Centralization of care for patients with advanced‐stage ovarian cancer

Abstract

BACKGROUND. The objective of this study was to evaluate the cost‐effectiveness of centralized referral of patients with advanced‐stage epithelial ovarian cancer who underwent primary cytoreductive surgery and adjuvant chemotherapy. METHODS. A decision‐analysis model was used to compare 2 referral strategies for patients with advanced‐stage ovarian cancer: 1) referral to an expert center, with a rate of optimal primary cytoreduction of 75% and utilization of combined intraperitoneal and intravenous adjuvant chemotherapy, and 2) referral to a less experienced center, with a rate of optimal primary cytoreduction of 25% and adjuvant treatment that consisted predominantly of intravenous chemotherapy alone. The cost‐effectiveness of each strategy was evaluated from the perspective of society. RESULTS. A cost‐effectiveness analysis revealed that the strategy of expert center referral had an overall cost per patient of $50,652 and had an effectiveness of 5.12 quality‐adjusted life years (QALYs). The strategy of referral to a less experienced center carried an overall cost of $39,957 and had an effectiveness of 2.33 QALYs. The expert center strategy was associated with an additional 2.78 QALYs at an incremental cost of $10,695 but was more cost‐effective, with a cost‐effective ratio of $9893 per QALY compared with $17,149 per QALY for the less experienced center referral strategy. Sensitivity analyses and a Monte Carlo simulation confirmed the robustness of the model. CONCLUSIONS. According to results from the decision‐analysis model, centralized referral of patients with ovarian cancer to an expert center was a cost‐effective healthcare strategy and represents a paradigm for quality cancer care, delivering superior patient outcomes at an economically affordable cost. Increased efforts to align current patterns of care with a universal strategy of centralized expert referral are warranted. Cancer 2007. © 2007 American Cancer Society.

Is centralization of ovarian cancer care warranted?

“…Our results roughly corroborate those by Bristow et al [9]. They reported that centralized care of patients with advanced-stage ovarian cancer was cost-effective based on hypothetical debulking scenarios.…”

“…Indeed, our scenario analyses evaluating a 70% optimal debulking rate in specialized hospitals indicated that referral to specialized hospitals would be a cost-effective strategy. The study of Bristow et al [9] taken together with our own results provides strong support for the concept of a concentration of expertise to improve survival and cost-effectiveness.…”

“…Furthermore, almost all of our cost and effectiveness estimates were based on actual patient data, whereas Bristow et al obtained clinical data and most of the cost estimates from the literature. The optimal debulking rates in our study population were higher in the nonspecialized settings and lower in the specialized settings than the hypothetical debulking rates of Bristow et al [9].…”

“…The study by Bristow et al [9] provides support for the notion that surgical success is an important determinant of overall survival benefit and subsequently costeffectiveness. Indeed, our scenario analyses evaluating a 70% optimal debulking rate in specialized hospitals indicated that referral to specialized hospitals would be a cost-effective strategy.…”

“…Bristow et al studied the costeffectiveness of centralized care for patients with advanced-stage ovarian cancer and used a decision model to compare two hypothetical extremes: treatment in a non-specialized setting attaining 25% optimal debulking rates versus treatment in specialized centers with 75% optimal debulking rates and intra-peritoneal chemotherapy [9]. They reported that centralized care for patients with ovarian cancer would result in cost-effective healthcare [9]. However, in the Netherlands, optimal debulking rates in non-specialized settings are slightly higher.…”