Economics of Malignant Gliomas: A Critical Review.

PURPOSE: Approximately 18,500 persons are diagnosed with malignant glioma in the United States annually. Few studies have investigated the comprehensive economic costs. We reviewed the literature to examine costs to patients with malignant glioma and their families, payers, and society. METHODS: A total of 18 fully extracted studies were included. Data were collected on direct and indirect costs, and cost estimates were converted to US dollars using the conversion rate calculated from the study's publication date, and updated to 2011 values after adjustment for inflation. A standardized data abstraction form was used. Data were extracted by one reviewer and checked by another. RESULTS: Before approval of effective chemotherapeutic agents for malignant gliomas, estimated total direct medical costs in the United States for surgery and radiation therapy per patient ranged from $50,600 to $92,700. The addition of temozolomide (TMZ) and bevacizumab to glioblastoma treatment regimens has resulted in increased overall costs for glioma care. Although health care costs are now less front-loaded, they have increased over the course of illness. Analysis using a willingness-to-pay threshold of $50,000 per quality-adjusted life-year suggests that the benefits of TMZ fall on the edge of acceptable therapies. Furthermore, indirect medical costs, such as productivity losses, are not trivial. CONCLUSION: With increased chemotherapy use for malignant glioma, the paradigm for treatment and associated out-of-pocket and total medical costs continue to evolve. Larger out-of-pocket costs may influence the choice of chemotherapeutic agents, the economic implications of which should be evaluated prospectively.

Effects of cancer comorbidity on disease management: making the case for diabetes education (a report from the SOAR program).

Individuals with type II diabetes have an increased risk of cancer diagnosis (relative risk [RR]=1.12-2.50) and mortality (RR=1.4) compared to normoglycemic individuals. Biologic mechanisms, including mitogenic effects of insulin, hyperglycemia, and increased oxidative stress, as well as behavioral factors (eg, difficulty managing the comorbidity) may explain the elevated risk. To investigate the effects of the comorbidity on disease management, the authors compared diabetes education utilization in individuals with diabetes-cancer co-morbidity to utilization by individuals with diabetes in the absence of cancer. The effect of diabetes education on outcomes was further assessed in the subset of individuals with diabetes-cancer comorbidity. Administrative claims data were used for this analysis. The study population included individuals >60 years of age and members of both commercial and Medicare Advantage health plans from a private national database of payer data, but excluded Medicare fee for service and Medicaid patients. Most of these individuals were eligible to receive reimbursement for diabetes education. Diabetes education utilization was identified using procedure codes. Outcomes were assessed for a 3-year time period. There was little difference in diabetes education utilization between individuals with diabetes in the absence of cancer (3.8% utilization) and those with diabetes-cancer comorbidity (3.5% utilization). Individuals who receive diabetes education are more likely to have multiple HbA1c tests per year, fewer emergency department visits, fewer hospital admissions, and lower care-associated costs (except for outpatient and pharmacy averages). When diabetes coexists with cancer, management of diabetes often lags, making diabetes education an imperative.

Costs and benefits associated with diabetes education: a review of the literature.

PURPOSE: The purpose of this article was to review the published literature and evaluate the economic benefits and costs associated with diabetes education. METHODS: The Medline database (1991--2006) and Google were searched. Articles that addressed the economic and/or financial outcomes of a diabetes-related self-care or educational intervention were included. The study aim, population, design, intervention, financial and economic outcomes, results, and conclusions were extracted from eligible articles. RESULTS: Twenty-six papers were identified that addressed diabetes self-management training and education. Study designs included meta-analysis (1); randomized controlled trials (8); prospective, quasi-experimental, and pre-post studies (8); and retrospective database analyses (9). The studies conducted cost analyses (6), cost-effectiveness analyses (13), cost-utilization analyses (7), and number needed to treat analyses (2). More than half (18) of the 26 papers identified by the literature review reported findings that associated diabetes education (and disease management) with decreased cost, cost saving, cost-effectiveness, or positive return on investment. Four studies reported neutral results, 1 study found that costs increased, and 3 studies did not fit into these categories. CONCLUSIONS: The findings indicate that the benefits associated with education on self-management and lifestyle modification for people with diabetes are positive and outweigh the costs associated with the intervention. More research is needed to validate that diabetes education provided by diabetes educators is cost-effective.

Cost considerations in the management of cancer in the older patient.

Patients aged 65 years and older represent 12% of the US population yet account for approximately 56% of cancer cases and 69% of all cancer mortalities. The overall cost of cancer in 2005 was $209.9 billion--$74 billion for direct medical costs and $118.4 billion for indirect mortality costs. This paper considers the direct, indirect, and out-of-pocket expenditures incurred by cancer patients > or = 50 years of age. Several major empirical studies on supportive care for older patients and cancer-related costs were reviewed. Insurance coverage, hematologic malignancies, squamous cell carcinoma of the head and neck, and cancers of the breast, prostate, colorectum, and lung were evaluated. Major sources of direct medical expenditures covered by third-party insurers for patients aged 65 years and older include extended length of hospital stay, home health assistance following hospital discharge, adjuvant prescription medications, lower-risk treatment (for prostate cancer), and advent of new pharmaceuticals (for colorectal cancer). The mean total direct medical cost for breast cancer is $35,164, and the cumulative cost for prostate cancer is $42,570. Emerging targeted cancer drug costs range from $20,000 to $50,000 annually per patient. Additional clinical trials and cost-effective treatments are needed for older patients to ameliorate the disproportionate economic burden among older individuals with cancer. Additional research about cancer costs may also lead to reforms in cancer care reimbursement, and therefore provide access to affordable health care for older patients.

Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening among Veterans.

PURPOSE: Colorectal cancer screening is underused, particularly in the Veterans Affairs (VA) population. In a randomized controlled trial, a health care provider-directed intervention that offered quarterly feedback to physicians on their patients' colorectal cancer screening rates led to a 9% increase in colorectal cancer screening rates among veterans. The objective of this secondary analysis was to assess the cost effectiveness of the colorectal cancer screening promotion intervention. METHODS: Providers in the intervention arm attended an educational workshop on colorectal cancer screening and received confidential feedback on individual and group-specific colorectal cancer screening rates. The primary end point was completion of colorectal cancer screening tests. Sensitivity analyses investigated cost-effectiveness estimates varying the data collection methods, costs of labor and technology, and the effectiveness of the intervention. RESULTS: Rates of colorectal cancer screening for the intervention versus control arms were 41.3% v 32.4%, respectively (P < .05). The incremental cost-effectiveness ratio was dollar 978 per additional veteran screened based on feedback reports generated from manual review of records. However, if feedback reports could be generated from information technology systems, sensitivity analyses indicate that the cost-effectiveness estimate would decrease to dollar 196 per additional veteran screened. CONCLUSION: An intervention based on quarterly feedback reports to physicians improved colorectal cancer screening rates at a VA medical center. This intervention would be cost effective if relevant data could be generated by existing information technology systems. Our findings may have broad applicability because a 2005 Medicare initiative will provide the VA electronic medical record system as a free benefit to all US physicians.

Granulocyte colony--stimulating factor for chemotherapy-induced neutropenia in patients with small cell lung cancer : the 40% rule revisited.

Recombinant granulocyte colony-stimulating factor (G-CSF) [filgrastim and lenograstim] and pegylated G-CSF (pegfilgrastim) have been shown to reduce the severity and duration of chemotherapy-associated febrile neutropenia (FN) when administered prophylactically to cancer patients receiving chemotherapeutic regimens. The American Society of Clinical Oncology (ASCO) evidence-based clinical guidelines published in 1994, 1996 and 1997 recommended primary prophylaxis with G-CSF for cancer patients. The 2000 ASCO update, with the same recommendation, highlights the importance of economic considerations in decision making for CSFs. This paper reviews the available cost-effectiveness evidence on the use of G-CSF as primary prophylaxis against FN in patients with small cell lung cancer (SCLC).Cost-effectiveness ratios from a healthcare payer perspective supported the use of filgrastim as primary prophylaxis for people with SCLC, on the basis of both clinical and economic benefits, treated with chemotherapeutic regimens that have an FN rate in the range of 40-60%. However, when indirect and patient out-of-pocket costs attributable to severe FN are included, available evidence suggests that the risk threshold may be reduced by more than half. Given that FN rates associated with chemotherapeutic regimens for SCLC are generally <40%, then few circumstances would warrant the use of G-CSFs (filgrastim and lenograstim) under the current rule. However, inclusion of indirect costs would lower the cost-effectiveness threshold. Future cost-effectiveness studies of medications such as pegfilgrastim should attempt to capture the societal perspective by incorporating productivity-related costs and using base-case rates of FN reported in the literature.

The financial burden of cancer: estimates from a study of insured women with breast cancer.

The financial impact of cancer can be large, even among persons with comprehensive health insurance policies. Prior studies have found that women with cancer are especially likely to suffer financial hardship. Although controversial, cancer insurance policies are designed to reduce the financial burden of cancer. In this study, we provide estimates of the costs incurred by a cohort of breast cancer patients who were covered by private, Medicare, or Medicaid health insurance. In all, 156 women were interviewed about cancer-related out-of-pocket costs and their knowledge and use of cancer insurance policies. Out-of-pocket expenditures and lost income costs averaged $1,455 per month and varied widely. The majority of out-of-pocket costs were for co-payments for hospitalizations and physician visits. The financial burden of breast cancer accounted for a mean of 98%, 41%, and 26% of monthly income among female breast cancer patients with annual household income levels of < or = $30,000, $30,001-$60,000, and > $60,000, respectively. Cancer insurance policies provided reimbursement for out-of-pocket expenditures for 3% of the women in our study. Our data indicate that even among women with comprehensive health insurance policies, the financial burden of breast cancer can be substantial. Affordable programs that provide reimbursement for medical and nonmedical costs incurred following a diagnosis of breast cancer should be developed, especially for lower income women.