Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis

Abstract

Background The impact of National Comprehensive Cancer Network (NCCN) treatment guideline concordance on costs, health care utilization, and mortality for patients with breast cancer and secondary metastases is unknown. Methods From 2007 to 2013, women with early‐stage breast cancer who received treatment for secondary metastases (n = 5651) were evaluated for first recorded systemic therapy concordance with NCCN guidelines within the Surveillance, Epidemiology, and End Results Program–Medicare linked database. Generalized linear and mixed effects models evaluated factors associated with nonconcordance and the relation between concordance status and health care utilization and costs. Mortality risk was estimated with Cox regression. Results Eighteen percent of the patients received nonconcordant therapy, with the most common being single‐agent, human epidermal growth factor receptor 2 (HER2)–targeted therapy (36%), therapy mismatched with the estrogen receptor/HER2 status (11%), unapproved bevacizumab regimens (10%), and adjuvant regimens in a metastatic setting (6%). A younger age, a hormone receptor–negative status, and a HER2‐positive status were associated with nonconcordance (P < .05). Nonconcordance was associated with 22% and 21% increased rates of emergency department visits and hospitalizations, respectively, and $1765 higher average monthly Medicare costs. Differences in adjusted mortality risk were noted by the category of nonconcordance; single‐agent, HER2‐targeted therapy was associated with decreased mortality risk (hazard ratio [HR], 0.66; 95% confidence limit [CL], 0.57‐0.76), and increased mortality risk was observed with unapproved bevacizumab use (HR, 1.40; 95% CL, 1.13‐1.74). Conclusions Most patients (82%) received treatment consistent with NCCN guidelines. Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation. Consideration of both patient and financial outcomes will be important as health systems increase the emphasis on guideline‐based care.

Clinical Molecular Marker Testing Data Capture to Promote Precision Medicine Research Within the Cancer Research Network

“…Although health systems generally have care pathways and national guidelines available for patient care, deviations for these guidelines are commonly reported. [37][38][39][40][41] There are patient factors, including financial burden, that contribute to the care that a patient receives in the real world. 42,43 There are also provider factors, such as specialty and years in practice, that are associated with variations in care.…”

Guideline Discordance and Patient Cost Responsibility in Medicare Beneficiaries With Metastatic Breast Cancer

“…9 Women with de novo (metastatic at diagnosis) MBC diagnosed in 2007 through 2013 or with stage I-III breast cancer diagnosed in 2000 through 2013 with subsequent secondary distant metastases in 2007 through 2013 who survived 1 year after index diagnosis were included in this study (Figure 1). 4,5 Metastatic disease was identified based on ICD-9 claims on 2 separate dates for secondary cancer (197.XX-198.XX), excluding breast (198.81, 198.82, 198.2) and lymph nodes (196.XX). 10,11 The index diagnosis date was defined as the de novo MBC diagnosis or the first claim date with ICD-9 codes for secondary cancer in patients with a primary early-stage breast cancer.…”

“…Details regarding the categorization of guideline discordance in this population were previously published. 4,5 In brief, treatment regimens containing single drugs or combination therapy (same-day billing for $2 drugs) were identified using National Drug evidence for existing drugs or new drug approvals. However, minor changes were observed during the time frame of our study.…”

“…3 According to previous research, approximately one-fifth of Medicare beneficiaries with MBC have received treatment discordant with NCCN Guidelines. 4,5 These patients had almost $2,000 USD higher monthly Medicare spending compared with those who received guideline-concordant care, yet no survival difference was seen between the groups. Although these studies found higher Medicare spending associated with NCCN Guideline discordance, a knowledge gap remains about how guideline discordance may affect patient-specific cost responsibility.…”

Adherence to surgical and oncologic standards improves survival in breast cancer patients

“…National guidelines, such as those set forth by the National Comprehensive Cancer Network (NCCN), provide scientifically‐based guidance for patients and practitioners. These guidelines have been shown to improve quality of care, reduce inappropriate interventions, decrease costs, and enhance consistency of care across centers . However, NCCN guidelines encompass all aspects of cancer care and primarily focus on medical management without specific attention to intraoperative management during the surgical treatment.…”