Abstract P3-10-03: Effects of guideline-concordant treatment on ED visits, hospitalizations, and cost in metastatic breast cancer
Authors: Rocque GB , Williams CP , Jackson BE , Halilova KL , Adewakun SA , Pisu M , Forero A , Bhatia S 
Published: February 2018

Purpose: The National Comprehensive Cancer Network (NCCN) developed treatment guidelines that have directed care of patients with cancer for over 20 years. Receipt of treatment according to these guidelines is increasingly recognized as a marker of high quality care. A knowledge gap exists regarding concordance of treatment regimens for metastatic breast cancer with NCCN guidelines, as well as the potential impact of this concordance (or lack thereof) on resource utilization and costs – an issue that assumes significance in the new era of value-based healthcare.

Methods: From 2007-2013, women with de novo (n=988) or recurrent, treated metastatic breast cancer (n=5,651) were evaluated for concordance of first-line systemic therapy with NCCN guidelines within the SEER–Medicare linked database. Types of non-concordant treatments were reviewed and categorized. Outcomes include monthly rates of ED visits, monthly rates of hospital admissions, total overall and Medicare costs, and mortality. Specific (hospitalizations, antineoplastic agents, growth factor) and total costs to Medicare (excluding home health, hospice, skilled nursing facility) were calculated from initiation of treatment until death or available follow-up and examined by concordance status. Part D costs were excluded because costs are shared by Medicare, other payers, and patients. Cox regression was used to evaluate mortality risk. Student's t-tests, generalized linear models, and generalized mixed effects models were utilized to evaluate the relationship between concordance status and outcomes.

Results: We previously reported the prevalence of non-concordant first-line systemic therapy for de novo metastatic breast cancer (19%) and recurrent metastatic breast cancer (18%). The adjusted risk of mortality was comparable by concordance status. In the current analysis, non-concordant treatments were associated with a 9% increased rate of ED visits and a 7% increased rate of hospitalizations (p&lt;.01). Total Medicare cost for patients receiving concordant and non-concordant treatments was $79,372 and $109,471, respectively (p&lt;.001). Significant cost differences were found when comparing patients receiving concordant and non-concordant treatments by antineoplastic agents ($14,256 vs $24,817, p&lt;.001) and growth factor ($1,754 vs $3,414, p&lt;.001). A trend toward lower cost attributed to hospitalizations was observed for patients receiving concordant treatment compared to those receiving non-concordant treatment ($28,113 vs $34,134, p=.06). Overall, hospitalizations, antineoplastic agents, and growth factor accounted for 56% of total Medicare costs. Average monthly Medicare costs were higher for non-concordant patients by $1,761 (p&lt;.01).

Conclusions: While not associated with increased overall mortality, non-concordant treatment is associated with higher health care utilization rates and cost. Increased costs attributed to non-concordant care were largely driven by antineoplastic agents and growth factor use. These findings may have policy implications for payment reform initiative, in particular pathway programs which aim to reduce variability in care and spending on medications.

Citation Format: Rocque GB, Williams CP, Jackson BE, Halilova KL, Adewakun SA, Pisu M, Forero A, Bhatia S. Effects of guideline-concordant treatment on ED visits, hospitalizations, and cost in metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-10-03.