bluuebunny/crossref_metadata_2025 huggingface dataset:
Molecular testing for colorectal and lung cancer at an academic cancer center satellite site: Opportunities for improvement.
Authors: Marmarelis Melina , Shulman Lawrence N. , Jacobson Joseph O. , Norden Andrew David
Published: February 2017

229

Background: Given their prevalence, colorectal and lung cancer are treated in both academic and community settings. Appropriate use of targeted therapies in these diseases is challenging given the need for biomarker testing prior to use. Rapidly changing practice standards, limited resources, and barriers to tissue processing make this particularly challenging in the community. We examined the use of biomarker testing and targeted therapies in colorectal and lung cancer at one of the Dana-Farber Cancer Institute satellite sites. Methods: Patients who had their first visit for colorectal cancer between 2011 and 2014 or for lung cancer in 2014 at one site were identified using ICD-9 codes. Notes and reports were reviewed for pathology, staging, molecular testing, and treatment. Results: In 2014, 46 patients had their first visit for colon cancer. MMR testing was done in 48% (22/46) of these patients. Of the 23 patients under 70 years old (NCCN guideline), 75% (17/23) were tested. From 2011 to 2014 there were 30 patients with newly diagnosed metastatic colorectal cancer. KRAS testing was done in 73% (22/30) of these patients and three were subsequently treated with EGFR targeted therapy (all 3 KRAS/BRAF wild type). In 2014, 90 patients were seen with a new diagnosis of lung cancer. Among the 36 patients with adenocarcinoma, 21 were stage IV at diagnosis and 57% (12/21) were tested for EGFR and ALK. The most common reason cited for not testing was tissue sample size (e.g. cytology from pleural fluid, CT-guided biopsy). Among the 9 patients not tested, 6 were noted to have insufficient material and in 3, testing was not requested. Conclusions: The largest discrepancy between guidelines and clinical practice was seen in EGFR and ALK testing in lung cancer. In colorectal cancer there was high concordance with NCCN guidelines and importantly these results appropriately guided EGFR directed therapy. Possible interventions to increase utilization include educational events, reflex testing on pathology, and an algorithm to pursue additional tissue when biomarker testing could significantly change therapy.
Transforming a unit’s culture to improve clinical outcomes.
Authors: Tonne Heidi , Woodrum Theresa , Romano Michael
Published: February 2017

243

Background: Leadership identified an unhealthy work environment existed in our Oncology Hematology Special Care Unit (OHSCU). This was evidenced by increased turnover, low National Database of Nursing Quality Indicators (NDNQI), and nurse sensitive quality indicator scores. In the fall of 2014 changes were made to the unit with a goal of creating within the unit a culture of clinical excellence, engagement, professionalism, accountability, and improve staff satisfaction. Methods: Leadership met to define the future state of the unit and develop a vision statement. The Quality Manager met with our Unit based Council (UBC) to review data, discuss shared accountability between leadership, and staff and the impact each individual can have on culture and clinical outcomes. Organizational Development facilitated staff focus groups without unit leadership present. Questions asked included: What behaviors would you like to see more or less of? What is your role in supporting change? Focus group results were shared with staff, and guided the development of an OHSCU Guidelines for Professional Behavior. Leadership met with lead staff nurses to discuss their willingness to embrace cultural change and unit vision. Leads completed the Crucial Conversations Class to help them provide immediate, direct, and specific feedback to staff. Leadership met with each staff member to review the guidelines and discuss their commitment to support change. The unit vision was incorporated in all written and verbal communication with staff. Changes in leadership behaviors included increased leadership presence on nights and weekends, daily rounding with patients and staff, and increased amount of positive feedback. Results: Fall injury scores were decreased from 1.55 to 0.25 per 1,000 patient days, target of 0.72. OHSCU has had no catheter associated urinary tract infections (CAUTI) or pressure ulcers in the last 17 months. Patient satisfaction scores have consistently improved over the last nine months. Response of hospital staff scores have increased from 53.6 to 70.9 and currently 90% of patients rate the hospital as a 9 or 10. Conclusions: Through focused efforts and thoughtful actions, it is possible to change the culture of a unit and have a positive impact on quality metrics.
Reducing wait time (WT) in the infusion center (IC).
Authors: Foster Gail , Lopez Lianne , Aschian Angela , Chan Betty , Inofuentes Martha , Truax Zoraida , Golingay Sally , Lynch Gwendoyn , Matsuura Peggy , Barzi Afsaneh
Published: February 2017

249

Background: Lengthy WT is the primary source of dis-satisfaction with IC services. We created a patient (PT) flow diagram outlining each step beginning from PT check-in to discharge and plotted the impact of multiple disciplines on the WT. A team of nurses, pharmacists, physicians, and administrators, analyzed the flow and identified ways to improve efficiencies. Methods: First attempt was to improve communications between pharmacy and nursing, coordinating the preparation of medications with patient’s check-in time; use of a simple clipboard facilitated this task and improved the efficiency of the system. Next, the team worked on re-routing administration of non-intravenous medications to clinic nurses. Administration of all non-intravenous medications, not requiring prolonged monitoring, was shifted to clinic nurses. Hospital policies reviewed and in-services regarding specific medication, monitoring, and administration techniques were conducted prior to this transition. Our scheduling template was ignorant of the capacity and time frames available for each PT, therefore allowing more PT than available slots. With help from information technology, the scheduling template was redesigned to include constraints that would allow scheduling to the maximum of available slots. Our center does not have an emergency room. Therefore, on a daily basis an average of 5-7% of PT load is related to urgent treatments such as blood transfusion, hydration, antibiotic therapy, etc. To proactively anticipate this volume, a virtual bed was assigned to treat only urgent cases leaving one bed open at all times. A nursing staffing plan was also developed to staff these urgent cases. Lastly, physicians were trained to turn in the chemotherapy orders ahead of the scheduled time and to be prompt in responding to pharmacy and nursing staff for order clarification. Results: We selected time from check-in to IC to start of chemotherapy as our outcome measures. Prior to implementation of changes the average WT was 3 hours (H) & 26 minutes (M). As a result of this project the WT was reduced to an average of 2 H & 46 M in the 2nd quarter and remained stable in the 3rdquarter despite a 20% increase in the volumes. Conclusions: Delivery of timely PT care is possible through multidisciplinary efforts.
Assessing the cost of cancer care delivery using a time-driven, activity-based costing software.
Authors: Incalcaterra James , Guzman Alexis B. , Huang Yu-Ting , DelValle-Garza Monica , Kolom Christian C. , Zhao Xin , Mutua Danson N , Dhingra Krishan , Feeley Thomas W.
Published: February 2017

25

Background: Poor costing systems and measurement have led to cross-subsidies and cost-shifting in health care. A large academic cancer center has adopted Robert Kaplan’s bottom-up cost accounting methodology called time-driven, activity-based costing (TDABC). TDABC in health care has been proven to be an effective cost accounting tool to measure and improve care delivery by standardizing and creating transparency around patient care processes. The project aims to process map and identify event triggers associated with each process map, use a software applications to compute the costs and resource capacities. Methods: Information technology and financial subject-matter experts integrated clinical, resource, and financial data from the institution’s enterprise information warehouse, general ledger, resource and asset management systems into the software application. Clinical business managers, nurse managers and other clinical content experts helped identify patient-level care processes. Results: The institution deployed a project team to integrate data from the institution’s enterprise information warehouse and aid in the process mapping across three multidisciplinary care centers. The team was able to successfully cost both direct and overhead costs associated with 69 head and neck, 18 endocrine, and 15-20 proton therapy patient-level processes over 7 different business department within 7 months. The resource capacity analysis was the most difficult to analyze due of the lack of transparency around resource’s clinical, administrative, and research responsibilities. Dashboards are currently being developed to help assess changes in patient care processes, cost or resource utilization. Conclusions: This methodology can be used across all health care organizations in all countries to analyze the true cost of care delivery.
Using a collaborative approach for rapid deployment of advance care planning in the outpatient oncology setting.
Authors: Severson Jane Alcyne , Smerage Jeffrey B. , Lindsay Jamie , Petersen Laura , Swetz Keith Mark , Kamal Arif
Published: February 2017

255

Background: The Michigan Oncology Quality Consortium (MOQC) is a quality collaborative supported by Blue Cross Blue Shield of Michigan with the goal of improving cancer care in Michigan by using data gathered as part of the national Quality Oncology Practice Initiative (QOPI) program. In spring 2014, MOQC launched a statewide collaborative focused on advance care planning (ACP) with the following aim: to provide training and resources on how to engage patients in a discussion of goals, preferences, and priorities for care. Methods: The collaborative was comprised of three half day learning sessionsthat included an overview of legal and documentation requirements, and facilitator-lead role play with patient actors. Lean resources (templates, workflows) to support standard work in the clinic were disseminated. Eight oncology practices participated ranging in size from 1-25 physicians. ASCO QOPI data were analyzed pre and post collaborative in spring 2014 and spring 2015. Results: Improvement in QOPI performance from spring 2014 to 2015 on “hospice enrollment, palliative care referral/services, or documented discussion” (73.8% to 77.6%) and “for patients not referred, hospice or palliative care discussed within the last 2 months of life” (17.7% to 23.9%) was noted for participating practices (n = 8). Collaborative participants also compared favorably to all other MOQC practices (n = 47) in spring 2015 on “hospice enrollment, palliative care referral or documented discussion” (77.6% vs. 66.2%) (p < 0.001). Conclusions: Use of a collaborative education modelthat includes facilitator-lead role play and dissemination of lean resources to create standard work may be an efficient and effective approach to improve discussion and documentation of advance care planning.
Quality and value of subspecialty reinterpretation of outside thoracic CT scans of patients referred to a tertiary cancer center.
Authors: Carter Brett W. , Erasmus Jeremy J. , Truong Mylene , Munden Reginald F. , Shepard Jo-Anne O. , Clarke Ryan Kristopher , Steele Joseph Rodgers
Published: February 2017

265

Background: At tertiary cancer centers, physicians frequently request reinterpretation of imaging studies performed at outside institutions. The purposes of this study were to determine the quality of outside computed tomography (CT) scans of the chest and compare the accuracy of accompanying radiology reports from outside institutions and our multidisciplinary cancer center. Methods: Two thoracic radiologists graded the quality of 59 outside chest CT scans and generated independent reports for 52 of the scans. A third thoracic radiologist scored the outside reports and reinterpretations for quality. Fisher’s exact tests were used to compare the frequency with which crucial items appeared in outside reports and reinterpretations. Next, two outside thoracic radiologists identified discrepancies between outside reports and reinterpretations (first radiologist) and determined whether the outside report or reinterpretation was more accurate in each case (second radiologist). Finally, the impact of discrepancies on management was evaluated, largely based on NCCN guidelines. Results: Of the 59 outside CT scans, 35 (59%) were of poor quality. Reinterpretations were more likely than outside reports to include information about lymph nodes, adrenal and liver metastasis, tumor nodules, and tumor texture. In 19 of 52 cases (37%), discrepancies were identified between outside reports and reinterpretations. In 17 of these cases, the reinterpretation was superior; in 2 cases, the reinterpretation and outside report were of equal quality. Among these 17 cases, reinterpretation allowed staging in nine cases that could not be staged with information from the outside reports; resulted in upstaging without management change in one case and upstaging with management change in four cases among the five cases with staging information present in both sets of reports; and revealed a significant omission (2 cases) or error (1 case) that changed management in three cases. In total, reinterpretation resulted in significant changes to 16 of 52 (31%) of CT scans. Conclusions: Subspecialty reinterpretation of chest CT scans can substantially improve clinical management.
Initiating a lymphedema screening program for breast cancer patients: Determining variability as a first step towards standardization.
Authors: Shaitelman Simona Flora , Ferguson Susan E , DeSnyder Sarah Marie , Kheirkhah Parviz , Lilly Susan , Travis Marigold , Johnson Theresa , Alvarez Ana , Rohe Duke , Buchholz Thomas A. , Bedrosian Isabelle
Published: February 2017

267

Background: Breast cancer-related lymphedema (BCRL) is a known morbidity from treatment, and yet published estimates of its incidence are highly variable. Typically, a single volume measurement is recorded and the degree of intra-rater variability undefined. A threshold 5% limb volume change over time is used to define “mild lymphedema.” Therefore, small variations in volume measurements could substantially lead to over or under-diagnosis of BRCL. Gage R&R is a measurement systems analysis tool that quantifies the amount of variability induced in measurements by the measurement system itself and compares this to the total variability observed. The objective of this study was to define the degree of variability in perometer arm volume measurements and factors contributing to this. Methods: A medical assistant (MA) was trained by a certified lymphedema therapist (CLT) to perform perometer-based lymphedema screening in the MD Anderson Nellie B. Connally Breast Center. Three measurements of each arm were taken and intra-rater variability against the mean calculated. Gage R&R testing was performed by the MA and CLT, to determine the degree of repeatability and reproducibility variation. As a part of this analysis, 30 patients had both their left and right arm volume measured 3 times by each measurer. Results: Over 6 months, 565 breast cancer patients had preoperative BCRL screening by the MA, with an overall intra-rater variability of 2.2%. Among the 30 patients in the Gage R&R study, median body mass index (BMI) was 27.7 (range 19.7-38.3), median height 1.61m (range 1.52-1.73m), intrarater variability of the MA was 2.07% and of the CLT was 1.21%. Gage R&R accounted for 4.77% of total variability, 1.26% repeatability and 3.51% reproducibility. Regression analysis demonstrated that patient BMI and height impacted variability in measurements (R2= 16.27). Conclusions: Intra-rater variability for perometer arm measurements diminishes with experience. Gage R&R variability is acceptable per industry standards, but there is room for improvement. Our findings suggest a role for targeted interventions to minimize variability in the diagnosis of BCRL based on patient characteristics.
Adopting QOPI metrics into a continuous plan for learning across a five hospital network.
Authors: Denny Diane , Dunn Kathleen , Hepler Marjorie , Allen Debra Kay , Markman Maurie
Published: February 2017

268

Background: Cancer Treatment Centers of America, Inc. (CTCA) is a national network of five hospitals that specialize in the treatment of patients fighting complex or advanced stage cancer. Utilizing metrics from the Quality Oncology Practice Initiative (QOPI), CTCA developed a “QOPI related continuous measures plan” from those areas of opportunity which fell greater than 10% below the QOPI aggregate score based upon its centers initial data abstraction efforts and findings. A total of 20 QOPI related measures were selected. The plan endorsed by clinical leaders and administration targeted at 50% improvement in these measures within 18 months. Methods: A crosswalk of metrics including patient inclusions and exclusions was developed for the continuous measures plan with data abstraction efforts based upon a review of new patients regardless of analytic or non-analytic status. As they progress through their treatment course, some measures are reported quarterly while others are reported semi-annually given volumes. A composite target of 71.2% was identified using T2 methodology, halving the distance between desired level of performance and the lowest facility baseline. Multiple educational efforts and strategies were deployed including efforts to redesign elements in the EHR. Results: The results are made visible in a number of different forums including a quality dashboard housing quarterly data and a monthly operations review process. A composite score in which data is rolled up from all 20 measures is reported as a key performance indicator across all five centers. Baseline composite through current performance is shown below by facility and in total. Conclusions: The QOPI related continuous measures plan is an evolving performance improvement process providing clinicians with an achievable goal for improving patient care. Team members anticipate surpassing the target through current and planned interventions. [Table: see text]
ASCO PRO workgroup update: Patient-reported outcome measures as a quality indicator.
Authors: Stover Angela M. , Chiang Anne C. , Basch Ethan M.
Published: February 2017

276

Background: Although patient questionnaires are commonly used to assess healthcare experiences (e.g., satisfaction with care), patient-reported outcome (PRO) measures assessing symptoms and physical functioning have not conventionally been used for quality assessment. More typically, quality of care is measured with administrative data, such as hospital readmission rates. There is an opportunity to advance the science of quality measurement by integrating a patient-centered approach. Methods: ASCO established a multi-stakeholder PRO Workgroup (including extensive patient input) to develop and test PRO-based performance measures (PRO-PMs). The ASCO PRO Workgroup outlined three initial PRO-PMs to test for patients receiving moderately/highly emetogenic chemotherapy: 1) process: proportion self-reporting symptoms at, or within 2 weeks, of last visit; 2) outcome: proportion experiencing moderate/high levels of nausea; and 3) outcome: proportion reporting moderate/high pain. We will give an update on progress of the ASCO PRO Workgroup and outline next steps needed to implement PRO measures as a quality metric. Results: Three key methodological advancements are needed before PRO measures can be used as a quality metric. First, areas of cancer care delivery need to be identified that are important to patients when considering quality of care and are amenable to performance evaluation with PRO measures (e.g., symptom control). Second, existing PRO questionnaires need to be systematically identified and evaluated for potential quality use. The review should evaluate psychometric properties, validity and reliability, and feasibility for clinical use. Third, testing is needed in representative practice settings to iteratively refine: 1) logistical strategy for systematically collecting this information at the practice level; 2) approaches for minimizing missing data, particularly from underserved populations; and 3) adjustments for patient characteristics (case-mix). Conclusions: Methodological advancements are necessary before PRO measures can be implemented as a quality metric. PRO measures have the potential to provide quality assessments that are useful to patients making health care decisions.
NCI Community Cancer Center Program (NCCCP): Disparities in time between cancer diagnosis and treatment initiation.
Authors: Teixeira-Poit Stephanie , Spain Pamela , Halpern Michael T. , Castro Kathleen M. , Prabhu Das Irene , Adjei Brenda A. , Clauser Steven
Published: February 2017

279

Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve care and reduce cancer disparities at community hospitals. This study examined the number of days between diagnosis and treatment for five National Quality Forum-endorsed cancer quality measures. Methods: A retrospective analysis of data from patients diagnosed and receiving breast or colon cancer treatment at 12 NCCCP sites was performed. We examined time to treatment for cancer quality measures, stratified by concordant and non-concordant patients. We compared patients diagnosed before (2006 – 2007) vs. during (2008-2013) the NCCCP period. Results: Concordant Cases. Time to treatment was significantly greater in the NCCCP vs. pre-NCCCP periods for three measures. Compared to pre-the NCCCP period, time to treatment in the NCCCP period was longer by 26 days for women with breast cancer receiving hormonal therapy (HT). Time to HT increased significantly among most patient and hospital subgroups (race, age, insurance, hospital size). Black, Medicaid, and/or uninsured patients generally had longer-than-average time to treatment for all measures when receiving guideline-concordant care. Non-Concordant Cases. Among women with breast cancer who received treatment outside the measure window, most eligible for multi-agent chemotherapy received treatment within one month after the cut-off. In contrast, a majority eligible for other cancer quality measures received treatment more than one after the cut-off. Among women who were non-concordant for HT, those with Medicare or private insurance were significantly more likely to begin HT within one month after the cut-off than were those with Medicaid. Conclusions: More than half of patients non-concordant on cancer quality measures received treatment more than one month after the treatment window. However, many were non-concordant because they were just outside the time window to be considered concordant (< 30 days), particularly Medicaid patients. Rapid reporting of quality indicators could inform targeted efforts to improve care coordination and concordance rates, particularly among certain patient subgroups.
Assessing the impact of restricted follow-up and small sample sizes on survival estimations in prostate cancer using registry data.
Authors: Shah Dhvani , Paly Victoria , Briggs Andrew , Sidhu Manpreet , Ma Esprit , Bonthapally Vijayveer
Published: February 2017

294

Background: Economic evaluations in oncology aim to assess the value of new therapies in the long term based on clinical trial data that often have restricted follow-up times (< 5 years) and small sample sizes (< 500 patients). This requires the use of extrapolation assumptions on long-term survival that go beyond the observed data. In this analysis, differences in survival extrapolation methods are tested in samples of sizes and follow-up reflecting typical clinical trials against a background of known survival in prostate cancer from a US based cancer registry. Methods: Data from the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) registry on long-term survival in patients with stage IV prostate cancer were employed. The data set comprised those patients diagnosed between 1988 and 2003, with follow-up data available until 2012. Additional survival for those who received surgery (compared to those who did not), was estimated based on extrapolations using standard parametric statistical models (exponential, Weibull, log-logistic, log-normal, Gamma) fitted to the observed data. Survival analyses were run for 5 sample size scenarios (n = 27,670, 1000, 500, 200, 50) and 6 follow-up scenarios (follow-up years = 25, 20, 10, 5, 2, 1) yielding 30 combination scenarios. Performance of the methods was tested relative to the maximum follow-up, maximum sample size scenario (i.e. reference case) from the SEER registry. Results: Log-logistic and log-normal models were associated with flat tails which led to inflated survival estimations. For scenarios with smaller sizes, gamma models often did not converge. Exponential models were the most frequently reported as best model fit (in approximately 50% of scenarios). Also, gains in OS were consistent when exponential models were selected, and closely matched gain in OS from the reference case. Conclusions: Since clinical trials in oncology are often associated with small patient sample sizes and restricted follow-up, selecting an exponential model may lead to the most consistent and stable results based on the experiment constructed here. Further research should confirm these results for other types of cancer.
Time trends in opioid use in cancer and noncancer patients: Observations from administrative data.
Authors: Barbera Lisa Catherine , DeAngelis Carlo , Earle Craig , Atzema Clare , Dudgeon Deborah Jane , Gomes Tara , Howell Doris , Husain Amna , O'Brien Mary Ann , Seow Hsien , Sussman Jonathan , Sutradhar Rinku , Chu Anna , Liu Ying
Published: February 2017

298

Background: Opioid prescribing has been increasingly scrutinized in the non-cancer patient population due to concerns with morbidity, mortality and diversion. Resulting regulatory changes have decreased prescribing. As an unintended consequence, we hypothesized that cancer patients might be similarly impacted. Methods: All Ontario residents ≥ 65 years are eligible for government paid pharmacare. For each year from 2004 to 2013, Ontarians ≥ 65 years were stratified into 3 groups: no cancer history, cancer diagnosis > 5 years ago and cancer diagnosis ≤ 5 years ago. We evaluated time trends in 2 outcomes: (1) opioid prescription rate = total number of pharmacare claims / total population of ≥ 65 year olds, and (2) mean daily opioid dose (in morphine equivalents) = sum of all patient’s mean daily opioid doses over their first 90 days of opioid therapy in each year / total patients with an opioid prescription in that year. Results: Ontario’s population of ≥ 65 year olds increased each year with 2.1 million residents in 2013 (5% recent cancer, 10% remote cancer). Demographics were similar by year for each group. Across all years, overall opioid prescription rates were highest for those with a recent cancer and lowest for those with no cancer history. Overall prescription rates increased over time by 23%, 14% and 10% in the non-cancer, remote cancer and recent cancer groups respectively, primarily due to increases in long acting opioids and immediate release single agents. Decreases were seen in long acting oxycodone and fentanyl prescriptions in all cancer groups. The mean daily opioid dose increased for patients receiving long acting oxycodone and fentanyl but was relatively stable for other drug classes. With the exception of immediate release single agents, the mean daily dose was similar between cancer groups regardless of drug class. Conclusions: Regulatory measures have succeeded in decreasing prescription rates in some but not all drug classes among Ontarians aged ≥ 65. Changes over time in both prescription rates and mean daily opioid dose were similar for all 3 groups, suggesting that factors influencing prescribing are affecting cancer and non-cancer patients similarly, possibly to the detriment of some cancer patients.
Factors affecting multidimensional caregiver burden: Results from national surveys.
Authors: Halpern Michael T. , Fiero Mallorie , Bell Melanie
Published: February 2017

301

Background: Quality of care for individuals with cancer is affected by the burden on their caregivers. For high quality care, it is important to understand domains of caregiver burden and factors affecting this burden. Methods: Using data from two national surveys, the National Survey of Caregiving (NSOC) linked to the National Health and Aging Trends Survey (NHATS), we identified all participants in the NHATS diagnosed with cancer who had a caregiver participating in the NSOC. Twenty-two items in the NSOC related to caregiver health, mood and outlook were included in factor analysis to develop scales capturing domains of burden. Multivariable regression analyses examined whether activities performed by caregivers and supports for caregivers were associated with these burden scales. Results: Analysis of responses from 245 caregivers of cancer patients identified three scales: emotional burden; psychological burden; and relationship with the patient. Providing assistance managing medical care was associated with increased emotional and psychological burden, while assistance with non-medical issues was increased psychological burden and worsened relationships with patients. Caregiver provision of direct patient care activities was also associated with increased burden but improved relationships with patients. Use of support services showed mixed associations with burden. Conclusions: Using a nationally-representative sample of cancer patients and their caregivers and brief publicly-available survey questions, we present three scales addressing different aspects of caregiver burden that are responsive to caregiver activities and social supports. This may assist in developing and evaluating intervention to decrease caregiver burden and thereby improve quality of care for individuals with cancer.
Ontario’s approach to tackling drug funding sustainability.
Authors: Anas Rebecca , Gavura Scott , McLeod Robin , McLaughlin Virginia , Earle Craig , Arias Jessica , Rey Michelle , Jamal Hasina
Published: February 2017

38

Background: One of the challenges facing Ontario relates to managing the rising costs of cancer drug treatments. The annual growth rate of cancer drug spending has increased by 10-20% since 2010, exceeding other therapeutic categories and is expected to continue to grow significantly faster than expenditures in other areas. Paradoxically, the price of a drug seems to have little relation to its demonstrated efficacy ( http://www.asco.org/practice-research/cancer-care-america-2015/focus-cost ). The Cancer Quality Council of Ontario (CQCO) and Cancer Care Ontario (CCO) embarked on a journey to systematically address this challenge. Methods: The CQCO and CCO focused on identifying and reviewing the critical success factors of a sustainable drug reimbursement program with international, pan-Canadian and internal input. Recognizing that drug funding sustainability is a challenge faced by health systems worldwide, the scope of this work was broadened from a provincial focus to one that was relevant across the Canadian context. Results: Ultimately, this work resulted in CQCO providing a core set of recommendations for CCO that may also be relevant to other reimbursement programs, in order to maximize the effectiveness of cancer drug use and support overall system sustainability in a patient-centred way. The recommendations to address drug funding sustainability included: (1) Transparency in drug funding decisions; (2) development of process to incorporate current best evidence to support system sustainability; (3) development of a consistent approach to gathering and analyzing real world evidence (RWE); (4) development of a consistent process for disinvestment and renegotiation of prices with buy-in from public, patients and clinicians; (5) development of a provincial process to maximize harmonization in cancer drug funding coverage decisions; (6) refinement of the algorithm and priority setting for review of drug submissions; and (7) incorporating RWE into funding decisions and downstream re-evaluation. Conclusions: CCO is determining an action plan based on the above recommendations and developing partnerships to support successful implementation to improve sustainability in regards to cancer drug funding.
Effect of insurance status on receiving standard quality care treatment in patients with stage III colon cancer.
Authors: Master Samip R. , Liu Lihong , Dhaibar Hemangini , Mills Glenn Morris , Shi Runhua
Published: February 2017

45

Background: NCCN (National comprehensive Cancer network) recommends adjuvant chemotherapy for stage 3 colon cancer patients. National Cancer Data Base (NCDB) data were analyzed to investigate the impact of insurance status on receiving standard quality of care with adjuvant chemotherapy for stage 3 colon cancer patients. Methods: Data was analyzed from 11,563 men and women, between ages 18-80 years, registered in the NCDB who were diagnosed with stage 3 colon cancer between 1998 and 2011 and had follow-ups to end of 2012. The primary predictor variable was payer status and the outcome variable was treatment received. Additional variables addressed and adjusted for included sex, age, race, Charlson Comorbidity index, education, income, distance traveled facility type and diagnosing/treating facility. Results: Among these 11,563 patients, the mean age at diagnosis was 60.3 years (median, 61 years). The mean ages at diagnosis were 53.3, 54.9, 53.9, 69.6, and 58.2 years for uninsured, private, Medicaid, Medicare and unknown payer status, respectively. In multiple logistic regression analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of not receiving adjuvant chemotherapy. Relative to privately insured patients, patients with Medicaid were 2.20 times, Uninsured were 2.16 times, Medicare was 1.76 times, and unknown insurance were 2.25 times more likely not to receive adjuvant chemotherapy, respectively. Compared to age group 18-49 years, patient with age group 50-64 years, 65-74 years and 75+ years were 1.59, 2.54 and 5.59 times more likely to not to received adjuvant chemotherapy, respectively. Of the factors analyzed, age, comorbidity index, insurance and distance travelled to treatment center were statistically significant predictors of a patient not receiving adjuvant chemotherapy. Conclusions: We observed that payer status has a statistically significant relationship with stage 3 colon cancer patients not receiving adjuvant chemotherapy. This remained true after adjusting for other predictive factors. Further research is necessary to investigate how the treatment disparities are associated with different types of insurance.
Eleven-year experience with a web-based medication occurrence (MO) reporting tool in a community oncology practice.
Authors: Hoverman J. Russell , Jang Tae W , Schwartz Jim R.
Published: February 2017

53

Background: At ASCO 2007, we presented 2 year experience with a web-based Medication Occurrence (MO) reporting tool. We now report the 11 year experience in a single outpatient oncology practice. Methods: Since December 2003, Texas Oncology (TxO) sites have entered information on Medication Occurrence (MO) reports in an electronic Variance Reporting tool. The pharmacy management team generates reports monthly for the Texas Oncology Quality Oversight Committee and each site Quality Committee for analysis and follow-up action. The data are analyzed according to a pre-set group of parameters (retail vs. clinic, near miss vs. actual occurrence, severity level 1-8, categories of occurrence). Recently these data were analyzed for the years 2004-2014 to assess trends in MOs. Results: Over 11 years there were 2,163,249 transactions for a chemotherapy infusion or injection. There were 10845 MOs of which 5,143 were adverse drug reactions (ADRs). Near misses accounted for 16.7% of unadjusted MO rate and 31.8% when ADRs were excluded. MO rate with ADR was 0.46%, without ADR 0.24%. Retail MO rate was 0.02% on 1,771,148 transactions. Rituximab was 20.9% and paclitaxel 16.4% of ADRs. Tying reporting to clinic performance increased reporting by site and number of sites. EHR related MOs and Near Misses were each reported as MOs and artificially inflate numbers due to double counting. There were 10 deaths over 11 years. With these data, we were able to 1) Promote an epinephrine protocol for severe drug reactions, 2) Obviate the need for AEDs at every site, 3) Find no difference in rituximab reactions by geographic region, 4) Make assessments regarding cost and toxicity of iron compounds, 5) Target specific drugs for ADR risk. 6) Assess prophylactic corticosteroid regimens in taxane administration. Conclusions: Web-based reporting in the outpatient community setting is feasible and identified many topics for quality improvement initiatives. The importance of double-checking and a culture of safety is reinforced by the number of avoided MOs indicated by the near miss percentage.
Accessibility and barriers to oncology appointments at 40 NCI-designated cancer centers.
Authors: Hamlyn Geoffrey , Hutchins Kathryn , Johnston Abby , Thomas Rishonda , Tian James , Kamal Arif
Published: February 2017

55

Background: Newly diagnosed cancer patients face fear and uncertainty regarding their prognosis and treatment options. As a first step, these patients and their family members may reach out to top-tier, comprehensive cancer centers for evaluation and treatment; however, recent literature reveals barriers to access. To identify these barriers, we evaluated obstacles patients and caregivers face in accessing services at major cancer centers. Methods: We used a ‘mystery shopper’ format to contact 40 NCI-designated, comprehensive cancer centers. We simulated a patient’s family member calling to make an initial consultation appointment using a standardized script. Each center received four calls on separate dates – two calls presented a patient with private insurance; two with Medicaid. Call order and patient name were randomized. We evaluated quantitative and qualitative components of the call, including time to next available appointment and availability of supportive services. Descriptive statistics were calculated for each quantitative measure. Results: We placed 160 calls to 40 NCI-designated cancer centers. 117 (73%) of calls were first answered by electronic prompts or voicemail, not a live person. Mean call duration was 9.4 minutes, with a range of 1 to 31.9 minutes. On average, callers spent 7.1 minutes speaking to an attendant and spent 2.4 minutes on hold or being transferred. Only a minority of callers (19.3%) were able to obtain an actual date for a next-available appointment without first registering into the cancer center’s records system. 51.3% were given an estimated date for a next-available appointment and 29.4% were told that a date for an appointment could not be estimated unless the patient was registered. When an appointment date was given (estimated or actual), only 27% were within a week. Specifically, only 1.3% of next-available appointments were within 1-2 days, 25.7% were within 3-7 days, 57.5% were within 7-14 days, 15% were not available until > 14 days. At the most extreme, the next-available appointment was not for 37 days. Conclusions: NCI-designated cancer centers often place significant roadblocks in front of patients and caregivers seeking an appointment.
Association of high rates of practice-level inpatient-intensity with end-of-life outcomes, readmission rates, and weekend hospitalizations among Medicare patients with cancer.
Authors: Clough Jeffrey D , Strawbridge Larisa M , LeBlanc Thomas William , Hammill Bradley G , Kamal Arif
Published: February 2017

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Background: Substantial practice-level variation exists in use of acute hospital care for patients receiving anti-cancer therapy. The aim of this study was to determine whether patient outcomes were associated with greater inpatient-intensity at the treating practices. Methods: Retrospective analysis of 397,646 Medicare beneficiaries receiving anti-cancer therapy in 2012. Each beneficiary was associated with a practice and practices were ranked based on average payments for inpatient admissions (inpatient intensity). Outcomes included 30-day readmission, weekend admissions, intensive-care unit (ICU) stays in the last month of life, and hospice stay of at least 7 days. Outcomes were measured for each quartile of practice inpatient-intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios for each outcome for each quartile of inpatient-intensity. Results: Total and unplanned 30-day readmissions increased from 22.8% to 31.9% (adjusted odds ratio and 95% confidence interval: 1.45 [1.39-1.50]) and 19.8% to 27.1% (1.36 [1.31-1.41]), respectively, for patients in practices in the lowest and highest quartiles of inpatient-intensity. The proportion of admissions occurring on the weekend was similar across quartiles. The proportion of decedents with an ICU stay in the last month of life increased from 18.0% to 25.5% (1.33, 1.19–1.49) while the proportion with a hospice stay of > = 7 days decreased from 50.9% to 42.5% (0.79, 0.74–0.86) between those in practices in the lowest and highest quartiles of inpatient intensity. Conclusions: Participants in oncology practice delivery reform may find significant opportunity to improve quality and reduce costs by initially focusing on processes related to improving end-of-life care and reducing readmissions.
Confidence in self-managing side effects from oral oncolytics among a sample of Michigan oncology practices.
Authors: Mackler Emily R. , Salgado Teresa M , Severson Jane Alcyne , Lindsay Jamie , Batra Peter , Petersen Laura , Farris Karen B
Published: February 2017

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Background: The aim of this study was to assess patient confidence to self-manage common side effects of oral oncolytic agents among cancer patients whose providers participated in the Michigan Oncology Quality Consortium (MOQC). Methods: This was a cross-sectional study conducted between August and September 2015, enrolling a convenience sample of 125 patients currently taking oral oncolytics in 10 oncology practices who completed a brief online survey. Demographics, clinical information, health literacy (3 items) and Patient Activation Measure (PAM, 13 items) were assessed. The PAM instrument assesses patient self-reported knowledge, skills and confidence for self-management. Participants were also asked to rate on a scale 0-10 how confident they felt self-managing 3 common oral oncolytic side-effects: fatigue, nausea and diarrhea. Differences by age, gender, education level, health literacy, and PAM level were examined. Results: Respondents were 66.2 (SD, 13.6) years old and 57.7% were female. The mean length of oral oncolytic therapy was 12.9 (SD, 13.8) months and average number of medications was 5.9 (SD, 3.2). Approximately three-quarters of patients assessed had high levels of patient activation (41.5% level 3 and 32.5% level 4), with the remaining 26.0% having low involvement in their care (17.1% level 1 and 8.9% level 2). Confidence to manage fatigue was high for 79% of patients, moderate for 12.1% and low for 8.9%. Confidence to manage nausea and diarrhea was higher with 85.5% and 88.7% patients reporting high confidence, respectively, but 6.5% and 4.8% reporting low confidence to manage these two symptoms. When combining the confidence measures to manage each of the three symptoms, patients with higher health literacy (p = 0.001), higher PAM levels (p = 0.018) and older patients (p = 0.041) exhibited higher confidence at a statistically significant degree. Conclusions: Healthliteracy and PAM were associated with patient confidence to self-manage oral oncolytic side effects. Health literacy screening in clinical practice may be an efficient means to identify patients with low self-management confidence and determine needs of further education and support.
The value of secondary pathology review.
Authors: Middleton Lavinia P , Mayo Tinisha L. , Spinks Tracy E. , Cheney Richard , Chu Peiguo , Cooper Harry S. , Dintzis Suzanne , Ehya Hormoz , Fletcher Christopher D. , Gerwirtz Amy , Magliocco Anthony Martin , Martin Sue Ellen , Rosenberg Andrew E. , Sherrod Andy , Tan Lee K , Wood Brent L. , Walters Ronald Stewart
Published: February 2017

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Background: Improving the value of cancer care is a major focus for the Alliance of Dedicated Cancer Centers (ADCC). Looking to align with the Institute of Medicine’s (IOM) initiative to “Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice,” the ADCC implemented a study to examine the clinical impact of expert secondary pathology review. The goal of this project was to: 1) demonstrate the value of secondary review of outside pathological specimens by ADCC subspecialty pathologists in identifying significant errors that can potentially impact treatment; and 2) create an opportunity to improve patient cancer care. Methods: All consult slides from patients referred to each ADCC center were reviewed by designated pathologists. Patient-level data for original and revised diagnoses were collected for two months in 2014. Discrepancies were classified as: 1) major - diagnosis changes treatment or surveillance; or, 2) minor - diagnosis does not change affect treatment or surveillance. To verify these assessments, disease-specific, multi-center teams of clinical experts reviewed each discrepant case and provided treatment recommendations for the original and revised diagnoses. Results: A total of 13,109 cases were collected across all ADCC centers and the discrepancy rate was 11% (1,488/1309); 3% (359/13,109) were major and 9% (1,129/13,109) were minor. The most common discrepancy was reclassification of the neoplasm cell type. The highest discrepancy rate was shown in the neuro-oncology and head and neck cases, with a 7% and 4% major discrepancy rate respectively. Conclusions: We identified an overall discrepancy rate of 11%, with 3% of cases leading to a change in treatment or surveillance. This demonstrates the importance of expert pathology review and that secondary pathology review can significantly improve clinical outcomes through precise and accurate pathological diagnoses. As indicated in the recent IOM report, this project further demonstrates that “diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions.”