SWOG S1820: A pilot randomized trial of the Altering Intake, Managing Bowel Symptoms Intervention in Survivors of Rectal Cancer

BACKGROUND

Survivors of rectal cancer experience persistent bowel dysfunction after treatments. Dietary interventions may be an effective approach for symptom management and posttreatment diet quality. SWOG S1820 was a pilot randomized trial of the Altering Intake, Managing Symptoms in Rectal Cancer (AIMS-RC) intervention for bowel dysfunction in survivors of rectal cancer.

METHODS

Ninety-three posttreatment survivors were randomized to the AIMS-RC group (N = 47) or the Healthy Living Education attention control group (N = 46) after informed consent and completion of a prerandomization run-in. Outcome measures were completed at baseline and at 18 and 26 weeks postrandomization. The primary end point was total bowel function score, and exploratory end points included low anterior resection syndrome (LARS) score, quality of life, dietary quality, motivation, self-efficacy, and positive/negative affect.

RESULTS

Most participants were White and college educated, with a mean age of 55.2 years and median time since surgery of 13.1 months. There were no statistically significant differences in total bowel function score by group, with the AIMS-RC group demonstrating statistically significant improvements in the exploratory end points of LARS (p = .01) and the frequency subscale of the bowel function index (p = .03). The AIMS-RC group reported significantly higher acceptability of the study.

CONCLUSIONS

SWOG S1820 did not provide evidence of benefit from the AIMS-RC intervention relative to the attention control. Select secondary end points did demonstrate improvements. The study was highly feasible and acceptable for participants in the National Cancer Institute Community Oncology Research Program. Findings provide strong support for further refinement and effectiveness testing of the AIMS-RC intervention.

A community oncology practice financial experience in oncology care model pilot (OCM)

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Background: Oncology Division of Michigan Health Professionals (MHP) participates in OCM, which requires effort from all MHP OCM providers to coordinate care at same or lower cost to Medicare. Palliative Care, Care Management, and End of Life Care programs established by MHP, in collaboration with Premiere Hospice and Integra Connect, have shown cost and quality benefits in the OCM patients. Quality improvement initiatives included monthly OCM provider meetings to review OCM results, identify cost & quality opportunities, and to design training and education sessions. In order to assess the impact of such a concerted initiative, this study aims to evaluate MHP OCM provider impact in OCM total cost of care relative to historical period. Methods: Retrospective review of reconciliation results provided by Centers for Medicare and Medicaid Innovation (CMMI) for OCM performance periods 1-4 (pp1-4). Total cost of care (ACTUAL) and cost categories were the summarized and adjusted expenditures during 6-month OCM period as reported by CMMI. ACTUAL and cost category experience was compared by OCM performance period to the trended-mean of matched historical OCM-eligible patients (Baseline Episodes from CMMI). Patients were matched by cancer type, comorbidity count, age group, radiation, surgery, and low-intensity/-risk cancer sub-type for prostate, bladder and breast cancers. Results: The largest pp1-4 cost category reductions were acute inpatient ($2.2M), physician services excluding drug-cost, imaging and labs ($1.2M), skilled nursing facility ($0.5M), ancillary which consists of imaging and lab ($0.5M), inpatient rehab ($0.3M), home health agency ($0.3M), radiation oncology ($0.1M). The largest pp1-4 increase in OCM expense relative to historical was Part D Drugs ($1.7M). Conclusions: MHP decreased non-drug costs by $5.1M compared to historical cost for matched patients. OCM costs were lower in facility (hospital and SNF) and physician sites of care. Drug costs increased by $1.7M. Study was limited by OCM claims available as of December 2019. Results may be refreshed as more data becomes available. [Table: see text]

A community oncology palliative care program: Pain-related inpatient utilization in oncology care model (OCM) patients

12094

Background: Oncology Division of Michigan Health Professionals (MHP) participates in OCM. A comprehensive community oncology program for early and timely involvement of palliative care (PC) was launched in September 2017 to help achieve the OCM program goals of high-quality, cost-effective, coordinated care. PC provides a single point of care for all-cause pain management. PC program included pre-program training and continuous education for early and timely involvement of PC. This study aims to assess the educative effect of PC to reduce pain-related inpatient admissions (Pain IP) in all MHP OCM patients, irrespective of PC-referral. Methods: This initiative was led by palliative care physicians and included continuous education and reinforcement of the benefits, every 2-4 weeks, by sharing PC outcomes data with MHP physicians. Physician feedback was part of the program enhancements that were regularly reviewed during monthly MHP physician meetings. Retrospective claims review was performed with OCM episodes from Oct 2016 – Mar 2019. Monthly Pain IP utilization (based on diagnosis code) per 1000 OCM patients (UPK) was analyzed within pre- and post- PC Program start (Sep 2017). Cost per Pain IP included mean of 30-day follow-up skilled nursing facility (SNF) stay and 30-day outpatient facility expenses. Monthly historical Pain IP (pre-PC UPK) was compared to post-PC Pain IP UPK to calculate OCM savings from PC education at MHP. Results: Pain IP peaked at 7.12 UPK in September 2017 when PC program training and education started, then fell as low as 0.87 UPK in January 2019. Unit cost per Pain IP was $12,473. Post-PC (Sep 2017 – Mar 2019), there were 40 fewer Pain IP admissions compared to Pre-PC Pain IP for a total cost savings of $498,920. Conclusions: After PC Program, Pain IP decreased in MHP OCM population (PC-referred and PC not referred). This trend suggests PC training and continuous education for OCM providers is reducing IP utilization. This also translated to a significant cost saving for OCM/Medicare of $498,920. Study was limited by OCM claims available as of December 2019. Results may be refreshed as more data becomes available.

OCM community oncology palliative care program: Opioid analgesic utilization

60

Background: Oncology Division of Michigan Health Professionals participates in Oncology Care Model (OCM ). A community oncology program for early and timely involvement of palliative care (PC) was launched in September 2017 to improve cancer pain management. Under-treatment of cancer pain leads to continued patient suffering and impaired quality of life. Appropriate dosing, rotation and frequent assessments are essential for better pain control. This study aims to see the effect of PC on opioid analgesic utilization. Methods: Retrospective claims review was performed with PC patients referred from September 2017 – December 2018 with an opioid class (as defined by CDC) Part D claim (within OCM data). Opioid utilization across agents was measured in morphine-milligram-equivalents (MME). MME per patient per opioid month (PPM) was compared between PC-referred and PC-not referred patients, pre- and post- PC start. Average MME PPM was compared between PC-Engaged and PC declined or unable to reach patients. Within these 2 cohorts, Long-Acting (LA) vs. Short-Acting (SA) opioid utilization was calculated. Results: PC-not referred patients appear to have little monthly variation in opioid dosing. PC-referred patients showed wide variation in opioid dosing before PC. After PC start, opioid dosing stabilized. PC-Engaged patients had more than double MME PPM vs PC declined or unable to reach (2481 MME PPM vs 1198 MME PPM respectively). PC-Engaged patients utilized a higher percentage of LA (43%) whereas PC declined or unable to reach used much less LA (8%). Conclusions: In patients with uncontrolled pain, PC-referral led to decreased variation in opioid dosing and better pain control. Better pain control may be the result of higher utilization of both SA & LA opioids. Patients who do not engage in PC may be at-risk for under-treatment. Study was limited by OCM claims available as of June 2019. Results may be refreshed as more data becomes available.

OCM community oncology palliative care program: Sites of patient care in last 180 days before hospice or death by cancer types

69

Background: Michigan Health Professionals (MHP) participates in Oncology Care Model (OCM). A community oncology program for early and timely involvement of palliative care (PC) was launched in 2017 to achieve OCM goals of high quality, cost-effective, coordinated care. Previously, we showed that early enrollment in PC increased hospice utilization, decreased hospitalization and outpatient facility cost in last 30-days of death or end of OCM episode. PC improved quality of care in OCM patients. This study aims to see the effect of PC by patient care setting in the last 180-days before hospice or death. Methods: Retrospective claims review was performed with PC patients referred from September 2017 – December 2018. Last 180-days was defined by the entry into hospice, patient death, or OCM claim limit (12/31/2018), whichever was first to occur. OCM claims were analyzed by Integra Connect. Patient care setting utilization, in days (LOS), was identified for FACILITY: inpatient, skilled nursing, outpatient facility (ER, observation, etc.), physician office, and HOME HEALTH: home health agency visits. When no claim was found within the last 180-days, the patient was assumed to be at home or with no-care (HOME). Results: PC-Engaged patients had lower LOS in FACILITY + HOME HEALTH care settings and more days at HOME vs PC declined or unable to reach (average difference of 14 days). PC-Engaged patients had lower LOS in FACILITY + HOME HEALTH vs. matched PC-not referred patients who died or entered hospice (average difference of 26 days). In lung cancer, PC-Engaged patients had lower LOS in FACILITY + HOME HEALTH vs. PC declined or unable to reach (average difference of 27 days). In pancreatic cancer, PC-Engaged patients had lower LOS in FACILITY + HOME HEALTH vs. PC declined or unable to reach (average difference of 17 days). Conclusions: Patients who are PC-Engaged spent more time at home and less time in facilities over the last 6 months before end-of-life. Patients who were referred to PC with advanced lung and pancreatic cancer showed the most opportunity for impact with PC engagement. Study was limited by OCM claims available as of June 2019. Results may be refreshed as more data becomes available.

A community oncology palliative program: Early results for cost and quality measures within OCM program claims data

11585

Background: Oncology Care Model (OCM) is an initiative of the Centers for Medicare and Medicaid Innovation which aims to provide higher quality and more coordinated oncology care while lowering the cost. Oncology Division of Michigan Health Professionals (MHP) participates in OCM. Palliative and End of Life care was identified as one of the quality improvement areas. A community oncology Palliative care (PC) program was launched in October 2017. Methods: The multidisciplinary PC team was led by Board certified palliative care and hospice physicians. Patients appropriate for PC referral were identified by participating medical oncologists. Patients were contacted by the PC team. If the patients agreed a Nurse Practitioner (NP) would assess and follow the patients at home. Care was coordinated by the NP’s in communication with the palliative care team and the primary medical oncologists. Last 30-day (limited by the OCM episode or patient death) OCM program claims data was analyzed by IntegraConnect. Results: From October 2017 to October 2018 a total of 273 patients were referred to the PC program. Fifty-eight patients were identified as having OCM episodes, of these 36 patients had claims data through June 30, 2018. Twenty patients accepted and were engaged with PC,16 patients declined or were unable to reach for PC and formed the comparison group. Even when drug and office costs were excluded, PC engaged patients spent 17% less versus the comparison group (93k vs 112k) in last 30-day claims data. PC engaged patients had a lower acute care facility costs which accounted for 50% (46k) of reimbursement, compared with 95% (105k) for the comparison group. Fourteen OCM patients referred to Palliative program died within episode. 80% (8/10) of engaged patients met quality measure for OCM-3, at least 3 days in hospice vs. 0% (0/4) of patients who declined palliative care, before episode-death. Conclusions: Palliative engaged OCM patients experienced more care at their homes at a lower cost. Palliative program improved practice performance in OCM-3 quality measure. MHP Palliative program is reaching patients in OCM episodes but the numbers are still small.

A community oncology end-of-life care program: Results for hospice length of stay analysis

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Background: Michigan Health Professionals (MHP) is a large multispecialty physician group. MHP Oncology Division participates in quality improvement projects. Palliative and End of Life (EOL) care has been identified as one of the quality improvement areas. A comprehensive community oncology program for early and timely involvement of palliative and EOL care was launched in October 2017. Methods: MHP Palliative and End of life care committee was created of mostly oncologists who are board certified in Palliative care and Hospice. The program, which included pre-program training, user-friendly referral process, and live physician engagement for early involvement of palliative care (PC) and EOL care was developed and implemented. A partnership was created with Premier Hospice to integrate EOL care services with the oncology offices and to collect data. Historical data for average hospice length of stay (LOS) in hospice service for MHP oncology patients was analyzed by Integra Connect. Results: From 1/1/2018 to 12/31/2018 a total of 133 patients (MHP-T) were referred and admitted to Hospice service. Sixty-one patients were on PC service (PC group) and 72 patients (NonPC group) were referred directly to hospice. Total of 527 patients from 2012 to 2017 were analyzed for historical comparison group (HC) and 124 patients were analyzed for MHP-T group. Average LOS was 16.8 days in the HC group. Average LOS for the MHP-T, PC group and NonPC group improved to 34, 35 and 33 days respectively. HC group had 82.2% of patients with average LOS < 30 days. After program implementation average LOS < 30 days improved to 63.7% MHP-T group, 60.0% PC group and 66.7% NonPC group. In HC group, 92 out of 527 patients had average LOS of 2 days or less. Only 2 patients out of 124 patients had average LOS of 2 days or less since the launch of MHP community oncology program. Conclusions: Early and timely patient referral to the EOL care services resulted in average hospice LOS which is more than double as compared to historical comparison group. Fewer number of patients had average LOS of < 30 days and LOS of 2 days or less as compared to the historical comparison group. There was a trend towards higher LOS observed for patients who were under palliative care (PC) before hospice admission.