Many factors can affect decisions about chemotherapy and supportive care, including disease outcome, patient quality of life, and drug toxicities. Chemotherapy and supportive therapy may require numerous medical visits that may significantly affect patients and their caregivers. It has recently been shown that practice resources should also be considered in evaluating the full impact of medical visits. To this end, increasing the efficiency of a practice may help ensure the viability of delivering quality care. Greater efficiency can lead to improvements in the quality of life of patients and their caregivers, lower practice operating expenditures, and increase practice capacity and productivity. Chemotherapy-induced anemia is common in patients with cancer, and erythropoiesis-stimulating proteins (ESPs) can lessen its incidence and severity but may require many additional medical visits. This article discusses the importance of establishing efficiency in the oncology practice and considers the role of coordinating tests and procedures, specifically the role of available scheduling options for growth factors. Synchronizing treatments with ESPs and chemotherapy may increase patient convenience and improve practice efficiencies.
The pressure on members of oncology practices to understand the costs of delivering care and to operate as efficiently as possible is building as a result of an increasing population of patients with cancer, a flat growth rate in the number of oncologists, a shortage of oncology nurses, and a decline in oncology-related reimbursement. Novel drugs and delivery mechanisms that require fewer medical visits or shorter administration time have the potential to facilitate practice efficiency and enhance patient quality of life, satisfaction, and convenience. Erythropoiesis-stimulating proteins (ESPs) have been shown to increase erythrocyte counts and hemoglobin levels, reduce the need for red blood cell transfusions, and improve anemia-associated deficits in quality of life in patients with chemotherapy-induced anemia (CIA).[1,2] Treatment with ESPs, however, may require numerous clinic visits over several weeks, potentially adding to the burden of chemotherapy and other supportive therapy through incremental direct and indirect costs and time incurred by patients and their caregivers,[3-6] overall cost of chemotherapy for payers and employers,[7,8] and human resource and indirect practice costs for providers.
Even relatively simple medical visits such as those associated with ESP treatment involve members of the medical and support staff, which translates into substantial human resource time and cost. These expenses are multiplied by the number of visits required for a given treatment in the context of the "normal" visits that might be required for other medical procedures. The reimbursement for any given medical visits may be minimal and insufficient for the direct and indirect cost of delivering care. Maximizing efficiency may help ensure that practices can continue to consistently manage anemia by lowering operating expenditures, increasing capacity, and maximizing productivity. Greater efficiency will also likely translate into improvements in the negative effects of medical visits on patients and their caregivers.
This article reviews studies that highlight the effects of CIA-related medical visits on patients, caregivers, and the practice. Recently published data that are useful in analyzing practice efficiency are detailed, and examples of tangible options to increase practice efficiency in managing CIA are summarized.
Effects of CIA Visits on Patients and Caregivers
Some of the ways in which medical visits affect patients and their caregivers are shown in Table 1. Medical visits for CIA may result in significant burdens to patients and their care-givers that extend beyond the visit itself. The clinical procedures for administering an ESP are relatively brief, but the medical visit required for the procedure comes with disproportionate consequences for patients. Fortner and colleagues found that the average patient time affected by a single ESP treatment was approximately 2.2 hours (standard deviation, 3.1 hours). Almost all patients (99%) reported that medical visits, including ESP visits, interfered with life activities such as time spent with friends and family, housework, employment, and hobbies.
Patients also incur out-of-pocket expenses resulting from copayments, transportation, meals, and securing assistance with normal responsibilities.[5,10,11-16] Documented indirect and out-of-pocket expenses associated with medical visits include lost wages from paid employment, the costs of child and elder care, over-the-counter and prescription medicines, food, home care, transportation, and overnight accommodations.[17-22] Moore estimated the monthly out-of-pocket expenses (mileage, parking, overnight accommodations, and meals) for patients with breast cancer at $360. Meehan and colleagues estimated the out-of-pocket expenses for a single ESP visit, not including copayments, to be $26. Direct and indirect costs are a concern as they have been shown to interfere with patients' willingness to receive treatment, especially members of minorities and patients with significant copayments or without insurance.
Transportation to and from the ESP visit is another concern for patients. Moore found that patients with breast cancer who were treated with chemotherapy averaged 4.5 trips per month, ranging up to 20 visits per month. Treatment with ESPs may add significantly to this burden, depending on the schedule of the ESP and the extent to which ESP visits overlap with other normally occurring medical procedures such as chemotherapy administration, laboratory tests, and radiologic procedures. In a rural outpatient setting, Meehan and colleagues found that the average distance traveled to the clinic for ESP treatment was 80 miles, and in another study, they found that the travel time to the clinic averaged 40 minutes. Difficulties with transportation, such as limitations in availability or having to travel long distances, have been shown to be barriers to treatment adherence, especially when several visits are required.[18,19]
While not as well documented, it is clear that cancer affects the lives of people who have attachments to the patient. One study found that more than 50% of patients had been accompanied by a caregiver to their last medical visit, and this same trend has been observed in ESP treatment. Caregivers may be more vulnerable to the ill effects of medical visits since they are more likely to be engaged in normal responsibilities like paid employment. Meehan and colleagues showed that caregivers were twice as likely as patients to miss paid employment because of an ESP treatment. Fortner and colleagues reported that the vast majority of patients reported receiving caregiver support for medical visits, which included activities such as providing transportation or emotional support and assisting with daily responsibilities. After averaging in zero time for the nearly 50% of patients who were not accompanied to their last ESP visit, caregiver time affected by the patients' last ESP visit averaged 1.3 hours (standard deviation, 2.5 hours). More studies are needed to understand the toll that medical visits may have on caregivers.
Effects of Medical Visitson Oncology Practice
The author has no significant financial interest or other relationship with the manufacturers of any productsor providers of any service mentioned in this article.
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