policy, guidelines, and disparities peter b. bach, md, mapp memorial sloan-kettering cancer center...
TRANSCRIPT
Policy, Guidelines, and Disparities
Peter B. Bach, MD, MAPPMemorial Sloan-Kettering Cancer Center
Overview
• The goal of practice guidelines is to:– Improve the quality of care?– Manage care?– Save money?– Monitor the quality of care?– Reduce disparities?– Give academics (with weird skills) something to
do?
Improve care quality
• Underlying assumption: care is sub-standard• Practice guidelines used broadly would raise
average level• Have to assume that deviations from
guidelines net harmful– As opposed to important personalization
• Clinical decision support can have a guidelines background
Clinical decision support
Manage care (oncology example)
• Pathways tell doctors which treatments to use in common conditions
• Mostly payer contracts linked to pathways ask for 80% adherence
Save money through competition
Save money: Guidelines for Metastatic Non-Small Cell Lung Cancer
NCCN(2009)
ACCP(2007)
CCO(2009)
Alberta(2009)
Australian(2004)
NICE(2009)
Pemetrexed/Cisplatin X X X X - X
Gemcitabine/Cisplatin X X X X X X
Docetaxel/Cisplatin X X X X X X
Irinotecan/Cisplatin X X X X X -
Vinorelbine/Cisplatin X X X X X X
Etoposide/Cisplatin X X X X X -
Vinblastine/Cisplatin X X X X X -
Paclitaxel/Cisplatin X X X X X X
Metastatic Non-Small Cell Lung CancerName Total
Chemotherapy Drug Cost
Monthly Chemotherapy Drug Cost
Total Cost (12 Weeks)
Monthly Cost
Pemetrexed/Cisplatin1-4,6 $16,913.37 $6,105.91 $19,594.13 $7,073.69
Gemcitabine/Cisplatin1-6 $9,745.83 $3,518.35 $13,303.24 $4,802.61
Docetaxel/Cisplatin1-6 $8,916.64 $3,219.00 $11,647.20 $4,204.77
Irinotecan/Cisplatin1-5 $934.60 $337.40 $7,984.63 $2,882.54
Vinorelbine/Cisplatin1-6 $519.45 $187.53 $4,929.03 $1,779.43
Etoposide/Cisplatin1-5 $217.06 $78.36 $4,453.86 $1,607.89
Vinblastine/Cisplatin1-5 $183.97 $66.41 $3,741.38 $1,350.68
Paclitaxel/Cisplatin1-6 $518.45 $187.17 $3,578.70 $1,291.95
1 National Comprehensive Cancer Center (NCCN), 2 American College of Chest Physicians, 3 Cancer Care Ontario (CCO), 4 Alberta Health Services, 5 Australian National Health and Medical Research Council, 6 National Institute for Health and Clinical Excellence (NICE)
Using episode payment
Pemetrexed/Carboplatin (1-
4,6)
Gemcitabine/Carboplatin (1-
6)
Docetaxel/Carboplatin
(1-6)
Irinotecan/Carboplatin (1-
5)
Vinorelbine/Carboplatin (1-
6)
Etoposide/Carboplatin
(1-5)
Vinblastine/Carboplatin (1-
5)
Paclitaxel/Carboplatin
(1-6)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
Administration Fees and Supportive Care Costs Chemotherapy Cost
Cost
per
Mon
th o
f Tre
atm
ent
Potential Profit for Physician
Potential Loss for Physician
Metastatic Hormone Refractory Prostate Cancer
Drug (does not include support or adminstration) Monthly Cost
Sipuleucel-T (Provenge) $ 37,668
Docetaxel (Generic) $ 772
Flutamide (Generic) $ 237
Bicalutamide (Casodex) $ 552
Bicalutamide (Generic) $ 43
Nilutamide (Nilandron) $ 749
Antiandrogen withdrawal $ -
Ketoconazole $ 201
Arbiraterone acetate (Zytiga) $ 5,778
Steroids negligible
Diethylstilbestrol (or other estrogen) negligible
Anti-
Andr
ogen
s
Monitor the quality of care
Reduce disparities
Give academics work
Org. Type of Statement
NLST Like Subjects?
Others? Basis
ACCP/ASCO/ATS
Evidence based guideline
Suggest it be offered No
Systematic review, meta-analysis, grading of evidence
ACS Interim guidance
May be considered No Interim guidance
pending full review
ALA Guidance Recommended No Not specified (selective literature)
NCCN Consensus guidelines Recommended
Yes, for some individuals based on risk
Not specified (selective literature)
IASLC StatementConsidered appropriate to discuss with physician
No Not specified
AATS Clinical guidelines Recommended
Yes, for some individuals based on risk
Not specified (selective literature)
Summary of Published Guidelines on LDCT Screening for Lung Cancer
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm280536.htm
Then there’s the dissemination challenge
NLST National
Number screened 26000 8000000
Number of deaths prevented 87 26769
Number of years 6 6Number lung cancer deaths avoided/year 14 4388
Laurie Fenton AmbrosePresident and CEO
Lung Cancer Alliance
Straight Extrapolation from the NLST
80,000 avoided deaths/yr
Two Views of the Population Benefit
•Available to anyone 50 years of age or older with a history of smoking or second hand smoke exposure•$199 for an individual, •$299 for a couple
“The findings were INDISPUTABLE, “low dose” Lung CT saves lives by 20%.”
•Available to: “Patients…age 40 and over, typically with a history of smoking of at least 100 cigarettes in a lifetime.”•$399http://www.sequoiahospital.org/Medical_Services/Cancer_Care_and_Early_Detection/SDR2_M177128
Dissemination Challenge
Thank you