(51) Economic and Clinical Impact of Dual Orexin Receptor Antagonists Versus Zolpidem in Medicare Part D Beneficiaries with Chronic Insomnia

Background: : Chronic insomnia affects roughly 10% of U.S. adults and is associated with increased fall risk and higher healthcare utilization. Dual Orexin Receptor Antagonists (DORAs) offer a safer alternative to zolpidem for patients that have a high risk of falls. High drug acquisition costs limit formulary access to DORAs, creating coverage barriers that affect both payers and patients.

Objective: : This study aims to evaluate the budget impact and cost-effectiveness of suvorexant and lemborexant versus zolpidem among Medicare Part D beneficiaries from 2020-2022. We hypothesize that DORAs would yield partial cost offsets through reductions in fall-related hospitalizations and improvements in clinical outcomes despite high drug cost. The primary objective is to estimate the net annual budget impact and cost-effectiveness of DORA use in a Medicare Part D population.

Methods: : Our research revolved around a population-based economic model using a cohort of 1,000,000 Medicare Part D beneficiaries. Prevalence rates of chronic insomnia, zolpidem failure, and DORA eligibility were applied to estimate the eligible treatment population. The Inflation Reduction Act (IRA) on Medicare Part D deductibles was incorporated into the model to reflect cost and accessibility. This was seen through annual per-patient drug costs, fall-related hospitalization rates, and associated injury costs between the two DORAs and zolpidem. Primary outcomes included net budget impact and incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) gained.

Results: : Results showed that 42,000 of 1,000,000 Medicare patients were estimated to be DORA-eligible for failure of zolpidem therapy. Through a 45% rebate adjusted cost, DORAs held a blended average of $3,373 annually versus $72 for zolpidem. Total drug costs for the DORA group reached $255.5 million annually, a $252.5 million increase over zolpidem. However, fall-related hospitalization cost offsets due to fall risk was $35 million. The number needed to treat (NNT) to prevent one fall-related hospitalization was approximately sixty-seven. A modeled ICER of $87,600 per gained suggests DORAs may be cost-effective under U.S. willingness-to-pay thresholds if indirect benefits are realized.

Conclusions: : In conclusion, DORAs may offer clinical and economic value in Medicare patients with chronic insomnia by reducing risk of fall and improving Quality of Life (QOL). Policy changes may increase accessibility of DORAs to patients by decreasing financial cost.

Sponsorship:: Prime Therapeutics, LLC
University of Colorado, Anschutz Skaggs School of Pharmacy & Pharmaceutical Sciences