In response to new evidence regarding the benefits of palliative care for patients with advanced cancer, and in recognition of the very real challenges physicians face when trying to broach the topic with patients, ASCO released a policy statement yesterday to help guide physicians through these difficult conversations. In addition, they announced plans to issue clinical guidance later this year to further help physicians initiate these conversations and integrate palliative care into oncology practice.
The core principles of the recommendations are:
- Physicians should initiate candid discussions about prognosis with their patients soon after an advanced cancer diagnosis. Such conversations currently occur with less than 40% of patients with advanced cancer.
- Quality of life should be an explicit priority throughout the course of advanced cancer care. Physicians must help their patients fully understand their prognosis, the potential risks and benefits of available cancer treatments, and quality of life considerations. In cases where active treatment is unlikely to extend survival, palliative care should be discussed as a concurrent or alternate therapy.
- Clinical trial opportunities should be increased. Currently, very few patients with advanced cancer participate in trials due to strict eligibility criteria, a dearth of trials that address quality of life issues, and other barriers. Increasing opportunities for these patients to potentially benefit from trials and to contribute to improving cancer care should be a high priority.
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Increasingly, community-based cancer programs are seeking to provide a more coordinated, multidisciplinary care experience to their patients. There are a few factors driving this trend, both clinical and market-oriented, as clinics provide the opportunity to improve outcomes and provide a more patient-centered experience, as well as serve as potential mechanism to achieve market differentiation. Multidisciplinary clinics have long been at the core of academic cancer care, but we've been receiving a lot of questions about executing on the concept at community hospitals. Those programs working with multiple groups of private practice physicians, or a mix of employed and private practices physicians often encounter a number of obstacles when seeking to implement multidisciplinary clinics. Below I've listed out the most common issues. At the end of this post I've included links to our most recent research which addresses many of these issues.
Addressing economic inefficiency - or making it worth their while
Private practice physicians are already incredibly busy, never more so than now as they are under increasing financial pressure, and quite frankly, these clinics are often not that efficient - often there is a lot of down time. During the time it takes for one clinic in which they might see 3 patients, they can often see twice as many in their office. There are ways to address this issue. First, is to guarantee payment for their time to ensure they don't lose out financially. Another option is to try to optimize efficiency via the "virtual clinic" concept in which the patient might see all of the relevant physicians in their own office in a short period of time (a week for instance) and then they'd discuss the patient at a weekly conference. In these sorts of models a care coordinator or patient navigator is essential to make sure all of the moving parts come together as planned.
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Yesterday I had the opportunity to participate in an excellent webcast sponsored by the Center to Advance Palliative Care (CAPC) and presented by Dr. David Weissman, professor emeritus from the Medical College of Wisconsin. Dr. Weissman discussed the potential to use consult triggers (i.e. objective patient- or disease-specific criteria) to help increase referrals for pallaitive care consults and increase the likelikhood that they are made in a timely way. Triggers may include disease variables such as a diagnosis of metstatic cancer or stage IV CHF, or patient variables such as two or more hospitalizations during a one month period or an ICU stay of longer than X days.
In the presentation, Dr. Weissman outlined five key steps for successful implementation:
- Define your goals. Hospitals may want to use consult triggers to increase referrals to palliative care, meet unmet patient needs or achieve specific institutional goals such as cost reduction. It's important to define these goals upfront and determine how the organization will measure progress against them.
- Evaluate staffing needs. In most cases, consult triggers will result in increased referrals to the pallaitive care team. Consequently hospitals must forecast this change and ensure that their pallaitive care team is staffed to manage the growth.
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I recently ran across an article in the Journal of Multidisciplinary Cancer Care in which Dr. Arash Asher from Cedars Sinai Medical Center describes a new program designed to help patients living with "chemo brain." Given the prevelance of this side effect, the lack of treatment options, and the growing interest in supporting post-treatment survivors, I thought it may be of interest. Dr. Asher writes:
"At Cedars-Sinai Medical Center, we have begun a 6-week psychoeducational series to provide strategies in coping with the symptoms of chemobrain. After carefully screening participants for potentially reversible medical contributors to cognitive dysfunction and neuropsychological testing to identify any objective cognitive impairment, patients may enroll in this program, called Emerging from the Haze. In collaboration with our neuropsychology service, the series provides tools to cope with the common issues that cancer survivors face that are believed to affect cognition. Topics addressed in the program include:
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A while back I posted some news about US Oncology's plans to develop an oncology-specific risk-based contracting model and it generated a lot of interest. As I suspected,this was but the first step in plans to test out the concept of an oncology-specific ACO, as detailed in this article. At first blush the impetus for their efforts appears to be a desire to participate in the Medicare Shared Saving's Demonstration. In our current national meeting research we detail what this might look like in a presentation entitled Transforming Cancer Care. Essentially, it would entail a group of providers (e.g., physicians, hospitals etc) - the ACO if you will -accountable for the care of at least 5,000 Medicare patients. Because medical oncologists typically become the main care provider once a patient is newly diagnosed with cancer, particularly if they receiving chemotherapy, they would serve as the "PCP" actively managing care and sharing in any of the savings they achieve. Several studies have already demonstrated that, with oncology patients, there is significant variation (and thus savings potential) in chemotherapy drug costs as well as IP admissions and ED utilization. While the typical oncology practice may not be large enough to cover 5,000, US Oncology certain has a large enough networking of physicians. Plus, they would have the IT infrastructure, pathways program (Innovent) and capital necessary. And US Oncology is thinking big - they plan to pursue this model both with Medicare and commercial payers.
There are still some unanswered questions such as: Is 5,000 patients large enough to hedge risk? Would the potential savings in oncology alone justify risk that might come from non-oncology medical issues from patients' co-morbidities (e.g., diabetes, CHF etc)? That said, this will definitely be an interesting story to keep an eye on. For hospitals, in terms of volumes, this could mean demand destruction through reduced IP admissions and ED Utilization per patient. In terms of larger ACO strategy, if this model comes to fruition, it could give US Oncology a lot of market power in specific markets, forcing hospitals to contract with them directly for medical oncology services.
Since the FDA's decision to revoke approval of Avastin for treatment of breast cancer, there has been considerable concern about whether payers will continue to pay for the drug, and consequently, whether breast cancer patients will be able to access it. According to a report in the San Francisco Chonicle, WellPoint, United Health, Aetna and Humana have all indicated that they will continue to reimburse providers for the drug, at least for the time being, based on the NCCN's recomendations.
The article also quotes a spokeman from CMS saying that "most if not all" Medicare contractors will still pay for Avastin for the treatment of breast cancer, at least while appeal of the FDA's decision is pending. The drug's manufacterer, Roche, is expected to file an appeal with the FDA by January 18. The agency has said that it will not decide whether or not to hold a hearing on the appeal until the end of February. One Medicare contractor, Palmetto GBA, had previously announced that it would discontinue coverage of Avastin based on the FDA's decision, but it later reversed its decision.
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The NCCN announced today the release of the NCCN Guidelines for Patients for melanoma, ovarian and prostate cancers. These documents take the NCCN's existing guidelines for specific disease sites and "translate" them into language that is more easily understood by the general public. The patient guidelines for breast cancer, non-small cell lung cancer, and multiple myeloma were relaeased earler this year.
A few weeks ago the NY Times wrote another article highlighting safety concerns with radiation therapy - this time turning the spotlight on multifunctional LINACS and the delivery of SRS. Frequent readers of this blog we'll recall that we've been following this issue closely so I wanted to bring this article to your attention.
The article opens with a story about a safety lapse at one particular hospital, but then proceeds into an in-depth discussion about why safety risks appear to be greatest with multifunctional LINACS, particularly those that have been upgraded with SRS capabilities and that may require integration of software between more than one vendor. Notably, the story documents safety lapses at several organizations, all with slightly different causes, but one thing in common - overradiation during SRS resulting from issues with their multifunctional LINAC. They go into a fair bit of detail into the causes and impact of these lapses.
As a reminder, given the emergence of these new safety concerns, we know many of you are revisiting your safety standards. To help in this process we created the Radiation Therapy Clinical Protocol Toolkit. We'll also continue to track these issues carefully moving forward.