bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving quality of pediatric cancer survivor care: Providers’ support of and experience with survivor care plans.
Authors: Warner Echo L. , Hacking Claire C , Wu Yelena , Kirchhoff Anne C.
Published: February 2017

190

Background: Clinical integration of Survivor Care Plans (SCPs) varies. This study assessed pediatric oncology providers’ familiarity with and preferences for providing survivor care and SCPs. This research aims to inform efforts to improve the quality of pediatric cancer survivorship care through increased implementation of SCPs. Methods: From November 2013-April 2014 oncology providers (physicians n=18; nurses n=23) were recruited from the Pediatric Oncology clinic at Primary Children’s Hospital in Salt Lake City, UT. Participants completed a 25-item survey (N=41). A subset participated in a 45 minute focus group (n=17). Participants reported their familiarity with and training on survivorship care, opinions on SCP efficacy, and barriers to using SCPs. To evaluate differences in survey responses for physicians and nurses, we generated Fischer’s exact tests. Focus group transcripts and open-ended survey responses were content analyzed. Results: More oncologists reported familiarity with SCPs (94% vs. 30%, p<0.01) than nurses. Top sources of training for cancer late effects included colleagues (66%), conferences (54%) and medical journals (37%). More oncologists (35%) than nurses (5%) reported ever providing a patient with an SCP (p=0.03). Oncologists also prioritized the clinical integration of SCPs more than nurses (69% vs. 29%, p=0.02). Top perceived barriers to using SCPs in clinical practice included: not knowing enough about SCPs (67%), using SCPs not expected (54%) and no champion (49%). In the qualitative comments, providers expressed that patient age variation made timing of SCP delivery difficult. Most participants were supportive of testing an SCP intervention program (95%) and felt this effort should be done within the context of the multidisciplinary healthcare team. Conclusions: As of now, this clinic has no standard procedures for disseminating SCP and survivorship care, yet the providers we surveyed supported testing an SCP program to improve the quality of their patients’ care. The implementation of coordinated pediatric cancer survivor care should include provider training and testing strategies to implement SCPs more consistently within clinical care.
Factors correlated with HPV vaccination in the LGBT community.
Authors: Anders Amber M. , Chagpar Anees B.
Published: February 2017

202

Background: Human papillomavirus (HPV) infections and related cancers including cervical and anogenital cancer disproportionately affect LGBT populations. Currently, little is known about HPV vaccination in this community. The purpose of this study was to determine what factors were correlated to HPV vaccine receipt in LGBT individuals. Methods: A prospective web-based survey was conducted with regards to cancer related risks in LGBT populations. The data set was restricted to individuals ≤26 years of age who identified as LGBT (n=206). All analyses were performed using SPSS software v.22. Results: Of the 206 individuals in this survey, 92.2% stated they had heard about the vaccine, and 53.4% had received it. Factors correlating with receipt of the vaccine on bivariate analysis are shown in the table below. On multivariate analysis, gender and having a usual site of care remained significant predictors of having received the vaccine. Women were 3.6 times more likely to receive the vaccine than men (95% CI: 1.97-6.71, p <0.0001), and those that had a usual place for health care were 2.9 times more likely to be vaccinated than those who did not (95% CI: 1.26-6.50, p< 0.012). (See Table.) Conclusions: In this survey, 53.4% of people reported having received the HPV vaccine. The only predictive factors of receipt of the vaccine were female gender and having a usual site of care. This reinforces the need for clinicians to be cognizant of vaccinating gay or bisexual men against HPV, and highlights the importance of having a usual site of care as a public health imperative in this population. [Table: see text]
Evaluation of national treatment trends in ovarian cancer.
Authors: Seal Brian S. , Yao Jianying , Kish Jonathan K , Stafkey-Mailey Dana , Eaddy Michael
Published: February 2017

204

Background: Evaluate patterns of care among women diagnosed with metastatic (M) and non-metastatic (NM) ovarian cancer (OvCa). Methods: Using MarketScan Commercial/Medicare databases, women ≥18 years old with primary diagnosis of OvCa continuously enrolled ≥6 months pre- and post-index diagnosis were selected. Patients receiving chemotherapy (chemo) prior to index diagnosis were excluded. Eligible patients were stratified into NM and M cohorts and M patients into those diagnosed with M ≤90 days (M1), 91-180 days (M2) and ≥ 181 days (M3) post index diagnosis. Types of treatments, time to initiation and adherence to NCCN treatment guidelines were evaluated. Results: A total of 64,483 women were included; 59,277 (91.9%) NM and 5,472 (8.1%) M. Among M patients, 70.5% were M1, 4.5% M2 and 25.0% M3. Of the NM 57.1% underwent surgery (mean = 43 days), 2.5% received chemoradiation (chemorad) therapy (mean = 618 days), 2.5% received chemo (mean = 213 (NCCN) to 496 (nonNCCN) days), 3.4% received any oral antineoplastic (chemo/non, hormone, other, mean = 635 (NCCN) to 584 (nonNCCN) days), and 1.7% received hormone therapy (mean = 537 days) post index diagnosis. In comparison 70.0% of M patients had surgery, 37.2% received chemorad, 63.9% received chemo, 10.2% received an oral antineoplastic, and 19.0% received hormone therapy. As time to M diagnosis increased, utilization of chemorad (33.5% M1 to 46.9% M3), hormone therapy (17.9% M1 to 21.6% M3), and oral antineoplastic (8.9%% M1 to 14.2% M3) increased while receipt of surgery (76.6% M1 to 53.1% M3) and chemo (68.6% M1 to 52.3% M3) decreased. Time to initiation of all treatments increased as time to M increased. Among NM patients receiving oral antineoplastic 1.9% received NCCN recommended agents compared to 66.0% of M patients (72.2% M1 to 55.7% M3).Similarly, 52.2% of NM patients receiving chemo received NCCN recommended treatment compared to 98.3% of M patients (99.0% M1 to 96.2% M3). Conclusions: As recommended by the NCCN guidelines surgery was the standard of care for all patients. Utilization of chemo, chemorad and oral antineoplastics were largely reserved for M patients. M patients with a longer duration between initial and M diagnosis were more likely to receive treatment not recommended by NCCN guidelines.
Do breast cancer treatment and imaging providers follow hereditary breast and ovarian cancer risk screening guidelines?
Authors: Tossas-Milligan Katherine Y. , Murphy Anne Marie , Weldon Christine B. , Trosman Julia Rachel , Simon Melissa A. , Roggenkamp Betty , Gradishar William J.
Published: February 2017

207

Background: Women with personal or family history suggestive of susceptibility to hereditary breast or ovarian cancer (HBOC) should be referred to genetic assessment (USPSTF, Ann Intern Med. 2005). Women with HBOC have a 50-85% lifetime risk of breast cancer, 30-50% of breast cancer before 50 years old,15-50% lifetime risk of ovarian cancer, and 40-60% chance of developing a second breast cancer (ASCO Cancer.net HBOC 8/2013). Our goal is to examine if this almost decade old guideline is followed in breast cancer treatment and breast cancer imaging centers in a large metropolitan area. Methods: We conducted an IRB approved web survey of all 35 breast cancer treatment sites (5 academic, 21 community, 9 public or safety net) and 58 breast imaging sites (5 academic, 27 community, 26 public or safety net) in Chicago. Results were analyzed using simple frequencies and Fisher's exact test. Results: We achieved a response rate of 91% (32/35 treatment sites, 53/58 imaging sites). We found that 56% (18/32) of treatment sites have a hereditary cancer syndrome (HBOC) screening process for newly diagnosed breast cancer patients. Most of these sites, 83% (15/18), always use genetic test results in surgical decisions, as compared to 21% (3/14) of sites that do not have an HBOC screening process, p=0.0009. Only 8% (4/53) of breast imaging sites have an HBOC screening process and provide indicated patients genetic assessment information and/or referrals. While 38% (20/53) of imaging sites conduct daily internal staff discussions of hereditary risk, only 15% of them (3/20) provide genetic assessment information to indicated patients. We found no statistically significant difference between practices of academic, community, public and safety net sites. Conclusions: Breast cancer treatment sites have partial adherence to HBOC risk screening guidelines; while breast imaging sites rarely adhere to HBOC risk assessment guidelines. Consistent HBOC risk screening protocols are needed in breast cancer treatment and breast cancer imaging sites that include providing indicated patients information about, and access to, genetic assessment.
Challenges with insurance and finances: Results from the 2012 Livestrong survey.
Authors: Nutt Stephanie , Bann Carla , Arvey Sarah R. , Squiers Linda , Rechis Ruth
Published: February 2017

208

Background: More than 1.5 million new cancer cases occur each year in the U.S., and accessing health care is critical for mortality as well as for improving survivorship outcomes for cancer survivors. Methods: LIVESTRONG conducted an online survey of cancer survivors from June to December 2012. The current analyses include 4,320 respondents who were U.S. residents and diagnosed in 2002 or later. Results: Survivors in this study reported that for those who did not receive all of the medical care they needed they did not receive care because the insurance company wouldn’t pay for the care (41%) or they couldn’t afford the care (23%), with nine percent being denied health insurance coverage due to a cancer diagnosis. Other challenges reported included insurance not paying for a second opinion (8%) or the doctor/facility of the survivor’s choice (18%). Controlling for demographic and cancer-related factors, those diagnosed most recently (2010-2012) were less likely to report experiencing these challenges. Compounding insurance issues was the financial burden. Thirty percent of survivors reported that they or their family members had to borrow money or go into debt because of their cancer and five percent of survivors reported spending down their assets to qualify for Medicaid or a cancer-related program. Conclusions: In previous studies, patients who lack sufficient health insurance coverage tend to have poorer health outcomes. Overall, the data highlights that more can be done to connect survivors with the needed insurance and financial resources they need to access adequate cancer care during their treatment and beyond. [Table: see text]
Integration of a cancer registry dataset into a hospital-wide central data warehouse.
Authors: Flaherty Stephen , Savage Robert , Stendhal Ingrid , Roston Susan , Makhe Abhijeet , Mead Veronica
Published: February 2017

212

Background: The ability to link cancer registry data to clinical and administrative data sets for quality improvement has long been desired. We sought to integrate registry data into a central data warehouse in an effort to make available for the first time consistent and reliable diagnosis and staging data to a broad hospital user group. Methods: After a short period of data analysis, the tables for Cancer Registry data (Oracle) were modeled. The source data (SQL Server) was conformed and integrated using an ETL tool (Informatica). All ETL QA work was performed with SQL queries. Cancer registry data was integrated into reporting architecture (Microstrategy) to facilitate design of standardized and ad hoc reports. Results: 140 distinct fields on demographics, staging (clinical, pathological, collaborative), site specific categories, diagnosis, and treatment were integrated into the Dana-Farber Analytics Reporting Tool (DART) for historic Cancer Registry data beginning with January 2010 newly diagnosed cancers. All Cancer Registry data and patient files (new and old) are updated in DART on a monthly basis. Conclusions: Individuals across the hospital now have the ability to link clinical and administrative data from our EMR, institutional QI data from varied systems, and pharmacy data to Cancer Registry data in the DART tool. One example of the integration of these multiple data sets is the linkage of staging data from the Cancer Registry data set and time to referral data from the administrative data set by patient MRN. As DFCI aims to cohort its patients based on their primary diagnosis for quality improvement and other internal reporting needs, the ability to analyze patients in this way becomes critical. This project sets an example for other centers as they integrate Cancer Registry data into user friendly business intelligence systems to help meet federal reporting mandates and aid internal improvement work. [Table: see text]
Effect of intervention on a quality measure of pain management at Medstar Washington Cancer Institute.
Authors: Ranpura Vishal Navnitray , Chokshi Puja , Yerasi Charan , Agrawal Sundeep , Wood Lynne , Harkness Jaylon , Self Linda , Jang Sekwon
Published: February 2017

218

Background: Appropriate cancer pain documentation is one of the quality indicators in American Society of Clinical Oncology (ASCO)’s Quality Oncology Practice Initiative (QOPI). Medstar Washington Cancer Institute (MWCI) has participated in QOPI since 2008. Documentation of plan of care for moderate/severe pain defined as a pain score of ≥4 on a numeric pain scale was 69%, (compared to QOPI aggregate of 79%) during the fall 2011 round which led to a quality improvement project with an aim of ≥ 90%. Methods: MWCI created a team of physicians, nurses and administrative staff. We attended ASCO’s quality training workshop from October 2013 to March 2014 for guidance. We implemented a Plan Do Study Act (PDSA) methodology for our quality improvement project. We created a process map, cause and effect diagram and Pareto chart based on survey of physicians citing common reasons for lack of documented plan of care for pain. Results: Baseline rate of documented plan of care for pain control in November 2013 was 70%. In January 2014, we implemented action plans to increase the awareness of pain documentation (Electronic Health Record (HER) trigger for pain ≥ 4, fellows and mid level education and faculty consensus on documenting management for pain unrelated to cancer). After intervention, the pain documentation rate was improved to 90.2% (Table). Conclusions: After one cycle of PDSA, we achieved our goal of pain documentation rate. In order to sustain our project, we will continue to monitor the pain documentation rate quarterly in 2014 and continue the process of education and orientation to new staff as well rotating residents and fellows. [Table: see text]
Use of a fever fast track tool to reduce time to antibiotic dose in febrile pediatric oncology patients.
Authors: Ananth Prasanna , Archer Natasha , Collins Natalie Bucheimer , Croteau Stacy , Hong Andrew Lee , Kamihara Junne , Kim Dan , Kort Kelly , Mersereau Robert , Mosadegh Sara , Billett Amy
Published: February 2017

222

Background: Given the risk of serious bacterial infection in immunocompromised cancer patients, fever should be promptly treated with empiric antibiotics. Our institutional standard is to administer antibiotics in ≤ 60 minutes from on-site fever or from arrival time with known fever. Review of our febrile outpatient pediatric oncology clinic patients from October-December 2013 revealed that 53% met this metric. Our aim: To achieve a sustained rate of 80% of febrile patients receiving antibiotics in ≤ 60 minutes within 8 weeks. Methods: We developed and implemented a fever fast track tool in our pediatric oncology clinic. Providers time stamped each step in the process from fever to antibiotic administration; additional time points were collected from the medical record. Interviews with staff were conducted to identify barriers. Five revisions of the fever fast track tool were made. We also streamlined same-day encounters for febrile patients in order to flag their acute visits and facilitate pre-arrival order entry. Results: 21 patients were treated for fever between 2/26/14 and 4/17/14. 4 fevers were documented in clinic. Time to antibiotics ranged from 23 minutes to 165 minutes. The median time to antibiotic administration was reduced from 58 minutes during the first four weeks to 40 minutes after the second 4-week block. Over the same period, patients receiving antibiotics in ≤ 60 minutes increased from 62% to 88%. Conclusions: Use of a fever fast track tool improved the proportion of febrile patients receiving antibiotics in ≤ 60 minutes. Modifications facilitating antibiotic order entry and pre-arrival awareness of febrile patients should prove helpful in sustaining this success.
The importance of caregivers in improving the care of geriatric oncology patients.
Authors: Bhagat Vicky , Isaiah Benjamin , Soriano-Pisaturo Maria , Somasundar Ponnandai
Published: February 2017

223

Background: Geriatric patients with cancer have special needs. The diagnosis of cancer is stressful for patients and their caregivers. A new age of medicine has emerged to facilitate caregivers in aiding elderly oncology patients through oncology programs. Many caregivers need support themselves. The purpose of this study is to evaluate our geriatric oncology program’s effectiveness and to demonstrate specific factors that caregivers believe have the greatest positive impact. The aim is to determine different interventions that can be implemented to help caregivers of geriatric oncology patients. Methods: This is a qualitative study that used a questionnaire completed by caregivers of patients enrolled in a geriatric oncology program directed towards easing the stressors encountered when caring for patients. Caregivers rated the effectiveness of the program by responding to 12 statements and 2 open-ended questions via telephone. Results: There were 94 patients in the program from November 2012 to November 2013. After excluding patients that did not meet criteria 71 caregivers were available. Analysis of results from 37 out of 71 caregivers enrolled identified six areas that the program most helped them with: time management of caregivers (82.8%), delivery of decision-making information (97.3%), resources available to caregivers and patients (88.23%), establishing goals of care (94.59%), and pain control for patients (100%). 83.78% of respondents agreed that the well-being and quality of their life improved with the program. Analysis on the patient survey conducted for the same time period also showed significant improvement. Conclusions: Caregivers play a vital role in cancer management of geriatric patients. In order to help both the patients and their caregivers, programs have emerged focusing on the teamwork of social workers, clinicians, and counselors. Caregivers express that this approach helps them effectively provide care to patients, and helps them get through this stressful period. The specific areas found to be most positively impacted by this type of organized program are what oncology departments may focus on in order to improve quality of life for caregivers which may ultimately improve the patient’s care.
Development of chemotherapy-induced extravasation management algorithm to facilitate and improve care of cancer patients.
Authors: Kim Sara S , Holcombe Randall F.
Published: February 2017

224

Background: Chemotherapy administration has up to a 6% incidence of extravasation, which can cause ulcer formation, tissue necrosis and loss of limb function, requiring surgical intervention (debridement and skin grafting). Because of its rare occurrences and the lack of uniform consensus on management strategies, much time is spent on decision making process by the patient care team and treatments are often delayed. To facilitate and improve the care of cancer patients in cases of chemotherapy extravasation, a task force was created to develop chemotherapy extravasation management algorithm. Methods: Chemotherapy extravasation management task force comprised of oncology pharmacy and oncology nursing leaderships. Literature search (limited to English language) was performed in PubMed (through April 2014) and of 34 “hits”, 13 articles on management of chemotherapy extravasation were reviewed. An algorithm was developed which contained 7 distinct intervention pathways dependent upon the drug involved in extravasation. The treatment algorithm was adopted after review by the cancer institute’s QI committee and oncology pharmacy and therapeutics subcommittee. Results: Chemotherapy extravasation algorithm provides the following guidance to nurses and providers: (1) Initial steps for nurses to follow in case of chemotherapy extravasation; (2) Chemotherapeutic agent-specific recommendations for cold or hot compress with antidote if indicated; (3) Nursing instruction for documentation of the adverse event and recommendation to photograph the site of extravasation; (4) Preparation and administration instruction of the antidotes (hyaluronidase, dexrazoxane, sodium thiosulfate, and DMSO). Finalized chemotherapy extravasation algorithm was made available in all oncology treatment areas and included in each extravasation kit. Conclusions: The development of algorithm for chemotherapy extravasation management provides clear and comprehensive instructions to oncology nurses and oncology providers on management and shortens the time to initiate management, thereby minimizing the risk of potentially debilitating sequelae from delayed management.
Improve optimal treatment in head and neck cancer patients (HNCA).
Authors: Mills Glenn Morris , DeKay Rebecca L. , Devarakonda Srinivas S. , Nicholson Jennifer , Maranto Lee Ann , Mehta Vikas
Published: February 2017

227

Background: Since 2011, 50% of HNCA patients receiving concurrent chemoradiation with Cisplatin (CIS/XRT) have not been able to complete their therapy per protocol (dose over time interval) leading to suboptimal therapy. Based on historical data, the non-completion rate for patients HNCA receiving radiation/ high dose Cisplatin was 15%. We aim to improve this in our patients. Methods: A chart review of patients on CIS/XRT conducted and, using a Pareto Chart, the data indicated Acute Kidney Iinjury as the major cause for failure of completion. Using methodology from ASCO’s Quality Training Program, a process map for patients on treatment was created and an Ishikawa diagram (cause and effect) assisted in pinpointing breaks in processes. A telephone survey of surviving patients further clarified inadequacies. Using the Plan, Do, Study, Act (PDSA) improvement cycle, inadequacies were identified. Results: Chart review showed that significant side effects from treatment began around the 2nd cycle of Cisplatin in spite of adequate IV hydration following chemotherapy. Inadequate documentation of dietary and speech pathology consultations, patient weight and serum creatinine levels during treatment were noted. Patients reported minimal PEG tube education and infrequent use of PEG tube for hydration. Analysis of post treatment weight and creatinine level revealed a significant change in creatinine clearance. Checking daily weights, speech pathology and dietary consult prior to initiation of therapy, added hydration instructions to EPIC PEG tube instruction sheet, and nurse practitioner education and follow-up in symptom management clinic were part of the PDSA cycle interventions. If 2lb. weight loss, patients were brought in for repeat lab and IV hydration. Conclusions: Patients with advanced head and neck cancer are frail and subject to acute toxicity from chemotherapy. Change in Creatinine Clearance is a sensitive measure of renal damage/likely predictor of non-completion. Post-intervention patients had fewer unplanned admissions leading to lower costs. PDSA helped identify inadequacies in our education and monitoring processes. More post intervention data are needed to determine if true improvement in patient outcomes exist.
Treatment-related costs of pediatric acute lymphoblastic leukemia.
Authors: Kaul Sapna , Lemons Richard S. , Korgenski Kent , Ng Christi , Nelson Richard , Raetz Elizabeth A. , Fluchel Mark , Kirchhoff Anne C.
Published: February 2017

23

Background: Few studies have examined costs of pediatric cancer care and we lack a clear understanding of cost trends. In this study, we examined longitudinal treatment- and patient-related hospitalization costs within 5 years of diagnosis of acute lymphoblastic leukemia (ALL), the most common childhood cancer in the United States. Methods: We used data on N=555 patients diagnosed with pediatric ALL from 1998 to 2013 identified through the Intermountain Healthcare System in UT. The majority of these patients (>95%) were diagnosed and treated at the Primary Children’s Hospital (PCH) in Salt Lake City, UT. PCH encompasses the largest coverage area in the continental U.S. served by a single children’s hospital. We computed the average annual per patient hospitalization cost (aggregate and by components such as room, care and nursing cost, pharmacy cost, therapy and diagnostics costs). We used the generalized estimating equations (GEE) regression framework to identify patient characteristics (sex, age, race, rural/urban residence, insurance, high vs. standard risk, relapse, bone marrow transplant (BMT), and year of diagnosis) associated with hospital-related treatment costs (total cost per encounter). Results: Annual average cost of per patient hospitalization increased by 26% from 1998-2005 to 2006-2013. Most of this increase was driven by annual increases in room, care and nursing costs (increased by 29%) and pharmacy cost (increased by 79%). Our GEE models indicated the greatest costs among relapsed patients (average difference (δ) =$15,507 vs. those without relapse), BMT patients (δ=$15,184 vs. no transplant) and patients older than 10 years at diagnosis (δ=$8,539 vs. patients younger than 10 years at diagnosis). Publically insured patients had per encounter hospitalization costs that were greater (δ=$931) than privately insured. Conclusions: Average annual cost of hospitalization for pediatric ALL care has increased over the past fifteen years. Management of room, care and nursing, and pharmacy costs need to be considered in efforts to address the cost burden. In addition, patient-centered strategies to manage higher costs, such as better management of patients who are older at diagnosis or publically insured, may be warranted.
A model to optimize treatment case-to-machine assignment in radiation oncology.
Authors: Kukshtel Nicholas Carl , Mersereau Robert , Kadish Sarah , Potiris Spyros , Vivenzio Todd , Martin Neil E.
Published: February 2017

231

Background: The department of Radiation Oncology at the Dana-Farber/Brigham and Women’s Cancer Center operates seven linear accelerators treating approximately 200 patients per day. These machines are regularly shut-down for upgrades, requiring the redistribution of patients to available machines. Previous machine downtimes have caused disruptions to patient care and required extended operating hours to accommodate displaced patient volume. For the next machine downtime, we sought to create a model to optimize the reassignment of patients to available machines, maximizing treatment type-machine compatibility while minimizing overtime, costs, and patient care impact. Methods: This collaboration between Radiation Oncology and the Process Improvement team retooled the Assignment Problem Method, an Industrial Engineering technique used to assign tasks, in order to solve for case allocation to radiation machines. A spreadsheet model was developed to optimize the allocation of treatment cases for each machine, without violating working hours or treatment type-machine constraints. Input data included case duration, radiation technique, daily demand, and machine compatibility for each treatment type. In addition to finding an optimal case allocation, department administrators created “what-if” scenarios to identify how demand fluctuations would shift cases across machines. Proposed solutions were validated by comparing the model’s output to feasible treatment volumes identified by department administrators. Results: The model revealed that under idealized conditions, the current daily patient volume can be accommodated with two fewer machines and 1.5 fewer operating hours each day. The time it took department administrators to prepare for the next downtime was reduced from several weeks of manual planning, to a few days using the model. Conclusions: Simple industrial engineering tools can help solve complex problems. Developing optimization models can eliminate complex calculations, allowing end-users to refine and implement a suitable solution without fear of mathematical error. A robust model can provide end users the ability to assess the impact of future changes in capacity or demand.
Improving advance care planning for UICC Oncology patients.
Authors: Ramadas Gowri , Golick Janet , Gorodinsky Polina , Jayakumar Udai , Dumayas Neriza , Branen Greg , Quinones Lydia , Engeseth Hope , Venepalli Neeta K.
Published: February 2017

234

Background: Advance care planning (ACP) in the ambulatory setting is underutilized and poorly documented at the University of Illinois Cancer Center (UICC). A baseline 8 week review noted 8.8% of metastatic solid tumor patients had ACP documentation in the electronic medical record (EMR) by the third visit and 23% in the previous two visits. Our aim was to increase ACP documentation to 75% of UICC metastatic solid tumor patient charts by the third visit through development of a standardized process for ACP discussion and documentation. Methods: A multidisciplinary team of oncology physicians, nurses, social workers (SW), and palliative care created a process map of ACP discussion. A new process for SW consults was piloted over 6 weeks. Additionally, all clinic staff participated in a standardized curriculum for ACP discussions. Post intervention data was prospectively collected over six weeks. Results: Total 94 encounters occurred during the pilot evaluating ACP in metastatic solid tumor patients of which 37/55 (39.4%) had documented ACP discussion. SW consults occurred in 18/94 (19.1%), leading to 18/18 (100%) with Power of Attorney (POA) forms in EMR. Evaluation by tumor subtypes showed 14/21 (66.7%) of gastrointestinal patients had ACP documentation with 9/21 (42.9%) with SW consults leading to 11/21 (52.4%) with POA forms in EMR. Of 39 total thoracic patients, 19/39 (48.7%) had ACP documentation of which 9/39 (23%) with SW consults and 7/39 (17.9%) with POA forms in EMR. Conclusions: UICC successfully piloted the creation and implementation of a process for ACP consults and standardization of ACP discussion and EMR documentation. While our initial aim of 75% a chart was not reached, the piloted process increased SW consults and completion of POA forms, as well as greater multidisciplinary effort and patient engagement. Compared to the pilot period, a multidisciplinary approach and use of the new process did improve ACP documentation. We plan to expand to all metastatic patients. [Table: see text]
Surveillance and evidence-based safety initiatives in radiation medicine.
Authors: Kapur Ajay , Potters Louis
Published: February 2017

247

Background: Moving towards safer radiation medicine requires an active surveillance of associated failures, their causes and effects, and evidence-based approaches for mitigation. In this study, by using retrospective and prospective surveillance, we have implemented evidence-based risk mitigation strategies in our radiation medicine practice. Methods: Incident learning has shown us that failures occur due to delays or defects in the radiation medicine process and that cultural error-provoking conditions raise these risks. Our initiatives were directed towards mitigation of defects in the high-risk process steps identified through a planning process FMEA. These included the standardization of care pathways and grading scale for assessing toxicity; pre-planning contour, directive peer review; electronic whiteboard for planning coordination and incident reporting, a process interlock policy to thwart delay-rushed processes; and the use of 6 sigma metrics to monitor individual staff operational efficiencies. Results: There has been a 3-fold increase over a 9 month period in incident reporting relative to the previous 6 previous years, by the peer group historically least likely to report, with no increase in adverse events. Evidence-based care pathways have been used with under 5% clinical non-compliance rates. The implementation of contour and directive pre-planning peer review has enhanced early defect detection. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Temporal trends demonstrate over 30% improvement in process Z-scores over the past three years. Conclusions: Driving these risk mitigation initiatives has challenged traditional norms such as expediting treatment initiation in delay-rushed environments or sustaining care pathways that are more experience rather than evidence-based. Therefore their implementation has met with substantial barriers. It is the focus on patient safety, statistical process control, policy enforcement, regular incident reviews, and use of quantitative metrics that has been instrumental in realizing these changes and crossing barriers.
Operational improvements to clinic flow.
Authors: Gross Katherine , Jacobs Kelli , Romano Michael
Published: February 2017

253

Background: With expanding clinic volume and future growth potential, we face an issue of limited physical clinic capacity. This has resulted in extended patient wait times, physician idle time, and longer clinics days. Each of these issues adds to both provider and patient dissatisfaction and operational inefficiencies. Methods: Key operational metrics and through put data was analyzed with the oncology team. Agreements and goals for the process improvement were: no provider would be told they could not see a sick patient, patient’s time would be respected and maximize provider productivity. Data demonstrated that the current state would not accommodate future growth. Several operational changes were agreed upon by physician and administrative leadership: level load the days of the week, require several providers to move their clinic days; place structure and real-time discussion into how we manage same day and future “add-on” patients though setting clear expectations around clinician template times; assign a full time staff member to function as a “clinic flow coordinator" to triage same day add-ons, and facilitate provider room assignments, communicate with providers, and identify system or people barriers to clinic flow; provide each of the patients a “restaurant style” pager that will light up when they are ready to be taken to a room, allowing them the freedom to leave the waiting room without fear of missing their appointment time; implement a room-utilization manager software program allowing staff to see and collectively manage real time clinic flow and room utilization. Results: Provider feedback was very positive related to the flow and utilization of clinic rooms. The check-in staff described a less full waiting room even though volumes remained constant. We will monitor patient perception by patient satisfaction scores. Conclusions: To date, much of the results have been anecdotal. In order for these changes to become practice there is a clear need to tie in satisfaction and operational efficiency metrics. There will be ongoing coaching and feedback with providers and staff related to adherence to the new processes. As new providers are added to the practice, we will be very purposeful when adding their creating their templates and adding their clinic days.
Cancer care transparency: Trying to move the dial in California.
Authors: Teleki Stephanie
Published: February 2017

256

Background: Each year in California, about 150,000 patients (more than 16 each hour) are diagnosed with cancer. Yet there is little useful information about the quality of cancer care to help patients, providers and payers make decisions about care. Methods: In 2012, the California HealthCare Foundation, an Oakland-based independent nonprofit philanthropy, launched an initiative focused on improving cancer care quality measurement and public reporting in the State. Since then, the Foundation has funded a number of projects aimed at filling information gaps; 2014 highlights include: (1) development of a Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience of cancer care survey (with NCI and AHRQ). CHCF is now funding 6 community oncology test sites in California; (2) analytic work to measure and report the number of cancer procedures performed by hospitals using State discharge data, for procedures where there is an established volume-outcome link; public reporting by hospital expected by early 2015 (with Stanford University); (3) a feasibility study of measuring cancer care quality at the medical group level in California using claims data combined with California Cancer Registry data (with Integrated Healthcare Association); (4) a report on cancer care spending in California, publication expected Winter 2014 (with Dana Farber); (5) a workgroup of State and national thought leaders to contemplate and articulate the challenges and opportunities of leveraging the California Cancer Registry for quality measurement and public reporting; Sacramento briefing to state legislators in Winter 2014 (with UCSF). Results: Significant challenges exist at the state level to provide information for improved decision-making about cancer care. Among them: access to data, especially cancer registry data that importantly includes detailed diagnostic information; lack of clinical outcome and patient experience measures; time needed to engage partners; and costs of carrying out quality measurement projects. Conclusions: This presentation will provide a 2014 update on efforts underway in California, focused especially on the challenges and opportunities at the state level for cancer quality measurement and public reporting.
Identifying targets for outpatient palliative care wait times in Ontario.
Authors: Zwicker Victoria , Buchman Sandy , Marshall Denise , Urowitz Sara
Published: February 2017

258

Background: A wait time indicator is being developed for outpatient palliative care services for cancer patients in Ontario. Once developed, this indicator will become the first palliative performance measure for Regional Cancer Centres (RCCs) across the province. The wait time indicator will serve as one measure of accessibility, a key dimension of health care quality. However, in order to create this indicator, it is first necessary to identify targets against which current performance can be compared. Methods: A systematic review of the academic literature was conducted to a) identify existing palliative care wait time standards, and b) to gather evidence on how delays in care impact patient outcomes. An environmental scan was also conducted to identify wait time standards and benchmarks used in other Canadian provinces or territories. In addition, existing palliative care triaging tools and wait time standards from Ontario RCCs were collected. A consensus panel comprised of palliative clinicians, patient and family advisors, and administrators was convened to articulate a maximum acceptable wait time and a provincial target for the percentage of patients who should be seen within the maximum acceptable wait time. Results: The environmental scan and literature review found no existing standards or benchmarks for outpatient palliative care services. However, there are a number of triaging tools and wait time standards in use at Ontario RCCs for these services. Taking these tools and standards into consideration, the consensus panel identified a wait time benchmark and a provincial target for Ontario RCCs. Conclusions: This foundational work will help to highlight gaps and variation in timely access to palliative care services in Ontario. The benchmarks and targets identified through this process as well as the methods used can be useful for other jurisdictions seeking to measure and improve wait times for these services. Next steps include ensuring that data is of sufficient quality, identifying incremental improvement targets for the province based on current performance, and further refining the implementation of a palliative care wait time indicator for quality improvement.
A patient-centered outcome measurement approach for bundled payments in cancer care.
Authors: Spinks Tracy , Lee Seohyun , Shah Kevin , Guzman Alexis B. , Feeley Thomas W.
Published: February 2017

266

Background: The project aims are to: 1) apply a patient-centered approach to evaluate quality of care in a bundled payment pilot for head & neck cancer; and, 2) measure quality at the condition-level; and, 3) incorporate patient-reported outcomes (PRO) in routine quality assessments. A three-tiered outcomes hierarchy developed by Michael Porter of Harvard Business School is used to define outcome measures, to be used for quality improvement and reporting during the pilot. Porter’s model evaluates outcomes over the full cycle of care, examining: (1) health status achieved/retained; (2) recovery process; and, (3) health sustainability. [Porter, M.E. (2010). What is value in health care? N Engl J Med, 363(26), 2477-2481. doi: 10.1056/NEJMp1011024.] Methods: An 11-member team of clinical, quality, data, and IT experts identified measure concepts, developed measure specifications, and implemented reporting. The project lead interviewed clinical experts to gain consensus around a focused set of measures and benchmarks. Measures were evaluated for importance to patients using feedback from patient focus groups. The team defined the measure specifications (numerator, denominator, etc.), selected a validated PRO instrument, and developed the work flow and tools for data collection and reporting. Process maps were created for training and reference purposes, and clinic staff trained. Testing was completed prior to implementation, with periodic process checks and additional staff training, as needed. Results: Measure development and implementation were completed using a streamlined approach over a 6-month period and required 12 team meetings before implementation. The project leveraged existing data streams, where possible, and IT development focused on quick-turnaround solutions. Conclusions: The project demonstrated that patient-centered outcomes measures can be developed and implemented in a compressed time frame. With provider and patient input, the measures focused on outcomes that are important to patients and actionable by clinicians. This created a scalable framework to be implemented in other disease sites and integrated into our EHR.
Treatment patterns of patients with metastatic colorectal cancer in a large national U.S. claims-based data.
Authors: Zhong Yue , Kamalakar Rajesh , Asche Carl V , Anderson Sibyl , Seal Brian S.
Published: February 2017

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Background: FDA approved therapeutic choices for patients with metastatic colorectal cancer (mCRC) have evolved, including cytotoxic agents such as 5-fluorouracil (5-FU)/ leucovorin or levoleucovorin (LV), capecitabine, oxaliplatin, and irinotecan, biological agents such as bevacizumab, cetuximab, panitumumab, and aflibercept, as well as regorafenib, an oral multi-kinase inhibitor. The present study examined treatment patterns among patients with mCRC. Methods: We identified patients aged 18 or older with at least one primary CRC diagnosis between 01/01/2008 and 03/31/2012 in the MarketScan databases. mCRC patients were identified if claims indicated the presence of distant metastases (ICD-9-CM codes: 196.x, 197.0 to 197.4, 197.6 to 197.8, 198.x, and 199.0). All systemic treatment claims were extracted during 60 days after initiation of treatment. Patients were followed for more than 6 months, until end of enrollment or study end date (03/01/2013) to capture type and number of treatment lines (TLs). We also assessed regimen compliance to the current National Comprehensive Cancer Network (NCCN) treatment standards. Results: Of the total 2,934 mCRC patients retained, 2,046 (69.7%) received at least one TL: 801 (39.1%) patients with one TL, 679 (33.2%) with two TLs, and 566 (27.7%) with three or more TLs. For patients receiving first-line treatment, the most common regimens prescribed were FOLFOX (19.1%), FOLFOX+ bevacizumab (18.6%), and 5-FU/LV (17.8%). For patients receiving second-line treatment (60.9%), FOLFOX (14.1%), FOLFOX+ bevacizumab (11.0%), and FOLFIRI+bevacizumab (11.0%) were most frequently prescribed. Treatment regimens varied in patients receiving three or more TLs. FOLFIRI + bevacizumab was most frequently prescribed in the third TL (16.8%). Proportion of patients receiving NCCN-recommended regimens was 81.7% for first TL, 54.4% for second TL, and 25.3% for third TL. Conclusions: About one third of mCRC patients didn’t receive any treatment. Among mCRC patients with treatment, two thirds received at least two TLs. FOLFOX (+/-biologics) was the most frequently prescribed first and second TL. Only a quarter of patients received NCCN-recommended regimens in the third TL.
Quality measures that focus on patient and family engagement in oncology.
Authors: Song Kyung Min , Mitchell Kristi
Published: February 2017

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Background: National Quality Strategy set forth by the Department of Health and Human Services emphasizes that each person and family is engaged as partners in their care. Appropriate use of quality measures can serve as a means of achieving this. Studies have shown that patient engagement can lead to improved healthcare outcomes, lower resource utilization, and reduced costs. As such, Avalere sought to identify oncology-related quality measures that address patient and family engagement, and determine ways to advance engagement in oncology through the use of quality measures. Methods: Avalere assessed publicly available sources to identify person and family engagement measures related to oncology, including measures related to patient education, care preferences, and care planning. Avalere also assessed the current use of these measures in CMS’ quality programs. Results: Avalere identified six oncology-specific measures related to person and family engagement. One of the measures is included in CMS’ Physician Quality Reporting System and the Electronic Health Record Incentive Programs. Three measures identified are related to documenting patients’ preferences during end of life care, two are related to care planning for pain and depression, respectively, and one is related to patient education on treatment. None of the measures are related to specific cancers. Conclusions: Avalere found lack of measures related to patient and family engagement in oncology. Given the importance of patient and family engagement during the course of disease management, opportunity exists to improve oncology care quality through measurement and evaluation of engagement. Oncology patients’ quality of care can be improved through data support, stakeholder buy-in, standardized methodology for measuring engagement, evidence linking engagement and outcomes, and implementation measures in incentive programs.