With the passage of the Medicare Access and CHIP Reauthorization Act, changes to how cancer care is delivered are fast approaching. This legislation aims to reward value-based care and incentivize alternative payment models that prize quality. The shift from quantity-based to value-based reimbursement is motivated in part by the rising cost of health care as well as the growing demand from patients, employers, and payers to better understand the quality of care being delivered. In cancer care, one area of high-cost and questionable value being examined is aggressive care at the end of life.
Research has found that high-intensity end-of-life care, including intensive care unit use, improves neither survival nor quality of life for advanced cancer patients. There is also considerable variation in end-of-life care and this variation signals that there is opportunity for improvement. In a study examining site of death for patients with cancer in seven developed countries, Bekelman et al. found that 27% of decedents in the United States were admitted to the ICU in the last 30 days of life, more than twice the rate of other countries. The National Quality Forum endorses ICU admissions in the last 30 days of life as a marker of poor-quality cancer care. We examined oncology patient deaths in the ICU, and our results were published recently in the Journal of Oncology Practice . Though a small sample size, our multidisciplinary review found that nearly half of these ICU deaths were potentially avoidable with different medical management. A significant number identified as clinically avoidable were due to absent or insufficient advance care planning. In this patient population, only 25% had documented advance directives and only 13% had an outpatient palliative care evaluation.
Innovative models in cancer care delivery are taking steps to address some of these deficits and improve care delivery for cancer patients. The Centers for Medicare and Medicaid Services recently launched the Oncology Care Model . The model seeks to improve care coordination with one goal being fewer avoidable hospitalizations and better end-of-life care. Participating Oncology Care Model practices must formulate a care plan that contains advance care planning documentation. Despite hospitals and professional societies, such as the American Society of Clinical Oncology, highlighting the importance of advance care planning, a recent study found no growth in the past decade in key advance care planning domains, such as discussion of end-of-life care preferences. Prior experiments in cancer care delivery, such as The Oncology Medical Home , have shown that patient-centered innovations, such as extended clinic hours, weekend services, and symptom algorithms can also result in health care savings by keeping patients out of the emergency room, hospital, and ICU at the end of life.
In addition to innovation in care delivery, technological advances also have the potential to improve care for advanced cancer patients. A recent randomized trial showed an improvement in survival and quality of life for patients with stage III/IV lung cancer assigned to a mobile friendly web application that allowed them to self-assess and electronically report their symptoms to their oncologist, compared with standard care follow-up. Based on the reported symptoms, the computer algorithm was able to trigger early supportive care as needed. The study author reported , “This approach introduces a new era of follow-up in which patients can give and receive continuous feedback between visits to their oncologist.” Other innovations, including decision support based on big data sets, integration of evidence-based clinical pathways into the electronic health record, and improved tools for prognosis and timing of palliative care referrals also hold promise to improve care delivery for advanced cancer patients.
The scientific pace of progress in cancer care is exciting, with 19 therapies approved or granted a new indication in 2015. New categories of drugs, such as immunotherapies, are changing how we treat patients. It is also a time of great change in how cancer care is being delivered in our clinics, hospitals, and academic institutions. We must be vigilant in learning from these experiments in care delivery to ensure that they deliver on their promise of value to patients.
Dr. Bobby Daly, Dr. Andrew Hantel, and Dr. Blase Polite are with the University of Chicago.