Cost of previously treated chronic lymphocytic leukemia (CLL) and
indolent non-hodgkin’s lymphoma (iNHL) in the United Kingdom (UK)
Magali Cognet1, Sylvain Druais1, Frédéric Gervais 1, Aline Gauthier1, Keith Abrams2
1 Amaris,
London, United Kingdom
of Health Sciences, University of Leicester, United Kingdom
2Department
METHODS
• A MEDLINE and UK Health Technology Appraisals (HTAs) reviews were
undertaken to identify studies documenting the cost of previously-treated
iNHL and CLL in the UK.
• To collect patients healthcare resource use, a retrospective database
analysis based on a primary care database (THIN) linked with a hospital
database (HES) was undertaken, providing access to anonymous
demographic, medical and prescription records covering both the primary
and secondary care at the patient level.
• Patients with CLL and iNHL were first selected in THIN according to
corresponding READ codes (the standard clinical terminology system used
in General Practice) for CLL/iNHL and then retrieved in HES where only
patients with at least one hospitalisation for a primary diagnosis (ICD-10
codes) of CLL/iNHL were kept. Among these, patients previously treated
had to have at least one record of a treatment (ICD-10 or OPSC4 codes)
related to chemotherapy to be included in the final study population.
• Patient characteristics including age, sex, ethnic category were extracted.
• Given the insufficient level of detail reported in HES to identify progression
free (PFS) and progressive disease (PD) health states, an algorithm based on
intervals between treatment and relying on the following assumption was
developed 3-7 :
o PD health states are marked by periods of 6-month treatment
(maximum, but can be shorter without any minimum duration required)
o Treatment administrations after 6 months are classified as maintenance
o If time from CLL/iNHL diagnosis to first treatment is less than 3 months,
this is considered as PD, whereas a time from diagnosis to treatment
longer than 3 months is identified as “watch and wait” or “PFS”.
• All hospital episodes with primary diagnosis of CLL/iNHL included in the
study population were costed according to the UK Payment by Result
system. Healthcare Resource Groups (HRGs) were retrieved via the NHS
HRG4 2014/2015 grouper 8 . Corresponding national tariffs were applied to
determine a cost for each episode.
• Overall survival was estimated as the duration from the first date of
diagnosis of iNHL or CLL to the date of the patient death. The date of
censoring was set to the earlier date between the date of loss to follow-up
in the database (due to a transfer of GP for example) or to the date of data
consolidation (1st March 2014).
• SAS V9.2 was used to perform the statistical analyses.
RESULTS
• Three HTAs submitted to the National Institute for Health and Care
Excellence (NICE) were identified as relevant, and cost estimates relied on
assumptions from clinical experts. Assumptions varied as TA193 related to
relapsed CLL assumed that healthcare visits were three times more
frequent post-progression (3 consultations/month: £86) than preprogression (1 consultation/month: £28.67) while another TA202 assumed
a rather constant number of visits across the two health states (1 clinic visit
per month: £121.11) 3-5 .
• Study population included 240 CLL patients and 50 iNHL patients followed
in databases for an average respectivelyof 51 months and 54 months.
• Males represented 70% of the CLL patients and 56% of the iNHL patients.
83% of CLL patients and 86% of iNHL patients were white. The mean age at
diagnosis of CLL patients was 66.4 years while it was 62.7 in iNHL patients.
• The median time to first progression was 1.69 years in the CLL population
and 2.16 years in the iNHL population. The total duration spent in each
Total durati on spent in PFS and in PD by CLL/iNHL patients (in months)
health state
CLL
iNHL
(PFS and PD)
PFS (n=234)
PD (n=240)
PFS (n=48)
PD (n=50)
by patients
Mean (SD)
47.94 (32.22)
4.29 (4.10)
52.27 (30.68)
3.77 (3.16)
is presented
Median
42.02
3.58
52.81
3.05
Minimum
3.12
0.03
3.44
0.03
in the table
Maximum
186.8
26.38
117.59
12.22
on the right .
• The mean costs and monthly cost of CLL and iNHL over the PFS and PD
periods are presented by periods of PFS and PD in the table below.
Mean (SD) costs and monthly costs by disease and periods
CLL
PFS (n=359)
PD (n=426)
Duration (months)
24.22 (22.42)
2.37 (2.09)
Cost (£)
3769.18 (6760.49) 4439.69 (5697.70)
Monthly cost (£)
257.84 (388.15)
7018.35 (35142.18)
Distribution of monthly costs in CLL by period
50
45
40
35
30
25
20
15
10
5
0
PFS
PD
0
1000
2000
3000
4000
iNHL
PFS (n=39)
32.94 (29.32)
5372.44 (9141.92)
408.25 (840.47)
PD (n=75)
2.51 (2.17)
5680.40 (4808.81)
7936.24(12989.55)
Distribution of monthly costs in iNHL by period
Proportion (%)
• Chronic lymphocytic leukaemia (CLL) is a haematological malignancy, one of
four main types of leukemia, affecting mature B lymphocytes and resulting
in their abnormal proliferation. Around 2,800 people are diagnosed with
CLL in the UK each year and 27,741 patients were admitted to UK hospitals
in 2012 with CLL as primary diagnosis 1 .
• Non-Hodgkin’s lymphomas (NHL) are a heterogeneous group of cancers
characterised by a malignant spread of the lymphoreticular cells. Indolent
NHLs (iNHL) are slow-growing lymphomas which have a longer median
survival times but are less likely to be cured by treatment. Around 4,700
people are diagnosed with iNHL in the UK each year and 10,282 patients
were admitted to UK hospitals in 2011 with iNHL as primary diagnosis 2 .
• Assessment of novel agents from a cost-effectiveness standpoint requires
accurate cost estimate.
• Healthcare resources can be potentially retrieved using the health
improvement network database (THIN) and the hospital episode statistics
database (HES), two of the largest medical databases in the UK .
• This study aimed to generate accurate cost estimates of the management
of CLL and iNHL in the UK based on database analysis. To date, no such data
had been published yet.
RESULTS
Proportion (%)
BACKGROUND & OBJECTIVES
5000
Monthly costs (£)
50
45
40
35
30
25
20
15
10
5
0
PFS
PD
0
1000
2000
3000
4000
5000
Monthly costs (£)
• The median overall survival was 6.0 years in CLL patients and 7.4 years in
iNHL patients.
DISCUSSION
• Cost estimates used in identified cost-effectiveness analyses3-5 submitted to
NICE are significantly lower than the cost estimates retrieved through this
databases analysis. This analysis showed a larger difference in costs
between PFS and PD whereas HTAs assumed similar costs.
• This study provides estimates based on real world data observed in clinical
practice, however it is associated with a number of limitations :
o Selection of patients relies on the quality of hospital records both in
terms of diagnoses and OPCS4 codes. A sample of only 50 selected
patients was available in the databases to conduct the iNHL analysis.
o The algorithm is based on treatment sequences to identify PFS and PD
periods of the disease. Although the algorithm was developed in line
with the rituximab label, it may not be applicable to all pharmacological
treatments considered for this analysis and should be validated with a
UK expert.
o No detail about the treatments received was available so that the
treatment pathway could not be fully characterised.
o There is uncertainty in the quality of coding which is hard to assess but
could have an important potential impact on the identification of PFS
and PD periods and their durations.
o NHS grouper provides an aggregate cost for each stay so that the cost of
pharmacological treatments could not be separated from the total
hospital costs.
• Previous study9 reported similar median survival for CLL ranging between 4
and 10 years in patients with intermediate to high risk and 7.5 years for
iNHL10 .
CONCLUSION
• To our knowledge, this is the first study using observational data to
generate estimates of the levels of health care resources and costs of
managing CLL and iNHL in the UK.
• Monthly costs of CLL were estimated at £258 and £7,018 for PFS and PD
health states respectively and the corresponding monthly costs of iNHL at
£408 and £7,936 based on observational data from patients in real clinical
practice in the UK.
• Despite limitations, great differences in monthly costs between PFS and PD
periods can be observed and will have to be accounted in the future in
cost-effectiveness analysis.
ACKNOWLEDGEMENT
This project was funded by Gilead.
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