scholarly journals Development and Implementation of a Clinical Pathway for Radiation of Bone Metastases on a Palliative Radiation Oncology Service

2016 ◽  
Vol 96 (2) ◽  
pp. E543
Author(s):  
L. Rotenstein ◽  
J.H. Killoran ◽  
T.A. Balboni ◽  
M.S. Krishnan ◽  
A. Taylor ◽  
...  
Keyword(s):  
Bone Metastases ◽  
Clinical Pathway ◽  
Radiation Oncology ◽  
Palliative Radiation ◽  
Oncology Service

Development and implementation of a clinical pathway for radiation of bone metastases on a palliative radiation oncology service.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 170-170
Author(s):  
Lisa Rotenstein ◽  
Joseph Killoran ◽  
Tracy A. Balboni ◽  
Monica Shalini Krishnan ◽  
Allison Taylor ◽  
...  
Keyword(s):  
Decision Support ◽  
Bone Metastases ◽  
Nurse Practitioners ◽  
Clinical Pathway ◽  
Radiation Oncology ◽  
Treatment Guidelines ◽  
Clinical Pathways ◽  
Support Tool ◽  
Palliative Radiation ◽  
Oncology Service

170 Background: Clinical pathways increase compliance with treatment guidelines and reduce in-hospital complications. Evidence around treatment of complicated bone metastases is increasingly nuanced and although ASTRO/ACR recommend single fraction radiation therapy for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on the practice patterns of our institution’s palliative radiation oncology service (SPRO), which sees 600 patients yearly and on a rotating basis, involves 23 physicians, 28 residents, 2 nurse practitioners, and 1 fellow. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of 8 Gy x 1 for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. This was translated to a secure electronic interface as a decision support tool and integrated into daily SPRO workflows. Providers were surveyed pre and post implementation to assess expectations and elicit feedback. Rates of pathway compliance and reasons for non-compliance were assessed. Rates of 8 Gy x 1 use for uncomplicated metastases were compared pre and post implementation. Our aim was for approximately 70-80% on-pathway rates. Results: The final pathway, which includes twenty endpoints, integrates several validated scoring systems, including assessments of life expectancy, spinal stability, and appropriateness of surgical management. The pathway has been well received on the SPRO service, with addition of extra steps to workflows being the main cause of resistance to use. Data on rates of pathway adherence will be reported, and rates of 8 Gy x 1 use will be compared to the baseline of 22%. Conclusions: Our experience suggests the utility of pathways-based decision support for bone metastases radiation on a palliation consult service. Next steps include assessing the pathway’s effects on guideline-concordant care and calculating associated cost savings.

Correlation of demographic factors with length of treatment and survival in a palliative radiation oncology population.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 123-123
Author(s):  
Lauren Michelle Hertan ◽  
Alexandra Nichipor ◽  
Yaseer Mohammed Khouj ◽  
Cierra Zaslowe-Dude ◽  
Tracy A. Balboni ◽  
...  
Keyword(s):  
Decision Making ◽  
Multivariate Analysis ◽  
Bone Metastases ◽  
Radiation Oncology ◽  
Background Radiation ◽  
Demographic Factors ◽  
Stereotactic Radiation Therapy ◽  
Stereotactic Radiation ◽  
Palliative Radiation ◽  
Length Of Treatment

123 Background: Radiation is often used to palliate symptoms in patients with advanced cancer and the number of fractions used can vary significantly from as short as a single fraction (SF) to up to a multiple week course. No data currently exists regarding demographic factors and their influence on survival and fractionation decisions. The aim of this project is to investigate the association of demographic factors with survival, likelihood of SF use in patients (pts) receiving RT for bone metastases, and likelihood of hypofractionation (HF) (≤ 5 fx) in pts being treated for any palliative reason, excluding those receiving partial brain RT (PBRT) which includes stereotactic radiosurgery, and stereotactic radiation therapy. Methods: We retrospectively reviewed charts of pts treated with palliative RT between 1/2015 – 5/2017 at 2 tertiary centers and 4 community satellite practices. Demographic factors analyzed are included in table 1. Logistic regression was used to evaluate the associations between the factors and outcomes. Results: A total of 928 pts were included in the survival analysis. In the two subset analyses, 373 pts were included in the bone metastasis analysis and 745 were included in the analysis of all patients excluding pts receiving PBRT. In pts treated for bone metastases, consult type (inpatient vs. outpatient) was the only significant factor on multivariate analysis, with inpatient consults being more likely to get SF (HR = 2.169, =.025). In the pts receiving palliative RT (excluding PBRT), race and consult location (tertiary vs. community) were significant. Non-white pts (HR=0.527, p=.012) and pts treated in the community (HR=.778, p<.001) were less likely to get HF. Gender (male vs. female), consult location (tertiary vs. community), and consult type (inpatient vs. outpatient) were significant on multivariate analysis for survival (HR=1.243, p=.028; HR=1.602, p<.001; HR=2.301, p<.001, respectively). Conclusions: This analysis suggests that demographic factors may affect both survival and decision making regarding fractionation in patients receiving palliative radiation. Further investigation into the reasons for these differences is needed.

Impact of a clinical pathway tool on appropriate palliative radiation therapy for bone metastases

2018 ◽  
Vol 8 (4) ◽  
pp. 266-274 ◽  
Author(s):  
Lisa S. Rotenstein ◽  
Alexander O. Kerman ◽  
Joseph Killoran ◽  
Tracy A. Balboni ◽  
Monica S. Krishnan ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Bone Metastases ◽  
Clinical Pathway ◽  
Palliative Radiation ◽  
Pathway Tool ◽  
Palliative Radiation Therapy

Propensity score matched analysis of a palliative radiation oncology consult service’s impact on length of stay and total costs during hospitalization.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 162-162
Author(s):  
Sanders Chang ◽  
Peter May ◽  
Nathan Goldstein ◽  
Doran Ricks ◽  
Kenneth Rosenzweig ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Propensity Score ◽  
Bone Metastases ◽  
Radiation Oncology ◽  
Hospital Cost ◽  
Total Hospital Cost ◽  
Service Model ◽  
Advanced Cancer Patients ◽  
Total Hospital ◽  
Palliative Radiation

162 Background: The Palliative Radiation Oncology Consult Service (PROC) was a clinical service model developed in 2013 at Mount Sinai Hospital to provide individualized, goal-directed treatment to advanced cancer patients requiring palliative radiation therapy (PRT). We assessed its impact on length of stay (LOS) and total costs incurred during a hospitalization among patients who underwent PRT for symptomatic bone metastases while in the hospital. Methods: In our observational cohort study, we identified patients who underwent their first PRT course for bone metastases during a hospitalization between 2/2010 and 12/2016. Total costs (direct and indirect costs) during the hospitalization were extracted from the institution’s cost accounting system. Propensity score matching (PSM) was performed against age, Charlson comorbidity index (CCI), gender, race, primary cancer, and health insurance status. Balance across groups was verified by standardized differences before and after PSM. Average treatment effects (ATE) of hospital costs and LOS were calculated from generalized linear models with a γ distribution and log link adjusted by propensity score weights. PRT patients treated before 2013 (before PROC was established) were compared to those treated after 2013 (after PROC was established). Results: In total, 181 patients were included, with 76 treated before and 105 treated after PROC. Before propensity score matching, patients treated prior to PROC’s establishment had a median total hospital cost of $72,787 (range, $5,981-$324,652) and a median LOS of 28 days (range, 2-105); whereas patients treated after PROC had a median total hospital cost of $49,950 ($7,585-$620,943) and a median LOS of 19 days (2-139). After matching, patients had an ATE of -$16,877 total hospital cost (95% CI [-33,250,-504], p = 0.043) and -8.5 days in LOS (95% CI [-13.9,-3.2], p = 0.002). Conclusions: PROC, a clinical service model that integrated principles of palliative care practice within radiation delivery, led to substantial cost-savings and shorter lengths of stay for advanced cancer patients requiring PRT for bone metastases during a hospitalization.

scholarly journals Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care

2014 ◽  
Vol 4 (4) ◽  
pp. 247-253 ◽  
Author(s):  
Yolanda D. Tseng ◽  
Monica S. Krishnan ◽  
Joshua A. Jones ◽  
Adam J. Sullivan ◽  
Daniel Gorman ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Cancer Care ◽  
Palliative Radiation ◽  
Oncology Service ◽  
Dedicated Service

Impact of a clinical pathway tool on appropriate palliative radiation therapy for bone metastases.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 97-97
Author(s):  
Lisa Rotenstein ◽  
Alexander O. Kerman ◽  
Neil E. Martin ◽  
Tracy A. Balboni ◽  
Monica Shalini Krishnan ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Bone Metastases ◽  
Clinical Pathway ◽  
Radiation Oncology ◽  
Treatment Guidelines ◽  
Clinical Pathways ◽  
Ease Of Use ◽  
Single Fraction ◽  
Pathway Tool ◽  
Oncology Practice

97 Background: Clinical pathways increase compliance with treatment guidelines, improve outcomes, and reduce costs. Guidelines recommend single fraction radiation therapy (SFRT) for palliation of uncomplicated bone metastases, but implementation is variable. We examined the effects of a clinical pathway tool on appropriate SFRT rates in an academic radiation oncology practice. Methods: Clinical pathways increase compliance with treatment guidelines, improve outcomes, and reduce costs. Guidelines recommend single fraction radiation therapy (SFRT) for palliation of uncomplicated bone metastases, but implementation is variable. We examined the effects of a clinical pathway tool on appropriate SFRT rates in an academic radiation oncology practice. Results: The final pathway was used in 38% of 723 bone metastases radiation prescription made since March 2016, with appropriate SFRT rates rising from 18% prior to implementation to 48% post-launch in cases where the pathway was used (p < 0.01). There was no increase in the appropriate SFRT rate for cases treated after March 2016 but not entered into the pathway tool as compared to cases prior to pathway tool implementation. Major reasons for rejecting recommendations included disagreement with life expectancy prognostication and patient convenience. The pathway increased physicians’ confidence regarding compliance with treatment guidelines and made it easier to find well-supported treatment recommendations. Workflow disruptions and the inability to handle nuanced situations emerged as limitations. Conclusions: Our experience demonstrates the utility of clinical pathway decision support for bone metastases in complex academic settings. Pathway use significantly increased appropriate care, more than doubling appropriate treatment rates relative to a synchronous group. Next steps include increasing the pathway’s ease of use, refining its prognostic abilities, and measuring related value effects.

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