Compliance with evidence-based guidelines for radiation of vertebral metastases.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 36-36
Author(s):  
Heather A Curry ◽  
Arlene A. Forastiere ◽  
Reshma Jagsi ◽  
M. Lou Palladino
Keyword(s):  
Radiation Treatment ◽  
Peer To Peer ◽  
Patterns Of Care ◽  
Dose Fractionation ◽  
Patient Specific ◽  
Evidence Based ◽  
Vertebral Metastases ◽  
Case Review ◽  
Treatment Plans ◽  
Evidence Based Guidelines

36 Background: Evidence based guidelines pertaining to the management of bony metastases have been published. However, up to 30% of oncology treatments deviate from evidence based standards and widespread variations in clinical practice continue to exist. To explore patterns of care in the treatment of vertebral metastases in a group of working age, insured patients, we assessed treatment plans submitted for preauthorization through eviti Connect. Methods: Eviti Connect is a web-based application that enables oncology providers to obtain automated precertification for patients. The platform evaluates treatment plans for consistency with EBM and compliance with payer policies and plan language. All requests for radiation treatment submitted during a two year period from 6/1/11-5/31/13 were reviewed. Peer to peer discussions were conducted in cases that deviated from EBM. Results: A total of 229 cases for the treatment of vertebral metastases were submitted. 46/229 plans (19.8%) did not meet EBM standards. Some cases displayed more than one deviation. Reasons for non-compliance included atypical treatment schedules (8.69%), SRS/SBRT (36.9%), IMRT (32.6%), and IGRT (58.7%). In 26/46 cases (56.5%) the treating physician provided a medical rationale for the deviation. In 9 cases the physician altered the plan to be compliant; in 5 cases the physician did not agree to a change. The most common dose fractionation schedules were 30 Gy/10 fractions (48.9%) and 37.5 Gy/15 fractions (20.5%). 17 cases were treated using 20 Gy/5 fractions and only 2 cases were treated using 8 Gy X 1. Conclusions: Radiation of vertebral metastases was prescribed in accordance with EBM in the majority of cases. The main reasons for deviation were patient-specific issues that justified the medical necessity of the variance. Case review and peer to peer discussion contributed to understanding the rationale for treatment deviation from guidelines and allowed providers to bring plans into compliance with EBM. Overall only 5% of plans were non-evidence based or lacked a medical justification for deviation. Consistent with patterns of care across the US, within this group of patients, single fraction and hypofractionated radiation regimens were underutilized.

Use of a Pan-Canadian indicator to measure treatment rates relative to evidence-based guidelines for rectal cancer.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 177-177
Author(s):  
Tonia Forte ◽  
Julie Klein-Geltink ◽  
Rami Rahal ◽  
Gina Lockwood ◽  
Heather E. Bryant ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Administrative Data ◽  
Chart Review ◽  
Radiation Treatment ◽  
Retrospective Chart Review ◽  
Cancer Registries ◽  
Patient Choice ◽  
Stage Ii ◽  
Evidence Based ◽  
Evidence Based Guidelines

177 Background: As part of the Canadian Partnership Against Cancer’s (CPAC) System Performance initiative, indicators measuring treatment practice patterns across the country are now available, offering the ability to compare against evidence-based guidelines. We report on the percentage of patients with stage II and III rectal cancer receiving pre-operative radiation treatment (RT) based on an analysis of Canadian administrative data. A retrospective chart review was conducted to examine reasons for non-treatment with RT, set performance targets, and inform quality improvements. Methods: Data on the percentage of stage II and III rectal cancer cases receiving preoperative RT were obtained from five provincial cancer registries using a standardized methodology for 2,854 cases diagnosed between 2007 and 2008, with 2009 data soon to be available. A retrospective chart review was conducted in five provinces on a random sample of 383 patients diagnosed in 2008 to examine reasons for non-referral and non-treatment. Results: Based on administrative data, an average of 45% of cases received RT preceding surgical resection for stage II or III rectal cancer, ranging from 36% to 48% across provinces. Preoperative RT rates were similar for men and women, but were lower in older patients. From 2007 to 2008, the percentage of patients receiving pre-operative RT increased in all provinces. Results from the chart review showed that, of those who did not receive preoperative RT, 33% were not referred by a surgeon to an oncologist. The most common documented reasons for non-referral were co-morbidities (26%) and patient choice (7%). Among patients referred to an oncologist, 42% were treated with preoperative RT, 30% were treated with post-operative RT and 28% received no treatment. Among those receiving no treatment, 29% were seen only by a medical oncologist, and 18% were not treated due to patient choice. Conclusions: Findings are being used to develop national targets for treatment rates and, working with national oncologist associations, to develop quality improvement strategies, including patient education efforts to promote informed decisions on treatment options.

A Web-based decision support platform to reduce non-evidence-based treatment of non-small cell lung cancer.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 71-71 ◽  
Author(s):  
Stephen H. Grund ◽  
Arlene A. Forastiere ◽  
William A. Flood ◽  
Elaine Whyler ◽  
Vlad Kozlovski ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Decision Support ◽  
Point Of Care ◽  
Peer To Peer ◽  
Evidence Based ◽  
Web Based ◽  
Evidence Based Treatment ◽  
Treatment Plans ◽  
Third Line ◽  
Automatic Code

71 Background: Published reports indicate 30% to 40% of oncology treatments deviate from evidence-based standards. Little is known about the extent of deviation from guidelines in lung cancer. Methods: eviti is a web-based decision support platform that incorporates all recognized guidelines (ASCO, NCI, NCCN, ASTRO, and others) and supporting literature. An automated precertification code is issued if planned treatment is evidence-based and meets payer language. Variances may be discussed in a peer-to-peer (P2P) with staff oncologists. We analyzed all treatment plans submitted for patients with stage I to IV NSCLC between 1/1/2011 and 5/10/2012 to understand reasons for non-compliance with practice guidelines. There were seven payers with a total of 650,000 covered lives encompassing 43 states. Results: 561 treatment plans were submitted. 241 (43%) received an automatic code, and another 256 (46%) were given preauthorization codes after submission of medical records. 117 treatment plans required a P2P. 26% of cases that required a P2P resulted in a change to evidence based treatment (31 cases or 5% of total cases submitted). 64 (11%) did not meet evidence-based standards and did not receive a code for pre-certification. The most common deviations were: 1. Non-evidence-based therapeutic regimen 59% (38 cases); 2. Use of supportive drugs not consistent with guidelines 23% (15 cases); 3. Non-evidence-based variation in dose and/or schedule of chemotherapy 6% (4 cases). In 7 cases the payer declined payment despite recommendation for coverage. 139 submitted treatment plans were for second line or greater and 88 were for third line or greater. Conclusions: After review for medically justified deviations and peer to peer discussions, decision support for automated pre-certification based on adherence to evidence-based standards reduced non-standard treatment plans from 30 to 11%. A Web-based, point-of-care decision-support that connects payers and providers can reduce unwarranted deviation from evidence-based standards, reducing variability and improving quality. Any such tool should promote compliance with evidence-based cancer care but allow flexibility for medically justified variances.

Overutilization of IMRT/IGRT in treatment of rectal cancer: Cost implications of deviation from evidence-based practices.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 34-34
Author(s):  
Heather A Curry ◽  
Arlene A. Forastiere ◽  
William A. Flood ◽  
Elaine Whyler ◽  
John Peter Plastaras ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Cost Savings ◽  
Peer To Peer ◽  
Current Evidence ◽  
Evidence Based ◽  
Case Review ◽  
Evidence Based Practices ◽  
Peer Discussion ◽  
Cost Implications ◽  
3D Crt

34 Background: Current evidence-based guidelines for management of rectal cancer (RC) caution against routine use of IMRT and do not address the role of IGRT. To explore patterns of care and cost implications for treatment of RC in commercially insured patients, we assessed treatment requests submitted for preauthorization through eviti Connect. Methods: A proprietary web-based application enables oncology providers to obtain automated precertification for patients insured by payers across the US that use the platform. All requests for pelvic radiation for treatment of RC submitted from 6/1/11-5/31/14 were reviewed. Treatment delivery costs for 3D CRT + weekly port films and for IMRT + IGRT were calculated based on average reimbursement rates from 3 payers for a typical course of 50.4 Gy/28 fractions. Results: A total of 195 cases for treatment of RC were submitted. At submission, 50.3% (98/195) of cases met evidence based standards and received automated preauthorization; 49.7% required treatment justification. Ninety-eight percent of deviations involved use of IMRT and/or IGRT. Upon review, 34.9% (68/195) had a medical rationale for the variance. Justification for IMRT/IGRT use included treatment volumes comparable to anal cancer, inadequate bowel displacement by routine techniques, and obesity. Fifteen percent (29/195) contained unwarranted deviations. In 23/29 cases peer to peer discussion resulted in the provider altering the plan to be compliant. Providers did not agree to changes in the other 6 cases. Cost for a course of 3D CRT + weekly port films was $6,591 vs. $32,292 for IMRT + daily IGRT. For these 195 cases, the estimated cost of overutilization of IMRT/IGRT was $745,000 ($25,700 X 29). Conclusions: Despite lack of endorsement by consensus group guidelines, IMRT and IGRT were prescribed for treatment of RC in nearly 50% of cases. Case review and peer to peer discussion clarified the rationale for treatment deviations from guidelines and allowed providers to bring plans into compliance with evidence based practices, reducing inappropriate use of IMRT/IGRT from 15% to 3%. Reduction in unwarranted use of high cost technologies can improve quality and yield significant cost savings.

A Web-Based Decision Support Platform to Reduce Non Evidence-Based Treatment of Hodgkin Lymphoma

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4267-4267
Author(s):  
Stephen Grund ◽  
Arlene Forastiere ◽  
William Flood ◽  
Whyler Elaine
Keyword(s):  
Decision Support ◽  
Hodgkin Lymphoma ◽  
Radiation Treatment ◽  
Hematologic Malignancy ◽  
Point Of Care ◽  
Standards Of Care ◽  
Evidence Based ◽  
Web Based ◽  
Evidence Based Treatment ◽  
Treatment Plans

Abstract Abstract 4267 Background: Published reports indicate 30–40% of oncology treatments deviate from evidence-based standards. Little is known about the extent of deviation from guidelines in Hodgkin Lymphoma, a highly curable cancer. Methods: eviti is a web-based decision support platform that incorporates all recognized guidelines (ASCO, NCI, NCCN, ASTRO and others) and supporting literature. An automated precertification code is issued if planned treatment is evidence based and meets payer language- Variances may be discussed in a peer to peer (P2P) with staff oncologists. We analyzed all treatment plans submitted for patients with stage I to IV Hodgkin's lymphoma (all pathology subtypes) between 1/1/2011 and 6/30/2012 to understand reasons for non-compliance with practice guidelines. There were six payers with a total of 605,412 covered lives encompassing 22 states. Results: 124 treatment plans were submitted, including 37 with radiation treatment as part of the plan or as primary treatment. 48 (39%) received an automatic code, and another 63 (51%) were given preauthorization codes after submission of medical records. 25 treatment plans (20%) required a P2P and 7 (6% of all cases) were changed to evidence-based treatments as a result. 5 plans were deemed evidence-based as a result of the P2P, while13 plans (10%) did not meet evidence-based standards and did not receive a code for pre-certification even after a P2P. 3 of these were resubmitted with evidence-based plans. The most common deviations were; 1.Use of supportive drugs not consistent with guidelines 6 cases (6%); 2. Non evidence-based therapeutic regimens 2% (2 cases); 3. Non evidence-based variation in dose and/or schedule of chemotherapy 2% (2 cases). 4. Use of IMRT with IGRT. Conclusions: Decision support for automated pre-certification reduced non- evidence-based treatment of Hodgkin lymphoma from 16% (20 cases) to 8% (10 cases). A Web-based, point of care decision-support platform connecting providers and payers can reduce unwarranted variability, improve quality and reduce payment for unwarranted care. It facilitates analysis of variations from accepted standards of care for any hematologic malignancy at a granular level. Any such tool should promote compliance with evidence-based cancer care but allow flexibility for medically justified variances. Disclosures: Grund: eviti: Employment. Forastiere:eviti: Employment. Flood:eviti: Employment. Elaine:eviti: Employment.

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