Safeguarding patient well-being by opposing off-site infusions

I am writing to vehemently argue against out-of-office infusions for my patients. There are many general reasons for this, which I will enumerate. There are also often patient-specific reasons, such as frailty, chronic noncompliance with recommendations (which do not reach the level of a psychiatric issue but which make offsite infusions less safe), and patient-perceived intolerance of infusions (even if we see no objective signs of a reaction). While these may not meet your standards for justifying in-cancer-center infusions, they do for the physician medically and legally responsible for the patient’s care.

I am an employed oncologist and do not profit in any way from the number of patients I see or where they are treated. My motivations are solely driven by concerns over patient safety and the patient experience. It is easy for the general public and medical providers to see that your motivation is to save money or increase your profits, with little regard for patient safety or convenience.

Your proposal (which involves patients coming to see their oncologist in the cancer center, then driving across town to a private infusion center to get their infusions) is disruptive and uncomfortable for patients who are frightened, anxious, or not feeling well. Is that the care you would want for your mother or child?

While patients are receiving their chemo infusions, I walk through the chemo suite several times a day. I chat with patients, answer their questions and the nurses’ questions, and respond quickly to concerns or reactions. The patients, often in wheelchairs or on oxygen, travel only 200 feet from the exam room to the chemo suite. This not only provides ongoing continuing care, but the patients also develop close bonds with the entire care team, which makes the treatment process easier for them. Furthermore, records of their infusion, premeds, vital signs during infusion, and any comments or reactions are stored in our EMR, accessible for review by all our providers, including inpatient and ER providers. Not only would this not be available under your proposal, but the record of agent delivery would also vanish from the EMR. Your out-of-office infusion mandate eliminates these features that provide comfort and ensure safety.

You presume I am comfortable or willing to write orders for toxic chemicals and biologics to be administered in a setting that is not supervised by me or staff I am familiar with. The fact that a patient may not have had a reaction previously is irrelevant, as these treatments can be associated with a reaction at any time. The American Society for Clinical Oncology (ASCO) discourages oncologists from writing orders for chemotherapy to be delivered outside of their oversight. This could be used against any oncologist facing a malpractice suit for treatment delivered at an offsite facility. I am including several other recommendations from ASCO for oncologists.

PBM statement: Strategies for controlling costs must not compromise oncologists’ ability to provide the right care, at the right time, for all their cancer patients.

Offsite infusion statement/liability: We strongly urge any payer to collaborate with oncologists before implementing a system that delivers pre-prepared antineoplastic drugs to clinical staff who are not part of the patient’s care team. Related to this is the issue of liability. An oncologist can currently accept liability for their patient’s safety because they oversee all aspects of their care. It is unclear whether and how liability would be assigned in the home infusion setting, when the managing care team is no longer responsible for all aspects of patient care.

Chemotherapy safety standard 1.4: A licensed independent practitioner is on-site and immediately available to staff who administer chemotherapy in the health care setting.

The hospital’s costs may be higher, but our cancer center provides a licensed, board-certified medical provider, oncology-certified chemo nurses, interpreters, financial navigators, social workers, and a fully staffed ER and code blue team. Independent infusion centers do not offer these services. Selectively diverting privately insured patients away from the cancer center will ultimately jeopardize its viability. If the cancer center shuts down or if the oncologist departs due to these practices, the community’s patients will not receive better service or become healthier. The role of private insurance companies in this collapse will be widely recognized.

I assume cost-cutting (or profit maximization) is the driving force behind white-bagging, brown-bagging, and offsite infusion demands. I urge you to try achieving this without compromising the patient experience or their safety. My greatest concern lies in patients receiving infusions where I and my highly trained team of nurses, pharmacists, and ER physicians cannot intervene for patient safety in the event of an unexpected adverse event.

Banu Symington is a hematology-oncology physician.


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