Cost analysis: treatment of chemotherapy-induced anemia with erythropoiesis-stimulating agents in five European countries

Figures & data

Table 1.  Analysis overview.

1	Initial patient sample
	IMS Hospital Disease Database, January 2003–June 2005 Cancer patients, receiving chemotherapy and ESA DARB (n = 539); EPO-A (n = 1594), EPO-B (n = 380)
2	Propensity score matching
	DARB (n = 429); EPO-A (n = 1584), EPO-B (n = 380)
3	Country-specific costs
	On propensity scores matched patients, replace Belgian costs with country-specific costs:
	• Drug costs (replace unit cost)
	• Procedures cost (replace on APR-DRG level)
	• Hospitalization cost (calculate APR-DRG country-specific day-cost and multiply with length of stay)
4	Population weights
	Adjust on country-specific chemotherapy use and cancer incidence using sample weighting:
	Chemotherapy use:	Cancer incidence:
	• On molecule level, assess the national ratio of sales in each country vs Belgium.	• For four major cancer types (breast, lung, ovarian, hematologic) assess the ratio of the incidence of each country vs Belgium.
	• Average of molecule ratios per patient is ‘chemotherapy weight’.	• The higher the ratio, the higher the patient has a country-specific cancer, the more weight the patient receives.
	• The higher the ratio, the higher the patient uses country-specific chemotherapy, the more weight the patient receives
5	Final weighting
	1. Final weight: Chemotherapy weight × Cancer weight
	2. Final normalized weight: Final weight adjusted for sample size per group (sum of weights has to equal sample size per treatment arm)

Table 2.  Epidemiology and demographic profiles.

		Belgium	Austria	France	Italy	Portugal	Spain
Total population, n	Females	5,442,557	4,269,959	30,082,766	30,669,537	5,358,646	22,921,983
	Males	5,224,309	4,048,633	32,047,441	28,949,747	5,080,268	22,355,470
	Total	10,666,866	8,318,592	62,130,207	59,619,284	10,438,914	45,277,453
% of total population	Females	51.02%	51.33%	51.58%	51.44%	51.33%	50.63%
	Males	48.98%	48.67%	48.42%	48.56%	48.67%	49.37%
	Total	100%	100%	100%	100%	100%	100%
Average age, years	Females	42.00	42.46	41.47	44.49	41.33	42.05
	Males	39.39	39.48	38.47	41.43	38.93	39.38
	Total	40.72	41.01	40.02	43.00	40.16	40.73
Total cancer incidence	Females	25,166	17,307	111,376	121,966	14,544	111,297
	Males	30,501	19,916	154,749	154,994	17,511	160,755
	Total	55,667	37,223	266,125	276,960	32,055	272,052
% of population with cancer	Females	0.46%	0.41%	0.35%	0.40%	0.27%	0.49%
	Males	0.58%	0.49%	0.51%	0.54%	0.34%	0.72%
	Total	0.52%	0.45%	0.43%	0.46%	0.31%	0.60%

Table 3.  Cancer incidence ratios*.

	Austria	France	Italy	Portugal	Spain
Hematological cancers	0.6377	1.1458	1.1823	0.5964	1.2094
Female breast cancer	0.5102	1.1852	0.7966	0.4820	0.5654
Lung cancer	0.5618	0.8939	1.0476	0.3422	0.6716
Ovarian cancer	0.7787	1.0402	1.0555	0.7149	0.9589

*Country ‘×’ over Belgium.

Figure 1.  Mean total management costs of patients treated with ESAs.

Table 4.  Mean (SE) total costs and anemia-related costs (including ESAs).

	Austria			France			Italy			Portugal			Spain
	DARB (n = 429)	EPO-A (n = 1584)	EPO-B (n = 380)	DARB (n = 429)	EPO-A (n = 1584)	EPO-B (n = 380)	DARB (n = 429)	EPO-A (n = 1584)	EPO-B (n = 380)	DARB (n = 429)	EPO-A (n = 1584)	EPO-B (n = 380)	DARB (n = 429)	EPO-A (n = 1584)	EPO-B (n = 380)
Total management cost, €	8825 (SE 970)	11,693 (SE 871**)	13,776 (SE 997**)	7893 (SE 738)	9779 (SE 652**)	9903 (SE 755**)	10,546 (SE 873)	14,063 (SE 745**)	13,274 (SE 910**)	7275 (SE 759)	9270 (SE 677**)	9057 (SE 775**)	7747 (SE 739)	10,466 (SE 644**)	9723 (SE 761**)
Total anemia cost, €	2585 (SE 154)	3102 (SE 99**)	2969 (SE 166)	2225 (SE 142)	2916 (SE 79**)	2656 (SE 152*)	3144 (SE 211)	5049 (SE 119**)	3656 (SE 230)	2153 (SE 117)	2446 (SE 63*)	2654 (SE 124**)	2378 (SE 143)	3349 (SE 75**)	2857 (SE 153*)
ESA cost, €	1966 (SE 112)	2319 (SE 71**)	2259 (SE 121)	1689 (SE 99)	2193 (SE 52**)	2170 (SE 106**)	2475 (SE 187)	4241 (SE 115**)	3115 (SE 203*)	1659 (SE 105)	1944 (SE 71**)	2340 (SE 111**)	1827 (SE 112)	2675 (SE 59**)	2348 (SE 120**)

*Statistically significant differences compared with DARB (p < 0.05); **Statistically significant differences compared with DARB (p < 0.01).

Table 5.  Comparison of total management costs and anemia-related costs between DARB and EPO-A or EPO-B per country.

	Austria	France		Italy	Portugal	Spain
% difference in mean total management costs
DARB vs EPO-A	−25% (p < 0.0001) [95% CI 1749, 3988]	−19% (p < 0.0001) [95% CI 991, 2781]	−25% (p < 0.0001) [95% CI 2321, 4713]		−22% (p < 0.0001) [95% CI 1106, 2884]	−26% (p < 0.0001) [95% CI 1774, 3664]
DARB vs EPO-B	−36% (p < 0.0001) [95% CI 3471, 6432]	−20% (p = 0.0009) [95% CI 823, 3196]	−21% (p = 0.0008) [95% CI 1137, 4318]		−20% (p = 0.0028) [95% CI 616, 2948]	−20% (p = 0.0019) [95% CI 731, 3222]
% difference in mean anemia-related costs
DARB vs EPO-A	−17% (p = 0.0011) [95% CI 208, 826]	−24% (p < 0.0001) [95% CI 385, 996]		−38% (p < 0.0001) [95% CI 1450, 2359]	−12% (p = 0.0235) [95% CI 39, 545]	−29% (p < 0.0001) [95% CI 654, 1289]
DARB vs EPO-B	−13% (p = 0.064) [95% CI-22, 791]	−16% (p = 0.0343) [95% CI 32, 829]		−14% (p = 0.0935) [95% CI-86, 1109]	−19% (p = 0.0028) [95% CI 172, 828]	−17% (p = 0.0226) [95% CI 67, 890]

Table 6.  Impact of country-specific adjustments on cost drivers.

		Belgium	Austria	France	Italy	Portugal	Spain
Mean (SE) treatment duration, days	DARB (n = 429)	41.39 (SE 2.33)	42.98 (SE 2.67)	41.74 (SE 2.45)	42.73 (SE 2.33)	45.95 (SE 2.62)	40.63 (SE 2.39)
	EPO-A (n = 1584)	52.82 (SE 1.28**)	54.72 (SE 1.81**)	53.57 (SE 1.42**)	53.34 (SE 1.22**)	56.85 (SE 1.35**)	53.59 (SE 1.25**)
	EPO-B (n = 380)	53.22 (SE 2.47**)	53.62 (SE 2.85**)	52.72 (SE 2.59**)	53.16 (SE 2.49**)	56.19 (SE 2.75**)	52.39 (SE 2.54**)
Mean (SE) length of hospitalization, days	DARB (n = 429)	6.79 (SE 2.42)	5.91 (SE 2.71)	6.55 (SE 2.66)	6.52 (SE 2.87)	7.34 (SE 2.79)	6.58 (SE 2.54)
	EPO-A (n = 1584)	9.59 (SE 2.33**)	9.35 (SE 2.63**)	9.72 (SE 2.57**)	10.44 (SE 2.78**)	10.57 (SE 2.69**)	10.39 (SE 2.43**)
	EPO-B (n = 380)	9.05 (SE 2.44)	7.82 (SE 2.74)	8.40 (SE 2.68)	8.22 (SE 2.89)	8.19 (SE 2.81)	8.05 (SE 2.56)
Mean (SE) % chemotherapy admissions, % of total	DARB (n = 429)	9.1 (SE 0.2)	9.3 (SE 0.2)	9.1 (SE 0.2)	9.0 (SE 0.2)	0.9 (SE 0.2)	9.2 (SE 0.2)
	EPO-A (n = 1584)	10.0 (SE 0.2**)	10.0 (SE 0.2**)	10.1 (SE 0.2**)	10.1 (SE 0.2**)	10.0 (SE 0.2**)	10.1 (SE 0.1**)
	EPO-B (n = 380)	10.1 (SE 0.2**)	9.5 (SE 0.2)	10.1 (SE 0.3**)	9.9 (SE 0.2**)	10.1 (SE 0.3**)	10.0 (SE 0.2**)
Mean (SE) % patients with RBC transfusion	DARB (n = 429)	37.5 (SE 3.5)	36.3 (SE 3.5)	36.5 (SE 3.2)	37.8 (SE 3.1)	42.9 (SE 2.4)	39.6 (SE 3.1)
	EPO-A (n = 1584)	39.9 (SE 2.9)	40.9 (SE 2.9)	41.8 (SE 2.5*)	43.0 (SE 2.3)	43.6 (SE 1.3)	44.4 (SE 2.3)
	EPO-B (n = 380)	34.7 (SE 3.6)	33.8 (SE 3.6)	32.6 (SE 3.3)	31.7 (SE 3.2)	30.3 (SE 2.5**)	33.9 (SE 3.2)

RBC, Red Blood Cell; *Statistically significant differences compared with DARB (p < 0.05); **Statistically significant differences compared with DARB (p < 0.01).