The Indirect Cost Burden of Cancer Care in Canada : A Systematic Literature Review

BACKGROUND AND OBJECTIVES: Cancer poses a substantial health and economic burden on patients and caregivers in Canada. Previous reviews have estimated the indirect cost burden as work-related productivity losses associated with cancer. However, these estimates require updating and complementing with more comprehensive data that include relevant dimensions beyond labor market costs, such as patient time, lost leisure time and home productivity losses. METHODS: A systematic review of the literature was conducted to identify studies published from 2006 to 2020 that measured and reported the indirect costs borne by cancer patients and their caregivers in Canada, from the patient, caregiver, employer, and societal perspectives. Study characteristics and cost estimation methods were extracted from relevant studies. Costs estimates were reported and converted to 2020 CAD for the following categories: lost earnings, caregiving time costs, home production losses, patient time (leisure), morbidity-, disability-, premature mortality-related costs, friction costs, and overall productivity losses. A quality assessment of individual studies was conducted for included studies using the Newcastle-Ottawa Assessment Tool. RESULTS: In total, 3980 studies were identified, of which 18 Canadian studies met the inclusion criteria for review. One-third of the studies used or developed prediction models, 38% enrolled patient cohorts, and 27% used administrative databases. Over one-third of the studies were conducted at a national level (38%). All studies employed the human capital approach to estimate costs, and 16% also used the friction cost approach. Lost earnings were higher among self-employed patients (43% vs 24% among employees) and females ($8200 vs$3200 for males). Caregiver costs ranged from $15,786 to$20,414 per patient per year. Household productivity losses were estimated to be up to $238,904 per household per year. Patient time (leisure) costs were estimated to be between$13,000 and $18,704 per patient per year. Premature annual mortality costs were estimated to be$2.98 billion overall in Quebec. Friction costs incurred by employers were estimated between $6400 and$23,987 per patient per year. Societal productivity losses associated with cancer were estimated between $75 million to$317 million, annually. CONCLUSIONS: This review suggests that the indirect cost burden of cancer is considerable from the patient, caregiver, employer, and societal perspectives. This up-to-date review of the literature provides a comprehensive understanding of the indirect cost burden by including non-labor market activity costs and by examining all relevant perspectives. These results provide a strong case for the government and employers to ensure there are supports in place to help patients and caregivers buffer the impact of cancer so they can continue to engage in productive activities and enjoy leisure time

The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review

Background: Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care. Methods: A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs. Results: Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15–400 in Canada, USD 4–609 in Western Europe, and USD 58–438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40–71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively. Conclusions: We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care

The psychosocial cost burden of cancer : A systematic literature review

BACKGROUND AND OBJECTIVE: Psychosocial costs, or quality of life costs, account for psychological distress, pain, suffering and other negative experiences associated with cancer. They contribute to the overall economic burden of cancer that patients experience. But this category of costs remains poorly understood. This hinders opportunities to make the best cancer control policy decisions. This study explored the psychosocial cost burden associated with cancer, how studies measure psychosocial costs and the impact of this burden. METHODS: A systematic literature review of academic and grey literature published from 2008 to 2018 was conducted by searching electronic databases, guided by the Institute of Medicine's conceptualization of psychosocial burden. Results were analyzed using a narrative synthesis and a weighted proportion of populations affected was calculated. Study quality was assessed using the Ottawa-Newcastle instrument. RESULTS: A total of 25 studies were included. There was variation in how psychosocial costs were conceptualized and an inconsistent approach to measurement. Most studies measured social dimensions and focused on the financial consequences of paying for care. Fewer studies assessed costs associated with the other domains of this burden, including psychological, physical, and spiritual dimensions. Fourty-four percent of cancer populations studied were impacted by psychosocial costs and this varied by disease site (38%-71%). Two studies monetized the psychosocial cost burden, estimating a lifetime cost per case ranging from CAD$427753 to CAD$528769. Studies were of varying quality; 60% of cross-sectional studies had a high risk of bias. CONCLUSIONS: Consistency in approach to measurement would help to elevate this issue for researchers and decision makers. At two-thirds of the total economic burden of cancer, economic evaluations should account for psychosocial costs to better inform decision-making. More support is needed to address the psychosocial cost burden faced by patients and their families

Economic evaluation of second line oral antidiabetics for Type 2 diabetes in Colombia

Q1Q1A608-A609Objectives: Establish incremental cost-effectiveness ratio (ICER) in cost per additional patient with glycemic control for all the oral antidiabetic medications available in Colombia, as a second-line treatment for adult patients with type 2 diabetes (DM2), who do not reach therapeutic targets with metformin and are not yet considered candidates for insulin therapy. Methods: Oral antidiabetic medications were divided into drug classes: sulfonylureas (divided between glibenclamide, other sulphonylureas), thiazolidinediones, GLP-1 receptor agonists, and DPP4 inhibitors. A systematic review of the literature was done to obtain transition probabilities in a Markov model (monthly cycles, time horizon one year) designed to represent the Colombian health system perspective. The main outcome considered was glycemic control, but data on adherence and adverse events were also collected. Costs (in 2014 Colombian pesos; 1 euro = COP 2,660) were estimated from base cases obtained from multidisciplinary expert panel meetings, with local costs applied from national tariff manuals and official drug price registries. Sensitivity analyses were performed. Results: Annual treatment costs ranged from € 116 for glibenclamide, and € 98 for other sulphonylureas, to € 12,205 for GLP-1 receptor agonists. Number of patients with glycemic control (per 1000) were glibenclamide 145, sulphonylureas 265, thiazolidinediones 472, GLP-1 receptor agonists 326, and DPP4 inhibitors 417: Compared against other sulfonylureas, glibenclamide was dominated, while ICERs per additional patient with glycemic control per year would be € 516 for DPP-4 inhibitors, € 712 for thiazolidinediones and € 66,790 for GLP-1 receptor agonists. Critical variables in the sensitivity analyses were drug costs (particularly for GLP-1 receptor agonists), but also patient adherence to medication (with insuficient local information). Conclusions: Sulfonylureas, other than glibenclamide, DPP-4 inhibitors and thiazolidinediones are cost-effective alternatives as second-line treatment for DM2 patients that require oral antidiabetics in Colombia. Patient adherence requires further local research

Impact of the COVID-19 pandemic on faecal immunochemical test-based colorectal cancer screening programmes in Australia, Canada, and the Netherlands: a comparative modelling study

Background: Colorectal cancer screening programmes worldwide have been disrupted during the COVID-19 pandemic. We aimed to estimate the impact of hypothetical disruptions to organised faecal immunochemical test-based colorectal cancer screening programmes on short-term and long-term colorectal cancer incidence and morta

Psoriatic Arthritis Screening: A Systematic Review, Meta-Analysis, and Economic Evaluation

Psoriatic arthritis (PsA) is an autoimmune disease that affects the skin and the musculoskeletal system. It causes joint damage and psoriasis of the skin. Untreated disease is usually related to a delayed diagnosis and has been associated with physical disability and high treatment costs later on. Although expensive biologic therapy has proven to slow disease progression and improve health outcomes, rheumatologists have suggested initiating treatment with less expensive Disease Modifying Anti-Rheumatic Drugs (DMARDs). Identifying early PsA is expected to improve health outcomes through early treatment with DMARDs. It is also expected to reduce the proportion of severe disease and biologic treatment. Given that the prevalence of PsA among psoriasis patients is relatively high, dermatologists are well-positioned to screen for arthritis symptoms with already validated self-administered screening questionnaires for patients with psoriasis. The goal of this thesis is to systematically review the characteristics and accuracy estimates of the validated PsA screening tools (chapter 2). It also seeks to evaluate the cost-effectiveness of implementing a PsA screening program in Canada relative to the current practice where psoriasis patients are not systematically screened (chapter 3). The National Institute of Health Research is currently developing a randomized controlled trial for PsA screening in the United Kingdom that will inform the cost-effectiveness model presented in this thesis

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Abstract Background Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools. Objective This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them. Methods A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized. Results Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early. Conclusions To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary

Evaluation of interventions to improve electronic health record documentation within the inpatient setting: a protocol for a systematic review

Abstract Background Electronic health records (EHRs) are increasing in popularity across national and international healthcare systems. Despite their augmented availability and use, the quality of electronic health records is problematic. There are various reasons for poor documentation quality within the EHR, and efforts have been made to address these areas. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or within paper documentation. This systematic review aims to assess the effectiveness of different interventions seeking to improve EHR documentation within an inpatient setting. Methods We will employ a comprehensive search strategy that encompasses four distinct themes: EHR, documentation, interventions, and study design. Four databases (MEDLINE, EMBASE, CENTRAL, and CINAHL) will be searched along with an in-depth examination of the grey literature and reference lists of relevant articles. A customized hybrid study quality assessment tool has been designed, integrating components of the Downs and Black and Newcastle-Ottawa Scales, into a REDCap data capture form to facilitate data extraction and analysis. Given the predicted high heterogeneity between studies, it may not be possible to standardize data for a quantitative comparison and meta-analysis. Thus, data will be synthesized in a narrative, semi-quantitative manner. Discussion This review will summarize the current level of evidence on the effectiveness of interventions implemented to improve inpatient EHR documentation, which could ultimately enhance data quality in administrative health databases. Systematic review registration PROSPERO CRD4201708349

Impact of the COVID-19 pandemic on faecal immunochemical test-based colorectal cancer screening programmes in Australia, Canada, and the Netherlands: a comparative modelling study

Background: Colorectal cancer screening programmes worldwide have been disrupted during the COVID-19 pandemic. We aimed to estimate the impact of hypothetical disruptions to organised faecal immunochemical test-based colorectal cancer screening programmes on short-term and long-term colorectal cancer incidence and mortality in three countries using microsimulation modelling. Methods: In this modelling study, we used four country-specific colorectal cancer microsimulation models–Policy1-Bowel (Australia), OncoSim (Canada), and ASCCA and MISCAN-Colon (the Netherlands)—to estimate the potential impact of COVID-19-related disruptions to screening on colorectal cancer incidence and mortality in Australia, Canada, and the Netherlands annually for the period 2020–24 and cumulatively for the period 2020–50. Modelled scenarios varied by duration of disruption (3, 6, and 12 months), decreases in screening participation after the period of disruption (0%, 25%, or 50% reduction), and catch-up screening strategies (within 6 months after the disruption period or all screening delayed by 6 months). Findings: Without catch-up screening, our analysis predicted that colorectal cancer deaths among individuals aged 50 years and older, a 3-month disruption would result in 414–902 additional new colorectal cancer diagnoses (relative increase 0·1–0·2%) and 324–440 additional deaths (relative increase 0·2–0·3%) in the Netherlands, 1672 additional diagnoses (relative increase 0·3%) and 979 additional deaths (relative increase 0·5%) in Australia, and 1671 additional diagnoses (relative increase 0·2%) and 799 additional deaths (relative increase 0·3%) in Canada between 2020 and 2050, compared with undisrupted screening. A 6-month disruption would result in 803–1803 additional diagnoses (relative increase 0·2–0·4%) and 678–881 additional deaths (relative increase 0·4–0·6%) in the Netherlands, 3552 additional diagnoses (relative increase 0·6%) and 1961 additional deaths (relative increase 1·0%) in Australia, and 2844 additional diagnoses (relative increase 0·3%) and 1319 additional deaths (relative increase 0·4%) in Canada between 2020 and 2050, compared with undisrupted screening. A 12-month disruption would result in 1619–3615 additional diagnoses (relative increase 0·4–0·9%) and 1360–1762 additional deaths (relative increase 0·8–1·2%) in the Netherlands, 7140 additional diagnoses (relative increase 1·2%) and 3968 additional deaths (relative increase 2·0%) in Australia, and 5212 additional diagnoses (relative increase 0·6%) and 2366 additional deaths (relative increase 0·8%) in Canada between 2020 and 2050, compared with undisrupted screening. Providing immediate catch-up screening could minimise the impact of the disruption, restricting the relative increase in colorectal cancer incidence and deaths between 2020 and 2050 to less than 0·1% in all countries. A post-disruption decrease in participation could increase colorectal cancer incidence by 0·2–0·9% and deaths by 0·6–1·6% between 2020 and 2050, compared with undisrupted screening. Interpretation: Although the projected effect of short-term disruption to colorectal cancer screening is modest, such disruption will have a marked impact on colorectal cancer incidence and deaths between 2020 and 2050 attributable to missed screening. Thus, it is crucial that, if disrupted, screening programmes ensure participation rates return to previously observed rates and provide catch-up screening wherever possible, since this could mitigate the impact on colorectal cancer deaths. Funding: Cancer Council New South Wales, Health Canada, and Dutch National Institute for Public Health and Environment