U.S. military veterans with malignant pleural mesothelioma can rely on the VA Boston Healthcare System’s national phone triage for improved access to specialized surgical advice and better treatment recommendations, according to a retrospective study.
Thoracic surgeons Drs. Abraham Lebenthal and Jeff Siegert helped establish the open access telephone triage in 2011, shortening the average time between a veteran’s initial phone screen and face-to-face surgical consultation to 14 days.
Many veterans facing a potential diagnosis of mesothelioma must navigate the historically mismanaged federal agency to get the treatment they need. Because of difficulties reaching a specialized doctor at the VA, they often settle for less than optimal care, which may lead to shorter survival.
Lebenthal and Siegert hope the telephone triage program will change that.
“Open access phone triage for veterans with MPM is possible, enabling timely specialized evidence-based care nationally,” the study shows. “We demonstrated that in a federal system, a multidisciplinary team of experts can be assembled and motivated to deliver quaternary centralized care that is typically possible only in a handful of elite teaching hospitals.”
How Does the Telephone Triage Work?
Veterans typically are seen first at their local VA health care facility or at an out-of-network medical center. If they suspect pleural mesothelioma is the problem, they can start the process.
The typical telephone triage follows these steps:
- A veteran with a possible mesothelioma diagnosis from their local VA hospital or tumor board calls the Boston VA’s thoracic surgery department at 857-203-6202.
- During the approximately one-hour call, a surgeon determines if the veteran is a U.S. veteran, has VA health care eligibility and a possible diagnosis of pleural mesothelioma.
- If the disease is confirmed, a medical release form is issued to allow access to the veteran’s electronic medical records, including imaging and pathology reports.
- A radiologist, pathologist and surgeon — all experienced in mesothelioma — review the records and craft a treatment plan.
- Patient is then contacted with initial recommendations that may include travel to the Boston VA for more extensive testing and an in-person evaluation by a mesothelioma surgical specialist.
- The veteran’s regional health care system makes the travel and housing accommodations at no cost to the patient.
- After additional tests, the Boston VA’s tumor board makes a final recommendation.
The entire telephone triage process, from the veteran’s first call to the Boston VA final diagnosis, takes an average of 14 days.
Telephone Triage Shows Impressive Results
The study included 60 U.S. military veterans — all men — from 26 states who had called the telephone triage for treatment advice about malignant pleural mesothelioma. A dozen more men had called, but they were excluded from the study because they were not U.S. veterans.
All these veterans had already received initial treatment recommendations from their local tumor boards.
After researchers and doctors in Boston gathered and reviewed local test results and confirmed mesothelioma diagnosis, 38 of these veterans traveled to the Boston VA hospital for additional tests.
Once there, treatment recommendations from the Boston VA doctors varied greatly from what the local tumor boards initially suggested.
For example, the local tumor boards suggested 21 patients receive only chemotherapy, but the Boston VA determined only four patients needed that treatment.
Another four patients were initially recommended multimodal therapy, a successful treatment using combinations of radiation, chemotherapy or surgery. But the Boston VA doctors said 29 patients who called the phone triage would benefit from that type of treatment.
Additional tests showed four patients initially diagnosed with the disease didn’t even have mesothelioma.
“One surprising thing from this study is that we were able to move veterans around the country within the VA system pretty effectively,” Siegert said. “And for a heckuva lot less money than if you weren’t a veteran. We used the system already in place, and it worked.”
Boston VA Works with Brigham and Women’s
The Boston VA shares staff and facilities with the nearby Brigham and Women’s Hospital, which is an elite, multidisciplinary center for mesothelioma patients.
The VA health care system pays for the travel, which is considerably less expensive than sending the patient to a local out-of-network facility. The Boston VA has complimentary housing for its out-of-town patients and families.
“By doing everything here, we can bypass a lot of the things that would happen so slowly in the system normally,” Siegert said. “If a patient gets a first whiff that it could be mesothelioma, we can abbreviate the time vastly, and that pays off for the veteran.”
Although the definitive diagnosis, aggressive surgery and aftercare for mesothelioma takes extra staff, effort and knowledge, the Boston VA can simplify the process with its resources already in place at Brigham.
“Mesothelioma is a disease so much different than any other,” Siegert said. “The treatment is so specialized. It requires so much work just to diagnose it, let alone treat it. You can’t expect these other facilities to have all that.”
Referrals Come Differently
One surprising aspect of the study was the nontraditional referral of the patients.
Only 24 percent were referred by a medical provider. The majority used internet resources, such as Asbestos.com, or they were self-referred.
“As a physician, I had always gotten patients the old-fashioned way, from other doctors,” he said. “But that’s not the algorithm anymore. Not for this disease.”