SAN ANTONIO—There have been calls for several years now advocating for early palliative care to be integrated into standard care (OT 11/25/15 issue); one big obstacle, though, as noted here at the American Society for Radiation Oncology Annual Meeting, is that there aren't enough palliative care doctors to go around.
“We need new innovative protocols, new information systems, and new collaborative methods to meet these needs,” said Paul W. Read, MD, PhD, Professor of Radiation Oncology and Otolaryngology/Head and Neck Surgery at the University of Virginia Health System, noting that patient-reported outcomes figure prominently in these systems.
The study he reported (Abstract LBA4) involved “re-engineered” models developed at the university to improve palliative radiotherapy for patients with advanced cancer, and he described the impact of these innovations on hospital cost and patient outcomes.
“Our collaborative patient reported outcome-based approach by palliative care and radiation oncology teams resulted in better outpatient symptom management, a decrease in end-of-life hospitalizations, and reduced costs for late-stage cancer patients,” he said.
3 New Programs
Read described three new programs for advanced cancer patients with bone lesions:
- MyCourse is an NIH-PROMIS (Patient-Reported Outcomes Measurement Information System)-based patient-reported outcomes survey that is embedded in the electronic medical records to share data on patient status and track patient status over time;
- The STAT RAD tomotherapy system uses a “Scan-Plan-Verify-Treat” workflow system for same-day radiotherapy for palliation of bone metastases, with a goal of treatment in three to four hours, from start to finish; and
- In CARE Track (Comprehensive Assessment Rapid Evaluation and Treatment), a palliative care team is alerted by the system about clinically significant reported changes in a patient's status.
“All these programs target patients with the highest symptom burdens because these are the patients with the higher costs of care,” he said.
$7,317 in Savings
To test the effectiveness of CARE Track, Read and his colleagues (all from the University of Virginia) compared end-of-life data for 368 CARE Track patients with that for 198 patients not enrolled in the program.
The CARE Track patients had significantly fewer end-of-life hospitalizations, with 48.3 percent of patients hospitalized in the final 90 days of life, compared with 64 percent from the control group.
CARE Track patients also received more hospice care than the control group (about 70% vs. 47%), which resulted in fewer hospital deaths for the CARE Track group (8.4% vs. 38.5%).
“This difference in end-of-life care resulted in a reduced mean total cost of $7,317 per patient in the last 90 days of life,” he said.
Turnaround Reduced to One Day from Two Weeks
The goal of the STAT RAD rapid workflow plan for palliative radiation therapy for patients with bone metastases was to turn a common treatment course of two to three weeks into a one-day treatment procedure with highly focused radiation treatment with the aim of reducing treatment-related toxicity.
A pilot trial enrolled 28 patients with painful bone metastases (37 target lesions) who received radiotherapy of 5 to 10 Gy per fraction for two to five fractions; an average of 21.6 Gy in 3.1 fractions was administered.
When the patients' pain response and quality of life were assessed, patients reported 80 to 90 percent partial or complete pain relief by three months, and quality of life was significantly improved.
Read noted that a second clinical trial is still accruing patients and is exploring single-fraction STAT RAD, with dose escalation from 8 to15 Gy so that the entire course of simulation, planning, quality assurance, and treatment can be completed in a single patient-centric procedure of just three to four hours.
“Integrating patient surveys to collect patient reported outcomes directly into electronic medical records, and incorporating them into routine clinical care can be done in most hospital systems, and single-fraction radiotherapy for palliation of bone metastases for patients with short life expectancies is accepted in national care guidelines,” he said. “So these programs can all be adopted into clinical practice at most health systems with minimal cost, training, and education.”
At a news conference, the moderator, Brian Kavanagh, MD, Interim Chair of the Department of Radiation Oncology at the University of Colorado School of Medicine—and President-elect of ASTRO's Board of Directors—said that initiatives such as CARE Track are very important in light of the rapidly approaching era of alternative payment models: “It's not far away that we'll become responsible, as a team of health care providers, for patients throughout their care experience, and we'll be held responsible financially and otherwise for unnecessary expenditures.
“A groundbreaking program like this is really setting the benchmark in terms of results that can be achieved.”
He said he hoped this team-based program will be a model for other centers, as it nicely integrates all the health care providers involved in the care of patients in the last stages of their lives. “This team not only did a terrific job providing better quality of care but also in reducing the costs, and this is a prime example of elevating the patient care experience and improving quality of life and quality of outcomes.”
Pushback from Hospital Administrators?
Kavanagh asked Read if there was any pushback from hospital administrators regarding the idea that “you're saving money, but also reducing cash flow.”
“Hospital administrators have gotten savvy over the past few years in that they don't like to see reduced revenue but they also do like to see improved quality metrics,” Read responded.
Benjamin Movsas, MD, Chairman of Radiation Oncology at Henry Ford Hospital in Detroit, who was the co-moderator of the clinical trials session where Read spoke, was asked afterwards to comment on the STAT RAD trial: “There's a lot more that we health care providers can do to better facilitate and enhance palliative care for our patients, and this was a great example of that,” Movsas said.
“We provide palliative care day in-day out, but we can do more to streamline it; we can do more to make it more accessible.”
He noted that this was a small pilot trial and that other institutions, including his own, are doing similar kinds of processes: “But it's important for people to see this and start thinking about how they can apply some of these principles. It's all about putting the patient in the center of what we do and getting the team to see that vision.”