The Effects of Adverse Events and Associated Costs on Value-Based Care for Metastatic Pancreatic Ductal Adenocarcinoma

<b>Background:</b> Rising oncology healthcare costs have led to value-based care reimbursement models that coordinate care and improve quality while reducing overall spending. These models are increasingly important for traditional Medicare and other payers. <b>Objectives:</b> To compare the incidence of adverse events (AEs), AE-associated excess costs, and total cost of care (TCOC) of 3 cohorts receiving first-line treatment for metastatic pancreatic ductal adenocarcinoma (mPDAC). <b>Methods:</b> We conducted a retrospective analysis of administrative claims data from 2018 to 2022 using the Medicare 100% Research Identifiable Files. We examined 3 cohorts receiving mPDAC treatment: FOLFIRINOX (FFX) (oxaliplatin, irinotecan, leucovorin, 5-FU bolus and infusion); modified FFX, (5-FU infusion only); and gemcitabine/nab-paclitaxel (gem/abrax). We compared the incidence of clinically significant AEs, TCOC, components of TCOC, and costs related to AEs/treatment toxicity. <b>Results:</b> Patient AE rates ranged from 6.2% to 51.7%. AEs occurred more frequently in patients receiving FFX with all 4 components. Patients receiving brand name gem/abrax had lower rates of febrile neutropenia (6.2%) and neutropenia (22.2%) than those receiving FFX with no 5-FU bolus (febrile neutropenia, 9.9%; neutropenia, 36.9%) and FFX with all 4 components (febrile neutropenia, 6.9%; neutropenia, 30.4%). Rates of most nonhematologic AEs were higher in patients receiving FFX with all 4 components, with diarrhea occurring in 28.3%, abdominal pain in 31.5%, and nausea/vomiting in 41.5% of patients. TCOC was lower in the gem/abrax cohort: <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:mn>6505</mml:mn> <mml:mi>v</mml:mi> <mml:mi>s</mml:mi> <mml:mi>F</mml:mi> <mml:mi>F</mml:mi> <mml:mi>X</mml:mi> <mml:mi>w</mml:mi> <mml:mi>i</mml:mi> <mml:mi>t</mml:mi> <mml:mi>h</mml:mi> <mml:mi>n</mml:mi> <mml:mi>o</mml:mi> <mml:mn>5</mml:mn> <mml:mo>-</mml:mo> <mml:mi>F</mml:mi> <mml:mi>U</mml:mi> <mml:mi>b</mml:mi> <mml:mi>o</mml:mi> <mml:mi>l</mml:mi> <mml:mi>u</mml:mi> <mml:mi>s</mml:mi> <mml:mo>(</mml:mo></mml:math> 6995) and FFX with all 4 components ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:mn>7142</mml:mn> <mml:mo>)</mml:mo> <mml:mi>p</mml:mi> <mml:mi>e</mml:mi> <mml:mi>r</mml:mi> <mml:mi>a</mml:mi> <mml:mi>d</mml:mi> <mml:mi>m</mml:mi> <mml:mi>i</mml:mi> <mml:mi>n</mml:mi> <mml:mi>i</mml:mi> <mml:mi>s</mml:mi> <mml:mi>t</mml:mi> <mml:mi>r</mml:mi> <mml:mi>a</mml:mi> <mml:mi>t</mml:mi> <mml:mi>i</mml:mi> <mml:mi>o</mml:mi> <mml:mi>n</mml:mi> <mml:mo>.</mml:mo> <mml:mi>T</mml:mi> <mml:mi>h</mml:mi> <mml:mi>e</mml:mi> <mml:mi>d</mml:mi> <mml:mi>e</mml:mi> <mml:mi>v</mml:mi> <mml:mi>e</mml:mi> <mml:mi>l</mml:mi> <mml:mi>o</mml:mi> <mml:mi>p</mml:mi> <mml:mi>m</mml:mi> <mml:mi>e</mml:mi> <mml:mi>n</mml:mi> <mml:mi>t</mml:mi> <mml:mi>o</mml:mi> <mml:mi>f</mml:mi> <mml:mi>a</mml:mi> <mml:mi>n</mml:mi> <mml:mi>y</mml:mi> <mml:mi>s</mml:mi> <mml:mi>t</mml:mi> <mml:mi>u</mml:mi> <mml:mi>d</mml:mi> <mml:mi>i</mml:mi> <mml:mi>e</mml:mi> <mml:mi>d</mml:mi> <mml:mi>h</mml:mi> <mml:mi>e</mml:mi> <mml:mi>m</mml:mi> <mml:mi>a</mml:mi> <mml:mi>t</mml:mi> <mml:mi>o</mml:mi> <mml:mi>l</mml:mi> <mml:mi>o</mml:mi> <mml:mi>g</mml:mi> <mml:mi>i</mml:mi> <mml:mi>c</mml:mi> <mml:mi>A</mml:mi> <mml:mi>E</mml:mi> <mml:mi>w</mml:mi> <mml:mi>a</mml:mi> <mml:mi>s</mml:mi> <mml:mi>a</mml:mi> <mml:mi>s</mml:mi> <mml:mi>s</mml:mi> <mml:mi>o</mml:mi> <mml:mi>c</mml:mi> <mml:mi>i</mml:mi> <mml:mi>a</mml:mi> <mml:mi>t</mml:mi> <mml:mi>e</mml:mi> <mml:mi>d</mml:mi> <mml:mi>w</mml:mi> <mml:mi>i</mml:mi> <mml:mi>t</mml:mi> <mml:mi>h</mml:mi> <mml:mi>a</mml:mi> <mml:mi>m</mml:mi> <mml:mi>e</mml:mi> <mml:mi>a</mml:mi> <mml:mi>n</mml:mi> <mml:mi>e</mml:mi> <mml:mi>x</mml:mi> <mml:mi>c</mml:mi> <mml:mi>e</mml:mi> <mml:mi>s</mml:mi> <mml:mi>s</mml:mi> <mml:mi>c</mml:mi> <mml:mi>o</mml:mi> <mml:mi>s</mml:mi> <mml:mi>t</mml:mi> <mml:mi>o</mml:mi> <mml:mi>f</mml:mi></mml:math> 5993 per administration, while the development of any studied nonhematological AE was associated with a mean per-administration excess cost of $3665. <b>Discussion:</b> Treatment decisions intended to minimize chemotherapy costs may lead to suboptimal decisions if the goal is to reduce TCOC. Our research suggests FFX is more costly than gem/abrax (TCOC per administration). Patients receiving gem/abrax were older and had higher baseline Charlson Comorbidity Index scores; however, other factors may be important in driving cost differences. <b>Conclusions:</b> Irrespective of drug cost, chemotherapy leading to a significant increase in AEs is associated with higher TCOC.