Cost-minimisation analysis of erlotinib in the second-line treatment of non-small-cell lung cancer: a Brazilian perspective

Abstract

Objective: A cost-minimisation and budget impact analysis of erlotinib versus docetaxel or pemetrexed as second-line treatment for advanced non-small-cell lung cancer (NSCLC).

Methods: Costs and budgetary impacts were estimated from the perspective of a Brazilian private healthcare payer, based on results of the BR.21 study of erlotinib and pivotal trials of docetaxel and pemetrexed. A 126-day timeframe was evaluated, based on the progression-free survival determined for erlotinib in BR.21. A Delphi panel identified local practices and associated costs in Brazil. Other costs accounted for included medical payments, pre- and post-chemotherapy medication and drug administration costs. Multivariate sensitivity analyses were performed, but given the short time frame used, discounting was not applied.

Results: Total costs were R$26,825 for erlotinib, R$42,284 for docetaxel and R$79,841 for pemetrexed. Cost savings with erlotinib were attributable to lower acquisition costs (R$26,795 vs. R$40,217 for docetaxel and R$78,911 for pemetrexed) and lower costs for the management of side effects. Sensitivity analyses confirmed the robustness of the results. The budget impact analysis showed savings with erlotinib in the first year, ranging from R$3 million to R$28 million.

Conclusion: Erlotinib is cost-saving over established chemotherapy in the second-line treatment of advanced NSCLC under the Brazilian private healthcare system.     

Pharmacological control of secondary hyperparathyroidism in hemodialysis subjects: a cost consequences analysis of data from the FARO study

Abstract

Background and objectives:

Secondary hyperparathyroidism (SHPT) is a frequent complication of CKD with incidence, prevalence, and costs increasing worldwide. The objective of this analysis was to estimate therapy cost of SHPT in a sub-population of the FARO study.

Materials and Methods:

In the FARO study, an observational survey aimed to evaluate patterns of treatment in patients with SHPT who had undergone hemodialysis, pharmacological treatments and biochemical parameters evolution data were collected in four surveys. Patients maintaining the same treatment in all sessions were grouped by type of treatment and evaluated for costs from the Italian National Health Service perspective.

Results:

Four cohorts were identified: patients treated with oral (PO) calcitriol (n?=?182), intravenous (IV) calcitriol (n?=?34), IV paricalcitol (n?=?62), and IV paricalcitol?+?cinacalcet therapy (n?=?20); the cinacalcet monotherapy group was not analysed due to low number of patients (n?=?9). Parathyroid hormone (PTH) level at baseline and effectiveness of treatments in suppressing PTH level were assessed to test comparability among cohorts: calcitriol PO patients were significantly less severe than others (PTH level at baseline lower than 300?pg/ml; p?<?0.0001); calcitriol IV patients did not reach significant reduction in PTH level. Paricalcitol and paricalcitol?+?cinacalcet treatment groups results were comparable, while only the IV paricalcitol cohort’s PTH level, weekly dosage, and cost decreased significantly from the first to the fourth survey (p?=?0.020, p?=?0.012, and p?=?0.0124, respectively). Total costs per week of treatment (including calcium-based phosphate binder and sevelamer) were significantly lower in the paricalcitol vs paricalcitol?+?cinacalcet cohort (p?<?0.001). Major limitations of this study are related to the survey design: not controlled and lack of comparability between cohorts; however, reflective of true practice patterns.

Conclusions:

The IV Paricalcitol cohort had significantly lower treatment costs compared with patients treated with paricalcitol?+?calcimemtics (p?<?0.001), without a significant difference in terms of baseline severity and PTH control.     

Targeted erlotinib for first-line treatment of advanced non-small cell lung cancer: a budget impact analysis

Objectives:

A recent phase III trial showed that patients with advanced non-small cell lung cancer (NSCLC) whose tumors harbor specific EGFR mutations significantly benefit from first-line treatment with erlotinib compared to chemotherapy. This study sought to estimate the budget impact if coverage for EGFR testing and erlotinib as first-line therapy were provided in a hypothetical 500,000-member managed care plan.

Methods:

The budget impact model was developed from a US health plan perspective to evaluate administration of the EGFR test and treatment with erlotinib for EGFR-positive patients, compared to non-targeted treatment with chemotherapy. The eligible patient population was estimated from age-stratified SEER incidence data. Clinical data were derived from key randomized controlled trials. Costs related to drug, administration, and adverse events were included. Sensitivity analyses were conducted to assess uncertainty.

Results:

In a plan of 500,000 members, it was estimated there would be 91 newly diagnosed advanced NSCLC patients annually; 11 are expected to be EGFR-positive. Based on the testing and treatment assumptions, it was estimated that 3 patients in Scenario 1 and 6 patients in Scenario 2 receive erlotinib. Overall health plan expenditures would increase by $0.013 per member per month (PMPM). This increase is largely attributable to erlotinib drug costs, in part due to lengthened progression-free survival and treatment periods experienced in erlotinib-treated patients. EGFR testing contributes slightly, whereas adverse event costs mitigate the budget impact. The budget impact did not exceed $0.019 PMPM in sensitivity analyses.

Conclusions:

Coverage for targeted first-line erlotinib therapy in NSCLC likely results in a small budget impact for US health plans. The estimated impact may vary by plan, or if second-line or maintenance therapy, dose changes/interruptions, or impact on patients’ quality-of-life were included.     

消费模式转型:国际金融危机视角下的反思

美国长期奉行的过度消费模式是本次国际金融危机的重要诱因.这种过度消费模式的形成既有其传统习惯的原因,也有其理论渊源和政府政策的引导.反观中国的消费模式,尽管已经发生或正在经历转型,但总体来说还是一种谨慎型消费,正是这种谨慎型消费,成为了中国抵御本次国际金融危机的一道屏障.在国际金融危机背景下中国应加快消费转型的步伐,大力促进适度消费,以实现经济又好又快发展.     

Budget impact of erlotinib for maintenance therapy in advanced non-small cell lung cancer

Abstract

Objective:

Assess the budgetary impact of adding erlotinib for maintenance therapy (MTx) in advanced non-small cell lung cancer (NSCLC) from a US health plan perspective.

Methods:

A budget impact model was developed to analyze the costs (drug, administration, adverse events) associated with adding erlotinib MTx to a hypothetical 500,000 member US health plan. Treatment durations and dosing were derived from randomized controlled trials, FDA labeling, and National Comprehensive Cancer Network guidelines. Treatment patterns and assumptions were based on market research data, the SEER registry, and published literature. Cost data were obtained from Centers for Medicare and Medicaid Services payment rates and a drug pricing database. Sensitivity analyses were conducted to assess uncertainty.

Results:

Overall health plan expenditures increased by $0.010 per member per month (PMPM). The main driver of additional cost was the erlotinib drug cost (～$66,000) with the administration ($464) and side-effect ($47) costs being relatively modest. One-way sensitivity analyses showed that the results were most sensitive to the proportion of members receiving MTx; however, the PMPM did not exceed $0.013.

Conclusions:

The overall budget impact to a health plan of expanding the use of erlotinib from the 2nd/3rd-line advanced NSCLC setting to include the maintenance setting was relatively small. This was primarily due to the proportion of patients who would receive erlotinib MTx, the low cost of side-effects and minimal cost of drug administration. Additional research may be warranted to estimate the relative clinical and economic impacts of erlotinib MTx versus alternative MTx treatments.     

保险业在金融危机中的角色：资产证券化视角

本轮金融危机与次贷产品链条及其机理缺陷直接相关。本文对资产证券化中的两种保险机制在金融危机中扮演的角色做了探讨。研究发现：按揭保险业发挥了逆周期的稳定器功能,减缓了系统性风险对住房金融体系冲击。债券保险业较深介入次贷债券及其衍生品的供需链条之中,是导致本轮金融危机中系统性风险爆发的一环。在对二者不同的风险特征做了比较分析之后,结合中国实际,提出完善中国保险业业务结构的若干建议。     

中医辨证配合化疗治疗晚期肺癌临床分析

目的探究中医辨证配合化疗对晚期肺癌患者的临床治疗效果。方法将我院2011年1月～2012年1月接诊的53例晚期肺癌患者作为研究对象,随机分为研究组与对照组。对照组患者单纯采用化疗治疗,研究组则在对照组的基础上配合中医辨证治疗。对两组病患的治疗效果进行总结与对比。结果研究组治疗前平均分为58.45分,治疗后为71.35分,对照组治疗前平均分为58.13分,治疗后为49.63分;研究组27例患者半年的生存率为81.48%,一年的生存率为48.15%,对照组26例患者半年生存率为46.15%,一年生存率为15.38%;治疗效果上,研究组总有效率为40.74%,对照组总有效率为15.38%。结论对于晚期肺癌患者而言,采用中医辨证配合西医化疗治疗,除了可以提高患者对化疗的耐受性之外,还能明显提高患者的生存质量,当属一种值得临床推广及应用的治疗方法。     

公共财政、金融支农与农村金融改革--基于贵州省及其样本县的调查分析

本文通过对贵州省及其样本县农户和金融机构的问卷调查和分析,得出了一些实证性的结论。一方面,贫困地区公共财政未能发挥其应有的作用,健全的农村金融体系无法建立;另一方面,将农村金融机构作为支农的工具,进一步扭曲了农村的金融体制。分析表明,只有让公共财政发挥应有的作用,才能进一步改革农村金融体系,形成商业可持续的农村金融体制。     

中国区域金融发展差异的解释——基于劳动分工理论与Shapley值分解方法

中国区域金融运行严重失衡,对中国经济金融发展造成了不利影响。本文建立了一个基于劳动分工理论的、涵盖教育和创新的金融发展模型,并运用1992—2004年的省际面板数据估计出区域金融发展的协整方程。然后以协整方程为基础运用夏普里值(Shapley value)分解法对中国区域金融发展差异进行分解。研究发现,区域金融发展水平和商品交易效率、金融交易效率、投资品的生产弹性系数、地区人均受教育年限、社会福利水平之间具有稳定的协整关系。分解结果显示,各省市区之间经济地理条件和国家制度倾斜等方面的差异是形成区域金融发展差异的主要原因,其平均贡献率为39.78%;由于先行优势和试点效应,在金融改革活跃时期,这种影响更加显著。人均受教育年限是区域金融发展差异的第二大贡献因素,其平均贡献率为36.23%。商品交易效率与金融交易效率对区域金融发展差异也具有重要贡献,其平均贡献率分别为13.08%和8.96%。     

Economic consequences of sequencing biologics in rheumatoid arthritis: a systematic review

Abstract

Background and objectives:

Tumor necrosis factor-alpha (anti-TNF) blocking agents are effective for the treatment of rheumatoid arthritis (RA), with mean response rates of 60–70%. Patients with incomplete response to initial anti-TNF treatment often are switched to other biologic treatments with some success. However, little is known about whether or not switching to anti-TNF or other non-TNF biologic treatments is cost-effective. This study sought to review the economic evidence of sequencing various biologic treatments in RA.

Methods:

A systematic review was conducted of published and unpublished literature (January 2000 to October 2012) on the cost-effectiveness of sequencing biologic treatments in RA after failure of an initial biologic treatment. It included modeling and other economic studies that assessed cost-effectiveness of one or more sequences of biologics. Studies were excluded that evaluated non-biologic sequencing.

Results:

This review of the available evidence suggests that there is limited evidentiary support favoring the cost-effectiveness of switching from one anti-TNF agent to another within the anti-TNF category of biologics. This is due, in large part, to the limited clinical evidence base supporting the incremental efficacy of second- and third-line anti-TNF treatments and to variation on how and when to assess non-response to the first-line biologic. When compared to anti-TNF agents, biologic treatments with a different mechanism of action are more cost-effective as second-line agents.

Limitations:

Not all sequences and patterns of switching, either within or outside of therapeutic class, have been evaluated for clinical benefit and cost-effectiveness, limiting the interpretation of these findings.

Conclusions:

Switching from one anti-TNF agent to another after first-line treatment failure may not be a cost-effective treatment strategy. However, when non-TNF biologics are included in the sequence they are likely to be more cost-effective than anti-TNF specific cycling sequences.     

The working for water programme: Evolution of a payments for ecosystem services mechanism that addresses both poverty and ecosystem service delivery in South Africa

A payments for ecosystem services (PES) system came about in South Africa with the establishment of the government-funded Working for Water (WfW) programme that clears mountain catchments and riparian zones of invasive alien plants to restore natural fire regimes, the productive potential of land, biodiversity, and hydrological functioning. The success of the programme is largely attributed to it being mainly funded as a poverty-relief initiative, although water users also contribute through their water fees. Nevertheless, as the hydrological benefits have become apparent, water utilities and municipalities have begun to contract WfW to restore catchments that affect their water supplies. This emerging PES system differs from others in that the service providers are previously unemployed individuals that tender for contracts to restore public or private lands, rather than the landowners themselves. The model has since expanded into other types of ecosystem restoration and these have the potential to merge into a general programme of ecosystem service provision within a broader public works programme. There is a strong case for concentrating on the most valuable services provided by ecosystems, such as water supply, carbon sequestration, and fire protection, and using these as ‘umbrella services’ to achieve a range of conservation goals. The future prospects for expansion of PES for hydrological services are further strengthened by the legal requirement that Catchment Management Agencies be established. These authorities will have an incentive to purchase hydrological services through organisations such as WfW so as to be able to supply more water to their users.     

Budget impact analysis of everolimus for the treatment of hormone receptor positive,human epidermal growth factor receptor-2 negative (HER2-) advanced breast cancer in the United States

Abstract

Objective:

To estimate the budget impact of everolimus as the first and second treatment option after letrozole or anastrozole (L/A) failure for post-menopausal women with hormone receptor positive (HR+), human epidermal growth factor receptor-2 negative (HER2-) advanced breast cancer (ABC).     

Costs of in-house genomic profiling and implications for economic evaluation: a case example of non-small cell lung cancer (NSCLC)

Abstract

Objectives

Genomic profiling in oncology is vital for determining eligible patients for mutation-specific targeted therapies. Use of commercial genomic testing has the potential to improve patient outcomes. Economic evaluations of in-house genomic profiling typically only include material costs while external commercial services include many other factors. Using non-small cell lung cancer (NSCLC) as an example, this study sought to characterize the unique challenges of costing testing services and their impact on results of economic evaluations.     

Confirming the timing of phase-based costing in oncology studies: a case example in advanced melanoma

Aims: The utilization of healthcare services and costs among patients with cancer is often estimated by the phase of care: initial, interim, or terminal. Although their durations are often set arbitrarily, we sought to establish data-driven phases of care using joinpoint regression in an advanced melanoma population as a case example.

Methods: A retrospective claims database study was conducted to assess the costs of advanced melanoma from distant metastasis diagnosis to death during January 2010–September 2014. Joinpoint regression analysis was applied to identify the best-fitting points, where statistically significant changes in the trend of average monthly costs occurred. To identify the initial phase, average monthly costs were modeled from metastasis diagnosis to death; and were modeled backward from death to metastasis diagnosis for the terminal phase. Points of monthly cost trend inflection denoted ending and starting points. The months between represented the interim phase.

Results: A total of 1,671 patients with advanced melanoma who died met the eligibility criteria. Initial phase was identified as the 5-month period starting with diagnosis of metastasis, after which there was a sharp, significant decline in monthly cost trend (monthly percent change [MPC]?=?–13.0%; 95% CI?=?–16.9% to –8.8%). Terminal phase was defined as the 5-month period before death (MPC?=?–14.0%; 95% CI?=?–17.6% to –10.2%).

Limitations: The claims-based algorithm may under-estimate patients due to misclassifications, and may over-estimate terminal phase costs because hospital and emergency visits were used as a death proxy. Also, recently approved therapies were not included, which may under-estimate advanced melanoma costs.

Conclusions: In this advanced melanoma population, optimal duration of the initial and terminal phases of care was 5 months immediately after diagnosis of metastasis and before death, respectively. Joinpoint regression can be used to provide data-supported phase of cancer care durations, but should be combined with clinical judgement.     

Ipilimumab in 2nd line treatment of patients with advanced melanoma: a cost-effectiveness analysis

Abstract

Objective:

To estimate the cost-effectiveness of ipilimumab (3?mg/kg) compared with best supportive care (BSC) in pre-treated advanced melanoma patients.     

Cost drivers for breast,lung, and colorectal cancer care in a commercially insured population over a 6-month episode: an economic analysis from a health plan perspective

Aims: In the absence of clinical data, accurate identification of cost drivers is needed for economic comparison in an alternate payment model. From a health plan perspective using claims data in a commercial population, the objective was to identify and quantify the effects of cost drivers in economic models of breast, lung, and colorectal cancer costs over a 6-month episode following initial chemotherapy.

Research design and methods: This study analyzed claims data from 9,748 Cigna beneficiaries with diagnosis of breast, lung, and colorectal cancer following initial chemotherapy from January 1, 2014 to December 31, 2015. We used multivariable regression models to quantify the impact of key factors on cost during the initial 6-month cancer care episode.

Results: Metastasis, facility provider affiliation, episode risk group (ERG) risk score, and radiation were cost drivers for all three types of cancer (breast, lung, and colorectal). In addition, younger age (p?p?p?p?p?Conclusions: Value-based reimbursement models in oncology should appropriately account for key cost drivers. Although claims-based methodologies may be further augmented with clinical data, this study recommends adjusting for the factors identified in these models to predict costs in breast, lung, and colorectal cancers.     

Treatment cost of non-small cell lung cancer in three European countries: comparisons across France,Germany, and England using administrative databases

Abstract

Introduction:

Lung cancer is a highly prevalent condition with non-small cell lung cancer (NSCLC), representing ～ 80%. Given its high prevalence and poor survival rates, it is important to understand costs associated with NSCLC treatment.     

Economic analysis of BRAF gene mutation testing in real world practice using claims data: costs of single gene versus panel tests in patients with lung cancer

Aims: To assess the time to BRAF testing, compare the characteristics of tested vs not-tested patients, and describe the costs for sequential vs next-generation sequencing (NGS) BRAF testing.

Methods: Patients diagnosed with lung cancer after December 1, 2013 were identified from two US claims databases; their characteristics were assessed during the 12 months before diagnosis (index date). Testing modalities were analyzed from the index date to end of continuous health plan enrollment or data availability (December 2015), based on combinations of Current Procedural Terminology (CPT) procedure codes. Time to BRAF testing was assessed using Kaplan-Meier analysis. Costs were analyzed from a payer’s perspective.

Results: A total of 28,011 patients newly-diagnosed with lung cancer were identified. Of them, 1,260 (4.5%) were tested for BRAF: 3.2% and 4.2% were tested at 6 and 12 months, respectively, after the index date. Compared to non-tested patients, tested patients were younger (58.3 vs 65.3 years; p?<?.001), had a lower Charlson Comorbidity Index (2.8 vs 2.9; p?=?.005), and a higher proportion had metastases (70.9% vs 43.4%; p?<?.001). In 76.0% of cases, BRAF was tested along with KRAS. BRAF was tested using NGS in 6.6% of cases. The average reimbursed amounts for the 10 most common CPT code combinations were $207–$2,074. Using the average costs of individual mutation tests, the total cost of sequential testing comprising KRAS, EGFR, ALK, ROS1, and BRAF tests was $3,763 ($464, $696, $1,070, $1,127, and $406, respectively), that of NGS was $2,860.

Limitations: Claims data did not include BRAF test results.

Conclusions: Among patients newly-diagnosed with lung cancer, 4.5% were tested for BRAF. Tested patients were younger and had a lower comorbidity burden, but more advanced disease. While reimbursed amounts varied greatly based on combinations of testing procedures, NGS testing was associated with cost savings compared to sequential testing of individual mutations.     

Financial constraints and investment: assessing the impact of a World Bank credit program on small and medium enterprises in Sri Lanka

Abstract.  This paper examines the investment behaviour of a sample of small, credit-constrained firms in Sri Lanka. Using a unique panel data set, we analyze and compare the activities of two groups of small firms distinguished by their differential access to financing; one group consists of firms with subsidized loans from the World Bank, while the other group consists of firms without such subsidies. The paper shows that the program led to higher levels of investment for financially constrained firms. However, the evidence is inconclusive on whether the program improved economic efficiency.