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Cost Accounting for Transarterial Chemoembolization
At the 2015 Society of Interventional Radiology Annual Scientific Meeting, Osman Ahmed, MD, and colleagues from Stanford University presented a poster titled “Cost Accounting as a Tool for Increasing Cost Transparency in Superselective Hepatic Transarterial Chemoembolization (ss-TACE).”1 The aim of the research was to analyze the direct cost of performing super selective TACE (ss-TACE) using cone beam CT (CBCT) to uncover differences in cost between the primary interventional oncology providers at Stanford. The authors also sought to identify tools for cost savings based on the results. Interventional Oncology 360 asked Dr. Ahmed to share details about their data.
Q: Is there any other existing data on cost of IO procedures? If so, what and was this helpful to you in your research?
A: A fair amount of cost data analysis work pertaining to chemoembolization has actually already been published. Such work dates back to 2000, when Abrahamson et al investigated the theoretical utility and cost effectiveness of chemembolization by defining its marginal direct cost compared to palliative care alone in a group of 21 patients.2 More recently, Beheshti et al explored the operational expense of 50 consecutive patients undergoing TACE at their academic institution, outlining a method for evaluating expenses from a hospital’s cost perspective.3 This study was particularly useful for our research as it laid the groundwork for identifying potential areas for savings in TACE procedures.
Q: You stated that operator choice of supplies could contribute to costs. Did you find this to be true? If this wasn’t found by your research, do you think it might still be true?
A: The data from our study showed that at our institution, the predominant force driving cost for chemoembolization was intraprocedural labor. This is likely a reflection of the labor climate in which our hospital is located; we found that the high labor costs overshadowed the variability in the choice of supplies between operators. Therefore, although operator choice in supplies did contribute and vary the overall cost of TACE, the variability was not seen to be statistically significant.
Q: What are the physical and pharmacy devices/medications that were used?
A: Variable physical supplies include the choice of sheath, catheters, wires, microcatheters, microwires, and any supplemental bland embolic or occlusion devices. Pharmaceutical medications include chemoembolic agents including lyophilized doxorubicin or doxorubicin loaded onto drug-eluting beads. Additionally, medications used for sedation (i.e. fentanyl, midazolam) are also charged by the pharmacy.
Q: You used the Bonferroni test and found differences between two of the physicians. Could you explain the difference?
A: The Bonferroni test is a statistical test that is commonly used in post hoc analysis of ANOVA tests to address type 1 errors encountered due to multiple comparisons. Bonferroni testing increases the significance threshold for individual comparisons between groups to compensate for the fact that the ANOVA is performing multiple hypotheses tests and can incorrectly reject the null hypothesis. The downside of the Bonferroni test is that it is conservative and overcorrects for type 1 error (i.e. has a lower power for finding statistical differences). Regarding the data, use of the Bonferroni test was done in a pairwise fashion and found a statistically significant difference between physicians 1 and 4 in terms of variable supply costs such that physician 1 utilized a significantly higher supply cost in performing TACE when compared with physician 4.
Q: How do you think cost can or will be reduced in the future?
A: Cost reduction in health care is a very important topic as we transition to value-based care. Interventional radiology, and specifically interventional oncology, are subspecialties of medicine in which there is a great deal of pressure to justify the expense related to these specialized procedures. For this reason, defining the cost of IO interventions and its variability among providers only represents the first step in understanding their value. Moving forward, future investigations can hopefully begin to focus on the clinical factors (i.e. tumor size, location, number, patient demographic variables) that may impact cost and eventually influence patient selection.
Q: How should we envision the overall cost effectiveness of TACE? In the big picture, compared to surgery or other procedures, are costs lower for TACE?
A: That’s a great question and I would have to reference existing literature to answer it. In 2012 Ray et al simulated the cost effectiveness of TACE compared to radiofrequency ablation and selective internal radiation therapy (i.e. radioembolization) for unresectable HCC.4 They found that when feasible, radiofrequency ablation was always the least costly of interventions according to their Monte Carlo simulation. Transarterial chemoebolization was the cheaper treatment when compared to radioembolization approximately two-thirds of the time, with the choice of therapy among the 2 largely influenced by the number of repeat TACE interventions needed for treatment. It is important to note such cost calculations were derived from a payer perspective (Medicare reimbursements) and any inferences of cost effectiveness were made from the assumption that all treatments provided equal treatment of HCC with regard to tumor response and overall survival. With respect to the overall big picture, it is well established from the literature that a survival benefit for unresectable HCC treated by TACE exists, justifying its comparably lower cost with other surgical techniques. Moving forward, the cost effectiveness of TACE should be further investigated in its role as an adjuvant treatment for downstaging to surgical resection or transplantation, as previous studies have shown varied results.
Q: Your conclusions state that cost accounting systems can be used to calculate TACE cost - how is this applied practically?
A: The practicality of cost accounting systems is that they are simple to use (for finance administrators that is) and can accurately break down the overall cost of a procedure (i.e. TACE) into its component costs. This practice increases cost transparency to a level that we as physicians can understand and allow us to identify areas for potential cost savings.
Q: What other studies should be done about cost effectiveness for TACE and other IO therapies?
A: As I’ve alluded to in my previous answers, cost analysis research for interventional radiology and interventional oncology remains in its infancy, with many potential avenues for future research. However, in my opinion perhaps the most important future research direction is to define any difference in survival outcomes with the many different interventional radiology strategies currently being used to treat HCC and hepatic metastases. Specifically, defining the difference in survival outcomes between the variations in technique for performing TACE may help to justify (or discourage) the routine practice of such technologies as cone beam CT, drug-eluting beads, or super-selective technique.
Q: What else would you like IO clinicians to know about your data?
A: I would first like to thank you for highlighting our work in your journal and bringing to light some of these key points. One last point is that as our research reflects cost data collected from a single institution in the notoriously expensive Silicon Valley, we would like to encourage IO clinicians to investigate for themselves the costing practices in their hospital system to better understand the individual variables that drive the expense of their IO therapies. If similar results are produced across different socioeconomic landscapes, this multi-institutional approach can serve to increase the generalizability of the current findings.
Editor’s note: Disclosure: Dr. Ahmed reports no disclosures related to the content herein.
Suggested citation: Ford J. Cost accounting for transarterial chemoembolization. Intervent Oncol 360. 2015;3(5):E52-E56.
References
- Ahmed O, Ward T, Patel MV, et al. Cost accounting as a tool for increasing cost transparency in super-selective hepatic transarterial chemoembolization (ss-TACE). Poster presented at: The 2015 Annual Scientific Meeting of the Society of Interventional Radiology (SIR); February 28 to March 5, 2015; Atlanta.
- Abramson RG, Rosen MP, Perry LJ, Brophy DP, Raeburn SL, Stuart KE. Cost-effectiveness of hepatic arterial chemoembolization for colorectal liver metastases refractory to systemic chemotherapy. Radiology. 2000;216(2):485-491.
- Beheshti MV, Meek J. Calculation of operating expenses for conventional transarterial chemoembolization in an academic medical center: a step toward defining the value of transarterial chemoembolization. J Vasc Interv Radiol. 2014;25(4):567-574.
- Ray CE, Battaglia C, Libby AM, Prochazka A, Xu S, Funaki B. Interventional radiologic treatment of hepatocellular carcinoma—a cost analysis from the payer perspective. J Vasc Interv Radiol. 2012;23:306-314.
