TREATMENT AND LONG-TERM COSTS OF PEDIATRIC ACUTE LYMPHOBLASTIC LEUKEMIA

9th ANNUAL UTAH HEALTH SERVICES RESEARCH CONFERENCE

April 30th, 2014

Sapna Kaul, PhD, MAPost-Doctoral Research Associate, Health EconomicsHematology/Oncology, Department of Pediatrics

INTRODUCTION

INTRODUCTION• Why study pediatric cancer costs?• Assess economic burden over time• Cost effectiveness analyses• Cost benefit analyses• Cost containment techniques

• Costs of pediatric cancer is an understudies area.• HCUP’s study on pediatric cancer hospitalizations, 2009.• Russell et al. (2012, Pediatrics)

Systematic review of economic evaluations of pediatric cancer treatments. Majority of the studies were by European investigators. Only 10 studies by U.S. investigators.

Approaches to Value Based Care

WHY ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)?

• Accounts for 25% to 30% of childhood cancer diagnoses.

• About 3,000 children and adolescents are diagnosed with ALL every year in the U.S.

• The incidence rate has gradually increased over time and survival rate 85% to 90%.

• Survival rates in Black and Hispanic children are lower than White children with ALL.

Blood Stem Cell

LymphoidB

LymphocyteT

Lymphocyte

Myeloid

ALL TREATMENT

Induction35 days

Post-InductionStandard Risk = 9

monthsHigh Risk = 7

months

Maintenance

Girls = 2 years

Boys= 3 years

Long-Term> 5 years

Vary by risk and sex …

Standard risk – WBC count less than 50,000/μL and age 1 to younger than 10 years.High risk – WBC count 50,000/μL or greater and/or age 10 years or older.

OBJECTIVES

• Examine hospitalizations costs of pediatric ALL over time.- Aggregate costs.- Disaggregate costs by cost components (room & care, diagnostics etc.) and treatment phases (induction, post-induction, maintenance, long-term).

• Investigate factors that affect hospitalization costs.‐ Treatment related factors (risk, relapse, infections etc.).‐ Socio-economic factors (insurance, distance from hospital).

DATA• N=553 pediatric ALL patients.

• Patients identified through the Intermountain Healthcare System.

• Diagnosed years 1998 to 2013.

• Longitudinal data – hospitalizations data with costs.

• Cost data adjusted for inflation using Consumer Price Index.

STATISTICAL METHODS

• Aggregate and disaggregate costs -Annual average per patient hospitalization costs.-Annual average costs by cost components and treatment phases.

• Factors that affect per patient hospitalization costs- Multivariable regression – GLM.- Separate regressions – within and after 5 years of diagnosis.

Analyses in STATA and R …..

Characteristics N %

Age at Diagnosis(years)

< 11- 55 - 10>10

19306100128

3551823

Sex FemaleMale

263290

4852

Race WhiteNon-White

48469

8712

Insurance at Diagnosis

PublicPrivateUninsured

13339921

24724

Residence at ALL Diagnosis

UTAZ, CO, ID, MT, NV, WYAK, CA, MO, WA

4411057

80191

Patients Characteristics

Treatment Related Characteristics

ALL Specific Characteristics N %

ALL RiskInfantsStandard RiskHigh Risk

19343191

36234

Phases for Standard and High Risk Patients

InductionPost-InductionMaintenanceLong-Term

52137633799

97726019

ALL RelapseYesNo

63490

1189

TransplantYesNo

45508

892

MortalityAliveDead

49063

8911

- 97% patients were diagnosed at Primary Children’s Hospital

- Annual diagnoses varied from 25 to 40 from 1998 to 2013

RESULTSAggregate Costs

2000 2005 2010

05

10

15

Per Patient Per Hospitalization Average Annual Costs

Years

Avera

ge C

osts

in $

1000

Average Costs Per Hospitalization among ALL Patients

Disaggregated Costs by Cost Components

2000 2005 2010

02

46

8

Per Patient Per Hospitalization Average Annual Costs

Years

Ave

rage C

ost

s in

$1000

Room & CareTherapyPharmacyDiagnostic

Average Costs Per Hospitalization among ALL Patients

Disaggregated Costs by Treatment Phases

2000 2005 2010

05

1015

20

Per Patient Per Hospitalization Average Annual Costs

Years

Ave

rage

Cos

ts in

$10

00

InductionPost-InductionMaintenanceLong-Term

Average Costs Per Hospitalization among ALL Patients

Multivariable Regression Analysis for Treatment Costs within 5 years of DiagnosisN=424, Hospitalizations=2887

Independent Variables Effect on Dependent

Variable

P-value

Treatment Related Characteristics

High Risk vs. Standard Risk

2298 <0.01

Relapse vs. no Relapse 3302 <0.01

Induction vs. Post-Induction

7160 <0.01

Infection vs. no Infection

1916 <0.05

Socio-Demographic Characteristics

Public vs. Private Insurance

1274 <0.01

Insignificant variables – race, sex, distance from facility etc. Controlled for fixed year effects.Exclusions – infants, residents of WA, AK, MO, CA, and diagnosis after 2010.

Variable Effect on Dependent

Variable

P-value

Treatment Related Characteristics

Relapse vs. no Relapse

4355 <0.01

Infection vs. no Infection

9884 <0.05

Socio-Demographic Characteristics

Uninsured vs. Private

-3827 <0.05

N=99, Hospitalizations=237

Multivariable Regression Analysis for Long-Term Costs Starting 5 years after Diagnosis

The remaining variables were insignificant.Exclusions – Residents of WA, AK, MO, CA.

CONCLUSIONS• Average cost per hospitalization has increased over time. Increase differs substantially by cost components and treatment phases.

• Factors that potentially increase costs:• Treatment related and socio-demographic characteristics.• Costs of treating infants very high – upper limit of $151,167 per visit.

• Value based care:• Cost-effective patient-centered care for High Risk and Relapsed patients.

• Emphasis on managing induction, room and care, and pharmacy costs.

• Insurance can provide leads on monitoring high cost patients.

LIMITATIONS

Economic

Burden of

Pediatric ALL

Hospitalization Costs

Other Medical Costs

e.g. Physician Costs,

Outpatient Costs

Indirect Medical Costs

NEXT STEPS• Use more refined treatment phase identifiers (e.g., LPs and pharmacy data).

• Incorporate physician costs and out-patient medical costs.

• Robust examination of late effects include patients diagnosed in 1980’s.

• Costs of all Pediatric cancers.

COLLABORATORS AND FUNDING

Anne C. Kirchhoff, PhD, MPHRichard Lemons, MDKent Korgenski, MSMark Fluchel, MDAnupam Verma, MDElizabeth Raetz, MDRichard Nelson, PhDJosh Schiffman, MDChristi Ng, MPHSeth Andrews, MBA

Funding Source: Primary Children’s Hospital’s Pediatric Cancer Program (PCHPCP)

OUTLINE• Introduction

• Objectives

• Data and Statistical Methods

• Results

• Conclusions

• Limitations and Next Steps