Impact of increased hypofractionation on treatment cost

Abstract

Purpose or Objective The increased use of hypofractionated radiotherapy (RT) for prostate and breast cancer changes the activity within a department. Ultra-hypofractionation has been an international standard of care in palliative RT, particularly for bone metastases, for over 20 years. While expected to be cost-effective due to reduced attendances, many resources requiring capital investment cannot be released when fractions are forgone. We analyse the extent to which treatment costs are fixed (buildings etc), stepped (linear accelerators), variable (materials) or semi-variable (staff) and how total cost, from a healthcare provider perspective, reacts to change in departmental activity. Materials and Methods Using the treatment of bone metastases (with five differing strategies) as an exemplar, we used a time-driven activity-based approach to estimate the cost of RT in a single, large NHS provider (Leeds Teaching Hospitals NHS Trust). Costs are included from a provider perspective for the 2016/17 financial. Hospital level overhead were included at 15.4%. We estimate the treatment cost of five bone metastasis treatment strategies from the healthcare provider perspective and compare to NHS reimbursement tariff. The share of these costs attributable to fixed, semi-variable, stepped and variable costs was assessed. To consider the consequences of hypofractionation, the departmental fraction activity was systematically reduced (by up to 10,000 fractions per year) to assess the impact of this change upon the total cost of delivering remaining treatments with varying levels of disinvestment from staff and equipment. Results The estimated cost of delivering RT for bone metastases ranges from £376 for a single fraction to £3,700 for a fractionated 45Gy in 25# course. These align closely with NHS reimbursement, except for the SABR strategy where tariff during early commissioning exceeds total provider costs by 15.3%. Whilst semi-variable staff costs account for 28.0-39.5% of the total treatment cost, a somewhat larger proportion (38.5-54.8%) is attributable to fixed and stepped costs (Fig.1). The consequences of reducing fraction activity, upon the cost of remaining treatment courses, are illustrated in Fig.2. The greatest impact is seen in fractionated treatments. Disinvestment from semi-variable (staff) costs has a relatively modest impact upon remaining total costs whilst disinvestment from stepped costs (linear accelerators) has a greater impact on total cost although this can only be realised at thresholds aligning to equipment capacity. Conclusion In the long-term, hypofractionation offers a cost efficient mechanism to treat an increasing number of patients within the existing linear accelerator capacity. As a large majority of treatment costs are fixed/stepped, however, disinvest is complex and short to medium-term imbalances between demand and capacity will result in increased treatment costs. This may act as a disincentive to delivering hypofractionated treatment when reimbursement is on a per fraction basis.