Estimated Indirect Cost Savings of Using Telehealth Among Nonelderly Patients With Cancer

This economic evaluation estimates the indirect cost savings of using telehealth among nonelderly patients with cancer.


Introduction
Financial toxicity includes both objective financial burden (ie, costs) and subjective financial distress. 1,2Costs of cancer care include: direct cost of care (cost sharing through higher deductibles, copayments, coinsurance, and even entire cost of care for uninsured patients) and indirect costs of care (lost productivity and cost of driving to and from appointments). 1,35][6] Strategies are needed to reduce the direct and indirect costs of cancer care delivery.
The rapid adoption of telehealth during the COVID-19 pandemic has allowed patients to receive care in a location that is convenient for them, which may reduce the costs of cancer care.To date, there has been limited research regarding the cost savings of telehealth among patients with cancer.
The COVID-19 pandemic is providing a unique opportunity to estimate the potential cost savings of telehealth in oncology care. 7Although it is well established that patients with cancer experience substantial financial toxicity, few studies have explored the indirect costs that they face.Thus, this study focused specifically on an oncologic population from a comprehensive cancer center with a substantially large sample size to estimate the indirect cost savings (driving costs and lost productivity) from telehealth visits.

Methods
This was an economic evaluation estimating cost savings from completed telemedicine visits at Moffitt Cancer Center (MCC), the only National Cancer Institute (NCI) -Designated Comprehensive Cancer Center in Florida.Data from telehealth visits were collected from April 1, 2020, to June 30, 2021.All patients aged between 18 and 65 years who completed telehealth visits within the designated time frame and had a Florida mailing address documented in their electronic medical record were included in the study cohort.All patients were offered telehealth if deemed appropriate by the clinical team.Telehealth visits were not offered to patients who needed physical examinations beyond what can be assessed during a telehealth visit.Patients who presented in person for chemotherapy infusion and/or radiation treatment were excluded from the analysis.This study was exempt from MCC institutional review board approval with a waiver of informed consent from patients because the study was deemed low risk.This study used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline. 8e to the COVID-19 pandemic, implementation of telehealth at MCC was accelerated in March 2020.Telehealth was defined as care delivered through a videoconferencing platform in real time.
Starting in April 2020, MCC instituted videoconferencing for their telehealth visits.Patient visits were defined as new, established, or follow-up.New patient visits were patients not having received any previous medical care from MCC; established patient visits had received care at MCC previously but were referred to a new subspecialty for consultation; and follow-up patient visits were seen at MCC for follow-up care by clinicians in the same subspecialty they had previously received care from.

Statistical Analysis
We assessed patient time, travel, and indirect cost savings from using telehealth for cancer care delivery (Figure 1).Analyses were guided by the framework recommended by Sanders and colleagues 9 for assessing the time and transportation costs of patients.Time savings were calculated as the difference between the roundtrip time required to travel from each patient's home address to an in-person consultation at MCC, plus in-person consultation time vs the time required to attend a telehealth visit from home (ie, time savings = roundtrip drive time + [time for in-person consultation -time for telehealth visit]).Travel savings were calculated as the roundtrip driving distance in miles from each patient's home address to an in-person consultation at MCC. Indirect cost savings were calculated as the roundtrip costs associated with traveling from each patient's home address to an The American Community Survey (ACS) 10 was used to determine census tract-level data for hourly median income per year.The census tract income data were then matched to the patient's address.This analysis focused on patients younger than 65 years, because these patients were more likely to be employed full time than those aged 65 years or older.
Two different models were generated with a combination of 2 different mileage rates and hourly wage rates determined via ACS census tract level data.Driving distance traveled in miles was calculated in October 2021 by Buxton Company, 11 an analytics organization that uses Alteryx's 12 analytic platform to provide geospatial data.Briefly, the locations are geocoded, and distance is calculated between the 2 geocoded locations by finding the route that results in the least amount of drive time between the 2 locations.
Calculations for different models were conducted using R (R Project for Statistical Computing). 13Details are available in the eMethods in Supplement 1. Data were analyzed from April 2020 to June 2021.

Results
A total of 25 496 telehealth visits for 11 688 patients were conducted for patients aged between 18 and 65 years during the study period.There were 4525 (3795 patients) new or established visits and 20 971 (10 049 patients) follow-up visits (Figure 2A).Telehealth was associated with an estimated $1 170 160 savings in lost productivity (income) due to driving time, $467 247 savings in lost productivity due to visit time, and $1 637 407 total savings in lost productivity ( follow-up visits, the following savings were noted: $925 027 savings in lost productivity due to driving time, $362 725 savings in lost productivity due to visit time, and $1 287 752 total savings in lost productivity.Mean (SD) savings in lost productivity per visit due to driving time were $45.9 (41.5) per visit overall, and $54.1 (47.9) for new or established visits and $44.1 (39.7) for follow-up visits (Table 2, Figure 3A).Mean (SD) savings per visit in lost productivity due to visit time was $18.3 (5.9) per visit overall, and $23.1 (6.9) for new or established visits and $17.3 (5.1) for follow-up visits.

Discussion
This economic evaluation study uses a large data set collected at an NCI-Designated Comprehensive Cancer Center to estimate patients' savings from using telehealth.From April 1, 2020, to June 30, 2021, a total of 25 496 telehealth visits were conducted.Telehealth was associated with a total savings of 3 789 963 roundtrip travel miles, which equates to traveling 152.2 times around the earth, and a total savings of 75 055 roundtrip drive hours, which equates to 8.6 calendar years.An Some of the main arguments for implementing telehealth are to increase access to care, patient convenience, and cost savings in outpatient clinics. 14Telehealth may also provide an opportunity to reduce emergency department visits, readmissions, and patient mortality. 14As patients' financial costs of cancer care increase, telehealth may reduce their burden of travel including costs associated with parking and lodging, and lost income from missing work.
The burden of travel has been identified as an important factor that can change access to diagnosis, treatment of cancer and participation in clinical trials. 15,16Transportation is a key determinant of health care access and has been identified as an important source of out-of-pocket nonmedical costs for patients receiving cancer care. 17Patients without adequate transportation are more likely to miss appointments and rely on emergency department care, 15 and there is substantial variability in the estimated parking costs throughout cancer treatment. 18In addition, a recent study noted that the number of rural hospitals has decreased over the last decade, resulting in almost double the number of people living outside a 60-minute radius of major hospitals and longer drive times to receive care. 19Thus, telehealth could be beneficial among rural patients in particular. 20 the models previously mentioned, we did not consider the cost savings of telehealth for cancer caregivers.Caregivers for patients with cancer spend substantial time and effort to coordinate and attend appointments with patients.In 2020, 53 million individuals were caregivers, 6% of whom were caregivers for patients with cancer.The vast majority of caregivers (80%) help with transportation; 18% report high financial strain; and 45% have experienced at least 1 financial impact as a result of caregiving. 21Although the current study was focused on indirect cost savings from patients' perspectives, future studies should include caregivers' indirect cost savings as often patients and caregivers function as a unit and share expenses.Therefore, savings from telehealth would be even higher if caregivers' savings from lost productivity were accounted for, especially when telehealth has the ability for multiple caregivers to join the same appointment from various geographical locations.
Although telehealth offers considerable cost savings to patients with cancer, it is well documented that telehealth adoption is affected by the digital divide.Factors associated with financial toxicity (eg, age, insurance, race, and education) are also associated with the digital divide. 22ture studies are needed to address inequities in telehealth uptake.Additionally, telehealth requires substantial infrastructure costs and investments from health systems with buy-in from administrators and clinicians to ensure high patient satisfaction. 23

Limitations
Our study has several limitations.This analysis was retrospectively conducted at a tertiary/ quaternary referral center, and so roundtrip travel distances may be higher than usual because this is a destination center for cancer care.Our assumption of employment rates and incomes for patients younger than 65 years may vary.Additionally, a percentage of patients on active treatment or following treatment may not be fully employed given their functional status, thus affecting the savings from lost productivity.Because we were unable to accurately capture employment among older adults, patients aged over 65 years were excluded; however, future studies should examine cost savings in this population.Cost savings due to lost productivity assumed that all patients are nonsalaried and the loss due to travel time and hours of visit time could not be made up for.
Therefore, the savings in this study might be considered a maximum amount of lost productivity.This study only considered telehealth visits that were completed via synchronous videoconference, and the costs of electronic devices and internet access were not considered.This study also did not assess other factors likely to affect cost savings, such as rural vs urban residences, race, education, or insurance type, all of which should be explored in future studies.Finally, further data are needed if long-term oncologic outcomes with telehealth visits are equivalent to those seen in person, which can change costs of treatment.

Conclusions
Patients with cancer spend a substantial amount of time and money traveling to receive care.Using a large data set, we found that cancer care delivery via telehealth was associated with time, travel, and cost savings for patients with cancer, which may reduce the financial toxicity of cancer care.
Future studies should explore other cost savings, such as the savings to cancer caregivers and how these vary for rural and urban patients with cancer.

JAMA Network Open | Health Policy
Estimated Indirect Cost Savings of Using Telehealth Among Nonelderly Patients With Cancer and 2C).An additional 29 626 hours of in-clinic visits were saved by using telehealth with a mean (SD) savings of 1.2 (0.13) hours per visit (Figure2D).For new or established visits, telehealth was associated with mean (SD) savings of 177.6 (161.6)roundtrip travel miles, 3.4 (2.6) hours of roundtrip driving time and 1.5 (0.0) hours of in-clinic time per visit (Figure2B, 2C, and 2D).For follow-up visits, telehealth was associated with mean (SD) savings of 142.4 (138.8)roundtrip travel miles, 2.8 (2.3) hours of roundtrip driving time and 1.1 (0.0) hours of in-clinic time per visit (Figure2B, 2C, and 2D).

Figure 2 .
Figure 2.Estimated Total Number of Visits, Roundtrip Drive Time, Roundtrip Distance, Total and Mean Lost Productivity Due to Drive Time, and Total and Mean Lost Productivity Due to Visit Time

additional 3 .
4 calendar years (29 626 hours) were saved in clinic visits by using telehealth.Depending on the visit types, mean savings in lost productivity per visit due to driving time ranged from $44.1 to $54.1, mean savings in lost productivity due to visit time ranged from $17.3 to $23.1, and mean total savings in lost productivity per visit ranged from $61.4 to $77.2.Mean driving cost savings per telehealth visits ranged from $79.71 to $146.0 depending on visit type and model used.Mean total cost savings per visit ranged from $141.1 to $222.8 depending on the visit type and model used.

Figure 3 .
Figure 3. Projected Cost Savings of Virtual Visits Seen at Moffitt Cancer Center From April 1, 2020, to June 30, 2021

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-person consultation at MCC.This included 2 components: the costs of travel and the potential loss of productivity due to the medical visit.

Table 2 ,
Figure 2B, 2C, and 2D).For new or established visits, the following savings were noted: $245 113 savings in lost productivity due to driving time, $104 522 savings in lost productivity due to visit time, and $349 655 total savings in lost productivity.ForFigure 1. Graphical Representation of Calculation of Estimated Indirect Total Cost Savings Due to Telehealth consultation − time for telehealth visit]).Potential travel savings was defined as roundtrip distance savings arising from the use of telemedicine, calculated as the distance the patient would have traveled for an in-person consultation at the MCC.

Table 1 .
Total Number of Visits, Roundtrip Drive Time, and Roundtrip Distance of Virtual Visits Seen at Moffitt Cancer Center From April 1, 2020, to June 30, 2021 a A portion of patients will have both NP/EP and subsequent follow-up visits.

Table 2 .
Projected Cost Savings of Virtual Visits Seen at Moffitt Cancer Center From April 1, 2020, to June 30, 2021 a A portion of patients will have both NP/EP and subsequent follow-up visits.bTwo different models were used with a range of costs per mile ($0.56/mile and $0.82/mile).