Abstract PD7-01: Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients
Authors: Williams CP , Azuero A , Pisu M , Halilova KI , Adewakun S , Yagnik SK , Goertz H-P , Rocque GB 
Published: February 2018

Introduction: National Comprehensive Cancer Network (NCCN) guideline-based treatment is increasingly recognized as a marker of high quality care. Payers are progressively limiting reimbursement for non-guideline based care as they move towards value-based cancer care. However, the impact of treatment regimen concordance with NCCN guidelines on cost and health care utilization in early stage breast cancer is unclear.

Methods: This was a secondary analysis of Medicare administrative claims data from 2012-2015 for all women aged ≥65 with stage I-III breast cancer who received care within the University of Alabama at Birmingham Cancer Community Network. Concordance to NCCN Clinical Practice guidelines was assessed for treatment regimens including hormonal medications, chemotherapy, and/or HER2-targeted therapy. Costs to Medicare (reimbursements to providers for all care received) were averaged monthly from the start of cancer treatment until death or available follow-up. Health care utilization (emergency department [ED] visits and hospitalizations) was identified from the start of cancer treatment until death or available follow-up. Cost and adjusted monthly utilization rates per thousand observations and their corresponding 95% confidence intervals (CI) were estimated using linear mixed effect models and generalized linear models, respectively, using the negative binomial distribution and log link function.

Results: Of 1042 patients on treatment for early stage breast cancer, 82% received a guideline concordant treatment, with 79% receiving a “preferred” treatment and 3% receiving an “other” but still on-guideline treatment. Those receiving guideline concordant treatment were more likely to be white, treated at large volume centers, have an earlier stage cancer, ER/PR positive, and HER2 negative (p&lt;0.05). Among patients receiving chemotherapy (N=496), 63% of patients received guideline concordant treatment (55% “preferred”, 8% “other”). After adjusting for age, race, treatment center volume, and stage, average monthly costs after initiation of treatment for guideline concordant patients were $1464 lower compared to guideline discordant patients (95% CI $1135-$1793, p&lt;.001). For guideline concordant patients, adjusted rates of ED visits per thousand observations were 41% lower at 51.3 per month (95% CI 44.0-59.8) compared to 77.9 per month (95% CI 62.6-96.9) for guideline discordant patients. Adjusted rates of hospitalizations per thousand observations were also 41% lower for guideline concordant patients at 28.2 per month (95% CI 23.5-33.8) compared to 42.7 per month (95% CI 32.9-55.5) for guideline discordant patients.

Conclusions: Despite the majority of early stage breast cancer patients receiving guideline concordant care, almost one in five did not, with an even higher proportion of guideline discordance in those receiving chemotherapy. Guideline concordant treatment was significantly associated with lower costs and lower rates of health care utilization after adjusting for patient and center characteristics. The appropriateness of guideline deviation should be examined from both the patient and payer perspectives.

Citation Format: Williams CP, Azuero A, Pisu M, Halilova KI, Adewakun S, Yagnik SK, Goertz H-P, Rocque GB. Impact of guideline concordant treatment on cost and health care utilization in early stage breast cancer patients [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 PD7-01.