RESEARCH ARTICLE For reprint orders, please contact: [email protected]
Evaluating treatments and corresponding costs of prostate cancer patients treated within an inpatient or hospital-based outpatient setting Brian Seal1, Sean D Sullivan2, Scott Ramsey3, Carl V Asche4, Kenneth M Shermock5, Syam Sarma6, Erin Zagadailov7, Eileen Farrelly7 & Michael Eaddy*,7
ABSTRACT Aim: To describe treatments and cost of care for prostate cancer (PCa) in hospital-based outpatient and inpatient settings. Methods: Hospital encounters associated with PCa (ICD-9 codes 185, 233.4) and PCa-related treatment in a hospital claims database were included. Results: There were 211,440 encounters for PCa between January 2006 and December 2010 (88,151 inpatient and 123,289 outpatient). Average cost per inpatient stay was US$12,286 versus US$4364 per outpatient visit. Most common treatment during an inpatient stay and outpatient visit was surgery (57%) and radiation (76%), respectively. A total of 80% of outpatient visits and 69.9% inpatient stays were associated with a single treatment; remaining encounters were associated with ≥2 treatments. Conclusion: Costs are consistent with previous estimates; however, multimodal therapy is an emerging trend that may be related to greater costs in the future which may also be a challenge for hospital decision makers. Prostate cancer (PCa) is the most common malignancy in men in the USA [1] .More than 241,700 new cases of PCa were diagnosed in 2012, representing 29% of all cancer diagnoses, and 28,170 men died from this cancer, encompassing 9% of all cancer deaths [2] . The lifetime risk of developing PCa for men in the USA is 16%, meaning that one in six men have a chance to be eventually diagnosed with this cancer [3] . The vast majority (93%) of patients present with localized or regional PCa have a 5-year survival rate of 100% [3] . In contrast, 4% of patients have metastatic prostate cancer (MPC) at diagnosis and have an unfavorable 5-year survival rate of 29% [3] . In addition, about a third of men are at risk of developing progressive PCa to distant sites (lymph nodes and bones, among others), despite initial diagnosis of early stage disease [4] . The treatment for early PCa is curative and comprises an individualized approach (radical prostatectomy, radiation or watchful waiting) based on life expectancy, comorbidities and toxicities of treatment [5] . The treatment of advanced PCa is palliative, with androgen deprivation therapy with medical or surgical castration being the preferred first-line treatment option [5] . At subsequent progressions, options such as abiraterone acetate, cabazitaxel, secondary androgen deprivation therapy and enrollment in a clinical trial can be considered, but there is no therapeutic consensus regarding the best agent to be used [5] . In addition, novel agents such as radium-223 and
KEYWORDS
• healthcare costs/trends • hospitalization • prostatic neoplasms • retrospective
studies
Bayer HealthCare Pharmaceuticals, 100 Bayer Boulevard Whippany, NJ 07981, USA University of Washington, Department of Pharmacy, Box 357630 Seattle, WA 98195-7630, USA 3 Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, PO Box 19024, Seattle, WA 98109-1024, USA 4 University of Illinois College of Medicine, 808 S Wood St, Chicago, IL 60612, USA 5 Johns Hopkins University, 600 N Wolfe St, Carnegie 180, Baltimore, MD 21287, USA 6 Independent Consultant, 7908 Kara Court, Greenbelt, MD 20770, USA 7 Xcenda, 4114 Woodlands Parkway, Ste 500, Palm Harbor, FL 34685, USA *Author for correspondence: Tel.: +1 727 771 4126; [email protected] 1 2
10.2217/FON.14.242 © 2015 Future Medicine Ltd
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Research Article Seal, Sullivan, Ramsey et al. enzalutamide have recently shown overall survival (OS) benefit and delayed the time to first on-study skeletal-related event in this patient population [6,7] . Overall, PCa is associated with a high economic burden in the USA; the total cost of care was estimated at about US$12 billion in 2010 (up from US$10 billion in 2006), ranking PCa as the fifth highest cancer in terms of national expenditures [8,9] . It is important to point out that this estimate did not include any of the recent therapeutic advances in the management of MPC that will likely impact patterns of care and healthcare spending. Furthermore, 2020 projections based on increasing prevalence of PCa are indicating that the cost for PCa will rise to US$16 billion [9] . The high economic burden of PCa was also predicted from a model analysis of the Surveillance Epidemiology and End Results (SEER) database that estimated a lifetime cost of US$110,520 (95% CI: US$110,324–110,739) per patient [10] . Keeping in mind the overall healthcare spending for PCa, it has been well documented that the majority of care occurs in an outpatient setting [11] . However, Milenkovic et al. found, using data from the Healthcare Cost and Utilization Project (HCUP), that nearly half a million hospitalizations in 2004 (81,300 as primary diagnosis; 416,700 as secondary diagnosis) in the USA involved PCa, highlighting that a substantial proportion of the cost was associated with PCa care completed in the inpatient hospital setting [12] . A considerable amount of inpatient care was also documented in retrospective analyses from the PharMetrics database (2000–2005) and the SEER-Medicare database (2000) [13,14] . However, no studies to date have documented specific treatment patterns of care within both the hospital-based outpatient and inpatient setting, which is crucial for hospital-based decision makers given the changing landscape of prostate cancer treatment. As such, this study sought to describe treatments used and the associated cost of care for PCa patients who have received PCarelated treatment in an inpatient or hospitalbased outpatient setting at some point during their care. Methods ●●Data source
Hospital claims data from the Premier Perspective Database were used to conduct the analyses. This database is the largest hospital database in the
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USA for determining hospital quality benchmarking and contains linked, de-identified inpatient medical, pharmacy and billing data from more than 500 geographically dispersed hospitals. Participating hospitals represent all regions of the USA, are predominantly small- to mid-sized nonteaching facilities and serve largely urban populations. The database contains a datestamped log of all billed items by cost accounting department, including medications and laboratory, diagnostic and therapeutic services, as well as primary and secondary diagnoses for each patient. In addition, de-identified, linked patient enrollment data, including demographic and payer information, as well as provider characteristics, are available in the discharge summary file. ●●Sample selection
Encounters associated with prostate cancer (International Classification of Diseases, 9th Revision [ICD-9] codes185.xx [malignant neoplasm of the prostate], 233.4 [carcinoma in situ, prostate]) between 1 January 2006 and 31 December 2010 were eligible for study inclusion. Encounters were also required to be associated with a patient who was ≥40 years of age and had at least one PCa-related treatment during the hospitalization or outpatient visit. PCa treatment was defined as the presence of a code or claim (e.g., Current Procedural Terminology [CPT] code, Healthcare Common Procedure Coding System [HCPCS] or hospital billing code) for prostate surgery, radiation treatment, chemotherapy, hormone therapy, radiopharmaceuticals or alternative treatments for prostate cancer (ketoconazole, aminoglutethimide, corticosteroid). All PCarelated treatments were independently reviewed by a radiation oncologist prior to inclusion in the analysis. Encounters were excluded if they had codes indicative of additional cancers (ICD-9 codes 140.xx–172.xx, 174.xx–184.xx, 186.xx, 187. xx, 189.xx–195.xx and 199.xx–208.xx). ●●Analysis of outcomes
The primary variables of interest were treatments utilized within the hospital stay or outpatient visit, the corresponding costs of treatments per hospitalization or visit and the length of stay. For the purpose of this analysis, the unit of analysis was the hospital encounter which included inpatient hospital stays and hospital-based outpatient visits. To provide a comprehensive description of where costs are incurred, costs were aggregated by the department billing for services.
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Evaluating treatments & corresponding costs of prostate cancer patients Descriptive summary statistics were constructed as frequencies and proportions for categorical data and means for continuous variables. Statistical analyses were conducted in SAS version 9.2.1 (SAS Business Analytics, NC, USA). Results ●●Sample characteristics & treatment
patterns
There were a total of 755,375 encounters identified where a patient had diagnosis of prostate cancer. Encounters were then excluded for
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having diagnoses of cancers other than prostate cancer (4%), encounters associated with a patient being less than 40 years of age (0.1%) and encounters associated with a patient being female (0.04%). These exclusions resulted in 723,783 encounters eligible for analysis, which represents 265,112 unique patients. Out of these eligible encounters, 71% did not have any evidence of PCa-related treatment, leaving a total of 211,440 encounters with evidence of treatment, which represented 118,300 unique patients. In the sample of 211,440 encounters, 88,151 were
Table 1. Hospital encounter characteristics. Characteristics
Mean age (SD), years Race (%): – African–American – Caucasian – Hispanic – Other Region (%): – Northeast – Midwest – South – West Hospital type (%): – Urban – Rural – Teaching – Nonteaching Payer type (%): – Medicare – Medicaid – Commercial/private – Self-pay – Other Bed size (%): – Average number of beds (n) – 0–200 – 201–400 – 401–600 – 601–1000 – >1000 Treatments (%): – Surgery – Radiation treatment – Chemotherapy – Primary hormonal therapy – Secondary hormonal therapy – Nuclear medicine-related PCa therapy
Treated PCa population Inpatient (n† = 88,151)
Hospital outpatient Total (n† = 211,440) (n† = 123,389)
69 (11)
70 (9)
69 (10)
12 68 3 17
12 63 3 22
12 65 3 20
21.9 20.6 38.1 19.4
8.8 23.6 47.5 20.1
14.3 22.4 43.5 19.8
90.0 10.0 46.1 53.9
81.6 18.4 34.3 65.7
85.2 14.8 39.2 60.8
56.7 2.1 37.4 0.9 2.9
65.3 2.4 27.3 1.5 3.5
61.7 2.3 31.5 1.3 3.2
466 10.2 35.5 30.3 19.5 4.5
408 11.7 45.1 27.4 14.7 1.1
432 11.0 41.1 28.6 16.8 2.5
57 4 3 30 39 0.5
9 76 11 11 10 8
29 46 8 19 22 5
Represents the number of hospitalizations among the sample of PCa patients treated in an inpatient setting and does not represent the number of unique patients. PCa: Prostate cancer; SD: Standard deviation. †
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Research Article Seal, Sullivan, Ramsey et al. hospital stays and 123,289 were hospital-based outpatient visits. Overall, most encounters took place in the South (43.5%) followed by the Midwest (22.4%) (Table 1) . Additionally, most encounters occurred at urban (85.2%), nonteaching (60.8%) hospitals where the average bed size was 432 (Table 1) . The mean age of the sample of encounters was 69 years, with 65% being Caucasian (Table 1) . The mean age is consistent with the most common payer type, Medicare (61.7%); however, 31.5% of encounters were associated with commercial/private payer reimbursement (Table 1) . For patients with an inpatient hospitalization, the mean length of stay was 4.40 days (SD: 7.89). The most common treatment provided during inpatient stays was hormonal therapy (69%), which included primary (30%) and secondary hormonal therapy (39%). Primary hormonal therapies included, but were not limited to, 5-α reductase inhibitors (e.g., finasteride), antiandrogens (e.g., bicalutamide) and gonadotropin-releasing hormones. Secondary hormonal therapy included steroid therapies such as prednisone and dexamethasone. In contrast, the most common treatment in the hospital outpatient setting was radiation (76%). The most common types of radiation procedures were high dose rate brachytherapy, interstitial brachytherapy and external beam radiation therapy. Surgery was associated with 57% of inpatient hospitalizations, making it the second-most common treatment associated with inpatient stays. The types of surgeries included, but were not limited to, transurethral resection of the prostate, radical prostatectomy, surgical prostatectomy and prostate ablation. Very few encounters were associated with the receipt of nuclear medicine-related PCa therapy (e.g., iodine-125, palladium and samarium-152 among others) in the inpatient and hospital outpatient settings: 0.5 and 8%, respectively. The majority of hospitalizations were associated with a primary diagnosis or admitting code for PCa (58.6%), while 78,489 hospitalizations (37.1%) were associated with a secondary diagnosis code for PCa only and the remaining 4.3% of the sample had both a primary/admitting and secondary diagnosis code for PCa. A summary of the primary diagnosis codes for men with a secondary diagnosis code of PCa is described in Table 2 . For men with a secondary diagnosis code for PCa only, the most common primary diagnosis codes were diseases of
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the circulatory system, diseases of the respiratory system and diseases of the genitourinary system for inpatient hospitalizations (Table 2) . With respect to hospital-based outpatient visits, the most common primary diagnosis code for men with a secondary diagnosis code of PCa was “Supplementary classification of factors influencing health status and contact with health services,” which is relatively more common in an outpatient setting. Overall, 160,026 encounters were associated with a single treatment for PCa, which accounted for the majority of both inpatient stays (69.6%) and outpatient visits (80.0%) (Tables 3 & 4) . Nearly all encounters associated with a single treatment during an inpatient stay were also associated with surgery (53.0%) or some form of hormone therapy (44.8%). In the outpatient setting, the majority of encounters with a single treatment were associated with radiation (80.8%). Approximately one in three encounters in the inpatient setting were associated with multimodal therapy, with 27.3% of inpatient stays associated with two treatments and 3.0% of inpatient stays associated with three or more treatments (Table 3) . For encounters associated with two treatments during an inpatient stay, the most common treatment combination was surgery combined with secondary hormonal therapy (55.5%), followed by a combination of primary and secondary hormonal therapies (21.1%). For encounters associated with three or more treatments during an inpatient stay, the majority received a combination of hormonal therapy with surgery (34.0%), radiation (24.1%) or chemotherapy (21.4%). Twenty percent of encounters were associated with multimodal therapy during a hospital-based outpatient visit, with 15.5% and 4.5% of outpatient visits associated with two and three or more treatments, respectively (Table 4) . For encounters associated with two treatments during an outpatient visit, the most common treatment combination was radiation combined with nuclear medicine (27.6%). For encounters associated with three or more treatments during an outpatient visit, the majority received combination hormonal therapy with radiation (32.3%). The total average cost per hospitalization for inpatient stays was US$12,286 (Table 5) . With an overall average length of stay at 4.4 days, room and board charges contributed 31% of the overall cost for PCa hospitalizations.
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Evaluating treatments & corresponding costs of prostate cancer patients
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Table 2. Primary diagnosis codes for encounters with secondary diagnosis code for prostate cancer. Primary ICD-9 diagnosis code(s)
Inpatient (n† = 36,487), % Outpatient (n† = 42,002), %
Total (n† = 78,489), %
Diseases of the circulatory system (390–459.9) Diseases of the respiratory system (460–519.9) Diseases of the genitourinary system (580–629.9) Diseases of the digestive system (520–579.9) Injury and poisoning (800–999.9) Infectious and parasitic diseases (001–139.8) Diseases of the musculoskeletal system and connective tissue (710–739.9) Symptoms, signs and ill-defined conditions (780–799.9) Endocrine, nutritional and metabolic diseases and immunity disorders (240–279.9) Supplementary classification of factors influencing health status and contact with health services (v01–v91.9) Other‡
18.9 13.5 12.9 7.4 7.2 6.1 5.1
0.9 0.7 3.7 0.8 0.7 0.1 1.0
9.3 6.7 8.0 3.8 3.7 2.9 2.9
4.3 3.3
2.0 0.4
3.1 1.7
3.3
83.7
46.3
17.9
6.0
11.6
Represents the number of hospitalizations among the sample of prostate cancer patients treated in an inpatient setting and does not represent the number of unique patients. ‡ Other primary diagnosis codes included, but are not limited to, diseases of the blood and blood-forming organs (280–289.9), diseases of the nervous system and sense organs (320–389.9) and diseases of the skin and subcutaneous tissue (680–709.9). ICD-9: International Classification of Diseases, 9th Revision. †
Surgery was the second-largest cost item overall and the largest treatment-related cost item, representing 26% of inpatient hospitalization costs. Pharmaceuticals accounted for 8% of total inpatient costs. Overall, PCa-related treatment represented about 30% of all inpatients costs:prostate surgery = US$1996 per encounter; radiation = US$11 per encounter; chemotherapy = US$23 per encounter; hormone therapy = US$44 per encounter; secondary hormonal therapy = US$13 per encounter; and nuclear medicine = US$99 per encounter. The total average cost per hospital-based outpatient visit was US$4364 (Table 5) . PCa-related treatment costs (US$3134) represented 71.8% of all hospital-based outpatient costs, of which radiation and nuclear medicine costs (US$2661) were the primary drivers of total outpatient costs and represented 62.3% of total hospital-based outpatient costs. Surgery and pharmacy costs were also key components of hospital-based outpatient costs. Discussion The purpose of this study was to describe treatments used and the associated cost of care for patients who have received PCa-related treatment in a hospital setting, which included inpatient stays and hospital-based outpatient visits. More specifically, this study provides a baseline of current treatment patterns and costs to which emerging patterns may be compared. This is particularly relevant to hospital administrators and clinicians who will seek to determine how the
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recent entrance of several novel agents (abiraterone acetate, cabazitaxel, radium-223 and enzalutamide) will impact or alter current treatment patterns. The primary variables of interest were treatments utilized during the encounter, the corresponding costs of treatments per encounter and length of stay. The average cost per encounter for inpatient stays was US$12,286, with the majority of treatment-related costs associated with surgery. In contrast, the average cost per outpatient visit was US$4364, with the majority of treatment-related costs associated with radiation. These results are consistent with a previous retrospective study of PCa patients by Crawford et al., who reported that surgery was the most common treatment among PCa patients [14] . Additionally, the majority of costs were due to inpatient resource utilization for patients who received surgery. The large proportion of outpatient stays associated with radiation therapy may be explained by recent findings from SEER by Nguyen et al. In a year-by-year analysis of utilization from 2002 to 2005, Nguyen et al. found rapidly increasing use of external radiation and supplemental intensity-modulated radiation therapy for patients receiving brachytherapy [15] . With respect to cost per encounter, our findings were similar to those found in the National Inpatient Sample (NIS) by the HCUP on PCa in 2004 [12] . On average, the mean cost per hospitalization in the HCUP sample was US$8100 in 2004, which is lower than our finding of US$12,286 per hospitalization; however this
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Research Article Seal, Sullivan, Ramsey et al. Table 3. Inpatient treatment patterns. Surgery
Radiation
Chemotherapy Primary hormonal therapy
Secondary hormonal therapy
Nuclear medicine
n (%)
X
X
32,557 (53.0) 967 (1.58) 324 (0.5) 15,767 (25.7) 11,733 (19.1) 38 (0.1)
X X X X
13,382 (55.5) 5074 (21.1) 2692 (11.2) 874 (3.6) 806 (3.3) 1220 (5.0)
X X X X X
905 (34.0) 643 (24.1) 571 (21.4) 148 (5.6) 111 (4.2) 289 (10.8)
Single treatment: 61,386 hospitalizations (69.6%) X
X
X
X
Two treatments: 24,098 hospitalizations (27.3%) X X X X Other treatment combinations†
X X
Three or more treatments: 2667 hospitalizations (3.0%) X X X X X X X Other treatment combinations†
X X X X
Includes total of other less commonly reported treatment combinations.
†
may be related to a shorter length of stay with the HCUP database (3.4 vs 4.4 days). Additionally, the marginally higher average cost per encounter in our analysis may also be related to the substantial number of patients who received multimodal therapy. In our study, nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were associated with the receipt of two or more treatments between 2006 and 2010. This is in contrast to Crawford et al., who reported less than 1% of PCa patients received multiple treatments between 2000 and 2005 [14] . Although the unit of analysis for the Crawford paper was different (patient) than our analysis (encounter), our analysis indicates that patients may continue to seek and receive multiple treatments, which will add to already heightened attention to control costs in a hospital setting. Last, our results showed that the majority of men with PCa treated in an inpatient setting received surgery or some form of hormone therapy. These findings are consistent with current treatment paradigms and indicate that the inpatient-treated PCa population in this study may represent a population with advanced
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disease, symptomatic disease or at a high risk for recurrence. Watchful waiting or active surveillance is common until progressive or symptomatic disease is evident, upon which treatment options such as surgery may be employed [5] . Additionally, primary hormonal therapy is a first-line treatment option for advanced PCa, which is often regarded as palliative treatment. Strengths & limitations This study has several strengths and limitations associated with its study design and data analysis. First, a retrospective claims data analysis limits the amount of clinical variables available (e.g., cancer grade), which would be valuable in further understanding of the treatment patterns. Second, the analysis relies on selecting claims based on ICD-9 codes that accurately represent the specific population of interest. Accordingly, there is a possibility that patients with PCa could be omitted if a diagnosis indicative of PCa was not included in standard diagnosis fields of the claims database, resulting in misclassification of patients; however, our analysis included 211,440 encounters for men who received PCa treatment in a nationally representative hospital
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Evaluating treatments & corresponding costs of prostate cancer patients database, giving a good sample for evaluation. It should be noted that patients having ICD-9 codes for rectal (ICD-9: 154) or bladder cancer (ICD-9: 188) or secondary cancer codes (ICD9: 196–198) in addition to the PCa diagnosis were not excluded given that PCa may invade into these areas. Posthoc analyses indicated that including these patients had little to no influence on parameter estimates. Also, patients having cancer diagnosis codes of 173.xx or 209–239.xx were not excluded, as these cancers were thought to have no clinical impact on patient survival. Inclusion of these patients was also shown to have no influence on parameter estimates. Additionally, our analysis sought to describe utilization and costs among patients who received treatment during their hospital encounter. As such, encounters that were not associated with treatment were excluded. As a result, encounters associated with a watchful waiting or active surveillance approach may have been excluded. Last, the total costs of each hospital encounter represent the total costs of treating a patient with metastatic PCa, which includes the costs of treating comorbid conditions and
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complications that may have occurred during the hospitalization. In an evaluation of the patient demographics for the inpatient-treated PCa population, the mean age was 69 years, which corresponds well with SEER data, which indicate that the mean age of diagnosis for PCa is 67 years [3] . This similarity in demographics gives our analysis good generalizability to the overall PCa population. However, 68% of the population was Caucasian men, while African–Americans represented approximately 12% of patients. Previous studies have demonstrated that PCa disproportionately affects African–American men and, worldwide, African–American men have the highest incidence of PCa [16,17] . Therefore, the difference in racial demographics in our population compared with the general PCa population could be considered a study limitation. Finally, newer therapies that entered the market shortly before (cabazitaxel) and after (abiraterone) the end date of this study were not reflected in the results. Future research re-evaluating this topic once these agents have become a part of the treatment paradigm will be necessary to determine emerging treatment patterns.
Table 4. Outpatient treatment patterns. Surgery
Radiation
Chemotherapy Primary hormonal therapy
Secondary hormonal therapy
Nuclear medicine
n (%)
X
X
4235 (4.3) 79,667(80.8) 3984 (4.0) 6818 (6.9) 3614 (3.7) 322 (0.3)
X X
X
5268 (27.6) 4979 (26.1) 3731 (19.6) 2110 (11.6) 1022 (5.4) 1842 (9.7)
X X X X
X
1808 (32.3) 1570 (28.0) 569 (10.2) 558 (10.0) 489 (8.7) 603 (10.8)
Single treatment: 98,640 hospitalizations (80.0%) X
X
X
X
Two treatments: 19,052 hospitalizations (15.5%) X X X X X X Other treatment combinations†
X
Three or more treatments: 5597 hospitalizations (4.5%) X X X X X X X X Other treatment combinations†
X X X
Includes total of other less commonly reported treatment combinations.
†
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Research Article Seal, Sullivan, Ramsey et al. Table 5. Inpatient stay and outpatient visit costs. Cost category
Mean treatment costs (US$)
Inpatient stays
Outpatient visits
General costs
PCa-specific costs
Total costs
General costs PCa-specific costs Total costs
All professional/administrative fees All surgery Blood bank All cardiology Central supply All diagnostic Emergency room Laboratory Pathology All pharmacy: – Chemotherapy – Primary hormonal therapy – Secondary hormonal therapy – All rehabilitation – Radiation and nuclear medicine – Radiation – Nuclear medicine Room and board Other† Total
240 1248 243 128 1852 388 121 403 149 949 – – – 157 147 – – 3830 328 10,101
– 1996 – – – – – – – 80 23 44 13 – 27 11 16 – – 2185
240 3244 243 128 1852 388 121 403 149 1029 – – – 157 174 – – 3830 328 12,286
66 363 7 17 267 231 5 23 7 177 – – – 1 59 – – 2 5 1230
†
– 158 – – – – – – – 315 153 161 1 – 2661 2353 308 – – 3134
66 521 7 17 267 231 5 23 7 492 – – – 1 2720 – – 2 5 4364
Other costs include ambulance, audiology, dialysis, durable medical equipment, home health, psychiatry and respiratory therapy.
Conclusion The results of our study demonstrate that the costs per encounter are consistent with previously published estimates; however, the emergence of multi-modal therapy in the outpatient and inpatient settings may result in greater costs of care in the future. PCa is associated with a high economic burden in the USA. Several novel treatments for PCa have been recently approved or are entering the market in the near future. Since no studies to date have documented specific treatment patterns of care within both the hospital-based outpatient and inpatient setting, this study sought to describe treatments used and the associated cost of care for PCa patients who have received PCa-related treatment in these settings. In the inpatient setting, the most common treatment provided was hormonal therapy (69%). In the hospital-based outpatient setting, the most common treatment was radiation (76%). The total average cost per encounter for inpatient stays and outpatient visits was US$12,286 and US$4364, respectively. Nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were associated with the receipt of two or more
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treatments, signifying an emerging increase in multi-modal therapy. Future perspective With new treatments that have entered the market and additional treatments that may enter the market in the near future, the PCa treatment landscape is rapidly evolving. As novel agents are prescribed and multi-modal therapy continues to increase, healthcare costs will continue to be of utmost importance in managing patients with metastatic and advanced PCa. As such, healthcare decision makers may become increasingly attentive to emerging treatment patterns, clinical pathways, sequencing and multi-modal therapy. Our study provides a baseline to which emerging treatment patterns and costs may be compared with. Financial & competing interests disclosure Bayer HealthCare provided support for this research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
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Evaluating treatments & corresponding costs of prostate cancer patients
Research Article
EXECUTIVE SUMMARY ●●
Prostate cancer (PCa) is associated with a high economic burden in the USA.
●●
Several novel treatments for PCa have been recently approved or are entering the market in the near future.
●●
No studies to date have documented specific treatment patterns of care within both the hospital-based outpatient
and inpatient setting, which is crucial for hospital-based decision makers given the changing landscape of prostate cancer treatment. ●●
This study sought to describe treatments used and the associated cost of care for PCa patients who have received PCa-related treatment in an inpatient or hospital-based outpatient setting.
●●
In the inpatient setting, the mean length of stay was 4.40 days and the most common treatment provided was hormonal therapy (69%), which included primary (30%) and secondary hormonal therapy (39%).
●●
In the hospital-based outpatient setting, the most common treatment was radiation (76%).
●●
The total average cost per encounter for inpatient stays and outpatient visits was US$12,286 and US$4364, respectively.
●●
Nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were
associated with the receipt of two or more treatments, signifying an emerging increase in multi-modal therapy, which may lead to greater costs of care in the future. References 1
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Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J. Clin. 62, 10–29 (2012).
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Amling CL, Blute ML, Bergstralh et al. Long-term hazard of progression after radical prostatectomy for clinically localized prostate cancer: continued risk of biochemical failure after 5 years. J. Urol. 164, 101–105 (2000). National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology™. Prostate cancer, v3.2012. NCCN. www.nccn.org Parker C, Nilsson S, Heinrich D et al. Updated analysis of the Phase III, doubleblind, randomized, multinational study of radium-223 chloride in castration-resistant prostate cancer (CPRC) patients with bone
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metastases (ALSYMPCA). Presented at: American Society of Clinical Oncology (ASCO). Orlando, FL, USA, 29 May–2 June 2009. 7
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HCUP Statistical Brief #30. May 2007 Agency for Healthcare Research and Quality, Rockville, MD, USA. www.hcup-us.ahrq.gov 13 Snyder CF, Frick KD, Blackford AL et al.
Costs of treatment for local/regional prostate cancer. Presented at: American Society of Clinical Oncology (ASCO). Chicago, IL, USA, 31 May–4 June 2012. 14 Crawford ED, Black L, Eaddy M et al. A
retrospective analysis illustrating the substantial clinical and economic burden of prostate cancer. Pros. Cancer Prostatic Dis. 13, 162–167 (2010). 15 Nguyen PL, Gu X, Lipsitz SR et al. Cost
implications of the rapid adoption of newer technologies for treating prostate cancer. J. Clin. Oncol. 29(12), 1517–1524 (2011). 16 Hoffman RM, Gilliland FD, Eley JW et al.
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Evaluating treatments and corresponding costs of prostate cancer patients treated within an inpatient or hospital-based outpatient setting Brian Seal1, Sean D Sullivan2, Scott Ramsey3, Carl V Asche4, Kenneth M Shermock5, Syam Sarma6, Erin Zagadailov7, Eileen Farrelly7 & Michael Eaddy*,7
ABSTRACT Aim: To describe treatments and cost of care for prostate cancer (PCa) in hospital-based outpatient and inpatient settings. Methods: Hospital encounters associated with PCa (ICD-9 codes 185, 233.4) and PCa-related treatment in a hospital claims database were included. Results: There were 211,440 encounters for PCa between January 2006 and December 2010 (88,151 inpatient and 123,289 outpatient). Average cost per inpatient stay was US$12,286 versus US$4364 per outpatient visit. Most common treatment during an inpatient stay and outpatient visit was surgery (57%) and radiation (76%), respectively. A total of 80% of outpatient visits and 69.9% inpatient stays were associated with a single treatment; remaining encounters were associated with ≥2 treatments. Conclusion: Costs are consistent with previous estimates; however, multimodal therapy is an emerging trend that may be related to greater costs in the future which may also be a challenge for hospital decision makers. Prostate cancer (PCa) is the most common malignancy in men in the USA [1] .More than 241,700 new cases of PCa were diagnosed in 2012, representing 29% of all cancer diagnoses, and 28,170 men died from this cancer, encompassing 9% of all cancer deaths [2] . The lifetime risk of developing PCa for men in the USA is 16%, meaning that one in six men have a chance to be eventually diagnosed with this cancer [3] . The vast majority (93%) of patients present with localized or regional PCa have a 5-year survival rate of 100% [3] . In contrast, 4% of patients have metastatic prostate cancer (MPC) at diagnosis and have an unfavorable 5-year survival rate of 29% [3] . In addition, about a third of men are at risk of developing progressive PCa to distant sites (lymph nodes and bones, among others), despite initial diagnosis of early stage disease [4] . The treatment for early PCa is curative and comprises an individualized approach (radical prostatectomy, radiation or watchful waiting) based on life expectancy, comorbidities and toxicities of treatment [5] . The treatment of advanced PCa is palliative, with androgen deprivation therapy with medical or surgical castration being the preferred first-line treatment option [5] . At subsequent progressions, options such as abiraterone acetate, cabazitaxel, secondary androgen deprivation therapy and enrollment in a clinical trial can be considered, but there is no therapeutic consensus regarding the best agent to be used [5] . In addition, novel agents such as radium-223 and
KEYWORDS
• healthcare costs/trends • hospitalization • prostatic neoplasms • retrospective
studies
Bayer HealthCare Pharmaceuticals, 100 Bayer Boulevard Whippany, NJ 07981, USA University of Washington, Department of Pharmacy, Box 357630 Seattle, WA 98195-7630, USA 3 Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, PO Box 19024, Seattle, WA 98109-1024, USA 4 University of Illinois College of Medicine, 808 S Wood St, Chicago, IL 60612, USA 5 Johns Hopkins University, 600 N Wolfe St, Carnegie 180, Baltimore, MD 21287, USA 6 Independent Consultant, 7908 Kara Court, Greenbelt, MD 20770, USA 7 Xcenda, 4114 Woodlands Parkway, Ste 500, Palm Harbor, FL 34685, USA *Author for correspondence: Tel.: +1 727 771 4126; [email protected] 1 2
10.2217/FON.14.242 © 2015 Future Medicine Ltd
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Research Article Seal, Sullivan, Ramsey et al. enzalutamide have recently shown overall survival (OS) benefit and delayed the time to first on-study skeletal-related event in this patient population [6,7] . Overall, PCa is associated with a high economic burden in the USA; the total cost of care was estimated at about US$12 billion in 2010 (up from US$10 billion in 2006), ranking PCa as the fifth highest cancer in terms of national expenditures [8,9] . It is important to point out that this estimate did not include any of the recent therapeutic advances in the management of MPC that will likely impact patterns of care and healthcare spending. Furthermore, 2020 projections based on increasing prevalence of PCa are indicating that the cost for PCa will rise to US$16 billion [9] . The high economic burden of PCa was also predicted from a model analysis of the Surveillance Epidemiology and End Results (SEER) database that estimated a lifetime cost of US$110,520 (95% CI: US$110,324–110,739) per patient [10] . Keeping in mind the overall healthcare spending for PCa, it has been well documented that the majority of care occurs in an outpatient setting [11] . However, Milenkovic et al. found, using data from the Healthcare Cost and Utilization Project (HCUP), that nearly half a million hospitalizations in 2004 (81,300 as primary diagnosis; 416,700 as secondary diagnosis) in the USA involved PCa, highlighting that a substantial proportion of the cost was associated with PCa care completed in the inpatient hospital setting [12] . A considerable amount of inpatient care was also documented in retrospective analyses from the PharMetrics database (2000–2005) and the SEER-Medicare database (2000) [13,14] . However, no studies to date have documented specific treatment patterns of care within both the hospital-based outpatient and inpatient setting, which is crucial for hospital-based decision makers given the changing landscape of prostate cancer treatment. As such, this study sought to describe treatments used and the associated cost of care for PCa patients who have received PCarelated treatment in an inpatient or hospitalbased outpatient setting at some point during their care. Methods ●●Data source
Hospital claims data from the Premier Perspective Database were used to conduct the analyses. This database is the largest hospital database in the
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USA for determining hospital quality benchmarking and contains linked, de-identified inpatient medical, pharmacy and billing data from more than 500 geographically dispersed hospitals. Participating hospitals represent all regions of the USA, are predominantly small- to mid-sized nonteaching facilities and serve largely urban populations. The database contains a datestamped log of all billed items by cost accounting department, including medications and laboratory, diagnostic and therapeutic services, as well as primary and secondary diagnoses for each patient. In addition, de-identified, linked patient enrollment data, including demographic and payer information, as well as provider characteristics, are available in the discharge summary file. ●●Sample selection
Encounters associated with prostate cancer (International Classification of Diseases, 9th Revision [ICD-9] codes185.xx [malignant neoplasm of the prostate], 233.4 [carcinoma in situ, prostate]) between 1 January 2006 and 31 December 2010 were eligible for study inclusion. Encounters were also required to be associated with a patient who was ≥40 years of age and had at least one PCa-related treatment during the hospitalization or outpatient visit. PCa treatment was defined as the presence of a code or claim (e.g., Current Procedural Terminology [CPT] code, Healthcare Common Procedure Coding System [HCPCS] or hospital billing code) for prostate surgery, radiation treatment, chemotherapy, hormone therapy, radiopharmaceuticals or alternative treatments for prostate cancer (ketoconazole, aminoglutethimide, corticosteroid). All PCarelated treatments were independently reviewed by a radiation oncologist prior to inclusion in the analysis. Encounters were excluded if they had codes indicative of additional cancers (ICD-9 codes 140.xx–172.xx, 174.xx–184.xx, 186.xx, 187. xx, 189.xx–195.xx and 199.xx–208.xx). ●●Analysis of outcomes
The primary variables of interest were treatments utilized within the hospital stay or outpatient visit, the corresponding costs of treatments per hospitalization or visit and the length of stay. For the purpose of this analysis, the unit of analysis was the hospital encounter which included inpatient hospital stays and hospital-based outpatient visits. To provide a comprehensive description of where costs are incurred, costs were aggregated by the department billing for services.
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Evaluating treatments & corresponding costs of prostate cancer patients Descriptive summary statistics were constructed as frequencies and proportions for categorical data and means for continuous variables. Statistical analyses were conducted in SAS version 9.2.1 (SAS Business Analytics, NC, USA). Results ●●Sample characteristics & treatment
patterns
There were a total of 755,375 encounters identified where a patient had diagnosis of prostate cancer. Encounters were then excluded for
Research Article
having diagnoses of cancers other than prostate cancer (4%), encounters associated with a patient being less than 40 years of age (0.1%) and encounters associated with a patient being female (0.04%). These exclusions resulted in 723,783 encounters eligible for analysis, which represents 265,112 unique patients. Out of these eligible encounters, 71% did not have any evidence of PCa-related treatment, leaving a total of 211,440 encounters with evidence of treatment, which represented 118,300 unique patients. In the sample of 211,440 encounters, 88,151 were
Table 1. Hospital encounter characteristics. Characteristics
Mean age (SD), years Race (%): – African–American – Caucasian – Hispanic – Other Region (%): – Northeast – Midwest – South – West Hospital type (%): – Urban – Rural – Teaching – Nonteaching Payer type (%): – Medicare – Medicaid – Commercial/private – Self-pay – Other Bed size (%): – Average number of beds (n) – 0–200 – 201–400 – 401–600 – 601–1000 – >1000 Treatments (%): – Surgery – Radiation treatment – Chemotherapy – Primary hormonal therapy – Secondary hormonal therapy – Nuclear medicine-related PCa therapy
Treated PCa population Inpatient (n† = 88,151)
Hospital outpatient Total (n† = 211,440) (n† = 123,389)
69 (11)
70 (9)
69 (10)
12 68 3 17
12 63 3 22
12 65 3 20
21.9 20.6 38.1 19.4
8.8 23.6 47.5 20.1
14.3 22.4 43.5 19.8
90.0 10.0 46.1 53.9
81.6 18.4 34.3 65.7
85.2 14.8 39.2 60.8
56.7 2.1 37.4 0.9 2.9
65.3 2.4 27.3 1.5 3.5
61.7 2.3 31.5 1.3 3.2
466 10.2 35.5 30.3 19.5 4.5
408 11.7 45.1 27.4 14.7 1.1
432 11.0 41.1 28.6 16.8 2.5
57 4 3 30 39 0.5
9 76 11 11 10 8
29 46 8 19 22 5
Represents the number of hospitalizations among the sample of PCa patients treated in an inpatient setting and does not represent the number of unique patients. PCa: Prostate cancer; SD: Standard deviation. †
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Research Article Seal, Sullivan, Ramsey et al. hospital stays and 123,289 were hospital-based outpatient visits. Overall, most encounters took place in the South (43.5%) followed by the Midwest (22.4%) (Table 1) . Additionally, most encounters occurred at urban (85.2%), nonteaching (60.8%) hospitals where the average bed size was 432 (Table 1) . The mean age of the sample of encounters was 69 years, with 65% being Caucasian (Table 1) . The mean age is consistent with the most common payer type, Medicare (61.7%); however, 31.5% of encounters were associated with commercial/private payer reimbursement (Table 1) . For patients with an inpatient hospitalization, the mean length of stay was 4.40 days (SD: 7.89). The most common treatment provided during inpatient stays was hormonal therapy (69%), which included primary (30%) and secondary hormonal therapy (39%). Primary hormonal therapies included, but were not limited to, 5-α reductase inhibitors (e.g., finasteride), antiandrogens (e.g., bicalutamide) and gonadotropin-releasing hormones. Secondary hormonal therapy included steroid therapies such as prednisone and dexamethasone. In contrast, the most common treatment in the hospital outpatient setting was radiation (76%). The most common types of radiation procedures were high dose rate brachytherapy, interstitial brachytherapy and external beam radiation therapy. Surgery was associated with 57% of inpatient hospitalizations, making it the second-most common treatment associated with inpatient stays. The types of surgeries included, but were not limited to, transurethral resection of the prostate, radical prostatectomy, surgical prostatectomy and prostate ablation. Very few encounters were associated with the receipt of nuclear medicine-related PCa therapy (e.g., iodine-125, palladium and samarium-152 among others) in the inpatient and hospital outpatient settings: 0.5 and 8%, respectively. The majority of hospitalizations were associated with a primary diagnosis or admitting code for PCa (58.6%), while 78,489 hospitalizations (37.1%) were associated with a secondary diagnosis code for PCa only and the remaining 4.3% of the sample had both a primary/admitting and secondary diagnosis code for PCa. A summary of the primary diagnosis codes for men with a secondary diagnosis code of PCa is described in Table 2 . For men with a secondary diagnosis code for PCa only, the most common primary diagnosis codes were diseases of
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the circulatory system, diseases of the respiratory system and diseases of the genitourinary system for inpatient hospitalizations (Table 2) . With respect to hospital-based outpatient visits, the most common primary diagnosis code for men with a secondary diagnosis code of PCa was “Supplementary classification of factors influencing health status and contact with health services,” which is relatively more common in an outpatient setting. Overall, 160,026 encounters were associated with a single treatment for PCa, which accounted for the majority of both inpatient stays (69.6%) and outpatient visits (80.0%) (Tables 3 & 4) . Nearly all encounters associated with a single treatment during an inpatient stay were also associated with surgery (53.0%) or some form of hormone therapy (44.8%). In the outpatient setting, the majority of encounters with a single treatment were associated with radiation (80.8%). Approximately one in three encounters in the inpatient setting were associated with multimodal therapy, with 27.3% of inpatient stays associated with two treatments and 3.0% of inpatient stays associated with three or more treatments (Table 3) . For encounters associated with two treatments during an inpatient stay, the most common treatment combination was surgery combined with secondary hormonal therapy (55.5%), followed by a combination of primary and secondary hormonal therapies (21.1%). For encounters associated with three or more treatments during an inpatient stay, the majority received a combination of hormonal therapy with surgery (34.0%), radiation (24.1%) or chemotherapy (21.4%). Twenty percent of encounters were associated with multimodal therapy during a hospital-based outpatient visit, with 15.5% and 4.5% of outpatient visits associated with two and three or more treatments, respectively (Table 4) . For encounters associated with two treatments during an outpatient visit, the most common treatment combination was radiation combined with nuclear medicine (27.6%). For encounters associated with three or more treatments during an outpatient visit, the majority received combination hormonal therapy with radiation (32.3%). The total average cost per hospitalization for inpatient stays was US$12,286 (Table 5) . With an overall average length of stay at 4.4 days, room and board charges contributed 31% of the overall cost for PCa hospitalizations.
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Evaluating treatments & corresponding costs of prostate cancer patients
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Table 2. Primary diagnosis codes for encounters with secondary diagnosis code for prostate cancer. Primary ICD-9 diagnosis code(s)
Inpatient (n† = 36,487), % Outpatient (n† = 42,002), %
Total (n† = 78,489), %
Diseases of the circulatory system (390–459.9) Diseases of the respiratory system (460–519.9) Diseases of the genitourinary system (580–629.9) Diseases of the digestive system (520–579.9) Injury and poisoning (800–999.9) Infectious and parasitic diseases (001–139.8) Diseases of the musculoskeletal system and connective tissue (710–739.9) Symptoms, signs and ill-defined conditions (780–799.9) Endocrine, nutritional and metabolic diseases and immunity disorders (240–279.9) Supplementary classification of factors influencing health status and contact with health services (v01–v91.9) Other‡
18.9 13.5 12.9 7.4 7.2 6.1 5.1
0.9 0.7 3.7 0.8 0.7 0.1 1.0
9.3 6.7 8.0 3.8 3.7 2.9 2.9
4.3 3.3
2.0 0.4
3.1 1.7
3.3
83.7
46.3
17.9
6.0
11.6
Represents the number of hospitalizations among the sample of prostate cancer patients treated in an inpatient setting and does not represent the number of unique patients. ‡ Other primary diagnosis codes included, but are not limited to, diseases of the blood and blood-forming organs (280–289.9), diseases of the nervous system and sense organs (320–389.9) and diseases of the skin and subcutaneous tissue (680–709.9). ICD-9: International Classification of Diseases, 9th Revision. †
Surgery was the second-largest cost item overall and the largest treatment-related cost item, representing 26% of inpatient hospitalization costs. Pharmaceuticals accounted for 8% of total inpatient costs. Overall, PCa-related treatment represented about 30% of all inpatients costs:prostate surgery = US$1996 per encounter; radiation = US$11 per encounter; chemotherapy = US$23 per encounter; hormone therapy = US$44 per encounter; secondary hormonal therapy = US$13 per encounter; and nuclear medicine = US$99 per encounter. The total average cost per hospital-based outpatient visit was US$4364 (Table 5) . PCa-related treatment costs (US$3134) represented 71.8% of all hospital-based outpatient costs, of which radiation and nuclear medicine costs (US$2661) were the primary drivers of total outpatient costs and represented 62.3% of total hospital-based outpatient costs. Surgery and pharmacy costs were also key components of hospital-based outpatient costs. Discussion The purpose of this study was to describe treatments used and the associated cost of care for patients who have received PCa-related treatment in a hospital setting, which included inpatient stays and hospital-based outpatient visits. More specifically, this study provides a baseline of current treatment patterns and costs to which emerging patterns may be compared. This is particularly relevant to hospital administrators and clinicians who will seek to determine how the
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recent entrance of several novel agents (abiraterone acetate, cabazitaxel, radium-223 and enzalutamide) will impact or alter current treatment patterns. The primary variables of interest were treatments utilized during the encounter, the corresponding costs of treatments per encounter and length of stay. The average cost per encounter for inpatient stays was US$12,286, with the majority of treatment-related costs associated with surgery. In contrast, the average cost per outpatient visit was US$4364, with the majority of treatment-related costs associated with radiation. These results are consistent with a previous retrospective study of PCa patients by Crawford et al., who reported that surgery was the most common treatment among PCa patients [14] . Additionally, the majority of costs were due to inpatient resource utilization for patients who received surgery. The large proportion of outpatient stays associated with radiation therapy may be explained by recent findings from SEER by Nguyen et al. In a year-by-year analysis of utilization from 2002 to 2005, Nguyen et al. found rapidly increasing use of external radiation and supplemental intensity-modulated radiation therapy for patients receiving brachytherapy [15] . With respect to cost per encounter, our findings were similar to those found in the National Inpatient Sample (NIS) by the HCUP on PCa in 2004 [12] . On average, the mean cost per hospitalization in the HCUP sample was US$8100 in 2004, which is lower than our finding of US$12,286 per hospitalization; however this
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Research Article Seal, Sullivan, Ramsey et al. Table 3. Inpatient treatment patterns. Surgery
Radiation
Chemotherapy Primary hormonal therapy
Secondary hormonal therapy
Nuclear medicine
n (%)
X
X
32,557 (53.0) 967 (1.58) 324 (0.5) 15,767 (25.7) 11,733 (19.1) 38 (0.1)
X X X X
13,382 (55.5) 5074 (21.1) 2692 (11.2) 874 (3.6) 806 (3.3) 1220 (5.0)
X X X X X
905 (34.0) 643 (24.1) 571 (21.4) 148 (5.6) 111 (4.2) 289 (10.8)
Single treatment: 61,386 hospitalizations (69.6%) X
X
X
X
Two treatments: 24,098 hospitalizations (27.3%) X X X X Other treatment combinations†
X X
Three or more treatments: 2667 hospitalizations (3.0%) X X X X X X X Other treatment combinations†
X X X X
Includes total of other less commonly reported treatment combinations.
†
may be related to a shorter length of stay with the HCUP database (3.4 vs 4.4 days). Additionally, the marginally higher average cost per encounter in our analysis may also be related to the substantial number of patients who received multimodal therapy. In our study, nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were associated with the receipt of two or more treatments between 2006 and 2010. This is in contrast to Crawford et al., who reported less than 1% of PCa patients received multiple treatments between 2000 and 2005 [14] . Although the unit of analysis for the Crawford paper was different (patient) than our analysis (encounter), our analysis indicates that patients may continue to seek and receive multiple treatments, which will add to already heightened attention to control costs in a hospital setting. Last, our results showed that the majority of men with PCa treated in an inpatient setting received surgery or some form of hormone therapy. These findings are consistent with current treatment paradigms and indicate that the inpatient-treated PCa population in this study may represent a population with advanced
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disease, symptomatic disease or at a high risk for recurrence. Watchful waiting or active surveillance is common until progressive or symptomatic disease is evident, upon which treatment options such as surgery may be employed [5] . Additionally, primary hormonal therapy is a first-line treatment option for advanced PCa, which is often regarded as palliative treatment. Strengths & limitations This study has several strengths and limitations associated with its study design and data analysis. First, a retrospective claims data analysis limits the amount of clinical variables available (e.g., cancer grade), which would be valuable in further understanding of the treatment patterns. Second, the analysis relies on selecting claims based on ICD-9 codes that accurately represent the specific population of interest. Accordingly, there is a possibility that patients with PCa could be omitted if a diagnosis indicative of PCa was not included in standard diagnosis fields of the claims database, resulting in misclassification of patients; however, our analysis included 211,440 encounters for men who received PCa treatment in a nationally representative hospital
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Evaluating treatments & corresponding costs of prostate cancer patients database, giving a good sample for evaluation. It should be noted that patients having ICD-9 codes for rectal (ICD-9: 154) or bladder cancer (ICD-9: 188) or secondary cancer codes (ICD9: 196–198) in addition to the PCa diagnosis were not excluded given that PCa may invade into these areas. Posthoc analyses indicated that including these patients had little to no influence on parameter estimates. Also, patients having cancer diagnosis codes of 173.xx or 209–239.xx were not excluded, as these cancers were thought to have no clinical impact on patient survival. Inclusion of these patients was also shown to have no influence on parameter estimates. Additionally, our analysis sought to describe utilization and costs among patients who received treatment during their hospital encounter. As such, encounters that were not associated with treatment were excluded. As a result, encounters associated with a watchful waiting or active surveillance approach may have been excluded. Last, the total costs of each hospital encounter represent the total costs of treating a patient with metastatic PCa, which includes the costs of treating comorbid conditions and
Research Article
complications that may have occurred during the hospitalization. In an evaluation of the patient demographics for the inpatient-treated PCa population, the mean age was 69 years, which corresponds well with SEER data, which indicate that the mean age of diagnosis for PCa is 67 years [3] . This similarity in demographics gives our analysis good generalizability to the overall PCa population. However, 68% of the population was Caucasian men, while African–Americans represented approximately 12% of patients. Previous studies have demonstrated that PCa disproportionately affects African–American men and, worldwide, African–American men have the highest incidence of PCa [16,17] . Therefore, the difference in racial demographics in our population compared with the general PCa population could be considered a study limitation. Finally, newer therapies that entered the market shortly before (cabazitaxel) and after (abiraterone) the end date of this study were not reflected in the results. Future research re-evaluating this topic once these agents have become a part of the treatment paradigm will be necessary to determine emerging treatment patterns.
Table 4. Outpatient treatment patterns. Surgery
Radiation
Chemotherapy Primary hormonal therapy
Secondary hormonal therapy
Nuclear medicine
n (%)
X
X
4235 (4.3) 79,667(80.8) 3984 (4.0) 6818 (6.9) 3614 (3.7) 322 (0.3)
X X
X
5268 (27.6) 4979 (26.1) 3731 (19.6) 2110 (11.6) 1022 (5.4) 1842 (9.7)
X X X X
X
1808 (32.3) 1570 (28.0) 569 (10.2) 558 (10.0) 489 (8.7) 603 (10.8)
Single treatment: 98,640 hospitalizations (80.0%) X
X
X
X
Two treatments: 19,052 hospitalizations (15.5%) X X X X X X Other treatment combinations†
X
Three or more treatments: 5597 hospitalizations (4.5%) X X X X X X X X Other treatment combinations†
X X X
Includes total of other less commonly reported treatment combinations.
†
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Research Article Seal, Sullivan, Ramsey et al. Table 5. Inpatient stay and outpatient visit costs. Cost category
Mean treatment costs (US$)
Inpatient stays
Outpatient visits
General costs
PCa-specific costs
Total costs
General costs PCa-specific costs Total costs
All professional/administrative fees All surgery Blood bank All cardiology Central supply All diagnostic Emergency room Laboratory Pathology All pharmacy: – Chemotherapy – Primary hormonal therapy – Secondary hormonal therapy – All rehabilitation – Radiation and nuclear medicine – Radiation – Nuclear medicine Room and board Other† Total
240 1248 243 128 1852 388 121 403 149 949 – – – 157 147 – – 3830 328 10,101
– 1996 – – – – – – – 80 23 44 13 – 27 11 16 – – 2185
240 3244 243 128 1852 388 121 403 149 1029 – – – 157 174 – – 3830 328 12,286
66 363 7 17 267 231 5 23 7 177 – – – 1 59 – – 2 5 1230
†
– 158 – – – – – – – 315 153 161 1 – 2661 2353 308 – – 3134
66 521 7 17 267 231 5 23 7 492 – – – 1 2720 – – 2 5 4364
Other costs include ambulance, audiology, dialysis, durable medical equipment, home health, psychiatry and respiratory therapy.
Conclusion The results of our study demonstrate that the costs per encounter are consistent with previously published estimates; however, the emergence of multi-modal therapy in the outpatient and inpatient settings may result in greater costs of care in the future. PCa is associated with a high economic burden in the USA. Several novel treatments for PCa have been recently approved or are entering the market in the near future. Since no studies to date have documented specific treatment patterns of care within both the hospital-based outpatient and inpatient setting, this study sought to describe treatments used and the associated cost of care for PCa patients who have received PCa-related treatment in these settings. In the inpatient setting, the most common treatment provided was hormonal therapy (69%). In the hospital-based outpatient setting, the most common treatment was radiation (76%). The total average cost per encounter for inpatient stays and outpatient visits was US$12,286 and US$4364, respectively. Nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were associated with the receipt of two or more
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treatments, signifying an emerging increase in multi-modal therapy. Future perspective With new treatments that have entered the market and additional treatments that may enter the market in the near future, the PCa treatment landscape is rapidly evolving. As novel agents are prescribed and multi-modal therapy continues to increase, healthcare costs will continue to be of utmost importance in managing patients with metastatic and advanced PCa. As such, healthcare decision makers may become increasingly attentive to emerging treatment patterns, clinical pathways, sequencing and multi-modal therapy. Our study provides a baseline to which emerging treatment patterns and costs may be compared with. Financial & competing interests disclosure Bayer HealthCare provided support for this research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
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Evaluating treatments & corresponding costs of prostate cancer patients
Research Article
EXECUTIVE SUMMARY ●●
Prostate cancer (PCa) is associated with a high economic burden in the USA.
●●
Several novel treatments for PCa have been recently approved or are entering the market in the near future.
●●
No studies to date have documented specific treatment patterns of care within both the hospital-based outpatient
and inpatient setting, which is crucial for hospital-based decision makers given the changing landscape of prostate cancer treatment. ●●
This study sought to describe treatments used and the associated cost of care for PCa patients who have received PCa-related treatment in an inpatient or hospital-based outpatient setting.
●●
In the inpatient setting, the mean length of stay was 4.40 days and the most common treatment provided was hormonal therapy (69%), which included primary (30%) and secondary hormonal therapy (39%).
●●
In the hospital-based outpatient setting, the most common treatment was radiation (76%).
●●
The total average cost per encounter for inpatient stays and outpatient visits was US$12,286 and US$4364, respectively.
●●
Nearly one in three encounters in an inpatient setting and one in five encounters in an outpatient setting were
associated with the receipt of two or more treatments, signifying an emerging increase in multi-modal therapy, which may lead to greater costs of care in the future. References 1
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Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J. Clin. 62, 10–29 (2012).
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HCUP Statistical Brief #30. May 2007 Agency for Healthcare Research and Quality, Rockville, MD, USA. www.hcup-us.ahrq.gov 13 Snyder CF, Frick KD, Blackford AL et al.
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