CAR T-Cell Therapy Leads to Shorter Hospital Stays, Lower Nonpharmacy Costs Despite High Overall Cost

Chendi Cui, PhD

CAR T-cell therapies have transformed the treatment landscape of multiple hematologic malignancies since they first rose to prominence, but they are associated with a high financial cost, both for the patient and the health care institution that provides them. Although the total and pharmacy cost to hospitals for the index procedure were higher when patients received CAR T-cell therapy than when they underwent stem cell transplant (SCT), nonpharmacy costs were lower, according to findings from a retrospective study published in Blood.¹

Findings from the real-world evidence study showed that the total mean cost in USD of the index procedure was $371,136 for CAR T-cell therapy, $96,515 for autologous SCT, and $169,269 for allogenic SCT. However, the mean index nonpharmacy cost for CAR T-cell therapy ($41,375) was lower than for allogenic SCT ($51,778) and autologous SCT ($111,594) therapies. The median nonpharmacy costs were $33,535 (IQR, $18,767$52,090; P < .0001), $46,402 (IQR, $33,094-$64,422), and $80,108 (IQR, $50,575-$127,054), respectively.

The mean pharmacy cost for patients who received CAR T-cell therapy was $330,070 vs $44,770 and $57,701 for autologous and allogeneic SCT, respectively. The median pharmacy costs were $357,170, $35,518, and $32,209, respectively.

“We did a comprehensive evaluation of the actual, real-cost nature associated with 3 procedures,” Chendi Cui, PhD, study coauthor and senior research scientist at PINC AI Applied Sciences in Charlotte, North Carolina, said in an interview with OncologyLive®. “Our study found that CAR T-cell therapy had higher pharmacy costs during the index procedure compared with both autologous and allogenic SCT procedures. This is not surprising because we know the CAR T-cell therapy has a high upfront cost. However, we found it interesting that CAR T-cell therapy also had a lower nonpharmacy cost and [a lower] health care resource utilization during the index procedure.”

To conduct their study, investigators examined treatments received by adults with large B-cell lymphoma (LBCL) in the PINC AI Database— who had either an inpatient or outpatient visit for CAR T-cell infusion or SCT transfusion—between January 1, 2017, and April 30, 2021. Excluded from the study were those patients who had undergone at least 2 CAR T-cell therapies and/ or SCTs and/or were treated at a hospital that did not have continuous data for the patients during the 365-day preprocedure period and 180-day follow-up period.

Index events were defined as the inpatient or outpatient infusion visits. Calculated values are conveyed in 2021 USD. No significant difference in size or teaching status of the treating hospitals was reported between the CAR T-cell therapy and SCT cohorts.

A total of 852 patients from 37 US hospital systems were included in the analysis. Most patients were treated at large facilities (71.4%), which were primarily hospitals (93.4%) and considered teaching facilities (84.5%). CAR T-cell therapy was given to 208 patients, 595 received autologous SCT, and 49 allogenic SCT. The mean age in each group was 60 years. Most patients were men (61.4% vs 66.3% vs 59.2%) and White (76.8% vs 74.5% vs 77.3%).

Moreover, in the CAR T-cell therapy arm, patients had Medicare (37.0%), Medicaid (13.9%), private insurance (38.5%), were uninsured (0.5%), or had another/unknown primary payor (10.1%). In the autologous SCT arm, rates of insurance coverage were 37.3%, 10.9%, 44.0%, 0.0%, and 7.7%, respectively. Among patients who received allogenic SCT, the rates were 20.4%, 10.2%, 65.3%, 0.0%, and 4.1%, respectively.

Comorbidities among patients that received CAR T-cell therapy included congestive heart failure (5.8%), chronic pulmonary disease (9.2%), diabetes (17.6%), and renal disease (6.6%). These comorbidities were present in patients in the autologous SCT cohort at a rate of 5.0%, 9.2%, 19.5%, and 6.7%, respectively. In the allogenic SCT cohort, they were reported in 10.2%, 8.2%, 8.2%, and 6.1% of patients, respectively.

Thirty-four patients in the CAR T-cell arm had an intensive care unit (ICU) stay compared with 167 patients and 13 patients in the autologous SCT and allogenic SCT arms, respectively. Most patients in each arm were inpatients (89.9% vs 94.8% vs 91.8%).

Other findings from the study showed that patients who received CAR T-cell therapy were in the ICU for a shorter length of stay (LOS) and incurred lower costs compared with patients treated with autologous SCT or allogenic SCT. The mean LOS was 7 days in the CAR T-cell therapy group vs 17 and 24 days in the autologous SCT and allogenic SCT groups, respectively. The mean cost among patients with an ICU stay was $86,755, $86,947, and $191,980, respectively. The median values for LOS and cost in the CAR T-cell arm were also lower compared with both SCT arms.

The mean LOS among those who underwent inpatient procedures was also lower in the CAR T-cell therapy group compared with the autologous SCT and allogenic SCT arms, at 18 days vs 21 days vs 28 days, respectively.

“[Patients treated with] CAR T-cell therapy had a lower ICU admission rate and a shorter LOS,” Cui said. “In addition, the study revealed a shorter preparatory time and a lower preparatory cost for patients receiving CAR T-cell therapy compared with SCT.” According to study coauthor Ning Rosenthal, MD, PhD, MPH, “the CAR T group had a lower overall cost than the allogenic SCT group.” Rosenthal, who is also principal, Applied Research, and project leader at PINC AI Applied Sciences, told OncologyLive that “although the treatment itself is a little bit more expensive, the cost is offset by the savings, and other aspects of doing the preparatory phase, and also index hospitalization, and it’s also important for the patient to be in the ICU for a shorter time.”

Rosenthal added that the findings could be limited by a significant portion of the results’ being pulled from community-based hospitals. Additionally, she said that follow-up times and treatments at facilities outside of the patient’s primary hospital were not taken into consideration, thus the overall cost could be an underestimation. However, it can safely be assumed that these added costs were substantially different among groups. It was also notable that the study drew data only from hospitals in the PINC AI Database, which consists of approximately 1100 hospitals, somewhat limiting its results.

“There are definitely limitations, like any study using realworld data,” she said. “Because it is from a hospital discharge database, the data were not collected for just doing research. We’d like some clinical details that we would like to know, including disease severity. We have indexes, but [those] may not capture all the clinical details.”

The investigators also highlighted that this was the first study of its kind to examine actuarial cost and health care resource utilization from the hospital system’s perspective using the most recent real-world use of CAR T and SCT. As more cases of CAR T-cell therapy treatment accumulate, an updated analysis in with a larger sample size may be performed in the future, Rosenthal said. Pulling the data into a population health project in which the information could be leveraged to make treatment decisions is a possibility.

“Historically, a lot of companies have looked towards community-based oncology datasets to [conduct] analyses,” Myla Maloney, MBA, BCMAS, chief commercial officer at PINC AI Applied Sciences said in an interview with OncologyLive. “There is a trend to look more toward data [such as] ours, that [is drawn from] health systems and hospitals, especially in CAR T, because [the therapy] is not done in the community setting, it’s done in a hospital or health system. These become critical data to consider where there’s going to be a gap in that patient’s [treatment]—you might see them before, you might see them after—but there’s this whole portion of treatment that’s missed without considering different datasets than what have traditionally been considered in oncology.”