balance etween quality and cost
TRANSCRIPT
BALANCE ETWEEN QUALITY AND COST IN CANCER MANAGEMENT
DR: SUMMAR MOHAMED ELMORSHIDY ASSISTANT LECTURER OF CLINICAL
ONCOLOGY CLINICAL ONCOLOGY DEPARTMENT
ASSIUT UNIVERSITY HOSPITALS
The Cost of Cancer Care Balancing Our Duties to Patients Versus Society:
Are They Mutually Exclusive?
Introduction It is a disturbing fact that the costs of health care are spiralling upwards
and that the best example of this troubling trend is the domain of oncology treatment and research.
By 2020, it is projected that cancer care will cost more than $150 billion annually in the United States. Although this represents only a relatively small fraction of total health care cost, cancer care is escalating more rapidly than most other specialties.
Many factors contribute to this unhappy situation, including the aging of the population, persistence of risk-taking by the community at large (smoking, excessive
sun exposure, and lack of attention to industrial pollution)
Introduction increasingly expensive research, diagnostic tests, surgical
approaches, radiotherapy techniques, and novel systemic therapies as well as some unrealistic expectations of patients, families, and the
community at large .
Introduction The prospect of cancer treatment is difficult to deal
with for most patients when one considers the nature of the treatment being offered and its potential consequences.
In addition, asymmetry of medical information, dislocation of patients and their families for
treatment far from their homes mean patients lose control over their lives, compounding their anxiety over a cancer
diagnosis and the treatment that follows.
Introduction At its simplest, the value proposition in health care
has been defined by Porter and Teisberg with the following equation:
Value=Outcomes/Cost
This equation makes sense and is routinely used in planning the strategy of cancer care for health care systems as it help to consider what is contributing to poor value in cancer care and allows resolution of those elements that are accessible.
(ESMO 2020 vision)
Cancer patients and their needs are at the
centre of all that we do: our profession is driven by our determination, individually and collectively, to secure the best possible outcomes for people with cancer across Europe and around the world.
As oncologists, we find ourselves asking: Is our duty to our individual patients, to society, or to both?
How will we do our part to contain health care costs while honoring therapeutic contracts and professional obligations to do the best for each patient?
How will the increasing pressure to control expenditures affect the way that oncologists communicate with patients about tests and treatments?
Is Our Duty to the Patient or to Society?
An ethical conflict arises when one feels that the interests of the patient are at odds with the interests of society!!!
Oncologists are bound by duty to patients as stated in the Hippocratic Oath: “I will prescribe regimens for the good of my patients
according to my ability and my judgment and never do harm to
anyone.”
Conflict arises when care delivered to an individual patient is part of a pattern that risks harm to society. In this case, the societal “harm”—or more accurately, burden—is in the form of skyrocketing costs of care.
Examples Oncologists are often asked by their patients with early-stage breast
cancer for periodic scans and tumor markers in hopes of detecting
metastatic disease before symptoms arise.
Randomized studies show that routine surveillance for metastatic
disease does not prolong survival or improve health-related quality of
life, may lead to unnecessary or invasive testing, and contributes
significantly to the cost of follow-up care.
As a rule, physicians should not feel compelled(forced or pressured) to
participate in expensive care that is not rooted in medical evidence.
Examples However, in some situations, the decision making becomes more
complex; that is, novel therapies may provide a marginal benefit, but at a high cost. For example, in the case of HER2-positive breast
cancer, data in the neoadjuvant and metastatic settings show that additional HER2-based therapies given with trastuzumab, such as lapatinib and pertuzumab, may further improve outcomes .
Most recently, trastuzumab-DM1 was approved for the treatment of metastatic HER2-positive breast cancer, and clinical trials in the adjuvant setting are planned.
If additional benefit of these drugs is confirmed in large adjuvant randomized trials, one can imagine a scenario in which oncologists are forced to decide on further improving outcomes versus doubling or tripling the cost of therapy. As
an example, the cost of trastuzumab-DM1 is $9,800
per month of treatment, for an additional 5.8
months of life in patients with metastatic disease.
How will we do our Part providing a Symmetrical System of
Cancer Care
CHOOSING WISELY
Shared Decision-Making: The Balance Between Evidence-Based Medicine and Patient-Centered Care?
CHOOSING WISELY One of the most important aspects to reduction of
unnecessary expenditure in oncology is the consideration of what is gained by the use of the available management approaches.
The Institute of Medicine has encouraged physicians to carefully consider the benefits and drawbacks associated, in particular, with expensive management options in the so-called “Choosing Wisely” campaign.
Shared Decision-Making: The Balance Between Evidence-Based Medicine and Patient-Centered Care? It is thought that two parallel philosophies predominate in
modern medicine: evidence-based medicine (EBM) and patient-centered care (PCC)
EBM is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
PCC focuses on the patient's preferences for treatment and participation in decision making.
EBM attempts to standardize care and create clinical algorithms,
whereas PCC aims to promote autonomy and the inclusion of the
individual patient in medical decision making. Both disciplines strive to
improve quality of care and, ultimately, health outcomes.
A growing body of literature indicates that patients who participate actively
in the decision-making process are more satisfied with the quality of care
However, the evidence has not uniformly incorporated into routine oncologic
care, and a minority of patients participate in a truly shared approach to
decisions
SUMMARY and Recommendations
The exponential increase in costs of health care is unnecessary and reflects many avoidable factors at a community level, including poor health practices, unrealistic expectations, corporate profiteering (unethical projects), and a poor medical decision process (which often contravenes level 1 to 2 evidence).
Physicians must increasingly consider true value (outcome/cost ratio) when creating management plans and include these considerations in transparent and realistic conversations with patients. Attention to these issues will dramatically reduce the increasing costs of cancer care in our community while improving the quality and value of care.
Recommendations TRAINING THE NEXT GENERATION OF PHYSICIANS TO
INCORPORATE THE VALUE PROPOSITION.
Training oncology residents to provide high-value care is key
to transforming the practice of oncology .
Expressed simply, residents who do not train in high-value
care settings are less likely to become high-value physicians.
Residency faculty must be skilled in the organization and
delivery of high-value care and in how to teach those skills.
Refrences D Raghavan, MW Legnini - American Society of Clinical Oncology …, 2016 -
ncbi.nlm.nih.gov Porter ME, Teisberg EO. How physicians can change the future of health care.
JAMA. 2007;297:1103-1111. Schnipper L, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology
identifies five key opportunities to improve care and reduce costs: the top five list for oncology: ASCO’s top five list. J Clin Oncol. 2012;30:1715-1724. PubMed | CrossRef
Cherny NI, Sullivan R, Dafni U, et al. A standardised, generic, validated approach to stratify the magnitude of clinical benefit that can be anticipated from anti-cancer therapies: the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). Ann Oncol. 2015;26:1547-1573.
Keirns CC, Goold SD. Patient-centered care and preference-sensitive decision making. JAMA. 2009;302:1805–1806. [PubMed]
Baselga J, Bradbury I, Eidtmann H, et al. Lapatinib with trastuzumab for HER2-positive early breast cancer (NeoALTTO): A randomised, open-label, multicentre, phase 3 trial. Lancet. 2012;379:633–640. [PubMed]
The GIVIO Investigators. Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. JAMA. 1994;271:1587–1592. [PubMed]