Table A4:
Lowery et al, 2013
| Lowery WJ, Lowery AW, Barnett JC, et al. Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer. Gynecol Oncol 2013;130:426–30 | |||
| Methods | |||
| Study details | Population | Interventions | |
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Type of economic analysis: CEA and CUA (sensitivity analysis) Study design: Decision tree model Perspective: Not stated, but can be inferred as a health care payers’ perspective Time horizon: 6 months |
Patients with recurrent, platinum-resistant ovarian cancer Mean age: NR Male: NR |
RC vs. RC plus early referral to a palliative medicine specialist (EPC) | |
| Approach to analysis | |||
| A decision model was constructed with a time horizon of 6 months to evaluate RC and EPC. The time horizon was chosen to reflect the early effects of palliative care intervention. In both strategies, a patient would receive RC at the discretion of the treating oncologist. EPC was defined as the initiation of outpatient palliative care at the time of diagnosis of platinum resistance. Patients receiving EPC would meet with a palliative care provider monthly to address symptoms, develop goals of care, and assist with decision-making about proposed treatments. Patients receiving RC would be referred to a palliative care provider only at the discretion of the treating physician or at the request of the patient or family. The primary model outcome was the average cost of care in each strategy. Model parameters included rates of inpatient admissions, ED visits, chemotherapy administration, and QOL. Costs of hospitalization, ED visits, chemotherapy, and EPC were included. | |||
| In the primary sensitivity analysis, potential QOL differences provided by EPC were modelled, with the assumption that the recurrent ovarian cancer population had the potential for a similar improvement in QOL to that observed by Temel et al (47) | |||
| Results | |||
| Costs | Health outcomes | Cost-effectiveness | |
|
Currency and cost year: 2012 US dollars Total costs (mean per person): RC $6303, EPC $5,017 incremental (RC–EPC) $1,285 Discount rate: 0% |
Primary outcome: QALY (in a sensitivity analysis) Total QALYs (mean per person): RC NR, EPC NR, incremental (RC–EPC): NR Discount rate: 0 |
Primary ICER: NR Other: Compared to RC, EPC was associated with a cost of $37,000 per QALY (in a sensitivity analysis) |
|
| Interpretation | |||
| Sensitivity analyses | Limitations and applicability | ||
| In the sensitivity analysis incorporating QOL, EPC was dominant (i.e., less costly and more effective) compared to routine care. In 1-way sensitivity analysis, the cost of EPC (estimate $468) had to exceed $1,753 before the average cost of the EPC strategy was higher than that of routine care. The cost of EPC had to exceed $2,400 before the ICER of EPC reached the common societal WTP threshold of $50,000/QALY, and had to exceed $3,000 before the ICER reached $100,000/QALY compared to routine care. When we assumed no clinical benefit of EPC other than QOL (i.e., no differences in chemotherapy administration, hospitalizations or ED visits between groups), EPC remained highly cost-effective, with an ICER of $37,440/QALY Treatment effectiveness: Outcomes that differed significantly between the EPC and RC strategies in the prior RCT (47) (rates of inpatient admissions, ED visits, and chemotherapy administration) were included in the model. The authors estimated inpatient hospitalizations, ED visits, and chemotherapy administrations in the RC group based on available ovarian cancer data. They calculated ORs for reductions in these events when EPC was introduced, based on what was observed in the prior RCT. The ORs for each clinical event (0.69 for hospitalizations, 0.74 for ED visits, and 0.77 for chemotherapy administration) were applied to the baseline event rates in ovarian cancer to determine their rates in the EPC group. This resulted in the base case assumption that EPC in the ovarian cancer population would potentially result in a reduction in hospitalizations from 70% to 48%, in ED visits from 30% to 22%, and in chemotherapy administration from 60% to 46% during the last 6 months of life |
Effectiveness evidence was from 1 source. (47) Extrapolation of the effectiveness evidence from patients with metastatic NSCLC to patients with recurrent platinum-resistant ovarian cancer. Assuming that the target population is treated reasonably similar between the US (North Carolina) and Ontario, the results could be considered applicable to Ontario Key Assumptions: (1) For purposes of cost calculation, all patients who were admitted to the hospital were assumed to be admitted once and all patients seen in the ED were assumed to be seen once during the 6-month time horizon; (2) the chemotherapy regimen was identical in both arms; for simplicity, the use of liposomal doxorubicin was assumed in this population; (3) patients receiving EPC were seen as outpatients for an initial visit, followed by 5 subsequent monthly visits; (4) QOL was not incorporated into the base case model; and (5) given that there are no data regarding the impact of EPC intervention on overall survival in patients with platinum-resistant ovarian cancer, we assumed equivalent survival between those receiving EPC and those receiving RC |
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| Data Sources | |||
| Clinical effectiveness: Temel et al (47) | |||
| Costs: The cost of palliative care was estimated as the 2012 Medicare reimbursement for an initial high-complexity encounter, followed by moderately high-complexity visits every 4 weeks. The cost of hospitalization was estimated as the mean cost of inpatient hospitalization for a diagnosis of small bowel obstruction, 1 of the most common reasons for admission at the end of life in ovarian cancer, using the AHRQ's Healthcare Cost and Utilization Project. The cost of an ED visit was derived as the average total payment from all sources for an ED visit using the AHRQ's Medical Expenditure Panel Survey. The cost of chemotherapy was estimated using Medicare reimbursement data using Current Procedural Terminology codes and drug J codes, and included the costs of a physician visit, infusion room costs, routine laboratory panels, chemotherapy, and support drugs | |||
| Quality of life: The base case utility score representing HRQOL during treatment of recurrent ovarian cancer (0.67) was derived from a prospective elicitation of the preferences of a member of the public using the time trade-off method. From the RCT, (47) the odds ratio representing the potential change in QOL with the addition of EPC (1.07) was based on the global QOL score changes seen with incorporation of EPC. This OR was applied to the baseline utility score associated with treatment of recurrent ovarian cancer to produce the utility (0.72) representing QOL improvement in the EPC group. These favourable QOL changes were incorporated only over the final 3 months of the 6-month time horizon to account for the fact that there is likely a delay in the development of QOL differences between EPC and RC | |||
| Funding | |||
| The authors have no conflicts of interest to report | |||
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; ED, emergency department; EPC, early palliative care; HRQOL, health-related quality of life; ICER, incremental cost-effectiveness ratio; NR, not reported; NSCLC, non-small-cell lung cancer; OR, odds ratio; QALY, quality-adjusted life-year; QOL, quality of life; RC, routine care; RCT, randomized controlled trial; WTP, willingness to pay.