E-consult program for immune-related toxicities reduces costs, increases patient access
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An electronic consult program for patients who developed endocrine immune-related adverse events has considerably reduced health care utilization.
“Side effects have existed for as long as cancer therapies have existed,” Afreen Shariff, MD, MBBS, director of the Duke Endo Oncology program and associate director of the cancer therapy toxicity program within Center for Cancer Immunotherapy at Duke Cancer Institute, told Healio.
“With the increased use of targeted therapies and immunotherapy, however, we’ve started seeing a different flavor of side effects that required going beyond the scope of what oncology is comfortable managing,” Shariff added. “That required specialists like me to step up and offer to help.”
Shariff, who created the acuity-based Duke Endo-Oncology Electronic Consultative Service in 2020, has since done consults for more than 300 patients.
The service has effectively reduced wait times for appointments and hospitalization rates, and also has reduced costs.
Association of Community Cancer Centers recognized Shariff as one of its 2023 ACCC Innovator Award recipients.
Healio spoke with Shariff about the origin of the project, the benefits observed since its implementation and how it may affect clinical practice in the long term.
Healio: What inspired you to specialize in caring for patients experiencing adverse events?
Shariff: I’ve been doing this for about 9 years now. I started doing it as a fellow and, within the first week I was on inpatient consults, I absolutely fell in love with the first case I got. I’d never heard of these drugs, and it was fascinating to see how nuanced yet familiar these diseases were that we had known for decades. The acuity and complexity of the cases was so intriguing — that’s how I decided this was what I wanted to do.
I’m very humbled when I see new patients and I’ve never heard of a particular drug. I’ll find myself looking at clinicaltrials.gov wondering, “What’s the pathway for this? Why is the patient getting this side effect?” One of the most challenging parts of what I do is keeping abreast with changes in cancer treatments.
When I started this, there was a palpable need for specialists who understood side effects. The average time to see a clinician like me was about 61 days, but it could go up to 90 days. A patient with cancer having to wait for 90 days to see an endocrinologist is unacceptable. While patients wait to see someone like me, they’re often going to the hospital two or three times because no one is able to help them. That’s a huge disservice not only to the patient, but to how we envision cancer care. We needed something that would connect oncologists and endocrinologists at the right time and right place, for the right person. We want to fix things before they get worse, and that was the idea behind e-consults.
Healio: Can you describe the launch?
Shariff: We had planned to use electronic consults as a means for outreach, because we have two networks. We have the Duke Cancer Institute Network, which is local, and then there is the Duke Cancer Network, which extends right up to Michigan. There was a need expressed by the outlying practices regarding poor access to endocrinologists locally, and patients aren’t likely to travel the distance to see someone who matches the expertise needed. While we were designing this initially for Duke Cancer Network, the COVID-19 pandemic created even bigger challenges with access even for local practices at Duke Cancer Institute. We then decided to pivot our launch to sites locally where we had better health record integration and alignment with resources. We’ve done more than 300 consults in the past 3 years, and we’ve reduced the hospital admission rate from 11% down to 2%, which is amazing.
Healio: How do e-consults work?
Shariff: An oncologist who suspects a patient has an endocrine side effect would go into the electronic health record and put in an electronic consult order for endocrinology. The consult order is sent to me and two other providers on my team. Within 24 to 48 working hours, we review the case, cancer history and treatment history, then provide written recommendations about diagnostic testing, management, and whether a visit is required with our team and — if so — how soon.
This is an acuity-based triage decision. When such cases go through a general referral system, the people who are doing the appointments don’t necessarily understand or know how sick the patient is. They base decisions on the physician’s next available appointment. If a physician reviews the case, he or she may realize they need to see the patient tomorrow. This is about seeing the patient at the right time and prioritizing cases based on need.
Healio: What benefits has this service provided?
Shariff: Patients are getting care from their oncologist with the backing of a specialist who can provide a deeper insight into a side effect and how it should be managed within 24 to 48 hours, plus they don’t need to drive somewhere to see an endocrinologist right away.
Their treatment is being started, and this specialist in the cloud has prevented them from going to the hospital.
Oncologists feel similarly supported. They feel confident treating the side effects knowing they have the backing of an endocrinologist. They don’t have to own every problem the patient has, and there is less burnout. There are fewer concerns about safety because everyone is making decisions they’re very good at. So, it takes much of the stress away from that decision-making.
It also moves treatment forward. If the oncologist waits for the endocrinologist to tell them whether a patient can continue treatment due to a side effect, they might need to wait for 2 or 3 months for the patient to see an endocrinologist in the community. Instead, the oncologist is getting an answer in 2 days, and they’re being told it is OK to proceed with treatment.
From my perspective as an endocrinologist, I have access to lab results and often gauge response to treatments done before a patient comes to see me. And I already know the patient when I do see them. That makes my job much easier, because when I do see the patient, I can see the effects of my recommendations. So, it’s a win-win.
From the health system perspective, there is a cost savings because people are kept out of the hospital. Insurance companies are saving money because there are fewer claims and better outcomes for patients. These patients can stay in the outpatient setting rather than the inpatient setting, which is a big win in so many ways.
Healio: What advice would you offer to other institutions that may want to implement a similar service?
Shariff: The biggest advice is to understand their own infrastructures and their needs. They should talk to their facility’s oncologists and their patients to understand where the gaps are. Every health system is designed differently — they’re great at some things and not so great at others, and the challenges can be very different when it comes to implementation.
Trying to identify a way to pay for these activities is essential. We could do this as a service to our patients and practices for some time but, in reality, for it to be sustainable and scalable, you need health systems and insurance payer third-party buy-in. This allows clinicians and health systems to be rewarded and reimbursed for the outcomes that they’re bringing in.
Healio: Is there anything else you’d like to mention?
Shariff: While we focus on cancer outcomes, it’s very important to also consider outcomes from side effects. We are moving into an era of very sophisticated cancer treatment. Cancer will be the next diabetes, the next hypertension or the next HIV. People have died of these conditions in the past. Now people live with them, but they also live with side effects. That’s why it’s so essential that side effects and side-effect management services get the same kind of attention as PFS. If we don’t focus on side effects, younger patients receiving treatment for cancer are going to live with them for a very long time. Managing side effects at the right time and doing the right intervention is just as important as moving the cancer from active therapy to surveillance to remission.
For more information:
Afreen Shariff, MD, MBBS, can be reached at Duke University, 30 Duke Medicine Circle, Clinic 1A, Durham, NC 27710; email: afreen.shariff@duke.edu.
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