Assessing the Economic Burden in Medicare Patients with Multiple Myeloma

Background: The substantial improvement in clinical outcomes for patients with multiple myeloma (MM) conferred by proteasome inhibitors (PIs), immunomodulatory drugs (IMiDs), and bisphosphonates is associated with an increased financial burden on the healthcare system. Few studies have addressed the cost patterns of newly diagnosed MM, first-relapsed MM and second-relapsed MM. This study aimed to characterize the direct costs of MM patients receiving first-line (1L), second-line (2L) and third-line (3L) therapy from a payer perspective.

Methods: Medicare beneficiaries (≥65 years old) with ≥2 outpatient claims or ≥1 inpatient claim with a primary diagnosis International Classification of Diseases 9^th Revision code for MM preceded by ≥6 months (i.e., baseline period) without a claim for MM were identified in the Truven MarketScan administrative claims database Medicare Supplemental files from 7/1/2006 to 12/31/2013, and followed until last visit or 12/31/2014, whichever occurred first. The index date was defined as the date of the 1 inpatient claim or earlier of the 2 outpatient claims that met these criteria. The sample was restricted to patients with a follow-up period of ≥12 months. Patients were excluded from the study if they had a stem cell transplant at any time or were diagnosed with another primary cancer in the baseline period. 1L therapy included all anti-MM treatments received following the first claim for an anti-MM oral prescription or administration of an anti-MM therapy. The end of any given line of therapy was defined as the first day of any gap in treatment >90 days or initiation of a salvage regimen. The total all-cause (all inpatient, outpatient and pharmacy claims) and anticancer pharmacological spending (all inpatient, outpatient and pharmacy claims for anti-MM treatments) in 1L, 2L, and 3L were calculated using a standard cost per-patient per-month (PPPM) metric. The duration of treatment in each line of therapy was estimated using descriptive analysis.

Results: A total of 4,214 Medicare beneficiaries met the study eligibility criteria, 3,019 (median age 75 years, 52% male) received care in the continuous enrollment window. Of the 3,019 patients, 1,961 (65%) initiated 1L therapy (median age 76 years, 53% male). 1,212 (62%) of the treated patients received a PI (bortezomib or carfilzomib) or IMiD (lenalidomide, thalidomide, or pomalidomide) in 1L. The average duration of 1L treatment was 8 months. Mean PPPM total and anti-MM treatment costs in 1L were $13,981 and $3,221 (2015$), respectively (Table 1). 986 (50%) patients progressed to 2L therapy and 59% of those patients received a PI or IMiD in 2L. The average duration of 2L treatment was 6 months. Mean PPPM total and anti-MM treatment costs in 2L were $15,579 and $3,262, respectively. 452 (46%) of the patients who received 2L treatment progressed to 3L therapy, and 53% of treated patients received a PI or IMiD in 3L. The average duration of 3L treatment was 5 months. Mean PPPM total and anti-MM treatment costs in 3L were $15,998 and $3,027, respectively.

Conclusion: Compared with patients in 1L treatment, total all-cause spending was higher among MM patients in 2L or 3L. Anticancer pharmacy spending was roughly the same across all 3 lines of therapy and represented about 20% of total all-cause spending for patients with MM. In Medicare patients with MM, the use of PI/IMiD decreased as disease progressed.

Table 1. Average PPPM Spending by Category and Line of Treatment (2015$)

	N	Mean ($)
1L
Total all-cause cost	1,961	13,981
Anti-MM pharmacy cost		3,221
2L
Total all-cause cost	986	15,579
Anti-MM pharmacy cost		3,262
3L
Total all-cause cost	452	15,998
Anti-MM pharmacy cost		3,027

Notes: All figures inflated to 2015$.