Determining the racial disparities in utilization patterns and cost-effectiveness of Hepatocellular Carcinoma treatment

Background: Racial disparities exist in the receipt of treatment for Hepatocellular Carcinoma (HCC) and such disparities lead to disparities in outcomes in HCC. However, to our knowledge, research about race/ethnic variation in health care cost and cost-effectiveness analysis in HCC treatment has not been conducted. Objective: The overall purpose of this study was to describe and estimate cancer disparities in HCC treatments and cost-effectiveness of liver transplantation (LT) and resection treatment by race/ethnicity in the Medicare population. Methods: A retrospective cohort study was conducted among HCC patients (age \u3e=65) through the SEER-Medicare linked database in 2000-2009. We measured the difference in HCC treatment utilization by race/ethnicity groups. We addressed the differences in utilization by using decomposition analysis to examine differences in patients at risk, environment, and delivery system characteristics among race/ethnicity groups. We also estimated the difference in total health care cost by race/ethnic groups to evaluate the effect of the difference in utilization by race on total health care cost in short term and long term periods. Cost-effectiveness analysis was conducted to compare liver transplantation and resection. Life-years gained, phase-of-care costs, and incremental cost-effectiveness ratio (ICER) were evaluated by race/ethnic groups with payer’s perspective. Results: Only about 42% of transplantable stage HCC patients received the recommended treatments and less than 30% of non-transplantable stage HCC patients had the recommend treatments. After adjusting patient, environment, and delivery system characteristics, Blacks were significantly less likely to receive recommended HCC treatments in non-transplantable stage. (OR: 0.595, CI: 0.423-0.837) The results of decomposition analysis between Black and White patients demonstrate that the difference in utilization rates among Blacks was exclusively explained by differences in the covariate coefficients. Short term and long term total health care costs vary depending on different cost estimation approaches and Asians and Hispanics were higher initial cancer care utilizers and incurred higher short term total health care costs compared to Whites and Blacks. Racial disparities in recommended treatments of HCC in non-transplantable stage between Blacks and Whites result in different health care spending patterns and probably unnecessary costs among Blacks in the short term but not in the long term. The ICER of LT was estimated at USD 33,213 per LYG compared to resection. Although ICERs between subgroups were similar, the results of bootstrapping and the analysis with individual race/ethnic groups suggest that racial variations exist in cost-effectiveness analysis. Conclusion: The study demonstrated that race/ethnic disparities exist in the receipt of recommended HCC treatments in non-transplantable stage patients and the difference in the initial recommended treatment utilization (treatment within a year after diagnosis) by race affects the total health care cost in the short term. There was heterogeneity in ICERs, which raise questions about the efficiency of the current treatment and resource allocation among race/ethnic groups.