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ORIGINAL ARTICLE

Costs in primary care of investigating symptoms suspicious of cancer in a defined population

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Pages 243-250 | Received 12 Jan 2006, Published online: 12 Jul 2009

Abstract

Objectives. To calculate total cost of investigating symptoms related to one of the four most common cancers: prostate, breast, colorectal, and pulmonary. Special attention was given to two non-specific and common symptoms: vertigo/dizziness and tiredness/fatigue. Design. Retrospective examination of patient records in a defined population. Setting. Primary health care (PHC) and hospital care. Main outcome measures. Investigation costs of selected ICD codes. Results. In total 6812 patients with 14 541 ICD codes were investigated to a total cost per registered ICD code, with one of the selected diagnostic measures, of SEK 800. Some 50% of the costs were due to X-ray examinations of which colonic X-ray was the most expensive single procedure. Symptoms related to colorectal cancer were the most expensive to investigate with vertigo/dizziness and tiredness/fatigue examined separately. Tiredness/fatigue symptoms cost SEK 395 and vertigo/dizziness SEK 197 per registered code to investigate and none of them yielded a detected malignancy. The incidence of cancer was 0.7%. The average cost of diagnosing one malignancy was SEK 236 700, if all diagnostic activities could be justified only for detection of malignancies. Conclusion. A high cost of diagnosing malignancy can be expected and justified, but many symptoms presented in PHC, such as tiredness/fatigue and vertigo/dizziness, have a relatively high investigation cost but detected no case of cancer in this study.

The broad adoption of evidence-based healthcare has disclosed lack of relevant information on cost-effectiveness in many fields. Particularly in primary health care (PHC) few clinical measures have been evaluated sufficiently in terms of effectiveness and cost-effectiveness. There is a lack of reliable data, but also relevant is the fact that health economic studies in specialized care based on well-specified diagnoses could not be directly translated into a PHC setting with a different patient mixture. Patients in PHC normally visit the physician early in an episode of disease with a panorama of symptoms, which could seldom be translated immediately into one or more specific diagnoses. Analyses of cost-effectiveness in PHC have to focus more on symptoms rather than well-defined diseases.

Examinations performed in relation to cancer are well known, but little is known about the costs of examining cancer-related symptoms, which have been studied in this paper.

  • Symptoms related to colorectal cancer are expensive to examine. When studying single symptoms the most expensive was blood in the stool and the cheapest was upper airways infection.

  • Diffuse and non-organic specified symptoms, such as tiredness/fatigue and vertigo/dizziness, have a relatively high investigation cost and a low rate of detecting cancer.

  • A high cost for the detection of a malignancy could be expected and justified, but it should be interpreted with attention to the yield of detected cancers.

During the last decade most PHC centres in Sweden have become computerized Citation[1]. A national network of PHC centres has performed a study on effectiveness and costs of routine care by using patient records Citation[2]. Investigations performed and their outcome, due to symptoms Citation[3], Citation[4] related to cancer, has also been studied in Sweden Citation[5].

To develop an evidence-based, systematic approach to cost-effective management of patients with symptoms related to cancer, such as vertigo/dizziness, a search was performed using the key words “vertigo/dizziness” and “tiredness/fatigue” in combination with “general practice”. Only one study with a weak degree of scientific evidence was found Citation[6]. No randomized trials were found. The same result appeared in a further Medline search up to the year 2003.

The objective of this study was to evaluate the total investigation costs due to the most common symptoms Citation[3], which could be related to the four most common cancer diseases (prostate, breast, colorectal, and pulmonary cancer), with special attention to two non-specific and common symptoms: vertigo/dizziness and tiredness/fatigue. A second objective was to calculate the average investigation cost in order to diagnose one case of the four most common cancers. This has not been studied previously from the perspective of activities and costs directly correlated to symptoms presenting in PHC.

Material and methods

Design and settings

This is a retrospective cost analysis calculated from all visits during a defined time period in a defined population served by four PHC centres in Sweden Citation[3]. The centres were strategically selected with physicians with proper ICD code settings and reflecting a mixture of urban and rural populations. The population consisted of 26 164 inhabitants (Habo with 9556 inhabitants (1995–97), Fritsla with 2893 inhabitants (1992–97), Olskroken with 4715 inhabitants (1993–97), and a PHC centre in Kungsbacka with 9000 inhabitants (1994–97). The study period was between 24 and 58 months depending on the size of the population in the area in order to roughly balance the material from the different centres. Permission for withdrawal of non-identifiable data from patients’ records was obtained from the operating managers in the four PHC centres.

Study population

The study populations were mixed with people living in rural, suburban, and urban areas. Inclusion criteria for selection of patients were: age >30 years, and one registration with an ICD code relating to a potential malignancy during the study period.

Registration and data extraction

At the PHC centres in the study all patients are registered according to the International Classification of Diseases (ICD9), from which we selected potential differential codes (). Every visit could result in one or several new ICD codes, or at a revisit for the same ailment with the same ICD code as before. Individuals and their records were traced via the computer system.

Table I.  Cost of investigations, expressed in SEK, related to the most frequently settled ICD codes. Less frequently ICD codes were merged with “Others”.

The most common symptoms from the four most common cancers (prostate, breast, colorectal, and pulmonary cancer) were selected Citation[5]. Further examinations on symptoms not included as the most common and quality control of a proper ICD code settlement were performed in other studies Citation[5], Citation[7]. Two symptoms from the most common symptoms of colorectal cancer were selected (vertigo/dizziness and tiredness/fatigue) in order to reflect the handling of diffuse and unspecific common symptoms in the PHC.

Besides the ordinary physical examinations all investigations that were performed at the PHC centres, referrals to clinical chemistry, microbiology, X-ray department, etc., and the first visit to a specialist, were collected from the records. Further investigations done by the specialist were not included.

Description of the material

During the study period averaging 36 months, 6812 individual patients (26% of the population) visited their PHC centre, with 14 541 of the selected ICD codes registered. The majority of the visits resulted in one or more new ICD codes (61%). The remaining 39% were classified as revisits (5682) with the same code within the study period. The total population basis years amounted to 78 955. For the population aged >30 years the number of basis years was 47 343, resulting in 0.31 selected ICD codes per person per annum.

Forty-nine cancers were detected in the PHC centres, 13 prostate, 7 breast, 19 colorectal and 6 pulmonary, and 4 other cancers.

Cost analysis

The costs of laboratory tests were based on the official calculated costs from the chemical, bacteriological, and virological laboratories in the county of Halland for 1997. Costs for X-ray examinations, endoscopies, and biopsies were based on official prices for particular services in the county council of Halland. The cost of the visit to a specialist was collected from an agreement between the county councils in the healthcare region, which regulates the reimbursement for a consultation. The inflation during the time period 1997–2005 could be estimated to +8.5%. In September 2005 €1 was worth SEK 9.32.

Data analysis

Descriptive statistics were used to calculate the costs of investigations performed in relation to the ICD codes and the occurrence of detected cancers.

Results

Symptom presentation in a general perspective

In total 6812 individual patients, with 14 541 selected ICD codes in 10 726 consultations, resulted in 18 664 diagnostic measures employing 16 203 laboratory tests, 1426 X-ray examinations, 340 endoscopies, 28 cytology tests, and 667 referrals to other specialists. The total cost including visits, investigations, and first referral to specialist amounted to SEK 11 600 000 and expressed per patient SEK 1700 or SEK 800 per registered ICD code. The most common chemical laboratory test () was Blood Hb (B-Hb): 2411 times at a cost of SEK 34 598. The most expensive tests were thyroid tests, which were performed 526 times at a cost of SEK 94 364, mostly performed for the symptom of tiredness. Approximately 50% of the costs of investigations were due to X-ray examinations (see ), which were dominated by colon X-rays (SEK 786 326) (). Chest X-rays cost less (SEK 276 536) in spite of the fact that chest X-rays were performed three times more often than colon X-rays. The average cost of a visit related to any of selected ICD codes was SEK 173 and per patient SEK 235.

Figure 1.  Number and costs of laboratory examinations.

Figure 1.  Number and costs of laboratory examinations.

Figure 2.  Number and costs of X-ray/ultrasound/radiorenogram.

Figure 2.  Number and costs of X-ray/ultrasound/radiorenogram.

The most expensive group of patients had symptoms from colorectal diseases, where the single most expensive ICD code was blood in the stool, which had a mean cost of SEK 2000 per registration. The cheapest was “upper airways infection” for which the mean cost of investigation was SEK 45 per registration.

Two selected ICD codes

Vertigo/dizziness was the second most common ICD code related to colorectal cancer and accounted for 6% of registered codes to the GP (n = 887). However, this symptom did not lead to any diagnosis of cancer. The average cost from this code was SEK 197.

Some 47% of the costs were due to biochemical laboratory tests (). The most common was B-Hb, performed 351 times at a cost of SEK 5037. The most expensive were thyroid tests, performed 110 times at a cost of SEK 19 734 for the ICD code vertigo/dizziness. X-ray examinations accounted for 24% of the cost and constituted mainly of CT brain scans and chest X-rays ().

Table II.  Cost and cost-efficacy due to detected cancers of examinations performed related to the ICD codes vertigo/dizziness and tiredness/fatigue.

Patients were referred to the emergency department in 1% of cases, to specialists in surgery in 0.5%, internal medicine 3%, and others 2%. The calculated cost of the first visit to a specialist accounted for 29% of the total cost of the code vertigo.

Tiredness/fatigue are common symptoms for visiting the GP (n = 109), but did not result in a detection of cancer in this study. The average cost per registered code was SEK 395.

Some 74% of the costs were due to biochemical laboratory tests (see ). The most common test was B-Hb, performed 65 times at a total cost of SEK 933. The most expensive were thyroid tests, performed 53 times at a total cost of SEK 9508 for the ICD code tiredness/fatigue. X-ray examinations accounted for 12% of the cost, mainly chest X-rays (see ). Patients were referred to specialists in ear/nose/throat in 3% of cases, surgery in 2%, internal medicine in 2%, and neurology in 1%. The calculated cost of the first visit to a specialist accounted for 12% of the total cost of the code tiredness.

Cost-analysis in a cancer perspective

In total, 49 malignancies were detected with an incidence in this selected group of 0.7%. If all diagnostic activities related to the defined symptoms could be justified only for the detection of malignancies, a cost of SEK 236 700 per confirmed cancer case can be calculated. When the costs for the consultations are subtracted, the cost of laboratory investigations and referrals per diagnosed case of cancer would be SEK 49 000 per patient. The actual costs to diagnose malignancy in total were SEK 88 406 (for the 49 identified patients with malignancy, primarily diagnosed at the PHC centre), which means SEK 1804 per diagnosed malignancy.

Discussion

Symptom presentation in a general perspective

This study was an attempt to describe the diagnostic activity with relation to symptom presentation and costs in the daily work of a GP. Unfocused conditions or symptoms, which were potentially related to at least one of the four most common malignancies related to more than one single organ or speciality area, accounted for approximately 25% of all visits in PHC Citation[7]. We have focused on the task of identifying the few malignancies presenting with symptoms in PHC among the “noise” of non-neoplastic diseases. The selected ICD codes Citation[5] relating to the four most common malignancies and their most common symptoms and signs represented one-fifth of the total visits in PHC. The relatively high cost of investigations and referrals for ICD codes related to colorectal diseases indicates the importance of an awareness of cost-effectiveness. This fact and the interest in handling diffuse and unspecific symptoms in the PHC led to the selection of the two symptoms vertigo and tiredness. The ICD codes related to bronco-pulmonary diseases were less expensive, due to common symptoms from upper airway diseases and frequent viral diseases with minimal investigation costs.

Two selected ICD codes

Vertigo/dizziness is a commonly presented symptom in the community Citation[8–11] and is the reason for 1–4% of all encounters in PHC Citation[12], Citation[13]. Most of the patients with vertigo/dizziness could be, and usually are, managed in PHC Citation[8], Citation[14] supported with guidelines in order to avoid unnecessary treatment Citation[15], but an evaluation of investigations performed Citation[16] in relation to costs and the yield of malignant diagnoses is necessary. Vertigo/dizziness had a total examination cost, which could be compared with investigations performed in other studies Citation[16]), and referrals in 12% with that ICD code Citation[13]. This is a relatively low cost for investigations, which could exclude or diagnose several serious and treatable medical conditions. However, in this study we found no malignancy.

Tiredness/fatigue is a common reason for encounter Citation[12], Citation[17–22] with several diagnostic options Citation[23–25]. Pathology testing for patients presenting with tiredness is high, but most tests do not yield a significant clinical diagnosis Citation[26]. Tiredness in our study had a total examination cost that was lower than in other studies Citation[23], Citation[26], probably due to stricter diagnostic criteria. Some 12% of the tests were abnormal Citation[26]. There is a need for further studies to elucidate the yield of diagnoses other than malignancy to justify the costs of investigations, mostly laboratory tests.

Cost-analysis in a cancer perspective

The outcome of a certain investigation in terms of number of malignant diagnoses per specific investigation as a measure of cost-effectiveness should be interpreted with caution. A number of chemical and microbiological tests were not aimed at diagnosing a malignancy, e.g. electrolytes, CRP, blood glucose, and thyroid tests, but were part of a general examination focused on various non-neoplastic disorders. There were also some not included ICD codes related to these cancers, which were not the most common ones. However, the relatively high cost of detecting a few malignancies gives rise to the thought that many probably unnecessary examinations were performed. To be able to judge whether the cost seems to be unreasonably high we have to know more about the tumour stage and what happened to the patients later in the care process. Compared with the cost for detecting one prostate cancer in a screening programme this cost seems not to be very high Citation[28].

General considerations

As a complement to prospective clinical trials it is of value to analyse actual performance in a systematic way. Studies of costs for investigations performed and the yield of diagnosing “serious” diseases such as malignancy are important in order to manage the essential priorities of the medical service. The strength of this study is our access to total population-based data on cancer incidence and number of visits related to the symptoms studied. The disadvantage is the incomplete information in a retrospective study and the difficulty of attributing the tests done to a particular ICD code, when patients consult the physician for different ailments at the same visit. The relationship between the symptoms and cancer could not be settled due to the information being obtained from the records retrospectively and many examinations were performed due to other diseases. However, this study focuses on the examinations performed in respect of selected symptoms, which could be related to cancer diseases. This study has mitigated the disadvantages of retrospective design through a systematic approach with searching on specific ICD-9 codes according to diagnoses and symptoms recorded by selected physicians, with a proper diagnostic coding. The validity of coding in each specific case could be discussed Citation[27], but the conformity seems to be relatively good at an aggregated level. The investigations performed were registered automatically and the outcome of malignancies was compared with the report to the Regional Cancer Registry. This study identifies the investigations performed in relation to cancer diseases, selected according to the most common ICD codes related to the four most common cancers, which could be the basis for identifying which investigation should be done (or not done) when a particular symptom is presented. Each ICD code could also be the same for different malignancies. To find a malignancy is only a small part of a GP's sphere of activity and the “cost per malignancy” should be interpreted with caution with regard to investigation costs due to other diseases. In another prospective study we have investigated the outcome of an information campaign concerning common symptoms of these four cancers, where we have found the outcome of other diagnosed diseases, due to symptoms in this study Citation[28]. However, the costs due to the selected specific ICD codes are a considerable amount of a GP's daily activity. Further studies are needed of other diseases with diffuse symptoms to relate the investigations needed prior to treatment, and to relate this to cost and outcomes.

Conclusions and implications

Health economic studies based solely in specialist centres and hospitals can give a skewed view of what is going on in PHC. Symptoms related to investigations performed are a primary key in PHC and the costs and yield of examinations performed are essential tools in order to evaluate the cost-effectiveness and to serve as a basis for priority decisions in medical service. A high cost will be expected and justified in order to diagnose a malignancy, but common symptoms presented in PHC such as tiredness/fatigue and vertigo/dizziness have a relatively high cost of investigations but a yield of no detected cancer in this study.

The study was performed with help from staff in the PHC centres of Habo, Fritsla, Olskroken, and Kungsbacka. The information on local cancer incidence was obtained from the Oncology Centre, the Sahlgrenska Academy at Göteborg University. The material was data processed by Eva Almqvist. The study received financial support from the Research and Development budget of the county of Halland.

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