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Policy, Guidelines, and Disparities
Peter B. Bach, MD, MAPP
Memorial Sloan-Kettering Cancer Center
[email protected]
Overview
• The goal of practice guidelines is to:
– Improve the quality of care?
– Manage care?
– Save money?
– Monitor the quality of care?
– Reduce disparities?
– Give academics (with weird skills) something to
do?
Improve care quality
• Underlying assumption: care is sub-standard
• Practice guidelines used broadly would raise
average level
• Have to assume that deviations from
guidelines net harmful
– As opposed to important personalization
• Clinical decision support can have a guidelines
background
Clinical decision support
Manage care (oncology example)
• Pathways tell doctors which treatments to use
in common conditions
• Mostly payer contracts linked to pathways ask
for 80% adherence
Save money through competition
Save money: Guidelines for Metastatic NonSmall Cell Lung Cancer
NCCN
(2009)
ACCP
(2007)
CCO
(2009)
Alberta
(2009)
Australian
(2004)
NICE
(2009)
Pemetrexed/Cisplatin
X
X
X
X
-
X
Gemcitabine/Cisplatin
X
X
X
X
X
X
Docetaxel/Cisplatin
X
X
X
X
X
X
Irinotecan/Cisplatin
X
X
X
X
X
-
Vinorelbine/Cisplatin
X
X
X
X
X
X
Etoposide/Cisplatin
X
X
X
X
X
-
Vinblastine/Cisplatin
X
X
X
X
X
-
Paclitaxel/Cisplatin
X
X
X
X
X
X
Metastatic Non-Small Cell Lung Cancer
Name
Total
Chemotherapy
Drug Cost
Monthly
Chemotherapy
Drug Cost
Total Cost
(12 Weeks)
Monthly
Cost
Pemetrexed/Cisplatin1-4,6
$16,913.37
$6,105.91
$19,594.13
$7,073.69
Gemcitabine/Cisplatin1-6
$9,745.83
$3,518.35
$13,303.24
$4,802.61
Docetaxel/Cisplatin1-6
$8,916.64
$3,219.00
$11,647.20
$4,204.77
Irinotecan/Cisplatin1-5
$934.60
$337.40
$7,984.63
$2,882.54
Vinorelbine/Cisplatin1-6
$519.45
$187.53
$4,929.03
$1,779.43
Etoposide/Cisplatin1-5
$217.06
$78.36
$4,453.86
$1,607.89
Vinblastine/Cisplatin1-5
$183.97
$66.41
$3,741.38
$1,350.68
Paclitaxel/Cisplatin1-6
$518.45
$187.17
$3,578.70
$1,291.95
1
National Comprehensive Cancer Center (NCCN), 2 American College of Chest Physicians, 3 Cancer Care Ontario (CCO), 4 Alberta
Health Services, 5 Australian National Health and Medical Research Council, 6 National Institute for Health and Clinical Excellence
(NICE)
Using episode payment
$8,000
$7,000
Cost per Month of Treatment
$6,000
$5,000
Administration Fees and Supportive Care Costs
Chemotherapy Cost
Potential
Loss for
Physician
$4,000
$3,000
$2,000
$1,000
$0
Potential
Profit for
Physician
Metastatic Hormone Refractory Prostate
Cancer
Drug (does not include support or adminstration)
Monthly Cost
$
37,668
Docetaxel (Generic)
$
772
Flutamide (Generic)
$
237
Bicalutamide (Casodex)
$
552
Bicalutamide (Generic)
$
43
Nilutamide (Nilandron)
$
749
Antiandrogen withdrawal
$
-
Ketoconazole
$
201
Arbiraterone acetate (Zytiga)
$
5,778
Anti-Androgens
Sipuleucel-T (Provenge)
Steroids
negligible
Diethylstilbestrol (or other estrogen)
negligible
Monitor the quality of care
Reduce disparities
Give academics work
Summary of Published Guidelines on LDCT Screening for Lung Cancer
Org.
Type of
NLST Like
Others?
Basis
Statement Subjects?
ACCP/
ASCO/
ATS
Evidence based Suggest it be
guideline
offered
No
Systematic review,
meta-analysis,
grading of evidence
ACS
Interim
guidance
May be
considered
No
Interim guidance
pending full review
ALA
Guidance
Recommended
No
Not specified
(selective literature)
NCCN
Consensus
guidelines
Recommended
Yes, for some
individuals
based on risk
Not specified
(selective literature)
IASLC
Statement
Considered
appropriate to
discuss with
physician
No
Not specified
AATS
Clinical
guidelines
Recommended
Yes, for some
individuals
based on risk
Not specified
(selective literature)
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm280536.htm
Then there’s the dissemination
challenge
Two Views of the Population Benefit
Laurie Fenton Ambrose
President and CEO
Lung Cancer Alliance
Straight Extrapolation from
the NLST
NLST
Number screened
Number of deaths
prevented
Number of years
Number lung
cancer deaths
avoided/year
80,000 avoided deaths/yr
National
26000 8000000
87
26769
6
6
14
4388
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Thank you