Oncologists' Views on Using Value to Guide Cancer Treatment Decisions.

OBJECTIVES: Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care. METHODS: We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis. RESULTS: Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community. CONCLUSIONS: Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare.

Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation.

BACKGROUND: The Veterans Choice Program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope. OBJECTIVES: We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns. RESEARCH DESIGN: We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015). SUBJECTS: Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues. RESULTS: In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care. CONCLUSIONS: There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

What do public housing residents say about their health?

BACKGROUND: Residents of public housing have poorer health indicators than comparably resourced individuals from the larger community. OBJECTIVES: To identify major health concerns, issues, and barriers to health of community members living in public housing developments, especially as related to cardiovascular disease prevention. To identify similarities and differences between data collected using two methods to inform future health promotion programs and policies. METHODS: Key informant interviews were conducted with resident leaders and analyzed qualitatively in eight housing developments. Results were compared with quantitative data collected from a resident health survey with a large sample that analyzed individual and development-level characteristics, major health concerns, and barriers. RESULTS: Several development-level characteristics were significantly associated with residents' health concerns and barriers, including development size, percentage of Spanish speakers, and presence of a tenant task force (TTF); important health promotion barriers included lack of resident engagement, inconsistency in programming, lack of knowledge of actions to prevent chronic disease, and lack of resources for health promotion. Safety-related health concerns were named as a priority. CONCLUSIONS: Multiple data collection methods can yield important data about community health priorities and barriers; areas of difference and similarity between methods are especially useful in guiding health promotion efforts and opportunities.

Connecting Boston's public housing developments to community health centers: who's ready for change?

BACKGROUND: Despite close proximity to community health centers, public housing residents are at increased risk of uncontrolled chronic disease, in part because of underutilization of routine health care. OBJECTIVES: To assist in program planning, the Partners in Health and Housing Prevention Research Center (PHH-PRC) used the Community Readiness Model to compare readiness of public housing developments and community health centers to address community-identified health priorities. The model assumes that program success to affect change depends on matching the community's level of readiness to address the issue. METHODS: Key respondent interviews were conducted across 15 communities: Eight housing developments and seven health centers. Interviews were scored across six dimensions on an anchored, 9-point scale and averaged to provide a composite readiness score. Higher scores indicate increasing levels of readiness. Interview transcripts were reviewed for consistent themes. RESULTS: Health centers scored significantly higher (mean, 5.88) than housing developments (mean, 3.33), corresponding with the Preparation stage of readiness compared with the Vague Awareness stage, respectively. Both scored highest in Existing Programs and Resources and lowest in Knowledge of Efforts. Qualitative analysis revealed a lack of existing partnerships between housing developments and health centers as well as significant social barriers preventing housing residents from engaging in care. CONCLUSION: We found a mismatch in readiness to address community health priorities. Although health centers have programs to address health issues, community awareness of programs is limited and barriers to engaging in care persist. The model provided a useful tool for engaging communities into shared program planning.

Feasibility of chronic disease patient navigation in an urban primary care practice.

The purpose of this study was to evaluate the feasibility of incorporating chronic disease navigation using lay health care workers trained in motivational interviewing (MI) into an existing mammography navigation program. Primary-care patient navigators implemented MI-based telephone conversations around mammography, smoking, depression, and obesity. We conducted a small-scale demonstration, using mixed methods to assess patient outcomes and provider satisfaction. One hundred nine patients participated. Ninety-four percent scheduled and 73% completed a mammography appointment. Seventy-one percent agreed to schedule a primary care appointment and 54% completed that appointment. Patients and providers responded positively. Incorporating telephone-based chronic disease navigation supported by MI into existing disease-specific navigation is efficacious and acceptable to those enrolled.

Assessing the impact of patient navigation: prevention and early detection metrics.

BACKGROUND: The lack of comparable metrics to evaluate prevention and early detection patient navigation programs impeded the ability to identify best practices. METHODS: The Prevention and Early Detection Workgroup of the Patient Navigation Leadership Summit was charged with making recommendations for common clinical metrics specific to the prevention and early detection phase of the cancer care continuum. The workgroup began with a review of existing literature to characterize variability in published navigation metrics; then developed a list of priority recommendations that would be applicable to the range of navigation settings (clinical, academic, or community-based). RESULTS: Recommendations for researchers and program evaluators included the following: 1) Clearly document key program characteristics; 2) Use a set of core data elements to form the basis of your reported metrics; and 3) Prioritize data collection using methods with the least amount of bias. CONCLUSIONS: If navigation programs explicitly state the context of their evaluation and choose from among the common set of data elements, meaningful comparisons among existing programs should be feasible.