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1.
BMC Health Serv Res ; 22(1): 538, 2022 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-35459238

RESUMO

BACKGROUND: Symptoms in patients with advanced cancer are often inadequately captured during encounters with the healthcare team. Emerging evidence demonstrates that weekly electronic home-based patient-reported symptom monitoring with automated alerts to clinicians reduces healthcare utilization, improves health-related quality of life, and lengthens survival. However, oncology practices have lagged in adopting remote symptom monitoring into routine practice, where specific patient populations may have unique barriers. One approach to overcoming barriers is utilizing resources from value-based payment models, such as patient navigators who are ideally positioned to assume a leadership role in remote symptom monitoring implementation. This implementation approach has not been tested in standard of care, and thus optimal implementation strategies are needed for large-scale roll-out. METHODS: This hybrid type 2 study design evaluates the implementation and effectiveness of remote symptom monitoring for all patients and for diverse populations in two Southern academic medical centers from 2021 to 2026. This study will utilize a pragmatic approach, evaluating real-world data collected during routine care for quantitative implementation and patient outcomes. The Consolidated Framework for Implementation Research (CFIR) will be used to conduct a qualitative evaluation at key time points to assess barriers and facilitators, implementation strategies, fidelity to implementation strategies, and perceived utility of these strategies. We will use a mixed-methods approach for data interpretation to finalize a formal implementation blueprint. DISCUSSION: This pragmatic evaluation of real-world implementation of remote symptom monitoring will generate a blueprint for future efforts to scale interventions across health systems with diverse patient populations within value-based healthcare models. TRIAL REGISTRATION: NCT04809740 ; date of registration 3/22/2021.


Assuntos
Neoplasias , Qualidade de Vida , Atenção à Saúde , Humanos , Neoplasias/terapia , Projetos de Pesquisa
2.
Cancer ; 127(3): 449-457, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33108023

RESUMO

BACKGROUND: The objective of the current study was to understand treatment preferences and their association with financial toxicity in Patient Advocate Foundation clients with breast cancer. METHODS: This choice-based conjoint analysis used data from a nationwide sample of women with breast cancer who received assistance from the Patient Advocate Foundation. Choice sets created from 13 attributes of 3 levels each elicited patient preferences and trade-offs. Latent class analysis segmented respondents into distinct preference archetypes. The Comprehensive Score for Financial Toxicity (COST) tool captured financial toxicity. Adjusted generalized linear models estimated COST score differences by preference archetype. RESULTS: Of 220 respondents (for a response rate of 10%), the median age was 58 years (interquartile range, 49-66 years); 28% of respondents were Black, indigenous, or people of color; and approximately 60% had household incomes <$40,000. The majority of respondents were diagnosed with early-stage cancer (91%), 38% had recurrent disease, and 61% were receiving treatment. Treatment choice was most affected by preferences related to affordability and impact on activities of daily living. Two distinct treatment preference archetypes emerged. The "cost-prioritizing group" (75% of respondents) was most concerned about affordability, impact on activities of daily living, and burdening care partners. The "functional independence-prioritizing group" (25% of respondents) was most concerned about their ability to work, physical side effects, and interference with life events. COST scores were found to be similar between the archetypes in adjusted models (cost-prioritizing group COST score, 12 [95% confidence interval, 9-14]; and functional independence-prioritizing COST score, 11 [95% confidence interval, 9-13]). CONCLUSIONS: Patients with breast cancer prioritized affordability or maintaining functional independence when making treatment decisions. Because of this variability, preference evaluation during treatment decision making could optimize patients' treatment experiences.


Assuntos
Neoplasias da Mama/terapia , Preferência do Paciente , Atividades Cotidianas , Idoso , Neoplasias da Mama/economia , Efeitos Psicossociais da Doença , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade
3.
Clin Breast Cancer ; 21(1): 37-46, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32741667

RESUMO

INTRODUCTION: Oncologists have increasingly been proponents of shared decision making (SDM) to enhance patient outcomes and reduce unnecessary health care spending. However, its effect on patient out-of-pocket costs is unknown. This study investigated the relationship between patient preferences for SDM and financial toxicity (FT) in patients with metastatic breast cancer (MBC). PATIENTS AND METHODS: This cross-sectional study utilized surveys of women aged ≥ 18 with MBC who received care at two academic hospitals in Alabama from 2017 to 2019. Patients self-reported their SDM preference (Control Preferences Scale) and FT (Comprehensive Score for Financial Toxicity [COST] tool; 11-item scale, with lower scores indicating worse FT). Effect sizes were calculated using the proportion of variance explained (R2) or Cramer's V. Differences in FT by SDM preference were estimated using mixed models clustered by site and treating medical oncologist. RESULTS: In 95 women with MBC, 44% preferred SDM, 29% preferred provider-driven decision making, and 27% preferred patient-driven decision making. Patients preferring SDM were more often college educated (53% vs. 39%; V = 0.12) with an income greater than $40,000/y (55% vs. 43%; V = 0.18). Overall median COST was 22 (interquartile range, 16-29). After adjusting for patient demographic and clinical characteristics, patients preferring patient-driven decision making trended toward worse FT (COST 17: 95% confidence interval, 12-22) compared to those preferring SDM (COST 19: 95% confidence interval, 15-23) and those preferring provider-driven decision making (COST 22: 95% confidence interval, 17-27). CONCLUSION: Patients preferring more patient-driven decision making reported worse FT, although differences did not reach statistical significance. Further research is needed to understand this relationship.


Assuntos
Neoplasias da Mama/terapia , Tomada de Decisão Compartilhada , Participação do Paciente/estatística & dados numéricos , Preferência do Paciente/estatística & dados numéricos , Relações Médico-Paciente , Adulto , Idoso , Neoplasias da Mama/psicologia , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Oncologistas/estatística & dados numéricos , Participação do Paciente/psicologia , Preferência do Paciente/psicologia
4.
Cancer Med ; 9(22): 8423-8431, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32955793

RESUMO

BACKGROUND: Burdens related to time spent receiving cancer care may be substantial for patients with incurable, life-limiting cancers such as metastatic breast cancer (MBC). Estimates of time spent on health care are needed to inform treatment-related decision-making. METHODS: Estimates of time spent receiving cancer-related health care in the initial 3 months of treatment for patients with MBC were calculated using the following data sources: (a) direct observations from a time-in-motion quality improvement evaluation (process mapping); (b) cross-sectional patient surveys; and (c) administrative claims. Average ambulatory, inpatient, and total health care time were calculated for specific treatments which differed by antineoplastic type and administration method, including fulvestrant (injection, hormonal), letrozole (oral, hormonal), capecitabine (oral, chemotherapy), and paclitaxel (infusion, chemotherapy). RESULTS: Average total time spent on health care ranged from 7% to 10% of all days included within the initial 3 months of treatment, depending on treatment. The greatest time contributions were time spent traveling for care and on inpatient services. Time with providers contributed modestly to total care time. Patients receiving infusion/injection treatments, compared with those receiving oral therapy, spent more time in ambulatory care. Health care time was higher for patients receiving chemotherapeutic agents compared to those receiving hormonal agents. CONCLUSION: Time spent traveling and receiving inpatient care represented a substantial burden to patients with MBC, with variation in time by treatment type and administration method.


Assuntos
Antineoplásicos/administração & dosagem , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/economia , Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Idoso , Antineoplásicos/efeitos adversos , Neoplasias da Mama/patologia , Estudos Transversais , Bases de Dados Factuais , Feminino , Estresse Financeiro/economia , Gastos em Saúde , Custos Hospitalares , Humanos , Pacientes Internados , Pessoa de Meia-Idade , Metástase Neoplásica , Serviço Hospitalar de Oncologia/economia , Estudos Prospectivos , Qualidade de Vida , Programa de SEER , Fatores de Tempo , Transporte de Pacientes/economia
5.
J Geriatr Oncol ; 10(5): 787-791, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30857937

RESUMO

BACKGROUND: Understanding factors that impact patient satisfaction with cancer care within the growing population of older adults living with cancer will contribute to tailoring programs that address patient needs and expectations. Further, patient satisfaction is a determinant of healthcare organizations' institutional performance. The purpose of this study was to investigate the relationship between patient satisfaction with care and health-related quality of life (HRQoL) among Medicare recipients with common cancers types (breast, prostate, or lung cancer). METHODS: Cross-sectional analysis of survey data from 637 Medicare beneficiaries (≥65 years) with breast (n = 304), lung (n = 158), or prostate cancer (n = 175) in twelve hospitals in the Southeastern United States. Participants responded eighteen satisfaction questions across five domains. HRQoL was measured with the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the SF-12.v2 instrument. RESULTS: SF-12 scores were positively associated with satisfaction domain scores. The magnitude of these associations was small with covariate-adjusted effect sizes r ranging from 0.05 to 0.12. Satisfaction scores were highest within the Quality of Care domain and lowest within the Patient Engagement domain. CONCLUSIONS: Patient satisfaction domains had only modest association with HRQoL, indicating that these constructs should not be assumed to correlate. Satisfaction domains, including how patients access care, coordinate care, and engage within the healthcare system, were identified as potential areas for improvement. Patient satisfaction assessment across age groups may inform oncology care providers on ways in which their patients perceive the quality of care received, which ultimately affect healthcare organizations' accreditation, ranking, and reimbursement.


Assuntos
Neoplasias/terapia , Participação do Paciente , Satisfação do Paciente , Qualidade da Assistência à Saúde , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/fisiopatologia , Neoplasias da Mama/psicologia , Neoplasias da Mama/terapia , Estudos Transversais , Feminino , Humanos , Neoplasias Pulmonares/fisiopatologia , Neoplasias Pulmonares/psicologia , Neoplasias Pulmonares/terapia , Masculino , Medicare , Neoplasias/fisiopatologia , Neoplasias/psicologia , Neoplasias da Próstata/fisiopatologia , Neoplasias da Próstata/psicologia , Neoplasias da Próstata/terapia , Sudeste dos Estados Unidos , Estados Unidos
6.
Oncologist ; 24(1): 31-37, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30120157

RESUMO

BACKGROUND: National Comprehensive Cancer Network (NCCN) guideline-based treatment is a marker of high-quality care. The impact of guideline discordance on cost and health care utilization is unclear. MATERIALS AND METHODS: This retrospective cohort study of Medicare claims data from 2012 to 2015 included women age ≥65 with stage I-III breast cancer receiving care within the University of Alabama at Birmingham Cancer Community Network. Concordance with NCCN guidelines was assessed for treatment regimens. Costs to Medicare and health care utilization were identified from start of cancer treatment until death or available follow-up. Adjusted monthly cost and utilization rates were estimated using linear mixed effect and generalized linear models. RESULTS: Of 1,177 patients, 16% received guideline-discordant treatment, which was associated with nonwhite race, estrogen receptor/progesterone receptor negative, human epidermal growth receptor 2 (HER2) positive, and later-stage cancer. Discordant therapy was primarily related to reduced-intensity treatments (single-agent chemotherapy, HER2-targeted therapy without chemotherapy, bevacizumab without chemotherapy, platinum combinations without anthracyclines). In adjusted models, average monthly costs for guideline-discordant patients were $936 higher compared with concordant (95% confidence limits $611, $1,260). For guideline-discordant patients, adjusted rates of emergency department visits and hospitalizations per thousand observations were 25% higher (49.9 vs. 39.9) and 19% higher (24.0 vs. 20.1) per month than concordant patients, respectively. CONCLUSION: One in six patients with early-stage breast cancer received guideline-discordant care, predominantly related to undertreatment, which was associated with higher costs and rates of health care utilization. Additional randomized trials are needed to test lower-toxicity regimens and guide clinicians in treatment for older breast cancer patients. IMPLICATIONS FOR PRACTICE: Previous studies lack details about types of deviations from chemotherapy guidelines that occur in older early-stage breast cancer patients. Understanding the patterns of guideline discordance and its impact on patient outcomes will be particularly important for these patients. This study found 16% received guideline-discordant care, predominantly related to reduced intensity treatment and associated with higher costs and rates of health care utilization. Increasing older adult participation in clinical trials should be a priority in order to fill the knowledge gap about how to treat older, less fit patients with breast cancer.


Assuntos
Neoplasias da Mama/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Estadiamento de Neoplasias , Estudos Retrospectivos
7.
Cancer ; 124(21): 4231-4240, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30317547

RESUMO

BACKGROUND: The impact of National Comprehensive Cancer Network (NCCN) treatment guideline concordance on costs, health care utilization, and mortality for patients with breast cancer and secondary metastases is unknown. METHODS: From 2007 to 2013, women with early-stage breast cancer who received treatment for secondary metastases (n = 5651) were evaluated for first recorded systemic therapy concordance with NCCN guidelines within the Surveillance, Epidemiology, and End Results Program-Medicare linked database. Generalized linear and mixed effects models evaluated factors associated with nonconcordance and the relation between concordance status and health care utilization and costs. Mortality risk was estimated with Cox regression. RESULTS: Eighteen percent of the patients received nonconcordant therapy, with the most common being single-agent, human epidermal growth factor receptor 2 (HER2)-targeted therapy (36%), therapy mismatched with the estrogen receptor/HER2 status (11%), unapproved bevacizumab regimens (10%), and adjuvant regimens in a metastatic setting (6%). A younger age, a hormone receptor-negative status, and a HER2-positive status were associated with nonconcordance (P < .05). Nonconcordance was associated with 22% and 21% increased rates of emergency department visits and hospitalizations, respectively, and $1765 higher average monthly Medicare costs. Differences in adjusted mortality risk were noted by the category of nonconcordance; single-agent, HER2-targeted therapy was associated with decreased mortality risk (hazard ratio [HR], 0.66; 95% confidence limit [CL], 0.57-0.76), and increased mortality risk was observed with unapproved bevacizumab use (HR, 1.40; 95% CL, 1.13-1.74). CONCLUSIONS: Most patients (82%) received treatment consistent with NCCN guidelines. Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation. Consideration of both patient and financial outcomes will be important as health systems increase the emphasis on guideline-based care.


Assuntos
Neoplasias da Mama/economia , Neoplasias da Mama/mortalidade , Neoplasias da Mama/terapia , Fidelidade a Diretrizes/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Oncologia/normas , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Redes Comunitárias/organização & administração , Redes Comunitárias/normas , Assistência Integral à Saúde/organização & administração , Assistência Integral à Saúde/normas , Feminino , Fidelidade a Diretrizes/economia , Humanos , Revisão da Utilização de Seguros , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Metástase Neoplásica , Guias de Prática Clínica como Assunto , Programa de SEER , Sociedades Médicas/normas , Estados Unidos/epidemiologia
8.
J Natl Compr Canc Netw ; 16(9): 1084-1091, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30181420

RESUMO

Background: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) have directed the care of patients with cancer for >20 years. Payers are implementing guideline-based pathway programs that restrict reimbursement for non-guideline-based care to control costs, yet evidence regarding impact of guidelines on outcomes, including mortality, Medicare costs, and healthcare utilization, is limited. Patients and Methods: This analysis evaluated concordance of first treatment with NCCN Guidelines for women with de novo stage IV metastatic breast cancer (MBC) included within the SEER-Medicare linked database and diagnosed between 2007 and 2013. Cox proportional hazards models were used to evaluate the association between mortality and guideline concordance. Linear mixed-effects and generalized linear models were used to evaluate total cost to Medicare and rates of healthcare utilization by concordance status. Results: We found that 19% of patients (188/988) with de novo MBC received nonconcordant treatment. Patients receiving nonconcordant treatment were more likely to be younger and have hormone receptor-negative and HER2-positive MBC. The most common category of nonconcordant treatment was use of adjuvant regimens in the metastatic setting (40%). Adjusted mortality risk was similar for patients receiving concordant and nonconcordant treatments (hazard ratio [HR], 0.85; 95% confidence limit [CL], 0.69, 1.05). When considering category of nonconcordance, patients receiving adjuvant regimens in the metastatic setting had a decreased risk of mortality (HR, 0.60; 95% CL, 0.43, 0.84). Nonconcordant treatments were associated with $1,867 higher average Medicare costs per month compared with concordant treatments (95% CL, $918, $2,817). Single-agent HER2-targeted therapy was the highest costing category of nonconcordance at $3,008 (95% CL, $1,014, $5,001). Healthcare utilization rates were similar for patients receiving concordant and nonconcordant treatments. Conclusions: Despite a lack of survival benefit, concordant care was associated with lower costs, suggesting potential benefit to increasing standardization of care. These findings may influence policy decisions regarding implementation of pathway programs as health systems transition to value-based models.


Assuntos
Neoplasias da Mama/terapia , Fidelidade a Diretrizes/estatística & dados numéricos , Custos de Cuidados de Saúde/normas , Medicare/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Neoplasias da Mama/mortalidade , Quimioterapia Adjuvante/economia , Quimioterapia Adjuvante/normas , Quimioterapia Adjuvante/estatística & dados numéricos , Utilização de Equipamentos e Suprimentos/economia , Utilização de Equipamentos e Suprimentos/normas , Utilização de Equipamentos e Suprimentos/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Mastectomia/economia , Mastectomia/normas , Oncologia/normas , Medicare/economia , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Programa de SEER/estatística & dados numéricos , Sociedades Médicas/normas , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos
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