Financial Incentives May Lead to Overuse of Rituximab Maintenance

On Saturday, December 9, at the American Society of Hematology’s 59th Annual Meeting and Exposition in Atlanta, Georgia, Scott Huntington, MD, MPH, will present his research team’s findings that the receipt of lymphoma care in the community-based setting is associated with guideline-discordant use of rituximab.¹

Maintenance rituximab monotherapy has been shown to improve progression-free survival in some lymphoma settings, but current guidelines support only 2 years of rituximab maintenance. Data from studies in other disease states suggest that financial incentives may influence the use of infused therapies in US patients, and Huntington and colleagues sought to determine whether community providers (who may have financial incentives to provide rituximab beyond guideline-based time periods) were more likely than hospital-employed providers to prescribe extended maintenance rituximab.

Using the SEER-Medicare database, the researchers identified older adults who were diagnosed with B-cell non-Hodgkin lymphoma between 2004 and 2011 and who had at least 1 claim for rituximab through 2013. Patients were included in the study if they had more than 7 months of claims for rituximab without a 200-day gap between claims.

The number of rituximab monotherapy claims and the duration of maintenance therapy were calculated for each patient until the receipt of chemotherapy, a 200-day gap in rituximab claims, or death, and the site of rituximab administration was classified as community or hospital-outpatient (as identified on Medicare claims). A logistic regression model was employed to assess the association between care setting and the prolonged use of rituximab monotherapy.

Overall, 2620 patients with 2 years of available follow-up after initiation of rituximab maintenance were identified; 75.1% received their rituximab therapy in a community setting. The median number of rituximab maintenance doses received was 9 (range, 1-103), and the median duration of maintenance was 14 months (range, 0-92), with 261 (10.0%) of patients receiving uninterrupted rituximab maintenance for more than 2 years.

Patients in the community setting were more likely to receive rituximab maintenance for longer than the guideline-recommended period; 11% of patients in the community setting versus 6.9% of patients in the hospital setting received more than 2 years of rituximab maintenance. Furthermore, treatment in a community setting was significantly associated with a patient’s receipt of more than 2 years of maintenance (adjusted odds ration [OR], 1.56; 95% CI, 1.10-2.20; P = .012) as well as with receipt of more than 12 doses of rituximab as monotherapy (adjusted OR = 2.01, 95% CI, 1.63-2.48; P < .001).

The authors concluded that receipt of lymphoma care in the community setting is associated with guideline-discordant use of rituximab, and that financial incentives for using anti-cancer therapies in this setting may contribute to the overuse of rituximab.

“Providers practicing in the physician-office setting are more likely to derive income directly from chemotherapy administration compared to hospital-employed physicians,” Huntington told The Center for Biosimilars® over email. “Prior research suggests physicians in community settings are more responsive to reimbursement changes in their choice of chemotherapy regimens compared to hospital-employed providers.”

While it is not known whether changes to reimbursement translate into treatment that is discordant with guidelines, Huntington said that “Financial incentives likely contribute to overutilization during rituximab maintenance, and future studies should consider treatment setting when evaluating cancer-therapy utilization. Our findings support ongoing efforts to minimize financial incentives tied to chemotherapy administration to better align payment with high quality care.”

Reference

1. Huntington S, Hoag J, Zhu W, Gross CP, Davidoff, AJ. Financial incentives and rituximab maintenance: association of treatment with prolonged maintenance in non-Hodgkin lymphoma patients treated in the United States. Presented at the American Society of Hematology 59th Annual Meeting and Exposition, December 9, 2017; Atlanta, Georgia. Abstract 2120. https://ash.confex.com/ash/2017/webprogram/Paper103349.html