Comparing cancer care, outcomes, and costs across health systems: charting the course.

This monograph highlights the multiple payoffs from comparing patterns of cancer care, costs, and outcomes across health systems, both within a single country or across countries, and at a point in time or over time. The focus of comparative studies can be on the relative performance of systems in delivering quality cancer care, in controlling the cost of cancer care, or in improving outcomes, such as reducing mortality rates and improving survival. The focus also can be on comparing the effectiveness, cost, or cost-effectiveness of competing cancer prevention and control interventions within a given system or across systems, while taking into account variations in patient characteristics, disease incidence and severity, resource availability, unit costs, and other factors influencing system performance. Two recurring themes in this monograph are: 1) the opportunities for cross-system analysis, learning, and improvement are enormous and just beginning to be tapped; and 2) the empirical and methodological challenges in realizing this potential are likewise enormous, but real progress is being made. In this concluding article, we revisit and illustrate both themes, with the aim of suggesting a research agenda for enhancing capacity to conduct strong empirical cross-system analyses in cancer care delivery. To focus the inquiry, we limit consideration to those cancer care systems, whether within or across countries, sufficiently developed to have access to registries that not only can document cancer incidence and mortality but, through linkage to additional data sources, can serve as platforms for patterns-of-care, costing, or other indepth studies. This necessarily puts the spotlight on developed nations; and among these, we concentrate on those in Europe and North America represented at the September 2010 workshop, “Combining Epidemiology and Economics for Measurement of Cancer Costs,” in Frascati, Italy (1). We distinguish between population-level studies, designed to compare the performance of health systems across countries or within a single country along specified dimensions, and patientlevel studies, designed to investigate the effectiveness, cost, or costeffectiveness of specific interventions and programs for individual patients (or individuals at risk for cancer) either within a given health-care system or across systems. In population-level studies, the outcome of interest might be summary measures of cancer mortality, survival, or other prominent patient outcome–oriented indexes of performance that are feasible to measure across systems for defined populations. Patient-level studies will often investigate the determinants of variations in patterns of care, costs, or outcomes, or apply economic evaluation methods to examine whether specific interventions offer good value for money. Although most patient-level studies to date are within-country or within-system, we note important examples of cross-country or cross-system analyses. In the next section, we highlight some examples of populationand patient-level studies. This sets the stage for the subsequent sections discussing a range of options, including some already in progress, for strengthening the data, methods, and organizational infrastructure to support policy-relevant comparative research on cancer outcomes and costs.