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Follow up of breast cancer in primary care vs specialist care: results of an economic evaluation |
Grunfeld E, Gray A, Mant D, Yudkin P, Adewuyi-Dalton R, Coyle D, Cole D, Stewart J, Fitzpatrick R, Vessey M |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Primary-care-centred follow up of breast cancer patients.
Economic study type Cost-effectiveness analysis.
Study population Women with breast cancer in remission and receiving regular follow-up.
Setting Hospital and general practice. The economic study was conducted in the UK.
Dates to which data relate The names of all patients diagnosed as having breast cancer between 1988-1992 were obtained from local cancer registries and their hospital records were reviewed. The duration of follow up was 18 months. Resource use referred to the follow-up period. The date of the price data was 1994.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data Costing was undertaken prospectively on the same patient sample as that considered in the effectiveness analysis.
Study sample The study sample consisted of 296 women with breast cancer in remission who were receiving regular follow-up either in hospital or in general practice. The women were randomised to one of two groups:
continued routine follow-up in hospital outpatient clinics according to the usual practice (hospital group: 148 patients), and
routine follow-up from their own GP (general practice group: 148 patients).
Follow-up groups were assigned by a telephone call to the trial co-ordination centre in Oxford. The trial was designed to detect a mean time to diagnosis between allocation groups of 3 months. To achieve 90% power with Alpha = 0.05, it was estimated that 30 recurrences would be required. Assuming an annual recurrence rate of about 7%, it was estimated that a sample size of 300 would be required, with 18 months planned follow-up. The general practice group was younger at diagnosis (mean age 55.6 versus 59.0 years) and at entry to the study (59.1 versus 62.4). There were more stage I patients in the hospital group (50.3% versus 40.4%). Otherwise the two groups were very similar in clinical characteristics and in baseline scores on all subscales of the quality of life instruments.
Study design The study took the form of a randomised controlled multi-centre trial. Groups were randomised by a telephone call to the trial co-ordination centre in Oxford. Random allocation was in blocks of 8. The follow up was 18 months. It is not clear whether there were any losses to follow-up.
Analysis of effectiveness The analysis was based on intention to treat. The health outcomes used in the analysis were: time between first presentation of symptoms to confirmation of recurrence, quality of life measured by specific dimensions of the SF-36 schedule: physical functioning, pain, social functioning, role functioning-physical, emotional-mental health, general health perception; the European Organisation for Research and Treatment of Cancer (EORTC) symptom scale-fatigue, appetite loss, pain, dyspnoea, sleep disturbance, and the hospital anxiety and depression scale.
Effectiveness results The effectiveness results were as follows:
Most recurrences (18/26, 69%) presented as interval events, and almost half (7/16, 44%) of the recurrences in the hospital group presented first to general practice.
The median time to hospital confirmation of recurrence was 21 days in the hospital group and 22 days in the GP group.
The differences between groups in the change in SF-36 mean scores from baseline were small: -1.8 (95% CI: -7.2 - 3.5) for social functioning, 0.5 (95% CI: -4.1 - 5.1) for mental health, and 0.6 (95% CI: -3.6 - 4.8) for general health perception.
The change from baseline in the mean depression score was higher in the GP group at the mid-trial assessment (difference 0.6, 95% CI: 0.1 - 1.2), but there was no statistically significant difference between groups in the anxiety score or the EORTC scales.
Clinical conclusions GP follow-up of women with breast cancer in remission is not associated with increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life.
Measure of benefits used in the economic analysis The authors did not provide a summary measure of benefits; the reader is referred to the health outcomes reported above. Due to the fact that there were no significant differences in primary clinical outcomes, the authors conducted a cost-minimisation analysis.
Direct costs Direct health service costs were considered and were collected at both hospital and general practice level by means of a record-of-visit form. The study hospitals provided unit costs for each type of test and for an average outpatient consultation, based on the total annual running and capital costs of the department averaged across the total number of attendance's; the equivalent total costs for an average GP consultation were taken from national averages. The price date was 1994. Costs were not discounted due to the short period of the study. Resources and costs were presented separately.
Statistical analysis of costs The two-tailed t test was used to assess the significance of between group difference in means. The Chi2 test was used to assess the significance of between group difference in proportions.
Indirect Costs A questionnaire was developed containing questions about the costs of the most recent follow-up visit, namely: out-of-pocket expenses, lost earnings as a result of time off work, time spent in attending the follow-up visit and costs incurred by accompanying persons. National 1994 average hourly wage rates were used for costing.
Estimated benefits used in the economic analysis Cost results The average costs per patient were as follows:
GP group: cost of visits, 40.9; cost of tests, 23.8; total costs, 64.7;
hospital group: cost of visits, 174.1; cost of tests, 20.9, total costs, 195.1.
The lower costs in general practice were attributable to lower physician costs per visit.
Synthesis of costs and benefits Authors' conclusions General practice follow-up of women with breast cancer in remission is not associated with increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life. Most recurrences are detected by women as interval events and present to the general practitioner, irrespective of continuing hospital follow-up. Process measures of the quality of clinical care such as frequency and length of visits were superior in primary care.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator (hospital follow-up of breast cancer) was that it was the common practice in the authors setting. You, as a database user, should consider if the same applies to your own setting.
Validity of estimate of measure of benefit The effectiveness evidence was derived from a well-designed randomised controlled trial. A summary measure of benefits was not developed as the results of the trial showed no difference in the primary clinical outcomes. Therefore, a cost-minimisation analysis was performed.
Validity of estimate of costs The prospective approach used in cost collection reinforces the validity of the cost results. Indirect costs were also considered, contributing to a complete picture of the costs involved in breast cancer follow-up. Extensive comparisons with similar studies were performed as regards costs.
Other issues The authors addressed the issue of generalisability to other settings in England. They acknowledged the absence of sensitivity analysis in their study, but went on to report that, even reducing the unit costs of outpatient consultation by 50%, would have minimal impact on the overall findings of the cost analysis. It was not possible to make comparisons with other studies as this was the first study investigating the cost-effectiveness of primary care follow up.
Implications of the study General practice follow-up of women with breast cancer in remission could replace hospital follow-up with no increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life, and with associated cost savings. However, the authors suggest that there is need for further research to be carried out.
Source of funding EG supported in part by the Ontario Ministry of Health. The Department of Health for England and Wales funded the research with a generous contribution from the Ballakermean school of the Isle of Man and support from the General Practice Research Group of the Imperial Cancer Research Fund.
Bibliographic details Grunfeld E, Gray A, Mant D, Yudkin P, Adewuyi-Dalton R, Coyle D, Cole D, Stewart J, Fitzpatrick R, Vessey M. Follow up of breast cancer in primary care vs specialist care: results of an economic evaluation. British Journal of Cancer 1999; 79(7-8): 1227-1233 Other publications of related interest Grunfeld E, Mant D, Yudkin P, Adewuyi-Dalton R, Cole D, Stewart J, Fitzpatrick R, Vessey M P V. Routine follow-up of breast cancer in primary care: a randomised trial. BMJ 1996;313:665-669.
Indexing Status Subject indexing assigned by NLM MeSH Breast Neoplasms /economics /therapy; Continuity of Patient Care /economics; Cost Allocation; Cost of Illness; Direct Service Costs /classification /statistics & Disease-Free Survival; England; Family Practice /economics; Female; Follow-Up Studies; Humans; Medical Oncology /economics; Outpatient Clinics, Hospital /economics; Quality of Life; numerical data AccessionNumber 21999000430 Date bibliographic record published 30/04/2001 Date abstract record published 30/04/2001 |
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