administrativeandfinancial issuesin geriatriconcologyeducation– board of education,...

19/11/2015

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Geriatric oncology training - educating the workforce of the future

Administrative and financial issues in

geriatric oncology education: a Brazilian example

Dr. Aldo L. Abbade Dettino, MD, PhD

Clinical Oncology dept.– Oncogeriatric Unit,A. C. Camargo Cancer Center (ACCCC), Sao Paulo, Brazil

PhD in Science (Pathology) – FMUSP/2008Post-graduation program – International Center for Research and

Education (CIPE)-ACCCC. Discipline: Therapeutic update to target therapy and translational

research.

SIOG 2015. 13/Oct/2015

[email protected]

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Disclosures (2013-2015):

none for this presentation

• 1. Honoraria: Astellas [lectures CRPC (enzalutamide)]; Bayer [speaker (Radium-223); AstraZeneca [lectures: lung (ITKs, gefitinib); breast (exemestane)]

• 2. Consulting/Advisory role: Janssen [CRPC (abiraterone)]; AstraZeneca [Lung (ITKs, gefitinib)].

• 3. Research funding (institutional): Astellas [CRPC, EAP (enzalutamide)]; Boehringer-Ingelheim, Pierre-Fabre[H&N (afatinib, vinflunine)]; Roche [gastric, pertuzumab]; Janssen [CRPC (abiraterone)]; Merck, AbbVie [lung (pembrolizumab, veliparib)];

• 4. Travel/accomodation expenses: Roche, Astellas, Pierre-Fabre, Sanofi, Janssen, Bayer.

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Presentation topics

• Importance

• Objectives – present and discuss:

– Needs and Challenges

• Experiences in Brazil

– Geriatric oncology education

• In our cancer center

• Feasibililty, difficulties

• Ideas and Perspectives

– Solutions?

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World population aging

http://esa.un.org/unpd/wpp/publications/files/key_findings_wpp_2015.pdfUnited Nations, Department of Economic and Social Affairs, Population Division (2013).

World Population Ageing 2013. ST/ESA/SER.A/348.4

- Potential Support Ratio (PSR):

number of people aged 20 to 64 by

the number of people aged 65 and

over - (“workers/retiree”)

• Decreasing for most of the

countries. Health, social &

ECONOMICAL impact

- Health care systems + old-age and

social protection systems

• fiscal and political pressure

• countries are likely to face in the

not-too-distant future

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Problems

• Demands from elderly increasing population

• GO education importance: up-to-date field, in

many instancies.

• Despite knowledge gained, gaps in research,

education and assistance in GO. Remarkably,

administrative and financial factors interfere

with that.

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Needs• More health professionals and social

plans for elders vs. “shortage of geriatricians"

• More and more: – nurses, physicians, physical therapists,

nutritionists etc; personal trainers…

• Caregivers, providers

• Architectural places: living, socializing, educating, caring

• Education and research for assistances – pts, families and caregivers, instruct other areas

• Money $$$$

• ETC

Are we …6

(Faces – Tarsila do Amaral)

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Needs• More health professionals and social

plans for olders vs. “shortage of geriatricians"

• More and more: – nurses, physicians, physical therapists,

nutritionists etc; personal trainners…

• Caregivers, providers

• Architectural places: living, socializing, educating, caring

• Education and research for assistances – pts, families and caregivers, instruct other areas

• Money $$$$

• ETC

Are we preparing ourselves?7

(Faces – Tarsila do Amaral)


Challenges

Political and health service/hospital managers (+ours) - CHOICES:

• No focus in geriatric oncology and prevalent issues and worst end-points, more costs and less quality of life (and survival?)?

• Investments to be able to make a strong effort to provide more (quality of) life?

• Remaining period of life may be better, p.ex. with less toxicities from treatments and

• better support

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(Laurence Olivier Hamlet:

To be or not to be)Copyright: Gian Salero, shutterstock.com

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Challenges

Political and health service/hospital managers (+ours) - CHOICES:

• No focus in geriatric oncology and prevalent issues and worst end-points, more costs and less quality of life (and survival?)?

• Investments to be able to make a strong effort to provide more (quality of) life?

• Remaining period of life may be better, p.ex. with less toxicities from treatments and

• better support

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Geriatric societies concerns

• Geriatrician/elderly

– Brazil: 2014 - open letter to population

• 2010 – around 1:5000

• ~2014 - 1 geriatrician for 20 thousand elderlies (60+?) –ideal 1:1000? (Brazilian Society of Gerontology and Geriatrics/SBGG; 2250 associates).

– USA:

• 2015 - 1:2526 (75+)

• 2015 – geriatric psychiatrists – 1:11526

• Projected 2030 – 1:20448

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http://portal.cfm.org.br, 18/Sep/2014

http://www.americangeriatrics.org/advocacy_public_policy (acessed 11/Nov/2015)

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Education and gerontology: challenges

and opportunities

• Gerontology: exchange of ideas and data

• interdisciplinary and multiprofissional field:

– Biology, medicine, social sciences, psychology, for

examples.

– Interfaces - works of geriatricians, physical

therapy, nursing, social assistance, law, clinical and

educational psychology etc…

Cachione M, Neri AL. [Educação e gerontologia: desafios e oportunidades].

RBCEH - Revista Brasileira de Ciências do Envelhecimento Humano, Passo Fundo, 99-115 - jan./jun. 2004.

http://www.upf.br/seer/index.php/rbceh/article/view/49/56 11


Education in GO

• Objectives. Need strategies:

• discuss teaching and learning• how to optimize education, and deal with

administrative and financial issues.

• How? Describe administrative andfinancial topics:– implementation and maintenance

– interference and how to improve education andresearch

– Offer good-quality assistance, based on the regional experience of the GO team

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Different settings• public or private

• acute or intensive care unit

• ambulatory, nursery

• hospice, home care

• Assistance, administrative, or research view

• Clinical, imaging, pathological, molecular parameters

• Institutional; regional, national, worldwide; health services

and systems, politics

• Different needs, available time and staff; AND GOALS

{(neo)adjuvant, curative; palliative, QoL, survival etc}

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Extermann M. Cancer Res Treat. 2010;42(2):61-68

Wildiers et al. J Clin Oncol 2014;32:2595-603

Drukker et al. EJC 2014;50,1045– 1054



GO education• POINTS OF VIEW - various

– Patient and caregivers/family

– Health professionals

– Health system, political system, economical context

– Assistance

– Education

– Research

• Different tasks, different payments vs. task

overlaps. Different objectives? How to integrate?

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GO education• POINTS OF VIEW - various

– Patient and caregivers/family

– Health professionals

– Health system, political system, economical context

– Assistance

– Education

– Research

• Different tasks, different payments vs. task

overlaps. Different objectives? How to integrate?

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"The disintegration of the inner life hits the heart of human existence.

Our whole life and heart is devoted to developing our personality.


Integrated Oncogeriatric Approach (IOGA) Model.

Tremblay D et al. BMJ Open 2012;2:e001483

©2012 by British Medical Journal Publishing Group16

Integrated approach: administrative and

financial support too

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Ideas from information technology

Networks must transform from complex hierarchies of fixed architecture into flat

standards-based topologies that are optimal for the any-to-any requirements of service

delivery.

Adapted from The transformation

from application delivery to service delivery.www.citrix.com (acessed 11/Sep/15)


`• Finances & COSTS – parallels with scholl and health

teaching programs

• Instructional expenditures

• Student/fellows and staff support

• Administration costs

• The “other” category

– http://www.greatschools.org/gk/articles/school-finance-issues/

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`• COSTS – parallels with scholl and health teaching programs

• Instructional expenditures:

– costs related to teachers/health professionals instructing students/fellows.

– salaries, supplies (textbooks, medias) and purchased instructional services,

libraries, curriculum development and training for staff/teachers.

• Student/fellows and staff support :

– funds spent on the cost of health, psychological, guidance and therapy

departments at a school/hospital. Staff support includes the cost of libraries,

media centers and training.

• Administration costs:

– includes expenditures for the administration of both schools and medical

programs.

– board of education, superintendencia, graduation expenses, central office

expenses such as budgeting, payroll, purchasing, planning and research.

• The “other” category includes all other types of expenditures.

– Examples of costs in this category include operations (utilities, maintenance

and security), food service, and the salaries of support staff.

http://www.greatschools.org/gk/articles/school-finance-issues/

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Our institutional recent numbers

(2014):

20Challenges >>>

• ~4,000 consultations /month in clinicaloncology

• ~10,000 pts / year

• ~ 2/3: 65+ years old.

• 20%: 70+ years old.

• Headquarter with 5 buildings; 1 near tower to publicand pediatric assistance, two satellite clinics in otherneighborhoods, 2 research and administrativecenters

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Our time line• Until 2009 – ideas

• 2009 – proposal, no administrative support yet

• 2010 – pilot phase – + 1 nurse and 1 psychologist

• 2011-3: more routine use of CGA – 2 nurses

• 2014: less adherence to CGA... Staff with multiple tasks, besides GO, such as pre-elective hospitalization(all ages); incresing volume. However:

• Some opportunities: previous data presentation (ESMO 2013, ASCO 2014), today´s opportunity (SIOG 2014)

• 2014: doctors and fellows, 2 nurses; other specialties referred inside the hospital (geriatric oncology unit, no formal geriatric expertise nearby).

[http://siog.org/images/SIOG_documents/Lisbon/f-dettino%20aldo.pdf]

• 2014-5/6 CHALLENGES:– Constraints: staff (dedicated), architectural space, heavy work

load

– Patient-family-health professional and institutional corporateneeds

– Care, research, education; administrative and financial issues

– How to convince fellows of the importance of topics vs. more work and more time demanded (complexities) vs. results andrevenues

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Procedures in numbers/y (all center)

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0

50'000

100'000

150'000

200'000

250'000

300'000

350'000

400'000

1 2 3 4 5

Ambulatorial attendances/2000 year

0

50

100

150

200

250

300

350

400

450

500

1 2 3 4 5

ICU (admissions)/2000 year

* increasing financial income at a rate of around 15%/year, 7% in 2015 so far, versus a

possible 2015 inflation of almost 10%

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Procedures in numbers/2000 years

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0

10'000

20'000

30'000

40'000

50'000

60'000

70'000

80'000

90'000

1 2 3 4 5

Surgeries

Chemotherapies (sessions)

Hospitalizations


TORREHILDA

Beds over time: recent new towers 2012 & 2013

* 2015: maybe it will take at least 4-5 years to increase, due to architectural, administrative and

economical concerns

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Size of the staff – Clinical Oncology dept.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

4 4 4 4 4 46 6

8 8 810

15 1518

12 12 12 12 12 1214

1620

2224

26

33

40

48

9 9 9 9 10 1114 15 16 17

2125

3032 33

21 21 21 21 22 2328

3136

39

45

51

63

72

81

Residents 1st year Residents total Medical staff Total

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Years 2000:


Size of the staff – Clinical Oncology dept.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

4 4 4 4 4 46 6

8 8 810

15 1518

12 12 12 12 12 1214

1620

2224

26

33

40

48

9 9 9 9 10 1114 15 16 17

2125

3032 33

21 21 21 21 22 2328

3136

39

45

51

63

72

81

Residents 1st year Residents total Medical staff Total

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Years 2000:

Strategic audience:

potentially more open-minded?

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From the Young SIOG mentorship program

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• Communication

• Collaboration - Join efforts

• Profit of societies and entities

experiences

• Know audiance: institution,

region, expertise, knowledge

• Technology – media reaching

• Innovation

• Diversification

• The future

THINK PAIR SHARE

Ideas – active young discussing people

� Partnerships with existing societies

� Connecting world and local institutions

� Opportunities of experiences with

mentors

� Gain experiences from researches in

GO, but also from other areas:

epidemiology, etc

� Open minded – youngs, mostly; needs

sponsorships – financial issue again

� Link of fellows with recently graduated

ex-fellows

� Repetition – change general medical

oncologists from non-believers


From the Young SIOG mentorship program

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• Communication

• Collaboration - Join efforts

• Profit of societies and entities

experiences

• Know audiance: institution,

region, expertise, knowledge

• Technology – media reaching

• Innovation

• Diversification

• The future

THINK PAIR SHARE

Ideas – active young discussing people

� Partnerships with existing societies

� Connecting world and local institutions

� Opportunities of experiences with

mentors

� Gain experiences from researches in

GO, but also from other areas:

epidemiology, etc

� Open minded – youngs, mostly; needs

sponsorships – financial issue again

� Link of fellows with recently graduated

ex-fellows

� Repetition – change general medical

oncologists from non-believers

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Ideas – face problems to better gains

• Healthcare programs for the elderly

• take into account the multi-dimensionality of health and social inequalities

• interventions can target the most affected elements of HRQOL as well as the most vulnerable subgroups of the population.

• Interventions for whomneed them.

• Improving QoL in mostcompromised situations

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Lima MG et al. Cad. Saúde Pública [online] 2009; 25(10): 2159-2167

http://dx.doi.org/10.1590/S0102-311X2009001000007


Lessons from other

fields/specialties

• The Crossroads

of Geriatric Cardiology

and Cardio-Oncology.

• [Professional's

expectations to improve

quality of care and social

services utilization in

geriatric oncology]

Health professionals and

geriatricians

• skills and insights pertaining to

various specialists

• Key roles in defining care

Inform and enhance

key management expertise

Coordination of a multidisciplinary

and multi-professional intervention

Optimizing links between

professionals Improve care planning,

health and social services utilization.

Coordination effort, a better

organization of the clinical activity in

geriatric oncology, to optimize

clinical practice and global cares

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Nguyen KLet al. Curr Geriatr Rep 2015;4(4):327-337

Antoine V et al. Bulletin du Cancer 2015;102(2):150–161

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Integrating Frailty into

Clinical Practice to

Prevent the Risk of

Dependency in the

Elderly.

• Epidemiological scenario – aging

• High healthcare costs for management of

dependent individuals - adoption of

strategies:

• preventing loss of physical function and

anticipate the take in charge of older persons

at risk of negative outcomes.

• Major medical specialties (e.g., oncology,

cardiology, neurology…) have already moved

to early stage of the diseases to be more

effective.

• Authors conclusion: Geriatric medicine must

do the same

• moving to frailty an early stage of

disability were intervention are more

likely to be effective.

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Vellas B. Nestle Nutr Inst Workshop Ser 2015;83:99-104

doi: 10.1159/00038209220


• “more research and

education of health

providers in certain

geriatric issues is required

for elderly patients.”

(Early-Stage)

Breast Cancer in

the Elderly:

Confronting an

Old Clinical

Problem.

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Dimitrakopoulos et al. J Breast Cancer 2015;18(3):207-17

doi: 10.4048/jbc.2015.18.3.207. Epub 2015 Sep 24

Ideas in some contexts

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Balducci. J Gastrointest Oncol 2015;6(1):75-8


Put some GO education in perspective• Difficult administrative, political & economical scenarios may happen, but

work must be done aiming to allow workers of the future to think and plan:

• PREVENT COMPLICATIONS - Detect predictive factors of complications in

oncological treatment. Room for screening?

• Prevent additional common complications in elderly: falls, polypharmacy,

undernutrition, depression, sarcopenia, for example.

• TREATMENT PROTOCOLS - Propose treatment protocols adapted to functional

capacity - avoid over and under treatment.

• REHAB - Offer ways to rehabilitation of reversible vulnerability and frailty, with

combined interprofessional work; & to treatment side effects.

• PSYCHOLOGIC AND COGNITIVE SUPPORT - Detect early signs of psychological

or cognitive alterations that may contribute to additional deficits.

• DIFFERENT SETTING SUPPORT, RESEARCH - Offer home, ambulatory and

hospital support to all patients, specially for the ones that cannot receive full

or specific cancer treatment (oncogeriatric palliative care).

• INTERDISCIPLINARITY

• ASSISTANCE, RESEARCH, then EDUCATING OTHERS – CYCLE RUNNING

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Put in perspective• Difficult political & economical scenario, but work must be done aiming to

allow workers of the future to think and plan for:

• PREVENT COMPLICATIONS - Detect predictive factors of complications in

oncological treatment. Room for screening?

• Prevent additional common complications in elderly: falls, polypharmacy,

undernutrition, depression, sarcopenia, for example.

• TREATMENT PROTOCOLS - Propose treatment protocols adapted to functional

capacity - avoid over and under treatment.

• REHAB - Offer ways to rehabilitation of reversible vulnerability and frailty, with

combined interprofessional work; & to treatment side effects.

• PSYCHOLOGIC AND COGNITIVE SUPPORT - Detect early signs of psychological

or cognitive alterations that may contribute to additional deficits.

• DIFFERENT SETTING SUPPORT - Offer home, ambulatory and hospital support

to all patients, specially for the ones that cannot receive full or specific cancer

treatment (oncogeriatric palliative care). Research.

• INTERDISCIPLINARITY - Combine assistance to comorbidities with the

oncology team, better GO interventions to better care.

• ASSISTANCE, RESEARCH, EDUCATING OTHERS – CYCLE RUNNING35


How to deal with uncertainty in

teaching/learning issues• Example:

• Integrating geriatric

assessment into

decision-making after

prostatectomy: adjuvant

radiotherapy, salvage

radiotherapy, or none?

36

Goineau A et al. Front Oncol 2015;5:227

doi: 10.3389/fonc.2015.00227. eCollection 2015.

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Geriatric oncology aspects

are part of a broader

complexity of health planning • Areas of

uncertainty: how

to (suggest)

teach(ing) patient-

centered

individualized

treatment?

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Goineau A et al. Front Oncol 2015;5:227

doi: 10.3389/fonc.2015.00227. eCollection 2015.


Geriatric oncology aspects

are part of a broader web

of health planning factors

• Example:

• Integrating geriatric assessment into decision-making after prostatectomy: adjuvant radiotherapy, salvage radiotherapy, or none?

• Areas of uncertainty: how to (suggest) teach(ing) patient-centered individualized treatment

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Image: Patrick Pleul/AFP/Getty Images

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Progress and remaining challenges for cancer control

in Latin America and the Caribbean.

• Funds, insurance coverage, doctors,

health-care workers, resources, and

equipment - very inequitably

distributed between and within

countries.

• Previous scarcity of cancer registries

hampered the design of credible cancer

plans, including initiatives for primary

prevention.

• The Lancet Oncology asked for update

– Comission sceptical that they would

uncover much change.

Strasser-Weippl et al. Lancet Oncol. 2015;16(14):1405-38. doi: 10.1016/S1470-2045(15)00218-1. 39

• Funding for health care

& education:• small percentage of

national gross

domestic product

• Even smaller percentage

of health-care funds

diverted to cancer care


Progress and remaining

challenges for cancer control

in Latin America and the

Caribbean.

• Much progress made in short

time.

– structural reforms in health-

care systems,

– new programs for

disenfranchised populations,

– expansion of cancer

registries and cancer plans,

and

– implementation of policies

to improve primary cancer

prevention.

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Strasser-Weippl et al. Lancet Oncol. 2015;16(14):1405-38. doi: 10.1016/S1470-2045(15)00218-1

Nelson R. Cancer Care Making Impressive Strides in Latin Americahttp://www.medscape.com/viewarticle/853622

Proportion of the regional population covered by high-

quality cancer incidence and mortality data.

Copyright © 2015 American Cancer Society,

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Conclusions and message

• Geriatric oncology education deals with

transdisciplinarity and complexities

• Local contextualization helps in defining

problems and priorities

• As medicine/sciences and (geriatric) oncology,

education has dynamic demands:

• For improvements, needs and challenges have

to be faced and overcome.

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* To those interested in discussing more, visit other

posters and presentations – this theme #110; plus others


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Education, teaching and learning

• “Jack of all trades, master of none”

vs.

• “Talent is cheaper than table salt. What

separates the talented individual from the

successful one is a lot of hard work.”

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Education in GO

• “Jack of all trades, master of none”

vs.

• “Talent is cheaper than table salt. What

separates the talented individual from the

successful ones is a lot of hard work.”

(Stephen King).

Thank you for your attention…

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Geriatric oncology professionals

[email protected]

19/11/2015

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Thank you again for your attention

(and trying not to starve)…


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50°5'58.653"N, 14°23'22.81"E®

Thank you again for listening (and trying not to starve)…

Hope we may enjoy the this sunset in

Diplomat Hotel 9th floor again…

Try SIOG LATAM/S. Paulo, Brazil, Aug/2016

administrativeandfinancial issuesin geriatriconcologyeducation– board of education,...

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