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Kolodziej MA, Klein I. Private Payers and Cancer Care: Revisiting the Land of Opportunity. JCO Oncol Pract 2024; 20:318-322. [PMID: 38181309 DOI: 10.1200/op.23.00632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 01/07/2024] Open
Abstract
Ten years ago we charted a course for oncology payment reform. We summarize what went wrong and propose ways to fix it.
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Aucoin M, Newton G, Leach M, Cooley K. Co-Design of an Evidence-Based Practice Continuing Education Course for Canadian Naturopathic Doctors. J Integr Complement Med 2023; 29:592-601. [PMID: 37093154 DOI: 10.1089/jicm.2022.0730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Objectives: Evidence-based practice (EBP) is a clinical decision-making process combining the best available scientific evidence with clinician expertise and patient preference. While EBP has been associated with a range of benefits, it is recognized that EBP is used suboptimally by a range of health professionals, including naturopathic doctors (NDs). Canadian NDs have expressed a high level of interest in opportunities to improve their EBP skills; however, barriers exist, including those that apply broadly to health professionals, and those that are unique to the naturopathic profession. The objective of the present project was to co-design an EBP continuing education (CE) course tailored to the needs and preferences of Canadian NDs. Design: These needs were solicited through the use of focus groups. Groups were stratified based on participants' use of evidence at baseline. The focus groups asked NDs about their definition of EBP, and their interest in an EBP course, including preferred content, and method of delivery. The focus group discussions were transcribed, and thematic analysis was completed. Subjects: Twenty-two Canadian NDs participated. Results: Participants reported a high level of understanding of EBP, a high level of interest in participating in an EBP course and provided actionable recommendations about course content and delivery. Some of the themes that emerged were consistent across the groups while others differed by stratification. Conclusions: The findings of this project will inform the development and evaluation of a future CE course.
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Affiliation(s)
- Monique Aucoin
- Canadian College of Naturopathic Medicine, Toronto, Canada
- University of Guelph, Guelph, Canada
| | | | | | - Kieran Cooley
- Canadian College of Naturopathic Medicine, Toronto, Canada
- Southern Cross University, Lismore, Australia
- University of Technology Sydney, Ultimo, Australia
- Pacific College of Health and Science, Chicago, IL, USA
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Liu Y, Mullangi S, Debono D, Chen X, Pham T, Fisch MJ, Gordon AS, Hershman DL. Association Between Oncology Clinical Pathway Utilization and Toxicity and Cost Outcomes in Patients With Metastatic Solid Tumors. JCO Oncol Pract 2023; 19:731-740. [PMID: 37384847 DOI: 10.1200/op.23.00199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/05/2023] [Accepted: 05/17/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE This retrospective observational study compared cancer care toxicity and cost outcomes for patients with metastatic cancer with nine different cancer types prescribed on- versus off-pathway regimens. METHODS This study used claims and authorization data from a national insurer between January 1, 2018, and October 31, 2021. Participants included adults with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, or uterine cancer, who were prescribed first-line anticancer regimens. Multivariable regressions were used to assess outcomes including counts of emergency room visits or hospitalizations, use of supportive care medications, immune-related adverse events (IRAEs), and health care costs. RESULTS Of the 8,357 patients in the study, 5,453 (65.3%) were prescribed on-pathway regimens. The on-pathway proportion trended downward, from 74.3% in 2018 to 59.8% in 2021. The on- and off-pathway groups had a similar proportion of patients with treatment-related hospitalization (adjusted odds ratio [aOR], 1.080; P = .201) and IRAEs (aOR, 0.961; P = .497). More all-cause hospitalizations (aOR, 1.679; P = .013) were observed among patients with melanoma treated on-pathway. The on-pathway group had higher use of supportive care drugs in bladder cancer (aOR, 4.602; P < .001) and colorectal cancer (aOR, 4.465; P < .001), and lower use in breast (aOR, 0.668; P = .001) and lung cancer (aOR, 0.550; P < .001). On average, on-pathway patients incurred $17,589 less total health care cost (P < .001), and $22,543 lower chemotherapy cost (P < .001) than those from the off-pathway group. CONCLUSION Our findings suggest that use of on-pathway regimens was associated with significant cost savings. Toxicity outcomes were variable by disease, but overall, there were similar numbers of treatment-related hospitalizations and IRAEs compared to off-pathway regimens. This cross-institutional study provides evidence to support the use of clinical pathway regimens for patients with metastatic cancer.
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Affiliation(s)
- Ying Liu
- Elevance Health, Inc, Indianapolis, IN
| | - Samyukta Mullangi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Xiaoxue Chen
- Elevance Health, Inc, Indianapolis, IN
- EMD Serono, Inc, Boston, MA
| | | | | | | | - Dawn L Hershman
- Department of Medicine, Columbia University Medical Center, New York, NY
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4
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Ellis PM. Evaluating Oncology Clinical Pathways: What Bar Are We Aiming for? JCO Oncol Pract 2023; 19:692-693. [PMID: 37603821 DOI: 10.1200/op.23.00376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/14/2023] [Indexed: 08/23/2023] Open
Abstract
Oncology clinical pathways may result in cost savings, but we need more understanding about patient outcomes and reasons for nonadherence.
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Affiliation(s)
- Peter M Ellis
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
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5
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Ojha RP, Lu Y, Narra K, Meadows RJ, Gehr AW, Mantilla E, Ghabach B. Survival After Implementation of a Decision Support Tool to Facilitate Evidence-Based Cancer Treatment. JCO Clin Cancer Inform 2023; 7:e2300001. [PMID: 37343196 PMCID: PMC10569767 DOI: 10.1200/cci.23.00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE Decision support tools (DSTs) to facilitate evidence-based cancer treatment are increasingly common in care delivery organizations. Implementation of these tools may improve process outcomes, but little is known about effects on patient outcomes such as survival. We aimed to evaluate the effect of implementing a DST for cancer treatment on overall survival (OS) among patients with breast, colorectal, and lung cancer. METHODS We used institutional cancer registry data to identify adults treated for first primary breast, colorectal, or lung cancer between December 2013 and December 2017. Our intervention of interest was implementation of a commercial DST for cancer treatment, and outcome of interest was OS. We emulated a single-arm trial with historical comparison and used a flexible parametric model to estimate standardized 3-year restricted mean survival time (RMST) difference and mortality risk ratio (RR) with 95% confidence limits (CLs). RESULTS Our study population comprised 1,059 patients with cancer (323 breast, 318 colorectal, and 418 lung). Depending on cancer type, median age was 55-60 years, 45%-67% were racial/ethnic minorities, and 49%-69% were uninsured. DST implementation had little effect on survival at 3 years. The largest effect was observed among patients with lung cancer (RMST difference, 1.7 months; 95% CL, -0.26 to 3.7; mortality RR, 0.95; 95% CL, 0.88 to 1.0). Adherence with tool-based treatment recommendations was >70% before and >90% across cancers. CONCLUSION Our results suggest that implementation of a DST for cancer treatment has nominal effect on OS, which may be partially attributable to high adherence with evidence-based treatment recommendations before tool implementation in our setting. Our results raise awareness that improved process outcomes may not translate to improved patient outcomes in some care delivery settings.
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Affiliation(s)
- Rohit P. Ojha
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Yan Lu
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Kalyani Narra
- Oncology and Infusion Center, JPS Health Network, Fort Worth, TX
| | - Rachel J. Meadows
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Aaron W. Gehr
- Center for Epidemiology & Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | | | - Bassam Ghabach
- Oncology and Infusion Center, JPS Health Network, Fort Worth, TX
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Blum TG, Morgan RL, Durieux V, Chorostowska-Wynimko J, Baldwin DR, Boyd J, Faivre-Finn C, Galateau-Salle F, Gamarra F, Grigoriu B, Hardavella G, Hauptmann M, Jakobsen E, Jovanovic D, Knaut P, Massard G, McPhelim J, Meert AP, Milroy R, Muhr R, Mutti L, Paesmans M, Powell P, Putora PM, Rawlinson J, Rich AL, Rigau D, de Ruysscher D, Sculier JP, Schepereel A, Subotic D, Van Schil P, Tonia T, Williams C, Berghmans T. European Respiratory Society guideline on various aspects of quality in lung cancer care. Eur Respir J 2023; 61:13993003.03201-2021. [PMID: 36396145 DOI: 10.1183/13993003.03201-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.
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Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - Bogdan Grigoriu
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Georgia Hardavella
- Department of Respiratory Medicine, King's College Hospital London, London, UK
- Department of Respiratory Medicine and Allergy, King's College London, London, UK
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Erik Jakobsen
- Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Paul Knaut
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg and Department of Thoracic Surgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - John McPhelim
- Lung Cancer Nurse Specialist, Hairmyres Hospital, NHS Lanarkshire, East Kilbride, UK
| | - Anne-Pascale Meert
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Robert Milroy
- Scottish Lung Cancer Forum, Glasgow Royal Infirmary, Glasgow, UK
| | - Riccardo Muhr
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Luciano Mutti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- SHRO/Temple University, Philadelphia, PA, USA
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Paul Martin Putora
- Departments of Radiation Oncology, Kantonsspital St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | - Anna L Rich
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Erasmus Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - Jean-Paul Sculier
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Schepereel
- Pulmonary and Thoracic Oncology, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Thierry Berghmans
- Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
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Bosserman LD, Mambetsariev I, Ladbury C, Barzi A, Johnson D, Morse D, Deaville D, Smith W, Rajurkar S, Merla A, Hajjar G, Kim D, Fricke J, Trisal V, Salgia R. Pyramidal Decision Support Framework Leverages Subspecialty Expertise across Enterprise to Achieve Superior Cancer Outcomes and Personalized, Precision Care Plans. J Clin Med 2022; 11:jcm11226738. [PMID: 36431215 PMCID: PMC9697355 DOI: 10.3390/jcm11226738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
The complexity of cancer care requires integrated and continuous support to deliver appropriate care. An expert network with complementary expertise and the capability of multidisciplinary care is an integral part of contemporary oncology care. Appropriate infrastructure is necessary to empower this network to deliver personalized precision care to their patients. Providing decision support as cancer care becomes exponentially more complex with new diagnostic and therapeutic choices remains challenging. City of Hope has developed a Pyramidal Decision Support Framework to address these challenges, which were exacerbated by the COVID pandemic, health plan restrictions, and growing geographic site diversity. Optimizing efficient and targeted decision support backed by multidisciplinary cancer expertise can improve individual patient treatment plans to achieve improved care and survival wherever patients are treated.
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Affiliation(s)
- Linda D. Bosserman
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Isa Mambetsariev
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA
| | - Afsaneh Barzi
- Department of Medical Oncology and Therapeutics Research, City of Hope, Irwindale, CA 91706, USA
| | - Deron Johnson
- Department of Clinical Informatics, City of Hope, Duarte, CA 91010, USA
| | - Denise Morse
- Department of Quality, Risk and Regulatory Management, City of Hope, Duarte, CA 91010, USA
| | - Debbie Deaville
- Department of Enterprise Business Intelligence, City of Hope, Irwindale, CA 91706, USA
| | - Wade Smith
- Department of Medical Oncology and Therapeutics Research, City of Hope, Newport Beach, CA 92660, USA
| | - Swapnil Rajurkar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Upland, CA 91784, USA
| | - Amartej Merla
- Department of Medical Oncology and Therapeutics Research, City of Hope, Antelope Valley, CA 93534, USA
| | - George Hajjar
- Department of Medical Oncology and Therapeutics Research, City of Hope, Mission Hills, CA 91345, USA
| | - Daniel Kim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Jeremy Fricke
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
| | - Vijay Trisal
- Department of Medicine, City of Hope, Duarte, CA 91010, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
- Correspondence:
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Dreyer TRF, Hamilton E, Dahl A, Desai B, Kircher S, Polite B, Schroeder C, Fukui M, Hayes-Lattin B, Horvath KA. Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model. JCO Oncol Pract 2022; 18:e1899-e1907. [PMID: 36252153 DOI: 10.1200/op.22.00211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is the largest value-based care model focusing on oncology, but the current pricing methodology excludes relevant data on the cancer stage and current clinical status, limiting the precision of the risk adjustment. METHODS This analysis evaluated 15,580 episodes of breast cancer, lung cancer, and multiple myeloma, starting between July 1, 2016, and January 1, 2020, with data from a cohort of OCM practices affiliated with academic medical centers. The authors merged clinical data with claims for OCM episodes defined by the Center for Medicare and Medicaid Innovation to identify potential quality improvement opportunities. The regression model evaluated the association of the cancer stage at initial diagnosis and current clinical status with variance to the OCM target price. RESULTS Cancer stage at the time of initial diagnosis was significant for breast and lung cancers, with stage IV episodes having the highest losses of -$6,700 (USD) for breast cancer (P < .001) and -$18,470 (USD) for lung cancer (P < .001). Current clinical status had a significant impact for all three cancers in the analysis, with losses correlated with clinical complexity. Breast cancer and multiple myeloma episodes categorized as recurrent or progressive disease had significantly higher losses than stable episodes, at -$6,755 (USD) for breast (P < .001) and -$19,448 (USD) for multiple myeloma (P < .001). Lung cancer episodes categorized as initial diagnosis had significantly fewer losses than stable episodes, at -$3,751 (USD) (P = .001). CONCLUSION As the Center for Medicare and Medicaid Innovation designs and launches new oncology-related models, the agency should adopt methodologies that more accurately set target prices, by incorporating relevant clinical data within cancer types to minimize penalizing practices that provide guideline-concordant cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | - Mayumi Fukui
- Oregon Health & Science University, Portland, OR
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Al Anazi SK, Al Zahrani WA, Alsanad MA, Alzahrani MS, Al Ghamdi IS, Alotaibi AA, Al maliki MA, Asiri HM, Alshehri GM, Alanazi AS, Al Anazi AK. A cross-sectional survey exploring the attitude, knowledge, and use of anesthesia teams toward evidence-based practice in Riyadh Saudi Arabia. Front Public Health 2022; 10:1017106. [PMID: 36388298 PMCID: PMC9659891 DOI: 10.3389/fpubh.2022.1017106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/05/2022] [Indexed: 01/28/2023] Open
Abstract
Background Evidence-based practice (EBP) plays a crucial role in improving the quality of healthcare services by ensuring the delivery of the highest and safest level of patient care since EBP helps in justifying treatment choices to patients. Studies that examine the levels of EBP knowledge, attitudes toward EBP, and use of the use of EBP within anesthetic teams' practice are lacking, hence it is necessary to explore this. Aim To evaluate anesthesia teams' levels of knowledge, attitude toward and use of the evidence-based practice in a local hospital in Saudi Arabia. Method In one hospital, a cross-sectional survey was conducted using a convenience sampling technique using a validated questionnaire instrument called the Evidence-Based Practice EBP Questionnaire. The questionnaire was distributed through an online method to 173 participants. Descriptive and inferential statistics Tests were utilized to analyse the retrieved data using the SPSS program. Results One hundred and forty questionnaires were completed and returned, yielding a response rate of 80.9%. Overall, anesthesia teams showed a high positive attitude toward EBP but low levels of knowledge and use of EBP. Participants with higher levels of education and/or work experience exhibited significantly higher levels of knowledge and use of EBP than those who had lower education levels and/or work experience. Also, higher levels of education and/or work experience exhibited a significant positive association toward a higher level of knowledge and use of EBP. However, attitude levels toward EBP did not exhibit either significant or associated. Physicians showed significantly higher knowledge and use of EBP than non-physicians. Lack of knowledge and lack of time due to workload were the leading barriers encountered by anesthesia teams ATs. Conclusion Education level, work experience and job position affect the knowledge, attitude, and use of EBP. Continuous education and minimizing barriers are recommended to enhance the knowledge, attitude, and use of EBP among anesthesia teams in Saudi Arabia.
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Affiliation(s)
- Salem Khalaf Al Anazi
- Anesthesia Technology Department, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia,Salem Khalaf Al Anazi
| | - Waleed Abdullah Al Zahrani
- Anesthesia Technology Department, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Mohammed Abdulaziz Alsanad
- College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Matar Saeed Alzahrani
- College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | | | - Abdulmueen Awadh Alotaibi
- College of Applied Sciences, AlMaarefa University, Riyadh, Saudi Arabia,*Correspondence: Abdulmueen Awadh Alotaibi
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10
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Pitter JG, Moizs M, Ezer ÉS, Lukács G, Szigeti A, Repa I, Csanádi M, Rutten-van Mölken MPMH, Islam K, Kaló Z, Vokó Z. Improved survival of non-small cell lung cancer patients after introducing patient navigation: A retrospective cohort study with propensity score weighted historic control. PLoS One 2022; 17:e0276719. [PMID: 36282840 PMCID: PMC9595513 DOI: 10.1371/journal.pone.0276719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
OnkoNetwork is a patient navigation program established in the Moritz Kaposi General Hospital to improve the timeliness and completeness of cancer investigations and treatment. The H2020 SELFIE consortium selected OnkoNetwork as a promising integrated care initiative in Hungary and conducted a multicriteria decision analysis based on health, patient experience, and cost outcomes. In this paper, a more detailed analysis of clinical impacts is provided in the largest subgroup, non-small cell lung cancer (NSCLC) patients. A retrospective cohort study was conducted, enrolling new cancer suspect patients with subsequently confirmed NSCLC in two annual periods, before and after OnkoNetwork implementation (control and intervention cohorts, respectively). To control for selection bias and confounding, baseline balance was improved via propensity score weighting. Overall survival was analyzed in univariate and multivariate weighted Cox regression models and the effect was further characterized in a counterfactual analysis. Our analysis included 123 intervention and 173 control NSCLC patients from early to advanced stage, with significant between-cohort baseline differences. The propensity score-based weighting resulted in good baseline balance. A large survival benefit was observed in the intervention cohort, and intervention was an independent predictor of longer survival in a multivariate analysis when all baseline characteristics were included (HR = 0.63, p = 0.039). When post-baseline variables were included in the model, belonging to the intervention cohort was not an independent predictor of survival, but the survival benefit was explained by slightly better stage distribution and ECOG status at treatment initiation, together with trends for broader use of PET-CT and higher resectability rate. In conclusion, patient navigation is a valuable tool to improve cancer outcomes by facilitating more timely and complete cancer diagnostics. Contradictory evidence in the literature may be explained by common sources of bias, including the wait-time paradox and adjustment to intermediate outcomes.
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Affiliation(s)
| | | | | | - Gábor Lukács
- Moritz Kaposi General Hospital, Kaposvár, Hungary
| | | | - Imre Repa
- Moritz Kaposi General Hospital, Kaposvár, Hungary
| | | | - Maureen P. M. H. Rutten-van Mölken
- Erasmus School of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kamrul Islam
- Department of Economics, University of Bergen, Bergen, Norway
- NORCE-Norwegian Research Centre, Bergen, Norway
| | - Zoltán Kaló
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
- * E-mail:
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11
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Zhang H, Cha EE, Lynch K, Gennarelli R, Brower J, Sherer MV, Golden DW, Chimonas S, Korenstein D, Gillespie EF. Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study. J Med Imaging Radiat Oncol 2022; 66:993-1002. [PMID: 35650174 PMCID: PMC9532345 DOI: 10.1111/1754-9485.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. METHODS We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. RESULTS Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). CONCLUSION Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.
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Affiliation(s)
- Helen Zhang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elaine E. Cha
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathleen Lynch
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Renee Gennarelli
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey Brower
- Radiation Oncology Associates–New England, Manchester, NH
| | - Michael V. Sherer
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Daniel W. Golden
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL
| | - Susan Chimonas
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Dickson NR, Beauchamp KD, Perry TS, Roush A, Goldschmidt D, Edwards ML, Blakely LJ. Impact of clinical pathways on treatment patterns and outcomes for patients with non-small-cell lung cancer: real-world evidence from a community oncology practice. J Comp Eff Res 2022; 11:609-619. [PMID: 35546311 DOI: 10.2217/cer-2021-0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The evolving treatment landscape for non-small-cell lung cancer (NSCLC) and complexities of regulations and reimbursement present challenges to community oncologists. Clinical pathways are tools to optimize care, but information on their value in the real world is limited. This retrospective study assessed treatment patterns and clinical outcomes in patients with Stage I-III NSCLC pre- and post-pathways implementation at Tennessee Oncology, a large, community-based oncology practice in the USA. Methods & Materials: Chart data were abstracted for adults diagnosed with Stage I-III NSCLC who received systemic treatment. Patients were divided into pre-pathways (treatment initiation 2014-2015) and post-pathways (treatment initiation 2016-2018) cohorts. Patient characteristics, treatment patterns and outcomes were summarized descriptively. Kaplan-Meier curves were used to assess time-dependent outcomes, and log-rank test was used to compare the cohorts. Results: 291 patients were included (Stage I-II: 38 pre-pathways, 55 post-pathways; Stage III: 105 pre-pathways, 93 post-pathways). Duration on first-line (1L) therapy was similar for Stage I-II patients pre- and post-pathways (median 1.9 months vs 2.1 months; p = 0.75), but increased for Stage III patients post-pathways (2.1 months vs 1.4 months pre-pathways; p < 0.01). Achievement of a complete or partial response with 1L therapy was similar post-pathways among Stage I-Stage -IIII patients (60.0% vs 55.2% pre-pathways), but increased for Stage III patients (56.0% vs 35.2% pre-pathways). Conclusion: Given that improvements in rates of treatment response post-pathways occurred only for patients diagnosed with Stage III NSCLC, among whom immunotherapy uptake increased post-pathways, such improvements may be attributable to evolving practices in cancer care, including advances in treatment and care delivery, rather than clinical pathways implementation. Further research is warranted to assess the impact of clinical pathways in the current treatment era, given that immunotherapy has now become the standard of care in NSCLC.
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13
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Brooks GA, Landrum MB, Kapadia NS, Liu PH, Wolf R, Riedel LE, Hsu VD, Jhatakia Parekh S, Simon C, Hassol A, Keating NL. Impact of the Oncology Care Model on Use of Supportive Care Medications During Cancer Treatment. J Clin Oncol 2022; 40:1763-1771. [PMID: 35213212 DOI: 10.1200/jco.21.02342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is an episode-based alternative payment model for cancer care that seeks to reduce Medicare spending while maintaining care quality. We evaluated the impact of OCM on appropriate use of supportive care medications during cancer treatment. METHODS We evaluated chemotherapy episodes assigned to OCM (n = 201) and comparison practices (n = 534) using Medicare claims (2013-2019). We assessed denosumab use for beneficiaries with bone metastases from breast, lung, or prostate cancer; prophylactic WBC growth factor use for beneficiaries receiving chemotherapy for breast, lung, or colorectal cancer; and prophylactic use of neurokinin-1 (NK1) antagonists and long-acting serotonin antagonists for beneficiaries receiving chemotherapy for any cancer type. Analyses used a difference-in-difference approach. RESULTS After its launch in 2016, OCM led to a relative reduction in the use of denosumab for beneficiaries with bone metastases receiving bone-modifying medications (eg, 5.0 percentage point relative reduction in breast cancer episodes [90% CI, -7.1 to -2.8]). There was no OCM impact on use of prophylactic WBC growth factors during chemotherapy with high or low risk for febrile neutropenia. Among beneficiaries receiving chemotherapy with intermediate febrile neutropenia risk, OCM led to a 7.6 percentage point reduction in the use of prophylactic WBC growth factors during breast cancer episodes (90% CI, -12.6 to -2.7); there was no OCM impact in lung or colorectal cancer episodes. Among beneficiaries receiving chemotherapy with high or moderate emetic risk, OCM led to reductions in the prophylactic use of NK1 antagonists and long-acting serotonin antagonists (eg, 6.0 percentage point reduction in the use of NK1 antagonists during high emetic risk chemotherapy [90% CI, -9.0 to -3.1]). CONCLUSION OCM led to the reduced use of some high-cost supportive care medications, suggesting more value-conscious care.
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Affiliation(s)
- Gabriel A Brooks
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Nirav S Kapadia
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Pang-Hsiang Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Robert Wolf
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Lauren E Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Van Doren Hsu
- General Dynamics Information Technology, Falls Church, VA
| | | | | | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
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14
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Saarenheimo J, Andersen H, Eigeliene N, Jekunen A. Gene-Guided Treatment Decision-Making in Non-Small Cell Lung Cancer - A Systematic Review. Front Oncol 2021; 11:754427. [PMID: 34712614 PMCID: PMC8546351 DOI: 10.3389/fonc.2021.754427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/24/2021] [Indexed: 01/20/2023] Open
Abstract
Decision-making in cancer treatment is part of clinicians’ everyday work, and it is especially challenging in non-small cell lung cancer (NSCLC) patients, for whom decisions are clearly dependent on gene alterations or the lack of them. The multimodality of treatments, involvement of gene alterations in defining systemic cancer therapies, and heterogeneous nature of tumors and their responsiveness provide extra challenges. This article reviews the existing literature to 2021 with extra effort to explore the role of genes and gene-driven therapies as part of decision-making. The process and elements in this decision-making participation are recognized and discussed comprehensively. Genetic health literacy aids are provided as a part of the review. Our systematic review, data extraction and analysis found that with current methods and broad gene panels, patients benefit from early molecular testing of liquid biopsy samples. An estimated 79% of liquid biopsy samples showed somatic mutations based on 8 original studies included in the systematic review. When both liquid biopsy samples and tissue samples are evaluated, the sensitivity to detect targetable mutations in NSCLC increases. We recommend early testing with liquid biopsy. Additional effort is needed for the logistics of obtaining and evaluating samples, and tissue samples should be saved and stored for tests that are not possible from liquid biopsy.
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Affiliation(s)
| | - Heidi Andersen
- Department of Oncology, Vaasa Central Hospital, Vaasa, Finland.,Tema Cancer, Karolinska University Hospital, Stockholm, Sweden.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Natalja Eigeliene
- Department of Oncology, Vaasa Central Hospital, Vaasa, Finland.,Department of Oncology and Radiotherapy, Turku University, Turku, Finland
| | - Antti Jekunen
- Department of Oncology, Vaasa Central Hospital, Vaasa, Finland.,Department of Oncology and Radiotherapy, Turku University, Turku, Finland
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15
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Ahmad Ghaus MG, Tuan Kamauzaman TH, Norhayati MN. Knowledge, Attitude, and Practice of Evidence-Based Medicine among Emergency Doctors in Kelantan, Malaysia. Int J Environ Res Public Health 2021; 18:11297. [PMID: 34769813 DOI: 10.3390/ijerph182111297] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/15/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022]
Abstract
This study aimed to determine the prevalence of high levels of knowledge, positive attitude, and good practice on evidence-based medicine (EBM) and identify the associated factors for practice score on EBM among emergency medicine doctors in Kelantan, Malaysia. This cross-sectional study was conducted in government hospitals in Kelantan. The data were collected from 200 emergency physicians and medical officers in the emergency department using the Noor Evidence-Based Medicine Questionnaire. Simple and general linear regressions analyses using SPSS were performed. A total of 183 responded, making a response rate of 91.5%. Of them, 49.7% had a high level of knowledge, 39.9% had a positive attitude and 2.1% had good practice. Sex, race, the average number of patients seen per day, internet access in workplace, having online quick reference application, and attitude towards EBM were significantly associated with EBM practice scores. It is recommended that appropriate authorities provide emergency doctors with broader access to evidence resources. EBM skill training should be enhanced in the current medical school curriculums.
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16
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Cheraghlou S, Christensen SR, Leffell DJ, Girardi M. Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma. JAMA Dermatol 2021; 157:531-539. [PMID: 33787836 DOI: 10.1001/jamadermatol.2021.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. Objective To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. Design, Setting, and Participants In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Exposures Treatment facility characteristics. Main Outcomes and Measures Overall survival. Results The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). Conclusions and Relevance In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Sean R Christensen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - David J Leffell
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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17
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Kline RM, Blau S, Buescher NR, Ellis AR, Hoverman JR, Oyer RA, Wilfong LS, Rocque GB. Secret Sauce-How Diverse Practices Succeed in Centers for Medicare & Medicaid Services Oncology Care Model. JCO Oncol Pract 2021; 17:734-743. [PMID: 34406820 DOI: 10.1200/op.21.00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE CMS' Oncology Care Model (OCM) is an episode-based alternative payment model designed to incent high-value care through the use of monthly payments for enhanced services and performance-based payments on the basis of decreases in spending compared with risk-adjusted historical benchmarks. Transitioning from a fee-for-service model to a value-based, alternative payment model in oncology can be difficult; some practices will perform better than others. We present detailed experiences of four successful OCM practices, each operating under diverse business models and in different geographic areas. METHODS Practices that achieved success in OCM, on the basis of financial metrics, describe pathways to success. The practices represent distinct business models: a medium-sized community oncology practice, a large statewide community oncology practice, a hospital-affiliated practice, and a large academic medical center. RESULTS Practices describe effective changes in practice culture such as new administrative flexibilities, physician champions, improved communication, changes in physician compensation, and increased physician-level transparency. New or improved clinical services include acute care clinics, care coordination, phone triage, end-of-life care programs, and adoption of treatment pathways that identify high-value drug use, including better use of supportive care drugs. CONCLUSION There is no one thing that will ensure success in OCM. Success requires whole practice transformation, encompassing both administrative and clinical changes. Communication between administrative and clinical teams is vital, along with improved data sharing and transparency. Clinical support services must expand to manage problems and symptoms in a timely way to prevent costly emergency department visits and hospitalizations, while constant attention must be paid to making high-value therapeutic choices in both oncolytic and supportive drug categories.
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Affiliation(s)
- Ronald M Kline
- Formerly Clinical Lead for the Oncology Care Model and Formerly Team Lead for Oncology Care First.,Currently United States Office of Personnel Management, Washington, DC
| | - Sibel Blau
- Northwest Medical Specialties, Tacoma, WA
| | | | | | | | | | | | - Gabrielle B Rocque
- Divisions of Hematology & Oncology, and Gerontology, Geriatrics, & Palliative Care, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
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18
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Woofter K, Kennedy EB, Adelson K, Bowman R, Brodie R, Dickson N, Gerber R, Fields KK, Murtaugh C, Polite B, Paschall M, Skelton M, Zoet D, Cox JV. Oncology Medical Home: ASCO and COA Standards. JCO Oncol Pract 2021; 17:475-492. [PMID: 34255551 DOI: 10.1200/op.21.00167] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide Standards on the basis of evidence and expert consensus for a pilot of the Oncology Medical Home (OMH) certification program. The OMH model is a system of care delivery that features coordinated, efficient, accessible, and evidence-based care and includes a process for measurement of outcomes to facilitate continuous quality improvement. The OMH pilot is intended to inform further refinement of Standards for OMH model implementation. METHODS An Expert Panel was formed, and a systematic review of the literature on the topics of OMH, clinical pathways, and survivorship care plans was performed using PubMed and Google Scholar. Using this evidence base and an informal consensus process, the Expert Panel developed a set of OMH Standards. Public comments were solicited and considered in preparation of the final manuscript. RESULTS Three comparative peer-reviewed studies of OMH met the inclusion criteria. In addition, the results from 16 studies of clinical pathways and one systematic review of survivorship care plans informed the evidence review. Limitations of the evidence base included the small number of studies of OMH and lack of longer-term outcomes data. More data were available to inform the specific Standards for pathways and survivorship care; however, outcomes were mixed for the latter intervention. The Expert Panel concluded that in the future, practices should be encouraged to publish the results of OMH interventions in peer-reviewed journals to improve the evidence base. STANDARDS Standards are provided for OMH in the areas of patient engagement, availability and access to care, evidence-based medicine, equitable and comprehensive team-based care, quality improvement, goals of care, palliative and end-of-life care discussions, and chemotherapy safety. Additional information, including a Standards implementation manual, is available at www.asco.org/standards.
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Affiliation(s)
- Kim Woofter
- Advanced Centers for Cancer Care, South Bend, IN
| | | | | | - Ronda Bowman
- American Society of Clinical Oncology, Alexandria, VA
| | - Rachel Brodie
- Purchaser Business Group on Health, San Francisco, CA
| | | | - Rose Gerber
- COA Patient Advocacy Network, Washington, DC
| | | | | | | | | | | | - Dennis Zoet
- Cancer and Hematology Centers of Western Michigan, Grand Rapids, MI
| | - John V Cox
- UT Southwestern Medical Center, Dallas, TX
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19
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Jackman DM, Foster E, Hamilton JM, Tremonti C, Bunnell CA, Stuver SO, Jacobson JO. Early Findings on the Use of Clinical Pathways for Management of Unwarranted Variation in Cancer Care. Am J Med Qual 2021. [PMID: 34108394 DOI: 10.1097/01.JMQ.0000749852.10699.bc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Clinical pathways have the potential to improve complex clinical decision-making in cancer care. The authors implemented pathways with customized content to assist oncologists to select treatments, aiming for an on-pathway rate of 70%-85%. Treatment decisions were captured as on or off pathway, and metrics were shared monthly with users. Oncologists were categorized into quintiles based on on-pathway performance during the first 90 days of use. On-pathway rates were then calculated for days 91-360 (N = 121). Median on-pathway quintile rates varied from 50% to 100% in the initial 90-day period. During follow-up, median on-pathway rates shifted into the prespecified goal range for all groups. Clinical pathways resulted in greater uniformity in medical oncology practice. Monthly feedback about usage, familiarity with the electronic platform, and regular content updates are some factors that may influence on-pathway rates. Clinical pathways hold promise to manage unwarranted variation in cancer care.
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20
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Abstract
Increasing cancer drug prices present global challenges to treatment access and cancer outcomes. Substantial variability exists in drug pricing across countries. In countries without universal health care, patients are responsible for treatment costs. Low- or middle-income countries are heavily impacted, with limited patient access to novel cancer treatments. Financial toxicity is seen across cancer types, countries, and health care systems. Those at highest risk include younger patients, new immigrants, visible minority groups, and those without private health coverage. Currently, cancer drug pricing does not correlate with value or clinical benefit. Value-based pricing of oncology drugs may incentivize development of higher-value medicines and eliminate excess spending on drugs that yield little benefit. Generics and biosimilars in oncology can also improve affordability and patient access, offering dramatic reductions in drug spending while maintaining patient benefit. Oncologists can promote value-based care by following evidence-based clinical guidelines that avoid low-value treatments. Researchers can also engage in value-based research that critically explores optimal cancer drug dosing, schedules, and treatment duration and defines patient populations most likely to benefit (e.g., through biomarker selection). Cancer Groundshot proposes that we improve outcomes for today's patients with cancer, including broader global access for high-value treatments, promotion of affordable cancer control strategies, and reduction of cancer morbidity and mortality through low-cost prevention and screening initiatives. Moving forward, major oncology societies recommend promoting uniform global access to essential cancer medicines and avoiding financial harm for patients as key principles in addressing the affordability of cancer drugs.
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Affiliation(s)
- Natasha B Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sharon Nirmalakumar
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Doreen A Ezeife
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
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21
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Schleicher SM, Chaudhry B, Dickson NR, Aviki E, Arrowsmith E, Parikh RB, Yue AT, Connor N, Schwartzberg L, Lyss AJ. Time to Rethink the Role of Clinical Pathways in the Era of Precision Medicine: A Lung Cancer Case Study. JCO Oncol Pract 2021; 17:379-381. [PMID: 33872069 DOI: 10.1200/op.21.00073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Emeline Aviki
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Ravi B Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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22
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Abstract
Clinical practice guidelines in oncology provide an evidence-based roadmap for most cancer care delivery but often lack directions for specific patient factors and disease conditions. Clinical pathways serve as a real-time clinical decision support system to translate guidelines to clinical practice. Pathways allow for the creation of a standardized, multidimensional roadmap for the continuum of care that can support clinical decision-making, maintain optimal outcomes, and limit unnecessary variation in cancer care. Here we describe the process to develop and implement clinical pathways in the electronic health record. This process includes building the appropriate foundation for a clinical pathways team with supports in the institutional ecosystem, creating visual representations of care paths, formalizing the pathway approval process, and translating clinical pathways into an electronic health record-integrated clinical decision support tool.
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23
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Affiliation(s)
- Ronald M Kline
- Formerly clinical lead for the Oncology Care Model and model lead for Oncology Care First
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24
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Bosserman LD, Cianfrocca M, Yuh B, Yeon C, Chen H, Sentovich S, Polverini A, Zachariah F, Deaville D, Lee AB, Sedrak MS, King E, Gray S, Morse D, Glaser S, Bhatt G, Adeimy C, Tan T, Chao J, Nam A, Paz IB, Kruper L, Rao P, Sokolov K, Kulkarni P, Salgia R, Yamzon J, Johnson D. Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience. J Clin Med 2021; 10:E188. [PMID: 33430334 DOI: 10.3390/jcm10020188] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/10/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022] Open
Abstract
As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope’s (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.
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26
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Ostropolets A, Zhang L, Hripcsak G. A scoping review of clinical decision support tools that generate new knowledge to support decision making in real time. J Am Med Inform Assoc 2020; 27:1968-1976. [PMID: 33120430 PMCID: PMC7824048 DOI: 10.1093/jamia/ocaa200] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/24/2020] [Accepted: 08/04/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE A growing body of observational data enabled its secondary use to facilitate clinical care for complex cases not covered by the existing evidence. We conducted a scoping review to characterize clinical decision support systems (CDSSs) that generate new knowledge to provide guidance for such cases in real time. MATERIALS AND METHODS PubMed, Embase, ProQuest, and IEEE Xplore were searched up to May 2020. The abstracts were screened by 2 reviewers. Full texts of the relevant articles were reviewed by the first author and approved by the second reviewer, accompanied by the screening of articles' references. The details of design, implementation and evaluation of included CDSSs were extracted. RESULTS Our search returned 3427 articles, 53 of which describing 25 CDSSs were selected. We identified 8 expert-based and 17 data-driven tools. Sixteen (64%) tools were developed in the United States, with the others mostly in Europe. Most of the tools (n = 16, 64%) were implemented in 1 site, with only 5 being actively used in clinical practice. Patient or quality outcomes were assessed for 3 (18%) CDSSs, 4 (16%) underwent user acceptance or usage testing and 7 (28%) functional testing. CONCLUSIONS We found a number of CDSSs that generate new knowledge, although only 1 addressed confounding and bias. Overall, the tools lacked demonstration of their utility. Improvement in clinical and quality outcomes were shown only for a few CDSSs, while the benefits of the others remain unclear. This review suggests a need for a further testing of such CDSSs and, if appropriate, their dissemination.
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Affiliation(s)
- Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Linying Zhang
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
- NewYork-Presbyterian Hospital, New York, New York, USA
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Bekelman JE, Gupta A, Fishman E, Debono D, Fisch MJ, Liu Y, Sylwestrzak G, Barron J, Navathe AS. Association Between a National Insurer's Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending. J Clin Oncol 2020; 38:4055-4063. [PMID: 33021865 DOI: 10.1200/jco.20.00890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending. METHODS We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period. RESULTS The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; P < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; P = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; P = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; P = .07) over the 6-month episode period. CONCLUSION P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.
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Affiliation(s)
- Justin E Bekelman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Healthcare Transformation Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Atul Gupta
- Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Ezra Fishman
- National Committee for Quality Assurance, Washington, DC
| | | | - Michael J Fisch
- AIM Specialty Health, Chicago, IL.,The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation at the Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA.,Healthcare Transformation Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Hull O, Niranjan SJ, Wallace AS, Williams BR, Turkman YE, Ingram SA, Williams CP, Smith T, Knight SJ, Bhatia S, Rocque GB. Should we be talking about guidelines with patients? A qualitative analysis in metastatic breast cancer. Breast Cancer Res Treat 2020; 184:115-121. [PMID: 32737711 DOI: 10.1007/s10549-020-05832-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little data exist on perceptions of guideline-based care in oncology. This qualitative analysis describes patients' and oncologists' views on the value of guideline-based care as well as discussing guidelines when making metastatic breast cancer (MBC) treatment decisions. PATIENTS AND METHODS In-person interviews completed with MBC patients and community oncologists and focus groups with academic oncologists were audio-recorded and transcribed. Two coders utilized a content analysis approach to analyze transcripts independently using NVivo. Major themes and exemplary quotes were extracted. RESULTS Participants included 20 MBC patients, 6 community oncologists, and 5 academic oncologists. Most patients were unfamiliar with the term "guidelines." All patients desired to know if they were receiving guideline-discordant treatment but were often willing to accept this treatment. Five themes emerged explaining this including trusting the oncologist, relying on the oncologist's experiences, being informed of rationale for deviation, personalized treatment, and openness to novel therapies. Physician discussions regarding the importance of guidelines revealed three themes: consistency with scientific evidence, insurance coverage, and limiting unusual practices. Oncologists identified three major limitations in using guidelines: lack of consensus, inability to "think outside the box" to personalize treatment, and lack of guideline timeliness. Although some oncologists discussed guidelines, it was often not considered a priority. CONCLUSIONS Patients expressed a desire to know whether they were receiving guideline-based care but were amenable to guideline-discordant treatment if the rationale was made clear. Providers' preference to limit discussions of guidelines is discordant with patients' desire for this information and may limit shared decision-making.
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Affiliation(s)
- Olivia Hull
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Soumya J Niranjan
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Audrey S Wallace
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Beverly R Williams
- Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yasemin E Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stacey A Ingram
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Tom Smith
- Division of Palliative Care, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara J Knight
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytical Sciences (IDEAS) Center, Department of Veteran Affairs, Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA. .,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Otty Z, Brown A, Sabesan S, Evans R, Larkins S. Optimal Care Pathways for People with Lung Cancer- a Scoping Review of the Literature. Int J Integr Care 2020; 20:14. [PMID: 33041731 PMCID: PMC7528692 DOI: 10.5334/ijic.5438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 09/08/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Much of the existing work around implementation of cancer optimal care pathways (OCP) has either focused exclusively on the clinical elements of care or has targeted individual stages in the cancer trajectory, rather than using a patient-centred or service delivery lens to inform the integration of care across the continuum. This review aimed to identify and summarise the available literature on lung cancer OCP. METHODS A scoping review was conducted, with literature across multiple databases and grey literature searched. Articles were included if the OCP was being used to manage adult patients with lung cancer and reported on either the development process and outcomes and/or barriers and facilitators associated with optimal care pathway development and/or uptake. RESULTS Of the 381 references screened, 32 articles were included. The lung cancer pathways reviewed varied significantly. A number of themes were identified including the development and implementation of the OCP; the use of quality indicators to audit the OCP; and studies on outcomes of the OCP incorporating timeliness of care delivery, patient experiences and health care utilisation and costs. CONCLUSIONS The limited number of relevant articles found in this review may suggest that an OCP for lung cancer is still in its preliminary stages across the broader health systems.
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Affiliation(s)
- Zulfiquer Otty
- Townsville Cancer Centre, Townsville University Hospital, Townsville, QLD, AU
- College of Medicine & Dentistry, James Cook University, Townsville, QLD, AU
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, AU
| | - Amy Brown
- Townsville Cancer Centre, Townsville University Hospital, Townsville, QLD, AU
| | - Sabe Sabesan
- Townsville Cancer Centre, Townsville University Hospital, Townsville, QLD, AU
- College of Medicine & Dentistry, James Cook University, Townsville, QLD, AU
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, AU
| | - Rebecca Evans
- College of Medicine & Dentistry, James Cook University, Townsville, QLD, AU
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, AU
| | - Sarah Larkins
- College of Medicine & Dentistry, James Cook University, Townsville, QLD, AU
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, AU
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Nasser JS, Speth KA, Billig JI, Wang L, Chung KC. Trigger Finger Treatment: Identifying Predictors of Nonadherence and Cost. Plast Reconstr Surg 2020; 146:177e-86e. [PMID: 32740586 DOI: 10.1097/PRS.0000000000006983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Evidence-based practices in medicine are linked with a higher quality of care and lower health care cost. For trigger finger, identifying patient factors associated with nonadherence to evidence-based practices will aid physicians in treatment decisions. The objectives were to (1) determine patient factors associated with treatment nonadherence, (2) examine the success rates of steroid injections, and (3) evaluate the economic consequences of nonadherence to treatment recommendations. METHODS The authors used data from the Clinformatics DataMart database from 2010 to 2017 to conduct a population-based analysis of patients with single-digit trigger finger. The authors calculated rates of steroid injection success and examined associations between injection success and patient factors using chi-square tests. In addition, the authors analyzed differences in the cost to the insurer, the cost to the patient, and total cost. RESULTS A total of 29,722 patients were included in this analysis. Injection success rates were similar for diabetic (72 percent) and nondiabetic patients (73 percent), women (73 percent), and men (73 percent). Nonetheless, diabetics (OR, 1.4; 95 percent CI, 1.4 to 1.5; p < 0.001) and women (OR, 1.2; 95 percent CI, 1.1 to 1.2; p < 0.001) were significantly more likely to receive nonadherent treatment. In total, $23 million (U.S. dollars) were spent on nonadherent trigger finger care. CONCLUSIONS Diabetics and women have increased odds of having surgery without a prior steroid injection, despite similar success rates of steroid injections compared to nondiabetics and men. Because performing surgical release before any steroid injections may represent a higher cost treatment option, providers should provide steroid injections before surgery for all patients regardless of diabetes status or sex to minimize overtreatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Hoverman JR. Rethinking clinical oncology drug research in an era of value-based cancer care: A role for chemotherapy pathways. Cancer Med 2020; 9:5306-5311. [PMID: 32524722 PMCID: PMC7404003 DOI: 10.1002/cam4.3193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 01/05/2023] Open
Abstract
The United States spends nearly 1/5th of its GDP on healthcare. Yet, to achieve value-based care, the Economist describes the US healthcare system as handicapped by multiple, disparate silos that prevent the organization and sharing of data. This paper explores the current state of clinical oncology drug research and its relationship to value-based cancer care. Clinical Chemotherapy Pathways are proposed as a unifying structure to bring together disparate sources of data to increase value.
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Affiliation(s)
- J. Russell Hoverman
- Value‐based ProgramsUS Oncology/McKesson Specialty HealthTexas OncologyDallasTXUSA
- US Oncology/McKesson Specialty HealthThe WoodlandsTXUSA
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Numico G, Viale M, Bellini R, Ippoliti R, Rossi M, Maan T, Carobene A, Pizzini A, Mistrangelo M, Bertetto O. Toward uniform and controlled clinical pathways in cancer care: a qualitative description. Int J Qual Health Care 2020; 31:781-786. [PMID: 30809643 DOI: 10.1093/intqhc/mzz015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/05/2019] [Accepted: 02/05/2019] [Indexed: 11/13/2022] Open
Abstract
QUALITY ISSUE The definition of clinical pathways (CPs) and their application are heterogeneous. Each center is used to choose whether to adopt this instrument or not and to variably conceive its features We consider CPs as the necessary description of the cancer patient journey and we emphasize their role as the user view of clinical processes rather than a local translation of guidelines. CHOICE OF SOLUTION We proposed a unique CPs model for all the centers of our regional network, with the aim of making CPs accountable and comparable. We also established a central quality evaluation. IMPLEMENTATION Through a multi-step process, the model was proposed to the 22 Regional centers. Landmark characteristics of the project were: the involvement of hospital administrations; reference to a unique set of guidelines; a peer-review and open evaluation. EVALUATION Of the 374 expected CPs, 253 (68%) were received and evaluated. A median number of 131 items were the object of evaluation in each hub center and 77 in each spoke center. About 79.5% items were considered well described, 15.5% were absent and 5.0% partially described. The median percentage of fulfilled indicators was 85.6% in hub CPs and 82.2% in spoke CPs. Although, not all diseases were equally covered through the territory a high degree of homogeneity and a good quality of compilation were achieved. LESSONS LEARNED The project was shown to be feasible and achieved its goal. We suggest this process as a functional way for building uniform cancer CPs.
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Affiliation(s)
- Gianmauro Numico
- Medical Oncology. SS Antonio e Biagio e C Arrigo Hospital; Via Venezia 16, Alessandria, Italy
| | - Monica Viale
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | - Roberta Bellini
- Quality and Management Control Unit, SS Antonio e Biagio e C Arrigo Hospital, Via Venezia 16, Alessandria, Italy
| | - Roberto Ippoliti
- Department of Business, Administration and Economics, University of Bielefeld, Bielefeld, Deutschland, Germany
| | - Maura Rossi
- Medical Oncology. SS Antonio e Biagio e C Arrigo Hospital; Via Venezia 16, Alessandria, Italy
| | - Tatiana Maan
- Quality and Management Control Unit, SS Antonio e Biagio e C Arrigo Hospital, Via Venezia 16, Alessandria, Italy
| | - Angelica Carobene
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | | | - Marinella Mistrangelo
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | - Oscar Bertetto
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
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Rajurkar S, Mambetsariev I, Pharaon R, Leach B, Tan T, Kulkarni P, Salgia R. Non-Small Cell Lung Cancer from Genomics to Therapeutics: A Framework for Community Practice Integration to Arrive at Personalized Therapy Strategies. J Clin Med 2020; 9:E1870. [PMID: 32549358 PMCID: PMC7356243 DOI: 10.3390/jcm9061870] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease, and therapeutic management has advanced with the identification of various key oncogenic mutations that promote lung cancer tumorigenesis. Subsequent studies have developed targeted therapies against these oncogenes in the hope of personalizing therapy based on the molecular genomics of the tumor. This review presents approved treatments against actionable mutations in NSCLC as well as promising targets and therapies. We also discuss the current status of molecular testing practices in community oncology sites that would help to direct oncologists in lung cancer decision-making. We propose a collaborative framework between community practice and academic sites that can help improve the utilization of personalized strategies in the community, through incorporation of increased testing rates, virtual molecular tumor boards, vendor-based oncology clinical pathways, and an academic-type singular electronic health record system.
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Affiliation(s)
| | | | | | | | | | | | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (S.R.); (I.M.); (R.P.); (B.L.); (T.T.); (P.K.)
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Urwin JW, Caldarella KL, Matloubieh SE, Lee E, Mugiishi M, Kohatsu L, Yoshimoto J, Tom J, Okamura S, Wang E, Zhu J, Emanuel EJ, Volpp KG, Navathe AS. Designing a commercial medical bundle for cancer care: Hawaii Medical Service Association's Cancer Episode Model. Healthc (Amst) 2020; 8:100422. [PMID: 32273240 DOI: 10.1016/j.hjdsi.2020.100422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/28/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Oncology care is expensive and exhibits substantial variation in cost and quality across clinicians and patients. Unlike many conditions with established bundled payment programs, cancer care includes a mix of inpatient and outpatient care that precludes hospital-based designs. In 2018, we worked with Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, to design a novel commercial bundle for cancer care, the Cancer Episode Model. METHODS Descriptive analysis of HMSA's Cancer Episode Model, including its inclusion criteria, episode definitions, suite of enhanced services, shared savings model, and incentivized quality metrics. We also compare HMSA's Cancer Episode Model to Medicare's Oncology Care Model and three major commercial oncologic alternative payment models offered by Anthem, UnitedHealthcare, and Aetna. RESULTS HMSA's Cancer Episode Model builds upon the successes and limitations of Medicare's Oncology Care Model and existing commercial alternative payment models. Compared to Medicare's Oncology Care Model, HMSA's Cancer Episode Model has stricter inclusion criteria, fewer incentivized quality metrics, a higher proportion of regional pricing, a different risk-adjustment model, and first-dollar shared savings. Compared to the majority of existing commercial models, HMSA's Cancer Episode Model includes total cost of care and a different risk-adjustment model. CONCLUSIONS Reviewing features of the Cancer Episode Model in comparison to other programs is intended to provide guidance to health plans and health policymakers in the design of programs and policies aimed at improving cancer care value. LEVEL OF EVIDENCE Level IV.
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Hertler A, Chau S, Khetarpal R, Bassin E, Dang J, Koppel D, Damarla V, Wade J. Utilization of Clinical Pathways Can Reduce Drug Spend Within the Oncology Care Model. JCO Oncol Pract 2020; 16:e456-e463. [PMID: 32196401 PMCID: PMC7224689 DOI: 10.1200/jop.19.00753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Reducing drug spend is one of the greatest challenges for practices participating in the Oncology Care Model (OCM). Evidence-based clinical pathways have the potential to decrease drug spend while maintaining clinical outcomes consistent with published evidence. The goal of this study was to determine whether voluntary use of clinical pathways by a practice can maximize OCM episodic cost savings. METHODS AND MATERIALS: A community oncology practice used evidence-based clinical pathways for OCM-attributed patients. All treatment plans were submitted to the pathway vendor in real time for clinical pathway adherence measurement. Analysis was conducted before implementation and on an ongoing daily and weekly basis to identify cases in which higher cost drugs or regimens were ordered. A clinical data governance committee met biweekly to review clinical pathway performance metrics and drug utilization. RESULTS: From quarter 1 of 2017 to quarter 1 of 2019, the median drug spend increased less rapidly for Cancer Care Specialists of Illinois (CCSI; 18.6%) compared with OCM (34.4%). Furthermore, the percent difference in drug spend for CCSI relative to OCM decreased from 13.5% to 0.1% (P < .001). Each quarter, there was approximately a 1.7% decrease (95% CI, 1.0% to 2.4%) in drug spend for CCSI relative to OCM. Additional analyses found that, over a 15-month period (October 2017 through December 2019), CCSI achieved an increase in pathway adherence from 69% to 81%. CONCLUSION: Reduction in drug spend is possible within a value-based care model, using evidence-based clinical pathways.
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Affiliation(s)
| | | | | | | | | | | | | | - James Wade
- Cancer Care Specialists of Illinois, Decatur, IL
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Speth KA, Yoon AP, Wang L, Chung KC. Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations. JAMA Netw Open 2020; 3:e1921626. [PMID: 32083690 PMCID: PMC7043191 DOI: 10.1001/jamanetworkopen.2019.21626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Optimal treatment for traumatic finger amputation is unknown to date. OBJECTIVE To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. DESIGN, SETTING, AND PARTICIPANTS This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. EXPOSURES Treatment with revision amputation or replantation. MAIN OUTCOMES AND MEASURES Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. RESULTS Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. CONCLUSIONS AND RELEVANCE The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.
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Affiliation(s)
- Kelly A. Speth
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Alfred P. Yoon
- Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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de Vasconcelos LP, de Oliveira Rodrigues L, Nobre MRC. Clinical guidelines and patient related outcomes: summary of evidence and recommendations. IJHG 2019. [DOI: 10.1108/ijhg-12-2018-0073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Purpose
Good medical practice, evidence-based medicine (EBM) and clinical practice guidelines (CPG) have been recurring subjects in the scientific literature. EBM advocates argue that good medical practice should be guided by evidence-based CPG. On the other hand, critical authors of EBM methodology argue that various interests undermine the quality of evidence and reliability of CPG recommendations. The purpose of this paper is to evaluate patient related outcomes of CPG implementation, in light of EBM critics.
Design/methodology/approach
The authors opted for a rapid literature review.
Findings
There are few studies evaluating the effectiveness of CPG in patient-related outcomes. The systematic reviews found are not conclusive, although they suggest a positive impact of CPGs in relevant outcomes.
Research limitations/implications
This work was not a systematic review of literature, which is its main limitation. On the other hand, arguments from EBM and CPG critics were considered, and thus it can enlighten health institutions to recognize the caveats and to establish policies toward care improvement.
Originality/value
The paper is the first of its kind to discuss, based on the published literature, next steps toward better health practice, while acknowledging the caveats of this process.
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Yabroff KR, Gansler T, Wender RC, Cullen KJ, Brawley OW. Minimizing the burden of cancer in the United States: Goals for a high-performing health care system. CA Cancer J Clin 2019; 69:166-183. [PMID: 30786025 DOI: 10.3322/caac.21556] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Between 1991 and 2015, the cancer mortality rate declined dramatically in the United States, reflecting improvements in cancer prevention, screening, treatment, and survivorship care. However, cancer outcomes in the United States vary substantially between populations defined by race/ethnicity, socioeconomic status, health insurance coverage, and geographic area of residence. Many potentially preventable cancer deaths occur in individuals who did not receive effective cancer prevention, screening, treatment, or survivorship care. At the same time, cancer care spending is large and growing, straining national, state, health insurance plans, and family budgets. Indeed, one of the most pressing issues in American medicine is how to ensure that all populations, in every community, derive the benefit from scientific research that has already been completed. Addressing these questions from the perspective of health care delivery is necessary to accelerate the decline in cancer mortality that began in the early 1990s. This article, part of the Cancer Control Blueprint series, describes challenges with the provision of care across the cancer control continuum in the United States. It also identifies goals for a high-performing health system that could reduce disparities and the burden of cancer by promoting the adoption of healthy lifestyles; access to a regular source of primary care; timely access to evidence-based care; patient-centeredness, including effective patient-provider communication; enhanced coordination and communication between providers, including primary care and specialty care providers; and affordability for patients, payers, and society.
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Affiliation(s)
- K Robin Yabroff
- Strategic Director, Surveillance and Health Services Research Program, American Cancer Society Inc, Atlanta, GA
| | - Ted Gansler
- Strategic Director of Pathology Research, American Cancer Society Inc, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society Inc, Atlanta, GA
| | - Kevin J Cullen
- Director, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society Inc, Atlanta, GA
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40
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Alpert A, Jacobson M. Impact of Oncology Drug Shortages on Chemotherapy Treatment. Clin Pharmacol Ther 2019; 106:415-421. [PMID: 30739322 DOI: 10.1002/cpt.1390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/21/2019] [Indexed: 12/24/2022]
Abstract
Prescription drug shortages began to increase markedly in the mid-2000s, including sterile injectable products such as chemotherapy drugs. Using Medicare claims linked to Surveillance Epidemiology and End Results (SEER), we examined outpatient chemotherapy use during shortage periods relative to the months before and after a shortage for newly diagnosed patients with breast, colorectal, leukemia, lung, lymphoma, ovarian, or pancreatic cancer (N = 182,470). For most drugs, we found little impact of shortages on either the fraction of patients receiving that drug or the quantity provided. In some cases, we found declines in utilization: 4% for doxorubicin and fluorouracil; 2.9% for oxaliplatin; and about 1% for cytarabine, dacarbazine, and leuprolide. Although shortages for a few drugs resulted in substantial reductions in use, in most cases, they resulted in little to no reduction. We discuss potential explanations for these counterintuitive findings, including potential limitations of current drug shortage reporting methods.
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Affiliation(s)
- Abby Alpert
- University of Pennsylvania and National Bureau of Economic Research, Philadelphia, Pennsylvania, USA
| | - Mireille Jacobson
- University of Southern California and National Bureau of Economic Research, Los Angeles, California, USA
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Nejati M, Razavi M, Harirchi I, Zendehdel K, Nejati P. The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review. PLoS One 2019; 14:e0214382. [PMID: 30951536 PMCID: PMC6450626 DOI: 10.1371/journal.pone.0214382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/12/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care. METHODS Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis. RESULTS Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes. CONCLUSION The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
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Affiliation(s)
- Mina Nejati
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Moaven Razavi
- The Schneider Institutes for Health Policy at the Heller School of Brandeis University, Waltham, MA, United States of America
| | - Iraj Harirchi
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Nejati
- Rasoule-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Hamilton JG, Genoff Garzon M, Westerman JS, Shuk E, Hay JL, Walters C, Elkin E, Bertelsen C, Cho J, Daly B, Gucalp A, Seidman AD, Zauderer MG, Epstein AS, Kris MG. "A Tool, Not a Crutch": Patient Perspectives About IBM Watson for Oncology Trained by Memorial Sloan Kettering. J Oncol Pract 2019; 15:e277-e288. [PMID: 30689492 DOI: 10.1200/jop.18.00417] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE IBM Watson for Oncology trained by Memorial Sloan Kettering (WFO) is a clinical decision support tool designed to assist physicians in choosing therapies for patients with cancer. Although substantial technical and clinical expertise has guided the development of WFO, patients' perspectives of this technology have not been examined. To facilitate the optimal delivery and implementation of this tool, we solicited patients' perceptions and preferences about WFO. METHODS We conducted nine focus groups with 46 patients with breast, lung, or colorectal cancer with various treatment experiences: neoadjuvant/adjuvant chemotherapy, chemotherapy for metastatic disease, or systemic therapy through a clinical trial. In-depth qualitative and quantitative data were collected and analyzed to describe patients' attitudes and perspectives concerning WFO and how it may be used in clinical care. RESULTS Analysis of the qualitative data identified three main themes: patient acceptance of WFO, physician competence and the physician-patient relationship, and practical and logistic aspects of WFO. Overall, participant feedback suggested high levels of patient interest, perceived value, and acceptance of WFO, as long as it was used as a supplementary tool to inform their physicians' decision making. Participants also described important concerns, including the need for strict processes to guarantee the integrity and completeness of the data presented and the possibility of physician overreliance on WFO. CONCLUSION Participants generally reacted favorably to the prospect of WFO being integrated into the cancer treatment decision-making process, but with caveats regarding the comprehensiveness and accuracy of the data powering the system and the potential for giving WFO excessive emphasis in the decision-making process. Addressing patients' perspectives will be critical to ensuring the smooth integration of WFO into cancer care.
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Affiliation(s)
- Jada G Hamilton
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Margaux Genoff Garzon
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Joy S Westerman
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Elyse Shuk
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Jennifer L Hay
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Chasity Walters
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Elena Elkin
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Corinna Bertelsen
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Jessica Cho
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Bobby Daly
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Ayca Gucalp
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Andrew D Seidman
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Marjorie G Zauderer
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Andrew S Epstein
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
| | - Mark G Kris
- 1 Memorial Sloan Kettering Cancer Center; and Weill Cornell Medical College, New York, NY
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Norden AD, Dankwa-Mullan I, Urman A, Suarez F, Rhee K. Realizing the Promise of Cognitive Computing in Cancer Care: Ushering in a New Era. JCO Clin Cancer Inform 2019; 2:1-6. [PMID: 30652560 DOI: 10.1200/cci.17.00049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | - Kyu Rhee
- All authors: IBM Watson Health, Cambridge MA
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Abstract
Drug shortages pose a significant public health concern in the United States, and cancer drugs are among those most affected. Shortages present serious safety risks for patients and substantial burden on providers and the healthcare system. Multifaceted drivers of this complex problem include manufacturing disruptions, raw material shortages, regulatory issues, market dynamics, and limited financial incentives that reward quality and production of off-patent drugs. Oncology drugs in short supply have resulted in substitution of less effective or more toxic alternatives, medication errors, and treatment delays, and are especially concerning for medications with no adequate substitute. Consequently, patient outcomes such as disease progression and survival have been adversely affected. Furthermore, emerging gray markets have contributed to cost-prohibitive markups and introduction of counterfeit products that compromise patient safety. The Food and Drug Administration plays a key role in preventing and managing pharmaceutical shortages, largely through regulations requiring early notification of manufacturing interruptions. Other proposed strategies similarly target upstream causes and center on reducing regulatory hurdles for manufacturers and increasing incentives for market entry and quality improvement. Despite progress in preventing supply disruptions, continued exploration of underlying systemic drivers remains critical to informing long-term solutions and alleviating the clinical and economic impact of drug shortages.
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Affiliation(s)
- Narissa J Nonzee
- Department of Health Policy and Management, University of California, Los Angeles, CA, USA.
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Patt DA. Understanding Utilization Management Policy: How to Manage This Increasingly Complex Environment in Collaboration and With Better Data. Am Soc Clin Oncol Educ Book 2018; 38:135-138. [PMID: 30231339 DOI: 10.1200/edbk_200891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
As innovation in cancer care continues and newer costly therapies receive approval, utilization management will continue to grow as an important way that payers can attempt to control costs and value while providing service to their patients. Although utilization management may be necessary, it takes many forms and is optimized when it ensures appropriate patient access to services and minimizes administrative burdens of physicians and staff. These opportunities are best explored in collaboration with payers. Information systems today provide an excellent platform for data sharing to facilitate collaborative efforts between care delivery organizations and payers to optimize these efforts. As state and national policies differ regarding utilization management, it is important for clinicians to be both aware and involved.
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Affiliation(s)
- Debra A Patt
- From the McKesson Specialty Health/US Oncology Network, Austin, TX
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Liu X, Tang LL, Mao YP, Liu Q, Sun Y, Chen L, Lin JC, Ma J. Evidence Underlying Recommendations and Payments from Industry to Authors of the National Comprehensive Cancer Network Guidelines. Oncologist 2018; 24:498-504. [PMID: 30459237 DOI: 10.1634/theoncologist.2017-0655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/20/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) guidelines are among the most widely used guidance in oncology. It is critical to understand the extent to which the recommendations in these guidelines are supported by evidence and to investigate whether these recommendations have been influenced by payments from industry to authors. MATERIALS AND METHODS We examined the quality and consistency of evidence, as scored by guidelines authors, for systemic treatment incorporated in the NCCN guidelines. Payments data in 2015 were manually abstracted using the Open Payments database, which discloses all payments between the industry and American physicians. Correlations between the percentage of authors who received payments and the proportion of recommendations developed from low-level evidence per guideline were calculated using Spearman rank correlation. RESULTS In total, 1,782 recommendations were identified in 29 guidelines, of which 1,282 (71.9%) were based on low-quality or low-consistency evidence (low-level evidence), including "case reports or clinical experience only" (18.9%). A substantial proportion (31/143, 21.7%) of category 1 (the highest level) recommendations were based on low-level evidence. The majority of authors (87.1%) received payments from industry. However, no association was found between the prevalence of payments among authors and the percentage of recommendations developed from low-level evidence per guideline. CONCLUSION The majority of systemic treatment recommendations in the NCCN guidelines are based on low-level evidence, including more than one in five category 1 recommendations. Payments from industry were prevalent among authors. However, industrial payments among authors were not associated with inclusion of regimen/agent for which there is no conclusive evidence in the guidelines. IMPLICATIONS FOR PRACTICE The authors found that the majority (71.9%) of systemic treatment recommendations issued in the current National Comprehensive Cancer Network guidelines were based on low-level evidence. Physicians should remain cautious when using current guidelines as the sole source guiding patient care decisions.
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Affiliation(s)
- Xu Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Ling-Long Tang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Yan-Ping Mao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Qing Liu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Ying Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Lei Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jin-Ching Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Jun Ma
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, People's Republic of China
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Cheraghlou S, Agogo GO, Girardi M. Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival. J Am Acad Dermatol 2018; 80:979-989. [PMID: 30365997 DOI: 10.1016/j.jaad.2018.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established. OBJECTIVE We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma. METHODS Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile. RESULTS Facility case volume was significantly associated with long-term patient survival (P < .0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities. LIMITATIONS Disease-specific survival was not available. CONCLUSIONS Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - George O Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Gautam S, Sylwestrzak G, Barron J, Chen X, Eleff M, Debono D, Nguyen A, Fisch M. Results From a Health Insurer's Clinical Pathway Program in Breast Cancer. J Oncol Pract 2018; 14:JOP1800157. [PMID: 30321101 DOI: 10.1200/jop.18.00157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
PURPOSE: Pathway regimens are value-driven, evidence-based therapies that aim at high-quality, affordable cancer care. There are few real-world data to support the value of such regimens, especially for patients with breast cancer. MATERIALS AND METHODS: Using nationally representative claims data from Anthem, together with clinical data from its Cancer Care Quality Program, we identified patients with breast cancer for whom chemotherapy was initiated between January 2015 and October 2016. On the basis of demographic and clinical characteristics, patients receiving a pathway regimen (on-pathway cohort) were matched to those who did not (off-pathway cohort) using 1:1 propensity score matching. We compared post-6-month quality-of-care outcomes including hospitalization, emergency department visits, need for supportive drugs such as granulocyte colony-stimulating factor, and cost outcomes between the cohorts. RESULTS: There were 959 patients in each cohort after matching. Patients in both cohorts had a similar age distribution (median age, 52 years in the off-pathway cohort v 53 years in the on-pathway cohort), and most presented with stage II disease (49.4% in the off-pathway cohort v 49.8% in the on-pathway cohort); nearly two thirds of each cohort had hormone receptor positive cancer (67.3% in the off-pathway cohort v 64.9% in the on-pathway cohort). The two cohorts had similar rates of hospitalization and emergency department visits; however, the rate of granulocyte colony-stimulating factor use was significantly lower in the on-pathway cohort (72.5% in the on-pathway cohort v 82.8% in the off-pathway cohort; odds ratio, 0.55; P ≤ .0001). The average post-6-month cost of care was $16,176 lower (95% CI, -$24,291 to -$8,061; P ≤ .0001) in the on-pathway cohort. CONCLUSION: Pathway regimens for breast cancer demonstrate an example of high-value care. They are associated with a reduced cost of care without compromising quality of care.
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Affiliation(s)
- Santosh Gautam
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - Gosia Sylwestrzak
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - John Barron
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - Xiaoxue Chen
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - Michael Eleff
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - David Debono
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - Ann Nguyen
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
| | - Michael Fisch
- HealthCore, Wilmington, DE; Anthem National Accounts, New York, NY; Anthem, Bloomfield Hills, MI; Oncology Solutions, Woodland Hills, CA; and AIM Specialty Health, Chicago, IL
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Rocque GB, Williams CP, Kenzik KM, Jackson BE, Azuero A, Halilova KI, Ingram SA, Pisu M, Forero A, Bhatia S. Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer 2018; 124:4231-4240. [DOI: 10.1002/cncr.31694] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Gabrielle B. Rocque
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Courtney P. Williams
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Kelly M. Kenzik
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Andres Azuero
- School of Nursing; University of Alabama at Birmingham; Birmingham Alabama
| | - Karina I. Halilova
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Stacey A. Ingram
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Maria Pisu
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Andres Forero
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Smita Bhatia
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
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50
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Davis JAM, Miller-Tate H, Texter KM. Launching a New Strategy for Multidisciplinary Management of Single-Ventricle Heart Defects. Crit Care Nurse 2018; 38:60-71. [PMID: 29437079 DOI: 10.4037/ccn2018190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with single-ventricle heart defects, particularly hypoplastic left heart syndrome, have a lifetime high risk of mortality and comorbidities. They have complex medical challenges in addition to their cardiac needs, including growth and feeding complications and neurodevelopmental issues. These concerns require a coordinated effort among specialties to help patients maximize their potential. Additionally, because many complex heart defects are diagnosed prenatally, coordination of care between the pre- and postnatal care teams is imperative. Nursing leadership improves program coordination and efficiency. The purpose of this article is to describe the development and implementation of our hospital's synchronized, multidisciplinary team to support children with single-ventricle heart defects and their families. (Critical Care Nurse. 2018;38[1]:60-71).
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Affiliation(s)
- Jo Ann M Davis
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio. .,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team. .,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital.
| | - Holly Miller-Tate
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
| | - Karen M Texter
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
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