Establishment of a Regional Virtual Tumor Board Program to Improve the Process of Care for Patients With Hepatocellular Carcinoma.

PURPOSE: Multidisciplinary evaluation (MDE) of hepatocellular cancer (HCC) is the current standard, often provided through a tumor board (TB) forum; this standard is limited by oncology workforce shortages and lack of a TB at every institution. Virtual TBs (VTBs) may help overcome these limitations. Our study aim was to assess the impact of a regional VTB on the MDE process for patients with HCC. METHODS: A retrospective cohort study was conducted, including patients with HCC referred to a tertiary cancer center from regional facilities (2009 to 2013). Baseline characteristics and outcomes were compared based on the referral mechanism: VTB versus subspecialty consultation (non-VTB). The primary outcome was comprehensive MDE (all required specialists present and key topics discussed). Secondary outcomes included timeliness of MDE and travel burden to complete MDE. Univariable and multivariable logistic regressions were performed to examine the association of a VTB with comprehensive MDE. RESULTS: A total of 116 patients were included in the study; 48 (41.4%) were evaluated through the VTB. A higher proportion of VTB patients received comprehensive MDE (91.7% v 64.7%; P = .001); the VTB was independently associated with higher odds of accomplishing comprehensive MDE (odds ratio, 6.0; 95% CI, 1.2 to 29.9; P = .02). VTB patients completed MDE significantly faster (median, 23 v 39 days; P < .001), with lower travel burden (median, 0 v 683 miles traveled; P < .001). CONCLUSION: This VTB program positively affected the process of care for patients with HCC by improving the quality and timeliness of the MDE process, while avoiding the burden arising from travel needs. Future studies should focus on implementation of VTB programs on a wider scale.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE: To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND: TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS: A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS: TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS: TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

The effect of a regional hepatopancreaticobiliary surgical program on clinical volume, quality of cancer care, and outcomes in the Veterans Affairs system.

IMPORTANCE: Malignant neoplasms of the hepatopancreaticobiliary (HPB) system constitute a significant public health problem worldwide. Treatment coordination for these tumors is challenging and can result in substandard care. Referral centers for HPB disease have been used as a strategy to improve postoperative outcomes, but their effect on accomplishing regionalization of care and improving quality of cancer care is not well known. OBJECTIVE: To evaluate the effect of implementing a multidisciplinary HPB surgical program (HPB-SP) on regionalization of care, the quality of cancer care, and surgical outcomes within an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: We designed a retrospective cohort study in a tertiary referral Veterans Affairs (VA) medical center within an 8-state designated VA health care region from November 23, 2005, through December 31, 2013. We compared patients with HPB tumors undergoing evaluation by the surgical oncology service before and after implementation of the HPB-SP on November 1, 2008. EXPOSURES: Implementation of the HPB-SP to improve access to specialized, multidisciplinary cancer care for veterans across the region. MAIN OUTCOMES AND MEASURES: Clinical and surgical volume, proportion of patients undergoing a comprehensive multidisciplinary evaluation, and postoperative adverse events included as a composite outcome defined by occurrence of postoperative mortality, severe complications, and/or reoperation. RESULTS: We identified 516 patients referred to the surgical oncology service. Establishment of the HPB-SP resulted in significant increases in regional referrals (17.3% vs 44.4%; P < .001), median monthly clinic visits (5 vs 20; P < .001), and median number of HPB surgical procedures (3 vs 9; P = .003) per quarter. Multidisciplinary assessment increased from 52.6% to 70.0% (P < .001). When we compared patients with hepatocellular carcinoma before (n = 55) and after (n = 131) implementation, more patients received any treatment (35 [63.6%] vs 109 [83.2%]; P = .004) with increased use of liver resection (0 vs 20 [15.3%]; P = .002), percutaneous ablation (0 vs 15 [11.5%]; P = .009), and oncosurgical strategies (0 vs 16 [12.2%]; P = .007) after implementation. Among patients with colorectal liver metastases (29 before vs 76 after implementation), a significant shift occurred from use of ablations (5 [17.2%] vs 3 [3.9]%; P = .02) to resections (6 [20.7%] vs 40 [52.6%]; P = .003), and use of perioperative chemotherapy increased (5 of 11 [45.5%] vs 33 of 43 [76.7%]; P = .01). The HPB-SP was associated with lower odds of postoperative adverse events, even after adjusting for important covariates (odds ratio, 0.29 [95% CI, 0.12-0.68]; P = .005), and a high rate of margin-negative liver (94.6%) and pancreatic (90.0%) resections. CONCLUSIONS AND RELEVANCE: The development of an HPB-SP led to regionalization of care and improved quality of cancer care and surgical outcomes. Establishment of regional programs within the VA system can help improve the quality of care for patients presenting with complex cancers requiring subspecialized care.