In the COVID-19 era, community oncology practices are making changes to serve their patients safely. They described these changes during the virtual Community Oncology Advocacy Summit sponsored by the Community Oncology Alliance (COA), whose membership is comprised of physician-owned practices.
“Taking care of patients during COVID is an entirely new experience,” said Rose Gerber, a cancer survivor and COA's Director of Patient Advocacy and Education. She noted that the COA Patient Advocacy Network focuses on and advocates for patients' needs at the federal, congressional, and community level.
“What is the new normal?” asked Ted Okon, MBA, Executive Director of COA. He noted that oncology practices had to rethink everything from the waiting room to the chemotherapy suite. “We have no idea right now when this will end...it really is a big black hole,” he added.
Embracing the Change
In mid-March 2020, community practices started experiencing a major drop in patients, according to summit speakers. About 30 percent of oncology practices saw at least a 30-49 percent drop in patient volume, said Lucio Gordan, MD, Managing Physician and President of Florida Cancer Specialists and Research Institute.
“It's very significant,” he said. The drop in volume primarily reflected a reduction in new patient encounters, but it also included return patients, Gordan noted. He also said most practices saw a drop of at least 30 percent in clinical trial participation, which can prevent cancer patients from getting cutting-edge therapies and delay trials whose results could bring potential new therapies to the oncology field.
But, Gordan stated that most practices have continued to maintain treatments on schedule and maintain their workforce without furloughs. “We are resilient.” He noted that “telehealth has been incredibly important” in continuing to provide care for patients. But he did say the pandemic has caused concern among community oncologists about their practices during upcoming months and beyond: “There is significant uncertainty about the future.”
Agreeing on the dip in patient volume in mid-March was Bobby Green, MD, Chief Medical Officer at Flatiron Health. Overall, he said Flatiron data on community oncology practices showed that beginning in mid-March there was more than a 70 percent increase in patient visit cancellations and a drop of more than 30 percent in daily non-infusion visits. Visits for mammography and colonoscopy screening plunged.
“At least in the cancer world, things are starting to get back to normal,” said Green. He agreed with Gordan that telehealth has been a boon, and hopes the reimbursement expansions adopted because of the pandemic remain. But he said this is a time of change: “I think there's a lot of uncertainty about what is going to happen next,” but acknowledged Flatiron is working with practices to help them support telehealth and remote care, track data, and leverage data to drive decisions.
Miriam Atkins, MD, FACP, an oncologist with Augusta Oncology and Medical Co-Chair of COA's Patient Advocacy Network, noted that changes were made to the office in her practice to help keep patients safe and give them reassurance. The practice instituted telehealth, changed the conformation of chairs in treatment rooms, and increased communication with patients to help keep them out of the emergency department. She said the message the staff conveyed was “Do not let fear get in the way of your health. It is safe to go the doctor's office and the hospital for procedures.”
Major changes were also made as a result of the pandemic in the practice of Lakshmi Aggarwal, MD, an oncologist with Fort Wayne Medical Oncology and Hematology and Medical Co-Chair of COA's Patient Advocacy Network. “Literally, we were flying the plane as we were building it,” she said. The practice established a COVID task force and studied guidelines from the Centers for Disease Control and Prevention every day. “The last thing we wanted was panic,” said Aggarwal. “It takes a crisis sometimes to get your laser focus together.” Literally overnight the practice had handmade masks and it had to establish additional financial resources for patients.
Because a significant proportion of cancer patients are elderly and have comorbid conditions, the practice had to frame risk scenarios for these patients, Aggarwal noted. There was a need to make difficult triage decisions about COVID risk versus the risk of cancer relapse or progression. Using a steep learning curve, oncologists employed telehealth for patient visits when appropriate, and it was valuable in including multiple family members on these virtual visits when patients asked for them. Telehealth with family members was especially helpful on end-of-life care issues, she said.
“In oncology, we had to have empathy,” said Aggarwal. “It's a human story of how we can transcend all these problems... It shows us the richness of the human experience and how much reserve we have.”
Atkins and Aggarwal were adamant about not doing home infusions for their cancer patients, and COA has stated publicly that it is against them because they are unsafe.
“In oncology, there is really no place for home infusions. There is nothing that replaces our eyeballs on the patient,” said Aggarwal. “Home infusion is quite dangerous and I am against it,” said Atkins. She noted that some infusion patients develop anaphylaxis, which can be life-threatening.
“We want to keep our patients out of the hospital unless absolutely necessary,” said Debra Patt, MD, MPH, MBA, Vice President of Texas Oncology in Austin. She believes telemedicine can help patients avoid the emergency department. Noting that she is seeing about a quarter of her patients by telemedicine, Patt said “it's safe and it provides great care.” She also believes that telemedicine can personalize discussions around the social aspects of care.
But Patt, who has given many telemedicine webinars, noted that telehealth requires good training, information technology support, and correct billing and coding. She also noted the importance of making sure the operating system is updated. She said there are two main system challenges: the ability of older patients to download a telemedicine application and limitations on high-speed bandwidth, especially in rural areas. While it is a valuable tool, “telemedicine is sort of like wearing a mask,” said Patt. “It's not something you would elect to do if it wasn't necessary.”
In telemedicine visits, patients also need to understand and appreciate the need for privacy, said Alti Rahman, MHA, MBA, CSSBB, Practice Administrator of Oncology Consultants in Houston. For example, he said patients should give their consent for a telemedicine visit (preferably in a digital form) and should not participate in such a visit in a public place.
“I think telemedicine is most important for rural patients,” Patt. She noted that it is not enough just to send a digital link to a patient for a telehealth visit, because “they'll think it's spam.” The telemedicine app requires a careful explanation. She stressed that advocacy for good telehealth regulation at the state and federal level requires the patient voice.
“There's no voice that's more powerful in trying to influence change in cancer care than patients.” While telemedicine can be a boon, especially during the pandemic, it is misleading to think that it causes more physician efficiency,” said Patt. “It takes longer; it's more difficult and challenging,” she emphasized.
Care After COVID
In a dialogue, two professionals at the summit said looking to the future of community cancer care post-COVID is likely to include specific changes and adaptations as a result of the pandemic.
Barry Russo, MBA, Chief Executive Officer for the Center for Cancer and Blood Disorders, and Anthony Scalzo, MD, President of Hematology-Oncology Associates of CNY, said these adaptations are likely to include the following:
- Continued COVID infectious disease testing of staff and patients, and COVID screening for visitors (if allowed) and delivery people, by temperature screening at the door, for example. Continued use of masks.
- Improvements in the use of telehealth, such as more structured software.
- Increased use of patient electronic communication systems for patients who will not be seen in the clinic as often as has historically been done. App-based, text-based communication should be made easier for patients.
- Management of pre-surgical patients in supportive ways that keep them out of the hospital before surgery.
- Isolation rooms for COVID-positive or possibly positive patients. Scalzo said at his institution an isolation room was established in the infusion area.
- Focused management of high-risk populations, including separate treatment areas and more electronic connectivity.
- Finding ways for interaction with and inclusion of family members and caregivers who can no longer accompany patients for treatment. “This is a huge challenge,” said Russo, because the caregiver is the patient's support system. Scalzo noted that he is making more calls to caregivers, and “they can't be left out.”
- Greater attention to disinfection and safety measures in waiting rooms, infusion suites, and radiation and radiology dressing rooms. The aha moment for Scalzo was concern about infection control. “Why weren't we doing this for flu season?” he asked.
- More patient education in a virtual world. Scalzo noted he is seeing more patient education on his institution's website, more chemotherapy education is being delivered by telehealth, and educational materials are being mailed to patients. Russo said he sees the future of patient education as being delivered via an app for a smartphone.
To help cancer patients who have experienced financial hardship due to COVID-19, COA established the Patient Practice Connector, a free program to ensure patients could find accessible treatments in their area.
COA also partnered with the patient support organization CancerCare to start the Patient Assistance Transportation Program, which provides free rides to and from treatments in sanitized vehicles, and started the Patient Financial Assistance Fund, which provides grants of $500 to help patients with living, transportation and treatment-related expenses.
Peggy Eastman is a contributing writer.
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