Impact on health service costs of medical technologies used in management of prostatic cancer

The economic burden of prostate cancer - a Swedish prevalence-based register study

Background

Incidence and prevalence of prostate cancer in Sweden have increased markedly due to prostate-specific antigen (PSA) testing. Moreover, new diagnostic tests and treatment technologies are expected to further increase the overall costs. Our aims were (i) to estimate the societal costs for existing testing, diagnosis, management and treatment of prostate cancer, and (ii) to provide reference values for future cost-effectiveness analyses of prostate cancer screening and treatment.

Methods

Taking a societal perspective, this study aimed to investigate the annual cost of prostate cancer in Sweden using a prevalence-based cost-of-illness approach. Resource utilisation and related costs within Stockholm Region during 2016 were quantified using data from the Stockholm PSA and Biopsy Register and other health and population registers. Costs included: (i) direct medical costs for health care utilisation at primary care, hospitals, palliative care and prescribed drugs; (ii) informal care; and (iii) indirect costs due to morbidity and premature mortality. The resource utilisation was valued using unit costs for direct medical costs and the human capital method for informal care and indirect costs. Costs for the Stockholm region were extrapolated to Sweden based on cancer prevalence and the average costs by age and resource type.

Results

The societal costs due to prostate cancer in Stockholm in 2016 were estimated to be €64 million Euro (€Mn), of which the direct medical costs, informal care and productivity losses represented 62, 28 and 10% of the total costs, respectively. The total annual costs extrapolated to Sweden were calculated to be €281 Mn. The average direct medical cost, average costs for informal care and productivity losses per prevalent case were €1510, €828 and €271, respectively. These estimates were sensitive to assumptions related to the proportion of primary care visits associated with PSA testing and the valuation method for informal care.

Conclusion

The societal costs due to prostate cancer were substantial and constitute a considerable burden to Swedish society. Data from this study are relevant for future cost-effectiveness evaluations of prostate cancer screening and treatment.

Nurse-Led Phone Call Follow-Up Clinics Are Effective for Patients With Prostate Cancer

Introduction:

The rising cost of healthcare requires rethinking in terms of resource utilisation care delivery. Nurse-led PSA phone follow-up clinics may provide a suitable option.

Materials and methods:

815 patients were recruited for the nurse-led stable prostate cancer telephone follow-up service. A convenience sample was selected for postal questionnaire assessment of their satisfaction.

Results:

815 patients had 3683 phone-call follow ups over 10 years. Patients’ own understanding of condition varied from average (76.3%) and good (9.2%) in the majority. 87.2% found the service convenient and 75.6% informative. 95.3% found the telephone assessment preferable to attending the outpatient department. 87.2% were keen on savings on transport/travel. 53.5% found it more reassuring. 91.9% of patients felt that everything they wanted to talk about was covered.

Discussion:

This service can be delivered in a high volume nurse-led service, with high levels of patient satisfaction, as an innovative service development.

Prostate cancerPrevalence‐based healthcare costs

OBJECTIVE

To calculate the total costs of in- and outpatient healthcare for patients with prostate cancer based on an episode-of-care approach. The cost analysis includes costs incurred during the first year of diagnosis, a longitudinal 3-year analysis and the incremental cost of prostate cancer during the first year of diagnosis.

MATERIAL AND METHODS

Patients registered with prostate cancer between 1998 and 2000, according to the data files of the Southern Swedish Regional Tumour Registry, were given encrypted identifiers that could also be used in the Patient Administrative System of the Region Skåne County Council, making it possible to identify consumption of healthcare on an episode-of-care basis. Itemized costs for resources used by each individual patient were calculated from the complete accounting system of the County Council.

RESULTS

Healthcare costs for prostate cancer during the first year varied between 45 000 and 51 000 SEK per patient. The second- and third-year costs were progressively lower, with an estimated total cost of 114 000 SEK over a period of 3 years. The age-standardized incremental cost of prostate cancer corresponded to 33 000 SEK during the first year, compared to the average cost per inhabitant.

CONCLUSIONS

The episode-of-care approach, based on encrypted identifiers for the identification of the diagnoses of individual patients and their utilization of healthcare, gives a unique opportunity to estimate the healthcare costs of specific diseases. The incremental healthcare cost per patient with prostate cancer corresponded to 33 000 SEK during the first year.

Methodological considerations in cost of prostate cancer studies: a systematic review

OBJECTIVES

Cost-of-illness (COI) studies estimate the overall economic burden of a specific disease, rather than simply treatment-related costs. While having been criticized for not allowing resource prioritization, COI studies can provide useful guidance, so long as they adhere to accepted methodology. Prostate cancer is an important disease in terms of economic implications because of its increasing incidence and health-care costs and therefore provides a relevant example with which to review COI study methodologies. The aim of this study was to review published COI studies on prostate cancer to analyze the methods used.

METHODS

First, we provide a general description of the COI method. COI studies relating to prostate cancer were then systematically reviewed, focussing on an analysis of the different methods used.

RESULTS

The methods, data sources, and estimated cost categories in each study varied widely. The review showed that COI studies adopted significantly different approaches to estimate the costs of prostate cancer, reflecting a lack of consensus on the methodology of COI studies in this area.

CONCLUSION

To increase its credibility, closer agreement among researchers on the methodological principles of the COI studies would be desirable.

Diffusion and Economic Consequences of Health Technologies in Prostate Cancer Care in Sweden, 1991–2002

OBJECTIVE

To describe the diffusion of six main health technologies used for management of prostate cancer, to estimate the economic consequences of technological changes, and to explore factors behind the diffusion.

METHODS

Data describing the diffusion 1991-2002 were obtained from population-based databases. Costs were obtained from Linköping University Hospital and Apoteket AB. Factors affecting the diffusion of the technologies were explored.

RESULTS

Utilization of technologies with a curative and/or palliative aim has increased over time, except for surgical castration. PSA-tests are used increasingly. The total cost of the study technologies has increased from 20 million euros in 1991 to 65 million euros in 2002. Classification of radical prostatectomy revealed a profile associated with a slow/limited diffusion, while classification of PSA-tests revealed a profile associated with a rapid/extensive diffusion.

CONCLUSIONS

Several technological changes in the management of prostate cancer have occurred without proven benefits and have contributed to increased costs. There are other factors, besides scientific evidence, that have an impact on the diffusion. Consequently, activities aimed at facilitating an appropriate diffusion of new technologies are needed. The analytical framework used here may be helpful in identifying technologies that are likely to experience inappropriate diffusion and therefore need particular attention.

THE ECONOMIC BURDEN OF METASTATIC AND PROSTATE SPECIFIC ANTIGEN PROGRESSION IN PATIENTS WITH PROSTATE CANCER: FINDINGS FROM A RETROSPECTIVE ANALYSIS OF HEALTH PLAN DATA

PURPOSE

We evaluated the economic burden of metastatic and prostate specific antigen (PSA) progression in patients with prostate cancer (CaP) using a cancer registry linked administrative database.

MATERIALS AND METHODS

A retrospective cohort evaluation of 2056 patients with CaP was done at Henry Ford Health System from 1995 to 2000. Records were examined for metastatic progression via International Classification of Disease-9-CM codes for metastasis and for PSA progression using accepted definitions based on initial therapy type. Health care resource charges 6 months and 1 year before and after progression were compared using pairwise t tests. A generalized linear model determined the effect of progression on charges and compared initial care, continuing care and terminal care charges in the progressed and nonprogressed groups, while controlling for baseline covariates (stage and age).

RESULTS

Patients with CaP had a mean age of 68 years, were mostly white (52%), had localized (88%) and moderately differentiated (66%) tumors, and a median baseline PSA of 7.0 ng/ml. Of patients 8.9% had metastatic progression at a mean followup of 3.6 years, while 16.1% had PSA progression at 4.5 years. After controlling for baseline covariates metastatic progression resulted in significant increases in charges (US dollars 92523 vs US dollars 58036, p < 0.0001). PSA progressed patients incurred significantly higher charges than nonprogressed patients (US dollars 69321 vs US dollars 58351, p = 0.0039), controlling for followup time, baseline stage, grade and treatment.

CONCLUSIONS

In CaP cases metastatic and PSA progression pose a significant economic burden irrespective of baseline stage, grade and treatment. Treatments that slows or prevents meta-static and PSA progression could offset this cost.

Technological changes in the management of prostate cancer result in increased healthcare costs--a retrospective study in a defined Swedish population

OBJECTIVE

In two previous studies we calculated direct costs for men with prostate cancer who died in 1984-85 and 1992-93, respectively. We have now performed a third cost analysis to enable a longitudinal cost comparison. The aim was to calculate direct costs for the management of prostate cancer, describe the economic consequences of technological changes over time and estimate total direct costs for prostate cancer in Sweden.

MATERIAL AND METHODS

A total of 204 men in a defined population with a diagnosis of prostate cancer and who died in 1997-98 were included. Data on utilization of health services were extracted from clinical records from time of diagnosis to death from a university hospital and from one county hospital in the county of Ostergötland.

RESULTS

The average direct cost per patient has been nearly stable over time (1984-85: 143 000 SEK; 1992-93: 150 000 SEK; 1997-98: 146 000 SEK). The share of costs for drugs increased from 7% in 1992-93 to 17% in 1997-98. The total direct costs for prostate cancer in Sweden have increased over time (1994-85: 610 MSEK; 1992-93: 860 MSEK; 1997-98: 970 MSEK).

CONCLUSIONS

Two-thirds of the total cost is incurred by inpatient care. The share of the total costs for drugs is increasing due to increased use of gonadotrophin-releasing hormone analogues. Small changes in average direct costs per patient despite greater use of technology are explained by the fact that more prostate cancers are detected at the early stages.

An economic overview of prostate carcinoma

BACKGROUND

In the United States in 2000, 180,400 new cases of prostate carcinoma were expected to occur, with 31,900 men expected to die from this illness. In addition, prostate carcinoma is the cause of over half a million disability-adjusted life-years. This study summarizes the current body of published literature about the economics of prostate carcinoma.

METHODS

The authors used a MEDLINE-based literature review for relevant articles from 1990 to the present.

RESULTS

The authors' search returned 216 articles, 56 of which met the criteria of interest. Prostate carcinoma is costly to treat, currently averaging above $20,000 per case. Cost of care is directly related to stage of disease and comorbidity. Substantial geographic variation exists, even within small locales, with regard to care patterns and cost. In-hospital mortality, length of stay, and cost are inversely related to case volume. Care rendered in health maintenance organizations is generally less technologically intensive than in the fee-for-service sector. Out of the 18 cost studies examined, 13 were cost-minimization analyses and five assessed cost-effectiveness. From a cost perspective, laparoscopic pelvic node dissection was favored over an open pelvic procedure; 3D conformal radiation therapy was favored over 2D; and radiation therapy was favored over radical prostatectomy. Cost-effectiveness analyses favored the use of metastron, mitroxantone plus prednisone over prednisone alone, flutamine with either medical or surgical castration, and orchiectomy as the androgen suppression therapy.

CONCLUSIONS

The literature on the economics of prostate carcinoma is relatively meager. Most cost studies were done on small samples, had short follow-up periods, used charges rather than cost data, and did not include adequate representation of all stages of disease. Additional research is needed.

Relationship of first-year costs of treating localized prostate cancer to initial choice of therapy and stage at diagnosis: results from the CAPSURE database

OBJECTIVES

To determine the relationship among the initial choice of therapy, stage at presentation, and first-year treatment costs in men with newly diagnosed localized prostate cancer.

METHODS

First-year resource use and clinical data were collected for 235 subjects with newly diagnosed localized prostate cancer. The costs were estimated from the standard Medicare payment schedules. The relationship among the initial therapy, stage at presentation, and overall cost was examined for the entire cohort and in the subgroup of patients who underwent radical prostatectomy. In addition, the inpatient, outpatient, and medication cost components were evaluated separately to determine what influenced the changes in cost by stage.

RESULTS

The mean first-year cost of treating localized prostate cancer in CaPSURE was $6375. When broken down by stage, the mean first-year cost for patients with Stage T1c was $5731, with T2a/b was $6426, and with Stage T2c was $6810 (P = 0.059). The initial treatment choice was significantly associated with the total first-year costs (P <0.001). The mean cost specifically for radical prostatectomy patients with Stage T1c disease was $6881, with T2a/b was $7216, and with T2c was $8027 (P = 0.004). The increases in the first-year cost with higher stage appeared to primarily be associated with increased inpatient resource use and the greater use of adjuvant hormonal therapy.

CONCLUSIONS

The first-year costs of treating localized prostate cancer in CaPSURE are associated with the choice of primary and adjuvant therapy. This supports the notion that cost savings may be possible with earlier detection of disease or by minimizing the use of hormonal adjuvant therapy.

Follow-up of prostate cancer patients by on-demand contacts with a specialist nurse: a randomized study

OBJECTIVE

The effectiveness of traditional follow-up programs and the intensive search for disease progression in men with prostate cancer have been questioned. The aims of this randomized multi-centre study were to evaluate medical safety, patient satisfaction and resource utilization in an on-demand follow-up by a specialist nurse compared with traditional follow-up by a urologist.

MATERIAL AND METHODS

Four hundred consecutively approached men with newly diagnosed or previously known prostate cancer in any stage at three hospitals in Sweden were randomized to follow-up in the nurse group (NG, 200 patients) or the urologist group (UG, 200 patients). In the NG, the nurse contacted the patient by phone every 6 months unless the patient himself initiated the contact. Patient satisfaction was evaluated twice a year via questionnaire. The questionnaire included the validated Hospital Anxiety and Depression Scale (HADS). The costs of all medical interventions and adverse events related to prostate cancer were calculated for all patients.

RESULTS

Medical safety, measured as complication frequency and lag time from symptoms to intervention, during the first 3 years of the observation period, was similar in the NG and the UG. The total number of interventions due to symptoms from prostate cancer was also similar in both groups. The analysis of accessibility and the HAD scale showed no significant differences between the groups. The mean outpatient cost (excluding pharmaceutical costs) per patient was lower in the NG compared to the UG, especially among patients without metastases at inclusion (37% lower cost).

CONCLUSIONS

Our study indicates that men with prostate cancer can be safely followed up by a specialist nurse. The study results show that this alternative follow-up is cost-effective, especially in men without metastases.

Economic evaluation of screening for prostate cancer: a randomized population based programme during a 10-year period in Sweden

Prostate cancer is a growing health problem representing considerable costs. Screening and early curative treatment may reduce morbidity and possibly prevent future escalating costs. However, population screening programmes are generally not well accepted at present due to uncertainty about whether screening for prostate cancer can result in reduced mortality. Evidence from large, randomized, controlled trials is still lacking. The objective of this study was to calculate clinical and economic consequences of general prostate cancer screening based on a limited screening trial in a Swedish community and a decision-tree model. A random selection of 1492 men (50-69 years) were invited to repeated screening in 1987. They have been examined every third year (four rounds). The other 7679 men in the population act as controls. The results show that the total incremental health care costs for prostate cancer will increase by 179 million SEK per year with screening compared to no-screening. The number of detected cases of localized cancer will increase by about 1000, which represents an additional cost of about 158,000 SEK per case. In conclusion, general screening for prostate cancer can be performed with a reasonable cost per detected localized cancer. Information on the long-term effect on life quality and cancer mortality is unknown.