Value framework tools made a splash in 2015, with five different groups unveiling methods to help physicians and patients compare therapies based on efficacy, toxicity, and/or cost. Now these potential users are beginning to examine and debate the tools, including how and whether they will work in everyday practice.
Even if these value decision support tools are operationalized, they will still need to be put in practice differently in different settings.— Christian Downs, JD, MHA
At a recent town hall meeting in Washington, DC, part of the Annual Meeting of the Association of Community Cancer Centers (ACCC), a community oncologist, a cancer center administrator, and a patient advocate talked about the new tools from their own perspectives, embarking on a discussion that is likely to continue at other meetings over the next few years.
Some of the tools, like ASCO’s Value Framework and the NCCN Guidelines with NCCN Evidence Blocks™, can be thought of as “value decision support tools,” noted the moderator, Christian Downs, JD, MHA, Executive Director of ACCC. They are designed explicitly to support decision-making based on individual patients’ values.
For instance, a breast cancer patient with young children “will almost exclusively focus on effectiveness and be less concerned about toxicity and affordability,” said National Comprehensive Cancer Network® (NCCN®) Chief Executive Officer Robert W. Carlson, MD, in a statement announcing the NCCN Evidence Blocks. “In contrast, an 80-year-old with identical breast cancer is more likely to focus on quality of life and perhaps affordability.”
Making Them Operational
You have to use your own judgment. In the end, it can’t be just a formula.— George Kovach, MD
From the perspective of a small community cancer center, the tools could facilitate a process that already is a regular part of daily practice, said George Kovach, MD, President of Iowa Cancer Specialists, Inc, in Davenport. “We already have discussions with patients, and yes, they ask about their out-of-pocket costs,” he said. Typically, the discussions take place over several visits, with costs coming last.
The tools will be helpful in this process, he predicted, in the same way the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) guidelines have proved to be. “The guidelines have turned out to be useful,” he said in an interview. “They set out treatment choices based on data and expert opinion; then doctors use their clinical judgment to decide which option is best for each patient.”
As for the time involved in such discussions, he pointed out that “the oncologist’s job is to take time to talk to patients about different treatments.” With a tool like this, “discussions can be briefer, more to the point.”
Asked if it was hard to talk about costs, when as a physician he was interested primarily in medicine, Dr. Kovach said that in his practice he needs to know about everything. But there is support from other staff members, including those who deal with insurance and cost issues, and they also know the patients, he said.
“Everybody in our office knows everything about the patients. If patients don’t tell me exactly what they want, they tell the nurse; the navigators at the hospital also talk to us. So we have all that information, and we function as a team,” he added.
From the perspective of at least one larger cancer center, however, it can be difficult for physicians to become involved in cost discussions, said panel member Thomas Gallo, MS, Executive Director of the Virginia Cancer Institute, Inc, in the Richmond metropolitan area. “Our physicians are already overburdened,” he said. They do focus on patient values when discussing treatments and medical outcomes, but a staff of financial experts deals with cost issues.
“It may be that the tools will be used differently, depending on the setting,” noted Mr. Downs. “Even if these value decision support tools are operationalized, they will still need to be put in practice differently in different settings.”
Customizing Their Use
Panelists also focused on the issue of whether users would be able to balance the tools’ systematized approach to decision-making with the individuality of patients.
“They are generic, and every patient is different,” noted Mr. Gallo. “So you have to weight different variables differently for each patient, and that is not allowed for.”
The cost conversation is hardest—You have to know when the patient is ready to talk about costs.— Alan Balch, PhD
Alan Balch, PhD, CEO of the Patient Advocate Foundation, agreed that the hard part of operationalizing the tools would be “customizing their use.” They could be used to systematize the process of discussing value with patients, he suggested. But it would be important to keep the content personalized. “Our mantra is one patient at a time.”
“Any tool is a guideline,” noted Dr. Kovach. “It gives you a foundation to start with; that’s what these are for.”
Dr. Balch suggested the need for tools that are inherently designed to not only engage patients in a thoughtful conversation about their own values and goals, but also to then align treatment options against those unique goals to help facilitate the creation of a goal-concordant care plan that is patient centered.
For instance, an online tool might be one that “patients can play with, giving different weights to different aspects of the issue, such as outcomes and toxicity, … something like the online tools they have for making various decisions like buying a car or finding a hotel that allows you to consider variables that are important to you when determining options.”
But cost, he agreed with the others, needs to come later in the discussion. “The cost conversation is hardest—You have to know when the patient is ready to talk about costs.”
“You have to use your own judgment,” agreed Dr. Kovach. “In the end, it can’t be just a formula.” ■
Disclosure: Drs. Carlson, Kovach, and Balch, Mr. Downs, and Mr. Gallo reported no potential conflicts of interest.