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Effects of Removing Reimbursement Restrictions on Targeted Therapy Accessibility for Non-Small Cell Lung Cancer Treatment in Taiwan: an Interrupted Time Series Study

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Effects of Removing Reimbursement Restrictions on Targeted Therapy Accessibility for Non-Small Cell Lung Cancer Treatment in Taiwan: an Interrupted Time Series Study Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022293 on 15 March 2019. Downloaded from Effects of removing reimbursement restrictions on targeted therapy accessibility for non-small cell lung cancer treatment in Taiwan: an interrupted time series study Jason C Hsu, 1 Chen-Fang Wei,2 Szu-Chun Yang3 To cite: Hsu JC, Wei C-F, ABSTRACT Strengths and limitations of this study Yang S-C. Effects of removing Interventions Targeted therapies have been proven to reimbursement restrictions provide clinical benefits to patients with metastatic non-small ► Both prescription rate and speed (time to prescrip- on targeted therapy cell lung cancer (NSCLC). Gefitinib was initially approved and accessibility for non-small tion) were used to measure drug accessibility. reimbursed as a third-line therapy for patients with advanced cell lung cancer treatment ► An interrupted time-series design, a strong qua- NSCLC by the Taiwan National Health Insurance (NHI) in 2004; in Taiwan: an interrupted si-experimental method, was applied. subsequently it became a second-line therapy (in 2007) time series study. BMJ Open ► A segmented linear regression model was used to and further a first-line therapy (in 2011) for patients with 2019;9:e022293. doi:10.1136/ estimate postpolicy changes in both the level and epidermal growth factor receptor mutation-positive advanced bmjopen-2018-022293 trend of these study outcomes. NSCLC. Another targeted therapy, erlotinib, was initially ► Prepublication history for ► Data from the claims' database of the Taiwan approved as a third-line therapy in 2007, and it became a this paper is available online. National Health Insurance research Database second-line therapy in 2008. To view these files, please visit were analysed that did not cover data for payments Objectives This study is aimed towards an exploration the journal online (http:// dx. doi. made by the patients themselves. org/ 10. 1136/ bmjopen- 2018- of the impacts of the Taiwan NHI reimbursement policies 022293). (removing reimbursement restrictions) related to accessibility of targeted therapies. Received 21 February 2018 Setting We retrieved 2004–2013 claims data for all patients approximately 221 130 new cases of lung http://bmjopen.bmj.com/ Revised 3 December 2018 with lung cancer diagnoses from the NHI Research Database. cancer (14% of all cancer diagnoses) were Accepted 31 January 2019 Design and outcome measures Using an interrupted time predicted, out of which 156 940 deaths (27% series design and segmented regression, we estimated of cancer deaths) were estimated to have been changes in the monthly prescribing rate by patient number due to lung cancer.2 In Taiwan, lung cancer and market shares by cost following each modification of the is also one of the most commonly diagnosed reimbursement policy for gefitinib and erlotinib for NSCLC cancers as well as the leading cause of cancer treatment. © Author(s) (or their deaths. Approximately 11 692 new cases of Results Totally 92 220 patients with NSCLC were identified. employer(s)) 2019. Re-use lung cancer (12% of all cancer diagnoses) permitted under CC BY-NC. No The prescribing rate of the targeted therapies increased by on September 27, 2021 by guest. Protected copyright. commercial re-use. See rights and 8587 deaths (20% of cancer deaths) 15.58%, decreased by 10.98% and increased by 6.31% 3 and permissions. Published by following the introduction of gefitinib as a second-line were predicted to occur in Taiwan in 2012. BMJ. treatment in 2007, erlotinib as a second-line treatment About 85% of all lung cancers are identified 1 School of Pharmacy and in 2008 and gefitinib as as first line treatment in 2011, as non-small cell, and approximately 75% of Institute of Clinical Pharmacy respectively. The average time to prescription reduced by these are metastatic or advanced at diagnosis, and Pharmaceutical Sciences, 65.84% and 41.59% following coverage of erlotinib by 4–7 College of Medicine, National for which no curative treatment is available. insurance and gefitinib/erlotinib as second-line treatments in Cheng Kung University, Tainan Since 2004, oral targeted therapies for City, Taiwan 2007–2008 and following gefitinib as the first-line treatment non-small cell lung cancer (NSCLC) have 2Department of Pharmacy, in 2011. been launched in the market for patients with Conclusions The changes in reimbursement policies had a National Taiwan University epidermal growth factor receptor (EGFR) Hospital Hsin-Chu Branch, significant impact on the accessibility of targeted therapies mutation in Taiwan. Two targeted drugs, Hsinchu, Taiwan for NSCLC treatment. Removing reimbursement restrictions 3Department of Internal can significantly increase the level and the speed of drug gefitinib and erlotinib, were first approved as Medicine, National Cheng Kung accessibility. third-line therapy for patients with advanced University Hospital, Tainan, NSCLC by the Taiwan Food and Drug Admin- Taiwan istration, based on results of randomised 8–10 Correspondence to INTRODUCTIOn clinical trials. For patients with advanced Dr Jason C Hsu; Lung cancer is the leading cause of cancer NSCLC with mutation-positive EGFR, two jasonhsuharvard@ gmail. com deaths worldwide.1 In USA, in 2011, drugs were further suggested to be used as Hsu JC, et al. BMJ Open 2019;9:e022293. doi:10.1136/bmjopen-2018-022293 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022293 on 15 March 2019. Downloaded from first-line therapy by the recent National Comprehensive with 97% of hospitals and clinics throughout the country. Cancer Network guideline,11 as a result of the cumula- The NHI covers a wide range of prescription medicines tive evidence showing a significant association between as well as inpatient and outpatient medical services.23 mutated EGFR and because of their clinical benefits.8 12–14 NSCLC-related prescriptions were identified using the According to ‘Directions for Drug Restricted Bene- International Classification of Diseases, Ninth Revision fits for National Health Insurance’, gefitinib and erlo- diagnosis codes for cancer (codes: 162). Patients with tinib have been reimbursed for the treatment of lung small cell lung cancer and patients who had used etopo- cancer in Taiwan since 2004 and 2007, respectively. side and topotecan were not included in the study. When reimbursement for gefitinib by the health insur- ance began in November 2004, considering the potential Drugs of interest significant impact of its use on the healthcare drug expen- We used the Anatomical Therapeutic Chemical (ATC) diture budget, its use was limited only to patients with Classification System from WHO. We identified all anti- NSCLC who had previously used platinum and docetaxel neoplastic agents using the ATC code ‘L01'. Targeted or paclitaxel chemotherapy, but who still partially therapies included in the analysis were protein kinase progressed or metastasised (for the third-line treatment). inhibitors (gefitinib and erlotinib). New targeted thera- Later, clinical studies have confirmed that the efficacy pies (afatinib, crizotinib and ceritinib) were not included and safety of gefitinib are better than those for chemo- in this study because they were not reimbursable by NHI therapy drugs, and that clinical treatment guidelines are prior to 2013. recommended for second-line treatment. To improve the accessibility of drugs and early use of new drugs, in Measurements November 2007, the Taiwan National Health Insurance To examine the trends in the accessibility of targeted (NHI) began to pay for gefitinib as a second-line treat- therapies (gefitinib and erlotinib) following the changes ment for patients who had previously used first-line plat- in reimbursement policies, we calculated the monthly inum-containing chemotherapy, or patients 70 years of number of patients who used each targeted therapy and age or older who had received first-line chemotherapy the related costs from 2004 to 2013. Then, we estimated but were still partially exacerbated or metastatic.14 15 the proportion of their use by patient number and the Finally, because clinical studies have confirmed that the market share by cost among total patient numbers and efficacy of first-line therapy is better than that of posterior total costs of all antineoplastic agents. The prescribing therapy, gefitinib has been further allowed to be used as a rate of the targeted therapies by patient number was esti- first-line therapy for patients with EGFR mutation-positive mated by using the number of patients who had used the advanced NSCLC since June 2011.12 16 17 Similarly, erlo- targeted therapies divided by the number of patients who tinib's use was limited for a third-line treatment in the had used antineoplastic agents, and the market share begining (June 2007), and it has been further allowed of targeted therapies by cost was estimated by using the http://bmjopen.bmj.com/ to be used as a first-line therapy for patients with EGFR cost of the targeted therapies divided by the cost of anti- mutation-positive advanced NSCLC since June 2013.18–22 neoplastic agents. The cost was adjusted using the yearly Little is known about the impacts of changes in Consumer Price Index (CPI).24 targeted therapy-related reimbursement policies (related to removing reimbursement restrictions and broadening Statistical analysis the eligible patient population) in Taiwan. The aim of The interrupted time series design,25 a strong quasi-ex- our longitudinal analyses was to address this gap by exam- perimental method, was adopted to evaluate the overall ining the recent trends in utilisation of and expenditures changes in drug utilisation (prescribing rate and market on September 27, 2021 by guest. Protected copyright. for targeted therapies (gefitinib and erlotinib) following share of cost) before and after the four modifications to changes in the reimbursement policy, which involve the the drug reimbursement policy: (1) Erlotinib was covered accessibility and economic burden of drugs. Further- by NHI in June 2007. (2) Gefitinib became available as a more, we also evaluated the changes in time to prescrip- second-line treatment in November 2007.
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