Treatment Costs in Ulcerative Colitis and Crohn's Disease
Treatment Costs in Ulcerative Colitis and Crohn's Disease
A total of 417,134 patients with at least one UC or CD diagnosis claim were identified in the database, of which 32,883 patients met the final study inclusion criteria (19,878 for UC and 13,005 for CD) (Figure 1). 5-ASA was the predominant index therapy in the UC group (69% of patients); 5-ASA was also the most common index therapy in the CD group (47% of patients). Corticosteroids, immunomodulators and biologics were more frequently used as the index therapy (40%, 8% and 5% of patients respectively) in CD patients than in UC patients (27%, 2% and 1% respectively) ( Table 1 ). In both UC and CD patients, baseline comorbidity burden was highest in patients initiating corticosteroids [UC: mean (s.d.) CCI = 0.8 (1.4); CD: mean (s.d.) CCI = 0.8 (1.3)] or biologics [UC: mean (s.d.) CCI = 0.9 (1.4); CD: mean (s.d.) CCI = 0.6 (1.0)], and lowest in patients initiating 5-ASAs [UC: mean (s.d.) CCI = 0.5 (1.0); UC: mean (s.d.) CCI = 0.5 (1.0)].
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Figure 1.
Sample attrition. UC, ulcerative colitis; CD, Crohn's disease; IBD, inflammatory bowel disease.
Table 2 summarises overall rates of various types of changes to the index therapy during the 12-month post-index period.
Discontinuation/Interruption. In both UC and CD patients, approximately half (51% and 52% respectively) of 5-ASA initiators discontinued or interrupted the initial treatment. Rates of index biologic discontinuation or interruption were also similar between UC and CD patients initiating infliximab (13% and 15% respectively).
Upward Dose Titration. With the exception of immunomodulators, upward dose titration was common for all index therapies in UC patients. Among UC patients initiating corticosteroids and 5-ASA, 37% and 20% of patients, respectively, had an upward titration. Among UC patients initiating a biologic, upward titration was substantially more common for infliximab (29%) than adalimumab (13%). Upward titration rates were similar in CD patients as in UC patients for each index therapy, with the exception of patients initiating 5-ASA for whom upward titration was substantially less frequent (6%) in CD patients. The prevalence of upward titration among all biologic initiators combined was 27% and 28% for UC and CD patients respectively (data not shown).
Switching. Among UC patients, switching occurred in 11% of adalimumab initiatiors, 9% of infliximab initiators, 9% of immunomodulator initiators and 6% of 5-ASA initiators. Switching was generally more common in CD patients: 11% of 5-ASA initiators, 11% of immunomodulator initiators, and 35%, 18% and 11% of certolizumab pegol, adalimumab and infliximab initiators respectively. Augmentation was common (at least 20%) for all index treatment groups in both UC and CD patients.
Among patients in each index therapy class who switched to an alternative treatment, Figure 2 summarises the distribution of the next agent used after switch. Among all UC and CD patients who switched index treatment, regardless of index therapy, the most common next agent after switch was corticosteroids (at least half of patients who switched across all index groups). Regardless of index therapy or IBD subtype, immunomodulators were the next most common agents used in switching.
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Figure 2.
Distribution of next agent used in switching from index therapy.* UC, ulcerative colitis; CD, Crohn's disease; 5-ASA, 5-aminosalicylate; CS, corticosteroid; IM, immunomodulator. *Not assessed for natalizumab initiators among UC patients (n = 1) or CD patients (n = 7), nor for certolizumab initiators among UC patients (n = 0). Tabular data for certolizumab initiators among CD patients (n = 23) available upon request.
Augmentation. Table 3 describes the proportion of patients and the agent used for augmenting the index therapy. Among UC and CD patients who initiated 5-ASA, the vast majority of those who augmented their therapy did so with corticosteroids (89% and 76% of patients who augmented respectively). Among patients initiating corticosteroids who augmented, 5-ASAs were the most common agents used in augmentation for both UC (87%) and CD (63%) patients. Among UC and CD patients who initiated infliximab and who later augmented therapy, choice of agent added to the index therapy was distributed more evenly across the available therapy options.
Other Therapeutic Events. Examining other therapeutic events, inadequate induction dosing for patients initiating biologics occurred in 50% of adalimumab users in the UC group and 46% of adalimumab users in the CD group (data not shown). Among CD patients initiating certolizumab pegol, 13% had inadequate induction dosing. Inadequate induction dosing was not observed for any infliximab initiators in either UC or CD patients. For both UC and CD patients, disease-related surgery and hospitalisation was most common among patients initiating the biologic therapies (except UC patients initiating adalimumab) (Figure 3). Prolonged corticosteroid use was similar across index treatment groups in UC patients (range: 10–11% across all index therapy groups), with the exception of patients initiating immunomodulators, in whom 24% had prolonged use. Prolonged corticosteroid use was also similar across index treatment groups in CD patients (range: 8–14.5% across all index therapy groups), with the exception of patients initiating corticosteroids (33% with prolonged use).
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Figure 3.
IBD-related surgery, hospitalisation and prolonged corticosteroid use. IBD, inflammatory bowel disease; UC, ulcerative colitis; CD, Crohn's disease; 5-ASA, 5-aminosalicylate; CS, corticosteroid; IM, immunomodulator.
Costs. Results of the cost analysis, stratified by patients with vs. without a measure of suboptimal therapy, are presented in Table 4 . In total, 81% and 80% of UC and CD patients, respectively, had at least one of the noted proxy measures for suboptimal therapy. In UC patients, total all-cause costs per patient were significantly higher in those with vs. without suboptimal therapy ($12 679 vs. $9653; P < 0.001), as were total IBD-related costs ($3378 vs. $2314; P < 0.001). Similarly, total all-cause costs per CD patient were significantly higher in those with vs. without suboptimal therapy ($18 736 vs. $10 878; P< 0.001), as were total IBD-related costs ($7367 vs. $3213; P< 0.001). In both UC and CD patients, costs were driven largely by out-patient and other ambulatory encounters as well as by prescription drugs.
Results
A total of 417,134 patients with at least one UC or CD diagnosis claim were identified in the database, of which 32,883 patients met the final study inclusion criteria (19,878 for UC and 13,005 for CD) (Figure 1). 5-ASA was the predominant index therapy in the UC group (69% of patients); 5-ASA was also the most common index therapy in the CD group (47% of patients). Corticosteroids, immunomodulators and biologics were more frequently used as the index therapy (40%, 8% and 5% of patients respectively) in CD patients than in UC patients (27%, 2% and 1% respectively) ( Table 1 ). In both UC and CD patients, baseline comorbidity burden was highest in patients initiating corticosteroids [UC: mean (s.d.) CCI = 0.8 (1.4); CD: mean (s.d.) CCI = 0.8 (1.3)] or biologics [UC: mean (s.d.) CCI = 0.9 (1.4); CD: mean (s.d.) CCI = 0.6 (1.0)], and lowest in patients initiating 5-ASAs [UC: mean (s.d.) CCI = 0.5 (1.0); UC: mean (s.d.) CCI = 0.5 (1.0)].
(Enlarge Image)
Figure 1.
Sample attrition. UC, ulcerative colitis; CD, Crohn's disease; IBD, inflammatory bowel disease.
Table 2 summarises overall rates of various types of changes to the index therapy during the 12-month post-index period.
Discontinuation/Interruption. In both UC and CD patients, approximately half (51% and 52% respectively) of 5-ASA initiators discontinued or interrupted the initial treatment. Rates of index biologic discontinuation or interruption were also similar between UC and CD patients initiating infliximab (13% and 15% respectively).
Upward Dose Titration. With the exception of immunomodulators, upward dose titration was common for all index therapies in UC patients. Among UC patients initiating corticosteroids and 5-ASA, 37% and 20% of patients, respectively, had an upward titration. Among UC patients initiating a biologic, upward titration was substantially more common for infliximab (29%) than adalimumab (13%). Upward titration rates were similar in CD patients as in UC patients for each index therapy, with the exception of patients initiating 5-ASA for whom upward titration was substantially less frequent (6%) in CD patients. The prevalence of upward titration among all biologic initiators combined was 27% and 28% for UC and CD patients respectively (data not shown).
Switching. Among UC patients, switching occurred in 11% of adalimumab initiatiors, 9% of infliximab initiators, 9% of immunomodulator initiators and 6% of 5-ASA initiators. Switching was generally more common in CD patients: 11% of 5-ASA initiators, 11% of immunomodulator initiators, and 35%, 18% and 11% of certolizumab pegol, adalimumab and infliximab initiators respectively. Augmentation was common (at least 20%) for all index treatment groups in both UC and CD patients.
Among patients in each index therapy class who switched to an alternative treatment, Figure 2 summarises the distribution of the next agent used after switch. Among all UC and CD patients who switched index treatment, regardless of index therapy, the most common next agent after switch was corticosteroids (at least half of patients who switched across all index groups). Regardless of index therapy or IBD subtype, immunomodulators were the next most common agents used in switching.
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Figure 2.
Distribution of next agent used in switching from index therapy.* UC, ulcerative colitis; CD, Crohn's disease; 5-ASA, 5-aminosalicylate; CS, corticosteroid; IM, immunomodulator. *Not assessed for natalizumab initiators among UC patients (n = 1) or CD patients (n = 7), nor for certolizumab initiators among UC patients (n = 0). Tabular data for certolizumab initiators among CD patients (n = 23) available upon request.
Augmentation. Table 3 describes the proportion of patients and the agent used for augmenting the index therapy. Among UC and CD patients who initiated 5-ASA, the vast majority of those who augmented their therapy did so with corticosteroids (89% and 76% of patients who augmented respectively). Among patients initiating corticosteroids who augmented, 5-ASAs were the most common agents used in augmentation for both UC (87%) and CD (63%) patients. Among UC and CD patients who initiated infliximab and who later augmented therapy, choice of agent added to the index therapy was distributed more evenly across the available therapy options.
Other Therapeutic Events. Examining other therapeutic events, inadequate induction dosing for patients initiating biologics occurred in 50% of adalimumab users in the UC group and 46% of adalimumab users in the CD group (data not shown). Among CD patients initiating certolizumab pegol, 13% had inadequate induction dosing. Inadequate induction dosing was not observed for any infliximab initiators in either UC or CD patients. For both UC and CD patients, disease-related surgery and hospitalisation was most common among patients initiating the biologic therapies (except UC patients initiating adalimumab) (Figure 3). Prolonged corticosteroid use was similar across index treatment groups in UC patients (range: 10–11% across all index therapy groups), with the exception of patients initiating immunomodulators, in whom 24% had prolonged use. Prolonged corticosteroid use was also similar across index treatment groups in CD patients (range: 8–14.5% across all index therapy groups), with the exception of patients initiating corticosteroids (33% with prolonged use).
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Figure 3.
IBD-related surgery, hospitalisation and prolonged corticosteroid use. IBD, inflammatory bowel disease; UC, ulcerative colitis; CD, Crohn's disease; 5-ASA, 5-aminosalicylate; CS, corticosteroid; IM, immunomodulator.
Costs. Results of the cost analysis, stratified by patients with vs. without a measure of suboptimal therapy, are presented in Table 4 . In total, 81% and 80% of UC and CD patients, respectively, had at least one of the noted proxy measures for suboptimal therapy. In UC patients, total all-cause costs per patient were significantly higher in those with vs. without suboptimal therapy ($12 679 vs. $9653; P < 0.001), as were total IBD-related costs ($3378 vs. $2314; P < 0.001). Similarly, total all-cause costs per CD patient were significantly higher in those with vs. without suboptimal therapy ($18 736 vs. $10 878; P< 0.001), as were total IBD-related costs ($7367 vs. $3213; P< 0.001). In both UC and CD patients, costs were driven largely by out-patient and other ambulatory encounters as well as by prescription drugs.