D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2018 . No. 8 BEST PRACTICES FOR REDUCING UNPLANNED ACUTE CARE FOR PATIENTS WITH CANCER Nathan R. Handley, Lynn M. Schuchter, Justin E. Bekelman Journal of Oncology Practice – published online before print April 17, 2018 KEYFINDINGS Reducing preventable and unplanned emergency department visits and hospitalizations is a major challenge in cancer care. In this review of best practices and supporting evidence, the authors identified five strategies that health systems and cancer programs can use to reduce acute care: (1) identify patients at high risk of unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new sites for urgent cancer care, and; (5) use early palliative care. THE QUESTION THE FINDINGS Unplanned acute care for patients with cancer is common – and costly – The authors identified five strategies, and specific interventions that in the United States. In 2010, cancer care cost an estimated $125 billon implement these strategies, to reduce unplanned acute care for patients and is projected to reach almost $160 billion by 2020. Acute cancer care, with cancer. Some have a stronger evidence base than others; some can including emergency department (ED) visits, hospitalizations, and 30-day be implemented easily, while others involve a significant commitment of rehospitalizations, accounts for the largest component of total spending resources. (48%) and is the largest driver of regional differences in spending on cancer care. A rule proposed in 2016 by the Centers for Medicare and Medicaid 1 I dentify patients at high risk of unplanned acute care. By targeting interventions to populations who may benefit most, practices can make the best use of scarce resources. Patients can be identified by Services (CMS) seeks to reduce unplanned acute care for Medicare monitoring known risk factors, using published risk-stratification models, beneficiaries receiving outpatient chemotherapy. If finalized, hospitals will or through predictive analytics. While predictive models and techniques have a financial incentive to reduce hospitalizations and ED visits within are still in their infancy, data suggest that they hold great promise, 30 days of chemotherapy for any of ten common conditions considered when used as a complement to, rather than a substitute for, physician preventable, including nausea and fever. involvement and discretion. While few examples of this strategy exist specific to cancer patients, it has been used successfully in other areas How can health systems and programs reduce unplanned acute care of medicine. One health system used predictive analytics to identify for their patients with cancer? To ascertain best practices, the authors high-risk patients with heart failure, and using a targeted intervention, reviewed the available evidence, quality guidelines, and common models was able to reduce rehospitalizations by 19%. of care to identify existing strategies, and assessed the impact on ED visits, hospitalizations, and rehospitalizations within 30 days. 2 Enhance access and care coordination. Better communication and coordination helps patients get the care they need when they need it, reducing the likelihood of preventable ED visits or hospitalizations. A number of low-tech interventions exist, such as providing clear and reliable mechanisms to contact the care team, improving care transitions, and developing patient navigator programs. In one program, COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI nonclinical navigators acted as liaisons between patients and providers THE IMPLICATIONS to clarify treatment plans, connect patients with resources, and In this review of best practices and supporting evidence, the authors encourage advance care planning. As a result, in the last 30 days of life, identified five strategies for reducing unplanned acute care for patients ED visits decreased by 20% and all-cause hospitalizations decreased by with cancer. Some of these strategies, such as integration of early about 7%. Telemonitoring and other ‘connected health’ approaches also palliative care, have a robust evidence base; others, such as predictive show promise; for example, one program that proactively elicits patient- analytics, are still early in their development. Oncology practices could reported outcomes among those getting chemotherapy led to a 17% implement these strategies separately, but may have more success reduction in ED visits and 8% reduction in all-cause hospitalizations. implementing them as a targeted, integrated program for patients with 3 Standardize clinical pathways for symptom management. As a way to reduce unwanted variation in care, standardized pathways carry significant benefits. Pathways dedicated to acute symptom cancer. However, implementing an integrated program will involve substantial resources, and evidence of its effectiveness is both limited and sobering. It may be most efficient to target interventions to patients management and phone triage may be particularly useful for most at risk, rather than build capacity for all patients. Structuring reducing acute care use. For example, one group developed and value-based payments to reward reduced acute care would likely speed implemented a set of customized symptom management protocols implementation efforts. for patients experiencing dehydration, diarrhea, insomnia, and delayed Proposed Medicare reimbursement changes amplify the need to focus chemotherapy-induced nausea and vomiting. Within five years, the on this issue, as the financial-wellbeing of cancer programs will be percentage of patients directed to the emergency room as a result of increasingly tied to reducing unplanned acute care. As these strategies a clinical call decreased by nearly 60% (12% to 5%) and a standardized are implemented, further studies are needed to build a more robust body protocol for diarrhea decreased preventable hospitalizations by 50%. of evidence on what works, and doesn’t work, in reducing the clinical and 4 Develop alternative sites for urgent cancer care. This strategy could be especially useful as an alternative for the cancer patient who presents to the ED during normal clinical hours. Example interventions financial burden of unplanned and preventable acute care for patients with cancer. include flexible scheduling and embedded urgent care clinics, cancer providers embedded in the ED, dedicated acute cancer treatment THE STUDY clinics and observation units, and dedicated cancer EDs. For instance, To review best practices in reducing acute cancer care, the authors one medical group of nine oncologists and one nurse practitioner searched PubMed for articles published between 2000 and 2017, adjusted its clinic schedule to create dedicated slots in the nurse reviewed quality guidelines published by professional organizations, and practictioner’s daily schedule for urgent visits. This strategy allowed evaluated five care models that have defined and developed systems to the group to arrange same-day or next-day appointments for 87% of deliver high quality oncology care. These models include: the National patients and unplanned hospitalizations for symptom-related care fell Committee for Quality Assurance patient-centered medical home, and by 31%. patient-centered specialty practice; the Community Oncology Medical Home; the CMS Oncology Care Model; and the Commission on 5 Use early palliative care. Some of the strongest evidence points to the use of early palliative care to improve both quality and duration of life. However, discussions of treatment goals and end-of-life planning Cancer Oncology Medical Home. They categorized their results into five strategies, and compiled available frequently occur late in a patient’s disease course (if at all), and often evidence on the effectiveness of interventions used to implement during an acute hospitalization. Earlier use of palliative care can be each strategy in terms of reducing ED visits, hospitalizations, and promoted by standardized teaching about symptom management rehospitalizations. They considered effects on planned, unplanned, and and end-of-life discussions, embedded outpatient palliative care clinics, preventable hospitalizations in reviewing and reporting their results. and integrated inpatient palliative care/oncology units. Standardized triggers for consultation can be an effective way to integrate palliative care. One group developed such triggers for a solid tumor oncology service, which led to increased palliative care consultations, increased Handley NR, Schuchter LM, & Bekelman JE (2018). Best Practices for hospice referrals, decreased chemotherapy use after discharge, and a Reducing Unplanned Acute Care for Patients With Cancer. Journal nearly 50% decrease in 30-day readmission rates. of Oncology Practice, JOP-17. DOI: 10.1200/JOP.17.00081 LEAD AUTHOR DR. NATHAN HANDLEY Nathan Handley, MD is a Hematology and Oncology Fellow at Penn Medicine and an MBA candidate at The Wharton School of the University of Pennsylvania. His interest in care delivery innovation dates back to Internal Medicine residency at the University of California San Francisco, where he participated in the Health Systems and Leadership track and studied strategies for improving access to specialty care in safety net hospitals. His clinical interests are in the area of genitourinary oncology.