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A cost minimization exercise. Dr. Judith Aaron* , Dr. Balurishna S, Dr. SunithaSusan Varghese, Dr. Jasmine P, Dr. Selvamani B. Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure. Introduction. - PowerPoint PPT Presentation
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Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure
A cost minimization exercise.
Dr. Judith Aaron*, Dr. Balurishna S, Dr. SunithaSusan Varghese, Dr. Jasmine P, Dr. Selvamani B
Introduction
Brachytherapy is an essential component of cancer cervix treatment.
It contributes significantly to the cost of cancer cervix treatment
Ext RT; 32590
Brachytherapy; 39250
Conc Chemo;
8000
Cost in Rs
Introduction 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
Introduction
Advantages: Patient co-operation – painless Adequate vaginal packing can be done
Introduction
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
Aim of this study
To minimise the cost of cancer cevix treatment (Brachytherapy component) without compromising on the tumour dose or dose to critical organs at risk.
Objectives
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.
Methodology
Patient selection
4 patients- due for HDR brachytherapy
Study patient- 1
Control patients -3
Treatment protocolSTUDY PATIENT First fraction:
Under anaesthesia in theatre Cervical sleeve sutured to the os Applicator placed insitu SimulationPlanning 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
Treatment protocolCONTROL PATIENTS
All three applications of HDR brachytherapy as inpatient Under anaesthesia in theatre Applicator placed insitu Simulation PlanningTreatment
CostingCost computation:
PatientMedical and Nonmedical cost
Hospital Societal
Cost comparison: Study patient versus Control patients
Effectiveness analysis
Comparison of Dose to point A Rectal dose Bladder dose
Study versus control patients
Other issues
Also looked at the Issues related to outpatient procedure Feasibility of continuing the practice
Cost of brachytherapy
Study patient
Total cost: Rs. 29673/-
Treatment 1 Treatment 2 Treatment 302000400060008000
10000120001400016000
Cost
in R
s.
Control patients
Per patient cost total cost- Rs. 39843/-
Treatment 1
Treatment 2
Treatment 3
Treatment 1
Treatment 2
Treatment 3
Treatment 1
Treatment 2
Treatment 3
CONTROL 1 CONTROL 2 CONTROL 3
0
2000
4000
6000
8000
10000
12000
14000
16000
Cost
in R
s.
Breakup of costing
Medical costs
Treatment 1 Treatment 2 Treatment 30
50100150200250300350400
Cost
in
Rs.
Treatment 1
Treatment 2
Treatment 3
050
100150200250300350400
Cost
in R
s.
STUDY PATIENT
CONTROL PATIENT
Treatment 1 Treatment 2 Treatment 3STUDY
0200400600800
10001200
ProfBed &N
Cost
in R
s.
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
CONTROL
0400800
1200
ProfBed &N
Cost
in R
s.
Admission/Bed/ Nursing and Professional charges
Medical costs
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
CONTROL
0
500
1000
1500
2000
2500
3000
AnaesTheatre
Cost
in R
s.
CONTROL PA-TIENT
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
STUDY
0
500
1000
1500
2000
2500
3000
AnaesTheatre
Cost
in R
s.
STUDY PA-TIENT
Theatre and Anaesthesia
Medical cost
Treatment 1 Treatment 2 Treatment 30
200
400
600
800
1000
1200
Cost
in R
s.
Treatment 1 Treatment 2 Treatment 30
200
400
600
800
1000
1200
Cost
in R
s.
STUDY PATIENT
CONTROL PATIENT
Premedication
Medical cost
Procedure/ Planning and Treatment
No change in cost
Non medical cost
Expenses for the patient Travel charges Cost of food
Expenses for attendants Travel Food Stay
Non medical cost
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/-
Societal cost
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
1 20
50
100
150
200
250
300
Cost
in R
s. IP
IP O
P OP
Hospital Savings ( Indirect )The following facilities can be used
for another patient:BedNursing careTheatre Anaesthetist’s time
Cost comparison
STUDY VS CONTROLS
Difference of Rs. 10000/-
STUDY CONTROL 1 CONTROL 2 CONTROL30
5000
10000
15000
20000
25000
30000
35000
40000
45000Co
st R
s.
Conclusion
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.
What do we compromise on ?
Effectiveness
To assess the effectiveness of the procedure done as outpatient
Is it as effective as the inpatient procedure with spinal anaesthesia ?
Absolute dose to point A
Treatment 1 Treatment 2 Treatment 3STUDY
0
100
200
300
400
500
600
700
Chart Title
Dos
e in
cG
ySTUDY PATIENT
Absolute dose to point A
Treatment 1 Treatment 2 Treatment 3CONTROL 1
0
100
200
300
400
500
600
700
Dos
e in
cG
y
Treatment 1 Treatment 2 Treatment 3CONTROL 2
0
100
200
300
400
500
600
700
Dos
e in
cG
y
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
CONTROL 3
0
100
200
300
400
500
600
700
Dos
e in
cG
y
CONTROL PATIENTS
Average Rectal dose
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3STUDY CONTROL 1 CONTROL 2 CONTROL 3
0
100
200
300
400
500
600
Average Rectal Dose
Average Rectal Dose
Dos
e in
cGy
Average Bladder doseTr
eatm
ent 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3
Trea
tmen
t 1
Trea
tmen
t 2
Trea
tmen
t 3STUDY CONTROL 1 CONTROL 2 CONTROL 3
0
100
200
300
400
500
600
Average Bladder Dose
Average Bladder Dose
Dos
e in
cG
y
Our inference 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.
Draw backs of this exercise Pain was not adequately controlled- Thus
vaginal packing was difficultThe following drugs were used for pain
management:Voveran patch- applied a day prior to procedurePremedication- Fortwin and PhenerganPost 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
To conclude
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
Thank you