Tbo-Filgrastim Delivers VHA Cost Savings, but Could a Change of Strategy Do More?

For health systems like the Veterans Health Administration (VHA), where controlling costs while providing high-quality care is of heightened concern, achieving the best value for money in the prophylaxis of neutropenia can help to control the cost of cancer care. 
Kelly Davio
December 04, 2018
While the prophylaxis of neutropenia is crucial for patients undergoing cytotoxic chemotherapy in order to maintain dose intensity of their anticancer regimens, using granulocyte colony-stimulating factor (G-CSF) agents does increase the cost of treatment. Long-acting G-CSF agents (such as pegfilgrastim) instead of short-acting agents (like filgrastim) has the potential to push costs even higher. For health systems like the Veterans Health Administration (VHA), where controlling costs while providing high-quality care is of heightened concern, achieving the best value for money in the prophylaxis of neutropenia can help to control the cost of cancer care. 

During the 60th American Society of Hematology Annual Meeting and Exposition in San Diego, California, Kevin Knopf, MD, of Highland Hospital in Oakland, California, and colleagues presented research on the most cost-effective approach to using G-CSF therapies in the VHA.1

Knopf and his team surveyed 23 VHA sites on their use of brand-name filgrastim (Neupogen); tbo-filgrastim (Granix), a follow-on filgrastim that was approved prior to the establishment of the US’ biosimilar approval pathway; biosimilar filgrastim (Zarxio); and brand-name pegfilgrastim (Neulasta). The researchers also estimated costs for the use of G-CSFs based on 340B pricing. Biosimilar pegfilgrastim was not included in this analysis.

The most cost-effective strategy, they found, was to use only tbo-filgrastim, as such an approach would result in a cost of $62,336 per 100 patient episodes. Eighteen of the 23 surveyed sites used tbo-filgrastim as their preferred treatment, making the VHA 73% efficient and highly cost-effective. Costs for G-CSF use in each of the sites ranged from a minimum of $62,336 per 100 patient episodes in 4 sites to a maximum of $201,356 per 100 patient episodes at 2 sites, delivering a mean cost of $99,080. Most sites, the researchers reported, were able to avoid the use of the long-acting and higher-cost pegfilgrastim; only 27% of patients across the surveyed hospitals had received Neulasta.

Furthermore, the adoption of biosimilar and follow-on filgrastim in the VHA has been rapid, said the researchers. None of the sites surveyed were using the brand-name filgrastim for new patients, and 6 of the 23 sites indicated that they were comfortable with switching patients who had previously received the branded filgrastim to a cost-saving option. Despite the willingness of the VHA to adopt follow-on and biosimilar filgrastim, however, simply switching patients to tbo-filgrastim from the brand-name option provided only a small cost savings—just 2.2%—under 340B pricing. 

According to the authors, other approaches to reducing the cost of G-CSF therapy are likely to have a greater impact on the overall cost of care than a switch to biosimilars. Such approaches include avoiding the use of G-CSF therapies in cases in which there is no convincing evidence of their efficacy (for example, in patients who are classified as low-risk), and continuing to use short-acting agents instead of long-acting ones whenever possible. 

Furthermore, said Knopf in an interview with The Center for Biosimilars®, there is some limited evidence that it may be feasible to prevent neutropenia by using 2-day or 4-day courses of filgrastim rather than 8-day courses. He cited a nonrandomized trial conducted in the 1990s that found that, in patients with early breast cancer, the frequency of G-CSF administration could be shortened to just 2 administrations, on days 8 and 12, without altering the patients’ outcomes.2 

Knopf emphasized that further investigation will be necessary to demonstrate whether shorter treatment courses are indeed effective, such an approach could deliver an additional 50% to 75% cost savings. 

1. Knopf K, Hrureshky W, Love B, Norris L, Bennett CL. Cost-effective use of white blood cell growth factors in the Veterans Administration. Presented at the 60th Annual Meeting and Exposition of the American Society of Hematology; December 1-4, 2018; San Diego, California. Abstract 4761. ash.confex.com/ash/2018/webprogram/Paper119724.html.

2. Papaldo P, Lopez M, Marolla P, et al. Impact of five prophylactic filgrastim schedules on hematologic toxicity in early breast cancer patients treated with epirubicin and cyclophosphamide. J Clin Oncol. 2005;23:6908-6918. doi: 10.1200/JCO.2005.03.099.


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