Economic Evaluation of Chimeric Antigen Receptor T-Cell Therapy by Site of Care Among Patients With Relapsed or Refractory Large B-Cell Lymphoma

Abstract

Importance: Chimeric antigen receptor (CAR) T-cell therapies are currently administered at a limited number of cancer centers and are primarily delivered in an inpatient setting. However, variations in total costs associated with these therapies remain unknown.

Objective: To estimate the economic differences in the administration of CAR T-cell therapy by the site of care and the incidence of key adverse events.

Design, setting, and participants: A decision-tree model was designed to capture clinical outcomes and associated costs during a predefined period (from lymphodepletion to 30 days after the receipt of CAR T-cell infusion) to account for the potential incidence of acute adverse events and to evaluate variations in total costs for the administration of CAR T-cell therapy by site of care. Cost estimates were from the health care practitioner perspective and were based on data obtained from the literature and publicly available databases, including the Healthcare Cost and Utilization Project National Inpatient Sample, the Medicare Hospital Outpatient Prospective Payment System, the Medicare physician fee schedule, the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System, and the IBM Micromedex RED BOOK. The model evaluated an average adult patient with relapsed or refractory large B-cell lymphoma who received CAR T-cell therapy in an academic inpatient hospital or nonacademic specialty oncology network.

Intervention: The administration of CAR T-cell therapy.

Main outcomes and measures: Total cost of the administration of CAR T-cell therapy by site of care. The costs associated with lymphodepletion, acquisition and infusion of CAR T cells, and management of acute adverse events were also examined.

Results: The estimated total cost of care associated with the administration of CAR T-cell therapy was $454 611 (95% CI, $452 466-$458 267) in the academic hospital inpatient setting compared with $421 624 (95% CI, $417 204-$422 325) in the nonacademic specialty oncology network setting, for a difference of $32 987. After excluding the CAR T-cell acquisition cost, hospitalization and office visit costs were $53 360 (65.3% of the total cost) in academic inpatient hospitals and $23 526 (48.4% of the total cost) in nonacademic specialty oncology networks. The administration of CAR T-cell therapy in nonacademic specialty oncology networks was associated with a $29 834 (55.9%) decrease in hospitalization and office visit costs and a $3154 (20.1%) decrease in procedure costs.

Conclusions and relevance: The potential availability of CAR T-cell therapies that are associated with a lower incidence of adverse events and are suitable for outpatient administration may reduce the total costs of care by enabling the use of these therapies in nonacademic specialty oncology networks.

Figure 1.. Decision-Tree Model

Adverse events (AEs) included in the model were cytokine release syndrome and neurological events. Costs incurred by patients who initiated treatment at an academic inpatient hospital or nonacademic specialty oncology network (NASON) were estimated by following the patient from the time of lymphodepletion to chimeric antigen receptor (CAR) T-cell infusion at the first decision-tree node, then following the patient through subsequent sites of care inclusive of AE management. The AE rates were applied to the probability nodes of the decision tree. Squares are decision nodes, indicating a decision to be made; circles are chance nodes, indicating multiple uncertain outcomes; and triangles are end point nodes, indicating a final outcome. ICU indicates intensive care unit; LBCL, large B-cell lymphoma.

Figure 2.. Base-Case and Scenario Analyses

A, In this analysis, 97.5% of patients had an adverse event. Costs in the inpatient hospital setting were $12 561 for drugs, $15 690 for procedures, and $53 360 for hospitalization and office visits, for a total cost of $81 611. Costs in the nonacademic specialty oncology network (NASON) setting were $12 561 for drugs, $12 537 for procedures, and $23 526 for hospitalization and office visits, for a total cost of $48 624. The total cost difference between the inpatient hospital and NASON settings was $32 987, reflecting a 40.4% cost reduction. The chimeric antigen receptor (CAR) T-cell acquisition cost, assumed to be $373 000, was excluded from the total costs. All costs are in US dollars. B, In this analysis, 50% of patients had an adverse event. Costs in the inpatient hospital setting were $6460 for drugs, $10 313 for procedures, and $42 003 for hospitalization and office visits, for a total cost of $58 776. Costs in the NASON setting were $6460 for drugs, $8718 for procedures, and $16 304 for hospitalization and office visits, for a total cost of $31 482. The total cost difference between the inpatient hospital and NASON settings was $27 294, reflecting a 46.4% cost reduction. The CAR T-cell acquisition cost, assumed to be $373 000, was excluded from the total costs. All costs are in US dollars.

Figure 3.. Sensitivity Analyses

A, One-way sensitivity analysis of net difference in costs in the base-case analysis. B, Probability sensitivity analysis of percentage of iterations by net difference in the base-case analysis. Dark blue bars indicate iterations in which the administration of CAR T-cell therapy in the nonacademic specialty oncology network (NASON) setting was associated with cost reduction (71.9% of total iterations). Light blue bars indicate iterations in which the administration of chimeric antigen receptor (CAR) T-cell therapy in the inpatient hospital setting was associated with cost reduction (28.1% of total iterations). Of 1000 iterations, 0.5% had costs greater than $200 000, 3.2% had costs between $150 001 and $200 000, 10.6% had costs between $100 001 and $150 000, 24.7% had costs between $50 001 and $100 000, 32.9% had costs between $1 and $50 000, 20.1% had costs between –$49 999 and $0, 6.8% had costs between –$99 999 and –$50 000, and 1.2% had costs less than –$100 000. C, Probability sensitivity analysis based on 97.5% of patients with adverse events (AEs) in the base-case analysis. The net difference in costs ranged from $14 654 to $25 251. D, Probability sensitivity analysis based on 50% of patients with AEs in the scenario analysis. The net difference in costs ranged from $21 199 to $24 935. CRS indicates cytokine release syndrome; NE, neurological event.