Abstract P4-12-10: Evaluation of quality, cost, and value in clinical stage IA breast cancer
Authors: Dvorak T , Rostorfer R , Smith J , Coltey D , Waters J , Mamounas E 
Published: February 2018

Abstract
Background: There is increasing emphasis in providing high-value care. Value can be interpreted as a ratio of quality of care delivered and the cost to provide that care. We set out to evaluate the value of our care by defining a set of quality metrics (points) for each patient, then evaluating our cost to the payors to the deliver this care.
Methods: Patients with clinical Stage IA breast cancer managed completely at our Cancer Center between 1/1/2014 and 12/31/2014 were identified from cancer registry. An IRB-approved retrospective review of clinical charts and financial data was performed. Based on The Advisory Board Company metrics, a set of 18 quality measures was developed. These included process measures (time to initial biopsy, rate of needle biopsy, time to pathology reports, ER/PR and HER2 assessment, pathology synoptic report generation, time to surgery or neoadjuvant chemotherapy), treatment measures (performance of sentinel node biopsy, administration of chemotherapy for ER- or HER2+ disease, administration of radiation for lumpectomy or pN2/pN3 disease after mastectomy, administration of endocrine therapy for ER+ disease), and complication measures (flap complication after reconstruction, chemotherapy ER visits and inpatient admissions). Depending on the treatment pathway, patients were eligible for a different number of quality points. A patient received a quality point if they were eligible for the measure and met it. Financial review identified actual technical revenue received by the hospital, and apportioned it accordingly to the various revenue centers. Revenue was included for 365 days after the date of first contact, and was used as a proxy for cost to the payors. All patients were included regardless of type of insurance or free-care.
Results: There were 110 patients treated. All patients (100%) underwent surgery (lumpectomy 69%; mastectomy 5%, mastectomy with reconstruction 26%). Chemotherapy was delivered in 20% of patients (neoadjuvant 13%; adjuvant 7%). Radiation therapy was delivered in 57% of patients. Most common treatment pathways were lumpectomy with radiation (46%), mastectomy with reconstruction alone (18%), and lumpectomy alone (14%). Number of potential quality points depended on care pathway, and ranged from 6 to 15 per patient. There were 939 quality points achieved out of possible 1104 (85%) in the entire cohort. Quality ratios per patient varied from 55% to 100%. Lowest quality measure was time-to-surgery &lt;=30 days at 75%. Overall revenue (cost to payors) was $6.2 million for the cohort. Medicare was 35% of patients. Average cost of care per patient was $56.5K (range $0 to $385K). The cost per point of quality was $6,443 (range $0 to $45.4K). Highest cost per quality point was in a commercial insurance patient treated with neoadjuvant TCHP, followed by bilateral mastectomy with DIEP reconstruction and radiation.
Conclusions: We have established a model to assess the value of breast cancer care provided as cost of care delivered per quality point achieved. To improve our value proposition to the payors, and ultimately to our patients, we plan to focus on improving our compliance with the quality measures, monitor care pathway utilization, and identify opportunities to lower the cost of care.
Citation Format: Dvorak T, Rostorfer R, Smith J, Coltey D, Waters J, Mamounas E. Evaluation of quality, cost, and value in clinical stage IA 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 P4-12-10.