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TREATMENT AND LONG-TERM COSTS OF PEDIATRIC ACUTE LYMPHOBLASTIC LEUKEMIA
9th ANNUAL UTAH HEALTH SERVICES RESEARCH CONFERENCE
April 30th, 2014
Sapna Kaul, PhD, MAPost-Doctoral Research Associate, Health EconomicsHematology/Oncology, Department of Pediatrics
INTRODUCTION
INTRODUCTION• Why study pediatric cancer costs?• Assess economic burden over time• Cost effectiveness analyses• Cost benefit analyses• Cost containment techniques
• Costs of pediatric cancer is an understudies area.• HCUP’s study on pediatric cancer hospitalizations, 2009.• Russell et al. (2012, Pediatrics)
Systematic review of economic evaluations of pediatric cancer treatments. Majority of the studies were by European investigators. Only 10 studies by U.S. investigators.
Approaches to Value Based Care
WHY ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)?
• Accounts for 25% to 30% of childhood cancer diagnoses.
• About 3,000 children and adolescents are diagnosed with ALL every year in the U.S.
• The incidence rate has gradually increased over time and survival rate 85% to 90%.
• Survival rates in Black and Hispanic children are lower than White children with ALL.
Blood Stem Cell
LymphoidB
LymphocyteT
Lymphocyte
Myeloid
ALL TREATMENT
Induction35 days
Post-InductionStandard Risk = 9
monthsHigh Risk = 7
months
Maintenance
Girls = 2 years
Boys= 3 years
Long-Term> 5 years
Vary by risk and sex …
Standard risk – WBC count less than 50,000/μL and age 1 to younger than 10 years.High risk – WBC count 50,000/μL or greater and/or age 10 years or older.
OBJECTIVES
• Examine hospitalizations costs of pediatric ALL over time.- Aggregate costs.- Disaggregate costs by cost components (room & care, diagnostics etc.) and treatment phases (induction, post-induction, maintenance, long-term).
• Investigate factors that affect hospitalization costs.‐ Treatment related factors (risk, relapse, infections etc.).‐ Socio-economic factors (insurance, distance from hospital).
DATA• N=553 pediatric ALL patients.
• Patients identified through the Intermountain Healthcare System.
• Diagnosed years 1998 to 2013.
• Longitudinal data – hospitalizations data with costs.
• Cost data adjusted for inflation using Consumer Price Index.
STATISTICAL METHODS
• Aggregate and disaggregate costs -Annual average per patient hospitalization costs.-Annual average costs by cost components and treatment phases.
• Factors that affect per patient hospitalization costs- Multivariable regression – GLM.- Separate regressions – within and after 5 years of diagnosis.
Analyses in STATA and R …..
Characteristics N %
Age at Diagnosis(years)
< 11- 55 - 10>10
19306100128
3551823
Sex FemaleMale
263290
4852
Race WhiteNon-White
48469
8712
Insurance at Diagnosis
PublicPrivateUninsured
13339921
24724
Residence at ALL Diagnosis
UTAZ, CO, ID, MT, NV, WYAK, CA, MO, WA
4411057
80191
Patients Characteristics
Treatment Related Characteristics
ALL Specific Characteristics N %
ALL RiskInfantsStandard RiskHigh Risk
19343191
36234
Phases for Standard and High Risk Patients
InductionPost-InductionMaintenanceLong-Term
52137633799
97726019
ALL RelapseYesNo
63490
1189
TransplantYesNo
45508
892
MortalityAliveDead
49063
8911
- 97% patients were diagnosed at Primary Children’s Hospital
- Annual diagnoses varied from 25 to 40 from 1998 to 2013
RESULTSAggregate Costs
2000 2005 2010
05
10
15
Per Patient Per Hospitalization Average Annual Costs
Years
Avera
ge C
osts
in $
1000
Average Costs Per Hospitalization among ALL Patients
Disaggregated Costs by Cost Components
2000 2005 2010
02
46
8
Per Patient Per Hospitalization Average Annual Costs
Years
Ave
rage C
ost
s in
$1000
Room & CareTherapyPharmacyDiagnostic
Average Costs Per Hospitalization among ALL Patients
Disaggregated Costs by Treatment Phases
2000 2005 2010
05
1015
20
Per Patient Per Hospitalization Average Annual Costs
Years
Ave
rage
Cos
ts in
$10
00
InductionPost-InductionMaintenanceLong-Term
Average Costs Per Hospitalization among ALL Patients
Multivariable Regression Analysis for Treatment Costs within 5 years of DiagnosisN=424, Hospitalizations=2887
Independent Variables Effect on Dependent
Variable
P-value
Treatment Related Characteristics
High Risk vs. Standard Risk
2298 <0.01
Relapse vs. no Relapse 3302 <0.01
Induction vs. Post-Induction
7160 <0.01
Infection vs. no Infection
1916 <0.05
Socio-Demographic Characteristics
Public vs. Private Insurance
1274 <0.01
Insignificant variables – race, sex, distance from facility etc. Controlled for fixed year effects.Exclusions – infants, residents of WA, AK, MO, CA, and diagnosis after 2010.
Variable Effect on Dependent
Variable
P-value
Treatment Related Characteristics
Relapse vs. no Relapse
4355 <0.01
Infection vs. no Infection
9884 <0.05
Socio-Demographic Characteristics
Uninsured vs. Private
-3827 <0.05
N=99, Hospitalizations=237
Multivariable Regression Analysis for Long-Term Costs Starting 5 years after Diagnosis
The remaining variables were insignificant.Exclusions – Residents of WA, AK, MO, CA.
CONCLUSIONS• Average cost per hospitalization has increased over time. Increase differs substantially by cost components and treatment phases.
• Factors that potentially increase costs:• Treatment related and socio-demographic characteristics.• Costs of treating infants very high – upper limit of $151,167 per visit.
• Value based care:• Cost-effective patient-centered care for High Risk and Relapsed patients.
• Emphasis on managing induction, room and care, and pharmacy costs.
• Insurance can provide leads on monitoring high cost patients.
LIMITATIONS
Economic
Burden of
Pediatric ALL
Hospitalization Costs
Other Medical Costs
e.g. Physician Costs,
Outpatient Costs
Indirect Medical Costs
NEXT STEPS• Use more refined treatment phase identifiers (e.g., LPs and pharmacy data).
• Incorporate physician costs and out-patient medical costs.
• Robust examination of late effects include patients diagnosed in 1980’s.
• Costs of all Pediatric cancers.
COLLABORATORS AND FUNDING
Anne C. Kirchhoff, PhD, MPHRichard Lemons, MDKent Korgenski, MSMark Fluchel, MDAnupam Verma, MDElizabeth Raetz, MDRichard Nelson, PhDJosh Schiffman, MDChristi Ng, MPHSeth Andrews, MBA
Funding Source: Primary Children’s Hospital’s Pediatric Cancer Program (PCHPCP)
OUTLINE• Introduction
• Objectives
• Data and Statistical Methods
• Results
• Conclusions
• Limitations and Next Steps
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