Access to innovative drugs in patients with metastatic lung cancer in French public hospitals (The TERRITOIRE Study)

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1 Access to innovative drugs in patients with metastatic lung cancer in French public hospitals (The ) Presenting author: Pr. Isabelle Durand-Zaleski (URC- Eco, Paris, France) A. Scherpereel, J. Fernandes, F.-E. Cotté, C. Blein, D. Debieuvre, I. Durand-Zaleski, A.-F. Gaudin, N. Ozan, B. Saitta, P.J. Souquet, A. Vainchtock, V. Westeel, C. Chouaïd Study sponsored by BMS France

2 Background and Goals Disparities in access to healthcare for patients with cancer have been identified in many societies Challenges are particularly relevant in lung cancer, due to high incidence, frequently late diagnosis and the variety of available treatment protocols First findings from the TERRITOIRE study in France indicate differences in survival of patients according to geographical and sociodemographic factors 1 Many innovative drugs are too expensive to be funded in hospitals through a fixed Diagnosis-Related Group (DRG) tariff In France, such drugs (mostly used in oncology) are fully reimbursed up to national reimbursement tariffs (extra-drg funding) to ensure equity of access Hospitals sign up to a care standards charter committing them to use innovative drugs in agreement with practice guidelines OBJECTIVE: Evaluate the access of patients with lung cancer to high cost drugs in France as a function of geographical and sociodemographic factors 1 Chouaïd et al. WCLC, Denver, Sept. 8th 2015

3 Methods (1) Data retrieved from French national hospital database including data on all acute hospital stays, rehabilitation stays and hospitalisation at home Reasons for hospitalisation identified by diagnostic codes linked to ICD-10 disease classification (Principal diagnosis / Related diagnosis / Significant associated diagnosis) Lung cancer incidence population: All patients with ICD-10 code C34 in hospital records in 2011 with no C34 code in previous 5 years Metastatic status: ICD-10 code for metastatic disease (C77, C78 or C79) Information on surgery, medical procedures and chemotherapy retrieved for each hospital stay Extra-DRG drugs database (i.e. FICHCOMP) is available for public hospitals only Source population: All incident patients with a lung cancer in France in 2011 Retrospective cohort: Metastatic patients with chemotherapy treatment in public hospitals only Follow-up: Death or 2-year censored

4 Methods (2) Data retrieved from French national statistics office (INSEE) on townships of residence for all hospitalised lung cancer patients Rurality classified by population size of the township of residence Rural (<2000 inhabitants) Semi-rural ( inhabitants) Semi-urban (10,000-99,999 inhabitants) Urban ( 100,000 inhabitants) Social deprivation index 1 of township calculated based on Unemployment rate Median household income Percentage of high school graduates in adult population Percentage of blue-collar workers in active population Divided into four classes (most deprived, deprived, privileged, most privileged) 1 Rey et al. BMC Public Health 2009, 9:33

5 Use of extra-drg drugs 11,602 patients in public hospitals received chemotherapy patients (63,9%) received an extra-drg drug at least once during the follow-up Pemetrexed was the most frequent treatment used 100% 75% 50% 25% 0% 63,9% Patients with extra-drg drugs *Removed from the list of extra-drg drugs during the follow-up period

6 Patient characteristics Patients accessing extra-drg drugs (N = 7417) Patients not accessing extra-drg drugs (N = 4146) p Age (years; mean ± SD) 61.1 ± ± 10.6 < Gender (men, %) 5094 (69.4%) 3078 (74.2%) < Comorbidities Hypertension 1489 (20.3%) 1119 (27.0%) < Diabetes 624 (8.5%) 543 (13.1%) < Renal failure 109 (1.5%) 117 (2.8%) < Other lung disease 1220 (16.6%) 939 (22.6%) < Hospital type 0.03 University hospital (29.8%) (27.6%) Local hospital (49.3%) (50.3%) Other (20.9%) 925 (22.1%)

7 Regional variation in prescription rates

8 Sociodemographic indicators Patients accessing extra-drg drugs (N = 7340)* Patients not accessing extra-drg drugs (N = 4146) p Rurality Rural 2568 (35.0%) 1543 (37.2%) Semi-rural 1923 (26.2%) 1088 (26.2%) Semi-urban 1986 (27.1%) 1018 (24.6%) Urban 863 (11.8%) 497 (12.0%) Social deprivation index Most deprived 1872 (25.5%) 1159 (28.0%) Deprived 2057 (28.0%) 1192 (28.8%) Privileged 1567 (21.3%) 894 (21.6%) Most privileged 1844 (25.1%) 901 (21.7%) *Residence code was missing for 116 patients.

9 Sociodemographic indicators - multivariate analysis - Rurality Social deprivation Odds ratios [95% CI] adjusted for age, gender and comorbidities

10 Conclusions and Perspectives Medico-administrative databases provide pertinent information on regional and sociodemographic disparities in management of lung cancer in France Living in socially-deprived townships appears to be associated with poorer access to innovative drugs, suggestive of lack of social equity However, rural environments appears to be associated with a similar access to innovative drugs as urban ones, indicating territorial equity Our data suggest that there is less a problem with resource provision than with socially deprived patients gaining access to care Late diagnosis, low committment to therapy and a higher prevalence of confounding comorbidities may contribute to the lack of social equity Such barriers to equitable access to care need to be identified and addressed Other indices of the quality of care documented in the database remain to be explored (eg time from diagnosis to treatment)