Herceptin® treatments in hospital and at CLSCs for breast cancer patients in Quebec: comparative analysis of costs and care trajectories.
Gerald Batist, MD, CM, CQ, FRCP, FACP, FAHC*; Geneviève Faucher, MD**; Sonia Joannette, RN***; Yanick Labrie, MA****; Giovanna Speranza, MD***.
ABSTRACT
Background: In the fall of 2019, a pilot project was initiated in Quebec in which 30 patients with HER2+ breast cancer received subcutaneous (SC) administration of Herceptin® at local community service centres (CLSCs) rather than receiving it intravenously (IV) in hospitals. Objectives: This multicentre study aimed to estimate all the direct and indirect costs of cancer treatments in both care settings. Method: Semi-structured interviews were conducted with 30 healthcare professionals at the six institutions participating in the pilot project—4 hematologist-oncologists, 2 hematology-oncology pharmacists, 2 pharmacy technicians, 16 nurse clinicians, and 6 administrative staff members—in order to map the steps in patients’ care trajectories and estimate the time required for each step. Interviews took place between June 9, 2021 and May 16, 2022. Official and administrative databases were used to measure the costs associated with the use of professional, medical, and administrative resources as part of the pilot project. Results: Mean total per-patient time for IV administration of Herceptin® was estimated as 111.4 minutes per treatment visit per patient in the hospital versus 36.8 minutes per cycle per patient for SC administration in the CLSC. The annual per-patient direct cost (excluding the medication) was estimated at $4,211 in the hospital (IV) and at $760 in the CLSC (SC). Incorporating lost work and leisure time, the annual per-patient cost climbs to $7,270 in the hospital and at $1,775 in the CLSC. Analyzing different scenarios on the potential number of eligible patients, we calculated that the savings for the Quebec government could vary between $5.4 million and $7.2 million annually for Herceptin® patients. Conclusion: The results of the Herceptin® pilot project implemented in three CLSCs in Quebec show that switching from IV mode to SC mode would alleviate the pressure on the medical teams of oncology clinics in hospitals, whose capacity is currently saturated. By using fewer health professionals and infusion chairs to treat the same number of patients with SC mode, these resources would then be available to be redeployed elsewhere in the healthcare system to treat other patients. This could help improve access to care for a greater number of Quebec patients.
Acknowledgements: n/a
Author(s) affiliations: *CIUSSS Centre-Ouest-de-l’Île-de-Montréal; **CISSS Des Laurentides; ***CISSS Montérégie Centre; ****Canadian Health Policy Institute.
Correspondence: Yanick Labrie ([email protected])
Cite: Batist, Gerald et al (2023). Herceptin® treatments in hospital and at CLSCs for breast cancer patients in Quebec: comparative analysis of costs and care trajectories. Canadian Health Policy, APR 2023. https://doi.org/10.54194/ZOLI9225. canadianhealthpolicy.com.
Disclosure: This research project received financial support from Hoffmann-La Roche Ltd. The research was conducted in a context in which the researchers, who are solely responsible for the results in this report, were fully and completely independent.
Journal: ISSN 2562-9492 | DOI https://doi.org/10.54194/XYCP5241
Key Words: Canada, cancer, pharmaceutical, innovation, health
Open access sponsor: n/a
Publisher: Canadian Health Policy Institute Inc. www.chpi.ca
Status: Peer reviewed.
Submitted: 28 MAR 2023. Published: 03 MAY 2023.
INTRODUCTION
In Canada, breast cancer is the most common type of cancer in women, representing one quarter of all new cancer cases diagnosed in 2021. It is estimated that approximately 6,900 of the 28,920 women who will be diagnosed with it during the current year will be in Quebec (Canadian Cancer Society, 2022). The number of new cases of breast cancer is likely to continue its upward trend for at least the next two decades because of the growth and aging of the population (Poirier et al., 2019).
These increasing cases of cancer are an enormous economic burden for Canadian citizens and governments. Researchers recently estimated that the societal cost of cancer Canada-wide was $26.2 billion in 2021. With respect to breast cancer, the same researchers estimated the societal cost as $2.14 billion for Canadians. This type of cancer represents the heaviest economic burden in the country, after lung cancer (Garaszczuk et al., 2022).
A particularly virulent form of breast cancer, HER2+, occurs in approximately 15%–25% of cases (Dent et al., 2019). Treatment for HER2+ patients also imposes substantial costs on public healthcare systems. Ontario researchers calculated that treatment for patients diagnosed between 2012 and 2017 required total government expenditures of $680 million (Brezden-Masley et al., 2021). By extrapolating across Canada, treatment costs might represent healthcare expenses of nearly $1.8 billion over five years for all governments.
In addition to those expenses, the rise in breast cancer cases results in increased pressure for outpatient oncology clinic staff at Quebec hospitals, which are already at full capacity. Therefore, it is increasingly crucial to try to optimize the use of human and material resources in the healthcare network, while maintaining the same quality-of-care standards for patients.
LITERATURE REVIEW
Trastuzumab (Herceptin®), developed by Hoffmann-La Roche, is a monoclonal antibody designed to target and block HER2+ protein function. By neutralizing the protein, the medication provides significant improvement in prognosis and chances of survival for patients with this form of cancer, as demonstrated in randomized clinical trials (Slamon et al. 2011; Pivot et al., 2017b). It has been commonly used in many European countries, in both intravenous (IV) and subcutaneous (SC) forms, since it was approved by the European Medicines Agency (EMA) (Lieutenant et al., 2015; Valachis et al., 2019).[1]
Clinical studies have demonstrated that the drug’s efficacy and safety were the same when Herceptin® was administered in either form, IV or SC (Ismael et al., 2012; Gligorov et al., 2017; Zambetti et al., 2017; Jackisch et al., 2019). However, with the SC formulation, healthcare professionals spend less time preparing and administering treatment than with the IV formulation. Many observational studies on treatment and travel times of patients cared for in hospital have shown gains in efficiency and time savings for patients and healthcare professionals with Herceptin® SC, compared with Herceptin® IV (Altini et al., 2021; Anderson et al., 2020; Burcombe et al., 2013; Farolfi et al., 2018; Favier et al., 2018; Franken et al., 2018; Hedayati et al., 2019; Jackisch et al., 2015; Lieutenant et al., 2015; Lopez-Vivanco et al., 2017; Maniakadis et al., 2017; Mitchell and Morrissey, 2019; North et al., 2019; O’Brien et al., 2019; Olofsson et al., 2016; Olsen et al., 2018; Papadmitriou et al., 2015; Pivot et al., 2017a; Tjalma et al., 2018; Valachis et al., 2019).
In one study, the authors calculated that the mean administration time was 22.6 minutes with Herceptin® SC, versus 77.8 minutes with Herceptin® IV. Mean work time needed by healthcare professionals was 5 minutes for preparing the SC formulation, versus 13.9 minutes for the IV formulation, and 9.8 minutes for administering Herceptin® SC, versus 17.9 minutes for administering Herceptin® IV (De Cock et al., 2016).
Researchers have also demonstrated in clinical studies that the subcutaneous form of Herceptin® provided significant improvement in the experience of patients and healthcare professionals. According to a recent investigation during which 467 patients with early breast cancer were interviewed, the majority (88.9%) preferred Herceptin© SC over its IV form, as did 77% of the 235 healthcare professionals surveyed (Pivot et al., 2014).
THE SUBCUTANEOUS HERCEPTIN® PILOT PROJECT AT CLSCS
In Quebec, Herceptin® is available for IV administration in hospitals because it appears on the List of Medications—Institutions. Although a new subcutaneous (SC) formulation was approved by Health Canada in September 2018 and recommended by the Institut national d’excellence en santé et services sociaux (INESSS) in January 2019 for inclusion on the List of Medications—Institutions for adjuvant treatment of breast cancer (exceptional medication), it is still not accessible to Quebec patients.[2]
Treatments with SC injection of the medication at three CLSCs (local community service centres) were tested as part of a pilot project initiated in the fall of 2019 at three Quebec CISSS/CIUSSSs (CIUSSS du Centre-Ouest-de-l’Île-de-Montréal, CISSS des Laurentides and CISSS de la Montérégie-Centre). The pilot project was intended to evaluate whether the SC treatment option is beneficial economically for the public network, by freeing up scarce resources, and clinically for the patients involved, by promoting better access to care and improved satisfaction with treatments.
Establishing oncology services at CLSCs for treating HER2+ breast cancer patients with the SC formulation of Herceptin® might be a beneficial option for Quebec, in line with one of the government’s priority objectives of reducing the cancer burden and promoting access to specialized services. That is one of the priorities set out in the Quebec Ministry of Health and Social Services 2019–2023 Strategic Plan (MSSS, 2021).
Moreover, the SC option in the community may be beneficial for patients, by saving them travel-related expenses. Since hospitals are often further from patients’ homes than CLSCs are, the costs of getting to hospital (travel and parking expenses) may be higher. Time away from work and family time may also be negatively affected by these greater distances to travel and the additional costs.
The Covid-19 pandemic that spread in the spring of 2020 brought its share of challenges for healthcare institutions and professionals and made it necessary to do a major re-organization of oncology care. One avenue increasingly considered in the medical community, particularly in Europe, involves reducing hospital visits and admissions as much as possible for cancer patients (van de Haar, 2020). In this context, administering Herceptin® SC in the community is likely to reduce the risks of infection and other immune system complications, without compromising the outcomes of cancer treatments.
Lastly, hospital expenses are rising and institutions would benefit from finding ways of improving their effectiveness and access to medically required patient care (Bilodeau et al., 2004). Quebec is still struggling with major wait-time problems in its public healthcare network, which were exacerbated by the Covid-19 pandemic (CIHI, 2023; Labrie, 2023). Consequently, receiving Herceptin® SC treatment at a CLSC instead of the IV form in hospital might free up scarce resources, thereby improving access to oncology centres for other patients who require an infusion in hospital.
OBJECTIVES AND METHODOLOGY
There were two main objectives of this multicentre study conducted in hospital and the community. The first objective was to map in detail the care trajectory of HER2+ breast cancer patients treated with the IV form of Herceptin® in three Quebec hospitals participating in the pilot project and of patients who received the SC form at the CLSCs affiliated with those institutions. This involved identifying each of the tasks and activities (direct and indirect) carried out by healthcare institution staff for both patient care trajectories.
The study’s second goal was to estimate all the direct and indirect costs of Herceptin® treatments at both sites (hospital versus CLSC) and for both routes of administration. Thus, the intention was to determine whether moving these treatments into the community may generate gains in efficiency for the healthcare network, by mobilizing fewer resources and reducing government spending.
DATA AND INDICATORS
A mixed methodological approach, combining semi-structured interviews and administrative databases, was used for this study.[3]
Semi-structured interviews: Interviews were conducted with staff members at six healthcare institutions: Montreal’s Jewish General Hospital (JGH), Hôpital régional de Saint-Jérôme (HSJ), Hôpital Charles-Le Moyne (HCL), CLSC de Benny Farm, CLSC Lafontaine and CLSC Samuel de Champlain. To avoid travel from the healthcare institutions involved, the interviews—which lasted approximately 30 minutes—were conducted remotely by videoconference using the TEAMS (Microsoft©) platform.
The interviews were used to measure the following indicators:
- Mean time for each step in the patient healthcare trajectory during treatment visits (in minutes), for both patients and staff members;
- Total time spent by patients at the hospital or CLSC during treatment visits, including wait time and transition between the various steps (in minutes);
- The extent of professional, medical, and administrative resources required during treatment visits with both routes of administration.
Administrative and official databases: To measure the costs associated with the use of professional, medical, and administrative resources as part of the pilot project, official databases and the healthcare institutions’ administrative databases were used. For healthcare network employees, we used the salary scales of the CPNSSS (Comité patronale de négociation du secteur de la santé et des services sociaux [healthcare and social services management negotiating committee]). The results of the Institut de la statistique du Québec (ISQ) Survey on Total Compensation (Racila, 2021) were consulted to obtain the average wages (including employee benefits) of various categories of healthcare professionals.
These databases were used to measure the following indicators:
- Cost of professional resources associated with Herceptin® treatments;
- Volume of medical consumables used during treatment visits and their costs;
- Extent of administration, operation, and maintenance expenses for equipment and buildings used for treatments;
- Expenses related to patient travel for treatment purposes (to hospital and CLSC);
- Productivity losses caused by absences from work or inability to work during treatment visits.
RESULTS
The steps in the patient healthcare trajectory were mapped and time taken was estimated from semi-structured interviews conducted with 30 healthcare professionals at the 6 institutions taking part in the pilot project: 4 hematologist-oncologists, 2 hematology-oncology pharmacists, 2 pharmacy technicians, 16 nurse clinicians, and 6 administrative staff members. Interviews were conducted between June 9, 2021 and May 16, 2022.
Comparing treatment times in hospital (IV) and at a CLSC (SC)
All the tasks associated with IV and SC administration of chemotherapy during a treatment visit were identified and are described in detail in Tables A1 and A2 in Appendix 1 of the report.
The time taken for all treatments over one year, consisting of 18 cycles per patient, was estimated for both administration routes and sites. Mean total time for IV Herceptin® therapy in hospital came to 2,005 minutes versus 663 minutes for SC administration at a CLSC (see Table 1).
Mean total per-patient time to finish each activity was then measured and pooled for each administration route for comparison purposes. Mean total time for IV administration was estimated as 111.4 minutes per treatment visit per patient versus 36.8 minutes per cycle per patient for SC administration.
SC administration was associated with a reduction in the mean total time to carry out the whole care trajectory for one patient, including a significant reduction in chair time during the treatment administration step (infusion). Compared with IV administration, SC administration of Herceptin® provided a 67% reduction (1 hour and 15 minutes) in the mean total per-patient time needed to carry out all planned activities for a typical treatment cycle. This time savings is comparable to what was obtained by Altini et al. (2021), who used a similar method using Italian data (1 hour and 18 minutes).
Comparing treatment costs in hospital (IV) and at a CLSC (SC)
Mean costs for both Herceptin® administration routes and sites for patients with HER2+ breast cancer were estimated from two perspectives, the government’s perspective and the perspective of society as a whole (which includes indirect costs borne by patients and their relatives).
Government perspective
Figure 1 presents the results of estimating the mean cost of IV treatments at a Quebec hospital in 2022. From the perspective of a government (which covers expenses for medically required services in the healthcare network), it costs approximately $4,211 annually per patient. This amount includes professional resources (nurses and other healthcare professionals), material and therapeutic resources (excluding the medication but including CVADs), and administration and general operating expenses (overhead) associated with IV therapy.
In comparison, Figure 1 also shows the mean estimated cost of annual treatment with Herceptin® SC at a Quebec CLSC. Thus, it would cost the government an estimated $760 annually, for an expenditure saving of 82% compared with IV therapy in hospital.
Societal perspective
As shown in Figure 2, with the addition of indirect costs (borne by patients and their relatives), the total per-patient cost rises to $7,270 (excluding the medication but including CVADs). These indirect costs include travel expenses and costs for work hours lost because of treatments required by patients and accompanying relatives.
In comparison, the mean total cost of one cycle of SC Herceptin® therapy at a CLSC is estimated as $1,775 per patient annually, when assessed from a societal perspective and including lost work and leisure time experienced by patients and their relatives, as well as their travel costs to the treatment site.
Therefore, from a societal perspective, the total cost of one cycle of SC therapy at a CLSC is 76% lower annually than the cost of one cycle of IV therapy in hospital.
A complete description of the items included in this analysis, with data sources used, can be found in Appendix 2 of this report.
Cost savings for the government
As shown by the analyses in the previous section, the total cost of IV therapy in hospital is 82% higher annually than SC therapy in the community, when considering only the perspective of the public payer. Therefore, there are potential savings for the government of Quebec in transferring these treatments outside the hospital network.
Data concerning the estimated number of eligible patients were used to evaluate the extent of the savings that the government might obtain by transferring even three quarters of patients requiring IV therapy in Quebec over a given year. As shown in Figure 3, savings would amount to $5.4 million annually using the worst-case scenario (1,558 patients), and to $7.2 million annually using the best-case scenario (2,077 patients). This represents the equivalent of the overall compensation for 53–71 full-time nurses for a n entire year.[4]
In addition to nurses, it is also worth noting that other scarce medical resources might be freed up and redeployed for other purposes within hospitals. It is important to consider the opportunity cost associated with prolonged use of infusion chairs in Quebec hospitals (Sandmann et al., 2018). By freeing up chair time and saving nurses’ work time, it might be possible to treat more patients and potentially improve access to care in the Quebec hospital network.
DISCUSSION AND CONCLUSION
The purpose of this study was to map the care trajectories of HER2+ breast cancer patients receiving subcutaneous Herceptin® at a CLSC as part of a pilot project initiated in the fall of 2019, and to compare that with the trajectories of patients treated intravenously (by IV) in hospital. Another objective of the study was to estimate all the direct and indirect costs of treatments in both care trajectories.
The method used was based on the activity-based costing method, and followed the traditional steps: mapping activities, calculating the cost of each activity, and calculating the unit cost of each procedure (Mercier and Naro, 2014). The mean time spent by administrative, nursing, and medical staff on professional activities during treatment visits was evaluated using semi-structured interviews conducted with 30 healthcare professionals at the six institutions participating in the pilot project between June 9, 2021 and May 16, 2022.
The mean total per-patient time taken to finish each activity was then measured. The SC route is associated with a reduction in the mean total time for carrying out the whole care trajectory for one patient and, especially, the mean per-patient time necessary for the therapeutic administration itself (chair time). The mean total per-patient time for IV administration was estimated as 111.4 minutes per treatment visit per patient versus 36.8 minutes per cycle per patient for SC administration. Thus, compared with IV administration, SC administration of Herceptin® provided a 67% reduction (1 hour and 15 minutes) in the mean total per-patient time needed to carry out all planned activities during a typical treatment visit.
From the government’s perspective, the annual per-patient cost is about $4,211. That includes professional resources (nurses and other healthcare professionals), material and therapeutic resources (excluding the medication but including CVADs) as well as the general administration and operation expenses (overhead) for IV treatments. In comparison, the mean cost of annual treatment with Herceptin® SC at a Quebec CLSC is estimated as $760 annually, for an 82% saving in expenses versus the costs of IV treatment for a patient in hospital.
The potential gains to be made by moving chemotherapy treatments from hospitals to CLSCs might be still higher if government regulations allowed other administration sites, such as neighbourhood pharmacies, infusion clinics, or patient homes.
In any event, in the short term, the results of this study show that switching from IV to SC administration might ease the pressure on healthcare staff in hospital oncology clinics where capacity is currently saturated. By using fewer healthcare staff and fewer infusion chairs to treat the same number of patients with SC administration, these resources would then be available to be redeployed elsewhere in the network for treating other patients.
Thus, the main expected outcome in the medium and long term is improved access to care for a larger number of patients. That contributes to Quebec’s Ministry of Health and Social Services objectives to increase oncology treatment capacity and be able to treat more patients in a timely fashion.
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