P354 Analysis of outcomes after non-medical switching of anti-tumor necrosis factor agents
D.T. Rubin*1, M. Skup2, S. Johnson3, J. Chao2, A. Gibofsky4
1University of Chicago , Medicine, Chicago, United States, 2AbbVie Inc., Global Health Economics & Outcomes Research, North Chicago, United States, 3Medicus Economics, LLC, , Milton, United States, 4Hospital for Special Surgery & Weill Cornell Medical College, , New York, United States
When multiple treatment options within a class are available, substitution with a less expensive or patient-preferred medicine may occur for cost-containment. We examined medical outcomes and outpatient resource use associated with cost-based non-medical switching (NMS) of anti-TNF agents.
Electronic health record data (Humedica 2007 to 2013) were searched to identify patients (pts) ≥18 years old treated with an anti-TNF agent for an immune disorder (rheumatoid arthritis [RA], psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease [CD], or ulcerative colitis [UC]). A natural language processing algorithm was used to categorize the reason for anti-TNF treatment adjustment (eg, switch, discontinuation) as related to cost or insurance, side effects, or lack of efficacy as indicated in physician chart notes. The NMS sample (N=158) included pts with stable disease in the 90-day baseline period (ie, no anti-TNF treatment change for side effects or lack of efficacy, no emergency room visit, and no hospitalization) who had a cost- or insurance-related switch to a different anti-TNF therapy. The NMS group was matched on key characteristics (including disease type, initial anti-TNF therapy, sex, and age) to controls who were stable and did not experience a medication change due to cost at baseline (N=4804). Outpatient resource utilization and rates of anti-TNF treatment adjustment for side effects and lack of efficacy were compared between the NMS group and controls in the 30 days, 90 days, and 1 year after the NMS date in unadjusted and adjusted analyses.
Most pts had RA (65% for NMS and 76% for controls); 6% of the NMS group and 3% of controls had UC or CD. Experiencing a cost-based NMS was predictive of an increased likelihood of a subsequent anti-TNF treatment adjustment due to lack of efficacy or side effects during 1 year of follow-up (62% for NMS and 20% for controls, p<0.001) (Figure).
Non-medical switching of anti-TNF agents was associated with an increase in side effects and lack of efficacy that led to subsequent treatment change as well as increases in health care utilization. Cost-related switching of medications in otherwise stable pts may have unintended consequences and should be avoided.
 Morgan, S, (2009), Comparison of tiered formularies and reference pricing policies: a systematic review, Open Med, 3(3):e131-9.
 Bates, M, (1995), Models of natural language understanding, Proc Natl Acad Sci U S A, Oct 24;92(22):9977-82.