RESOURCE UTILIZATION - HIGH-DOSE-RATE VERSUS LOW-DOSE RATE BRACHYTHERAPY FOR GYNECOLOGIC CANCER

A comparative analysis of anesthesia use, perioperative morbidity and mortality, capital, and treatment cost of high dose rate versus low do se rate intracavitary brachytherapy for gynecologic malignancy is pres ented. To assess current anesthesia utilization, application location, and high dose rate afterloader availability for gynecologic brachythe rapy in private and academic practices, a nine-question survey was sen t to 150 radiotherapy centers in the United States, of which 95 (63%) responded. Of these 95 respondents, 95% used low dose rate brachythera py, and 18% possessed high dose rate capability. General anesthesia wa s used in 95% of programs for tandem + ovoid and in 31% for ovoids-onl y placement. Differences among private and academic practice responden ts were minimal. In our institution, a cost comparison for low dose ra te therapy (two applications with 3 hospital days per application, ope rating and recovery room use, spinal anesthesia, radiotherapy) versus high dose rate treatment (five outpatient departmental applications, i ntravenous anesthesia without an anesthesiologist, radiotherapy) revea led a 244% higher overall charge for low dose rate treatment, primaril y due to hospital and operating room expenses. In addition to its abil ity to save thousands of dollars per intracavitary patient, high dose rate therapy generated a ''cost-shift,'' increasing radiotherapy depar tmental billings by 438%. More importantly, perioperative morbidity an d mortality in our experience of 500+ high dose rate applications comp ared favorably with recently reported data using low dose rate intraca vitary treatment. Capital investment, maintenance requirements, and de preciation costs for high dose rate capability are reviewed. Applicati on of the defined ''revenue-cost ratio'' formula demonstrates the impo rtance of high application numbers and consistent reimbursement for pa rity in high dose rate operation. Logically, inadequate third-party re imbursement (e.g., Medicare) reduces high dose rate parity and threate ns the future availability of high dose rate technology.