Os dados e análises agora são amplamente utilizados nos negócios para resolver uma série de problemas. Nos cuidados de saúde, as apostas são indiscutivelmente muito mais altas, mas as ferramentas são igualmente aplicáveis. Cada vez mais, grandes conjuntos de dados e análises poderosas podem ser usadas para cortar a neblina que obtém a tomada de decisões, orientando médicos e médicos para os melhores testes de diagnóstico e caminhos de cuidados - aumentando a prática de melhores resultados. testes de diagnóstico. A equipe concordou em usar a adoção do diagnóstico do receptor do fator de crescimento epidérmico (EGFR) entre pacientes com câncer de pulmão de células não pequenas metastático (NSCLC) como o caso de teste, e o BCG avaliou uma amostra ampla de pacientes que não foram indicados por meio de 2017. Extrapolando os resultados para a população dos EUA, que se traduz em 43.000 pacientes metastáticos de NSCLC. Como resultado, alguns pacientes podem ter sofrido atrasos no início do tratamento quimioterápico ou recebido um tratamento inadequado, possivelmente resultando em progressão e morte de doenças mais rápidas. Por que alguns pacientes receberam o diagnóstico, enquanto outros não? Surpreendentemente, o maior fator foram seus oncologistas, que têm uma ampla discrição em relação à solicitação do teste. Ao usar essas ferramentas, médicos, sistemas de saúde, empresas de biofarma e outras partes interessadas podem avaliar melhor a qualidade dos cuidados que um paciente recebe, identificar a causa raiz das variações nos cuidados e, finalmente, ajudar os pacientes a viver mais vidas saudáveis e saudáveis.
To show the power of this approach, BCG recently partnered with AdvaMedDx, an industry association of medical diagnostics companies, to examine the barriers to adoption for potentially lifesaving diagnostic tests. The team agreed to use the adoption of epidermal growth factor receptor (EGFR) diagnostics among patients with metastatic nonsmall cell lung cancer (NSCLC) as the test case, and BCG evaluated a broad sampling of US patients.
The results showed that roughly 30% of patients presenting with this disease from 2011 through 2017 did not receive this critical and clinically indicated diagnostic test. Extrapolating the results to the US population, that translates into 43,000 metastatic NSCLC patients. As a result, some patients may have experienced delays in starting chemotherapy treatment or received an inappropriate treatment, possibly resulting in faster disease progression and death. Why did some patients receive the diagnostic while others did not? Surprisingly, the biggest factor was their oncologists, who have wide discretion with regard to ordering the test.
These findings are striking, and they underscore the clarity that proper analysis across large data sets can create. By using these tools, physicians, health systems, biopharma companies, and other stakeholders can better assess the quality of care a patient population receives, identify the root cause of variations in care, and ultimately help patients live longer, healthier lives.
The clarity created by the proper analysis of large data sets is striking.
Aplicando dados e análises ao diagnóstico
A inovação no diagnóstico clínico trouxe um valor significativo aos cuidados de saúde e levou a melhorias na jornada do paciente oncológico. Os médicos têm novas maneiras de prever quais pacientes têm um alto risco de desenvolver uma doença, melhores ensaios para diagnosticar os pacientes, melhorar os painéis de teste para ajudar a personalizar terapias e abordagens mais relevantes para monitorar doenças crônicas. Mas os pacientes não colhem os benefícios dessas novas inovações, a menos que os pagadores, sistemas de saúde e médicos adotem os novos protocolos em suas práticas clínicas. Em pacientes com uma mutação relevante do gene EGFR, os TKIs podem melhorar substancialmente a taxa de sobrevivência geral; O benefício supera os riscos. Por outro lado, em pacientes sem mutação por EGFR, os TKIs não têm benefícios terapêuticos; Eles expõem os pacientes a toxicidades, mas não melhoram suas chances de vida. Analisamos os registros para determinar o seguinte:
According to the guidelines of the National Comprehensive Cancer Network, all patients with advanced NSCLC should receive an EGFR test to determine if certain chemotherapy agents—namely, tyrosine kinase inhibitors (TKIs)—should be used. In patients with a relevant mutation of the EGFR gene, TKIs can substantially improve the overall survival rate; the benefit outweighs the risks. Conversely, in patients without an EGFR mutation, TKIs have no therapeutic benefit; they expose patients to toxicities but don’t improve their chances of living.
Thus, it is critical to test patients with this disease for EGFR mutations before deciding on a chemotherapy regimen.
Using a data set of deidentified electronic health records from the health care services company Optum®, we examined 5,687 records of individuals in the US who were diagnosed with metastatic NSCLC from 2011 through 2017. We analyzed the records to determine the following:
- O uso do teste de EGFR em pacientes com esta doença
- As disparidades nos testes e os potenciais fatores dessas lacunas
- The impact of oncologists’ individual testing rates on the likelihood of patient survival
- The relationship between EGFR testing and TKI treatment
Oncologists are increasingly testing patients. From 2011 through 2017, the percentage of metastatic NSCLC patients who received a test to evaluate EGFR mutations nearly doubled, from 35% to 69%. (See Exhibit 1.) That is notable progress. Still, the failure to test approximately 30% of the patients for EGFR mutations means that some 1,700 patients in this study may have experienced delays in starting chemotherapy or received an inappropriate treatment, possibly resulting in faster disease progression and death.
The choice of an oncologist is the biggest factor behind use disparities. An evaluation of patient and physician factors that were associated with the likelihood of EGFR testing showed that men were 40% less likely to receive the test than women. Perhaps not surprisingly, patients with no insurance were 50% less likely to have an EGFR test than insured patients. However, the largest driver of use disparities was the managing oncologist, whose individual preference for ordering an indicated medical diagnostic often determines whether a patient receives that test.
Variations in testing rates correspond to changes in survival rates. We segmented oncologists into quartiles on the basis of their EGFR testing rates. (See Exhibit 2.) The oncologists in the top quartile were more than twice as likely to order the EGFR test as those in the bottom quartile. Even after adjusting for patient factors, patients treated by top-quartile oncologists saw an 11% decrease in mortality rate, compared with patients treated by bottom-quartile oncologists.
Some patients received unnecessary chemotherapy, while others who needed treatment did not get it. Our analysis of the sample showed that 16% of the patients received TKI therapies (such as Tarceva, Iressa, and Tagrisso) without EGFR testing. Of those patients, only 30% were likely to have a EGFR gene mutation and therefore benefit from these drugs. The remaining 70% most likely received these treatments unnecessarily, putting them at risk from side effects—including immune system suppression, liver toxicity, and gastrointestinal problems—without any chance of benefiting. A secondary but not insubstantial issue is cost; these medications typically run about $10,000 per month.
We extrapolated our findings to estimate the impact on the broader US population. (See Exhibit 3.) In 2017, there were about 137,000 incidences of advanced NSCLC in the US, and approximately 30%, or 41,000 patients, were not tested for EGFR mutations. Of those, roughly 7,000 were placed on TKI therapy, which exposed them to iatrogenic harm without the potential benefit. Additionally, by not testing some 34,000 patients with this disease, more than 10,000 life years were lost.
Translating Insights into Action
Resolving use disparities requires more than physician education. To drive systemic change, hospitals and oncology practices must adopt evidence-based protocols for the use of diagnostics, rather than leave it to the discretion of physicians. Initiating standard protocols such as automatic lab testing or automatic flags in patient records are two potential approaches. Likewise, physicians could be rewarded (or penalized) on the basis of their adherence to protocols. Above all, hospitals and oncology practices—and the health care industry more broadly—must become more transparent about outcomes, and that requires not only a robust tracking system to identify physician performance but also a mandate to take action on the basis of the findings.
Driving systemic change requires a robust tracking system and a mandate to take action on the basis of the findings.
Às vezes, o progresso nos cuidados de saúde requer novos avanços radicais em técnicas e tecnologia. Outras vezes, simplesmente requer garantir que provedores e pacientes sigam protocolos de atendimento padrão. Ao destacar variações no atendimento entre prestadores e instituições - e as causas subjacentes dessas variações - dados e análises podem ajudar a gerar uma imagem mais clara de como os tratamentos estão afetando um determinado conjunto de pacientes. Dessa forma, essas ferramentas estão se tornando uma nova e poderosa maneira de ajudar o sistema de saúde a se estender e salvar a vida dos pacientes.
