Background
Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers, from diagnosis to death [
1,
2]. Perioperative and post-operative complications, high recurrence rates, intensive surveillance strategies, and expensive treatment costs are the key contributors to the economic and health-services burden of this disease [
3]. BC is the second most prevalent urological cancer worldwide and the fifth most common diagnosed malignancy in Canada, with 8000 incident cases and 2200 deaths expected for 2014 [
4]. In the USA, 74 690 new cases and 15 580 deaths from BC are estimated for this year [
5]. A quarter of patients present with muscle invasive BC, and about half of these individuals have occult distant metastases at the time of presentation [
3]. Transurethral resection of the bladder tumor (TURBT) is a diagnostic and therapeutic intervention in cases of superficial disease, while muscle invasive bladder cancer often requires radical cystectomy (RC) [
6]. Epidemiologic trends, aging and evolving population demographics along with technological advances in endoscopy, diagnostic and surgical technique will make the management of patients with bladder cancer in the near future a more substantial economic challenge [
7,
8]. There is a lack of studies on the trajectories of BC patients in the continuum of care with respect to costs and the use of medical services [
8]. Therefore, the objective of the present study was to describe health-care utilization and associated costs among patients who underwent RC for BC in the province of Quebec - Canada, as from the public healthcare system perspective.
Methods
Study design
We conducted a descriptive study analyzing health-care services utilization and costs associated with BC in a retrospective cohort of patients who underwent radical cystectomy in Quebec between the years 2000 and 2009.
Data source
The cohort was built with the linkage of two provincial health administrative databases: the medical billing records database of the Régie de l’assurance maladie du Québec (RAMQ), and the Fichier des évenements démographiques de l’Institut de la statistique du Québec (ISQ). The RAMQ is the government body that administers healthcare provision in the province. All healthcare services are recorded in the RAMQ administrative databases and its associated claims files. The RAMQ claim file provides information on medical services dispensed to all Quebec residents (information on physician-based ICD-9 diagnostic codes, act codes for therapeutic procedures, their calendar dates and associated costs, characteristics of the patient, health care providers and hospital facilities). The ISQ administers the Fichier des événements démographiques which provides vital status data. The linkage between RAMQ and ISQ data is possible using a patients’ anonymous identifier (generated from the Numéro d’assurance maladie - NAM, which is a unique identifier for all legal residents of Quebec). The use of the data was approved by the Comission de l’acces a l’information (CAI) of Quebec. Ethics approval was obtained from the Research Ethics Board of the McGill University Health Centre.
Study population
Patients were selected from January 1st 2000 to September 30th 2009. We excluded subjects aged less than 40 years-old (the age cut-off point for micro-hematuria workup in Canada) [
9]. The index date is the date on which each patient entered into the cohort (calendar date of RC).
Health-care services utilization
We identified health-care services utilization for patients who underwent RC for BC cancer during the 4 months period before RC. The 4 months’ time frame was adopted to assure that all medical services consumed by patients were associated to RC for BC. We identified the following components of health-care utilization: 1) Pre-surgery period (pre-and post-urologist consultations, urologist consultations, cystoscopies, TURBTs, pathology and imaging procedures), 2) Surgical period (RC), and 3) Post-surgery period (post-operative urologist, medical oncologist, and other consultations, and imaging procedures). Post-surgery health services were determined up to one year after surgery.
Cost assignments
Analogously to the time frame adopted for the identification of health-care services, we calculated average costs per patient and total costs for the following components of costs on the continuum of care for BC : 1) Pre-surgery costs (cost of pre-urologist consultations, cost of post-urologist consultations, cost of urologist consultations, costs of cystoscopies, costs of TURBTs, costs of pathologic and imaging procedures; 2) Costs of RC, and 3) Post-surgery costs (costs of urologist consultations, costs of post-operative consultations, costs of medical oncologist consultations, costs of imaging procedures and costs of post-operative complications management). The unit cost of each medical service for consultations and imaging procedures was documented from the RAMQ’s list of medical procedures act codes approved for physician reimbursement fees in Quebec [
10,
11]. We did not include costs associated to equipment and maintenance when computing costs for imaging procedures. When applicable, average and total costs for cystoscopy, TURBT and RC included estimation of hospitalization costs, pathology reports, urine cytology, anesthetist fees and surgical cardio-pulmonary monitoring. We assumed that each cystoscopy generates one urine cytology report; each TURBT leads to a same-day hospitalization stay and 1 pathology report, and each RC leads to 7 days hospitalization and 1 pathology report. Post-operative complications were identified by means of RAMQ procedure flash act codes, as described in previous work [
12]. Hospitalization and pathology costs were estimated from the
Ministere de la Sante et des Services Sociaux (MSSS) du Quebec and the McGill University Health Centre administration, respectively [
13,
14]. The unit costs and sources are presented in Table
1. All costs were assigned in Canadian dollars and were estimated from the 2014 Quebec’s public healthcare system perspective.
Table 1
Costs associated with bladder cancer: Cost Components and Unit cost. Time horizon: from 4 months prior to radical cystectomy until 1 year after surgerya
PRE-SURGERY |
Pre-urologist consultations |
• Physician fees | $ 50 | Bladder cancer cohort |
Range: $ 15.20 – $ 94.4 |
Post-urologist consultations |
• Physician fees | $ 50 | Bladder cancer cohort |
Range: $ 15.20 – $ 94.4 |
Urologist consultations |
• Physician fees | $ 40 | Bladder cancer cohort |
Range: $16.9 – 45.6 |
Cystoscopies |
• Physician fees | $ 50.9 | RAMQ reimbursement act code list (10,11) |
• Procedure fees | $ 192.3 | Quebec MSSS (14) |
• Urinary cytology | $ 87 | MUHC administration |
TURBT |
• Physician fees | $ 208 | RAMQ reimbursement act code list (10,11) |
• Hospitalization | $ 1371 | Quebec MSSS (14) |
• Anesthesia physician fees | $ 150 | RAMQ reimbursement act code list (10,11) |
• Pathology report | $ 40 | MUHC administration |
Imaging |
• Physician fees | $ 45 | Bladder cancer cohort |
Range: $ 16.5 - $200 |
RADICAL CYSTECTOMY |
• Physician fees | $ 1 880 | RAMQ reimbursement act code list (10,11) |
• Hospitalization | $ 14 855 | Quebec MSSS (14) |
• Anesthesia physician fees | $ 1 160 | RAMQ reimbursement act code list (10,11) |
• Pathology report | $ 450 | MUHC administration |
POST-SURGERY |
Post-operative consultations |
• Physician fees | $ 50 | Bladder cancer cohort |
Range: $ 15.20 – $ 94.4 |
Post-operative urologist consultations |
• Physician fees | $ 40 | Bladder cancer cohort |
Range: $16.9 – 45.6 |
Post-operative medical oncologist consultations |
• Physician fees | $ 39 | Bladder cancer cohort |
Range: $ 16.9 - $ 98 |
Post-operative imaging |
• Physician fees | $ 45 | Bladder cancer cohort |
Range: $ 16.5 - $200 |
Post-operative complications |
• Physician fees | $ 550 | Bladder cancer cohort |
Range: $ 61.5 - $ 1184 |
• Hospitalization | $ 1371 | Quebec MSSS (14) |
Covariates
We analysed BC-associated costs across two groups of variables: 1) Patient-related variables: age (four categories: less than 60, 60–69, 70–75, more than 75 years) and gender (dichotomous); and 2) Health-care services related variables: hospital facility where RC was performed, hospitals hosting an urology teaching program (dichotomous), surgeons’ annual RC case load (three categories: surgeons who perform less than 3 RC/year, surgeons who perform between 3–9 RC per year and surgeons who perform more than 9 RC/year), geo-administrative region where RC was performed (4 regions, grouped A to D) and calendar date of RC. Geo-administrative division is based on the MSSS’s Academic Integrated Network of Health which divides the province of Quebec into four regions according to provision of medical services and university affiliation [
15].
Statistical analyses
Demographic characteristics, age and gender-specific information of the study population was retrieved. Descriptive statistical analyses, including mean, median, standard deviation (SD) and range of costs were calculated, along with patient’s units of medical services related to each component of costs. Normality of data distribution was analysed by the Shapiro–Wilk test. Comparisons of average costs between groups were performed by t-tests and ANOVA tests, when applicable. We used autoregressive integrated moving average (ARIMA) models to evaluate trends in average total costs per patient, average radical cystectomy costs per patient and post-surgery costs per patient. We analysed differences between observed and forecasted average costs per patient over 117-month periods ranging from January 2000 to September 2009. Cut-off points for comparison between observed and forecasted values were established after seasonal trends inspection of the time series plot for each component of cost. Stationarity was assessed using the autocorrelation function and the augmented Dickey Fuller test. The autocorrelation, partial autocorrelation, and inverse autocorrelation graphic functions were used to model parameter appropriateness and seasonality. The presence of white noise was assessed by examining the autocorrelation at various lags using the Lung-Box chi squared test. All analyses were two-sided with p ≤ 0.05 being considered significant. SAS 9.3 (SAS Institute Inc., Cary, NC, USA) was used to conduct the calculations.
Discussion
Previous studies have shown that radical cystectomy accounts for the largest proportion of payments for bladder cancer care; these costs showing great variability depending on the country [
8,
16]. For example, average European RC reimbursement costs in US dollars, (including hospitalizations costs and medical fees) varies from 5684 $ in the United Kingdom, 9697 $ in France, 10 932 $ in Belgium and 15 419 $ in Germany [
7]. The cost of radical cystectomy including lymphadenectomy and urinary diversion at an academic hospital center in the USA was calculated at 30 000 $ with most costs attributed to the operating room and hospital stay [
8]. In our study, RC costs in Quebec lies between the estimates for Europe and North America and represents 69 % of average costs of bladder cancer requiring RC from diagnosis to one year after surgery. This variation in surgery costs estimates across countries is probably attributable to differences in practices such as inpatient or outpatient care, duration of hospitalization, methods of calculating costs and billing, disease incidence, and the type of surgical procedure (open, laparoscopic, or robot-assisted) [
17].
Our findings also showed variations in costs for RC within the provincial health-care system. Costs of surgery varied across patient gender, patient age group, and administrative region where RC was performed. Cost variations were also detected across individual hospitals, with the majority of facilities performing surgeries at a higher than the average cost. Although these disparities were relatively small, we detected a significant 1000 $ greater average cost per patient between community hospitals compared to hospitals hosting a urology training program. Given that hospitalization and operation room costs were estimated with the provincial ministry of health’s data and attributed equally to all surgical procedures in all hospitals in our cohort, we believe that this difference is caused by the greater amount of medical fees reimbursed to physicians in community hospitals. Indeed, we found that among community hospitals, surgeries are performed by an average of 2.9 surgeons (SD: 1.15), compared to 1.76 (SD: 0.9) among hospitals hosting a urology training program. This is likely explained by the fact that in academic centers the primary surgeon is often assisted by resident house staff that does not require reimbursement by the RAMQ, as opposed to community hospitals where 2 or more surgeons are involved, each billing the RAMQ. It has been reported that logistical difficulties inherent to the additional burden of excess travel time for patients and physicians and the potential marginalization of lower-volume hospitals may increase the indirect costs attributable to surgery in community hospitals [
18]. Our results may be useful in identifying potential geographic disparities in the cost of BC cancer care.
Given that BC requires patients to undergo laboratory tests and invasive procedures for diagnosis, much of the costs during the management of the disease are attributed to cystoscopy and TURBT [
19]. The frequent number of these procedures among bladder cancer patients results in significant cumulative costs [
20]. Reimbursement for cystoscopy in the USA by Medicare is approximately 223 $ [
8]. Average costs of cystoscopy in our study (323 $) were higher than some European countries with similar publically funded health system, such as Italy (76 $), Germany (61 $), France (51 $), but considerably lower than UK (620 $) [
7]. On the other hand, average costs of TURBT in Quebec (2159 $) showed to be similar to these countries (UK: 2154 $; Germany: 1967 $, France: 1124 $, Italy: 2741 $ and Belgium: 2201 $) [
7]. TURBT represents the first line of treatment for new tumors and accounts for a substantial portion of total bladder treatment costs [
6]. In the USA, after accounting for costs of anesthesia and the operating room, these costs were estimated to be higher than 2900 $ [
21]. Costs at an academic US medical center ranged from 3000 $ to 6000 $ depending on patients average hospitalization duration [
8]. In this study, the mean length of stay was 2 days which contributed to this variation of TURBT costs. In some centers, patients spend an average of 4 days in the hospital after a TURBT. One day surgery is common in Quebec [
13,
14].
Surgery for bladder cancer carries a high risk for perioperative and post-operative complications with rates varying from 20 % to 60 % [
22,
23]. A recent study conducted by our group estimated that in Quebec postoperative complications occur in 30 % of RC cases [
12]. Complications of radical cystectomy prolong the patient’s length of hospital stay and significantly increase the total bladder cancer costs [
24]. Estimated costs of complications vary greatly across different studies according to definitions and categorization of post-operative complications, and consequently duration of hospital stay. One of the highest costs attributable to an adverse event after cystectomy was shown for sepsis in the USA [
25]. In this study, length of stay for patients with septicemia was estimated at 29 days compared with 10 days for controls. Hospital charges for bacterial infections was 107 724 $. Average costs for selected post-operative complications [
12] in our study was estimated at 5703 $, which is lower than other average estimates in the literature [
8]. A great variation in costs was observed between hospitals in Quebec with a range of 4109 $ - 7732 $. Similar to what was detected for RC average costs, community hospitals showed higher average post-operative complication costs per patients, compared to academic hospitals. More studies investigating predictors of higher costs and the impact of cost disparities and its relation to outcome and survival are needed.
Average total costs per patient in Quebec was found to be lower than the Canadian province of Ontario (27 388 $ in Quebec versus 33 759 $ in Ontario) [
26]. Although we cannot establish causal relations between medical costs and patient outcomes based on such ecological data, it is noteworthy that 5-year overall survival after RC in Quebec is 46 %, while the rate is 35 % in Ontario [
18].
During the study period, total costs of bladder cancer requiring RC from diagnosis up to one year of follow up were estimated at more than 70 million dollars, with more than 70 % of this total expenditure attributed to health care associated to surgery. Total costs of surgery and post-operative complications were estimated at 50 million dollars and 4 million dollars, respectively. Total costs in our cohort represent a small fraction of what was estimated in the USA for 2010 (3.98 billion dollars, for all cases confounded) [
27]. Reasons for the rising cost of bladder cancer in the USA are attributable to the fact that most patients in the US are part of the Medicare Program [
1]. In addition, Medicare reviewed its reimbursement fees for office-based endoscopic procedures in 2005, which led to an increased number of bladder lesions detected and a higher total number of bladder cancer-related procedures being performed [
28]. Total costs estimates in the United Kingdom included estimates of indirect costs from loss of earnings and reached 125.2 million in 2010 [
29]. Cost of the annual medical care was estimated to be about 1 million dollars in Sweden [
19] and 27 million dollars in South Korea [
30]. These remarkable variations are due to differences in both disease incidence and costs of per patient treatment in each national health system. Analyses of specific explanatory differences in clinical structure or the availability of resources have not been extensively investigated [
1]. A noteworthy result of our study was a decreasing trend in the average post-operative costs and total costs caused by a lower average cost for consultations observed in the year 2009.
To our knowledge, this is the first study to describe costs attributed to the number of pre and post-urologist consultations to general practitioners and other specialists, as well as the costs associated to urologist consultation during the pre and post-operative period. Given the paucity of detailed descriptive studies on the health economics of BC in Canada [
26], our results provide some evidence-based data of interest to health care providers and policy-makers to better understand the relationship between resource-utilization and costs associated with the disease, and to improve the efficiency and outcomes.
This study had some significant limitations inherent to the use of administrative databases. We were unable to measure some factors that can play an important role on costs of BC requiring RC, such as grade, stage and severity of the tumor. Data on comorbidity and patient functional status are also lacking. More importantly, since we did not know the actual hospitalization period for each patient undergoing RC, we could not be more precise in attributing costs to RC and post-operative complications. The actual variance of health services costs is hence, mainly due to the overall differences in billing codes for physicians’ payments. This information would be very important in order to compare costs and efficiencies between administrative regions, individual hospitals, and surgeons. The imputation of some economic component for medical services may have caused some degree of information bias in the calculation of average costs per patient. Nevertheless, if information bias is present, it is certainly non-differential, which not undermine internal validity of our findings. Given that we do not have data on some medical services such as prescriptions filled by patients, we could not compare our findings with an external cohort of patients that would serve as control group for estimation and comparison of attributable and net costs. Moreover, considering the intrinsic discrepancies in the management of BC across different health care systems, we are not convinced that comparing of our findings in the province of Quebec with a different “control cohort” would decrease the possibility of information bias.
Also, our study did not account for the burden of indirect costs in our analyses, for which we acknowledge that these costs in the form of patients’ and caregivers’ time, as well as reduced physical and social functioning contribute to the overall burden of bladder cancer on society. On the other hand, the fact that the RAMQ is single-payer and public funded system with universal healthcare coverage allows the collection of prospective information for a large sample size, which increases external validity of our findings. The linkage between the two databases was done using a unique patient identifier, which permitted a very reliable correspondence of medical services data [
31].
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Competing interests
The authors have no conflicts of interest to declare.
Authors’ contributions
Each author has participated actively and sufficiently in this study. FS conducted the study, performed the analyses, and led the writing of the manuscript. AZ, WK and AD helped to interpret the results, and revised the manuscript for important intellectual content. AA conceived and supervised the study. All authors read and approved the final manuscript.