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ASTRO13: Key Takes on Health Care Reform and Smarter Research

DiGiulio, Sarah

doi: 10.1097/01.COT.0000438501.48962.d4


ATLANTA—With pervasive system-wide changes due to changing health care law, rising costs of care, and new technology, focusing on the patient is important now more than ever. So said ASTRO 2012-13 President Colleen A.F. Lawton, MD, FASTRO, speaking here at the opening news briefing at the Society's Annual Meeting. “If we focus on the patient and think about what's best for the patient—and think about the science related to what's best for the patient—the rest will naturally follow, such as payment and good care.”



That was the overall theme of the meeting—patient-centered care and the importance of the physician's role in helping with patient-reported outcomes and the quality and safety of patient care.

During the first keynote address, Darrell G. Kirch, MD, President and CEO of the Association of American Medical Colleges, said it was physicians' ethical obligation to patients to practice more responsible, sustainable care.

“Health care now in the United States is showing all the features of pricing services extended past the natural level. It's unsustainable,” Kirch explained during his lecture, which he titled, “Is There Hope for ‘Healing’ Health Care?”

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Reining in Costs

The U.S. national debt (as of the time he spoke) was just shy of $17 trillion—a number larger than the country's annual gross domestic product, Kirch noted. And specifically in health care, the U.S. has seen a loss in income per capita since 2000, but a dramatic increase in health care spending, which is not improving quality of care, he added. “We not only are breaking the bank in an unsustainable way, but our outcomes are suffering—and the system is riddled with overutilization and favors—a very toxic combination.”

The goal in reining in costs, he said, is to create an overall health care system that provides better care experiences for individuals and better health overall for populations—the concept known as the “Triple Aim” (coined in 2008 by Donald Berwick et al—Health Affairs 2008;27:759-769). “I would argue that we not only want to be the solution, but we have to be, because all those other entities that we're blaming for health care costs actually have less overall control than we do,” Kirch said.

He listed six action items for all clinicians to focus on, which he said would move health care closer to the Triple Aim:

  1. Move the institutional culture of health care away from being hierarchal, competitive, individualistic, and expert-centered, to being more collaborative and patient-centered;
  2. Harness the power of interprofessional teams at the organization level (to not only provide team-based care, but also to help figure out how to fix the delivery system);
  3. Make care truly patient-centered by engaging individuals more in their care so that they have realistic expectations;
  4. Look for future leaders who are “multipliers”—those who lead by bringing out the “genius” in those around them rather than by acting alone;
  5. Foster medical students and residents to follow these changes; and
  6. Take responsibility to fix the problems facing health care (rather than blaming other players, such as politicians or insurers).


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Quality, Payment Reform, and Patient Care

During a session titled “Overuse, Underuse, and Misuse of Radiation Therapy and the Future of Radiation Oncology: Impact on Quality, Payment Reform, and Patient Care,” speakers addressed the implications of the Institute of Medicine's recent “Delivering High Quality Cancer Care” report (10/10/13 issue).

A coauthor of the report, James Alan Hayman, MD, MBA, Professor in the Department of Radiation Oncology at the University of Michigan, summed up the report's conclusions: “The cancer care delivery system is in crisis; and cancer care is often not as patient-centered, accessible, coordinated, or evidence-based as it could be.”

The recommendations emphasize making health care more affordable by eliminating waste and reforming payment models. To move ahead, professional societies like ASTRO need to engage in those efforts—efforts that ASTRO is already engaged in, but will need to continue to increasingly be a part of, he said.

ASTRO's ‘Choosing Wisely’ list (OT 10/25/13 issue) is a first step, but the next step is finding new payment models that move away from traditional fee-for-service models, he said.

The Chairman of ASTRO's Health Policy Council, Brian Kavanagh, MD, MPH, and Professor at the University of Colorado Denver, highlighted ASTRO's three-phase plan for payment reform, which the Society announced earlier this year (OT 6/10/13 issue): (1) redesign key radiation therapy codes, (2) implement quality-based incentive payments, and (3) incentivize cost-effective cancer care.

“The goal ultimately is to figure out systems that would reward radiation oncologists for improving quality through various initiatives while lowering costs,” Kavanagh said. The mantra for ASTRO, in terms of a strategy for such reform, is the value proposition—a concept discussed, he noted, at the 2012 ASTRO meeting by Michael E. Porter, PhD, MBA, of Harvard Business School (OT 12/25/12 issue): “If we keep as our mantra, our theme, and our objective that everything we do is meant to be better for our patients, we really won't go too far off course,” Kavanagh said.





Among the more innovative reform models currently being researched, he noted, are:

  • Pathway-type models, which encourage the consistent delivery of value-driven, evidence-based treatment with the goal of delineating treatment options that maximize survival benefit, minimize toxicities, and provide cost-saving advantages (a model currently being tested in eight U.S. Oncology Network practices);
  • Episodic models, which bundle costs of care to include potentially preventable complications (to try to reduce overall costs managing toxicities, which would encourage care integration); and
  • Conditional management (i.e., a “retainer” model), which pays providers to manage a condition rather than every “piece of care.”

But, he added in an interview after the session, no matter what cost models are explored, the patients' interests come first: “We can't let quality of care go down—that is the point of no compromise.”

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Patient-Reported Outcomes

The focus on quality and on patients continued through the scientific sessions at the meeting. The relevance of using patient-reported outcomes (PROs) in research to improve care was the topic of a Presidential Symposium Session, as well as an education session and a plenary paper.

The idea is that patient-reported assessment of quality of life taken before, during, and after treatment can improve patients' quality of life and survival, said Jeff Sloan, PhD, Professor of Biostatistics and Oncology at Mayo Clinic, speaking during a Presidential Symposium Session. “The message from today is that this is doable. It's scientifically sound and doable.”

Research has shown that, in studies that collect PRO data, those measures are accurate prognostic factors for survival that can help clinicians improve quality of life and consequently quality of care, he noted during an education session on how clinicians can use PROs.

One review he cited found that in 36 of 39 studies, at least one PRO measure was significantly associated with survival, and PROs were better predictors of survival than performance status was (JCO 2008;26:1355-1363). Another large-scale meta-analysis of 104 studies found that quality-of-life measures were significant predictors of survival duration across patients with lung, breast, gastro-esophageal, colorectal, head and neck, melanoma, and other cancers (Health and Quality of Life Outcomes 2009;7:102).



PROs should be used as an integrated tool that help clinicians understand when patients have concerns, and adjust treatments or make referrals accordingly to improve patients' quality of life, he said. “On top of performance status, we know that if you add overall QOL and fatigue assessment, you can account for a lot more variability in the survival model.”



Sloan and his team are evaluating a biomarker tool that asks one question: On a scale of one to 10—one being as bad as it can be, 10 being as high as it can be—how is your quality of life? In their analysis of 23 trials, which include more than 3,700 patients, they have shown that across gastrointestinal, genitourinary, lung, and breast cancers, and comparing for age, race, and disease status, patients who score five or less on that scale have twice the risk of death as the patients who report higher scores.

The model that works, he explained, is asking a limited number of simple questions that serve as screens to alert clinicians where patients may be experiencing quality-of-life concerns—for example, saying something like. “We're going to ask a couple of questions: How's your quality of life? and What's your single biggest concern right now?”

The second plenary abstract ( at the meeting reported quality-of-life data from the RTOG 0617 trial of 357 patients with locally advanced non-small cell lung cancer, revealing the reason patients receiving higher doses of radiation had fared worse than patients receiving lower doses—and illustrated the value of collecting patient-reported outcomes in clinical trials (see page 12).

The message, the lead author, Benjamin Movsas, MD, FASTRO, Chair of the Department of Radiation Oncology at Henry Ford Health System, explained during a news briefing, is to use not just the objective, provider-based toxicity information. “Talk to your patients. Find out what they're experiencing. Incorporate quality of life into your studies and your clinic—that will provide you with a much broader perspective in determining those next steps and how to move forward with new strategies.”

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‘PROs Have Traction’

ASTRO's efforts behind health services research are growing—and patient reported outcomes are an important piece, Michael L. Steinberg, MD, FASTRO, now Immediate Past Chairman of the Board of Directors, explained in an interview at the meeting. “The concept of patient-reported outcomes has been around, but it has traction now in our society.”

ASTRO is currently funding research to create a patient-reported outcomes tool specific to radiation oncology, and the goal is to have it ready to be presented at next year's Annual Meeting, he said.

“There's a science to what we're doing in payment reform. There's a science in terms of how we react with our patients and improve those communications. The science learned will help engage the value proposition—and ultimately benefit the patient. Value needs to be expressed in terms of the customer. In this sense the customer or the receiver of the value is the patient.””

© 2013 by Lippincott Williams & Wilkins, Inc.
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