Background: Glioma patients are prone to gaps in treatment due to the cognitive morbidity of the disease and the need for multimodal adjuvant treatment.
Methods: This was a retrospective cohort study. Glioma patients undergoing unplanned surgery between 2015-2018 were included. Unplanned surgery was defined as that which occurred through initial presentation to the emergency department or as a direct transfer from the emergency department of another facility. The intervention consisted of face-to-face nurse-driven multidisciplinary care coordination. Historical controls were used. Primary outcomes were (1) time to neuro-oncology follow-up, (2) time to radiation treatment, and (3) time to chemotherapy.
Results: Among 225 patients screened, 66 (29.3%) had unplanned surgery. The intervention and historical control groups had similar baseline characteristics. The intervention group was associated with more patients following up with neuro-oncology at 2 weeks (51.1% in the intervention group compared with 30.0% in the historical control group), more patients starting radiation at 30 days (43.6% and 25.0%, respectively), and more patients starting chemotherapy at 30 days (59.0% and 35.0%, respectively). Time-to-event analysis showed that the intervention group trended toward earlier initiation of chemotherapy (P = .076) and revealed that insurance status was significantly associated with initiating chemotherapy at the 30-day mark (P = .023).
Conclusion: The intervention was associated with more timely postoperative care. However, insurance status seems to also impact follow-up and needs to be studied further. Face-to-face multidisciplinary care coordination and the guidance of a neuro-oncology nurse navigator are indispensable components of a neurosurgical oncology program.
The diagnosis of high-grade glioma carries a grim prognosis. The median survival is 15 months, and the 5-year survival rate is less than 5.6%.1-3 Standard of care is almost uniformly multimodal, and continuity of care after surgery is essential to optimize outcomes.4 This process can be especially challenging for the underinsured, those with poor access to care, and those with unplanned hospitalizations. These treatment gaps are not unique to glioma patients.5 Whereas some of these barriers are unavoidable, certain institutional protocols can be developed to improve the quality of care delivered and address modifiable factors affecting patient outcomes. The current standard of care for patients with high-grade gliomas (grades III and IV) is surgical resection followed by concurrent temozolomide and radiation therapy.3 Studies in glioma patients have shown a correlation between socioeconomic status and overall survival.6 Improving access to care, which is a modifiable barrier to care, may ensure more timely delivery of adjuvant treatment and improve overall survival. Studies in other malignancies have revealed a survival disparity associated with delays in follow-up due to education, poor insurance status, and lack of routine access to a healthcare provider.7,8 Along these same lines, both lack of education and cognitive dysfunction can make it challenging to keep follow-up appointments.9,10 Thus, since there is a relatively high incidence of memory deficits in patients with gliomas, care coordination is essential to ensure adherence to the treatment plan.10
The timing of adjuvant treatment for high-grade gliomas is under some debate.11-19 Nonetheless, adjuvant treatment starting with a modest delay (30-34 days after surgery) may improve overall survival compared with earlier or later treatment timing.20 It is generally accepted that reliable follow-up and physician-physician communication is critical to ensure proper delivery of multidisciplinary care. The pathways for care coordination in glioma patients are not widely studied, and the optimal mechanism for such coordination is still unknown. Large structural interventions are not always feasible and tend to be costly. The purpose of this study was to estimate the impact of a nurse-driven multidisciplinary intervention for hospitalized patients undergoing unplanned surgery for gliomas. The intervention was simple. It consisted of face-to-face communication between the inpatient neurosurgeon and the outpatient neurooncology nurse navigator. The anticipated impact of the intervention was a higher percentage of patients meeting the expected follow-up times (2 weeks for first neuro-oncology appointment and 30 days for initiation of radiation and chemotherapy).
Patients and Methods
All patients with a glioma diagnosis who received surgery at our institution from 2015 to 2018 were eligible for inclusion. Only patients with unplanned surgery were included. We chose this population because we anticipated that they would be the most vulnerable to delayed follow-up. To identify this cohort, Current Procedural Terminology codes 61510, 61140, and 61750 were queried through an internal database, and only patients with gliomas on final pathology were included. Unplanned surgery was defined as surgery after hospital admission through the emergency department or as a direct transfer from another facility. Those included were either admitted for surgery during the index hospitalization or had surgery scheduled within a week of admission. Patients were excluded from the final analysis if they died before the first follow-up or were discharged to hospice. Only patients with high-grade glioma were included for the analysis of adjuvant treatment timing because low-grade glioma patients generally have a more indolent course, and adjuvant treatment is not universally provided.21 Patients were retrospectively placed into either the intervention group or the historical control group based on the date of surgery. The intervention group had surgery on or after November 11, 2016, which was the date of implementation of our intervention. The historical control group had surgery prior to that date. The study was approved by the Office of Human Research Ethics (IRB# 18-3130).
The planned intervention included departmentwide access to a shared multidisciplinary follow-up list through the electronic medical record (EMR). The list was created to facilitate weekly face-to-face discussions between a neuro-oncology nurse navigator and neurosurgeon managing the inpatients after surgery. Historically, only the neuro-oncologist was notified about each patient through direct communication with the neurosurgeon, brain tumor conference discussion, or through outpatient referrals after a final histopathologic diagnosis was made. No structured face-to-face multidisciplinary discussion occurred on a routine basis. Furthermore, with the new 2016 WHO classification,22 molecular-based grading of gliomas became standardized.23 Additional molecular testing has prolonged the final histopathologic diagnosis and added complexity to the treatment decisions in some cases. For these reasons, a short 10-minute weekly face-to-face, nurse-driven multidisciplinary care coordination meeting was held after the brain tumor conference to facilitate follow-up even before the final histopathologic diagnosis was made. For each patient, 3 items were generally discussed: (1) preliminary diagnosis (based on imaging, risk factors, and intraoperative frozen pathology), (2) performance status and expected postoperative disposition (home, skilled nursing facility, or rehabilitation), and (3) insurance status (Figure 1). The list was checked weekly by the nurse navigator and the oncology outpatient patient scheduler. If the frozen section suggested possible metastatic disease, immediate follow-up with neurooncology was delayed until pathology was finalized. As soon as a glioma diagnosis was visible in the EMR, the process of scheduling and authorization for expected treatment was initiated. Patients with metastatic disease were directed to the appropriate clinic and thus not included in this study. The intervention group (postintervention) was compared with the historical controls (preintervention).
Patient characteristics and treatment variables were collected from a retrospective review of medical records. Primary end points were time variables calculated from the date of surgery to first neuro-oncology appointment, initiation of radiation, and initiation of chemotherapy. Patients are expected to follow up with neuro-oncology within 2 weeks to discuss next steps in treatment, and the target time to radiation therapy and chemotherapy was 1 month (30 days).
Descriptive statistics were used to characterize the patient population. The Fisher exact test was used to evaluate the association between factors categorized into contingency tables. The Wilcoxon rank sum test was used for 2-group comparisons of continuous factors. The Kaplan-Meier method was used to estimate the time to first neuro-oncology follow-up, time to radiation therapy, and time to chemotherapy. The median times as well as estimated cumulative incidence at 14 days for neuro-oncology follow-up and at 30 days for treatment outcomes were calculated along with the 95% confidence intervals. For each grouping factor, the log-rank test was used to compare time to events across groups. The cumulative incidence plots were provided to show the time to events by group. Statistical analyses were conducted using SAS software version 9.4 and R version 3.4.024 with survival package.25,26 All tests were 2-sided at a significance level of .05.
During the study period, 225 patients had either a craniotomy or biopsy for glioma, and 66 (29.3%) were defined as unplanned. There were 21 patients in the historical control group and 45 patients in the intervention group. Table 1 shows the demographic and clinical characteristics of the 2 groups. Baseline characteristics of the 2 groups were similar with regard to age, sex, insurance status, pathology, and discharge location. The distribution of discharge disposition was similar in the groups (Table 1). Most patients were discharged home (47/66, 71%). One patient was discharged to hospice and 2 patients died prior to discharge, and these patients were excluded from the final analysis.
Median time to neuro-oncology follow-up was 28 days in the historical controls and 15 days in the intervention group. There was no difference in time to radiation treatment. Median time to chemotherapy was 37 days in the historical controls and 26 days in the intervention group (Table 1). For our primary end points, the percentages of patients in the 2 groups who presented within our expected time frame of 2 weeks for neuro-oncology follow-up and obtained adjuvant treatment (radiation and chemotherapy) by 30 days are shown in Table 2. Across all measures, the intervention group was associated with more patients reaching the primary end points within the expected time frame compared with historical controls. The estimated cumulative incidences showing the probabilities of achieving primary end points in each group are shown in Figure 2. There was a strong trend toward earlier initiation of chemotherapy in the intervention group (P = .076), but other end points were unchanged.
Insurance status showed no difference between groups (Table 1; P = .54). However, insurance status was associated with earlier initiation of chemotherapy (Figure 3; P = .023). Interestingly, patients without insurance fared the best overall and had much earlier time to chemotherapy and radiation therapy than the Medicare group (Figure 3).
This study presents a single institution experience after the implementation of a simple nurse-driven multidisciplinary intervention facilitated by a shared EMR list. The goal of the intervention was to improve follow-up for patients with unplanned surgery for glioma. Data were analyzed for 3 primary outcomes: time to first neuro-oncology appointment, time to first radiation treatment, and time to first chemotherapy treatment. Time-to-event analyses showed a trend toward earlier follow-up times and earlier time to first chemotherapy treatment in the intervention group compared with the historical control group. In addition, there was a significant correlation between insurance status and earlier administration of chemotherapy. In agreement with our findings, other studies have shown that multidisciplinary treatment. 27,28 This study, however, is the first to show that the care coordination may actually affect the efficiency and delivery of postoperative care. The trend toward earlier postoperative care is clinically significant. Notably, a greater proportion of patients reached primary end points within our expected time frames (Table 2).
During the study, we observed the important role of the neuro-oncology nurse navigator. Early identification and communication of patients’ needs allowed for more rapid navigation of barriers to care that would otherwise cause delays. One of these barriers was insurance, as we have shown here (Figure 3). Almost half of our study patients had either Medicare, Medicaid, or no insurance. This highlights the need for better and earlier communication of insurance needs to expedite postoperative care in patients with unplanned surgery. An interesting finding was that patients without insurance started adjuvant treatment at comparable, or better, times than those with private insurance. These patients may have experienced the greatest benefit from the intervention because we were able to apply early for charitable insurance coverage and pharmacy assistance, which can be instituted retroactively.
This study has limitations. Primarily, it is a single institution retrospective study with a limited sample size. The sample size could be increased by including all postoperative glioma patients, although we argue that there are certain subsets of patients who are at higher risk for erratic follow-up, which we have attempted to study here. A better powered prospective study or, ideally, a prospective randomized trial would strengthen the confidence in our results. Regardless, few would argue against multidisciplinary care in neuro-oncology. Our study utilizes a very simple checklist (Figure 1), which can easily be incorporated into any program. We find it important to share our experience with this simple intervention that emphasizes (1) face-to-face multidisciplinary care coordination, and (2) the importance of the neuro-oncology nurse navigator. Despite similarities between the 2 groups, results are subject to selection bias and confounding due to other interventions that occurred during this time period (eg, more staff were hired to expedite insurance application completion).
In conclusion, timely follow-up after unplanned surgery for gliomas is critical to ensure proper delivery of adjuvant treatment. Follow-up depends on a number of factors, including insurance, discharge disposition, and face-to-face multidisciplinary care coordination. We recommend that all neurosurgical oncology programs invest in a neuro-oncology nurse navigator to guide patients through this challenging time in their life.
Funding, Conflict of Interest
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