Economic Analysis of Port and PICC in Long-term Intravenous Administration for Malignant Tumor Patients in Chinese Oncology Hospital Setting

To Lio (陶立波), Jin Yong (靳 勇), Jing Litin (蔣理添), Chen Liping (陳麗萍),Bi Xuming (白旭明), Wng Jin (王 劍)

aInstitute of Health Economic Research, School of Pharmacy, Sun Yat-sen Univertsity, Guangzhou 510275, China;

bBeijing Medical and Health Economic Research Association, Beijing 100871, China;

cThe Second Af filiated Hospital of Soochow University, Suzhou 215004, China;

dSun Yat-sen University Cancer Center, Guangzhou 510275, China

ABSTRACT OBJECTIVE: To calculate and compare the cost of Port and PICC's application in long-term intravenous administration, and to support the decision making of hospital manager. METHODS: Literature review and patient survey in 2 oncology centers in China were carried out to investigate the cost and impact of Port and PICC for patients. The cost at different time of intravenous administration was calculated and compared. One-way sensitivity analysis was performed and tornado graph was drawn. RESULTS: Direct cost of Port at 0.5, 1, 1.5, and 2 years were 7442, 8005, 8553, and 9131 CNY, and 4700, 9399, 14032, 18799 CNY for PICC respectively. Direct & indirect cost at 0.5, 1, 1.5, and 2 years were 9291, 11704, 14101, 16529 CNY for Port and 9697, 19393, 29023, 38787 CNY for PICC. Sensitivity analysis showed that productivity loss and device maintenance cost were the most in fluential factors to the result. CONCLUSION: Port had higher cost in short term and less in long term compared with PICC. Patients expected to get intravenous administration more than 0.5 year should use Port if both direct and indirect costs were included.

KEYWORDS: Long-term intravenous administration; Implantable central venous port; Peripherally inserted central catheter; Cost

Long-term intravenous administration is widely applied in clinical treatments nowadays[1]. Patients with severe chronic condition, especially tumor patients, often need this technology to help take drugs, nutrients, electrolytes, etc. It could setup a safe and stable delivery channel for patients to get medicine they need continuously during a long period[2].

In order to achieve high quality intravenous administration in a long time, suitable medical device should be chosen in the treatment. Among different intravenous administration devices, the implantable central venous port (Port) and peripherally inserted central catheter (PICC) are 2 kinds of widely used technologies[3]. They are popular in hospitals especially in oncology clinics.

Compared with PICC, Port is a relatively newer technology, with less intravenous administration related complications and better patient's experience[4-9]. But the price of Port is higher than PICC's usually[10], and it concerns the hospital managers in China who are facing strict cost control policy from payer and government.Port vendor would argue that, due to the advantages of Port, the total cost of Port's application might be less than PICC's. But obviously, decision makers would need scientific data to settle the debate, and economic analysis would be helpful.

In order to support the decision-making of hospital managers and purchasers, in this study we performed economic analysis on costs of Port and PICC's application in long-term intravenous administration in a Chinese oncology hospital setting.

METHODS

Patient survey

From May to July 2018, a patient survey was carried out in 2 oncology centers at Suzhou and Guangzhou,China. The center in Suzhou is a part of the Second Affiliated Hospital of Soochow University, with 1408 beds and more than 65000 hospitalizations every year,and the center in Guangzhou is an independent oncology hospital affiliated to Sun Yat-Sen University, with 1488 beds and more than 95000 hospitalizations every year.Both oncology centers are public tertiary hospital.

The patient inclusion criteria were as follow: 1.Patients with malignant tumor confirmed by pathology; 2.Age18; 3. Patients during an intravenous administration more than 6 month expected. No exclusion criteria were set. The patients were included in the study following real-world clinical practice, not randomized. Ethical approval was obtained from the Ethics Committees of both hospitals, and all patients confirmed consent before inclusion of the study.

A semi-constructed questionnaire was developed for patient survey. The questionnaire was set in tablet computers and patients finished the questionnaire by themselves onsite, with the support of trained nurses as assistant and monitor. The data collected included following items: 1. patients' general information; 2.diagnosis and treatment information; 3. intravenous administration device information; 4. influence of using intravenous administration device to patients' life and work.

The monitor nurses double-checked the general information, medical information, and device information with medical records of hospitals, and reviewed all data input in the tablet computers to ensure the quality of data.

Other data collection

The prices and unit costs of treatments and devices were obtained from Chinese Health Statistics Annual Book (2016), public procurement website, and also a paper published at 2013 describing the direct medical costs of Port and PICC's application in a public tertiary Chinese hospital. All cost data were transferred to 2016 price level with medical service price index from the health statistics annual book.

The incidence rates of intravenous administration related complications were not investigated in the patient survey due to sample size limitation. Three kinds of complications (infection, device block, and thrombus) were involved in study based on comments of clinical experts[11]. A literature review (2010-2018,Chinese) was performed to get the incidence rates of these complications from CNKI database with relevant key words including intravenous administration, Port,VPA, PICC, complication, infection, block, thrombus,etc. Complication incidence rates obtained from different paper were merged with meta-analysis of random-effects models. The observational periods in different paper were different, so we made all of them to 2-year incidence rate with linear method.

Cost calculation

Three parts of cost were calculated for Port and PICC in this study, including price of medical device with implant and maintenance cost, treatment cost of intravenous administration related complications, and patient's loss of productivity due to using Port or PICC.

Prices of Port and PICC were obtained from public procurement website. We took the average price for base-case analysis. The device implant cost was obtained from literature, and so do maintenance cost.The treatment costs of complications were estimated by clinicians in the hospitals. The productivity loss was calculated based on Chinese GDP per capita in 2016 and data from patient survey. The first 2 parts were direct cost and the last one was indirect cost as defined in health economics.

We calculated the costs of Port and PICC in different time points every half year from 0.5 to 2 years,comparing the total cost of Port and PICC to find out the turning point.

Sensitivity analysis

We performed one-way sensitivity analysis,especially for the device price, to find out the impact of different factors to the result of economic analysis[12]. The cost even formula at 0.5, 1, 1.5, and 2 years was derived to demonstrate the relationship of Port's price and PICC's price. Other variables' sensitivity analysis was performed on cost difference of Port vs. PICC at 2 years with 20%upper and lower value, and tornado graph was drawn to show their impact to the results.

RESULTS

Features of oncology centers and patients enrolled in the survey

From the 2 oncology centers, we enrolled 208 Port users and 225 PICC users in February 2018. The average ages were 50.7 and 51.2 years old for Port group and PICC group respectively. There were 32.2% male patients in Port group and 49.8% in PICC group, 39.4% breast cancer patients in Port group and 13.8% in PICC group,14.7% patients with other diseases in Port group and 9.6%in PICC group. See Table 1.

Table 1. General information of patients enrolled in the survey

Based on data above, there was a clear difference between Port and PICC group that there were more female breast cancer patients using Port.

Cost of Port and PICC

All three parts of cost for Port and PICC were calculated in the study.

The average price of Port was 5500 CNY and 2700 CNY for PICC[13]. The implant cost for Port was 1378 CNY (only once) and 192 CNY for PICC (every half year). The maintenance cost for Port was 90 CNY every month and 66 CNY for PICC every week[14].

For intravenous administration related complications[15-25],1) the infection was mostly happened to PICC users with incidence rate 1.96% and 8.42% for Port and PICC respectively within 2 years. The usual treatment of this complication in China was to change a new catheter and treat with Vancomycin. Cost estimated was 4212 CNY each time. 2) The catheter block was mostly happened for PICC too with incidence rate 2.05% and 7.28%respectively. The treatment was catheter flushing with heparin, with cost estimated as 50 CNY each time. 3) The blood clot incidence rate for Port and PICC were 1.11%and 2.71% respectively. The usual treatment was heparin administration for a week, with cost estimated as 600 CNY each time.

The productivity loss could happen in 2 steps. The first one was productivity loss due to device maintenance.Every time the maintenance would cost patient half a day.With Chinese GDP per capita in 2016 (54,000 CNY) we got the monetary value of half a day as 74 CNY. In the patient survey we found out the Port user averagely took maintenance 1.09 times per month and PICC user 3.69. In that way the cost for Port and PICC in this part were 81 and 273 CNY every month.

The second one was the impact of using Port or PICC to patient's productivity. In the patient survey we found out that Port would lead to 7.09% loss of the productivity and PICC 17.44%. Every month the patient would spend 7 days for hospitalization and also time mentioned above for device maintenance. Getting rid of these, the costs of Port and PICC in this part were 228 CNY and 560 CNY every month.

With costs mentioned above, we calculated the total costs for Port and PICC at different time point of intravenous administration. Costs of Port and PICC at 0.5, 1, 1.5, and 2 years were calculated and compared as just direct cost (price, implant, maintenance, and complications treatment) or both direct and indirect cost(productivity loss) included. The results of comparison could be seen in Figure 1. It showed that if only direct cost was taken into consideration, at about 1 year of intravenous administration the cost of PICC could be even with Port's, and if both direct and indirect cost included, at about 0.5 year they got even. After the even point, PICC's cost would be higher than Port's and the gap was increasing as time went by.

Sensitivity analysis

We derived the cost even formula at different time points for Port and PICC. At each point, a formula was got to show the relationship of their prices. For 0.5 year,it was Pport=Ppicc+3206 demonstrating that the even-breakpoint was Port's price equivalent to PICC's price plus 3206 CNY, and any price of Port less than this could make Port's total cost less than PICC's. For 1, 1.5, and 2 years,the formula were Pport=Ppicc*2+7789, Pport=Ppicc*3+12323,and Pport=Ppicc*4+16957 respectively.

One-way sensitivity for other factors showed thatproductivity loss of PICC, price of PICC, productivity of Port, maintenance cost of PICC, and price of Port had relatively big impact to the cost difference of Port vs.PICC in 2 years. The incidence rates of complications and their treatment costs had no significant impact to the result. See Figure 2.

Table 2. The costs of Port and PICC's application during different intravenous administration period (CNY)

Figure 1. Comparison of costs (CNY) of Port vs. PICC at different time points

DISCUSSION

In this study we calculated and compared the cost of Port and PICC's application in long-term intravenous administration of malignant tumor patient in Chinese public tertiary oncology hospital setting. If both direct and indirect costs were taken into consideration, Port should be applied while intravenous administration period more than 0.5 year expected, and if only direct cost included,it should be more than 1 year. The results could be used to support decision-making of hospital manager on when Port should be applied compared with PICC.

Figure 2. Tornado graph of sensitivity analysis on 2-year cost difference of Port vs. PICC

The reason why we talked about direct and indirect costs separately, was that the decision-making mechanism in Chinese public hospital was multi-dimensional. As a hospital with cost control policies, it should look at the direct medical cost happened there and try to make it under control. In this case, it should focus on direct cost and only patients needing more than 1-year intravenous administration can use Port. But, as public hospital, it should take social welfare into consideration and care about the productivity of patients. In this case, both direct and indirect cost should be included and patients needing 0.5 year intravenous administration could use Port to archive better patient experience. But it will bring more medical cost. So, we put both results in the paper and let the hospital managers to make their decision themselves.

It was well known that the results of economic analysis would change along with the change of price and other factors such as incidence rate or treatment cost. The change of prices of Port and PICC would be inevitable due to market fluctuations. We gave the formula for their prices for decision makers to apply. Generally, the prices' relationship depended on how long the intravenous administration would be. Every half year extended, the price of Port could be added one more time of PICC's price and other more money. The hospital managers could make the decision based on the average time of intravenous administration in their hospitals.

Apart from the devices' price, other factors should be taken into consideration in decision making if they had significant impact on the results. Based on the results in this study, the productivity loss and maintenance cost of Port and PICC were the most in fluential factors.In clinical practice, usually doctors and nurses would pay attention to the intravenous administration related complications, but due to their low cost and incidence rate, the complications were not so important in the economics. These reminded hospital managers that they should pay more attention to productivity loss and maintenance cost in their decision making rather than focusing on complications.

The data used in this study came from different resources, some from statistic annual book, some from patient survey, some from literature, and some from clinical experts' estimation. The productivity loss and maintenance cost were the most influential factors based on sensitivity analysis. The former came from patient survey and latter from a paper published at 2013. The investigation of productivity loss in the survey was just a question for the patient to estimate how much the application of Port or PICC would reduce their productivity. It is relatively simple and more detailed investigation should be performed in the future. For the maintenance cost, it was detailed reported in the paper but clinical practice might be progressed in recent years and the data should be adjusted. So, both of them needed validation in big sample-size real-world studies in the future, and it could be the guide for study next.

Overall, in this study we analyzed the main aspects of cost of Port and PICC's application for long-term intravenous administration and the most influential factors for decision making. The survey and analysis were carried out in a Chinese oncology hospital setting,but the analysis logic and results could be used to support decision making in other types of hospitals and hospitals in other areas with fine adaptation.

CONCLUSION

Port had higher cost in short-term due to higher price but lower cost in the long-term due to less implant, maintenance, complication treatment cost and less productivity. If both direct and indirect cost included, patients with more than 0.5 year intravenous administration expected should use Port, and if only direct cost included it should be more than 1 year. The price of device, maintenance cost, and productivity loss were most in fluential factors to the results and should be pay attention to the decision making.

ACKNOWLEDGEMENTS

We acknowledge the doctors and nurses who performed the patient survey and also contributed expert comments and estimations in our study.

DISCLOSURE

The authors report no conflicts of interest in this work.