Belen Fraile

Novel data sharing between a comprehensive cancer center and a private payer to better understand care at the end of life.

1 Background: Assessment of care at the end of life (EOL) is critical to improving the quality of care for oncology patients. EOL measures based on guidelines from the National Quality Forum (NQF) and ASCO have been examined in older cancer patients using Medicare claims. We performed a project to evaluate the use of private payer claims data to enumerate EOL measures in patients of all ages at a comprehensive cancer center. METHODS Claims data were obtained for Dana-Farber Cancer Institute (DFCI) adult patients who died between July 1, 2010, and December 31, 2012, and were insured by Blue Cross Blue Shield of Massachusetts (BCBSMA). We assessed NQF-based measures related to hospitalizations, emergency department visits, and intensive care unit admissions in the last 30 days of life, chemotherapy in the last 14 days, hospice stay, and death in a hospital. In addition, we examined red blood cell and platelet transfusions, radiation therapy, and surgery in the last 30 days of life, as well as death in the ICU. RESULTS Of a total of 674 patients, 580 had solid tumors and 82 had hematologic malignancies; their median age was 59 years (range, 18-92). The Table provides results for the EOL measures examined. Up to 50% of the measured events did not occur at a DFCI-affiliated hospital. CONCLUSIONS Using private insurance claims data in conjunction with medical records, we were able to successfully capture a broad range of EOL quality measures. Access to the claims data provided information not readily available in hospital medical records and for care not occurring at DFCI. Data sharing between private payers and cancer centers may provide a unique method of comprehensively examining quality of EOL care for oncology patients. [Table: see text].

Understanding Oral Chemotherapy Prescribing Patterns at the End of Life at a Comprehensive Cancer Center: Analysis of a Massachusetts Payer Claims Database.

PURPOSE Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. Specific measures defining appropriate end-of-life use of oral agents have not yet been described, and little is known about prescribing patterns. METHODS We conducted an exploratory analysis of 371 patients at Dana-Farber Cancer Institute who were covered by the Blue Cross Blue Shield of Massachusetts pharmacy benefit and died during 2012 to 2013. We analyzed processed claims as a surrogate for chemotherapy administration. We compared oral with parenteral chemotherapy claims in the last 6 months of life. RESULTS In the last 6 months of life, 294 patients (79%) had chemotherapy claims, including 81 (22%) prescribed an oral agent; 20 patients had claims for oral chemotherapy in the last 30 days of life. For eight patients (40%), this was the initial start of that oral agent. In the last 14 days of life, only 23 patients had chemotherapy claims, including six patients prescribed an oral agent. CONCLUSION The collection of oral chemotherapy use data through insurance claims was feasible. Processed claims for chemotherapy, including oral, sharply declined during the last 30 days of life, consistent with a shift to palliative management. These results highlight the need for a more comprehensive analysis of oral chemotherapy prescribing patterns and development of specific measures to define the appropriate use of oral chemotherapy at the end of life.

Health care institutional charges associated with ambulatory bloodstream infections in pediatric oncology and stem cell transplant patients

The impact of ambulatory bloodstream infections (Amb‐BSIs) in pediatric oncology and stem cell transplant (PO/SCT) patients is poorly understood, although a large portion of their treatment increasingly occurs in this setting. This study aimed to understand the economic impact and length of stay (LOS) associated with these infections.

Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non–Small-Cell Lung Cancer

PURPOSE Increasing costs and medical complexity are significant challenges in modern oncology. We explored the use of clinical pathways to support clinical decision making and manage resources prospectively across our network. MATERIALS AND METHODS We created customized lung cancer pathways and partnered with a commercial vendor to provide a Web-based platform for real-time decision support and post-treatment data aggregation. Dana-Farber Cancer Institute (DFCI) Pathways for non-small cell lung cancer (NSCLC) were introduced in January 2014. We identified all DFCI patients who were diagnosed and treated for stage IV NSCLC in 2012 (before pathways) and 2014 (after pathways). Costs of care were determined for 1 year from the time of diagnosis. RESULTS Pre- and postpathway cohorts included 160 and 210 patients with stage IV NSCLC, respectively. The prepathway group had more women but was otherwise similarly matched for demographic and tumor characteristics. The total 12-month cost of care (adjusted for age, sex, race, distance to DFCI, clinical trial enrollment, and EGFR and ALK status) demonstrated a

A comparison of skin cancer screening and treatment costs at a Massachusetts cancer center, 2008 versus 2013

15,013 savings after the implementation of pathways (

Characteristics associated with in-hospital death in commercially insured decedent.

67,050 before pathways v

Understanding oral chemotherapy use at the end of life: Analysis of a Massachusetts claims database.

52,037 after pathways). Antineoplastics were the largest source of cost savings. Clinical outcomes were not compromised, with similar median overall survival times (10.7 months before v 11.2 months after pathways; P = .08). CONCLUSION After introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly, with no compromise in survival. In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of clinical pathways may provide a means to coalesce and disseminate institutional expertise and track and learn from care decisions.

Cost and survival analysis before and after implementation of Dana-Farber Clinical Pathways for Patients with Stage IV Non-Small Cell Lung Cancer.

Background Temporal analyses of skin cancer costs are needed to examine how expenditure differences between diagnoses are changing. Objective To tabulate the costs of skin cancer–related care (SCRC), including both screening and treatment, at an academic cancer center at 2 time points. Methods Cost data (insurance and patient payments) at an academic cancer center from 2008 and 2013 were queried for International Classification of Diseases, Ninth Revision, codes pertaining to skin cancer. Screening costs were separated from treatment costs through associated Current Procedural Terminology codes. Results The total annual cost of SCRC increased by 64%, the number of patients receiving SCRC increased by 45%, and the mean cost per patient treated increased by 13%. Screening accounted for 17% and 16% of total annual costs in 2008 and 2013, respectively. The mean cost per patient with melanoma increased by 84%, which was the largest increase among skin cancer diagnoses. In 2013, the few patients with melanoma who were treated with ipilimumab (n = 48 [4% of patients with melanoma]) accounted for 42% of melanoma treatment costs and 20% of SCRC costs. Limitations Prescription costs were unavailable. Conclusions Melanoma costs have increased as a result of the introduction of ipilimumab. Ongoing studies are needed to monitor the cost‐effectiveness of SCRC at a national level.

Novel Data Sharing Between a Comprehensive Cancer Center and a Private Payer to Better Understand Care at the End of Life

35 Background: A majority of patients with poor-prognosis cancer express a preference for in-home death, however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death among commercially-insured decedents. METHODS Building on a data-sharing project between our institution and Blue Cross/Blue Shield of MA, we obtained health care claims records for a sample of commercially insured decedents who died between July 2010 and December 2013. All patients received cancer care at Dana-Farber. In-hospital vs. out-of-hospital death was ascertained from hospital claims. Odds ratios (OR) and 95% confidence intervals (CI) were used to evaluate the association of in-hospital death with patient characteristics and established retrospective measures of end-of-life (EOL) care quality. RESULTS 904 commercially insured decedents were included in our sample, and 537 decedents (59%) enrolled in hospice prior to death. There were 254 in-hospital deaths (28% of all deaths), and 79 in-hospital deaths (31%) occurred at unaffiliated hospitals. Three measures of EOL care quality were found to be associated with in-hospital death, including chemotherapy within 14 days (OR 4.0 [95% CI 2.6-6.2]) or 15-30 days (OR 2.1 [1.4-3.1]) of death, 2 or more ED visits within the last 30 days of life (OR 3.0 [2.1-4.3]), and non-enrollment in hospice (OR 28.8 [18.7-44.3]). Hematologic malignancy, but not other cancer types, was significantly associated with in-hospital death (OR 5.09 [3.1-8.5]). Age at death, sex, marital status, race/ethnicity, and distance of residence from the cancer center were not significantly associated with in-hospital death, though sample sizes for some comparison groups were small. CONCLUSIONS In-hospital deaths are common among commercially insured cancer patients, and data sharing identified nearly 1/3 of in-hospital deaths that occurred at unaffiliated hospitals. Retrospective measures of intensive EOL care quality were significantly associated with in-hospital death, and patients enrolled in hospice were dramatically less likely to experience an in-hospital death.

Characteristics Associated with In-Hospital Death among Commercially Insured Decedents with Cancer

8 Background: Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. But the appropriateness of oral chemotherapy specifically is not yet described, and there are little available data on utilization of oral chemotherapy at the end of life. METHODS We analyzed results from 200 patients of Dana-Farber Cancer Institute, covered by the Blue Cross/Blue Shield of Massachusetts (BCBSMA) pharmacy benefit, and who died in 2012. We collected data on chemotherapy use in the last 6 months of life. We analyzed oral chemotherapy use in the categories of any oral prescription and timing of first oral prescription. We compared results to intravenous (IV) and any other administration route. RESULTS Most of our target population had gastrointestinal, thoracic, or breast malignancies. In the last 6 months of life, 75% received some form of chemotherapy, including 23.5% who were prescribed an oral agent. 11 patients were prescribed oral chemotherapy in the last 30 days of life. For 45% (n=5) this was the first oral prescription. In the last 14 days of life, only 5.5% of patients received any chemotherapy, including one patient prescribed an oral agent. CONCLUSIONS The collection of oral chemotherapy utilization data through insurance claims was feasible. Use of any chemotherapy, including oral, sharply declined during the last 30 and 14 days of life, consistent with a shift to palliative end-of-life management. This analysis highlights the need for a more comprehensive understanding of oral chemotherapy use at the end of life. Furthermore, with the growing use of oral chemotherapy, the development of measures to define quality of end-of-life care with these agents is warranted. [Table: see text].