Julie Chevalier

Complete Cytoreductive Surgery Plus Intraperitoneal Chemohyperthermia With Oxaliplatin for Peritoneal Carcinomatosis of Colorectal Origin

PURPOSE To compare the long-term survival of patients with isolated and resectable peritoneal carcinomatosis (PC) in comparable groups of patients treated with systemic chemotherapy containing oxaliplatin or irinotecan or by cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS All patients with gross PC from colorectal adenocarcinoma who had undergone cytoreductive surgery plus HIPEC from 1998 to 2003 were evaluated. The standard group was constituted by selecting patients with colorectal PC treated with palliative chemotherapy during the same period, but who had not benefited from HIPEC because the technique was unavailable in the center at that time. RESULTS Forty-eight patients were retrospectively included in the standard group and were compared with 48 patients who had undergone HIPEC and were evaluated prospectively. All characteristics were comparable except age and tumor differentiation. There was no difference in systemic chemotherapy, with a mean of 2.3 lines per patient. Median follow-up was 95.7 months in the standard group versus 63 months in the HIPEC group. Two-year and 5-year overall survival rates were 81% and 51% for the HIPEC group, respectively, and 65% and 13% for the standard group, respectively. Median survival was 23.9 months in the standard group versus 62.7 months in the HIPEC group (P < .05, log-rank test). CONCLUSION Patients with isolated, resectable PC achieve a median survival of 24 months with modern chemotherapies, but only surgical cytoreduction plus HIPEC is able to prolong median survival to roughly 63 months, with a 5-year survival rate of 51%.

Valuing EQ-5D using Time Trade-Off in France

ObjectivesWhile a French language version of the EQ-5D exists, to date, there has been no French value set to accompany it. The objective of our study was then to derive the French TTO value set of the EQ-5D.MethodsA total of 452 respondents aged over 18 were recruited who were representative of the French population with regard to age, gender, and socio-professional group. The direct valuation of 24 health states was first obtained by Time Trade-Off (TTO), and the negative TTO values were bounded using the monotonic transformation. Several alternative model specifications were investigated to estimate the values for all 243 states in the EQ-5D descriptive system. Only the best fitting model is presented in this paper. The analysis was conducted at an individual level to make the maximum use of the available data, and we estimated mixed models with random intercept. Models were compared through the Akaike information criterion (AIC), the mean absolute error (MAE), and the Pearson correlation coefficient between the observed and the predicted values of each model.ResultsAfter exclusion, 443 respondents took part in the study. The best fitting model included the same variables as the N3-model used in UK.ConclusionThis study provides the French value set of the EQ-5D based on the stated preferences of the French general public facilitating cost-effectiveness analysis.

Cost-Effectiveness of Intraperitoneal Chemohyperthermia in the Treatment of Peritoneal Carcinomatosis from Colorectal Cancer

OBJECTIVES Our purpose was to assess the cost-effectiveness of intraperitoneal chemohyperthermia (IPCH) compared to palliative chemotherapy (STANDARD) against peritoneal carcinomatosis arising from colorectal cancer. METHODS We performed a retrospective study of 96 patients whose peritoneal carcinomatosis had been diagnosed between January 1998 and December 2003 and treated either with IPCH or with palliative chemotherapy in French comprehensive cancer centers. Patients were followed up over a 3-year period. Effectiveness was measured by restricted mean survival at 3 years. The Bang and Tsiatis method was used to handle cost-censored data. The confidence limits of the mean cost per patient in each group and the mean incremental cost per life-year saved were computed using 1000 bootstrapreplicates. We also computed an acceptability curve for the incremental cost-effectiveness ratio (ICER). RESULTS We found that IPCH improved survival and was more costly than STANDARD treatment. Over a 3-year observation period, IPCH yielded an average survival gain of 8.3 months at the additional cost of euro58,086 (95% confidence interval 35,893-112,839) per life-year saved. CONCLUSION The ICER of IPCH is acceptable given the severity and burden of peritoneal carcinomatosis for which there is no alternative curative treatment.

Implications of learning effects for hospital costs of new health technologies: The case of intensity modulated radiation therapy

OBJECTIVES The impact of learning effects on the variability of costs of new health technologies in a prospective payment system (PPS) through the case of intensity modulated radiation therapy (IMRT) was studied. METHODS A series of consecutive patients treated in nine medical centers was enrolled in a prospective study. Direct costs were assessed from the perspective of the healthcare providers. We used a two-level model to explain the variability of costs: patients nested within centers. Learning effects at the center level were considered through a fixed effect (the learning curve slope) and a random effect (the initial cost level). Covariates were introduced to explain the patterns of variation in terms of patient characteristics. RESULTS The mean direct cost of IMRT was 5,962 euro (range, 2,414 euro-24,733 euro). Manpower accounted for 53 percent of this cost. Learning effects explained 42 percent of the variance between centers (which was 88 percent of the total variance) and were associated with a substantial decrease in treatment costs. The mean initial treatment direct cost was 6,332 euro in centers with a previous experience of IMRT, whereas it was 14,192 euro in centers implementing IMRT for the first time. Including logistics costs and overhead, the full cost of IMRT was 10,916 euro. Average reimbursement was 6,987 euro. CONCLUSIONS Learning effects are a strong confounding factor in the analysis of costs of innovative health technologies involving learning effects. In a PPS, innovative health technology involving learning effects necessitates specific reimbursement mechanisms.

The economic burden of melanoma in France: assessing healthcare use in a hospital setting.

The objective of this experiment was to describe healthcare use for the treatment of melanoma in a hospital setting and to assess the related annual cost using French hospital records for the year 2004. The 2004 French national database was the main source of data. Hospital stays related to melanoma care were extracted from this database, which exhaustively records hospital stays in the country. We selected stays that included at least one diagnosis of melanoma: International Classification of Diseases (ICD)-10 codes C43 ‘malignant melanoma of skin’ or D03 ‘melanoma in situ’. A second database (the French National Hospital Costs Survey) was used to compute unit costs. For each diagnosis-related group involved in melanoma care, we calculated an average cost per day from this database. Unit costs were then applied to the duration of each hospital stay related to melanoma from the 2004 national database. A total of 42 911 stays related to melanoma were identified for the year 2004. New patients, estimated by the number of surgical stays with a melanoma ICD code as the main diagnosis, amounted to 6897. Annual hospital costs for melanoma care were estimated at 59 million euros. Almost half of these costs (27 million euros) were attributable to stays with a metastasis ICD code. The main cost drivers were surgery (38% of hospital costs), follow-up evaluations (20%) and chemotherapy (17%). It was concluded that the impact of melanoma on hospital expenditures for cancer was modest. Hospital costs for stays related to melanoma represented less than 1% of total annual hospital costs for cancer for the year 2004.

Cost-Effectiveness of Treatments for Relapsing Remitting Multiple Sclerosis: A French Societal Perspective

Objectives The paper aimed to estimate the incremental cost-effectiveness ratio (ICER) at the public published price for delayed-release dimethyl fumarate versus relevant Multiple Sclerosis disease-modifying therapies available in France in June 2015. Methods The economic model was adapted to the French setting in accordance with the Haute Autorité de Santé guidelines using a model previously developed for NICE. A cohort of Relapsing Remitting Multiple Sclerosis patients was simulated over a 30-year time horizon. Twenty one health states were taken into account: Kurtzke Expanded Disability Status Scale (EDSS) 0–9 for Relapsing Remitting Multiple Sclerosis patients, EDSS 0–9 for Secondary Progressive Multiple Sclerosis patients, and death. Estimates of relative treatment efficacy were determined using a mixed-treatment comparison. Probabilities of events were derived from the dimethyl fumarate pivotal clinical trials and the London Ontario Dataset. Costs and utilities were extracted from the published literature from both the payer and societal perspectives. Univariate and probabilistic sensitivity analyses were performed to assess the robustness of the model results. Results From both perspectives, dimethyl fumarate and interferon beta-1a (IFN beta-1a) 44mcg were the two optimal treatments, as the other treatments (IFN beta-1a 30mcg, IFN beta-1b 250mcg, teriflunomide, glatiramer acetate, fingolimod) were dominated on the efficiency frontier. From the societal perspective, dimethyl fumarate versus IFN beta-1a 44mcg incurred an incremental cost of €3,684 and an incremental quality-adjusted life year (QALY) of 0.281, corresponding to an ICER of €13,110/QALY. Conclusions Despite no reference threshold for France, dimethyl fumarate can be considered as a cost-effective option as it is on the efficiency frontier.

Access to innovation: Is there a difference in the use of expensive anticancer drugs between French hospitals?

In DRG-based hospital payment systems, expensive drugs are often funded separately. In France, specific expensive drugs (including a large proportion of anticancer drugs) are fully reimbursed up to national reimbursement tariffs to ensure equity of access. Our objective was to analyse the use of expensive anticancer drugs in public and private hospitals, and between regions. We had access to sales per anticancer drug and per hospital in the year 2008. We used a multilevel model to study the variation in the mean expenditure of expensive anticancer drugs per course of chemotherapy and per hospital. The mean expenditure per course of chemotherapy was €922 [95% CI: 890-954]. At the hospital level, specialisation in chemotherapies for breast cancers was associated with a higher expenditure of anticancer drugs per course for those hospitals with the highest proportion of cancers at this site. There were no differences in the use of expensive drugs between the private and the public hospital sector after controlling for case mix. There were no differences between the mean expenditures per region. The absence of disparities in the use of expensive anticancer drugs between hospitals and regions may indicate that exempting chemotherapies from DRG-based payments and providing additional reimbursement for these drugs has been successful at ensuring equal access to care.

UT1 VALUING EQ-5D USING TIME TRADE-OFF IN FRANCE

patients with T2DM in the UK had significantly lower (p 0.0001) physical summary scores than other EU countries. Patients experiencing depression symptoms were more likely to visit the ER [OR 1.74; 95% CI:(1.35, 2.23); p 0.0001], be hospitalized [OR 1.43; 95% CI:(1.11, 1.84); p 0.005] and had more physician visits in the last six months ( 5.37, p 0.0001). Patients in Spain had significantly more provider visits (p 0.05) and ER visits (p 0.0001) than UK patients, while patients in France were hospitalized more often than UK patients (p 0.05). CONCLUSIONS: Comorbid depression in patients with T2DM greatly decreases physical and mental summary scores of the SF-12, and increases resource use. Further research is needed to clarify associations between the two conditions, including geographical and cultural influences on health outcomes in this cohort.

CAPECO: Cost evaluation of community acquired pneumonia managed in primary care

BACKGROUND Estimating the economic burden of community acquired pneumonia (CAP) managed in ambulatory setting is needed in France since no data are available. METHOD A retrospective study (CAPECO) was conducted based on a prospective French study describing patients with suspected CAP managed in primary care (CAPA). The aim of the CAPECO study was to estimate and explain medical costs of a disease episode in CAP patients only followed in ambulatory care and in hospitalised patients. Primary endpoints were the direct medical costs, impact on productivity and costs of incident CAP over one year. Secondary endpoint was to describe predictive factors of costs, hospital admission and stay length. RESULTS In this cohort of 886 patients, resulting in an incidence of CAP of 400 per 100,000 inhabitants per year, the mean direct medical cost of a disease episode of CAP was € 118.8 for strictly ambulatory patients with an equal weight for medical time, drugs, diagnostic procedures and tests. This direct cost was € 102.1 before admission for patients who were finally hospitalised. The mean cost of hospital admissions was € 3522.9. Main predictive factors of hospital admission and stay length were respectively a history of chronic respiratory disease and older age. Factors of direct medical cost were prescribing X-ray examination and having a positive X-ray. The impact of a disease episode on productivity was € 1980 (sd 1400) per ambulatory episode and € 5425 (sd 4760) per episode leading to hospital admission. CONCLUSION Costs per ambulatory episode were modest but increased substantially in hospitalised patients, who were more numerous when chronic respiratory disorders were present and in the elderly. Indirect costs were significant. Deciders should thus consider both direct and indirect costs when assessing preventive interventions in the context of this disease.