relates to DEI and informs survey instrument refinement.

Utilization of opportunistic cervical cancer screening in Nigeria

BACKGROUND

While various interventions have been conducted to decrease cervical cancer's burden in Nigeria, no study has examined the trends in cervical cancer screening uptake over time. The present study sought to fill this gap in knowledge using data collected at Jos University Teaching Hospital (JUTH) in Nigeria.

METHODS

Data collected continuously between 2006 and 2016 were analyzed to identify trends in screening uptake, changes in risk factors for cervical cancer, and to identify factors for women screened at Jos University Teaching Hospital (JUTH) in Jos, Nigeria. Categorical analyses and logistic regression models were used to describe patient characteristics by year, and to identify factors associated with repeated screening uptake.

RESULTS

A total of 14,088 women who were screened between 2006 and 2016 were included in the database; 2,800 women had more than one screening visit. Overall, screening uptake differed significantly by year. On average women were first screened at age 38. About 2% of women screened were women living with HIV. Most women (86%) had normal pap smear at first screening, with the greatest decreased risk of abnormalities observed between 2011 and 2014. Odds of a follow-up screening after a normal result decreased significantly between 2008 and 2016 compared to women screened in 2006 and 2007. Finally, women living with HIV had increased odds of follow-up screening after having a normal pap smear.

CONCLUSIONS

These findings contribute to our understanding of the potential social and health system barriers to cervical cancer control in Nigeria. The findings may assist policy makers to design interventions to increase access and compliance to recommended screening schedules in this vulnerable population.

The economic burden of Ebola virus disease: a review and recommendations for analysis

BACKGROUND

Ebola virus disease (EVD) continues to be a major public health threat globally, particularly in the low-and-middle-income countries (LMICs) of Africa. The social and economic burdens of EVD are substantial and have triggered extensive research into prevention and control. We aim to highlight the impact and economic implications, identify research gaps, and offer recommendations for future economic studies pertaining to EVD.

METHOD

We conducted a comprehensive librarian-led search in PubMed/Medline, Embase, Google Scholar, EconLit and Scopus for economic evaluations of EVD. After study selection and data extraction, findings on the impact and economics of EVD were synthesized using a narrative approach, while identifying gaps, and recommending critical areas for future EVD economic studies.

RESULTS

The economic evaluations focused on the burden of illness, vaccine cost-effectiveness, willingness-to-pay for a vaccine, EVD funding, and preparedness costs. The estimated economic impact of the 2014 EVD outbreak in Guinea, Liberia, and Sierra Leone across studies ranged from $30 billion to $50 billion. Facility construction and modification emerged as significant cost drivers for preparedness. The EVD vaccine demonstrated cost-effectiveness in a dynamic transmission model; resulting in an incremental cost-effectiveness ratio of about $96 per additional disability adjusted life year averted. Individuals exhibited greater willingness to be vaccinated if it incurred no personal cost, with a minority willing to pay about $1 for the vaccine.

CONCLUSIONS

The severe impact of EVD puts pressure on governments and the international community for better resource utilization and re-allocation. Several technical and methodological issues related to economic evaluation of EVD remain to be addressed, especially for LMICs. We recommend conducting cost-of-sequelae and cost-of-distribution analyses in addition to adapting existing economic analytical methods to EVD. Characteristics of the affected regions should be considered to provide evidence-based economic plans and economic-evaluation of mitigations that enhance resource allocation for prevention and treatment.

The impact of the COVID-19 pandemic on routine HIV care and cervical cancer screening in North-Central Nigeria

INTRODUCTION

Cervical cancer is the fourth most diagnosed cancer among women globally, with much of the burden being carried by women in limited-resource settings often worsened by the high prevalence of HIV. Furthermore, the COVID-19 pandemic disrupted organized screening efforts and HIV management regimens worldwide, and the impact of these disruptions have not been examined in these settings. The purpose of this paper is to describe whether uptake of cervical cancer screening and HIV management changed before, during, and since the COVID-19 pandemic in North-Central Nigeria.

METHODS

Longitudinal healthcare administration data for women who obtained care between January 2018 and December 2021 were abstracted from the AIDS Prevention Initiative Nigeria (APIN) clinic at Jos University Teaching Hospital. Patient demographics, pap smear outcomes, and HIV management indicators such as viral load and treatment regimen were abstracted and assessed using descriptive and regression analyses. All analyses were conducted comparing two years prior to the COVID-19 pandemic, the four quarters in 2020, and the year following COVID-19 restrictions.

RESULTS

We included 2304 women in the study, most of whom were between 44 and 47 years of age, were married, and had completed secondary education. About 85% of women were treated with first line highly active retroviral therapy (HAART). Additionally, 84% of women screened using pap smear had normal results. The average age of women who sought care at APIN was significantly lower in Quarter 3, 2020 (p = 0.015) compared to the other periods examined in this study. Conversely, the average viral load for women who sought care during that period was significantly higher in adjusted models (p < 0.0001). Finally, we determined that the average viral load at each clinic visit was significantly associated with the period in which women sought care.

CONCLUSIONS

Overall, we found that COVID-19 pandemic mitigation efforts significantly influenced women's ability to obtain cervical cancer screening and routine HIV management at APIN clinic. This study buttresses the challenges in accessing routine and preventive care during the COVID-19 pandemic, especially in low-resource settings. Further research is needed to determine how these disruptions to care may influence long-term health in this and similar at-risk populations.

Economic Evaluation of Three BRAF + MEK Inhibitors for the Treatment of Advanced Unresectable Melanoma With BRAF Mutation From a US Payer Perspective

BACKGROUND

The combinations of BRAF + MEK inhibitors-encorafenib (ENC) + binimetinib (BIN), cobimetinib (COB) + vemurafenib (VEM), and dabrafenib (DAB) + trametinib (TRA)-are recommended for the treatment of BRAF-mutated advanced melanoma.

OBJECTIVE

To assess the cost-effectiveness and cost-utility of ENC + BIN versus COB + VEM versus DAB + TRA from a US payer perspective.

METHODS

A Markov model was constructed to simulate a hypothetical cohort over a time horizon of 10 years. The overall survival (OS) and progression-free survival (PFS) curves were independently digitized from a randomized controlled trial for ENC + BIN and fitted using R software. Published and indirectly estimated hazard ratios were used to fit OS and PFS curves for COB + VEM and DAB + TRA. Costs, life-year gains, and quality-adjusted life years (QALYs) associated with the 3 treatment combinations were estimated. A base case analysis and probabilistic sensitivity analysis (PSA) were conducted to estimate the incremental cost-utility ratio (ICUR). A discount rate of 3.5% was applied on cost and outcomes.

RESULTS

The ENC + BIN versus COB + VEM comparison was associated with an ICUR of $656 233 per QALY gained. The ENC + BIN versus DAB + TRA comparison was associated with an ICUR of $3 135 269 per QALY gained. The DAB + TRA combination dominated COB + VEM. The base case analysis estimates were confirmed by the PSA estimates. ENC + BIN was the most cost-effective combination at a high willingness-to-pay (WTP) threshold of $573 000 per QALY and $1.5 million/QALY when compared to COB + VEM and DAB + TRA, respectively.

CONCLUSION AND RELEVANCE

Given current prices and acceptable WTP thresholds, our study suggests that DAB + TRA is the optimum treatment. In this study, ENC + BIN was cost-effective only at a very high WTP per QALY threshold.

Overall survival, efficacy, and safety outcomes beyond front-line modern therapies in metastatic clear-cell renal cell carcinoma

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Background: Due to the ever-changing front-line landscape therapeutic options for m-ccRCC, the second-line (2L) treatment decision remains challenging due to limited information comparing each of the options. We present a survival, efficacy, and safety comparison of the 2L treatment regimens based on the most recent drug approvals for m-ccRCC. Methods: Inclusion criteria for our NMA included phase II/III RTCs that evaluated 2L and beyond for metastatic ccRCC. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and severe adverse events (SAE) hazard ratios (HRs), odds ratios (OR), and 95% confidence intervals (CI) of the treatment differences were abstracted. The p-scores were used to rank treatments. Data were analyzed in a fixed effects model using the netmeta package in R v.1.5-0. Results: Nine studies with 10 therapies included demonstrated some level of efficacy over placebo (Table). Pairwise comparisons using the NMA matrix revealed no differential OS benefit between axitinib (A), cabozantinib (C), lenvatinib+everolimus (LE), and nivolumab (N). Other regimens had no OS benefit when compared to placebo. Table was ordered based on p-score ranking the certainty that one treatment is better than another averaged over all competing treatments for OS. Placebo represents the reference of 1. Conclusions: LE had the lowest safety profile, although did prove to have the best OS and efficacy based on PFS/ORR. C and N, both had significant improvement in OS and efficacy over placebo with lower rates of SAEs compared to LE. Therefore, while further direct comparison studies are warranted to inform clinical practice, for now, we rely on the limitations inherent in indirect treatment comparisons of a NMA. [Table: see text]

Comorbidities and perceived health status in persons with history of cancer in the USA

PURPOSE

Comorbidities can further challenge prognosis and general wellbeing of cancer patients. This study aimed to assess the association between comorbidities and perceived health status (PHS) of US persons with cancer.

METHODS

This cross-sectional study used 2019 Medical Expenditure Panel Survey (MEPS) data and included individuals who were alive throughout the year, aged 18 to 84 years, and had diagnosis for cancer. Using adjusted logistic regression models, we estimated the association of comorbidities (no, few [1/2], and more [3 or more] comorbidities) with PHS. Analyses accounted for the complex design of MEPS.

RESULTS

The dataset included 28,512 participants, 1739 of which were eligible for the study. Of these, 11.16% (95% CI 9.64, 12.59%); 41.73% (95% CI 39.21, 43.96%); and 47.10% (95% CI 44.86, 49.73%) reported having no, few, and more comorbidities, respectively. While breast (N = 356), prostate (N = 276), and melanoma (N = 273) were the most common cancers, hypertension (88.3%), hypercholesterolemia (49.5%), and arthritis (48%) were the most prevalent comorbidities. Adjusted logistic regression showed that, compared with those with no comorbidities, persons with few and more comorbidities had 1.58 (95% CI = 0.79, 3.15) and 2.27 (95% CI = 1.19, 4.32) times greater odds of poor PHS. Younger or male patients, those with less formal education, low-income, pain, functional limitation, or poor perception of mental health were more likely to regard their health as poor.

CONCLUSION

About 88% of persons with history of cancer in the USA aged 18-84 years reported at least one comorbidity. Having more comorbidities, along with several other variables, was associated with poor PHS. Comorbidities management must be given special consideration to improve the prognosis and general wellbeing of persons with cancer.

Perceived Normalization of Drug Trafficking and Adolescent Substance Use on the US-Mexico Border

BACKGROUND

Historically marginalized youth are at risk for daily substance use. Daily use may be associated with social and environmental factors.

METHODS

In March 2018, we surveyed primarily Latino adolescents ages 14-18 who lived on the US-Mexico border and assessed associations between daily substance use, neighborhood stress, border community and immigration stress, and family support.

RESULTS

Of 443 surveyed adolescents, 41 (9%) reported daily use. Those who used daily were more likely to be older, identify as male, and reported lower social support and higher neighborhood and border community stress compared to those who did not use daily. Perceived neighborhood stress (OR = 1.95, 95% CI 1.37-2.80) and border community and immigration stress (OR = 1.55, 95% CI 1.12-2.02) were associated with increased odds of daily substance use.

DISCUSSION

Latino adolescents who live near the US-Mexico border experience unique socioenvironmental stress which is associated with daily substance use.

Economic evaluations of adjunctive osimertinib treatment in surgically resected epidermal growth factor receptor-positive (EGFR+) non-small cell lung cancer (NSCLC): Analysis for stage 2 disease

e20506

Background: Following surgical resection, patients with NSCLC require monitoring due to the risk of recurrence. Studies have demonstrated the clinical benefit of osimertinib, a tyrosine kinase inhibitor, as adjunctive therapy in surgically resected EGFR+ NSCLC, including in stage 2 disease. We performed a cost effectiveness/utility analysis of adjunctive osimertinib therapy in stage 2 disease following surgical resection. Methods: A two state partitioned survival model differentiating disease free survival (DFS) from disease recurrence and death was specified (US payer perspective). Parametric functions were fit to digitized overall survival (OS) and DFS curves. A 5 year time horizon was specified, with a 3% discount rate applied to costs and utilities beyond year 1. Costs of treatment (wholesale acquisition cost), adverse events (grade 3/4 except all grades for immunotherapy related AEs), and monitoring were sourced from, respectively, Redbook, literature, and Physician Fee Schedules (US $2021). DFS life years (DFSLY) and quality adjusted life years (DFSQALY), incremental cost effectiveness/utility ratios (ICER/ICUR) in terms of DFSLY and DFSQALY gained (g) were estimated in base case analyses (BSA) and probabilistic sensitivity analyses (PSA). Results: Exponential regression was used to extrapolate osimertinib and placebo Kaplan-Meier curves. As detailed below, in BCA (PSA) the incremental cost of osimertinib over placebo was $778,315 ($778,202). The incremental DFSLY was 1.740 (1.738), which yielded ICER of $447,349/DFSLYg ($447,768/DFSLYg). The incremental DFS QALY was 1.234 (1.232), yielding ICUR of $630,910/DFSQALYg ($631,498/DFSQALYg). Conclusions: As to disease recurrence in stage 2 surgically resected EGFR+ NSCLC, our model associated adjunctive osimertinib therapy with incremental clinical gains of 1.740 (1.738) DFSLY and 1.234 (1.232) DFSQALY compared to placebo, however at marked incremental cost. As adjunctive osimertinib treatment is indicated in EGFR+ NSCLC disease stages 1B and 3A, the present stage 2 cost effectiveness/utility results should be compared to those for stages 1B and 3A.[Table: see text]

Economic evaluations of adjunctive osimertinib treatment in surgically resected epidermal growth factor receptor positive (EGFR+) non-small cell lung cancer (NSCLC): Analysis for stage 3A disease

e20505

Background: Patients with surgically resected EGFR+ NSCLC remain at risk of recurrence after surgery. Osimertinib, a tyrosine kinase inhibitor, had been assessed clinically as adjunctive therapy in surgically resected EGFR+ NSCLC including stage 3A. We conducted a cost effectiveness/utility analysis of adjunctive osimertinib therapy in stage 3A surgically resected EGFR+ NSCLC. Methods: We specified a two state partitioned survival model of disease free survival (DFS) versus disease recurrence and death in a), with a 5 year time horizon (US payer perspective). DFS and overall survival curves were extrapolated per parametric functions. A 3% discount rate was utilized to costs and utilities beyond year 1. Costs of therapies (wholesale acquisition cost), adverse events (AE; grade 3/4; all grades for immunotherapy related AEs), and monitoring costs were based on Redbook, publications, and Physician Fee Schedules, respectively (US $2021). Costs, DFS life years (DFSLY) and DFS quality adjusted life years (DFSQALY) were used to determine the incremental cost effectiveness/utility ratios (ICER/ICUR) of the additional cost needed to gain (g) a DFSLY and DFSQALY in base case (BSA) and probabilistic sensitivity analyses (PSA). Results: Exponential regression was used to extrapolate the Kaplan-Meier curves of osimertinib and placebo,. As shown in the table, the BCA (PSA) estimated the incremental cost at $669,369 ($670,274). The incremental DFSLY was 1.895 (1.899), yielding ICER of $353,125/DFSLYg ($352,963/DFSLYg). The incremental DFS QALY was 1.35, yielding an ICUR of $497,905/DFSQALYg ($497,676/DFSQALYg). Conclusions: In stage 3A surgically resected EGFR+ NSCLC, adjunctive osimertinib therapy showed incremental benefits of 1.895 (1.899) DSFLYg and 1.344 (1.349) QALYg compared to placebo, however at marked incremental cost. As adjunctive osimertinib treatment is indicated in EGFR+ NSCLC disease stages1B and 2, the present stage 3A cost effectiveness/utility results should be compared to those for stages 1B and 2.[Table: see text]

Economic evaluations of adjunctive osimertinib treatment in surgically resected epidermal growth factor receptor positive (EGFR+) non-small cell lung cancer (NSCLC): Analysis for stage 1B disease

e20502

Background: Patients with stage 1B non-small cell lung cancer (NSCLC) who receive surgical resection are at continued risk of disease recurrence and death after the surgery. Osimertinib, a tyrosine kinase inhibitor indicated for epidermal growth factor receptor positive (EGFR+) NSCLC, has been used post-operatively as adjunctive therapy to improve clinical outcomes in surgically resected EGFR+ stage 1B NSCLC. We evaluated the cost effectiveness/utility of adjunctive osimertinib treatment post-surgically in stage 1B. Methods: A two state partitioned survival model with disease free survival (DFS) and disease recurrence or death was specified (US payer perspective). Kaplan-Meier DFS curves were fitted to parametric functions. A 5 year time horizon was adopted and a 3% discount rate was applied to costs and utilities after year 1. Wholesale acquisition costs for treatments were sourced from Redbook, adverse event costs (grade 3/4; all grades for immunotherapy related AEs) utilized published data, and monitoring costs were based on Physician Fee Schedules (US $2021). We estimated incremental costs, DFS life years (DFSLY), and DFS quality adjusted life years (DFSQALY). Based on DFSLY and DFSQALY gained (g), incremental cost effectiveness/utility ratios (ICER/ICUR) were determined in base case analyses (BCA) and probabilistic sensitivity analyses (PSA). Results: Exponential regression was utilized to extrapolate the osimertinib DFS Kaplan-Meier curve, while Weibull regression was applied for extrapolation of the placebo DFS curve. Shown in the table below, the BCA (PSA) revealed incremental cost of $774,710 ($775,941) and ncremental DFSLY of 0.813 (0.954), yielding an ICER of $952,797/DFSLYg ($813,162/DFSLYg); and incremental DFSQALY of 0.576 (0.676), yielding an ICUR of $1,345,340/DFSQALYg (1,147,793/DFSQALYg). Conclusions: In surgically resected stage 1B EGFR+ NSCLC, the model estimated incremental benefits of 0.813 (0.954) LYg and 0.576 (0.676) QALYg, however at marked incremental cost. As adjunctive osimertinib treatment is indicated in EGFR+ NSCLC disease stages 2 and 3A, the present stage 1B cost effectiveness/utility results should be compared to those for stages 2 and 3A.[Table: see text]

Network meta-analysis (NMA) of second-line (2L) treatment options in metastatic renal cell carcinoma

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Background: Immune checkpoint inhibitors, in combination either with a cytotoxic T-lymphocyte-associated protein 4 or tyrosine kinase inhibitor are approved for first-line (1L) therapy of metastatic renal cell carcinoma (mRCC). Of those, several have been shown to improve median progression-free survival (mPFS) in the 2L. A recent NMA by Irbaz et al. (PMID 33824031) identified the most effective 1L treatments for mRCC. In the absence of head-to-head randomized clinical trials (RCT), we performed an indirect comparison of 2L treatments for mRCC. Methods: We conducted literature searches in Medline, Embase, Cochrane Library, and Google Scholar to identify RCTs evaluating 2L treatments in mRCC. We extracted the mPFS hazard ratios (HR) and 95% confidence intervals (CI). We used a normal likelihood model that incorporates log HRs of the treatment differences for conducting the NMA. P-scores, measuring the certainty that one treatment is better than another averaged over all competing treatments, were used to rank treatments. Higher p scores indicate better outcomes. Data were analyzed with R netmeta package v.1.5-0. Results: All 8 therapies included in this analysis showed benefits in mPFS over placebo (Table). The combination of lenvatinib+everolimus had the lowest hazard of disease progression or death and pazopanib was the highest compared to placebo. Lenvatinib+everolimus ranked highest with a p-score of 0.96 followed by cabozantinib (0.88), and lenvatinib (0.79); with others having p-scores of 0.60 or less (placebo p-score 0.00). Conclusions: This NMA revealed that lenvatinib+everolimus and cabozantinib are most likely to produce the highest PFS benefit in 2L in mRCC. Future studies are needed to evaluate 1L and 2L sequencing options to further inform clinical practice. [Table: see text]

Comparative value-based pricing of an Ebola vaccine in resource-constrained countries based on cost-effectiveness analysis

OBJECTIVES

Pricing, affordability, and access are important deliberations around infectious disease interventions. Determining a fair price that not only incentivizes development but ensures value and access for patients is critical given the increasing global health crisis. Using Ebola virus disease (EVD) as an exemplar, we aim to elucidate the estimation of a jurisdiction-specific value-based price (VBP) for a vaccine package and to consider how prices compare across selected countries that have experienced EVD outbreaks.

METHODS

Using a dynamic transmission model, we assessed the cost-effectiveness of a vaccine package - composed of the vaccine, storage, maintenance, and administration - for vaccination toward herd immunity in 4 countries affected with EVD (Democratic Republic of Congo, Liberia, Sierra Leone, Uganda). Based on the cost-effectiveness metrics and using willingness-to-pay thresholds equal to varying percentages of the Gross Domestic Product (GDP), we demonstrated how a VBP is calculated using a cost-effectiveness-based approach.

RESULTS

The VBP for the vaccine is directly proportional to effectiveness (DALYs prevented), cost-effectiveness (ICER) and GDP per capita. Higher effectiveness, greater cost-effectiveness, and higher GDP per capita resulted in higher price ceilings compared to lower cost-effectiveness and lower GDP.

CONCLUSION

Despite the concerns with the cost-effectiveness-based approach, we illustrated that it is an easily comprehensible method for determining the VBP of a vaccine using cost-effectiveness analysis. Choice of data, population characteristics, and disease dynamics are among the factors that need to be considered when comparisons are made across countries.

Comparing jurisdiction-specific pharmaco-economic evaluations using medical purchasing power parities

OBJECTIVES

To demonstrate how medical purchasing power parities (mPPP) may harmonize economic evaluations from different jurisdictions and enable comparisons across jurisdictions.

METHODS

We describe the use of mPPPs and illustrate this with an example of economic evaluations of nab-paclitaxel with gemcitabine (Nab-P + Gem) versus gemcitabine monotherapy in the setting of metastatic pancreatic cancer. Following a literature search, we extracted data from cost-effectiveness studies on these treatments performed in various countries. mPPPs from the Organization for Economic Co-operation and Development were used to convert reported costs in the jurisdiction of origins to US dollars for the most current year using two possible pathways: (1) reported costs first adjusted by mPPP then adjusted by exchange index; and (2) reported costs first adjusted by exchange index then adjusted by mPPP.

RESULTS

Despite many of the pharmaco-economic evaluations sharing similar assumptions and inputs, even after mPPP conversion, residual heterogeneity was attributable to perspectives, discount rate, outcomes, and costs, among others; including in studies conducted in the same jurisdiction.

CONCLUSION

Despite the methodological challenges and heterogeneity within and across jurisdictions, we demonstrated that mPPP offers a way to compare economic evaluations across jurisdictions.

Economic evaluation using dynamic transition modeling of ebola virus vaccination in lower-and-middle-income countries

BACKGROUND

With the increasing occurrence of infectious diseases in lower-and-middle-income countries (LMICs), emergency preparedness is essential for rapid response and mitigation. Economic evaluations of mitigation technologies and strategies have been recommended for inclusion in emergency preparedness plans. We aimed to perform an economic evaluation using dynamic transition modeling of ebola virus disease (EVD) vaccination in a hypothetical community of 1,000 persons in the Democratic Republic of Congo (DRC).

METHOD

Using a modified SEIR (Susceptible, Exposed, Infectious, Recovered, with Death added [SEIR-D]) model that accounted for death and epidemiological data from an EVD outbreak in the DRC, we modeled the transmission of EVD in a hypothetical population of 1,000. With our model, we estimated the cost-effectiveness of an EVD vaccine and an EVD vaccination intervention.

RESULTS

The results showed vaccinating 50% of the population at risk prevented 670 cases, 538 deaths, and 22,022 disability-adjusted life years (DALYs). The vaccine was found to be cost-effective with an incremental cost-effectiveness ratio (ICER) of $95.63 per DALY averted. We also determined the minimum required vaccination coverage for cost-effectiveness to be 40%. Sensitivity analysis showed our model to be fairly robust, assuring relatively consistent results even with variations in such input parameters as cost of screening, as well as transmission, infection, incubation, and case fatality rates.

CONCLUSION

EVD vaccination in our hypothetical population was found to be cost-effective from the payer perspective. Our model presents an efficient and reliable approach for conducting economic evaluations of infectious disease interventions as part of an emergency preparedness plan.

No margin for non-adherence: Probabilistic kaplan-meier modeling of imatinib non-adherence and treatment response in CML (ADAGIO study)

BACKGROUND

Although adherence to imatinib is critical for attaining treatment responses in chronic myeloid leukemia, there is evidence of varying adherence among patients. Our aim was to model and determine the margin of tolerance, if any, required to ensure treatment responses among patients prescribed imatinib before treatment response is at risk.

METHOD

We performed post hoc analyses of the ADAGIO study conducted in Belgium on 169 evaluable patients (Blood 2009). Applying Kaplan-Meier methods using adherence instead of the conventional time variable, we modeled the likelihood of complete cytogenetic (CCyR), complete hematological (CHR), major molecular (MMR) and optimal (OR) response as a function of 90-day pill count adherence.

RESULTS

Analyses showed that ∼100 % adherence of prescribed dose is associated with probabilities of 0.84 for CHR, 0.83 for CCyR, 0.82 for OR, and 0.77 for MMR; compared to, 0.37 (CHR and CCyR), 0.35 (OR), and 0.39 (MMR) at 90 % adherence. Increasing intake of imatinib from 90 % to 100 % of the prescribed dose increased the likelihood of the various treatment responses by 1.95-2.35-fold.

CONCLUSION

There is virtually no margin for nonadherence, if the objective is to optimize the likelihood of treatment response, and a minimal margin to avoid impaired treatment response.

Economic evaluation of six and 12 month (m) treatment with isatuximab and carfilzomib and dexamethasone (IKd) versus daratumumab and carfilzomib and dexamethasone (DKd) in patients with relapsed or refractory multiple myeloma (RRMM)

e20010

Background: Isatuximab and daratumumab target the CD38 transmembrane glycoprotein on MM cells. IKd and DKd regimens have shown reductions of HR=0.53 (95%CI 0.32-0.89) and HR=0.63 (95%CI 0.46-0.85) resp. in progression or death risk compared to Kd in RRMM. In the absence of a direct IKd vs DKd trial, we performed an indirect treatment comparison on progression free survival (PFS) to enable cost-effectiveness analyses. Methods: A 3-state (pre-progression, progression, death) partitioned survival model was specified. NMA-adjusted transition probabilities were estimated from fitted exponential functions (time horizon of 6 and 12 m; cycle length 28 days). Inputs included the Wholesale Acquisition Cost of IKd, DKd, and premedications; cost of medication administration; and cost of adverse event management. Utility inputs for pre-progression (0.65) and progression (0.61) were per literature. Costs and utilities were discounted at 3.5%/y. A payer perspective was adopted. Life years (LY), quality adjusted LY (QALY), and incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR) were estimated in base case (BCA) and probabilistic sensitivity analyses (PSA). Cost-effectiveness acceptability curves (CEAC) were generated. Results: As detailed in the Table, 6m of IKd treatment was associated with incremental gains of 0.01 (PSA 0.01) LYs but no gains in QALYs at cost savings of $24,188 ($23,762), yielding a dominant ICER of $ -2,418,800 ($-2,376,200) per LYg (ICUR not estimable). Further, 12m of IKd treatment was associated with incremental gains of 0.04 (PSA 0.04) LYs (or 0.48m) and 0.02 (0.03) QALYs at incremental cost of $1,585 ($2,239), yielding ICER of $39,625 ($55,975) per LYg and ICUR of $79,250 ($74,633) per QALYg. Per CEAC, IKd is the dominated strategy in the 6m model and had probability of 50% of being cost-effective at WTP of $100,000 in the 12m model. Conclusions: Clinically, compared to DKd, IKd is associated with slight incremental gains in LYs of 0.12m over 6m and 0.48m over 1y. The 6m clinical gain comes with cost savings of approximately $24,000 or about 15% of IKd therapy, while the 12m gain requires a minimal cost commitment of around $2,000 or 0.6% of DKd treatment. These findings imply a clinico-economic benefit of isatuximab compared to daratumumab containing regimens in RRMM. [Table: see text]

Ixazomib (IXA), carfilzomib (CAR), elotuzumab (ELO) or daratumumab (DAR) with lenalidomide and dexamethasone (LEN+DEX) versus LEN+DEX only in relapsed/refractory multiple myeloma (R/R MM): A comparative cost-effectiveness analysis

8043

Background: IXA, CAR, ELO and DARin combination with LEN+DEXhave been found superior in efficacy compared to LEN+DEX in the management of R/R MM. Applying indirect treatment comparisons from a network meta-analysis (NMA), this economic evaluation aimed to estimate the comparative cost-effectiveness and cost-utility of these four triplet regimens in terms of progression-free survival (PFS). Methods: In the absence of direct treatment comparison from a single clinical trial, NMA was used to indirectly estimate the comparative PFS benefit of each regimen. A 2-state Markov model simulating the health outcomes and costs was used to evaluate PFS life years (LY) and quality-adjusted life years (QALY) with the triplet regimens over LEN+DEX and expressed as the incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR). Probability sensitivity analyses were conducted to assess the influence of parameter uncertainty on the model. Results: The NMA revealed that DAR+LEN+DEX was superior to the other triplet therapies, which did not differ statistically amongst them. As detailed in the Table, in our cost-effectiveness analysis, all 4 triplet regimens were associated with increased PFSLY and PFSQALY gained (g) over LEN+DEX at an additional cost. DAR+LEN+DEX emerged the most cost-effective with ICER and ICUR of $667,652/PFSLYg and $813,322/PFSQALYg, respectively. The highest probability of cost-effectiveness occurred at a willingness-to-pay threshold of $1,040,000/QALYg. Conclusions: Our economic analysis shows that all the triplet regimens were more expensive than LEN +DEX only but were also more effective with respect to PFSLY and PFSQALY gained. Relative to the other regimens, the daratumumab regimen was the most cost-effective.[Table: see text]

Novel application of Kaplan-Meier methods to model tolerance for nonadherence to imatinib in patients with chronic myeloid leukemia (CML) in the ADAGIO study

7038

Background: Although adherence to imatinib treatment has been shown to be critical for attaining treatment response among patients with CML, some studies have suggested a 7.3-9.9% nonadherence tolerance margin before loss of treatment effects. We aimed to model probabilistically the margin of tolerance required to ensure treatment response among patients prescribed imatinib and the margin, if any, before treatment response is at risk. Methods: We performed a post hoc analysis of the ADAGIO study conducted in Belgium on 169 evaluable patients ( Blood 2009). Using the pill count ratio as, what in conventional survival analysis would be, the time variable, we modeled the cumulative likelihood of treatment response as a function of increasing pill count adherence. We applied Kaplan-Meier methods to model the likelihood of complete cytogenetic (CCyR), complete hematological (CHR), major molecular (MMR) and optimal (OR) (as defined by the European Leukemia Net) response as a function of 90-day pill count adherence. Kaplan-Meier methods thus estimated the tolerance for nonadherence to imatinib by calculating the 1 minus Kaplan-Meier estimate for treatment response. Results: Analyses (see Table) showed that ̃100% adherence of prescribed dose is associated with probabilities (rounded) of 0.84 for CHR, 0.83 for CCyR, 0.82 for OR, and 0.77 for MMR; compared to, 0.37 (CHR and CCyR), 0.35 (OR), and 0.39 (MMR) at 90% adherence. (of 0.7698 (MMR). Increasing the intake of imatinib from 90% to 100% of the prescribed dose increased the likelihood of the various treatment responses by 1.95 to 2.35-fold. Conclusions: Our findings challenge any previously estimated tolerance for nonadherence. There is virtually no margin for nonadherence if the objective is to optimize the likelihood of treatment response, and only a minimal margin to avoid impaired treatment response. Under such adherence, response rates similar to those in the pivotal IRIS trial can be obtained. Clinicians must assess and promote patient adherence, and patients must be perfectly adherent.[Table: see text]

Time-to-onset of treatment for hypertension and hyperlipidaemia in South African diabetes mellitus patients: A survival analysis using medicine claims data

WHAT IS KNOWN AND OBJECTIVE

Hypertension and hyperlipidaemia have high prevalence among diabetics and increase patients' risk of cardiovascular diseases, ultimately affecting prognosis negatively. Medicine claims data have gained prominence in the study of drug-related events and outcomes. There is paucity of publications on the time-to-onset of treatment for these conditions among South African diabetics using secondary data. This study aims to determine the time-to-onset of treatment for hypertension and hyperlipidaemia among diabetics using a South African medicine claims data.

METHODS

Survival analysis was conducted using retrospective data of patients enrolled continuously with a Pharmaceutical Benefit Management (PBM) company in South Africa from 1 January 2008 to 31 December 2016. We identified patients based on International Classification of Diseases, Tenth Revision (ICD-10) diagnoses codes for type 2 diabetes mellitus (E11) who were receiving antidiabetic medication according to the National Pharmaceutical Product Index (NAPPI) codes provided by the Monthly Index of Medical Specialities (MIMS) classification code 19.1 (N = 2996). Among these patients, we then selected those who had ICD-10 codes for hypertension (I10, I11, I12, I13, I15, O10 and O11) who were receiving antihypertensive medications, and those who had hyperlipidaemia (E78.5), who received antihyperlipidaemics during the study period. Data were extracted using SAS^® system version 9.4 classification codes. The Kaplan-Meier approach, used to compare the survival experience of patients who commenced treatment for hypertension and hyperlipidaemia, was conducted using IBM^® SPSS^® version 25. The time to the commencement of treatment of hypertension and hyperlipidaemia among the diabetics were measured in days. With 2008 serving as the index year, we followed up on patients until 31 December 2016.

RESULTS AND DISCUSSION

A total of 494 patients with an average age of 53.5 (SD 11.1) years were included in the study, 34.8% of whom were females. Prevalence of hyperlipidaemia and hypertension among patients were 35.0% and 45.6%, respectively. Average time-to-onset of treatment for hyperlipidaemia was 2684.4 (SD 42.2) days compared to 2434.2 (SD 47.6) days for hypertension. There was no statistically significant difference in age and sex among patients who started treatment for either of these conditions during the study (P = 0.404; Cohen's d = 0.132 for hyperlipidaemia and P = 0.644, Cohen's d = 0.059 for hypertension).

WHAT IS NEW AND CONCLUSION

Within an average of 6 years after an index period of 1 year free of disease, diabetics may commence treatment for hyperlipidaemia, hypertension or both. With all significant data appropriately captured, medicine claims data can be effectively used in survival analysis to determine time-to-onset of treatment for hyperlipidaemia and hypertension among diabetics.