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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