1. 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

2. How Do We Choose Health Care?

3. 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

5. 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

7. 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

9. 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

10. 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

11. 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? 

12. 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:

13. Is the care itself very similar?

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

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

16. 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:

17. Regional Average: 22.8%

18. 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.

19. What information do we need to choose the right place?

21. 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?

24. 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

25. 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

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

27. ICHOM: Lung Cancer (cont)

28. 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)

29. Cost of Care Can Vary Substantially!

30. Value equation: Cost (HICOR data)

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

33. 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

34. 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

35. Thank you!