Health Cost Modelisation of Home Versus Hospital Administration of Bortezomib. Experience of a French Hematologic Care Network

Among innovative drugs used for hematological malignancies, Bortezomib (BTZ) is widely prescribed by systemic route in multiple myeloma (MM). Frequent hospitalizations required by the recommended schedule of administration, usually 4 infusions every 21 days, reduce quality of life for patients (pts), increase the medical team workload and health costs of care and transport. Therefore, we previously conducted a feasibility study for a home administration of chemotherapy (ASH: Blood, Nov 2010; 116: 3823). The aim of this study is to evaluate the economic weight of a cohort of 54 consecutive unselected pts with MM treated as a combinated management associating Hospital Outpatient (HO) and “Hospital at Home” (HaH) in Limousin's region, a French rural area. The costs are compared towards an exclusive HO management.

A French hematological care network (HEMATOLIM) aggregating a reference university hospital, distant non-university hospitals and HaH units, has validated secure risk procedures for home injection of chemotherapy according to a multi-steps process. The first cycle of BTZ and the first infusion of each subsequent cycle are performed in HO. Remaining infusions are performed in HaH. Chemotherapy is prepared in hospital pharmacy according with legal requirements.

Consecutive willing MM pts treated with BTZ from January 2009 to December 2011, treated at least, one day in HaH.

Costs were recorded in three categories: Medication, transports and drug administration. The cost of BTZ is US$ 368.28 (US$ 1 = € 0.87093738). The administration cost in HO is US$ 456.49 for all pts. The administration cost for HaH, depends on 4 criteria 1) the main diagnosis (chemotherapy infusion); 2) associated procedures; 3) Karnofsky index; 4) length of stay. With these data, HaH costs vary from US$ 153.36 to US$ 283.04 per day for both public and private sector. Transportation was calculated according to the number of kilometers (km) and the mode of transport (taxi, ambulance, private car…). The distance was calculated in km using Google map between the patient's home and the HO. All the costs are based on 2012 national French insurance tariffs. All pts gave their consent for the study and provided us with their mode of transport. This work has received the agreement of local ethic comity.

Among 88 pts treated by BTZ in HO/HaH, 54 fulfilled inclusion criteria: median age was 65 years (40–89). Sex ratio was 1.08. The total number of infusions of BTZ was 1292 (900 in HaH and 392 in HO). The mean number of infusions of BTZ in HaH per pts was 16.7 (1–44) and 7.3 (1–30) in HO. The mean duration of treatment with BTZ in HaH was 5.7 months (1day, >2 years). The median home-hospital distance was 34.2 kms (2–140). Transport was performed by taxi 59.3 %, private car 31.4%, ambulance 7.4% and other 1.9%. Karnofsky index average was 68% (50–90). The following table summarizes the unit costs per pts (US$).

Modelisation of pts's management according to the administration (HO/HaH versus HO) is shown in graphs. The total health cost for the 54 pts was US$ 1,409,000 (HO/HaH) versus US$ 1,696,000 (HO) with a significative Wilcoxon signed-rank test difference (p<0.0001) between the two categories (US$ 287,000=16.5% less).

This study showed that administration of BTZ in a combined HO/HaH setting is less expensive for the society health costs than the exclusive administration in HO. This is the first time in France we get the proof that there is a significant medico-economic interest for this kind of management. This work was carried out under real conditions in a rural region and these encouraging results justify development of home administration of BTZ not only for the benefit economic but also for improving the quality of life.

The innovative molecules such as BTZ could be administered in HaH settings with safety conditions conferred by organization and processes of a regional hematological care network. Our study^* provides an objective saving in health cost of 16.5%. Furthermore, quality of life of this willing MM pts has been improved and this will be objectivated in future studies by quality researches.

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Touati:JANSSEN-CILAG: Research Funding. Lamarsalle:JANSSEN-CILAG: Honoraria.