Matthew Gavidia

At this year’s Community Oncology Alliance (COA) Virtual Payer Exchange Summit, the conversation on driving change within cancer care and cost reduction involves not only community-based oncology practices, but the 

 and employer health groups who work with them as well.

 of the American population receiving health insurance through their employers, this year’s 

 placed a distinct focus on the role of these organizations, particularly how they can improve the quality, experience, and cost of cancer care.


However, as cancer care, or even general health care, is not typically the expertise of employers nationwide, how can these groups initiate change in a system they may not fully understand?


“Assessing Provider Quality & Value in Cancer Care: What Should Employers & Self-Funded Companies Be Looking For,”

 on day 1 of the 2020 COA Virtual Payer Exchange Summit, moderator Robert Baird Jr, RN, MSA, president of the National Cancer Treatment Alliance, opened the discussion by first asking  Lalan Wilfong, MD, executive vice president of Value-Based Care & Quality Programs at Texas Oncology and COA Payment Reform co-chair, what signifies value and quality in oncology.


Wilfong, who was joined on the panel by John Fox, MD, chief boundary spanner at Foxworthy Healthcare Consulting LLC, and Lee Schwartzberg, MD, FACP, executive director at the West Cancer Center & Research Institute, discussed that while many major cancer centers advertise the quality of the care they provide, none have defined exactly what quality is.

“Is it access in getting patients in on a timely fashion? Is it following national standard guidelines? Is it patient outcomes, such as hospitalizations and emergency department visits....I think there's a lot of different aspects that go into what defines a good quality oncology experience for a patient, but it's hard to define that in a granular fashion to show that you are a good quality practice,” said Wilfong.


Building on the definition of quality in cancer care, Schwartzberg credited the introduction of the Oncology Care Model (OCM) in helping his organization delineate patient needs and pressure points to address from a quality perspective. Focusing primarily on reducing costs and improving the care process, he says that for those oncology practices who have addressed these concerns, a transition to outcomes that matter to employers, such as return to work or return to work for caregivers, is warranted.


While outcomes like overall survival may serve as the basis of quality assessment in clinical trials, from an employer perspective, it may not be as important as employees may not stay with their respective employers for an extended period of time, explained Schwartzberg. “I think we need to really dialogue with our employers and see what they feel are really tangible, important, quality metrics beyond what we've done already.”


Fox, whose occupation involves consulting directly with employers large, medium, and small, noted that information detailed in annual reviews include high-cost patients, their conditions, and their high-cost drugs. Moreover, Fox highlighted that the primary question asked by employers is based not on quality, but on what payers are doing to help control these costs.

This issue served as the primary takeaway from the panel discussion, in which improvement in transparency and effort is needed between payers, employers, and community cancer centers to delineate what quality is and how to maintain quality while additionally prioritizing cost-saving.

“We need to distinguish what is truly appropriate guideline-based therapy that helps patients do better, live longer, have better quality lives, versus those things that are potentially wasteful. And it's challenging sometimes to make that distinction, especially for employers who don't have knowledge of oncology and cancer therapy,” said Wilfong.


Addressing the total cost of care, panelists provided key strategies that employers should consider, including greater use of screening among employees and their family members, assessing cost related to site of service, and the use of biosimilars to drive down cost. Additionally, pathway management was referenced, which Wilfong notes for employers to approach with caution due to its growing use among oncology practices as an all-encompassing service.

“I have seen pathways where it's clear that the pathways weren't driven by efficacy measures, they were driven more by relationships, rebates,” explained Wilfong. “I would just take a step back, when you look at pathways, really make sure that there's not an underlying negative influence on developing those other than providing the best, most cost-effective care to patients.”


Developing a set criteria to identify practices associated with high value and cost-effectiveness was recommended by panelists, which Fox said can become a responsibility for payers to help bridge the gap in communication between employers and community oncology practices.


“The reality is that most practices don't have relationships with employers,” said Fox. “In defining a high value practice, I think payers can help filter for employers and identify those high performing practices so that employers, employees could search out those practices.”

In tackling the major disconnect between community oncology and employers, panelists concluded on how to improve the connection between community oncology and employers, which Schwartzberg said can prove difficult, especially among large employers due to the national scale of care required and the complicated nature of cancer.

“Having that dialogue is tough, I think probably the best way to do it is to do consortium discussions, like local business groups on health….with people that are well informed coming together and trying to solve this as a group rather than as an individual,” said Schwartzberg.

Articles

A panel of key opinion leaders discuss how employers and self-funded companies should assess provider quality and value in cancer care at the 2020 Community Oncology Alliance Virtual Payer Exchange Summit. 

Defining Quality, Value in Cancer Care: What Employers Should Seek From Providers

A skin test to detect clumping of alpha-synuclein (α‐synuclein), an abnormal protein suggested to have a central role in the pathogenesis of Parkinson disease (PD), may assist in improving earlier detection of the condition, according to study findings published in 

With no definitive approach to diagnosing PD without postmortem autopsy, current standards of diagnosis rely on clinical signs and symptoms. These factors have contributed to common 

 early in the disease course, which study author Thomas Beach, MD, head of the Civin Laboratory at Banner Sun Health Research Institute, notes in a 

 has complicated clinical trials investigating the efficacy of novel PD therapies.

“The clinical diagnostic accuracy for early-stage PD has been quite poor, only around 50% to 70%. And since clinical trials really need to be done at an early stage to avoid further brain damage, they have been critically hampered because they have been including large percentages of people who may not actually have the disease,” said Beach. “Improving clinical diagnostic accuracy is, in my view, the very first thing we need to do in order to find new useful treatments for PD.”

In prior research, Beach and fellow study author Charles Adler, MD, professor of neurology at Mayo Clinic Arizona, investigated a method known as the real-time quaking induced conversion assay. After several years of optimizing the assay to detect misfolded proteins in similar human and animal disorders, both researchers found that misfolded α‐synuclein proteins accumulate in body tissues in addition to the brain, including the skin.

Building on these findings, researchers conducted a blinded study of 50 skin samples from autopsied subjects, 25 each from patients with and without PD, provided by the 

Arizona Study of Aging and Neurodegenerative Disorders and Brain and Body Donation Program

 based at Banner Sun Health Research Institute.

Utilizing the protein assay to examine these frozen skin tissues, researchers correctly diagnosed 24 of the 25 patients with PD (96% sensitivity and 96% specificity), with only 1 of the 25 controls showing to have the protein clumping. Conversely, 9 of 12 patients with PD and 10 of 12 controls were detected to have accumulation of α‐synuclein via formalin‐fixed paraffin‐embedded skin sections, which resulted in a sensitivity of 75% and specificity of 83%.

“These results indicate tremendously high sensitivity and specificity which is critical for a diagnostic test,” said Adler in a 

In examining the study findings, lead study author Anumantha Kanthasamy, PhD, distinguished professor of biomedical sciences at Iowa State University, said in the study’s accompanying 

 that testing skin samples could lead to earlier detection of PD, which can then allow physicians to test therapeutic strategies designed to slow or prevent the development of advanced symptoms.

“Our blinded study results clearly demonstrate the feasibility of using skin tissues for clinical diagnosis of PD by detecting pathological α‐synuclein,” concluded the study authors. “Moreover, this peripheral biomarker discovery study may have broader translational value in detecting misfolded proteins in skin samples as a longitudinal progression marker.”

Kanthasamy A, Beach TG, Adler CH, et al. Blinded RT‐QuIC analysis of α‐synuclein biomarker in skin tissue from Parkinson disease patients. 

. Published online September 22, 2020. doi:10.1002/mds.28242

A skin test to detect clumping of alpha-synuclein, an abnormal protein suggested to have a central role in the pathogenesis of Parkinson disease, may assist in improving earlier detection of the condition, according to study findings. 

Skin Samples May Improve Earlier Diagnosis of Parkinson Disease

Eli Lilly Stops Antibody Trial on Hospitalized Patients With COVID-19

Eli Lilly & Co. announced today it will be ending the clinical trial of its antibody drug bamlanivimab, in combination with remdesivir, a day after the National Institutes of Health (NIH) found the combination therapy to exhibit no significant improvement among patients hospitalized with coronavirus disease 2019 (COVID-19). According to 

, the study had initially been paused by the pharmaceutical company on October 13 due to a potential safety concern. While the trial showed no clinical benefit for patients taking the combination therapy, both Eli Lilly and the NIH still plan to pursue several additional trials involving the antibody drug, with the subsequent trials examining its efficacy among patients with less advanced stages of COVID-19.


Pros and Cons of Telemedicine, In-Person Visit

With the emergence of telehealth amid the COVID-19 pandemic, a piece by 

 details the pros and cons of both remote and in-person medical and behavioral health visits. As noted in the article, patient satisfaction of telehealth is high, with distinct advantages including quicker appointments that can be conducted in the comfort of the home or a workplace setting and saving time, as well as costs on gas and parking. While convenient, virtual visits are not recommended in cases where doctors need to touch patients to properly assess their condition, such as in diabetes-related neuropathy. Children were additionally said to benefit greater from in-person health care visits.

The American Academy of Pediatrics (AAP) issued new guidance on opioid use in pregnancy with aims to improve care for women and newborns affected by their mothers’ drug use. 

 reported that the incidence of affected women and infants has risen in recent years, with insufficient treatment cited as a notable issue, as well as the ongoing COVID-19 pandemic. According to the AAP report,  pregnant women should have access to medication to treat opioid abuse, with 2 opioids, buprenorphine and methadone, indicated as effective treatments. Furthermore, the AAP says hospitals should have written protocols for assessing and treating newborns affected by opioid abuse.

Eli Lilly will end its clinical trial of bamlanivimab in patients hospitalized with coronavirus disease 2019; pros and cons of telemedicine and in-person care; new guidance on opioid use in pregnancy. 

What We're Reading: Eli Lilly Ends Antibody Trial; Pros, Cons of Telehealth; AAP Issues New Opioid Guidelines

 apnea (OSA) who are not adherent to continuous positive airway pressure (CPAP) therapy were found to be more likely to be hospitalized with influenza than those who used CPAP, according to 

For the approximately 30 million American adults with OSA, disruptions in sleep caused by the condition may adversely impact immune system functioning, note the researchers. Amid the coronavirus disease 2019 (COVID-19) pandemic, this can have an extensive 

 on risk of infection and adverse outcomes among this patient population. Moreover, the emergence of the flu season may further exacerbate this risk, as patients with OSA may require hospitalization amid 

One common treatment for OSA, CPAP therapy, has emerged as a viable solution that works by using mild air pressure to keep the airways open during sleep. The researchers sought to investigate whether patients with OSA who undergo CPAP therapy would be at a lesser risk of hospitalization due to influenza infection than nonadherent patients.

Deriving medical records of patients at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, who had both OSA and a new, laboratory-confirmed influenza infection between 2016 and 2018 (N = 53), the study reviewed results of polysomnography, CPAP usage, influenza vaccination records, confirmation of influenza infection, and influenza-related hospitalizations and complications.

The researchers compared results of those adherent (n = 25; mean age, 60 years; 52% male) and nonadherent (n = 28; mean age, 63 years; 54% male) to CPAP therapy. Adherence was defined as usage of at least 4 hours per night for at least 70% of nights.

In comparing odds of hospitalization from influenza infections, patients conservatively treated without CPAP or nonadherent to CPAP therapy were at a nearly 5-times greater risk of hospitalization than those adherent to CPAP (odds ratio, 4.7; 95% CI, 1.3-19.5, 

After examining both groups for receiving the flu vaccine, the nonadherent CPAP patient group was found to be more likely (75%) to have been given the vaccine than the adherent group (56%), which the researchers say may be an indication of the negative impact that poor sleep has on vaccine responsiveness. However, the difference in vaccination was not statistically significant.

Overall, 61% (17 of 28) of patients not prescribed or nonadherent to CPAP therapy were hospitalized with the flu compared with 24% (6 of 25) of adherent patients. Although greater rates of hospitalization were observed, no higher odds of complications from influenza were seen among either group.

"These results would suggest that use of a treatment, CPAP, that improves sleep quality reduces the severity of influenza infection as determined by rate of hospitalization," said study author Glen Greenough, MD, associate professor of medicine, psychiatry, and neurology at the Dartmouth-Hitchcock Medical Center, in a 

. "This might suggest that treating sleep apnea and thereby improving sleep quality has a beneficial effect on the immune system. It also suggests that treating sleep apnea with CPAP could help reduce hospitalizations, thereby reducing health care costs."

Mok EM, Greenough G, Pollack CC. Untreated obstructive sleep apnea is associated with increased hospitalization from influenza infection. 

. Published online August 11, 2020. doi:10.5664/jcsm.8744

Adults with obstructive sleep apnea who are not adherent to continuous positive airway pressure (CPAP) therapy were found to be more likely to be hospitalized with influenza than those who used CPAP.

Author | Matthew Gavidia

Articles

Defining Quality, Value in Cancer Care: What Employers Should Seek From Providers

Skin Samples May Improve Earlier Diagnosis of Parkinson Disease

What We're Reading: Eli Lilly Ends Antibody Trial; Pros, Cons of Telehealth; AAP Issues New Opioid Guidelines

Untreated Sleep Apnea Linked With Flu Hospitalization