4.3.1 Implications for future CME

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Education is needed around the tools that are more ideal for assessing a patient’s functional, cognitive, and support status. The importance of administering these tools at baseline and during treatment to assess any changes in metrics will be reinforced by highlighting the benefits to both the patient and multidisciplinary care team. Clinical vignettes may also be used in this setting to reinforce these concepts in a simulation of what clinicians encounter during daily practice.

4.4 Practice Performance Gap #3: Recognizing and overcoming the barriers that lead to poor compliance in the geriatric patient population

Compliance was frequently identified as a particular problem in geriatric patients with cancer, which seems to be rooted in a variety of causes. Poor monitoring and management of side effects can lead to poor compliance, as noted by a geriatrician:

“Sometimes patients stop [treatment and office visits] because the [medication] made them feel sick. They can’t do their housework, and it’s your fault, so the heck with this.”

To overcome this barrier, better education around monitoring and management of side effects, as detailed in Practice Gaps #1 and #2, would be valuable. An additional component would be communicating with the patient and/or caregiver regarding what to expect with treatment, so that expectations are managed and support systems put into place to mitigate unpleasant effects stemming from treatment. Enhanced communication at this stage may also lead to an alteration of the treatment plan that is more aligned with patients’ goals, which may lead to increased compliance. Physicians recognize a need for improvement, with “Communicate with the geriatric patient, family, and caregivers about treatment options and patient concerns” rated as a perceived need. The need for better physician-patient communication is exemplified by question 3, in which the hypothetical patient specifically requested a form of chemotherapy, and despite this, 24% of respondents chose best supportive care as the treatment they would offer the patient.

Education of and communication with geriatric patients and their caregivers can be challenging in a number of ways, as identified by the medical oncologists interviewed. Elderly patients tend to be hard of hearing and tend to be reluctant to acknowledge when they don’t understand something. They may also have difficulty in remembering to take their medications as directed, or keeping track of many appointments, particularly if they experience cognitive decline as a result of their treatment. Additional complications may include language, religious, or cultural barriers that may impact effective education and communication. It is not unusual for close family members to act as interpreters for geriatric patients, and care must be given that the physician’s message is reaching the patient accurately. As a geriatrician stated:

“You don’t know what they’re hearing. I usually train people that with the interpreter, you’ll see if the patient has any questions or wants anything explained. And if they say ‘No, give it to my granddaughter. She’s fantastic. She’s a nurse…I trust her.’ …Then I say ‘Okay.’ But we need to check and make sure.”

Notably, medical oncologists in the survey rated their present ability to “Address language, religious, and other cultural issues that may affect management of the geriatric patient with cancer” the absolute lowest of all competency domains, and indicated a desire for improvement.

In comparison to younger patients, geriatric patients are typically in need of greater social support during treatment. This includes help with remembering medications and keeping track of appointments, but can extend to a need for assistance with transportation to and from appointments, assistance during appointments, help with self-care while at home, and close observation of possible side effects, which elderly patients tend to be reluctant to self-report. Unfortunately, despite being in greater need of social support, geriatric patients are more likely to have fewer close relatives and friends upon which to rely. Many geriatric patients tend to have deceased spouses and little or no close family nearby.

Integration of individuals such as oncology nurse navigators (ONNs), patient navigators, case managers, etc., into a multidisciplinary approach may help improve patient-physician communication and education. However, it should be noted that integration of ONNs or other navigators/managers is not meant to replace the role of the practicing oncologist in effective communication with the patient, but rather to augment the physician and, ultimately, to offer a fully multidisciplinary approach to care. Additionally, these individuals are specialists in identifying and overcoming the physical and social barriers that lead to poor compliance. In our survey of clinical practices, “Use of resources to educate patients” and “Refer geriatric patients for a consult” fell almost exactly at the midpoint on the agreement scale, indicating that while clinicians may be aware of these resources, they may not be utilizing them fully.

An additional barrier to compliance typically observed in the geriatric patient population is cost of treatment. The medical oncologists in our survey agreed that “High cost to patients” was a significant barrier to adoption of new therapies. Most geriatric patients are on Medicare only, and may lack the income required to cover necessary co-pays, some of which can be large. Beyond the expense of medication, there are additional financial burdens involved in receiving treatment. As an oncology clinical nurse educator put it:

“[With patients on fixed incomes], you’re telling them that they have to eat this certain food, or they should take these supplements, and they can’t even afford food. [Sometimes] these patients can’t pay their electricity bill, and you want them to go back and forth…to the hospital 3 times per week, and that’s… not going to be a priority to them.”

Cost is another barrier that may be overcome with the assistance of patient navigators or case managers, who have experience dealing with financial concerns and may have methods to address them.