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Improving care for cancer patients

Two new papers detail how Kaiser Permanente restructured processes to enhance care for patients with breast and lung cancer


Quality improvement programs implemented by Kaiser Permanente Northern California (KPNC) oncologists successfully streamlined and improved management of care for cancer patients, new Kaiser Permanente research shows.

Raymond Liu, MD

The research was published in a special series in JCO Oncology Practice on team approaches to cancer care delivery. The special issue was released in conjunction with the 2022 American Society of Clinical Oncology (ASCO) Quality Care Symposium, held from September 30 to October 1, in Chicago and online.

Cancer care has become increasingly complex over the past 2 decades, and team-based approaches are widely viewed as the best way for oncologists to coordinate patient care with pathologists, physical therapists, fertility preservation specialists, and other providers. Team-based approaches also help oncologists determine the order and timing of a patient’s treatments.

The first study analyzed the implementation of a team-based care model called 4R Oncology — Right Information, Right Care, Right Patient, Right Time — for patients treated at the breast cancer clinic in San Francisco and for lung cancer patients treated by oncologists in Oakland, San Francisco, and the Central Valley.

To implement the 4R Model, the oncology care team first collaboratively identifies and addresses potential barriers to improving care timing and coordination — a process called 4R optimization. The study found that the oncologists optimized 40 aspects of care provision, 23 in breast cancer and 17 in lung cancer in order to reduce treatment delays. The optimization process set the stage for the oncologists to introduce improved patient-centered care sequences that integrated biomarker, genetic, and imaging tests needed to determine cancer treatment along with supportive care, and primary care for other health issues.

Our patient population reflects the community broadly, and we can test and scale sustainable, generalizable interventions to create high quality and affordable care.
— Raymond Liu, MD

Following up on these findings, the KPNC breast surgical teams intend to implement the model later this year.

“Care coordination is one of the biggest challenges in modern oncology care,” said Raymond Liu, MD, an adjunct investigator with the Kaiser Permanente Northern California Division of Research and a medical oncologist and hematologist with The Permanente Medical Group (TPMG), who co-authored both studies. “We demonstrated that many of the impactful optimizations we used to improve care were relatively low effort. They also could likely be replicated fairly easily by any high-functioning oncology team in the U.S.”

Reducing time to treatment

The second study evaluated a proposed optimization plan to streamline genetic tumor testing for newly diagnosed patients with metastatic non-small-cell lung cancer. These tests are necessary to determine which cancer therapies should be used. The new process introduced an automated, electronic weekly report that helped oncologists more quickly identify the patients with metastatic non-small cell lung cancer who needed genomic tumor tests. It also included a new agreement with the outside laboratory that conducts the testing to accept specimens 7 days a week instead of 4. The study showed the new plan reduced the time it took the oncologists to receive test results by 10 days. It also reduced the time from diagnosis to the start of treatment by 11 days.

The research team hopes to expand the pilot to other KPNC sites.

Time from pathology results to genetic test results in newly diagnosed metastatic non–small-cell lung cancer, Dec. 2018 to Aug. 2020.

“Getting the external vendor to accept samples on more days has helped not just our medical center, but all KPNC sites and more broadly anyone in the country that sends cancer samples to this vendor,” said Liu. “Small things add up and can make a big impact over time.”

Both studies add to the nationwide efforts led by the National Cancer Institute and the American Society for Clinical Oncology Teams in Cancer Care Initiative to promote the use of team-based care models and programs.

“KPNC is an ideal place to study care coordination and implementation because we have a strong culture of aligning systems, providers, and patients in one integrated model,” said Liu. “Our patient population reflects the community broadly, and we can test and scale sustainable, generalizable interventions to create high-quality and affordable care.”

Funding for the first study was provided by Genentech, Inc., and funding for the second study was provided by the Kaiser Permanente Northern California Graduate Medical Education Program.

Co-authors of the first study include Nancy Gordon, ScD, and Lori C. Sakoda, PhD, of the Division of Research; Christine Weldon, MBA, and Julie Trosman, PhD, of Northwestern University; Elizabeth Linehan, MD, Thea Abbe, RN, Marti Hennings, RN, Hennie James, RN, Jed Katzel, MD, Chun Ng, MD, Megumi Tomita, MD, Jeffrey B. Velotta, MD, Stephanie Ossowski, MD, Sharon Likely Sprague, DNP, RN, Anna Dowling, RN, and Kimberly Beringer, MSN, RN, of The Permanente Medical Group; and Arliene Ravelo, MPH, and Elaine Yu, PharmD, of Genentech, Inc.

Co-authors of the second study include Stephanie Ossowski, MD, MPH, Elad Neeman, MD, Amy Lin, MD, Dinesh Kotak, MD, Sachdev Thomas, MD, J. Marie Suga, MD, MPH, of The Permanente Medical Group; Charles Borden, MBA, of Hartford HealthCare Cancer Institute; Douglas Stram, MSc, of the Division of Research; and Lucy Giraldo, PA (ASCP), MS, of the Diagnostic Pathology Medical Group in Sacramento.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.

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