Outpatient Chemoradiation Regimen Matches Inpatient Care Outcomes, at Lower Costs

Charles Bankhead

March 2014, Vol 5, No 2 - Head and Neck Cancer

Scottsdale, AZ—Definitive chemoradiation with single-agent outpatient chemotherapy for head and neck cancer led to disease control and survival equivalent to that of inpatient multi-agent therapy, at an annualized savings of almost $650,000, according to results of a small randomized trial presented at the 2014 Multidisciplinary Head and Neck Cancer Symposium.

The net revenue did not differ materially between the 2 strategies in the overall analysis, but calculations based on a Medicare perspective yielded a $2600 loss per patient treated with the inpatient regimen. The estimated cost-savings for 2013 reached almost $900,000, reported John Greskovich, Jr, MD, Radiation Oncologist, Cleveland Clinic, OH.

“Using a value-based framework, we determined that outpatient cisplatin delivered more value to our patients than inpatient cisplatin–5-FU [fluorouracil] chemotherapy, when combined with definitive radiation therapy for locally advanced head and neck cancer,” said Dr Greskovich. “The clinical outcomes were statistically the same.”

“Financially, net income per patient was not materially different between the 2 arms, but the total cost of care was approximately $18,000 less per patient with the outpatient regimen.”

Study Details
The results came from a randomized trial involving 69 patients with grade 3 to grade 4 squamous-cell head and neck cancer. More than 80% of the patients had oropharyngeal cancer, and 75% tested positive for the human papillomavirus.

The investigators tested the hypothesis that inpatient administration of a 5-FU–cisplatin chemotherapy regimen in addition to radiation therapy would lead to an absolute 20% improvement in relapse-free survival compared with outpatient administration of cisplatin plus radiotherapy (ie, 55% vs 75%).

As reported at the 2013 American Society of Clinical Oncology annual meeting, both regimens exceeded expectations with respect to disease control. After a median follow-up of 29 months, relapse-free survival was 94% with the cisplatin regimen and 85% with the 5-FU–cisplatin regimen. Local control, regional control, distant control, and overall survival did not differ significantly between groups, but all of the end points favored the outpatient regimen.

Cost Analysis
At the head and neck cancer symposium, Dr Greskovich presented data from an analysis of healthcare value comprising 388 patient encounters with 21 patients (11 inpatient, 10 outpatient). The results showed that hospitalization (planned or unplanned) was the primary driver of costs, and that toxicity was the principal cause of hospitalization, as all but 1 hospitalization occurred during the treatment period.

The net income per patient was similar between the 2 treatment groups, but the inpatient regimen generated $19,338 higher net revenue per patient, most of which was offset by $18,664 higher per-patient cost.

Different Toxicity Profiles Not surprising, the 2 chemotherapy regimens had different toxicity profiles. The outpatient cisplatin regimen was associated with more nephrotoxicity (26% vs 3%; P = .007) and ototoxicity (11% vs 0%; P = .042). The inpatient 5-FU–cisplatin combination was associated with more grade 2+ radiation toxicity (68% vs 43%; P = .038), neutropenia (65% vs 34%; P = .012), and unplanned hospitalization (68% vs 43%; P = .038).

Medicare Perspective
Dr Greskovich and colleagues then analyzed revenue, cost, and income from a Medicare reimbursement perspective. The cost per patient remained $18,664 for the inpatient regimen, but the revenue per patient decreased to $16,035, resulting in a loss of $2629 per patient. After factoring in an estimated cost shift of $624 per patient in the outpatient group, the inpatient regimen resulted in a net loss per patient.

The use of the outpatient regimen resulted in a cost-savings of $643,838 from 2011 to 2012. The estimated savings for 2013 was $884,000.