Cost Effectiveness and Cost Effectiveness and Cancer RehabilitationCancer Rehabilitation
Andrea L Cheville, MD, MSCEAndrea L Cheville, MD, MSCE
Associate Professor and Research ChairAssociate Professor and Research Chair
Department of Physical Medicine and RehabilitationDepartment of Physical Medicine and Rehabilitation
Mayo Clinic, RochesterMayo Clinic, Rochester
Why cost mattersWhy cost matters
Most health care $ spent Most health care $ spent per capitaper capita on cancer on cancer
Cancer costs are increasingCancer costs are increasing
US health care costs currently 17.9% GDPUS health care costs currently 17.9% GDPTo increaseTo increase >>7 4% annually after 20147 4% annually after 2014To increase To increase >>7.4% annually after 20147.4% annually after 2014
Estimated 20% GDP in 2021Estimated 20% GDP in 2021
Willingness to Willingness to pay for valuepay for value
yNumber 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?What constitutes good value?
NICE NICE ---- Explicit, transparent and highly Explicit, transparent and highly structured methodsstructured methodsQALYs range from 0 (death) to1(perfect health)QALYs range from 0 (death) to1(perfect health)
Blindness = 0.67Blindness = 0.67
Paraplegia = 0.43Paraplegia = 0.43
Refractory major depression = 0.24Refractory 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).
What constitutes good value?What constitutes good value?
£20 000£20 000 -- £30 000 per QALY gained is the range£30 000 per QALY gained is the range
Total costRehab – Total cost No Rehab
QALYSRehab – QALYS No Rehab
=Incremental cost
Incremental effect
£20,000 £20,000 -- £30,000 per QALY gained is the range.£30,000 per QALY gained is the range.
>£30,000 per QALY: society should spend healthcare >£30,000 per QALY: society should spend healthcare £ elsewhere.£ elsewhere.
Is cancer rehabilitation good value? Is cancer rehabilitation good value? Return on invested resources?Return on invested resources?
1.1. Are we getting the most functional Are we getting the most functional improvement per program dollar?improvement per program dollar?improvement per program dollar?improvement per program dollar?
2.2. Can we demonstrate that cancer Can we demonstrate that cancer rehabilitation services are a bargain relative rehabilitation services are a bargain relative to the alternatives?to the alternatives?
Somewhat mootSomewhat moot
Few patients at tertiary cancer centers receive Few patients at tertiary cancer centers receive rehabilitation services until frankly disabledrehabilitation services until frankly disabled
Odds of receiving outpatient care for a physical Odds of receiving outpatient care for a physical i ii iimpairment impairment Cheville A, JCO, 2008Cheville A, JCO, 2008
… 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 Falls short of potential benefits and the vision of its foundersthe vision of its founders
Integrated, multidisciplinary team providing Integrated, multidisciplinary team providing individualized services to sustain functionality individualized services to sustain functionality across the cancer trajectoryacross the cancer trajectory Di t 1969Di t 1969across the cancer trajectory across the cancer trajectory Dietz 1969Dietz 1969
RestorativeRestorative
SupportiveSupportive
PreventivePreventive
PalliativePalliative
Can a shift from reactive to Can a shift from reactive to proactive rehabilitation enhance proactive rehabilitation enhance
cost effectiveness?cost effectiveness?High impairment prevalenceHigh impairment prevalence65.8% mixed cancer cohort 65.8% mixed cancer cohort Cheville A, JSCC, 2008Cheville A, JSCC, 2008
Impairments Impairments -- 92% Stage IV breast 92% Stage IV breast Cheville A, JCO, 2008Cheville A, JCO, 2008
Impairments may increase utilizationImpairments may increase utilizationBreast cancer survivors with lymphedema cost Breast cancer survivors with lymphedema cost
$7K more per year $7K more per year Shih, JCO, 2009Shih, JCO, 2009
It is time to revitalize the link between cancer survivorship and cancer rehabilitation and investigate a new model of comprehensive cancer rehabilitation, involving a multidisciplinary team of providers that aims to optimize the patient’s physical, psychologic, vocational, and social functioning...
PrePre--op & at 3,6, 9 monthsop & at 3,6, 9 months
Improved outcomesImproved outcomes1,21,2
↓↓ arm volumesarm volumes
↑↑ shoulder recoveryshoulder recovery1. Gerber LH, Stout N, McGarvey C, et al. Factors predicting clinically significant fatigue in women following treatment for primary breast cancer. Support Care Cancer. Oct;19(10):1581-1591.2. Springer BA, Levy E, McGarvey C, et al. Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Res Treat. Feb;120(1):135-147.
Opportunity for cost savings Opportunity for cost savings
Identification of high risk subgroups for moreIdentification of high risk subgroups for more$ Identification of high risk subgroups for more Identification of high risk subgroups for more intense screeningintense screening$
Two important barriersTwo important barriers
Identifying the right patients at the right timeIdentifying the right patients at the right time
Current care Current care delivery models delivery models rely on primaryrely on primaryrely on primary rely on primary
disease disease managementmanagement
Lack of hysteresisLack of hysteresis
Loss of:Loss of:Lean muscle massLean muscle mass
Vascular toneVascular tone
Bone minerali ationBone minerali ationBone mineralizationBone mineralization
Intravascular volumeIntravascular volume
ConfidenceConfidence
Receptivity to rehabilitationReceptivity to rehabilitation
Interest among patients with mobility < high Interest among patients with mobility < high level ambulatorlevel ambulator“NO” 79.7% (n=1277)“NO” 79.7% (n=1277) NO 79.7% (n 1277)NO 79.7% (n 1277)
Too busy Too busy Fighting cancer (13)Fighting cancer (13)Appointments (8)Appointments (8)Other things to worry about/problems/complications Other things to worry about/problems/complications
(10)(10)
UnnecessaryUnnecessaryHave plenty of help (40)Have plenty of help (40)Not that bad off (33)Not that bad off (33) I can take care of myself (36)I can take care of myself (36)
Cost is a critical force in healthcare Cost is a critical force in healthcare
Cancer rehabilitation currently lacks an evidence Cancer rehabilitation currently lacks an evidence base and is rarely prescribedbase and is rarely prescribedAbsence evidence of effectiveness Absence evidence of effectiveness ≠≠ Evidence of Evidence of
absence of effectivenessabsence of effectiveness
Opportunities to reduce costs during the last year Opportunities to reduce costs during the last year of life and longof life and long--term survivorshipterm survivorshipNeed sensitive and specific screening techniquesNeed sensitive and specific screening techniques
Need patient AND clinician buy inNeed patient AND clinician buy in
Robust findings needed to support expendituresRobust findings needed to support expenditures
