Abstract
Objective:
Current radiation therapy capacities in Serbia and most of Eastern Europe are heavily lagging behind population needs. The primary study aim was assessment of direct costs of cancer medical care for patients suffering from cancer with assigned radiotherapy-based treatment protocols. Identification of key cost drivers and trends during 2010–2013 comparing brachytherapy and teleradiotherapy was a secondary objective of the study.
Methods:
Retrospective, bottom-up database analysis was conducted on electronic discharge invoices. Payer’s perspective has been adopted with a 1-year long time horizon. Total sample size was 2544 patients during a 4-years long observation period (2010–2013). The sample consisted of all patients with confirmed malignancy disorder receiving inpatient radiation therapy in a large university hospital.
Results:
Diagnostics and treatment cost of cancer in the largest Western Balkans market of Serbia were heavily dominated by radiation therapy related direct medical costs. Total costs of care as well as mean cost per patient were steadily decreasing due to budget cuts caused by global recession. The paradox is that at the same time the budget share of radiotherapy increased for almost 15% and in value-based terms for €109 per patient (in total €109,330). Second ranked cost drivers were nursing care and imaging diagnostics. Costs of high-tech visualizing examinations were heavily dominated by nuclear medicine tests.
Conclusion:
The budget impact of radiation oncology to the large tertiary care university clinics of the Balkans is likely to remain significant in the future. Brachytherapy exhibited a slow growth pattern, while teleradiotherapy remained stable in terms of value-based turnover of medical services. Upcoming heavy investment into the national network of radiotherapy facilities will emphasize the unsatisfied needs. Huge contemporary budget share of radiotherapy coupled with rising cancer prevalence brings this issue into the hot spot of the ongoing cost containment efforts by local governments.
Introduction
Cancer will remain highly ranked among prosperity diseases for its economic burden in all aging industrial nations of the northern hemisphereCitation1. This is the case due to complex treatment strategies, unpredictable outcomes, and heavy impact that different malignancies expose to long-term survival and life qualityCitation2. Out of a variety of treatment approaches, common conventional protocols consist of a cytostatic drug regimen combined with either surgery and/or radiation therapy. Radiation treatment of malignancies will remain one of the long-term pillars of cancer treatmentCitation3. Besides its adverse effects, the main practical issue affecting its spreading is necessity of heavy investment into expensive equipment, bunkers architecture, maintenance, and human resource capacity buildingCitation4.
International Atomic Energy Agency (IAEA), Division of Human Health runs comprehensive Directory of Radiotherapy Resources (DIRAC) on countries and regions across the globe. According to IAEA latest official release, Serbia’s national capacities in this area belongs to prevailing Eastern European pattern hosting in between 1–3 radiotherapy machines per million peopleCitation5. Out of seven tertiary care centers providing such services, six are university associated hospitals. Most of them own external beam, brachytherapy, and dosimetry-related equipment. Current national capacities in this area are heavily insufficient. In some of these centers, particularly in the northern region of the country, common waiting times for radiotherapy are even several months. The current waiting list in the capital of Belgrade consists of ∼600 patients. Serbia’s 7.2 million population has at its disposal only 10 fully operational linear accelerators (14 in total), while it should have at least triple that much. Intensive 24/7 functioning of these machines leads to frequent technical troubles with slow administrative repair procedures. Available capacities for brachytherapy as well as human resources such as radiation oncology specialists and experienced radiotherapy technicians are rather short too. Approximately one half of an estimated acute need for equipment investment will be covered out of a recently approved World Bank US$ 22 million loan to Serbia’s health system intended for acquisition of six more linear acceleratorsCitation6.
The aforementioned seriousness of health policy associated to radiation therapy in the largest Western Balkans market has prompted us to investigate actual costs of such treatment in a local setting. Acquiring such pioneering knowledge in this region would allow evidence-based budget planningCitation7. Efficient resource planning in this area would help target disputed patient access to radiotherapy while improving survival rates and prognosis.
Patients and methods
Study design
Retrospective, bottom-up, case series study design was adopted while implementing 1 year time horizon and payer’s perspective. Authors had no substantial insight into the clinical background of each case (e.g., tumor type, use of different diagnostic procedures, and treatment data) except for confirmed ICD-10 diagnosis and basic demography (see ).
Figure 1. Sample structure across ICD-10 diagnostic malignancy groups (joined 2010-2013 patient population) (number of patients).
Setting
Out of the aforementioned seven national radiotherapy centers, authors selected the one located in the geographical core of the country, associated to one of the largest university tertiary care hospitals (1297 beds). All of the observed patients received complex oncology treatment protocols following clinically-confirmed diagnosis. Overall medical care was not limited to radiation treatment, but included the entire course of diagnostics and treatment such as nursing care, surgery, cytostatic regimens, and rehabilitation services. Resource use and costs incurred during any single year out of the 2010–2013 time span was observed.
Data
The source of data on medical consumption was a database consisting of electronic hospital discharge invoices. These invoices represent prices adopted bythe national health insurance fund as the core first party payer financing almost all of public and a large part of private healthcare. Observed university hospital as all other key oncology facilities in the country are not-for-profit hospitals. Therefore, the applied pricelist for medical goods and services is based on the value reimbursed by the Fund to the hospitals. Conventional cancer treatment and medical care are actually fully reimbursed and not charged to patients. Limited exceptions to this rule are restrictions that apply only to the most expensive pharmaceuticals such as monoclonal antibodies and protein kinase inhibitorsCitation8.
The observed tertiary care university hospital has processed a total of 12,505 patients suffering from cancer during 2010–2013. There were 37,978 hospital admissions in a target facility within the observed time span. Inclusion criteria included patient with laboratory, imaging, and histologically confirmed cancer on biopsy specimens; with any prescription of radiation therapy oncology treatment regimen; both sexes. Exclusion criteria where: absence of a radiotherapy-based oncology treatment protocol; presence of another severe concomitant physical illness; and lack of significant study data. The final sample size of patients undergoing radiation therapy with or without involvement of other treatment approaches (surgical, pharmacological ones) was 2544 patients with 2571 hospital admissions. All inpatients fulfilling the aforementioned criteria were considered, regardless of clinic of admission (Oncology and Radiotherapy Centre, Surgical wards, Internal Medicine Clinic etc.). Outpatients receiving radiotherapy as well as cancer patients assigned to surgical and/or pharmacology treatment options exclusively were omitted from the study (see ).
Table 1. Total prevalence-based pool of patients with pathohistology, laboratory, and imaging diagnostics confirmed malignancies treated as inpatients in targeted university clinic.
Data analysis
Micro-costing analysis has been conducted on available data on complete tertiary care level in- and outpatient medical services consumed. All direct medical costs related to health service utilization such as physician consultations, diagnostics (such as imaging, laboratory), surgical interventions, radiation therapy regimens, and prescription of pharmaceuticals are described. Simple descriptive statistics were used with analytics provided in Microsoft Excel 2010. Relevant data are presented in terms of mean, median, standard deviation, minimum and maximum values, and 95% confidence intervals.
Ethical committee approval
The study was conducted in line with The Declaration of Helsinki (sixth revision, 2008) and has been approved by the regional Ethics Committee of the University Clinical Center Kragujevac, Serbia. Decision number 01-5978 was issued on May 28, 2013. Personal data remained protected during the study, in line with positive legislation on biomedical research in human subjects in Serbia, via anonymous handling of patient files.
Results
Observing the ICD-10 landscape of diagnostic groups of malignancies, we see that our sample was dominated by thyroid gland cancer (598 patients; 24%), breast cancer (576 patients; 23%), lung and bronchial carcinoma (422 patients; 17%), gastrointestinal malignancies (252 patients; 10%), colorectal carcinoma, and head and neck malignancies (224 patients; 9%) (see ). Median direct medical costs of inpatient care ranged from €1467 in 2010 to €1329 in 2013. Diagnostics and treatment cost of cancer were dominated by radiation therapy, nursing care, and imaging diagnostics-related direct medical costs in decreasing order of appearance (see ). In hospital oncology, the budget share of radiotherapy among patients with assigned radiation treatment protocols gained momentum from 34.2% (€426,108) in 2010 towards 49.7% (€535,438) in 2013. The period observed was unfortunately characterized by growth in overall oncological morbidity, increasing frequency of hospital admissions, and number of patients demanding treatment (see ). Due to higher unit utilization of medical services and work load, as well as imposed budget constraints by the national health insurance fund, median costs per patient were steadily falling from €1467 (radiotherapy €575) in 2010 to €1329 (radiotherapy €554) in 2013. Second ranked cost drivers were nursing care, falling from €311146 in 2010 to €257113 in 2013 and imaging diagnostics, which value fell from €223,022 (2010) to €201,760 (2013) (see ). It is essential to emphasize that these costs of high-tech visualizing examinations were heavily dominated by nuclear medicine tests. The proportion of nuclear diagnostics, mostly related to the search for metastasis in bones, lymph nodes, and liver, originating from primary malignancies in endocrine glands and elsewhere, was 88.8% in 2010 or €197,990 out of €223,022, while it was 94.1% or €189,805 out of €201,760 in 2013. The mdian value of nuclear tests per patient actually recorded an increase from €670 (95% CI = €787–€1021) in 2010 to €940 (95% CI = €945–€1085) in 2013. The most sudden drop in value-based turnover happened to pharmaceuticals, mostly due to the policy-maker’s decision to narrow reimbursement criteria of expensive anti-neoplastic agents such as monoclonal antibodies and protein kinase inhibitors (€212,976 (2010) to €49,501 (2013)) (see ). Hospital administration was partially successful in shortening exceptionally long hospital stays by almost 4 days, from 27.5 in 2010 to 23.8 in 2013. Mean brachytherapy costs per patient suffered from a short recession-induced decline in 2012, with evident recovery in 2013. Mean teleradiotherapy costs, although substantially lower, remained stable during the 4 year time span (see ). On average, median brachytherapy treatment per patient was 4-fold more expensive compared to the median teleradiotherapy-based protocol, €2202 vs €565 in 2010, and almost 6-fold more expensive in 2013 (€3008 vs €551). Annual growth of radiotherapy costs was €27.25 per patient, amounting to a total of €109,330 during the 4-year time span.
Figure 2. Four year trend on total direct medical costs of radiotherapy related oncological care.
Figure 3. Brachytherapy and teleradiotherapy comparison 2010–2013 (mean +/- 95% confidence intervals).
Table 2. Cost domains of radiation-treated patients suffering from various malignancies.
Discussion
Total costs of care as well as mean cost per patient were steadily decreasing due to imposed budget cuts by local authorities due to expanding public healthcare related debtCitation9. Paradox is that at the same time total budget share of radiotherapy increased for almost 15%, while its value-based turnover was raised substantially. These were difficult years for Eastern European healthcare systems severely constrained due to global recessionCitation10. Most of value gain in radiation oncology services should be attributed to budget cuts for pharmaceuticalsCitation11. Such cost savings were achieved by implementation of narrow reimbursement criteria for expensive anti-neoplastic agents and biologicalsCitation12. Two consecutive cost drivers, nursing care, and imaging diagnostics were rather predictable findings due to the demanding nature of illness and needs for frequent high-tech visual examinations. Although the latter was already documented by local evidenceCitation13, a large portion of these costs were actually attributable to nuclear medicine methodsCitation14. The relevance of this sophisticated branch of clinical medicine for hospital budget planning has already been processed in health economic literatureCitation15.
Cost containment strategies made without defining public health targets actually don’t make a lot of sense in the long runCitation16. General populations across Eastern Europe, including those among admitted European Union (EU) members, are still not systematically educated towards healthy lifestyles, preventing core risk factors for cancerCitation17. Many patients were denied access to preventive medical services and cancer screening tests due to economic crisis worsened budgetary constraintsCitation18. Some of them are being diagnosed with advanced stage, occasionally even metastatic diseaseCitation19. These facts coupled with insufficient national capacities for radiation treatment jointly contribute to slowly rising cancer mortality rates in Serbia, unlike the steady decrease in most of the EU’s high income membersCitation20.
Clinical peculiarities of radiotherapy among other modalities of cancer treatment are its acceptable adverse events coupled with long-term benefits in terms of improved life quality and survival rates. As this study reveals, the proportion of patients actually receiving radiotherapy in Serbia and most of South-Eastern Europe is approximately one fifth of all diagnosed with cancerCitation21. This is far beneath the desired targets, while in some countries with advanced radiation oncology over 50% of patients undergo irradiation-based protocolsCitation22. Serbia might be regarded representative of a broader Central & Eastern European region. These countries share common historical heritage in healthcare funding, management, and massive health system based on hospital rather than preventive and primary medical care. The growing burden of cancer and budget impact of novel technologies in oncology will pose a challenge to financial sustainability of many national health systems across the globeCitation23. So far, there are far less published estimates on cost-effectiveness of particular radiation oncology treatment methods in defined indication fields compared to medicinesCitation24–26. There is evidence that wise management and implementation of advanced software might help improve radiotherapy efficiency and decrease costsCitation27. Obtaining reliable and extensive local assessments on budget impact and costs of radiotherapy will be highly relevant for policy and planning in many world regions. We hope that our pioneering results will spark the debate on health economics of radiotherapy among Eastern European countries, as has already been the case with some western EU economiesCitation28.
Study limitations
This descriptive cost analysis relied on data from one of the four largest Oncology and radiotherapy treatment centers in Serbia. Societal perspective and longer time horizons are more common in economic evaluations of cancer care. Nevertheless, Payer’s perspective and 1-year time horizon were adopted due to financial and data access constraints. This single large university clinic was selected on grounds of being the first one in the country to establish electronic patient files in 2007. Central Serbia remains the only region of the country where reliable statistics on cancer morbidity and mortality, stratified across the ICD-10 landscape, is officially released in annual reports. Hospital databases in the University Clinic of Kragujevac are far more advanced compared to few similar range tertiary care facilities across the country. A multi-center study encompassing similar facilities throughout other Central and Eastern European countries would give much more reliable conclusions on short-term trends and budget impact of radiotherapy in the region. More advanced econometrics might have been deployed, but mostly conditional to better availability of clinical background data. Inclusion of data on survival and patient-centered life quality assessments would give substantial weight to future similar research projects. All of the aforementioned weaknesses of the current study request much stronger funding and access to classified patient registries. Based on current legislation on data privacy protection and numerous administrative obstacles, retrospective studies of cancer economics remain very scarce in Eastern Europe.
Conclusion
Access to radiation oncology services presents the core weakness of public cancer strategies in Serbia and most of Eastern Europe. Its budget impact is highly likely to grow further both in absolute and percentage terms of the overall size of the oncology market. Undergoing heavy investment into equipment will improve the outlook for regional patients but still far from satisfactory levels. Waiting times will get shorter, but delivery of radiotherapy will not be timely, except for prioritized exceptionally young patients or the ones with confirmed metastatic illness. Reversing the increasing cancer morbidity trend will demand long-term devotion by the authorities. Saving human lives in most productive ages would not only be ethical, but give an important boost to the national economy as well. Cost savings achieved by local governments in other therapeutic fields open room for allocation towards cancer prevention and early screening strategies.
Transparency
Declaration of funding
The Ministry of Education Science and Technological Development of the Republic of Serbia has funded this study through Grant OI 175014. Publication of results was not contingent to the Ministry’s censorship or approval.
Declaration of financial/other relationships
There are no financial relationships to be declared for any of the authors in relation to the study results.
Acknowledgments
There were no other contributors to this study except the ones by authors listed.
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