The economic burden of brain metastasis among lung cancer patients in the United States

Figures & data

Figure 1. Sample selection flowchart.

Figure 2. Study design.

Table 1. Patient characteristics at first observed diagnosis of brain metastasis.

	n = 132
Demographic and insurance characteristics
Age (years), mean [median] (SD)	55.4 [56.2] (5.7)
Age categories (years), n (%)
25–40, inclusive	1 (0.8)
41–50, inclusive	23 (17.4)
51–60, inclusive	83 (62.9)
61–64, inclusive	25 (18.9)
Female, n (%)	55 (41.7)
Region of residence, n (%)
South	49 (37.1)
Midwest	36 (27.3)
Northeast	34 (25.8)
West	13 (9.8)
Insurance plan type, n (%)
Preferred provider organization	58 (43.9)
Point of service	38 (28.8)
Health maintenance organization	16 (12.1)
Indemnity	10 (7.6)
Other	10 (7.6)
Employee characteristics
Work status, n (%)
Leave of absence	28 (21.2)
Long-term disability	8 (6.1)
Not on a leave of absence nor long-term   disability program	96 (72.7)
Industry, n (%)
Technology	36 (27.3)
Transport	28 (21.2)
Manufacturing and packaging	21 (15.9)
Telecommunications	13 (9.8)
Consumer goods	10 (7.6)
Financial services	6 (4.5)
Other	18 (13.6)
Disease characteristics
Charlson-Quan co-morbidity index*,†,  mean [median] (SD)	5.7 [6.0] (2.2)
Comorbidities†, n (%)
Chronic obstructive pulmonary disease	60 (45.5)
Hypertension	39 (29.5)
Diabetes	19 (14.4)
Mild liver disease	16 (12.1)
Cerebrovascular disease	8 (6.1)
Congestive heart failure	8 (6.1)
Peripheral vascular disease	6 (4.5)
Myocardial infarction	5 (3.8)
Year of first observed diagnosis of brain metastasis
Year, n (%)
1999–2001	23 (17.4)
2002–2004	34 (25.8)
2005–2007	30 (22.7)
2008–2010	25 (18.9)
2011–2013	20 (15.2)

*Quan et al.30.

†Comorbidities were measured over the pre-diagnosis period.

n, number; SD, standard deviation.

Table 2. Comparison of healthcare resource utilization during the pre- and post-diagnosis periods.

	Mean (SD) utilization per-person-per-6-months		Difference [B]−[A]	p-value$
	Pre-diagnosis period† [A], n = 132	Post-diagnosis period‡ [B], n = 132
Inpatient admissions	0.80 (1.07)	1.85 (2.14)	1.05	<0.001***
Inpatient days	6.04 (10.69)	16.71 (20.75)	10.67	<0.001***
Emergency room visits	0.54 (1.21)	0.78 (1.67)	0.24	0.054
Outpatient visits	41.49 (30.49)	37.72 (22.97)	−3.76	0.261
Other medical services	8.82 (20.41)	16.04 (27.10)	7.22	<0.001***
Patient’s home care	5.23 (19.54)	8.55 (22.18)	3.33	<0.001***
Hospice	0.00 (0.00)	3.59 (13.89)	3.59	<0.001***
Extended care facility	0.07 (0.76)	0.91 (3.92)	0.84	0.007**

†The Pre-Diagnosis Period has been defined as 30 days prior to a patient’s first observed lung cancer diagnosis to 30 days prior to his/her first observed diagnosis of brain metastasis.

‡The Post-Diagnosis Period has been defined as 30 days prior to the patient’s first observed diagnosis of brain metastasis to the end of his/her continuous eligibility or the end of data availability, whichever occurred first.

$p-values have been calculated using Wilcoxon signed-rank tests. Significance at 5%, 1%, and 0.1% has been denoted by *, **, and ***, respectively.

SD, standard deviation.

Table 3. Comparison of healthcare costs between pre- and post-diagnosis periods.

	Mean (SD) cost per-person-per-6-months, 2013 USD		Difference [B]−[A]	p-value$
	Pre-diagnosis period† [A], n = 132	Post-diagnosis period‡ [B], n = 132
Medical costs	$44,608 ($38,961)	$70,187 ($68,740)	$25,579	<0.001***
By site of care
Inpatient	$17,586 ($27,834)	$40,481 ($58,682)	$22,895	<0.001***
Outpatient	$25,813 ($24,665)	$26,763 ($28,281)	$950	0.558
Emergency room	$337 ($930)	$846 ($3088)	$509	0.037*
Other (home, hospice, extended care   facility, lab)¶	$872 ($2194)	$2097 ($3957)	$1225	0.002**
By select procedure††
Radiotherapy	$6828 ($13,034)	$7558 ($11,004)	$731	0.038*
Stereotactic radiosurgery	$55 ($608)	$741 ($2540)	$686	<0.001***
Imaging test	$2103 ($2585)	$2514 ($2849)	$412	0.013*
X-ray test	$182 ($268)	$155 ($245)	−$27	0.128
By select disease category relevant to brain metastasis‡‡
I. Neoplasms	$35,341 ($34,361)	$58,646 ($64,562)	$23,305	<0.001***
Malignant neoplasms	$34,670 ($33,900)	$57,960 ($64,128)	$23,290	<0.001***
Brain metastasis	$0 ($0)	$26,263 ($35,145)	$26,263	<0.001***
Lung cancer	$32,499 ($32,603)	$23,532 ($24,494)	−$8967	<0.006**
II. Nervous system and sense organs	$451 ($2882)	$2367 ($8687)	$1915	<0.001***
Degenerative/hereditary CNS diseases	$19 ($195)	$220 ($1776)	$201	0.003**
Other CNS disorders	$358 ($2853)	$1925 ($8448)	$1566	<0.001***
Epilepsy and recurrent seizures	$11 ($124)	$162 ($1233)	$152	0.012*
Other brain conditions	$100 ($476)	$1815 ($8368)	$1714	<0.001***
Cerebral edema	$0 ($0)	$1297 ($8055)	$1297	<0.001***
III. Circulatory system	$3987 ($10,930)	$5334 ($14,284)	$1347	0.113
Pulmonary circulation diseases	$671 ($6133)	$1252 ($5481)	$581	0.043*
Cerebrovascular disease	$197 ($1818)	$2019 ($11,018)	$1822	<0.001***
Intracerebral hemorrhage	$0 ($0)	$1119 ($8853)	$1119	0.031*
IV. Symptoms, signs, and ill-defined conditions	$4589 ($6275)	$8160 ($16,376)	$3571	0.351
General symptoms	$267 ($899)	$2943 ($7637)	$2676	<0.001***
Alteration of consciousness	$3 ($26)	$445 ($4149)	$442	<0.001***
Convulsions	$5 ($59)	$1565 ($5848)	$1560	<0.001***
Dizziness and giddiness	$14 ($107)	$225 ($1447)	$211	0.009**
Malaise and fatigue	$80 ($494)	$207 ($481)	$127	<0.001***
Involving nervous/musculoskeletal systems	$58 ($608)	$237 ($1617)	$179	<0.001***
Involving head and neck	$189 ($561)	$767 ($2723)	$578	0.004**
Pharmacy costs	$25,549 ($29,130)	$15,840 ($18,902)	−$9709	<0.001***
By select therapy
Chemotherapy	$17,901 ($25,245)	$9054 ($14,712)	−$8847	<0.001***
Targeted therapy$$	$2093 ($8752)	$1947 ($6859)	−$146	0.546
Total costs	$70,157 ($50,211)	$86,027 ($71,458)	$15,870	0.021*

†The Pre-Diagnosis Period has been defined as 30 days prior to a patient’s first observed lung cancer diagnosis to 30 days prior to his/her first observed diagnosis of brain metastasis.

‡The Post-Diagnosis Period has been defined as 30 days prior to the patient’s first observed diagnosis of brain metastasis to the end of his/her continuous eligibility or the end of data availability, whichever occurred first.

$p-values have been calculated using Wilcoxon signed-rank tests. Significance at 5%, 1%, and 0.1% has been denoted by *, **, and ***, respectively.

¶Other sites of care include patient’s home care, hospice, independent labs, and extended care facilities like skilled nursing facilities.

††Costs for the following procedures have been determined as follows:

Radiotherapy-related costs: claims associated with a radiotherapy procedure.

Stereotactic radiosurgery (SRS): claims associated with an SRS procedure and no radiotherapy procedure.

Imaging test: claims associated with an imaging procedure and no SRS or radiotherapy procedures. Imaging tests included computed tomography (CT) scans, positron emission tomography (PET) scans, and magnetic resonance imaging (MRI) scans.

X-ray test: claims associated with an x-ray procedure and no imaging test, SRS, or radiotherapy procedure

‡‡Disease sub-categories with significant pre-/post-diagnosis period differences and absolute values greater than $100 per-person-per-6-months have been presented. Costs pertain to those incurred in both inpatient and outpatient settings.

$$Targeted therapy costs are mutually exclusive from chemotherapy costs.

CNS, central nervous system; SD, standard deviation.

Table 4. Comparison of productivity loss during the pre- and post-diagnosis periods.

	Pre-diagnosis period† [A], n = 132	Post-diagnosis period‡ [B], n = 132	Difference [B]−[A]	p-value$
Productivity loss, n (%)
Patients with ≥1 work loss day	132 (100.0)	132 (100.0)	0	–
With ≥1 disability day	49 (37.1)	55 (41.7)	6	0.201
With ≥1 medically-related absenteeism day	125 (94.7)	104 (78.8)	−21	<0.001***
Productivity loss PPP6M, mean (SD)
Total days of productivity loss	51.01 (41.65)	64.72 (42.64)	13.71	<0.001***
Days on disability benefits	31.90 (47.55)	39.44 (54.70)	7.54	0.018*
Medically-related absenteeism	19.11 (16.27)	25.27 (23.59)	6.16	0.006**
Paid sick days	5.89 (4.15)	2.35 (3.41)	−3.54	<0.001***
Unpaid sick days	13.22 (14.27)	22.92 (22.75)	9.70	<0.001***

†The Pre-Diagnosis Period has been defined as 30 days prior to a patient’s first observed lung cancer diagnosis to 30 days prior to his/her first observed diagnosis of brain metastasis.

‡The Post-Diagnosis Period has been defined as 30 days prior to the patient’s first observed diagnosis of brain metastasis to the end of his/her continuous eligibility or the end of data availability, whichever occurred first.

$p-values have been calculated using McNemar’s test for dichotomous variables and Wilcoxon signed-rank tests for continuous variables. Significance at 5%, 1%, and 0.1% has been denoted by *, **, and ***, respectively.

PPP6M, per-person-per-6-months; SD, standard deviation.

Table 5. Comparison of productivity loss-related costs during the pre- and post-diagnosis periods.

	Mean (SD) cost per-person-per-6-months, 2013 USD		Difference [B]−[A]	p-value$
	Pre-diagnosis period† [A], n = 132	Post-diagnosis period‡ [B], n = 132
Payer perspective
Cost of disability benefits	$5940 ($13,983)	$8496 ($21,632)	$2557	0.019*
Patient perspective
Total salary loss	$5675 ($5769)	$8528 ($7757)	$2853	<0.001***
Salary loss due to disability	$2534 ($5503)	$3021 ($7420)	$487	0.705
Salary loss due to medically-related   absenteeism	$3141 ($3852)	$5507 ($5961)	$2366	<0.001***
Employer perspective
Total cost of productivity loss	$13,085 ($16,214)	$17,655 ($22,152)	$4570	<0.001***
Cost of medically-related absenteeism	$1470 ($1620)	$631 ($1357)	−$840	<0.001***

†The Pre-Diagnosis Period has been defined as 30 days prior to a patient’s first observed lung cancer diagnosis to 30 days prior to his/her first observed diagnosis of brain metastasis.

‡The Post-Diagnosis Period has been defined as 30 days prior to the patient’s first observed diagnosis of brain metastasis to the end of his/her continuous eligibility or the end of data availability, whichever occurred first.

$p-values have been calculated using Wilcoxon signed-rank tests. Significance at 5%, 1%, and 0.1% have been denoted by *, **, and ***, respectively.

SD, standard deviation.

Quan H, Sundararajan V, Halfon P, et al. Coding algorithms and for defining comorbidities data in ICD-9-CM administrative. Med Care 2005;43:1130-9

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