500081_ASTRO_HO_Econ_Poster3.ppt - PowerPoint Presentation

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					                                                      Cost-Effectiveness of Radiation vs. NSAID Administration for Prevention of
                                                      Heterotopic Ossification after Total Hip Arthroplasty

               Jonathan B Strauss MD, MBA; Sea S Chen MD, PhD; Anand P Shah MD; Alan B Coon MD, PhD; Adam T Dickler MD
                              Department of Radiation Oncology; Rush University Medical Center; Chicago, Illinois
Purpose/Objective:                                            Medicare Reimbursement Calculations:                                                                                       Total Costs Per Patient
                                                                                                                                                                                                                                             Radiation NSAIDs
Heterotopic ossification (HO), or abnomal bone
formation, is a common sequela of total hip                  Reimbursement                                                                                                          Direct Medical Cost of Treatment                          $898.55   $33.56
                                                                                                                                                                                     Cost of Reoperation                                       $217.19  $699.84
arthroplasty (THA). Often, this abnormal bone can            CF  P N P  RVUWP  GPCIW  RVUPCP  GPCIPC  RVUPLIP  GPCIPLI                                                   Cost of In-Hospital Severe Bleed                           $85.17  $190.79
impair joint function. Once formed, abnormal bone                                                                                                                                    Cost of GI Bleed Admission                                   $0     $47.91
                                                           The Geographic Practice Cost Index (for Chicago, Illinois) for cost of living (GPCIW) is 1.025, for practice costs
must be surgically removed to restore mobility. HO         (GPCIPC) is 1.128, and for professional liability insurance (GPCIPLI) is 1.837. The conversion factor (CF) for            Income lost due to Hospitalization                         $6.15    $18.53
can be prevented by postoperative NSAID use or             2007 is 35.9848.                                                                                                          Total                                                    $1,207.06 $990.63
                                                           NP is the number of units for CPT procedure P. RVUWP, RVUPCP, and RVUPLIP are the Relative Value Units for
radiation to the periarticular tissues. NSAIDs are         physician work (W), practice cost (PC) and profession liability insurance (PLI), respectively, for each CPT
associated with multiple toxicities including gastritis,   procedure P (found in the 2007 Fee Schedule).
bleeding events and renal impairment. Although             Direct Medical Cost of Radiation:                                                                                         If one considers only the direct medical costs of treatment,
radiation has been shown to be more efficacious than       Procedure                     CPT Code # of Units RVUW    GPCIw   RVUPC GPCIpc RVUPLI GPCIpli    CF    Total              then radiation appears to be much more expensive than
NSAID administration in randomized trials and a            Inpatient Consult 3
                                                           Simulation - Simple
                                                                                                                                                  1.837 $35.9848 $124.28
                                                                                                                                                  1.837 $35.9848 $220.99             NSAID administration for prevention of HO ($899 vs. $34).
meta-analysis, its cost-effectiveness has been             Basic Dosimetry Calculation    77300        2      0.62   1.025    1.19  1.128   0.1   1.837 $35.9848 $155.56             However, if one considers the additional costs associated
                                                           Clinical Tx Plan Simple        77261        1      1.39   1.025    0.49  1.128  0.07   1.837 $35.9848 $75.79
questioned.1,2                                             Wkly QA Med Phys Cns           77336        1        0    1.025    1.14  1.128  0.16   1.837 $35.9848 $56.85              with treatment failure and treatment induced morbidity,
                                                           Daily Tx - Smpl 6-10mv         77403        1        0    1.025    3.76  1.128  0.11   1.837 $35.9848 $159.89
                                                                                                                                                                                     these costs converge ($1,207 vs. $991). This analysis is
             Materials/Methods:                            Weekly tx mgt 1-2 fx           77431        1      1.81   1.025     0.8  1.128  0.09   1.837 $35.9848 $105.18
                                                                                                                                                         Total    $898.55            limited in that it did not attempt to assign a monetary value
We performed an analysis of the cost-effectiveness of
                                                           Direct Medical Cost of Re-operation for HO:
                                                                                                                                                                                     to the impairment in quality of life associated with
single fraction post-operative radiation therapy to the
                                                                                                                                                                                     symptomatic HO recurrence and the risk of death
hip as compared to NSAID administration from the           Rate of Brooker Grade 3-4 HO Recurrence:                                                       Cost Per Patient
                                                            Radiation 0.9%, NSAIDs 2.9% 2                                                          1400                              associated with GI hemorrhage (estimated at 5-10% of all
societal perspective. We took into account the added
                                                           1)Professional fee for revision THA:                                                                        Total Cost    patients admitted with NSAID induced GI bleeding).9
costs of surgery for failure of HO prophylaxis, the cost                                                                                           1200
                                                                                                                                                                       Direct Cost
                                                             CPT 27137: $1,558.04 4                                                                                                  These considerations lead the authors to recommend

                                                                                                                                     Cost ($ US)
of hospitalization for treatment induced morbidity, and                                                                                            1000
                                                           2)Anesthesia fee for revision THA:                                                                                        radiation as the preferred modality for use in
productivity loss from missed work.         The direct      CPT 01215: $397.32 4                                                                   800
                                                                                                                                                                                     prophylaxis against HO after THA, even when cost-
medical costs of radiation, surgical revision for          3)All other hospital costs based on:                                                    600
                                                                                                                                                                                     effectiveness is taken into consideration.
recurrent HO, and treatment of NSAID toxicity were          DRG 545: $22,117.20 5                                                                  400
estimated using the 2007 Medicare Fee Schedule             4)Total cost per revision: $24,132.56                                                                                     Citations:
and pricer software for 2007 Medicare inpatient DRG        5)Cost per patient:                                                                                                       1 Sell S, Wilms R, Jany R, et al. The suppression of heterotopic ossifications:
                                                            Radiation = $217.19, NSAIDs = $699.84                                                                                      Radiation versus NSAID therapy – a prospective study. J Arthroplasty.
codes. The frequencies of these toxicities were taken                                                                                                0
from published randomized trials and the package           Anesthesia cost formula: 2007 CF = 18.06
                                                                                                                                                           XRT       NSAIDs          2 Pakos E, Ioannidis J. Radiotherapy vs. nonsteroidal anti-inflammatory drugs for

insert for indomethacin. The indirect costs of lost        Cost = {base units + (OR time * units/h)} * CF                                                                              the prevention of heterotopic ossification after major hip procedures: A meta-
                                                                                                                                                                                       analysis of randomized trials. IJROBP. 2004;60:888-895.
wages were estimated using 2005 median salary data         Direct Medical Cost of Hospitalization for GI Bleeding:                                                                   3 Drugstore.com

from the U.S. Census Bureau.                               1)Rate of GI bleed during init hospitalization: Radiation 0.9% vs. NSAIDs 2.0% 6                                          4 Estimated using 2007 Medicare Fee Schedule
                                                                                                                                                                                     5 Estimated using pricer software for 2007 Medicare Inpatient DRG Code
                                                           2)Rate of admission for GI bleed - 6 weeks of indomethacin use 0.5% 7
Results:                                                   3)Cost of hospitalization for GI bleeding event (DRG 174): $9581.78 5
                                                                                                                                                                                     6 Fransen M, Anderson C, Douglas J, et al. Safety and efficacy of routine

                                                                                                                                                                                       postoperative ibuprofen for pain and disability related to ectopic bone formation
Direct Medical Cost of NSAIDs:                             4)Cost per patient: Radiation = $85.17, NSAIDs = $238.70                                                                    after hip replacement surgery (HIPAID): Randomized controlled trial. BMJ.
                                                                                                                                                                                       2006;333:519. Epub 2006 Aug 2.
Standard NSAID regimen: 25mg Indomethacin tid x6 weeks     Indirect Costs of Missed Work Days                                                                                        7 Estimated from package insert for Indomethacin
25 mg (30 tabs) = $7.99.                                   1)Median length of hospital stay for re-operation or GI bleed: 4 days 5                                                   8 2005 Median salary data from U.S. Census Bureau
3 pills/day x 7days/week x 6 weeks = 126 pills.            2)Income forgone per day of hospitalization: $85.94 8                                                                     9 Armstrong CP, Blower AL. Non-steroidal anti-inflammatory drugs and life-

126 / 30 * 7.99 = $33.56 3                                 3)Income lost due to hospitalization: Radiation = $6.15, NSAIDs = $18.53                                                    threatening complication of peptic ulceration. Gut. 1987;28:527-532.

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