August 2017 VOL 8, NO 8

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Breast Cancer

Advancing High-Value Early-Stage Breast Cancer Care

Cancer costs are rising, but the implementation of evidence-based quality improvement strategies in early-stage breast cancer care can reduce costs and improve patient quality of life, according to Angie Meillier, RN, MS, from Abbott Northwestern Piper Breast Center in Minneapolis, MN.

“Fifteen years ago we didn’t talk about value in the same way we do now,” said Ms Meillier at the 2017 Association of Community Cancer Centers (ACCC) Annual Meeting: CANCERSCAPE. “We got patients in the door, treated them, and hopefully got them out the door. We didn’t think about the total cost of care the patient might be incurring while in the hospital or during the aftercare phase. But things have changed dramatically.”

National expenditures for cancer care in the United States have been projected to increase by at least 27% between 2010 and 2020 due to the growing rates of diagnoses and length of survival in the aging population, thereby creating a need for high-quality, low-cost cancer care. In breast cancer care in particular, high-value opportunities exist across the entire continuum, she said.

Complexity versus Impact

According to Ms Meillier, the complexity of a project should be weighed against its potential impact. She and her colleagues at Abbott identified evidence-based improvement opportunities in various areas of breast cancer care, but by using this “complexity versus impact” method they narrowed their scope to 4 quality improvement projects: cancer rehabilitation for patients receiving curative-intent chemotherapy, shared decision-making (SDM) for breast-conserving surgery versus mastectomy, use of short-course radiation planning, and reduction of reexcision rates.

In the area of cancer rehabilitation, her team aimed to increase referrals from 10% to 25% by the end of 2015 while minimizing negative treatment effects. By the end of 2015, 67% of patients were referred to cancer rehabilitation, most during their first cycle of chemotherapy. She and her colleagues identified scheduling challenges, proactively identified impairment with comprehensive treatment, and expedited the assessment and treatment of new functional issues. Patient feedback rated the program value at 9.2 of 10 (10 = extremely valuable). Although referral rates increased significantly, the rate of actual rehabilitation visits was lower, she noted, and the issue has been taken to a patient advisory council to determine how best to impress upon patients the importance of cancer rehabilitation.

A 2-Part Shared Decision-Making Process

Ms Meillier and her team surpassed their goal of conducting 2-part SDM conversations with at least 50% of eligible patients undergoing surgical treatment planning in 2016. “Patients who go through SDM tend to select less invasive and less costly procedures, and that’s what we wanted to test,” she said. They were able to move 57% of eligible patients through the process in 2016 and aim for 70% and 90% of eligible patients in 2017 and 2018, respectively.

During these conversations, the patient and a Registered Nurse Cancer Care Coordinator (RNCCC) discuss surgical treatment options, review risks and benefits, and assess the patient’s values and preferences. She noted that this project “slowed down care” and was met with some resistance. “We didn’t want to diagnose and do surgery within 72 hours. These women have to live with this decision for a very long time, and we feel like the pendulum has swung too far,” she said, noting that in the case of an emergency, patients are moved through the process quickly.

“In doing this we changed the model,” she said. The RNCCC connects with the patient within 24 hours of diagnosis and conducts an initial conversation over the phone during which the concept of SDM is introduced. After this conversation, the patient is given a paper decision aid and has time to talk with family and significant others before a surgical consult. The RNCCC shares the relevant information with the surgeon before another SDM conversation takes place between the surgeon and the patient, and finally the best surgical treatment option is mutually agreed upon and aligned with the patient’s values and preferences.

“It’s not only about patient preferences and values,” she said. “Maybe the patient is scared because her mother got sick. The RNCCC is able to elicit that from the patient because they have the luxury of time that the surgeon just doesn’t have.”

According to Ms Meillier, there was initial pushback from surgeons regarding the idea of SDM, but the project was pushed forward, implemented, and eventually well received by all parties. She said the surgeons expressed their appreciation for preparing patients for care conversations, patients expressed how valuable it was to be involved in these conversations rather than being on the sidelines, and care coordinators found it decreased the number of questions and calls that typically follow a surgical consult.

The last piece of SDM is tied to affordability, she said, and they were able to reach their goal of increasing the utilization of hypofractionated radiotherapy in eligible breast cancer patients who completed breast-conserving surgery, in addition to decreasing margin reexcision rates.

From Conceptualization to Results

To see real results, identify potential opportunities, she said. Evaluate the evidence, investigate internal clinical and practice variations, and grade implementation complexity. Draft the project scope and goals, and stick to them. “Unless there’s a really good reason, stay with the goals that were originally set,” she added.

Engage champions, including clinical, operations, and project management, and secure executive leadership support. “Securing leadership support all the way to the top is essential when you’re making big changes,” she said. Identify opportunities to publicize the project through payer engagement and internal communications. Obtain oversight committee approval, develop a work plan, and regularly assess its scope. Create a consensus guideline to structure the plan, and leverage data, performance transparency, and senior leadership, she added.

Finally, utilize technical and adaptive change. “These are important terms. A technical fix is getting an order set in; adaptive change is figuring out why no one is using it,” she said. “Be tenacious; this work is hard, and it doesn’t happen overnight.”

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