Concerns over high costs, poor outcomes, and poor access to health care in the United States have prompted legislation that emphasizes value and quality of care over quantity. The goal of health care delivery under these legislative changes will be to improve the value and efficiency of care, measuring the outcomes achieved relative to the cost. (Also see, “New payment models emphasize outcomes, value")
Quality and cost concerns are particularly relevant in the diagnosis and management of urothelial carcinoma of the bladder (UCB). UCB has the highest lifetime treatment cost of all cancers,1 with estimated expenditures of approximately $187,000 per case and, in 2010, a cost of approximately $4 billion to treat.1,2 There is significant variation among providers in the clinical management of UCB, with concerns that compliance with treatment guidelines should be optimized to help improve patient outcomes.3-5
In addition, more care does not necessarily mean better care. In an analysis of the Surveillance, Epidemiology and End Results (SEER)–Medicare database, there was no association between survival and the intensity or frequency of the surveillance protocols for bladder cancer.4 Moreover, we have to consider the potential consequences that changes in legislation, billing, and reimbursement can have on our practice patterns. As an example, changes to the reimbursement of in-office cystoscopy provided unintended incentives that increased the utilization of in-office cystoscopy by over 640%, decreasing the overall cost efficiency of cystoscopy with an increase in redundant office-based procedures and decrease in diagnostic yield.6
Bladder cancer care delivery represents an opportunity to provide smarter care and improve outcomes while reducing wasteful spending. We will review the evidence and identify potential areas of improvement that can help reduce costs associated with UCB management while improving outcomes.
Bladder cancer diagnosis
The goal for bladder cancer screening is to detect tumors at an earlier stage. Studies of screening for bladder cancer have had conflicting results; some have found a survival7,8 and potential cost-effectiveness benefit9-11 with screening, while others have not.12-15 Current guidelines do not recommend routine screening for bladder cancer in an asymptomatic population because screening would result in increased exposure to unnecessary diagnostic procedures without a relative benefit.15,16
The management of low-grade, low-risk nonmuscle-invasive bladder cancer (NMIBC) represents an area of possible cost reduction. Expectant management of low-grade NMIBC with active surveillance has been successfully implemented with low risks of progression.17-19 Because the risk of progression is low, there may be significant overtreatment of low-grade NMIBC that can expose patients to excess harm and increased costs without much benefit.16 Implementation of active surveillance for low-grade, low-risk disease may help decrease the risks of overtreatment and overdiagnosis and in turn decrease the overall costs of bladder cancer care.16
In patients with asymptomatic microhematuria, AUA guidelines recommend cystoscopy and upper tract imaging, with a multiphasic computed tomography (CT) scan as the most sensitive and specific test to detect an upper tract urothelial carcinoma.20 However, a recent cost-effectiveness analysis by Halpern et al21 found that the use of ultrasound and cystoscopy could substantially reduce costs, decrease radiation exposure, and not compromise detection of cancer. Halpern et al found that the use of renal ultrasound with cystoscopy had an incremental cost per cancer detected of about $50,000, while the incremental cost per cancer detected was about $6.5 million with a CT scan and cystoscopy, and that replacing the renal ultrasound with a CT scan detected just one more malignancy per 10,000 patients evaluated. These findings suggest that there can be significant reductions in unnecessary costs if ultrasound is used as a first-line diagnostic modality in place of CT scans.