Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients with Localized Muscle-Invasive Bladder Cancer

Stephen Williams, Yong Shan, Mohamed Ray-Zack, Hogan K. Hudgins, Usama Jazzar, Douglas Tyler, Stephen J. Freedland, Todd Swanson, Jacques Baillargeon, Jim C. Hu, Sapna Kaul, Ashish M. Kamat, John L. Gore, Hemalkumar Mehta

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Abstract

Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83754 vs $68692; median difference, $11805; 95% CI, $7745-$15864), 180 days ($187162 vs $109078; median difference, $62370; 95% CI, $55581-$69160), and 365 days ($289142 vs $148757; median difference, $109027; 95% CI, $98692-$119363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136935 (95% CI, $122131-$152115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Original languageEnglish (US)
JournalJAMA Surgery
DOIs
StatePublished - Jan 1 2019

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Cystectomy
Urinary Bladder Neoplasms
Costs and Cost Analysis
Muscles
Therapeutics
Medicare
Radiology
Propensity Score
Selection Bias
Ambulatory Care
Hispanic Americans
African Americans
Epidemiology
Cohort Studies
Outcome Assessment (Health Care)
Databases
Pathology

ASJC Scopus subject areas

  • Surgery

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Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients with Localized Muscle-Invasive Bladder Cancer. / Williams, Stephen; Shan, Yong; Ray-Zack, Mohamed; Hudgins, Hogan K.; Jazzar, Usama; Tyler, Douglas; Freedland, Stephen J.; Swanson, Todd; Baillargeon, Jacques; Hu, Jim C.; Kaul, Sapna; Kamat, Ashish M.; Gore, John L.; Mehta, Hemalkumar.

In: JAMA Surgery, 01.01.2019.

Research output: Contribution to journalArticle

Williams, Stephen ; Shan, Yong ; Ray-Zack, Mohamed ; Hudgins, Hogan K. ; Jazzar, Usama ; Tyler, Douglas ; Freedland, Stephen J. ; Swanson, Todd ; Baillargeon, Jacques ; Hu, Jim C. ; Kaul, Sapna ; Kamat, Ashish M. ; Gore, John L. ; Mehta, Hemalkumar. / Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients with Localized Muscle-Invasive Bladder Cancer. In: JAMA Surgery. 2019.
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abstract = "Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8{\%}) were women, 2591 (87.4{\%}) were white, 129 (4.4{\%}) were African American, and 98 (3.3{\%}) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83754 vs $68692; median difference, $11805; 95{\%} CI, $7745-$15864), 180 days ($187162 vs $109078; median difference, $62370; 95{\%} CI, $55581-$69160), and 365 days ($289142 vs $148757; median difference, $109027; 95{\%} CI, $98692-$119363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136935 (95{\%} CI, $122131-$152115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.",
author = "Stephen Williams and Yong Shan and Mohamed Ray-Zack and Hudgins, {Hogan K.} and Usama Jazzar and Douglas Tyler and Freedland, {Stephen J.} and Todd Swanson and Jacques Baillargeon and Hu, {Jim C.} and Sapna Kaul and Kamat, {Ashish M.} and Gore, {John L.} and Hemalkumar Mehta",
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AU - Williams, Stephen

AU - Shan, Yong

AU - Ray-Zack, Mohamed

AU - Hudgins, Hogan K.

AU - Jazzar, Usama

AU - Tyler, Douglas

AU - Freedland, Stephen J.

AU - Swanson, Todd

AU - Baillargeon, Jacques

AU - Hu, Jim C.

AU - Kaul, Sapna

AU - Kamat, Ashish M.

AU - Gore, John L.

AU - Mehta, Hemalkumar

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N2 - Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83754 vs $68692; median difference, $11805; 95% CI, $7745-$15864), 180 days ($187162 vs $109078; median difference, $62370; 95% CI, $55581-$69160), and 365 days ($289142 vs $148757; median difference, $109027; 95% CI, $98692-$119363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136935 (95% CI, $122131-$152115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

AB - Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83754 vs $68692; median difference, $11805; 95% CI, $7745-$15864), 180 days ($187162 vs $109078; median difference, $62370; 95% CI, $55581-$69160), and 365 days ($289142 vs $148757; median difference, $109027; 95% CI, $98692-$119363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136935 (95% CI, $122131-$152115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

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