Seattle Children's Hospital Leukemia Program Offers Multidisciplinary Care to Underserved Population

Journal of Clinical Pathways spoke with Todd Cooper, DO, director of the pediatric leukemia and lymphoma programs and Evans family endowed chair in pediatric cancer at The Seattle Children's Hospital.

In this podcast, Dr. Cooper discusses a new program launched at The Seattle Children's Hospital for patients with high-risk leukemia. A multidisciplinary approach will be used throughout each patient’s course of care, featuring diagnostic tests for placement in cutting-edge clinical trials.

Transcript

Hello everyone and welcome back to the Journal of Clinical Pathways podcast. My name is Zack Bessette, associate editor of the journal, joined by my colleague Amanda Del Signore, managing editor of the journal.

Joining us today is Dr Todd Cooper, DO, the director of pediatric leukemia and lymphoma program and Evans family endowed chair in pediatric cancer at the Seattle Children’s Hospital.

The Seattle Children’s Hospital recently launched a new program for patients with high-risk leukemia. A multidisciplinary approach will be used throughout each patient’s course of care, featuring diagnostic tests for placement in cutting-edge clinical trials. 

Dr. Cooper has been kind enough to speak more in depth on this topic today so thank you for joining us today, Dr. Cooper.

Thank you.

What was the inspiration for the program? When did it launch and what is the ultimate goal?

The inspiration for this program was really patient-based. I wanted to put a program together that would allow patients to have access to their primary oncologist as well as all consultants in a single visit so that they could leave there with as comprehensive a plan as possible. That is the main inspiration.

The other inspiration is to set up a clinic in a way that is best going to marry science and clinical acumen in their therapy. What I mean by that is find a great way to put clinical research, bench research, diagnostics, and the best minds around one table to come up with this comprehensive a program for kids with relapse and refractory leukemias as I can. 

The program launched in January of 2018. It has really been being planned for about a year, year and a half before that in terms of getting the infrastructure together, getting all the people together, and finding out the most practical way to launch this program.

Now that the program has been active for a few months, what have been some of the early takeaways and successes that you've noticed?

The main successes that I have seen are that patients and families are appreciative and impressed at the level of collaboration and thought put into their child’s individual treatment plan. They have overwhelmingly expressed their appreciation and support for being able to, in one visit, get a very comprehensive plan from not only their pediatric oncologist, but from their bone marrow transplant physician and any important consultant such as cardio-oncology and infectious disease. I think most patients' families are used to having to go to multiple clinic visits over a period of a long time and different locations to get a plan for their child. Getting all the consultants to communicate and to be on the same page regarding their care I think is a big challenge. I think with this kind of a system patients and their families can have less lab draws. And they tend to get less varying opinions.

In addition, what I think families are seeing and understanding is that the next generation diagnostics and follow-up for each of these patients is an outstanding advantage to them. They know that in Seattle we're dedicated to the latest and greatest therapies and diagnostics and technologies for them and I think that they can probably see that difference for them to have the feeling that so many people are putting their heads together for their kid and under one roof and leaving with the comprehensive plan for their child I think is making these families feel like they have not left any stones unturned.

Have there been any challenges stemming from the program?

Well, absolutely. Putting something like this together that involves more than one program within an institution and integrating all the details around scheduling and collaborations taking place under one roof, I think all that is always a challenge. It is pushing the envelope a little bit. It is making people think outside the box in terms of how they take care of patients and where they take care of patients so that has certainly been a challenge, but that is why we worked for about 12-18 months on setting it up before we launched it so that has so gone extremely well.

I think this concept of build it and they will come is something that we are seeing which is both an advantage and a disadvantage. What I mean by that is we are already getting lots of patient consultations from outside the Seattle area. We are accommodating these by having formal consultative phone calls each week with patient families and  referring physicians. We try to do this in a way that does not necessarily bring the kids to Seattle but just offers a consultative service that highlights the advantages of our program. The word is getting out there, so  volumes are going up and up and so you know there are challenges in terms making sure that each family is accommodated.

The other challenge is when families are wanting to come here, dealing with the details around insurance and approvals and getting this done in a very timely manner. Sometimes this process takes a very long time yet there is urgency for all these kids that are often sick and starting these therapies and these delays are very difficult and navigating the insurance companies and approvals has proven to be a big challenge. 

Do you believe that clinical pathways could play a role in any step of this? Is there a place for standardized practice in this program?

I do believe that clinical pathways can be extremely helpful, and we have tried to implement those into our program. So, for example, what we obtain next-generation sequencing on each of these patients, and we need to set up a clinical pathway by wherein we setup how these are ordered, what we order, and how these are billed and how we get the results back.

Other really important clinical pathways that we have set up is we have involved our infectious disease team in the management of these patients and this management starts before they arrive. We request records from outside on all the infections that a patient may have had and how they have been managed. We have a clinical pathway in place for a consult from these folks and what exactly they are going to order on each patient.

In addition, we have a clinical pathway put in place from an infectious disease perspective where there are patient-specific antibiotic plans that are set up for each of these patients so that when a patient comes to the emergency room or to any non-hematology/oncology part in the hospital it's readily visible in the electronic medical record as to what antibiotics they can and cannot have. This also takes place within cardio-oncology in terms of testing and treatment for left ventricular systolic dysfunction. And I could go on, but absolutely clinical pathways have played a very important part in the management of these kids.

This program is the first of its kind. Is there any indication that it could service as a model for other health systems that are designing a pediatric care program for patients with leukemia or other blood malignancies?

I think so. I think that this program represents a new paradigm in the treatment of children with high risk hematologic malignancies. What I mean by that is I think that the standard way of treating children with hematologic malignancies is by assigning these children an individual physician or an individual care team and that care team is the center of not only their therapy but also in arranging consultations, etc. And what this does is it is bringing everybody that needs to be involved in this child's care under one roof in the management of these children. So yeah, I do think it's a new paradigm.

It's important to note that the high-risk leukemia team sees this patients in what we call a nodal way, meaning the entire high-risk leukemia health care team is not seeing the patient on every single visit yet is seeing them as a consultative service along their cancer journey so at diagnosis, at relapse and after transplant, etc., and is helping coordinate their care all the way through. So, yeah, I do think that this is a different paradigm compared to what families are going through currently.

Well, great. Thank you for that comprehensive look at your program. Are there any other points you'd like to make for audience?

Well, the only point I would make is that this program I do believe is unique. It does take a lot of work to put together and we are continuing to refine the program, but I do think that this only benefits the patients and this kind of interdisciplinary care model I think is a great paradigm for the future. It puts all the best heads together from every aspect of their care in a single visit. And it is really an outstanding and efficient way to take care of kids with leukemia.

Dr Cooper would also like to include that this program is working hard to standardize a prior authorization process by which patients can come to Seattle Children’s Hospital and be seen in an efficient manner. The longer this is done, the more the inefficiencies in the process can be ironed out.