Patient factors and costs associated with prophylactic neurokinin-1 receptor antagonist use among women with invasive breast cancer.
In April 2012, the American Society of Clinical Oncology joined the Choosing Wisely (CW) initiative to reduce the use of low-value oncology services. Neurokinin-1 receptor antagonists (NK1-RAs) are a class of expensive antiemetic drugs and are not recommended for patients who receive low to moderate risk emetogenic anticancer agents.
To identify patient factors and costs associated with NK1-RAs prophylactic use in a real- world setting post-Choosing Wisely among patients with breast cancer.
Using Optum's de-identified Clinformatics® Data Mart Database (2013 to 2018), a retrospective cohort study was conducted for women aged 18 years and older with breast cancer who initiated a low/minimal/moderate emetogenic chemotherapy (index date) and received prophylactic antiemetics 2 weeks prior to the index date through the day after index (N = 18,515). Patients with no claims for antiemetics or who had negative costs were excluded from the costs analysis (n = 12,068). All US Food and Drug Administration-approved NK1-RAs were included. A multivariable logistic regression model was used to assess the association between patient demographic and socioeconomic characteristics, health system and environmental factors, and NK1-RA use, with results presented as adjusted odds ratios (AORs) and 95% CIs. A generalized linear model with gamma distribution and log link and two-part model were used to model mean third-party and out-of-pocket antiemetic-specific costs per patient, respectively, controlling for baseline patient characteristics.
Out of 18,515 women included, 7.7% (n = 1,429) received NK1-RAs. As compared with women aged 75 years and older, those aged 50-64 and 65-74 years had 1.96 (95% Cl = 1.50-2.57) and 1.39 (95% Cl = 1.19-1.63) times higher odds to receive NK1-RAs, respectively. Black women (AOR: 1.35; 95% Cl = 1.12-1.63), intravenous low-emetogenic chemotherapy (AOR: 3.94; 95% Cl = 3.16-4.91), enrolled in Medicare low-income subsidy (AOR: 1.49; 95% Cl = 1.08-2.07), had higher odds of receiving prophylactic NK1-RAs as compared with White patients, intravenous moderate emetic risk chemotherapy, and commercial insurance, respectively. In the adjusted analysis for costs, the mean total third-party payer antiemetic-specific costs for women who received steroids only, first-generation serotonin-receptor antagonists (5HT3-RAs) with or without steroids, or second-generation 5HT3-RAs with or without steroids were found to be significantly lower by 97.8% (P < 0.001), 95.0% (P < 0.001), and 42.1% (P = 0.023), respectively, when compared with those who received NK1-RAs.
Variability in the potential overuse of NK1-RAs was driven by certain patient- (age, race and ethnicity), clinical- (emetic risk), and health care- (insurance, health plan type) related factors. Furthermore, the mean total costs reimbursed by payers were significantly higher for those who received NK1-RAs as compared with other antiemetics, except for those who received both first- and second-generation 5HT3-RAs with or without steroids. Guideline-concordant use of NK1-RAs could result in significant cost-avoidance for patients and payers.
To identify patient factors and costs associated with NK1-RAs prophylactic use in a real- world setting post-Choosing Wisely among patients with breast cancer.
Using Optum's de-identified Clinformatics® Data Mart Database (2013 to 2018), a retrospective cohort study was conducted for women aged 18 years and older with breast cancer who initiated a low/minimal/moderate emetogenic chemotherapy (index date) and received prophylactic antiemetics 2 weeks prior to the index date through the day after index (N = 18,515). Patients with no claims for antiemetics or who had negative costs were excluded from the costs analysis (n = 12,068). All US Food and Drug Administration-approved NK1-RAs were included. A multivariable logistic regression model was used to assess the association between patient demographic and socioeconomic characteristics, health system and environmental factors, and NK1-RA use, with results presented as adjusted odds ratios (AORs) and 95% CIs. A generalized linear model with gamma distribution and log link and two-part model were used to model mean third-party and out-of-pocket antiemetic-specific costs per patient, respectively, controlling for baseline patient characteristics.
Out of 18,515 women included, 7.7% (n = 1,429) received NK1-RAs. As compared with women aged 75 years and older, those aged 50-64 and 65-74 years had 1.96 (95% Cl = 1.50-2.57) and 1.39 (95% Cl = 1.19-1.63) times higher odds to receive NK1-RAs, respectively. Black women (AOR: 1.35; 95% Cl = 1.12-1.63), intravenous low-emetogenic chemotherapy (AOR: 3.94; 95% Cl = 3.16-4.91), enrolled in Medicare low-income subsidy (AOR: 1.49; 95% Cl = 1.08-2.07), had higher odds of receiving prophylactic NK1-RAs as compared with White patients, intravenous moderate emetic risk chemotherapy, and commercial insurance, respectively. In the adjusted analysis for costs, the mean total third-party payer antiemetic-specific costs for women who received steroids only, first-generation serotonin-receptor antagonists (5HT3-RAs) with or without steroids, or second-generation 5HT3-RAs with or without steroids were found to be significantly lower by 97.8% (P < 0.001), 95.0% (P < 0.001), and 42.1% (P = 0.023), respectively, when compared with those who received NK1-RAs.
Variability in the potential overuse of NK1-RAs was driven by certain patient- (age, race and ethnicity), clinical- (emetic risk), and health care- (insurance, health plan type) related factors. Furthermore, the mean total costs reimbursed by payers were significantly higher for those who received NK1-RAs as compared with other antiemetics, except for those who received both first- and second-generation 5HT3-RAs with or without steroids. Guideline-concordant use of NK1-RAs could result in significant cost-avoidance for patients and payers.