Association Between Patient-Reported Outcomes and Health Care Resource Utilization: Toward Developing Patient-Centered Value Measures in Cancer Care

PURPOSE: Value of care is defined as patient-relevant outcomes achieved per dollar spent. We examined the association between patient-reported outcomes (PROs) and health resource utilization in the year after cancer diagnosis, with a view to develop PRO-based measures of value in cancer care. METHODS: This was a population-based cohort study of adults with cancer in the province of Ontario, Canada, between 2008 and 2019. The exposure was symptom burden measured using the Edmonton Symptom Assessment System (ESAS) scores. The outcome was total health care cost 30 days following ESAS reporting, further stratified into cancer-directed therapies or ancillary health services including emergency department visits, home care, and complex continuing care. Linear regression models with log-transformed costs were built. RESULTS: A total of 1,728,025 ESAS assessments from 285,924 patients were analyzed. Forty-eight percent of the patient cohort comprised patients with stage I to II disease. Tiredness, depression, and poor well-being were the top three symptoms reported by all patients. Patients with respiratory and head and neck tumors carried the greatest burden of moderate to severe symptoms (ESAS score ≥4) in the year following diagnosis. GI, breast, and CNS were the most resource intensive cancers with median 30-day costs after ESAS of $85K in 2020 Canadian dollars (CAD), $81K (CAD), and $78K (CAD) per patient, respectively. Each 10-point increase in total ESAS score was associated with a 9.4% decrease in the cost of cancer-directed treatment because of decreased utilization of therapies. Conversely, each 10-point increase in total ESAS score was associated with an 18% increase in costs of ancillary health care resources because of increased utilization of these services. CONCLUSION: High symptom burden was associated with a decreased use of cancer-directed therapies, but increased use of ancillary health care resources. Proactive symptom management may facilitate cancer-directed therapies, while mitigating unnecessary health care utilization and low value-added care.