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Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure PowerPoint Presentation
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Changing practice of Inpatient HDR brachytherapy in Carcinoma Cervix to an Outpatient procedure - PowerPoint PPT Presentation


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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. Introduction.

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Presentation Transcript
slide1
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

introduction
Introduction
  • Brachytherapy is an essential component of cancer cervix treatment.
  • It contributes significantly to the cost of cancer cervix treatment
introduction1
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
introduction2
Introduction
  • Advantages:
    • Patient co-operation – painless
    • Adequate vaginal packing can be done
introduction3
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

aim of this study
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.
objectives
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.
treatment protocol
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
slide11
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:
treatment protocol1
Treatment protocol

CONTROL PATIENTS

  • All three applications of HDR brachytherapy as inpatient
    • Under anaesthesia in theatre
    • Applicator placed insitu
    • Simulation PlanningTreatment
costing
Costing
  • Cost computation:
    • Patient
      • Medical and Nonmedical cost
    • Hospital
    • Societal
  • Cost comparison: Study patient versus Control patients
effectiveness analysis
Effectiveness analysis
  • Comparison of
    • Dose to point A
    • Rectal dose
    • Bladder dose

Study versus control patients

other issues
Other issues
  • Also looked at the
    • Issues related to outpatient procedure
    • Feasibility of continuing the practice
study patient
Study patient
  • Total cost: Rs. 29673/-
control patients
Control patients
  • Per patient cost total cost- Rs. 39843/-
medical costs
Medical costs

Admission/Bed/ Nursing and Professional charges

STUDY PATIENT

CONTROL PATIENT

medical costs1
Medical costs

Theatre and Anaesthesia

medical cost
Medical cost

Premedication

STUDY PATIENT

CONTROL PATIENT

medical cost1
Medical cost

Procedure/ Planning and Treatment

  • No change in cost
non medical cost
Non medical cost
  • Expenses for the patient
    • Travel charges
    • Cost of food
  • Expenses for attendants
    • Travel
    • Food
    • Stay
non medical cost1
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/-

societal cost
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

hospital savings indirect
Hospital Savings ( Indirect )
  • The following facilities can be used for another patient:
    • Bed
    • Nursing care
    • Theatre
    • Anaesthetist’s time
study vs controls
STUDY VS CONTROLS
  • Difference of Rs. 10000/-
conclusion
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.
effectiveness
Effectiveness
  • To assess the effectiveness of the procedure done as outpatient
  • Is it as effective as the inpatient procedure with spinal anaesthesia ?
absolute dose to point a1
Absolute dose to point A

CONTROL PATIENTS

our inference
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.
draw backs of this exercise
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
to conclude
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