Variations in Surgeon Treatment Preferences and The Impact on the Cost-Utility of Surgery for Soft Tissue Sarcoma

Abstract

Background The primary treatment for soft tissue sarcoma (STS) is surgical excision of the tumor. There are variations in the surgical strategies used to excise the tumor. It is unknown which surgical strategy is more cost-effective in treating STS and whether the perspectives of surgeons compared to patients and the general public about the health states following these surgical strategies leads to inefficient allocation of surgical resources to treat STS. Objective To quantify surgeons’ health state utility preferences for sarcoma health states and if their preferences predict their choices for surgical treatment strategies of STS. To calculate the economic consequences of variations in surgeon treatment strategies and surgeon health state preferences on patient health outcomes, societal costs, and cost-effectiveness. Methods A review of the STS health state literature was conducted and health states for STS were developed. An online questionnaire and standard gamble (SG) exercise was administered to orthopaedic and surgical oncologists to elicit health state utility values from a surgeon’s perspective. A cost-utility model was used to compare the projected cost-utility of alternative surgical strategies based on the surgeon preferences about health states as compared to those of either patients or the general population. Results This study found that there is significant variation among surgeons in their valuations of LE-STS-related health states. Acceptable function following primary excision of STS has significant impact on perceived quality of life with the median utility decrement ranging from -0.20 to - 0.26 depending on margin status, but local recurrence has a somewhat higher median utility decrement of close to -0.30. For the patient and societal perspectives, over both a 10-year and lifetime time horizon, the surgical strategy of AM with an adverse functional outcome (AM-F) dominates—i.e., lower cost and better outcomes—the surgical strategy of IM with an acceptable functional outcome (IM+F). For surgeons, the incremental cost-effectiveness ratio (ICER) of IM+F compared with AM-F was $8,284 per QALY gained over a 10-year time horizon, but the AM-F strategy was dominant in the lifetime horizon. Conclusions The results generally supported the hypothesis that surgeons’ utility for LE-STS-related health states influence their choice of surgical treatment strategy for STS. If the average surgical strategy followed the preferences of surgeons, it would produce lower health gains (i.e., QALYs) for a typical patient as compared to a strategy reflecting community or patient’s valuation of health states. From the standpoint of cost-utility from a health system perspective, therefore, there will be a welfare loss if the default strategy is based on surgeons’ preferences.