Impact of Nonconcordance With NCCN Guidelines on Resource Utilization, Cost, and Mortality in De Novo Metastatic Breast Cancer

View More View Less
  • a University of Alabama at Birmingham Comprehensive Cancer Center, and Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama; JPS Health Network Center for Outcomes Research, Fort Worth, Texas; and Division of Preventive Medicine, Institute for Cancer Outcomes and Survivorship, and School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama.
Restricted access

Background: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) have directed the care of patients with cancer for >20 years. Payers are implementing guideline-based pathway programs that restrict reimbursement for non–guideline-based care to control costs, yet evidence regarding impact of guidelines on outcomes, including mortality, Medicare costs, and healthcare utilization, is limited. Patients and Methods: This analysis evaluated concordance of first treatment with NCCN Guidelines for women with de novo stage IV metastatic breast cancer (MBC) included within the SEER-Medicare linked database and diagnosed between 2007 and 2013. Cox proportional hazards models were used to evaluate the association between mortality and guideline concordance. Linear mixed-effects and generalized linear models were used to evaluate total cost to Medicare and rates of healthcare utilization by concordance status. Results: We found that 19% of patients (188/988) with de novo MBC received nonconcordant treatment. Patients receiving nonconcordant treatment were more likely to be younger and have hormone receptor–negative and HER2-positive MBC. The most common category of nonconcordant treatment was use of adjuvant regimens in the metastatic setting (40%). Adjusted mortality risk was similar for patients receiving concordant and nonconcordant treatments (hazard ratio [HR], 0.85; 95% confidence limit [CL], 0.69, 1.05). When considering category of nonconcordance, patients receiving adjuvant regimens in the metastatic setting had a decreased risk of mortality (HR, 0.60; 95% CL, 0.43, 0.84). Nonconcordant treatments were associated with $1,867 higher average Medicare costs per month compared with concordant treatments (95% CL, $918, $2,817). Single-agent HER2-targeted therapy was the highest costing category of nonconcordance at $3,008 (95% CL, $1,014, $5,001). Healthcare utilization rates were similar for patients receiving concordant and nonconcordant treatments. Conclusions: Despite a lack of survival benefit, concordant care was associated with lower costs, suggesting potential benefit to increasing standardization of care. These findings may influence policy decisions regarding implementation of pathway programs as health systems transition to value-based models.

Correspondence: Gabrielle B. Rocque, MD, MSPH, Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL 35294. Email: grocque@uabmc.edu
  • 1.

    NCCN. Development and Update of the NCCN Guidelines. Available at: http://www.nccn.org/professionals/development.aspx. Accessed May 11, 2015.

    • Search Google Scholar
    • Export Citation
  • 2.

    Gradishar WJ, Anderson BO, Balassanian R. Breast cancer version 2.2015. J Natl Compr Canc Netw 2015;13:448475.

  • 3.

    Eaton AA, Sima CS, Panageas KS. Prevalence and safety of off-label use of chemotherapeutic agents in older patients with breast cancer: estimates from SEER-Medicare data. J Natl Compr Canc Netw 2016;14:5765.

    • Search Google Scholar
    • Export Citation
  • 4.

    Hamel S, McNair DS, Birkett NJ. Off-label use of cancer therapies in women diagnosed with breast cancer in the United States. Springerplus 2015;4:209.

    • Search Google Scholar
    • Export Citation
  • 5.

    Shih YC, Ganz PA, Aberle D. Delivering high-quality and affordable care throughout the cancer care continuum. J Clin Oncol 2013;31:41514157.

    • Search Google Scholar
    • Export Citation
  • 6.

    Conti RM, Bernstein AC, Villaflor VM. Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists. J Clin Oncol 2013;31:11341139.

    • Search Google Scholar
    • Export Citation
  • 7.

    Zon RT, Frame JN, Neuss MN. American Society of Clinical Oncology policy statement on clinical pathways in oncology. J Oncol Pract 2016;12:261266.

    • Search Google Scholar
    • Export Citation
  • 8.

    Neubauer MA, Hoverman JR, Kolodziej M. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract 2010;6:1218.

    • Search Google Scholar
    • Export Citation
  • 9.

    Hoverman JR, Cartwright TH, Patt DA. Pathways, outcomes, and costs in colon cancer: retrospective evaluations in 2 distinct databases. Am J Manag Care 2011;17(Suppl 5):SP4552.

    • Search Google Scholar
    • Export Citation
  • 10.

    Polite BN, Page RD, Nabhan C. Oncology pathways—preventing a good idea from going bad. JAMA Oncol 2016;2:297298.

  • 11.

    Ambs A, Warren JL, Bellizzi KM. Overview of the SEER-Medicare Health Outcomes Survey linked dataset. Health Care Financ Rev 2008;29:521.

  • 12.

    Klabunde CN, Potosky AL, Legler JM, Warren JL. Development of a comorbidity index using physician claims data. J Clin Epidemiol 2000;53:12581267.

    • Search Google Scholar
    • Export Citation
  • 13.

    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373383.

    • Search Google Scholar
    • Export Citation
  • 14.

    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613619.

    • Search Google Scholar
    • Export Citation
  • 15.

    Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994;81:515526.

  • 16.

    Schwentner L, Wockel A, Konig J. Adherence to treatment guidelines and survival in triple-negative breast cancer: a retrospective multi-center cohort study with 9,156 patients. BMC Cancer 2013;13:487.

    • Search Google Scholar
    • Export Citation
  • 17.

    Wockel A, Kurzeder C, Geyer V. Effects of guideline adherence in primary breast cancer—a 5-year multi-center cohort study of 3976 patients. Breast 2010;19:120127.

    • Search Google Scholar
    • Export Citation
  • 18.

    Denu RA, Hampton JM, Currey A. Influence of patient, physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer. Cancer Epidemiol 2016;40:714.

    • Search Google Scholar
    • Export Citation
  • 19.

    Carrick S, Parker S, Wilcken N. Single agent versus combination chemotherapy for metastatic breast cancer. Cochrane Database Syst Rev 2005:CD003372.

    • Search Google Scholar
    • Export Citation
  • 20.

    Carrick S, Parker S, Thornton CE. Single agent versus combination chemotherapy for metastatic breast cancer. Cochrane Database Syst Rev 2009:CD003372.

    • Search Google Scholar
    • Export Citation
  • 21.

    Dear RF, McGeechan K, Jenkins MC. Combination versus sequential single agent chemotherapy for metastatic breast cancer. Cochrane Database Syst Rev 2013:CD008792.

    • Search Google Scholar
    • Export Citation
  • 22.

    Treska V, Cerna M, Kydlicek T, Treskova I. Prognostic factors of breast cancer liver metastasis surgery. Arch Med Sci 2015;11:683685.

  • 23.

    New NCCN Guidelines include evidence blocks to illustrate value in breast, colon, kidney, and rectal cancers. J Natl Compr Canc Netw 2016;14:xxxivxxxv.

    • Search Google Scholar
    • Export Citation
  • 24.

    Feinberg BA, Lang J, Grzegorczyk J. Implementation of cancer clinical care pathways: a successful model of collaboration between payers and providers. J Oncol Pract 2012;8(3 Suppl):e38s43s.

    • Search Google Scholar
    • Export Citation
  • 25.

    Kreys ED, Koeller JM. Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer's perspective. J Oncol Pract 2013;9:e241247.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 593 403 16
PDF Downloads 280 193 12
EPUB Downloads 0 0 0