ASTRO 2015

Patient-reported feedback improves outcomes of palliative radiation therapy and care

Prof Paul Read – University of Virginia Health System, Charlottesville, USA

Over half a million patients in the United States are going to die of cancer. We were fortunate to receive a large grant from the Centres for Medicare Services, CMS, as part of their Innovation Healthcare Challenge Award programme. We focussed on trying to tackle the management, the outpatient management, situation of advanced cancer patients, i.e. how could we improve patient management so that patients didn’t have to get hospitalised towards the end of life, mainly for symptom management or iatrogenic toxicities. The real question was could we build programmes where we would listen carefully to our patients, we would identify if they were having rapidly changing situations like escalating pain that needed to be managed quickly before they escalated to the point of having to be hospitalised. So we built systems to do just that.

The way we listened to patients in addition to interviewing them and talking to them when they come to clinic is to have them fill out a little patient reported outcomes survey that we actually integrated into our electronic medical record. This is very simple for patients to do on a tablet or their phone, and then we can track their symptoms longitudinally so we know if their pain is escalating because we can see that from two weeks ago until now their pain was a four and now it’s a seven, something’s happening. We can target our discussions with them based on the changes in this status. In addition to that we built a palliative care team that included not just palliative care physicians but radiation oncologists, pain anaesthesiologists, some surgical oncologists and medical oncologists as well as pharmacists and social workers, all to help manage these patients. We meet once a week, we talk about the most symptomatic ten or twelve patients and come up with co-ordinated care plans for them. As part of this programme to rapidly respond to patients’ needs we built a radiation treatment strategy for patients with advanced bone metastases that are causing pain where patients can come and have their CT scan, the planning for their treatment, the quality assurance and the actual very high dose treatment that’s very localised and conformal to their treatment, all in about three or four hours as opposed to spending two or three weeks having that done which is very common in the United States.

Could you describe the study that you did?

We looked at a control patient population which were patients who were deceased at our institution that never saw palliative care in the outpatient setting and compared that to these patients who were followed on our CARE Track programme. CARE Track stands for comprehensive assessment, rapid evaluation and treatment. We saw dramatic reductions in hospitalisations when these programmes were implemented. There was a 20% reduction in hospitalisations in the last 90 days of life; there was a 50% reduction in hospitalisations going from 60% in the control group to 30%, roughly, in the CARE Track programme group in the last month of life. Patients dying in the hospital was only about 8.4% of patients died in the hospital in the CARE Track group versus approximately 38% of patients in the control group. Hospice was utilised more commonly and for longer periods of time in the CARE Track group and there was an average cost saving of about $7,300 for patients. All of that was due to reduced in-patient costs.

How applicable is the clinical paradigm used to the wider setting of radiation oncology?

What we built is fairly straightforward; building a little questionnaire into an electronic medical record is fairly simple, any place can do that. We happened to call this PRO, this patient reported system, My Course so that patients knew why they were filling it out and what we were doing with it to give it a name. The supportive care tumour board where a group of people get together, oncologists are used to doing that every week to take care of curative cancer patients so that’s not a foreign concept, it’s simple to do, it doesn’t cost anything really and the ability to treat people in a single day. I’m hopeful that some of the research that we’ve done, especially implementing new quality assurance systems, that we can help push that out into more cancer centres. Actually, I’ve been approached by several people here at ASTRO after my talk asking if we could help them actually do just that, build such programmes.

Is there anything else about the programme that you would like to highlight?

I do think that as we move into value-based cancer payment reform that programmes like this that focus on the patient, that are patient-centric. The supportive care tumour board creates these unique patient-centric care plans that are co-ordinated amongst specialists. The treating the patient with radiation, for example, in one day requires a totally new kind of workflow where instead of somebody doing something one day, somebody doing it the next and the next, that that is also very patient-centric. I think that we’re going to have to get used to that, moving forward because, at least in the United States, healthcare reimbursement is going to be value-based and that our speciality and all specialties are going to have to work together to deliver the best patient-centric care that really adds value and, where possible, reduces costs.

What is your take home message?

I would say think about building programmes that if you had cancer or your family member had cancer you would want for yourself or them. I think that’s going to be the types of programmes that survive in a value-based environment.