6565 Background: New cancer drugs are increasingly expensive and raise difficult questions about the magnitude of therapeutic benefit needed to justify their incremental cost. In this context, it is unclear whether oncologists endorse standard thresholds of $50,000 to $100,000 per year of life. Methods: We surveyed 1,379 U.S. and 356 Canadian (Cdn) oncologists and asked how much longer a patient would need to survive metastatic cancer to justify the expense of a new treatment. To determine the stability of attitudes towards cost-effectiveness (CE) we randomized oncologists to receive two different versions of the scenario in which the price of the new treatment was varied (higher versus lower drug cost). In the U.S. survey, oncologists were also randomized to receive surveys in which we varied the provision of contextual information about the CE of several familiar interventions. Both U.S. and Cdn oncologists were asked to indicate what they “thought was ‘good value for money’ expressed as cost per life-year gained (LYG).” Results: Response rate was 57% in the U.S. and 48% in Canada. CE ratios implied by oncologists’ responses differed significantly between the groups randomized to the higher versus lower price of the hypothetical treatment (p < 0.001 U.S., p < 0.0001 Canada), but were independent of randomization to varying contextual information (p > 0.1). The median willingness to pay for a quality-adjusted year of life ranged from $150,000 (for oncologists considering the lower priced drug) to $250,000 (for those considering the more expensive drug) in both countries. Among those who considered the more expensive drug, 25% of respondents implicitly endorsed a CE ratio greater than $600,000 (U.S.) and $500,000 (Canada). In contrast, when asked directly to indicate CE ratios that were good value for the money outside of the clinical scenario, 70% (U.S.) and 64% (Canada) of respondents indicated values of less than $100,000 per LYG. Conclusions: Oncologists responding to our survey provided inconsistent views on how much benefit expensive new drugs should provide to be worthwhile. This suggests that means of eliciting input from physicians that reflect more stable attitudes need to be developed to appropriately inform decision-makers. No significant financial relationships to disclose.
Background: Substantial evidence exists that quitting smoking after a cancer diagnosis can result in improved treatment efficacy and safety, decreased risk of recurrence and second primary cancers, and lower mortality. Based on this evidence, Cancer Care Ontario (CCO) implemented a smoking cessation program for new ambulatory cancer patients in Ontario's 14 Regional Cancer Centers (RCCs) in 2014. Implementation is monitored centrally by CCO using performance indicators and monthly discussions with regional champions. Significant variation in implementation processes and performance metrics amongst RCCs highlighted a need for quality improvements. Method: Funding received from the Canadian Partnership Against Cancer enabled CCO to undertake a series of initiatives to enhance provider and patient education and to standardize processes. Based on program learnings and emerging evidence, the program model was revised from 5As (Ask, Advise, Assess, Assist, Arrange) to 3As (Ask, Advise, Act), and site-specific recommendations were provided to support consistency in implementation. Patient-facing materials, an on-line learning module, scripts and videos were developed to educate healthcare providers and patients on the health benefits of smoking cessation in order to improve rates of screening and referrals to cessation services. Importantly, two performance indicators have been included on CCO's Regional Scorecard, which measures performance against targets and determines an RCC's overall performance ranking within the province. Result: Performance on the Tobacco Use Screening indicator (proportion of new cancer patients screened for tobacco use) was 42.0% across Ontario in April 2015 when first included on the Scorecard. By March 2017, performance had improved to 62.7%, with significant improvements seen among the lowest-performing RCCs. The Accepted a Cessation Referral indicator (proportion of tobacco users who accepted referral to cessation services) improved only modestly from 19.7% in Q1 of 2016/17 to 23.4% in Q4. This indicator will be added to the Regional Scorecard starting in 2017/18. Both indicators are discussed at the quarterly performance reviews with the Regional Vice-Presidents responsible for cancer services. In 2016/17, lung cancer patients accounted for the largest percentage of current users of tobacco by tumor site (21.9%); in addition, almost a quarter of all patients accepting a referral (24.3%) were lung cancer patients. Conclusion: The CCO performance Scorecard is a strong driver of quality improvement. CCO is encouraged by regional enthusiasm to adopt the refined 3As model, and anticipates further improvements in the performance metrics, especially in the number of tobacco users who accept referral to cessation services.
9502 Background: Drug costs and reimbursement issues offer significant challenges to U.S. and Canadian oncologists even though they practice in substantially different health care systems. However, little is known about the attitudes of American and Canadian oncologists towards these issues. Methods: We surveyed 1,379 U.S. and 356 Cdn oncologists to assess their attitudes to cancer drug costs, CE and reimbursement policies. Results: Response rate was 57% in the U.S. and 48% in Canada. Oncologists in both countries stated that patients' “out-of-pocket” drug costs influenced their treatment recommendations (84% U.S., 80% Cdn respondents). Most respondents felt that every patient should have access to effective cancer treatments regardless of cost (66% US; 54% Cdn), while 59% of U.S. and 72% of Cdn and respondents believed that patients should only have access to effective cancer treatments that provided “good value for money.” 70% of U.S. and 64% Cdn respondents felt that <$100,000 per life year gained was a reasonable definition of “good value for money” but less than half of respondents (42% US, 49% Cdn) felt well prepared to interpret and use CE information in their treatment decisions. A majority of respondents (57% US, 69% Cdn) felt government price controls for cancer drugs are needed while a minority felt that more cost-sharing by patients was needed (29% US, 37% Cdn). Most oncologists felt that evaluating whether a drug provides “good value” should be overseen by an independent non-profit agency (57% US, 71% Cdn) or physicians (61% US and Cdn); in contrast, few believed that government (21% US, 33% Cdn), patients (36% US, 37% Cdn) or insurance companies (6% US, 10% Cdn) should determine “good value”. 79% of U.S. and 69% of Cdn respondents felt more use of CE data in coverage and reimbursement decisions is needed. Conclusions: Oncologists in the U.S. and Canada share many similar attitudes to cancer drug costs, CE, and reimbursement policies despite differences in their health care systems. In both countries, oncologists favor more use of CE information. No significant financial relationships to disclose.
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