Cost of Drug Wastage From Dose Modification and Discontinuation of Oral Anticancer Drugs

Lam, Michael; Thibault, Olivier; Haslam, Alyson; Tuia, Jordan; Prasad, Vinay

doi:10.1001/jamaoncol.2023.2306

Cited by 5 publications

(5 citation statements)

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“…Pharmacy integration could also reduce unnecessary health care spending by incentivizing the use of oral therapies, which are dispensed by pharmacies, and integration could act as a counterweight against the overuse of expensive infused therapies . On-site pharmacies could also avert waste that can occur with mail orders, whose unused supplies must be discarded when a dose is changed or a course of treatment is discontinued …”

Section: Introductionmentioning

confidence: 99%

Cancer Treatment Before and After Physician-Pharmacy Integration

Kanter,

Ozluk,

Chi

et al. 2024

JAMA Netw Open

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ImportanceIntegration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this integration affects drug use, expenditures, medication adherence, or time to treatment initiation.ObjectiveTo examine the association of physician-pharmacy integration with oral oncology drug expenditures, use, and patient-centered measures.Design, Setting, and ParticipantsThis cohort study used claims data from a large commercial insurer in the US to analyze changes in outcome measures among patients treated by pharmacy-integrating vs nonintegrating community oncologists in 14 states between January 1, 2011, and December 31, 2019. Commercially insured patients were aged 18 to 64 years with 1 of the following advanced-stage diagnoses: breast cancer, colorectal cancer, kidney cancer, lung cancer, melanoma, or prostate cancer. Data analysis was conducted from May 2023 to March 2024.ExposureTreatment by a pharmacy-integrating oncologist, ascertained by the presence of an on-site pharmacy or nonpharmacy dispensing site.Main Outcomes and MeasuresOral, intravenous (IV), total, and out-of-pocket drug expenditures for a 6-month episode of care; share of patients prescribed oral drugs; days’ supply of oral drugs; medication adherence measured by proportion of days covered; and time to treatment initiation. The association between an oncologist’s pharmacy integration and each outcome of interest was estimated using the difference-in-differences estimator.ResultsBetween 2012 and 2019, 3159 oncologists (745 females [27.1%], 2002 males [72.9%]) treated 23 968 patients (66.4% female; 53.4% aged 55-64 years). Of the 3159 oncologists, 578 (18.3%) worked in practices that integrated with pharmacies (with a low rate in 2011 of 0% and a high rate in 2019 of 31.5%). In the full sample (including all cancer sites), after physician-pharmacy integration, no significant changes were found in oral drug expenditures, IV drug expenditures, or total drug expenditures. There was, however, an increase in days’ supply of oral drugs (5.96 days; 95% CI, 0.64-11.28 days; P = .001). There were no significant changes in out-of-pocket expenditures, medication adherence, or time to treatment initiation of oral drugs. In the breast cancer sample, there was an increase in oral drug expenditures ($244; 95% CI, $41-$446; P = .02) and a decrease in IV drug expenditures (–$4187; 95% CI, –$8293 to –$80; P = .05).Conclusions and RelevanceResults of this cohort study indicated that the integration of oncology practices with pharmacies was not associated with significant changes in expenditures or clear patient-centered benefits.

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Section: Introductionmentioning

confidence: 99%

Cancer Treatment Before and After Physician-Pharmacy Integration

Kanter,

Ozluk,

Chi

et al. 2024

JAMA Netw Open

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“…Oral chemotherapy drug waste is another large source of drug waste not addressed here. 26 On a broader level, reductions in vial pricing may ultimately lower global costs more than any optimization of how vials are created or used. Clinical trials and other studies are needed to confirm the safety and feasibility of strategies such as dose splitting or preservation of vials across treatment days.…”

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confidence: 99%

Opportunity Strikes for Reducing Cancer Drug Waste: Bortezomib as an Example of Vial Mis-Sizing in Oncology

Abrams,

Chen,

Banerjee

2024

JCO Oncol Pract

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“…different strengths combined with a high rate of dose reductions. Lam et al 10 reported that overall costs associated with discarded drugs was less than 2% of the total cost of patients' expenses for their treatment, but given the high cost of anticancer drugs, 2% can add up to considerable costs to patients, insurers, and society.…”

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confidence: 99%

“…Lam et al 10 used published clinical trial data for the subset of drugs they selected to inform their approach to estimate cost, most likely resulting in an underestimate of the magnitude of costs due to discarded oral drugs. It is well established that prescription drugs often perform differently and are used differently in clinical settings than in highly controlled clinical trials.…”

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confidence: 99%

“…Currently, reimbursement incentivizes the manufacture of drugs at different strengths without penalty when drugs are discarded. Lam et al 10 noted that the highest cost resulted from drugs with multiple levels of dose reductions. An important difference between oral and infused drugs is that regulations such as drugs must be discarded within 6 hours of use only apply to infused drugs.…”

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confidence: 99%

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Discarded Targeted Oral Anticancer Medication—A Hard Pill to Swallow?

Yabroff

Shih

2023

JAMA Oncol

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Oral targeted agents for cancer are among the most expensive outpatient prescription drugs dispensed in the US. 1 These drugs, often distributed as specialty drugs, can cost more than $170 000 per patient per year. 2 Patients in the US pay a greater share of their health care costs than patients living in other developed countries. As a result, terms such as "financial burden," "financial hardship," and "financial toxicity" have risen, especially in the US, to describe the untenable phenomenon patients, particularly those treated for cancer, face: treatment can result in long-term financial hardship 3 that may be so severe as to result in medical bankruptcy 4,5 or inability to complete recommended treatment protocols. 6 Moreover, the cost of targeted oral medications for cancer treatment continues to rise. One study 7 using Surveillance, Epidemiology, and End Results (SEER)-Medicare data reported that oral prescription drugs for leukemia increased by 27% between 2007 and 2013, reaching $2.35 billion. Another study 8 analyzing the SEER-Medicare 5% Cancer File showed that mean 30-day total spending on targeted oral anticancer drugs more than doubled in 5 years, from $4011 in 2011 to $8857 in 2016.Federal, state, and private health insurance plans alongside patients pay for oral anticancer drugs. Drugs that are purchased but discarded can represent a substantial cost given the high price of oral anticancer drugs. For payers, the cost associated with discarded targeted oral agents depends on a combination of the cost of the drug and the total number of refills, whereas for patients the cost of discarded drugs varies by the insurance design of their pharmacy benefit, specifically the copayment or coinsurance for a prescription, and limits on annual out-of-pocket payments, if any. 9 In absence of a prescription drug insurance plan, patients may cover the full costs of all prescriptions filled. A change in dose or medication, disease progression, or patient noncompliance, which may be driven by financial reasons, can result in discarded drugs. Reasons for discarded drugs are beyond the patient's and insurer's control, such as medications dispensed in a quantity or dosage that is not easily adjusted through multiples of the initially prescribed dosage.In this issue, Lam et al 10 estimated the cost of oral anticancer drugs discarded owing to dose modification or discontinuation. The authors narrowed the top 50 best-selling pharmaceuticals from drugdiscoverytrends.com to 22 oral anticancer drugs. Using data from published clinical trials associated with the drugs, the investigators applied wholesale drug prices and multiplied by the percentages of patients who required dose reduction or discontinued the drug altogether. Reasonable assumptions were made about the number of remaining unused pills. They estimated that the median cost associated with discarded pills was $1751 with a range of $43 to $27 200-the high upper bound attributable to a drug with a high cost and multiple dose reductions at Opinion

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Cost of Drug Wastage From Dose Modification and Discontinuation of Oral Anticancer Drugs

Cited by 5 publications

References 46 publications

Cancer Treatment Before and After Physician-Pharmacy Integration

Cancer Treatment Before and After Physician-Pharmacy Integration

Opportunity Strikes for Reducing Cancer Drug Waste: Bortezomib as an Example of Vial Mis-Sizing in Oncology

Discarded Targeted Oral Anticancer Medication—A Hard Pill to Swallow?

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