Annual patient and caregiver burden of oncology clinic visits for granulocyte-colony stimulating factor therapy in the US

Figures & data

Figure 1. Treatment volume and cost estimation model overview.

Table 1. Summary of data sources and assumptions used for estimating patient and caregiver costs.

Category	Source(s)	Assumptions/estimates used
National annual clinic visits for G-CSF injection following MC
Cancer Prevalence, by type	SEER Cancer Statistics Review 1975–201238	2012 5-year prevalence estimates, 1st invasive tumor ever
Percentage of cancer patients receiving chemotherapy	American Cancer Society report Cancer Treatment & Survivorship Facts & Figures 2014–201539	Estimates made in seven cancer categories. Average across all non-myeloid cancers was 28%
Chemotherapy cycles per patient	Chemocare.com: How Long is Chemotherapy Given?40	Used four cycles per patient as conservative estimate
G-CSF cycle penetration rates, by cancer type	OSCER database41	Estimates made in seven cancer categories. Average across all non-myeloid cancers was 31.5%
Percentage of G-CSF cycles by daily vs long-acting	OSCER database41	68% long-acting, 32% daily
Average days treated per cycle (Daily G-CSFs)	OSCER database41	2.4 days per cycle
Percentage delivered in office (vs at home)	Daily G-CSFs: IMS G-CSF Report from June 201341. Long-acting G-CSFs: from Phillips et al.42	60% daily G-CSFs 91% long-acting G-CSFs
Patient and caregiver time devoted to G-CSF visits (per visit)
Mean travel time (round-trip)	CABS Survey41	62 min
Mean clinic time	CABS Survey41	41 min
Percentage of trips accompanied	CABS Survey41	66.3%
Economic value of patient time	BLS National average wage all occupations as of May 201443	$22.71 per h
Economic value of caregiver time	Average of state minimum wages44, BLS mean home health aide wage43 and Median private pay cost of hiring a homehealth aide45	$12.80 per h
Travel costs
Average travel distance to treatment (round-trip)	Converted travel time to miles, based on mean travel speed of 34 MPH (from Houts et al.14)	35.13 miles
Mode of transport	CABS Survey41	33.5% self-drive, 64.5% other driver, 1% taxi, 1% public transit
Per mile costs for self-driven, other driver miles	Based on 2015 IRS mileage rates46. Medical rate applied to self-transported miles. Full business rate applied to other driver miles	Self-drive: 23 cents per mile Other drivers: 57.5 cents per mile
Costs of other modes of transport	American Public Transit Association (APTA) 2014 Fact Book47. Summary of US Taxi Fares from taxifarefinder.com48	Cost per mile for Taxis: $2.91 Cost per trip: Taxis: $2.85 + mileage, Public Transit: $2.13 per trip
Insurance cost-sharing/co-pays
G-CSF market share by insurance segment	Payer Mix for 2014 for the Neulasta and Neupogen franchises (Amgen, Inc. data on file41)	Assumed payer mix in office/OPD setting would mirror mix across all settings
Cost-share (co-pay) per visit	Commercial Plans: from Tomic et al.16. Medicare FFS: Based on 20% coinsurance for Part B services, multiplied by Medicare Allowed amounts49. Medicaid: Based on average of state-level office co-pays50	Assumed 83% of Medicare FFS had supplemental insurance51 Medicare Advantage: same as commercial. VA, Military, Uninsured: assumed no cost sharing

MC, myelosuppressive chemotherapy; BLS, Bureau of Labor Statistics; FFS, Fee for Service.

Table 2. Sensitivity analysis: Plausible ranges of values, sources, and rationales.

Variable	Lower boundary	Baseline	Upper boundary
Mean time in clinic visit (h)^a	0.517	0.685	1.20
Mean one-way travel time (h)^b	0.450	0.517	0.667
Transport cost per mile^c	$0.230	$0.457	$0.575
Time opportunity cost per hour^d	$17.95	$18.76	$21.63
% Trips accompanied by caregiver^e	40.0%	66.3%	66.3%
Mean travel speed (MPH)^f	26.7	34.0	43.0
Annual visits^g	1,668,000	1,713,000	1,743,000
Average co-pay per visit^h	$33.86	$35.64	$37.42
% of trips self-driven^i	60.0%	33.5%	33.5%
% of trips by automobile^j	100%	98%	93%

^aLower bound is from Beveridge et al.57. Upper bound is from Houts et al.14.

^bLower bound is from Houts et al.14. Upper bound is from Meehan et al.58.

^cLower bound is the 2015 IRS mileage rate for medical travel. Upper bound is the 2015 IRS mileage rate for business travel46.

^dLower bound represents the weighted average of the Bureau of Labor Statistics (BLS)43 national average wage for all occupations applied to patients’ time, and the national average Home Health Aide wage applied to caregivers time. Upper bound uses the same wage as lower bound for patients’ time and the 2014 median private pay cost of hiring a home health aide45 applied to caregivers time.

^eLower bound is from Haithcox et al.15. The percentage of trips with other drivers was also adjusted to this percentage. Upper bound is the same as baseline—no higher estimates were found in the literature.

^fLower bound is from Beveridge et al.57. Upper bound is from Shreay et al.59.

^gLower bound is from the Sales and Pricing model. Upper bound is from the Epidemiology model.

^hRange is ±5% of the baseline, based on sensitivity testing in the co-pay model.

ⁱLower bound is from Haithcox et al.15. Trips driven by other drivers was adjusted down to get to 60% self-drive. Upper bound is the same as baseline—no higher estimates were found in the literature.

^jLower bound is set to maximum possible value. Upper bound is from Meehan et al.60. Self-drive and other drive percentages from baseline were reduced proportionally and taxi and public transit percentages were increased proportionally to obtain the target mix of transport types.

Table 3. 2015 Estimated patient and caregiver cost burden of G-CSF clinic visits.

	n	n (Visits)	Transport costs	Time value	Cost-sharing	Total costs
Patients	403,000	1,713,000	$6.6 million	$66.8 million	$61.1 million	$134.5 million
Caregivers	268,000	1,135,719	$22.3 million	$25.0 million	–	$47.3 million
Total	403,000	1,713,000	$28.9 million	$91.8 million	$61.1 million	$181.8 million

Table 4. 2015 Patient and caregiver cost burden per patient and per visit.

	Transport costs*	Time value*	Cost-sharing	Total costs*
Per patient	$71.71	$227.79	$151.61	$451.11
Per visit	$16.87	$53.59	$35.64	$106.10

*Includes caregiver costs.

Table 5. 2015 Estimated patient and caregiver travel and time burden of G-CSF visits.

	Clinic visits	Travel miles	Travel time (h)	Clinic time (h)	Total time (h)
Patients	1,713,000	60.2 million	1.8 million	1.1 million	2.9 million
Caregivers	1,135,719	38.8 million	1.2 million	0.8 million	2.0 million
Total	1,713,000	60.2 million	3.0 million	1.9 million	4.9 million

Figure 2. One-way sensitivity analysis—key factors influencing costs.

Howlader N, Noone A-M, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2012. Bethesda, MD: National Cancer Institute, 2015. http://seer.cancer.gov/csr/1975_2012/. Accessed May 22, 2015

 Google Scholar

American Cancer Society. Cancer treatment & survivorship facts & figures 2014–2015. Atlanta, GA: American Cancer Society, 2015. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf. Accessed June 9, 2015

 Google Scholar

Chemocare.com. How long is chemotherapy given? - What is chemotherapy? - Chemocare. http://chemocare.com/chemotherapy/what-is-chemotherapy/how-long-is-chemotherapy-given.aspx. Accessed September 8, 2015 Chemocare.com, Cleveland OH, 2015

 Google Scholar

Amgen, Inc. Data on File. Amgen, Inc., 2015 Thousand Oaks, CA

 Google Scholar

Phillips J, Ritter S, Starner C, et al. Filgrastim (Neupogen) and pegfilgrastim (Neulasta): cost analysis and utilization management opportunity assessment. 2012 https://www.primetherapeutics.com/specialty/assets/pdf/NeupogenNeulastaUMOpportunity.pdf. Accessed May 12, 2015 Poster presented at the AMCP 24th Annual Meeting April 20, 2012 San Francisco CA

 Google Scholar

Bureau of Labor Statistics. Occupational Employment Statistics (OES) data as of May 2014. Bureau of Labor Statistics. http://www.bls.gov/oes/current/oes_nat.htm#00-0000. Accessed April 8, 2015 National Conference of State Legislatures, Washington DC. Published 2015 Poster presented at the AMCP 24th Annual Meeting April 20, 2012 San Francisco CA.

 Google Scholar

National Conference of State Legislatures. State Minimum Wages | 2015 Minimum Wage by State. http://www.ncsl.org/research/labor-and-employment/state-minimum-wage-chart.aspx#1. Accessed September 14, 2015

 Google Scholar

Genworth Financial. Genworth 2014 Cost of Care Survey, April 2014. 2014. https://www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/130568_032514_CostofCare_FINAL_nonsecure.pdf. Accessed September 3, 2015 Genworth Financial, Richmond VA

 Google Scholar

Houts AC, Loh GA, Fortner BV, et al. Patient and caregiver time burden associated with anaemia treatment in different patient populations. Support Care Cancer 2006;14:1195-204

 PubMed Web of Science ®Google Scholar

Internal Revenue Service. Standard mileage rates. IRS. 2015. http://www.irs.gov/Tax-Professionals/Standard-Mileage-Rates. Accessed September 8, 2015 Washington DC

 Google Scholar

APTA. 2014 Public Transportation Fact Book. Washington, DC: American Public Transportation Association, 2014. http://www.apta.com/resources/statistics/Documents/FactBook/2014-APTA-Fact-Book.pdf. Accessed September 3, 2015

 Google Scholar

TaxiFareFinder. Summary taxi rates for US Cities. TaxiFareFinder. http://www.taxifarefinder.com/rates.php. Published 2015. Accessed September 3, 2015

 Google Scholar

Tomic K, Long S, Li X, et al. A retrospective study of patients’ out-of-pocket costs for granulocyte colony-stimulating factors. J Oncol Pharm Pract January 2013 :1078155212473001. doi:10.1177/1078155212473001. 2013 Dec;19(4):328-37.

 Google Scholar

Centers for Medicare & Medicaid Services. ASP Drug Pricing Files. Centers for Medicare & Medicaid Services. 2015. http://www.cms.gov/apps/ama/license.asp?file=/McrPartBDrugAvgSalesPrice/downloads/2015-April-ASP-Pricing-File.zip. Accessed September 3, 2015 Baltimore MD

 Google Scholar

Kaiser Family Foundation. Medicaid benefits: physician services. Kaiser Family Foundation, 2015. http://kff.org/medicaid/state-indicator/physician-services/. Accessed September 11, 2015

 Google Scholar

Medicare Payment Advisory Commission (US). Health Care spending and the Medicare Program: a data book June 2015. Washington, DC: Medicare Payment Advisory Commission, 2015. http://www.medpac.gov/documents/data-book/june-2015-databook-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Accessed August 27, 2015 Washington DC

 Google Scholar

Beveridge RA, Rifkin RM, Moleski RJ, et al. Impact of long-acting growth factors on practice dynamics and patient satisfaction. Pharmacother J Hum Pharmacol Drug Ther 2003;23:101S-109S

 Google Scholar

Meehan K, Tchekmedyian, S, Ciesla G. The burden of weekly epoetin alfa injections to patients and their caregivers abstract 2186. J Support Oncol 2003;1(Suppl):28

 Google Scholar

Haithcox S, R Ramnes C, Lee H, et al. The impact of frequent injections for hematopoietic growth factor support on patients receiving chemotherapy: an observational study. BMC Nurs 2003;2:22

 Google Scholar

Shreay S, Desrosiers M-P, Corey-Lisle P, et al. A retrospective study to evaluate the time burden associated with outpatient red blood transfusions indicated for anemia due to concomitantly administered chemotherapy in cancer patients. Support Care Cancer 2013;21:1335-40

 PubMed Web of Science ®Google Scholar

Meehan K, Tchekmedyian, S, Smith S. An activity-based costing estimate of anemia correction activities in an oncology practice. Abstract 5595. Blood 2002;100:

 Web of Science ®Google Scholar