The application of evidence-based care by oncologists was enhanced through participation in a project with serial simulations of patients with metastatic lung cancer and early-stage breast cancer. The findings of this study were recently published in the Journal of Oncology Practice.
To improve the quality of care in the oncology setting, efforts to reduce variation in clinical practice have been employed to make cancer care more consistent. This research utilized serial patient simulations, or clinical and performance vignettes (CPVs), to evaluate the physician’s clinical decision making for advanced lung cancer and early-stage breast cancer patients.
Background of the Oncology Research
103 oncologists with experience in treating patients with solid tumor cancers were recruited from a large clinically integrated network for this study. Each agreed to participate in two simulated patient platforms that were administered every 4 months for one year between 2016 and 2017. In total, 12 different patient cases were randomly assigned to a participant for each round of the study, six cases of early-stage breast cancer and six cases of advanced lung cancer. Each case required six hours to complete.
The web-based CPVs used in this study were used to analyze the oncologists’ decisions in areas such as history taking, ordering of diagnostic tests, physical exams, diagnoses, treatment plans, and follow-up recommendations. Their responses were submitted in an open-ended format and were given a percentage score by trained physician abstractors.
The participating oncologists received feedback on each case through “an overall quality score, benchmarked peer performance … quality improvement opportunities, relevant guideline references, and a detailed list, with costs, of unnecessary tests ordered.” Participation in telebroadcast discussions that focused on prominent areas of clinical variation was offered to the oncologists in the study as well.
Results of the Study
Baseline data revealed that the participants had an average age of 51.9 years, an average of 18 years in practice and that 90% of them see over 40 patients per week. Response data from the first CPV case regarding the workup of early-stage breast cancer were validated due to strong agreement with real-world clinical practice patterns.
Responses to the first CPV simulation indicated high variability across participants, with the average CPV quality scores being 61.5% overall and 48.7% for the treatment domain. A comparison of response results for the first and final two CPV cases showed an overall increase in CPV quality score of 10.7% (P <.001) and 12.9% (P <.001) for breast and lung cancer cases, respectively.
The inclusion of palliative care in the simulated patient’s care plan, specifically, increased from 39.6% at baseline to 61.6% at the end of the study (P <.001). This is a particularly relevant treatment approach for patients with metastatic lung cancer. It was also found that palliative care and end-of-life needs were not considered in roughly 40% of the simulated cases that they could have applied to.
This study also found that the prescribing of programmed cell death-ligand 1 (PD-L1) treatments in metastatic lung cancer patients increased significantly after the inclusion of this recommendation in the National Comprehensive Cancer Network (NCCN) guidelines while the study was underway.
“These data show a clear and significant (P <.001) gradient in tumor PD-L1 testing, which demonstrates a quick, but not complete, adoption rate in the 5 months after the release of the guidelines,” the authors noted.
The researchers note that their results still indicated a need for additional education, with responses in favor of tumor PD-L1 testing being 67.3% at the end of the sixth simulated patient case. In cases of asymptomatic early-stage breast cancer, the ordering of a metastatic work-up decreased from the baseline 31.5% to 21.1% at the end of the study, coinciding with significant cost implications.
Limitations of this study include the lack of a control group and the limited amount of real-world data available for comparison to the simulated cases, as per the study’s authors.
“This study shows that patient simulations are a valid measure of practice patterns in oncology that, when administered serially with individual and group feedback, lead to more evidence-based, cost-effective care,” they concluded.
Patient Simulation Project in Lung, Breast Cancers Points to Improvements in Quality of Care https://t.co/cHfEbXlGr7
— Darcy Burbage, DNP, RN, AOCN (@DarcyBurbage) October 30, 2019