Cost Estimates of Managing Grade III and IV Pleural Effusions, Pericardial Effusions, and Non-Variceal Gastrointestinal Hemorrhages in Cancer Patients.

Objective: Grade III or IV non-hematologic events are often associated with substantial morbidity and mortality for cancer patients, which may also contribute to increased costs of treatment. The purpose of this study was to estimate overall inpatient costs for procedures corresponding to the management of Grade III and IV pleural effusions, pericardial effusions, and non-variceal gastrointestinal hemorrhages in individuals with primary diagnoses of cancer. Particular attention was directed toward these events due to the paucity of empiric research within the literature and due to their potentially large cost consequences.

Methods: This investigation employed a mixed costing methodology wherein elements of gross- and micro-costing approaches were used to determine direct medical costs incurred from the perspective of the payer in the United States. Variables including inpatient charges, average lengths of stay, and mortality were collected based upon principal procedures (i.e., procedures performed as definitive treatment that were neither exploratory nor diagnostic) and subsequently by principal cancer diagnosis or related condition. Procedures selected included thoracentesis, pleurosclerosis (with or without chemicals, excluding injection of antibiotics and chemotherapeutic agents), pericardiotomy (including tube pericardiostomy), and endoscopic control of gastric hemorrhage. All inpatient data were obtained from the 2003 Health Cost Utilization Project (H-CUP) Nationwide Inpatient Sample (NIS) sponsored by the Agency for Healthcare Research and Quality (AHRQ), which is a nationally-representative sample across all disease states. In addition to inpatient charges, professional fees for 2005 were considered and were obtained from current fee and coding references. Cost drivers of these fees were defined according to Common Terminology Criteria for Adverse Events (CTAEC) and published oncology-specific treatment algorithms that described relevant hospital imaging services, laboratories, surgical procedures, anesthesia, and clinical care. Costs were estimated utilizing a cost-to-charge ratio of 0.55 obtained from Centers for Medicare and Medicaid Services (CMS) reports for year 2000 data and were adjusted to 2006 dollars using the medical component of the consumer price index.

Results: The mean estimated inpatient cost per event in cancer patients was from $18,004 to $25,490 for thoracentesis, $32,558 to $34,499 for pleurosclerosis, $22,920 for chemical pleurosclerosis, and $38,772 to $47,647 for pericardiotomy. Endoscopic control gastric hemorrhage in patients with gastrointestinal hemorrhages not otherwise specified was $18,366. Professional fees at the 75th percentile constituted between 11 and 18% of total estimated costs. Most episodes of care for the procedures exceeded a one-week length of stay, and in-hospital mortalities ranged from 2.9 to 23.7%.

Conclusion: Procedures relating to the management of Grade III or IV events may contribute greatly to the costs of treatment. Results from this study indicated that costs incurred by payers are substantial for procedures relating to serious pleural effusions, pericardial effusions, and non-variceal gastrointestinal hemorrhages. Given that only selected principal diagnoses could be investigated, caution should be exercised when generalizing to other cancers. Continued research is warranted in quantifying costs within more specific forms of disease and in controlling for various risk factors.