A virtual multi-disciplinary meeting is a cost-effective method of triaging referrals to a regional musculoskeletal oncology service.

BACKGROUND AND AIMS: In 2010, a virtual sarcoma referral model was implemented, which aims to provide a centralised multidisciplinary team (MDT) to provide rapid advice, avoiding unnecessary appointments and providing a streamlined service. The aim of this study is to examine the feasibility of this screening tool in reducing the service burden and expediting patient journey. METHODS AND RESULTS: All referrals made to a single tertiary referral sarcoma unit from January 2010 to December 2018 were extracted from a prospective database. Only 26.0% events discussed required review directly. 30.3% were discharged back to referrer. 16.5% required further investigations. 22.5% required a biopsy prior to review. There was a reduction in the rate of patients reviewed at the sarcoma clinic, and a higher discharge rate from the MDT in 2018 versus 2010 (p < 0.001). This gives a potential cost saving of 670,700 GBP over the 9 year period. CONCLUSION: An MDT meeting which triages referrals is cost-effective at reducing unnecessary referrals. This can limit unnecessary exposure of patients who may have an underlying diagnosis of cancer to a high-risk environment, and reduces burden on services as it copes with increasing demands during the COVID-19 pandemic.

Health care-related time costs in patients with metastatic breast cancer.

BACKGROUND: Burdens related to time spent receiving cancer care may be substantial for patients with incurable, life-limiting cancers such as metastatic breast cancer (MBC). Estimates of time spent on health care are needed to inform treatment-related decision-making. METHODS: Estimates of time spent receiving cancer-related health care in the initial 3 months of treatment for patients with MBC were calculated using the following data sources: (a) direct observations from a time-in-motion quality improvement evaluation (process mapping); (b) cross-sectional patient surveys; and (c) administrative claims. Average ambulatory, inpatient, and total health care time were calculated for specific treatments which differed by antineoplastic type and administration method, including fulvestrant (injection, hormonal), letrozole (oral, hormonal), capecitabine (oral, chemotherapy), and paclitaxel (infusion, chemotherapy). RESULTS: Average total time spent on health care ranged from 7% to 10% of all days included within the initial 3 months of treatment, depending on treatment. The greatest time contributions were time spent traveling for care and on inpatient services. Time with providers contributed modestly to total care time. Patients receiving infusion/injection treatments, compared with those receiving oral therapy, spent more time in ambulatory care. Health care time was higher for patients receiving chemotherapeutic agents compared to those receiving hormonal agents. CONCLUSION: Time spent traveling and receiving inpatient care represented a substantial burden to patients with MBC, with variation in time by treatment type and administration method.

Real-world costing analysis for diffuse large B-cell lymphoma in British Columbia.

Introduction: Diffuse large B-cell lymphoma (dlbcl) accounts for 30%-40% of all non-Hodgkin lymphomas. Approximately 60% of patients are cured with standard treatment. Targeted treatments are being investigated and might improve disease outcomes; however, their effect on cancer drug budgets will be significant. For the present study, we conducted an analysis of real-world costs for dlbcl patients treated in British Columbia, useful for health care system planning. Methods: Patient records from a retrospective cohort of patients diagnosed with dlbcl in British Columbia during 2004-2013 were anonymously linked across multiple administrative data sources: systemic therapy, radiotherapy, hospitalizations, oncologist services, outpatient medications, and fee-for-service physician services. Using generalized linear modelling regression, time-dependent costs (in 2015 Canadian dollars) were estimated in 6-month intervals over a 5-year period. The inverse probability weighting method was applied to account for censored observations. Nonparametric bootstrapping was used to estimate standard errors for the mean cost at each time interval. Results: The cohort consisted of 678 patients (5-year overall survival: 67%). Mean age at diagnosis was 64 ± 14 years; median follow-up was 3.2 years. Mean total cost of care was highest in the first 6 months after diagnosis ($29,120; 95% confidence interval: $28,986 to $29,170) and after disease progression ($18,480; 95% confidence interval: $15,187 to $24,772). Systemic therapy and hospitalization costs were the largest cost drivers. At each time interval, costs were observed to be positively skewed. Conclusions: Our results depict real-world costs for the treatment of dlbcl patients with standard chop-r therapy. Cost-model parameters are also provided for economic modelling of dlbcl interventions.

Implications of parenteral chemotherapy dose standardisation in a tertiary oncology centre.

BACKGROUND: Dose banding parenteral chemotherapy has the potential to optimise aseptic unit capacity and reduce drug expenditure without compromising the service provided. METHODS: Dose banding tables from NHS England were implemented into the electronic chemotherapy prescribing system. Compliance to the dose bands was analysed and submitted quarterly. Analysis of drug expenditure, drug use and cost per milligram data was also collected. RESULTS: Expenditure on the 17 drugs identified in the 2016/17 dose standardisation CQUIN reduced by approximately £100,000 per month over the CQUIN despite an increase in the number of prescribed doses of these drugs. At the beginning of the year, the percentage of work compounded in house was 60%, which was reduced to 51% of total workload at the end of the year due to outsourcing commonly prescribed doses from commercial pharmaceutical aseptic manufacturers. CONCLUSION: Dose banding parenteral chemotherapy is an efficient cost-saving strategy which also can help to increase the capacity of the aseptic unit.

Radiation Oncology Practice: Adjusting to a New Reimbursement Model.

PURPOSE: Use of hypofractionation is increasing in radiation oncology because of several factors. The effects of increasing hypofractionation use on departments and staff currently based on fee-for-service models are not well studied. METHODS: We modeled the effects of moving to hypofractionation for prostate, breast, and lung cancer and palliative treatments in a typical-sized hospital-based radiation oncology department. Year 2015 relative value unit (RVU) data were used to determine changes in reimbursement. The change in number of fractions was used to model the effects on machine volume, staff time, and workforce predictions. RESULTS: The per-case marginal reduction in technical revenue was $1,777, $4,297, $9,041, and $9,498 for palliative and breast, prostate, and lung cancer cases, respectively. The physician reduction per case in RVUs was 5.22, 10.44, 43.02, and 43.02 respectively. A department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 hours per day from a hypofractionation rate of 40%. CONCLUSION: The move to hypofractionation in the United States will lead to increased pressures on departments to address budget shortfalls resulting from the decrease in per-patient revenue. This may be done through a combination of an increase in patient volume, recognition of the increased skill sets required to deliver hypofractionated radiotherapy, delay in capital purchases, and/or reduction in staff. In a value-based environment, these evolutions should improve the value proposition of radiation oncology over a fee-for-service model.

How different is the care of terminal pancreatic cancer patients in inpatient palliative care units and acute hospital wards? A nationwide population-based study.

BACKGROUND: Inpatient palliative care is important for patients with terminal pancreatic cancer. However, the differences between inpatient palliative care and acute hospital care for inpatients with pancreatic cancer have not been explored in a population-based study. METHODS: This population-based nationwide study was conducted using data from the Taiwan National Health Insurance database to analyze the differences between inpatient palliative care and acute hospital care for inpatients with pancreatic cancer. We identified 854 patients with terminal pancreatic cancer, who had received in-hospital end-of-life care between January 2003 and December 2006. These patients were then sub-divided and matched 1:1 (using propensity score matching) according to whether they received inpatient palliative care (n = 276) or acute hospital care (n = 276). These groups were subsequently compared to evaluate any differences in the use of aggressive procedures, prescribed medications, and medical costs. RESULTS: Inpatient palliative care was typically provided by family physicians (39%) and oncologists (25%), while acute hospital care was typically provided by oncologists (29%) and gastroenterologists (24%). The inpatient palliative care group used natural opium alkaloids significantly more frequently than the acute hospital care group (84.4% vs. 56.5%, respectively; P < 0.001). The inpatient palliative care group also had shorter hospital stays (10.6 ± 11.1 days vs. 20.6 ± 16.3 days, respectively; P < 0.001), fewer aggressive procedures, and lower medical costs (both, P < 0.005). CONCLUSIONS: Compared to patients in acute hospital wards, patients with pancreatic cancer in inpatient palliative care units received more frequent pain control treatments, underwent fewer aggressive procedures, and incurred lower medical costs. Therefore, inpatient palliative care should be considered a viable option for patients with terminal pancreatic cancer.

Financiamento da atenção especializada em Pernambuco para o tratamento oncológico de mama e próstata / Financing of specialized care in Pernambuco for the oncological treatment of breast and prostate

Os custos da assistência oncológica é a sua estrutura de tratamento diferenciada, pois seus custos são baseados nos procedimentos realizados e no estadiamento ou nível da neoplasia. Ressalta-se que são realizados por ressarcimento, ou seja, os repasses financeiros são calculados com base no valor total do tratamento e divididos pela quantidade de meses, independentemente da quantidade de ciclos que o tratamento terá no mês. Esta forma de pagamento evita um novo ressarcimento de um tratamento já concluído. O objetivo do estudo foi verificar a alocação de recursos Fundo a Fundo do Ministério da Saúde para a Atenção Especializada em Pernambuco entre os anos de 2008 e 2014, para o tratamento oncológico de mama e próstata. Caracteriza-se como uma pesquisa com bases de dados secundários de domínio público e de abordagem quantitativa, de cunho epidemiológico e estruturada segundo os critérios de um estudo observacional e retrospectivo. Analisando a participação dos hospitais por natureza jurídica no Brasil, observou-se que 67,45% (R$ 4.439.213.694,41) dos valores ressarcidos no SUS para o tratamento de câncer no Brasil se concentraram nos hospitais de regime privado, enquanto 32,55% (R$ 2.142.179.536,14) foram destinados aos públicos. Demonstrando importantes fluxos financeiros para a rede privada. Os valores ressarcidos por paciente internada para cobrir os serviços do tratamento oncológico em CA de mama para o Hospital do Câncer de Pernambuco teve um crescimento de 280,44%, com média R$ 1.297,10 por ano e total de R$ 9.079,73. Em relação aos óbitos, a supracitada Unidade de Saúde teve um crescimento de 37,26%, com média de 10 óbitos a cada 100 internações ao ano e total de 73 óbitos a cada 100 internações no período em análise. Quanto à ampliação de valores ressarcidos por paciente internado para cobrir os serviços do tratamento oncológico em CA de próstata ao Instituto Materno Infantil de Pernambuco teve uma redução de 23,91%, com média R$ 2.666,94 por ano e total de R$ 18.668,61. Em relação aos óbitos, a supracitada Unidade de Saúde teve 4200% de crescimento de óbitos, com média de 6 óbitos a cada 100 internações ao ano e total de 43 óbitos a cada 100 internações no período em análise. Reafirma-se a necessidade de se avaliar as Políticas Públicas em saúde que fortaleçam o SUS, não permitindo que os hospitais de natureza jurídica pública se tornem sucateados e os privados canalizem para si todos os gastos relacionados à Atenção Especializada em Oncologia. Sugere-se fortemente uma distribuição equitativa dos gastos, levando-se em conta um maior investimento nas unidades do interior brasileiro, de maneira a fortalecer a estrutura geral do tratamento oncológico, aumentar o número de diagnósticos precoces, reduzirem as taxas de morbi-mortalidade e dos custos indiretos associados ao tratamento dos pacientes.(AU)

The cost of cancer care is its differentiated treatment structure, since its costs are based on the procedures performed and the staging or level of the neoplasia. It is emphasized that they are performed by reimbursement, that is, financial transfers are calculated based on the total value of the treatment and divided by the number of months, regardless of the amount of cycles that the treatment will have in the month. This form of payment avoids a new reimbursement of a treatment already completed. The objective of the study was to verify the allocation of resources Fund to Fund of the Ministry of Health for the Specialized Attention in Pernambuco between the years of 2008 and 2014, for the cancer treatment of breast and prostate. It is characterized as a research with secondary databases of public domain and of quantitative approach, of epidemiological character and structured according to the criteria of an observational and retrospective study. Analyzing the participation of the hospitals by legal nature in Brazil, it was observed that 67.45% (R $ 4,439,213,694.41) of the amounts reimbursed in the SUS for the treatment of cancer in Brazil were concentrated in private regime hospitals, while 32,55% (R $ 2,142,179,536.14) were allocated to the public. Demonstrating significant financial flows to the private network. The amounts reimbursed per inpatient to cover the services of the cancer treatment in CA of breast to Hospital do Câncer de Pernambuco had an increase of 280.44%, with average R $ 1,297.10 per year and a total of R $ 9,079.73 . In relation to the deaths, the above-mentioned Health Unit had a growth of 37.26%, with an average of 10 deaths per 100 hospitalizations per year and a total of 73 deaths per 100 admissions in the period under analysis. Regarding the increase in the amounts reimbursed by hospitalized patients to cover the services of the cancer treatment in CA of prostate to Instituto Materno Infantil de Pernambuco had a reduction of 23.91%, with a mean of R $ 2,666.94 per year and a total of R $ 18,668 , 61. Regarding the deaths, the above-mentioned Health Unit had a 4200% increase in deaths, with a mean of 6 deaths per 100 hospitalizations per year and a total of 43 deaths per 100 admissions in the period under analysis. It is reaffirmed the need to evaluate Public Health Policies that strengthen the SUS, not allowing hospitals of a public legal nature to become scrapped and private ones to channel all the expenses related to Specialized Attention to Oncology. It is strongly suggested that there be a fair distribution of expenditures, taking into account a greater investment in the units of the Brazilian interior, in order to strengthen the general structure of cancer treatment, increase the number of early diagnoses, reduce morbidity and mortality rates, and of the indirect costs associated with the treatment of patients.(AU)

Real-world resource use and costs of adjuvant treatment for stage III colon cancer.

Since the generalisability of trial-based economic evaluations may be limited, there is an increasing focus on real-world cost-effectiveness. Real-world studies involve evaluating the effects and costs of treatments in daily clinical practice. This study reports on the real-world resource use and costs of adjuvant treatments of stage III colon cancer in a population-based observational study. Analyses were based on a detailed retrospective medical chart review which was conducted for 206 patients with colon cancer treated in 2005 and 2006 in the Netherlands. Mean total costs per patient were €9681 for 5-FU/LV, €9736 for capecitabine, €32,793 for FOLFOX and €18,361 for CAPOX. Drug costs and the costs related to hospitalisations for chemotherapy administration were the main cost drivers. We identified a potential for substantial cost-savings when the 48 h administration of 5FU/LV in the FOLFOX regimen were to take place in an outpatient setting or be replaced by oral capecitabine as in the CAPOX regimen. This analysis based on detailed real-life data clearly indicates that clinical choices made in oncology based on efficacy of therapy have economic consequences. Considering today's reality of finite healthcare resources, these economic consequences deserve a formal role in clinical decision making, for instance in guideline development.

Economic impact of a head and neck oncologic surgeon: the case mix index.

BACKGROUND: Head and neck oncologic surgery is a time-consuming specialty that requires extensive resources and manpower. Case mix index (CMI) is used in evaluating the complexity and economic impact of surgeons. Head and neck oncologic surgeons generate significant revenue for hospitals, yet compensation is relatively low. METHODS: Retrospective review of a tertiary hospital's case mix data for 605 otolaryngology admissions from 2009 to 2011 was performed. CMI comparison for head and neck oncologic surgeons versus general otolaryngology was performed. RESULTS: In an otolaryngology department of 9 surgeons; there was a significant difference (p < .01) in the CMI and a significantly greater chance to have a "good CMI" (CMI >1) favoring head and neck oncologic surgeons. CONCLUSION: Head and neck oncologic surgeons increase the CMI for hospitals and ultimately influence the hospital's reimbursement. There is a need for increased collaboration between hospitals and departments in fostering and furthering their head and neck surgical oncology programs by taking CMI into consideration.

Volume-outcome effects for children undergoing resection of renal malignancies.

INTRODUCTION: Adults undergoing oncologic resections at low-volume centers experience increased perioperative morbidity and mortality. The volume-outcome effect has not been extensively studied in pediatric oncologic resections. METHODS: To clarify volume-outcome effects in pediatric oncologic resections, we analyzed resection of renal malignancies in children less than 15 y of age. We conducted a cross-sectional analysis of hospital discharges included in the health care utilization project kids' inpatient database from 1997 to 2009, examining in-hospital operative complications, length of stay (LOS), and inflation-adjusted hospital charges. Hospital volume was expressed as low (n = 1-2), medium (n = 3-4), and high (n > 4) annual volume of resections. RESULTS: One thousand five hundred thirty-eight patients underwent renal malignancy resection. Of these, 527 patients had resection in low-, 422 in medium-, and 589 in high-volume hospitals. Relative to low-volume hospitals, those resected in medium-volume hospitals had an odds ratio of 0.62 (95% confidence interval 0.39-0.99, P = 0.046) for operative complication and those in high-volume hospitals had an odds ratio of 1.02 (95% confidence interval 0.63-1.65, P = 0.95). There was no detectable association with LOS (P = 0.113) or inflation-adjusted charges (P = 0.331). CONCLUSIONS: The number of complications, total charges, and LOS attributable to resection of a childhood renal malignancy did not differ among high-, medium-, or low-operative volume hospitals, although oncologic outcomes could not be determined because of the limited nature of this administrative database.

Unverifiable accomplishments and publications on applications for gynecologic oncology fellowships.

OBJECTIVE: Selection of physicians for fellowships in obstetrics and gynecology subspecialties has become increasingly competitive. The number and quality of research publications is an important factor in the selection process. We sought to estimate the incidence of unverifiable publications among gynecologic oncology fellowship applicants. METHODS: We reviewed the applications to a single gynecologic oncology fellowship program during 2004-2008. Articles and book chapters reported as published, in press, submitted, or in progress were searched for systematically by three reviewers using PubMed and Google. χ2 analysis was used to evaluate associations between demographic factors and unverifiable publications. RESULTS: Two hundred forty-three applications met the inclusion criteria. Of the 35 applicants who listed membership in Alpha Omega Alpha, four (11%) were not listed on the organization's web site as inductees. Of the 464 articles reported as published or in press, only 387 (83%) could be verified. Of the 148 applicants who reported at least one published or in press article, 44 (30%) had at least one unverifiable publication. On multivariable analysis, only male gender increased the likelihood of unverifiable ("ghost") publications (odds ratio 2.1, 95% confidence interval 1.1-4.1). Of the 282 manuscripts reported as submitted or in progress, only 126 (45%) were published. Of the 124 applicants who reported at least one submitted or in progress manuscript, 88 (71%) had at least one unverifiable manuscript. CONCLUSION: The proportion of unverifiable publications listed on gynecologic oncology fellowship applications is concerning. Stringent review of applications before interview invitations and match list submission is warranted.