Measuring the use of examination room time in oncology clinics: a novel approach to assessing clinic efficiency and patient flow

Extended duration of treatment using reduced-frequency dosing of anti-PD-1 therapy in patients with advanced melanoma and Merkel cell carcinoma

BACKGROUND

Optimal duration of treatment (DoT) with immune checkpoint inhibitors (ICI) in metastatic cancers remains unclear. Many patients, especially those without radiologic complete remission, develop progressive disease after ICI discontinuation. Extending DoT with ICI may potentially improve efficacy outcomes but presents major logistical and cost challenges with standard frequency dosing (SFD). Receptor occupancy data supports reduced frequency dosing (RFD) of anti-PD-1 antibodies, which may represent a more practical and economically viable option to extend DoT.

METHODS

We conducted a retrospective study of patients with metastatic melanoma and Merkel cell carcinoma (MCC), who received ICI at RFD administered every 3 months, after initial disease control at SFD. We evaluated efficacy, safety, and cost-savings of the RFD approach in this cohort.

RESULTS

Between 2014 and 2021, 23 patients with advanced melanoma (N = 18) or MCC (N = 5) received anti-PD-1 therapy at RFD. Median DoT was 1.1 years at SFD and 1.2 years at RFD. The 3 year PFS after start of RFD was 73% in melanoma and 100% in MCC patients, which compare favorably to historical control rates. In the subset of 15 patients who received at least 2 years of therapy, total savings amounted to $1.1 million in drug costs and 384 h saved despite the extended DoT (median 3.4 years), as compared to the calculated cost of 2 years at SFD.

CONCLUSIONS

ICI administration at RFD can allow extension of treatment duration, while preserving efficacy and reducing logistical and financial burden. RFD approach deserves further exploration in prospective clinical trials.

Health Resource and Cost Savings Achieved in a Multidisciplinary Lung Cancer Clinic

Background: Lung cancer (LC) care is resource and cost intensive. We launched a Multidisciplinary LC Clinic (MDC), where patients with a new LC diagnosis received concurrent oncology consultation, resulting in improved time to LC assessment and treatment. Here, we evaluate the impact of MDC on health resource utilization, patient and caregiver costs, and secondary patient benefits. Methods: We retrospectively analyzed patients in a rapid assessment clinic with a new LC diagnosis pre-MDC (September 2016-February 2017) and post-MDC implementation (February 2017-December 2018). Data are reported as means; unpaired t-tests and ANOVA were used to assess for significance. We also conducted a cost analysis. Resource utilization, out-of-pocket costs, procedure-related costs, and indirect costs were evaluated from the societal perspective and presented in 2019 Canadian dollars (CAD); multi-way worst/best case and threshold sensitivity analyses were conducted. Results: We reviewed 428 patients (78 traditional model, 350 MDC). Patients in the MDC model required significantly fewer oncology visits from LC diagnosis to first LC treatment (1.62 vs. 2.68, p < 0.001), which was significant for patients with stage 1, 3, and 4 disease. Compared with the traditional model, there was no change in mean biopsies/patient (1.32 traditional vs. 1.17 MDC, p = 0.18) or staging investigations/patient (2.24 traditional vs. 2.02 MDC, p = 0.20). Post-MDC, there was an increase in invasive mediastinal staging for patients with stage 2/3 LC (15.0% vs. 60.0%, p < 0.001). Over 22 months, MDC resulted in savings of CAD 48,389 including CAD 24,167 CAD in direct patient out-of-pocket expenses. For the threshold analyses, MDC was estimated to cost CAD 25,708 per quality-adjusted life year (QALY), considered to be below current willingness to pay thresholds (at CAD 80,000 per QALY). MDC also facilitated oncology assessment for 29 non-LC patients. Conclusions: An MDC led to a reduction in patient visits and direct patient and caregiver costs.

Feasibility and acceptability of the "Day 100 Talk": An interdisciplinary communication intervention during the first six months of childhood cancer treatment

BACKGROUND

Communication gaps arise early in the childhood cancer trajectory and may persist. The authors conducted a pilot study of the feasibility and acceptability of a communication intervention, the Day 100 Talk (D100). D100 involves an interprofessional family conference during initial months of treatment between oncologists, psychosocial clinicians, and parents, facilitated by a 3-part conversation tool.

METHODS

The authors enrolled English-speaking parents of children with nonrelapsed, nonprogressive cancer who were receiving continuity care from enrolled pediatric oncologists and psychosocial clinicians at a single site. The a priori feasibility threshold was 60% parent completion of the D100 intervention. Surveys from parents and professionals and debrief interviews with professionals assessed D100 acceptability.

RESULTS

Thirty-seven parents (77%) and 38 oncology professionals (67%) enrolled. Twenty of 33 evaluable parents (61%) participated in a D100 family conference. Most commonly, parents did not complete the D100 intervention because of scheduling difficulties related to clinical team constraints. All 17 parents who completed a post-D100 survey agreed or strongly agreed that D100 participation was helpful. In debrief interviews, professionals identified D100 benefits, namely, stepping back to the big picture and getting on the same page, and barriers related to logistical challenges and professionals' anticipatory dread.

CONCLUSIONS

The D100 intervention pilot demonstrates high acceptability among parents of children with cancer. Despite meeting the prespecified feasibility threshold, findings highlight important barriers to D100 dissemination, namely, perceived burdens on professionals. Potential strategies to reduce burden may include using virtual visit platforms, incorporating D100 elements across multiple visits, or prioritizing intervention delivery to parents with the greatest need for enhanced communication.

Evaluating waiting time with real-world health information in a high-volume cancer center

Wait time and scheduling for outpatient chemotherapy administration depends on various factors including infusion room hours of operation, availability of oncologists, nursing and pharmacy staffing, and physical space limitations. The aim of this study was to use the electronic event log of patients on health information system (HIS) to map and analyze patient flow in advanced metastatic colorectal patients at an academic cancer center. From January 2009 to December 2014, patients who were diagnosed with metastatic colorectal cancer and received outpatient chemotherapy confined to FOLFIRI (fluorouracil, leucovorin, and irinotecan) or FOLFOX (folinic acid, fluorouracil, and oxaliplatin) were identified. From the HIS, patient flow was mapped by collection of event records including blood collection and pretreatment laboratory test, arrival to outpatient clinics, outpatient session (interview, drug accountability and appointment scheduling), and initiation of chemotherapy. A total of 10,638 patients were analyzed for 136,281 outpatient visits. The total office stay time from outpatient registration to initiation of chemotherapy was 92.58 ± 87.96 (mean ± standard deviation) minutes. Each outpatient session lasted 23.75 ± 51.55 minutes. After completing the outpatient session, patients waited 1,657.23 ± 3,027.65 minutes before chemotherapy and 46.66 ± 75.94 minutes within infusion room. Compared to the prior first come first serve rule, the new reservation system showed an improvement in overall waiting time from 2,432.3 ± 4,822.9 to 2,386.7 ± 143.4 minutes; however, waiting time within infusion room slightly increased from 36.68 ± 49.33 to 48.13 ± 46.32 minutes. Our findings indicate that transaction data analytics from HIS can be used to evaluate patient flow within oncology outpatient practice based on real-world hospital data.

Chemotherapy Wait Times in a Network of Pediatric Oncology Clinics

Patient satisfaction with medical care delivery is an important aspect of value-based health care. Providers strive to provide optimal patient satisfaction. Among a network of ambulatory pediatric oncology affiliate clinics, we conducted patient satisfaction surveys and found that the lowest scores were related to delays in the administration of chemotherapy. To address this shortcoming, we used continuous improvement methodologies to reduce the delay in chemotherapy administration in 3 affiliate clinics. To evaluate the efficacy of the quality improvement interventions implemented at each affiliate clinic, we measured the time from patient arrival to the start of chemotherapy administration over a 2-week period before and after the interventions. Wait times for chemotherapy administration were reduced in each clinic by 7% to 15%, exceeding the preestablished goal of a 5% reduction without affecting patient safety. Patient satisfaction for chemotherapy wait times was also marginally increased. In conclusion, implementation of quality improvement interventions across a clinical network can improve specific aspects of patient satisfaction, thereby improving the overall patient experience.

Differential impact of cognitive computing augmented by real world evidence on novice and expert oncologists

INTRODUCTION

Cognitive computing point-of-care decision support tools which ingest patient attributes from electronic health records and display treatment options based on expert training and medical literature, supplemented by real world evidence (RWE), might prove useful to expert and novice oncologists. The concordance of augmented intelligence systems with best medical practices and potential influences on physician behavior remain unknown.

METHODS

Electronic health records from 88 breast cancer patients evaluated at a USA tertiary care center were presented to subspecialist experts and oncologists focusing on other disease states with and without reviewing the IBM Watson for Oncology with Cota RWE platform.

RESULTS

The cognitive computing "recommended" option was concordant with selection by breast cancer experts in 78.5% and "for consideration" option was selected in 9.4%, yielding agreements in 87.9%. Fifty-nine percent of non-concordant responses were generated from 8% of cases. In the Cota observational database 69.3% of matched controls were treated with "recommended," 11.4% "for consideration", and 19.3% "not recommended." Without guidance from Watson for Oncology (WfO)/Cota RWE, novice oncologists chose 75.5% recommended/for consideration treatments which improved to 95.3% with WfO/Cota RWE. The novices were more likely than experts to choose a non-recommended option (P < .01) without WfO/Cota RWE and changed decisions in 39% cases.

CONCLUSIONS

Watson for Oncology with Cota RWE options were largely concordant with disease expert judged best oncology practices, and was able to improve treatment decisions among breast cancer novices. The observation that nearly a fifth of patients with similar disease characteristics received non-recommended options in a real world database highlights a need for decision support.

Designing and Testing Apps to Support Patients With Cancer: Looking to Behavioral Science to Lead the Way

Background

Behavioral science has a long and strong tradition of rigorous experimental and applied methodologies, which have produced several influential and far-reaching theoretical frameworks and have guided countless inquiries of human behavior in various contexts. In cancer care, behavioral scientists have established a firm foundation of research focused on understanding the experience of cancer and using that understanding to design and implement theory- and evidenced-based interventions to help patients cope with the cancer experience. Given the rich behavioral research base in oncology, behavioral scientists are ideally positioned to lead the integration of evidence-based science on behavior and behavior change into the development of smartphone apps supporting patients with cancer. Smartphone apps are being disseminated to patients with cancer with claims of being able to help them negotiate areas of vulnerability in their cancer experience. However, the vast majority of these apps are developed without the rigor and expertise of behavioral scientists.

Objective

In this article, we have illustrated the importance of behavioral science leading the development and evaluation of apps to support patients with cancer by providing an illustrative scientific process that our team of behavioral scientists, patient stakeholders, medical oncologists, and software developers used to empirically design and evaluate 2 patient-focused apps: the Discussion of Cost App (DISCO App) and MyPatientPal.

Methods

Using a focused literature review and a descriptive roadmap of our team’s process for designing and evaluating patient-focused behavioral apps for patients with cancer, we have demonstrated how behavioral scientists are integral to the development of empirically sound apps to help support patients with cancer. Specifically, we have illustrated the process by which our multidisciplinary team combined the established user-centered design principles and behavioral science theory and scientific rigor to design and evaluate 2 patient-focused apps.

Results

On the basis of initial acceptability and feasibility testing among patients and providers, our team has demonstrated how critical behavioral science is for designing and evaluating app-based interventions for patients with cancer.

Conclusions

Behavioral science can and should be coupled with user-centered design principles to provide theoretical guidance and the rigor of the scientific method, thereby adding the much-needed and critical evidence for these types of app-based interventions for patients with cancer.