rosanna tarricone cost effectiveness of the ... · that counts” mae west did she invent the...
TRANSCRIPT
www.excemed.org
IMPROVING THE PATIENT’S LIFE THROUGH
MEDICAL EDUCATION
Cost effectiveness of the multidisciplinary management of cancer
Rosanna Tarricone
Italy
Economic rationality in clinical decision-making: why?
Basic principles of cost-effectiveness analysis (CEA)
Multidisciplinary management of cancer:
is it cost-effective?
for what?
for who?
Conclusions
Agenda:
Evidence-based medicine and Economic Evaluation Analysis: where is the gap?
The primary purpose of evidence-based medicine (EBM) had always been to guide clinical choices to improve patients’ health
EBM has dominated the allocation of scarce resources for decades
In recent times, decision-makers claimed for additional tools, besides EBM, to allocate scarce resources
This happened in response to global trends:
Rapid pace of technological innovation
Ageing of the populations
High epidemiological and economic burdens of chromic diseases
Opportunity cost and economic evaluation analysis
In times of scarcity, resources need to be allocated to maximise
health benefits:
opportunity cost = benefits forgone
Economic evaluation analysis aim at comparing and assessing
costs and benefits of different alternatives so to choose the
one that maximise health benefits per unit of cost
4
5
Cost-Effectiveness Analysis (CEA)
• CEA aims at helping decision-makers allocate scarce resources
• The underlying assumption is that for a given budget, society
wishes to maximise total health benefits
• The analytical tool of CEA is the incremental cost-effectiveness
ratio (ICER) given by the difference in costs between two
programs divided by the difference in outcomes between the
programs with the comparison normally being between a new
program and the existing approach
The Incremental Cost-Effectiveness Ratio (ICER)
CB CA
EB EA
6
ICER =
What measurement unit for effectiveness?
Life years saved Quality-adjusted life years
“It’s not the years
in your life, but the
life in your years,
that counts”
Mae West
Did she invent the QALYs?
7
ICER calculation: an example
Health Programs Costs (Euro) Effectiveness (QALYs) ICER
A (new technology) 1,000,000 800
B (standard of care) 500,000 750
ICER 500,000 50 10,000
8
How do we decide whether the health program is worth introducing?
Threshold value: NICE recommendation on Bevacizumab for breast cancer (1)
9
Threshold value: NICE recommendation on Bevacizumab for breast cancer (2)
EMA recommends that bevacizumab, when used to
treat metastatic breast cancer, should be used only in
combination with the taxane paclitaxel
Bevacizumab in combination with paclitaxel or
docetaxel has a marketing authorisation for “first-line
treatment of patients with metastatic breast cancer”
10
Threshold value: NICE recommendation on Bevacizumab for breast cancer (3)
NICE concludes that ICER is in the range of UKP
110,000-259,000 per QALY gained
“.. Overall, [the drug] didn't show enough of a demonstrable benefit for it to be considered a cost-effective use of National Health Service resources....“ (Andrew Dillon, NICE Chief Executive)
Bevacizumab in combination with a taxane is NOT recommended for the first-line treatment of metastic breast cancer
11
ICER and threshold value: impact onto cancer drugs in UK
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
Insufficient evidence
of effectiveness
Uncertainty issues Methodological
issues
ICER explicit reason
for restriction
ICER lack of
evidence
ICER evidence too
high
Period 00-06 (N=15) Period 06-08 (N=10)
Source: Mason & Drummond. Public funding of new cancer drugs: Is NICE guidance getting nastier? EJC 2009(45):1188-1192
ICER calculation: a (real) example
Treatments Cost (€) Δ Cost
(€) LYs ΔLYs QALYs ΔQALYs €/LY €/QALY
TARE 31,071 1,782 2.531 0.956 1.178 0.540 1,865 3,302
Sorafenib 29,289 1.575 0.638
Intermediate stage
ICER calculation: a (real) example (2)
Advanced stage
Strategy Cost (€) Δ Cost
(€) LYs ΔLYs QALYs ΔQALYs €/LY €/QALY
TARE 21,961 1.445 0.139 0.639 0.071 dominant dominant
Sorafenib 30,750 8,788 1.306 0.568
Multidisciplinary teams (MDTs) in cancer care
• Cancer care is undergoing an important paradigm shift from a disease-focused management to a patient-centered approach
• A growing attention is given to survivorship issues, quality of life, patient’s preferences and economic sustainability
• Decision-making in cancer is being increasingly associated with multidisciplinary teams (MDTs)
• Clinical outcomes, healthcare costs and organizational aspects related to MDTs are still a matter of debate in the integrated cancer care community
Cost-(effectiveness) studies of MDTs in oncology
• A literature search in PubMed was conducted using keywords as “multidisciplinary”, “cancer” and “cost”
• 4 original studies reporting cost (or cost-effectiveness) results for MDTs in oncology were identified in the last few years:
Study Cancer Location Data collection Results Recommendation for MDTs
De Ieso (2013) Various UK Retrospective Only costs High costs, effectiveness to be proven
Chinai (2013) Colorectal UK Prospective Costs and outcomes reported separately
No, high resources and small clinical impact
Freeman (2015) Lung US Retrospective Costs and outcomes reported separately
Yes, MDTs improve the timeliness and quality of care and reduce costs
Wein (2015) Colorectal Germany Prospective Costs and outcomes reported separately
Yes, better outcomes and lower costs
• Analysis of electronic patient records of 551 newly diagnosed patients (solid tumors and lymphoma)
• Core members: surgeons, medical oncologists, radiologists, histopathologists, clinical nurse specialists and MDM coordinators
(1) De Ieso et al. (2013)
47 colorectal cancer cases prospectively observed over 3 months at Derriford Hospital (UK)
Core members: surgeons (n=8), radiologists (n=2), pathologists (n=1), and oncologists (n=2)
Extended members: nurse specialists (n=3), junior doctors, MDT meeting coordinator, administrative support
For three patients only there were significant differences between the preliminary consultant decision and MDT recommendations
(2) Chinai et al. 2013
(3) Freeman et al. 2015
• Non-small cell lung cancer (NSCLC) patients referring to 77 different hospitals between 2008 and 2012 were identified through a database
• Multidisciplinary Care Conference (MDC) was defined as a conference attended by medical and radiation oncology and thoracic surgery at least every 2 weeks and focused on prospective treatment planning
• Analysis of the mean costs before the initiation of treatments in the two cohorts (MDC vs. non-MDC) found a significant difference (p<0.0001)
• Most of the cost difference (85%) was attributable to the more frequent use of imaging studies (imaging of the abdomen, bone scintigraphy, magnetic resonance imaging) in the non-MDC group
• Patients with NSCLC realize improved quality and timeliness of care when that care is coordinated through a MCC. The use of MDC was also associated with a reduction in cost.
The Effects of a Multidisciplinary Care Conference on the Quality and Cost
of Care for Lung Cancer Patients.
(4) Wein et al. 2015
A total of 82 patients with colon or rectum cancer (CRC) were enrolled at three centers (A, B and C)
The characteristics of the patients (age, gender, primary tumor location, metastases, ECOG) were comparable across the centers
The patients of the center (A) with the closest and most intensive interdisciplinary cooperation had the most favorable outcomes and their treatment was associated with the lowest costs.
The management of CRC must be a multimodal approach by an experienced multidisciplinary expert team.
Palliative treatment of colorectal
cancer with secondary metastasis resection in Germany - impact of the
multidisciplinary treatment approach on prognosis and cost: the Northern Bavaria
IVOPAK I Project.
MDTs: open questions
+ Quicker time to diagnosis and treatment
Increased recruitment into clinical trials
Adherence to clinical guidelines and evidence-based decisions
Improved communications and educational opportunities among
healthcare professionals
Potentially better survival outcomes
- Costs/Cost-effectiveness
Medical-legal implications
Feasibility for peripheral centers
Real impact on survival and quality of life
Conclusions
• Cancer treatment need to adopt a multidisciplinary approach
• More research is needed on the outcomes of MDTs in oncology in terms of patient’s satisfaction, overall survival, quality of life.
• The evidence around the cost-effectiveness of multidisciplinary activities for the management of cancer patients is still very limited
• New technologies such as telemedicine, teleconferencing and mhealth might improve patient-doctor and doctor-doctor communication and potentially reduce costs of the multidisciplinary approach
References
• Bossi P, Alfieri S. The benefit of a multidisciplinary approach to the patient treated with (chemo)-radiation for head and neck cancer. Curr Treat Options in Oncol 2016: 17:53.
• Chinai N, Bintcliffe F, Armstrong EM, et al. Does every patient need to be discussed at a multidisciplinary team meeting? Clin Radiol 2013: 68(8): 760-1.
• De Ieso PB, Coward JI, Letsa I, et al. A study of the decision outcomes and financial costs of multidisciplinary team meetings (MDMs) in oncology. Br J Cancer 2013: 109(9): 2295-300.
• Freeman RK, Ascioti AJ, Dake M, et al. The effects of a multidisciplinary care conference on the quality and cost of care for lung cancer patients. Ann Thorac Surg 2015: 100(5): 1834-8.
• Rognoni C, Sommariva S, Ciani O, Tarricone R. Cost-effectiveness analysis of TARE vs Sorafenib for treating intermediate-advanced stage hepatocellular carcinoma. Value in Health 2016
• Wein A, Emmert M, Merkel S, et al. Palliative treatment of colorectal cancer with secondary metastasis resection in Germany - impact of the multidisciplinary treatment approach on prognosis and cost: the Northern Bavaria IVOPAK I Project. Oncology. 2015;88(2):103-21.