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Patient-reported feedback improves end-of-life care, reduces costs among patients with advanced cancers
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Coordinating palliative care and radiation oncology for advanced cancers based on patient-reported outcomes improved outpatient symptom management and reduced costs and hospitalizations at the end of life, according to study results presented at the ASTRO Annual Meeting.
Further, a rapid palliative radiotherapy modality that included a shorter but more intense course of treatment appeared to hasten pain relief.
“If we listen to our patients carefully, talk to them about their changing medical and emotional needs and develop rapid and coordinated treatment plans we can improve their quality of life and reduce their need for hospitalization for symptom management at the end of life,” Paul W. Read, MD, PhD, professor of radiation oncology at University of Virginia, said in a press release. “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.”
Read and colleagues developed a patient care program in 2012 for patients with advanced cancer by integrating a Patient Reported Outcomes Measurement Information System-based patient reported outcomes database — named MyCourse — into their electronic medical record. The methodology included a patient questionnaire that tracked emotional and physical data, which would alert a comprehensive assessment and rapid evaluation and treatment (CARE Track) palliative care team to any clinically significant changes to a patient’s reported status.
Researchers began testing patient-reported outcomes as a measure for the care model in February 2013 and implemented them as a permanent measure in October 2013.
Overall, 646 patients were enrolled into the CARE Track program. Researchers compared end-of-life data from 368 deceased CARE Track patients with 198 patients in a cohort of matched deceased institutional controls.
The 368 deceased CARE Track patients completed 967 patient-reported surveys. This cohort had significantly fewer end-of-life hospitalizations than controls; 48.3% were hospitalized within the final 3 months of their life compared with 64% of the control arm (P = .0004).
Further, more CARE Track patients received hospice care (69.6% vs. 47%) and spent longer in hospice (median stay, 22 days vs. 13 days; P = .0004) than patients in the control group. This resulted in fewer hospital deaths for the CARE Track patients compared with controls (8.4% vs. 38.5%; P < .0001 for both).
Results of a cost analysis showed these reductions in hospitalizations and hospital deaths decreased the mean total cost of care per patient by $7,317 in the final 90 days of life (P = .0128). Mean inpatient costs in the final 90 days of life also were significantly smaller ($12,976 vs. $20,398; P = .0065).
As a second component of the study, a multidisciplinary supportive care tumor board developed rapid and coordinated care plans for highly symptomatic patients in an effort to respond more quickly to pain control. The board developed a workflow called STAT RAD that expedited a typical 2- to 3-week radiation treatment course into a 1-day procedure for patients with bone metastases. This approach also included a highly focused radiation treatment to reduce toxicity.
The pilot clinical trial to test STAT RAD enrolled 28 patients. Each patient had one to three painful bone metastases (a total of 37 target lesions) and received 5 Gy to 10 Gy per fraction for two to five fractions. On average, patients received 21.6 Gy in 3.1 fractions.
The researchers measured pain response and quality of life following STAT RAD. Patients reported between 80% to 90% partial or complete pain relief by 3 months. Further, quality of life significantly increased for patients between 1 to 26 weeks post STAT RAD.
Read indicated that a second trial was still accruing patients and will explore single fraction STAT RAD with dose escalations between 8 Gy to 15 Gy so the entire course can be completed in one patient session.
“The concept of tumor boards for multi-specialty care planning of curative cancer patients is practiced throughout the country, and extending this concept to palliative care management is easy and straightforward,” Read said. “Single fraction radiation therapy for palliation of the bone metastases for advanced cancer patients with short life expectancies is an accepted national care guideline and has been studied for decades in clinical trials. Therefore, these programs can all be adopted into clinical practice at most health systems with minimal cost, training or education.” – by Anthony SanFilippo
For more information: Read PW, et al. Abstract LBA 6689. Presented at: ASTRO Annual Meeting; Oct. 18-21, 2015; San Antonio, Texas.
Disclosure: HemOnc Today was unable to confirm the researchers’ relevant financial disclosures at the time of reporting.
Perspective
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Bhupesh Parashar, MD
At present, patients receiving palliative treatments for advanced/metastatic cancers are offered treatment options including chemotherapy, radiation, radiofrequency ablation, or surgery (for select patients) either alone or as a combination. Usually — in most cancer centers in the U.S. or around the world — it’s a fragmented approach with referrals made to different specialties either by the primary care team or by a team of medical/radiation oncologists. This system is inadequate for many reasons — the assessment of the palliative needs of the patient is frequently made by individual physicians who may not be adequately trained in all aspects of palliative care. Therefore, patients end up getting inadequate care and compromised end-of-life management including highly variable treatment recommendations. In addition, because of the lack of centralized system of palliative care, patients are inadequately managed and can be lost to follow-up in between specialists (ie, either patient did not communicate or physicians did not make contact).Read and colleagues at University of Virginia tried to address these issues using a unique approach of patient-reported outcomes (PRO), quick centralized data entry into electronic medical records (EMR), a system of alerts to critical changes, and rapid evaluation and treatment by a palliative care team. This team integrated a PROMIS-based PRO database, called MyCourse, into their EMR. Critical patient changes triggered an alert for comprehensive assessment and rapid evaluation and treatment (CARE Track) by a palliative care team. In addition, a multidisciplinary Supportive Care Tumor Board met regularly and developed plans for highly symptomatic patients. They implemented a “one day Scan-Plan-QA-Treat radiation workflow” and piloted high-dose and highly conformal 2 to 5 fraction (STAT RT) and 1 fraction (STAT RAD) treatment for bone metastases.
Using this system, a total of 646 patients with cancer were enrolled into the CARE Track program. Researchers found that CARE Track patients had significantly fewer end-of-life hospitalizations and hospital deaths and were more likely to receive hospice care, resulting in a reduced mean total cost of $7,317 per patient in the last 90 days of life. All health metrics were significantly better in the CARE Track cohort — including hospitalization in the last 30 or 90 days, death in the hospital, provision of hospice care and hospice median stay.
Regarding the outcomes of the STAT RT pilot study, patients reported 80% to 90% partial or complete pain relief and quality of life was significantly improved 1 to 26 weeks after STAT RT. The conclusion of their study was that collaborative palliative care can re-engineer patient-centric workflows to improve health, health care and reduce end of life costs.
This is an excellent approach to an important, although under-researched, issue. This system, if successful, can significantly improve quality of life in end-of-life patients and also improve palliative care delivery.
Reference:
Malhotra C, et al. BMC Palliat Care. 2015;doi: 10.1186/s12904-015-0050-y.
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