A cost minimization exercise. Dr. Judith Aaron*, Dr. Balurishna S, Dr. SunithaSusan Varghese, Dr. Jasmine P, Dr. Selvamani B

 Brachytherapy is an essential component of cancer cervix treatment.  It contributes significantly to the cost of cancer cervix treatment

 Our institution has the practice of executing the procedure as inpatient.  Placement of applicator under spinal anaethesia in theatre  Simulation  Treatment  This procedure is repeated for each fraction

 Advantages:  Patient co-operation – painless  Adequate vaginal packing can be done

 Drawbacks :  Cost of treatment  Spinal anaethesia – every fraction  The number of fractions of HDR brachytherapy limited At our institution a dose of Gy is prescribed X 3 fractions

 To minimise the cost of cancer cevix treatment (Brachytherapy component) without compromising on the tumour dose or dose to critical organs at risk.

 Assess the feasibility of outpatient brachytherapy To fix a cervical sleeve to the os at first fraction under anaesthesia and then execute the placement of applicators as outpatient for the second and third fractions of brachytherapy.  To carry out a cost effectiveness analysis of the treatment done as inpatient versus outpatient.

4 patients- due for HDR brachytherapy Study patient- 1Control patients -3

STUDY PATIENT  First fraction:  Under anaesthesia in theatre  Cervical sleeve sutured to the os  Applicator placed insitu  Simulation  Planning  Treatment  Second and third fractions  Under sedation in brachytherapy suite  Applicator placed insitu  Simulation  Planning  Treatment

CERVICAL SLEEVE  Cervical sleeve:  Advantage:  Eliminates multiple dilatations of cervix  Faster and less traumatic insertions  Reduced chance of uterine perforation  Disadvantages  It may get dislodged  Patient dicomfort during the duration of brachytherapy  Not possible for advanced cases

CONTROL PATIENTS  All three applications of HDR brachytherapy as inpatient  Under anaesthesia in theatre  Applicator placed insitu  Simulation  Planning  Treatment

 Cost computation:  Patient  Medical and Nonmedical cost  Hospital  Societal  Cost comparison: Study patient versus Control patients

 Comparison of  Dose to point A  Rectal dose  Bladder dose Study versus control patients

 Also looked at the  Issues related to outpatient procedure  Feasibility of continuing the practice

 Total cost: Rs /-

 Per patient cost total cost- Rs /-

STUDY PATIENTCONTROL PATIENT Admission/Bed/ Nursing and Professional charges

Theatre and Anaesthesia

STUDY PATIENTCONTROL PATIENT Premedication

Procedure/ Planning and Treatment  No change in cost

 Expenses for the patient  Travel charges  Cost of food  Expenses for attendants  Travel  Food  Stay

 Reduced by almost half  Expenditure on food and stay were considerably less Non medical cost incurred by Study patient- Rs. 1200/- Non medical cost incurred by a Control patient- Rs – 2400/-

By making it an outpatient procedure:  Duration the patient is separated from family reduced  Loss of wage and cost of food for relative who accompanies the patient is lowered LOSS OF WAGE COST OF FOOD

 The following facilities can be used for another patient:  Bed  Nursing care  Theatre  Anaesthetist’s time

 Difference of Rs /-

 Thus from these slides it is quite clear that the cost of treatment as outpatient is significantly less.  The actual cost is reduced by almost half at second and third fractions.  The indirect savings in terms of hospital resources and personnel time will be more.

 To assess the effectiveness of the procedure done as outpatient  Is it as effective as the inpatient procedure with spinal anaesthesia ?

STUDY PATIENT

CONTROL PATIENTS

 It is feasible to execute HDR intravaginal intrauterine brachytherapy as outpatient for select patients.  Outpatient application of HDR brachytherapy does not adversely affect the tumour, bladder or rectal dose.  As we reduce cost and utilization of resources more number of fractions per patient can be introduced which is now improbable due to logistics.  This would in-turn reduce late reactions.

 Pain was not adequately controlled- Thus vaginal packing was difficult The following drugs were used for pain management: Voveran patch- applied a day prior to procedure Premedication- Fortwin and Phenergan Post procedure- Tramadol boluses till the end of treatment Combiflam thrice daily for 3 days  Intangible costs such as pain and patient comfort were not measured

 We have attempted to change practice in our institution  A cost minimisation exercise helps make administrative decisions  Indirect benefit by making more number of fractions practical hence reducing Late reactions