VALUE-BASED HEALTHCARE STRATEGIES for better prostate … · 2017-03-20 · VALUE-BASED HEALTHCARE STRATEGIES for better prostate cancer outcomes Frank Sullivan MB MRCPI FFRRSCI Adjunct

VALUE-BASED HEALTHCARE STRATEGIES

for better prostate cancer outcomes

Frank Sullivan MB MRCPI FFRRSCI

Adjunct Professor in Medicine

Director, Prostate Cancer Institute, NUIG

IMSTA Annual Conference

22ND MARCH 2017

Are these the new buzzwords in Irish healthcare?

• “Patient centred care” and “personalized medicine”

• “Money follows the patient” and “Value-based Healthcare” • How do we measure value?

• On what basis should the money “follow the patient”?

• Quality: Not everything you can count…counts!

• Value for money in Health in Ireland? • Are ‘Pharma and Med Tech’ the only sectors really being assessed?

2

• How do doctors judge the value? (of E.G. surgery vs radiation)

• Regulators: what care do we permit/promote?

• HIQA

• Funders: What to reimburse?

• Government or Insurer

• NCPE/NICE

• Preferred providers

• Patients: What treatment to choose?

• Which hospital?

• Which doctor?

“Value is in the eye of the beholder”

3

• Current approaches to healthcare “quality” or what passes for quality

• Importance/tyranny of the “PROM”

• Can measuring a PROM really make patients or healthcare better? • From PROMS to QALY’s

• Costs? Bring on the Health Economists! • From Uncle Sam to Bismarck to Beveridge

• “Research is not just for academics” • Importance to the Observational Study in determining Value

• Back to the future!

A snapshot of this talk?

Prostate Cancer in Ireland

• Usually curable, early detection

• Incidence 3000 Irish men/per year

• Costs Eu45.6M (2010; Burns et al)

• Many options for men (early stage) • Active surveillance

• Surgery (open, lap, robotic)

• Radiation (EBRT, SRS, brachytherapy)

• Cyro, HIFU, PDT

5

0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8

WexfordKilkenny

MonaghanWaterfordTipperary

ClareLongford

MeathLimerick

LouthDublin

DonegalCavan

KildareKerry

CarlowWestmeath

WicklowOffalyMayoCork

LaoisRoscommon

SligoLeitrimGalway

observed/expected

The Burden of Healthcare Costs Associated with Prostate Cancer in Ireland 2010 (R. Burns et al, submitted 2016) 45.6M





• Research is not just for academics • Importance to the Observational Study

• Back to the future


So what are we measuring globally to show quality…and increase value in our health system? We are a long way from measuring the right stuff….

8

Out of 674 clinical measures endorsed by NQF, only 208 classified as outcomes

466

0

100

200

300

400

500

600

700

No. of measures

NQF outcome measures

208

Non-outcome measures NQF measures

674

Note: Only measures endorsed by NQF included in this analysis Source: National Quality Forum

Of those 208, only 124 are outcomes that matter to patients

84

0

20

40

60

80

100

120

140

160

180

200

220

Non-outcome measures (e.g., HbA1c, lipid levels)

Real outcome measures (mortality)

38

Real outcome measures (non-mortality)

86

NQF outcome measures

208

No. of measures

124 true outcome measures

(60%)

Note: Only measures endorsed by NQF included in this analysis Source: National Quality Forum

What are the NCCP measuring as quality?

11

How do doctors and researchers value prostate treatments?

3/20/2017 13

Outcomes are the powerful lever to unlock a value-based healthcare system

Value = Cost of delivering those outcomes

Patient health outcomes achieved

Improve outcomes

Starting point is to focus on

improving health results that

matter most for a patient's

condition

Reduce overall costs

Better quality of care is often less

expensive over the long-term

Increase value

Better quality care at

equal or lower cost leads to

higher value

in the system

15

Outcomes also…eye of the beholder

• Value = Outcomes/Costs

• Outcomes What outcomes are needed?

• Health States CBA, CEA, CUA?

• Utility Experienced vs decision?

• How do we measure Utility as a public good or state of health? • Can we put a value on health?

The Localized Prostate Cancer Working Group exists of physicians,

patients and registry leaders from across the world

Sweden Anna Bill-Axelson | Uppsala University Hospital; National Prostate Cancer Register (NPCR) of Sweden United Kingdom Adam Glaser | Leeds Teaching Hospitals NHS Trust James Catto | Academic Urology Unit and Academic Unit of Molecular Oncology, CR-UK/YCR Sheffield Cancer Research Centre

Ireland Frank Sullivan | Galway University Hospital; Prostate Cancer Institute at NUI Galway John Fitzpatrick | Irish Cancer Society Israel Jabob Ramon | Sheba Medical Center Italy Alberto Briganti | Vita-Salute San Raffaele University Hospital Netherlands Chris Bangma | Erasmus Medical Center

United States Steven Jay Frank | MD Anderson Cancer Center David Swanson | MD Anderson Cancer Center Andrew Vickers | Memorial Sloan-Kettering Cancer Center Adam Kibel | Dana-Farber Cancer Institute; Brigham and Women's Hospital Anthony D’Amico | Dana-Farber Cancer Institute; Brigham and Women's Hospital

Australia Kim Moretti | South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC); The Queen Elizabeth Hospital Mark Frydenberg | Prostate Cancer Registry of Victoria; Monash University Ian Roos* | Melbourne Graduate School of Education, University of Melbourne; Cancer Voices Victoria

Germany Hartwig Huland & Markus Graefen | Martini-Klinik at University Medical Center Hamburg-Eppendorf Michael Froehner | University Hospital Carl Gustav Carus, Technical University of Dresden Günter Feick* | Bundesverband Prostatakrebs Selbsthilfe (BPS); Europa UOMO Thomas Wiegel | University Hospital Ulm

Neil Martin | Dana-Farber Cancer Institute; Brigham and Women's Hospital Michael Blute | Massachusetts General Hospital Howard Sandler | Cedars-Sinai Medical Center Ronald Chen | University of North Carolina Lineberger Comprehensive Cancer Center Daniel Hamstra | University of Michigan Health System Ashutosh Tewari | Icahn School of Medicine at Mount Sinai Hospital *Patient representative

Galway prostate brachytherapy outcomes study (2006-2020)

• Retrospective cohort study for outcomes [n=1350] 2006-2016

• Prospective cohort study for value [n=300] 2016-2020

• Goals:

• Better patient decision tools

• Better information for policy makers

Galway prostate suite of outcomes for “value” 5 domains

1. Risk stratification (who are you treating?)

2. Disease metrics (alive, dead, relapsed)

3. Chance of harm provider measured

4. Patient reported outcomes (PROM’s)

5. Costs

19 Defining a Standard Set of Patient-centered Outcomes for Men with Localized Prostate Cancer; Martin,…Sullivan et al. in Eur Urol, 2015;67:460-7.

Galway Brachytherapy: Survival and Relapse rates

Patient Characteristics Category Number Percentage

Recurrence Event No 476 95.6%

Yes 22 4.4%

Survival Alive 497 99%

Death from PrCa 2 0.4%

Death other cause 3 0.6%

0.00

0.25

0.50

0.75

1.00

Ove

rall

Sur

viva

l

0 1 2 3 4 5

Years Since Brachytherapy

Overall Patient Survival

0.00

0.25

0.50

0.75

1.00

Rec

urra

nce

Free

Sur

viva

l

0 1 2 3 4 5

Year Since Brachytherapy

Recurrence Free Survival

20

Galway Brachytherapy: disease free survival curve by D’Amico Risk Categorisation








Literature Review

Relieved

Unrelieved

Dead

Has health related outcome measures moved past this simple three point

model ?

EPIC CP Questionnaire

EPIC-CP Questionnaire

Sensitive to treatment related Quality of Life changes over time

Split into five domains: • UIS: Urinary Incontinence Symptom Score

(out of 12) • UIOS: Urinary Irritation/Obstruction

Symptom Score (out of 12) • BS: Bowel Symptom Score (out of 12) • SS: Sexual Symptom Score (out of 12) • VHS: Vitality/Hormonal Symptom Score (out

of 12)




• Bring on the Health Economists! • From Uncle Sam to Bismarck to Beveridge




Galway PCI Brachytherapy: n= 473 patients EPIC-CP domain scores at baseline and all follow up

Quality of Life and Satisfaction with outcome among Prostate Cancer

Patients (Sanda; NEJM, 2008)

Figure 1. Changes in Quality of Life after

Primary Treatment for Prostate Cancer.

The graphs show unadjusted changes in

mean quality-of-life scores over time for

each domain, stratified according to

study group. Scores on the Expanded

Prostate Cancer Index Composite

domains range from 0 to 100, with

higher values representing a more

favourable health-related quality of life.

(Sanda et al. NEJM, 2008)

27

September 14, 2016, at NEJM.org.

What is a QALY and how does it help?

Cost

effectiveness

It’s all about the QALY

Utility

For PROMS to yield QALY’s in Prostate Cancer • Value must be disease/condition specific (Porter et al)

• PROM’s are disease/domain specific • Urinary • Bowel • Sexual • General

• QALY for CUA/CEA must be generalizable

• Must involve utility measurement

• Measured with different instruments (e.g. EQ5D5L)

• Do we need a link from EQ5D5L to prostate cancer?

• PORPUS?

Dolan, Kahneman. Economic Journal, 118 (January) 215-234

Linking utility to PROM








What about the “costs” part of the value?

• Health Economic Approaches

• Welfarist and extra-welfarist frameworks • Cost benefit • Cost effectiveness • HTA’s • ? Market Value “willingness to pay” • Cost of illness studies • Top down/bottom up • Top slicing public or health insurance data • Time driven/activity based costing

The Burden of Healthcare Costs Associated with Prostate Cancer in Ireland 2010 (R. Burns et al, submitted 2016) 45.6M

GUH: Radiation beam vs. Brachytherapy Seeds

Activity Activity Qty

Total cost Unit cost Per

Patient

New Patient Visit 5 763

153

Volume Study 3 568

114

Rad Information 5 358

72

CT Simulation (2 activities bundled)

9 +8 2,135

427

Contouring 7 1,106

221

U/S IGRT Preparation (3 activities bundled)

6 +6+5 1405

281

IMRT Planning (8 activities bundled) 5 (x 8) 6,972

1,395

RT Peer Review 5 702

140

External Beam Treatment 185 20,163

4,033

OTV (Nursing) 44 2,720

543

Follow-up Visit 12 1,204

241

Phone Consult 2 32

6

Grand Total 342 38,136 7,627

Activity Activity

Quantity Total cost

Unit cost Per Patient

New Patient Visit: 1 5 763 153

Volume Study 6 1,135 227

Brachy Planning Seed 4 219 44

Pre Assess Clinic 5 240 48

Permanent Implant Pr 5 19,114 3,823

OTV (Nursing) 1 60 12

CT Simulation 5 616 123

Dosimetry Approval 3 397 79

CT Scan Post Procedure 5 1,250 250

Follow-up Visit 14 1,405 281

Phone Consult 3 48 10

Grand Total 56 25,245 5,049

Activity Activity Qty Total cost Unit cost Per

Patient

The cost truth and healthcare?

• Somewhere in the middle

• Not purely “top down”

• Not purely “activity based”

• Effectiveness must be factored in

• CEA/CUA/CBA • Uncle Sam/Porter/Beveridge/Bismarck

• However we do it, we must find a way to factor costs into everyone’s equation!

• Not just IMSTA





• Research is not just for academics • Importance to the Observational Study in Value



Galway prostate brachytherapy outcomes study (2006-2020)

• Retrospective cohort study for outcomes [n=1350] 2006-2016

• Prospective cohort study for value [n=300] 2016-2020

• Goals:

• Better patient decision tools

• Better information for policy makers

Prostate Cancer Galway ‘BT- Value’ Project:

• Disease/condition focus (early state prostate cancer) • Treatment focus (brachytherapy)

• PROM combined with toxicities (AE) = Global Health Status

• Delta is the change in PROM/QALY with time

• Probability from side effect data (AE)

• Utility from discrete choice experiments (DCE and PORPUS)

• Costs from activity based costs but phase specific

• CUA = Costs/QALY = Value!






• Back to the future!


Communicating Value in Health Care Using Radar Charts: A Case Study of Prostate Cancer Nikhil G. Thaker, MD, Tariq N. Ali, MD, MBA, Michael E. Porter, PhD, MBA, Thomas W. Feeley, MD, Robert S. Kaplan, PhD,

and Steven J. Frank, MD. Volume 12 / Issue 9 / September 2016

Can we use this to help patients?

Need for more effective tools

Copyright © 2016 by American Society of Clinical Oncology Volume 12 / Issue 9 / September 2016 n jop.ascopubs.org

The future of Value in Healthcare: Policy Makers

• We now have the methodology to measure value across the different treatments for localized prostate cancer • Cost/QALY comparison (surgery, radiation, brachy)

• Akin to a HTA for the NCPE!

• Transparency in outcomes and value for regulators, patients and payers • Altered payment structure: payment for quality

• Staggered payments, bundled payments

• Changes in health delivery structures: integrated provider units

The future of Value in Healthcare: Patient decision tools

• Complex decision (E.G. surgery, radiation, brachytherapy)

• Multiple attributes • Chance of cure the same • Chances of serious harm with all, but quite rare • QOL • Costs?

Behavioral economics • Importance of utility • Discrete choice experiments (ongoing)

• Patients can find out a lot about the correct treatment for them:

• Doctor/nurse consultation

• Personal research

• Online research

• Other: media etc

• But how can the patient find the best doctor/healthcare facility for them?

• Why can’t you google the best

doctor for prostate cancer?

• Lack of transparency

• Asymmetric market

• Non market ‘good’

Summary

• CUA costs per QALY can be derived from a value (outcomes) approach

• Must be disease (condition) focussed

• If expanded across all treatment options, then cost effectiveness judgements possible/desirable

• Transparency for payers and patients

• Competition possible

• Value based healthcare to improve quality and lower global costs

Acknowledgements and Thanks!

Prostate Cancer Healthcare Value Team:

• Radiation Oncology Teams (GUH, GC) • Rachel Lee (Axis Consulting)

• Brenda Dooley (Axis Consulting)

• Ruth Corcoran

• Davood Roshansangachin

• Brendan Kennelly

• Paddy Gillespie • Ciaran O’Neill

• Eamonn O’Shea

• Diarmuid O’Donovan

• Martin O’Donnell

VALUE-BASED HEALTHCARE STRATEGIES for better prostate … · 2017-03-20 · VALUE-BASED HEALTHCARE STRATEGIES for better prostate cancer outcomes Frank Sullivan MB MRCPI FFRRSCI Adjunct

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