After introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly, with no compromise in survival. In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of clinical pathways may provide a means to coalesce and disseminate institutional expertise and track and learn from care decisions.

Policy Points:r The perioperative surgical home (PSH) is complementary to the patient-centered medical home (PCMH) and defines methods for improving the patient experience and clinical outcomes, and controlling costs for the care of surgical patients.r The PSH is a physician-led care delivery model that includes multispecialty care teams and cost-efficient use of resources at all levels through a patient-centered, continuity of care delivery model with shared decision making.r The PSH emphasizes "prehabilitation" of the patient before surgery, intraoperative optimization, improved return to function through follow-up, and effective transitions to home or post-acute care to reduce complications and readmissions. Context:The evolving concept of more rigorously coordinated and integrated perioperative management, often referred to as the perioperative surgical home (PSH), parallels the well-known concept of a patient-centered medical home (PCMH), as they share a vision of improved clinical outcomes and reductions in cost of care through patient engagement and care coordination. Elements of the PSH and similar surgical care coordination models have been studied in the United States and other countries. 796The Perioperative Surgical Home 797 results of studies of PSH elements in the United States and in other countries. We reviewed more than 250 potentially relevant studies. At the conclusion of the selection process, our search had yielded a total of 152 peer-reviewed articles published between 1980 and 2013. Findings:The literature reports consistent and significant positive findings related to PSH initiatives. Both US and non-US studies stress the role of anesthesiologists in perioperative patient management. The PSH may have the greatest impact on preparing patients for surgery and ensuring their safe and effective transition to home or other postoperative rehabilitation. There appear to be some subtle differences between US and non-US research on the PSH. The literature in non-US settings seems to focus strictly on the comparison of outcomes from changing policies or practices, whereas US research seems to be more focused on the discovery of innovative practice models and other less direct changes, for example, information technology, that may be contributing to the evolution toward the PSH model. Conclusions:The PSH model may have significant implications for policymakers, payers, administrators, clinicians, and patients. The potential for policy-relevant cost savings and quality improvement is apparent across the perioperative continuum of care, especially for integrated care organizations, bundled payment, and value-based purchasing.

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US cancer care costs totaled $80.2 billion in 2015 and are expected to grow to $206 billion by 2020. Simultaneously, novel payment programs such as the Oncology Care Model are focused on reimbursing for episodes of care rather than discrete treatments, leaving health care organizations to figure out how to cost-effectively address diverse patient needs during episodes of cancer treatment. Progression of disease, treatment complications, and end of life (particularly among patients with low socioeconomic status) are known to be linked to greater health care use among patients with cancer.Increasing evidence now suggests an association between underlying comorbidities and health care utilization among cancer patients. Among elderly patients with gastrointestinal cancer, the presence of comorbidities is associated with unplanned hospitalization. 1 Patients with higher levels of comorbidity are less likely to receive standard cancer treatments, have higher postoperative complication rates, and have lower chances of completing appropriate cancer treatment courses. 2 Analysis of data from our own institution, Dana-Farber Cancer Institute, supports the association between comorbidities and health care utilization. In our commercially insured population, heart failure and chronic obstructive pulmonary disease had the strongest associations with emergency department use and hospital readmission, with depression, diabetes, and renal failure exhibiting significant but lesser associations. 3 While perhaps underscoring an intuitive link, these findings highlight opportunities for action in a cancer care landscape characterized by an increasing prevalence of chronic disease as cancer patients survive longer. Given the traditional role and expertise of primary care physicians (PCPs) in treating and managing chronic, noncommunicable disease over the long term, these findings also suggest a ripe opportunity for tighter links between primary and oncology care.As noted in a case study from the National Cancer Institute and the American Society of Clinical Oncology, lack of coordination between PCPs and oncologists during cancer treatment can lead to exacerbation of chronic conditions such as heart failure and diabetes, with risk for decompensation. 4 Yet there are known barriers to collaboration between primary care and oncology once a patient has been diagnosed with cancer. These barriers include specialist-driven models of care, uncertainty among oncologists and PCPs of PCPs' knowledge or appropriate contributions, and discordance among expectations regarding roles. Many patients lose touch with their PCP during cancer treatment, with oncologists often serving as de facto PCPs during the course of cancer treatment.

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In-hospital deaths are common among commercially insured cancer patients. Patients with hematologic malignancy and patients who die without receiving hospice services have a substantially higher incidence of in-hospital death.

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35 Background: A majority of patients with poor-prognosis cancer express a preference for in-home death, however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death among commercially-insured decedents. Methods: Building on a data-sharing project between our institution and Blue Cross/Blue Shield of MA, we obtained health care claims records for a sample of commercially insured decedents who died between July 2010 and December 2013. All patients received cancer care at Dana-Farber. In-hospital vs. out-of-hospital death was ascertained from hospital claims. Odds ratios (OR) and 95% confidence intervals (CI) were used to evaluate the association of in-hospital death with patient characteristics and established retrospective measures of end-of-life (EOL) care quality. Results: 904 commercially insured decedents were included in our sample, and 537 decedents (59%) enrolled in hospice prior to death. There were 254 in-hospital deaths (28% of all deaths), and 79 in-hospital deaths (31%) occurred at unaffiliated hospitals. Three measures of EOL care quality were found to be associated with in-hospital death, including chemotherapy within 14 days (OR 4.0 [95% CI 2.6-6.2]) or 15-30 days (OR 2.1 [1.4-3.1]) of death, 2 or more ED visits within the last 30 days of life (OR 3.0 [2.1-4.3]), and non-enrollment in hospice (OR 28.8 [18.7-44.3]). Hematologic malignancy, but not other cancer types, was significantly associated with in-hospital death (OR 5.09 [3.1-8.5]). Age at death, sex, marital status, race/ethnicity, and distance of residence from the cancer center were not significantly associated with in-hospital death, though sample sizes for some comparison groups were small. Conclusions: In-hospital deaths are common among commercially insured cancer patients, and data sharing identified nearly 1/3 of in-hospital deaths that occurred at unaffiliated hospitals. Retrospective measures of intensive EOL care quality were significantly associated with in-hospital death, and patients enrolled in hospice were dramatically less likely to experience an in-hospital death.