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Are patient-reported outcomes data sufficient to safely reduce face-to-face oncology visits?
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Yes.
We must use PROs to reduce face-to-face visits for patients with cancer when doing so allows us to provide better and more patient-centered care. Although it may ultimately reduce medical expenses, the primary goal for PROs as part of a virtual visit strategy should be to provide what matters most to patients: confidence that their care will result in the best long-term outcomes, symptom control and the ability to receive care on their own terms. If done right, such a strategy can lead to healthier and happier patients, more satisfied providers and a better financial footing for the health care system.
PROs can never replace visits during which diagnostic testing is required or when the physical exam is an important component. Perhaps most importantly, in-person visits are critical to establish a relationship between patient and provider, help a patient understand a diagnosis and prognosis, discuss goals and options, voice concerns and have questions answered. Although they may be few in oncology, there are visits when none of these are taking place, when diagnostic testing is completed in advance or for patients in remission.
PROs would be best used for visits when the goal is to screen for symptoms and ensure good quality of life. A PRO that assesses disease-specific symptoms, such as dyspnea, could be assigned to patients at home alongside PROs that assess functional status, quality of life and pain. A provider could use those PROs to determine that a face-to-face visit is unnecessary, and that patient might relish avoiding the time and expense associated with an office visit. If the PROs revealed symptoms or poor function, a patient and provider might decide a face-to-face visit is more appropriate. Even for the healthy, asymptomatic patient, PROs must be paired with the opportunity for patients to have their concerns addressed; often this can be accomplished with a phone call or video visit. Importantly, these may not save time for providers, but they likely would provide patients with a more convenient option.
In addition to providing care that better suits a patient’s needs, PROs are better than history-taking at detecting specific symptoms or functional changes. At my institution, the use of PROs for mental health screening, for example, has revealed depression previously hidden by the bustle of multiple conditions and providers. In addition, PROs are valid and reliable in their diagnostic sensitivity. Further, patients may be more honest about their symptoms when answering electronically. Some patients do not want to disappoint their providers or be a pest. We have countless examples of PROs revealing symptoms — particularly sexual symptoms — poor function, mental health issues or poor quality of life that the patient was reticent to bring up in person.
PROs may be used to avoid visits but, perhaps more importantly, PROs in oncology enhance standard visits and may even prompt an additional office visit. If we can harness their diagnostic power, we may achieve better and more patient-centered care at lower cost.
Neil Wagle, MD, MBA, is associate chief quality officer at Partners HealthCare and primary care physician at Brigham and Women’s Hospital. He can be reached at nwagle1@partners.org. Disclosure: Wagle reports no relevant financial disclosures.
No.
Ethan Basch, MD, presented a study at this year’s ASCO Annual Meeting that showed an intervention providing computer-based PROs to alert clinicians about patient symptom status reduced ED visits in a sample of 766 patients with cancer. This is an exciting finding, especially given evidence that many ED visits by patients with cancer are potentially preventable.
The question remains: Are we ready to move to using PROs as a substitute for patient visits? My answer is no.
One reason is the need for replication and confirmation. Findings from one center are not a convincing basis for policy change. Outcomes of other studies in the literature do not come to the same conclusions. For example, a randomized controlled trial by Wheelock and colleagues showed that PRO symptom questionnaires completed by women with breast cancer who received follow-up by nurse practitioners had no effects on appointments or medical tests over 18 months. Additionally, a Cochrane review that looked at the impact of regular PRO monitoring in patients with asthma did not find support for reduced ED visits. We need more evidence and replication in other centers to warrant moving to wide-scale practice changes. Fortunately, some of this work is under way.
Another reason for caution is that we need to know more about the kinds of patients for whom dispensing with in-person assessment is safe and efficacious. In the study by Basch and colleagues, the positive impact of the intervention appeared much greater for patients who were not familiar with computers; in fact, many findings were nonsignificant among the computer savvy. We need to know if this approach works better and is more appropriate for certain kinds of patients, diseases and regimens.
Finally, the key to reducing ED visits is not the act of a patient completing a questionnaire, it is what happens next. It seems likely that at Memorial Sloan Kettering Cancer Center — where the study took place — protocols exist for how patient symptom reports are addressed by nurse practitioners over the telephone between visits, and by oncologists at office visits. Not all centers or providers have the information or support to manage symptoms successfully. Without resources in place to address patient concerns, PRO reports will not translate into meaningful impact.
There are many reasons why incorporating PRO assessments in cancer care is a good idea. We need to avoid premature adoption of PRO assessments as a vehicle to reduce in-person visits, while focusing on how these assessments with appropriate follow-up can lead to more efficacious and efficient care.
References:
Absolom K, et al. BMC Cancer. 2017;doi:10.1186/s12885-017-3303-8.
Basch EM, et al. Abstract LBA2. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Kew KM, et al. Cochrane Database Syst Rev. 2016;doi:10.1002/14651858.CD011714.pub2.
Panattoni LE, et al. Abstract 6505. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Wheelock AE, et al. Cancer. 2014;doi:10.1002/cncr.29088.
Carolyn Gotay, PhD, FCAHS, is professor of medicine and Canadian Cancer Society chair in cancer primary prevention at University of British Columbia. She can be reached at carolyn.gotay@ubc.ca. Disclosure: Gotay reports no relevant financial disclosures.
No.
Increasing evidence strongly supports the value of incorporating PRO assessment into the clinical care of patients with cancer. However, these data are derived from studies that largely test the utility of adding collection of PROs to usual care to enhance delivery of patient-centered care and improve outcomes inclusive of quality of life, health care use and survival.
For example, Basch and colleagues demonstrated that a web-based tool used to regularly report symptoms to providers between routine clinic visits improved OS for patients with advanced cancer. These data provide compelling evidence of the dramatic impact that PRO collection can have if readily incorporated into real-time management of patients.
How does PRO collection improve outcomes? Collection of symptom-based PROs between routine visits provides a more comprehensive assessment of disease-related and treatment-associated symptoms, which can help optimize informed decision-making regarding supportive care and therapeutic management. Providers receive comprehensive and real-time information. Symptoms can be treated quickly, thereby potentially averting more serious consequences such as development of disability or hospitalization, which may interfere with delivery of therapy.
Early recognition of symptoms may be particularly important for older adults or those with multiple chronic conditions who are most susceptible to rapid clinical deterioration with increasing symptom burden and who are less likely to quickly recover. In short, routine collection of PROs can help providers take better care of their patients between and during in-person visits.
Available data do not support substituting PRO reporting for provider visits. There is no substitute for in-person observation and communication in patient-centered care. The challenge in oncology is not that patients are seen too frequently, but that ever-increasing pressures of patient volume, treatment complexity and provider shortages make it difficult to learn as much as we can from each patient to optimize his or her care. Integration of systematic PRO collection, if done efficiently using existing technologies, can augment the care we provide.
PROs may be used to avoid visits but, perhaps more importantly, PROs in oncology enhance standard visits or may even prompt an additional office visit. If we can harness their diagnostic power, we may achieve better and more patient-centered care at lower cost.
Reference:
Basch E, et al. JAMA. 2017;doi:10.1001/jama.2017.7156.
Heidi Diana Klepin, MD, is associate professor of hematology and oncology at Wake Forest Baptist Health. She can be reached at hklepin@wakehealth.edu. Disclosure: Klepin reports consultant roles with Genentech and Celgene.