High-Value Oncology Practices Have Key Features
NEW YORK (Reuters Health) - A new study has identified more than a dozen attributes that characterize high-value oncology practices, and three of these carry the highest immediate potential for lowering spending without compromising quality of care.
"At first, I thought many of our findings were obvious and pedestrian,” Dr. Douglas W. Blayney from Stanford Cancer Institute, in Stanford, California, told Reuters Health by email. “But then as I got further into the investigation, I realized how hard it is to change a team’s behavior.”
Variations in oncology practices contribute to significant differences in total spending incurred by patients and in quality of care. Adopting qualities that characterize high-value practices could improve care and reduce overall costs.
Dr. Blayney and colleagues, whose findings appear online November 16 in JAMA Oncology, used mixed quantitative and qualitative methods and site visits to seven U.S. oncology practices to identify 13 attributes that likely contribute to high-value cancer care.
Five attributes, in particular, were unique to high-value practices: a conservative approach to diagnostic testing; setting goals after explicit discussion on the benefits, limits, and consequences of treatment; proactive support for patients during predictably stressful periods; the use of experienced oncology nurses and other non-oncologist care providers; and close affiliation with a large health system or with a health plan that employs physicians.
The team identified three attributes - palliative care incorporated early in the care arc; normalized, ambulatory rapid response for patients with unstable conditions; and discussion of limits and consequences of treatment - as having the highest potential contribution to cost and quality.
“High-value oncology is a ‘team sport,’” Dr. Blayney said. “The high-value oncologists and their teams which stood out had a conservative approach to testing and imaging as exemplified by the quote, ‘We don’t order a test unless it will influence our treatment.’ High-value oncologists also integrated palliative care, provided either by themselves or by dedicated palliative care teams, early into the patients’ treatment arc. Palliative care was normalized - ‘that’s the way we always do it’ - so patients didn’t equate palliative care with ‘the end is near,’ but as a normal part of the complex care we render to cancer patients.”
“Change comes incrementally,” he concluded. “Tackle one small problem at a time, measure the results, adjust, and keep at it.”
Dr. Harold C. Sox from Patient-Centered Outcomes Research Institute, in Washington, D.C., who co-authored an invited commentary related to this report, told Reuters Health by email, "High-value care means better care at lower cost. It should be a goal of the medical profession, but it hasn’t been up to now, and U.S. medical care lags far behind other prosperous nations in providing high-value care. The purchasers of U.S. healthcare aren’t satisfied. They, not the profession, are driving the process of change. It is a revolution in medical practice.”
“Oncology practices are under increasing pressure to deliver higher-quality care for less money,” he said. “Adaptation need not be trial-and-error. This article describes specific ways to do it. It deals with the fine structure of patient care.”
His editorial concludes, “Far too often, debates about how to improve the care of patients cycle endlessly around modifications in incentive structures and payment and treat the details of care as a black box - uninteresting or impenetrable. People who give and receive care know better; they know that the details of care matter. They know that, no matter how clever the payment system is, nothing about the experiences and outcomes of care - or ‘value’ - changes until the care changes. And they know that studies like this one, which illuminate the fine structure of care, will in the end do far more to help clinicians and organizations achieve better care at lower cost than will a thousand more treatises on econometrics and incentives.”
Dr. Robin T. Zon from Michiana Hematology Oncology, in South Bend, Indiana, has researched various aspects of oncology care. She told Reuters Health by email, "The identification of attributes was not terribly surprising, as some of these same attributes have been discussed separately in other articles and published data - for example, following guidelines or pathways can control cost by standardization - which is why these utilization tools continue to proliferate.
Dr. Zon, who was not involved in the new work, added, “And some of the attributes are in part intuitive, based on past practice experiences. For example, a culture of RN nurse involvement and paraprofessionals in patient care can assist in optimizing care and managing expectations/goals of patients and their support system.”
“What I look forward to - with anticipation - is how these attributes once validated can be maximally utilized to redesign and/or at the very least, enhance current organizational infrastructure,” she said. “However, we must be mindful that some of the described attributes will require resources and financial investments not currently directly reimbursed in the healthcare system. As reimbursement continues to challenge practices, advocacy strategies may be needed to assist in paying for the services provided in the delivery of high quality care.”
“Additionally,” she said, “as organizations adopt the attributes, collection of outcomes (from patient, provider, and payer perspectives) will be needed to evolve and optimize the attributes, structure, and culture going forward.”
Dr. Arif H. Kemal from Duke Cancer Institute, in Durham, North Carolina, who recently reviewed oncology and palliative care integration, said, “This research adds to a consistent message coming out about the value of patient navigation, palliative care, and prudent use of healthcare resources in increasing quality and lowering costs.”
“There remains a myth that the quandary of high-cost oncology care is mostly a product of drug pricing, and that oncology practices have very little relative contribution to the discussion on higher-quality, lower-cost cancer care,” he said. “These authors demonstrate several best practices and attributes that rest squarely within the power of oncology practices to implement. It is now up to our oncology community to evolve towards these high-value practices.”
Dr. Kemal added that the three highest-value attributes “are principles of palliative care practice. Palliative care is the responsibility of the primary oncology team for all patients with cancer, and in some complex cases, an opportunity to collaborate with palliative care specialists. This article emphasizes the value of oncologist-delivered palliative care, alongside the need to include palliative care specialists when everyone could benefit from ‘an extra layer of support.’”
JAMA Oncol 2017.