Download Good Medicine…

Good Medicine
is
Good Business
John E. Hennessy
Kansas City Cancer Center
Trends in Cancer Care
• Aging population
• Patients living longer: “survivors” or future
customers
• Informed patients (internet, price transparency)
• Personalized medicine/patient specific care
• Strong evidence? Lack of clinical trials patients
• Cost & Systemic (delivery) crisis
• Decreasing cancer care workforce
US Healthcare System
• Stakeholders - All you can eat “Buffet” (Payors,
patients, physicians, pharma, hospitals, lawyers,
govt., etc.)
• Misplaced incentives
• Unsustainable trajectory of healthcare spending
Value/Quality
Drug Cost
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Camptosar
Oxaliplatin
Avastin
Neulasta
Revlimid
Tarceva
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$6000/mth
$6700/mth
$5000-$8000/mth
$3000/dose
$6000/mth
$2300/mth
Kansas City Cancer Center: Quality
Improvement and Clinical Pathways
KCCC Practice Overview
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26 Medical Oncologists
2 Leukemia/BMT specialists
8 Radiation Oncologists
12 Nurse Practitioners
11 Sites of Service
KCCC QI Committee
• In existence since 1997
• Over 15 different projects to improve the quality of
cancer care
• Fundamentals: improving cancer care is better for
the practice...is better for the patient…is better for
the customer/payor…is better for our community
• Measuring clinical and economic improvements
QI Committee Members 2006
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Marc Neubauer, MD, co-chair
Stephanie Dutton, co-chair
Joseph McGuirk, DO
Lori Lindstrom, MD
Elizabeth Kent, MD
Daniel Keleti, MD
Lee Pendleton
Lori Rone
Kay Aron
Debi Konrade
Kathy Dickstein
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Sandy Simmons
Angela Asta
Jim Hanus
John Hennessy
Linda Eckerman
Vickie Thomas
Sharon Roeder
Patty Gerken
Brenda Lang
Julie Wilhauk
QI Committee: Current Teams*
Team
Sub-committee Chair
Patient communication
Lori Rone
Clinical research
Vickie Thomas, RN
Standard of care (clinical
pathways)
Marc Neubauer, MD
Cancer genetics
Sandy Simmons, CRNP
Anti-depression
Barb Adkins, CRNP
Palliative/End-of-life Care
Patty Gerken, CRNP
Life beyond cancer
Sharon Roeder
Radiation Oncology
Darren Kistler
*as of June 2006
KCCC QI Process
• Identify a problem or deficiency
• Evaluate the frequency, severity and source of the
problem
• Develop and implement a plan for improvement
• Reevaluate to determine whether corrective
measures have led to improvement
• Report results to the proper personnel (e.g., QI
committee, executive committee, directly to those
who will benefit)
Clinical Research
• Improve provider awareness of clinical trials
• Improve referring physician awareness of clinical
trials
• Improve clinical trial selection
• Improve data collection and submittal
• Results: reduced expense per trial; improved
opportunities for patients to access novel agents;
reduced costs for patients and payors; advances
the science of cancer care.
Why Quality Improvement?
• Good Medicine…continually improving the quality
of care in both best practices and consistency is
good for patients and the population
• Good Business…consistent, high quality, evidencebased care is a good value for patients, which leads
to increased customer satisfaction, both the patient
and the payor
• Good Medicine is Good Business
Pain Management
• Pain as the 5th vital sign
• Pain is a significant driver a patient dissatisfaction with
his/her provider
• City of Hope: uncontrolled pain accounted for 26% of
unscheduled admissions and $5M of expense
• Results: Pain discussed overtly and documented; greater
recognition and management of pain
• Likely Outcomes: reduced hospitalizations—less provider
time in hospitals and reduced patient and payor costs;
improved patient satisfaction
Nurse Practitioners
• Evaluated care provided before and 12 months after
introduction of nurse practitioners
– 100% 1:1 pre-chemotherapy evaluation and teaching
– Increased office-based urgent care visits
– Decreased hospital visits
• Results increased practice revenue; increased
patient satisafcation and understanding of their
care; reduced costs for patients and payors ($1.9M
in hospitalization costs avoided Q4 2002)
Objectives of Life Beyond Cancer
Committee
• Develop evidence-based clinical practice guidelines for
survivorship care
• Provide our patients with a written summary of their disease
and treatment
• Provide our patients with a written care plan
• Improve our communications with primary care physician in
the long-term care of survivors
• Identify and educate on potential short-term complications
and long-term complications of treatment
• Educate the patient on signs and symptoms of recurrent and
secondary cancers
• Identify and discuss quality-of-life issues with our patients
• Refer to rehabilitation and psycho-social resources as
appropriate
“From Cancer Patient to Cancer Survivor: Lost in Transition”
Institute of Medicine, Nov. 7, 2005
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In the United States, half of all men and one-third of all women will
develop cancer in their lifetimes. Advances in the detection and
treatment of cancer, combined with an aging population, mean greater
numbers of cancer survivors in the near future.
…the lack of clear evidence for what constitutes best practices in caring
for patients with a history of cancer contributes to wide variation in care.
Citing shortfalls in the care currently provided to the country's 10 million
cancer survivors, From Cancer Patient to Cancer Survivor: Lost in
Transition recommends that each cancer patient receive a "survivorship
care plan." Such plans should summarize information critical to the
individual's long-term care, such as: the cancer diagnosis, treatment,
and potential consequences; the timing and content of follow-up visits;
and, tips on maintaining a healthy lifestyle and preventing recurrent or
new cancers…
ADJUVANT INVASIVE BREAST CANCER FOLLOW-UP PATHWAY
NAME:
CANCER DIAGNOSIS AND STAGE:
DATE OF DIAGNOSIS:
FOLLOW-UP VISITS:
DATE OF BIRTH:
1.First visit with physician at 1 month post- treatment (including radiation)
2.Return visit in 1 month with Nurse Practitioner for end of treatment visit
ASCO/NCCN/KCCC Guideline
History and Physical every 3-6 months for first 5 years
If lumpectomy, 1st mammogram 4-6 months after completion of XRT
Mammogram annually
Yearly pap/pelvic, if uterus present
If aromatase inhibitor or ovarian failure due to treatment, bone density should be assessed
upon initiation and every 1-2 years.
Not recommended: CXR, Bone Scan, Tumor markers, CBC, Chemistry
Follow up established by:
Clinical Trial Name & #
_____________
_________________
_______________________________________________________________________________
_______________________________________________________________________________
Sponsor:
_________________
Other: based on co morbidity or disease factors:
Visit every
months X
years; then every
years; then annually
Mammogram every
months
Labs:
____________ Frequency:
Diagnostic: CBC CMP Chem-19 CA 27-29 CEA Other___________
Pap/pelvic yearly if uterus present Bone density  Other________________
months X
Late and Long-Term Effects
TOPICS FOR EDUCATION:
RISK ASSESSMENT
DATE:
Genetic risk—Consider age, Family history, Male breast cancer,
Bilateral breast cancer, Ashkenazi Jewish decent
__________ Pedigree completed
LONG TERM OR LATE SIDE EFFECTS:
__________Neuropathy (LiveStrong Neuropathy)
__________Cognitive function (LiveStrong Cognitive Changes)
__________Fatigue (LiveStrong Fatigue)
__________Chronic Pain (LiveStrong Chronic Pain)
__________Bone density/Osteopenia/Osteoperosis (LiveStrong Osteoporosis)
__________Menopausal symptoms (People Living with Cancer Menopausal Symptoms)
__________Lymphedema (ACS Lymphedema or LiveStrong Lymphedema)
SEXUALITY (Live Strong Female Sexual Dysfunction)
__________Atrophic vaginitis
__________Dyspareunia
__________Libido
PSYCHOSOCIAL
__________Turning Point
__________Counseling
__________Body Image (LiveStrong Body Image)
__________Emotional Effects (LiveStrong Emotional Effects of Cancer)
HEALTHY LIFE STYLES
__________Healthy Behaviors (LiveStrong Healthy Behaviors)
__________Diet (Life after Breast Cancer – Diet, Nutrition, and Lifestyle Factors)
__________Age appropriate wellness behaviors
REFERRALS:
GENETIC COUNSELOR
GYNECOLOGIST
COUNSELOR/PSYCHOLOGIST
PAIN MANAGEMENT
DIETICIAN
OTHER________________________
LYMPHEDEMA MANAGEMENT
Healthy Behaviors
Recommendations of Age Appropriate Wellness Behaviors
AGE 40 - 65
Go to the dentist every 6-12 months for an exam and cleaning.*
If you have vision problems, continue to have an eye exam every 2 years. Everyone (those with and without
eye problems) should begin to have regular eye exams every 2 years after the age of 40. Once you turn
45, make sure that you also have tonometry done to check for glaucoma.**
Have your blood pressure checked every year.**
If your cholesterol level is normal, have it rechecked every 5 years.**
Have a physical exam every 1 - 5 years. With each exam, you should have your height and weight checked.
Other routine diagnostic tests are not recommended.**
Men and women should begin at age 50, Fecal Occult Blood Test yearly or Flexible sigmoidoscopy every 5
years or Double contrast barium enema every 5 years or Colonoscopy every 10 years.***
Men should have a yearly digital rectal exam and Prostatic Specific Antigen (PSA) blood level to check for
prostate cancer after the age of 50. unless high risk should begin at 45 years of age.***
Women should perform a monthly breast self-exam.***
Women should have a yearly pelvic exam and Pap smear done to check for cervical cancer and other
disorders. If your Pap smears are negative for 3 years in a row, have your Pap smear done every 2 - 3
years. ***
Women over the age of 40 should have a mammogram done every year to check for breast cancer. Early
mammograms may be recommended for women at high risk for breast cancer.***
Have a tetanus-diptheria booster vaccination every 10 years. Receive a flu vaccine every year after the age
of 50. ****
Good Medicine
• Consistent follow up care for patients at risk for
recurrence; reduce unwarranted variation
• Patients are better informed of their future path
• Staff has consistent expectation of future care path
• Reduction in the variation in lab tests and imaging
tests; expecting improved compliance with needed
testing
• Increased patient satisfaction
Good Business
• A plan to stay connected to what should be our
most loyal customers and our best advertising
• More likely to have ancillary testing at an affiliated
facility
• Reduced variation, predictability of costs, and the
right test at the right time controls costs for the
patient/payor/community
Anti-Depression Committee
• Depression under-recognized at KCCC
• Untreated depression affects patient productivity,
satisfaction with treatment, and treatment outcomes
• Chart review for recognition of depression
• Educate nurse practitioners and physicians
• Implement a tool to identify depression
• Post-implementation chart review to measure
results
Results of Depression Recognition Project
Jan 2003
(n = 80)
Dec 2003
(n = 80)
No. of pts evaluated for
depression
21 (26%)
47 (59%)
No. of pts evaluated for
loss of interest in
activities
20 (25%)
57 (71%)
No. of pts diagnosed with
depression
10 (12%)
17 (21%)
Adkins, B. Recognizing depression in an outpatient oncology population: A quality
improvement project.
Proceedings of ASCO 2005, #8102
Good Medicine
• Treating depression is a good thing; acknowledging
and addressing depression is a good thing
• Patients with depression may be more likely to be
non-compliant with home or office-based treatment
Good Business
• Patients with depression sap the economic
productivity of themselves and their family
• Patients are more likely to be dissatisfied with their
care
• Management of depression may support retail
pharmacy or counseling services within the
practice
Clinical Treatment Pathways:
Definition
• Pathways define treatment for our patients
throughout the practice
• 100% compliance is mandated
• Exceptions are allowed with justification and review
• Therefore, pathways differ from guidelines which
are “recommendations”.
KCCC: Impetus for Developing Pathways
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Practice growth
Rising cost of cancer treatment
Desire to improve efficiencies
Desire to improve quality
Guiding Principles in Pathway
Development
• Evidence-based medicine
• Value = Quality/Cost
Advantages of Pathways
• Promotes evidence-based medicine
• Offers uniform care throughout the practice
– “clinic without walls”
• Reduces errors
– Less variability for nurses, pharmacists
• Improves efficiencies
• Emphasizes clinical research
• Cost of care reduced for payor and patient
– Value (quality/cost) is increased
• Measure outcomes
KCCC Pathways
• Initiated: March 1, 2004
• Over 2 years of data
NSCLC by Stage
70
60
Clinical Trial
Taxol/Carbo
Navelbine
Exception
Alimta
Taxotere
Tarceva
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40
30
20
10
0
1st line
2nd line
From Dec 21-June 6
158 treatments; 15 exceptions
3rd line
4th line
Oncology Case Series: NOCR*
1st line stage IV NSCLC
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Taxol/Carboplatin
Taxotere/Carbo
Gemzar + a taxane
Cisplatinum/Navelbine
Gemzar/Carbo
Other
41%
32%
3%
1%
19%
4%
*Network for Oncology Communication and Research
Colon Cancer: KCCC Results
35
30
25
20
15
10
5
0
Adjuvant
1st line
From Dec 21-June 6
171 total treatments; 15 exceptions
2nd line
3rd line
5-FU/LV
FLOX
FOLFOX
FOLFOX + A
IRI
FOLFIRI
Xeloda
Erbitux
Erbitux + IRI
Clinical Trial
Exception
Good Medicine
• Patients get consistent evidence-based care in all
practice sites
• Clinical trial opportunities are highlighted at each
line of care and stage of disease
• Exceptions are peer reviewed in a second-opinion
process
• Use of multiple lines of therapy is limited to where
there is evidential support or a clinical trial
• Palliative care discussions are advanced
Good Business
• Evidence based regimens are far less likely to be
denied or reviewed
• Use of lower cost alternatives when outcomes are
otherwise expected to be equal benefit the patient,
the payor, and the practice
• Consistent patterns of care and peer review are
attractive to payors
• Increased accruals to clinical trials benefits all
parties, and advances the science of cancer care
Practice Variation: The Achilles’ Heel in
Quality Cancer Care
• “Quality cancer care does not depend only on research
findings, treatment improvements, and practice guidelines
because they are all for naught unless they are converted
into day-to-day practice by clinical oncologists”
• “Unless there is adherence to a guideline, a guideline will
not improve the quality of cancer care”
David Dilts, JCO, Sept. 1, 2005, page 5881
(Editorial on the ASCO QOPI project publication in the same issue)
Delivering on the Commitment to Quality
Making patient-focused, evidence based
care happen in the oncology office setting
Where the Rubber Meets the Road…
• It is easier to agree that we have to deliver high
quality care, than to agree on what that is
• With the broad evidence base we have in oncology,
it is not that hard to define good cancer care; it
does seem harder to define what does not qualify
as good cancer care
• Phase III studies vs. promising results in Europe
Don’t Fix What Ain’t Broke
• In many practices, physicians are allowed to define
quality care by their own standard; in that model, is
anything ever broke?
• Group think and peer review need to be models of
behavior and governance
• A vision of excellence has to be one that
incorporates self-criticism and change
Herding the Cats
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Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse (?)
Keys to a Focus on Quality
• Bottom up focus
• A leader can provide a vision, but the troops have to
sustain the battle and the war
• Broad physician, nursing, administration, and
clerical participation in quality improvement—not
just sitting there
Keys to a Focus on Quality
• Listen to your customers
• Patients…don’t just assume you know what they
want or should want—ask them
– Focus groups, 1-on-1 teaching
– Avoid “flat” surveys
• Be aware of payor initiatives, from Medicare to the
local employers, and participate
– Mid America Coalition on Healthcare Depression
project
Keys to a Focus on Quality
• The Quality
Cycle/Deming Cycle
– Plan
– Act
– Check
– Do
• Must have a
commitment to
measuring, and
reporting…good or bad
Keys to a Focus on Quality
• A commitment to clinical trials
• A commitment to improving care must extend
beyond the walls and be a commitment to
improving all of cancer care
• The same commitment to expanding clinical quality
must be matched by a commitment to help the
community improve operational quality
Keys to a Focus on Quality
• The practice must have the courage to ask
questions where the answers are not known and
may not be pretty
– “No speculation, no information, nothing? I've asked
you three times for information on that thing and
you've been unable to supply it. Insufficient
information is not sufficient, Mr. Spock! You're the
science officer. You're supposed to have sufficient
data all the time”– Capt. J.T. Kirk
– Insufficient information, and challenging that, is
fodder for great improvements
It is good business
• KCCC has no ASP-based contracts; KCCC has premium
reimbursement in all other lines of service, with multi-year
contracts preserving this model of reimbursement
• KCCC Diagnostic Imaging is firmly entrenched in all payor
networks
• KCCC has built alliances with the employer community
(MidAmerica Coalition on HealthCare, Sprint, Cerner)
• KCCC has strng cooperative ties to national and local
payors
• KCCC hasstrong partnerships with the NFP community
(Midwest Bioethics Center, Turning Point, Young Survival
Coalition, Cancer Action, KC Hospice)
The Rewards are Great…
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We have been recognized internally
We have been recognized by our peers
We have been recognized by our customers
Morale and motivation are high as we continue to
do what we do today better than we did yesterday