Session: 902. Health Services Research—Malignant Conditions (Lymphoid Disease) I
Hematology Disease Topics & Pathways:
Non-Biological, Therapies, chemotherapy, Clinically relevant
METHODS: We developed a model to recapitulate scarce chemotherapy allocation at the hospital level. Simulated patients enter the model when they require treatment and are ordered in a queue to receive the scarce chemotherapy—or their best alternative regimen—according to ethically-accepted strategies that prioritize by (1) youngest age, (2) greater efficacy per volume, (3) worse alternatives, or (4) first-come, first-served (the default strategy). For the vincristine use-case, demographic, disease, and treatment data were abstracted from 1689 patients treated at Dana-Farber Cancer Institute from 2015-2019; 3-year treatment regimen survival probabilities and disease risk-adjustments were abstracted from publications cited in the National Comprehensive Cancer Network guidelines. Modeled survival outcomes were validated against Surveillance, Epidemiology, and End-Results Program (SEER) data. Based on the length of the recent vincristine shortage, mean survival rates for a 9-month scenario were modeled according to individual and combination allocation strategies across varying supply levels.
RESULTS: Model functions and risk-adjusted survival probabilities demonstrated no significant differences between the cohort and SEER data, respectively. During the 9-month shortage scenario, a strategy that prioritized patients by greater efficacy per volume significantly increased the mean number of patients surviving at 3-years by >5% across 34.8% of possible vincristine supply levels (grey line and shaded region in Figure) compared to the default of first-come, first-served (red line; all p<0.01). The mean difference in survival over this range was 6.6%. Though a strategy that prioritized drug for those with worse alternatives did not produce improvements over the default by itself, a combination strategy that prioritized by both greater efficacy and worse alternatives produced significant and >5% differences in the mean number of patients surviving across 56.7% of possible supply levels (all p<0.01; blue line and shaded region). The mean survival difference over this range was 7.2%. As compared to the number of patients surviving without any shortage, this combination strategy and the efficacy-only strategy kept statistically similar mean numbers of patients alive for supply reductions 16.7% greater than the default of first-come, first-served (72.2% versus 88.9% of adequate supply, respectively; arrows in Figure). The combination strategy also resulted in a <2.3-year difference in the mean age of surviving patients compared to the youngest age strategy and no increase in mean times to treatment compared to the first-come, first served strategy.
CONCLUSIONS: During a simulated vincristine shortage, a strategy that allocated by both greater efficacy per volume and worse alternatives improved survival compared to either alone, younger age, or the default of first-come, first-served. Moreover, this combined strategy ameliorated reductions in survival across a larger range of drug scarcity than the default. Such a model can be adapted for use for future chemotherapy shortages when multiple ethical allocation strategies exist.
Disclosures: No relevant conflicts of interest to declare.
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