Treatment patterns and cost-effectiveness of first line treatment of advanced non-squamous non-small cell lung cancer in Medicare patients.

AIM: To assess the cost-effectiveness of first-line pemetrexed/platinum and other commonly administered regimens in a representative US elderly population with advanced non-squamous non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: This study utilized the Surveillance Epidemiology and End Results (SEER) cancer registry linked to Medicare claims records. The study population included all SEER-Medicare patients diagnosed in 2008-2009 with advanced non-squamous NSCLC (stages IIIB-IV) as their only primary cancer and who started chemotherapy within 90 days of diagnosis. The study evaluated the four most commonly observed first-line regimens: paclitaxel/carboplatin, platinum monotherapy, pemetrexed/platinum, and paclitaxel/carboplatin/bevacizumab. Overall survival and total healthcare cost comparisons as well as incremental cost-effectiveness ratios (ICERs) were calculated for pemetrexed/platinum vs each of the other three. Unstratified analyses and analyses stratified by initial disease stage were conducted. RESULTS: The final study population consisted of 2,461 patients. Greater administrative censorship of pemetrexed recipients at the end of the study period disproportionately reduced the observed mean survival for pemetrexed/platinum recipients. The disease stage-stratified ICER analysis found that the pemetrexed/platinum incurred total Medicare costs of $536,424 and $283,560 per observed additional year of life relative to platinum monotherapy and paclitaxel/carboplatin, respectively. The pemetrexed/platinum vs triplet comparator analysis indicated that pemetrexed/platinum was associated with considerably lower total Medicare costs, with no appreciable survival difference. LIMITATIONS: Limitations included differential censorship of the study regimen recipients and differential administration of radiotherapy. CONCLUSIONS: Pemetrexed/platinum yielded either improved survival at increased cost or similar survival at reduced cost relative to comparator regimens in the treatment of advanced non-squamous NSCLC. Limitations in the study methodology suggest that the observed pemetrexed survival benefit was likely conservative.

Managing Medicare's HIV caseload in the era of suppressive therapy.

OBJECTIVES: The 1996 introduction of antiretroviral medications changed Medicare's role in providing HIV care. We analyzed Medicare's patient database in an effort to document the new HIV therapies' effects on expenditures and outcomes. METHODS: We examined the medical billing records of a 5% national Medicare sample from 1997 through 2003. The cohort was stratified by year and categorized by age, race/ethnicity, gender, and Medicare status. Population summaries were categorized according to presence of major chronic diseases and HIV-related conditions. RESULTS: The number of Medicare beneficiaries with HIV increased from 42520 in 1997 to 76500 in 2003, whereas mortality among this group fell by 35%. HIV-associated infections declined by as much as 43% (mycoses). Heart and liver disease and diabetes increased by more than 50%. Adjusted annual per person Medicare expenditures fell 28%; expenditures were 49% higher for Blacks than for Whites. CONCLUSIONS: Improved HIV medical management has led to fewer deaths and has shifted treatment toward chronic care. However, successful management is complicated by conditions that have not been historically linked to HIV and whose effects vary according to race/ethnicity.