More than half of Washington state cancer patients undergoing chemotherapy are hospitalized or treated in the emergency room for side effects such as nausea, pain, fever or fatigue.
To health care economists and physicians alike, this is a disturbing statistic and shorthand for preventable suffering and unnecessary cost.
This week, Fred Hutchinson Cancer Research Center and its Seattle-area neighbor Microsoft Corp. announced a unique collaboration agreement to develop and pilot test technology to help cancer patients avoid the emergency room through better management of their chemotherapy side effects.
For Fred Hutch’s Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research, or HICOR, the agreement is an opportunity to marry the Hutch’s experience in clinical and data science with Microsoft’s expertise in artificial intelligence and machine learning. “The idea is to identify patients who are getting into trouble early,” he said.
Dr. Peter Lee, corporate vice president for Microsoft AI + Research, said that the new pilot project with HICOR has the aim of “better predicting distressing episodes and enabling clinical intervention before complications become emergencies.”
Closer monitoring of symptoms, quicker administration of the right anti-nausea or pain drugs, and timely counseling can often avoid emergency room visits, or signal the need for more intensive intervention sooner, when it can be more effective.
The announcement was one of the highlights of HICOR's fifth annual Value in Cancer Care Summit, a conference that brought together a coalition of hospitals, insurers, cancer clinicians and patient advocates to discuss research and strategies designed to improve the quality and control the cost of cancer care.
Much of the Thursday meeting in Seattle centered around HICOR’s release on Tuesday of their Community Cancer Care in Washington State report, the product of five years of cooperative efforts to develop tools for measuring both the cost and quality of cancer care. The report pooled insurance and cancer registry data covering more than 70 percent of cancer patients in Washington state from 2014–2016.
Susie Dade, deputy director of the Washington Health Alliance, offered high praise for the effort, and for the stakeholders who agreed to share the information that made it possible. “In most states there is very little to no transparency on costs,” she said. “I’m really pleased you brought quality and cost together in the HICOR report.”
Dade noted that a report that publicly releases measures of quality and cost for cancer care breaks new ground and may create anxiety for industries that provide and pay for care, but she urged continued transparency to improve patient care. “Those who have the most to lose by change are often the loudest voices against change,” she said. “Some said ‘the sky would fall.’ It didn’t, not even a little bit.”
In her keynote address, University of Michigan’s Dr. Eve Kerr, director of the Ann Arbor VA Center for Clinical Management Research, said the HICOR effort will promote high-value, patient-centered care. “It is truly a model for the rest of the nation,” she said.
Among the areas of focus in the new report was the analysis of emergency room use and hospital stays at 27 cancer care providers throughout Washington state. The report confirmed that 52 percent of patients had either an emergency room visit or an inpatient hospital stay within six months of starting chemotherapy. It also used cost and quality metrics to compare each of those clinics and hospitals to the state average. It found per-patient costs varied by as much as $20,000, and quality measures varied by 23 percent.
Among the highest performing cancer centers in both cost and quality emergency room use and hospitalization was the Everett Clinic, which is connected by a skybridge with its partner Providence Everett Medical Center, in that Snohomish County city of 110,000.
In an hour-long session, managers from Everett discussed how they developed techniques that gave them such a high score — comparative results that were a pleasant surprise to them.
“We focused proactively on preventing side effects and toxicities,” said Renee Curtis, an oncology pharmacist at the Everett Clinic. She said the clinic staff built “homegrown pathways” — a kind of treatment checklist tailored for each patient — and “brought cost and quality awareness to our physicians.”
The clinic relies on nurses with advanced degrees to handle interventions designed to keep patients out of the emergency room. A phone bank is set up so patients can talk directly to these nurses. “We get a live person on the phone to discuss clinical symptoms,” added Kelly Mardesich, clinical practice manager for the Providence Regional Partnership. “There is trust and respect for clinical decision making of advanced practitioners,” she said. “Our core value is to do what is right for the patient.”
This was music to Ramsey’s ears. “One of the purposes of this conference is to share best practices,” he said. He noted that despite the good performance logged by the Everett Clinic, the nurses wanted to improve their record in providing value in end-of-life care.
“The data give clinics specific information on where they can get better, and clinics can focus quality-improvement efforts on those areas,” he said.
The conference also featured a panel of patients who urged the doctors, nurses, hospitals and insurers to pay more attention to the frustrations, anxieties and concerns of those they are treating.
“The reality for a lot of underserved communities is that people of color are definitely treated very differently than our Caucasian counterparts,” said Bridgette Hempstead, a metastatic breast cancer patient and the founder of Cierra Sisters, an African-American cancer and support organization.
Diane Mapes, a breast cancer survivor and writer for Fred Hutch, said patients need to feel that their doctors and nurses are partners in their care, and that too often patient concerns are dismissed. “Patients are experts on their own bodies, and how their bodies react to drugs,” she said.
Janet Freeman-Daily, a retired aerospace engineer and stage 4 lung cancer patient and advocate, called for a more consumer-friendly version of the community cancer report so that patients can look at issues such as out-of-pocket costs. “The health care system does not make it easy for all people to be able to afford cancer care,” she said, “and quality is not just giving the right drug to a patient, but also outcomes in terms of how the patient felt.”
HICOR director Ramsey stressed that the next step for participants who helped create the Community Cancer Care report will be to take those findings to heart and to take meaningful actions based on it.
“We’ve got the numbers,” Ramsey said as he closed out the daylong meeting. “Now it’s time to do something. … We want to move those numbers. We want to raise the bar for care. We want to break the cost trend if we can in oncology. We want to make the patients have a better experience.”
Sabin Russell is a former staff writer at Fred Hutchinson Cancer Center. For two decades he covered medical science, global health and health care economics for the San Francisco Chronicle, and he wrote extensively about infectious diseases, including HIV/AIDS. He was a Knight Science Journalism Fellow at MIT and a freelance writer for the New York Times and Health Affairs.