Outcomes and costs with the introduction of robotic-assisted thoracic surgery in public hospitals

Robotic-assisted thoracic surgery (RATS) is an effective treatment of non-small cell lung cancer (NSCLC) but the effects of its implementation in university hospital networks has not been described. We analyzed the early clinical outcomes, estimated costs, and revenues associated with three robotic systems implemented in the Paris Public Hospital network. A retrospective study included patients who underwent RATS for NSCLC in 2019 and 2020. Ninety-day morbidity, mortality, hospital costs, and hospital revenues were described. Economic analyses were conducted either from the hospital center or from the French health insurance system perspectives. Cost drivers were tested using univariate and multivariable analyses. Sensitivity analyses were performed to assess uncertainty over in-hospital length of stay (LOS), number of robotic surgeries per year, investment cost, operating room occupancy time, maintenance cost, and commercial discount. The study included 188 patients (65.8 ± 9.3 years; Charlson 4.1 ± 1.4; stage I 76.6%). Median in-hospital LOS was 6 days [5-9.5], 90-day mortality was 1.6%. Mean hospital expenses and revenues were €12,732 ± 4914 and €11,983 ± 5708 per patient, respectively. In multivariable analysis, factors associated with hospital costs were body mass index, DLCO, major complications, and transfer to intensive care unit. Sensitivity analyses showed that in-hospital LOS (€11,802-€15,010) and commercial discounts on the list price (€11,458-€12,732) had an important impact on costs. During the first 2 years following the installation of three robotic systems in Paris Public Hospitals, the clinical outcomes of RATS for NSCLC have been satisfactory. Without commercial discount, hospital expenses would have exceeded hospital revenues.Clinical registration number CNIL, N°2221601, CERC-SFCTCV-2021-07-20-Num17_MOPI_robolution.

Cost-effectiveness of stepwise provisional versus systematic dual stenting strategies in patients with distal bifurcation left main stem lesions: economic analysis of the EBC MAIN trial

BACKGROUND

In patients with distal bifurcation left main stem lesions requiring intervention, the European Bifurcation Club Left Main Coronary Stent Study trial found a non-significant difference in major adverse cardiac events (MACEs, composite of all-cause death, non-fatal myocardial infarction and target lesion revascularisation) favouring the stepwise provisional strategy, compared with the systematic dual stenting.

AIMS

To estimate the 1-year cost-effectiveness of stepwise provisional versus systematic dual stenting strategies.

METHODS

Costs in France and the UK, and MACE were calculated in both groups to estimate the incremental cost-effectiveness ratio (ICER). Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the healthcare provider with a time horizon of 1 year.

RESULTS

The cost difference between the two groups was €-755 (€5700 in the stepwise provisional group and €6455 in the systematic dual stenting group, p value<0.01) in France and €-647 (€6728 and €7375, respectively, p value=0.08) in the UK. The point estimates for the ICERs found that stepwise provisional strategy was cost saving and improved outcomes with a probabilistic sensitivity analysis confirming dominance with an 80% probability.

CONCLUSION

The stepwise provisional strategy at 1 year is dominant compared with the systematic dual stenting strategy on both economic and clinical outcomes.

Economic evaluation and budget-impact of accelerated partial breast irradiation (APBI) versus standard or hypofractionated whole breast irradiation (WBI) in postmenopausal women with early-stage breast cancer. Results from the French SHARE randomized trial

PURPOSE

This economic evaluation reports the incremental cost-utility ratio and national budget impact in France of accelerated partial breast irradiation (APBI) vs standard or hypofractionated whole breast irradiation (WBI) in breast cancer patients at low risk of local recurrence.

MATERIALS AND METHODS

We compared 490 women randomized to the APBI (ten fractions delivered twice daily over one week) with 488 women in the WBI arm (one fraction per day delivered five days per week over three or six weeks). We took the perspective of the French national health insurance with a three-year time horizon. The outcome was quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio was estimated and uncertainty was explored by probabilistic bootstrapping. Transportation and sick leave costs were added in a sensitivity analysis and a national budget impact analysis based on the incidence of breast cancer estimates in France performed.

RESULTS

At three years, the average cost per patient was €2,549 (±1,954) in the APBI arm and €4,468 (±1,586) in the WBI arm (p-value < 0.001), radiotherapy was the main driver of the difference between the two arms. No significant difference was found in QALYs. For an average of 60,000 new cases of breast cancer diagnosed annually in France, 28,000 would be eligible for treatment with APBI. A 100% uptake of APBI would result in a yearly30 million€ cost saving.

CONCLUSION

APBI for the treatment of postmenopausal women with early-stage breast cancer is cost saving, with no difference in outcome measured by QALYs.

Abstract P1-10-13: Economic comparison of standard external beam whole breast (WBI) versus accelerated partial breast irradiation (ABPI) in postmenopausal women with early-stage breast cancer. Results from the French SHARE randomized trial

Purpose: The economic evaluation reports the incremental cost utility ratio and budget impact of APBI vs standard external beam WBI for the treatment of post-menopausal women with early stage breast cancer.

Methods and materials: We compared 488 women in the standard arm (1 fraction per day delivered 5 days per week over 3 or 6/6.5 weeks) to 490 women in the ABPI arm (ten fractions delivered twice per day over one week). We took the perspective of the healthcare system, a 3-year time horizon; the outcomes were quality adjusted life years (QALYs). QALYs were calculated from the EQ5D5L questionnaires at baseline, 3 months, 6 months, 12 months and yearly after irradiation; scores were converted into utilities using the French value set and QALYs computed with the area under the curve approach. Measures of within-trial use of hospital resources were based on routine hospital data via patient-level information. We used the itemized and DRG cost data from each individual patient. Transportation costs were added in a sensitivity analysis. A 2.5% discount rate was applied to costs and QALYs. An incremental analysis with differences in costs and QALYs was performed to calculate the cost utility ratio. Bootstrapping was used to quantify uncertainty on the joint distribution of costs and outcomes, and 1,000 paired estimates of mean differential costs and QALYs were reported on a cost-effectiveness plane. A budget impact analysis based on incidence of breast cancer estimates was added. All analyses followed the intent to treat principle.

Results: Cost and utilities were available for the entire population. Costs and QALY results are presented in table 1. The 2 925 € (95% IC, -3 364 €; - 2 452 €) significant difference in total costs favoring ABPI was driven by the difference in radiotherapy costs and partly by lower transportation costs. No significant difference was found in QALYs. Figure 1 shows the uncertainty of the joint distribution of costs and QALYs. All replication are in the lower half of the plane indicating that ABPI is cost saving with QALYs distributed on each side of the vertical axis indicating equal distribution of QALYs. would be eligible for treatment with ABPI. The uptake of ABPI for 16% of these women would result in a 16 million€ cost saving.

Conclusions: At three years, ABPI for the treatment of postmenopausal women with early-stage breast cancer was found to be cost saving, with no difference in outcome measured by QALYs.

Table 1.

Figure 1.

Citation Format: Alicia Le Bras, Yazid Belkacemi, céline Bourgier, Isabelle Gabelle-Flandin, Adeline Petit, Philippe Guilbert, Julien Geffrelot, Christian Carrie, Eleonor RIVIN DEL CAMPO, Chantal Hanzen, claire charra-brunaud, Guillaume Auzac, Thomas Lacornerie, Jérôme Lemonnier, Eric Lartigau, Isabelle Durand-Zaleski. Economic comparison of standard external beam whole breast (WBI) versus accelerated partial breast irradiation (ABPI) in postmenopausal women with early-stage breast cancer. Results from the French SHARE randomized trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-10-13.

Implementing Technologies: Assessment of Telemedicine Experiments in the Paris Region: Reasons for Success or Failure of the Evaluations and of the Deployment of the Projects

BACKGROUND

Telemedicine is increasingly viewed as a tool to provide a wide range of health services. This article presents policy lessons drawn from the evaluation of telemedicine experiments conducted in the Paris region.

METHODS

We used a mixed method design to study telemedicine projects commissioned by the Paris Regional Health Agency between 2013 and 2017. We combined data analysis of the telemedicine projects, review of the protocols, and interviews with stakeholders.

RESULTS

We identified the following reasons for disappointing outcomes: the outcome measure was requested too early during the experiments because payers required information for budgetary decisions; and the learning curve, technical problems, diversion of use, insufficient number of inclusions, and a lack of adherence prevented the demonstration of successful outcomes of the projects.

CONCLUSION

The evaluation of telemedicine should be undertaken after sufficient uptake to ensure barriers to implementation are overcome, and to obtain the sample size necessary for statistical power and reduce the average cost for one telemedicine request. Randomized controlled trials should be encouraged with appropriate funding and the follow-up period should be extended.

Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study

BACKGROUND AND PURPOSE

MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms.

MATERIALS AND METHODS

A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later.

RESULTS

Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time.

CONCLUSIONS

Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.

Economic evaluation of fractional flow reserve-guided versus angiography-guided multivessel revascularisation in ST-segment elevation myocardial infarction patients in the FLOWER-MI randomised trial

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) who have multivessel disease, the FLOWER-MI trial found no significant clinical benefit to fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) compared to angiography-guided PCI.

AIMS

Our aim was to estimate the cost-effectiveness and cost-utility of FFR-guided PCI, the secondary endpoint of the FLOWER-MI trial.

METHODS

Costs, major adverse cardiovascular events (composite of all-cause death, non-fatal myocardial infarction [MI], and unplanned hospitalisation leading to urgent revascularisation), and quality-adjusted life years were calculated in both groups. The incremental cost-effectiveness and cost-utility ratios were estimated. Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the health care provider with a time horizon of one year.

RESULTS

At one year, the average cost per patient was 7,560€ (±2,218) in the FFR-guided group and 7,089€ (±1,991) in the angiography-guided group (p-value<0.01). The point estimates for the incremental cost-effectiveness and cost-utility ratios found that the angiography-guided strategy was cost saving and improved outcomes, with a probabilistic sensitivity analysis confirming dominance.

CONCLUSIONS

The FFR-guided strategy at one year is unlikely to be cost effective compared to the angiography-guided strategy on both clinical and quality of life outcomes.

Compared Outcomes of ST-Elevation Myocardial Infarction Patients with Multivessel Disease Treated with Primary Percutaneous Coronary Intervention and Preserved Fractional Flow Reserve of Non-Culprit Lesions Treated Conservatively and of Those with Low Fractional Flow Reserve Managed Invasively: Insights from the FLOWER MI trial

Background: In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, percutaneous coronary intervention (PCI) for non-culprit lesions guided by FFR is superior to treatment of the culprit lesion alone. Whether deferring non-culprit PCI is safe in this specific context is questionable. We aimed to assess clinical outcomes at one-year in STEMI patients with multivessel coronary artery disease and an FFR-guided strategy for non-culprit lesions, according to whether or not ≥1 PCI was performed. Methods: Outcomes were analyzed in patients of the randomized FLOWER MI (Flow Evaluation to Guide Revascularization in Multivessel ST-Elevation Myocardial Infarction) trial in whom, after successful primary PCI, non-culprit lesions were assessed using FFR. The primary outcome was a composite of all-cause death, non-fatal MI, and unplanned hospitalization with urgent revascularization at one year. Results: Among 1,171 patients enrolled in this study, 586 were assigned to the FFR-guided group: 388 (66%) of them had ≥1 PCI and 198 (34%) had no PCI. Mean FFR before decision (i.e., PCI or not) of non-culprit lesions were 0.75±0.10 and 0.88±0.06, respectively. During follow-up, a primary outcome event occurred in 16 of 388 patients (4.1%) in patients with PCI and in 16 of 198 patients (8.1%) in patients without PCI (adjusted hazard ratio, 0.42; 95% confidence interval, 0.20 to 0.88; P = 0.02). Conclusions: In patients with STEMI undergoing complete revascularization guided by FFR measurement, those with ≥1 PCI had lower event rates at 1 year, compared with patients with deferred PCI, suggesting that deferring lesions judged relevant by visual estimation but with FFR >0.80 may not be optimal in this context. Future randomized studies are needed to confirm this data.

Cost-effectiveness of rituximab versus azathioprine for maintenance treatment in antineutrophil cytoplasmic antibody-associated vasculitis

OBJECTIVES

Rituximab was proven superior to azathioprine for maintenance treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). The high cost of rituximab might, however, limit its routine use. This study determined the cost-effectiveness of intravenous rituximab (5 x 500 mg until month 18), versus oral azathioprine (2 mg/kg per day, gradually decreased between month 12 and 22), for maintenance treatment of patients with granulomatosis with polyangiitis, microscopic polyangiitis, or renal-limited vasculitis, aged 18-75.

METHODS

We performed a single-trial based economic evaluation. MAINRITSAN was a 28-month multicentre, prospective, randomised, controlled open-label trial. We estimated the cost of healthcare resources and quality of life using prospectively collected data. Healthcare costs were estimated from the perspective of the French Social Health Insurance's perspective, using 2016 tariffs for reimbursement. Utilities were derived from Short Form 36 scores. We estimated total average cost, incremental cost per incremental relapse averted and per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to assess uncertainty over relapses, severe adverse events, discount rate, utility weights, time horizon and the cost of rituximab. Costs drivers were tested using a generalised linear model.

RESULTS

Total average costs were €13,387 (€11,605-€15,646) and €10,217 (€7,567-12,949) in the rituximab and azathioprine groups respectively. The incremental cost-effectiveness ratio (ICER) was €12,824 per relapse averted and the incremental cost-utility ratio (ICUR) €37,782 per QALY gained. Besides the unit cost of rituximab, the major cost drivers were relapses and severe adverse events.

CONCLUSIONS

Maintenance treatment by rituximab could be cost-effective for preventing relapses in patients with AAV.

Trends, seasonality and forecasts of pulmonary tuberculosis in Portugal

SETTING

Tuberculosis (TB) is a global public health concern. Surveillance programmes present invaluable epidemiological information regarding its temporal evolution, particularly for pulmonary tuberculosis (PTB), the most common form of TB and the one that presents the greatest challenge in public health.

OBJECTIVES

To characterise, model and predict monthly incidence rates for PTB in Portugal disaggregated by high/low-incidence areas, sex and age groups.

DESIGN

PTB monthly incidence rates were estimated based on PTB cases diagnosed in 2000-2010, disaggregated by population and geographic characteristics. Seasonal-trend LOESS (STL) decomposition was employed to model trend and seasonality. Seasonal autoregressive integrated moving average (SARIMA) models were fit to characterise series behaviour and forecast PTB monthly incidence rates.

RESULTS

Overall, the time series showed a downward trend in and seasonality of PTB diagnosis, with a peak in March and a trough in December. The mean seasonal amplitude was consistently higher in high-incidence areas, in males and in adults aged 25-54 years. SARIMA models were found to adequately fit and forecast the time series, thus predicting trend and seasonal persistence.

CONCLUSIONS

STL and SARIMA findings concurred and were accurate. Endemic PTB seems to be slowly declining and case diagnosis is likely seasonal, which can be expected to persist if past conditions continue.