Optimizing Care for Cancer Patients: Treatment
In previous posts for this series, we described our oncology research project with AstraZeneca, as well as findings and resources the team developed for assessment and care coordination, and for biomarker testing. In this last post of the series, we explore treatment.
Looking at health system site data related to treatment documentation, we noticed several things:
- Breast cancer – Most patients, who did not meet the measure criteria, either did not meet criteria for adjuvant therapy or had a timing-of-therapy issue. Other observed reasons included co-occurring cancers, individual treatment decisions and disease progression.
- Ovarian cancer – In documentation of maintenance therapy for post-primary treatment, we observed notation of patients progressing and receiving palliative treatment or hospice care – or patients declining further treatment after receiving systemic therapy. Additionally, some patients were treated at other facilities; therefore, some information, such as biomarkers, chemotherapy, and other therapies, were not iterated in the notes.
- Chronic lymphocytic leukemia – The sites had a 92 percent adherence rate to guideline-recommended care. The observed reasons for the remaining 8 percent of patients not receiving guideline-recommended care were co-occurring lymphomas or multiple myelomas that required different treatment pathways.
- Non-small cell lung cancer (NSCLC) – In the metastatic setting, sites showed more than 90 percent adherence to guideline-recommended care for patients with documented Exon 19 del or L858R mutations.
For NSCLC sub-populations, approximately 54 percent of Stage IB-IIIA patients had documented adjuvant chemotherapy after resection. Surveillance was also guideline-appropriate, and it was observed that patients elected it due to declining adjuvant treatment or to comorbidities. Of those fully resected patients with documented PD-L1 >1 percent or EGFR mutations, 45 percent received guideline-recommended adjuvant therapy. Observed reasons for excluding therapies included patients declining further treatment, not completing adjuvant chemotherapy cycles due to progression or recurrence during adjuvant treatment, or increased use of adjuvant therapy that the FDA approved in January 2023.
Of Stage II/III unresectable patients or patients not medically fit for surgery with documented chemoradiotherapy, approximately 52 percent had documented guideline-recommended therapy. Observed reasons where patients did not receive therapy were related to non-completion of chemoradiotherapy due to intolerance and/or declining performance status. The higher-risk nature of a patient’s cancer stage also saw those with rapid progression and distant metastasis receiving alternate therapies, which are also appropriate care.
- Small cell lung cancer – Of patients with documented extensive-stage SCLC at diagnosis or due to progression, approximately 77 percent received guideline-recommended chemoimmunotherapy. Observed reasons for not receiving these therapies included loss to follow-up (hospice transfer, death, hospital transfer, treatment) or discontinuation of therapy due to intolerance, adverse events, declining performance or patient declining.
Additionally, many of the real-world evidence council advisors, subject matter experts and providers in health systems reported challenges in obtaining insurance authorization and reimbursement for treatment.1,2 They noted that approval may be denied for certain treatments, and that this varies by cancer type. The less comprehensive a patient’s insurance, the harder it can be to obtain prior authorization. Therefore, there is administrative burden to provide additional information or clarification, or to conduct denial appeals.
Even when a therapy is approved, both by the FDA and by pharmacy and therapeutics committees, providers and patients might not have access right away due to payment issues or if billing codes need to be created.
To address this challenge, our team developed a prior authorization toolkit to help providers and patients better navigate insurance issues and prior authorizations that can affect the timeliness of needed treatments and supportive care. The toolkit contains prior authorization best practices, a prior authorization support dotphrase, and a dotphrase implementation guide.
Site feedback indicated that the toolkit information could help improve consistency and standardization and could be used as a training tool to outline the elements needed for authorization. Users generally expressed that the toolkit was helpful and would allow health systems to work with their IT and other departments to customize it.
Suggestions for improvement included combining the prior authorization dotphrase with the testing and treatment tracker dotphrase. There were also suggestions to include CPT code, ICD-10 code, surgery date, discharge date, and specific path date and document number for pathology. Based on this feedback, the team updated and streamlined the content into a concise, one-page document.
Authors:
Misty Anderson, MBAHM, BSN, RN, LSSMBB, oversees the Improvement Science team of Premier Applied Sciences (PAS). She is responsible for building standards that support evidence-based review, qualitative analysis, research and quality methods, content management and training for new and existing customers within PAS.
Cate Polacek, MLIS, CMPP, ELS, is a Senior Medical Writer on the Applied Research team within PAS. She provides writing, editing, academic research and publication services across PAS. She writes journal articles, patient and provider education, white papers, study protocols, literature reviews and qualitative analyses for all major therapeutic areas.
Nicholas Travis, MSN, BSN, RN, FNP-C, is a Manager of Content Generation on the PAS Improvement Science team. He develops tools, resources and other clinical content to support various projects. He creates frameworks, care pathways, webinar presentations, clinical support tools, patient and provider facing materials, and other clinical content for projects.
Erika Klump, MS, is the Technical Product Director on the Data, Technology and Innovation team of PAS. She works with research teams, health care systems, engineers and informaticists to ensure PAS projects have the structured or unstructured data and technology needed for project objectives.
Erica Robichaud, PT, DPT, MHA, is the Project Owner and Director on the Improvement Science team. She is responsible for overseeing the project, ensuring the quality and timeliness of deliverables and maintaining customer services. Her collaboration with the team, sites, providers and subject matter experts is key to the successful execution and completion of the project.
Andrew Long is an Analytics Developer on the Data, Technology, and Innovation team of PAS. He works to develop data pipelines integrating structured and unstructured data. He informs and implements data validation and optimization strategy for leveraging NLP solutions and supports various other PAS data solutions.
Nancy Rios is a Research Analyst on the Data, Technology, and Innovation team. She collaborates closely with cross-functional teams including research, health care systems and technology experts. Her responsibilities extend to developing and implementing data validation procedures, leveraging natural language processing solutions for data optimization and informing data quality enhancement strategies.
References:
1. Trapani D, Kraemer L, Rugo HS, Lin NU. Impact of Prior Authorization on Patient Access to Cancer Care. Am Soc Clin Oncol Educ Book. May 2023;43:e100036. doi:10.1200/EDBK_100036
2. Chino F, Baez A, Elkins IB, Aviki EM, Ghazal LV, Thom B. The Patient Experience of Prior Authorization for Cancer Care. JAMA Netw Open. Oct 2 2023;6(10):e2338182. doi:10.1001/jamanetworkopen.2023.38182