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Oncology

Implementation and Outcomes of Virtual Care Across a Tertiary Cancer Center During COVID-19

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Oncology

Published Online: January 7, 2021

Brief Report

Article Information and Disclosures

Author Affiliations

¹Smart Cancer Care Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
²Data Science Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
³Techna Institute, University Health Network, Toronto, Ontario, Canada
⁴Department of Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
⁵Healthcare Human Factors, University Health Network, Toronto, Ontario, Canada
⁶Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
⁷Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
⁸University Health Network Digital, University Health Network, Toronto, Ontario, Canada
⁹Women’s College Hospital, Toronto, Ontario, Canada
¹⁰Rotman School of Management, University of Toronto, Toronto, Ontario, Canada
¹¹eHealth Innovation, University Health Network, Toronto, Ontario, Canada
¹²Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
¹³Division of Medical Sciences, National Cancer Centre Singapore, Singapore
¹⁴Oncology Academic Programme, Duke-NUS Medical School, Singapore
¹⁵Ontario Health, Cancer Care Ontario, Ontario, Canada
¹⁶The Cancer Quality Lab, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

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Key Points

Question Can virtual care (VC) be rapidly implemented across a tertiary center during the coronavirus disease 2019 (COVID-19) pandemic, and what are service capacity and quality outcomes?

Findings This cohort study of 22 085 VC visits at a single cancer center suggests feasibility of an agile service design process for implementation of VC at scale. This approach preserved outpatient caseloads and maintained care quality in all 6 care-quality domains of care quality laid out by the Institute of Medicine while rendering high patient and practitioner satisfaction.

Meaning These data support the value proposition of VC to safeguard system capacity, while minimizing the disruption to patient care during a pandemic.

Abstract

Importance The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few quantitative data support its rapid implementation and positive associations with service capacity and quality.

Objective To examine the outcomes of a cancer center–wide virtual care program in response to the COVID-19 pandemic.

Design, Setting, and Participants This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020.

Main Outcomes and Measures Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients.

Results The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946.

Conclusions and Relevance These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.

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Article Information

Accepted for Publication: October 6, 2020.

Published Online: January 7, 2021. doi:10.1001/jamaoncol.2020.6982

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Berlin A et al. JAMA Oncology.

Corresponding Author: Alejandro Berlin, MD, MSc, Princess Margaret Cancer Centre, 700 University Ave, Office 7-317, Toronto, Ontario M5G 1Z5, Canada (alejandro.berlin@rmp.uhn.ca).

Author Contributions: Drs Berlin and Z. A. Liu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Berlin, Lovas, Truong, Melwani, J. Liu, Badzynski, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Stewart, Krzyzanowska.

Acquisition, analysis, or interpretation of data: Berlin, Lovas, Truong, Melwani, Z. Liu, Carpenter, Virtanen, Morley, Bhattacharyya, Moody, Goldfarb, Cafazzo, Chua, Krzyzanowska.

Drafting of the manuscript: Berlin, Lovas, Truong, Bhattacharyya, Moody, Goldfarb, Chua, Stewart.

Critical revision of the manuscript for important intellectual content: Berlin, Lovas, Truong, Melwani, J. Liu, Z. A. Liu, Badzynski, Carpenter, Virtanen, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Stewart, Krzyzanowska.

Statistical analysis: Berlin, Z. A. Liu, Morley, Bhattacharyya.

Obtained funding: Berlin, Brzozowski, Cafazzo.

Administrative, technical, or material support: Berlin, Lovas, Truong, Melwani, J. Liu, Carpenter, Virtanen, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Krzyzanowska.

Supervision: Berlin, Lovas, Melwani, Virtanen, Bhattacharyya, Goldfarb, Cafazzo.

Conflict of Interest Disclosures: Dr Melwani reported receiving funding from the Princess Margaret Cancer Foundation at University Health Network. Dr Goldfarb reported receiving personal fees from Boehringer Ingelheim, McKesson, Creative Destruction Lab, and the Neighbourhood Pharmacy Association of Canada outside the submitted work; receiving grants from the Sloan Foundation, the Social Sciences and Humanities Research Council of Canada, the National Science Foundation, Google, WPP, the Net Institute, Plurimus Corporation, and the Social Science Research Council; running a consulting company, Goldfarb Analytics Corporation, that advises organizations on digital and artificial intelligence strategies; receiving payment for lectures from Amazon, Bloomberg, BMC, Boehringer Ingelheim, eBay, Facebook, Google, the Hospital for Sick Children, Indigo, INTACT, McKesson, Microsoft, Netflix, Neoway, the Neighbourhood Pharmacy Association of Canada, Pinterest, RBC, ScotiaBank, Sisense, and Zetta Venture Partners; serving as the chief data scientist at the Creative Destruction Lab; and holding shares in many technology and health care companies. Dr Krzyzanowska reported receiving grants and personal fees from Eisai, grants from Exelixis and Ipsen, and personal fees from Bayer outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Princess Margaret Cancer Foundation.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: This work would not have been possible without the trust of our patients and the instrumental and passionate engagement of the staff of the Princess Margaret Cancer Centre.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.