Background. Real-world evidence can be a valuable tool when clinical trial data are incomplete or... more Background. Real-world evidence can be a valuable tool when clinical trial data are incomplete or uncertain. Bevacizumab was adopted as first-line therapy for metastatic colorectal cancer (mCRC) based on significant survival improvements in initial clinical trials; however, survival benefit diminished in subsequent analyses. Consequently, there is uncertainty surrounding the cost-effectiveness of bevacizumab therapy achieved in practice. Objective. To assess real-world cost-effectiveness of first-line bevacizumab with irinotecan-based chemotherapy versus irinotecan-based chemotherapy alone for mCRC in British Columbia (BC), Saskatchewan, and Ontario, Canada. Methods. Using provincial cancer registries and linked administrative databases, we identified mCRC patients who initiated publicly funded irinotecan-based chemotherapy, with or without bevacizumab, in 2000 to 2015. We compared bevacizumab-treated patients to historical controls (treated before bevacizumab funding) and contempor...
Purpose Precision oncology has the potential to improve patient health and reduce treatment costs... more Purpose Precision oncology has the potential to improve patient health and reduce treatment costs. Yet the up-front cost of genomic testing with next-generation sequencing (NGS) technologies can be prohibitive. Our study is a structured review of economic evaluations of precision oncology informed by NGS. The aim is to characterize the availability and scope of economic evidence. Materials and Methods We searched Medline (PubMed), Embase (Ovid), and Web of Science databases for English-language full-text peer-reviewed articles published between 2000 and 2016. We focused our search on articles that estimated the benefit of precision oncology in relation to its costs. We excluded studies that did not undertake full economic evaluations or did not focus on NGS technologies. We reviewed all included studies and summarized key methodological and empirical study characteristics. Results Fifty-five economic evaluations met our inclusion criteria. The number of published studies increased s...
International Journal of Technology Assessment in Health Care
Introduction:Methods that accommodate heterogeneity in outcomes are not widely used in economic e... more Introduction:Methods that accommodate heterogeneity in outcomes are not widely used in economic evaluation. With the growth of precision medicine (PM), where choice of treatment is informed by the molecular characteristics of the patient or disease, we expect to see greater heterogeneity in effectiveness and cost of interventions. Our objective was to compare analytical frameworks for valuing heterogeneity in economic evaluation, and consider their strengths and weaknesses for applications in PM.Methods:We conducted a literature review to identify papers that proposed an analytical framework for economic evaluation of a health intervention, and that placed a value on heterogeneous effects. We compared the frameworks considering the purpose of the analysis, including where in the product lifecycle the framework could be used, the types of PM interventions where the framework could be applied, and its ability to address methodological challenges of evaluating PM.Results:Five analytica...
International Journal of Technology Assessment in Health Care
Introduction:Proponents of precision oncology report that genomic testing has the potential to re... more Introduction:Proponents of precision oncology report that genomic testing has the potential to reduce health system costs and improve patient health. Yet, testing also involves significant expenditures that challenge the sustainability of adopting technologies into routine practice. Our study explores the availability and scope of economic evaluations of precision oncology informed by next-generation sequencing (NGS).Methods:We searched Medline (PubMed), Embase (Ovid), and Web of Science databases for English-language full-text peer reviewed articles published between 2000 and 2016. We focused our search on articles that estimated the benefit of precision oncology in relation to its costs. We excluded studies that did not undertake full economic evaluations or did not focus on NGS. We reviewed all included studies and summarized key methodological and empirical study characteristics.Results:Fifty-five economic evaluations met our inclusion criteria. The first study was published in ...
Expenditure on systemic therapy for cancer has been increasing quickly owing to population growth... more Expenditure on systemic therapy for cancer has been increasing quickly owing to population growth, increased use, both in the number of users and in prescription volume, and rising drug prices. Our objective was to describe trends in expenditure in British Columbia and Saskatchewan's cancer care systems and to elucidate these drivers of growth. In this trend analysis, we obtained pharmacy dispensing records from the BC Cancer and Saskatchewan Cancer Agency pharmacies for all anticancer therapies dispensed in 2006-2013. We calculated total annual expenditure directly from the data and conducted a trend analysis of crude and standardized annual expenditure using generalized linear models. We estimated trends in the following components of total expenditure: cancer incidence, number of systemic therapy users per incident case, number of dispensed prescriptions per user and cost per prescription. Analysis was stratified by patient age group, cancer site and route of administration (...
57 Background: Many publications use administrative health care data to describe quality of care ... more 57 Background: Many publications use administrative health care data to describe quality of care indicators at the end of life (EOL). However, very little is available to help decide on optimal rates for these indicators. The purpose of this abstract is to develop data-driven and achievable benchmark rates for EOL quality indicators using administrative data from 4 provinces in Canada. Methods: Five quality indicators of EOL care were defined and measured using linked administrative data for each of the 33 regions across British Columbia, Alberta, Ontario and Nova Scotia. These were: emergency department (ED) use, intensive care unit (ICU) admission, physician house calls (MD) and nursing visits at home (RN) prior to death, and death in hospital (DH). First, an empiric benchmark was defined by determining indicator rates among the top ranked regions to include the top decile of patients overall. Second, funnel plots were used to graph the age and sex adjusted indicator rates for eac...
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, Aug 9, 2017
Lung cancer risk prediction models have the potential to make programs more affordable; however, ... more Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited. Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the PLCOm2009 risk-prediction tool. The high-risk subgroup was assessed for lung cancer incidences and demographic character compared with the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan)-an observational study, that was high-risk selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model, using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency. Use of the PLCOm2009 risk prediction tool with a threshold set at 2% over 6 years would have reduced the number needed to screen in the NLST b...
Healthcare policy = Politiques de sante, Feb 1, 2017
Costing studies are useful to measure the economic burden of cancer. Comparing costs between heal... more Costing studies are useful to measure the economic burden of cancer. Comparing costs between healthcare systems can inform evaluation, development or modification of cancer care policies. To estimate and compare cancer costs in British Columbia and Ontario from the payers' perspectives. Using linked cancer registry and administrative data, and standardized costing methodology and analyses, we estimated costs for 21 cancer sites by phase of care to determine potential differences between provinces. Overall, costs were higher in Ontario. Costs were highest in the initial post-diagnosis and pre-death phases and lowest in the pre-diagnosis and continuing phases, and generally higher for brain cancer and multiple myeloma, and lower for melanoma. Hospitalization was the major cost category. Costs for physician services and diagnostic tests differed the most between provinces. The standardization of data and costing methodology is challenging, but it enables interprovincial and interna...
Cancer is a major public health issue and represents a significant economic burden to health care... more Cancer is a major public health issue and represents a significant economic burden to health care systems worldwide. The objective of this analysis was to estimate phase-specific, 5-year and lifetime net costs for the 21 most prevalent cancer sites, and remaining tumour sites combined, in Ontario, Canada. We selected all adult patients diagnosed with a primary cancer between 1997 and 2007, with valid ICD-O site and histology codes, and who survived 30 days or more after diagnosis, from the Ontario Cancer Registry (N = 394,092). Patients were linked to treatment data from Cancer Care Ontario and administrative health care databases at the Institute for Clinical and Evaluative Sciences. Net costs (i.e., cost difference between patients and matched non-cancer control subjects) were estimated by phase of care and sex, and used to estimate 5-year and lifetime costs. Mean net costs of care (2009 CAD) were highest in the initial (6 months post-diagnosis) and terminal (12 months pre-death) ...
Most cancer patients want to die at home, but scaleable models to achieve this are not well resea... more Most cancer patients want to die at home, but scaleable models to achieve this are not well researched. Our objective was to investigate the temporal association of homecare nursing, especially by generalist nurses, with reduced end-of-life hospitalizations. We conducted a retrospective Canadian cohort study of end-of-life cancer decedents during 2004-2009 in Ontario (ON), Nova Scotia (NS), and British Columbia (BC), which have homecare systems that use generalist nurses to provide end-of-life care. Each province linked administrative databases to examine the association during the last six months of life between the homecare nursing rate and the hospitalization rate in the subsequent week, using standardized definitions and controlling for other covariates. We dichotomized nursing into standard and end-of-life care intent. Our cohort included 83,827 cancer decedents. Approximately 55% of decedents were older than 70 and the most common cancer was lung. Nearly 85% of the cohort had at least one hospital admission. Receiving end-of-life compared to standard homecare nursing significantly reduced a patient's hospitalization rate by 34%, 33%, and 17% in ON, BC, and NS. In the last month of life patients having a standard nursing rate of greater than five hours compared to one hour per week had a significantly lower hospitalization rate (relative reduction of 15%-23%) across the three provinces. Our study showed a protective effect of nursing with an end-of-life intent on hospitalization across the last six months of life and of standard nursing in the last month. This finding's generalizability is strengthened, since the trends were similar across three different homecare systems.
Journal of pain and symptom management, Jan 26, 2015
Despite being commonplace in health care systems, little research has described homecare nursing&... more Despite being commonplace in health care systems, little research has described homecare nursing's effectiveness to reduce acute care use at the end of life. To examine the temporal association between homecare nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada between 2004-2009 by linking administrative databases. We examined the association between homecare nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. Our cohort included 54,576 decedents who used homecare nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life homecare nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ...
Journal of oncology practice / American Society of Clinical Oncology, Jan 28, 2015
To develop data-driven and achievable benchmark rates for end-of-life quality indicators using ad... more To develop data-driven and achievable benchmark rates for end-of-life quality indicators using administrative data from four provinces in Canada. Indicators of end-of-life care were defined and measured using linked administrative data for 33 health regions across British Columbia, Alberta, Ontario, and Nova Scotia. These were emergency department use, intensive care unit admission, physician house calls and home care visits before death, and death in hospital. An empiric benchmark was defined using indicator rates from the top-ranked regions to include the top decile of patients overall. Funnel plots were used to graph each region's age- and sex-adjusted indicator rates along with the overall rate and 95% confidence limits. Rates varied approximately two- to four-fold across the regions, with physician house calls showing the greatest variation. Benchmark rates based on the top decile performers were emergency department use, 34%; intensive care unit admission, 2%; physician ho...
The sensitivity of screening mammography is much lower among women who have dense breast tissue, ... more The sensitivity of screening mammography is much lower among women who have dense breast tissue, compared with women who have largely fatty breasts, and they are also at much higher risk of developing the disease. Increasing mammography screening frequency from biennially to annually has been suggested as a policy option to address the elevated risk in this population. The purpose of this study was to assess the cost-effectiveness of annual versus biennial screening mammography among women aged 50-79 with dense breast tissue. A Markov model was constructed based on screening, diagnostic, and treatment pathways for the population-based screening and cancer care programme in British Columbia, Canada. Model probabilities and screening costs were calculated from screening programme data. Costs for breast cancer treatment were calculated from treatment data, and utility values were obtained from the literature. Incremental cost-effectiveness was expressed as cost per quality adjusted lif...
The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought... more The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought to estimate costs for the 21 most common cancers in Ontario in the 3-month period before and the first year after diagnosis. We used the Ontario Cancer Registry to select patients who received diagnoses between 1997 and 2007 at 19 years of age or older, with valid International Classification of Diseases for Oncology (ICD-O) and histology codes, who survived 30 days or longer after diagnosis and had no second cancer within 90 days of the initial cancer (n = 402Â 399). We used linked administrative data to calculate mean costs for each cancer during the pre- and postdiagnosis periods for patients who died within 1 year after diagnosis and patients who survived beyond 1 year after diagnosis. Mean prediagnosis costs were $2060 (95% confidence interval [CI] $2023-$2098) for all patients with cancer. Costs ranged from $890 (95% CI $795-$985) for melanoma to $4128 (95% CI $3591-$4664) for live...
Cancer incidence and treatment-related costs are rising in Canada. We estimated health care use a... more Cancer incidence and treatment-related costs are rising in Canada. We estimated health care use and costs in the first year after diagnosis for patients with 7Â common types of cancer in Ontario to examine temporal trends in patterns of care and costs. We selected patients aged 19-44Â years who had received a diagnosis of melanoma, breast cancer (female only), testicular cancer or thyroid cancer, in addition to patients aged 45 years and older who had received a diagnosis of breast (female only), prostate, lung or colorectal cancer, between 1997 and 2007. Patients were identified from the Ontario Cancer Registry. Using linked administrative databases, we determined use and costs of chemotherapy, radiotherapy, cancer-related surgery, other admissions to hospital and home care. We adjusted all costs to 2009 Canadian dollars. We identified 20 821 patients aged 19-44 years and 178 797 patients aged 45 years and older. The greatest increases in costs during the study period were for melano...
Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs... more Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs considerable risk of over diagnosis and potential harm to quality of life. Our objective was to evaluate the cost-effectiveness of PSA screening, with and without adjustment for quality of life, for the British Columbia (BC) population. We adapted an existing natural history model using BC incidence, treatment, cost and mortality patterns. The modeled mortality benefit of screening derives from a stage-shift mechanism, assuming mortality reduction consistent with the European Study of Randomized Screening for Prostate Cancer. The model projected outcomes for 40-year-old men under 14 combinations of screening ages and frequencies. Cost and utility estimates were explored with deterministic sensitivity analysis. The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. The marginal benefits of increasing screening frequency to 2 years or starting screening at age 40 years were small and came at significant cost. After utility adjustment, all screening strategies resulted in a loss of quality-adjusted life years (QALYs); however, this result was very sensitive to utility estimates. Plausible outcomes under a range of screening strategies inform discussion of prostate cancer screening policy in BC and similar jurisdictions. Screening may be cost-effective, but the sensitivity of results to utility values suggests individual preferences for quality versus quantity of life should be a key consideration.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, Jan 9, 2015
An important challenge with the application of next-generation sequencing technology is the possi... more An important challenge with the application of next-generation sequencing technology is the possibility of uncovering incidental genomic findings. A paucity of evidence on personal utility for incidental findings has hindered clinical guidelines. Our objective was to estimate personal utility for complex information derived from incidental genomic findings. We used a discrete-choice experiment to evaluate participants' personal utility for the following attributes: disease penetrance, disease treatability, disease severity, carrier status and cost. Study participants were drawn from the Canadian public. We analyzed the data with a mixed logit model. In total, 1200 participants completed our questionnaire (available in English and French). Participants valued receiving information about high-penetrance disorders but expressed disutility for receiving information on low-penetrance disorders. The average willingness to pay was $445 (95% confidence interval [CI] $322-$567) to receiv...
Background. Real-world evidence can be a valuable tool when clinical trial data are incomplete or... more Background. Real-world evidence can be a valuable tool when clinical trial data are incomplete or uncertain. Bevacizumab was adopted as first-line therapy for metastatic colorectal cancer (mCRC) based on significant survival improvements in initial clinical trials; however, survival benefit diminished in subsequent analyses. Consequently, there is uncertainty surrounding the cost-effectiveness of bevacizumab therapy achieved in practice. Objective. To assess real-world cost-effectiveness of first-line bevacizumab with irinotecan-based chemotherapy versus irinotecan-based chemotherapy alone for mCRC in British Columbia (BC), Saskatchewan, and Ontario, Canada. Methods. Using provincial cancer registries and linked administrative databases, we identified mCRC patients who initiated publicly funded irinotecan-based chemotherapy, with or without bevacizumab, in 2000 to 2015. We compared bevacizumab-treated patients to historical controls (treated before bevacizumab funding) and contempor...
Purpose Precision oncology has the potential to improve patient health and reduce treatment costs... more Purpose Precision oncology has the potential to improve patient health and reduce treatment costs. Yet the up-front cost of genomic testing with next-generation sequencing (NGS) technologies can be prohibitive. Our study is a structured review of economic evaluations of precision oncology informed by NGS. The aim is to characterize the availability and scope of economic evidence. Materials and Methods We searched Medline (PubMed), Embase (Ovid), and Web of Science databases for English-language full-text peer-reviewed articles published between 2000 and 2016. We focused our search on articles that estimated the benefit of precision oncology in relation to its costs. We excluded studies that did not undertake full economic evaluations or did not focus on NGS technologies. We reviewed all included studies and summarized key methodological and empirical study characteristics. Results Fifty-five economic evaluations met our inclusion criteria. The number of published studies increased s...
International Journal of Technology Assessment in Health Care
Introduction:Methods that accommodate heterogeneity in outcomes are not widely used in economic e... more Introduction:Methods that accommodate heterogeneity in outcomes are not widely used in economic evaluation. With the growth of precision medicine (PM), where choice of treatment is informed by the molecular characteristics of the patient or disease, we expect to see greater heterogeneity in effectiveness and cost of interventions. Our objective was to compare analytical frameworks for valuing heterogeneity in economic evaluation, and consider their strengths and weaknesses for applications in PM.Methods:We conducted a literature review to identify papers that proposed an analytical framework for economic evaluation of a health intervention, and that placed a value on heterogeneous effects. We compared the frameworks considering the purpose of the analysis, including where in the product lifecycle the framework could be used, the types of PM interventions where the framework could be applied, and its ability to address methodological challenges of evaluating PM.Results:Five analytica...
International Journal of Technology Assessment in Health Care
Introduction:Proponents of precision oncology report that genomic testing has the potential to re... more Introduction:Proponents of precision oncology report that genomic testing has the potential to reduce health system costs and improve patient health. Yet, testing also involves significant expenditures that challenge the sustainability of adopting technologies into routine practice. Our study explores the availability and scope of economic evaluations of precision oncology informed by next-generation sequencing (NGS).Methods:We searched Medline (PubMed), Embase (Ovid), and Web of Science databases for English-language full-text peer reviewed articles published between 2000 and 2016. We focused our search on articles that estimated the benefit of precision oncology in relation to its costs. We excluded studies that did not undertake full economic evaluations or did not focus on NGS. We reviewed all included studies and summarized key methodological and empirical study characteristics.Results:Fifty-five economic evaluations met our inclusion criteria. The first study was published in ...
Expenditure on systemic therapy for cancer has been increasing quickly owing to population growth... more Expenditure on systemic therapy for cancer has been increasing quickly owing to population growth, increased use, both in the number of users and in prescription volume, and rising drug prices. Our objective was to describe trends in expenditure in British Columbia and Saskatchewan's cancer care systems and to elucidate these drivers of growth. In this trend analysis, we obtained pharmacy dispensing records from the BC Cancer and Saskatchewan Cancer Agency pharmacies for all anticancer therapies dispensed in 2006-2013. We calculated total annual expenditure directly from the data and conducted a trend analysis of crude and standardized annual expenditure using generalized linear models. We estimated trends in the following components of total expenditure: cancer incidence, number of systemic therapy users per incident case, number of dispensed prescriptions per user and cost per prescription. Analysis was stratified by patient age group, cancer site and route of administration (...
57 Background: Many publications use administrative health care data to describe quality of care ... more 57 Background: Many publications use administrative health care data to describe quality of care indicators at the end of life (EOL). However, very little is available to help decide on optimal rates for these indicators. The purpose of this abstract is to develop data-driven and achievable benchmark rates for EOL quality indicators using administrative data from 4 provinces in Canada. Methods: Five quality indicators of EOL care were defined and measured using linked administrative data for each of the 33 regions across British Columbia, Alberta, Ontario and Nova Scotia. These were: emergency department (ED) use, intensive care unit (ICU) admission, physician house calls (MD) and nursing visits at home (RN) prior to death, and death in hospital (DH). First, an empiric benchmark was defined by determining indicator rates among the top ranked regions to include the top decile of patients overall. Second, funnel plots were used to graph the age and sex adjusted indicator rates for eac...
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, Aug 9, 2017
Lung cancer risk prediction models have the potential to make programs more affordable; however, ... more Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited. Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the PLCOm2009 risk-prediction tool. The high-risk subgroup was assessed for lung cancer incidences and demographic character compared with the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan)-an observational study, that was high-risk selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model, using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency. Use of the PLCOm2009 risk prediction tool with a threshold set at 2% over 6 years would have reduced the number needed to screen in the NLST b...
Healthcare policy = Politiques de sante, Feb 1, 2017
Costing studies are useful to measure the economic burden of cancer. Comparing costs between heal... more Costing studies are useful to measure the economic burden of cancer. Comparing costs between healthcare systems can inform evaluation, development or modification of cancer care policies. To estimate and compare cancer costs in British Columbia and Ontario from the payers' perspectives. Using linked cancer registry and administrative data, and standardized costing methodology and analyses, we estimated costs for 21 cancer sites by phase of care to determine potential differences between provinces. Overall, costs were higher in Ontario. Costs were highest in the initial post-diagnosis and pre-death phases and lowest in the pre-diagnosis and continuing phases, and generally higher for brain cancer and multiple myeloma, and lower for melanoma. Hospitalization was the major cost category. Costs for physician services and diagnostic tests differed the most between provinces. The standardization of data and costing methodology is challenging, but it enables interprovincial and interna...
Cancer is a major public health issue and represents a significant economic burden to health care... more Cancer is a major public health issue and represents a significant economic burden to health care systems worldwide. The objective of this analysis was to estimate phase-specific, 5-year and lifetime net costs for the 21 most prevalent cancer sites, and remaining tumour sites combined, in Ontario, Canada. We selected all adult patients diagnosed with a primary cancer between 1997 and 2007, with valid ICD-O site and histology codes, and who survived 30 days or more after diagnosis, from the Ontario Cancer Registry (N = 394,092). Patients were linked to treatment data from Cancer Care Ontario and administrative health care databases at the Institute for Clinical and Evaluative Sciences. Net costs (i.e., cost difference between patients and matched non-cancer control subjects) were estimated by phase of care and sex, and used to estimate 5-year and lifetime costs. Mean net costs of care (2009 CAD) were highest in the initial (6 months post-diagnosis) and terminal (12 months pre-death) ...
Most cancer patients want to die at home, but scaleable models to achieve this are not well resea... more Most cancer patients want to die at home, but scaleable models to achieve this are not well researched. Our objective was to investigate the temporal association of homecare nursing, especially by generalist nurses, with reduced end-of-life hospitalizations. We conducted a retrospective Canadian cohort study of end-of-life cancer decedents during 2004-2009 in Ontario (ON), Nova Scotia (NS), and British Columbia (BC), which have homecare systems that use generalist nurses to provide end-of-life care. Each province linked administrative databases to examine the association during the last six months of life between the homecare nursing rate and the hospitalization rate in the subsequent week, using standardized definitions and controlling for other covariates. We dichotomized nursing into standard and end-of-life care intent. Our cohort included 83,827 cancer decedents. Approximately 55% of decedents were older than 70 and the most common cancer was lung. Nearly 85% of the cohort had at least one hospital admission. Receiving end-of-life compared to standard homecare nursing significantly reduced a patient's hospitalization rate by 34%, 33%, and 17% in ON, BC, and NS. In the last month of life patients having a standard nursing rate of greater than five hours compared to one hour per week had a significantly lower hospitalization rate (relative reduction of 15%-23%) across the three provinces. Our study showed a protective effect of nursing with an end-of-life intent on hospitalization across the last six months of life and of standard nursing in the last month. This finding's generalizability is strengthened, since the trends were similar across three different homecare systems.
Journal of pain and symptom management, Jan 26, 2015
Despite being commonplace in health care systems, little research has described homecare nursing&... more Despite being commonplace in health care systems, little research has described homecare nursing's effectiveness to reduce acute care use at the end of life. To examine the temporal association between homecare nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada between 2004-2009 by linking administrative databases. We examined the association between homecare nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. Our cohort included 54,576 decedents who used homecare nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life homecare nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ...
Journal of oncology practice / American Society of Clinical Oncology, Jan 28, 2015
To develop data-driven and achievable benchmark rates for end-of-life quality indicators using ad... more To develop data-driven and achievable benchmark rates for end-of-life quality indicators using administrative data from four provinces in Canada. Indicators of end-of-life care were defined and measured using linked administrative data for 33 health regions across British Columbia, Alberta, Ontario, and Nova Scotia. These were emergency department use, intensive care unit admission, physician house calls and home care visits before death, and death in hospital. An empiric benchmark was defined using indicator rates from the top-ranked regions to include the top decile of patients overall. Funnel plots were used to graph each region's age- and sex-adjusted indicator rates along with the overall rate and 95% confidence limits. Rates varied approximately two- to four-fold across the regions, with physician house calls showing the greatest variation. Benchmark rates based on the top decile performers were emergency department use, 34%; intensive care unit admission, 2%; physician ho...
The sensitivity of screening mammography is much lower among women who have dense breast tissue, ... more The sensitivity of screening mammography is much lower among women who have dense breast tissue, compared with women who have largely fatty breasts, and they are also at much higher risk of developing the disease. Increasing mammography screening frequency from biennially to annually has been suggested as a policy option to address the elevated risk in this population. The purpose of this study was to assess the cost-effectiveness of annual versus biennial screening mammography among women aged 50-79 with dense breast tissue. A Markov model was constructed based on screening, diagnostic, and treatment pathways for the population-based screening and cancer care programme in British Columbia, Canada. Model probabilities and screening costs were calculated from screening programme data. Costs for breast cancer treatment were calculated from treatment data, and utility values were obtained from the literature. Incremental cost-effectiveness was expressed as cost per quality adjusted lif...
The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought... more The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought to estimate costs for the 21 most common cancers in Ontario in the 3-month period before and the first year after diagnosis. We used the Ontario Cancer Registry to select patients who received diagnoses between 1997 and 2007 at 19 years of age or older, with valid International Classification of Diseases for Oncology (ICD-O) and histology codes, who survived 30 days or longer after diagnosis and had no second cancer within 90 days of the initial cancer (n = 402Â 399). We used linked administrative data to calculate mean costs for each cancer during the pre- and postdiagnosis periods for patients who died within 1 year after diagnosis and patients who survived beyond 1 year after diagnosis. Mean prediagnosis costs were $2060 (95% confidence interval [CI] $2023-$2098) for all patients with cancer. Costs ranged from $890 (95% CI $795-$985) for melanoma to $4128 (95% CI $3591-$4664) for live...
Cancer incidence and treatment-related costs are rising in Canada. We estimated health care use a... more Cancer incidence and treatment-related costs are rising in Canada. We estimated health care use and costs in the first year after diagnosis for patients with 7Â common types of cancer in Ontario to examine temporal trends in patterns of care and costs. We selected patients aged 19-44Â years who had received a diagnosis of melanoma, breast cancer (female only), testicular cancer or thyroid cancer, in addition to patients aged 45 years and older who had received a diagnosis of breast (female only), prostate, lung or colorectal cancer, between 1997 and 2007. Patients were identified from the Ontario Cancer Registry. Using linked administrative databases, we determined use and costs of chemotherapy, radiotherapy, cancer-related surgery, other admissions to hospital and home care. We adjusted all costs to 2009 Canadian dollars. We identified 20 821 patients aged 19-44 years and 178 797 patients aged 45 years and older. The greatest increases in costs during the study period were for melano...
Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs... more Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs considerable risk of over diagnosis and potential harm to quality of life. Our objective was to evaluate the cost-effectiveness of PSA screening, with and without adjustment for quality of life, for the British Columbia (BC) population. We adapted an existing natural history model using BC incidence, treatment, cost and mortality patterns. The modeled mortality benefit of screening derives from a stage-shift mechanism, assuming mortality reduction consistent with the European Study of Randomized Screening for Prostate Cancer. The model projected outcomes for 40-year-old men under 14 combinations of screening ages and frequencies. Cost and utility estimates were explored with deterministic sensitivity analysis. The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. The marginal benefits of increasing screening frequency to 2 years or starting screening at age 40 years were small and came at significant cost. After utility adjustment, all screening strategies resulted in a loss of quality-adjusted life years (QALYs); however, this result was very sensitive to utility estimates. Plausible outcomes under a range of screening strategies inform discussion of prostate cancer screening policy in BC and similar jurisdictions. Screening may be cost-effective, but the sensitivity of results to utility values suggests individual preferences for quality versus quantity of life should be a key consideration.
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, Jan 9, 2015
An important challenge with the application of next-generation sequencing technology is the possi... more An important challenge with the application of next-generation sequencing technology is the possibility of uncovering incidental genomic findings. A paucity of evidence on personal utility for incidental findings has hindered clinical guidelines. Our objective was to estimate personal utility for complex information derived from incidental genomic findings. We used a discrete-choice experiment to evaluate participants' personal utility for the following attributes: disease penetrance, disease treatability, disease severity, carrier status and cost. Study participants were drawn from the Canadian public. We analyzed the data with a mixed logit model. In total, 1200 participants completed our questionnaire (available in English and French). Participants valued receiving information about high-penetrance disorders but expressed disutility for receiving information on low-penetrance disorders. The average willingness to pay was $445 (95% confidence interval [CI] $322-$567) to receiv...
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