[Episode-based bundled payment model: evaluation of medical costs for early operable breast cancer]. / Financement à l'épisode de soins : évaluation du coût d'une chirurgie première pour cancer du sein précoce.

INTRODUCTION: Episode-based bundled payment model is actually opposing to fee-for-service model, intending to incentivize coordinated care. The aims of these study were to determine episode-based costs for surgery in early breast cancer patients and to propose a payment model. METHODS: OPTISOINS01 was a multicenter prospective study including early breast cancer patients from diagnosis to one-year follow up. Direct medical costs, quality and patient reported outcomes were collected. RESULTS: Data from 604 patients were analyzed. Episode-based costs for surgery were higher in case of: planned radical surgery (OR=9,47 ; IC95 % [3,49-28,01]; P<0,001), hospitalization during more than one night (OR=6,73; IC95% [2,59-17,46]; P<0,001), home hospitalization (OR=11,07 ; IC95 % [3,01-173][3,01-54][3,01-543][3,01-54,33]; P<0,001) and re-hospitalization (OR=25,71 ; IC95 % [9,24-89,17; P<0,001). The average cost was 5 268 € [2 947-18 461] when a lumpectomy was planned and 7408 € [4 222-22 565] in case of radical mastectomy. Bootstrap method was applied for internal validation of the cost model showing the reliability of the model with an area under the curve of 0,83 (95 % CI [0,80-0,86]). Care quality and patient reported outcomes were not related to the costs. DISCUSSION: This is the first report of episode-based costs for breast cancer surgery. An external validation will be necessary to validate our payment model.

An exploratory instrumental variable analysis of the outcomes of localized breast cancer treatments in a medicare population.

This study is motivated by the potential problem of using observational data to draw inferences about treatment outcomes when experimental data are not available. We compare two statistical approaches, ordinary least-squares (OLS) and instrumental variables (IV) regression analysis, to estimate the outcomes (three-year post-treatment survival) of three treatments for early stage breast cancer in elderly women: mastectomy (MST), breast conserving surgery with radiation therapy (BCSRT), and breast conserving surgery only (BCSO). The primary data source was Medicare claims for a national random sample of 2907 women (age 67 or older) with localized breast cancer who were treated between 1992 and 1994. Contrary to randomized clinical trial (RCT) results, analysis with the observational data found highly significant differences in survival among the three treatment alternatives: 79.2% survival for BCSO, 85.3% for MST, and 93.0% for BCSRT. Using OLS to control for the effects of observable characteristics narrowed the estimated survival rate differences, which remained statistically significant. In contrast, the IV analysis estimated survival rate differences that were not significantly different from 0. However, the IV-point estimates of the treatment effects were quantitatively larger than the OLS estimates, unstable, and not significantly different from the OLS results. In addition, both sets of estimates were in the same quantitative range as the RCT results.We conclude that unadjusted observational data on health outcomes of alternative treatments for localized breast cancer should not be used for cost-effectiveness studies. Our comparisons suggest that whether one places greater confidence in the OLS or the IV results depends on at least three factors: (1) the extent of observable health information that can be used as controls in OLS estimation, (2) the outcomes of statistical tests of the validity of the instrumental variable method, and (3) the similarity of the OLS and IV estimates. In this particular analysis, the OLS estimates appear to be preferable because of the instability of the IV estimates.

[Cost-effectiveness of MR-imaging in the preoperative work-up of suspicious breast lesions]. / Kosten-Wirksamkeits-Analyse der präoperativen MR-Mammographie bei suspekten Mammaläsionen.

UNLABELLED: Cost-effectiveness of MR-imaging in the preoperative work-up of suspicious breast lesions. PURPOSE: To assess the clinical and economic consequences of a preoperative magnetic resonance mammography (MRM) in patients with suspicious breast lesions. PATIENTS AND METHODS: 483 out of 2426 patients operated because of breast neoplasms at the University Hospital of Jena between August 1995 and March 1999 underwent preoperative Gd-enhanced breast MRI in addition to mammography and breast ultrasound because of suspicious breast lesions. The histological assessment was correlated with the results of the diagnostic imaging work-up in 447 cases. The costs of surgery for malignant lesions were calculated based on case- dependent billing agreements, costs of surgery of benign lesions were calculated based on current billing procedure. In 36 cases no surgery was performed due to the exclusion of malignancy by breast MRI. 140 benign lesions were treated surgically in spite of negative breast MRI diagnosis. The hospitalization time related costs caused by these cases were compared to the costs of preoperative MR-imaging. RESULTS: The total costs for MR mammography in all 483 patients amounted to DM 499,857. In 11 cases false positive results in MRM led to additional costs of DM 32,565. Assuming that there is no need for surgical treatment of benign breast lesions, total savings of DM 521,048 due to avoided hospitalization in 176 cases could have been possible. The savings per patient amount in these 176 cases are DM 2,960.50 compared to DM 1,034.90 costs for breast MRI. CONCLUSION: Despite the currently still high costs of breast MRI a major cost reduction can be achieved by prevention of unnecessary surgery, avoidance of additional surgery and associated trauma for patients.

Observation interval for evaluating the costs of surgical interventions for older women with a new diagnosis of breast cancer.

OBJECTIVE: To estimate the episodic costs of surgical treatments for breast cancer. METHODS: The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model. RESULTS: It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P <0.05) less costly than a mastectomy alone ($4,955 vs. $9,049). CONCLUSIONS: By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.

Cost analysis of breast conservation surgery compared with modified radical mastectomy with and without reconstruction.

BACKGROUND: Breast conservation surgery (BCS), consisting of lumpectomy, axillary lymph node dissection, and radiation therapy, is as effective as modified radical mastectomy (MRM) for the treatment of early stage breast cancer. The costs of these treatment options have not been adequately addressed in the current era of increasing utilization of BCS and breast reconstruction. The purpose of this study is to determine differences in treatment costs among BCS, MRM alone, and MRM with reconstruction. METHODS: Patients with stage I and II breast cancer receiving inpatient treatment at a private university-affiliated hospital between January 1996 and July 1997 were analyzed (n = 230). Charges were determined as follows: inpatient and radiotherapy charges from the hospital billing department, surgeon fees from group practice billing codes, and radiotherapy physician fees from the radiation oncology group practice. Inpatient length of stay was obtained from hospital medical records. RESULTS: Average hospital inpatient charge for BCS was $4,748 (n = 74), $6,280 for MRM alone (P <0.001, n = 132), and $11,946 for MRM with reconstruction (P <0.001, n = 24). Surgeons' fees for BCS were $2,840, $3,500 for MRM alone, and $10,774 for MRM with reconstruction. The average radiotherapy charge was $18,742. Average length of stay was 1.03 days for BCS, 2.44 days for MRM alone (P <0.001), and 3.71 days for MRM with reconstruction (P <0. 001). Average total cost of BCS ($26,330) was significantly greater than the average total cost of either MRM alone ($9,780, P <0.001) or MRM with reconstruction ($22,720, P <0.001). CONCLUSIONS: BCS is more expensive than MRM with or without reconstruction. It is the addition of radiotherapy that results in the higher total cost of CS.

Charges for partial, radical mastectomy vary by region.

Data Library: Breast cancer survival rates are going up, largely due to early detection and diagnosis. Surgery remains a mainstay of treatment, most often by a modified radical mastectomy but increasingly by the less drastic partial mastectomy, or lumpectomy. This MetLife analysis of charges and utilization for radical and partial mastectomy reveals some noteworthy geographic variations.

Framing and labelling effects in health descriptions: quality adjusted life years for treatment of breast cancer.

At present there is a growing interest in the use of cost-utility analysis (CUA) to a point where it merits serious consideration by health care decision makers. However, there remain a number of theoretical and practical issues to be resolved including the way in which quality of life information is presented and described to subjects. Two potential sources of influence in the construction of the quality adjusted life year (QALY) values elicited for a recent Australian CUA of mammography screening have been investigated. 180 subjects were randomly allocated to nine different presentations of two breast cancer health descriptions to investigate the impact of some framing and labelling effects. No statistically significant differences were found in the valuations placed on these descriptions when framing and labelling effects were taken into account, either as separate framing and labelling factors or as interactions with one another. A significant difference was found in the particular values of descriptions that were written in the third person that differed in terms of whether the word "cancer" was used. The main contribution of these data is to the robustness of the health descriptions used in the cost-utility analysis of mammography screening.

The cost of hospital stay for operable breast cancer.

The cost of the first hospital stay for operable breast cancer was deducted by analysing a random sample of 100 admissions to the National Institute of Cancer during the period January-December 1989. The aims of the study were: (1) to describe and calculate the cost component of the stay; (2) to analyse whether any procedure, service rendered or stage of the pathology might explain differences in the total costs of the stay; and (3) to acquire a better knowledge of the organizational aspects to be improved. With an average length of stay of 14.1 days, the overall total cost observed was 4.9 million lira (US $3.800, 1989 US dollars). A significant correlation between total cost and duration of stay was found (R2 = 0.982), while no or very little correlation was found between cost and the anatomical extent of disease (TNM stage) and different cost items (laboratory, imaging tests, operating room, etc.). Two homogeneous groups of cases were found: patients with quadrantectomy and patients with mastectomy. The cost of the latter was 40% greater than that of the former (P < 0.001) with a length of stay 52% longer (p < 0.001). This study does not concern the costs immediately following the stay, which namely are higher for the quadrantectomy because the radiotherapy outpatient procedures. Attention should be paid to reducing the length of stay, keeping waiting time for organizational procedures to a minimum during the stay.

The role of reconstruction in breast cancer.

Lumpectomy and irradiation is an increasingly popular treatment option for women with breast cancer. Currently, modified radical mastectomy is selected about as often. Most women choosing to have a mastectomy desire reconstruction to improve the cosmetic result; this procedure can be done immediately or at a later time. If immediate reconstruction using a plastic implant is selected, an expander can be used if the skin cover is inadequate. A myocutaneous flap can be used either immediately or later and whether sufficient skin is available. The trans rectus abdominal myocutaneous (TRAM) flap is increasingly popular because a large amount of tissue can be transferred and the cosmetic blemish from tissue transfer is preferable on the lower abdomen than elsewhere. Treatment costs are of some importance. The cheapest procedure is the modified radical mastectomy; lumpectomy with iridium implant is the most expensive, and the other treatments fall in between.