Indicators of clinical performance in monitoring soft tissue sarcoma management: a population-based perspective.

Background: Soft tissue sarcomas (STS) are rare malignancies which prognosis varies significantly by primary site, histological subtype, and tumor stage. Their low incidence, and the complexity of their clinico-pathological characteristics demand standardized, cancer-tailored diagnostics and therapies managed at high-volume, multidisciplinary care centers. This study evaluates the quality of STS management in north-east Italy (Veneto Region) through a list of ad hoc defined clinical indicators. Methods: This population-based study concerns all incident cases of STS in 2018 (214 cases) recorded in the adult population censored by the Veneto's regional Cancer Registry. Based on the international literature, a multidisciplinary working group of experts identified a set of indicators for monitoring the quality of diagnostic, therapeutic, and end-of-life clinical interventions. The quality of care was assessed by comparing the reference thresholds with the indicators' values achieved in clinical practice. Results: Diagnostic procedures showed poor adherence to the thresholds, with a low percentage of histological diagnoses validated by a second opinion. The indicators relating to the surgical treatment of superficial, small, low-grade STS, or of medium, high-grade STS of the head-neck, trunk, or limbs were consistent with the thresholds, while for intermediate, high-grade (large-sized, deep) and retroperitoneal STS they fell significantly below the thresholds. Conclusion: A critical evaluation of the clinical indicators allowed to uncover the procedures needing corrective action. Monitoring clinical care indicators improves cancer care, confirms the importance of managing rare cancers at highly specialized, high-volume centers, and promotes the ethical sustainability of the healthcare system.

Direct Costs of Care for Adults with Soft Tissue Sarcomas: A Population-Based Study.

The clinical treatment of soft tissue sarcoma (STS) has evolved substantially over the last decade. This population-based cohort study based on real-world data included all incidental STS recorded by the Veneto Cancer Registry in 2017. Data on hospital admissions, emergency department and outpatient visits, drug prescriptions, and use of medical devices within two years from STS diagnosis were obtained from administrative databases. The average per-patient real-world costs over this two-year period, in total and by single expenditure item, were calculated and stratified by stage of disease at diagnosis, tumor histology and tumor site. The mean total cost per patient amounted to EUR 16,793. A higher TNM stage at diagnosis was associated with higher healthcare costs, as follows: compared with stage I, the average total cost per patient was 1.32, 2.18 and 3.36 times greater for stages II, III and IV, respectively. Hospital stays generated the greatest costs (averaging EUR 7950 per patient), followed by outpatient visits (mean EUR 3947 per patient) and drug prescriptions (mean EUR 3664 per patient). Given the paucity of population-based studies, the present results can serve as a reference for further cost-effectiveness analyses on care strategies for patients with STS.

Health and health service usage outcomes of case management for patients with long-term conditions: a review of reviews.

OBJECTIVE: There have been plenty of articles published in recent decades on patient care in the form of case management (CM), but conclusions regarding health outcomes and costs have often been discordant. The objective of this study was to examine previous systematic reviews and meta-analyses with a view to assessing and pooling the overwhelming amount of data available on CM-based health outcomes and resource usage. METHODS: We conducted a review of reviews of secondary studies (meta-analyses and systematic reviews) addressing the effectiveness of CM compared with usual care (or other organizational models) in adult (18+) with long-term conditions. PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) were searched from 2000 to the end of December 2017. The outcomes of interest are related to process of care, health measures, and resource usage. RESULTS: Twenty-two articles were ultimately considered: 4 meta-analyses and 18 systematic reviews. There is strong evidence of CM increasing adherence to treatment guidelines and improving patient satisfaction, but none of the secondary studies considered demonstrated any effect on patient survival. Based on the available literature, there is contrasting evidence regarding all the other health outcomes, such as quality of life (QOL), clinical outcomes, and functional status. Good-quality secondary studies consistently found nothing to indicate that CM prompts any reduction in the use of hospital resources. CONCLUSION: The source of variability in the literature on the consistency of the evidence for most outcomes is unclear. It may stem from the heterogeneity of CM programs in terms of what their intervention entails, the populations targeted, and the tools used to measure the results. That said, there was consistently strong evidence of CM being associated with a greater adherence to treatment guidelines and higher patient satisfaction, but not with a longer survival or better use of hospital resources.

Estimation of direct costs of melanoma in the Veneto Region: a budget assessment and cost-consequence analysis.

BACKGROUND: While many evidence-based pathways have been introduced to drive quality improvements in cancer care, most of these do not include evidence about their affordability. The main aim of this study was to provide an estimation of the overall budget to cover all the needs of melanoma patients in Veneto Region, managed according to the clinical pathway defined by the Rete Oncologica Veneta. A second objective is to conduct a cost-consequence analysis, comparing two different treatments. METHODS: A very detailed whole-disease model was developed describing the patient's pathway from diagnosis through the first year of follow-up. Each procedure involved in the model was associated with a likelihood measure and a cost. The model can be used to estimate the expected direct costs associated with melanoma. RESULTS: We can observe that 0 and I stage, despite accounting for a huge percentage of new melanoma cases are characterized by a small percentage of the total costs. Stage III can be considered as the most expensive stage accounting for 54% of the total costs with a 12% of patients. Finally, the stage IV patients, although very few accounts for almost the 7% of the total costs. Regarding the cost-consequence analysis, it was estimated that the therapies introduced in 2016 led to an approximately 14% increase in the total costs. CONCLUSIONS: Modeling a clinical pathway with a high level of detail enables to identify the main sources of spending. The consequent analysis can thus help policymakers to plan the future resources allocation.

Cost-effectiveness of a melanoma screening programme using whole disease modelling.

OBJECTIVE: To assess the potential impact of a melanoma screening programme, compared with usual care, on direct costs and life expectancy in the era of targeted drugs and cancer immunotherapy. METHODS: Using a Whole Disease Model approach, a Markov simulation model with a time horizon of 25 years was devised to analyse the cost-effectiveness of a one-time, general practitioner-based melanoma screening strategy in the population aged over 20, compared with no screening. The study considered the most up-to-date drug therapy and was conducted from the perspective of the Veneto regional healthcare system within the Italian National Health Service. Only direct costs were considered. Sensitivity analyses, both one-way and probabilistic, were performed to identify the parameters with the greatest impact on cost-effectiveness, and to assess the robustness of our model. RESULTS: Over a 25-year time horizon, the screening intervention dominated usual care. The probabilistic sensitivity analyses confirmed the robustness of these findings. The key drivers of the model were the proportion of melanomas detected by the screening procedure and the adherence of the target population to the screening programme. CONCLUSIONS: The screening programme proved to be a dominant option compared with usual care. These findings should prompt serious consideration of the design and implementation of a regional or national melanoma screening strategy within a National Health Service.