Cadth 2015 b1 presentation 15 04-09
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Cadth 2015 b1 presentation 15 04-09
- 1. Advancing Health Economics, Services, Policy and Ethics Reka Pataky CADTH Symposium, April 13, 2015
- 2. Ontario Team: Dr. Murray Krahn (PI) Dr. Claire de Oliveira Karen Bremner Dr. Kelvin Chan Dr. Jeff Hoch Funded by the Canadian Cancer Society Research Institute All inferences, opinions, and conclusions drawn in this presentation are those of the authors, and do not reflect the opinions or policies of the Data Steward(s). 2 Acknowledgements: BC Team: Dr. Stuart Peacock Dr. Paulos Teckle Dr. Winson Cheung
- 3. • Objective – To estimate direct medical costs and predictors of these costs for 21 common types of cancer and 4 phases of care (pre-diagnosis, initial, continuing care, and terminal), using linked administrative data in BC and Ontario • Cases from BC Cancer Registry and Ontario Cancer Registry diagnosed in 1997-2007 • Follow up to the end of 2009 BC-ON Costing Study 3
- 4. Phase-based costing • Course of disease divided into distinct phases • Observation time after diagnosis is allocated to phases hierarchically: Terminal Phase (12 mo) > Initial Phase (6 mo) > Continuing Care Phase 4 time (months) -3 3 6 9 12 15 18 21 24 … 60 63 66 69 72 75 … A 1 B 2 C 3 … 4 D … …
- 5. 0 2 4 6 8 10 12 14 16 18 20 Frequency(%ofprovincialtotal) BC ON Study Cohorts BC Ontario N=150,971 N=402,399 Age at diagnosis Mean (SD) 65.0 (14.01) 63.5 (13.95) Median (IQR) 66 (56-75) 65 (54-74) Sex, n (%) Female 71,635 (47.4) 196,017 (48.7) Male 79,400 (52.6) 206,382 (51.3) 5
- 6. 6 British Columbia Ontario Hospitalization Discharge Abstract Database (Hospital Separations) Discharge Abstract Database Physician services Medical Services Plan (MSP) Payment Information File; BCCA Schedule data Ontario Health Insurance Plan (OHIP) claims Outpatient prescription drugs PharmaNet Ontario Drug Benefit (ODB) Program Chemotherapy BCCA Provincial Systemic Therapy Program New Drug Funding Program, ODB, National Ambulatory Care Reporting System (NACRS) Radiotherapy BCCA Radiotherapy database Cancer Care Ontario Activity Level Reporting System Home and Community Care Home and Community Care (Continuing Care) Data ON Home Care Database, Continuing Care Reporting System, ODB database Diagnostics MSP Payment Information File, BCCA Schedule and Document data OHIP claims
- 7. • Registry data – Diagnosis date definition: clinical vs. pathological • Oncologist services: – ON: claims or shadow billing in OHIP, except for RadOncs – BC: no fee-for-service; used BCCA appointment data • Diagnostics – ON: claims in OHIP; professional and technical components – BC: some claims in MSP; limited data for lab/imaging services from budgets • Radiotherapy – ON: NHPIP workload measurement – BC: estimated from BCCA radiotherapy data and unit cost per fraction Key Differences
- 8. • Chemotherapy drug cost: • Chemotherapy delivery cost: – ON: visits identified in OHIP and NACRS; costs from NACRS – BC: delivery at BCCA sites is in data, others missing • Hospitalization cost: – Same method, but total cost is very sensitive to assumptions about cost per weighted case Key Differences Ontario BC I.V. drugs New, $ NDFP BCCA Old, $ NACRS (RIW) BCCA Oral drugs < 65 yrs No data BCCA ≥ 65 yrs* ODB BCCA
- 9. PRE-DIAGNOSIS British Columbia Ontario Mean 95% CI Mean 95% CI Bladder $2,279 2,140-2,421 $2,607 2,483-2,738 Brain $3,141 2,924-3,383 $2,956 2,790-3,131 Breast (female) $1,132 1,098-1,167 $1,817 1,707-1,934 Cervix $791 686-900 $1,314 1,242-1,390 Colorectal $1,928 1,870-1,990 $2,533 2,411-2,662 Corpus uteri $1,209 1,130-1,288 $1,848 1,732-1,970 Esophagus $1,758 1,592-1,937 $2,313 2,175-2,459 Gastric $1,992 1,845-2,150 $2,767 2,654-2,884 Head and Neck $1,396 1,290-1,507 $1,663 1,496-1,848 Kidney $2,812 2,659-2,979 $3,336 3,073-3,621 Leukemia $1,909 1,766-2,065 $2,373 2,228-2,527 Liver $2,518 2,243-2,819 $4,505 4,136-4,907 Lung $2,706 2,638-2,779 $3,445 3,378-3,512 Lymphoma $2,107 2,000-2,226 $2,812 2,710-2,918 Melanoma $733 671-793 $1,016 942-1,095 Myeloma $3,240 2,991-3,517 $4,660 4,463-4,866 Other $2,685 2,574-2,798 $3,129 3,009-3,253 Ovary $1,693 1,557-1,835 $2,653 2,571-2,738 Pancreas $3,833 3,622-4,045 $3,631 3,517-3,748 Prostate $1,140 1,104-1,178 $1,636 1,546-1,730 Testicular $762 703-833 $1,549 1,463-1,640 Thyroid $1,039 942-1,146 $1,487 1,439-1,536 9
- 10. Pre-diagnosis costs (BC) 10 British Columbia Pre-diagnosis phase (3 months)
- 11. INITIAL PHASE British Columbia Ontario Mean 95% CI Mean 95% CI Bladder $14,183 13,664-14,765 $14,116 13,449-14,815 Brain $32,376 30,975-33,815 $33,102 31,599-34,676 Breast (female) $12,751 12,655-12,852 $13,188 12,986-13,393 Cervix $12,047 11,574-12,527 $15,049 14,463-15,658 Colorectal $22,838 22,546-23,173 $27,972 27,547-28,404 Corpus uteri $12,000 11,746-12,279 $13,491 13,047-13,950 Esophagus $28,907 26,937-31,233 $43,409 40,837-46,143 Gastric $30,060 28,455-31,862 $34,588 33,195-36,041 Head and Neck $15,897 15,318-16,538 $21,070 20,294-21,875 Kidney $15,159 14,622-15,770 $17,763 17,198-18,345 Leukemia $18,406 17,374-19,599 $22,682 21,381-24,063 Liver $14,998 13,238-16,780 $23,882 22,131-25,772 Lung $17,451 17,084-17,827 $23,957 23,526-24,397 Lymphoma $18,090 17,522-18,674 $19,380 18,765-20,015 Melanoma $3,422 3,281-3,570 $5,250 4,974-5,541 Myeloma $24,182 22,685-25,801 $27,049 25,109-29,138 Other $18,256 17,727-18,834 $20,981 20,338-21,644 Ovary $23,059 22,322-23,823 $24,429 23,567-25,322 Pancreas $28,906 26,903-31,458 $33,710 32,278-35,206 Prostate $7,466 7,372-7,564 $9,751 9,604-9,901 Testicular $9,531 8,384-11,110 $11,560 10,615-12,589 Thyroid $9,834 9,443-10,281 $9,941 9,673-10,217 11
- 12. Initial phase costs (BC) 12 British Columbia Initial phase (6 months)
- 13. CONTINUING CARE British Columbia Ontario Mean 95% CI Mean 95% CI Bladder $7,960 7,580-8,347 $11,004 10,568-11,457 Brain $7,490 6,670-8,450 $10,169 8,899-11,620 Breast (female) $6,197 6,087-6,313 $9,041 8,874-9,210 Cervix $3,266 2,897-3,690 $4,308 3,959-4,688 Colorectal $7,529 7,355-7,696 $11,688 11,429-11,953 Corpus uteri $4,319 4,090-4,557 $7,666 7,261-8,094 Esophagus $7,964 6,850-9,320 $10,265 9,073-11,613 Gastric $6,573 5,883-7,307 $9,291 8,602-10,035 Head and Neck $5,744 5,440-6,094 $8,576 8,140-9,034 Kidney $5,633 5,270-5,997 $9,228 8,805-9,672 Leukemia $10,306 9,764-10,857 $11,500 10,942-12,086 Liver $8,405 7,300-9,611 $14,708 13,556-15,958 Lung $7,182 6,891-7,491 $10,090 9,737-10,456 Lymphoma $6,571 6,347-6,806 $8,891 8,554-9,241 Melanoma $3,092 2,925-3,273 $5,584 5,323-5,857 Myeloma $16,992 15,993-18,029 $19,340 18,570-20,142 Other $6,715 6,405-7,019 $10,288 9,900-10,692 Ovary $5,805 5,367-6,301 $7,631 7,085-8,220 Pancreas $9,721 8,102-11,697 $10,889 9,401-12,613 Prostate $5,630 5,539-5,723 $8,506 8,358-8,656 Testicular $1,978 1,703-2,329 $2,858 2,713-3,010 Thyroid $2,841 2,644-3,074 $4,886 4,673-5,109 13
- 14. Continuing care costs (BC) 14 British Columbia Continuing care phase (12 months)
- 15. TERMINAL British Columbia Ontario Mean 95% CI Mean 95% CI Bladder $49,021 47,315-50,934 $57,121 55,856-58,416 Brain $75,950 72,872-79,105 $86,153 83,702-88,675 Breast (female) $41,919 41,015-42,802 $45,357 44,775-45,946 Cervix $45,856 42,483-49,715 $55,774 53,171-58,504 Colorectal $47,504 46,571-48,391 $54,589 53,980-55,204 Corpus uteri $43,221 40,750-45,901 $47,823 45,994-49,724 Esophagus $55,762 53,094-58,599 $70,894 68,520-73,352 Gastric $58,410 56,055-61,126 $69,581 67,774-71,436 Head and Neck $45,612 43,534-47,811 $57,191 55,680-58,743 Kidney $48,562 46,126-50,742 $59,707 57,832-61,642 Leukemia $60,007 57,466-62,737 $89,544 86,733-92,446 Liver $44,047 41,250-47,626 $51,760 49,143-54,517 Lung $45,862 45,179-46,568 $58,570 57,956-59,191 Lymphoma $59,579 57,477-61,746 $72,821 70,740-74,962 Melanoma $33,632 31,973-35,406 $39,645 38,547-40,774 Myeloma $57,329 55,007-60,173 $69,751 67,673-71,893 Other $57,433 55,962-58,932 $62,542 61,451-63,652 Ovary $47,300 45,327-49,383 $58,094 56,711-59,510 Pancreas $61,931 59,918-64,026 $70,305 68,646-72,003 Prostate $37,895 37,087-38,717 $44,222 43,592-44,862 Testicular $75,911 38,140-140,149 $74,558 63,662-87,318 Thyroid $44,327 37,029-51,841 $55,016 50,260-60,222 15
- 16. Terminal phase costs (BC) 16 British Columbia Terminal care phase (12 months)
- 17. • Same sites consistently high – myeloma, pancreas, brain • …or low across phases – melanoma, cervix, prostate • High initial-phase costs for aggressive cancers but not necessarily terminal phase – Cost of dying is consistently high • Phases not appropriate for all cancers Patterns by phase and site 17
- 18. Patterns in BC and Ontario • Cost estimates tend to be lower for BC • Unavoidable differences in costing methods – Some can be accommodated by comparing component costs • Separating true differences across provinces from differences in methods is challenging 18
- 19. • Population-based admin data well-suited to costing studies – Analysis of cost trajectories, patterns – Inputs for future economic evaluation • Aligning service definitions and component costs is a foundational step • Familiarity with the data is essential! – ICES, Population Data BC Conclusions
- 20. Advancing Health Economics, Services, Policy and Ethics Thank you • Contact: rpataky@bccrc.ca • Ontario Team: Dr. Murray Krahn (PI), Dr. Claire de Oliveira, Dr. Jeff Hoch, Karen Bremner, Dr. Kelvin Chan • BC Team: Dr. Stuart Peacock, Dr. Paulos Teckle, Dr. Winson Cheung • Funding provided by the Canadian Cancer Society Research Institute (grant #020200) 20
Editor's Notes
- Outline: BC Cancer Agency data BC-ON costing study Data sources and key differences Preliminary phase-based cost results comparative analysis using admin data from BC and ON to highlight the issues/challenges, strengths and limitations around the standardization of the existing costing methods. I think this would be really important to focus on as it will be the main challenge we will face when we try to replicate our work for other provinces.
- Include Popdata/MoH disclaimer
- By “cost” we mean direct medical costs, not direct non-medical (e.g. travel cost) or indirect (e.g. lost productivity) Thankfully, even though costs change over time, they follow a predicable pattern
- Phases correspond to major changes in cost function, but are also clinically relevant 4 phases: 1 – Pre-diagnosis phase (green) – 3 months prior to diagnosis 2 – Initial phase (navy) – up to 6 month following diagnosis 3 – Continuing phase (light blue) – length varies 4 – Terminal care phase (purple) – up to last 12 months of life We calculated average cost per phase by cancer site, with non-parametric bootstrapping for 95% confidence intervals.
- All differences are statistically significant. BC is slightly older, slightly higher proportion of males. Registry audience probably knows more about these differences than I do...
- In BC: BC Cancer Agency, BC Ministry of Health, PharmaNet, and BC Vital Statistics Agency approved data access and use facilitated by Population Data BC In Ontario: Data from Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care Linkage and analysis conducted by Institute for Clinical Evaluative Sciences … So using these data sources and our own costing methods, we went away and calculated our own costs in both provinces and came back with estimates that were dramatically different.
- Pre-diagnosis phase – cost expressed for 90 days before diagnosis Top three for each province and sex marked in yellow, bottom three in blue ~6 fold difference between top ($4660 for myeloma in Ontario, vs. $733 for testicular cancer in BC) Values for BC tend to be lower; but ranks are similar The biggest difference here is likely to do differences in diagnostics – there are differences in two main areas: physician services and diagnostics. They act in opposite directions, but the net effect is higher costs in Ontario. We need to unpack this more:
- Initial care phase – cost expressed for 6 months after diagnosis (~180 days) Top three for each province and sex marked in yellow, bottom three in blue 12-fold difference between top ($43,400 for esophageal cancer in Ontario, vs. $3400 for melanoma in BC) Values for BC tend to be lower; but ranks are similar
- Continuing care phase – cost expressed per year (~360 days) Top three for each province and sex marked in yellow, bottom three in blue 9 fold difference between top ($19,300 for myeloma in Ontario, vs. $2000 for testicular cancer in BC) Values for Ontario tend to be higher; but ranks are similar -This is also where sex differences appear, although not shown. Costs for women tend to be higher than for men This is phase where (I think) control matching with have the greatest effect – we’re dealing with an older population with relatively high service use regardless of cancer
- Big mix of services – Myeloma highest by far Driven by maintenance therapy with lenalidomide Highest cost drugs in BC data: Myeloma: pamidronate, thalidomide, lenalidomide, bortezomib Leukemia: imatinib, rituximab, fludarabine, dasatinib
- Terminal phase – cost expressed for last year of life Top three for each province and sex marked in yellow, bottom three in blue Less than a 3-fold difference between top ($78,200 for brain cancer in Ontario women, vs. $34,100 for melanoma in men in BC) A note re: testicular cancer: there are few deaths in both cohorts; 95% CI’s (not shown) are wide Values for BC tend to be lower; but ranks are similar
- Mostly inpatient – more home and community care These are also not selected for cause of death – mix of cancer and non-cancer
- Part of the challenge in interpreting “phases” for all cancers is that sometimes they’re not appropriate. Eg. For aggressive cancers, few patients survive to contribute time to “continuing care” phase (e.g brain). These are probably atypical cases, so it’s hard to draw any conclusions. For cancers with low mortality, most patients we capture in the terminal phases are dying of other causes (e.g melanoma)
- Caution that we haven’t done bootstrapping to compare 95% CI’s – results for BC show that intervals generally narrow for common cancer sites (as we’d expect) but for less common cancers (e.g. testicular, terminal phase) 95% CI’s are wide Not just differences in methods – there are structural differences in the organization and delivery of care that influence the data and cost available.