August 2013 Vol 6, No 6 Special Issue - Health Economics
Wayne Kuznar

Chicago, IL—Inappropriate deviation from evidence-based standards of care for cancer raises costs in excess of $25,000 per patient, stated Arlene A. Forastiere, MD, Senior Vice President of Medical Affairs at eviti, Inc, Philadelphia, PA, in a poster presented at the 2013 American Society of Clinical Oncology annual meeting.

In Dr Forastiere’s review of oncology treatment plans for 2544 patients, approximately 25% of the patients had treatment plans that did not conform to evidence-based standards.

The finding “is an argument for decision support tools that are used at the point of care,” noted Dr Forastiere. “We can’t change this if we’re always at the back end.”

Eviti is an independent health in­for­mation technology company that reviews treatment plans for commercial payers. For this study, treatment plans for all cancer types were reviewed from March 2009 to March 2012 for adherence to national guideline recommendations. The cost difference between the proposed treatment and the expected treatment (when the treatment was nonadherent or not a medically justified deviation) was calculated.

For prospective reviews, “we had discussions with oncologists to see if there was some patient-specific factor to justify a deviation. If that wasn’t the case, if in our conversation with the doctor the treatment was changed to a recommended drug, we calculated the exact cost related to what the doctor initially wanted to do versus what they changed the treatment to,” Dr Forastiere observed.

In retrospective situations in which no justification for a treatment could be identified, the lowest-cost evidence-based treatment that yielded a comparable outcome was used as the comparator. Average wholesale pricing was used for chemotherapy and for supportive drugs. Medicare pricing was used for radiation therapy.

Some of the major deviations in drug use were growth factor overutilization (in particular, the overuse of white blood cell growth factor), the use of combination therapies that have not been shown to be beneficial or indicated, more cycles of chemotherapy than are recommended in an adjuvant setting, and the use of drugs that are not approved for a particular indication, according to Dr Forastiere.

For radiation, the overutilization of technologies, such as image-guided radiation or intensity-modulated radiation, could qualify as deviations.
Of the 2544 patients included in this analysis, 730 (28.7%) had “unjustified” non–evidence-based treatment plans. The mean per-patient excess cost for unjustified deviations was $25,579.

With an expected annual incidence of 2500 new cancer cases per 1 million commercially insured lives, 1875 patients would receive chemotherapy or radiation therapy as part of their treatment. With a 28.7% rate of in­appropriate deviations from evidence-based standards of care, 538 patients would receive treatment outside of these standards, and the overspending in this group would be >$13 million, based on a $25,000 cost per patient, according to Dr Forastiere.

She concluded, “Another way of looking at it, which is even more striking, is that we know that there are 1.6 million new cases of cancer diagnosed per year in the [United States] currently. If you consider that 1 in 4 [patients] is likely getting some treatment that is inappropriate, multiply that by $25,000, and you’re talking about billions of dollars. That $25,000 is a very conservative number, because it’s just first-order savings. It doesn’t include hospitalizations as a result of overtreatment or complications.”

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Last modified: August 22, 2013
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