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\begin{document}

\title{Healthcare Cost and Utilization for Chimeric Antigen Receptor (CAR)
T-Cell Therapy in the Treatment of Pediatric Acute Lymphoblastic
Leukemia: A Commercial Insurance Claims Database Analysis}



\author[1]{Alex Hoover}%
\author[2]{Paige Reimche}%
\author[2]{David Watson}%
\author[2]{Lynn Tanner}%
\author[2]{Laura Gilchrist}%
\author[2]{Mike Finch}%
\author[2]{Yoav Messinger}%
\author[1]{Lucie Turcotte}%
\affil[1]{University of Minnesota Twin Cities School of Medicine}%
\affil[2]{Children's Minnesota}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
BACKGROUND: Acute lymphoblastic leukemia (ALL) is the most common
malignancy of childhood. With the introduction of novel cellular
therapies, cost of care is a critical component and financial toxicity
experienced by patients and society requires evaluation. This study aims
to assess the total cost of CAR-T therapy for pediatric ALL patients
with commercial insurance coverage in the United States. STUDY DESIGN:
Using de-identified commercial insurance data from the OptumLabs
\selectlanguage{ngerman}\textsuperscript{®} Data Warehouse, a cohort of 37 patients, aged 1-25
years, with B-ALL treated with CAR-T therapy between Oct 2016 and Dec
2021 in the United States was identified. Cost was evaluated for a 90
day period encompassing CAR-T infusion and by administration and
complication characteristics. RESULTS: Among the 37 identified ALL
patients that received a CAR-T product infusion, 14 patients were
female, median age at administration was 13 years. The median 90-day
total cost was \$620,500 (Mean: \$589,108). Inpatient cost accounted for
approximately 71\% of the total cost with an average of 28 inpatient
days per patient. Although inpatient cost was slightly higher in the
older age group (aged 10-25 years) and in patients with a code for CRS,
these differences were not statistically significant. CONCLUSION: This
real-world cost analysis shows for the first time the encompassing cost
of CAR-T therapy for pediatric ALL patients in the US with commercial
insurance. This study provides a valuable benchmark that can be used to
analyze the financial implications of CAR-T therapy for pediatric ALL
therapy on health systems.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


Healthcare Cost and Utilization for Chimeric Antigen Receptor (CAR)
T-Cell Therapy in the Treatment of Pediatric Acute Lymphoblastic
Leukemia: A Commercial Insurance Claims Database Analysis

Alex Hoover\textsuperscript{1}, Paige Reimche\textsuperscript{2}, Dave
Watson\textsuperscript{2}, Lynn Tanner\textsuperscript{2}, Laura
Gilchrist\textsuperscript{2,3}, Mike Finch\textsuperscript{2}, Yoav H
Messinger\textsuperscript{2}, Lucie M. Turcotte\textsuperscript{1}

Affiliations: 1. Optum Labs Visiting Fellow, University of Minnesota
Medical School, Minneapolis, MN; 2. Children's Minnesota, Minneapolis,
MN. 3. St. Catherine University, St. Paul, MN.

Funding: This work was supported in part by the NIH-NRSA Research
Fellowship in Translational \& Genomic Pediatric Cancer Epidemiology -
T32CA099936 (AH), the National Cancer Institute Grant No. K08CA234232
(LMT); the Pine Tree Apple Classic Fund (LG, YHM); and the Children's
Cancer Research Fund (LMT).

Corresponding author: Alex Hoover, MD, Division of Pediatric Blood and
Marrow Transplantation, University of Minnesota Medical School, 420
Delaware St SE, Minneapolis, MN 55455; email: hoove231@umn.edu

Abstract word count: 245 words

Main text word count: 1993 words

2 tables, 2 figures included

Keywords: cost, CAR-T, pediatric, ALL

Running head: Cost of CAR-T Therapy in Pediatric ALL

Abbreviations Table\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
ALL & Acute Lymphoblastic Leukemia\tabularnewline
\midrule
\endhead
B-ALL & B-cell Acute Lymphoblastic Leukemia\tabularnewline
CAR-T & Chimeric Antigen Receptor--T-cell\tabularnewline
US & United States\tabularnewline
CR & Complete Remission\tabularnewline
CRi & Complete Remission with incomplete hematopoietic
recovery\tabularnewline
RFS & Relapse-Free Survival\tabularnewline
CI & Confidence Interval\tabularnewline
FDA & Food and Drug Administration\tabularnewline
CRS & Cytokine Release Syndrome\tabularnewline
ICANS & Immune-effector Cell Associated Neurotoxicity
Syndrome\tabularnewline
ICD-10 & International statistical Classification of
Diseases\tabularnewline
CPT & Current Procedural Terminology\tabularnewline
IQR & Inter-Quartile Range\tabularnewline
EMR & Electronic Medical Record\tabularnewline
\bottomrule
\end{longtable}

Prior presentations: Results from this study were presented at the 2022
American Society of Hematology (ASH) Annual Meeting, New Orleans, LA,
12/11/2022.

Disclaimers: The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National
Institutes of Health or the U.S. government.

\textbf{Abstract}

BACKGROUND: Acute lymphoblastic leukemia (ALL) is the most common
malignancy of childhood. With the introduction of novel cellular
therapies, cost of care is a critical component and financial toxicity
experienced by patients and society requires evaluation. This study aims
to assess the total cost of CAR-T therapy for pediatric ALL patients
with commercial insurance coverage in the United States.

STUDY DESIGN: Using de-identified commercial insurance data from the
OptumLabs\selectlanguage{ngerman}\textsuperscript{®} Data Warehouse, a cohort of 37 patients,
aged 1-25 years, with B-ALL treated with CAR-T therapy between Oct 2016
and Dec 2021 in the United States was identified. Cost was evaluated for
a 90 day period encompassing CAR-T infusion and by administration and
complication characteristics.

RESULTS: Among the 37 identified ALL patients that received a CAR-T
product infusion, 14 patients were female, median age at administration
was 13 years. The median 90-day total cost was \$620,500 (Mean:
\$589,108). Inpatient cost accounted for approximately 71\% of the total
cost with an average of 28 inpatient days per patient. Although
inpatient cost was slightly higher in the older age group (aged 10-25
years) and in patients with a code for CRS, these differences were not
statistically significant.

CONCLUSION: This real-world cost analysis shows for the first time the
encompassing cost of CAR-T therapy for pediatric ALL patients in the US
with commercial insurance. This study provides a valuable benchmark that
can be used to analyze the financial implications of CAR-T therapy for
pediatric ALL therapy on health systems.

Introduction

Acute lymphoblastic leukemia (ALL) is the most common cancer of
childhood and adolescence, with approximately 3000 new cases diagnosed
each year in individuals under age 18 years of age in the United States
(US).\textsuperscript{1} Approximately 85\% of pediatric ALL expresses
B-cell lineage cell-surface and cytoplasmic markers
(B-ALL).\textsuperscript{2} Over the last five decades, survival of
children with B-ALL has improved drastically from less than 10\% in the
1960s to over 90\% today.\textsuperscript{2,3} However, relapsed and
refractory B-ALL remains a significant and challenging issue with 5-year
survival for patients with relapsed disease ranging from
40-60\%.\textsuperscript{4-7}

Chimeric antigen receptor (CAR) T-cells targeting CD19 on B-ALL leukemic
blasts have changed the landscape of treatment for relapsed and
refractory disease. The landmark ELIANA trial that led to the FDA
approval of Novartis's tisagenlecleucel (Kymriah), a CD19 CAR-T product,
showed an 82\% rate of complete remission (CR) or CR with incomplete
hematologic recovery (CRi) in 79 infused children, adolescents, and
young adults.\textsuperscript{8,9} Among 65 responders, the median
relapse-free survival (RFS) was 43 months and 5-year RFS rate was 44\%
(95\% confidence interval (CI), 31\%-56\%).\textsuperscript{10} In
addition to prompting FDA approval for tisagenlecleucel, this trial and
subsequent studies of the real world efficacy of this therapy have shown
that CAR-T therapy can be a curative treatment option for heavily
pretreated pediatric and young adult patients with relapsed or
refractory B-ALL.\textsuperscript{11-14}

Upon FDA approval for tisagenlecleucel in 2017, the product was priced
at \$475,000 for commercial use in the United
States.\textsuperscript{15} Notably however, this price tag does not
capture the cost to payers for the full course of treatment for patients
who receive this therapy. Total cost of the therapy includes that of
leukapheresis, lymphodepleting chemotherapy, treatment of complications
such as cytokine release syndrome (CRS) and immune effector
cell-associated neurotoxicity syndrome (ICANS) and hospitalization for
necessary supportive care.\textsuperscript{16} In the ELIANA trial, 77\%
of patients experienced some degree of CRS and 48\% received
tocilizumab,\textsuperscript{8} an IL-6 monoclonal antibody that also
contributes to the total cost of care outside the listed price of
tisagenlecleucel.\textsuperscript{17}

There are limited data regarding the comprehensive cost of delivering
commercial cellular therapy in the US. Previous studies have been
limited to cost-effectiveness analyses based on listed drug prices or
have used algorithms or proxies as estimates for
cost.\textsuperscript{17-21} There are also multiple studies
investigating the cost of CAR-T therapy delivery in other countries'
health systems,\textsuperscript{22-29} however studies of comprehensive
real-life cost of cellular therapy for pediatric B-ALL are not available
in the US.

Previously, our group utilized commercial insurance claims data to
investigate the utilization and cost of pediatric ALL care in newly
diagnosed patients in the US.\textsuperscript{30} With rising US
healthcare costs and the profound financial burden of childhood cancer
to patients and society,\textsuperscript{31} it is imperative that we
understand the current cost of treatment so that the incremental cost
and benefit of future therapeutic modifications can be considered. The
aim of this study was to use administrative claims data to evaluate the
real-world comprehensive cost of CAR-T therapy for B-ALL in the US, for
a cohort of commercially insured pediatric patients.

Materials and Methods

\emph{Data Source}

OptumLabs\textsuperscript{®} Data Warehouse includes de-identified
medical and pharmacy claims for over 88 million commercially insured
individuals living in the US.\textsuperscript{32} The database contains
de-identified, longitudinal health information on enrollees and
patients, representing a mixture of ages, ethnicities, and geographical
regions across the US. A broad range of clinical and demographic data
are available, including reimbursement and clinical utilization.
Publicly insured patients and those receiving care through managed-care
organizations are not included in the database. This study was reviewed
by the institutional review board at the University of Minnesota.

\emph{Cohort Identification and Outcomes}

A cohort of patients aged 1-25 years, with ALL who received CAR-T
therapy between Oct 2016 and Dec 2021 in the United States was
identified. CAR-T product administration was confirmed with use of
ICD-10 codes for non-specific or specific CAR-T products: XW033C3,
XW033C7, XW033J7, XW043C3, XW043C7, XW043J7; or the CPT code for the
administration itself: 0540T. ALL diagnosis was confirmed based on
ICD-10 diagnostic codes: C91.00, C91.01, C91.02. To be included,
individuals were required to have had continuous insurance coverage for
30 days prior to and 60 days after CAR-T product administration, unless
patient death occurred during this time period. This time frame was
chosen to include the majority of therapy-related complications while
avoiding variation from pre-leukapheresis salvage therapies and
potential post-infusion relapse therapies.

Outcomes of interest included both cost and utilization of care. Here,
cost is defined as total reimbursement paid by the commercial payer.
Inpatient cost corresponds to claims with a place of service at an
inpatient hospital, and outpatient cost correspond to a place of service
at an office or hospital-based outpatient clinic. Utilization was
summarized as inpatient days, inpatient encounters, and outpatient
encounters. An inpatient encounter corresponded to claims with an
inpatient place of service with distinct start and end dates, and an
outpatient encounter was defined as a unique physician claim with the
place of service either being an office or hospital-based outpatient
clinic.

\emph{Statistical Analysis}

Total cost and utilization were summarized for the cohort for the 90-day
time period of interest. Cost was further characterized by the location
of service provided, the presence of ICD-10 codes for the complications
of CRS (D89.831-D89.835, D89.839) and/or ICANS (G92.00-G92.05). Total
cost was analyzed by age group (1-9 years vs. 10-25 years) as a proxy
for upfront ALL risk group and by the occurrence of CRS. Analyses were
performed using R.\textsuperscript{33}

Results

A cohort of 37 patients aged 1-25 years was identified with a
concomitant ICD-10 code for ALL and CPT code for CAR-T cell
administration (Table 1). All patients had continuous coverage
enrollment from one month prior to infusion through two months
post-infusion except patients who died during the time period. Thirteen
patients (35\%) were under 10 years of age at the time of cell infusion;
median age at administration was 13 years (interquartile range {[}IQR{]}
7-19 years). Fourteen patients (37.8\%) were female, and while 14
patients were reported to be White, race and ethnicity were unknown in
43\% of individuals.

Over the 90 day period encompassing 30 days prior to CAR-T infusion
through 60 days post-infusion, the median cost for the full cohort was
\$620,500 (mean, \$585,398). Overall utilization and cost findings are
shown in Table 2. Median cost was not significantly different between
patients under vs. over age 10 (\$620,279 vs \$633,137, respectively).
Inpatient cost accounted for approximately 71\% of the total cost with a
median inpatient cost of \$556,492. Median outpatient cost was \$70,545.
There were no statistically significant differences between inpatient or
outpatient total cost between the two age cohorts (Figure 1).

The median number of inpatient encounters across the cohort was 2, with
patients spending a median of 21 days in the hospital. Patients had an
average of 7 outpatient visits in the 30 days prior to CAR-T therapy and
an average of 9 outpatient visits in the 60 days following infusion.
Similar to cost, there was no significant difference between the
utilization of care based on age.

Within the cohort, less than 11 patients had a diagnostic code for
cytokine release syndrome at some point during the study period
(n\textless{}11 cannot be identified per OptumLabs data guidelines). No
patients in the dataset had a diagnostic code for ICANS. When stratified
into CRS and non-CRS cohorts, there were no significant differences in
total, inpatient or outpatient cost between the cohorts (Figure 2).
Greater than zero but less than 11 patients had a diagnosis code
indicative of death during the 60 days post-infusion.

Discussion

In this study, we examined the healthcare cost and utilization for
pediatric patients receiving CAR-T cell therapy for B-ALL using a
commercial claims database, the first analysis of its kind in this
patient population. Patients were predominantly male and most were
adolescents, which is consistent with prior studies that have shown that
in the pediatric population, male sex and age \textgreater{}10 years are
significant predictors of inferior post-relapse survival and therefore
require novel therapies such as CAR-T.\textsuperscript{34}

Almost all patients received the CAR-T therapy in the inpatient setting,
and thus, inpatient cost was significantly higher than outpatient cost,
likely reflecting the price of the tisagenlecleucel product itself in
addition to the cost of lymphodepleting chemotherapy and care for
post-infusion complications. Costs of emergency department care and home
health-related care contributed minimally to the overall cost burden in
the 90 day period of interest around CAR-T infusion.

The median total cost across the entire cohort for the period of
interest was \$620,500, indicating that the typical cost of care,
excluding the listed drug price for tisagenlecleucel of \$475,000, was
approximately \$145,500. This is fairly consistent with cost modeling
performed for tisagenlecleucel in pediatric B-ALL patients by Lin et al.
which predicted the total cost to be between \$548,000 and
\$599,000.\textsuperscript{18} This is also consistent with other
reports of cost associated with the real-world care for patients
receiving CAR-T therapies in adults with relapsed or refractory
lymphomas.\textsuperscript{35,36}

Our study has several limitations. The landmark ELIANA trial of
tisagenlecleucel study reported a CRS rate of 77\% and neurotoxicity
rate of 40\% with this therapy.\textsuperscript{8} Prior to October
2020, no ICD-10 diagnosis codes for CRS or ICANS had been adopted by the
Centers for Medicare \& Medicaid Services. Therefore, other studies have
utilized claims-based algorithms for CRS and neurotoxicity via expert
clinical opinion and based on the clinical manifestations of these
complications.\textsuperscript{35} However, given the lack of ability to
validate these algorithms with electronic medical record (EMR)-based
records, the interpretation of these algorithms is challenging. Less
than 11 patients in our cohort had a recorded ICD-10 for cytokine
release syndrome (CRS) and no patients had a diagnostic code for
immune-effector cell associated neurotoxicity syndrome (ICANS). This is
expected given the cohort was primarily treated prior to October 2020
when ICD-10 codes for these diagnoses were introduced, however it
unfortunately impacts our ability to detect whether there was higher
cost and utilization of care for patients with vs without CRS. Cost that
may not have been captured in this analysis include those of
leukapheresis, which often occurs greater than 30 days prior to the
administration of the CAR-T product, as well as the longer term cost of
B-cell aplasia and secondary hypogammaglobulinemia following CAR-T
infusion, treated with immune globulin replacement therapy.

Consistent with most commercial claims databases, some demographic and
clinical characteristics, such as race/ethnicity or prior therapies such
as stem cell transplant, were absent or missing from the OptumLabs
data.\textsuperscript{35} This limits our ability to analyze the effect
of race/ethnicity on cost, a key component of health equity and
opportunity in the current era of healthcare in the United States. The
relatively small sample size of this study limits the power to detect
differences between cohorts and the lack of clinical information or
ability to validate diagnostic coding with EMR-based data limits
analysis of the effect of disease characteristics, performance index or
prior therapies and hinders cost-benefit analyses. Additionally, the
OptumLabs Data Warehouse is limited to commercially insured individuals,
thus excluding publicly insured or managed care patients from this
analysis and limiting the generalizability of these results.

Conclusions

This robust real-world cost analysis shows for the first time the true
cost and peri-infusion care utilization of CAR-T therapy for pediatric
B-ALL. This encompasses not only the commercial cost of the cellular
therapy product itself, but the care involved prior to cell product
infusion and the management of its complications. The total cost and
utilization of care is not significantly impacted by patient age. Mean
and median total cost well exceeded \$500,000 US dollars, as expected
with the listed commercial price of tisagenlecleucel of \$475,000. This
study provides a valuable benchmark that can be used to analyze the
financial toxicity of CAR-T therapy for pediatric ALL therapy on health
systems, patients and families. The cost of this therapy can be
reassessed over time as other novel therapeutics are introduced into ALL
therapy and long-term outcome data for this therapy are established

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TABLE 1 Demographics\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Characteristic}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Category}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%) - 37}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0-9\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
13 (35)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
10+\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
24 (65)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Sex\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Female\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
14 (38)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Male\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
23 (62)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Setting of CAR-T Therapy\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Inpatient\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textgreater{}70\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Outpatient\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textless{}30\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Region\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Midwest\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Northeast\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
South\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
14\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
West\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Unknown\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*Blank cells correspond to censoring cells with less than 11 counts;
multiple cells need to be blanked (even if not \textless{} 11) and
percentages adjusted so frequencies cannot be recovered, per OptumLabs
guidelines.

TABLE 2 Analysis of median and mean total care utilization and cost\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& & \textbf{90 day analysis period} & \textbf{90 day analysis period}
&\tabularnewline
\midrule
\endhead
\textbf{Utilization} & \textbf{Utilization} & Median & Mean &
p-value\tabularnewline
Inpatient encounters & Overall & 2.00 & 1.88 &\tabularnewline
& 0-9 years & 2.00 & 2.33 & 0.1299\tabularnewline
& 10+ years & 1.00 & 1.62 &\tabularnewline
Inpatient days & Overall & 21.00 & 28.15 &\tabularnewline
& 0-9 years & 20.50 & 26.17 & 0.7307\tabularnewline
& 10+ years & 21.00 & 29.29 &\tabularnewline
Outpatient encounters & Overall & 17.00 & 16.78 &\tabularnewline
& 0-9 years & 19.00 & 19.38 & \textless{}0.001\tabularnewline
& 10+ years & 16.00 & 15.38 &\tabularnewline
& Before CAR-T & 7.00 & 7.38 &\tabularnewline
& After CAR-T & 9.00 & 8.81 &\tabularnewline
\textbf{Cost} & \textbf{Cost} & Median (\$) & Mean (\$) &\tabularnewline
Total cost & Overall & \$620,500.40 & \$589,108.20 &\tabularnewline
& 0-9 years & \$620,279.20 & \$553,328.10 & 0.6287\tabularnewline
& 10+ years & \$633,137.20 & \$608,489.10 &\tabularnewline
Inpatient cost & Overall & \$556,492.04 & \$465,191.20 &\tabularnewline
& 0-9 years & \$565,398.00 & \$451,359.00 & 0.8225\tabularnewline
& 10+ years & \$234,144.00 & \$472,408.00 &\tabularnewline
Outpatient cost & Overall & \$70,545.08 & \$148,253.40 &\tabularnewline
& 0-9 years & \$38,311.87 & \$133,205.61 & 0.7426\tabularnewline
& 10+ years & \$80,038.59 & \$156,758.66 &\tabularnewline
\bottomrule
\end{longtable}

Figure 1. Mean Cost by Service Location \& Age\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 2. Mean Cost by Service Location \& CRS Occurrence\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

