By Louis Potters, MD, FASTRO
Three weeks feels like years when on any given day things change hour to hour. The transformation of our lives and jobs in caring for cancer patients has completely and utterly been remade in ways many of us never imagined. And the situation remains fluid and continuing to change further. It just happens that this is the first time in three weeks I have had time to reflect, even a little, on what has transpired.
As of March 26, Northwell Health has diagnosed 4,399 positive COVID-19 patients which is about 20% of NY State and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That’s it.
Radiation Medicine at Northwell consists of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachy cases. That of course was three weeks ago.
During this crisis we have maintained two guiding principles: Do everything to keep the staff well and safe and maintain access to cancer patients needing our services.
To achieve these goals we have summarized five key takeaways:
- Actively manage your staff
- Decrease treatment volume
- Implement telehealth
- Multidisciplinary discussions are critical
- Do not compromise on treatment safety
Actively Manage Staff
It is important to recognize that linacs do not treat our patients, people treat our patients. And without a workforce that is present and engaged we are dead in the water. Our techs are at the front line of COVID-19 potentially exposed to each other and to patients. Some will convert to positive and that will then domino through the staff. One needs to actively manage their anxiety and fears before and when that happens. We have done the following:
- Decrease treatment volume
- Spaced out, rather than bunch up treatments to decrease foot traffic through the department
- Assigned two techs to treat patients only
- Either create manageable shifts for the techs or provide rotating breaks
- One facility has created treatment teams working every other day
- Have a back-up plan ready
- We will have residents and attendings work with a tech to keep treating, if it gets to that.
- Work from home
- Outside the obvious such as a rotating secretarial staff and billing staff working from home, we have instituted physics and dosimetry working from home
- Plan to need extra laptops and VPN access, especially for treatment planning off site
- Daily Huddles
- The staff want to understand what is going on. They have many questions. As leaders we are provided with access to a lot of information that the staff do not have. It is vital to share as much with them as possible.
- Be Flexible (and admit to that flexibility)
- Things change rapidly and we have written more policies in the past two weeks than collectively in the past several years. Be sure to communicate these changes effectively.
- Watch for ad hoc rule making. The staff will feel like they need to be proactive and may institute some ad hoc changes. Sometimes these are helpful and sometime, not.
Decrease Treatment Volume
It is important to decrease treatment volume. And it is critical to recognize that it will take up to two weeks to meaningfully lower volumes. You cannot start planning too soon. We developed prioritization criteria and had an extended faculty case review of all pending treatment starts. On a first pass, we were able to re-prioritize with consensus 50% of our patients to delayed starts. As things are changing, that will not be enough and we continue to work on the list based on resources and volume at a local site.
Communication with patients is critical. They are anxious and scared. Documentation is also important. Once we achieve a satisfactory decrease in volume at our sites, we will develop a new start triage list to pre-plan the order in which these furloughed patients start treatment.
These are cases where a delay of treatment may result in a loss of life, progression of disease or a permanent loss of neurological or other function. These patients are to be assessed and managed accordingly.
Priority II patients may defer treatment for up to four weeks where such delay in treatment is unlikely to result in a loss of life or (significantly) negatively impact a patient’s prognosis.
Priority II patients may be seen in consult or contacted (by phone or telehealth) to ascertain their clinical condition and will be informed that their care is not urgent.
The majority of patients requiring radiation treatment will be considered as priority II.
Priority III patients are those that may be delayed for greater than 30 days, where such delay in radiation treatment is unlikely to result in a loss of life or negatively impact a patient’s prognosis.
Examples of priority III patients include but are not limited to breast cancer and prostate cancer, but may also include any of our patients on a case-by-case basis.
If there is any one bright spot in this crisis is that the future has been thrust upon us. I doubt we will go back from telehealth. You will need to work with your hospital and health system to implement a telehealth strategy. A physician and administrative super-user will help with implementation. We have decided to install the systems in the examination rooms so that a consult can be performed along with the advanced care provider (or resident) and the attending. Another bright spot of telehealth is that it improves wait times as patients expect these interactions to start on time.
We did not wait for our telehealth system to be installed. We started two weeks ago with good old “Ma Bell” – calling follow ups and documenting. We also did not wait for billing codes but at present there are codes.
As noted, all cancer surgery in our system has been cancelled. As a result there is a new found respect for organ preservation treatments. The irony is that we also have to prioritize care. It is important to continue with tumor boards and have the discussion about best options for patients and to actively manage patient lists together in order to develop the best path forward. An observation is that the culture of these discussions will evolve from denial to acceptance as the overall crisis takes hold. This is a good opportunity to strengthen our relationships across disciplines in the effort of doing the best we can for our patients.
Maintain the Culture of Safety
It is critical in a crisis to maintain the rules and policies you put into place regarding patient safety. This is not the time to relax them or allow for work arounds, but rather to assess and view these rules as the foundation of providing safe care. Opportunities to explore modifications of these rules given the COVID-19 crisis provides fresh perspective. We have refrained from making those changes at this time and rather, are cataloguing them for future discussion and potential changes later.
Posted: March 27, 2020
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By Dave Adler, Vice President, Advocacy
The coronavirus is challenging the nation’s health care infrastructure in unprecedented ways, and radiation oncology clinics are adapting to this rapidly changing environment in response to the crisis. Similarly, ASTRO’s advocacy must adjust course on key priorities, including tackling new initiatives to support the membership’s response to this crisis and a shift to ensure a smooth transition to value-based payments, particularly at this challenging time.
On March 10, the long-awaited Center for Medicare and Medicaid Innovation’s (CMMI) Radiation Oncology Model (RO Model) moved to its final stage of review at the Trump administration’s Office of Management and Budget (OMB). This final review could last a few weeks or even months before the agency publicly releases the details of this all-important regulation for implementing the model. Even during these final days of government review, ASTRO continues to advocate strongly for necessary reforms to what CMMI proposed last summer, including major changes to the scope of the model and the payment methodology.
ASTRO has expressed concern to CMMI about the potential that one-third of all oncology practices would be required to implement the model on July 1, which CMMI has said is its goal, leaving only a few months for practices to review the final rule details and make practice changes to implement the model. ASTRO also has shared concerns about the aggressive implementation timeline with radiation oncology champions on Capitol Hill, particularly since the model has taken so long to be released.
In recent days, as the coronavirus crisis has spiked and nearly every aspect of the health care system and our daily lives have been impacted, causing ASTRO’s concern with the planned implementation timeline to be exacerbated. We are hearing from both freestanding centers and hospital-based clinics that the combined burden of addressing the coronavirus and implementing the likely mandatory RO Model would be overwhelming.
Data from China indicates that cancer patients are at greater risk of contracting the COVID-19 virus and have poorer outcomes once infected. Radiation oncology practices are making drastic coronavirus-related preparations and changes, such as postponing follow-up visits and non-urgent treatments. Practices report that non-essential staff — such as coding and billing staff that would play a major role in RO model implementation — are now working from home, while some hospitals are retraining clinical staff to help handle the expected surge in coronavirus patients.
Given this highly disruptive, but hopefully short-term emergency, ASTRO is reaching out to CMMI and Congress to discuss a delay in implementation. While ASTRO wants the RO Model, with our recommended reforms, implemented sooner rather than later, this situation necessitates delay to allow radiation oncology clinics, their patients and the broader health system to combat the crisis facing our country.
ASTRO also has heard from members that are seeking best practices for how to deal with the coronavirus, and ASTRO advocacy is working to help. ASTRO has been in contact with senior Centers for Disease Control and Prevention (CDC) officials, and we’ve requested that the agency provide coronavirus-specific recommended best practices and considerations for cancer patients. We hope to have more information from the CDC soon.
Unfortunately, due to travel restrictions placed on our members and the importance of reducing the risk of coronavirus transmission, ASTRO has cancelled Advocacy Day 2020. While this premier advocacy meeting is called off until 2021, the spirit of advocacy must continue. It’s important for the radiation oncology community to continue to push Congress and the administration for policies that support high-quality cancer care. To that end, ASTRO will be providing members with opportunities to communicate issues virtually, including direct conversations with Congress on existing priorities and new issues brought to the forefront.
Stay tuned as we roll these changes out in the coming weeks in a manner that supports your essential mission of serving your patients and communities during this challenging time. Please comment below or via the ROhub on how the coronavirus is impacting your practice and patients and how ASTRO can support radiation oncology at this time.
Posted: March 13, 2020
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By Theodore DeWeese, MD, FASTRO, ASTRO Board Chair
Next week, the National Resident Matching Program® kicks off Match Week, which will culminate with Match Day on March 20. This is an important and exciting day for both students and training programs and represents the first glimpse at the future leaders of our field. We are fortunate to recruit outstanding resident physicians to our field, a group who values the key role radiation oncology plays in the care of patients and who can pursue the future of research in oncology. We anticipate that like last year, there will be an imbalance between the number of programs offering positions and the number of students who match into the radiation oncology specialty. Radiation oncology was not the only specialty to experience a market correction last year, and there are numerous factors that contributed to the expected gap this year. We also recognize that over the last decade there has been a gradual but steady expansion in residency programs and positions, and it is unlikely for this imbalance to be corrected in just a year or two. While outside factors such as board certification exams, program-level training issues and institutional hiring practices are beyond ASTRO’s direct control, there are a number of things that we as a membership society did in the past year to address some of the field’s challenges, and I want to share some of what has been done to-date.
Exams and Training
As a normal course of business, the ASTRO Board regularly discusses the future of the field with an eye toward new treatment options such as theranostics to expand the role of radiation oncologists as leaders in oncology care. With this and other opportunities in mind, ASTRO submitted comments to the ACGME last spring to help shape future training requirements for residents. As the field continues to mature, so too the ACGME Radiation Oncology Program Requirements should evolve. The ASTRO Board also publicly supported the proposal that the ABR make the radiation oncology examination blueprint accessible on its website, including topics and the percentage of the examination dedicated to a topic. We understand the ABR has agreed to develop these blueprints, and this transparency will provide important guidance for trainees, allowing them to focus their studying efforts.
To address resident training and education, ADROP, the Association for Directors of Radiation Oncology Programs, created an information exchange network. This allows programs to share resources, including curricula, with radiation oncology residency program directors, assistant program directors and associate program directors. In addition, leaders of the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) discuss resident issues during their monthly leadership calls and at their Annual Meeting, keeping the topic and the well-being of the field top of mind.
And we continue to listen. During ASTRO19, the ASTRO Board invited the ARRO Chair to share trainee perspectives on priority issues including the board examination processes. The Board also met with leaders from the ABR and ADROP to talk more about resident physician training. We also wanted to hear from recent residents who matched into the specialty about their experiences. I am heartened by residents like Amishi Bajaj, MD, who matched into radiation oncology in 2018 at the McGaw Medical Center of Northwestern University. As she noted, “I matched at my dream program in my dream institution. I absolutely love my department and my institution, and I am endlessly inspired by my attendings and coresidents, who are not only brilliant physicians but also wonderfully kind people.”
As a way to support the next generation of researchers and to improve outcomes and quality of life for cancer patients, ASTRO created two new Research Training Fellowships with industry partners AstraZeneca and Varian. The Fellowships are designed to advance the field of radiation oncology by providing new research opportunities in an industry setting. The program will allow each Fellow to gain experience in medical affairs, clinical research and research/development from an industry perspective. We received many high-quality submissions and nominations, and we will be making the announcement about the two Fellow recipients in the weeks to come.
Commitment to Diversity and Inclusion
In an effort to introduce radiation oncology to students from historically underrepresented groups, ASTRO led an effort to connect with Chicago-area high school and college students and invited budding scientists to come to ASTRO19. The students met a range of ASTRO members, including radiation oncologists, residents and medical physicists. The students were also given a tour of the Exhibit Hall where they met leaders from a variety of companies to learn more about the latest medical advances. Because most medical schools do not require a rotation through radiation oncology, it is our hope that introducing young women and men from underrepresented minority groups to our field at this formative stage of their education will inform their future career decisions.
Addressing Patient Needs
We have heard concern about the job market and the timing of job offers for those completing residency, and we understand that many residents seek to work in academic settings. In fact, a recent Red Journal article, “Top Concerns of Radiation Oncology Trainees in 2019: Job Market, Board Examinations and Residency Expansion,” by Kahn, et al noted that “graduates strongly prefer jobs that are located in large cities (population >500,000) and that specific geographic regions, such as the Midwest, are considered to be less desirable.” Those preferences are certainly consistent with previous resident graduates. Interestingly, and importantly from a job search perspective, an analysis done for the ASTRO Rural Task Force revealed that 15% of Americans live in a non-metro area with only 6% of radiation oncologists practicing in these non-metro areas. Such information is not widely known and may help future residents consider these opportunities. Working in non-metro and smaller community settings can have tangible and direct impact where there is high patient need for quality oncologic care.
Volunteering Makes the Field Stronger
We want our field to grow in a healthy way, and the best way to change the course of the field or ASTRO as a membership society is for you to get involved. By serving as a volunteer on a committee or task force, your voice and perspective have more impact and weight.
One thing we continue to hear is that many medical students aren’t introduced to the specialty or have minimal exposure to what radiation oncology entails. As Mudit Chowdhary, MD, chief resident at Rush University Medical Center noted, “In hindsight, I realize how lucky I was to have learned about radiation oncology. Like many, I had never heard of this field even after two years of medical school. During this time, my future brother-in-law matched into a radiation oncology residency program and encouraged me to learn more about the specialty.” Another thing you can do without joining a formal committee is take the opportunity to educate your peer physicians or the medical students you encounter. The volunteers in ASTRO’s Communications Committee recently released updated slide decks that all ASTRO members can access to introduce or educate your colleagues and patients about the latest advances in radiation therapy. There is one RT overview presentation for the general public and two presentations for medical professionals: a general overview and the first in a series of disease-site specific trainings, this one focused on lung cancer treatments.
Amishi noted in her essay: “To the medical students out there who similarly identify as lovers of medicine in all its forms: Don’t forget to consider radiation oncology. You really can have it all.” As we look ahead to the Match results to come, we remain thankful to all those who are currently practicing and training in radiation oncology, and for the commitment of medical students seeking to help cancer patients by joining the radiation oncology field. ASTRO will continue to be an advocate for the field and do its best to influence how the scope of the specialty continues to evolve.
Read previous posts:
The Residency Training Landscape
(posted March 20, 2019)
The Residency Training Landscape, continued
(posted May 28, 2019)
Posted: March 10, 2020
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By Ksenija Kujundzic, Quality Improvement Manager
This year, Patient Safety Awareness Week (PSAW), sponsored by the Institute for Healthcare Improvement, will take place March 8-14. The week offers the opportunity to celebrate the numerous quality and safety initiatives already in place and to identify what more can be done to improve patient safety.
On any given day within a radiation oncology practice, radiation oncology professionals commit themselves to delivering safe and high-quality treatment. In this team effort, everyone plays a critical role. For example, radiation therapists perform time-outs, dosimetrists develop safe treatment plans, medical physicists conduct quality assurance tests on machines, radiation oncologists discuss patient cases during peer review meetings, and the entire team develops standard processes and promotes a positive safety culture. Radiation oncology professionals commit themselves to safety every day, and PSAW is a great time to celebrate this commitment.
There are a number of ways you can join ASTRO in promoting safety during PSAW:
Share your practices’ safety initiatives. ASTRO invites clinicians and practices to share on social media how you are a #SafetyChampion by describing a local initiative implemented to promote patient safety. Post a brief video (one to two minutes) or short statement (two to three sentences) on social media using the hashtags #SafetyChampion and #PSAW20 and tag @ASTRO_org. For details, such as tips on creating a video, read more about the #SafetyChampion initiative.
Pursue accreditation. Any practice that starts an application for Accreditation Program for Excellence (APEx®) by March 31, 2020, will receive $1,500 off the total application price. This discount is valid for new practices and those practices seeking reaccreditation. The application process includes providing practice information (e.g., annual number of new patients treated, treatments offered, equipment and physician names), signing agreements and submitting payment.
APEx evaluates all aspects of a radiation oncology practice to further promote consistent patient-centered care. Facilities accredited by APEx are recognized as having demonstrated a commitment to providing safe, high-quality care to patients and elevating the culture of safety.
Contact ASTRO staff to learn more about the program and available discount.
Join RO-ILS and/or report safety events. RO-ILS: Radiation Oncology Incident Learning System® is one of the few specialty-specific programs that collects safety data via a federally listed patient safety organization, with more than 500 facilities across the U.S. already enrolled. Join for free today!
Already enrolled in RO-ILS?
- Highlight to staff the importance of reporting all safety events, including incidents, near misses, and more into RO-ILS.
- Analyze your practice’s data utilizing the Analysis Wizard within the RO-ILS portal.
- Celebrate safety interventions implemented in the past year.
- Thank and praise staff for submitting events, going above and beyond and for catching an incident before it reached the patient.
Read the RO-ILS and APEx program reports. RO-ILS and APEx 2019 reports will be released during PSAW on the ASTRO website. As key components of ASTRO's patient safety initiative, Target Safely, RO-ILS and APEx demonstrates the Society’s and the field’s commitment to improving quality and safety. The RO-ILS report will highlight advancements in incident learning, such as an automated prioritization and triage mechanism. The APEx report will discuss low performing evidence indicators that practices should strive to improve.
Engage with the radiation oncology and health care community. Join the conversation about patient safety on discussion threads in ASTRO’s online community, ROhub. Ask safety-related questions of your fellow radiation oncology clinicians.
Engage with the larger house of medicine on social media and help us raise the profile of radiation oncology. For example, share interesting articles related to patient safety. Celebrate your team’s efforts toward improving quality by posting a photo of you and your team with a PSAW sign (see example, right, from last year). With all related 2020 social media posts, be sure to include the hashtags #PSAW20 and #ROSafety and tag @ASTRO_org.
Discuss safety with patients.Some patients worry about the safety of radiation therapy. Radiation has been used successfully to treat patients for more than 100 years. In that time, many advances have been made to ensure that radiation therapy is safe and effective. Share ASTRO’s RTAnswers resources with patients, which include disease site-specific resources and a video and handout with questions for patients to ask their doctor about radiation safety.
Review scientific literature on patient safety. One of the key focus areas of Practical Radiation Oncology (PRO), ASTRO’s official clinical practice journal, is patient safety. The recent consensus paper on Minimum Data Elements for Radiation Oncology highlights the importance of homogeneity in data definitions for safe care coordination. Previous editions of PRO have published articles on safety culture, incident learning and ASTRO white papers, including ones on Standardizing Dose Prescriptions and Standardizing Normal Tissue Contouring for Radiation Therapy Treatment Planning.
Add to the body of scientific literature on patient safety by conducting research and submitting original articles to PRO. Additionally, implement recommendations published in PRO, the Red Journal, Advances and other scientific journals.
There are many ways you can improve patient safety during PSAW and throughout the year. ASTRO encourages every practice and every member of the radiation oncology team to make safety a priority every day. Comment below with how you or your practice will be honoring this year’s awareness week.
Posted: March 3, 2020
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By Constantine Mantz, MD, ASTRO Health Policy Council Vice-chair
In the last two weeks, I’ve joined fellow ASTRO advocacy leaders in critical meetings with senior officials at the Centers for Medicare and Medicaid Services (CMS) on a variety of pressing payment issues facing the specialty.
The Radiation Oncology Model (RO Model), of course, continues to be the focus of ASTRO’s attention, as we continue pressing the Trump administration on necessary reforms. However, with the RO Model final rule going through the last stages of administration clearance, federal rules restrict agency staff from discussing the model. ASTRO continues to expect the model to be released in 2020. Contrary to rumors, there is no delay and practices should be preparing.
The key issues on our agenda for these meetings were those keeping me, ASTRO leaders and the membership up at night: How can recent payment stability be maintained? How can new medical oncology-focused payment models ensure appropriate radiation therapy utilization?
Given that the Agency is pursuing formal rulemaking on all of these issues, the ASTRO team did not expect to hear any final answers to these key questions from the high-level staff at the CMS’ Hospital and Ambulatory Payment Group (HAPG), which oversees physician fee schedule and hospital outpatient payments, nor the senior team at the Center for Medicare and Medicaid Innovation (CMMI), which is responsible for oncology alternative payment models, including the RO Model and the next iteration of the Oncology Care Model (OCM), known as Oncology Care First. Instead, these meetings provided an opportunity for ASTRO to press our case face-to-face with decision makers, enhancing our numerous letters with real-world illustrations of how Medicare payment policy impacts clinical and business decisions on the ground in radiation oncology.
On February 4, the ASTRO team met in Baltimore with CMS HAPG senior staff to urge the agency to again extend the G codes and payment rates for treatment delivery, IMRT and image guidance delivered in freestanding centers under the physician fee schedule until the end of 2021. ASTRO initiated and extended this payment freeze through legislation, and successfully advocated for CMS to continue the freeze through its regulatory authority in 2020. As the radiation oncology community transitions to the RO Model, which has numerous components that are linked with the physician fee schedule, we argued that continued payment stability in the fee schedule is essential to ensure successful adoption of value-based radiation oncology payments.
In addition, ASTRO again discussed the need for the agency to increase reimbursement for hospital-based brachytherapy payments, most notably for cervical cancer, where there is a gap in covering the costs of the standard of care due to CMS’ approach to packaging payments. ASTRO appreciated the HAPG attention to our issues, and we look forward to seeing the direction CMS takes when the Agency releases proposed payment rules for hospitals and freestanding centers this summer.
On February 18, our team returned to Baltimore to meet with CMMI to discuss concerns that radiation therapy utilization may be shrinking inappropriately under the OCM. We focused on ASTRO’s longstanding concerns about the perverse incentives to reduce radiation therapy utilization under the OCM. Our goal was to convince CMMI to avoid replicating the problem in the next iteration of the model, and we left with a better understanding of the Agency’s goals and agreement to explore some potential fixes that ensure radiation oncologists are better positioned under the model to be equal partners in multidisciplinary cancer care with other cancer specialists.
Each time I travel to CMS offices, I’m struck by the candid and constructive discussions we have with policymakers as we work to solve the complex radiation oncology health policy problems to the benefit of our patients. While we may not always agree with the Agency, ASTRO has established itself as a credible voice with key officials, and the data and ideas we provide are treated with respect.
When the RO Model final rule and other Medicare payment rules are released in coming months, ASTRO will be ready with a strong response that protects cancer patients’ access to radiation therapy.
Posted: February 25, 2020
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