Sep 19, 2019
Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Ethan Basch. He holds several professional titles at the University of North Carolina at Chapel Hill, including Distinguished Professor of Oncology and Director of the Cancer Outcomes Research Program. Dr. Basch is a member of ASCO's board of directors and recently served as the program chair of the ASCO Quality Cancer Symposium. Dr. Basch, welcome to the podcast.
Thanks so much. Nice to be here.
We're glad you're here. So you've just returned from the
conference. How was this year's event compared with previous
years?
This year's event was a great success. Similar to prior years, the
conference focused on quality of care delivery. But increasingly,
we have seen a move towards research and practical presentations
around value-based care and alternative payment models. I would say
that what was particularly successful this year was the bringing
together quality activities in the community with academic research
that is being conducted by health services research.
Increasingly, we've been seeing that community-based quality
initiatives are beginning to use more rigorous scientific methods
and similarly that academic research is becoming more practical and
community-based. And this conference really shows the marriage of
the two at this moment in oncology.
That's great. So which presentations or abstracts did you find the
most compelling or practice-changing?
There were so many terrific abstracts this year, we had a very
difficult time choosing the oral abstracts for the meeting. And we
had more than 500 submissions of scientific abstracts for the
meeting. I thought I would go over three of the abstracts that I
found particularly exciting and that I think reflected some of the
overall themes of the meeting.
The first was from Kerin Adelson, who's a medical oncologist and a
quality officer at Yale Cancer Center. And Yale is one of the
participating sites in the Oncology Care Model, which is the
Medicare Innovation Center's demonstration project for an
alternative payment model in oncology. And they've been
participating over the past several years implementing a number of
value-based care initiatives to try and reduce costs and improve
quality.
This has included broadening their care coordination and navigation
services, providing an alternative pathway to the ER to an acute
care center, providing access to providers 24/7 with access to the
electronic health record, and several other patient-oriented
initiatives.
And over time, they've looked at the impact of these initiatives on
their total cost of care. And they've broken it down into different
categories. And at the meeting this year, Dr. Adelson presented
what's happened specifically to the cost of emergency room and
hospital utilization, as well as pharmaceuticals.
And what they found at Yale is that as they progressively
implemented these value-based programs, they also progressively
decreased the amount of emergency room and hospital utilization
quite substantially and significantly, yielding a decrease in
cost.
However, simultaneously, the cost of drugs increased as we all in
oncology are acutely aware of. In fact, the cost of pharmaceuticals
went up by about 9% per year. So while they very substantially
drove down the costs of emergency room visits and hospitalization,
they were barely able to keep up with the rising costs of
pharmaceuticals.
The second abstract, I think, of particular interest also relates
to the cost of drugs. This was a presentation by Bernardo Goulart
from Scott Ramsey's group at Fred Hutch Cancer Research Center in
Seattle. They are particularly interested in the relationships
between the costs of drugs and adherence and other outcomes.
Now, previously, there have been several studies published by
investigators like Stacy Dusetzina at Vanderbilt showing that as
the incremental out-of-pocket costs of drugs goes up that adherence
with drugs goes down, i.e. the more that people have to pay out of
pocket, the less they take their drugs. And drugs that this has
been particularly shown for are oral tyrosine kinase ACE
inhibitors. And this has been looked at in a number of different
diseases.
In this particular study, Dr. Goulart and colleagues looked at the
relationship between higher patient out-of-pocket TKI costs and
both adherence to drugs, but also overall survival. And consistent
with prior studies, they found that greater out-of-pocket costs
were again associated with lower adherence. But in this case, they
added on the overall survival metric and found that in fact, higher
out-of-pocket costs were associated with worse survival.
This is important information as we as a country think about how
out-of-pocket costs are structured within benefits programs, that
in fact, there is a vigorous debate in Washington currently around
Medicare Part D and patient out-of-pocket obligations. And this
study provides additional evidence that the greater burden our
patients face in terms of their financial toxicity from their
out-of-pocket costs, the worse their outcomes are going to be.
The third abstract that I would like to highlight is by Erin
Elizabeth Hahn from Kaiser Permanente Southern California. This
study is on a slightly different tack. This is around
implementation of distress screening and patient-reported outcomes
in clinical practice.
Now, many listeners may know that patient-reported outcomes is an
area of particular interest to me, but also to many of us who are
involved in value-based care because previously, implementation of
patient-reported outcomes in clinical practice has been shown to
drive down ER visits and hospitalization, to lengthen the amount of
time people can tolerate chemotherapy to improve health-related
quality of life and to improve overall survival.
But one of the challenges around distress screening and
patient-reported reported outcomes has been implementation because
it is simply difficult logistically to implement collection of
information from patients about their symptoms and functioning
during routine practice, which is already crowded with all sorts of
things that we need to do.
So in this study they employed a pragmatic clinical trial design
and did a randomized study of using cutting edge implementation
science and quality improvement methods to roll out
patient-reported outcomes in practice. And they did this in their
very large practice. And what they found was that when they used QI
principles and implementation science to roll out patient-reported
outcomes and distress screening, they had very successful
uptake.
In fact, 94% of patients who were in the arm that used cutting edge
implementation science and QI approaches completed their distress
screening and patient-reported outcomes, which was significantly
and substantially higher than the arm in control that did not use
those approaches.
This suggests that for any health system or practice that wants to
implement patient-reported outcomes or distress screening and be
successful at it really should use our standard QI processes that
iteratively work with providers and in this case with patients to
make sure that there's understanding, training, uptake, and
sustainability.
That's great. It sounds like great strides are really being made in
value-based care. Were there any other takeaways that you saw as
important during the conference?
Well, I think that overall across the conference, we saw a lot of
enthusiasm around the kind of value-based care initiatives that are
reflected by these three abstracts. There's a lot of activity
across the country, and also, I should note in Canada because
there's a very substantial Canadian representation, to try to build
in some of these value-based care approaches and figure out how
best to implement them and to try to understand better their impact
on costs and utilization.
That's great. Again, today, my guest has been Dr. Ethan Basch.
Thanks so much for joining us again on our podcast.
Thanks so much. Pleasure to be here.
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