COST-EFFECTIVENESS ANALYSIS OF ORAL CAVITY CANCER IN TAIWAN: A POPULATION-BASED STUDY

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1 COST-EFFECTIVENESS ANALYSIS OF ORAL CAVITY CANCER IN TAIWAN: A POPULATION-BASED STUDY Hsiang-Tsai Chiang Chun-Yi Tu Lie-Fen Lin Ph.D. Program of Business, Ph.D. Program of Business, Ph.D. Program of Business, Feng Chia University,No.100, Feng Chia University,No.100, Feng Chia University,No.100, Wenhwa Rd, Seatwen,Taichung, Wenhwa Rd, Seatwen,Taichung, Wenhwa Rd, Seatwen,Taichung, Taiwan Taiwan Taiwan Abstract-The incidence and mortality rates of oral cavity cancer (OCC) have been increasing in Taiwan. OCC is ranked fifth in terms of mortality for malignant tumors. This study aimed to investigate the survival rate and conducted a cost analysis for OCC in patients aged years in Taiwan during the period from 2007 to Methods: Data were obtained from the Taiwan Cancer Registry. Chi-square, Kaplan Meier survival, multiple regression, and logistic regression analyses were used to analyze the data. The results indicated that OCC significantly reduced OCC mortality and improved cost-effectiveness. Data regarding patients gender, age, region, and family history were analyzed to achieve statistical significance. This research indicated that OCC is a valuable cancer prevention strategy. The government and health administration authorities should promote preventive for OCC to improve survival rates and cost-effectiveness. Keyword: Cost, Oral Cavity Cancer, Survival Rate I. INTRODUCTION The incidence rates of oral cavity cancer (OCC) differ globally and regionally; with 600,000 diagnoses worldwide, it currently accounts for 4% of the global cancer incidence as the sixth most common cancer diagnosis [1]. Moreover, two-thirds of diagnoses of OCC have been identified in developing countries, with incidence rates in men 1.7 times higher than those in women [2]. Although advancement is evident in the development of treatments for OCC, limited growth has been identified in survival rates; specifically, 5- year survival rates have remained at approximately 50% over the past few decades [3]. In 2014, newly diagnosed cases of OCC amounted to 28,000 persons in the United States, 50% of the incidence was older than 65 years; in addition, the mean age at death is 68 years and totaling 5,800 deaths[4]. In Taiwan, OCC (including oropharynx and hypopharynx cancer) has been among the ten most common cancer diagnoses since 1991; related statistics indicate that male cancer mortality has accelerated annually in Taiwan [5]. And in recent years, the prevalence of betel nut chewing showed similar growth trend in Taiwan [6]. In 2015, newly diagnosed cases of OCC amounted to 7,190 persons in Taiwan; in addition, statistics revealed that OCC had the fifth highest death rate among cancers, totaling 2,667 deaths and accounting for 11.45% of the cause-specific mortality rate and 7.8% of the 18

2 standardized mortality rate; male mortality is 11.1 times that of female mortality. In addition, the mean age at death is 58 years [7]. Because the development of OCC is gradual, early examinations may enable the identification of relevant signs or the earlystage development of cancer, considering that active treatments in early stages have higher survival rates than the complex treatments in later stages [8]. Moreover, a national annual report in Taiwan indicated that s for oral mucosal lesions may reduce OCC mortality in men who smoke and drink [7]. In 2004, medical expenditures for OCC totaled US$1.2 billion in the United States [9], with the highest expenses in the first year after initial diagnosis and the last year before the death of a patient. Related influences include the specific diagnosed region, pathological stage, type of care, and length of survival [10]; in addition to the negative correlation between age and medical expense [11], length of hospitalization, acceptance of surgery, physiological function, chronic disease, complications, and residential population density were all revealed to be influential factors [12]. In a 2004 study tracking 425,294 patients with major cancers (defined as having one of the top 17 primary cancers) during , medical expenditures for OCC were revealed to total US$107.6 million [13]. This study investigated patients with OCC and aged between years in Taiwan, using epidemiology and costeffectiveness analysis as a reference for the related prevention and treatment of OCC. II. METHODS Using registration files and claim data from the National Health Insurance Research Database, a retrospective cohort study was conducted. OCC patients with diagnosis codes beginning with 140, 141, 143, 144, 145, 146, 148, and 149 (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)) recorded during were analyzed. Examination coverage included the registry for catastrophic illness (HV), ambulatory care expenditures by visits (CD), inpatient expenditures by admissions (DD), registry for beneficiaries (ID), and registry for contracted medical facilities (HOSB). In addition, patients aged years were categorized into screened and nonscreened groups. The examined variables included sex, age, insurance premium, urbanization level, marital status, initial diagnosis date, date of death, and. Specifically, a chi-square analysis and Kaplan Meier survival analysis were employed to estimate the survival rate for patients with OCC, multiple regression was employed for a multivariable analysis of cost, and logistic regression was used to analyze the correlation coefficient. III. RESULTS Because the ratio of nonscreened OCC was 96%, unmarried and female patients with OCC was relatively high, this study suggests that associated risk factors that may have been underestimated in women and patients with poor living habits such as smoking and drinking. In addition, the high incidence rates of OCC in remote areas were found to be related to the prevalence of betel nut chewing among Taiwanese indigenous people. A previous study indicated an approximately 11.2% prevalence of betel nut chewing in Taiwan, of which indigenous people were found to be the largest population (36.6%). The results of this study revealed that the highest medical costs in men aged years($59,484.49), suggesting that the loss of this age group may affect the core economic structure of families, causing substantial burdens and leading to consequential social problems in Taiwan. 19

3 The medical costs in deceased groups ($60,094.61) is higher than surviving groups ($21,107.70). The average life expectancy of screened patients (1.68 years) is higher than nonscreened patients (1.37 years); the average total direct medical costs in the screened and nonscreened groups were $40, and $39, (Table 1). Five-year survival rates for screened and nonscreened patient groups are depicted 20 in Figure 1. The red line indicates five-year survival rates for screened patient group and blue line indicates five-year survival rates for nonscreened patient group (Figure 1), respectively, and the results of a costeffectiveness analysis (Incremental Cost-Effectiveness Ratio = $3,705.26) confirmed that the adoption of the OCC test was cost-effective. TABLE I : Relationships among test adoption, medical expense and various Cost In Cost Screening (%) Screening n mean SD p bata P Patients Patients p Odds(95%CI) p Total without with Constant Term Sex Female 2 24, , (2.94) 1 Male 44 40, , (4.12) 1.71( ) 0.48 Age , , (2.88) 0.58( ) , , (4.55) 0.90( ) , , (6.09) 1 Screening 0.71 Patients 23 39, , without Patients with 23 40, , Life Status Surviving 24 21, , (2.71) 0.37( ) 0.01 Deceased 22 60, , (7.07) 1 Life Expectancy Life Expectancy * Life Status Payroll Bracket $ , , (4.59) 0.95( ) 0.71 $ , , (4.95) 1 $ , , (3.77) 0.57( ) 0.32 $>= , , (3.31) 0.31( ) 0.95 Marital Status Unmarried 44 40, , (2.69) ( ) Married 2 29, (0.89) 1 Urbanization Status Regions with 22 40, , (3.13) 0.31( ) 0.08 high to low urbanization or emerging cities General or 10 32, , (4.67) 0.59( ) 0.94 aging cities/towns Agro-town 10 57, , (4.48) 0.58( ) 0.96 Remote regions 4 6, , (8.82) 1

4 Fig.1Five-year survival rates for screened and nonscreened patient groups IV. CONCLUSIONS The development of preventive medicine for OCC has become a primary emphasis in public health policies. However, the main obstacles to facilitating preventive policies for OCC are insufficient government funding and inefficient implementation of health care policies. The World Health Organization has identified that effective preventive strategies and early programs should be the primary goals in controlling the global incidence rates of OCC. Considering the increasing medical expenditures and financial difficulties under current economic conditions, policymakers should realize the importance of implementing cost control and managing and evaluating the cost-effectiveness of OCC strategies. Our study demonstrated that early diagnosis and treatment can save considerable medical resources for the healthcare system, realizing the goal of existing health prevention strategies. OCC is a ferocious and expensive disease. Although this research indicated that OCC reducing OCC mortality and improving cost effectiveness, limited growth has been identified in 5-year survival rates. It may be associated with pathological stage, too late and treatment. Future research can be studied in depth to clarify the problems. The costeffectiveness analysis for OCC has proved to be an effective management strategy for the substantial medical costs incurred by OCC treatment. Therefore, the current medical resources invested in strategies can save substantial medical expenses for the Taiwanese healthcare system, namely by reducing direct costs (e.g., chemotherapy, targeted therapy, complications, and emergency hospitalization) and indirect costs (e.g., lost work hours for familial caregivers) observed in later-stage OCC cases. Similarly, various international studies related to medical decision-making have affirmed that the cost-effectiveness of OCC can be a useful reference in the development of policies for medical s. Furthermore, a related epidemiology study in the United States reported that the incidence rates of human papilloma virus (HPV) have increased the incidence of oropharynx and hypopharynx cancer among individuals aged years [14]. Considering how HPV is not covered by the current Taiwanese National Health Insurance policy and public willingness to pay out-ofpocket for tests remains low, HPV and vaccination programs may be developed in future planning for OCC strategies. Accordingly, we suggest that related policy makers in Taiwan should devise long term plans for OCC. Additionally, clinical institutions should be responsible for promoting public health education to enhance the acceptance and policy effectiveness of OCC. V. REFERENCES [1] J. Ferlay, I. Soerjomataram, R. Dikshit, S. Eser, C. Mathers, and M. Rebelo, Cancer incidence and mortality worldwide: sources, methods, and major patterns in GLOBOCAN Int J Cancer 2015; 136: E [2] R. L. Siegel, K. D. Miller, and A. Jemal, Global Cancer Statistics; CA Cancer J Clin; 2016; 66:

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