Patterns of treatment and costs of intermediate and advanced hepatocellular carcinoma management in four Italian centers

Figures & data

Figure 1 Updated staging system and treatment strategy.

Notes: Reprinted from the Journal of Hepatology, Volume 56, European Association for the Study of the Liver; European Organisation for Research and Treatment of Cancer, EASL–EORTC clinical practice guidelines: management of hepatocellular carcinoma. Pages 908–943. Copyright 2012, with permission from Elsevier.¹⁵
Abbreviations: HCC, hepatocellular carcinoma; PST, performance status test; CLT, cadaveric liver transplantation; LDLT, liver donor liver transplantation; RF, radio frequency ablation; PEI, percutaneous ethanol injection; TACE, transarterial chemoembolization; OS, overall survival.

Table 1 Resources consumption and costs

Item	Description	Unit cost (€)	References
Professional resources	Interventional radiologist	74.20/h	Conferenza Stato-Regioni 21/11/2014 – Rapporto STEM^Citation40
	Hepatologist	74.20/h
	Anesthetist	74.20/h
	Nuclear medicine physician	74.20/h
	Nurse	34.03/h
	Radiology technician	34.03/h
	Hospital pharmacist	61.42/h
Drugs	Doxorubicin	0.83/mg	Italian Medicines Agency^Citation41
	Farmorubicin	1.39/mg
	Ethiodized oil	2.40/vial
	Sorafenib	28.70/tablet
Consumables	Angiographic sterile field	39.96	Selection of public tenders data in 23 relevant Italian hospitals; prices include VAT
	Angiographic introducer	161.33
	Catheter	87.22
	Microcatheter	764.25
	Guide	80.55
	Microguide	439.06
	DC Beads^®	822.60
	Hemostasis system	17.78
	Spiral	592.90
	Technetium	1,245.95
	SIR-Spheres microspheres	11,000.00
Overheads	Gastroenterology admission	522.17/day	Setacci et al^Citation42
	Nuclear medicine admission	600.50/day
	Angiographic room	7.50/min

Figure 2 Distribution of total patients treated.

Figure 3 First-line treatments of patients with intermediate and advanced HCC.

Abbreviations: TACE, transarterial chemoembolization; TAE, transarterial embolization; TARE, transarterial radioembolization; HCC, hepatocellular carcinoma.

Figure 4 Second-line and subsequent treatments for patients with intermediate and advanced HCC.

Abbreviations: TACE, transarterial chemoembolization; TAE, transarterial embolization; TARE, transarterial radioembolization; HCC, hepatocellular carcinoma.

Table 2 Resources according to type of treatment

Resource/treatment	Sorafenib	TACE	TARE
Specialist visit (hepatologist)	× (outpatients)	× (outpatients)	× (inpatients)
Diagnostic procedures	× (outpatients)	× (outpatients)	× (inpatients)
Prehospitalization workup
Hepatic scintigraphy			× (inpatients)
Radiopharmaceutical evaluation			× (inpatients)
Drug distribution	× (outpatients)
Patient preparation		× (inpatients)	× (inpatients)
Complete angiography		× (inpatients)	× (inpatients)
Medical device (ie, DC Beads^®) or contrast medium (ethiodized oil) injection		× (inpatients)	× (inpatients)
Chemotherapy drug injection		× (outpatients)

Notes: ×, all resource used for each specific treatment.

Abbreviations: TACE, transarterial chemoembolization; TARE, transarterial radioembolization.

Table 3 Per-patient resource consumption and costs of consumables by procedure

Consumablesa	Unitary costs (€)	TACE		TARE
		Average number/patient	Cost/patient/procedure (€)	Average number/patient	Cost/patient/procedure (€)
Angiographic sterile field	39.96	1.00	39.96	1.00	39.96
Angiographic introducer	161.33	1.00	161.33	1.10	177.47
Catheter	87.22	1.15	100.31	1.10	95.95
Microcatheter	764.25	1.05	802.46	1.10	840.68
Guide wire	80.55	0.74	59.61	1.10	88.61
Microguide wire	439.06	0.57	250.27	–	–
DC Beads^®	822.60	1.06	871.96	–	–
Hemostasis system	17.78	0.56	9.96	1.00	17.78
Metal spiral	592.90	–	–	10.00	5,929.00
Technetium	1,245.95	–	–	0.03	41.54
SIR-Spheres microspheres	11,000.00	–	–	0.50	5,500.00
Total consumables		–	2,295.86	–	12,730.99

Note:

a Sorafenib is not included in this table because, as it is an oral treatment, no consumables are necessary to deliver the treatment.

Abbreviations: TACE, transarterial chemoembolization; TARE, transarterial radioembolization.

Table 4 Per-patient resource consumption and costs of professional resources by treatment

Professional resources	Hourly costs (€)	Sorafenib		TACE		TARE
		Hours/patient/prescription (mean)	Cost/procedure/patient (€)	Hours/patient/prescription (mean)	Cost/procedure/patient (€)	Hours/patient/prescription (mean)	Cost/procedure/patient (€)
Interventional radiologist	74.20	–	–	1.90	141.11	2.83	210.25
Hepatologist	74.20	0.17	12.37	–	–	–	–
Anaesthetist	74.20	–	–	0.49	36.15	–	–
Nuclear medicine physician	74.20	–	–	–	–	0.33	24.74
Nurse	34.03	–	–	1.71	58.34	2.50	85.09
Radiology technician	34.03	–	–	0.85	28.96	–	–
Hospital pharmacist	61.42	0.17	10.24	–	–	–	–
Total professional resources		0.34	22.61	4.95	264.56	5.66	320.08

Abbreviations: TACE, transarterial chemoembolization; TARE, transarterial radioembolization.

Table 5 Overall cost per patient by type of treatment

Costs (€)	Sorafenib	TACE	TARE
Total consumables/procedure/patient		2,295.86	12,730.99
Angiographic sterile field	–	39.96	39.96
Angiographic introducer	–	161.33	177.47
Catheter	–	100.31	95.95
Microcatheter	–	802.46	840.68
Guide wire	–	59.61	88.61
Microguide wire	–	250.27	–
DC Beads^®	–	871.96	–
Hemostasis system	–	9.96	17.78
Metal spiral	–		5,929.00
Technetium	–		41.54
SIR-Spheres microspheres	–		5,500.00
Total drugs/procedure month/patient	1,986.36	68.26	–
Ethiodized oil (per procedure)	–	1.44	–
Doxorubicin (per procedure)	–	42.01	–
Farmorubicin (per procedure)	–	24.81	–
Sorafenib (month of therapy)	1,986.36	–	–
Total professional resources/procedure month/patient	22.61	264.56	320.08
Interventional radiologist	–	141.11	210.25
Hepatologist	12.37	–	–
Anesthetist	–	36.45	–
Nuclear medicine physician	–	–	24.74
Radiology technician	–	28.96	–
Nuclear medicine technician	–	–	–
Nurse	–	58.34	85.09
Hospital pharmacist	10.24	–	–
Overheads/procedure/patient	–	2,675.07	4,352.98
Occupation of angiographic rooma	–	604.19	750.00
Gastroenterology ward admissionb	–	2,070.88	–
Nuclear medicine admissionb		–	3,602.98
Total cost per procedure-month of treatment/patient	2,008.97	5,303.75	17,404.05
Average number of treatments	6.08	2.53	1.50
Average total cost of treatment/patient	12,214.54	13,418.49	26,106.08

Notes:

a Average occupation of angiographic room per procedure was 80.6 minutes for TACE and 100 minutes for TARE.

b The average length of stay in the gastroenterology ward was 4 days for TACE, and the average length of stay in the nuclear medicine ward was 6 days for TARE.

Abbreviations: TACE, transarterial chemoembolization; TARE, transarterial radioembolization.

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