One of the ways the federal government hopes to reform health care, is to get doctors to follow what are known as “best practices.”
Those are established by crunching through mounds of data to find out which actions result in the best outcomes for patients.
In a nutshell, it means doctors have to follow a set of guidelines rather than relying only on their experience and education.
Kristian Foden-Vencil visited one small hospital in Bend, to see what happened when it adopted guidelines for cancer treatment.
Back in 2006, the St. Charles Medical Center in Bend got some bad news.
While its five-year survival rates for people suffering from breast, prostate and colorectal cancers were above the national average - its survival rates for lung cancer were below average.
“We wanted to get rid of those pockets of questionable care,” says medical director Linyee Chang. They set up a Cancer Committee to see what to do.
“We knew that evidence-based practice was something that was getting a lot of attention, it was throughout the news. And we knew that guidelines exist. And to be able to standardize that best care, we knew that we needed to be able to prove that we were adhering to best practice.”
After looking at the practices of several larger cancer hospitals around the nation, Chang says they decided to adopt guidelines set by the National Comprehensive Cancer Network or NCCN. That’s a group specifically dedicated to improving the quality, effectiveness and efficiency of cancer care.
But Chang says adopting new guidelines, and convincing doctors who’ve been doing things their own way for 20 years, are two very different things.
Physician buy-in took more than a year.
“It was a new approach for me to actually look at guidelines instead of just making a decision off the top of my head,” recalled Dr. Stephen Kornfeld a medical oncologist at St. Charles.
“But very quickly they have become so pivotal in my practice. They’re very practical. They are updated frequently. There are guidelines that have already been updated five times in 2013,” Kornfeld said.
So, what’s in some of the guidelines?
“The guidelines sort of help docs decide what testing they should get and what testing they shouldn’t get perhaps before surgery. The guidelines might suggest what minor surgical procedures should be performed before major surgical procedures. And then the guidelines take it a step further, they’ll suggest what therapies might be appropriate after surgery. And they’ll even have a page about what’s the appropriate follow-up,” according to Kornfeld.
Kornfeld says the National Comprehensive Cancer Network guidelines give patients confidence that their team isn’t just winging it.
“In each one of my examination rooms I have a computer screen. I have NCCN up on every screen. So as I’m talking to patients, when I first meet them, I can refer to the NCCN guidelines. I can tell them I’m making this recommendation, and here’s the reason.”
It sounds sensible.
But have the results of cancer care improved at St. Charles?
The hospital did make gains over a five-year period. The numbers show the lung cancer five-year survival rate at St. Charles improved almost six-percent, pushing it higher than the national average — and similar to the rates seen at some large cancer specialist centers.
“I think our attempt to be standardized and follow national guidelines is ahead of the curve. This is what health care reform would like to happen in cancer across the board and in all other disease states,” Kornfeld says.
Chang says doctors have better legal protections when they stick to guidelines. Patients also get a better idea of what their treatment might be — and how much it might cost.
Diane Tolley lives in Redmond and makes a living selling medical testing equipment. In January, she went to her doctor for a check-up.
“Typical story. I went in for my normal mammogram. Every year I get it, the first part of the year. They called me back. They said we need to do an ultra sound. I said okay. They called me back again and next thing I know, I’m having a biopsy in Dr. Higgins’ office,” Tolley remembers.
She had breast cancer.
With that kind of diagnosis, many people, particularly in smaller, rural areas, decide to get treated at a large hospital in a metropolitan area — where there’s a big staff, with a lot of experience.
But not Tolley. She’d lost a daughter to cancer in 1988. Through that experience she’d come to know and like the local oncologists at St. Charles.
She says the guidelines also gave her confidence.
“You’re listening to what your doctor’s saying. You believe them. But at the end of the line, at the end of that sentence, is a punctuation that says it isn’t just him talking, it’s this whole group talking.”
Tolley says she also liked the idea of getting care locally, because she could rest up at home after radiation treatment, and avoid hours of driving to Portland or Seattle.
“That is a huge expense that is not covered by insurance,” Tolley points out.
There is one caveat to the guidelines. And that is that if a cancer is rare or complicated, then perhaps securing care at a dedicated cancer center is a better idea.
Doctor Michael LeFevre of the U.S. Preventive Service Task Force says cases will always come up where the guidelines don’t match the specific clinical situation and patients need to go to centers with more experience and expertise.
It’s a situation that St. Charles oncologist, Dr. Stephen Kornfeld recognizes.
“The guidelines for common cancers are very well designed. There’s lots of data. They’re very up to date. So in these circumstances I feel very comfortable and confident following the guidelines. But for uncommon cancers, for which there are less clinical trials, the guidelines are a lot looser. And so there’s many times in which the guidelines are not enough.”
Meanwhile, St. Charles is considering guidelines for diseases other than cancer. And around the nation, the Affordable Care Act calls for standardizing care using similar guidelines.