The Burden of Being a Medicare Patient With NSCLC

An emerging concept in value-based cancer care, treatment burden is a distinct entity that stands separate from disease burden and symptom burden. New research by clinicians at the Yale University School of Medicine and the Mayo Clinic, has found that Medicare patients with early-stage non—small cell lung cancer (NSCLC) have too high a number of physician visits, emergency department visits, and medications prescribed, raising questions about unnecessary patient burden.

The authors extracted data from the SEER-Medicare database on 7955 individuals (aged 67-94 years) diagnosed with stage 1 NSCLC between 2007 and 2011, who were subsequently treated with surgery, stereotactic body radiation therapy (SBRT), or external beam radiation therapy. The comparator group was matched patients without cancer. Primary outcome measures of the study were encounter days (interaction with the healthcare system), number of physicians involved in a patient’s care, and number of medications prescribed. The source for this information were claims files from MedPAR (inpatient hospitalizations, including skilled nursing facilities), Outpatient, Carrier (physician and supplier services), Home Health Agency, and Part D Drug Events.

The authors found that the patients in their study cohort spent 1 of 3 days interacting with the healthcare system early in their treatment (first 60 days). A median 44 encounter days (interquartile range [IQR], 29-66) were documented during the year following treatment initiation. A median of 20 physicians (IQR, 14 to 28 days) were involved and a median of 12 medications were prescribed (IQR, 8-17). The authors report that surgical patients had a high treatment burden (predicted probability, 21.6%; 95% CI, 20.2-23.1) compared with patients provided SBRT (predicted probability, 16.1%; 95% CI, 12.9-19.3), while patients given external beam radiation therapy had the highest burden (predicted probability, 46.8%; 95% CI, 43.3 to 50.2).

Further, patient comorbidities complicated patient treatment burden—patients with 3 or more comorbidities who had surgery had a 35.8% predicted probability of experiencing high treatment burden, compared with 29.0% in adults who were treated with SBRT.

The study’s first author, Carolyn Presley, MD, said, “These numbers are very high, and a lot to expect of older patients who often have mobility issues or functional limitations. With every additional visit and prescription, there is additional room for errors.” She emphasized the need for efforts to streamline cancer treatment to avoid unnecessary visits to healthcare centers.

“These findings highlight a need to improve cancer care coordination. It’s also a call for providers to think about the burden we might be placing on patients,” Presley added, calling for reducing the number of visits, combining appointments into a single visit, as well as reducing redundant laboratory tests and medications. The authors recommend that follow-up work to their findings should delve into shared decision-making interventions for treatment selection, comparison of different treatment modalities and their impact on patient-reported treatment burden in early-stage NSCLC, and identifying interventions that will streamline care delivery.

Reference

Presley CJ, Soulos PR, Tinetti M, Montori VM, Yu JB, Gross CP. Treatment burden of Medicare beneficiaries with stage I non—small-cell lung cancer [published online December 20, 2016]. J Oncol Pract. doi: 20:JOP2016014100.