Economic studies of health technology changes in prostate cancer care

• Introduction: New health technologies are one of the major drivers of increasing health care costs, although not all technologies have been shown to be effective. Initiation of activities for ensuring an appropriate diffusion of new health technologies is therefore an important task for a society. To ensure a choice of relevant policy actions, it is necessary to have knowledge about what factors affect the rate and extent of diffusion and what consequences can be expected from adopting a new health technology.Aim: The aim of this thesis is to estimate economic consequences and cost-effectiveness of health technology changes and to explore factors affecting the diffusion of health technologies. To elucidate these issues, prostate cancer was used as the subject of study.Material and Methods: The diffusion of six selected technologies for prostate cancer care was analysed and the economic consequences of these technological changes estimated. Data describing the diffusion and costs were obtained from relevant databases. Economic consequences of technological changes in prostate cancer care were also estimated with a cohort approach using 204 men with a diagnosis of prostate cancer who died in 1997-98. Data on health service utilization were extracted from clinical records and the results were compared with those of corresponding cohorts of men who died in 1984-85 or in 1992-93. The cost-effectiveness and expected economic consequences of introduction of prostate cancer screening in Sweden were estimated based on randomized studies in the city of Norrköping (n=9,171) and in the city of Gothenburg (n=20,000). The potential value of a technological change in the treatment of prostate cancer pain was estimated based on data from 1,156 men with a diagnosis of prostate cancer.Results: The utilization of all selected technologies has increased over time with the exception of orchiectomy, which shows a decreasing use. The total cost of these technologies has increased from 200 MSEK in 1991 to 600 MSEK in 2002. Classification of radical prostatectomy revealed a profile associated with a slow/limited diffusion, while classification of PSA tests revealed a profile associated with a rapid/extensive diffusion. The total health care costs for prostate cancer in Sweden have increased from 610 MSEK in 1984-85 to 970 MSEK in 1997-98, but the average cost per patient has been nearly stable over time. The incremental cost per extra detected localized cancer in a prostate cancer screening programme was estimated at 168,000 SEK and 98,000 SEK, respectively, and per curative aimed treated cancer at 356,000 SEK and 236,000 SEK. Introducing a screening programme for prostate cancer in Sweden would yield 244 MSEK and 92 MSEK, respectively, in additional costs per year for screening and treatment compared to a non-screening strategy. An optimal treatment that would reduce pain to zero during the whole episode of disease would add on average 0.85 quality-adjusted life-years for every man with prostate cancer. A rough estimate for Sweden is a total expected loss of 4,421 QALYs per year at a monetary value of 840 MSEK.Conclusions: Many technological changes occur in prostate cancer care and result in cost increases with minor or uncertain health improvements. A number of factors in addition to cost-effectiveness of the technology influence the diffusion. To ensure an appropriate diffusion of health technologies in society, one necessary condition is a system for early identification and assessment of cost-effectiveness and economic consequences. Another is an appropriate use of decision models populated with data from early clinical trials, epidemiology and costs. The combination of assessment of the costs and effects and identification of the diffusion profile of the technology may facilitate the design of relevant policy actions to promote an effective utilization of health technologies.

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