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. 2020 Nov 5;13(2):103–112. doi: 10.2217/imt-2020-0152

Immune checkpoint inhibitor use, multimorbidity and healthcare expenditures among older adults with late-stage melanoma

Pragya Rai 1,*, Chan Shen 2, Joanna Kolodney 3, Kimberly M Kelly 1, Virginia G Scott 1, Usha Sambamoorthi 1
PMCID: PMC8008205  PMID: 33148082

Abstract

Background:

The objective of this study is to assess the impact of immune checkpoint inhibitors (ICIs) and multimorbidity on healthcare expenditures among older patients with late-stage melanoma.

Materials & methods:

A retrospective longitudinal cohort study using Surveillance, Epidemiology and End Results linked with Medicare claims was conducted. Generalized linear mixed models were used to analyze adjusted relationships of ICI, multimorbidity and ICI–multimorbidity interaction on average healthcare expenditures.

Results:

Patients who received ICI and those who had multimorbidity had significantly higher average total healthcare expenditures compared with ICI nonusers and no multimorbidity. In the fully adjusted model using ICI–multimorbidity interaction, no excess cost was added by multimorbidity.

Conclusion:

Use of ICIs, regardless of multimorbidity, is associated with increased healthcare expenditures.

Keywords: : healthcare expenditures, immune checkpoint inhibitors, ipilimumab, medicare beneficiaries, melanoma, metastatic melanoma, multimorbidity, nivolumab, older patients, pembrolizumab

Cancer exerts a substantial burden on the morbidity and mortality of patients [1,2]. In addition, cancer exerts a significant economic burden on not only the patients, but also on payers and society as well [3]. Cancer is one of the top five most expensive chronic conditions [3]. There is robust evidence showing that cancer substantially increases healthcare expenditures [4–7]. For example, it has been reported that adults with cancer have four-times higher expenditures compared with those without cancer [7,8]. Furthermore, the healthcare cost of cancer differs by the type and stage of cancer. Healthcare costs were highest for cancers with poor survival rates such as brain cancers and lowest for cancers with higher survival rates, such as melanoma [8]. However, the cost increases substantially when the cancer metastasizes [3,8,9]. For example, 55% of the annual direct costs for treating melanoma were related to treating late-stage melanoma [10].

While many factors can influence healthcare costs among cancer patients, expensive drugs approved for cancer, the administration of these drugs and supportive care (monitoring, surveillance, and management of side effects and hospitalizations) are some of the main factors [11]. For example, in metastatic melanoma patients initiated on an immune therapy agent ipilimumab, the average all-cause healthcare expenditures for a treatment episode was estimated to be $153,062 [12]. The immune checkpoint inhibitors (ICIs) were first approved for the treatment of late-stage melanoma nine years ago after their success in improving survival was established by randomized clinical trials [13]. However, the high cost of ICIs may hinder their widespread adoption in real-world clinical settings. The average wholesale price in 2015 of a single dose for a 70 kg patient was $5732 for nivolumab, $33,162 for ipilimumab and $35,073 for the combination therapy [14]. As these drugs need to be administered by healthcare professionals in outpatient settings, the total costs are even higher [15]. This is compounded by the fact that an optimum dose for ICIs remains unknown which entails continuous use of ICI until regression of the disease or appearance of adverse events [16–18]. Oncologists estimated that treatment cost for the highest and most often administered dose, 26 courses of an ICI, can be as high as $1,009,944 with a 20% copay [19].

Thus, a vast majority of patients cannot afford ICI treatment unless covered by health insurance [20–23]. In the US, insurance and type of insurance coverage are often associated with prognosis, treatment and survival of cancer patients. Specifically, using the National Cancer Database, Jain and coauthors (2020) reported that the stage of diagnosis and receipt of ICIs were associated with insurance status [24]. A high proportion of individuals with late-stage melanoma were enrolled in Medicare and were as likely as those with commercial insurance to receive ICI [21,25]. These findings suggest that Medicare may bear a disproportionate share of late-stage melanoma expenditures. Furthermore, older Medicare beneficiaries (age >65 years) are of particular interest for several reasons; 96% are covered by Medicare; higher incidence of cancer/late-stage melanoma is observed among these patients and Medicare patients are facing an evolving payment landscape, such as Oncology Care Model (OCM), aimed toward improving cancer care continuum while reducing costs in older patients [26–29].

The newer payment models also include patients in high-risk groups, such as those with multimorbidity [29]. This is because 68% of the Medicare population reported having multimorbidity and resulted in 80% of Medicare payments [30–33]. Similarly, an overwhelming majority (85%) of Medicare enrollees with late-stage melanoma were found to have multimorbidity [34]. Expert and systematic reviews have concluded that patients with multimorbidity have higher costs compared with those without multimorbidity [35,36]. Patients with multimorbidity and cancer have higher expenditures compared with those without any multimorbidity [37,38]. Furthermore, multimorbidity is highly prevalent in older adults with late-stage melanoma [34]. If ICI are added to this mix, patients with multimorbidity and ICI may have even higher costs than those without either. Therefore, the objectives of this study are: to estimate the impact of ICI use and to assess the impact of the interaction of ICI and multimorbidity on healthcare expenditures among older patients with late-stage melanoma. We hypothesize that ICI use will be associated with high expenditures throughout the treatment period compared with those without ICI use, and those with multimorbidity and ICI will have even higher costs than those without either.

Materials & methods

Study design

A retrospective observational longitudinal cohort design with a 12-month baseline (pre-index) and a 12-month follow-up (post-index) period was used; incident diagnosis of late-stage (stage III/IV) melanoma diagnosis was defined as the index date. Independent variables were assessed in the baseline period while treatments (chemotherapy, radiation and ICI) received were assessed in the follow-up period. Healthcare expenditures were measured every 120 days (t1, t2, t3, t4, t5 and t6) during the 24-month observation period to ensure robust findings by reducing the ‘signal-to-noise’ ratio (Figure 1) [39].

Figure 1. . Schematic of the study design.

Figure 1. 

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Each individual was observed for 24 months with a 12-month pre-index and 12-month post-index period. Healthcare expenditures and selected independent variables were measured repeatedly every 120 days during the pre-index (t1, t2 and t3) and post-index (t4, t5 and t6) periods, yielding a total of six repeated measures for every individual.

Data sources

Surveillance, Epidemiology and End Results (SEER) cancer registry linked with fee-for-service Medicare claims was used as the data source. Information on clinical variables related to cancer (such as stage of cancer at diagnosis) was obtained from the SEER data. Information on healthcare encounters of beneficiaries when enrolled and using Medicare covered health services including Medicare payments, and provider settings was obtained from Medicare claims.

Study population

The study population comprised older (>65 years) adults diagnosed with incident melanoma between 2012 and 2015, identified using International Classification of Diseases-O-3 site codes (C44.0–C44.9) and ICI-O-3 histology codes (8720–8790). Late-stage (stage III/IV) of melanoma was identified based on the TNM classification using American Joint Committee on Cancer 7th Edition. After excluding patients with local or regional (stage I/II) melanoma, non-incident melanoma, ages 66 years and below, not continuously enrolled in fee-for-service Medicare part A and part B during the observation period, and diagnosed with late-stage cancer during autopsy, the final cohort consisted of 4519 patients.

Measures

Dependent variable: total & type of healthcare expenditures

Total healthcare expenditures consisted of the sum of Medicare payments for inpatient, outpatient services (including carrier claims) for any care, home healthcare and durable medical equipment. We also analyzed type of healthcare expenditures by site of care (inpatient and outpatient, and home healthcare). All healthcare expenditures were adjusted by the Consumer Price Index for medical services [40] and expressed in 2016 USD.

Independent variables

The use of ICI (yes/no) was identified in the postdiagnosis period. The three ICIs approved for late-stage melanoma treatment, ipilimumab, nivolumab and pembrolizumab, were identified using healthcare common procedure coding system codes (J9228, J9299, J9271). Overlapping procedure codes for chemotherapy and ICI (96413, 96415) were excluded to ensure that chemotherapy was not misclassified as ICI.

Multimorbidity (yes/no) was defined as the presence of two or more chronic conditions in in this study. These conditions were obtained from a list of 18 chronic conditions developed by Multiple Chronic Conditions working group within the US Department of Health and Human Services Office of Assistant Secretary of Health [41]. Pre-existing autoimmune diseases were added to the list based on the current challenges with ICI use in patients with these conditions [42]. All the chronic conditions were identified with International Classification of Diseases, 9th Edition.

To examine the effects of ICI–multimorbidity interaction on cost, an ICI–multimorbidity interaction term was created, which was categorized into four groups: ICI and multimorbidity, ICI and no multimorbidity, no ICI and multimorbidity, and no ICI and no multimorbidity.

Other independent variables included biological factors, social factors, community resources, economic status and year of diagnosis. Biological factors consisted of age (66–69 years, 70–74 years, 75–79 years and ≥80 years), sex (male/female) and race (white/non-white). Social factors included marital status (married/not married). Oncologist visits (yes/no) and primary care physician visits (yes/no) were measured every 120 days. Dual Medicare/Medicaid enrollment (yes/no) was used as a proxy for low economic status. To control for changes in practice patterns, years of incident melanoma diagnosis (2012–2015) was used.

Statistical analyses

Unadjusted subgroup differences in time-invariant characteristics between ICI users were tested with chi-square statistics. The associations of ICI and multimorbidity to healthcare expenditures were tested within the framework of Generalized Linear Models (GLM) with gamma distribution and log-link. This specification was chosen for GLM because of several reasons: GLM does not require normal distribution of errors; better aligns the variance function to the mean function; and does not require smearing correction, which can be easily converted to original dollars [43]. Modified Park test confirmed the choice of gamma distribution with log-link was selected. Each individual had six observations, three 120-day periods pre-index and three 120-day periods post-index. Generalized linear mixed models (GLMMs) with gamma distribution and log-link was used to analyze adjusted relationships between ICI and non-ICI user groups and ICI–multimorbidity interaction. The GLMMs included all independent variables and time. Both unadjusted and adjusted models used GLMMs. Adjusted GLMMs included a time squared as one of the independent variables, to control for the nonlinear relationship of healthcare expenditures over time. All analyses were conducted on STATA (StataCorp 2015).

Results

The study population comprised predominantly of males (64.2%), non-Hispanic Whites (96.1%) and those 70 years or older (70.4%). Most older patients with late-stage melanoma had multimorbidity (85%) and 6% received ICI. The mean time from index date to ICI initiation was 48 days. The characteristics of the study population are presented in Appendix 1.

Overall healthcare expenditures

The average total, outpatient, home health and inpatient healthcare expenditures in the pre-index period (t1, t2 and t3) were significantly (p < 0.001) lower than the expenditures in the post-index period (t4, t5 and t6) (Figure 2). All healthcare expenditures in the 120-day post-late-stage melanoma diagnosis period (t4) were significantly higher compared with other pre- and post-index time periods (t1, t2, t3, t5 and t6).

Figure 2. . Mean total and type of healthcare expenditures.

Figure 2. 

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(A) Mean total and type of healthcare expenditures over time. (B) Mean total healthcare expenditures by ICI user status. Based on six repeated observation of 4519 older adults with incident late-stage (stage III/IV) melanoma continuously enrolled in Medicare Parts A and B fee-for-service programs 12-months prior to incident cancer diagnosis.

HHA: Home healthcare; ICI: Immune checkpoint inhibitors; USD: United States Dollars.

Healthcare expenditures among ICI users & non-users

The average total, outpatient, home healthcare and inpatient healthcare expenditures were significantly higher among ICI users compared with non-ICI users. Among ICI users, the average total and inpatient expenditures were significantly higher in t4 (representing 120 days after cancer diagnosis) compared with other time periods (t1, t2, t3, t5 and t6) while average outpatient and home healthcare expenditures did not differ significantly in t4 and t5 and t4 and t6 time periods, respectively. Among non-ICI users, average total, outpatient, home healthcare and inpatient expenditures were significantly higher in t4 compared with other time periods.

Healthcare expenditures among those with & without multimorbidity

The average total, outpatient, home healthcare and inpatient healthcare expenditures were significantly higher among those with multimorbidity compared with those without multimorbidity. Compared with t4, the average total, outpatient, home healthcare and inpatient expenditures were significantly lower in other time periods (t1, t2, t3, t5 and t6) among those with multimorbidity. The average home healthcare expenditure did not significantly differ in t4 and t6 time periods among those without multimorbidity.

Healthcare expenditures & ICI–multimorbidity interaction

The average total, outpatient, home healthcare and inpatient healthcare expenditures were significantly higher among ICI users and with multimorbidity group compared with ICI non-users and without multimorbidity. Average total expenditures by the ICI–multimorbidity groups are displayed in Figure 3. Compared with t4, the average total, outpatient, home healthcare and inpatient expenditures were significantly lower in other time periods (t1, t2, t3, t5 and t6) among ICI users and with multimorbidity.

Figure 3. . Mean total healthcare expenditures by ICI–multimorbidity groups during pre-index and post-index periods.

Figure 3. 

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Based on six repeated observation of 4519 older adults with incident late-stage (stage III/IV) melanoma continuously enrolled in Medicare Parts A and B fee-for-service programs 12-months prior to incident cancer diagnosis.

ICI: Immune checkpoint inhibitors; USD: United States Dollars.

Adjusted associations of ICI & multimorbidity to total healthcare expenditures

Table 1 presents the unadjusted and adjusted parameters of GLMM on average total healthcare expenditures. The unadjusted and fully adjusted models showed similar results. In the model that was adjusted for time and time-squared, those with ICI had significantly higher average expenditures than those without ICI (β = 1.34, standard error [SE] = 0.52; p < 0.001). When adjusted for multimorbidity, ICI users and those with multimorbidity had higher average expenditures compared with ICI non-users or no multimorbidity. In the fully adjusted model, the average total expenditure significantly increased with time (β = 0.49, SE = 0.04; p < 0.001). Patients who received ICI (β = 0.91, SE = 0.07; p < 0.001) and those who had multimorbidity (β = 0.72, SE = 0.07; p < 0.001) had significantly higher average total expenditures compared with those who did not receive ICI or did not have multimorbidity.

Table 1. . Parameter estimates of select variables of generalized linear mixed model on average total healthcare expenditures.

Variables No interaction With interaction
  Unadjusted analysis
  Beta SE Prob Beta SE Prob
Time 0.83 0.04 <0.001 0.83 0.04 <0.001
ICI use       N/A    
 Yes 1.34 0.52 <0.001      
 No (ref)          
Multimorbidity       N/A    
 Yes 0.96 0.74 <0.001      
 No (ref)          
ICI–multimorbidity interaction N/A          
 Yes ICI and yes multimorbidity       0.19 0.10 0.051
 Yes ICI and no multimorbidity       (ref)    
 No ICI and yes multimorbidity       -0.97 0.09 <0.001
 No ICI and no multimorbidity       -1.99 0.12 <0.001
Time squared -0.15 0.01 <0.001 -0.15 0.01 <0.001
  No interaction With interaction
  Fully adjusted analysis†
  Beta SE Prob Beta SE Prob
Time 0.49 0.04 <0.001 0.50 0.04 <0.001
ICI use       N/A    
 Yes 0.91 0.07 <0.001      
 No (ref)          
Multimorbidity       N/A    
 Yes 0.72 0.07 <0.001      
 No (ref)          
ICI-multimorbidity Interaction N/A          
 Yes ICI and yes multimorbidity       0.02 0.16 0.90
 Yes ICI and no multimorbidity       (ref)    
 No ICI and yes multimorbidity       -0.73 0.14 <0.001
 No ICI and no multimorbidity       -1.51 0.15 <0.001
Time squared -0.12 0.01 <0.001 -0.12 0.01 <0.001
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Note: Based on six repeated observation of 4519 older adults with incident late-stage (stage III/IV) melanoma continuously enrolled in Medicare Parts A and B fee-for-service programs 12-months prior to incident cancer diagnosis.

†

Fully adjusted model also included year of diagnosis, age, sex, race, marital status, dual eligibility, oncologist visit and primary care physician visits.

Probability p < 0.05 was considered significant.

GLMM: Generalized linear mixed model; ICI: Immune checkpoint inhibitors; N/A: Not applicable; Prob: Probability; ref: Reference; SE: Standard error.

Other variables with significant findings were age, dual eligibility and visits to oncologists and primary care physicians. Significantly higher average total expenditures were reported in patients aged 75–79 years (β = 0.17, SE = 0.07; p = 0.015) and 80 years and older (β = 0.26, SE = 0.06; p < 0.001) compared with those aged between 65 and 69 years, who were dual eligible (β = 0.28, SE = 0.11; p = 0.011) versus those who were not, who had visited oncologists (β = 1.75, SE = 0.05; p < 0.001) versus no oncologist visits, and who had visited primary care physician (β = 1.38, SE = 0.05; p < 0.001) versus no primary care physician visits.

We also conducted GLMM on average total expenditures by ICI–multimorbidity interaction. In the fully adjusted model, compared with no ICI/no multimorbidity, average total expenditures were significantly higher in all other groups, namely in patients who used ICI and had multimorbidity (β = 17889.18, SE = 1260.794; p < 0.001), who used ICI but did not have multimorbidity (β = 16178.22, SE = 2951.45; p < 0.001), and who did not use ICI but had multimorbidity (β = 1510.35, SE = 368.74; p < 0.001). The contrast in average healthcare expenditures was examined by ICI use and multimorbidity by using ICI-no multimorbidity as the comparator group (Table 1). In the fully adjusted model, the average total healthcare expenditure significantly increased with time (β = 0.50, SE = 0.04; p < 0.001). Patients who were non-ICI users and had multimorbidity (β = -0.73, SE = 0.14; p < 0.001) and non-ICI users and with no multimorbidity (β = -1.51, SE = 0.15; p < 0.001) had significantly lower costs compared with patients who were ICI users and had no multimorbidity. However, there was no significant difference between patients who were ICI users and had multimorbidity and patients who were ICI users and had no multimorbidity. Other variables with significant findings were same as above.

Adjusted relationships between ICI, multimorbidity & type of healthcare expenditures

The relationship between ICI and multimorbidity by type of expenditures (outpatient, home healthcare and inpatient) was further explored. The findings for average outpatient expenditures were similar to total expenditures (Supplementary data Appendix 2).

While patients with multimorbidity had significantly higher average home healthcare and inpatient expenditures compared with those without multimorbidity, ICI use was not significantly associated with those expenditures (Supplementary data Appendix 3 & 4, respectively). Similarly, the unadjusted and adjusted models of the effect of ICI and multimorbidity interaction on average home healthcare and inpatient expenditures were similar. In the fully adjusted model, the average home healthcare (β = 0.19, SE = 0.06; p = 0.002) and inpatient expenditure (β = 1.56, SE = 0.22; p < 0.001) significantly increased with time. However, no significant difference was observed among the ICI and multimorbidity groups.

Discussion

This study confirms previous findings and also presents some new findings. First, this study reports that average healthcare expenditures significantly increased after a terminal cancer, in other words, late-stage melanoma, diagnosis, which is in line with published studies. Cancer diagnosis exerts a huge financial burden on patients, payers and healthcare systems, with four-times higher costs in cancer cohort compared with the noncancer cohort [3,7]. Late-stage cancers tend to be more expensive than early-stage cancers [4,8,44,45]. Although costs of early-stage versus late-stage melanoma were not compared, these findings still relay that late-stage melanoma diagnosis among older patients places enormous burden on the payers. These findings have implications for the new OCM that are being experimented by the the Centers for Medicare & Medicaid Services (CMS). Under the OCM providers are expected to ‘provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare’ [29]. The OCM organizes care around six-month episodes [29]. By providing information on total healthcare expenditures by time periods, our cost estimates can serve as benchmarks for episode-driven payments.

Second, this study found that ICI use is associated with higher average healthcare expenditures among older Medicare beneficiaries with late-stage melanoma. This is the first study to the best of our knowledge to assess the association of ICI use on healthcare expenditures among older adults with late-stage melanoma. Despite having similar expenditures during the pre-index periods (t1, t2 and t3), use of ICI significantly increased post-index date (t4, t5 and t6) expenditures. As seen in our study, outpatient expenditures were the major drivers of healthcare expenditures, contributing to 83% of the total expenditures. This study also found that ICI use was not associated with inpatient expenditures. Taken together these findings suggest that healthcare costs of ICI users may be driven by supportive care. Reasons for these findings are speculated as follows. It is reported that administration costs associated with ICIs are higher compared with other therapies [15]. Intravenous infusion of ICI requires constant monitoring by a healthcare professional, which may lead to higher healthcare utilization [46]. Infusion reactions or immune-related adverse events may occur thereby increasing healthcare resource utilization [46]. Another possible reason could be the constant monitoring and testing of patients in the outpatient settings being treated with ICI [46]. Prior to and after infusion, late-stage melanoma patients are usually tested for serum biomarkers, enzyme level and blood count [46]. The study findings confirm that cancer-related treatments have shifted from inpatient to outpatient settings [45,47].

Third, older Medicare beneficiaries with multimorbidity had higher average total expenditures compared with those without multimorbidity. Across a range of healthcare settings and population, disproportionately higher costs were accounted for in a small number of patients and multimorbidity was highly prevalent in those patients [48]. A majority of older adults with late-stage melanoma also had multimorbidity [34]. Therefore, higher total expenditures among older adults with multimorbidity corroborates findings from other studies [6,37]. Many alternatives to traditional healthcare practices and payment models are being considered to account for the complex need of patients with multimorbidity [36]. Accountable Care Organizations and patient-centered medical homes over traditional practice models and bundled payment of services, which is more patient-centric than disease-centric, are a few such efforts [36]. Though there are numerous challenges to adopting such policies on a larger scale [36], future studies need to explore whether these emerging models are effective in providing value-based care at lower costs for cancer patients in general and late-stage cancer patients in particular.

Fourth, the ICI–multimorbidity interaction revealed that multimorbidity did not play a significant role in the increase of expenditures. Rather, the high expenditures were due to the use of ICI. Although multimorbidity was associated with higher average expenditures in this study, the expenditures due to ICI use supersede those expenditures. The possible reasons for the increased average expenditures with ICI use are discussed above. These results further strengthen the need for newer payment models such as OCM, which focus on reducing cost of cancer care.

The findings of this study should be interpreted considering its limitations. First, Part D costs were not included. This is because patients with multimorbidity will have higher prescription costs compared with those without multimorbidity. This may show even higher costs for patients with multimorbidity, which would be unrelated to cancer care. However, the current therapies for melanoma are covered under Part B. Therefore, melanoma-related treatment costs were adequately captured in this study. Second, information on severity of co-existing illnesses may have provided insights into cluster of conditions which may lead to higher healthcare expenditures. Third, the findings of this study cannot be generalized to all Medicare beneficiaries as the study population was limited to only those residing in SEER regions. Fourth, a 12-month follow-up period may not be adequately assessing the impact of various factors on healthcare expenditures. Although ICI use has been shown to significantly improve 5-year survival in patients with late-stage melanoma, the patients who respond to ICI remain low. Therefore, the mean overall survival for late-stage melanoma still remains approximately a year for most of the older patients. Therefore, a 12-month follow-up period was chosen. Despite these limitations, the study has several strengths. This study adopted a longitudinal design and compared expenditures over time. Additionally, no study to-date has focused on impact of ICI on healthcare expenditures among older adults with multimorbidity and late-stage melanoma. This study provides payers with strong evidence on the influences of various factors on healthcare expenditures.

Conclusion

The results of this study illustrate that the healthcare expenditures were higher after a late-stage melanoma diagnosis. Use of ICIs and presence of multimorbidity were associated with higher expenditures. Outpatient expenditures contributed largely to the increase in total expenditures. However, the ICI–multimorbidity interaction revealed that ICI was the driving force behind the higher expenditures. Future studies are needed to explore healthcare utilization among older patients with multimorbidity and late-stage melanoma and explore its effect on healthcare expenditures.

Future perspective

The healthcare expenditures related to novel therapies, such as ICIs, will continue to rise. To reduce costs, newer payment models that focus on value are being developed and tested. Future studies need to examine whether such models can achieve the triple aims of ‘better health, better value and lower costs’.

Summary points.

  • While many factors are associated with high cost in cancer, expensive drugs, such as immune checkpoint inhibitors (ICIs), approved for cancer, the administration of these drugs and underlying multimorbidity may be the main factors.

  • This study estimated the impact of ICI use and ICI–multimorbidity interaction on healthcare expenditure among older patients with late-stage melanoma.

  • A cohort of 4519 older (>65 years) adults diagnosed with incident melanoma between 2012 and 2015 was identified and healthcare expenditures were measured in 120-day time periods during 12-month pre- and post-index periods.

  • The total, outpatient, home health and inpatient healthcare expenditures in the pre-index period were lower than the expenditures in the post-index period.

  • The total, outpatient, home healthcare and inpatient healthcare expenditures were significantly higher among ICI users compared with non-ICI users.

  • The total, outpatient, home healthcare and inpatient healthcare expenditures were significantly higher among those with multimorbidity compared with those without multimorbidity.

  • The ICI–multimorbidity interaction revealed that irrespective of the multimorbidity status, ICI was the driving force behind the total healthcare expenditures.

  • Although only 6% received ICI, they contributed to 78% of the total expenditures.

  • Understanding the reasons for high expenditures may help focus on high-value resource use, like those in the outpatient settings.

Supplementary Material

Click here for additional data file. (28.5KB, docx)

Footnotes

Supplementary data

To view the supplementary data that accompany this paper please visit the journal website at: www.futuremedicine.com/doi/suppl/10.2217/imt-2020-0152

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research

The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

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