Coordination of Care Based on Patient-Reported Outcomes Improves End-of-Life Care and Lowers Costs

Coordinating radiation therapy teams and palliative care teams based on patient reported outcomes (PROs) improved outpatient symptom management and decreased end-of-life hospitalizations, as well as costs of care for patients with late-stage cancer, according to interim results from an initiative at the University of Virginia Health System.

The data, presented at the 57^thAnnual Meeting of ASTRO, also showed that rapid palliative radiation therapy with shorter, higher doses of radiotherapy (hypofractionation) led to pain relief from bone metastases within 1 week for a substantial proportion of patients.

The integrated patient care program for patients with advanced cancer undergoing radiotherapy was initiated in 2012 at the University of Virginia Health System. The program used PRO information with the goal of improving patients’ health, quality of life (QOL), and reducing costs of care, with an emphasis on reducing hospitalizations and improving outpatient management.

“This shows that if we listen to our patients carefully, talk to them about their changing medical and emotional needs, and develop rapid and coordinated treatment plans based on their feedback, we can improve their quality of life and reduce the need for hospitalization and symptom management at the end of life,” said lead author Paul W. Read, MD, PhD, professor of radiation oncology at the University of Virginia Health System.

This program revealed a need for earlier integration of palliative care into management of patients with advanced-stage cancer. “But there are not enough palliative care specialists to go around, so we need to innovate and collaborate,” he explained. “Our solution is collaborative care with three programs to target patients with the highest symptom burdens.

The three programs are: CARE Track, a data-driven palliative care team that meets weekly and develops coordinated care plans; MY COURSE, a PRO program integrated into electronic health records that triggers email alerts for patients in declining status; and STAD RAD, a same-day highly conformal palliative radiation program with the goal of treating painful bone metastases within 3 to 4 hours.

The program underwent a pilot test in February 2013, and then PRO assessments were taken for all patients starting in October of that year.

The CARE Track program enrolled 646 cancer patients. End-of-life (EOL) care compared data from 368 CARE Track patients with 198 patients not enrolled in the program (the control group). CARE Track patients completed a total of 967 PRO surveys.

Patients enrolled in CARE Track had significantly fewer EOL hospitalizations compared with the control group: in the final 90 days of life, 48.3% were hospitalized compared with 64% of controls (P= .0004). Hospice care was delivered to more CARE Track patients: 69.6% compared with 47% of controls (P<.0001), leading to fewer hospital deaths for patients on CARE Track: 8.4% versus 38.5% (P<.0001). Moreover, CARE Track resulted in a per-patient reduction of $7317 in total costs of care during the last 90 days of life compared with controls (P= .0128).

As part of CARE Track, the multidisciplinary team developed a STAT RAD initiative to improve time to response for initiating pain control in patients with bone metastases. The goal of this workflow effort was to transform a 2-to-3-week treatment program into a 1-day treatment procedure with highly focused radiation treatment to reduce treatment-related toxicity.

The STAT RT pilot trial enrolled 28 patients with 1 to 3 painful bone metastases; 37 target lesions were treated with radiotherapy of 5 to 10 Gy per fraction, for between 2 and 5 fractions (mean of 26.1 Gy in 3.1 fractions).

The International Bone Metastasis Consensus Working Party criteria were used to assess pain response; by 3 weeks, partial or complete pain relief was achieved in 80% to 90% of patients. Using the Functional Assessment of Cancer Therapy (FACT)—Bone Pain Scale, QOL was significantly improved 1 to 26 weeks post treatment.

A second clinical trial called STAT RAD is accruing patients to assess another schedule of radiation with the aim of shortening the radiation schedule even further using single fraction STAT RAD, so it can be completed in a single 3- to 4-hour procedure.

&ldquo;Integrating patient surveys to collect patient reported outcomes directly into electronic health records, and incorporating them into routine clinical care can be done in most hospital systems. The concept of Tumor Boards for multispecialty care planning of curative cancer patients is practiced throughout the country, and extending this concept to palliative care management is easy and straightforward. Single fraction radiation therapy for palliation of bone metastases for advanced cancer patients with short life expectancies is an accepted national care guideline and has been studied for decades in clinical trials. Therefore, these programs can all be adopted into clinical practice at most health systems, with minimal cost, training, or education,&rdquo; Read said.

References

1. Incrocci L. Hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year oncologic outcomes of the Dutch randomized phase 3 HYPRO trial. Presented at the 57^thAnnual Meeting of ASTRO. October 18, 2015. Abstract LBA 6689/LBA 4.