Does site-of-care for oncology infusion therapy influence treatment patterns, cost, and quality in the United States?

BACKGROUND: The increase in hospital acquisition of community oncology clinics in the US has led to a shift in the site-of-care (SOC) for infusion therapy from the physician office (PO) to the hospital outpatient (HO) setting. OBJECTIVE: To investigate differences by SOC in treatment patterns, quality, and cost among patients with cancer undergoing first-line infusion therapy. RESEARCH DESIGN AND METHODS: This retrospective analysis identified adult patients from Humana medical claims who initiated infusion therapy from 2008-2012 for five common cancer types in which infusion therapy is likely, including early stage breast cancer; metastatic breast, lung, and colorectal cancers; and non-Hodgkin's lymphoma or chronic lymphocytic leukemia. Differences by SOC in first-line treatment patterns and quality of care at end-of-life, defined as infusions or hospitalizations 30 days prior to death, were evaluated using Wilcoxon-Rank Sum and Chi-square tests where appropriate. Differences in cost by SOC were evaluated using risk-adjusted generalized linear models. MAIN OUTCOME MEASURES: Treatment patterns, quality of care at end of life, healthcare costs. RESULTS: There were differences in duration of therapy and number of infusions for some therapy regimens by SOC, in which patients in the HO had shorter duration of therapy and fewer infusions. There were no differences in quality of care at end-of-life by SOC. Total healthcare costs were 15% higher among patients in HO ($55,965) compared with PO ($48,439), p < .0001. LIMITATIONS: Analyses was restricted to a claims-based population of cancer patients within a health plan. CONCLUSION: This study, in an older, predominantly Medicare Advantage oncology cohort, found differences by SOC in treatment patterns and cost, but not quality. Where differences were found, patients receiving care in the HO had shorter duration of therapy and fewer infusions for specific treatment regimens, but higher healthcare costs than those treated in a PO.

Tools for Communication: Novel infrastructure to address patient-perceived gaps in oncology care
.

BACKGROUND: Healthcare providers (HCPs) and patient communication are integral to high-quality oncology care. The patient and HCP perspectives are needed to identify gaps in care and develop communication tools.
. OBJECTIVES: This study aimed to understand patient- and HCP-perceived elements of and gaps in high-quality care to develop novel communication tools to improve care. 
. METHODS: Qualitative interviews were conducted among 16 patients with cancer and 10 HCPs in the United States. Trained interviewers elicited patients' and HCPs' concerns, views, and perceived needs for communication tools. A thematic analysis was used to identify four quality of care domains, depicted in a conceptual model, and two draft communication tools were developed to address identified gaps.
. FINDINGS: No patients reported previously using a communication tool, and gaps in communication regarding treatment aims and education were evident. Two tools were developed to assess patients' life and treatment goals and the importance of ongoing education.

Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient's Breast Cancer Care Initiation.

Radiologists aspire to improve patient experience and engagement, as part of the Triple Aim of health reform. Patient engagement requires active partnerships among health providers and patients, and rigorous teamwork provides a mechanism for this. Patient and care team engagement are crucial at the time of cancer diagnosis and care initiation but are complicated by the necessity to orchestrate many interdependent consultations and care events in a short time. Radiology often serves as the patient entry point into the cancer care system, especially for breast cancer. It is uniquely positioned to play the value-adding role of facilitating patient and team engagement during cancer care initiation. The 4R approach (Right Information and Right Care to the Right Patient at the Right Time), previously proposed for optimizing teamwork and care delivery during cancer treatment, could be applied at the time of diagnosis. The 4R approach considers care for every patient with cancer as a project, using project management to plan and manage care interdependencies, assign clear responsibilities, and designate a quarterback function. The authors propose that radiology assume the quarterback function during breast cancer care initiation, developing the care initiation sequence, as a project care plan for newly diagnosed patients, and engaging patients and their care teams in timely, coordinated activities. After initial consultations and treatment plan development, the quarterback function is transitioned to surgery or medical oncology. This model provides radiologists with opportunities to offer value-added services and solidifies radiology's relevance in the evolving health care environment. To implement 4R at cancer care initiation, it will be necessary to change the radiology practice model to incorporate patient interaction and teamwork, develop 4R content and local adaption approaches, and enrich radiology training with relevant clinical knowledge, patient interaction competence, and teamwork skill set.

Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery.

Cancer care is highly complex and suffers from fragmentation and lack of coordination across provider specialties and clinical domains. As a result, patients often find that they must coordinate care on their own. Coordinated delivery teams may address these challenges and improve quality of cancer care. Task interdependence is a core principle of rigorous teamwork and is essential to addressing the complexity of cancer care, which is highly interdependent across specialties and modalities. We examined challenges faced by a patient with early-stage breast cancer that resulted from difficulties in understanding and managing task interdependence across clinical domains involved in this patient's care. We used team science supported by the project management discipline to discuss how various task interdependence aspects can be recognized, deliberately designed, and systematically managed to prevent care breakdowns. This case highlights how effective task interdependence management facilitated by project management methods could markedly improve the course of a patient's care. This work informs efforts of cancer centers and practices to redesign cancer care delivery through innovative, practical, and patient-centered approaches to management of task interdependence in cancer care. Future patient-reported outcomes research will help to determine optimal ways to engage patients, including those who are medically underserved, in managing task interdependence in their own care.

The value of colonoscopic colorectal cancer screening of adults aged 50 to 64.

OBJECTIVES: The purpose of this study was to determine the value of life-years saved due to colorectal cancer (CRC) screening with colonoscopy for the population aged 50 to 64 years. The cost perspective is that of a private (commercial) insurer, while the value perspective includes survival past age 65 years, when most of the US population is insured by Medicare. We focused on colonoscopy because it is not only diagnostic but also therapeutic; because positive results on other screening tests generally are followed up with colonoscopy; and to build on previous study results that colonoscopy is ultimately more cost-effective than other screening, even considering its expense. STUDY DESIGN: Monte Carlo simulation. METHODS: Using a large multi-state cancer registry, a large national administrative claims database, and a model of CRC development based on published clinical literature, we estimated the impact of screening with colonoscopy on incidence of CRC, aggregate cost of colonoscopies and CRC, and life-years saved. RESULTS: Assuming 2013 commercial reimbursement rates for screening and treatment, we found that increasing screening adherence from 50% to 100% would cost about $3 per member per month (2013 US$) and reduce CRC treatment costs by about $1 per member per month. The cost per life-year saved is approximately $12,000, an amount that is much lower than for cervical or breast cancer screening and comparable to lung cancer screening. CONCLUSIONS: Our results suggest that commercial insurers and employers should promote CRC screening as a high-value service. Promoting such screening through high-quality, low-cost providers would be an exemplar of efficient system innovation.

Service setting impact on costs for bevacizumab-treated oncology patients.

OBJECTIVES: To investigate treatment patterns and healthcare costs of patients with metastatic colorectal cancer (mCRC) or lung cancer (LC) who were treated with bevacizumab in a physician office (OFF) setting versus a hospital outpatient (HOP) setting. STUDY DESIGN: Retrospective analysis of claims from a national US health plan. METHODS: mCRC and LC patients initiating treatment with bevacizumab (index date) between January 1, 2006, and July 31, 2012, were identified. Patients were aged ≥18 years with ≥6-month pre- (baseline) and ≥6-month post index (follow-up) data, retaining patients who died with <6 months of follow-up. Differences by site of service were analyzed by χ2 and t test (bevacizumab administrations, dose) and general linear model adjusted for demographic and clinical characteristics (all-cause healthcare costs). RESULTS: A total of 1687 mCRC (OFF: 1292; HOP: 395) and 1232 LC patients (OFF: 983; HOP: 249) were identified. Mean age was 61.3 years, 56.3% were male, and 78% were treated in OFF. Treatment in OFF declined from 2006 (84% of patients) to 2012 (61%). For OFF versus HOP, mean length of treatment (208.3 vs 191.0 days; P=.007), number of bevacizumab administrations per month (1.4 vs 1.1; P<.001), and mean weekly dose (eg, for 2012, 4.34 vs 3.11 mg/kg, P<.05) were higher in OFF. Adjusted monthly HOP costs (vs OFF) were higher by 37.8% for mCRC patients (cost ratio=1.378; 95% CI, 1.282-1.482) and 31.1% for LC patients (cost ratio=1.311; 95% CI, 1.204-1.427) CONCLUSIONS: Despite fewer administrations and lower weekly dose of bevacizumab in HOP, adjusted total costs were 31% to 38% higher for mCRC and LC patients treated in the HOP setting.

Oncology comparative effectiveness research: a multistakeholder perspective on principles for conduct and reporting.

Comparative effectiveness research (CER) can assist patients, clinicians, purchasers, and policy makers in making more informed decisions that will improve cancer care and outcomes. Despite its promise, the factors that distinguish CER from other types of evidence remain mysterious to many oncologists. One concern is whether CER studies will improve decision making in oncology or only add to the massive amount of research information that decision makers must sift through as part of their professional responsibilities. In this report, we highlight several issues that distinguish CER from the most common way evidence is generated for cancer therapy-phase I-III clinical trials. To identify the issues that are most relevant to busy decision makers, we assembled a panel of active professionals with a wide range of roles in cancer care delivery. This panel identified five themes that they considered most important for CER in oncology, as well as fundamental threats to the validity of individual CER studies-threats they termed the "kiss of death" for their applicability to practice. In discussing these concepts, we also touched upon the notion of whether cancer is special among health issues with regard to how evidence is generated and used.