As a result of advancements in oncological therapies, patients now have a longer life expectancy. However, a higher life expectancy is not equivalent to better Quality of Life (QoL).
With this in mind, the Lung Cancer Department at AZ Delta, led by Professor Dr. Ingel Demedts, aimed for a more mutldisciplinary approach for lung cancer care patients. They aimed for care was focused on improving patient outcomes while keeping an eye on efficiency and cost. Their department aimed to provide value-based healthcare to their patients.
They chose to implement this vision with Awell Health in the form of an integrated digital lung cancer pathway which went live in 2018.
In November 2021, the extraordinary results of this vision were published in the Lung Cancer Journal. They showcase that treating lung cancer patients within a digital care pathway leads to longer survival, fewer emergency visits and reduced length of stay in the day clinic.
Professor dr. Ingel Demedts and his team are a true example of Value-Based Healthcare in practice. The days of theory are long gone, this proves it’s prime time for VBHC.
In May 2022 we invited Professor Demedts to share best practices and lessons learned wile implement the digital care pathway in our masterclass. The gist of this conversation is written in the article below.
Each year lung cancer departments in Belgium receive a report from the government on the survival rate from their lung cancer patients. This data is than compared with other hospital. Despite ranking among the top three Belgian hospitals and having a high one-year survival rate, the team was not satisfied. Because, as discussed earlier, higher survival rates are not equal to better quality of care.
Professor Demedts and his team were frustrated with a few things, such as:
- They had no information on the Qualit of Life (QoL) of their patients
- They had no idea on which quality indicators they should measure if they wanted to measure quality of care
- They had low to none patient empowerment
- Patients lacked early supportive, palliative care
- There was no involvement from the general practitioner (GPs) during the cancer treatment
All of these motivated professor and his team to do better. To change their current way of working. The question was: what
So the question was not whether they wanted to change, it was how to change. This became clear at the ASCO conference in 2016, were Eaton Bash presented a study that demonstrated that when you use digital monitoring of Patient-Reported Outcomes (PROs) patients live longer than when you don’t do it. Arround that same time a systematic review, focused on lung cancer patients, showed similar results.
So, with those incentives in mind, the team decided to develop a transmural care pathway for lung cancer patients together with Awell Health.
One of the biggest challenges while developing the care pathway was determining which outcomes they wanted to measure. As a care team you could track various outcomes, but it’s critical that the outcomes that you track are relevant and comparable to colleagues in other hospitals.
After some research, we decided to use the Lung Cancer standard set from the International Consortium of Health Outcomes Measurement (ICHOM) which includes a set of indicatiors that you need to collect if you want to monitor the quality of care for lung cancer patients. This standard set is established by a group of lung cancer specialists and patients, besides lung cancer ICHOM also has standard sets for advanced prostate cancer, heart failure, low back pain and many other (chronic) diseases.
We used this standard set as a basis to develop the care pathway further. For instance, the red dot in the image indicates the beginning of the patient’s journey. At this point, one should collect mixed variables, including tumor type, comorbidity, performance status of the patient’s educational levels, and smoking habits. And then collect PROMs at three months at six months, and at one year, and then every year thereafter.
While the ICHOM standard set is a great basis to start with, we decided to not follow the standard set entirely. While the standard set proposes that you collect PROMs at three months, six months, at one year and then every year thereafter we decided to use PROMs more frequently. During treatment patients would receive a weekly PROM questionnaire to actively follow up on (potential) complications. Besides that, patient would also receive the EORTC QLQ C-30 (= general cancer PROM questionnaire) and the EORTC QLQ-LC13 (= specific lung cancer PROM questionnaire) every six weeks.
Adding Feedback Loops to The Care Pathway
Once you start using PROMs in clinical practice, it’s crucial to add feedback loops into your care delivery process. Because if you ask your patients to fill in long PROM questionnaires every week, but you don’t give any feedback, patients will feel that what they fill in is not used byy the clinical team. As a result they will stop filling in the PROM questionnaires and this was something that we wanted to prevent.
That’s why we decided to add multiple feedback loops to the care pathway. Some examples:
- If the patient loses weight, an alert is send to the nutritionist and she will contact the patient to discuss the patient’s nutrition plan
- If the patient reports a complication, an information brochure is send to the patient with tips to reduce those complications. In addition, the oncoloy nurse is alerted and will contact the patient to ask how they are doing
- If the patient reports that they have financial problems, an alert is send to the social work who will contact the patient to discuss this further
These are just three examples of feedback loops in the care pathway, the list goes on and on.
The crucial part is that patients need to feel valued for their time filling out the PROM questionnaires and this should be done by adding feedback loops. These feedback loops need to involve the multidisciplinary team that helps the patients in all aspects of their life. It’s not just the physician or the nurse that needs those feedback loops. It’s really everyone.
Because of these feedback loops, we managed to achieve of PROMs compliance of 93% (read this article if you want to achieve similar companice rates). So these feedback loops empowers the patients, increases compliance rates and helps you the your journey to provide value-based care.
The impact of the digital care pathway on patient outcomes
As mentioned earlier, in 2021 the impact of the digital care pathway on patient outcomes were published in the Lung Cancer Journal. They showcased following results:
- 221 lung cancer patients were included in the care pathway
- 3091 weekly questionnaires were digitally collected. Compliance with the weekly digital follow-uo was 92% (2835 of 3091 were completed)
- Patients in the care pathway had significantly less emergency room visits (3.5% vs 4.8%, p 0.04) and a shorter length of stay at the day clinic (2.5h vs 4.1, p < 0,05) compared to routine clinical care.
- In stage IV lung cancer patients, overall survival rate was significantly higher in the care pathway (447 days) compared to routine care (287 days)
Besides, we also collected data on what patients themselves thought of the system:
As you can see, the majority of the patients found that the questions were easy to understand, that the system was easy to use, and the questions were relevant. They also found that the system improved discussions with the doctor or the nurse and most importantly that 90% of the patients would recommend the system to others.
How to get started?
You're reading this and probably wondering: okay interesting but how can I achieve similar results? In his masterclass, professor Demedts discussed lots of things. You have PROMs, feedback loops, taking a multidisciplinary approach… The conclusion of this implementation is that you can think big but you better start small. Don’t aim to implement a care pathway that covers multiple treatment types in one big bang. Start with one treatment type, learn from this implementation and adapt your process.
The lung cancer care pathway changed many times since we started in 2017 and we’re still doing evaluations and changes all the time. A care pathway is never finished. But really: never. Treatments are changing, new research is coming in, you’re collecting data that will provide you with insights… You need to create a continuously loop off improvements to make this work. So just do it. Start collecting those PROMs you were planning to collect 6 months ago. Start building a first version of a care pathway that is already in your head for multiple years. Jump. Go and improve patient outcomes.
And when you do, don’t forget that change management is an important part of the puzzle. Because implementing a care pathway in clinical practice will have an impact on your current way of working. But don’t be scared from this change, implementing a care pathway is what we call good change. It will change the life of many patients. It will impact many families. It will impact our healthcare system as a whole.
Healthcare organizations face multiple challenges in offering quality care to lung cancer patients. While advancements in treatment options have improved their survival, quality of care is an important challenge to tackle.
The above issues can be tackled through a digital care pathway. Digital monitoring and feedback loop improves compliance and survival rate and reduces emergency department visits.
If you want to start delivering better care for your patients, schedule a call with one of our experts and start improving patient outcomes in days.