Shereef M. Elnahal

Organizing a multidisciplinary clinic

Multidisciplinary cancer care models have become increasingly more popular in recent years. This comprehensive approach to care delivery has evolved to address numerous medical and social aspects critical to all patients diagnosed with cancer. Because of the sheer number of specialists involved in the care trajectory of patients with cancer, multidisciplinary care models add significant value in facilitating communication between specialists and in coordinating care. Multidisciplinary models also allow for new and innovative therapies to be incorporated more quickly than is seen in single provider care. Two principal modes of multidisciplinary care have been described-the tumor board and the multidisciplinary clinic. While tumor boards are well established in oncology literature and practice, there is growing support favoring the use of multidisciplinary clinics, bringing providers together at the point of care. In this section, we describe recent data demonstrating the value of the multidisciplinary approach, with particular focus on the creation and potential benefits of a formal multidisciplinary clinic.

Patients and Physicians Can Discuss Costs of Cancer Treatment in the Clinic

PURPOSE As one solution to reducing costs and medical bankruptcies, experts have suggested that patients and physicians should discuss the cost of care up front. Whether these discussions are possible in an oncology setting and what their effects on the doctor-patient relationship are is not known. METHODS We used the National Comprehensive Cancer Network (NCCN) Guidelines and the eviti Advisor platform to show patients with metastatic breast, lung, or colorectal cancer the costs associated with their chemotherapy and/or targeted therapy options during an oncology consultation. We measured provider attitudes and assessed patient satisfaction when consultations included discussion of costs. RESULTS We approached 107 patients; 96 (90%) enrolled onto the study, three (3%) asked if they could be interviewed at a later date, and eight (7%) did not want to participate. Only five of 18 oncologists (28%) felt comfortable discussing costs, and only one of 18 (6%) regularly asked patients about financial difficulties. The majority of patients (80%) wanted cost information, and 84% reported that these conversations would be even more important if their co-pays were to increase. In total, 72% of patients responded that no health care professional has ever discussed costs with them. The majority of patients (80%) had no negative feelings about hearing cost information. CONCLUSION In an era of rising co-pays, patients with cancer want cost-of-treatment discussions, and these conversations do not lead to negative feelings in the majority of patients. Additional training to prepare clinicians for how to discuss costs with their patients is needed.

Engaging patients and stakeholders in the process of designing a clinical trial and patient education platform.

63 Background: Patient engagement during the initiation, development, and implementation of a study has been shown to improve the ethical nature of research and the appropriateness of treatment methods, and insights into how best to partner with patients are needed. We describe our patient engagement experience in developing a clinical trial for non-metastatic pancreatic cancer (PCA). METHODS A team of patient research partners (PRPs) was consulted to design a multi-institutional study to evaluate the efficacy of chemotherapy, stereotactic body radiation therapy, and early palliative care (EPC) in patients with PCA who are typically ineligible for clinical trials due to advanced age, poor performance status, or preexisting comorbidities. PRPs included patients, caregivers, clinical researchers, patient advocacy organizations, and pharmaceutical companies. A 22-item initial survey on personal interests and a 5-item follow-up survey on study design were anonymously completed after two in-person meetings. RESULTS Of 15 PRPs involved, 9 completed the initial survey and 10 completed the follow-up survey. PRPs were most interested in improving quality of life (QOL, 89%), care coordination (78%), symptom management (67%), stress/anxiety (56%), and survival (56%). Confidence in the care team, hope, QOL, education and understanding, dignity, and pain management were reported to be the most important factors throughout the cancer experience. The majority (89%) requested that study participants have access to the study protocol and research publications supporting the study design. Because all PRPs suggested that a personal website be used to provide information to study participants and to disseminate the results of the study, an online patient education platform was adopted and customized for patients (and caregivers). Furthermore, integration of EPC into the treatment regimen was unanimously endorsed. CONCLUSIONS Engaging PRPs in the process of designing a clinical trial for PCA appears to be feasible and valuable in identifying the study objectives most important to patients. PRPs conveyed that maintaining a good QOL is essential, and adoption of EPC in these patients should be considered.

Prevalence and significance of subcentimeter hepatic lesions in patients with localized pancreatic adenocarcinoma

PURPOSE To determine the prevalence and significance of incidental, subcentimeter hepatic lesions in patients with a new diagnosis of pancreatic cancer. MATERIALS AND METHODS This Institutional Review Board-approved retrospective study included 101 patients [45% men, median age 63 years (34-85)] treated for localized pancreatic adenocarcinoma at Brigham and Womens Hospital and Dana Farber Cancer Institute from January 1999 to December 2007. Initial staging and follow-up computed tomographic scans were reviewed to determine the frequency of liver lesions that were initially too small to characterize and later proved to be metastases. Clinical variables known to be prognostic for patients with pancreatic cancer were also recorded. Using Cox regression, we calculated adjusted hazard ratios to determine the association between presence of liver lesions and overall survival. RESULTS A total of 31 patients (30.7%) had subcentimeter hepatic lesions on staging scans. Of these patients, 21 (20.7% of total, 67.7% of patients with lesions) had eventual metastases to the liver. Finally, of this group, 5 patients (5.0% of total, 16.1% of patients with lesions) eventually had a metastatic focus at the specific site of the original lesion. Liver lesions predicted the occurrence of metastatic disease to the liver compared with patients without lesions (67.7% with lesions vs 44.4% without, P = .034). The presence of subcentimeter liver lesions at diagnosis was significantly associated with reduced overall survival (hazard ratio 1.65; 95% confidence interval 1.03-2.64, P = .036). CONCLUSIONS Subcentimeter lesions in the liver are common in patients with a new diagnosis of pancreatic cancer. Approximately 16% of these lesions represent metastases. The presence of indeterminate liver lesions may be associated with reduced overall survival.

A Tale of Two Systems Combining Forces to Improve Veteran and Military Health Care

Meeting the health care needs of America’s veterans and active duty military personnel is a crucial imperative in the face of escalating global conflicts. The Military Health System (MHS), which provides care services to active duty personnel and their families, and the Veterans Health Administration (VHA), the agency that administers care to veterans, face an unprecedented set of recent challenges in meeting the care needs of a combined 20 million lives. In 2014, national media revealed long wait times for veterans at more than 40 Veterans Affairs (VA) facilities, highlighting a crisis of undercapacity. In the MHS, many facilities face the converse problem: in an environment of sequestration, the Pentagon is considering closing several facilities, especially underperforming centers according to a recent quality review. Systematic improvement is needed. Current policy initiatives fall short of comprehensive solutions. The Veterans Access, Choice, and Accountability Act (Choice Act) authorized

Preliminary decision-tree analysis of costs to payors associated with a pancreatic multidisciplinary clinic.

5 billion for the VHA to hire providers. Per publicly reported national data as of April 2015, veterans are still waiting an average of 8 days longer than clinically appropriate for appointments. To decrease this to goal levels solely by hiring physicians, thousands of new doctors are needed at current daily volumes. This may take years to achieve. Furthermore, the Veterans Choice Fund, granting

IMPROVING SAFE PATIENT THROUGHPUT IN A MULTIDISCIPLINARY ONCOLOGY CLINIC.

10 billion to cover civilian services for delayed veterans, can provide only short-term relief. And although the Pentagon’s plans to downsize low-volume facilities may reduce costs, this strategy would be a lost opportunity to utilize or repurpose excess capacity and does not address quality deficits. Legislation or top-down mandates cannot solve either agency’s dilemma. We feel that a few key facilities within both agencies are already implementing an effective solution: cross-agency collaboration, encouraging local innovation while balancing independence and interdependence. A more nuanced analysis of the problems in the VA and MHS reveals that each agency’s strengths (and problems) are complementary. The VA faces a crisis of undercapacity while many MHS facilities would benefit by accepting more patients. This creates a ripe environment for collaboration—one that stands to benefit patients in both health systems. The Buckeye Federal Health Consortium in Ohio is a distinguishing example of cross-agency cooperation that has used best practices from specific facilities to benefit others, harnessing comparative advantages. Under the Consortium, Wright-Patterson Medical Center, a comprehensive Air Force treatment facility, is already accepting patients from Ohio VAs. As of 2015, approximately 19 VA inpatients per month were transferred to Wright-Patterson, as well as more than 20 VA specialty outpatient appointments. Since patient sharing within the Consortium began to accelerate in the beginning of 2015, Ohio VAs achieved improvements in their most scrutinized metric: outpatient wait times. Columbus VA, the pioneering facility that began sharing patients with Wright-Patterson, saw a 9% drop in the number of patients with appointments scheduled beyond 30 days. As relationships grow and trust builds that patients can be shared safely between facilities, transfers are likely to increase. Moreover, these are highacuity patients; in 2015, accepted patients are 13% more complex (measured by relative weighted product) than they were one year ago. Because Wright-Patterson treats the highest acuity patients in the Air Force, they are poised to accept older and more complex VA patients. By training MHS care teams to care for more complex patients, the Consortium also is allowing Wright-Patterson to better meet their mission of Military Readiness, an essential part of the Quadruple Aims of the MHS. Cooperative consortia between the MHS and VA also would allow for significant savings on purchased care. Currently, the Choice Act allows patients waiting longer than 30 days for an appointment to seek care in civilian hospitals. If these patients were instead transferred to MHS 613581 AJMXXX10.1177/1062860615613581American Journal of Medical QualityElnahal et al research-article2015

More Than the Sum of Its Parts: How Multidisciplinary Cancer Care Can Benefit Patients, Providers, and Health Systems

118 Background: Multidisciplinary clinics (MDC) are well-established formats for delivering thorough oncologic evaluation and treatment. Although much evidence identifies an association between MDCs and superior clinical outcomes, their effect on total costs to payors is not well described. We performed a preliminary decision analysis of likely costs associated with a pancreatic MDC versus other settings, referring to known changes in diagnosis resulting from our pancreatic MDC (Pawlik, Ann Surg Oncol.2008; 15(8):2081-8). METHODS We extracted cost data from previous decision-analyses to determine expected cancer treatment costs for patients with resectable (Ljungman, World J Surg. 2011; 35:662-670), locally advanced (Murphy, Cancer. 2011;118:1119-1129), and metastatic disease (Attard. J Clin Oncol. 2012 [suppl 4; abstr 199]), using the most updated studies available. We then mapped these costs to a decision-analysis, modeling staging patterns that change after referral to the MDC. The expected cost of each disease stage was multiplied by its frequency of occurrence for both scenarios. A unique Markov analysis with consistent assumptions was not available at submission, but will be at the time of the meeting. RESULTS From the literature, an initial diagnosis of resectable disease was associated with the highest cost, and metastatic disease with the lowest. The percentage of patients managed for each disease stage in both clinic settings are indicated in the table. Because the MDC scenario resulted in a lower frequency of resectable and a higher frequency of metastatic staging at initial diagnosis, costs were 4.7% lower in the MDC scenario. CONCLUSIONS In this preliminary analysis, the MDC showed potential to achieve up to 4.7% in cost-savings over treatment in conventional clinic settings, suggesting that the MDC setting for pancreatic cancer may be cost-saving to payors. [Table: see text].