Current status of cost research in IR - 2017

2. Disclosures
•none

3. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

4. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

5. METHODS
• 2013 Journal of Hepatology
• Meta-analysis informed Markov
model
• 17 studies in meta-analysis
• Base cases estimates from Italian
National Health System and
Medicare payments
• Cost-effectiveness analysis via
EVEREST guidelines
• Estimation of treatment costs
(systemic therapies, transplant,
etc.) were not considered
RESULTS
• Pts undergoing RFA:
• Were significantly older
• Less likely to be in Child-Pugh A
• Had shorter hospital stays
• Pt survival and disease-free survival
were similar for solitary lesion <
2cm
• RFA was more cost-effective for
lesions <2cm or multiple lesions
<3cm

6. METHODS
• 2015 World Journal of Surgery
• Based on a reference case
• Survival benefit in QALY
($50,000/QALY threshold)
• Literature informed model
• Costs derived from single
institution cost-effective analysis
from 1995 (variable costs)*
RESULTS
• Liver transplant not cost-effective
as compared to liver resection or
radiofrequency ablation
• RFA with lower lifetime costs for
all HCCs <5cm
• Only Child-Pugh A patients were
modeled
*Sarasin et al. Partial hepatectomy or orthotopic liver transplantation for the treatment of resectable
hepatocellular carcinoma? A cost-effectiveness perspective. Hepatology 1998; 28(2)-436-442.

7. METHODS
• 2014 JVIR
• Calculated 3 costs:
• Cost of angiography suite
• Cost of recovery
• Cost of consumable material
• 36 patients; 50 TACE procedures
(conventional TACE)
• Costs derived from cost center
reporting and divided into
variable and fixed costs
• Hourly costs derived for each
component
RESULTS
• Angiography suite = $589/hr
• Each square foot of the hospital cost
$18.40/yr
• IR overhead = $110,336
($21.24/hr)
• Recovery hourly rate = $108/hr
• Overall, TACE cost $2223 - $5654
(median = $3269)
• Consumables = 62% of costs

8. METHODS
• 2014 JVIR
• Stage 1A/1B, SEER-Medicare data,
matched by propensity scores
• 2007-2009
• Costs derived from Medicare claims
data (total payments)
• Inpatient, outpatient, carrier files
• Costs calculated from treatment, as
well as 1, 3, 12, 18, and 24 months
after treatment (partitioned inverse
probability weighted estimator)
• Payer perspective costs
RESULTS
• No difference in survival
• $16,105 median difference in costs
between treatments
• Ablation cheaper
• Ablation patients required shorter
length of stay (2 days vs 6 days)

9. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

10. METHODS
• 2000 Hepatology
• Developed a decision model
• Assumed same all-cause mortality for
TIPS and endoscopic arms
• Probabilities for complications derived
from MEDLINE search (1990-2000)
• Costs derived from two medical
centers
• Direct costs calculated by activity-
based costing and TSI systems
solutions
• Avg cost of hospitalization for
each diagnosis
RESULTS
• Incremental cost to prevent one episode
of bleeding with TIPS as compared to
sclerotherapy ($8803) and ligation
($12,660)
• $25,000/QALY chosen as threshold
value to change therapies (vs.
$50,000 per life year saved)
• Total annual costs:
• Sclero = $23,459
• Ligation = $23,111
• TIPS = $26,275
• 30% of costs in sclero and ligation groups
were cross-over to TIPS
• Assumed 40% 1-year stenosis rate of TIPS

11. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

12. METHODS
• 2008 JVIR
• 28 hospitals, Netherlands (177 pts,
prospective)
• 4 cost categories:
• Direct medical in-hospital costs
• Out-of-hospital costs
• Direct non-medical costs
• Indirect costs (work absence)
• Direct medical costs derived from “true”
economic cost calculations from hospital
management system in the Academic Medical
Center, Amsterdam
• Complications costs collected prospectively
RESULTS
• Mean total costs of UAE were
significantly lower than
hysterectomy
• $6396 less
• Attributable to direct in-
hospital costs and indirect
costs

13. METHODS
• 2014 Journal of Comparative Effectiveness Res
• Markov Model informed by the literature
• 2 cost categories:
• Direct medical costs
• Direct and indirect non-medical costs
• Costs of treatment derived from 2003-2010
Marketscan data
• Procedure costs calculated as the sum of
payments made by patients and insurers
on the day of surgery (outpatient) or
during entire hospitalization (inpatient)
• Societal perspective
RESULTS
• Difference in effectiveness
between myomectomy,
MRgFUS, and UAE was
minimal
• But myomectomy and
MRgFUS both had better
costs/QALY
• MRgFUS found to be more
cost-effective than UAE

14. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

15. METHODS
• 2012 JVIR
• Retrospective cohort analysis
• 5% anonymized Medicare files 1999-
2009
• Primary variables = total costs, LOS,
in-hospital mortality
• Total costs = Sum of amounts paid by
Medicare and non-Medicare insurers
for the claim that covered the hospital
admission
• Co-morbidities controlled
RESULTS
• Percutaneous therapy:
• $13,565 total cost saving
• 4.1 fewer day hospitalization
• Twice as likely to be discharged
home
• 10x odds of being discharged to
hospice
• Surgery
• 8x more likely to be discharged
to another inpatient facility

16. 1) Oncology
2) Esophageal varices
3) Uterine fibroids
4) Vertebral fracture
5) Central venous access

17. METHODS
• 2015 JACR
• Retrospective cohort analysis
• Single-center
• Procedural, short, and long term
complications
• Costs excluded professional service
fees and charges
• Stratified into 4 components:
• Total variable labor
• Total variable supply
• Total variable other
• Total fixed cost
RESULTS
• Mean length of procedure shorter in
IR (37 min vs 69 min)
• Costs of placing port in the OR =
193% more expensive than in IR
• Early and late complications equal
between both groups
• No difference in procedural
complications

18. METHODS
• 2010 JVIR
• Retrospective cohort analysis
• Single-center
• Bacteremia and thrombosis (30-day)
were only complications recorded
• Costs derived from hospital-level cost
databases
• Out-of-pocket travel expenses and
productivity losses using average
income and average cost of travel per
mile
RESULTS
• Mean length of procedure shorter in
IR (84.9 min vs 112.8 min)
• Ward cost = most expensive
• IR insertion less costly ($13,817 less
per 100 patients)
• Significantly fewer complications in IR
vs surgery (p = 0.039)
• Incremental cost-effectiveness ratio of
$9,579 per complication averted per
100 patients

19. Costs of Complications from
Central Venous Access (preview*)
• Central venous stenosis occurs in 5—8%
of children with long-term central venous
access
• Leads to 10-17 more days in the hospital
• $200,000 - $250,000 per patient more
expensive (nearly 100% increase)
• *Kokabi et al; to be presented at SIR 2017

20. What is the current status of
cost research in IR?
• Wide variation in calculating costs from
provider, payer, and patient perspectives
• Wide variation in reported absolute costs
between single-institution studies
• Payments do not seem to be the dominant
surrogate for costs
• In nearly all aspects, IR appears to be cost-
effective

21. Matt Hawkins, MD
@MattHawkinsMD
matt.hawkins@emory.edu