Abstract
Purpose: The purpose of this analysis was to determine the cost-effectiveness of a Collaborative Care Model (CCM)-based, centralized telecare approach to delivering rehabilitation services to late-stage cancer patients experiencing functional limitations. Methods: Data for this analysis came from the Collaborative Care to Preserve Performance in Cancer (COPE) trial, a randomized control trial of 516 patients assigned to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Patient quality of life was measured using the EQ-5D-3L at baseline, 3-month, and 6-month follow-up. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained from their medical records, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients for whom comprehensive cost capture was possible. Results: In the intervention-only model, tele-rehabilitation (arm B) was found to be the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of $15 494/QALY. At the $100 000 willingness-to-pay threshold, this tele-rehabilitation was the cost-effective strategy in 95.4% of simulations. It was found to be cost saving compared to enhanced usual care once the downstream hospitalization costs were taken into account. In the total cost analysis, total inpatient hospitalization costs were significantly lower in both tele-rehabilitation (arm B) and tele-rehabilitation plus pain management (arm C) compared to control (arm A), (P =.048). Conclusion: The delivery of a CCM-based, centralized tele-rehabilitation intervention to patients with advanced stage cancer is highly cost-effective. Clinicians and care teams working with this vulnerable population should consider incorporating such interventions into their patient care plans.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 2723-2731 |
| Number of pages | 9 |
| Journal | Cancer medicine |
| Volume | 9 |
| Issue number | 8 |
| DOIs | |
| State | Published - Apr 1 2020 |
Keywords
- cost effectivness
- healthcare utilization
- hospitalization
- physical function
- telecare
ASJC Scopus subject areas
- Oncology
- Radiology Nuclear Medicine and imaging
- Cancer Research
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Cost-effectiveness of the Collaborative Care to Preserve Performance in Cancer (COPE) trial tele-rehabilitation interventions for patients with advanced cancers. / Longacre, Colleen F.; Nyman, John A.; Visscher, Sue L. et al.
In: Cancer medicine, Vol. 9, No. 8, 01.04.2020, p. 2723-2731.Research output: Contribution to journal › Article › peer-review
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TY - JOUR
T1 - Cost-effectiveness of the Collaborative Care to Preserve Performance in Cancer (COPE) trial tele-rehabilitation interventions for patients with advanced cancers
AU - Longacre, Colleen F.
AU - Nyman, John A.
AU - Visscher, Sue L.
AU - Borah, Bijan J.
AU - Cheville, Andrea L.
N1 - Funding Information: The randomized clinical COPE trial assigned 516 patients who were experiencing functional limitations to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Clinical outcomes of this trial have been reported elsewhere. All arms underwent automated home-based monitoring of physical functioning and pain via telephone and/or internet, with reporting of these data to their care teams. Participants in arms B and C received centralized tele-rehabilitation based on the collaborative care model (CCM) provided by a physical therapist (PT) physician team. The tele-rehabilitation intervention included a pedometer-based walking program and a resistive exercise program, both validated. Direction was provided remotely via telephone during one-to-one calls between participants and the study PTs. Arm C participants also received similarly delivered, nurse-coordinated pain management based on an iteration of the CCM previously validated among patients with cancer. Participants who did not complete their scheduled assessments, did not adhere to the recommended frequency of exercise sessions, or reported functional losses were contacted by a PT for further follow-up. The COPE trial was conducted at three academic medical centers located in the upper Midwest, Southwest, and Southeast sections of the United States. All sites were part of a single health-care system and National Cancer Institute-designated comprehensive cancer center. COPE trial participants were seen for at least two visits in an outpatient medical oncology or hematology clinic at one of the sites. Patient quality of life was measured using the EQ-5D-3L at baseline, and at 3- and 6-month follow-up. The EQ-5D-3L has robust support for validity in populations with advanced malignancies. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained through abstracting the medical record, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients living in Olmsted County, whose data were available from the Rochester Epidemiology Project (REP). The randomized clinical COPE trial assigned 516 patients who were experiencing functional limitations to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Clinical outcomes of this trial have been reported elsewhere. All arms underwent automated home-based monitoring of physical functioning and pain via telephone and/or internet, with reporting of these data to their care teams. Participants in arms B and C received centralized tele-rehabilitation based on the collaborative care model (CCM) provided by a physical therapist (PT) physician team. The tele-rehabilitation intervention included a pedometer-based walking program and a resistive exercise program, both validated. Direction was provided remotely via telephone during one-to-one calls between participants and the study PTs. Arm C participants also received similarly delivered, nurse-coordinated pain management based on an iteration of the CCM previously validated among patients with cancer. Participants who did not complete their scheduled assessments, did not adhere to the recommended frequency of exercise sessions, or reported functional losses were contacted by a PT for further follow-up. The COPE trial was conducted at three academic medical centers located in the upper Midwest, Southwest, and Southeast sections of the United States. All sites were part of a single health-care system and National Cancer Institute-designated comprehensive cancer center. COPE trial participants were seen for at least two visits in an outpatient medical oncology or hematology clinic at one of the sites. Patient quality of life was measured using the EQ-5D-3L at baseline, and at 3- and 6-month follow-up. The EQ-5D-3L has robust support for validity in populations with advanced malignancies. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained through abstracting the medical record, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients living in Olmsted County, whose data were available from the Rochester Epidemiology Project (REP). A decision-analytic model was constructed using TreeAgePro software (2017) to assess the three intervention strategies examined in the COPE trial (Figure). Participants were assumed to receive the full intervention of the arm to which they were assigned. Participants could experience health-care utilization in the form of hospitalizations. Each hospitalization was associated with a length of stay (in days). Table provides the full list of parameter estimates and distributions used in the model. The incremental utility gain per arm was measured by the incremental change in EQ-5D-3L score per arm over the course of the trial. We assumed a linear increase in effectiveness between baseline and 6 months and that utility gains only lasted until the conclusion of the trial. The incremental utility gain over the 6-month trial period was then converted into quality-adjusted life years (QALYs) for the cost-effectiveness analysis. Fixed intervention costs for participants in trial arm B included: (a) the cost of instructional DVDs and elastic resistance bands used by the “Rapid Easy Strength Training” resistive exercise program; and (b) the cost of pedometers associated with the “First Step Program”, an incremental pedometer-based walking program. Variable intervention costs for participants in trial arm B included time spent on the phone with a PT, the “fitness care manager” (FCM), who has specialized in cancer rehabilitation. The dates and lengths of these telephone calls were recorded, and the cost of the calls were calculated based on the salaries of the FCMs participating in the trial. In addition to the fixed and variable costs associated with arm B, the variable costs for arm C included the time spent on the phone with a nurse “pain care manager” (PCM), who reached out to those patients with high pain scores and provided treatment recommendations to the study participant's oncologic, hematologic, or primary care team, who were responsible for prescribing all medications. The dates and lengths of telephone calls with patients were recorded, and these time costs were calculated, based on the salaries of the PCMs participating in the trial. Consultative meetings were held biweekly and the time spent in these meetings was not tracked by the patient; therefore, PCM time costs for meetings are considered fixed. We estimated health-care utilization costs in two ways: (a) by applying unit cost estimates from the literature to collected hospital utilization data and (b) collecting cost data from a subset of the patient population of the COPE trial tracked by the REP. The COPE trial tracked utilization (participant hospitalizations and hospital lengths of stay), but did not track the total costs associated with these visits. As a result, hospitalization costs were estimated using unit costs from the literature. Because patients in the COPE trial with stage III-IV cancers are likely to be significantly different from the overall population of hospital patients surveyed in most cost studies, estimates of cancer treatment costs were not included. Instead, because we had participant length of stay, we used a measure of the hospital-adjusted expenses per inpatient day, estimated from the Kaiser Family Foundation in 2015. This figure provides an estimate of expenses incurred by the hospital to provide a day of inpatient care, but does not include the cost of specific services (procedures or treatments) provided to the patient. While complete utilization cost data were not available for all trial participants, these data were available from the REP for a subset of COPE trial participants who were living in Olmsted County, Minnesota. The REP is a medical records-linkage system that tracks virtually all health-care services provided to the residents of Olmsted County, Minnesota by Olmsted County-based providers. The population counts obtained by the REP Census match those obtained by the US Census, indicating that the population of the county is captured by the system. The REP tracks the vital and residential status of all Olmsted residents, and capture billing codes for all their health care. From the REP data, we estimated the total costs, cancer-related inpatient costs, cancer-related outpatient costs, cancer-related emergency department costs, and all-cause clinic costs. The REP reports standardized costs, which are created from an internally developed algorithm that applies Medicare reimbursement to professional services, multiplies the charges for hospital services by the appropriate Medicare cost report cost-to-charge ratios, and adjusts for inflation with the GDP implicit price deflator. This standardization process, however, renders these costs incomparable with the costs of the direct intervention because of the proprietary nature of the standardization algorithm. Therefore, we did not calculate cost-effectiveness measures from these data. Instead, we calculated Wilcoxon scores (rank sums) for these cost measures and determined whether these costs varied significantly across the three arms using the Kruskal-Wallis nonparametric analysis of variance test. We used the ICER as a point estimate of the cost-effective treatment strategy. Where appropriate, we then ran a probabilistic sensitivity analysis (PSA) of 100 000 simulations using the means, assumed distribution and confidence intervals from the cost and effectiveness results to determine and construct the cost-effectiveness acceptability curve (CEAC) associated with the treatment strategies. The CEAC allows us to summarize which strategy is more likely to be cost-effective at various willingness-to-pay thresholds. Publisher Copyright: © 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.
PY - 2020/4/1
Y1 - 2020/4/1
N2 - Purpose: The purpose of this analysis was to determine the cost-effectiveness of a Collaborative Care Model (CCM)-based, centralized telecare approach to delivering rehabilitation services to late-stage cancer patients experiencing functional limitations. Methods: Data for this analysis came from the Collaborative Care to Preserve Performance in Cancer (COPE) trial, a randomized control trial of 516 patients assigned to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Patient quality of life was measured using the EQ-5D-3L at baseline, 3-month, and 6-month follow-up. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained from their medical records, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients for whom comprehensive cost capture was possible. Results: In the intervention-only model, tele-rehabilitation (arm B) was found to be the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of $15 494/QALY. At the $100 000 willingness-to-pay threshold, this tele-rehabilitation was the cost-effective strategy in 95.4% of simulations. It was found to be cost saving compared to enhanced usual care once the downstream hospitalization costs were taken into account. In the total cost analysis, total inpatient hospitalization costs were significantly lower in both tele-rehabilitation (arm B) and tele-rehabilitation plus pain management (arm C) compared to control (arm A), (P =.048). Conclusion: The delivery of a CCM-based, centralized tele-rehabilitation intervention to patients with advanced stage cancer is highly cost-effective. Clinicians and care teams working with this vulnerable population should consider incorporating such interventions into their patient care plans.
AB - Purpose: The purpose of this analysis was to determine the cost-effectiveness of a Collaborative Care Model (CCM)-based, centralized telecare approach to delivering rehabilitation services to late-stage cancer patients experiencing functional limitations. Methods: Data for this analysis came from the Collaborative Care to Preserve Performance in Cancer (COPE) trial, a randomized control trial of 516 patients assigned to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Patient quality of life was measured using the EQ-5D-3L at baseline, 3-month, and 6-month follow-up. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained from their medical records, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients for whom comprehensive cost capture was possible. Results: In the intervention-only model, tele-rehabilitation (arm B) was found to be the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of $15 494/QALY. At the $100 000 willingness-to-pay threshold, this tele-rehabilitation was the cost-effective strategy in 95.4% of simulations. It was found to be cost saving compared to enhanced usual care once the downstream hospitalization costs were taken into account. In the total cost analysis, total inpatient hospitalization costs were significantly lower in both tele-rehabilitation (arm B) and tele-rehabilitation plus pain management (arm C) compared to control (arm A), (P =.048). Conclusion: The delivery of a CCM-based, centralized tele-rehabilitation intervention to patients with advanced stage cancer is highly cost-effective. Clinicians and care teams working with this vulnerable population should consider incorporating such interventions into their patient care plans.
KW - cost effectivness
KW - healthcare utilization
KW - hospitalization
KW - physical function
KW - telecare
UR - http://www.scopus.com/inward/record.url?scp=85083621813&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85083621813&partnerID=8YFLogxK
U2 - 10.1002/cam4.2837
DO - 10.1002/cam4.2837
M3 - Article
C2 - 32090502
AN - SCOPUS:85083621813
SN - 2045-7634
VL - 9
SP - 2723
EP - 2731
JO - Cancer Medicine
JF - Cancer Medicine
IS - 8
ER -