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Inpatient costs higher for young adults than children with acute lymphoblastic leukemia
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SAN DIEGO — Overall inpatient costs and the number of days spent in inpatient care appeared higher among young adults than among children with acute lymphoblastic leukemia, according to a population-based study conducted in California and presented at ASH Annual Meeting and Exposition.
Among both age groups, inpatient care for the full course of therapy was more expensive for those who received treatment at specialized cancer centers compared with community hospitals.
“Our findings really highlight the need for [young adults] to be referred to treated at specialized cancer centers,” Theresa H.M. Keegan, PhD, MS, cancer epidemiologist and associate professor at UC Davis Health, said during her presentation. “But there are potential cost implications, as well as hospital utilization differences, associated with this recommendation that have not previously been examined.”
Studies have concluded that receiving all cancer treatment at specialized cancer centers in California is associated with better leukemia-specific survival among children (age 0-18 years) and young adults (age 19-39 years) with ALL.
However, only 36% of young adults with ALL undergo treatment at specialized cancer centers, compared with 84% of children.
A cost analysis that could help explain this difference had not previously been conducted.
Researchers used the California Cancer Registry to identify 5,167 children and young adults with first primary ALL who had impatient treatment between 1995 and 2014 and at least 3 years of follow-up. All patients in the primary analysis had at least 80% of charge data.
Researchers classified these patients as receiving all or part/none of their treatment at a specialized cancer center within the first 3 years of their diagnosis.
The mean total cost — adjusted for inflation to 2016 U.S. dollars — for children with ALL receiving all care at specialized cancer centers was $216,439 (median, $121,039) compared with $191,082 (median, $84,529) for children who received all their care at community hospitals (P mean = 0.008; P median < .001).
The cost per day for children was higher at specialized cancer centers than at nonspecialized centers (mean, $2,840 vs. $2,283; P < .001; median, $2,529 vs. $1,865; P < .001).
Inpatient days for children within the first 3 years of diagnosis appeared similar for those treated entirely at specialized cancer centers compared with those who were not (70 days vs. 72 days).
For the young adult subgroup, total costs were higher for those receiving their entire treatment at specialized cancer centers compared with nonspecialized centers (mean, $380,556 vs. $346,706; P = .02; median, $308,864 vs. $241,847; P < .001).
The cost per day also was higher at specialized cancer centers in the young adult group (mean, $3,730 vs. $3,224; P < .001; median, $3,537 vs. $2,917; P < .001)
Inpatient days for young adults within the first 3 years of diagnosis appeared similar for those who were treated entirely at specialized cancer centers compared with those who were not (99 days vs. 101 days).
Researchers also conducted sensitivity analyses that were limited to only patients with all charge data available (n = 5,118) and that excluded patients with stem cell transplant (n = 693) to determine the impact of these factors.
Results showed similar results for the group that had complete charge data. After excluding patients receiving a transplant, the mean cost was lower at both specialized and nonspecialized centers, but the cost differences between children and young adults by location persisted.
Future studies should consider how location of care impacts out-of-pocket, outpatient and ED costs, researchers said.
Researchers were unable to include other costs incurred by individuals and the health care system, including outpatient costs. They also could not consider costs associated with medication type, clinical trials or disease characteristics, Keegan said.
“Despite these limitations, our findings are likely generalizable [because] we used population-based data and included a large, diverse population of pediatric and young adult ALL patients,” Keegan said. “[Because] inpatient costs do not reflect the total burden associated with cancer care, future studies should consider how location of care impacts outpatient costs, emergency department visits and out of pocket costs for these cancer patients.” – by John DeRosier
Reference:
Keegan T, et al. Abstract 324. Presented at: ASH Annual Meeting and Exposition; Dec. 1-4, 2018; San Diego.
Disclosures : The authors report no relevant financial disclosures.
Perspective
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Greg Knight, MD
We know that adolescent and young adult (AYA) patients who are treated at specialized cancer centers are more likely to receive AYA regimens. Current research suggests that only 25% of AYAs with ALL treated in a community setting would receive a pediatric ALL regimen as frontline therapy. Pediatric ALL regimens/trials are more likely to need intensive follow-up as a general rule and can use new and more expensive drugs — which leads to increasing costs — but also are thought to be superior in results for this patient population (although that was not necessarily true in the authors’ initial paper).
Instead, in that prior paper they felt the improved outcomes might have come from unmeasured factors that have been shown to favor the specialized cancer setting, such as minimal residual disease-driven ALL treatment algorithms, greater clinical trial enrollment and improved therapeutic adherence. The resources available — including ancillary services — at specialized cancer centers are more likely to be well developed, which can help with outcomes and the unmeasured factors that they identified but obviously come at a cost.
Insurance definitely plays a major part in the AYA population, as they are more likely to be uninsured or underinsured. There is also likely a referral bias, as upfront adult ALL regimens such as Hyper-CVAD are fairly easy to administer for a hospital system rather than the pediatric regimens, which can be intensive in terms of hospital system utilization.
One major issue in the AYA population is adherence. In terms of medications, clinical trials of AYA patients with leukemia and lymphoma suggest that up to 63% of AYA patients have difficulties adhering to oral treatment regimens. We also know that AYA patients are more likely to miss appointments and potentially have increased unexpected hospitalizations due to acute illness. These behaviors are driven by emotional, financial and social issues, and this is another reason that a specialized cancer center that is set up to address some of these issues will likely have better outcomes.
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