Rank #1: The Paradox of Prescribing Late Chemotherapy: Oncologists Explain
Dr. Pennell talks to co-author Dr. Maria Silveira about why it can be so difficult for oncologists to refuse chemotherapy treatment to patients near death.
Oct 04 2016
Rank #2: Open Oncology Notes: A Qualitative Study of Oncology Patients’ Experiences Reading Their Cancer Care Notes
Dr. Nathan Pennell and author Dr. Thomas W. LeBlanc discuss how open notes have become a routine part of the patient experience, and why physicians might want to elicit and address concerns that arise from notes.
Read the related article "Open Oncology Notes: A Qualitative Study of Oncology Patients’ Experiences Reading Their Cancer Care Notes" on JOP
Apr 30 2018
Rank #3: State of Cancer Care in America
Dr. Blase Polite discusses the latest State of Cancer Care in America report, and the opportunities and challenges confronting the cancer care community.
Read the related article "The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey" on JOP
Jun 20 2018
Rank #4: What Does a Cancer Diagnosis Mean? Public Expectations in a Shifting Therapeutic Environment
Mar 12 2018
Rank #5: CancerLinQ Update
Dr. Robert Miller provides an update on CancerLinQ (Cancer Learning Intelligence Network for Quality), ASCO’s big-data, health information technology platform for oncology practices nationwide.
Oct 21 2016
Rank #6: Assessing Clinical Trial–Associated Workload in Community-Based Research Programs Using the ASCO Clinical Trial Workload Assessment Tool
Author Marge Good discusses the results from this project which demonstrate that trial-specific acuity measurement is a better measure of workload than simply counting the number of patients. The ASCO Clinical Trial Workload Assessment Tool was shown to be feasible and useable in diverse community-based research settings.
Jun 03 2016
Rank #7: The Farid Fata Medicare Fraud Case and Misplaced Incentives in Oncology Care
The author shares his experience as an expert witness in an oncology Medicare fraud case in Michigan.
Jan 05 2016
Rank #8: Screening for Pancreatic Adenocarcinoma using Signals from Web Search Logs: Feasibility Study and Results
Dr. Horvitz and his co-authors found that signals about patterns of queries in search logs can predict the future appearance of queries that are highly suggestive of a diagnosis of pancreatic adenocarcinoma.
Jun 14 2016
Rank #9: Opioids and Cancer Pain: Patients’ Needs and Access Challenges
Hello, and welcome to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. The opioid crisis continues to be a major public health issue, with increasing attention at both the state and national level. Efforts to address this issue are highly relevant to oncologists, because we treat a unique population of cancer patients for which opioid prescriptions are an established standard of care. So how will these efforts to address the opioid crisis impact the care of our patients? And what role can oncologists play on this issue? Today, we're going to be talking about this topic with Dr. Ray Page medical oncologist and hematologist at the Center for Cancer and Blood Disorders in Fort Worth, Texas, who currently serves as chair of ASCO's Clinical Practice Committee, is on the ASCO Government Relations Committee, and is the current ASCO delegate to the AMA House of Delegates, about his new editorial titled, "Opioids and Cancer Pain, Patients' Needs and Access Challenges," which will be published in the April 2019 JOP. Ray, thanks for joining me today. Thank you. So can you start out by giving our listeners a little background on the magnitude of the opioid problem in the US. Sure, Nate. Let me just first say, the opioid epidemic is real and is startling. The CBC reported that in 2017 that over 72,000 in the United States died from drug overdoses. And this included over 47,000 people who involved in drug overdoses of opioids. And most of us have heard from the media that the biggest increase in use is through that synthetic opioid fentanyl. And it's often laced with heroin. And the recent volumes that have confiscated at the US border are enough to kill ever single US citizen. And the escalation of opioid abuse is really complex societal issue. And it includes contribution from all of those social determinants of health and mental illness. And when policymakers sometimes they like to look at a one size fits all kind of solution, which means they oftentimes want to largely focus on physician prescribing habits and just regulating patient access to opioids. Is there evidence that this kind of solution of targeting opioid prescriptions is impacting opioid prescribing in cancer patients? There is a negative impact there. But let me just say that cancer pain is very real and it's very frightening. And we know that cancer pain is historically undertreated. 8 out of 10 advanced cancer patients experience moderate to severe pain. And about 55% of cancer patients and 40% of cancer survivors experience chronic cancer related pain. So upwards of 43% of cancer patients and 10% of survivors use opioids to manage chronic cancer pain. Because of the heightened media awareness about the opioid epidemic, cancer patients are really experiences a lot of fear firsthand. Many of my patients have expressed to me that they actually have a fear of dying from taking opioids. And there's also of addition. And then on the other hand, they also have a fear that they may not even be able to get their hands on pain medicines at all. That actually is a really interesting topic that I hadn't thought of because I have the same problem with my patients worrying about taking opioids. You think that this being so much in the public eye is really influencing cancer patients' ideas about whether they should be taking opioids or not. They feel like they're at risk for addiction and contributing to the problem. Our cancer patients I think do have those real concerns and they have fear over it. And we're actually seeing that about a 1/3 of cancer patients and survivors are actually having difficulty to getting access to their prescribed opioid medications. And that has continued to increase markedly since just a few years ago in 2016. And the vast US oncology practices are concerned that restrictions on opioid prescribing is going to ultimately result in undertreatment of cancer pain. So it's these kind of dynamics what makes it difficult for physicians to treat pain, particularly cancer and cancer survivors. And while judicious prescribing is important, patients with cancer and cancer related pain, they need to have consistent access to pain control. Well, I think we can all agree on that. Before we talk about how we can protect cancer patients' access to these drugs, can you talk a little bit about what is being done sort of at the state and national level to address the opioid crisis and sort of how that's impacting our cancer patients? Yeah, absolutely. The opioid epidemic will continue to be a bipartisan priority for both state and federal governments with currently over 100 state bills that are out there that are identified. In a lot of upcoming state legislative sessions, there will be consideration of bills that are related to such things prescription fill limits and prescription drug monitoring programs and opioid prescribing guidelines. And we're all expecting to see bills that are going to be related to the identification of outlier prescribers and bills that are promoting the utilization of opioid alternative therapies in the cases of both acute and chronic pain. Just on the federal level, you know in 2016, President Obama, he signed the first major federal addiction law in 40 years. And that was the Comprehensive Addiction Recovery Act. And that bipartisan legislation authorized evidence-based prevention and treatment programs and recovery programs and law enforcement initiatives to help prevent overdose death and proper prescriptions. And as you had asked, in 2017 when President Trump came into office, he announced that his administration was declaring an opioid crisis and made a national public health emergency under federal law. And as a result, the White House office of the national drug control policy directed numerous federal agencies to address the opioid problem. But that was largely within their current budgetary confinements. But I think actions by both administrations had positive impacts on the opioid problem primarily just by initiating activity in our government agencies. So when the various laws and policies are passed, do they have built in protections for vulnerable populations that need access to opioids, like cancer patients? Yeah, that's one thing that we've pushed a lot for. And in general, most of them do. And so President Trump signed a sweeping legislation in 2018 that was touted as the single largest bill to combat the drug crisis in our countries history. And there was a lot of efforts to do things like expanding access to treatment for substance abuse disorders and those kind of things. But, for example, January 1st of this year, as part of that law, it included new opioid prescribing policies that will impact Part D beneficiaries and the prescribers. And this includes such things as real-time safety alerts on pharmacy dispensing of opioids and drug management and utilization tools and the improvement of communications between the pharmacists and the physicians. But as you asked, one important note about this legislation that was passed is that residents of long-term care facilities and those that are in hospice care and patients receiving palliative care or end of life care, and patients being treated for active cancer related pain, they are exempt from a lot of these interventions. Well, it's good that at least someone is considering our patients in this. But I know that certainly-- I believe ASCO has quite a bit of concern about maintaining access to patients. So what role is ASCO playing in this issue? You know, Nate, ASCO is very sensitive to the needs, to address the opioid crisis and to support thoughtful and evidence-based interventions aimed at decreasing substance misuse and abuse and overdose death. However, ASCO really continues to advocate for appropriate access to pain medications for cancer patients, recognizing that that typical one size fits all solution risks oftentimes marginalizing our cancer patients and their needs. And so in 2016, ASCO released an ASCO policy statement on opioid therapy which emphasizes the unique pain management needs of patients with cancer and especially those with advanced disease. And in this policy statement, ASCO points out a lot of core principles to balance public health concerns and cancer patients' needs. Well, I really like the fact that ASCO is focusing not so much on specific individual needs, but rather making sure everyone recognizes that there is no one size fits all solution here and also you know acknowledging that there is a real problem with opioid misuse in the United States, but that our patients need to be considered carefully in this. One of the things I liked about your editorial was focusing on how physicians might actually be able to learn about managing pain in cancer patients and not necessarily just focusing on the use of opioids. Can you talk a little bit about that? Yes, sure. You know, just in general, as we all know, as oncologists, we rely heavily on the use of opioids. But we should never rely solely on the use of opioids. And we need to determine if opioids are indeed the right drug for particular type of cancer-related pain. And so ASCO published recent clinical practice guidelines for chronic pain management in cancer survivors that gives advice on careful assessment of pain and its effects on function and of the possible risk associated with an opioid. And so I generally recommend that clinicians review some of these practice guidelines because many of these recommendations can help reduce opioid prescribing and actually consider other good, viable non-opioid alternatives, such as using pain specialists and other interventional procedures. Yeah, I think everyone would benefit from being aware of the problem and making sure that they are using opioids appropriately. I guess I'm just a little concerned about how all this attention is impacting our patients and their access to drugs. We did a JOP podcast, oh, I think a year or so ago with Dr. Bruera, who is a palliative care specialist at MD Anderson, who published a study showing that palliative care physicians were actually prescribing significantly less morphine equivalents for cancer patients. And there was a lot of alternative treatments, such as tramadol, that were being used. And we had a nice discussion about how perhaps some of that was a good idea. But they're also putting sometimes patients at risk of being under treated. Yeah, that dynamic is very complex, because I think we all realize that are certain types of pain that do get effectiveness with opioids to get appropriate pain relief. But the palliative doctors are usually very good and many oncologists also about entertaining those alternatives. And so oftentimes there are many kinds of cancer pain syndromes, both acute and chronic that can be managed with non-opioid alternatives. We as oncologists, we realize that this is a really vulnerable patient population. And we'll continue to develop and utilize all the latest advances in the comprehensive management of cancer in accordance with published evidence-based physician developed guidelines. However, we also want to design the statutory and regulatory requirements do not unduly restrict access to opioids and acknowledge the need to exempt cancer-related pain in our opioid policies. And I think that's absolutely critically important. And you know this is exactly the kind of function that societies like ASCO and the AMA really exist for, to protect our patients and the physicians who are prescribing these necessary medications to our patients. Well, it's been my pleasure to share this publication with you. And I hope it will be an important educational tool for the oncologists to work on to deal the opioid access problem for our patients. Thank you so much for joining me. I also want to thank all of our listeners out there who joined us for this podcast. The full text of the paper will be available online at ascopubs.org/Journal/JOP in April 2019. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Apr 24 2019
Rank #10: Improving Timeliness of Oncology Assessment and Cancer Treatment through Implementation of a Multidisciplinary Lung Cancer Clinic
Hello, and welcome to the ASCO Journal of Oncology Practice Podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. On this month's podcast, we're going to be talking about a new study from the JOP Quality and Action series, titled Improving Timeliness of Oncology Assessment and Cancer Treatment Through Implementation of a Multidisciplinary Lung Cancer Clinic, published online in the JOP, January, 2019. Joining me today on this podcast is the author, Dr. Genevieve Digby, assistant professor in the division of respirology at Queen's University School of Medicine, where she's also the clinical lead for the lung diagnostic assessment program. She has an active interest in quality improvement projects, which is what led to this paper that we're going to be discussing today. Dr. Digby, thank you for joining me. Thank you so much for the invitation. Obviously, everyone likes to be seen as quickly as possible when they're trying to get into the doctor, but can you give us just a little bit of background into what led you to do this particular quality project? Why is the timeliness of care more important for cancer patients or, specifically, lung cancer patients? So great questions, Nate. Timely care is very important for patients, as you pointed out. In fact, the Institute of Medicine has timeliness as one of the six dimensions of quality. And for lung cancer patients this is particularly important, as we know that there's evidence to show that patients who have delays in their diagnosis or delays in treatment, that this is associated with progression of disease, and there's evidence to show that more advanced disease is associated with worse outcomes. And as we know from the lung cancer screening trials, earlier detection of disease is associated with better outcomes. Not only is timeliness of care important for patients from the point of view of getting their treatment underway, but it also is important in terms of the anxiety and distress that patients have. So we know that the longer delays are associated with more distress, and lung cancer patients to begin with are some of the patients who have the highest levels of anxiety and distress amongst oncology patients. So for us, the study arose because of an identification locally that there were delays in our care processes in regards to transitioning patients from the diagnostic phase of the lung cancer pathway to the treatment phase and a desire to improve those care processes. I think that that really resonates with me. I know at my institution we've been paying attention to the time to initiate treatment for a while, and it's not like going to see the dermatologist. When you're diagnosed with cancer, you really have a lot of anxiety, and you want to get in to get treatment as quickly as possible. And of course, as you've mentioned, especially for early stage lung cancer, there's pretty good data suggesting that the longer someone waits to make a diagnosis, the more likely they are to have their potentially earlier stage cancer turn into a later stage cancer with worse outcomes. So I applaud you for addressing this. And in your particular project, you focused on the establishment of a multidisciplinary clinic. And this is something where I think a lot of the literature out there on looking at processes and time to treatment has focused on that. So is there data suggesting that multidisciplinary clinics specifically are a good intervention for improving timeliness of care? So that's a good question. And the literature varies in terms of its robustness based on the type of cancer that we look at. So my group published a systematic review looking at multidisciplinary clinic models in lung cancer specifically. And we were surprised, actually, by the relative paucity of data in terms of what the optimal catalytic characteristics are, even just in terms of the number of studies that's actually evaluated a multidisciplinary clinic, per se. In other cancer types, there is evidence that multidisciplinary clinics lead to better collaboration between specialists. There is some evidence, even in lung cancer, that perhaps there's better compliance with staging guidelines and guideline-based care when care is delivered in a multidisciplinary clinic. And there's also some evidence, though limited again, especially for lung cancer, surrounding the patient experience and patient satisfaction with their care when it's delivered in a multidisciplinary clinic model. Yeah. Honestly, I don't think I've ever heard anyone argue that there's a downside to a multidisciplinary clinic. But I do appreciate studying measurable metrics that may demonstrate benefits because, of course, you have to get support for these sorts of things. So why don't you take me through your project's design, and what were the goals that you tried to achieve? So this is a quality improvement study. We started by identifying what our overall goals and outcome measures were and how we would go about achieving those goals. For us, the focus was to improve our transitions from the point of care of receiving a diagnosis of lung cancer through to starting treatment with an oncologist. So this particular setup was due to the fact that in our center we have a separate thoracic surgery program where patients with suspected early stage disease directly go to a thoracic surgery program and those with more advanced disease or suspected non-operable disease are initially managed by a respirologist, and then are seen through with the appropriate thoracic oncology specialist subsequently. So for us, we looked at our data, and we actually identified that that time from transition, where a patient receives a diagnosis of lung cancer, to when they're first assessed by an oncologist was upwards of about two weeks. The time then to go on and start their first treatment for cancer was in the range of 40 to 45 days. And we identified that there was room to improve and set a target of reducing both of these individual time frames by about 10 days. We hypothesized that if it could improve timeliness to seeing an oncologist from about 14 days to closer to 4 days-- 3 to 4 days-- that we would similarly lead to maybe about a 10-day improvement in time to treatment on the other end. So our improvement plan was to launch this multidisciplinary clinic. And we used a quality improvement called plan, do, study, act cycles, or PDSA cycles, to help facilitate that and fine-tune our multidisciplinary clinic along the way to make it even more efficient. That sounds great. It sounds like a very worthy project. So what did you find? We found that by implementing a multidisciplinary clinic, even within a very short time of implementing it, that we were able to significantly reduce the time from a patient's lung cancer diagnosis to when they were first assessed by an oncologist. In fact, just with the implementation of the clinic, we led to about a 10-day improvement. We fine-tuned our processes to help create sustainability of the teams. Initially, there was still some variability. And we were able to maintain about a 10-day improvement overall over time. What we found though, and what was really interesting, was that as we went about our change processes, we had ongoing improvement in time to treatment, so that time from lung cancer diagnosis to time to first treatment. With our initial clinic implementation, we had about a 10-day improvement in time to treatment as well. But as we noticed, as we fine-tuned our processes, that improvement actually increased such that we overall reduced time to treatment from about 40 days at baseline to 15 to 20 days by the end of our quality improvement initiative. And that is incredible. I think, to me, was the most impressive thing is not so much that you, by moving up your evaluation by 10 days, you improved time to treat by 10 days, which makes perfect sense, but that somehow implementing this entire project, you greatly exceeded your expected improvement in time to treat. And so, did you look at what specific interventions might have led to that even better improvement than you expected? So that's a great question. And as you said, what surprised us was the extent to which timeliness, in terms of receiving first treatment improved, even beyond just time to seeing an oncologist. And when we considered the data, some of the things that came out were likely the increase in collaboration that we were seeing amongst specialists, particularly medical and radiation oncologists in terms of being able to decide on a treatment plan a bit sooner and get that plan up and running. In fact, when we looked at the data, the patients that had the greatest improvement in time to treatment were those with stage 2 and 3 lung cancer, and also including patients with stage 4 lung cancer. And those are often-- especially stage 2 and 3-- where patients are most likely to need a concurrent chemoradiation, where the treatment plans are often decided together amongst the radiation oncologist and the medical oncologist. And so having that ability to discuss the treatment plans and come up with a clear plan sooner is what we hypothesized is leading to be faster kind of treatment. To evaluate this further, we actually also have recently completed a qualitative study, where we interviewed physicians, and including patients and caregivers, about the impact of a multidisciplinary clinic. And while I don't want to give away all the results yet before it's published, one of the themes that comes up certainly for the physicians and particularly oncologists is just the overall ability to collaborate and have real-time discussions with each other and with the patients about what their treatment plans would be, leading to a faster implementation of that plan. Well there you go, listeners. You're getting a sneak peek of a future study going to be coming out of this group. But I think that makes perfect sense. So again, as a group that has, at least internally, been focusing on improving our time to getting patients to treatment, I think just having an emphasis on studying how long it takes to treat and that everyone understanding that it's a priority to try to make that as short as possible seems to just lead to improvements because everyone's aware that it's an important aspect of treatment. And things tend to show improvements without any real specific interventions taking place. And then, of course, the multidisciplinary clinic. It makes perfect sense that multidisciplinary care would be better coordinated. So I think that that's a really nice validation of what you were trying to do. So how would other centers that maybe are starting to look at this, how would they take what you've done and apply it to their own programs? So that's a great question. I think there's a few things to consider. Firstly, quality improvement processes can be instituted in any organization. And part of quality improvement is identifying what the main barriers are to achieving the timeliness of care goals that an individual center has and just implementing the PDSA cycles at their own institution to help achieve those targets because the barriers can be different between different organizations. So where possible, I think eliminating the silos that exist in our care models of the traditional model of seeing one person at a time and really trying to get people to work together, that can be challenging administratively. But once those barriers are overcome, it's actually more convenient for people to really work collaboratively to improve patient care as a whole. That's great. And this really fits in nicely with both the US National Cancer Institute and ASCO, in particular, have really paid a lot of attention in recent years to teamwork and building team science to help improve outcomes. And I think that your study is a wonderful example of how that can lead to direct and measurable improvements in care. Well, thank you. We certainly think that we've led to some improvement locally and hope that other centers can learn from what we've learned to help drive change. Dr. Digby, thank you so much for talking with me today about your study. And I really want to thank you for sharing the results of your project because I think high quality quality improvement projects that are going on all over the world, really, but oftentimes don't get shared outside of the individual team or institution where they're doing them. And this is going to allow, hopefully, a lot of people to see how investments in teamwork and trying to improve on these metrics can lead to really important results for our patients. I completely agree. It's important to share the knowledge that's learned, particularly with quality improvement. We're all working towards common goals for delivering better patient care, and it's great to be able to share those learned experiences with others. And I also want to thank our listeners out there who joined us for this podcast. The full text of the paper was published online at ascopubs.org/journal/jop on January 7, 2019. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Mar 25 2019
Rank #11: ASCO Core Curriculum for Cancer Survivorship Education
The author discusses survivorship care, one of the most
challenging problems oncologists face today and in the near future.
The core curriculum and competencies outline in his manuscript are
fundamental to the relatively new field of survivorship care, and
provide the framework necessary to generate appropriate referrals
depending on local practices and expertise
Apr 28 2016
Rank #12: Lag Time Between Evidence and Guidelines: Can Clinical Pathways Bridge the Gap?
Hello, and welcome to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the Journal. The best available evidence for cancer treatment seems to change at just a staggering pace. And yet, as physicians, we're expected to keep up with these changes and always give the most evidence-based treatment, which is obviously an incredible ongoing challenge. Guidelines from major organizations can play a role in helping us stay up to date. However, considerable variability exists, even in situations where the best practice seems to be clear. This creates an opportunity where things like care pathways might play a role. Today, we're going to be talking about this topic and about a new paper titled "Lag time between evidence and guidelines-- can clinical pathways bridge the gap?" which will be published in the March 2019 JOP. Joining me today for the podcast is the senior author of the paper Dr. Sushil Beriwal, professor of radiation oncology at the University of Pittsburgh and deputy director of radiation services at UPMC Hillman Cancer Center. Dr. Beriwal, thank you for joining me today. It's my pleasure. Thanks for having me. So why do you think there is so much variability in care, especially around things where a lot of people have broad agreement? So the example in your paper that you use is hypofractionated whole-breast radiation, which has been part of a major guideline since 2011. And yet, it seems as though many people don't use it. So we do see variability in the cancer care. And hypofractionated radiation therapy is one of a good example. What is exactly? It's hard to pinpoint. But I think it's for multiple reasons. Could be a physician is used to practicing a certain why. They don't want to change the practice. They're not aware of the newer data and guidelines. Or it could be the fact that they're concerned about increased side effects and toxicities with this newer approach. They may not have technology or resources to do it. And last, but not the least, sometimes the fee-for-service model may have a detrimental effect in accepting a shorter course of treatment. Oh, I hadn't even thought of that, but that's a good point. So can you take me a little bit through your study? What was the problem that you were trying to solve? As you know, there have been various studies which have come out in the last 5 or 10 years, looking at adoption of hypofractionation for breast cancer care, even though the randomized data suggests that hypofractionation is similar for cancer outcome and possible less side effects, [? with ?] the adoption rate based on the National Cancer Database analysis, or some keyword industries, or some state data, it's somewhere within 10% to 50%. So there is wide variation and acceptance and adoption. And we were trying to figure out a way to make it more uniform so the patient get similar kind of care based on the best available evidence for that patient. Is care pathways or clinical pathways something that you've had experience with working with before? And I guess, maybe just for our listeners, kind of explain to us what a clinical pathway is. Clinical pathways are like additional [? aid ?] tool which basically guides the physician to decide about the care of the patient based on the stage, grade, and other factors associated with that patient. So we at UPMC Hillman Cancer Center started the clinical pathway in a very rudimentary form about 14, 15 years ago. It has come a long way from being a paper trail to an electronic format. The way it works out is anybody who sees a patient in our network of 25 sites has to enter a decision to-- in the care pathway model created by this company called Via Oncology, which was initially part of UPMC, but this year, it was bought by somebody. Well, it was an outside company called [INAUDIBLE]. So say, for example, if I see a patient in my clinic, I go to care pathway website. And automatically, it will ask me for stage, grade, and what needs to be done. And then it gives me the option of what to do. So if the option for that patient is hypofractionated radiation therapy, that's what I have to choose. I see. And how do you decide what goes into these care pathways? Is this determined by an outside group? Is this something that you get to determine within your own institution? When we started, it was within our own institution. But now we have oncologists from all over the country who participate, who are part of the same care pathway module. We have chair and co-chair for each site. And we have committee members for each site. So we meet every six months on a regular conference call. And whatever evidence has come out in the last six months, we try to incorporate that in our discussion and make changes accordingly. So initially, the agenda is discussed. The committee decides and discusses. It goes back and forth. And once the committee agrees, then it's sent out to all the members for voting. And once everybody agrees in the voting, then it is implemented. And that becomes the care pathway for that disease and stage. And so what were the results of your intervention? So we went by a very stepwise manner. So initially, the 10-year data for hypofractionation from the UK group came out in 2013. So when that came out, we as a group decided to mandate hypofractionation for somebody who is 50 and above, like postmenopausal women with early-stage breast cancer. When you're trying to keep breast or just [INAUDIBLE] level to use. And we found when we assessed the outcome that there was a very high acceptance rate of hypofractionation. But one of the concerns we found that the physician had in accepting hypofractionation was how best to do it, because those papers and the data did not define fully the best way to deliver the dose, how best to achieve dose homogeneity, what should be the [INAUDIBLE] and the hard dose. So within our own network, we came up with a very good guideline of how best to achieve dose homogeneity to deliver this dose safely and make it better for the patient. Once we got success with that, then we took the next step of implementing this for younger women. And since we already had the track record, we found that the resistance to the acceptance of hypofractionation was much-- there was much wider acceptance, because people knew how to do it from the previous experience. And the acceptance was much more wider and much more-- the numbers were close to 95% to 100%, which was very reassuring and which was very gratifying to see that patients across our network were getting similar kind of care. No, actually, the numbers are staggering. I mean, in 2015, the number was only 4.2%. But by the second intervention, you said it was 96.5%. So were the doctors actually mandated to use this? Did they have the option of changing it if they wanted to? So the way our system works is the only option we had was to do hypofractionation, but they can change it. But they need to have an evidence-based discussion of why they want to change it. And see, I'm department director for the breast. So anybody who wants to do something different, then he will send an email to me, that he doesn't agree with the pathway recommendation. And these are the reasons why he wants to do it. If the evidence-based discussion is consistent, then we say, go ahead and do the conventional fractionation. Well, it clearly was very effective. I'm curious if you saw pushback from the doctors in making this change? Did people have a problem with being directed towards this particular treatment? Initially, I did. Initially, when we did it for the first time, there was a lot of communication back and forth. And people made different kind of arguments, like we only have 10 years' data. We don't have 20 years' data. And we don't know whether it is safe or not. Or [? they could ?] quote previously have done studies which have shown poor outcome. But they were done with different techniques and different philosophy. So there were a lot of discussions back and forth. And to alleviate some of the concern, I did a [INAUDIBLE] conference in our network, where we mandated all of our physicians to participate and listen to the [INAUDIBLE] conference, where we defined how best to do hypofractionation in terms of dose homogeneity, in terms of heart and lung dose. The most important factor was dose homogeneity. And once physicians understood that the dose homogeneity is the more important component than the fractionation, and they could see the results from the patient's perspective and from physician's perspective, the adoption became like a no-brainer. The other thing that is remarkable to me about the pathways at the University of Pittsburgh and the people who use the Via Oncology Pathways, so my own institution at the Cleveland Clinic, we also come up with our own evidence-based care paths. And we try to educate people about them. But there isn't really a good way to track how well people adhere to them. How important do you think having the web-based monitoring, where people actually have to track what they're doing, is to adherence to these care pathways? Well, it definitely helps us, because there are two ways we monitor it. One is like the [INAUDIBLE] tool. Then anytime you go off pathway, it comes to the pathway director as an email for him to respond to the rationale behind our pathway and whether he or she agrees with it. And if he agrees with it, then it goes into the system as "On Pathway," even though the track was not on pathway. And the second thing is you may say you're doing something, but you may not be doing it. So we have an audit system built in where we have one of our staff members audit the charts randomly across our network and match what has been done to the patient to what has been entered into the clinical pathway, to make sure they match. If other centers wanted to start adopting clinical pathways in order to help improve the quality of their care, what are some of the take-home lessons you learned during this process that you can pass on to them? I think it's important that you have the buy-in from the providers. So in our pathway, it's not like the total is 1% of [INAUDIBLE]. It's a committee, it's a member, and it's an open discussion. If you don't have the buy-in from the people, then it's hard to implement it. You need to explain to the patients it's not taking over their autonomy. The physicians still have the autonomy. It's just helping them guide better to have uniformity of care. And having some-- there are system guidelines. And there are other guidance available. But they try to keep it very lighter in terms of options. The difference between the guidelines of the pathways is there's much more [INAUDIBLE]. Like, for example, we call it the philosophy of efficacy, toxicity, and the cost. All things being equal, the one which is most efficacious gets number one ranking. If it is equally efficacious, then the toxicity gets the high ranking. And if it is equally efficacious and toxic, then the cost gets the high ranking. So the hypofractionation for the breast, it's similarly in approximation to efficacy to [INAUDIBLE] fraction. The toxicity is somewhat better with hypofractionation. And the cost is much better. I think that's a critical point to illustrate, that the first and most important thing is that we make sure that it's just as effective and also at least as tolerable, if not better. We want to make sure people understand that the clinical pathways such as this are not designed just to save money but also to improve actual patient care. And what are the next steps? Where are going from here? So just to take this concept to the next step, like we have recently adopted hypofractionation for prostate cancer. And we have implemented in our data our guidelines how best to do it. So our next step is to look at the adoption of hypofractionation for prostate cancer, which is like nine weeks treatment versus six weeks treatment, with the guidance of how best to do it. And the next thing we'll be executing is whether we are able to successfully do that or not for prostate cancer too. I think this has given us a benchmark and a platform to take it to the next level for other disease sites, and to make sure that we are following the data and evidence to the best of what we can do. Thank you for agreeing to talk to me today. I think this is going to be really of interest to the listeners of the podcast. Thanks for having us. And it was a pleasure talking to you. And I hope that this can send the right message to the audience for them to take these steps in their own practices. I also want to thank our listeners out there who joined us for this podcast. The full text of the paper was published online at ascopubs.org/journal/jop on December 7, 2018, and will be in the March 2019 JOP. This is Dr. Nate Pennell for the Journal of Oncology Practice, signing off.
Mar 22 2019
Rank #13: CancerLinQ: Cutting the Gordian Knot of Interoperability
With the care of patients with cancer strewn across numerous settings, are electronic health records (EHRs) meeting the definition of interoperability according to the 21st Century Cures Act? Dr. Pennell speaks with author Wendy Rubinstein.
Read the related article "CancerLinQ: Cutting the Gordian Knot of Interoperability" on JOP.
Hello and welcome to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. Most oncologists in America today use an electronic medical record, or EMR. But for a number of reasons, few of us are able to access records for patients outside of our own practice, a concept that's known as interoperability. Today we're going to be talking about a new editorial published as part of a series called "The State of Cancer Care in America." This editorial is titled "CancerLinQ-- Cutting the Gordian Knot of Interoperability," published in the January 2019 issue of the JOP. Joining me on this podcast is the author Dr. Wendy Rubinstein medical geneticist and Deputy Medical Director at CancerLinQ, LLC. Dr. Rubinstein, thank you for joining me today. Thanks for having me. So I know that this is not going to be a surprise to any of our listeners, but would you mind just kind of giving us a little background on the issue of EHR interoperability, and how did we end up with the scenario that we have today? Well, sure. Of course, electronic health records systems weren't built with interoperability in mind. The overarching goal for hospitals was documentation to support billing, and it hasn't been a priority for hospitals to make it easy for their patients to interact with other health systems. But to be fair, people didn't talk much about interoperability 10 to 15 years ago. And I'm not even sure an official definition existed. So now the 21st Century Cures Act provides a definition. So basically, electronic health information should be able to be securely exchanged with other health information technology. And there should be no special effort required by the user, especially and including patients. And the data exchange for the authorized use, it needs to be completely enabled under applicable laws, and any information blocking is prohibited. So what this comes down to, basically, is that a patient should be able to have care at one medical office, and then go to a separate system across town, without having to fill out another paper form with their complete medical history, medication list, and review of systems all over again. So part of the article talks about, and you mentioned, the ASCO Oncology Practice Census. And in 2017, the practice census found that 40% of practices were unable to accept any patient information from other practices. And you might think that the problem is getting better with attention to it, but actually, it's getting worse. In the 2016 practice census, 34% of oncology practices said that their EHR was interoperable with hospitals in their region. But in 2017, only 10% were interoperable with regional hospitals. So in oncology, this is especially important because cancer patients typically have their care strewn across multiple specialists, surgery, radiation oncology, medical oncology, and more. So with their care being decentralized and being complex, how can we really subject our patients to recounting their entire history every time they come to a new specialist? And we're relying on them to be savvy about their cancer history and to be accurate about it. And this is often the worst time of their life. So without quite saying it to them, we're basically letting them know that we don't communicate with our other doctors. And I have to say, sometimes my own medical profession embarrasses me. Yeah, it's interesting. I mean, it's a couple of different issues, the first being of just simple interoperability and having access to your patients' records when they're not within your system. The traditional way of doing this is you've typed up a letter or a note from what you've done, and then you mail it to the other physicians who are either the primary care doctor or the person who referred to you the patient. And strangely enough, that's still mostly how this happens. I have a sophisticated electronic medical record that puts together a sophisticated note filled with all kinds of important information, which gets printed out and put it in an envelope and mailed to someone, rather than sending that electronically and having it available whenever they need it. They have to somehow come up with a way to scan that into their system so that they can read it. So it's really remarkable that we're still in that system. And I now have limited interoperability with other people through my own EMR, and it's just astonishing how much easier it is to keep track of people with that. Once you start to get a taste of the potential of that, it's really hard to go back and not be able to access patient's records anymore. Everyone I think is a little bit aware of this issue and becoming increasingly aware of this issue. What are the barriers out there to making EHRs interoperable? It just seems like such an obvious thing to do, and yet it somehow is a difficult process. To attempt to maybe take something complex and bring it to some basic issues, I can call out a couple of issues. One is extreme customization, and the other is that we need a common language that can speak across different implementations of electronic health records. So with extreme customization, and this is how I would characterize it. So customization is very effective at locking up health information and preventing it from being exchanged. And for any EHR vendor, offering a way for clinicians to customize their reports, their documentation, it really is a great way to satisfy them. And in fact in my own experience, my cancer genetics practice became very efficient by creating templates for notes and letters about genetic testing and managing patients at high risk of cancer. But if you think about it, when I recorded a diagnosis of colon cancer in a letter to the patient or the clinician, it wasn't mapped to any standard vocabulary or code. It can't be shared other than as a TXT file. When you talked about bringing in scanned documents, yes, you can look at them, but they're not machine computable. In fact, if you like to know how many ways you can say total neutrophil count in an electronic health record, CancerLinQ was in the unfortunate position of figuring this out. So in the first 30 oncology practices that CancerLinQ received data from, there were 76 distinct ways to say total neutrophil count, like white blood cell count or WBC. And that means that there were more than two names per organization on average, even within an organization. There's no agreement on what to call this. So it's certainly true. We, as human beings, we can all semantically process different terms for total neutrophil count, but a computer can't. It can't do that, unless we provide a mapping or we create it. So this basically locks up the data and reduces its value. So to extract the value, we apply natural language processing and human observation using interfaces. But that's expensive, and the problem is it doesn't help at the source. You still have the EHR, it's not really aggregated together yet, and in the day to day workings, you're not really doing anything to solve the problem. So the other problem which is very much related is we need a lingua franca. We need a common language to make the proper use of the data that we have in EHRs. And so on a higher level, ASCO and CancerLinQ have convened a volunteer stakeholder group, and this represents diverse perspectives in oncology, different specialties coming to the table. And the purpose is to create a core set of data elements from oncology called mCODE. So mCODE stands for Minimal Common Oncology Data Elements. And ASCO is aligned with other medical organizations, as well, and the Biden Cancer Initiative, so that together we can inform oncology EHR vendor design. We can inform their decisions and, hopefully, prompt interoperability to improve cancer care. One of the things that's-- of course, you now work with CancerLinQ. Can you tell us just a little bit about CancerLinQ and how CancerLinQ can work to overcome some of these issues? Sure, I'd love to. So CancerLinQ is a major initiative at ASCO. And the goal was to create a learning health system for oncology. So first and foremost, CancerLinQ is a quality measurement and reporting system. We have over 100 health care organizations. These are large and small, they're community and academic, that are participating in CancerLinQ. And so far, we've established data flows with 47 organizations, and we've integrated data for over a million patients with cancer. And that reflects their comprehensive longitudinal record of health. So by doing this, the reason to do this is we're enabling practicing oncologists to measure, and report, and improve the quality in patient care. So when you look at, for example, the 2017 ASCO Oncology Practice Census, about 25% to 30% of practices, they called out quality measurement and reporting activities as a top burden for them. In order for them to do this, they have to actually do manual extraction from electronic health records, if you can wrap your mind around that. You have to pay to do that. So the CancerLinQ platform reduces the reporting burden by displaying the quality measures for MIPS, MACRA reporting and also supports ASCO's QOPI certification. And what this means is that clinicians can actually see the time window they have left to take specific actions to meet the quality benchmarks. The other part of CancerLinQ is that we provide statistically de-identified data sets from the cohort to researchers and to FDA. And in that way, we're trying to accelerate discovery and scientific improvements to cancer care. Yeah, it's a fantastic initiative, and I'm glad to see that it seems to be growing and doing well. The next question would be, how can CancerLinQ, aside from individual practices being able to use the data for quality metrics and, of course, the anonymized pool data for research, how is this working to overcome problems of interoperability? So CancerLinQ is somewhat unique in that we've integrated data from practices, so far using seven different electronic health records. So we don't limit, we feel we can't limit the data aggregation to a single EHR type because the overall goal is to learn from all patients. But there are some common problems that we share with other big data providers. So any entity that's performing data aggregation, they're also coming up against the same problem we have, as needing a common language for oncology, such as mCODE. And as I mentioned, ASCO is looking to engage everyone who has this common problem to solve it together. One barrier I can't resist talking about as a geneticist is the way genomic data is handled. The one disturbing practice is that really the way DNA sequencing data exists is it's completely structured in machine computable when it comes off the sequencer. I mean, almost by definition. And then the results get reported by paper, and even if there is an electronic file sent to the practitioner with the report, there's nowhere in the electronic health record to store the genetic test data in its rich detail. So the report might get scanned or copied someplace, and it'll get attended somewhere where you can go visualize it. If it's scanned in, it loses all of its structure, and then it requires optical character recognition and very messed up tables to try to make sense. So if you think about it, like what we want to do with that data, how can we automatically run clinical quality measures for colon cancer without having a place for KRAS gene test results? That's already in all the quality measures. If an oncology practice is running Molecular Tumor Board, how can they do that with reading off of this piece of paper? They need the files to really run that activity. And the same thing is true for identifying patients who are eligible for a clinical trial, increasingly based on a molecular variant result. So we can do that to some extent. We can do all these things, but we really can't scale precision oncology with these kinds of limitations. So I think a common theme across CancerLinQ and other entities that are trying to aggregate data and especially to combine it with the rich phenotypic data in electronic health records, the molecular diagnostics laboratory should routinely make these results available to the ordering clinicians as structured data files. It may be difficult for them to maintain it themselves. The electronic health record really should have a place for this, which with mCODE, that will definitely be a part of mCODE. Where do we go from here? How do we get from where we are today to the world where all this information is easily shareable across EHRs? The technical challenges there, but really it's about collaboration and having a will to solve this across the entire ecosystem. So we have created an organization called the Oncology Leadership Council. So CancerLinQ's Oncology Leadership Council includes corporate nonprofit and government collaborators and, for example, the American Society for Radiation Oncology, National Cancer Institute, FDA, the Cancer Informatics for Cancer Centers, Ci4CC, AstraZeneca, College American Pathologists, American College of Medical Genetics and Genomics, and many others. Now ASCO doesn't think that this is something that we could or should solve alone. This really means helping the entire oncology community to improve care by solving the problem at the source. And that means capture all of the important oncology data as structured, computable information. And we have to do this without imposing any more documentation burdens on physicians. And frankly, we shouldn't really be hiring an army of data entry clerks to do this either. I like to think about call to action. What can people do, given the situation? So I would like the listeners to know that the Office for the National Coordinator for Health IT is right now soliciting comments on what they call the strategy on reducing regulatory and administrative burden relating to the use of health IT and EHRs. So ASCO is currently preparing comments, and you'll have a chance to review and provide feedback. And I also wanted to let listeners know that you can also participate in the writing of comments, which is going on by the American Medical Informatics Association, AMIA. The comments are due soon, on January 28, 2019, but input would be very valuable. I'd also like to mention that CancerLinQ is concerned about information blocking. And as I mentioned before, information blocking is prohibited by ONC. And lastly, I can't resist inviting people, that if you're interested in joining CancerLinQ, please contact us. Excellent. I think that was a good idea to put that message out there. And I will also put the plug in that joining CancerLinQ is actually free of cost to get this wonderful resource. You bet. Dr. Rubinstein, thank you so much for talking with me today. Thank you, it's a great opportunity and a real pleasure. And I also want to thank our listeners out there who joined us for this podcast. The full text of Dr. Rubinstein's paper, "CancerLinQ-- Cutting the Gordian Knot of Interoperability," is available online now at ASCOpubs.org, backslash journal, backslash JOP in the January 2019 issue. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Jan 31 2019
Rank #14: Online Communities as Sources of Peer Support for People Living With Cancer
Dr. Pennell and Dr. Schapira discuss the risks and benefits of online communities and provide recommendations for improving communication between clinicians and patients about the use of online resources.
Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, Medical Oncologist at the Cleveland Clinic and Consultant Editor for the JOP. So it won't be news to any of the listeners of this podcast that living with cancer and dealing with the sequelae of cancer treatment is a terribly stressful proposition and that cancer patients and their caregivers benefit from support services and survivorship programs. Most of us, however, think of providing these support services for cancer patients in terms of in-person interventions, but increasingly, people are looking online for these kinds of support. I suppose that's probably true for many other aspects of our lives as well. Online communities have been forming in an effort to improve access to support for cancer survivors. But how much do we really know about these communities, and what evidence is there that they are genuinely helpful? Joining me today to talk about this fascinating topic is Dr. Lidia Schapira, Associate Professor of Medicine at the Stanford University Medical Center and Director of Cancer Survivorship at the Stanford Comprehensive Cancer Institute. Dr. Schapira is also the Editor in Chief of ASCO's patient information website, cancer.net, and is a fellow of ASCO. Today we'll be discussing her paper titled Online Communities as Sources of Peer Support for People Living With Cancer-- A Commentary. Lidia, thanks so much for joining me today. Thank you so much for the invitation. So first, this is obviously too big a topic for this podcast, but explain a little bit about why cancer support services in survivorship is important for cancer survivors. And I guess more importantly, where is there an unmet need, that people might need to seek that somewhere else, such as online? Sure. So we think of support as something that is delivered in person. And certainly in traditional medical settings, we offer support, I hope, through empathic communication, through referrals to social services, through programs. We are very much aware that going through cancer alone is much harder and that support is both important just strategically to get through it but also emotionally. I think that increasingly we also realize that people are seeking support in other ways that are not traditional and have been less well studied, and that's where the online services and supports really are playing a very important, an increasingly important, role for many patients and caregivers as well. This is coming up actually a lot among patients of mine, especially younger patients. So can you just tell us a little bit, when we talk about an online community, what exactly is that? So there are two words and each one is really important here. Community means, really, a group, so it's not just a one time exchange, but belonging to something, a sense of belonging to a group. And the group shares a common interest. In this case it's something related to cancer. And online refers to where this group, or this community, meets. It could be through instant messaging. It could be through other new media or platforms. It could be through email. It could be through a website. And that is going to change as technologies change. What we're basically saying as a way of meeting people not in person but meeting over time and through a shared expressed common interest. And there's lots of different examples of kinds of online communities that you described in your paper. Can you tell us a little bit about them? I know that there's some that are a little bit more formal and structured and others that are really kind of left up to the patients to moderate themselves. Exactly. And to somebody who is not a digital native, like myself, this has been a real interesting process of discovery. We tend to think, perhaps incorrectly, that online means improvised, and it's anything but improvised. A good online community that is mature, that keeps the interest of its members over time, requires some management, requires some decision, requires some effort on the part of the people who are starting the community. And so we learned that there are different types. There are different media. Some have actually some formal facilitation with social workers and really function similarly to the way an in-person support group functions. And some are much more informal, people sort of coming together. So there are some online communities that are sort of offered through large advocacy organizations like the American Cancer Society or CancerCare. And there are others that are not, and those typically occur in spaces like Twitter or Facebook. And now there are even some privately sponsored online communities such as Smart Patients. And we reference Smart Patients because their headquarters are in Mountain View, California, and we got to do a visit and really learn a lot about them just, again, to get a better understanding of what's available for our patients. Well it's nice that there's so many different options. How do patients even find these? Do you know? I think patients just find information in ways that come naturally to them. There are lots of groups for young cancer patients and survivors that have fun names, Stupid Cancer and so on, that are terrific. And there are some that are more formal through other societies. Facebook and Twitter are probably places that people go to, and they're just basically looking for others with a shared diagnosis. And so it's hard for me to answer that. It depends a little bit on how familiar people are searching for things and then what pops up when they are actually looking for something. And one of the things that, as an experienced oncologist, I always worry about is how safe they are. I think what first comes to mind is, oh my goodness, people may be misinformed, or they may have exaggerated ideas about one treatment or so on just by asking these questions without really doing some formal research. But it's amazing actually how much good information is also transmitted through these very informal groups, some of which are absolutely not monitored. But people just really push each other to learn and to look for information in addition to giving each other support. When we started this, the driving question that I had-- and my co-author was then a chief resident at Stanford and is now an oncology fellow. The question we had was really, are people looking for information about cancer and cancer treatment, or are people really looking to connect with each other and help each other through a difficult experience? And what we found actually is that it's both, and it was very difficult to tease out where the good information becomes also a source of support. I would say that this sounds wonderful, and taking it at face value is probably fine. But because we are academics, we always look for data. And so is there actual data? Are there studies on the benefits and risks of patients participating in these online communities? Unfortunately, I would say there is little rigorous data. We looked for it, and we were hoping to be able to find sufficient numbers of well-designed randomized controlled trials or other good trial designs where we could actually study this. And one of the things we are interested in is, of course, is it safe? And also, if it is helpful, in what way is it helpful? I mean, do people cope better? Do people feel that they're better able to handle their illness, in other words? Could we find measures of self-efficacy or coping or information or something that was measurable? And we found many studies done but, unfortunately, few that were of high quality and few that were high quality and relevant to cancer. So what we found was actually not sufficient to come up with either a sound recommendation or to go a little deeper and do a systematic review or some more rigorous review of evidence. Yeah, it's interesting. You cite in your paper a few studies that have shown some improvement, at least in things like self-efficacy and decreasing anxiety or at least perceived improvements in these, and then some that are worse and many that really don't seem to show a significant difference. Is that something that you think can change? Are there plans to do more rigorous research? Our group has actually been very interested in trying to find the proper design for a study. And we've brought together social scientists, mental health scientists, and oncologists, and people who really understand the technologies, and we're trying to figure out how one could possibly study it. We think it needs to be done, and I'd be delighted to collaborate with others who are looking into this. I mean, we know social media can help patients find each other or find, perhaps, centers where they're doing research. Certainly, patients with rare diseases find that it's a very useful way of connecting with others. But what we were really interested also in trying to identify how much-- what is the dose of social media? What is the best venue? Is there a way of matching a patient to group so that he or she may find what they're looking for, and when is this benefit transmitted? Our hunch is that it's probably early on in the cancer experience that people derive the greatest benefit from feeling connected and that what actually happens is that they feel some validation. They feel better able to handle it. They actually learn how to ask better questions. But it would be wonderful if we could actually find a way of studying it. As you may well imagine, it's hard to study something that people are already doing, so finding the proper study design and population is what I think is keeping us still from being able to answer these questions. Sure. So when you see a patient who's, let's say, just gone through surgery for breast cancer and is just embarking on her long adjuvant therapy, how do you talk to them about these resources online? How do you-- or really to all of us oncologists out there, how do we guide our patients to wade into this brave new world in a responsible and helpful way? So for me the first step was to just recommend in my after visit summary that patients visit cancer.net as a way of getting informed. That to me was already sort of an important step. And the next step, and I'm still thinking through this, is to try to have this conversation with as many patients as I can, those were receptive to this. And as I ask them, do you feel supported, do you need a referral, I should also say, there are some online groups. Some of the times I do. It's still not part of my routine, but I bet you in a couple of years it will be. No, that makes sense. I actually for a while was handing out to people a little card which had some responsible, what I thought were good websites, but mostly, again, for information as opposed to actual communities where they could meet other patients. So that's definitely worth some thought. Well, Lidia, thank you so much for agreeing to speak with me today. I'm sure our listeners got a lot out of this. Thank you so much for the opportunity, Nate. And I also want to thank our listeners out there who joined us today for this podcast. The full text of the paper is available at asacopubs.org/journal/jop, published online in September 2018. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Dec 18 2018
Rank #15: Design Challenges of an Episode-Based Payment Model in Oncology – The CMS Oncology Care Model
Jul 12 2017
Rank #16: 2017 ASCO Quality Care Symposium: Nurturing a New and Growing Community of Practitioners
Sep 19 2017
Rank #17: The Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States
Dr. Pennell and Dr. Nancy Lin discuss whether prior authorizations reduce overall health expenditures.
Read the related article "Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States" on JOP.
Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. Today, we're going to talk about a topic that I think is going to resonate with just about every clinical oncologist in America-- prior authorizations. Although these have been around for longer than I've been practicing, it really seemed to me over the last couple of years that more and more claims have been denied by insurance companies, more requirements for prior authorizations, and often for things that really didn't seem like they used to need prior authorizations, such as inexpensive medications. And now, based on data from the 2017 ASCO Oncology Practice Survey, we have some hard data that isn't just my imagination. This is a real phenomenon that is putting stress on an already stressed health system. Joining me today to talk about this topic is Dr. Nancy Lin, associate professor of medicine at Harvard Medical School and director of the Metastatic Breast Cancer Program at the Dana-Farber Cancer Institute in Boston. She's going to discuss her and her co-author's editorial titled "The Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States." For 2018, the JOP is publishing a series of papers on the state of cancer care in America, and this is part of that series. Welcome, Nancy. Thanks for joining me. Thank you. I know probably most people listening to this are familiar with prior authorizations. But can you talk just a little bit about, what is the intended purpose of prior authorizations? And is this something that ever made sense before the current craziness? Sure. Before I start, I would just like to acknowledge my co-authors on this editorial, Harvey Bichkoff, the CEO of Marin Cancer Care, and Dr. Michael Hassett, a medical oncologist at Dana-Farber. So together, we run the spectrum between academic oncologists, community practices, as well as Dr. Hassett has an interest in health policy-- so kind of running the gamut of interests here. You know, I think we can all agree that the cost of cancer care continues to increase-- I don't think that's a controversy at all-- and that continuation along this trajectory is not sustainable in the long term. So insurers, whether they are public or private, are struggling to keep premiums down while keeping up with all the new advances in diagnostics and treatments, and many of these are quite expensive. So, you think prior authorizations came out of this, which is that an attempt to try to maintain some cost containment in a way that, at least at the outset, the hope was that this would be in a fashion that would lead to the use of treatments in a medically indicated fashion and reduce the use of non-indicated treatments. That sort of makes sense, doesn't it? If people are doing things that don't have a lot of data behind them or are using the most trendy, expensive test or medication, it might actually make sense to have some control to make sure that they're following some reasonable practice or guideline. Yeah, I don't think that what is most upsetting oncologists, or oncology nurses, or front-line staff is denial of unproven or unuseful treatments. I think it's really the many and what seems to be increasing hoops that one needs to jump through in order to get testing or treatments that are really the right thing to do for patients that are really well within the standard of care. So while the PA system might have started with good intentions, I think as it is often currently constituted-- I don't want to lump all the systems together in one. But I think it contributes in a way to sort of a siege mentality. So I think if you talk to any practicing oncologist, you will hear stories of the kinds of struggles they have had getting very standard treatments approved in a timely fashion. And while in the short term, most of us make these heroic efforts to get things approved, I think that process really as set up is really counterproductive in terms of the long-term health of our health care system. So at the institution I work with at Dana-Farber, we tried to actually do a project where we quantified some of these kind of gestalt feelings. And so what we did is we actually looked at all prior authorizations for outpatient medications originating from the breast medical oncology practice over a six-month period of time. And we focused only on outpatient medication. So we're not talking about scan authorizations or IV chemotherapy but just outpatient oral medications, whether antineoplastic or not. And we found that we had to process over 300 PAs over a six-month period of time and that 97% of the PAs that were requested were approved on the very first try. We went back, and we coded whether the medications were being prescribed in accordance to NCCN guidelines. And yes, most of the time they were. And strikingly, we actually found that 15% of our PA requests were for generic medicines, like tamoxifen, aromatase inhibitors. These are medicines where there's just absolutely no debate about the efficacy or importance of the treatments. They've been around forever-- maybe not forever, but for many, many years. They're available in generic form. They're inexpensive. And then seemingly random treatments, no matter how much we appealed, we couldn't get through the PA process. And this includes a scopolamine patch for refractory chemotherapy-induced nausea or Lupron for the purpose of ovarian suppression. And I think that when clinicians deal with this on a daily basis, they see that almost 98% of their prior auths go through the first time, that you get these sort of bizarre requests for all sorts of paperwork for tamoxifen, for goodness sakes. It really gives a sense of being besieged by paperwork and process and not really being able to see a clear benefit of the PA system. And I think that really is what contributes to this burnout and the sense that the prior authorization process is broken. And it's not just your colleagues in Boston. I know, certainly, I've had that sensation here. But now we have some national data suggesting this is a problem being felt everywhere. I know that the most recent ASCO practice census, and maybe you could give us a little background on what that is, seems to show that this is a burden everywhere. ASCO actually conducted an oncology practice survey. So they've surveyed about 395 practices in 2017. This actually represented about almost 60% of the US hematology-oncology workforce. So was is a pretty big survey. There were 7,200-or-so respondents. And what was found, the key point was that payer pressures were actually the most important pressure that was felt by practices. And this was felt across all types of practices-- academic, physician-owned, rural, urban-- and that prior authorizations were actually the most commonly cited pain point, and they were cited by 78% of the respondents. So this is really something that people are feeling, truly, on a daily basis. And this is not limited just to oncology. There was a related survey by the American Medical Association. This covered not only medical oncology but primary care and other specialties and, basically, found very similar findings. Prior authorizations are a huge burden on practices. In fact, in the AMA survey, 90% of practices reported delays in care because of PAs. Almost 80% abandoned treatment plans at least some of the time because the PA is too burdensome. So these are things that have direct effects on patients. Oh, absolutely. And I think what was striking to me about the practice censuses, you may think this has always been a major issue, but this is a real change in the most recent year's survey. It was, I think, the third or fourth top concern of practices until this survey where, suddenly, it's now far and away the top burden on practices. And there is also some data I see here looking at quantifying the amount of time that it's taking staff and money, that practices are having to invest in trying to work around this pretty significant burden. There are some studies that suggest that US practices spend nearly four times as much money interacting with payers than do practices, for example, in Canada, which has obviously a very different health care model. In some studies, the costs have been estimated somewhere in the $80,000 to $90,000 per 1.0 full-time FTE physician per year just to deal with prior authorization. And in the ASCO survey, the 2017 survey, the [? hema ?] practices that were surveyed reported a requirement for an average of 6.1 FTE staff to manage prior authorization. So that's a huge burden. And I think what's important is that, more importantly than sort of the-- obviously, there's a bottom line to practices. You have to pay for these FTE. But the reality is that leaves practices to have to make decisions about how they're going to allocate their money, right? So how much are you going to support a social worker, a program nurse, a practice coordinator? How much are you going to support all of the staff required for PAs? And what proportion of the front-line physician staff, nurse practitioner staff, PA staff will be spent during office hours-- because, often, that's when one needs to do these-- interacting with payers versus providing direct patient care? So I think that this doesn't all happen in a vacuum, and that's also very important. And when you spend money in one place, you're making trade-offs in other places. Oh, absolutely. It's something that no one can ignore now. Do you know, is their actual data showing that all of these denials and prior auths, does that actually save money in health care? You know, there's not a lot of information specifically looking at oncology. That's really looking at the global picture. Because if you think about it, if you don't pay for an antiemetic, you might save money on the antiemetic, but the person may end up in the hospital with need for IV fluids. And so I haven't seen very large kind of studies that are comprehensive in that way to look at the full cost of cancer care with and without various types of prior authorization processes. That has been done in some other disease types. And in those disease types, there have been sort of mixed data as far as whether there are differences in the overall costs, for example, in the mental health area where requirements by insurers to switch from one antidepressant to another may then lead to a, for example, psychiatric hospitalization. So there, there's been a little bit more study for that. And it does seem, at least in some studies, that the overall cost of care may go up. That's not been seen in all studies. I'm not aware of really well-done studies in oncology-- they may be out there, I'm just not aware of them-- looking at the sort of overall picture, which, I think, is what we worry about. And we also worry about the other part-- is that what we can't really measure is what happens to the vulnerable patient who goes to a practice that just isn't as well resourced, and we just can't get or the practice just can't get something through that's really medically indicated, and the patient has a adverse oncology outcome as a result. And that's not really something that we, at least to date, have been able to really appropriately measure in terms of what potential impacts might be of not only prior authorizations but all the sort of different types of barriers that are present to affect care of vulnerable populations. To some extent, you have to conclude that it must be saving at least the insurance companies some money since it seems like they're doing it more and more. And that almost has to be driven by a certain percentage of claims that are people just sort of drop it because they don't want to go through all of the time that it takes to do that. That certainly doesn't seem like a very good system for patient care. I know, certainly, when I'm called to do a peer-to-peer, I always have a moment where I sort of put my head in my hands and wonder how badly I really want to do this. But obviously, if it matters, you have to push it through. And as you pointed out, when you finally get to the peer-to-peer, almost always they approve reasonable requests based on the exact same information they had when you submitted it the first time. It's not like you had to give some special, secret information to the reviewer to get it approved. That's exactly right. And I think the arbitrariness of the program or the process is part of what oncologists are responding to, those sort of lack of transparency, the sense that one could easily talk to a computer and just punch in the key for the response and get the same results. I mean, I think there is this anecdotal sense of that. And how much of that is true it's hard to know without a definitive study. But I think that is a sense that people have out in the front lines, and that's part of the frustration. Yeah. Well, so you state unequivocally that the system is broken. And I'm going to go out on a limb and say that I think you may be on to something. So what can we do? Or what are some possible solutions to this? So, I mean, I think we can all agree that a shared goal is to deliver timely, high-quality care to patients with cancer. And I really emphasize both the timely part and the high-quality part because they really go hand in hand. And so whatever we do to try to constrain costs, we really want to make sure that we're not affecting the timeliness and the quality of the care that we provide to patients with cancer. We make a number of recommendations in our editorial. But I think one key point is that we believe there is a role for some cost-containment strategies from payers. I mean, we recognize the need for it. But we think that payer-based coverage guidelines, prior authorizations, whatever sort of mechanism is there really should be the exception rather than the rule. And when they are in place, they should reflect the best and most up-to-date evidence. We shouldn't be arguing for something that was approved three years ago. And I don't know that it's really the goal or the role of insurers to micromanage every aspect of a patient's cancer care. And so I think some possibilities, like insurers have these really large [? beta ?] databases, so trying to understand and focus on which expensive medications are frequently not used according to guidelines, having two-way conversations with oncology and patient advocacy organizations in areas of controversy to try to come up to some consensus of where these somewhat more soft indications might be covered, demonstration projects to look at alternatives to prior authorizations. And I think all of these would be welcomed by the oncology community. I don't think the oncology community is unaware or doesn't care about this big elephant in the room, which is the high cost, right? But I think the pushback is really just the implementation in a way that just doesn't feel like it-- it feels like it's actually getting us away from timely, high-quality care. I think that's where the dissatisfaction comes from. And when prior authorizations, or pathways, or whatever cost-containment tool was implemented, I think listening to the oncology community is really important. So are there processes that can be simplified so that you can achieve similar results with less pain? Are there ways to make the processes or forms more uniform? So between the myriad of insurers that every provider deals with on a daily basis, every form is different. Every check box is different. Everything is different. It's a pathway. If there are pathways, you don't want to be navigating 20 different pathways, and the person on one insurance gets one chemotherapy in the third line. Maybe another on the other insurance gets this. I mean, it's just this is-- you don't want that to be how we practice medicine. And when PAs are denied, I think we want to have a streamlined appeal process. I mean, we want to ensure that the person on the other end is qualified as a peer reviewer-- which, I think, there is a sense that that's not always the case-- and also empowered to use their clinical judgment. So even when there is a clearly qualified peer reviewer, sometimes they just don't have the latitude to make clinical judgments. They're constrained in internal ways. And so I think that also gives the sense that the patient isn't the priority. And I think we just can't forget, right, the patient is the priority. Yeah, I mean, I think giving everyone the benefit of the doubt here, I think everyone's goal is to deliver the best value care, the best quality of care to the patients, and to try to keep in mind the incredible problem of the rising costs of care. And the insurance companies have been placed in a difficult position where they really have had to take something into their own hands, which means we need to get everyone to the table to try to solve this. All right, well, thanks so much for joining us. Thank you for inviting me. And I also want to thank all of you out there who joined us for the podcast. The full text of the paper is available at ascopubs.org/journal/jop, published online in August 2018. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Sep 27 2018
Rank #18: Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance
Dr. Thomas Knight talks to Dr. Pennell about a major issue in cancer care: financial toxicity.
Read the related article.
Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. The rising costs of medical care is on everyone's mind these days. But while policymakers or physicians tend to discuss this more of as a societal or economic problem, the real consequences of the high costs of cancer care are ultimately being felt by our patients. But how do we measure the financial burdens of cancer care? And how does this impact our patients' lives and ultimately their outcomes from treatment? Today, we're going to be talking about a new paper titled, Financial Toxicity in Adults With Cancer Adverse Outcomes in Noncompliance, published in the November 2018 JOP. Joining me for this podcast is Dr. Greg Knight, medical oncologist at the Levine Cancer Institute in Charlotte, North Carolina. Greg, thanks so much for joining me today. Thank you so much for having me. So I thought this was a really interesting paper. Can we just start with a little bit of terminology? So what do you mean when you're talking about financial toxicity? I've heard people use this term bandied about. I think it's a term that oncologists are used to dealing with. And obviously, we know that health care is expensive. But this implies that there is a harmful element to this. Yeah, sure. The term financial toxicity is still a relatively new term. We first started to use it probably around 2013. Dr. Zafar at Duke published a paper first looking at this in terms of the costs and the harm to patients. And the idea behind it is we want to be able to quantify what we're doing in terms of harm to the patient with the costs of treatment. As oncologists, one of the things that we're really good at is grading toxicities. So we worry about nausea. We worry about neuropathy. We worry about hair loss. But one of the things that we weren't very good at was also looking at the harm we were doing to patients with the costs of our treatment. And when I refer to cost of treatment, this term actually encompasses a lot, in terms of not just what we usually think of, which is offices, it's medications, hospitalizations, all those bills that they get from us, but there's other costs that go along with having a cancer diagnosis. Those are things like transportation, clothing, lost wages, child care. All of these things are impacting our patients. And we need to quantify this because it does have implications on their treatment and how they're going to do. Well, that makes perfect sense. And I think that's something relatable to everyone who's treating cancer patients today. Can you give us a little bit of an idea of the magnitude of this issue in the United States? Is there existing data before your particular study came out? There were some both small scale papers and some large database looking papers. And the general consensus was, at the time when we started this study was about 1/3 of patients are going to have severe or catastrophic financial difficulties associated with their treatment. Wow. That's a huge number. So why don't you tell me a little bit about your study and what was the intention of the study and how did you go about it. One of the things we really wanted to do with this study, which was part of a much larger study we had at the University of North Carolina, was we wanted to evaluate both prevalence of this financial toxicity. Because again, there had been some database studies. There had been some smaller scale studies. But we wanted to get actual patient reported data on the prevalence of this financial toxicity and in a wide variety of cancers. But we also really wanted to look and see other things. How did it impact health services? Basically what are targets that we could intervene on to try to improve this? And so really with this study, what we did was we went into the clinics of all of the oncology clinics at UNC, and we embedded researchers in there and approached pretty much any patient that came to the clinic. Wildly successful actually, we had over 52% of our approached individuals actually enrolled in our study. And then within two weeks of that enrollment, we had interviews conducted by our staff using basically a computer assisted telephone interview. Now as I said, this was part of a much larger project. And what we were trying to do was basically get this comprehensive database of both clinical and interview data. And then we paired that with biologic specimens and tumor tissue. However, our piece of it was we were really trying to delve down on this financial question and then look at quality of life and how it impacted their care. Are their existing instruments that look at financial toxicity? Or is this built into existing PRO surveys? At the time when we started this, there actually was not. Dr. De Souza at the University of Chicago actually developed the cost measure, basically posted that after we had started with us. Having said that, and I love the cost measure. I think it's a fantastic. It's a nine question survey basically looking at grading financial toxicity. One of the things that we really were hoping to do with our primitive attempts at this was to find maybe one question things we can do in a busy clinic to try to identify high risk populations. And so with this one what we used was actually a statement from the PSUA team, which was, you have to pay for more medical care than you can afford. And then patients were asked to respond to the statement basically strongly agree, agree, uncertain, disagree, or strongly disagree. And we dichotomized them as basically exhibiting financial toxicity if you strongly or agreed with that statement, or not exhibiting financial toxicity with any other response. That sounds like a pretty clear and straightforward question. Was there like a free form portion where they could talk about, did this affect their ability to take their medicines, or go to doctor visits, things like that? There was. And we actually did a couple of different things. So we both did standardized questionnaires, so we did things like the fact GP, which is looking at multiple facets of patient well-being. We also looked at other health related quality of life issues. We also had developed our own access to health care questionnaire, which was looking at certain things like, were you having problems getting to your appointments? Are you being able to pay for your medications? We did several questions about paying for lab tests, paying for office visits. And then also, we really wanted to make sure that we knew if the reason you were missing these things was because of cost, or if there were other reasons. Because obviously, we don't want to attribute this all to cost if that's not what's causing the harm. OK, yeah. So it sounds like a lot of information gathered. So what did you find? In our study, we had almost 2,000 participants. And we had over a quarter, so 26% agreed or strongly agreed that they had to pay more for medical care than they could afford, which is in line with other studies. I would have thought it might have been higher than that. But it sounds like this is a nice validation that your survey was a pretty accurate instrument, even with such a simple question. Unfortunately, what we found is that when you take this population, the population that tells us that they are having financial toxicity by our definition, what we were finding was much higher rates of noncompliance. And that was a very scary thing when you're talking about cancer patients. Our patients who had reported financial toxicity were much more likely to report needing but unable to afford prescriptions, over-the-counter medications. They were also reporting noncompliance due to cost concerns for medical care like doctor's visits, medical tests, mental health care. All these things for the majority of patients undergoing active chemo is a really scary thing. And there's been some really good research in this area recently. There was a recent study where they were looking at imatinib and CML, and it found that individuals who had copayments greater than $53 a month were 70% more likely to discontinue within six months. So it's real world implications of this concept. Absolutely. And were there any other factors that were associated with financial toxicity, things that you might be able to use to screen or predict for this? In terms of the predictor, we basically validated what it had been thought of before, which is that there were certain factors that seem to be more predictive for exhibiting financial toxicity. The ones that we really know of are age less than 65 years, being non-white race, less education. All of those things had been previously described. It was nice to see with a large population model that we could validate those findings that would have been found in smaller studies. But it does seem that those patients are at much higher risk for financial difficulties. Yeah, and the less than 65 is interesting to me. So I assume that that's probably related to Medicare coverage, that that somehow makes it less of a financial burden. That's what it looks like. And I think that, obviously, Medicare is a nice protection for a lot of our patients over the age of 65, in that they don't see a lot of some of the costs our younger patients, especially our underinsured patients see. However, there was a recent study where individuals with cancer that were insured by Medicare alone were incurring mean out-of-pocket costs that were 1/4 of their household income. So I would say even though they have probably less bills for a lot of those patients, they're on fixed income. There is not other income coming in. So a lot of the folks over the age of 65 are still having financial toxicity even with the better insurance coverage. Did you look at insurance coverage in this? Was that a variable in the analysis? It was not. It was one of those things that when you go back and you wish you would have done it at the time. We felt like we had covered every single base. And it actually was a thing where we thought we were going to be able to pull that data from a database. But ultimately, we were unable to do it. It's now built into every model going forward. But we unfortunately did not have that data. So you did a great job of identifying these patients and all the consequences of the financial toxicity. So what are we to take from this? Presumably, the idea would be to try to figure out a way to intervene on these patients. So what can we do? Yeah, I think that, I mean, obviously, the first step is to identify the problem. And I think that that's always an issue. There's been multiple surveys of oncologists who feel it feels very wrong to discuss costs with patients. I think that we get very wrapped up in the science. And we have the latest and greatest drug that we just know is going to work. But obviously, drugs are getting more expensive plus all the treatment time and coming to and from the hospital, and basically outpatient versus inpatient chemotherapy. All these things need to be thought of when you're thinking about your treatment plans. Having said that, once identified, if you're screening your patients for this, there are specific areas it seems like we can intervene. In our study, what we found was there were pretty interveneable reasons people were saying that they were having problems with their care. They include things like not having transportation, a lack of insurance, the inability to pay for travel. They can't take time off work. They don't have child care. These are things that are specific issues that they're having, that with foundational support, with local and community support, you can usually intervene on. But you really do need to identify them. I know our group and the group out in Washington has done some research in the use of trained financial navigators to help patients. And that group in Washington has shown fantastic results saving a lot of money annually for these patients. And in our group, we've also done things like treatment plans based on where you live. So can we get you treatment close to home? And if not, how can we get ride share? How can we get gas cards? Can we do things to help you? And then also, I mean, again, there are actually a decent amount of foundational money out there if you're looking for it. There are groups out there that are there to help. But again, like I said, a lot of times, we just miss the problem. Yeah. I mean, I know that I feel vastly unqualified to discuss costs of care with my patients. Oftentimes, I really don't even have a good idea of how much things cost. But it sounds like there ought to be a way to screen patients right up front beyond simply what their level of insurance is to see if they might benefit from these extra services. And then it's important for cancer centers to have these kind of interventions to be able to help provide with transport and identify patients who would benefit from that foundational help. So I don't know how broadly available those kinds of services. I know we have them there. And your cancer center is actually run by our old boss, who used to run our cancer center, Dr. Raghavan. So I'm not surprised that you might have those as well. Is this something that is broadly available in oncology offices throughout the country? It's not. I mean, honestly, it is not. And one of the things that I'm kind of one of my big pushes in terms of the research is that I think that everyone has their own issue that they're very passionate about. And I think that we could survey patients until the cows come home about different issues and try to identify patients at risk. And so one of things we've really tried to do is a couple of things. Number one is to identify specific questions, especially in this case and some of our other studies, one or two question surveys where we can identify patients that are at very high risk for having these difficulties and identify that subset of population. And then one of the things that we're actually also working on in association with a couple other foundations and a couple of national organizations is we are actually hoping at some point to be able to start to roll out telemedicine, tele financial counseling basically and internet and other programs. There's a pilot going on in Boston right now. There's another program we're going to be rolling out here in January, where we are trying to intervene on the problem even just from financial planning standpoint. There's a large amount of patients who it doesn't matter where you are in terms of your financial situation, financial planning is incredibly important. You could have a lot of money in the bank and good insurance, and then you get hit with a cancer diagnosis. And you're trying to figure out what you're going to do with your assets, versus a lot of our patients, which are you now can't work. And there's no money coming in. How are the bills going to be paid? How are you going to basic budget? Again, I think this is going to resonate with everyone who treats cancer, no matter where you are. Because a big segment of our patients really struggle with this. And while it might not be immediately visible, if you dig down a little bit, it's not hard to find. Well, Greg, thanks so much for talking to me today. Thank you. And I also want to thank all our listeners out there who joined us for this podcast. The full text of the paper is available online now at ASCOpubs.org/journal/jop in the November 2018 issue. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.
Dec 21 2018
Rank #19: What Should the Role of Radiation Oncologists Be in the Future?
Dr. Pennell and Dr. Neha Vapiwala discuss the role of radiation oncologists be in the future.
Feb 22 2018
Rank #20: Cost and Survival Analysis before and after Implementation of Dana-Farber Clinical Pathways for Patients with Stage IV Non-Small Cell Lung Cancer
Dr. David Jackman of Dana-Farber Cancer Institute discusses how after introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly with no compromise in survival.
Mar 04 2017