Disparities in Time to First Prescription Fill for Lenalidomide in Patients with Newly Diagnosed Multiple Myeloma

Background: The complex process of obtaining lenalidomide, including the risk evaluation and mitigation strategy (REMS) program requirements for patients and providers to complete mandatory surveys (before a prescription can be ordered), insurance prior authorization process, navigating patient support programs to help pay for out-of-pocket costs, and dispensing only via specialty pharmacies, can lead to delays in treatment initiation for multiple myeloma. This study aimed to quantify the time from first prescription order to fill for lenalidomide and corticosteroids and measure disparities in the timing of lenalidomide prescription fill based on demographic characteristics and social determinants of health.

Methods: This retrospective cohort study used Taussig Cancer Center’s Myeloma Patient Registry to identify adults who were newly diagnosed with multiple myeloma between January 1, 2017-December 31, 2021, and had a prescription for lenalidomide. Electronic health records from Cleveland Clinic’s Northeast Ohio sites, including linked Surescripts dispensation records, captured time from the first available prescription order to fill for lenalidomide and oral corticosteroids, with follow-up through December 31, 2022.

We calculated the proportions of patients who filled their first prescriptions within 7 days. Log-rank tests were used to compare the cumulative incidence curves based on socio-demographic variables. Multivariable Cox regression models were used to examine the associations of age at diagnosis, sex, race, primary insurance type, urbanicity, area deprivation index (ADI) quartile, treatment facility, ECOG performance status, diagnosis during an inpatient admission, and the year of diagnosis, with filling a prescription within 7 days for a) lenalidomide and b) oral corticosteroid.

Results: We identified 400 patients with a median age at diagnosis of 67 years (interquartile range [IQR], 60-73; 54% were male, 77% White, 22% Black, 1% other races, covered by private insurance (35%), traditional Medicare (30%), Medicare Advantage (25%), Medicaid (9%) and self-paying or other (2%). Over a third of patients (38%) lived in an area in the most disadvantaged ADI quartile.

Overall, 55% of those with lenalidomide prescriptions and 88% of those with oral corticosteroids had their prescriptions filled within 7 days. Among those with filled prescriptions, the median time to fill the prescription was 6 days (IQR, 1-12) for lenalidomide vs. 0 days [same day fill] (IQR, 0-0) for oral corticosteroids.

The cumulative incidences of filling first lenalidomide prescription within 7 days differed significantly by race and whether initial diagnosis occurred during hospital admission; it was 57% (95% confidence interval [CI] 51-62) in White and 47% (95% CI, 37-58) in non-White patients (P=.04); 42% (95% CI, 31-53) in those diagnosed during a hospital admission vs. 58% (95% CI, 52-63) who were not (P=.03). The cumulative incidences of filling first oral corticosteroid prescription within 7 days differed significantly by urbanicity and treatment facility; it was 89% (95% CI, 85-93) in patients living in a metropolitan area, 95% (95% CI, 83-99) in micropolitan, and 67% (95% CI, 43-85) in small town or rural areas (P=.006); 90% (95% CI, 85-93) in those treated at Taussig Cancer Center and 82% (95% CI, 69-91) at regional hospitals (P=.02).

In the multivariable Cox regression model for leanalidomide, Medicaid insurance (vs. traditional Medicare, adjusted hazard ratio [aHR], 0.49, 95% CI, 0.25-0.98) was negatively associated with filling a prescription within 7 days, while other socio-demographic and clinical variables were not significant. For oral corticosteroids, only small town/rural residence (vs. metropolitan, aHR, 0.49, 95% CI, 0.27-0.88) was negatively associated with filling a prescription within 7 days. Both models satisfied the proportional hazards assumption.

Conclusions: In this study of 400 patients with newly diagnosed multiple myeloma, it took a median of 6 days to fill a prescription for lenalidomide and one in four took 12 days or more. In contrast, most patients filled oral corticosteroids on the same day. Patients with Medicaid were less likely to fill lenalidomide at 7 days. Our findings suggest that the complex process of obtaining lenalidomide and insurance create barriers to accessing this costly oral medication in a timely manner.