Bringing Academic Oncology Best Practices to Community Care: Anasuya Gunturi, MD, PhD

Limited resources and financial incentives may deter community health institutions from catering to certain needs, as these institutions may provide other means of aid to serve their community still and ensure their patients receive necessary care, Anasuya Gunturi, MD, PhD, chief and medical director at Lowell General Hospital, said in an interview with The American Journal of Managed Care^®.

The difference between community health institutions and academic health centers was a pivotal topic during the Boston Regional Institute for Value-Based Medicine^® (IVBM) event on February 5.

In this Q&A, Gunturi, a panelist at the event, emphasized the importance of collaboration between the 2 institutions to optimize patient resources to advance care.

The transcript was lightly edited for clarity.

AJMC: From your perspective, what distinguishes academic “best practices” that translate well into community settings from those that tend to struggle outside large academic centers—and why?

Gunturi: I think when people get care at an academic center, one of the first things that they see is a really well-connected team of doctors. Especially in oncology, you need the surgeon and a radiation oncologist, oftentimes involved in the care, along with the medical oncologists and a lot of people who support the care, like nutritionists and palliative care, and all of these things. I think academic institutions do a really good job of presenting that at the very beginning of the patient's journey.

Sometimes in community hospitals, we have all the pieces, but sometimes it looks a little fragmented because we're all in different buildings or different practices. Sometimes we have private practices that are providing certain services; medical oncology might be more hospital-based. But I think as a physician who works in the community, over the last few years, I've noticed that if we really want to bring this to an elevated level of care that looks more like an academic institution, the best way to do it is to create a team and bring everybody in and get everybody's buy-in, and that way we have a more cohesive team.

We did this, in fact, with the breast program. We have a breast oncologist, a breast surgeon, a radiologist, an oncologist, and a geneticist—all the different parts of it—and we made a committee. And together, we see patients at the same time in a multidisciplinary clinic and are able to navigate patients through the entire journey from diagnosis to treatment to survivorship.

I think academic institutions do this really well, and that's something that we can learn in the community and try to emulate. But for it to happen, we really need to get the buy-in from all the players and have good communication among all the different doctors.

AJMC: Can you share an example of a practice or service that required meaningful adaptation before it could work effectively in a community oncology environment? What drove those changes?

Gunturi: As I mentioned, the breast program was one of the key areas that we developed. Specifically, I would point out the genetics program. We used to really struggle with that because we didn't have a full-time geneticist in our community, and so anytime we had a patient who needed genetic testing, we would have to send them to Boston, and half the people would never go because it's a long drive and it's difficult for them in terms of taking time off or transportation and things like that.

Instead, we came up with an idea. We have genetic counselors or nurse practitioners who provide genetic counseling, and then we have an attending from an academic institution who provides some oversight and some expert supervision for these providers. That way, we're able to provide the hands-on genetic testing in the community, because it's really hard for most patients to travel long distances to reach an academic center.

I would say that the genetics program was a success story, and so is how we were able to work with an academic center and use it to deliver care locally, which we would have otherwise not been able to do.

AJMC: What capabilities or support do community practices most often need from academic partners to confidently deliver increasingly complex therapies?

Gunturi: There are lots of different ways the academic institutions can help us in the community. A lot of the surgical expertise, for example, comes from academic institutions. In our institution, we have a plastic surgeon who comes from a Boston institution and provides care two days a week. He's able to do pretty complex breast reconstruction and plastic surgeries that we would not have otherwise been able to provide. We also have a gynecologist who comes from Boston and provides expert surgical care, but I think even for chemotherapies and some of these more intense protocols, as a community hospital, sometimes we're not confident that we will be able to manage all the toxicities that may come with it.

It really helps to have somebody who has more experience and who has done these types of treatments in a larger volume to guide us, for example, simply giving us a particular protocol that they follow, or the exact dosing, or the way they monitor for toxicity and manage the toxicities.

There's a lot to be learned from experience, and I think that's what academic institutions and the doctors who work there can provide us. Additionally, having a forum where we can talk to each other and discuss these kinds of things, maybe like a continuing medical education or a talk inviting the academic clinicians to the community to share their knowledge and their experience, I think, is the way to go, and it will only strengthen what we can do in the community.

AJMC: How do financial, operational, or administrative pressures influence which innovations ultimately make it from academic centers into routine community practice?

Gunturi: I think the higher-ups, the senior administrators of the hospitals, do some financial analysis as to which treatments they think would be worth it. For example, in radiation oncology, in certain disease sites, they provide a specific type of radiation therapy called brachytherapy, and it requires certain equipment and apparatus for it to be done. It's actually very expensive to set up a center that can do brachytherapy, so for a community hospital like ours, it's too expensive to do all of that for the few cases that we may be treating.

It may make more sense, in fact, to send the patients to Boston and help them get there, maybe pay for their transportation or give them some support services, so they can get the same treatment elsewhere. I think institutions do have to decide because you can't provide everything that Boston is doing, or an academic institution is doing, out in the community. You can do a lot of it, but not everything, and it just doesn't make financial sense, or maybe there's not enough support staff.

Nursing is an important part of what we do. Sometimes, the nursing expertise or comfort level isn't there in the community, and it's just too hard to overcome that. There have been times when I've proposed certain types of treatments or things that I thought maybe we would be able to do in the community, and the nursing staff really didn't feel comfortable or felt that they didn't have the expertise to be able to take care of patients and provide the support that they're supposed to. Financially, the resources that we have put a limit on what we can do in the community.