Value in Cancer Care Renato G Martins Stephen H. Petersdorf Endowed Chair in Cancer Care Medical Director Thoracic/Head and Neck Medical Oncology Professor University of Washington

How Do We Choose Health Care?

Case A friend of the family develops a cough which does not get better and after 2 weeks he goes to see his primary care physician A chest x-ray is performed

Case He is placed on antibiotics and symptoms improve but his PCP asks him to come back to document that the chest x-ray returned to normal

Case He is placed on antibiotics and symptoms improve but his PCP asks him to come back to document that the chest x-ray returned to normal A CT scan is performed

Case He is placed on antibiotics and symptoms improve but his PCP asks him to come back to document that the chest x-ray returned to normal A CT scan is performed A CT guided biopsy shows adenocarcinoma of the lung

If he asked you how he should decide where to be treated you would suggest: Ask the PCP and follow his recommendation You heard on the radio that a hospital in town has a lung cancer center and he should go there You have a cousin who had surgery for lung cancer at hospital X and he really liked it You have a friend who is a diabetes doctor and you will ask him for the best place

Perhaps good parking should be a factor?  The first important question is: Does it matter? Are outcomes so similar that one can get therapy anywhere? Perhaps good parking should be a factor? 

Surgery by Whom? 44% p<0.0001 36% Figure 1. Survival of Medicare Beneficiaries 65 Years of Age or Older Who Received a Diagnosis of Stage I, II, or IIIA Non-Small-Cell Lung Cancer between 1985 and 1996 and Underwent Resection for Lung Cancer, According to the Volume of Such Procedures Performed Annually at the Hospitals Where the Patients Were Treated. Procedure volume was determined on the basis of data from the 1997 Nationwide Inpatient Sample. A total of 2118 patients were included in the analysis. Bach P et al. N Engl J Med 2001;345:181-188

Is the care itself very similar?

Hutchinson Institute for Cancer Outcomes Research (HICOR): WA State Data

Hutchinson Institute for Cancer Outcomes Research (HICOR): WA State Data

Temel JS, Greer JA, Muzikansky A. et al. N Engl J Med;363:733-42. Early Palliative Care Aggressive care( chemotherapy last 14 days before death; no hospice care; admission to hospice 3 days or less before death): 54% in the standard of care arm and 33% in the early palliative care arm Temel JS, Greer JA, Muzikansky A. et al. N Engl J Med;363:733-42.

Regional Average: 22.8%

Seattle Cancer Care Alliance: Office of Quality, Safety and Value END OF LIFE CARE METRICS Month Chemo in last 14 days of life ER Visits in the last 30 days of life ICU Deaths   Yes # of Deaths % of Yes Sep-14 4 47 8.5% 7 14.9% 2 4.3% Aug-14 3 6.4% 13 27.7% Jul-14 6 80 7.5% 17 21.3% 11 13.8% Jun-14 67 9.0% 20 29.9% 10.4% May-14 5 76 6.6% 12 15.8% Apr-14 65 6.2% 14 21.5% 4.6% Mar-14 68 4.4% 15 22.1% 5.9% Feb-14 73 9.6% 20.5% 4.1% Jan-14 82 6.1% 18.3% Dec-13 8 9.8% Nov-13 70 10.0% 24.3% 8.6% Oct-13 5.3% 18 23.7% Sep-13 78 7.7% 17.9% 5.1% Aug-13 24.7% 8.2% Jul-13 88 4.5% 9 10.2% 79 1072 7.4% 219 20.4% 81 7.6% Breakdown of occurrence by measure. Again, we have this for each disease group, but caution against reviewing monthly percentages at that level as the n’s are extremely low.

What information do we need to choose the right place?

Is the Ferrari 458 a better value? Is the performance 9 times better? Is the interior 9 times more comfortable? Is it 9 times safer? 9 times more reliable?

Value in Health Care Value in Health Care: Health Outcome/dollar of cost expended “Mandatory measurement and reporting of results is perhaps the single most important step in reforming the health care system.” Results: Those that matter to patients and are based on specific medical conditions Redefining Health Care. Michael E. Porter and Elizabeth O. Teisberg . Harvard Business Review Press 2006

International Consortium for Health Outcomes Measurement (ICHOM) “ICHOM’s mission is to unlock the potential of value-based health care by defining global Standard Sets of outcome measures that really matter to patients” Defining Health Outcomes Bring together patients who received treatment for the condition and leading physicians from across the globe

International Consortium for Health Outcomes Measurement (ICHOM): Lung Cancer

ICHOM: Lung Cancer (cont)

Cancer Cost: NIH Projections in 2011 Expected to reach $158 billion dollars in 2020, an increase of 27% over 2010 2010: breast cancer ($16.5 billion); colorectal Cancer ($14 billion); lymphoma ( $ 12 billion); lung cancer ($12 billion); prostate cancer ($12 billion) http://www.cancer.gov/newscenter/newsfromnci/2011/CostCancer2020

Cost of Care Can Vary Substantially!

Value equation: Cost (HICOR data)

2-29-2012 4-29-2015

August 2015: Completed the 150 mile fundraiser bike ride for the FHCRC

Back to your friend…. Just imagine if he knew: For lung cancer surgery, hospital X has an in-hospital mortality of 2% while in hospital Y this number is 4% The 5 year survival of patients operated for lung cancer is 55% in hospital X and 51% in hospital Y Thirty days after lung cancer surgery, 90% of patients are free of pain medication while in hospital Y this number is 80% The median cost of lung cancer surgery (and post-op care) in hospital X is $38,000 while in hospital Y it is $41,000

Conclusions The Health Care “Market” is very imperfect Consumers do not have access to the information to make an informed decision This is changing and that is VERY good news to patients

Thank you! rgmart@uw.edu