Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure

1. A cost minimization exercise. Dr. Judith Aaron*, Dr. Balurishna S, Dr. SunithaSusan Varghese, Dr. Jasmine P, Dr. Selvamani B Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure

2. Introduction • Brachytherapy is an essential component of cancer cervix treatment. • It contributes significantly to the cost of cancer cervix treatment

3. Introduction • Our institution has the practice of executing the procedure as inpatient. • Placement of applicator under spinal anaethesia in theatre • Simulation • Treatment • This procedure is repeated for each fraction

4. Introduction • Advantages: • Patient co-operation – painless • Adequate vaginal packing can be done

5. Introduction • Drawbacks : • Cost of treatment • Spinal anaethesia – every fraction • The number of fractions of HDR brachytherapy limited At our institution a dose of 6-7.2 Gy is prescribed X 3 fractions

6. Aim of this study • To minimise the cost of cancer cevix treatment (Brachytherapy component) without compromising on the tumour dose or dose to critical organs at risk.

7. Objectives • Assess the feasibility of outpatient brachytherapy To fix a cervical sleeve to the os at first fraction under anaesthesia and then execute the placement of applicators as outpatient for the second and third fractions of brachytherapy. • To carry out a cost effectiveness analysis of the treatment done as inpatient versus outpatient.

8. Methodology

9. Patient selection

10. Treatment protocol STUDY PATIENT • First fraction: • Under anaesthesia in theatre • Cervical sleeve sutured to the os • Applicator placed insitu • SimulationPlanning  Treatment • Second and third fractions • Under sedation in brachytherapy suite • Applicator placed insitu • Simulation Planning Treatment

11. Cervical sleeve Advantage: Eliminates multiple dilatations of cervix Faster and less traumatic insertions Reduced chance of uterine perforation Disadvantages It may get dislodged Patient dicomfort during the duration of brachytherapy Not possible for advanced cases • Cervical sleeve:

12. Treatment protocol CONTROL PATIENTS • All three applications of HDR brachytherapy as inpatient • Under anaesthesia in theatre • Applicator placed insitu • Simulation PlanningTreatment

13. Costing • Cost computation: • Patient • Medical and Nonmedical cost • Hospital • Societal • Cost comparison: Study patient versus Control patients

14. Effectiveness analysis • Comparison of • Dose to point A • Rectal dose • Bladder dose Study versus control patients

15. Other issues • Also looked at the • Issues related to outpatient procedure • Feasibility of continuing the practice

16. Cost of brachytherapy

17. Study patient • Total cost: Rs. 29673/-

18. Control patients • Per patient cost total cost- Rs. 39843/-

19. Breakup of costing

20. Medical costs Admission/Bed/ Nursing and Professional charges STUDY PATIENT CONTROL PATIENT

21. Medical costs Theatre and Anaesthesia

22. Medical cost Premedication STUDY PATIENT CONTROL PATIENT

23. Medical cost Procedure/ Planning and Treatment • No change in cost

24. Non medical cost • Expenses for the patient • Travel charges • Cost of food • Expenses for attendants • Travel • Food • Stay

25. Non medical cost • Reduced by almost half • Expenditure on food and stay were considerably less Non medical cost incurred by Study patient- Rs. 1200/- Non medical cost incurred by a Control patient- Rs. 2000 – 2400/-

26. Societal cost By making it an outpatient procedure: • Duration the patient is separated from family reduced • Loss of wage and cost of food for relative who accompanies the patient is lowered LOSS OF WAGE COST OF FOOD

27. Hospital Savings ( Indirect ) • The following facilities can be used for another patient: • Bed • Nursing care • Theatre • Anaesthetist’s time

28. Cost comparison

29. STUDY VS CONTROLS • Difference of Rs. 10000/-

30. Conclusion • Thus from these slides it is quite clear that the cost of treatment as outpatient is significantly less. • The actual cost is reduced by almost half at second and third fractions. • The indirect savings in terms of hospital resources and personnel time will be more.

31. What do we compromise on ?

32. Effectiveness • To assess the effectiveness of the procedure done as outpatient • Is it as effective as the inpatient procedure with spinal anaesthesia ?

33. Absolute dose to point A STUDY PATIENT

34. Absolute dose to point A CONTROL PATIENTS

35. Average Rectal dose

36. Average Bladder dose

37. Our inference • It is feasible to execute HDR intravaginal intrauterine brachytherapy as outpatient for select patients. • Outpatient application of HDR brachytherapy does not adversely affect the tumour, bladder or rectal dose. • As we reduce cost and utilization of resources more number of fractions per patient can be introduced which is now improbable due to logistics. • This would in-turn reduce late reactions.

38. Draw backs of this exercise • Pain was not adequately controlled- Thus vaginal packing was difficult The following drugs were used for pain management: Voveran patch- applied a day prior to procedure Premedication- Fortwin and Phenergan Post procedure- Tramadol boluses till the end of treatment Combiflam thrice daily for 3 days • Intangible costs such as pain and patient comfort were not measured

39. To conclude • We have attempted to change practice in our institution • A cost minimisation exercise helps make administrative decisions • Indirect benefit by making more number of fractions practical hence reducing Late reactions

40. Thank you