Health Care Delivery
Original Contribution
Clinic Offering Affordable Radiation Therapy to Increase Access to Care for Patients Enrolled in Hospice By Jessica M. Schuster, MD, Thomas J. Smith, MD, Patrick J. Coyne, MSN, APRN, Stephen Lutz, MD, MS, Mitchell S. Anscher, MD, and Drew Moghanaki, MD
Abstract Purpose: A majority of patients enrolled in hospice have advanced cancer. Most of them are burdened by symptoms related to uncontrolled tumor growth. Although palliative radiation therapy (RT) is highly effective, only 1% of hospice patients are ever referred. Commonly cited concerns include high treatment cost, burden of travel for multiple visits, and a perceived reluctance of radiation oncologists to deliver single-fraction RT.
Methods: A clinic offering affordable RT to patients in hospice was developed to simplify the intake, reduce cost, and minimize travel to a single visit. The goal was to evaluate, simulate and plan treatment, and treat patients with a single fraction of palliative RT within a 4-hour period.
Results: The initial 18-month experience is reported in this Health Information Portability and Accountability Act– compli-
Introduction Patients with incurable malignancies make up approximately 50% of those who are enrolled in hospice.1 Unfortunately, a majority are burdened by symptoms that result from uncontrolled tumor growth.2 To meet eligibility for hospice benefits, patients must first surrender Medicare and/or private insurance coverage for chemotherapy. They also have to relinquish coverage for radiation therapy (RT), although it provides meaningful palliation pain relief in up to 80% of patients with bone metastasis3-7 and is highly effective at relieving symptoms related to bleeding, dyspnea, and dysphagia.8,9 Although 90% of hospice professionals recognize that RT can improve patient quality of life, less than 1% of patients in hospice are ever referred for this treatment.1 Surveys conducted by the American Academy of Hospice and Palliative Medicine and American Society of Radiation Oncology determined that the main barriers are related to the direct and indirect costs of treatment, the burden of travel on patients and family for multiple treatment visits, and a perceived reluctance of radiation oncologists to offer single-fraction palliative RT (SFPRT) when it is just as effective as longer courses of treatment.1 In the United States, palliative RT can cost more than $10,000 and is almost always prescribed over 2 to 3 weeks.10-13 Thus, it is understandably prohibitive for many hospice agencies that currently operate under a median pere390
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ant report that was approved by the Viriginia Commonwealth University Institutional Review Board. Eight referrals were received from local hospice agencies that had not referred any patients in previous years. A telephone screening process avoided unnecessary travel for two patients who were not candidates for RT. Two additional patients who were evaluated with a same-day computed tomography simulation were not good candidates for RT. Ultimately, four patients were successfully treated with single-fraction palliative RT of 8 Gy. None had to disenroll from hospice.
Conclusion: This novel program increased access to palliative RT for patients in hospice who would otherwise not have been referred. The main challenge identified was a need for ongoing educational activities at hospice agencies where staff turnover may be high and understanding about palliative RT can be limited.
diem reimbursement rate of only $150, from which all services must be provided.14,15 To address the aforementioned barriers, a multidisciplinary group of clinicians dedicated to palliative care developed a novel program at our institution. A clinic offering affordable radiotherapy (CART) was designed to simplify the intake, evaluation, and treatment process into a half-day appointment that offers SFPRT to patients who are enrolled in hospice. This report summarizes our experience after the first 18 months.
Methods This Health Information Portability and Accountability Act– compliant report was approved by the Viriginia Commonwealth University Institutional Review Board.
Program Development and Promotion In the spring of 2012, a multidisciplinary team of physicians and nurses held several meetings to address the issue of limited access to palliative RT for patients enrolled in hospice. The program was designed to be simple enough to complete the consultation, computed tomography (CT) simulation, treatment planning, and delivery of treatment in a single visit (Figure 1). The model was similar to protocols used for palliative RT emergencies at our institution.
V O L . 10, I S S U E 6
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Massey Cancer Center, Virginia Commonwealth University; Hunter Holmes McGuire Veterans Affairs Hospital, Richmond, VA; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Blanchard Valley Health System, Findlay, OH
Affordable Radiation Therapy for Hospice Patients
Hospice nurse determines need for radiotherapy Hospice director approves referral
4-hour visit Physician assessment CT simulation Patient returns home
Physics QA check Single-page form faxed to radiation oncology
Delivery of single-fraction palliative radiotherapy Figure 1. Simplifying palliative radiotherapy. CT, computed tomography; QA, quality assurance.
Intake Process and Screening The referral process was simplified to a single-page fax that could be completed by any hospice-based clinician who was involved in the patient’s care. Once the fax was received, a follow-up screening call was made to assess the appropriateness for scheduling a formal consultation (Table 1). Factors included each patient’s pathologic confirmation of a cancer diagnosis, identification of a localized symptom that could be palliated, ability to provide informed consent, and safety for travel to the clinic. Screened patients were scheduled for a sameday consultation, CT simulation, and treatment machine time slot. Transportation was the responsibility of the patient or hospice agency.
Patient Evaluation, RT Planning, and Treatment Delivery The face-to-face evaluation included a focused history and physical examination, discussion about the risk and benefits of palliative RT, and completion of the informed consent process. A same-day CT simulation was performed to investigate for a Table 1. Criteria for Scheduling Radiation Therapy Evaluation Criteria Determined by Screening Phone Call No previous definitive (high dose) radiation to site Symptom to palliate Patient is stable for transportation Patient has ability to provide consent for treatment
Copyright © 2014 by American Society of Clinical Oncology
malignant lesion that was consistent with the patient’s clinical symptom(s); a radiologist was generally not involved. Once a tumor target was identified, treatment fields were designed with a simple parallel-opposed beam arrangement without secondary collimation. Treatment was delivered with either 6 or 18 MV photons. All fields were rectangular, but could be modified by collimator rotation to minimize unnecessary normal tissue exposure. The radiation prescription dose calculation point was carefully selected by the radiation oncologist using three-dimensional CT references and then calculated to midplane by a radiation therapist. This process intentionally omitted the participation of a dosimetrist because that would increase department resource usage, increase patient time in the clinic, and was perceived to be unnecessary for a simple rectangular field calculated at midplane. In addition, according to department policy, all treatment plans underwent a secondary quality assurance check by a medical physicist. Treatment was delivered only after patient alignment and verification of portal imaging was approved by an attending radiation oncologist. The standard treatment was 8 Gy in a single fraction. Electron therapy planning was available but not used for any of the patients described in this report.
Follow-Up Hospice agencies were sent a single bill for all services. This did not include any procedural codes or itemized descriptions and was below the current Medicare billing rate for SFPRT. For patient convenience, we did not require any formal follow-up, given that there was no reason to believe outcomes would deviate from those in the reported literature.
Results Program Establishment CART was launched on July 1, 2012, 5 months after initial discussions by members of the multidisciplinary team. This delay was related primarily to a need for multiple conversations with hospital billing administrators, who raised concerns about billing far below Medicare reimbursement rates. Acceptance was ultimately achieved once there was an awareness that patients in hospice are almost never referred for RT, and that this program therefore represented an opportunity to increase referrals. The compassionate aspect of this program was also ac-
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All eight hospice agencies within 50 miles of our radiation oncology facility were contacted multiple times. In-service educational sessions were welcomed at five of these, and a total of eight presentations were given because one hospice had multiple teams that covered different geographic locations. In-service sessions were given by either an attending radiation oncologist (D.M.) or resident (J.M.S.). They were typically conducted at multidisciplinary meetings that included social workers, medical assistants, hospice nurses, medical directors, and sometimes billing coordinators. Presentations focused on the efficacy of palliative RT and equivalence of SFPRT when compared with longer treatment schedules. Additional educational outreach efforts included invited lectures at local and statewide conferences that focused on hospice and palliative care.
Schuster et al
Table 2. Rationale for Not Delivering Radiation Therapy With CART
Case 2. A 75-year-old man with hormone-refractory metastatic prostate cancer was referred for pain, which he scored as 8 on a scale of 1 to 10, in his lumbar spine and bilateral shoulders, with increased intolerance of opioids. CT simulation identified destructive lesions in all of three regions. Three separate nonoverlapping AP/PA fields were used to target each of these sites.
Reasons why patients were not scheduled Inability to consent for treatment Recent definitive radiation to site of concern in the neck Reasons why patients were not treated after physician evaluation Pain well controlled Concern for possible toxicity: two prior courses of radiotherapy had already exposed brachial plexus Abbreviation: CART, clinic offering affordable radiotherapy.
Patient Experience During the initial 18 months of CART, eight outpatients were referred by three hospice agencies for palliative RT. This represented approximately one new referral every 3 months. In contrast, no patients had been referred in previous years from any local hospice agency. Furthermore, hospice administrators confirmed that none of these patients would have been referred without the more streamlined and affordable CART program. All referrals were submitted by a hospice nurse using the single-page intake form. After contacting the referring nurse, six patients (75%) were scheduled, given that they met criteria for a formal evaluation (Table 1). Two patients were not scheduled because they either could not provide informed consent or had recently completed a high dose of definitive RT to the area of concern in the neck (Table 2). Of the six patients who were evaluated in person, all underwent a CT simulation for treatment planning. Two patients were deemed inappropriate for SFPRT with a simple beam arrangement. In one of these two patients, there was concern about brachial plexus injury because of two previous courses of RT that overlapped within the area of concern; the second patient had an extensive amount of indolent lung cancer, but good performance status with borderline pulmonary function, and was otherwise doing well with pain control using low doses of oral pain medications. Case summaries are provided for the four treated patients to illustrate the simplicity of the process. All patients had a Karnofsky performance score of 70 or less, and their characteristics are further summarized in Appendix Table A1 (online only). All patients completed their evaluation, received a single fraction of 8 Gy, and left the clinic within 3.5 to 5 hours of initial registration in our department. None had to disenroll from hospice. Case 1. An 82-year-old man with metastatic lung cancer was referred for uncontrolled right shoulder pain after he developed severe constipation from opioids. Physical examination and CT simulation identified a destructive lesion in the right acromion measuring less than 3 cm. This was targeted with a single anteroposterior/posteroanterior (AP/PA) field (Appendix Figure A1, online only). e392
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Case 4. An 89-year-old man with previously untreated, locally advanced lung cancer was referred with symptomatic dyspnea. Complete occlusion of his right main stem bronchus was shown on CT simulation. A small AP/PA field was designed to treat a large perihilar mass, with assurance that the RT avoided any exposure of the esophagus.
Discussion CART established a simplified process to address the three main barriers that are commonly believed to limit access to care for patients in hospice who seek palliative RT: high cost, burden of multiple treatment visits, and a perceived reluctance of radiation oncologists to deliver SFPRT.1,10 Within 18 months, a total of eight patients were referred. The emergence of referrals to our department from hospice agencies confirmed our hypothesis that a simplified and affordable program would increase access to care for this population. No patient had to disenroll from hospice. The four patients who had an indication for palliative RT received their treatment within 5 hours of initial entry to the clinic, and all were able to go home afterward. Hospice providers confirmed that none of these patients would have been referred without this program. In several Canadian institutions, similar changes to radiation oncology clinic infrastructure increased referrals after addressing logistic and communication problems between specialists, knowledge gaps about RT, and the inconvenience of multiple clinic visits.15,16,17 The Rapid Response Radiotherapy Program at the Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada, offered a simplified referral pathway with a nurse as the community liaison.17 In addition, the Rapid Access Palliative Radiotherapy Program (RAPRP) at the Cross Cancer Institute in Edmonton, Ontario, Canada, integrated a reducedvisit multidisciplinary patient evaluation with a radiation oncologist, nurse, clinical pharmacist, radiation therapist, occupational therapist, social worker, and registered dietician.18 The RAPRP reported 100% patient satisfaction with symptom stabilization or improvement in more than 75% of patients receiving palliative RT. Highlighting the success of the RAPRP, a second palliative RT clinic was opened to expand capacity.18 With an estimated 567,000 patients with cancer currently enrolled in hospice, and an average of 70% dying with pain
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knowledged by administrators, which influenced the final decision for approval. Promotion of the program included in-service sessions at local hospice agencies as well as presentations at local and statewide conferences focusing on hospice and palliative care, and was performed over a 12-month period.
Case 3. A 50-year-old woman with metastatic colon cancer was referred for uncontrolled back pain, scored as 10 of 10, but was found on history to also have upper abdominal pain, scored as 6 of 10. The CT simulation identified a large destructive lesion in her upper lumbar spine, and also identified a large malignant mass in the portocaval region. These two lesions were contoured on the CT scan, and separate nonoverlapping rectangular AP/PA fields were designed to target each of these sites.
Affordable Radiation Therapy for Hospice Patients
peated in-services and amidst high staff turnover. Within months, many care providers who had heard our initial inservice session no longer worked at the hospice agencies. Thus, the need to continue education is clear, and such efforts will likely only be successful if there is high-level engagement with administrators and nursing directors for the purpose of internal promotion. In conclusion, through simplifying the intake, evaluation, and treatment delivery process, and improving affordability, CART successfully increased access to palliative RT for patients enrolled in hospice. Such a program helps fulfill the triple aim of improved symptom management, better quality of care, and reduced cost. However, more work needs to be performed to foster relationships and education between radiation oncologists and hospice professionals. There is significant staff turnover at many hospice agencies, and ongoing educational activities are required to ensure awareness of palliative RT for providers who may have a limited background in principles of oncology. On the basis of our experience, empowering hospice administrators and nursing directors to internally educate their staff about palliative RT will likely have the greatest impact with respect to increasing access to this care. Authors’ Disclosures of Potential Conflicts of Interest The authors declared no potential conflicts of interest.
Author Contributions Conception and design: Thomas J. Smith, Patrick J. Coyne, Stephen Lutz, Mitchell S. Anscher, Drew Moghanaki Collection and assembly of data: Jessica M. Schuster, Drew Moghanaki Data analysis and interpretation: Jessica M. Schuster, Thomas J. Smith, Drew Moghanaki Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Jessica M. Schuster, MD, Department of Radiation Oncology, Virginia Commonwealth University, 401 College St, PO Box 980058, Richmond, VA 23298; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001505; published online ahead of print at jop.ascopubs.org on September 30, 2014.
References 1. Lutz S, Spence C, Chow E, et al: Survey on use of palliative radiotherapy in hospice care. J Clin Oncol 22:3581-3586, 2004 2. Miller SC, Mor V, Teno J: Hospice enrollment and pain assessment and management in nursing homes. J Pain Symptom Manage 26:791-799, 2003 3. Anderson PR, Coia LR: Fractionation and outcomes with palliative radiation therapy. Semin Radiat Oncol 10:191-199, 2000 4. Chen AM, Vaughan A, Narayan S, et al: Palliative radiation therapy for head and neck cancer: Toward an optimal fractionation scheme. Head Neck 30:15861591, 2008 5. Hartsell WF, Scott CB, Bruner DW, et al: Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97:798-804, 2005
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6. Nielsen OS, Bentzen SM, Sandberg E, et al: Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases. Radiother Oncol 47:233-240, 1998 7. Steenland E, Leer JW, van Houwelingen H, et al: The effect of a single fraction compared to multiple fractions on painful bone metastases: A global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 52:101-109, 1999 8. Lutz ST, Chow EL, Hartsell WF, et al: A review of hypofractionated palliative radiotherapy. Cancer 109:1462-1470, 2007 9. Kim MM, Rana V, Janjan NA, et al: Clinical benefit of palliative radiation therapy in advanced gastric cancer. Acta Oncol 47:421-427, 2008 10. Fairchild A, Barnes E, Ghosh S, et al: International patterns of practice in palliative radiotherapy for painful bone metastases: Evidence-based practice? Int J Radiat Oncol Biol Phys 75:1501-1510, 2009
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during the final weeks of life, there is a potential to benefit over 397,000 patients each year with palliative RT if access could be increased.2,15,19 This represents a public health issue that is unfortunately not a current priority. At present, patients in hospice who are interested in this care must often first disenroll to re-establish insurance coverage. Whether or not they re-enroll, hospice agencies are at risk during audits because they are required by Medicare to provide all services necessary for palliation.20 Medicare’s guidelines state that hospice agencies should not accept patients if they cannot provide illness-related symptom relief services in a timely fashion.21 They further state that palliative RT should be considered, but unfortunately provide little guidance as to when it should be considered. Medicare’s policies indicate that determination should be “based on the patient’s condition and the Hospice care giving philosophy,” while emphasizing that “no additional Medicare payment may be made regardless of the cost of [radiotherapy] services.”20 How should we move forward? The simplest solution would be to amend the hospice reimbursement schedule to provide additional financial benefits to agencies that use palliative RT. However, until that happens, we believe that programs such as CART provide a reasonable opportunity to increase access while minimizing burden to radiation oncology clinics and hospices. Once information about CART was shared, a willingness to refer patients increased, confirming that the burden of travel for multiple visits and cost were indeed barriers that had limited access. Another interesting observation was made that further explained why referrals from hospice agencies were limited both before and after the implementation of CART. During in-service education sessions, many hospice providers shared that they actually had no previous oncology experience and had little knowledge about RT in general. Meanwhile, educational topics about palliative RT were met with a range of responses, from enthusiasm to borderline disbelief about the effectiveness of palliative RT, particularly in regard to SFPRT. Through extensive direct communication and a recently published survey of the same hospice facilities in our area, we learned that more than 75% of administrators and nursing directors were simply unaware that palliative RT is as effective in a single fraction versus longer courses of treatment.12 Unfortunately, despite initial enthusiasm about CART, awareness of our program seemed to fade quickly without re-
Schuster et al
11. Haddad P, Wong RK, Pond GR, et al: Factors influencing the use of single vs multiple fractions of palliative radiotherapy for bone metastases: A 5-year review. Clin Oncol (R Coll Radiol) 17:430-434, 2005
17. Wu JS, Kerba M, Wong RK, et al: Patterns of practice in palliative radiotherapy for painful bone metastases: Impact of a regional rapid access clinic on access to care. Int J Radiat Oncol Biol Phys 78:533-538, 2010
12. Schuster J, Han T, Anscher M, et al: Hospice providers awareness of the benefits and availability of single-fraction palliative radiotherapy. J Hosp Palliat Nurs 16:67-72, 2014
18. Fairchild A, Pituskin E, Rose B, et al: The rapid access palliative radiotherapy program: Blueprint for initiation of a one-stop multidisciplinary bone metastases clinic. Support Care Cancer 17:163-170, 2009
13. Bekelman JE, Epstein AJ, Emanuel EJ: Single- vs multiple-fraction radiotherapy for bone metastases from prostate cancer. JAMA 310:1501-1502, 2013 14. Centers for Medicare and Medicaid Services: Update to the hospice payment rates, hospice cap, hospice wage index and the hospice pricer for FY 2013. Washington, DC, Centers for Medicare and Medicaid Services, 2012. http:// www.cms.hhs.gov/transmittals/downloads/R2497CP.pdf
16. Samant RS, Fitzgibbon E, Meng J, et al: Barriers to palliative radiotherapy referral: A Canadian perspective. Acta Oncologica 46:659-663, 2007
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20. Centers for Medicare and Medicaid Services: Medicare Benefit Policy Manual: Coverage of hospice services under hospital insurance. Washington, DC, Centers for Medicare and Medicaid Services, 2012, pp 1-46 http://www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf 21. Centers for Medicare and Medicaid Services: State operations manual: Appendix M—Guidance to surveyors: Hospice. Washington, DC, Centers for Medicare and Medicaid Services, 2014. http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
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15. National Hospice and Palliative Care Organization: NHPCO facts and figures: Hospice care in America. Alexandria, VA, National Hospice and Palliative Care Organization, 2012. http://www.nhpco.org/sites/default/files/public/Statistics_ Research/2012_Facts_Figures.pdf
19. Morden NE, Chang CH, Jacobson JO, et al: End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely. Health affairs 31:786-796, 2012
Affordable Radiation Therapy for Hospice Patients
Appendix Table A1. Patient Characteristics
Patient
Age (years)
1
52
2 3
Time From Hospice Enrollment to Death (months)
40
3
3
Right shoulder pain
70
6
8
Lower back pain
Lower back, left shoulder, right shoulder pain
50
4
9
Dyspnea
Dyspnea
60
2
4
3.5
5.9
Diagnosis
Symptoms at Presentation
Colon cancer, metastatic
Back/abdominal pain
Back/abdominal pain
56
Lung cancer, metastatic
Extremity pain
81
Prostate cancer, metastatic
4
89
Locally advanced lung
Average
69
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KPS
Time From Treatment to Death (months)
Reason for Referral
Abbreviation: KPS, Karnofsky performance score.
Figure A1. Field design (anteroposterior/posteroanterior) use to treat destructive lesion of right acromion as described in patient case 1.
Copyright © 2014 by American Society of Clinical Oncology
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Original Contribution
Clinic Offering Affordable Radiation Therapy to Increase Access to Care for Patients Enrolled in Hospice By Jessica M. Schuster, MD, Thomas J. Smith, MD, Patrick J. Coyne, MSN, APRN, Stephen Lutz, MD, MS, Mitchell S. Anscher, MD, and Drew Moghanaki, MD
Abstract Purpose: A majority of patients enrolled in hospice have advanced cancer. Most of them are burdened by symptoms related to uncontrolled tumor growth. Although palliative radiation therapy (RT) is highly effective, only 1% of hospice patients are ever referred. Commonly cited concerns include high treatment cost, burden of travel for multiple visits, and a perceived reluctance of radiation oncologists to deliver single-fraction RT.
Methods: A clinic offering affordable RT to patients in hospice was developed to simplify the intake, reduce cost, and minimize travel to a single visit. The goal was to evaluate, simulate and plan treatment, and treat patients with a single fraction of palliative RT within a 4-hour period.
Results: The initial 18-month experience is reported in this Health Information Portability and Accountability Act– compli-
Introduction Patients with incurable malignancies make up approximately 50% of those who are enrolled in hospice.1 Unfortunately, a majority are burdened by symptoms that result from uncontrolled tumor growth.2 To meet eligibility for hospice benefits, patients must first surrender Medicare and/or private insurance coverage for chemotherapy. They also have to relinquish coverage for radiation therapy (RT), although it provides meaningful palliation pain relief in up to 80% of patients with bone metastasis3-7 and is highly effective at relieving symptoms related to bleeding, dyspnea, and dysphagia.8,9 Although 90% of hospice professionals recognize that RT can improve patient quality of life, less than 1% of patients in hospice are ever referred for this treatment.1 Surveys conducted by the American Academy of Hospice and Palliative Medicine and American Society of Radiation Oncology determined that the main barriers are related to the direct and indirect costs of treatment, the burden of travel on patients and family for multiple treatment visits, and a perceived reluctance of radiation oncologists to offer single-fraction palliative RT (SFPRT) when it is just as effective as longer courses of treatment.1 In the United States, palliative RT can cost more than $10,000 and is almost always prescribed over 2 to 3 weeks.10-13 Thus, it is understandably prohibitive for many hospice agencies that currently operate under a median pere390
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ant report that was approved by the Viriginia Commonwealth University Institutional Review Board. Eight referrals were received from local hospice agencies that had not referred any patients in previous years. A telephone screening process avoided unnecessary travel for two patients who were not candidates for RT. Two additional patients who were evaluated with a same-day computed tomography simulation were not good candidates for RT. Ultimately, four patients were successfully treated with single-fraction palliative RT of 8 Gy. None had to disenroll from hospice.
Conclusion: This novel program increased access to palliative RT for patients in hospice who would otherwise not have been referred. The main challenge identified was a need for ongoing educational activities at hospice agencies where staff turnover may be high and understanding about palliative RT can be limited.
diem reimbursement rate of only $150, from which all services must be provided.14,15 To address the aforementioned barriers, a multidisciplinary group of clinicians dedicated to palliative care developed a novel program at our institution. A clinic offering affordable radiotherapy (CART) was designed to simplify the intake, evaluation, and treatment process into a half-day appointment that offers SFPRT to patients who are enrolled in hospice. This report summarizes our experience after the first 18 months.
Methods This Health Information Portability and Accountability Act– compliant report was approved by the Viriginia Commonwealth University Institutional Review Board.
Program Development and Promotion In the spring of 2012, a multidisciplinary team of physicians and nurses held several meetings to address the issue of limited access to palliative RT for patients enrolled in hospice. The program was designed to be simple enough to complete the consultation, computed tomography (CT) simulation, treatment planning, and delivery of treatment in a single visit (Figure 1). The model was similar to protocols used for palliative RT emergencies at our institution.
V O L . 10, I S S U E 6
Copyright © 2014 by American Society of Clinical Oncology
Downloaded from jop.ascopubs.org on June 9, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Massey Cancer Center, Virginia Commonwealth University; Hunter Holmes McGuire Veterans Affairs Hospital, Richmond, VA; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD; and Blanchard Valley Health System, Findlay, OH
Affordable Radiation Therapy for Hospice Patients
Hospice nurse determines need for radiotherapy Hospice director approves referral
4-hour visit Physician assessment CT simulation Patient returns home
Physics QA check Single-page form faxed to radiation oncology
Delivery of single-fraction palliative radiotherapy Figure 1. Simplifying palliative radiotherapy. CT, computed tomography; QA, quality assurance.
Intake Process and Screening The referral process was simplified to a single-page fax that could be completed by any hospice-based clinician who was involved in the patient’s care. Once the fax was received, a follow-up screening call was made to assess the appropriateness for scheduling a formal consultation (Table 1). Factors included each patient’s pathologic confirmation of a cancer diagnosis, identification of a localized symptom that could be palliated, ability to provide informed consent, and safety for travel to the clinic. Screened patients were scheduled for a sameday consultation, CT simulation, and treatment machine time slot. Transportation was the responsibility of the patient or hospice agency.
Patient Evaluation, RT Planning, and Treatment Delivery The face-to-face evaluation included a focused history and physical examination, discussion about the risk and benefits of palliative RT, and completion of the informed consent process. A same-day CT simulation was performed to investigate for a Table 1. Criteria for Scheduling Radiation Therapy Evaluation Criteria Determined by Screening Phone Call No previous definitive (high dose) radiation to site Symptom to palliate Patient is stable for transportation Patient has ability to provide consent for treatment
Copyright © 2014 by American Society of Clinical Oncology
malignant lesion that was consistent with the patient’s clinical symptom(s); a radiologist was generally not involved. Once a tumor target was identified, treatment fields were designed with a simple parallel-opposed beam arrangement without secondary collimation. Treatment was delivered with either 6 or 18 MV photons. All fields were rectangular, but could be modified by collimator rotation to minimize unnecessary normal tissue exposure. The radiation prescription dose calculation point was carefully selected by the radiation oncologist using three-dimensional CT references and then calculated to midplane by a radiation therapist. This process intentionally omitted the participation of a dosimetrist because that would increase department resource usage, increase patient time in the clinic, and was perceived to be unnecessary for a simple rectangular field calculated at midplane. In addition, according to department policy, all treatment plans underwent a secondary quality assurance check by a medical physicist. Treatment was delivered only after patient alignment and verification of portal imaging was approved by an attending radiation oncologist. The standard treatment was 8 Gy in a single fraction. Electron therapy planning was available but not used for any of the patients described in this report.
Follow-Up Hospice agencies were sent a single bill for all services. This did not include any procedural codes or itemized descriptions and was below the current Medicare billing rate for SFPRT. For patient convenience, we did not require any formal follow-up, given that there was no reason to believe outcomes would deviate from those in the reported literature.
Results Program Establishment CART was launched on July 1, 2012, 5 months after initial discussions by members of the multidisciplinary team. This delay was related primarily to a need for multiple conversations with hospital billing administrators, who raised concerns about billing far below Medicare reimbursement rates. Acceptance was ultimately achieved once there was an awareness that patients in hospice are almost never referred for RT, and that this program therefore represented an opportunity to increase referrals. The compassionate aspect of this program was also ac-
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All eight hospice agencies within 50 miles of our radiation oncology facility were contacted multiple times. In-service educational sessions were welcomed at five of these, and a total of eight presentations were given because one hospice had multiple teams that covered different geographic locations. In-service sessions were given by either an attending radiation oncologist (D.M.) or resident (J.M.S.). They were typically conducted at multidisciplinary meetings that included social workers, medical assistants, hospice nurses, medical directors, and sometimes billing coordinators. Presentations focused on the efficacy of palliative RT and equivalence of SFPRT when compared with longer treatment schedules. Additional educational outreach efforts included invited lectures at local and statewide conferences that focused on hospice and palliative care.
Schuster et al
Table 2. Rationale for Not Delivering Radiation Therapy With CART
Case 2. A 75-year-old man with hormone-refractory metastatic prostate cancer was referred for pain, which he scored as 8 on a scale of 1 to 10, in his lumbar spine and bilateral shoulders, with increased intolerance of opioids. CT simulation identified destructive lesions in all of three regions. Three separate nonoverlapping AP/PA fields were used to target each of these sites.
Reasons why patients were not scheduled Inability to consent for treatment Recent definitive radiation to site of concern in the neck Reasons why patients were not treated after physician evaluation Pain well controlled Concern for possible toxicity: two prior courses of radiotherapy had already exposed brachial plexus Abbreviation: CART, clinic offering affordable radiotherapy.
Patient Experience During the initial 18 months of CART, eight outpatients were referred by three hospice agencies for palliative RT. This represented approximately one new referral every 3 months. In contrast, no patients had been referred in previous years from any local hospice agency. Furthermore, hospice administrators confirmed that none of these patients would have been referred without the more streamlined and affordable CART program. All referrals were submitted by a hospice nurse using the single-page intake form. After contacting the referring nurse, six patients (75%) were scheduled, given that they met criteria for a formal evaluation (Table 1). Two patients were not scheduled because they either could not provide informed consent or had recently completed a high dose of definitive RT to the area of concern in the neck (Table 2). Of the six patients who were evaluated in person, all underwent a CT simulation for treatment planning. Two patients were deemed inappropriate for SFPRT with a simple beam arrangement. In one of these two patients, there was concern about brachial plexus injury because of two previous courses of RT that overlapped within the area of concern; the second patient had an extensive amount of indolent lung cancer, but good performance status with borderline pulmonary function, and was otherwise doing well with pain control using low doses of oral pain medications. Case summaries are provided for the four treated patients to illustrate the simplicity of the process. All patients had a Karnofsky performance score of 70 or less, and their characteristics are further summarized in Appendix Table A1 (online only). All patients completed their evaluation, received a single fraction of 8 Gy, and left the clinic within 3.5 to 5 hours of initial registration in our department. None had to disenroll from hospice. Case 1. An 82-year-old man with metastatic lung cancer was referred for uncontrolled right shoulder pain after he developed severe constipation from opioids. Physical examination and CT simulation identified a destructive lesion in the right acromion measuring less than 3 cm. This was targeted with a single anteroposterior/posteroanterior (AP/PA) field (Appendix Figure A1, online only). e392
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Case 4. An 89-year-old man with previously untreated, locally advanced lung cancer was referred with symptomatic dyspnea. Complete occlusion of his right main stem bronchus was shown on CT simulation. A small AP/PA field was designed to treat a large perihilar mass, with assurance that the RT avoided any exposure of the esophagus.
Discussion CART established a simplified process to address the three main barriers that are commonly believed to limit access to care for patients in hospice who seek palliative RT: high cost, burden of multiple treatment visits, and a perceived reluctance of radiation oncologists to deliver SFPRT.1,10 Within 18 months, a total of eight patients were referred. The emergence of referrals to our department from hospice agencies confirmed our hypothesis that a simplified and affordable program would increase access to care for this population. No patient had to disenroll from hospice. The four patients who had an indication for palliative RT received their treatment within 5 hours of initial entry to the clinic, and all were able to go home afterward. Hospice providers confirmed that none of these patients would have been referred without this program. In several Canadian institutions, similar changes to radiation oncology clinic infrastructure increased referrals after addressing logistic and communication problems between specialists, knowledge gaps about RT, and the inconvenience of multiple clinic visits.15,16,17 The Rapid Response Radiotherapy Program at the Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada, offered a simplified referral pathway with a nurse as the community liaison.17 In addition, the Rapid Access Palliative Radiotherapy Program (RAPRP) at the Cross Cancer Institute in Edmonton, Ontario, Canada, integrated a reducedvisit multidisciplinary patient evaluation with a radiation oncologist, nurse, clinical pharmacist, radiation therapist, occupational therapist, social worker, and registered dietician.18 The RAPRP reported 100% patient satisfaction with symptom stabilization or improvement in more than 75% of patients receiving palliative RT. Highlighting the success of the RAPRP, a second palliative RT clinic was opened to expand capacity.18 With an estimated 567,000 patients with cancer currently enrolled in hospice, and an average of 70% dying with pain
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knowledged by administrators, which influenced the final decision for approval. Promotion of the program included in-service sessions at local hospice agencies as well as presentations at local and statewide conferences focusing on hospice and palliative care, and was performed over a 12-month period.
Case 3. A 50-year-old woman with metastatic colon cancer was referred for uncontrolled back pain, scored as 10 of 10, but was found on history to also have upper abdominal pain, scored as 6 of 10. The CT simulation identified a large destructive lesion in her upper lumbar spine, and also identified a large malignant mass in the portocaval region. These two lesions were contoured on the CT scan, and separate nonoverlapping rectangular AP/PA fields were designed to target each of these sites.
Affordable Radiation Therapy for Hospice Patients
peated in-services and amidst high staff turnover. Within months, many care providers who had heard our initial inservice session no longer worked at the hospice agencies. Thus, the need to continue education is clear, and such efforts will likely only be successful if there is high-level engagement with administrators and nursing directors for the purpose of internal promotion. In conclusion, through simplifying the intake, evaluation, and treatment delivery process, and improving affordability, CART successfully increased access to palliative RT for patients enrolled in hospice. Such a program helps fulfill the triple aim of improved symptom management, better quality of care, and reduced cost. However, more work needs to be performed to foster relationships and education between radiation oncologists and hospice professionals. There is significant staff turnover at many hospice agencies, and ongoing educational activities are required to ensure awareness of palliative RT for providers who may have a limited background in principles of oncology. On the basis of our experience, empowering hospice administrators and nursing directors to internally educate their staff about palliative RT will likely have the greatest impact with respect to increasing access to this care. Authors’ Disclosures of Potential Conflicts of Interest The authors declared no potential conflicts of interest.
Author Contributions Conception and design: Thomas J. Smith, Patrick J. Coyne, Stephen Lutz, Mitchell S. Anscher, Drew Moghanaki Collection and assembly of data: Jessica M. Schuster, Drew Moghanaki Data analysis and interpretation: Jessica M. Schuster, Thomas J. Smith, Drew Moghanaki Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Jessica M. Schuster, MD, Department of Radiation Oncology, Virginia Commonwealth University, 401 College St, PO Box 980058, Richmond, VA 23298; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001505; published online ahead of print at jop.ascopubs.org on September 30, 2014.
References 1. Lutz S, Spence C, Chow E, et al: Survey on use of palliative radiotherapy in hospice care. J Clin Oncol 22:3581-3586, 2004 2. Miller SC, Mor V, Teno J: Hospice enrollment and pain assessment and management in nursing homes. J Pain Symptom Manage 26:791-799, 2003 3. Anderson PR, Coia LR: Fractionation and outcomes with palliative radiation therapy. Semin Radiat Oncol 10:191-199, 2000 4. Chen AM, Vaughan A, Narayan S, et al: Palliative radiation therapy for head and neck cancer: Toward an optimal fractionation scheme. Head Neck 30:15861591, 2008 5. Hartsell WF, Scott CB, Bruner DW, et al: Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97:798-804, 2005
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6. Nielsen OS, Bentzen SM, Sandberg E, et al: Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases. Radiother Oncol 47:233-240, 1998 7. Steenland E, Leer JW, van Houwelingen H, et al: The effect of a single fraction compared to multiple fractions on painful bone metastases: A global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 52:101-109, 1999 8. Lutz ST, Chow EL, Hartsell WF, et al: A review of hypofractionated palliative radiotherapy. Cancer 109:1462-1470, 2007 9. Kim MM, Rana V, Janjan NA, et al: Clinical benefit of palliative radiation therapy in advanced gastric cancer. Acta Oncol 47:421-427, 2008 10. Fairchild A, Barnes E, Ghosh S, et al: International patterns of practice in palliative radiotherapy for painful bone metastases: Evidence-based practice? Int J Radiat Oncol Biol Phys 75:1501-1510, 2009
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during the final weeks of life, there is a potential to benefit over 397,000 patients each year with palliative RT if access could be increased.2,15,19 This represents a public health issue that is unfortunately not a current priority. At present, patients in hospice who are interested in this care must often first disenroll to re-establish insurance coverage. Whether or not they re-enroll, hospice agencies are at risk during audits because they are required by Medicare to provide all services necessary for palliation.20 Medicare’s guidelines state that hospice agencies should not accept patients if they cannot provide illness-related symptom relief services in a timely fashion.21 They further state that palliative RT should be considered, but unfortunately provide little guidance as to when it should be considered. Medicare’s policies indicate that determination should be “based on the patient’s condition and the Hospice care giving philosophy,” while emphasizing that “no additional Medicare payment may be made regardless of the cost of [radiotherapy] services.”20 How should we move forward? The simplest solution would be to amend the hospice reimbursement schedule to provide additional financial benefits to agencies that use palliative RT. However, until that happens, we believe that programs such as CART provide a reasonable opportunity to increase access while minimizing burden to radiation oncology clinics and hospices. Once information about CART was shared, a willingness to refer patients increased, confirming that the burden of travel for multiple visits and cost were indeed barriers that had limited access. Another interesting observation was made that further explained why referrals from hospice agencies were limited both before and after the implementation of CART. During in-service education sessions, many hospice providers shared that they actually had no previous oncology experience and had little knowledge about RT in general. Meanwhile, educational topics about palliative RT were met with a range of responses, from enthusiasm to borderline disbelief about the effectiveness of palliative RT, particularly in regard to SFPRT. Through extensive direct communication and a recently published survey of the same hospice facilities in our area, we learned that more than 75% of administrators and nursing directors were simply unaware that palliative RT is as effective in a single fraction versus longer courses of treatment.12 Unfortunately, despite initial enthusiasm about CART, awareness of our program seemed to fade quickly without re-
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11. Haddad P, Wong RK, Pond GR, et al: Factors influencing the use of single vs multiple fractions of palliative radiotherapy for bone metastases: A 5-year review. Clin Oncol (R Coll Radiol) 17:430-434, 2005
17. Wu JS, Kerba M, Wong RK, et al: Patterns of practice in palliative radiotherapy for painful bone metastases: Impact of a regional rapid access clinic on access to care. Int J Radiat Oncol Biol Phys 78:533-538, 2010
12. Schuster J, Han T, Anscher M, et al: Hospice providers awareness of the benefits and availability of single-fraction palliative radiotherapy. J Hosp Palliat Nurs 16:67-72, 2014
18. Fairchild A, Pituskin E, Rose B, et al: The rapid access palliative radiotherapy program: Blueprint for initiation of a one-stop multidisciplinary bone metastases clinic. Support Care Cancer 17:163-170, 2009
13. Bekelman JE, Epstein AJ, Emanuel EJ: Single- vs multiple-fraction radiotherapy for bone metastases from prostate cancer. JAMA 310:1501-1502, 2013 14. Centers for Medicare and Medicaid Services: Update to the hospice payment rates, hospice cap, hospice wage index and the hospice pricer for FY 2013. Washington, DC, Centers for Medicare and Medicaid Services, 2012. http:// www.cms.hhs.gov/transmittals/downloads/R2497CP.pdf
16. Samant RS, Fitzgibbon E, Meng J, et al: Barriers to palliative radiotherapy referral: A Canadian perspective. Acta Oncologica 46:659-663, 2007
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20. Centers for Medicare and Medicaid Services: Medicare Benefit Policy Manual: Coverage of hospice services under hospital insurance. Washington, DC, Centers for Medicare and Medicaid Services, 2012, pp 1-46 http://www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf 21. Centers for Medicare and Medicaid Services: State operations manual: Appendix M—Guidance to surveyors: Hospice. Washington, DC, Centers for Medicare and Medicaid Services, 2014. http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
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15. National Hospice and Palliative Care Organization: NHPCO facts and figures: Hospice care in America. Alexandria, VA, National Hospice and Palliative Care Organization, 2012. http://www.nhpco.org/sites/default/files/public/Statistics_ Research/2012_Facts_Figures.pdf
19. Morden NE, Chang CH, Jacobson JO, et al: End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely. Health affairs 31:786-796, 2012
Affordable Radiation Therapy for Hospice Patients
Appendix Table A1. Patient Characteristics
Patient
Age (years)
1
52
2 3
Time From Hospice Enrollment to Death (months)
40
3
3
Right shoulder pain
70
6
8
Lower back pain
Lower back, left shoulder, right shoulder pain
50
4
9
Dyspnea
Dyspnea
60
2
4
3.5
5.9
Diagnosis
Symptoms at Presentation
Colon cancer, metastatic
Back/abdominal pain
Back/abdominal pain
56
Lung cancer, metastatic
Extremity pain
81
Prostate cancer, metastatic
4
89
Locally advanced lung
Average
69
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KPS
Time From Treatment to Death (months)
Reason for Referral
Abbreviation: KPS, Karnofsky performance score.
Figure A1. Field design (anteroposterior/posteroanterior) use to treat destructive lesion of right acromion as described in patient case 1.
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