In the Literature - July 2016

VBCN - July 2016 Volume 3, No 2

In This Article

Multiple Sclerosis Tops Neurology Drug Costs in Medicare Payments

Medicare spent $103 billion alone on prescription drugs in 2013. Despite a relatively small number of providers, neurologists account for one of the highest total prescription and per-claim costs. A new retrospective, cross-sectional analysis of the 2013 Medicare Part D payments focused on the cost of drugs prescribed by neurologists in recent years (De Lott LB, et al. Neurology. 2016;86:1491-1498).

Of the 1,049,381 unique providers or facilities recorded by Medicare in 2013, 13,060 (1.2%) were neurologists, representing 99.3% of all active practicing neurologists. A total of $5 billion (4.8%) of the $103.6 billion in Medicare Part D drug payments in 2013 were in neurologist-prescribed drugs—the third highest of all specialties; the majority (75.7%) of drug claims were for generic medications. The median payment per neurologist claim was $176 and the median monthly payment was $141—the fifth highest among specialties.

Multiple sclerosis (MS) drugs had the highest total payments for drugs prescribed by neurologists, accounting for $1.8 billion, representing 44.1% of total payments for drugs prescribed by neurologists. At the time, no MS drugs were available as generics, and monthly payments for the medications available in 2013 ranged from $4149 monthly for teriflunomide (Aubagio) to $5072 monthly for fingolimod (Gilenya). Antiepileptic drugs were the second highest category of drug payments by neurologists, accounting for $499 million, 33.6% of which was from generics. The next highest categories were dementia medications ($389 million), Parkinson's disease medications ($332 million), and neuropathic pain medications ($215 million).

If all brand-name neurologist-prescribed medications were substituted with generics, the total payments for neurology drugs would decrease by $269 million (6.5%). If Medicare prices were the same as Veterans Affairs (VA) pricing for specific diseases, the total payments would result in $1.5 billion in savings. For example, for MS drugs, VA drug pricing would reduce payments by $724 million if prescribed by neurologists.

“MS drugs in the United States are extremely expensive, prices vary little, and costs have risen although more medications have entered the market,” the researchers noted, adding that unlike other countries and the VA system, Medicare is prohibited from directly negotiating drug prices.

They made several suggestions on how to lower drug expenditures. One option is allowing Medicare to negotiate drug prices directly with pharmaceutical companies, although this is controversial. Another option is limiting the use of brand-name drugs through federal policies that permit direct substitution of generic drugs.

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Considering a Patient's Immune Status May Improve Treatment Outcomes in Glioblastoma

Glioblastoma is the most common and aggressive form of brain cancer, with a poor prognosis. Considering the poor outcome after standard treatment, immunotherapy as an additional approach is under investigation. Several immune-related parameters have also been reported for predicting patient prognosis, underscoring the importance of distinct immune status in determining glioma outcome. Despite growing interest in immunotherapies, few studies have systematically investigated the immune microenvironment in glioma. A new study now investigated the value of the patient's immune status on prognosis in glioblastoma (Cheng W, et al. Neurology. 2016;86:2226-2234).

Using messenger RNA microarray from the Chinese Glioma Genome Atlas database, the researchers obtained whole genome expression data from 297 patients with brain cancer. The researchers profiled the immune- related phenotype according to histologic grade and classification. A histologic diagnosis defined 170 of the tumors as lower-grade glioma (grade II or III) and 127 as glioblastoma. Of the 322 immune-related genes analyzed, 8 genes were shown to play a role in glioblastoma.

Patients with glioblastoma were classified as high- or low-risk profiles based on the 8-genes signature. The overall survival after diagnosis was significantly shorter in high-risk patients (348 days) compared with low-risk patients (493 days).

Similarly, the median progression-­free survival was significantly reduced in high-risk patients compared with low-risk patients (242 days vs 369 days, respectively; P <.005). The findings were validated externally with an independent cohort of 536 patients with glioblastoma from the Cancer Genome Atlas database.

This local immune signature in glioblastoma may help to expedite the development of immunotherapy for patients with this deadly form of brain cancer.

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AAN Updates Its Quality Measures for Parkinson's Disease to Improve Patient Care

Parkinson's disease is one of the most common neurologic disorders involving motor and nonmotor features that are often underdiagnosed and have limited treatment options.

The American Academy of Neurology (AAN) has created quality measurements to address the gaps in care for patients with Parkinson's disease. In 2014, the AAN formed a multidisciplinary work group to update the 2010 measurements to help facilitate better care for patients with this disease. The AAN recently published an executive summary that details the updated quality measurements (Factor SA, et al. Neurology. 2016;86:2278-2283).

“The new quality measure set was developed to promote quality improvement, drive improved outcomes for patients with PD [Parkinson's disease], and assist in establishing threshold performance rates, and through continued data gathering to drive quality improvement,” stated the researchers.

The updated quality measurement set includes 11 measures, 7 of which were maintained or revised from the original set and 4 new quality measures. These 11 measures include:

  • Annual diagnosis review
  • Avoiding dopamine-blocking medications
  • Assessing for psychiatric symptoms
  • Assessing for cognitive impairment or dysfunction
  • Assessing for symptoms of autonomic dysfunction
  • Checking for sleep disturbances
  • Recording falls outcomes
  • Discussing with patients rehabilitation options
  • Counseling patients about regular exercise
  • Asking about medication-related motor complications
  • Discussing advance care planning.

Data have shown that exercise has many important health benefits that should be recommended to all patients with Parkinson's disease. As for avoiding dopamine-blocking agents, the group said it was an important measure in ambulatory and hospital practice settings. The prescribing of dopamine-blocking agents is a common medical error that can result in worsening of motor symptoms in patients with Parkinson's disease and lead to further disability and falls. The group noted ­2 exceptions—quetiapine and cloza­pine—but these 2 drugs should also be used with caution.

The group changed the fall measure from a process to an outcome measure. The group recommends that when any fall occurs, patients should be referred for multidisciplinary gait assessment and should be counseled about the importance of exercise for preventing falls.

Finally, advance care directives was added to help ensure that a patient's treatment preferences and treatment goals are being considered. The work group recommends that all patients with Parkinson's disease have an advance care directive completed or have a designated power of attorney for medical decisions in the last 12 months of life.

These updated quality measures provide opportunities for improved care and treatment for patients with Parkinson's disease. AAN will continue to update the measures every 3 years.

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