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?

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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)

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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”

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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

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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.