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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
Staggering opportunity costsStaggering opportunity costsEducationEducation
Domestic infrastructureDomestic infrastructure
Civic resourcesCivic resources
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Health outcomes do not reflect our Health outcomes do not reflect our national investmentnational investment
CMS & IOM Triple mandateCMS & IOM Triple mandate
Patient centeredPatient centered
Empirically shown to improve outcomesEmpirically shown to improve outcomes
Lowers costLowers cost
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Cost-effectiveness analyses examine the cost of:
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).
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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
Any intervention 1:88Any intervention 1:88
PhysicianPhysician--directed intervention 1: >500directed intervention 1: >500
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… 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
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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 ExperienceBethesda Naval Hospital ExperiencePT evaluation componentsPT evaluation componentsPRO PRO -- upper quadrant impairmentupper quadrant impairment
Limb volumeLimb volume
Range of motionRange of motion
PalpationPalpation
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
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Net costs from hospitalization Net costs from hospitalization
Two important challengesTwo important challenges
1.1. Identifying the right patients at the right timeIdentifying the right patients at the right time
2.2. Securing patient buySecuring patient buy--inin
729
.447
.0 51.4
65.6 70
.5
9
40
50
60
70
80
SymptomFunctional problem
Per
cent
age
Clinician documentation of patient Clinician documentation of patient identified problems by subtypeidentified problems by subtype
22.7
0.0 0.0 0.0 0.01.6 2.8 3.9 4.4
7.7 10.5
19.4 23
.9
0
10
20
30
Feel week
Bladder issues
Fatigue
Bow
el issuesN
ausea
Pain
Difficulty lifting
Difficulty bending
Difficulty getting in / out bed
Needs assist w
ith AD
LsInsufficient strength for A
DLs
Cognitive changes
Need support w
hen walking
Standing from
chair/toiletS
peech changesC
oughing when drinking
Difficulty w
ith balanceP
roblems w
ith ambulation
P
Cheville A, JSCC 08’
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Some difficulty indoing moderate orstrenuous activities
Some difficulty in moving insidea building andlimited in going M
obil
ity
Sco
reAM PAC CAT scores of decedentsAM PAC CAT scores of decedents
Limited in bed, basic transfers
Limited mobilityinside of
building; Unable todo bending/reaching
activities
outdoors
Months Prior to Death
AM
PA
C C
AT
Bas
ic M
How to operationalize?How to operationalize?
Tablet computer input at clinical encountersTablet computer input at clinical encounters
Interactive voice responseInteractive voice response
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
Securing patient buySecuring patient buy--inin
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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)
“YES” 10.4% (n=166)“YES” 10.4% (n=166)
Interest among patients rating functional distress Interest among patients rating functional distress >>4 (114 (11--point numerical rating scale)point numerical rating scale)“NO” 72.3% (n=513)“NO” 72.3% (n=513)
“YES” 17.0 % (n=121)“YES” 17.0 % (n=121)
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Receptivity to rehabilitationReceptivity to rehabilitation
Interest among patients with AM PAC CAT <65Interest among patients with AM PAC CAT <65“NO” 79.7% (n=1277)“NO” 79.7% (n=1277)
“YES” 10.4% (n=166)“YES” 10.4% (n=166)
Interest among patients rating functional distress Interest among patients rating functional distress >>44“NO” 72.3% (n=513)“NO” 72.3% (n=513)
“YES” 17.0 % (n=121)“YES” 17.0 % (n=121)
Not beneficialNot beneficialWouldn’t do any good/nothing would change (27)Wouldn’t do any good/nothing would change (27)
Patients’ attitudes regarding Patients’ attitudes regarding rehabilitation services (n=364)rehabilitation services (n=364)
No time/energy/air left (17)No time/energy/air left (17)
BurdensomeBurdensomeWorsening symptoms (28)Worsening symptoms (28)
Travel (12)Travel (12)
Patients’ attitudes regarding Patients’ attitudes regarding rehabilitation services (n=364)rehabilitation services (n=364)
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)
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WaitingWaitingRecovery from chemotherapy/radiation/surgery Recovery from chemotherapy/radiation/surgery
Patients’ attitudes regarding Patients’ attitudes regarding rehabilitation services (n=364)rehabilitation services (n=364)
(17)(17)
Symptoms to improve (4)Symptoms to improve (4)
Test results (6)Test results (6)
Treatment to work (7)Treatment to work (7)
Limited appreciation of Limited appreciation of symptomatic benefits of exercisesymptomatic benefits of exercise
>> 45 minute in depth interviews conducted 45 minute in depth interviews conducted with 20 patients & caregiverswith 20 patients & caregivers11
Usual activities sufficientUsual activities sufficient
Overestimation usual activities rigorOverestimation usual activities rigor
Assumed endorsement of oncology care teamAssumed endorsement of oncology care team
Caregivers reluctant to become “coaches”Caregivers reluctant to become “coaches”
1. Cheville AL, Dose AM, Basford JR, Rhudy LR. JPSM, 2012.
ConclusionsConclusions
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
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Thank you for your time Thank you for your time and attentionand attention
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