High-Value Cancer Care Keeps Costs Down? Yes, It's Possible!

Roxanne Nelson, RN, BSN

November 16, 2017

NOVEMBER 21, 2017 — UPDATED WITH INTERVIEW //  It is possible to both provide high-value cancer care and keep costs in check, new findings suggest.

In a survey of seven US oncology practices, researchers identified several attributes that were associated with high-quality, low-cost care.

The attributes that set high-value practices apart from average-value ones included the following:

  • Taking a more conservative approach to diagnostic testing;

  • Early discussion with patients about the limitations and goals of cancer care;

  • Early involvement and normalization of palliative care;

  • Allowing staff to practice at the highest level of their license and competence; and

  • Having smaller units of care delivery affiliated with a larger healthcare system.

"Our findings suggest that many of the places that provide high-value care are also particularly good at providing these often unreimbursed, nonmedical services," said lead author, Douglas Blayney, MD, a professor of medicine at Stanford University School of Medicine in California, and a former president of the American Society of Clinical Oncology (ASCO).

The results were published November 16 in JAMA Oncology.

Reducing cost while at the same time providing high-quality care to patients has long been a goal of the oncology community. The implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act, the Oncology Care Model, and Accountable Care Organizations have  also provided financial incentives for institutions that provide high-value care, thus making the issue even more timely.

One initiative designed to improve quality in ambulatory settings, where most cancer care is delivered, is the Quality Oncology Practice Initiative (QOPI)  developed by ASCO.

QOPI is an oncologist-led, practice-based quality assessment program that is "designed to promote excellence in cancer care by helping practices create a culture of self-examination and improvement." Previous research has shown that outpatient oncology practices participating in QOPI demonstrated marked improvement  in overall quality of care, as reported by Medscape Medical News.

Looking at Practice Level

In this "exploratory hypothesis-generating study," Dr Blayney and colleagues looked at the variation in total spending and quality of care in order to evaluate oncology practice attributes demonstrating high value. They used the "positive deviance" technique, which identifies uncommon but successful behaviors or strategies that result in solutions superior to existing ones.

The study included seven oncology practices located near the US Pacific Northwest and Midwest that had low mean insurer-allowed spending and  were QOPI certified. The cohort comprised four positive deviant oncology practices ( low spending) and three practices that ranked near the middle of the spending distribution.

"The ground-breaking part of this is that we went at a very granular level to look at doctors and teams to see how they delivered high-quality care," Dr Blayney told Medscape Medical News. "There have been a lot of high-quality studies of what organizations, health plans, large networks, and third-party payers do to stimulate or deliver high-value, but none at this level."

He explained that the researchers looked at value from the practice level, at individual doctors, nurses, nurse practitioners, and front office staff, and how they delivered high-value care.

"Some of these attributes will be relatively easy for other practices to implement, while others will take time and require development of the team," explained Dr Blayney, "And some are just ways of looking at things we already do."

One example of a high-value intervention was what is referred to as rapid ambulatory response. "When a patient calls with a symptom or problem, rather than directing them to the emergency department, which is commonly done, the high-value practices will try to figure out a way to handle it," he said.

If pain relief, antibiotics, or hydration is needed, for instance, they will try to treat the patient at their facility or refer to a local urgent care center. "So that's an example of reconfiguring something we already do," Dr Blayney said.  

Attributes Emerge

The study design included site visits to interview practice personnel with a structured tool that was designed before site visits and contained questions covering clinical, nonclinical, and quality management topics. A panel of experienced oncologists then reviewed the attributes that occurred uniquely or frequently and assessed their contribution to improving value.

They identified a total of 13 attributes that likely affected care cost and quality. Of this group, the authors further identified 5 attributes that were "unique" and detected only in high-value practices. An additional 5 "distinguishing" attributes were seen more frequently in high-value practices but were also found in the comparator groups. The remaining 3 attributes were considered "nondistinguishing" and occurred at the same rates in both high-value and comparator practices.

Within the 13 attributes, 5 themes emerged: treatment planning and goal setting, services that support the patient's journey, technical support and physical layout, care team organization and function, and external context.

The 5 attributes that were most associated with high-value practice sites were the conservative use of imaging, early discussion of the limitations and consequences of treatment, single point of contact, making maximum use of registered nurses for interventions, and a multicomponent healthcare system.

The expert oncologist panel further found that early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences had the greatest immediate potential to decrease cost without affecting quality of care.

A similar paper published online November 13 in Annals of Family Medicine  looked at the distinguishing features of high-value primary care practices. "These studies are unprecedented, not only in what they examined, but in their potential to affect the practice of medicine on a national level," said Arnold Milstein, MD, MPH, a senior author of both studies and professor of medicine at Stanford University, in a statement.

Good Starting Point

Approached for an independent comment, Jeffrey Peppercorn, MD, MPH, an associate professor of medicine at Harvard Medical School and director of the Massachusetts General Hospital Cancer Survivorship Program in Boston, noted that the three "key" attributes identified by the authors were important.

"A number of studies have shown that we provide a tremendous amount of care in the last year of life, some of which may be necessary and desirable and some of which is disease directed care — active chemotherapy," he said. "But we know, also from studies, that if we have longer discussions with patients and give them options, in some cases patients would forgo that. And in some settings, patients may live longer and better if they are getting palliative care alone rather than additional lines of therapy."

The way that this attribute may save money is presumably by reducing emergency department visits and steering patients more toward comfort and symptom-focused care rather than expensive oncology drugs and intensive care unit admissions, he noted. "And also by not ordering unneeded labs and imaging, and avoiding duplication."

"The key here is saving money and delivering high-quality care," said Dr. Peppercorn. "But if you're the patient, you want outcomes that are just as good, care that is just as good, and to have your physical, emotional and disease needs addressed. And if that can be done more efficiently, then who wouldn't be interested in that."

The need for early palliative care has been demonstrated in a growing body of research, he noted. "A number of studies have shown that we spend a tremendous amount of care in the in the last year of life, some of which may be necessary and desirable and some of which is disease-directed care."

"But we know, also from studies, that if we have longer discussions with patients and give them options, in some cases patients would forgo that," said Dr Peppercorn. "And in some settings, patients may live longer and better if they are getting palliative care alone rather than additional lines of therapy. "

In addition to this study, there is a lot of evidence that this is the way to go in oncology. "The message is out there, ASCO [American Society of Clinical Oncology] has embraced it, I've been part of the effort to put out policy statements on the need to individualize cancer care," he continued. "We have guidelines related to palliative care and calling for early palliative care, and I think it is encouraging that practices that are implementing this, and meeting the basic quality metrics, are apparently lowering overall costs."

But he also pointed out that not everyone has access to palliative care, and as the authors acknowledge, the most effective components of palliative care to control symptom burden and improve quality of life have not yet been well defined. "So the question is, Can this be done in all settings?" he said. "These practices were all affiliated with a larger healthcare system, and there could be barriers for practices that don't have that affiliation, but there is a need to address that."

The same is true for being able to keep patients out of emergency care. "Again, not every practice is set up or has the resources to have their own urgent care or walk-in clinic," Dr Peppercorn explained, pointing out that these practices had contracted with an urgent care center or had  established the means to care for patients at their own facility.

"But this again seems to me far more desirable than having to send the patient to the [emergency department]," he said. "So I think that all practices big and small should be looking for ways to provide better urgent care for cancer patients."


"Tantalizing," but Limitations Persist

The study on the high-value oncology practices takes an "innovative and thoughtful approach to clearly and specifically identifying attributes" of such practices, say editorialists writing in an invited commentary in JAMA Oncology. The authors are Harold Sox, MD, from the Patient-Centered Outcomes Research Institute in Washington, DC; Ethan Basch, MD, from the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill; and Donald Berwick, MD, from the Institute for Healthcare Improvement, Cambridge, Massachusetts.

"The promise of this study — that these attributes might be replicable and foster high-value care in community oncology practice — is tantalizing," they write.

Nevertheless, there are many limitations, they caution. The study doesn't investigate whether the attributes identified are directly responsible for value, or whether they may just be correlates of "upstream true causes, such as leadership, culture, and staffing," they note.

Another limitation is that the study does not give any in-depth information on how the high-value practices implement the 5 attributes.

The study is also too small to reach any conclusions. "A sample comprising only 4 high-value practices and 3 average-value practices offers stimulating ideas, not proof that implementing the attributes associated with high-value practices will lower cost and improve quality," the editorialists comment. In addition, the quality of care within these practices was not independently confirmed.

Finally, there is no input from the patients themselves, as far as ratings or observations about their care.

But despite the limitations, the editorialists note that the "authors deserve our thanks."

This study is "especially refreshing in its close attention to specific designs and processes in care," and it "provides a framework for future work connecting processes with overall value and potentially with clinical outcomes," the editorialists comment.

Dr Blayney noted that they are developing learning videos, which will run about  6 to 8 minutes and are suitable for a small team to effect change and physician behavior. "We are looking at venues and looking to test efficacy of the videos, so that will be our next step."

This study was supported by a grant from the Peterson Center on Healthcare to the Clinical Excellence Research Center, Stanford University (Dr Milstein, principal investigator). Dr Blayney reported serving as a paid consultant for the Michigan Oncology Quality Consortium, a volunteer leader of the Quality Oncology Practice Initiative certification program for ASCO, and as a paid consultant for and stockholder in Physician Resource Management Inc and CARET. Melora Simon has an immediate family member who is employed by and is a shareholder of Guardant Health Inc. No other financial relationships were disclosed. The editorialists have disclosed no relevant financial relationships

JAMA Oncol. Published online November 16, 2017. Study full text, Editorial

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