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The COVID-19 pandemic has brought many challenges to oncology care; an area of medicine that typically involves frequent, in-person patient visits to complete a course of treatment.
In many ways, COVID-19 has served as a stress test for the specialty, and has catalyzed adaptive changes that we hope will make the oncology care, and the health care system in general, more resilient going forward.
Data suggests that patients with active and remote histories of cancer are both at significantly increased risk for COVID-19 infection as well as worse outcomes (such as ventilator support and mortality rates) relative to matched peers. As such, in an effort to minimize patients’ touchpoints with the health care system — which protects both patients and clinic staff from unnecessary COVID exposure — cancer practices rapidly expanded their telemedicine capabilities.
Telemedicine has no doubt been a lifesaver for patients and practices alike during this unprecedented time. However, with new technologies come new challenges; healthcare workers have had to adapt to new ways of managing patients and clinic work streams. And it remains to be seen whether legislation directing reimbursement for telemedicine will last beyond the duration of the pandemic.
But the reshaping of the health care landscape due to the COVID-19 pandemic has drastically reduced new cancer diagnoses — for example, by over 50% for patients with breast cancer — due to deferred non-urgent screening tests and patient desires to avoid the healthcare system when possible.
While this has contributed to reduced clinic and treatment room throughput during this pandemic, there is concern that capacity issues may develop after the pandemic ends as patients resume appropriate screening recommendations leading to an influx of new cancer diagnoses.
Delayed cancer screenings and subsequent delays in cancer detection might also cause more patients to present with later stage disease, which may lead to worsened morbidity and mortality for patients with cancer for years to come.
In addition to tele-visits, electronic patient engagement platforms offer another increasingly popular venue for physicians and oncology patients to interface with each other in response to constraints on face-to-face meetings during the pandemic.
Patient engagement platforms provide a mechanism for proactive symptom monitoring, and have been shown to result in impressive survival and quality-of-life outcomes. Prior to the pandemic, though, the use of electronic patient-reported outcome (ePRO) platforms have largely been in the context of clinical trials, and predominantly situated at large urban academic centers. This is partly because routine use of these platforms has been a logistical hurdle for practices, and might also stem from possible equity issues, as many patients lack the technological capabilities to engage with an electronic platform from home.
During the pandemic, however, use of ePRO platforms has grown. For example, a recently presented study found that, at one community cancer center practice, roughly 1,000 new patients were activated onto the ePRO platform each month from March 2020 to May 2020 (representing a 15% increase in activation from pre-COVID). Further, patients also demonstrated receptivity to this type of communication with their physician, with an 8% increase in response rates to treatment questionnaires from the pre-COVID era.
We hope that patient engagement with the ePRO system correlates with better patient-provider communication, and ultimately with superior outcomes.
In another measure aimed at minimizing patient exposure to clinic, practices have reduced treatment intensity whenever possible, as long as such changes do not affect outcomes. For example, certain immunotherapies can be dosed with different frequencies — such as every four weeks instead of every two weeks. In addition, some chemotherapies typically given via infusion can be replaced with medications taken by mouth in order to reduce the time patients spend in medical oncology clinics.
Using less frequent dosing or alternative routes of administration helps reduce clinic and treatment room throughput, which protects patients and staff alike. It also reduces chaos in the clinic, which may help prevent burnout.
Finally, the pandemic also impacted cancer center non-clinical staff operations in a significant way. Where other industries have had varying familiarity with the idea of staff working from home, health care has traditionally never been so tech-adapted as to allow this. COVID-19 facilitated the perfect opportunity to test leaner on-site operations on such measures as productivity, work/life balance, and reduced turnover. At Tennessee Oncology, such telecommuting of revenue cycle management staff (n=130 employees) demonstrated gains in all of the aforementioned measures, and even improved billing measures such as days in accounts receivable and patient payments, suggesting improved productivity by working at home.
Perhaps most important was that over 96% of employees reported improvement in work/life balance as compared to pre-COVID times, which we believe was integral to reducing burnout for these important team members during this challenging time.
In the past year, the COVID-19 pandemic exposed several fault lines within the U.S. health care sector that affect patients and health care workers. A few examples of these are absent public health infrastructure, a resistance to the adoption of new technologies, a near-total reliance on in-person patient-provider contact, and fee-for-service reimbursement structure that incentivizes high clinic volumes to generate revenue.
The pandemic has forced a reckoning with these features of the health care system, and we are hopeful that the resultant care delivery innovations will lead to greater patient-centered care. However, as with any innovation, we must be aware of and responsive to new challenges that may arise, and continue efforts to prevent workforce burnout.
Samyukta Mullangi, MD, MBA is a hematology/oncology Fellow at Memorial Sloan Kettering Cancer Center
Johnetta Blakely, MD, MS, MMHC is a practicing medical oncologist and Executive Director of Health Economics Outcomes Research for Tennessee Oncology.
Stephen Schleicher, MD, MBA is a practicing medical oncologist and Medical Director of Value-Based care at Tennessee Oncology.