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Specialized Admission Pathway Improves Care of Patients with Single Brain Mass

Key findings

  • A single, specialized, multidisciplinary team at Massachusetts General Hospital created an admission and evaluation pathway for patients who present with a new single brain mass and no history of systemic cancer
  • Following implementation of the pathway, there were significant reductions in time to surgery, length of stay and unnecessary body imaging, with no increase in the 30-day readmission rate
  • Estimated average cost savings were at least $2,344 per patient discharged home

About 80% of patients who present with a new single brain mass, normal chest X-ray and no cancer history are eventually diagnosed with a primary brain tumor. Massachusetts General Hospital now works to ensure that patients with a single brain mass receive early, coordinated, multidisciplinary care thanks to standardized consultation with specialty neurosurgeons.

After noting the variation in clinical care pathways for these patients, William T. Curry, MD, co-director of Mass General Neuroscience, and colleagues convened a multidisciplinary team from the hospital's departments of hematology and oncology, neurology, neuro-oncology, neurosurgery and emergency medicine. By discussing workflow, team members identified several opportunities to optimize patient admission and triage.

In the Journal of Oncology Practice, the team describes the Single Brain Mass Pathway protocol they developed and based on their retrospective chart review, they says the pathway has improved patient outcomes and reduced costs.

Description of the Pathway

The pathway specifies that the emergency department (ED) team, neuromedical ED resident and/or neurosurgery ED resident will be the caregivers in the ED, and the neuro-oncology fellow will serve as a consultant. It provides guidelines for initial evaluation, with a focus on diagnostic imaging, and reviews the process and timing for involving consulting services.

The default hospital admission is to the neuromedical oncology service. Admission to the neurologic intensive care unit is to be considered for patients with signs of elevated intracranial pressure, hemodynamic instability or respiratory compromise.

The pathway also provides guidance about the use of corticosteroids (to be avoided in patients with suspected lymphoma) and key signs and symptoms of non-cancerous brain lesions.

Retrospective Study of the Pathway

Dr. Batchelor's team compared data on 96 patients with a new single brain mass who were admitted to the ED before implementation of the pathway (between January 1, 2010 and November 15, 2012) and 110 who were admitted afterward (between November 15, 2012 to May 1, 2016).

Overall, 88% of patients were eventually diagnosed with a primary brain tumor, 4% with metastatic disease from a new systemic cancer and 4% with non-cancerous brain lesions.

Comparison of the pre- and post-implementation cohorts yielded the following results:

  • Admission to the neuromedical oncology service: zero patients before implementation of the pathway versus 97% afterward (P < .001)
  • Surgery by a neurosurgical oncologist rather than a general neurosurgeon: 30% of patients versus 85% (P < .001)
  • Median length of stay: seven versus six days (P < .04)
  • Median time from hospital admission to surgery: 3.5 versus 2.7 days (P = .006)
  • Computed tomography of the chest, abdomen and pelvis: 47% of patients versus 12% (P < .001)
  • 30-day readmission rate: 8% versus 12% (P = NS)

Cost Implications

The researchers believe the decrease in time to surgery and unnecessary imaging played a role in reducing the length of stay. That could have important implications for health care costs, they point out.

At Mass General, the average cost savings per patient per each additional day of stay between 1996 and 2002 was $1,172. By extrapolation, implementation of the pathway probably saved an average of $2,344 per patient discharged home.

The Mass General team believes the model may be useful to other health care systems that have access to neuro-oncology specialists and wish to increase care efficiency.

patients admitted to neuromedical oncology before implementation of the pathway

patients admitted to neuromedical oncology after the implementation of the pathway

Refer a patient to the Mass General Department of Neurosurgery

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