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Overutilization of IMRT/IGRT in treatment of rectal cancer: Cost implications of deviation from evidence-based practices.

34 Background: Current evidence-based guidelines for management of rectal cancer (RC) caution against routine use of IMRT and do not address the role of IGRT. To explore patterns of care and cost implications for treatment of RC in commercially insured patients, we assessed treatment requests submitted for preauthorization through eviti Connect.


METHODS
A proprietary web-based application enables oncology providers to obtain automated precertification for patients insured by payers across the US that use the platform. All requests for pelvic radiation for treatment of RC submitted from 6/1/11-5/31/14 were reviewed. Treatment delivery costs for 3D CRT + weekly port films and for IMRT + IGRT were calculated based on average reimbursement rates from 3 payers for a typical course of 50.4 Gy/28 fractions.


RESULTS
A total of 195 cases for treatment of RC were submitted. At submission, 50.3% (98/195) of cases met evidence based standards and received automated preauthorization; 49.7% required treatment justification. Ninety-eight percent of deviations involved use of IMRT and/or IGRT. Upon review, 34.9% (68/195) had a medical rationale for the variance. Justification for IMRT/IGRT use included treatment volumes comparable to anal cancer, inadequate bowel displacement by routine techniques, and obesity. Fifteen percent (29/195) contained unwarranted deviations. In 23/29 cases peer to peer discussion resulted in the provider altering the plan to be compliant. Providers did not agree to changes in the other 6 cases. Cost for a course of 3D CRT + weekly port films was $6,591 vs. $32,292 for IMRT + daily IGRT. For these 195 cases, the estimated cost of overutilization of IMRT/IGRT was $745,000 ($25,700 X 29).


CONCLUSIONS
Despite lack of endorsement by consensus group guidelines, IMRT and IGRT were prescribed for treatment of RC in nearly 50% of cases. Case review and peer to peer discussion clarified the rationale for treatment deviations from guidelines and allowed providers to bring plans into compliance with evidence based practices, reducing inappropriate use of IMRT/IGRT from 15% to 3%. Reduction in unwarranted use of high cost technologies can improve quality and yield significant cost savings.