Quality improvement project bridges ‘significant gap’ in biomarker testing for lung cancer
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Next-generation technologies and diagnostic tests offer the promise of improved cancer care, but they also present challenges related to ensuring widespread access to these innovations.
To ensure accessibility of these tools to patients for whom they may be beneficial, Oncology Hematology Care (OHC) conducted a 1-year quality improvement project focused on implementing and standardizing comprehensive biomarker testing for patients with metastatic non-small cell lung cancer.
The project — which ran from September 2021 to August 2022 — resulted in an increase in biomarker testing rates, from 68% at the start of the effort to 92% by its conclusion.
Association for Community Cancer Centers recognized the effort with its 2023 Innovator Award.
“We knew that every patient deserved to be tested, but we found there was a fairly significant gap,” Molly Mendenhall, MBOE, LSSBB, BSN, RN, director of quality and compliance at OHC, told Healio. “It’s important to note, though, that this is not unique to us. It goes beyond community practices and affects hospitals and academic centers, as well. Sadly, this is a universal problem.”
Healio spoke with Mendenhall about the inspiration for the project, its performance at OHC sites and how other practices can implement similar programs.
Healio: Why are rates of biomarker testing so low overall?
Mendenhall: Physician burden plays a big role. There is a heavy burden placed on providers, with complex and constantly changing workflows. We need more of a system to help us streamline and bridge that gap.
There are different types of biomarker testing, too. It’s whole-panel testing, including PD-L1, where the majority of the gap comes into play. We know in health care — and in the treatment of patients with cancer — it’s extremely complex to get all of these moving pieces completed, not only in lung cancer but for other diagnoses, as well. Making sure we have these processes to help physicians provide the best possible care at the right time is essential. We really can achieve this goal and help with that physician burden. This project was successful for us, and I hope it can be for other practices, as well.
Healio: What inspired you to initiate this program?
Mendenhall: Everyone deserves comprehensive biomarker testing, but not everyone receives it. Testing rates vary across the board nationally and even globally. In the United States, testing rates average less than 50%. Part of that is the physician burden we discussed, but also difficulty even ordering the tests. The shift today toward personalized medicine, if properly implemented, can provide targeted therapies to extend survival. About 45% to 50% of patients will have an actionable biomarker. Nearly 70% of these patients will have a finding that will affect first-line treatment. In the past 10 years, there have been major advances in lung cancer treatment, and there are a multitude of targeted therapies. This innovation shows patients with advanced NSCLC should receive this testing. Internally, we found that our pre-project testing rates were 68%, and we still felt we had a significant gap we needed to bridge. That really inspired us to implement a system to help us bridge that gap.
Healio: How did the program work?
Mendenhall: The barebones structure involved building this program off the success of past projects we had completed, specifically a project on genetic testing for patients with breast cancer. Utilizing that structure, we looked to scale it into the NSCLC space. A big part of that was using Lean 6 Sigma and Plan, Do, Check, Act (PDCA)methodology.
Over the course of this 1-year project, we were able to successfully implement and standardize a physician note template into our electronic health record. The template incorporated National Comprehensive Cancer Network guidelines and other, internal OHC requirements for this subset of patients. The template includes information about staging, ordering biomarker testing, ordering scans and potentially looking at a research referral. We wanted to create a one-stop shop.
In tandem with the template, we created an NSCLC order set, which enabled the physician to place all orders with one click, which included the comprehensive biomarker testing panel in it. With these tools, we created a built-in, seamless workflow for physicians.
We also created three 2-minute videos that we texted or emailed to physicians. This helped to allow self-directed education. After rollout, we built custom reports so we could track every patient in this population. With these custom reports, we could do monitoring and real-time re-education with our physicians. If they missed part of the workflow steps, we could educate them in real time and make tweaks to the workflow to make it more seamless for them.
Ultimately, just by streamlining this process into their existing workflow, compliance and adoption were so much easier. We saw a massive uptick immediately.
Healio: How is this being scaled throughout OHC sites?
Mendenhall: Internally, we’re already looking at the next cancer type that we want to scale this out to, but I think the bigger discussion here is on the national scale. This project is being tested and scaled through McKesson and US Oncology. We’re working to roll this out nationwide as a best practice, looking at our template and our order set. It’s a quality improvement project that can be rolled out with a few tweaks to the physician workflow, with little to no financial investment. can be mirrored nationwide regardless of the EHR a practice is on. I think that’s one of the great benefits of making this scalable and reproducible. More importantly, it can be applied to other diagnosis states such as prostate cancer, which is next on our agenda. So, it’s even bigger than just the NSCLC space.
Healio: What advice would you offer other institutions that may want to replicate this project?
Mendenhall: First, I would advise others to start small. Given the additional burdens being placed on physicians and providers, it’s crucial to build a system that can guide the physician through all necessary requirements in a seamless manner. OHC did this simply by building these guidelines into existing workflows and templates.
The second component is ease of use, which is crucial to success in terms of immediate uptake and physician compliance. The third element is education. Consider having conversations with physicians about the “why” behind this effort and the impact it can have on quality of care.
Lastly, I’d emphasize the importance of standardization. The more a practice can standardize and streamline workflows, the more efficient physicians will be at ordering comprehensive biomarker testing. At the end of the day, standardization is going to help decrease ambiguity and increase quality testing rates. Ultimately, it’s also going to ensure consistency and increase productivity.
Reference:
- ACCC. Closing the testing gap: Standardization of comprehensive biomarker testing in NSCLC (press release). Available at: https://www.accc-cancer.org/acccbuzz/blog-post-template/accc-buzz/2023/08/25/closing-the-testing-gap-standardization-of-comprehensive-biomarker-testing-in-nsclc. Posted Aug. 25, 2023. Accessed Jan. 25, 2024.
For more information:
Molly Mendenhall, MBOE, LSSBB, BSN, RN, can be reached at Oncology Hematology Care Corporate Office, 5053 Wooster Road, Cincinnati, OH 45226; email: molly.mendenhall@usoncology.com.
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