Direct and indirect costs in a prospective cohort of patients with pancreatic cancer

Economic Burden of Pancreatic Cancer in Europe: a Literature Review

PURPOSE

Pancreatic cancer is characterized by its high mortality, usually attributed to its diagnosis in already advanced stages. This article aims at presenting an overview of the economic burden of pancreatic cancer in Europe.

METHODS

A systematic literature review was conducted. It made use of the search engines EconLit, Google Scholar, PubMed and Web of Science, and retrieved articles published after December 31st, 1992, and before April 1st, 2020. Study characteristics and cost information were extracted. Cost per patient and cost per patient per month (PPM) were calculated, and drivers of estimate heterogeneity was analysed. Results were converted into 2019 Euros.

RESULTS

The literature review yielded 26 studies on the economic burden attributable to pancreatic cancer in Europe. Cost per patient was on average 40,357 euros (median 15,991), while figures PPM were on average 3,656 euros (median 1,536). Indirect costs were found to be on average 154,257 euros per patient or 14,568 euros PPM, while direct costs 20,108 euros per patient and 2,004 euros PPM. Nevertheless, variation on cost estimations was large and driven by study methodology, patient sample characteristics, such as type of tumour and cancer stage and cost components included in analyses, such as type of procedure.

CONCLUSION

Pancreatic cancer direct costs PPM are in the upper bound relative to other cancer types; however, direct per patient costs are likely to be lower because of shorter survival. Indirect costs are substantial, mainly attributed to high mortality.

Projected economic burden of pancreatic cancer in Sweden in 2030

BACKGROUND

Pancreatic cancer is predicted to become the second most common cause of cancer-related death by 2030. The objective of this study was to estimate the economic burden of pancreatic cancer for the years 2018 and 2030 based on changing demographics and incidence rates in Sweden.

METHOD

The incidence of pancreatic cancer in Sweden and additional relevant data were obtained from official statistics. A linear regression model and the mean incidence rates 2008-2018 were applied to calculate the incidence in 2030. An economic model based on the human capital method was created to calculate the indirect cost of pancreatic cancer in 2018 and 2030. Costs associated with surgery, radiology, oncology, and palliative care constituted the direct costs. A sensitivity analysis was performed.

RESULTS

The incidence of pancreatic cancer in Sweden in the year 2018 was 1352 patients and projected to between 1554 (+15%) and 1736 (+28%) in 2030. The total cost was calculated to €125 million in 2018 and between €210 million (+68%) and €225 million (+80%) in 2030. The indirect cost in the ≤65-year-old group was €328,344 in 2018 and between €380,738 and €382,109 per individual in 2030.

CONCLUSIONS

The economic burden of pancreatic cancer is expected to increase in Sweden by 2030 due to the increasing incidence of the disease and changing demographics. Pancreatic cancer is a growing health care problem in urgent need of advancements in prevention, early detection, treatment, and control of the disease.

Estimating the cost of implementing a facility and community score card for maternal and newborn care service delivery in a rural district in Uganda

INTRODUCTION

This paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service.

METHODS

This costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system.

RESULTS

The total and average cost of implementing CSC for five quarterly rounds over a period of 18 months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers.

CONCLUSION

Our analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach.

Familial Pancreatic Cancer

Familial pancreatic cancer accounts for 10% of all patients with pancreatic cancer. Because the 5-year survival rate of pancreatic cancer is only 7%, screening programs for high-risk individuals are essential and might be advantageous. Pancreatic ductal adenocarcinoma mostly shows symptoms at an advanced state and treatment is not efficient enough to cure most patients. People with hereditary tumor syndromes or their affected relatives can also be included in such screening programs. Besides the collection of data to investigate the background of the disease, these screening programs aim to diagnose and treat precursor lesions so that more dangerous, invasive lesions are prevented. These precursor lesions can be pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. This review summarizes the latest knowledge of pancreatic screening programs, shows the procedure of pancreatic cancer screening, and gives an overview of current guidelines.

Informative Patterns of Health-Care Utilization Prior to the Diagnosis of Pancreatic Ductal Adenocarcinoma

Early-detection tests for pancreatic ductal adenocarcinoma (PDAC) are needed. Since a hypothetical screening test would be applied during antecedent clinical encounters, we sought to define the variability in health-care utilization leading up to PDAC diagnosis. This was a retrospective cohort study that included patients diagnosed with PDAC in the Indianapolis, Indiana, area between 1999 and 2013 with at least 1 health-care encounter during the antecedent 36-month period (n = 1,023). Patients were classified by unique patterns of health-care utilization using a group-based trajectory model. The prevalences of PDAC signals, such as diabetes mellitus (DM) and chronic pancreatitis, were compared. Four distinct trajectories were identified, the most common (42.0%) being having few clinical encounters more than 6 months prior to PDAC diagnosis (late acceleration). In all cases, a minority of persons had DM (30.6%, with 9.5% <1.5 years before PDAC) or any pancreatic disorder (39.9%); these were least common in the late-acceleration group (DM, 14.7%; any pancreatic disorder, 32.1% (P < 0.001)). The most common pattern of antecedent care was having few clinical encounters until shortly before PDAC diagnosis. Since the majority of patients diagnosed with PDAC do not have an antecedent PDAC signal, early-detection strategies limited to these groups may not apply to the majority of cases.

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

BACKGROUND

There is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC.

METHODS

Sequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL.

RESULTS

Of 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62-1.37), oncologic treatment (CR 0.66, 95% CI 0.32-1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77-1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16-0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens.

CONCLUSIONS

SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Pancreatic Cancer Incidence and Lethality Rates in Brazil: An Ecological Study

OBJECTIVES

To describe incidence and lethality time trends rates of pancreatic cancer (PC) in Brazil.

METHODS

Data from Brazilian Health National Public System (SUS) were retrospectively collected with regard to PC from January 2005 to December 2012. Pancreatic cancer incidence and lethality rates were estimated from SUS hospitalizations and in-hospital PC deaths and adjusted to total available hospital beds.

RESULTS

From 2005 to 2012, a total of 36,332 admissions for PC were registered in Brazil. Pancreatic cancer incidence nearly doubled from 2.4/100,000 to 4.5/100,000, particularly among patients older than 70 years, whereas no difference in sex was noted. The greatest incidence rates increase (+109%) occurred in the northeast, a less developed region that has recently achieved significant economic advances. Dynamic changes were observed, notably a shift to increasing PC incidence in rural areas. Lethality rates increased from mean 25% to 27%, the highest rates registered in those 70 years or older.

CONCLUSIONS

Overall increase trends in PC incidence and lethality were observed. Pancreatic cancer remains an urban disease in Brazil, the highest incidence found in the most developed regions as in large metropolitan integrated municipalities. Improvement in diagnosis, notification quality, a rapidly aging population, and a great demographic dynamism could in part explain this fact.

A Systematic Review of the Burden of Pancreatic Cancer in Europe: Real-World Impact on Survival, Quality of Life and Costs

PURPOSE

The purpose of this study was to assess the overall burden of pancreatic cancer in Europe, with a focus on survival time in a real-world setting, and the overall healthy life lost to the disease.

METHODS

Real-world data were retrieved from peer-reviewed, observational studies identified by an electronic search. We performed two de novo analyses: a proportional shortfall analysis to quantify the proportion of healthy life lost to pancreatic cancer and an estimation of the aggregate life-years lost annually in Europe.

RESULTS

Ninety-one studies were included. The median, age-standardised incidence of pancreatic cancer per 100,000 was 7.6 in men and 4.9 in women. Overall median survival from diagnosis was 4.6 months; median survival was 2.8-5.7 months in patients with metastatic disease. The proportional shortfall analysis showed that pancreatic cancer results in a 98 % loss of healthy life, with a life expectancy at diagnosis of 4.6 months compared to 15.1 years for an age-matched healthy population. Annually, 610,000-915,000 quality-adjusted life-years (QALYs) are lost to pancreatic cancer in Europe. Patients had significantly lower scores on validated health-related quality of life instruments versus population norms.

CONCLUSIONS

To the best of our knowledge, this is the first study to systematically review real-world overall survival and patient outcomes of pancreatic cancer patients in Europe outside the context of clinical trials. Our findings confirm the poor prognosis and short survival reported by national studies. Pancreatic cancer is a substantial burden in Europe, with nearly a million aggregate life-years lost annually and almost complete loss of healthy life in affected individuals.

Comparative analysis of the revenues of pylorus-preserving pancreatic head resections and laparoscopic cholecystectomies as prototypic surgical procedures in the German health-care system

BACKGROUND

Although centralization of complex surgical procedures such as pancreaticoduodenectomies is associated with a reduction in morbidity and mortality rates, it is unclear whether such surgeries are adequately represented in the German disease-related group (DRG) system.

PATIENTS AND METHODS

Out of all patients who underwent pancreatic resections (n = 450) at our institution between January 2008 and November 2011, 76 patients who underwent a pylorus-preserving pancreatic head resection due to pancreatic head adenocarcinoma were selected for analysis. The revenues generated by these surgical procedures were compared with those of 144 patients who had undergone elective laparoscopic cholecystectomies for symptomatic gallstone disease between January 2009 and September 2010 in our hospital.

RESULTS

In patients undergoing pylorus-preserving pancreaticoduodenectomy, revenues per case were 1,585.55 Euros, with an average length of hospital stay (ALOS) of 19.9 days (range 7-55 days) and an average postoperative hospital stay of 16 days; however, if the ALOS was exceeded, expenditures increasingly exceeded returns. Analysis of the cohort of patients with pylorus-preserving pancreaticoduodenectomies demonstrated average revenues per day of 79.27 Euros. In contrast, for laparoscopic cholecystectomy, which was treated with high surgical standardization and stringent case management, the ALOS was only 2.8 days, producing average revenues of 288.80 Euros per day and total revenues of 817.53 Euros per case.

CONCLUSION

At university hospitals, cost-effective realization of major pancreatic surgery is difficult, while highly standardized surgeries such as laparoscopic cholecystectomies can be performed at a favorable balance. This may be due to, firstly, an underrepresentation of university hospitals in the German DRG calculation basis and, secondly, to a relatively long preoperative hospital stay as a result of extensive diagnostic measures. We consider this kind of preoperative assessment paramount for an academic pancreatic center and thus argue for an increased reimbursement for these procedures.

Costs and trends in pancreatic cancer treatment

BACKGROUND

Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population-based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time.

METHODS

In the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer-free beneficiaries.

RESULTS

A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer-directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700.

CONCLUSIONS

Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future.

Pancreatic cancer, healthcare cost, and loss of productivity: a register-based approach

BACKGROUND

Despite the fact that pancreatic cancer is the fourth leading cause of cancer-related death, there is little empirical evidence on its direct healthcare costs and, especially, its indirect costs due to loss of production.

METHODS

The present study is a retrospective analysis of all patients with pancreatic cancer (excluding endocrine cancer) in the primary catchment area of Lund University Hospital, Sweden, during the period 2005-2007. Detailed information on all diagnostic and therapeutic investigations, interventions, and postoperative course and long-term follow-up was collected, as well as absenteeism from work due to the health problem, from which direct costs were calculated. The indirect costs for loss of production due to sickness and premature death were calculated by the human capital method. A total of 83 patients were included, for an incidence rate of 9.9 patients/100,000 inhabitants.

RESULTS

Direct treatment cost per pancreatic-cancer patient was estimated at EUR 16,066 for each patient's remaining lifetime. Hospitalization accounted for the major expenditure-60% of the lifetime treatment cost. Patients with resectable tumor had a mean cost of EUR 19,809; locally advanced disease, EUR 14,899; and metastatic disease, <euro>16,179. Younger patients and men had a higher than average lifetime treatment cost. The loss of productivity was estimated at EUR 287,420 per patient younger than 65 years of age, of which premature mortality accounted for 79%.

CONCLUSIONS

Adding the cost of palliative care estimated in a previous Swedish study, health-care costs and productivity losses for pancreatic cancer would add up to a substantial economic burden for Sweden at large in 2009 (population 9.1 million), between EUR 86 million and EUR 93 million.

Productivity loss as a major component of disease-related costs in patients with hypercholesterolemia in Germany

OBJECTIVE

Hypercholesterolemia is a common risk factor for cardiovascular diseases; however, there are only few data available on associated costs. The objective of this study is, therefore, to analyse direct and indirect costs in patients with hypercholesterolemia and to determine predictors of costs.

METHODS

The ORBITAL Study is a randomised controlled trial evaluating the effectiveness of a compliance-enhancing program in patients with statin therapy. Consecutive patients eligible for statin therapy according to the Joint European Guidelines were enrolled nationwide in 1961 primary care practices in Germany. For the present cost-of-illness analysis, patients were asked retrospectively about medical resource use and employment status in the 6 months preceding enrollment. The perspective chosen was societal. Factors associated with costs were determined using linear regression.

RESULTS

A total of 7,640 patients (56% men, mean age 60 +/- 10 years, and 44% women, 64 +/- 10 years) were included. Of these patients, 32% were employed, 17% had a history of myocardial infarction, 7% a history of stroke, 58% had hypertension, and 29% diabetes. Total disease-related costs amounted to a mean of 2,498 +/- 4,898 Euros per patient over 6 months, comprising direct (44%) and indirect (56%) costs. Disease-related early retirement was responsible for 42% of costs, followed by hospital visits (19%), medication (15%), workdays lost (14%), physician visits (5%), outpatient therapy (2%), and rehabilitation (2%). In multivariable analyses, factors associated with direct costs included coronary interventions, risk stratum, and medical history. Factors associated with indirect costs included disease-related early retirement, other socio-economic and lifestyle factors, coronary interventions, risk stratum, and medical history.

CONCLUSION

The considerable economic burden associated with hypercholesterolemia indicates the need to assess long-term cost-effectiveness of health care programs in patients with this disorder.

A clinical and economic evaluation of endoscopic ultrasound for patients at risk for familial pancreatic adenocarcinoma

BACKGROUND AND AIMS

Approximately 10% of pancreatic adenocarcinoma is familial. Approximately 50% of 1st-degree relatives (FDRs) have endoscopic ultrasound (EUS) findings of chronic pancreatitis. We modeled the natural history of these patients to compare 4 management strategies.

METHODS

We performed a systematic review, and created a Markov model for 45-year-old male FDRs, with findings of chronic pancreatitis on screening EUS. We compared 4 strategies: doing nothing, prophylactic total pancreatectomy (PTP), annual surveillance by EUS, and annual surveillance with EUS and fine needle aspiration (EUS/FNA). Outcomes incorporated mortality, quality of life, procedural complications, and costs.

RESULTS

In the Do Nothing strategy, the lifetime risk of cancer was 20%. Doing nothing provided the greatest remaining years of life, the lowest cost, and the greatest remaining quality-adjusted life years (QALYs). PTP provided the fewest remaining years of life, and the fewest remaining QALYs. Screening with EUS provided nearly identical results to PTP, and screening with EUS/FNA provided intermediate results between PTP and doing nothing. PTP provided the longest life expectancy if the lifetime risk of pancreatic cancer was at least 46%, and provided the most QALYs if the risk was at least 68%.

CONCLUSIONS

FDRs from familial pancreatic cancer kindreds, who have EUS findings of chronic pancreatitis, have increased risk for cancer, but their precise risk is unknown. Without the ability to further quantify that risk, the most effective strategy is to do nothing.