1. DiGiulio, Sarah

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How to deliver better value in cancer care is a question with a lot of different answers. In a new study, researchers took a closer look at patterns and structures within oncology practices across the U.S. to better quantify and make sense of some of those answers.

Douglas Blayney, MD,... - Click to enlarge in new windowDouglas Blayney, MD, FACP. Douglas Blayney, MD, FACP

The research identified three attributes-early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences-associated with practices that deliver the highest value care and had the highest potential for lowering spending without compromising the quality of care, according to the data published in JAMA Oncology (2018;4(2):164-171).


"We tried to find out what the distinguishing difference was [among the practices that delivered high-value care]," Douglas Blayney, MD, Professor of Medicine (Oncology) at Stanford University, told Oncology Times. "Early integration of palliative care, discussing limitations, and ambulatory rapid response of outpatient treatment problems before they became emergent were important."


For the study, the researchers looked at the top seven oncology practices in the Midwest and Pacific Northwest regions that consistently scored the highest on either QOPI measures or Choosing Wisely measures, and for which cost data was available, as measured by insurance claims data. Staff in those practices (including doctors, nurse practitioners, nurses, front office staff, and others who worked in the practice) completed questionnaires about what factors they felt allowed them to deliver high-value care. The researchers also conducted site visits to each of the practices, observed the staff's actions, and asked additional questions of staff. The researchers grouped the responses into themes and then identified 13 attributes overall that helped the teams deliver high-value care. Of those 13, researchers ranked each in terms of the attribute's potential to improve quality of care and lower cost.


The aforementioned attributes were the ones most able to push the needle in both directions. Here's what else Blayney said about the findings.


1 Your research identified three attributes that distinguished the highest-value oncology practices in the subset of practices you reviewed. Can you explain those attributes in more detail?

"The high-value practices seemed to have three things that really stood out. The first included early incorporation of palliative care; and importantly, palliative care was a normal part of the practice and patient care. It wasn't anything that only happened at the end of life. The second thing was what we called ambulatory rapid response, which was ability to rapidly evaluate and care for patients who are having urgent problems before they turned into emergent problems and have to go to the emergency department or be hospitalized. [The third] was that the consequences and limitations of cancer treatment were discussed with patients and their families. And this was an early discussion [in the course of a patient's cancer care].


"Many of the high-value attributes represent a cultural shift in the way oncologists and medical oncologists practice, including early implementation of palliative care and making sure patients understand that, even though we're trying to cure them, some of the treatments we use do have limitations. Those are difficult cultural shifts, but they don't require huge investment in equipment or expensive changes."


2 There were other attributes you identified as being helpful in terms of delivering value. Can you explain those attributes and if any were unexpected?

"There was support for the patient. [Another attribute was that] care team members functioned at the highest level of their license and training. All of the practices, for instance, utilized the nurse practitioners and nurses to deal with symptom management within the scope of their licenses.


"[Another attribute was that] the physical layout and technical support facilitated high-value care. There was a team approach around the patient throughout the care trajectory-meaning, for instance, it wasn't just tech at the infusion center. It was the doctor and the team around the doctor.


"And, finally, we found that practices that function as a small unit, even if they work within a large health care system, tend to deliver higher-value care. And practices where EHRs were effectively used for communication among various components of the practice was foundational.


"I was surprised that there were no major academic medical centers-at least by our standards for this study-that were 'high value.' That's a disappointment to me because I work in one and I think we do deliver high-value care. But it points out that we all have work to do."


3 There's been a lot of research on how to deliver value in oncology. Why is this research important and why are these findings important and relevant now?

"If we move into a prospective payment system, much of the economic risk that was formerly born by insurance companies will be pushed downstream to patients and practices. So it's particularly timely that this research be highlighted so these systems are constructed and these payment models that we build implement these attributes.


"There may be more [attributes] that we have missed or we may be wrong. We've incorporated measures of quality and measures of cost into these questions in asking and answering questions about value. The next thing I think we need to [do is] incorporate the voice of the patient into the discussions around value and the procedures and processes that deliver high-value care.


"I think we have a good start, or [have proposed] a good start, to research methods to answer these questions."