Barriers to clinical practice guidelines adherence in the community oncology setting.

Shah, Lopa; Carino, Tanisha; Hanger, Morgan; Barnes, Lara-Marie; Weinstein, Alyona

doi:10.1200/jco.2011.29.15_suppl.e19687

Cited by 4 publications

(3 citation statements)

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“…25,26 However, given the inherent heterogeneity among patients, flexible guidelines that are able to accommodate patient heterogeneity are needed. 27,28 Using statistical learning, we estimated that, if the principal clinical objective is to maximize the patient's hand strength, patients whose injury involves a single finger should be treated with revision amputation, and patients with other injury characteristics may be appropriately treated with replantation. This outcome may be most important for individuals employed in construction trades or childcare, for example.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

et al. 2020

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IMPORTANCE Optimal treatment for traumatic finger amputation is unknown to date. OBJECTIVE To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. DESIGN, SETTING, AND PARTICIPANTS This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. EXPOSURES Treatment with revision amputation or replantation. MAIN OUTCOMES AND MEASURES Outcome measures were hand strength, dexterity, handrelated quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. RESULTS Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. CONCLUSIONS AND RELEVANCE The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.

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Section: Discussionmentioning

confidence: 99%

“…Clinical practice guidelines that incorporate evidence-based medicine exist in all areas of medicine and improve patient care and lower health care costs . However, given the inherent heterogeneity among patients, flexible guidelines that are able to accommodate patient heterogeneity are needed …”

Section: Discussionmentioning

confidence: 99%

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

et al. 2020

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“…Most practicing oncologists acknowledge being aware of these standards, with recent data generated by the Association of Community Cancer Centers reporting that 80% to 96% of practicing oncologists endorse following the guidelines most of the time. 7,8 Of course, some barriers continue to exist to the widespread adoption of clinical practice guidelines. 9,10 Even so, concern regarding variability in evidence-based care is clearly manifest within the oncology community, with notable examples including the development of the Quality Oncology Practice Initiative 11 by ASCO and explicitly in the naming of the annual NCCN meeting: "Clinical Practice Guidelines & Quality Cancer Care."…”

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confidence: 99%

Improving Quality and Addressing the Rising Costs of Cancer Care: Two Birds, One Stone

Luke

Mirkin

2011

JOP

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Many health care analysts and oncology professionals have begun to question the long-term viability of medical oncology given the rising costs associated with cancer care. 1,2 Cancer care, based on per-person costs, has been described as the most expensive area of health care, 3 constituting approximately 5% of total health care spending. 4 Thus, while the costs associated with cancer can be, and often are, quite high, the benefit of that spending is limited to only a fraction of the population.We recently published a proposal 5 that could provide a framework for a Medicare pilot program in an attempt to improve the quality of cancer care while addressing the major cost drivers in the practice of medical oncology. We described a rational way to link clinical practice to evidence-based guidelines and at the same time realign practitioner incentives such that spending on drugs could be lowered incrementally by using a market-based approach. Further, we proposed that our approach could be executed through Medicare in a manner that would not radically alter physician practice economics and would allow for adequate monitoring of best practices and outcomes.Before discussion of the specifics of our proposal, it is important to note that the practice of medical oncology has two important characteristics that are central to the development of our model. These include published standards of care for the treatment of the most common cancers, by multiple professional societies, as well as readily defined treatment periods that could serve as the "episodes" of care. Given this, it is possible to generate a list of treatment options that could be considered to be appropriate for the vast majority of patients with a specific diagnosis, as well as allow for a way to break down ongoing therapy into manageable blocks from a reimbursement standpoint.With these factors in mind, we have proposed an episodebased reimbursement approach in which Medicare would deliver a set reimbursement to providers (or provider networks) to pay for a period of care (eg, 1 month or 3 months) for a particular patient with a defined condition (such as metastatic lung or colon cancer).As an example of our model, consider the case of non-smallcell lung cancer (NSCLC). There are currently eight combinations of chemotherapeutics that are recommended as first-line treatment for this disease, according to the National Comprehensive Cancer Network (NCCN) and a number of other practice guidelines. The costs of these regimens (with administrative and supportive care fees) to Medicare vary quite substantially, however, from approximately $1,292 to $7,092 per month. If these regimens are largely interchangeable and of similar efficacy, an episode-based payment framework could result in savings without harming quality.For instance, imagine if the rate of reimbursement for a 1-month episode of treatment of NSCLC were set at $4,000 per month, and that payment was intended to support the costs of the chemotherapy, supportive care, and drug administration. This would ...

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An Analysis of the Evidence Informing Clinical Practice Guidelines in the Management and Treatment of Breast Cancer

Snider

Moore

Walters

et al. 2022

Clinical Breast Cancer

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Barriers to clinical practice guidelines adherence in the community oncology setting.

Cited by 4 publications

References 0 publications

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

Improving Quality and Addressing the Rising Costs of Cancer Care: Two Birds, One Stone

An Analysis of the Evidence Informing Clinical Practice Guidelines in the Management and Treatment of Breast Cancer

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