Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click we are focusing on oncology. Full, printable issues of the Click are available in the CoramClick archive for easy reference!

	Home Care for the Oncology Patient Cancer is the second leading cause of death in the U.S., at 23 percent of fatalities per year. Home care allows oncology patients to return home to their family and friends.		Bug of the Month: Nosocomial Infections These hospital-acquired infections are presenting a steadily increasing risk with significant clinical and economic impact.
	Supportive Management of the Oncology Patient Guidelines for supportive home care include pain and palliative care, nutrition support, management of fever and neutropenia, and blood and marrow transplant management.		Do You Know? Which patient population has the highest rate of infections caused by resistant pathogens?   a) Children   b) Adults   c) Elderly
	Common ICD-9 Oncology Codes A list of the most widely used ICD-9 codes for diagnosing oncology.		Resource Center: Oncology Focus National Breast Cancer Awareness Month, the American Society of Clinical Oncology, and fever and neutropenia guidelines.
	Subscribe to the CoramClick. Please include your email, first and last name, company, and city and state.

Home Care for the Oncology Patient

Cancer is the second leading cause of death in the U.S., with 23 percent of fatalities per year. The treatment schedule is intense and encompassing, with the acute care setting historically being the site of care for these patients. However, given rising healthcare costs and growing trends of nosocomial infections in the hospital environment, transitioning these patients to a home care environment has become a safe, effective model for healthcare utilization. Home care provides a continuum for oncology patients to return to their homes and families.

In a study conducted by Serrate, et al. in 2001, two groups of oncology patients were observed; the control group being managed in the hospital and the other in the home. The total cost of healthcare for the home population was 64 percent of that of the hospital patients. The daily costs were three times lower in the home than in the hospital. Pharmaceutical costs were six times lower, and the 24-hour telephone support of the home care team avoided 27 nursing visits in total. ¹

Miano, et al., showed similar findings in a pediatric population who had undergone stem cell transplants. Of the 28 children that entered the study, 17 were home for follow up and support therapy administration, and nine were followed up for graft versus host disease and/or CMV. Median support for each child was 25 days. The patients had a total of 822 visits in the home versus 459 and 363 outpatient and inpatient days of hospitalization. The cost of care in the home was dramatically lower in those patients versus the cost of hospitalization. ²

Patient satisfaction also improves in the home setting. In a 1999 study, Hooker and Kohler looked at a pediatric oncology population and gauged parent satisfaction as the true acceptability of the home care model. Results of the study showed that 72 percent of parents felt the home model aided their coping skills, 75 percent reported a higher sense of control, and 82 percent reported they learned more about their child’s illness and treatment. ³

The trend is clear — caring for cancer patients in a home setting is safe and cost effective and is preferred by the patient.

Supportive Management of the Oncology Patient

The National Comprehensive Cancer Network, an evidence-based consortium, has established guidelines to support home care, including pain and palliative care, nutrition support, management of fever and neutropenia in the home, and blood and marrow transplant management.

Pain and Palliative Care
The word, “palliate” — or “to make feel better” — is the goal of palliative care. The palliative care model, which aims at relieving suffering and improving quality of life in conjunction with other appropriate treatments,⁴ extends through the continuum of care at the time of diagnosis through cure or death, including risk and bereavement. The model is all-encompassing and should be applied without the weight of diagnosis.

The growing library of literature shows impact on not only quality, but quantity for patients suffering a chronic, potentially life-limiting disease process. It is the goal of many providers to extend this model to all patients seeking treatment.

• More than 1,500 hospitals nationally have a program focus for palliative care.
• U.S. News & World Report includes palliative care in its criteria for “America’s Best Hospitals.”
• Top payors around the country have identified the importance of the palliative care program model, to not only maximize cost utilization, but to enhance overall quality of life for their members.

Nutrition Support
Nutrition care and support is an important adjunctive component of cancer treatment. Often, health and weight can be maintained with an oral diet adjusted to meet the person’s changing tastes during cancer treatment. There may, however, be times when a patient needs more intensive nutrition therapy, such as enteral (tube feeding) or parenteral nutrition.

While enteral or parenteral nutrition support is not an anti-cancer therapy, it is focused on maintaining and/or improving the nutritional status of the person with cancer so that the patient can tolerate the anti-cancer treatments. For example, patients with head and neck cancer often experience difficulty swallowing and can benefit from an enteral feeding via a gastrostomy to maintain nutrient intake during treatment and throughout recovery. ⁵ The goal for all patients is to provide this specialized nutrition support, when needed, during treatment and recovery, and to carefully transition back to an oral diet.

A nutrition assessment, completed by a registered dietitian, is the first step in determining the cancer patient’s nutrient requirements and the route of administration. According to “A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients,” enteral or parenteral nutrition support is appropriate during anti-cancer therapy in malnourished patients unable to adequately consume or absorb nutrients. ⁶ Prevention of malnutrition is also important. Marin Caro, et al., suggest that nutritional intervention (oral diet, enteral or parenteral nutrition) should be started as early as possible, as this can reduce and even reverse poor nutritional status, improve performance status and, consequently, quality of life. ⁷

Studies indicate that home parenteral nutrition (HPN) as an adjunct therapy for cancer patients with nonfunctional G.I. tracts improves quality of life and functional status, and that HPN preserves patients’ nutritional status from progressive deterioration, potentially helping to prolong survival. August, et al., reviewed the use of HPN in patients with inoperable malignant bowel obstruction. Patients and families viewed HPN treatment as “highly beneficial” or “beneficial contributing to improved quality of life.” ⁸ Outcomes published in Nutrition in Clinical Practice, 2002, found that of 81 cancer patients studied, 69 percent lost more than 10 percent of their body weight before HPN was initiated. ⁹ Patients who are allowed to lose more than 10 percent of their body weight before starting home parenteral and enteral nutrition (HPEN) have a lower functional status, which can be improved with effective nutrition support. Nutrition screening to identify potential nutrition problems and intervention with nutrition support, whether oral, enteral or parenteral, are important components of the care of an oncology patient.

Fever and Neutropenia
Infection is one of the leading causes of morbidity and mortality among oncology patients. Patients receiving chemotherapy, radiation therapy, or a blood or marrow transplant experience a two- to four-week period, during which they do not have normal levels of red blood cells, white blood cells or platelets. This results in the complications of neutropenia (low white blood cell count), anemia (low red blood cell count) and thrombocytopenia (low platelet count). Neutropenia is life threatening because patients become more susceptible to infection and sepsis.

Neutropenia is often determined by evaluating the absolute neutrophil count (ANC). The ANC is the percentage of the total white blood cell count that is comprised of segmented (segs) and banded (bands) neutrophils. A normal ANC is above 1,500 ul/ml. When the ANC is between 1,000 to 1,500, the patient is at risk for infection. An ANC between 500 to 1,000 is considered neutropenia and the patient is at a higher or moderate risk for infection. Severe neutropenia is defined as an ANC of less than 500 ul/ml, which puts the patient at a very high risk for infection.

Fever with neutropenia requires prompt attention and assessment. The patient is unable to mount an immune response, and an untreated infection can be fatal. In the event of fever or suspected infection in the neutropenic patient, cultures must be obtained, and appropriate IV antimicrobial therapy prescribed. While the location of treatment varies, it is often administered via home care once the patient has been evaluated, is deemed an appropriate home care candidate and/or the cause of the infection or fever is determined.

Blood and Marrow Transplantation
Blood and marrow transplantation (BMT), also referred to as blood stem cell transplant (BCT), is an expensive yet therapeutic treatment option for a multitude of disease states. It has evolved from experimental therapy in the 1970s to an accepted treatment modality for numerous malignant and non-malignant diseases. The use of transplantation as a therapeutic or curative treatment option, however, depends on many factors, including but not limited to the underlying diagnosis, co-morbidities, and the patient’s physical and emotional functioning. A careful evaluation to determine candidacy is necessary.

The underlying premise for transplantation is the recognition that chemotherapy treatment can often produce long-term remissions for cancer patients. Still, many patients relapse following such therapy. By significantly increasing the chemotherapy dose, a prolonged survival/remission for many types of cancers has been demonstrated. Unfortunately, high dose chemotherapy and radiation therapy destroy rapidly dividing cells, including the essential life sustaining red and white blood cells and platelets that comprise the body’s hematopoietic system and immune system. The reinfusion or transplantation of the patient’s own cells or donor hematopoietic stem cells to reconstitute these systems is essential for patient survival.

Complications following transplantation are common and can involve almost every organ system. The complications that cause the highest morbidity and mortality are infection, graft-versus-host disease (allogeneic transplant only) and disease recurrence.

There is significant emphasis placed on choosing a “Center of Excellence” for transplantation, with a focus on clinical as well as economic outcomes. Simultaneously, lengths of stays are decreasing and the location of all or parts of transplant patient care is shifting from the inpatient to the outpatient setting. Included is an increased focus on providing transplant services in the ancillary care setting. During the past decade for example, homecare, most notably high-tech home infusion services, has played a major role in the support of the blood and marrow transplant recipient. The ability to provide transplant-specific assessment and care, anti-infective therapies, nutrition support, antiemetics, pain management, IVIG and other therapies in the home setting has enabled earlier hospital discharge when appropriate. Home infusion also promotes patient quality of life, a decreased risk of nosocomial infections and cost effective treatment location options. It is accepted that due to the costs and complexity of BMT, specialized medical teams and experienced transplant centers with documented positive clinical outcomes should be managing transplant patients. The onus is now on the payor community to extend their evaluation of “Centers of Excellence” to include outpatient and home infusion services as part of the transplant continuum, expecting and accepting only proven strategies and outcomes for the care of this complex, high-acuity patient population.

Common ICD-9 Oncology Codes

Below is a comprehensive list of the most widely used ICD-9 codes for diagnosing oncology. Please note that this list is not all inclusive.

Bug of the Month

S. marcescens (above) is an opportunistic pathogen, which means that it is usually not a cause of disease; however, under immuno-compromised circumstances this bacterium can be found the culprit responsible for nosocomial infections such as endocarditis and pneumonia. Image courtesy of the CDC.

Nosocomial Infections
Nosocomial infections (also known as hospital-acquired infections) are those infections that develop as a result of treatment in a hospital or long-term care facility, secondary to the primary reason for admission. Infections are termed nosocomial if they appear 48 hours or more after hospital admission. Hospital-acquired infections present a steadily increasing risk, with significant clinical and economic impact.

According to the Centers for Disease Control and Prevention (CDC), five to ten percent of patients acquire an infection during a hospital stay — nearly two-million patients annually. Mortality is the end result for approximately 90,000 of those patients. Alarmingly, more than 70 percent of the bacteria that cause nosocomial infections are resistant to at least one of the antibiotics most commonly used to treat them.

Depending on the causative organisms and clinical status of the patient, the cost of treating a nosocomial infection can reach $35,000 per patient, or an annual national cost of over $65 billon. One factor contributing to increased cost is increased hospital length of stay (LOS). For example, the average LOS attributable to a resistant Staphylococcus aureus infection is reported to be 20 days, nearly three times the average of a nonresistant infection. Other factors contributing to higher cost are increased morbidity with resulting additive treatment costs, increased mortality, need for administration of more expensive and often multiple antibiotics, and an increased use of laboratory services — for both the patient and the hospital’s surveillance staff.

Multiple factors contribute to the incidence of nosocomial infections, including:

• An increasingly ill hospitalized patient
• Hospital LOS
• Staffing issues which may contribute to non-compliance with hand-washing and other preventive measures
• Ineffectively cleaned equipment
• Invasive procedures — central venous catheters, ventilators, urinary catheters, etc.
  Unnecessary and multiple use of antibiotics, including prophylactic and empiric therapies
• Public demand for and noncompliance with prescribed antibiotic therapy. In fact, it is estimated that 50 percent of antibiotic prescriptions written for children are unnecessary

Fortunately, there are a number of ways to control and reduce nosocomial infections in the hospital or long-term care facility. Decreasing inappropriate use of antibiotics is the best way to control resistance. Effective hand-washing in the clinical setting can also curb infections. This can be accomplished by adding alcohol-based hand rubs. Other preventative measures include:

• Revised orientation, training and compliance monitoring for control and contact infections precautions, equipment cleaning, transport, etc.
• Patient screening and isolation and/or cohorting PRN
• Restrictive pharmacy formulary to avoid overuse of antibiotics at risk for becoming ineffective
• Infection surveillance and tracking protocols within the hospital

Perhaps the most effective way to avoid nosocomial infections to remove the patient from the hospital setting altogether. Moving the patient into a home healthcare setting minimizes the risk of him or her contracting a nosocomial disease, and decreases the chances of these diseases spreading among the hospital’s patient population.

Bibliography

1. Serrate S.R., Ferrer-Roca O., Gonzalex-Davila E. (2001). A cost -minimization analysis of oncology home care versus hospital care. J Telemed Telecare. 7(4):226-32.
2. Miano M., Manfedini L., Garaventa A., Fieramosca S. Tanasini R. Morreale G. Manzitti C., Dini G. (2003). Home care for children following haematopoietic stem cell transplantation. Bone Marrow Transplantation. 31(7):607-10.
3. Hooker L., Kohler J. (1999). Safety, efficacy, and acceptability of home intravenous therapy administered by parents of pediatric oncology patients. Med Pediatr Oncol. 32(6);421-6.
4. Center to Advance Palliative Care. Definition of Palliative Care.
5. Raykher A., Russo L., Schattner M., et al. Enteral nutrition support of head and neck cancer patients. Nutr Clin Prac 2007;22(1):68-73.
6. A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN 26 (Suppl: 82SA-84SA, 2002).
7. Marin Caro M.M., Laviano A., Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr 2007;26:289-301.
8. August D.A., Thorn D., Fisher R.L., et al. Home Parenteral Nutrition for Patients with Inoperable Malignant Bowel Obstruction. J Paren and Enter Nutr 1991;15:323-327.
9. Ireton-Jones C., DeLegge M. Quality of Life Outcomes in Cancer Patients Receiving Home Parenteral Nutrition Support. Nutr Clin Prac 2002.

Do You Know?

Which patient population has the highest rate of infections caused by resistant pathogens:
a) Children, b) Adults or c) Elderly?

Answer - a) Children
Children are at a significant risk for resistant infection because this population has the highest rate of antibiotic use and thus the highest rate of infections caused by resistant pathogens.  

Resource Center

October is National Breast Cancer Awareness Month
Since its beginning more than 20 years ago, the National Breast Cancer Awareness Month (NBCAM) organization has been dedicated to increasing awareness of breast cancer issues, especially the importance of early detection. The NBCAM is comprised of several national public service organizations, professional medical associations and government agencies working in partnership to build breast cancer awareness, share information and provide access to screening services. The NBCAM is a year-round resource for patients, survivors, caregivers and the general public. For more information, please visit www.nbcam.com.

The American Society of Clinical Oncology
The American Society of Clinical Oncology (ASCO) is a non-profit organization, founded in 1964, with overarching goals of improving cancer care and prevention and ensuring that all patients with cancer receive care of the highest quality. As the world’s leading professional organization representing physicians who treat people with cancer, ASCO is committed to advancing the education of oncologists and other oncology professionals, to advocating for policies that provide access to high-quality cancer care, and to supporting the clinical trials system and the need for increased clinical and translational research. For more information, visit ASCO website.

Fever and Neutropenia Guidelines
The American Cancer Society (ACS) in combination with the National Comprehensive Cancer Network (NCCN) have developed and published treatment guidelines for patients with cancer who experience fever and neutropenia. These guidelines offer a more in depth discussion of fever and neutropenia along with definitions and treatment algorithms. These guidelines are available in both English and Spanish and are updated as new information becomes available. The most recent version of these guidelines is available online at www.cancer.org or www.nccn.org. You can also call the ACS at 800.ACS.2345 (800.227.2345) or NCCN at 888.909.NCCN (888.909.6226).

The CoramClick, brought to you by Coram Inc., is a bimonthly publication that is provided free of charge to the community. Opinions expressed by contributing authors and sources are not necessarily those of the publisher. Information contained in this newsletter is for educational purposes only and is not intended as a substitute for medical advice. Do not use this information to diagnose or treat a health problem or disease without consulting a qualified physician. Please consult your physician before starting any course of supplementation or treatment, particularly if you are currently under medical care. Never disregard medical advice or delay in seeking it because of something you have read in this newsletter. © 2007 Coram Inc. All rights reserved. No part of this publication may be distributed, reprinted or photocopied without prior written permission of copyright owner. All service marks, trademarks and trade names presented or referred to in this newsletter are the property of their respective owners.