Traditional versus streamlined management of basal cell carcinoma (BCC): A cost analysis

Abstract

Background: Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC.

Objective: We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment.

Methods: A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule.

Results: The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery-indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery-indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios.

Limitations: Model parameter values may vary based on individual practices.

Conclusions: A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.

Keywords: basal cell carcinoma; chemocheck; cost analysis; decision analysis model; detect-and-treat scheme; shave removal.

Figure 1

Decision trees for clinically diagnosed non-MMS-indicated (A) and MMS-indicated (B) lesions. Hypothetical patients move from the initial decision node (square) along branches of the tree according to the probabilities associated with the events represented at each chance node (circles) to the terminal nodes (triangle). The cost at each terminal node is a weighted sum of the probability multiplied by the cost from each branch that leads to that terminal node.

Figure 2

One-way sensitivity analysis of the impact of clinical diagnostic accuracy on total cost in non-MMS-indicated BCC (A) and MMS-indicated BCC (A). The intersection of the lines in each figure reflects the value at which the two management schemes have equal cost.

Figure 3

Two-way sensitivity analysis varying clinical diagnostic accuracy and rate of shave removal success for non-MMS-indicated BCC management. The dotted area indicates all combinations of values for which the cost associated with the DAT scheme is less than the Traditional scheme. The border between the dotted and checkered regions is the line of cost equivalence between the two management schemes.