Download Cost Effectiveness and Cancer Rehabilitation

Cost Effectiveness and
Cancer Rehabilitation
Andrea L Cheville, MD, MSCE
Associate Professor and Research Chair
Department of Physical Medicine and Rehabilitation
Mayo Clinic, Rochester
Why cost matters
 Most
health care $ spent per capita on cancer
 Cancer costs are increasing
 US health care costs currently 17.9% GDP
 To
increase >7.4%
7 4% annually after 2014
 Estimated 20% GDP in 2021
 Staggering
opportunity costs
 Education
 Domestic
 Civic
infrastructure
resources
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
1
Health outcomes do not reflect our
national investment
CMS & IOM Triple mandate
 Patient
centered
 Empirically
 Lowers
shown to improve outcomes
cost
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
2
Willingness to
pay for value
 Cost-effectiveness
analyses
y examine the cost of:
 Number
of cases of disease prevented
 Non-monetary measurement of benefits



Degrees recovered shoulder ROM
Distance ambulated
FIM score change
 Number
of QALYs obtained
What constitutes good value?
 NICE
-- Explicit, transparent and highly
structured methods
 QALYs



range from 0 (death) to1(perfect health)
Blindness = 0.67
Paraplegia = 0.43
Refractory major depression = 0.24
 Society
would prefer a person to live three years with
paraplegia (0.43 x 3 = 1.29), than have one year of
good health (1.0).
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
3
What constitutes good value?
Total costRehab – Total cost No Rehab
QALYSRehab – QALYS No Rehab
 £20
£20,000
000
Incremental cost
=
Incremental effect
- £30,000
£30 000 per QALY gained is the range.
range
 >£30,000
per QALY: society should spend healthcare
£ elsewhere.
Is cancer rehabilitation good value?
Return on invested resources?
1.
Are we getting the most functional
improvement per program dollar?
2.
Can we demonstrate that cancer
rehabilitation services are a bargain relative
to the alternatives?
Somewhat moot
 Few
patients at tertiary cancer centers receive
rehabilitation services until frankly disabled
 Odds of receiving outpatient care for a physical
i
impairment
i
Cheville A, JCO, 2008
 Any
intervention 1:88
intervention 1: >500
 PhysicianPhysician-directed
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
4

… in a study of services offered by National Cancer
Institute – designated comprehensive cancer centers,
70% of centers had a lymphedema management
program, but no comprehensive cancer rehabilitation
programs were reported.
Falls short of potential benefits and
the vision of its founders
 Integrated,
multidisciplinary team providing
individualized services to sustain functionality
across the cancer trajectory Di
Dietz
t 1969
 Restorative
 Supportive
 Preventive
 Palliative
Can a shift from reactive to
proactive rehabilitation enhance
cost effectiveness?
 High
impairment prevalence
 65.8%
mixed cancer cohort Cheville A, JSCC, 2008
- 92% Stage IV breast Cheville A, JCO, 2008
 Impairments
 Impairments
may increase utilization
 Breast
cancer survivors with lymphedema cost
$7K more per year Shih, JCO, 2009
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5

It is time to revitalize the link between cancer survivorship and
cancer rehabilitation and investigate a new model of
comprehensive cancer rehabilitation, involving a
multidisciplinary team of providers that aims to optimize the
patient’s physical, psychologic, vocational, and social
functioning...
Bethesda Naval Hospital Experience
 PT
evaluation components
 PRO
- upper quadrant impairment
volume
 Range of motion
 Palpation
 Limb
 Pre
Pre--op
& at 3,6, 9 months
outcomes1,2
 Improved
↓
arm volumes
 ↑ shoulder recovery
1.
Gerber LH, Stout N, McGarvey C, et al. Factors predicting clinically significant fatigue in women following treatment for
primary breast cancer. Support Care Cancer. Oct;19(10):1581-1591.
2.
Springer BA, Levy E, McGarvey C, et al. Pre-operative assessment enables early diagnosis and recovery of shoulder function in
patients with breast cancer. Breast Cancer Res Treat. Feb;120(1):135-147.
Opportunity for cost savings
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
6
10 .5
7.7
4.4
3.9
10
1.6
2.8
23 .9
9
19 .4
70
0
ding
tin g
n
ulat io
a mb
with
le ms
Prob
lanc e
ith ba
ulty w
Dif fic
ng
dr inki
w hen
hin g
Co ug
s
ange
ch ch
Spee
ilet
a ir/to
om ch
ing fr
lk in g
Sta nd
n wa
rt whe
su ppo
Ne ed
s
ange
tive ch
DL s
Co gni
for A
ngth
t st re
icien
Insu ff
A DLs
t w ith
a ss is
t b ed
in / ou
s
Ne ed
ty get
ty ben
a
su es
es
l issu
Na use
P ain
ting
ulty lif
Diff ic
ul
Diff ic
0.0
70 .5
65 .6
80
0.0
51 .4
Symptom
60
Bowe
ue
Fatig
we ek
e r is
Bladd
Feel
Cheville A, JSCC 08’
Functional problem
47 .0
2.
0.0
29 .4
Identifying the right patients at the right time
Securing patient buybuy-in
1.
ul
Diff ic
0.0
30
22 .7
7
50
40
Percentage
P
Net costs from hospitalization
Two important challenges
Clinician documentation of patient
identified problems by subtype
20
7
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
AM PAC CAT scores of decedents
Some difficulty
in moving inside
a building and
limited in going
outdoors
Limited mobility
inside of
building; Unable to
do bending/reaching
activities
AM PAC CAT Basic M
Mobility Score
Some difficulty in
doing moderate or
strenuous activities
Limited in bed,
basic transfers
Months Prior to Death
How to operationalize?
 Tablet
computer input at clinical encounters
voice response
 Identification of high risk subgroups for more
intense screening
 Interactive
$
Two important barriers
 Identifying
 Securing
the right patients at the right time
patient buybuy-in
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
8
Current care
delivery models
rely on primary
disease
management
Lack of hysteresis
 Loss
of:
 Lean
muscle mass
tone
 Bone mineralization
minerali ation
 Intravascular volume
 Confidence
 Vascular
Receptivity to rehabilitation
 Interest
among patients with mobility < high
level ambulator
 “NO”
NO
79.7% (n
(n=1277)
1277)
10.4% (n=166)
 “YES”
 Interest
among patients rating functional distress
>4 (11(11-point numerical rating scale)
 “NO”
72.3% (n=513)
17.0 % (n=121)
 “YES”
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
9
Receptivity to rehabilitation
 Interest
 “NO”
among patients with AM PAC CAT <65
79.7% (n=1277)
10.4% (n=166)
 “YES”
 Interest
among patients rating functional distress
>4
 “NO”
72.3% (n=513)
17.0 % (n=121)
 “YES”
Patients’ attitudes regarding
rehabilitation services (n=364)
 Not
beneficial
 Wouldn’t
do any good/nothing would change (27)
 No time/energy/air left (17)
 Burdensome
 Worsening
 Travel
symptoms (28)
(12)
Patients’ attitudes regarding
rehabilitation services (n=364)
 Too
busy
 Fighting
cancer (13)
(8)
 Other things to worry about/problems/complications
(10)
 Appointments
 Unnecessary
 Have
plenty of help (40)
that bad off (33)
 I can take care of myself (36)
 Not
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
10
Patients’ attitudes regarding
rehabilitation services (n=364)
 Waiting
 Recovery
from chemotherapy/radiation/surgery
(17)
 Symptoms to improve (4)
 Test results (6)
 Treatment to work (7)
Limited appreciation of
symptomatic benefits of exercise
>
45 minute in depth interviews conducted
with 20 patients & caregivers1
 Usual
activities sufficient
usual activities rigor
 Assumed endorsement of oncology care team
 Caregivers reluctant to become “coaches”
 Overestimation
1. Cheville AL, Dose AM, Basford JR, Rhudy LR. JPSM, 2012.
Conclusions
 Cost
is a critical force in healthcare
 Cancer rehabilitation currently lacks an evidence
base and is rarely prescribed
evidence of effectiveness ≠ Evidence of
absence of effectiveness
 Absence
 Opportunities
to reduce costs during the last year
of life and longlong-term survivorship
 Need
 Need
 Robust
sensitive and specific screening techniques
patient AND clinician buy in
findings needed to support expenditures
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
11
Thank you for your time
and attention
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
12