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Güth U, Elfgen C, Zadeh SN, Meier S, Varga Z, Tinguely M, Papassotiropoulos B, Däster K, Tausch CJ. The impact of intraoperative frozen section in patients with clinically node-negative breast cancer (cN0/ycN0) who received neoadjuvant systemic therapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1423-1428. [PMID: 37183046 DOI: 10.1016/j.ejso.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND When surgical axillary staging reveals residual metastatic deposits in breast cancer (BC) patients who had received neoadjuvant chemotherapy (NACT), axillary lymphonodectomy is indicated. In this study, we investigate whether it is reasonable to perform intraoperative frozen section (FS) of the removed sentinel lymph nodes (SLNs) in cases where NACT had been administered in patients who had a clinically negative nodal status at the time of diagnosis. PATIENTS AND METHODS We analyzed data from 101 BCE patients with 103 carcinomas who were diagnosed between 2014 and 2021 and met the above-mentioned criteria. RESULTS In three cases (2.8% of the study group), histologically active tumor tissue was detected in the removed axillary LNs. Discontinuation of therapy/the use of a low-dose NACT regimen was a significant factor for positive LNs (p = 0.02) at the subsequent surgical procedure; tumor progression during therapy approached borderline significance (p = 0.058). Among patients who had completed NACT with the planned standard dose regimen, and in which the primary tumors showed a response to therapy (n = 94), only one case had histologically detected residual metastases in the SLNs. CONCLUSIONS Certified breast centers aim to improve the outcome of the patients. However, these specialized centers should also focus on economic aspects. This means that diagnostic and therapeutic procedures should be continuously critically reviewed in order to avoid unnecessary expenses. In BC patients with clinically node negative disease who completed NACT as planned and in which the tumor showed a good response to therapy, time consuming and costly FS of the SLNs removed should be omitted.
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Affiliation(s)
- Uwe Güth
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland; University of Basel, Faculty of Medicine, Klingelbergstrasse 61, CH-4056, Basel, Switzerland.
| | - Constanze Elfgen
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland; University of Witten/Herdecke, Faculty of Medicine, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany
| | - Shadi Najaf Zadeh
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland
| | - Simon Meier
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital of Zurich, Schmelzbergstrasse 12, CH-8091, Zurich, Switzerland
| | - Marianne Tinguely
- Institute of Pathology Enge, Hardturmstrasse 133, CH-8055, Zurich, Switzerland; University of Zurich, Medical Faculty, Pestalozzistrasse 3, CH-8032, Zurich, Switzerland
| | - Bärbel Papassotiropoulos
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland
| | - Kavitha Däster
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland
| | - Christoph J Tausch
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, CH-8008, Zurich, Switzerland; University of Basel, Faculty of Medicine, Klingelbergstrasse 61, CH-4056, Basel, Switzerland
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Khan SA, Hernandez-Villafuerte K, Hernandez D, Schlander M. Estimation of the stage-wise costs of breast cancer in Germany using a modeling approach. Front Public Health 2023; 10:946544. [PMID: 36684975 PMCID: PMC9853539 DOI: 10.3389/fpubh.2022.946544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Breast cancer (BC) is a heterogeneous disease representing a substantial economic burden. In order to develop policies that successfully decrease this burden, the factors affecting costs need to be fully understood. Evidence suggests that early-stage BC has a lower cost than a late stage BC. We aim to provide conservative estimates of BC's stage-wise medical costs from German healthcare and the payer's perspective. To this end, we conducted a literature review of articles evaluating stage-wise costs of BC in Germany through PubMed, Web of Science, and Econ Lit databases supplemented by Google Scholar. We developed a decision tree model to estimate BC-related medical costs in Germany using available treatment and cost information. The review generated seven studies; none estimated the stage-wise costs of BC. The studies were classified into two groups: case scenarios (five studies) and two studies based on administrative data. The first sickness funds data study (Gruber et al., 2012) used information from the year 1999 to approach BC attributable cost; their results suggest a range between €3,929 and €11,787 depending on age. The second study (Kreis, Plöthner et al., 2020) used 2011-2014 data and suggested an initial phase incremental cost of €21,499, an intermediate phase cost of €2,620, and a terminal phase cost of €34,513 per incident case. Our decision tree model-based BC stage-wise cost estimates were €21,523 for stage I, €25,679 for stage II, €30,156 for stage III, and €42,086 for stage IV. Alternatively, the modeled cost estimates are €20,284 for the initial phase of care, €851 for the intermediate phase of care, and €34,963 for the terminal phase of care. Our estimates for phases of care are consistent with recent German estimates provided by Kreis et al. Furthermore, the data collected by sickness funds are collected primarily for reimbursement purposes, where the German ICD-10 classification system defines a cancer diagnosis. As a result, claims data lack the clinical information necessary to understand stage-wise BC costs. Our model-based estimates fill the gap and inform future economic evaluations of BC interventions.
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Affiliation(s)
- Shah Alam Khan
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Diego Hernandez
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Faculty of Economics and Social Sciences, Alfred Weber Institute (AWI), University of Heidelberg, Heidelberg, Germany
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3
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Cheng CY, Datzmann T, Hernandez D, Schmitt J, Schlander M. Do certified cancer centers provide more cost-effective care? A health economic analysis of colon cancer care in Germany using administrative data. Int J Cancer 2021; 149:1744-1754. [PMID: 34213799 DOI: 10.1002/ijc.33728] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 12/24/2022]
Abstract
Hospital certification has become an important measure to improve cancer care quality, with the potential effect of prolonging patient survival and reducing medical spending. However, yet to be explored is the cost-effectiveness of cancer care provided in certified hospitals, considering significant additional costs incurred from certification requirements. We performed a cost-effectiveness analysis (CEA) using two colon cancer populations (N = 1909) treated in different levels of certified hospitals (CHs) vs noncertified hospitals (NCHs) from a healthcare system's perspective. We matched patient-level data of incident colon cancer cases, diagnosed between 2008 and 2013 from a large statutory health insurance in Saxony, Germany, to calculate net treatment costs by phase (initial, continuing and terminal phase). The costs were supplemented with extra costs from 31 additional services required for certification. Effectiveness measure was total survival time in life-years. Outcome of interest was incremental costs per additional life-year. The annualized net colon cancer treatment costs by phase showed a U shape with high costs in the initial (mean €26 855; 95% CI €25 058-€28 652) and the terminal phases (mean €30 096; 95% CI €26 199-€33 993). The base-case CEA results and all sensitivity analyses consistently demonstrated longer survival and lower costs for the colon cancer cohort treated in CHs vs NCHs. To conclude, we used administrative data to derive the first cost-effectiveness evidence supporting that colon cancer care delivered in the certified cancer centers in Germany improves survival outcomes and saves costs from a healthcare system's perspective. Generalization of the study results should be exercised with caution.
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Affiliation(s)
- Chih-Yuan Cheng
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany
| | - Thomas Datzmann
- Center for Evidence-based Healthcare (ZEGV), University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Diego Hernandez
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare (ZEGV), University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany.,Alfred Weber Institute, University of Heidelberg, Heidelberg, Germany.,German Cancer Consortium (DKTK), Core Center Heidelberg, Heidelberg, Germany
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4
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Formago M, Schrauder MG, Rauh C, Hack CC, Jud SM, Hildebrandt T, Schulz-Wendtland R, Frentz S, Graubert S, Beckmann MW, Lux MP. Should Breast Cancer Surgery Be Done in an Outpatient Setting?: Health Economics From the Perspective of Service Providers. Geburtshilfe Frauenheilkd 2017; 77:879-886. [PMID: 28845052 DOI: 10.1055/s-0043-114427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION The care of patients with breast cancer is extremely complex and requires interdisciplinary care in certified facilities. These specialized facilities provide numerous services without being correspondingly remunerated. The question whether breast cancer surgery should be performed in an outpatient setting to reduce costs is increasingly being debated. This study compares inpatient surgical treatment with a model of the same surgery performed on an outpatient basis to examine the potential financial impact. MATERIAL AND METHODS A theoretical model was developed and the DRG fees for surgical interventions to treat primary breast cancer were calculated. A theoretical 1-day DRG was then calculated to permit comparisons with outpatient procedures. The costs of outpatient surgery were calculated based on the remuneration rates of the AOP (Outpatient Surgery) Contract and the EBM (Uniform Assessment Scale) and compared to the costs of the 1-day DRG. RESULTS The DRG fee for both breast-conserving surgery and mastectomy is higher than the fee paid in the context of the EBM system, although the same procedures were carried out in both systems. If a hospital were to carry out breast-conserving surgery as an outpatient procedure, the fee would be € 1313.81; depending on the type of surgery, the hospital would therefore only receive between 39.20% and 52.82% of the DRG fee. This was the case even for a 1-day treatment. Compared to the real DRG fees the difference would be even more striking. CONCLUSION Carrying out breast cancer surgery as an outpatient procedure would result in a significant shortfall of revenues. Additional services from certified centers, such as the interdisciplinary planning of treatment, psycho-oncological and social-medical care with the involvement of relatives, detailed documentation, etc., which are currently provided without surcharge or adequate remuneration, could no longer be maintained. The quality of processes and excellent results which have been achieved and ultimately the care given by certified facilities would be significantly at risk.
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Affiliation(s)
- Margaret Formago
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Michael G Schrauder
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Claudia Rauh
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Carolin C Hack
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sebastian M Jud
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Thomas Hildebrandt
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Rüdiger Schulz-Wendtland
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Radiology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - S Frentz
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Commercial Directorate, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - S Graubert
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Commercial Directorate, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Matthias W Beckmann
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Michael P Lux
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Obstetrics and Gynecology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
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Jacke CO, Albert US, Reinhard I, Kalder M. Convergence with SEER database achieved by a breast cancer network: a longitudinal benchmark of 5-year relative survival. J Cancer Res Clin Oncol 2014; 141:1109-18. [PMID: 25512079 DOI: 10.1007/s00432-014-1879-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/18/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE To benchmark outcomes of a German breast cancer network with the Surveillance Epidemiology and End Results programme (SEER) of the USA from a longitudinal point of view. METHODS All women receiving primary breast cancer therapy of three hospitals in a rural district of Marburg-Biedenkopf (Germany) of time intervals 1996-1997 and 2003-2004 were used to define local benchmark objects. Data from SEER-programme contributed longitudinal benchmark objects from national level (1988-2004). All benchmark objects were compared with the time-fixed benchmark reference of SEER (2004). Stage distributions and 5-year relative survival ratios were combined to estimate standardized screening-, case-mix-, work-up-, treatment- and relative overall performance index. RESULTS From the entry cohort of 877 German women, 97.7 % of the patients accounted for the institutional sample (N = 857) and 65.8 % accounted for the regional sample (N = 577). Stage distributions, relative survival ratios and indices of the German breast cancer network improved over time. Developed indices converged with SEER (2004). CONCLUSIONS Effectiveness gap between one exemplary German breast cancer network and international benchmark defined by SEER has been closed. Reasons are manifold, and further research is recommended.
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Affiliation(s)
- Christian O Jacke
- Central Institute of Mental Health, Medical Faculty Mannheim, University Heidelberg, Square J5, 68159, Mannheim, Germany,
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6
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Lux MP, Sell CS, Fasching PA, Seidl-Ertel J, Bani MR, Schrauder MG, Jud SM, Loehberg CR, Rauh C, Hartmann A, Schulz-Wendtland R, Strnad V, Beckmann MW. Time and Resources Needed to Document Patients with Breast Cancer from Primary Diagnosis to Follow-up - Results of a Single-center Study. Geburtshilfe Frauenheilkd 2014; 74:743-751. [PMID: 25221342 DOI: 10.1055/s-0034-1382980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 01/23/2023] Open
Abstract
Aim: Certification of breast centers helps improve the quality of care but requires additional resources, particularly for documentation. There are currently no published data on the actual staff costs and financial resources required for such documentation. The aim of this study was to determine the time and resources required to document a patient with primary breast cancer from diagnosis to the end of follow-up, to establish a database for future strategic decisions. Material and Methods: All diagnostic and therapeutic procedures of patients with primary breast cancer were recorded at the University Breast Center of Franconia. All time points for documentation were evaluated using structured interviews. The times required to document a representative number of patients were determined and combined with the staff costs of the different professional groups, to calculate the financial resources required for documentation. Results: A total of 494 time points for documentation were identified. The study also identified 21 departments and 20 different professional groups involved in the documentation. The majority (54 %) of documentation was done by physicians. 62 % of all documentation involved outpatients. The results of different scenarios for the diagnosis, therapy and follow-up of breast cancer patients in a certified breast center showed that the time required for documentation can be as much as 105 hours, costing € 4135. Conclusion: This analysis shows the substantial staffing and financial costs required for documentation in certified centers. A multi-center study will be carried out to compare the costs for certified breast centers of varying sizes with the costs of non-certified care facilities.
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Affiliation(s)
- M P Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - C S Sell
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - P A Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - J Seidl-Ertel
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - M R Bani
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - M G Schrauder
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - S M Jud
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - C R Loehberg
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - C Rauh
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - A Hartmann
- Pathologisches Institut der Universität Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - R Schulz-Wendtland
- Radiologisches Institut, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - V Strnad
- Strahlenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
| | - M W Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen
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7
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Lux M, Hildebrandt T, Beyer-Finkler E, Bani M, Loehberg C, Jud S, Rauh C, Schrauder M, Fasching P, Beckmann M. Relevance of health economics in breast cancer treatment - the view of certified breast centres and their patients. ACTA ACUST UNITED AC 2014; 8:15-21. [PMID: 24715838 DOI: 10.1159/000347098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Breast cancer centres - certified in accordance with the criteria of the German Cancer Association and the German Mastology Association - are established throughout Germany. Although the setting up of centres and the subsequent need for certification are associated with a marked increase in costs, initial data show positive effects on quality. Certified centres are cost-effective from the point of view of health economics - they lead to improved quality in processes and results without creating any increase in costs for the funding bodies. However, the organization of the necessary structures, with interdisciplinary treatment, documentation and quality-assurance measures, requires considerable resources. Increasing consolidation of inpatient services is also involved, while shortening of the patients' hospitalization periods is leading to reduced remuneration from the funding bodies. The current cost deficits, which have resulted from the increased resources required, need to be recouped through additional charges. It will only be possible to maintain the high quality achieved if additional charges become available to cover the centres' added costs. Good data are increasingly becoming available as a basis for negotiations on charges - e.g., with regard to the quality of results and the National Cancer Plan - as well as clear support from patients.
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Affiliation(s)
- Michael Lux
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Thomas Hildebrandt
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | | | - Mayada Bani
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Christian Loehberg
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Sebastian Jud
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Claudia Rauh
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Michael Schrauder
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Peter Fasching
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
| | - Matthias Beckmann
- University Breast Centre for Franconia, Department of Gynaecology, Erlangen University Hospital, Erlangen, Germany
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8
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Jacobs VR, Bogner G, Schausberger CE, Reitsamer R, Fischer T. Relevance of health economics in breast cancer treatment: integration of economics in the management of breast cancer at the clinic level. ACTA ACUST UNITED AC 2014; 8:7-14. [PMID: 24715837 DOI: 10.1159/000348370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Since the introduction of the diagnosis-related groups (DRG) system with cost-related and entity-specific flat-rate reimbursements for all in-patients in 2004 in Germany, economics have become an important focus in medical care, including breast centers. Since then, physicians and hospitals have had to gradually take on more and more financial responsibilities for their medical care to avoid losses for their institutions. Due to financial limitations of resources, most medical services have to be adjusted to correlating revenues, which results in the development of a variety of active measures to understand, steer, and optimize costs, resources and related processes for breast cancer treatment. In this review, the challenging task to implement microeconomic management at the clinic level for breast cancer treatment is analyzed from breast cancer-specific publications. The newly developed economic management perspective is identified for different stakeholders in the healthcare system, and successful microeconomic projects and future aspects are described.
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Affiliation(s)
- Volker R Jacobs
- Frauenklinik (OB/GYN) of Salzburger Landeskrankenanstalten (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | - Gerhard Bogner
- Frauenklinik (OB/GYN) of Salzburger Landeskrankenanstalten (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | - Christiane E Schausberger
- Frauenklinik (OB/GYN) of Salzburger Landeskrankenanstalten (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | - Roland Reitsamer
- Frauenklinik (OB/GYN) of Salzburger Landeskrankenanstalten (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | - Thorsten Fischer
- Frauenklinik (OB/GYN) of Salzburger Landeskrankenanstalten (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
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9
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Seidel RP, Lux MP, Hoellthaler J, Beckmann MW, Voigt W. Economic constraints - the growing challenge for Western breast cancer centers. Breast Care (Basel) 2013; 8:41-7. [PMID: 24715842 PMCID: PMC3971806 DOI: 10.1159/000348356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Breast cancer care in Western countries has reached a considerable level of quality and standardization, which has contributed to the decline in breast cancer mortality. Certified Breast Cancer Centers (BCC) represent an important element of this development. Related to changes in reimbursement and growing costs, BCC face economic constraints which ultimately could endanger the achievements of the past. Thus, BCC have to optimize their care strategies from an economic perspective, particularly by increasing efficiency but also by adapting their service portfolio. This could result in competitive advantages and additional revenue by increasing case numbers and extra charges to patients. Furthermore, an intensification of collaboration with the outpatient sector resulting in an integrated and managed 'trans-sectoral' care approach which could allow to shift unprofitable procedures to the outpatient sector - in the sense of a win-win situation for both sectors and without loss of care quality - seems reasonable. Structured and specialized consulting approaches can further be a lever to fulfill economic requirements in order to avoid cuts in medical care quality for the sake of a balanced budget. In this review, economic constraints of BCC with a focus on the German healthcare system and potential approaches to ameliorate these financial burdens are being discussed.
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Affiliation(s)
- Rene P. Seidel
- Siemens AG, Healthcare Sector, Customer Solutions Division, H CX CRM-VA HCC ONC, Friedrich Alexander University, Erlangen, Germany
| | - Michael P. Lux
- University Breast Centre Franconia, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
| | - Josef Hoellthaler
- Siemens AG, Healthcare Sector, Customer Solutions Division, H CX CRM-VA HCC ONC, Friedrich Alexander University, Erlangen, Germany
| | - Matthias W. Beckmann
- University Breast Centre Franconia, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
| | - Wieland Voigt
- Siemens AG, Healthcare Sector, Customer Solutions Division, H CX CRM-VA HCC ONC, Friedrich Alexander University, Erlangen, Germany
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10
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Thiel FC, Scharl A, Hildebrandt T, Kotziabassis E, Schrauder MG, Bani MR, Müller A, Hauzenberger T, Loehberg CR, Jud SM, Fasching PA, Hartmann A, Schulz-Wendtland R, Strnad V, Beckmann MW, Lux MP. Financing of certified centers: a willingness-to-pay analysis. Arch Gynecol Obstet 2012; 287:495-509. [PMID: 23080545 DOI: 10.1007/s00404-012-2572-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 09/11/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although care in certified breast centers is now established throughout Germany, numerous services are still not being reimbursed. This also affects other centers involved in the specialty of gynecology such as gynecological cancer centers, perinatal centers, and endometriosis centers. Although a certified center is entitled to charge additional fees, these are in most cases not reimbursed. Calculation of additional costs is limited by the fact that data from the Institute for the Hospital Reimbursement System (Institut für das Entgeltsystem im Krankenhaus, InEK) do not reflect interdisciplinary services and procedures. For decision-makers, society's willingness to pay is an important factor in guiding decisions on the basis of social priorities. A hypothetical maximum willingness to pay can be calculated using a willingness-to-pay analysis, making it possible to identify deficiencies in the arbitrary setting of health budgets at the macro-level. MATERIALS AND METHODS In a multicenter study conducted between November 2009 and December 2010, 2,469 patients at a university hospital and at a non-university hospital were asked about the extent of their awareness of certified centers, the influence of centers on hospital presentation, and about personal attitudes toward quality-oriented reimbursement. A subjective assessment of possible additional charges was calculated using a willingness-to-pay analysis. RESULTS In the overall group, 53.4 % of the patients were aware of what a certified center is and 27.4 % had specific information (obstetrics 40.0/32.3 %; mastology 66.8/23.2 %; gynecological oncology 54.7/27.3 %; P < 0.001). For 43.8 %, a certified center was one reason or the major reason for presentation (obstetrics 26.2 %; mastology 66.8 %; gynecological oncology 46.6 %; P < 0.001). A total of 72.6 % were in favor of quality-oriented reimbursement and 69.7 % were in favor of an additional charge for a certified center amounting to €538.56 (mastology €643.65, obstetrics €474.67, gynecological oncology €532.47). In all, 33.9 % would accept an increase in health-insurance fees (averaging 0.3865 %), and 28.3 % were in favor of reduced remuneration for non-certified centers. CONCLUSIONS The existence of certified centers is being increasingly recognized by patients. Additional charges for certified centers are generally supported. There is therefore a clear demand for them-from patients as well. This may be useful when negotiations are being conducted.
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Affiliation(s)
- Falk C Thiel
- Department of Gynecology, Erlangen University Hospital, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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11
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Hoffmann J, Wallwiener D. Breast cancer surgery and financial reimbursement in Germany. Breast Care (Basel) 2012; 7:384-8. [PMID: 24647777 DOI: 10.1159/000343294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The reimbursement for breast cancer-specific operative interventions in Germany is regulated by the diagnosis-related group (DRG) system. The essential elements of the German DRG system, which was developed as a per-case lump-sum payment system, are presented, including the participating institutions. The actual treatment situation in breast cancer surgery is now aptly reflected in the introduction of the OPS (operation and treatment procedure classification) 2012. This is oriented on the classification model of Hoffmann and Wallwiener, with its complexity-based differentiation that reflects the basic idea of different resource usage. Despite the actual potential of the appropriately differentiated encryption of surgical procedures, which illustrates their differences in resource costs and consumption, appropriate reimbursement has still not been achieved. Hopefully, in the future the calculation of the DRGs in the field of breast cancer surgery will be based on data feedback from the hospitals and treatment institutions, and will be more suited to the main purpose of the DRG system, i.e. that reimbursement reflects resource expenditure. A necessary basic tool for differentiated, complexity-oriented encryption has been achieved with the OPS 2012, which mirrors our classification model for oncological, oncoplastic and reconstructive breast surgery.
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Wallwiener M, Brucker SY, Wallwiener D. Multidisciplinary breast centres in Germany: a review and update of quality assurance through benchmarking and certification. Arch Gynecol Obstet 2012; 285:1671-83. [PMID: 22314433 PMCID: PMC3351617 DOI: 10.1007/s00404-011-2212-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 12/31/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE This review summarizes the rationale for the creation of breast centres and discusses the studies conducted in Germany to obtain proof of principle for a voluntary, external benchmarking programme and proof of concept for third-party dual certification of breast centres and their mandatory quality management systems to the German Cancer Society (DKG) and German Society of Senology (DGS) Requirements of Breast Centres and ISO 9001 or similar. In addition, we report the most recent data on benchmarking and certification of breast centres in Germany. METHODS Review and summary of pertinent publications. Literature searches to identify additional relevant studies. Updates from the DKG/DGS programmes. RESULTS AND CONCLUSIONS Improvements in surrogate parameters as represented by structural and process quality indicators suggest that outcome quality is improving. The voluntary benchmarking programme has gained wide acceptance among DKG/DGS-certified breast centres. This is evidenced by early results from one of the largest studies in multidisciplinary cancer services research, initiated by the DKG and DGS to implement certified breast centres. The goal of establishing a nationwide network of certified breast centres in Germany can be considered largely achieved. Nonetheless the network still needs to be improved, and there is potential for optimization along the chain of care from mammography screening, interventional diagnosis and treatment through to follow-up. Specialization, guideline-concordant procedures as well as certification and recertification of breast centres remain essential to achieve further improvements in quality of breast cancer care and to stabilize and enhance the nationwide provision of high-quality breast cancer care.
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Affiliation(s)
- Markus Wallwiener
- Department of Obstetrics and Gynaecology, University of Heidelberg, Voßstraße 9, 69115 Heidelberg, Germany.
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13
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Abstract
The primary focus of the establishment and certification of specialized cancer centers in the context of the National Cancer Plan is to improve the quality of care for patients with various carcinoma entities. The era of organ center certification started with the establishment of specialized breast cancer centers in line with the high incidence of breast cancer, the high mortality rate and the high level of interdisciplinary cooperation in the diagnosis and therapy of breast cancer. The introduction of quality management and external monitoring aims to provide high quality care in the diagnosis and therapy of breast cancer and is expected to improve long-term quality data (disease-free survival and overall survival) and to reduce mortality rates by about 25-30%. Certification requires the implementation of a quality management system and care provision structures assuring diagnosis and therapy according to the quality guidelines and recommendations of the specialist societies. Basic requirements for improving the quality of breast cancer patient care are centralization, specialization and interdisciplinarity. It has been demonstrated that the improvement of overall survival is associated with an increasing annual case load of a center, an increasing case load per surgeon per year, study participation and interdisciplinarity. Tumor documentation will be harmonized in the future by the establishment of local clinical cancer registries and cross-linking them with the National Cancer Registry. The data collection and analysis of several quality markers and current follow-up and survival data for each breast cancer patient will allow direct comparison of participating institutions. Individual breast cancer centers may demonstrate quality improvement longitudinally. Both certification and specialization require additional services which are associated with a substantial increase in costs. Preliminary data suggest that certified breast cancer centers are dependent on cross-financing by the participating departments of a hospital. Up to now cost-effective analyses for certified breast cancer centers are not available due to a substantial lack of data defining the additional financial burden.
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Affiliation(s)
- K Hellerhoff
- Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität, Campus Grosshadern, Marchioninistr. 15, 81377, München, Deutschland.
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Lux MP, Fasching PA, Loehberg CR, Jud SM, Schrauder MG, Bani MR, Thiel FC, Hack CC, Hildebrandt T, Beckmann MW. Health Services Research and Health Economy - Quality Care Training in Gynaecology, with Focus On Gynaecological Oncology. Geburtshilfe Frauenheilkd 2011; 71:1046-1055. [PMID: 26640282 PMCID: PMC4651110 DOI: 10.1055/s-0031-1280435] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/10/2011] [Indexed: 10/14/2022] Open
Abstract
In the era of cost increases and reduced resources in the German healthcare system, the value of health services research and health economics is increasing more and more. Health services research attempts to develop concepts for the most effective ways to organise, manage, finance and deliver high-quality care and evaluates the implementation of these concepts with regard to daily routine conditions. Goals are the assessment of benefits and the economic advantages and disadvantages of new and established diagnostic methods, drugs and vaccines. Regarding these goals, it is clear that health services research goes hand in hand with health economics, which evaluates the benefits of diagnostic and therapeutic procedures in relation to the costs. Both scientific fields have focus principally on gynaecology and particularly on gynaecological oncology in Germany, as can be seen by numerous publications. These present several advantages compared with clinical trials - they uncover gaps in health care, question the material, staffing and consequently the financial resources required and they allow the estimation of value and the comparison of different innovations to identify the best options for our patients.
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Affiliation(s)
- M P Lux
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - P A Fasching
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - C R Loehberg
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - S M Jud
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - M G Schrauder
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - M R Bani
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - F C Thiel
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - C C Hack
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - T Hildebrandt
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
| | - M W Beckmann
- Department of Gynaecology, University Hospital of Erlangen, Erlangen
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Gesundheitsökonomische Aspekte und finanzielle Probleme in den zertifizierten Strukturen des Fachgebietes. DER GYNÄKOLOGE 2011. [DOI: 10.1007/s00129-011-2807-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Weikert S, Baumunk D, Stephan C, Cash H, Jahnke K, Steiner U, Werthemann P, Kempkensteffen C, Magheli A, Hinz S, Jagota A, Reichelt U, Busch J, Klopf C, Miller K, Schostak M. Etablierung von interdisziplinären Prostatakrebszentren nach den Empfehlungen der DKG. Urologe A 2011; 50:1083-8. [DOI: 10.1007/s00120-011-2629-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Affiliation(s)
- Serban-Dan Costa
- Universitätsfrauenklinik, Otto-von-Guericke-Universität Magdeburg, Germany
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Arai H, Kikuchi W, Ishida A, Takada G. Dexamethasone-Induced Prenatal Alveolar Wall Thinning Is Associated with a Decrease in EIIIA+ Fibronectin Isoform in the Fetal Rat Lung. Neonatology 2005; 87:113-20. [PMID: 15539768 DOI: 10.1159/000082119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 09/01/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Glucocorticoid hormones play an important role in architectural and biochemical lung maturation. Although much of the molecular mechanism of their action in the lung is not fully understood, glucocorticoids directly or indirectly regulate lung maturation. Indirect effects of glucocorticoids may involve the modulation of cell-cell or cell-matrix interactions. Fibronectin (FN) is the major constituent of the pulmonary extracellular matrix and exists in multiple isoforms arising from alternative RNA splicing. EIIIA is the major alternatively spliced segment, and its expression is regulated in a spatiotemporal and oncodevelopmental manner. OBJECTIVES The present study focuses on the regulation of EIIIA-containing FN isoforms (referred to as EIIIA+ FN) by glucocorticoids in the developing lung. METHODS Dexamethasone (DEX) or saline was injected daily into pregnant rats from day 15 of gestation (term = day 22) until 24 h before sacrifice. The expression of EIIIA+ FN and proliferating cell nuclear antigen (PCNA), a biochemical marker for cell proliferation, was investigated in the fetal rat lung. RESULTS At day 20 of gestation (the canalicular stage), the DEX-treated lung showed a significant decrease in weight and saccular septal wall thickness, while the messenger RNA expression of the surfactant protein SP-B was increased in the DEX-treated lung, as compared with the control lung. The expression of EIIIA+ FN and PCNA around the distal airspaces was less extensive in the DEX-treated lung than in the control lung at day 20 of gestation. CONCLUSIONS Given the finding in vitro that EIIIA+ FN regulated the cell cycle, our results suggest that the change of EIIIA+ FN expression in the DEX-treated lung affected pulmonary cell proliferation.
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Affiliation(s)
- Hirokazu Arai
- Department of Pediatrics, Akita University School of Medicine, Hondo 1-1-1, Akita, Akita 010-8543, Japan.
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