28 Intensity-modulatedradiotherapyKCE reports 62 5.2.3 Conclusion At present, no conclusive economic evaluation of the IMRT technique has been made. As a result, no firm conclusion can be drawn on the cost-effectiveness of IMRT in comparison to alternative health care interventions, in particular 3DCRT. Ideally, (direct medical) cost and utility data would be collected within the wider framework of a randomized controlled trial. In this respect, further full costing analyses, preferably activity based, at hospital-level are a prerequisite necessity to establish the relative financial impact with respect to the indirect costs of alternative radiotherapy techniques in routine practice. It should, however, be stressed that prevailing reimbursement schemes may prohibit the set-up of such a comparative design as IMRT may evolve into a universally promoted standard before its incremental cost-effectiveness has been established. Key points • No firm conclusion can be drawn on the cost-effectiveness of IMRT in comparison to alternative interventions, in particular 3DCRT. • IMRT may evolve into a universally promoted standard before its incremental cost-effectiveness has been established.
KCE reports 62 Intensity-modulatedradiotherapy 29 6 ORGANISATIONAL ISSUES This chapter offers a succinct description of the principal organisational issues at stake in the adoption and implementation of IMRT. We will discuss equipment and staffing needed to implement an IMRT program and the possible tensions at play between ruling levels of reimbursement and actual costs. The main perspective chosen for our discussion is that of a provider (radiotherapy department) already equipped with 3DCRT technology as this reference case was considered most in keeping with the Belgian context. 6.1 METHODS As stated in the preceding chapter (cf. supra), our general economic search filter yielded twenty-eight publications with regard to the organisational aspects of IMRT. These results were further complemented through a google-based grey search and contacts with the group of external experts linked to our research project. Furthermore, Belgian industry representatives were contacted with the request to transmit relevant information. 6.2 RESULTS 6.2.1 Equipment needs Five separate sources 72 , 73 , 74 , 75 , 76 offer a full overview of minimal equipment needs for the implementation of IMRT for (country, year of reference): the USA 2002, the USA 2003, France 2003, Spain 2005, Belgium 2006. A detailed overview of these cost estimates can be found in appendix 5. As can be concluded from these sources capital start-up costs both for 3DCRT and IMRT therapy are considerable, especially when taking into account that there are indications that proper working conditions require at least two functioning and similar linear accelerators at each treatment site 73 . Martin 2003 73 offers the most complete cost estimate, reaching the conclusion that the minimal set-up cost for a new IMRTcapable radiotherapy unit will be around 7 100 000€. This amount covers bunker facilities for a cost ranged between 380 000€ and 600 000€. A further point of interest is the substantial cost added by upgrading an already operational 3DCRT treatment unit to an IMRT unit (up to 50% of the initial capital cost of the 3DCRT unit). Through our grey search we identified various independent sources quoting cost estimates for IMRT-capable linear accelerators (see Table 4). Cost estimates range between 1 200 000$ (around 900 000€) and 1 300 000£ (around 1 900 000€), illustrating the fact that a large part of overall start-up equipment costs can be accounted for by the purchasing cost of a linear accelerator. As the (often concise) cost item description indicates, however, differences in (optional) functionalities may go some way in accounting for the price variation. Table 4 Various cost estimates reported for IMRT-capable linear accelerators (“linacs”) Description Indicated Cost Country Year Reference "Linac IMRT" 1 600 000€ Germany 2006 77 "IMRT, portal imaging, multi leaf collimation and respiratory gating" 3 500 000$ (NZD) New-Zealand 2004 78 "High Energy Linac with MLC and portal vision facilities" 1 300 000£ United Kingdom 2004 79 "MV Cone Beam with a Linac" (Siemens) 1 200 000$ 2004 80 United States of "Average Sales Price IMRT" (Varian) 1 900 000$ America 2005 81