IMPACT OF INDISCRIMINATE USE OF PUMP INFUSION SET (PIS) ON THE COST OF CHEMOTHERAPY TREATMENTS:
A COST MINIMIZATION STUDY
Alves AFF, Castro APC, Medina P, Nishikawa AM
Evidências - Kantar Health, Campinas, Brazil
PCN18
Table 1. Incremental Cost of Pump Infusion Sets in the Treatment of Breast Cancer
ABSTRACT
Daily Cost of
Infusion with PIS as
Recommended by
the Manufacturer
Breast Cancer
Treatments
OBJECTIVES: Cancer incidence has increased in the last decades. Meanwhile, new and costly
intravenous chemotherapy (CT) drugs are added to current treatment options. Cost of
chemotherapy is not restricted to drugs themselves, and some of the equipment used for
infusion can impact the final value. CT can be administered on simple IV lines although some
schemes require the use of pump infusion sets (PIS) which can be PVC free or photo-protective
depending on the drug. Nonetheless, several cancer centers in Brazil adopt CT pump infusion
as a rule, despite manufacturers instructions. We aim to assess the added cost of unnecessary
PIS use during CT infusion.
METHODS: In this cost-minimization study we compared 2 scenarios: use of PIS according to
manufacturers’ recommendations or as a indiscriminately for all CT. Chemotherapy
treatments for breast cancer (AC-T, AC-TH, TAC, FAC, CMF and FEC100), lung cancer (carboplatin/
with and without bevacizumab, vinorelbine/cisplatin, cisplatin/paclitaxel and pemetrexed/
cisplatin) and colon cancer (fluorouracil/leucovorin, FOLFIRI, FOLFOX, cetuximab/irinotecan)
were listed from the Brazilian Society of Clinical Oncology (SBOC) manual. Minimum, mean
and maximal costs for drugs and equipment were retrieved from the official price list (SIMPRO),
daily cost of infusion and increment in cost were also calculated in Brazilian Reais (R$).
Daily Cost of
Infusion with
Indiscriminate Use
of PIS
Incremental Cost
AC-T
R$ 515.97
R$ 1,510.32
(R$ 100.80 - R$ 1,512.92) (R$ 287.33 - R$ 2,748.43)
R$ 994.35
TAC
R$ 281.15
R$ 2,050.38
(R$ 37.70 - R$ 722.42) (R$ 478.50 - R$ 3,622.34)
R$ 1,769.23
FAC; CMF; FEC 100
R$ 113.16
R$ 1,952.70
(R$ 1.20 - R$ 603.18) (R$ 120.00 - R$ 3,808.08)
R$ 1,839.54
AC-TH
R$ 553.69
R$ 2,161.22
(R$ 101.20 - R$ 1,713.98) (R$ 327.33 - R$ 4,017.79)
R$ 1,607.53
RESULTS: Fifteen CT combinations were evaluated (6 for breast, 5 for colon and 4 for lung cancer).
For breast cancer, the mean incremental cost per day of infusion with PIS varied from R$ 994.35
to R$ 1,839.54, depending on the chemotherapy scheme used. For lung cancer these values
varied from R$ 356.34 to R$ 1,201.53 and for colon cancer treatment the incremental cost was
R$ 1,226.36.
Table 2. Incremental Cost of Pump Infusion Sets in the Treatment of Lung Cancer
CONCLUSION: Although medications are the main source of expense in cancer treatment,
unnecessary use of PIS can add considerable costs to chemotherapy and correct use according
to manufacturer recommendation should be reinforced.
INTRODUCTION
• Cancer is an important cause of hospitalization, morbidity and mortality worldwide. 1-3
Lung Cancer
Treatments
Daily Cost of
Infusion with PIS as
Recommended by
the Manufacturer
Carboplatin +
Paclitaxel
R$ 478.25
R$ 859.42
(R$ 100.40 - R$ 1,311.86) (R$ 247.33 - R$ 1,479.07)
Vinorelbine + Cisplatin
or Pemetrexed +
Cisplatin
According to the National Institute of Cancer José Alencar Gomes da Silva (INCA) 21.4 million new cases of cancer are projected to 2030. 4
• Healthcare expenditure is increasing globally. According to data published by the Brazilian
R$ 69.09
(R$ 20.12 - 256.26)
Daily Cost of
Infusion with
Indiscriminate Use
of PIS
R$ 1,270.62
(R$ 110.16 - R$ 2,425.00)
Incremental Cost
R$ 381.17
R$ 1,201.53
Carboplatin
+ Paclitaxel +
Bevacizumab
R$ 515.97
R$ 1,510.32
(R$ 100.80 - R$ 1,512.92) (R$ 287.33 - R$ 2,748.43)
R$ 994.35
Cisplatin + Paclitaxel
R$ 471.90
R$ 828.24
(R$ 119.72 - R$ 1,166.00) (R$ 277.49 - R$ 1,365.35)
R$ 356.34
National Health Agency (ANS), medical and hospital revenues in the first semester of 2014
were 14.9% higher than in the same period of 2013, while expenses were 15.6% higher. 5
• Chemotherapy (CT) costs are a constant source of concern for healthcare systems managers,
since new drugs have increasingly higher prices. 6,7 Nevertheless, CT costs are not limited
to the cost of drugs, per se, as several other relatively inexpensive items must be added,
such as needles, syringes, infusions sets, etc. 8
• Infusion sets, defined as clear, flexible, plastic tubes used for intravenous infusions, are
frequent items in the list of expenses of any oncology treatment unit. Some medications must
be infused through special equipment (PVC free sets or tubes with photo-protection), while
some drugs must be infused in a time-controlled fashion requiring the use of infusion pumps.
Table 3. Incremental Cost of Pump Infusion Sets in the Treatment of Colon Cancer
Colon Cancer
Treatments
Daily Cost of
Infusion with PIS as
Recommended by
the Manufacturer
Daily Cost of
Infusion with
Indiscriminate Use
of PIS
Incremental Cost
Fluorouracil +
Leucovorin or
Cetuximab +
Irinotecan
R$ 75.44
(R$ 0.80 - 402.12)
R$ 1,301.80
(R$ 80.00 - R$ 2,538.72)
R$ 1,226.36
R$ 616.44
R$ 1,842.80
(R$ 472.30 - R$ 982.12) (R$ 551.50 - R$ 3,118.72)
R$ 1,226.36
• Despite being necessary to only a limited group of drugs, it is common practice in Brazilian
oncology centers to use pump infusion sets (PIS) to administer any CT medication.
Although these sets are not high-cost equipment, excessive use can impact the final cost
of treatment for payers.
• Our goal was to compare the use of PIS according to manufacturer recommendations
versus indiscriminate use in oncology centers in Brazil and perform a cost-minimization
analysis (CMA).
FOLFIRI or FOLFOX
METHODOLOGY
• A panel of expert oncologists selected the most frequently prescribed chemotherapy
schemes from the Brazilian Society of Oncology’s Clinical Guideline (Manual Clínico da
Sociedade Brasileira de Oncologia Clínica - SBOC) for the more prevalent cancers in Brazil.
DISCUSSION
• The panelist selected the following schemes:
Breast cancer: AC-T, AC-TH, TAC, FAC, CMF and FEC100
• Fee-for-service is the most used method of payment in the supplementary healthcare sector
Lung cancer: carboplatin + paclitaxel, paclitaxel plus or minus bevacizumab, vinorelbine
+ cisplatin, cisplatin + paclitaxel and pemetrexed + cisplatin
in Brazil. 10 This payment model however, may incite service providers to use high-cost
materials in order to demand a higher reimbursement price from health insurance
companies (HIC). The scenario becomes even more complicated since oftentimes most HIC
already pay full-price for drugs and equipment, while providers are able to buy them at
discounted prices. This gap between buying and reimbursing prices may lead providers to
choose items with the largest difference to achieve greater profit.
Colon cancer: fluorouracil plus leucovorin, FOLFIRI, FOLFOX, cetuximab plus irinotecan
• All schemes with the respective drugs and the equipment necessary to perform the
infusions were input on Excel spreadsheets. Special infusion sets required for specific drugs
(photo-protection, PVC free and DEHP free) were also considered.
• Thus, a conflict of interests emerges, turning the choice of infusion sets from clinical need to
profit margin. Also, the preference for PIS may be based on attempts to reduce the workload
of nurses, who can rely on the equipment’s alarms and mechanisms, being thus free to care
for other patients.
• Minimum, maximum and mean costs as well as daily cost of infusion and incremental costs
were all calculated based on the official list of prices known as SIMPRO and are listed in
Brazilian Reais (R$) with an exchange rate of 1US$ to 3.2R$. 9
• HIC in Brazil must be attentive to the issue discussed here, implement control methods and
• All drugs and equipment had the proper legal approval from the National Agency for
find the best reimbursement agreement to avoid waste during chemotherapy treatments.
Sanitary Vigilance (ANVISA) for use and commercialization in Brazil.
• Although PIS may facilitate the work of nurses, chemotherapy infusions can be easily monitored
by dripping rate and the level of content on the vial.
Figure 1. Study Scope and Design
CONCLUSION
•
The incremental costs secondary to the indiscriminate use of PIS are relevant in absolute
terms and should be considered when analyzing oncologic treatments.
• The price of infusion sets is widely variable, even when one considers equipment within the
same characteristics.
• We found that the incremental costs due to the indiscriminate use of PIS in the most frequently
used chemotherapy treatments of breast, lung and colon cancer varied from R$ 356.34
to R$ 1,839.04.
• The incremental costs due to the indiscriminate use of PIS can be considered unnecessary,
since not all drugs must be infused in a precisely, time-controlled manner. When manufacturer’s
instructions are followed it is possible to reduce the waste of resources in cancer treatments.
References
RESULTS
1.
2.
3.
4.
• We evaluated 15 chemotherapy schemes: 6 for breast cancer, 5 for colon and 4 for lung cancer.
5.
6.
7.
8.
• Detailed results are depicted on Tables 1, 2 and 3.
9.
10.
Some drugs are commonly used in more than one scheme and for more than one disease.
Fitzmaurice C, Dicker D, Pain A, et al. The Global Burden of Cancer 2013. JAMA Oncol. 2015;1(4):505-527.
Santos SS, Melo LR, Koifman RJ, Koifman S. Breast cancer incidence and mortality in women under 50 years of age in Brazil. Cadernos de Saúde Pública.
2013;29:2230-2240.
Santos SS, Melo LR, Koifman RJ, Koifman S. Cancer incidence, hospital morbidity, and mortality in young adults in Brazil. Cadernos de Saúde Pública. 2013;29:1029-1040.
Instituto Nacional de Câncer José Alencar Gomes da Silva INCA. Estimativa 2014 Incidência de Câncer no Brasil. 2013; http://www.inca.gov.br/estimativa/2014/index.asp?ID=1. Accessed June, 2015.
Ministério da Saúde. Caderno de Informação da Saúde Suplementar: Beneficiários, Operadoras e Planos. Rio de Janeiro, Brasil. 2014.
Bach PB. Limits on Medicare’s ability to control rising spending on cancer drugs. N Engl J Med. 2009;360(6):626-633.
Bach PB. Reforming the payment system for medical oncology. JAMA. 2013;310(3):261-262.
Nobrega CR, Lima AnFC. Procedures costs related to outpatient chemotherapy treatment of women suffering from breast cancer. Revista da Escola de Enfermagem da USP. 2014;48:699-705.
SIMPRO. Revista SIMPRO. Sao Paulo (Brazil): SIMPRO; 2013.
Escrivão Junior A, Koyama MF. O relacionamento entre hospitais e operadoras de planos de saúde no âmbito do Programa de Qualificação da Saúde Suplementar
da ANS. Ciência & Saúde Coletiva. 2007;12:903-914.
Poster Presented at the ISPOR 5th Latin America Conference 6 -8 September 2015 Santiago, Chile
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