Policy, Guidelines, and Disparities Peter B. Bach, MD, MAPP Memorial Sloan-Kettering Cancer Center [email protected].

Policy, Guidelines, and Disparities

Peter B. Bach, MD, MAPPMemorial Sloan-Kettering Cancer Center

[email protected]

Overview

• The goal of practice guidelines is to:– Improve the quality of care?– Manage care?– Save money?– Monitor the quality of care?– Reduce disparities?– Give academics (with weird skills) something to

do?

Improve care quality

• Underlying assumption: care is sub-standard• Practice guidelines used broadly would raise

average level• Have to assume that deviations from

guidelines net harmful– As opposed to important personalization

• Clinical decision support can have a guidelines background

Clinical decision support

Manage care (oncology example)

• Pathways tell doctors which treatments to use in common conditions

• Mostly payer contracts linked to pathways ask for 80% adherence

Save money through competition

Save money: Guidelines for Metastatic Non-Small Cell Lung Cancer

NCCN(2009)

ACCP(2007)

CCO(2009)

Alberta(2009)

Australian(2004)

NICE(2009)

Pemetrexed/Cisplatin X X X X - X

Gemcitabine/Cisplatin X X X X X X

Docetaxel/Cisplatin X X X X X X

Irinotecan/Cisplatin X X X X X -

Vinorelbine/Cisplatin X X X X X X

Etoposide/Cisplatin X X X X X -

Vinblastine/Cisplatin X X X X X -

Paclitaxel/Cisplatin X X X X X X

Metastatic Non-Small Cell Lung CancerName Total

Chemotherapy Drug Cost

Monthly Chemotherapy Drug Cost

Total Cost (12 Weeks)

Monthly Cost

Pemetrexed/Cisplatin1-4,6 $16,913.37 $6,105.91 $19,594.13 $7,073.69

Gemcitabine/Cisplatin1-6 $9,745.83 $3,518.35 $13,303.24 $4,802.61

Docetaxel/Cisplatin1-6 $8,916.64 $3,219.00 $11,647.20 $4,204.77

Irinotecan/Cisplatin1-5 $934.60 $337.40 $7,984.63 $2,882.54

Vinorelbine/Cisplatin1-6 $519.45 $187.53 $4,929.03 $1,779.43

Etoposide/Cisplatin1-5 $217.06 $78.36 $4,453.86 $1,607.89

Vinblastine/Cisplatin1-5 $183.97 $66.41 $3,741.38 $1,350.68

Paclitaxel/Cisplatin1-6 $518.45 $187.17 $3,578.70 $1,291.95

1 National Comprehensive Cancer Center (NCCN), 2 American College of Chest Physicians, 3 Cancer Care Ontario (CCO), 4 Alberta Health Services, 5 Australian National Health and Medical Research Council, 6 National Institute for Health and Clinical Excellence (NICE)

Using episode payment

Pemetrexed/Carboplatin (1-

4,6)

Gemcitabine/Carboplatin (1-

6)

Docetaxel/Carboplatin

(1-6)

Irinotecan/Carboplatin (1-

5)

Vinorelbine/Carboplatin (1-

6)

Etoposide/Carboplatin

(1-5)

Vinblastine/Carboplatin (1-

5)

Paclitaxel/Carboplatin

(1-6)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Administration Fees and Supportive Care Costs Chemotherapy Cost

Cost

per

Mon

th o

f Tre

atm

ent

Potential Profit for Physician

Potential Loss for Physician

Metastatic Hormone Refractory Prostate Cancer

Drug (does not include support or adminstration) Monthly Cost

Sipuleucel-T (Provenge) $ 37,668

Docetaxel (Generic) $ 772

Flutamide (Generic) $ 237

Bicalutamide (Casodex) $ 552

Bicalutamide (Generic) $ 43

Nilutamide (Nilandron) $ 749

Antiandrogen withdrawal $ -

Ketoconazole $ 201

Arbiraterone acetate (Zytiga) $ 5,778

Steroids negligible

Diethylstilbestrol (or other estrogen) negligible

Anti-

Andr

ogen

s

Monitor the quality of care

Reduce disparities

Give academics work

Org. Type of Statement

NLST Like Subjects?

Others? Basis

ACCP/ASCO/ATS

Evidence based guideline

Suggest it be offered No

Systematic review, meta-analysis, grading of evidence

ACS Interim guidance

May be considered No Interim guidance

pending full review

ALA Guidance Recommended No Not specified (selective literature)

NCCN Consensus guidelines Recommended

Yes, for some individuals based on risk

Not specified (selective literature)

IASLC StatementConsidered appropriate to discuss with physician

No Not specified

AATS Clinical guidelines Recommended

Yes, for some individuals based on risk

Not specified (selective literature)

Summary of Published Guidelines on LDCT Screening for Lung Cancer

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm280536.htm

Then there’s the dissemination challenge

NLST National

Number screened 26000 8000000

Number of deaths prevented 87 26769

Number of years 6 6Number lung cancer deaths avoided/year 14 4388

Laurie Fenton AmbrosePresident and CEO

Lung Cancer Alliance

Straight Extrapolation from the NLST

80,000 avoided deaths/yr

Two Views of the Population Benefit

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Dissemination Challenge

Thank you