The cost of cancer – A comparative analysis of the direct medical costs of cancer and other major chronic diseases in Europe

Background Cancer poses a significant mortality, morbidity, economic and humanistic burden to patients and health systems. This study aims to better understand healthcare expenditure on cancer relative to other major chronic diseases across France, Germany, Italy, Spain and the United Kingdom, whilst also considering the burden of illness posed by these conditions. Methods A targeted literature review was performed to identify and extract relevant demographic, epidemiological and economic data. A health care payer perspective was adopted for the analysis, with a focus on direct healthcare costs. Results Between 2006–2015, the cancer-related disability-adjusted life year (DALY) disease burden decreased by 9.3% despite a 6.5% increase in prevalence. Whilst the per patient drug costs increased by a compound annual growth rate (CAGR) of 5.1%, the overall per patient cancer costs decreased over the 10-year study period (CAGR of -1.4%). Compared to cardiovascular disease, neurological/mental disorders and diabetes, cancer was associated with the highest disease burden (20.8% of DALYs across all diseases) but the second-lowest healthcare expenditure levels (4.8% of total healthcare expenditure) among the studied major chronic diseases. Conclusions Our study suggests that the costs associated with treating cancer account for a low proportion of total healthcare expenditure relative to the burden of the disease and compared to other major chronic diseases across the countries included in the analysis.

Cost-effectiveness analysis of using the TBX6-associated congenital scoliosis risk score (TACScore) in genetic diagnosis of congenital scoliosis

Background We previously reported a novel clinically distinguishable subtype of congenital scoliosis (CS), namely, TBX6-associated congenital scoliosis (TACS). We further developed the TBX6-associated CS risk score (TACScore), a multivariate phenotype-based model to predict TACS according to the patient’s clinical manifestations. In this study, we aimed to evaluate whether using the TACScore as a screening method prior to performing whole-exome sequencing (WES) is more cost-effective than using WES as the first-line genetic test for CS. Methods We retrospectively collected the molecular data of 416 CS patients in the Deciphering disorders Involving Scoliosis and COmorbidities (DISCO) study. A decision tree was constructed to estimate the cost and the diagnostic time required for the two alternative strategies (TACScore versus WES). Bootstrapping simulations and sensitivity analyses were performed to examine the distributions and robustness of the estimates. The economic evaluation considered both the health care payer and the personal budget perspectives. Results From the health care payer perspective, the strategy of using the TACScore as the primary screening method resulted in an average cost of $1074.2 (95%CI: $1044.8 to $1103.5) and an average diagnostic duration of 38.7d (95%CI: 37.8d to 39.6d) to obtain a molecular diagnosis for each patient. In contrast, the corresponding values were $1169.6 (95%CI: $1166.9 to $1172.2) and 41.4d (95%CI: 41.1d to 41.7d) taking WES as the first-line test (P < 0.001). From the personal budget perspective, patients who were predicted to be positive by the TACScore received a result with an average cost of $715.1 (95%CI: $594.5 to $835.7) and an average diagnostic duration of 30.4d (95%CI: 26.3d to 34.6d). Comparatively, the strategy of WES as the first-line test was estimated to have significantly longer diagnostic time with an average of 44.0d (95%CI: 43.2d to 44.9d), and more expensive with an average of $1193.4 (95%CI: $1185.5 to $1201.3) (P < 0.001). In 100% of the bootstrapping simulations, the TACScore strategy was significantly less costly and more time-saving than WES. The sensitivity analyses revealed that the TACScore strategy remained cost-effective even when the cost per WES decreased to $8.8. Conclusions This retrospective study provides clinicians with economic evidence to integrate the TACScore into clinical practice. The TACScore can be considered a cost-effective tool when it serves as a screening test prior to performing WES.

Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy

Objective The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. Study Design This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5–24.9), overweight (25.0–29.9), obesity class 1 (30.0–34.9), obesity class 2 (35.0–39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities. Results The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01–1.74) for women with overweight BMI and 2.03 (95% CI: 1.57–2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95–1.66) for overweight women and 1.38 (95% CI: 1.04–1.84) for women with obesity. The ORs suggested a dose–response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00. Conclusion Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period. Key Points

Perspectives of Health Care Payer Organizations on Cancer Care Delivery Redesign: A National Study

INTRODUCTION: Despite advancements in cancer care, persistent gaps remain in the delivery of high-value end-of-life cancer care. The aim of this study was to examine views of health care payer organization stakeholders on approaches to the redesign of end-of-life cancer care delivery strategies to improve care. METHODS: We conducted semistructured interviews with 34 key stakeholders (eg, chief medical officers, medical directors) in 12 health plans and 22 medical group organizations across the United States. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis. RESULTS: Participants endorsed strategies to redesign end-of-life cancer care delivery to improve end-of-life care. Participants supported the use of nonprofessionals to deliver some cancer services through alternative formats (eg, telephone, Internet) and delivery of services in nonclinical settings. Participants reported that using nonprofessional providers to offer some services, such as goals of care discussions and symptom assessments, via telephone in community-based settings or in patients’ homes, may be more effective and efficient ways to deliver high-value cancer care services. Participants described challenges to redesign, including coordination with and acceptance by oncology providers and payment models required to financially support clinical changes. Some participants suggested solutions, including providing funding and logistic support to encourage implementation of care delivery innovations and to financially reward practices for delivery of high-value end-of-life cancer care services. CONCLUSION: Stakeholders from payer organizations endorsed opportunities to redesign cancer care delivery, and some are willing to provide logistic, design, and financial support to practices interested in improving end-of-life cancer care.

Cost Implications of Reactive Versus Prospective Testing for Dihydropyrimidine Dehydrogenase Deficiency in Patients With Colorectal Cancer: A Single-Institution Experience

Background: Severe toxicity is experienced by a substantial minority of patients receiving fluoropyrimidine-based chemotherapy, with approximately 20% of these severe toxicities attributable to polymorphisms in the DPYD gene. The DPYD codes for the enzyme dihydropyrimidine dehydrogenase (DPD) important in the metabolism of fluoropyrimidine-based chemotherapy. We questioned whether prospective DPYD mutation analysis in all patients commencing such therapy would prove more cost-effective than reactive testing of patients experiencing severe toxicity. Methods: All patients experiencing severe toxicity from fluoropyrimidine-based chemotherapy for colorectal cancer in an Irish private hospital over a 3-year period were tested for 4 DPYD polymorphisms previously associated with toxicity. The costs associated with an index admission for toxicity in DPD-deficient patients were examined. A cost analysis was undertaken comparing the anticipated cost of implementing screening for DPYD mutations versus current usual care. One-way sensitivity analysis was conducted on known input variables. An alternative scenario analysis from the perspective of the Irish health-care payer (responsible for public hospitals) was also performed. Results: Of 134 patients commencing first-line fluoropyrimidine chemotherapy over 3 years, 30 (23%) patients developed grade 3/4 toxicity. Of these, 17% revealed heterozygote DPYD mutations. The cost of hospitalization for the DPYD-mutated patients was €232 061, while prospectively testing all 134 patients would have cost €23 718. Prospective testing would result in cost savings across all scenarios. Conclusions: The cost of hospital admission for severe chemotherapy-related toxicity is significantly higher than the cost of prospective DPYD testing of each patient commencing fluoropyrimidine chemotherapy.