Impact of Less Frequent Injections on Patients, Caregivers, and Practices

July 1, 2006

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.

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.[9]

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.[9] 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).[10] 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.[11] Meehan and colleagues estimated the out-of-pocket expenses for a single ESP visit, not including copayments, to be $26.[23] 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.[24]

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.[11] 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[23] found that the average distance traveled to the clinic for ESP treatment was 80 miles, and in another study,[4] 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,[10] and this same trend has been observed in ESP treatment.[4] 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.[4] 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).[10] More studies are needed to understand the toll that medical visits may have on caregivers.

Effects of Medical Visitson Oncology Practice

The administration of an ESP is relatively brief and may require a minimum of skilled nursing time. Meehan and colleagues estimated the nursing time for an ESP injection to approach 10 minutes.[23] However, the total HR time required for an ESP visit includes time spent by employees across the entire spectrum of the clinic. Patients treated with ESPs typically interact with numerous staff and additional areas of the clinic, including the reception area, phlebotomy, laboratory, nurse triage, billing, and scheduling.[25] Although many of these interactions may be brief, the total HR time and costs can be substantial.

Fortner and colleagues, using numbers for Q1 2005,[25] investigated the human resource times and costs in delivering chemotherapy and ESP therapy for CIA in community oncology practices by using a practice model that had been developed to evaluate the human resource costs associated with delivering chemotherapy and managing chemotherapy-induced neutropenia.[9] This model used data from surveys of 400 medical and support staff at 20 community oncology practices in the United States and assessed professional tasks and the time to complete those tasks at medical visits. The model consists of discrete staff tasks, events (groups of related tasks), and encounters (types of medical visits) that can be strung together statistically to evaluate clinical scenarios.[9] The ESP event consisted of 14 tasks performed by 3 types of personnel, and the ESP encounter consisted of 9 events and 80 tasks. Table 2 lists the events, time, and human resource cost associated with an ESP visit.[25] The total human resource time for an encounter for CIA treatment was estimated at approximately 2 hours and a cost of $40.[25] This finding raises concern because the 2005 Medicare reimbursement for ESP administration is only $19.13.[26]

Increasing Practice Efficiency

The importance of treating CIA has been shown, but as noted previously the numerous medical visits required for ESP treatment are substantial. It seems important to give ESP treatment in a manner that has the least negative consequence for the patient, caregiver, and practice. Strategies that result in fewer ESP clinic visits would be desirable on several fronts.

One strategy to reduce the number of overall medical visits is to perform tests and procedures at the same visit whenever possible. For example, reducing the number of ESP-only visits by synchronizing the treatments with chemotherapy may translate into considerable time saved for the patient and the caregiver and lower human resource time and costs. Longer- acting ESPs such as darbepoetin alfa (Aranesp) can be given once a week or once every 3 weeks.[27,28] The ESP dosing options raise the possibility of maximizing the administration of ESP with other required medical visits and thereby reducing the overall number of medical visits required.

Such an approach may help build a more efficient oncology practice by lowering costs and maximizing production capacity. Fortner and colleagues recently described basic concepts related to costs, efficiency, and opportunity and showed the potential role of efficiency for outpatient oncology practices.[29] The basic unit of production can be defined as the delivery of an identified unit of medical care. The key rate-limiting factor for production (eg, total human resources, chemotherapy-related human resources, chemotherapy nurse time) is defined as the productivity factor. Resource expenditure is defined in terms of the amount of productivity factor (eg, physician time, nurse time) expended (ie, how much resource is expended for a unit of production). The lost production capacity when a decision is made to perform a task that has greater resource expenditure than the alternative is the opportunity cost. Opportunity costs can be reduced or increased by varying the efficiency, defined as the ratio of expenditure to production (Figure 1). Productivity can be maximized if both efficiency and capacity are maximized.

It is possible to increase gross revenue but not operating capital if efficiency is not maintained or increased. Fortner and colleagues illustrated these concepts by comparing the costs of administering carboplatin and docetaxel in 7-day cycles and in 21-day cycles (Table 3).[29] Using the conventional approach, the gross calculated operating capital with the 7-day regimen ($2,727) would seem to be preferable to that with the 21-day regimen ($1,716). However, by definition, patients treated in 7-day cycles come to the clinic three times more often than those treated in 21-day cycles. Consequently, it takes three times the chemotherapy chair time to administer 7-day regimens. The revenue productivity rate takes into account both the revenue generated by an activity and the expenditures necessary for the revenue. Treatment with 7-day cycles resulted in operating capital of $364 per chair-hour and with 21-day cycles in $660 per chair-hour. When considering the nurse time, the revenue productivity rate is $779 per nurse-hour with 7-day cycles and $1,430 per nurse-hour with 21-day cycles. Using the relative opportunity quotient, a multiplier that equates two treatment options on resource expenditure an opportunity cost of $1,011 ($2,727-$1,716) was calculated for filling chair time with a patient who is seen once a week rather than one who is seen once every 3 weeks.

A maximized model illustrating the potential benefits of a synchronized schedule of ESP treatment with chemotherapy is presented in Table 4. When considered in relation to six cycles of 21-day chemotherapy with one midcycle laboratory visit in the first cycle, considerable time savings are seen for patient caregivers and the practice when ESP treatments are less frequent and synchronized with chemotherapy visits.[25]

Discussion

Practice efficiency has many evident benefits for the patient, the caregiver, and the practice. Understanding practice costs by developing a reference table of chair and nurse time may help in identifing scenarios that perpetuate high costs. In the new era of oncology care, members of medical practices should consider implementing scenarios that can maximize and create opportunity for efficiency, such as scheduling tests and procedures to coincide as much as possible.

These efforts appear to be possible with long-acting growth factors. CIA can have serious clinical and quality-of-life consequences if not adequately treated. ESPs are effective in reducing the incidence and severity of CIA, but the frequent medical visits required for treatment are not desirable for the patient, caregiver, or practice. Less frequent dosing and synchronizing longer-acting ESP with other medical visits may minimize the burden of delivering ESP treatment. Fewer medical visits may help improve patients' quality of life and reduce their dependence on caregivers. Moreover, adopting strategies to simplify the management of CIA may have a positive effect on the use of human resources and fit into an overall practice strategy of delivering the highest quality supportive care in the most efficient manner.

Disclosures:

The author has no significant financial interest or other relationship with the manufacturers of any productsor providers of any service mentioned in this article.

References:

1. Glaspy J, Bukowski R, Steinberg D, et al: Impact of therapy with epoetin alfa on clinical outcomes in patients with nonmyeloid malignancies during cancer chemotherapy in community oncology practice. Procrit Study Group. JClin Oncol 15:1218-1234, 1997.

2. Demetri GD, Kris M, Wade J, et al: Quality-of-life benefit in chemotherapy patients treated with epoetin alfa is independent of disease response or tumor type: Results from a prospective community oncology study. Procrit Study Group. J Clin Oncol 16:3412-3425, 1998.

3. Haithcox S, Ramnes CR, Lee H, et al: The impact of frequent injections for hematopoietic growth factor support on patients receiving chemotherapy: An observational study. BMC Nurs 2:2, 2003.

4. Meehan K, Tchekmedyian S, Ciesla G, et al: The burden of weekly epoetin alfa injections to patients and their caregivers (abstract 2186). Proc Am Soc Clin Oncol 22:543, 2003.

5. Moore K, Fortner B, Okon T: The impact of medical visits on patients with cancer (abstract 73). Oncol Nurs Forum 30:128, 2003.

6. Payne S, Jarrett N, Jeffs D: The impact of travel on cancer patients' experiences of treatment: A literature review. Eur J Cancer Care(Engl) 9:197-203, 2000.

7. Lyman GH, Berndt ER, Kallich JD, et al: The economic burden of anemia in cancer patients receiving chemotherapy. Value Health 8:149-156, 2005.

8. Berndt E, Kallich J, McDermott A, et al: Reductions in anaemia and fatigue are associated with improvements in productivity in cancer patients receiving chemotherapy. Pharmacoeconomics 23:505-514, 2005.

9. Fortner BV, Okon TA, Zhu L, et al: Costs of human resources in delivering cancer chemotherapy and managing chemotherapy-induced neutropenia in community practice. Community Oncol 1:23-28, 2004.

10. Fortner BV, Tauer K, Ahu L, et al: The impact of medical visits for chemotherapy- induced anemia and neutropenia on the patient and caregiver. Community Oncol 1:211-217, 2004.

<11. Moore KA: Breast cancer patients' out-of-pocket expenses. Cancer Nurs 22:389-396, 1999.

12. Carelle N, Piotto E, Bellanger A, et al: Changing patient perceptions of the side effects of cancer chemotherapy. Cancer 95:155-163, 2002.

13. Cella D: The Functional Assessment of Cancer Therapy-Anemia (FACT-An) Scale: A new tool for the assessment of outcomes in cancer anemia and fatigue. Semin Hematol 34(3 suppl 2):13-19, 1997.

14. Kallich JD, Tchekmedyian NS, Damiano AM, et al: Psychological outcomes associated with anemia-related fatigue in cancer patients. Oncology 16(9 suppl 10):117-124, 2002.

15. Moore K: Impact of neutropenia on the patient. Point of Care Perspectives April 2002:1-4.

16. Moore K: Impact of medical visits on the patient and caregiver: Every day counts. Point of Care Perspectives July 2002:1-4.

17. Pearce S, Kelly D, Stevens W: 'More than just money'-widening the understanding of the costs involved in cancer care. J Adv Nurs 33:371-379, 2001.

18. Hinds C, Moyer A: Support as experienced by patients with cancer during radiotherapy treatments. J Adv Nurs 26:371-379, 1997.

19. Junor EJ, Macbeth FR, Barrett A: An audit of travel and waiting times for outpatient radiotherapy. Clin Oncol (R Coll Radiol) 4:174-176, 1992.

20. Goodwin JS, Hunt WC, Samet JM: Determinants of cancer therapy in elderly patients. Cancer 72:594-601, 1993.

21. Matthews BA, Baker F, Spillers RL: Oncology professionals and patient requests for cancer support services. Support Care Cancer 12:731-738, 2004.

22. Wagner L, Lacey MD: The hidden costs of cancer care: An overview with implications and referral resources for oncology nurses. Clin J Oncol Nurs 8:279-287, 2004.

23. Meehan KR, Tchekmedyian S, Smith Jr RE, et al: An activity-based costing estimate of anemia correction activities in an oncology practice (abstract 5595). Blood 100:502b, 2002.

24. Guidry UA, Sumita PD, Vega J, et al: Impact of a simple inexpensive quality assurance effort on physician's choice of thrombolytic agents and door-to-needle time: Implication for costs of management. J ThrombosisThrombolysis 5:151-157,1998.

25. Fortner BV, Miles K, Zhu L, et al: The development of a community oncology human resource (HR) cost model for chemotherapy-induced anemia (CIA). Presented at: MASCC/ISOO 16th International Symposium; June 24-27, 2004; Miami, Florida.

26. Department of Health and Human Services: Rules and regulations. Federal Register, 69:66405. Available at: http://www.cms.hhs. gov/QuarterlyProviderUpdate. Accessed May 1, 2006.

27. Vansteenkiste J, Pirker R, Massuti B, et al: Double-blind, placebo-controlled, randomized phase III trial of darbepoetin alfa in lung cancer patients receiving chemotherapy. J Natl Cancer Inst 94:1211-1220, 2002.

28. Kotasek D, Steger G, Faught W, et al: Darbepoetin alfa administered every 3 weeks alleviates anaemia in patients with solid tumours receiving chemotherapy: Results of a double-blind, placebo-controlled, randomised study. Eur J Cancer 39:2026-2034, 2003.

29. Fortner BV, Zhu L, Okon T: The new language of cancer care: Contribution to working capital, human resource costs, practice efficiency, and opportunity costs. Community Oncol 2:357-362, 2005.