Evaluation of Long-Term Chronic Myeloid Leukemia Treatment Practices with Tyrosine Kinase Inhibitors in a National Cohort of Veterans.

STUDY OBJECTIVE: To evaluate nationwide chronic myeloid leukemia (CML) treatment practices over an extended period and across multiple lines of tyrosine kinase inhibitor (TKI) therapy with imatinib, dasatinib, and nilotinib. DESIGN: Retrospective cohort study. DATA SOURCE: Veterans Health Administration (VHA) national database. PATIENTS: A total of 2873 VHA beneficiaries aged 18-89 years who had at least one encounter at any of the ~150 VHA hospitals and 800 VHA clinics, had a diagnosis code for CML, and filled at least one prescription for imatinib, nilotinib, or dasatinib between October 1, 2001, and September 30, 2010. MEASUREMENT AND MAIN RESULTS: The VHA database was used for the time period of October 1, 2000, to September 30, 2012, allowing for a 1-year observation period to identify CML treatments prior to study enrollment and a minimum of a 2-year follow-up period to assess study end points. Primary study end points included change in TKI treatment, gaps in TKI treatment, TKI treatment persistence, and patient survival. Persistence for each distinct line of treatment was defined as the time of continuous therapy, quantified by the number of days covered by the drug from treatment initiation until a 60-day gap in treatment was identified or a switch in treatment occurred. A Kaplan-Meier model was used to evaluate persistence and survival. Of the 2873 patients receiving first-line TKI treatment, 586 (20.4%) switched to a different TKI, constituting second-line treatment. Overall, 245 patients (8.5%) were switched again to third-line treatment. Only 4.4% of patients receiving first-line treatment experienced a gap in therapy of 60 or more days. First-line treatment persistence rates were 75%, 65%, and 55% for the first, second, and third years of treatment, respectively. Five-year survival with first-line treatment was 62%. CONCLUSION: In this national cohort of VHA patients, 1-year persistence of first-line TKI treatment was similar to that in prior studies. Five-year survival was comparable with that in other observational studies but was lower than that in prospective clinical trials. Persistence rates declined after the introduction of the new TKIs.

Impact of cancer supportive care pathways compliance on emergency department visits and hospitalizations.

PURPOSE: To evaluate the effects of compliance to cancer supportive care pathways on emergency department (ED) visits and hospitalizations as a result of neutropenia, anemia, and chemotherapy-induced nausea and vomiting (CINV). METHODS: CareFirst claims database was used to evaluate data spanning 2 years of the clinical pathways program. Frequency of ED visits/hospitalizations for neutropenia, anemia, and CINV were compared between compliant and noncompliant pathway utilization of granulocyte colony-stimulating factors (G-CSFs), erythropoiesis-stimulating agents (ESAs), and antiemetics, respectively. Logistic regression analysis was used to control for drug expenditures and cancer types. RESULTS: A total of 4,144 lines of therapy were received by 3,191 patients from 46 practices across three states. Overall, there were 472 ED visits/hospitalizations for neutropenia, 34 visits for anemia, and 799 visits for CINV. G-CSF pathway-compliant treatment was associated with a significant reduction in neutropenia ED visits/hospitalizations compared with noncompliant treatment (odds ratio [OR] = 0.34; 95% CI, 0.25 to 0.45; P < .001). Adjusting for cancer type and G-CSF drug expenditures, a similar reduction in neutropenia ED visits/hospitalizations was observed (OR = 0.42; 95% CI 0.30 to 0.58; P < .001). Analogous analyses did not demonstrate a significant association between ESA and antiemetic pathway compliance and ED visits/hospitalizations for anemia (P = .069) and CINV (P = .106), respectively. G-CSF therapy pathway compliance was also associated with an average decrease of $1,085 in ED visit/hospitalization costs per line of therapy (P < .001). CONCLUSION: G-CSF pathway compliance was associated with a significant decrease in the rate of neutropenia ED visits/hospitalizations and resulting costs.

Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer's perspective.

PURPOSE: Clinical pathways are viewed as valuable practice tools leading to presumed cost savings. CareFirst BlueCross BlueShield partnering with P4 Pathways implemented a multistate oncology clinical pathways program in 2008. This is the first comprehensive evaluation to our knowledge of a pathways program implemented on a broad scale. METHODS: This study used a retrospective single-group, pretest-post-test design. Data representing preclinical pathways (year -1) and 2 years after program initiation (years +1 and +2) were obtained from claims data. Participating sites with ≥one claim for breast, lung, or colorectal cancer treatment from each year were included in the evaluation. Compliance was defined as site attainment of prespecified annual thresholds for the use of chemotherapy and supportive care. Savings were determined by comparing per-patient changes in drug and hospital costs through year +2 with the projected annual expenditure increases of 12% and 7%, respectively. RESULTS: Forty-six sites representing 4,713 patients met inclusion criteria. The unadjusted site compliance rate for chemotherapy was 83% and 54% for years +1 and +2, respectively; supportive care site compliance was 74% for both years. Per-patient drug costs increased from $16,494 in year -1 to $16,906 in year +2 (P=.587), whereas hospitalization costs decreased from $2,502 to $1,064 (P=.004). Compared with projected cost increases, pathways resulted in $10.3 million in savings by participant sites ($7.0 million from drugs and $3.3 million from hospitalizations) or $30.9 million when extrapolated to the entire health plan. CONCLUSION: Broadly implemented clinical pathways can achieve reasonable physician compliance, resulting in substantial cost savings.