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

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3000

AnaesTheatre

Cost

in R

s.

STUDY PA-TIENT

Theatre and Anaesthesia

Medical cost

Treatment 1 Treatment 2 Treatment 30

200

400

600

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1000

1200

Cost

in R

s.

Treatment 1 Treatment 2 Treatment 30

200

400

600

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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

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700

Chart Title

Dos

e in

cG

ySTUDY PATIENT

Absolute dose to point A

Treatment 1 Treatment 2 Treatment 3CONTROL 1

0

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600

700

Dos

e in

cG

y

Treatment 1 Treatment 2 Treatment 3CONTROL 2

0

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500

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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

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Trea

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Trea

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Trea

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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

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Trea

tmen

t 1

Trea

tmen

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Trea

tmen

t 3STUDY CONTROL 1 CONTROL 2 CONTROL 3

0

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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