Measuring the value of care in the management of bladder cancer
How should we define success in disease management and track the level of achievement in order to continuously improve the health care system to be functional and sustainable? Dr. Zenichi Ihara, Health Economics Manager, Commercial Excellence, Olympus, offers a few suggestions
Every action we take delivers an outcome and comes at a cost. What are then the tangible outcomes we would like to see delivered in disease management and the cost it takes to deliver them? It sounds like a trivial question to ask, while in many cases there is no answer, or we have not been looking at it correctly. The outcomes and cost determines the value in health care, although an agreement for a meaningful outcome or the causality with the costs and its breakdown are often missing. (1)
Bladder cancer management, as in most of the progressive chronic diseases starts with a healthy population: to prevent or delay the onset of the disease. In suspected cases, early detection is vital, as well as effective, efficient, and minimally invasive treatment to be implemented. The cycle of detection and treatment may be iterated before reaching a state of recovery, control, or palliative care. In order to monitor the status and determine the actions within each of these steps and across the entire care pathway, an agreed set of measures of success is needed along with the resource requirement associated so the framework be improved, optimized, and made sustainable.
Under the auspices of a European dialogue that brought the stakeholders together – such as policy makers, medical and clinical professionals, academic experts, patients, payers, and industry – the open discussion led to a common ground of recognition around the unmet needs and areas for improvement. Some of my key suggestions are as follows.
Awareness and endorsement
If bladder cancer appreciated less attention in the past compared to the other fields of cancer such as colorectal, lung, or prostate cancer, a systemic approach may be needed to promote the burden of the condition, the current status and future direction. Although the incidence, prevalence, and mortality might be relatively lower than those mentioned above , bladder cancer has one of the highest lifetime treatment costs per patient of all cancers, if not the highest . The high recurrence rate and ongoing invasive monitoring requirement are the key contributors.
Set standards of health outcomes and track the success of bladder cancer management
Also in contrast to those “major” cancer areas where a standard set of health outcome measures are defined and agreed, bladder cancer does not seem to have such KPIs as of yet. (4) This should be the priority since any kinds of measurement and monitoring will be dependent on the relevant data determined prospectively.
When an intervention is performed, correct implementation becomes important. Early diagnosis involving flexible cystoscopy or minimally invasive procedures such as plasma resection cannot yield the highest extent of benefit unless the operator is trained and maintains the learning curve. Objective assessment of success and clarification for improvement are possible by tracking the agreed measures of outcome. To that end, working on a screening program and focusing on large-scale registry sounds sensible to collect real-world data in view of connecting the outcomes defined and the costs incurred to deliver them. The use of medical devices and outcomes will also be tracked.
Cost of care and value proposition of interventions
While there is indication of the costs of bladder cancer, most of the evidence is around aggregated macroeconomic figures reported in the health systems that do not relate to the resources used to deliver a particular outcome. (5) Costs associated with certain types of therapy are documented, while this does not say about the particular technology used or the results provided. (6)
The funding scheme such as outpatient payment for diagnostic cystoscopy or DRG tariff for resection procedure has at least two limitations: 1) it does not account for all costs involved in the delivery of care, notably the CapEx costs; and 2) it has no clear mechanism to incentivize better outcomes or superior efficiency and penalise worse ones. For instance, a new technological feature (e.g. narrow-band imaging) that improves the diagnostic yield of cystoscopy or reduces the recurrence are reimbursed the same at the provider level today. These intrinsic shortcomings should be brought to the attention of the policy makers so the outcomes and costs are considered together.
The economic value should be combined with the outcome measures that optimize operational costs of the healthcare system, provide better socioeconomic outcomes, and save associated costs with preventing expenditure of onset and progression of disease. (7, 8) To look at a solution to a problem through the filter of value (and not only the price) should be a change management all of us should adopt.
There is much enthusiasm in bringing the focus on the management of bladder cancer. A costly disease has also a big opportunity to improve its status by increasing the awareness, defining and tracking the success, as well as clarifying the costs and managing the funding scheme.
1. Porter, M.E., What Is Value in Health Care? New England Journal of Medicine, 2010. 363(26): p. 2477-2481.
2. International Agency for Research on Cancer (IARC), GLOBOCAN. 2012, WHO.
3. Sievert, K., et al., Economic aspects of bladder cancer: what are the benefits and costs? World J Urol, 2009. 27(3): p. 295–300.
4. ICHOM. The International Consortium for Health Outcomes Measurement. 2016; Available from: http://www.ichom.org/.
5. Leal, J., et al., Economic Burden of Bladder Cancer Across the European Union. European Urology, 2016. 69(3): p. 438-447.
6. Svatek, R.S., et al., The Economics of Bladder Cancer: Costs and Considerations of Caring for This Disease. European Urology, 2014. 66(2): p. 253-262.
7. Gerecke, G., J. Clawson, and Y. Verboven, Procurement: The Unexpected Driver of Value-Based Health Care, the Boston Scientific Group, Editor. 2015: bcg.perspectives.
8. MedTech Europe, Economic Value as a guide to invest in Health and Care, MetTech Europe, Editor. 2016.