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Sep 19, 2019

Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Ethan Basch. He holds several professional titles at the University of North Carolina at Chapel Hill, including Distinguished Professor of Oncology and Director of the Cancer Outcomes Research Program. Dr. Basch is a member of ASCO's board of directors and recently served as the program chair of the ASCO Quality Cancer Symposium. Dr. Basch, welcome to the podcast.

Thanks so much. Nice to be here.

We're glad you're here. So you've just returned from the conference. How was this year's event compared with previous years?

This year's event was a great success. Similar to prior years, the conference focused on quality of care delivery. But increasingly, we have seen a move towards research and practical presentations around value-based care and alternative payment models. I would say that what was particularly successful this year was the bringing together quality activities in the community with academic research that is being conducted by health services research.

Increasingly, we've been seeing that community-based quality initiatives are beginning to use more rigorous scientific methods and similarly that academic research is becoming more practical and community-based. And this conference really shows the marriage of the two at this moment in oncology.

That's great. So which presentations or abstracts did you find the most compelling or practice-changing?

There were so many terrific abstracts this year, we had a very difficult time choosing the oral abstracts for the meeting. And we had more than 500 submissions of scientific abstracts for the meeting. I thought I would go over three of the abstracts that I found particularly exciting and that I think reflected some of the overall themes of the meeting.

The first was from Kerin Adelson, who's a medical oncologist and a quality officer at Yale Cancer Center. And Yale is one of the participating sites in the Oncology Care Model, which is the Medicare Innovation Center's demonstration project for an alternative payment model in oncology. And they've been participating over the past several years implementing a number of value-based care initiatives to try and reduce costs and improve quality.

This has included broadening their care coordination and navigation services, providing an alternative pathway to the ER to an acute care center, providing access to providers 24/7 with access to the electronic health record, and several other patient-oriented initiatives.

And over time, they've looked at the impact of these initiatives on their total cost of care. And they've broken it down into different categories. And at the meeting this year, Dr. Adelson presented what's happened specifically to the cost of emergency room and hospital utilization, as well as pharmaceuticals.

And what they found at Yale is that as they progressively implemented these value-based programs, they also progressively decreased the amount of emergency room and hospital utilization quite substantially and significantly, yielding a decrease in cost.
However, simultaneously, the cost of drugs increased as we all in oncology are acutely aware of. In fact, the cost of pharmaceuticals went up by about 9% per year. So while they very substantially drove down the costs of emergency room visits and hospitalization, they were barely able to keep up with the rising costs of pharmaceuticals.

The second abstract, I think, of particular interest also relates to the cost of drugs. This was a presentation by Bernardo Goulart from Scott Ramsey's group at Fred Hutch Cancer Research Center in Seattle. They are particularly interested in the relationships between the costs of drugs and adherence and other outcomes.
Now, previously, there have been several studies published by investigators like Stacy Dusetzina at Vanderbilt showing that as the incremental out-of-pocket costs of drugs goes up that adherence with drugs goes down, i.e. the more that people have to pay out of pocket, the less they take their drugs. And drugs that this has been particularly shown for are oral tyrosine kinase ACE inhibitors. And this has been looked at in a number of different diseases.
In this particular study, Dr. Goulart and colleagues looked at the relationship between higher patient out-of-pocket TKI costs and both adherence to drugs, but also overall survival. And consistent with prior studies, they found that greater out-of-pocket costs were again associated with lower adherence. But in this case, they added on the overall survival metric and found that in fact, higher out-of-pocket costs were associated with worse survival.

This is important information as we as a country think about how out-of-pocket costs are structured within benefits programs, that in fact, there is a vigorous debate in Washington currently around Medicare Part D and patient out-of-pocket obligations. And this study provides additional evidence that the greater burden our patients face in terms of their financial toxicity from their out-of-pocket costs, the worse their outcomes are going to be.
The third abstract that I would like to highlight is by Erin Elizabeth Hahn from Kaiser Permanente Southern California. This study is on a slightly different tack. This is around implementation of distress screening and patient-reported outcomes in clinical practice.
Now, many listeners may know that patient-reported outcomes is an area of particular interest to me, but also to many of us who are involved in value-based care because previously, implementation of patient-reported outcomes in clinical practice has been shown to drive down ER visits and hospitalization, to lengthen the amount of time people can tolerate chemotherapy to improve health-related quality of life and to improve overall survival.

But one of the challenges around distress screening and patient-reported reported outcomes has been implementation because it is simply difficult logistically to implement collection of information from patients about their symptoms and functioning during routine practice, which is already crowded with all sorts of things that we need to do.

So in this study they employed a pragmatic clinical trial design and did a randomized study of using cutting edge implementation science and quality improvement methods to roll out patient-reported outcomes in practice. And they did this in their very large practice. And what they found was that when they used QI principles and implementation science to roll out patient-reported outcomes and distress screening, they had very successful uptake.
In fact, 94% of patients who were in the arm that used cutting edge implementation science and QI approaches completed their distress screening and patient-reported outcomes, which was significantly and substantially higher than the arm in control that did not use those approaches.

This suggests that for any health system or practice that wants to implement patient-reported outcomes or distress screening and be successful at it really should use our standard QI processes that iteratively work with providers and in this case with patients to make sure that there's understanding, training, uptake, and sustainability.

That's great. It sounds like great strides are really being made in value-based care. Were there any other takeaways that you saw as important during the conference?

Well, I think that overall across the conference, we saw a lot of enthusiasm around the kind of value-based care initiatives that are reflected by these three abstracts. There's a lot of activity across the country, and also, I should note in Canada because there's a very substantial Canadian representation, to try to build in some of these value-based care approaches and figure out how best to implement them and to try to understand better their impact on costs and utilization.

That's great. Again, today, my guest has been Dr. Ethan Basch. Thanks so much for joining us again on our podcast.

Thanks so much. Pleasure to be here.

And to our listeners, thank you for tuning into the ASCO Daily News podcast. You can find all of our podcasts on If you're enjoying the content, we encourage you to rate and review us on Apple podcast.
The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.