Continuing medical education initiatives can improve patient care, change physician practice behavior, and reduce costs. But to achieve these goals, CME providers need to look outside the traditional models. A case in point is the Buffalo Niagara Prostate Cancer Consortium in New York.
For men who have prostate cancer, there are multiple treatment options available. The problem is that the treatment recommendations patients receive vary considerably, often depending on the type of specialist they consult. So what can be done to address that problem?
When Michael R. Kuettel, MD, PhD, arrived at Roswell Park Cancer Institute, Buffalo, N.Y., as chief of radiation medicine, he developed the idea of a consortium/peer review concept that would incorporate community physicians, academic centers, and patient advocates. He sent out invitations to all physicians involved in the treatment of prostate cancer in the western New York area to attend a retreat to discuss prostate cancer detection, work-up, treatment, and follow-up. The result was the creation of the BNPCC, which brings together community urologists; radiation oncologists; patient advocates from Us Too!, an international patient support and advocacy group; and representatives from academic institutions, healthcare organizations, and insurance carriers. Patients can have their cases go through a peer-review process by these members. By bringing together the various disciplines at one table, the general biases associated with each of the disciplines are overcome.
How It Works
After a patient sees his own urologist, he usually sees Kuettel for an additional consultation. The patient's information is then presented anonymously to the group during multidisciplinary consortium meetings that take place twice a month. Each session is certified for one hour of AMA Category 1 credit.
The consortium reviews the patient's case, then informs the patient of the proposed treatment recommendations by phone within 24 hours, and also notifies the patient's urologist and primary care physician. The patient, urologist, and primary care physician then discuss the treatment recommendations and decide which one to implement.
All consortium members receive minutes of the peer-review meetings. In addition, the consortium has developed relationships with experts around the country. The M.D. Anderson Cancer Center in Houston does peer reviews of medical physics and radiation oncology. Washington University Medical Center (Medical Physics) in St. Louis performs a post-plan digital data peer review (a process whereby treatment plans are sent electronically to other institutions for review), and the Radiation Therapy Oncology Group in Philadelphia reviews both clinical and physics data and serves as the operations and statistical center.
All pathology is re-reviewed by pathologists who are proficient in evaluating prostate morphology. If they make any changes to the original pathology report after examining a patient's biopsy, the pathology is reviewed again by a panel of three pathologists from Roswell Park Cancer Institute. The BNPCC sends a percentage of pathology specimens to be reviewed by other experts in the United States.
It Gets Results
As experts in outcome measurements advise, CME providers need to decide the results they want before designing activities. The specialists who spearheaded the prostate cancer initiative did just that. Before developing their program, they decided there was a need to create a consortium to
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enhance prostate cancer screening and diagnosis;
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standardize prostate cancer treatment and recommendations;
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follow National Comprehensive Cancer Network (NCCN) guidelines for patient work-up, treatment recommendations, follow-up, and testing;
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offer eligible patients the choice of entering clinical trials;
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track and publish patient outcomes;
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and work with local insurance carriers to improve quality, while containing costs.
The BNPCC also developed a system for measuring the outcomes and benefits. The group tracks more than 250 variables for each patient and has reviewed more than 600 patient cases since January 2001. The consortium has noted immediate changes in physician practice, including the following:
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Approximately 70 percent of all eligible patients have been entered into NIH/NCI-sponsored clinical trials.
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The use of computed tomography and bone scans for low-risk patients, and the overall use of hormone therapy, were reduced as follows (figures are from the first nine months of operation):
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73 percent reduction in the use of unnecessary CTs,
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93 percent reduction in the use of unnecessary bone scans,
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39 percent reduction in use of hormone therapy.
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Ten percent of the reviewed pathology required reclassification of the Gleason score, used to measure the aggressiveness of the cancer, resulting in a change of treatment recommendations. Another six patients had their prostate cancer diagnosis reversed — they were found not to have prostate cancer at all.
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Favorable economics, including higher reimbursement rates and rising referrals from non-consortium sources.
Why It Works
This approach has been successful for several reasons. Patients can seek out the BNPCC on their own, or they can be referred by their urologist or primary care physician. There is no charge to the patient — insurance companies pay for the cost of the consult. This process also allows patients and their physicians the opportunity to discuss treatment recommendations together so the patient can make an informed treatment decision.
From the physician's standpoint, previously existing biases are eliminated when they agree to follow the NCCN guidelines for patient work-up, treatment recommendations, follow-up, and testing. The participating physicians did not perceive this consortium as a threat because patients were always referred back to their own physician. That “trust factor” is what has allowed this consortium to attract new members in an ever-expanding geographical region. The AMA Category 1 credit was just an added incentive to encourage participation.
Insurance companies also see the added value in a process that entails following guidelines and tracking outcomes. And in exchange, physicians receive higher reimbursement rates.
It Can Work for You, Too
This consortium model, which has worked so well for members of the BNPCC, can be applied to other areas of medicine to enhance screening and diagnosis, standardize treatment options and recommendations, and track patient outcomes. It would be most easily applied to those disciplines that have a set of national standards and guidelines for patient care in a particular clinical area or disease site. This tends to eliminate differences of opinion.
In this era of managed care, this is one way healthcare providers, patients, and payers can work collaboratively to improve the quality of care while containing costs.
Joanne Bond, MS, is director of CME, and Susan Walsh, RN, is department administrator, program management, with the Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, N.Y.
