1. Policy, Guidelines, and Disparities Peter B. Bach, MD, MAPP Memorial Sloan-Kettering Cancer Center bachp@mskcc.org

2. 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?

3. 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

4. Clinical decision support

5. Manage care (oncology example) Pathways tell doctors which treatments to use in common conditions Mostly payer contracts linked to pathways ask for 80% adherence

6. Save money through competition

7. Save money: Guidelines for Metastatic Non- Small Cell Lung Cancer NCCN (2009) ACCP (2007) CCO (2009) Alberta (2009) Australian (2004) NICE (2009) Pemetrexed/CisplatinXXXX-X Gemcitabine/CisplatinXXXXXX Docetaxel/CisplatinXXXXXX Irinotecan/CisplatinXXXXX- Vinorelbine/CisplatinXXXXXX Etoposide/CisplatinXXXXX- Vinblastine/CisplatinXXXXX- Paclitaxel/CisplatinXXXXXX

8. Metastatic Non-Small Cell Lung Cancer Name Total Chemotherapy Drug Cost Monthly Chemotherapy Drug Cost Total Cost (12 Weeks) Monthly Cost Pemetrexed/Cisplatin 1-4,6 $16,913.37$6,105.91$19,594.13$7,073.69 Gemcitabine/Cisplatin 1-6 $9,745.83$3,518.35$13,303.24$4,802.61 Docetaxel/Cisplatin 1-6 $8,916.64$3,219.00$11,647.20$4,204.77 Irinotecan/Cisplatin 1-5 $934.60$337.40$7,984.63$2,882.54 Vinorelbine/Cisplatin 1-6 $519.45$187.53$4,929.03$1,779.43 Etoposide/Cisplatin 1-5 $217.06$78.36$4,453.86$1,607.89 Vinblastine/Cisplatin 1-5 $183.97$66.41$3,741.38$1,350.68 Paclitaxel/Cisplatin 1-6 $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)

9. Using episode payment

10. Metastatic Hormone Refractory Prostate Cancer

11. 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-Androgens

12. Monitor the quality of care

13. Reduce disparities

14. Give academics work

15. 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 GuidanceRecommendedNo Not specified (selective literature) NCCN Consensus guidelines Recommended Yes, for some individuals based on risk Not specified (selective literature) IASLC Statement Considered appropriate to discuss with physician NoNot 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

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

18. Then there’s the dissemination challenge

19. Laurie Fenton Ambrose President and CEO Lung Cancer Alliance Straight Extrapolation from the NLST 80,000 avoided deaths/yr Two Views of the Population Benefit

20. Available to anyone 50 years of age or older with a history of smoking or second hand smoke exposure $199 for an individual, $299 for a couple “The findings were INDISPUTABLE, “low dose” Lung CT saves lives by 20%.” Available to: “Patients…age 40 and over, typically with a history of smoking of at least 100 cigarettes in a lifetime.” $399 http://www.sequoiahospital.org/Medical_Services/Cancer_Care_and_Early_ Detection/SDR2_M177128 Dissemination Challenge

21. Thank you