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

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

3.  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

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

5.  Drawbacks :  Cost of treatment  Spinal anaethesia – every fraction  The number of fractions of HDR brachytherapy limited At our institution a dose of 6-7.2 Gy is prescribed X 3 fractions

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

7.  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.

9. 4 patients- due for HDR brachytherapy Study patient- 1Control patients -3

10. 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

11. 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

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

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

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

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

17.  Total cost: Rs. 29673/-

18.  Per patient cost total cost- Rs. 39843/-

20. STUDY PATIENTCONTROL PATIENT Admission/Bed/ Nursing and Professional charges

21. Theatre and Anaesthesia

22. STUDY PATIENTCONTROL PATIENT Premedication

23. Procedure/ Planning and Treatment  No change in cost

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

25.  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. 2000 – 2400/-

26. 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

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

29.  Difference of Rs. 10000/-

30.  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.

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

33. STUDY PATIENT

34. CONTROL PATIENTS

37.  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.

38.  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

39.  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