Value Propositions

September 2010, Vol 1, No 4

Trastuzumab Extends Stomach Cancer Survival, But Is It Worth It?

Adding trastuzumab to standard cisplatinum/fluoropyrimidine chemotherapy for patients with HER2-positive advanced gastric cancer results in a median survival of 13.8 months, compared with 11.1 months with chemotherapy alone, according to a new study (Lancet. 2010;376 [9742]:687-97. Epub 2010 Aug 19). But an accompanying editorial questions whether that added survival is worth the cost. The multinational, randomized, controlled phase 3 trial included 584 patients (294 in the trastuzumab group, 290 in the chemotherapy group), and adverse event rates were similar in both groups. For those with high levels of HER2, the median survival was 16 months in the trastuzumab group and 11.8 months the chemotherapy only group. Commentators outside the study pointed to the £55,000 cost per life-year gained as a troubling fact of such new therapies.

Determining the Value of CTC Screening for Colorectal Cancer

A simulation model to calculate lifetime costs and life expectancies for 15 colorectal cancer screening strategies finds that computed tomographic colonography (CTC) is not cost-effective if reimbursed at the same rate as colonoscopy (J Natl Cancer Inst. 2010;102[16]:1238-52. Epub 2010 Jul 27). Investigators examined whether CTC screening every 5 years could be cost effective compared to currently reimbursed colorectal screening tests in an unscreened cohort of Medicare beneficiaries. The number of life-years gained by CTC screening every 5 years was only slightly lower than the number gained from colonoscopy screening every 10 years. If CTC was reimbursed at the same rate as colonoscopy ($488), lifetime costs associated with this screening exceeded those of colonoscopy. The Centers for Medicare and Medicaid Services does not currently reimburse CTC screening. The authors point out that “comparative effectiveness research, and cost-effectiveness analyses in particular, can also be used to inform reimbursement levels.”

Spending Grows, Mortality Remains Constant

A retrospective database analysis of patients at 122 hospitals from 2000 and 2004 found little correlation between reduced mortality for 7 commonly diagnosed conditions (acute myocardial infarction [AMI], chronic obstructive pulmonary disease, community-acquired pneumonia, congestive heart failure, cerebrovascular accident, sepsis, or urinary tract infection) and increased spending on patients with those conditions. Absolute mortality decreased for all conditions between 2000 and 2004, and relative mortality reductions ranged from 1% (for sepsis) to 21% (for AMI). The greatest relative mortality reductions occurred in the diseases with active quality improvement and public reporting efforts (AMI, pneumonia, and heart failure). During the same time, inflation-adjusted costs increased for all diagnoses, with relative cost increases ranging from 26% for pneumonia to 60% for heart failure. The dollars spent, say the authors, have produced inconsistent value, with wide variation in the cost per life-year saved(Health Aff [Millwood]. 2010;29[8]:1523-1531).

Limiting Access, Cutting Costs

Restricting access to some medications can save insurers money without causing a concomitant increase in other types of healthcare utilization, according to a meta-analysis of 29 studies (Green CJ, Maclure M, Fortin PM, et al. Pharmaceutical policies: effects of restrictions on reimbursement. Cochrane Database Syst Rev. 2010;8:CD008654). The most common restriction was a prior authorization policy; in some cases, restricting reimbursement led to almost immediate cost savings and decreased drug use (ie, in the case of branded gastric acid suppressants). In others (ie, branded antipsychotic drugs), health services did increase and costs were not reduced. Although the policies do appear to save money in several studies, the Cochrane researchers say that there should be more studies measuring the direct health influence of these policies, especially in cases where there are no clear alternatives to the restricted drugs.

Initial Prostate Cancer Treatment Choice Impacts Long-Term Costs

A study looking at short- and long-term costs associated with different prostate cancer treatments finds that treatments that are initially less expensive may incur higher long-term costs (Cancer. 2010 Aug 23. [Epub ahead of print]). The researchers looked at initial treatment approaches (watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery) and costs short term (1-12 months), long-term (> 12 months) and overall (months 1-60). For most cases, costs were initially high, dropped sharply, and then remained steady. Watchful waiting had the lowest initial ($4270) and 5-year costs; initial costs were highest for hormonal therapy plus radiation ($17,474). Hormonal therapy had low initial costs but the highest 5-year costs ($26,896). Hormonal therapy plus radiation ($25,097) and surgery ($19,214) had the second and third highest 5-year total costs.

App Shortcut for Clinical Trial Adversity

Printed information on the adverse events patients may face in clinical trials has been converted to digital form and formatted for use with the iPhone and iPod Touch. Researchers at the Center for Biomedical Informatics at The Children’s Hospital of Philadelphia created the app, which is free to download. The National Cancer Institute’s Common Terminology Criteria for Adverse Events CTCAE) is a 200-page handbook in its most recent edition (version 4.0) and is used to help standardize record-keeping of side effects occurring in patients enrolled in clinical trials.

Pricey Premiums as Health Insurance Costs Rise

The annual premium for a family health plan sponsored by an employer cost about 54% more in 2009 ($13,027) than it did in 2000 ($8437), according to inflation-adjusted figures from the Agency for Healthcare Research and Quality. The annual premium cost for a single coverage plan rose by 41% (to $4669 from $3308) in that same time period. New York had the highest average premiums ($13,757 for family/$5121 for single); Ohio the lowest ($11,870 for family/$4261 for single). The average annual employee contributions for health insurance premiums were $3474 for family coverage (which covered 26.7% of the average family premium) and $957 for single coverage (20.5% of the average single premium). Data were collected from the Medical Expenditure Panel Survey.

It’s Where You Are, Not What They Know

For older patients with kidney failure, the type and intensity of treatment received depends less on evidence-based practice guidelines and patient preferences and more on the region in which they receive care (JAMA. 2010;304[2]:180-186). Regions with high-intensity end-of-life care had a higher density of nephrologists and higher rates of kidney failure, but patients with kidney failure in these regions were less likely to have seen a nephrologist before starting dialysis. The decision of when to start and stop receiving dialysis can be a difficult one, the researchers said, and the study points out the need for better training of kidney specialists and better team care with geriatricians and palliative care specialists. “We need to get serious about optimizing end-of- life care,” said senior author Manjula Kurella Tamura, MD.

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