Innovative Radiotherapy Techniques Time-Driven Activity-Based Costing Yolande Lievens, MD, PhD Radiation Oncology University Hospital Gent © 2010 Universitair Ziekenhuis Gent UNAMEC – November 5th 2014 the aim of radiotherapy: improve local control, survival and quality of life technologic advances: equitoxic dose escalation vs. reduced side effects Normal tissue damage Effect Tumour control Tumour Dose Dose escalation Increase the tumour dose for the same dose to the healthy tissues Decrease toxicity (ALARA) Reduce the dose to the healthy tissues for the same tumour dose 2D RT 60Gy/2Gy 3D-CRT 66-70Gy/2Gy IMRT >70Gy/2Gy SBRT 60Gy/20Gy Fang et al. IJROBP 2006 Lagerwaard et al. IJROBP 2008 Liao et al. IJROBP, 2009 Veldeman et al. Lancet Oncology 2008 Buxton’s Law It’s always too early to evaluate a technology, until, suddenly, it’s too late! Financing CEA - BIA Cost calculation? Effectiveness? Performance & safety extent clinical use investment premarket development emerging diffusing established obsolete in silico studies RCT unethical? Phase I-II Widespread use still avoidable? in selected centres t * Patient Assessment Imaging for RT Planning 3D-CRT IMRT SBRT preparation Treatment Planning Pre-Treatment Review and Verification IGRT Treatment Delivery x times ART (Adaptive RT) * Equipment and Software Quality Management Image-Guided RT On-Treatment Quality Management delivery x N Fractions Post –Treatment Completion AAPM process map, Ford et al. more complex treatments more time more resources capital investments sophisticated equipment buildings human resources treatment maintenance more costly historical evolution of the cost of radiation therapy over 20 years corrected for inflation and exchange rates Ploquin and Dunscombe, R&O 2008 what we want for our patients early availability of new and promising treatments what society wants for all patients maximise health within a given budget minimise cost per life year gained high-tech, high cost, high reimbursements (?) « The difference between the reimbursement in the United States and most European health care systems has been proposed as a contributing factor in explaining the slower introduction of IMRT in European centres. Although favourable reimbursement may ensure cost-effectiveness from a departmental perspective, it clearly does not guarantee cost-effectiveness from the society or the health service point of view. » Bentzen IJROBP 2004 ideally reimbursement should cover the costs adapt to technology evolution endorse quality account for effectiveness Belgian radiotherapy reimbursement no correlation to costs lags behind on technology evolution does not support quality is not related to effectiveness Hulstaert et al, Rapport 198 KCE 2013 reimbursement for SBRT ? what is the (level 1) evidence? the cost? the value for money? the budgetary impact? coverage with evidence development Innovative radiotherapy techniques NIHDI Define the indications Define the costs to be covered Define the evidence generation KCE Evidence generation and follow-up CR In close collaboration with the radiotherapy departments Technique Cancer Indication Safety monitoring (clinical trial ) APBI APBI Intraoperative boost Breast (low risk group only) Breast (medium risk) Breast No** Yes No** SBRT SBRT SBRT SBRT SBRT SBRT SBRT SBRT SBRT SBRT SBRT Lung Prostate Renal Pancreatic Head & Neck Primary Hepatic Hepatic Metastases Spinal and paraspinal Oligometastases (other) Lung Metastases Lymph Node Metastases No Yes Yes Yes Yes Yes No No Yes No Yes Kaplan and Porter, Harvard Business Review 2011 microcosting gross costing total budget allocated to specific services top down microcosting simplicity & low cost lack of sensitivity time and motion studies detailed resource use analysis bottom up sensitivity & precision complexity & cost gross costing top down bottom up radiotherapy resources consumables resource costs personnel equipment buildings overhead “1st stage cost drivers” “resource drivers” e.g. time percentages direct allocation indirect allocation using cost drivers activities “2nd stage cost drivers” “activity drivers” number of activities… time costobjects treatments time-driven Activity-Based Costing activities consume resources to produce products Lievens et al. IJROBP, 2003 Van de Werf et al. R&O, 2012 INDIRECT DIRECT Equipment Personnel Material Overhead Material Time driven RT patient related activities Intake consultation Medical review … Activity consumption Treatment cost SBRT – lung – APBI 5 fractions brachytherapy RT support act. Equipment Maint. & QA Other Out of scope RT patient related RT support Non-RT, care activities Non- care activities Per fraction … 56.6% Mark-up % on treatment cost 80% fraction 20% patient Hulstaert et al, Report 198 KCE 2013 16000 average cost SBRT: 6,221€ 14000 Free breathing - center A 12000 Free breathing - center B Cost (€) 10000 Free breathing - center C Free breathing - center D 8000 Free breathing - center E Free breathing - center F 6000 Gating - center G 4000 Gating - center H Tracking - center I 2000 Tracking or Free breathing - center J 0 3 4-6 N of fractions 7-10 Hulstaert et al, Report 198 KCE 2013 Hulstaert et al, Report 198 KCE 2013 4-year provisional financing of SBRT prospective evaluation real-life setting Which departments? Which indications? Which technology? What standards of care? What outcome? What budget? Prostate IMRT 33-40 fractions 9 561 10 000 9 000 Cost per treatment (€) 8 000 8 418 7 289 7 304 7 000 6 378 6 000 5 116 8 701 8 519 7 522 6 400 5 134 5 000 4 000 3 000 2 000 1 000 Average A B C D E F G H I J Hulstaert et al, Report 198 KCE 2013 Equipment + personnel cost per treatment (€) Average cost per process step for all external radiotherapy treatments 4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 A B C D E F First patient contact Simulation Delineation Treatment delivery Adaptative RT End of treatment G H I J Planning Hulstaert et al, Report 198 KCE 2013 Most Important Input Parameters Country for Cost Evaluation: RadiationTreatments South Africa Fractionation Schedules long (> 25) intermediate (11-25) short (<11) Rand Distribution of Fractionation Schedules 20% 10% 70% Patient Number:3000 Treatment Using Blocks 60% 30% 10% 30% 5% Nurse Administrative Personnel Currency Used for Results: Personnel Time Radiation Oncologist Patient-Related EBRT Time Total Overhead Equipment Anticipated Number of Equipment Proportional Use of Equipment 55% 45% Cobalt 70% 30% Orthovoltage 85% 15% Linac 100% 0% Simulator 75% 25% TPS 75% 25% Mould Room 2 1 4 2 3 1 30% 10% 60% 85% 15% 60% Cost per Treatment Type Total Operating Costs Salaries 22% Treatment Using Immobilization 50% Senior Junior Medical Radiation Radiation Physicist Technologist Technologist Amort. 24% Inclusive Departmental Overhead 25000,0 20000,0 15000,0 18136 10000,0 Maint. 54% 5000,0 ,0 10334 3882 1703 3309 4325 Short Intermediate Long Building & Equipment Cost Personnel Cost Most Important Input Parameters Country for Cost Evaluation: RadiationTreatments South Africa Fractionation Schedules long (> 25) intermediate (11-25) short (<11) Rand Distribution of Fractionation Schedules 20% 10% 70% Patient Number:3000 Treatment Using Blocks 60% 30% 10% 30% 5% Nurse Administrative Personnel Currency Used for Results: Personnel Time Radiation Oncologist Patient-Related EBRT Time Total Overhead Equipment Anticipated Number of Equipment Proportional Use of Equipment Treatment Using Immobilization 50% Senior Junior Medical Radiation Radiation Physicist Technologist Technologist 55% 45% Cobalt 70% 30% Orthovoltage 85% 15% Linac 100% 0% Simulator 75% 25% TPS 75% 25% Mould Room 2 1 4 2 3 1 30% 10% 60% 85% 15% 60% Personnel Utilization Total Time EBRT Time Only 120% 100% 98% 98% 94% 89% 80% 62% 60% 93% 83% 51% 67% 63% 57% 70% 40% 20% 0% Radiation Oncologist Medical Physicist Senior Radiation Technologist Junior Radiation Technologist Nurse Administrative Personnel NEEDS translation CCORE utilisation to Europan countries National CCORE Societies AVAILABILITY equipment & staffing guidelines reimbursement National Societies ACTIVITY-BASED COSTING at the national level in European countries National Societies ESTRO Clinical Committee ECONOMIC EVALUATION at the national level in European countries National CCORE Societies IAEA HERO-project a wider scope, the (near) future • Breast reconstruction techniques after mastectomy: description and costing of the medical subcomponents (HTA Study 2014-25) • New Generation Sequencing panel tests in oncology • Cost of medical imaging techniques (MRI/CT/… ) •… adapt (part) of the nomenclature review hospital financing based on actual costs Take-home messages Rapid evolution of radiotherapy, reimbursement inadequate Need for correct cost data, for reliable effectiveness data Coverage with evidence development TD-ABC used in several radiotherapy settings TD-ABC is a possible model to support market access of innovative medical technologies in Belgium Thanks to the Belgian Health Care Knowledge Centre Frank Hulstaert & Caroline Obyn Anne-Sophie Mertens & Dries Van Halewyck the Belgian Cancer Registry and the RIZIV-INAMI Jan Verstraete & Evelyn van de Werf Barbara Vanderstraeten the IAEA Vic Levin, Branislav Jeremic, Eduardo Zubizerrato the ESTRO-HEROes Cai Grau, Noémie Defourny, Peter Dunscombe & Chiara Gasparotto Thank you for your attention !
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