Failure to initiate TKIs linked to higher inpatient costs for older patients with CML
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Approximately 29% of older patients with chronic myeloid leukemia did not initiate tyrosine kinase inhibitor therapy within 6 months of diagnosis, according to study results published in Cancer.
Cost-sharing subsidies continued to be associated with higher rates of treatment initiation, and researchers observed higher inpatient costs among those not treated with TKIs, with a difference of nearly $8,000 per patient within the first 6 months.
“Financial toxicity among patients requiring cancer treatment is too common,” Erlene K. Seymour, MD, assistant professor in the department of oncology in the division of hematology and oncology at Karmanos Cancer Institute at Wayne State University, told Healio. “In a 2016 study published in Journal of Clinical Oncology, Winn and colleagues evaluated factors associated with treatment delays after initiation of TKIs for CML. This study showed that about 40% of patients did not start therapy within 180 days after diagnosis. However, patients with cost-sharing subsidies had treatment sooner.”
The subsidies can substantially reduce copayments during the first month of TKI treatment, which can range from $0 to thousands of dollars per month depending on insurance coverage, according to researchers.
“We therefore wanted to delineate further the clinical outcomes of these patients who delayed therapy and whether there were differences in health care utilization,” Seymour said. “We also sought to evaluate whether known factors associated with delays in treatment persisted over time.”
Seymour and colleagues used SEER-Medicare data to evaluate differences in TKI initiation, health care use, cost and survival among 941 adults aged older than 65 years who were diagnosed with CML between 2007 and 2015. Patients had continuous Medicare Parts A and B and Part D coverage.
Overall, 29% of patients did not initiate TKI treatment within 6 months of diagnosis and 21% of patients did not receive TKIs during the study observation period.
Results of univariate analyses showed significant differences between TKI users and non-TKI users in terms of age (P < .001), marital status (P = .002) and low-income cost-sharing subsidy status (P = .014). Patients aged 75 years and older had lower TKI initiation rates than younger patients in 2007, but the difference decreased over time.
The odds of receiving TKI treatment within the first 6 months of diagnosis increased by 13% per year (OR = 1.13; 95% CI, 1.06-1.2) for all patients and by 33% per year (OR = 1.33; 95% CI, 1.2-1.5) for those who received full cost-sharing subsidies.
Researchers additionally observed lower rates of BCR-ABL testing among non-TKI users, who also were more likely to have at least one inpatient hospitalization within the first 6 months of CML diagnosis (P = .015).
Although patients treated with TKIs had greater total Medicare costs — nearly half of which were due to TKI expenses — non-TKI users had higher inpatient costs even after adjusting for age and comorbidities, with a difference of nearly $8,000 per patient within the first 6 months.
Moreover, compared with median OS of 40 months (95% CI, 34-48) among non-TKI users, median OS was 86 months (95% CI, 73 to not reached) among TKI users. The more than twofold higher risk for death among non-TKI users remained consistent after adjusting for age, comorbidities and subsidy status (HR = 2.23; 95% CI, 1.77-2.81).
“We demonstrated that there is still a high number of patients who delay TKIs after 6 months, and among the CML patients who delayed therapy past 6 months, there were more hospitalizations and inpatient hospital costs — even when excluding hospitalizations when diagnosis might have been made,” Seymour said. “These patients also had worse OS, even when controlling for other factors including age and comorbidity. Over time, TKI initiation actually improved for all patients, including those who were older and those with comorbidities. However, the difference in TKI initiation between patients with and without cost-sharing subsidies remains the same.”
Future research should evaluate similar patterns among younger patients, as well as among those with commercial insurance, to determine population trends, Seymour added.
“There is ongoing and future research evaluating interventions to decrease costs for patients either by implementing financial counseling and/or aid or modifying insurance designs, such as cost-sharing caps or value-based insurance design,” she said.
For more information:
Erlene K. Seymour, MD, can be reached at Karmanos Cancer Institute, 4100 John R. St., Detroit, MI 48201; email: seymoure@karmanos.org.
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