Cost Utility and Budget Impact Analysis of 5-fluorouracil and Capecitabine Based Regimens for Management of Colorectal Cancer at Kenyatta National Hospital
Abstract
Background
Colorectal cancer (CRC) is the third most common cancer globally and it is the fourth leading
cause of cancer-related mortality. Management of CRC has progressively improved over the
years, with a number of treatment options available. The cost of managing CRC poses a financial
burden to the patients and the society due to the high costs involved. Cost effectiveness studies
for capecitabine based and 5-fluorouracil based regimens have been conducted in other parts of
the world, however applicability of this data in Africa is limited given the variation in economic
status, treatment patterns and advances in technology. In Kenya, Kenyatta National Hospital as
the largest national referral hospital and serves a high number of cancer patients with a challenge
of limited bed capacity. In addition, the National Hospital Insurance Fund covers only part of the
oncology care for cancer patients. Therefore, it is important to establish the most cost-effective
regimen for the management of CRC.
Objectives
The main objective of the study was to compare the cost effectiveness of 5-fluorouracil and
capecitabine based regimens for management of colorectal cancer in Kenyatta National Hospital.
In addition, a budget impact analysis of the adoption of capecitabine based regimen was
conducted.
Methods
A mixed study design was used. The study was divided into four parts. The first part was a
descriptive cross sectional study that was conducted in the oncology wards at Kenyatta National
Hospital to establish the cost of managing colorectal cancer and its complications. For this study,
the study population was patients diagnosed with colorectal cancer and admitted in Kenyatta
National hospital between January 2014 and December 2019.
The second part of the study was a key informant interview that was carried out amongst the
administrative officers in charge of billing and procurement to collect information on cost of
procuring drugs and other resources used for management of colorectal and its complications.
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The third part of the study was a cost utility analysis which is one of the four designs accepted in
Pharmacoeconomics. A markov decision model was developed using a theoretical cohort of
colorectal cancer patients. Markov modelling was done to estimate long-term costs and benefits
of 5-Fluorouracil compared to capecitabine based regimens for the management of colorectal
cancer. The study was conducted from a provider perspective with a time horizon of 5 years.
Effectiveness data was derived from literature. Lastly a budget impact analysis was conducted to
assess the cost impact of the adoption of capecitabine based regimen on the budget at Kenyatta
National Hospital.
Descriptive and exploratory data analysis was performed using STATA version 13 software; for
data obtained from retrospective review of patients’ files and chart review. The level of
significance was set at 0.05. The quantitative data on costs was tabulated and summarized in MS
Excel spreadsheet. The R version 3.6.0, ―heemod‖ package was used for costing, probabilistic
and sensitivity analysis.
Results
The demographic and clinical characteristics of the participants showed that, majority of the
participants were male (55.4%) and the elderly (>55years) (51.0%). Most participants were
diagnosed with late stage disease (62.3%). Majority of the patients were on 5-FU regimens
(67.2%). Neutropenia was the most common occurring side effect. Metastasis was the most
common outcome (28.9%) while mortality was at 24.1%. The determinants for prescribing
capecitabine regimen were presence of metastasis, patients who received radiotherapy and those
who underwent any chemotherapy switch (p<0.001).
FOLFOX was the most expensive regimen(Ksh. 577,270) compared to XELOX (Ksh.207,486).
XELOX was found to be the most cost effective regimen with an incremental cost effectiveness
ratio (ICER) of Ksh.-38632.74 per quality adjusted life years (QALY) gained. The ICER was
negative for XELOX due to the lower cost and more QALY gained.
The results show that the use of XELOX for managing colorectal cancer is cost saving each year.
The impact of adopting XELOX on the KNH annual budget and medicines budget over 5 years
ranged between 2.27% to 2.90%.
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Conclusion
FOLFOX is the mainstay therapy for CRC management in KNH; it is however more expensive
compared to XELOX. XELOX is the most cost effective regimen as compared to FOLFOX from
the provider perspective and should be considered as a drug of choice in the management of
colorectal cancer in Kenya.
Publisher
University of Nairobi
Rights
Attribution-NonCommercial-NoDerivs 3.0 United StatesUsage Rights
http://creativecommons.org/licenses/by-nc-nd/3.0/us/Collections
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