bluuebunny/crossref_metadata_2025 huggingface dataset:
Applying treatment advances in castration-resistant prostate cancer: The influence of serial digital education on the uro-oncology team.
Authors: Ackbarali Tariqa , Turell Wendy , del Nido Elizabeth L. , Shore Neal D.
Published: September 2021

20

Background: Improvements in the understanding of prostate tumor development have spurred advances in biomarker testing and new therapies for prostate cancer, providing clinicians with expanded testing and treatment options. However, these changes have led to competence gaps regarding the use of biomarker testing, integration of PARP inhibitors, application of new data for nmCRPC and mCRPC, and adverse event management. To address these needs, a serial educational initiative was designed for the urology-oncology team. Methods: A 4-part CE activity was launched live-online in December, 2020, and remains on-demand through December, 2021 at UroCareLive.com and OMedLive.com. The activity was launched in partnership with Large Urology Group Practice Association (LUGPA) and included case presentations, live polling, and Q&A. Knowledge and competence questions were administered pre-activity, immediate post-activity, and 2-months post-activity. Patient and clinical practice-impact questions were also asked at the 2-month follow-up. Data from these questions were analyzed to determine engagement and clinical impact. Results: To date, 761 clinicians have participated in the activity. All 12 CE test questions reflected improvements in knowledge and competence, 11 of which were statistically significant. Questions focused on: genomic testing, biomarker analysis, recent clinical trial study results, newly approved therapies, and adverse event management. At 2-mos. follow-up, 70% reported improved behavioral impact on clinical practice and 63% reported impact on patient experience and outcomes. Clinicians provided write-in examples of these changes, illustrating improvements in patient-reported satisfaction, genetic testing, and use of newer therapies, including PARP inhibitors. Practice pattern questions pertaining to biomarker testing and the use of emerging therapies showed the majority of post-program respondents (42%) preferred to utilize blood/serum-based biomarker tests for their patient vs urine- or tissue-based tests. The greatest reported challenges to biomarker testing were affordability (30%) and lack of guideline clarity (23%). The top 2 barriers to adoption of new agents were reported as lack of awareness and lack of experience (32% and 20%, respectively). Conclusions: The activity successfully improved uro-oncology team knowledge of genetic testing and newer therapies to manage castration-resistant prostate cancer. Learners demonstrated significant improvements in competence concerning biomarker testing, treatment personalization, and adverse event management. Open-ended responses to behavioral impact questions illustrated improvements in biomarker usage, application of newer therapies, and confidence in patient counseling regarding treatment options.
The benefits and burdens of patient advocacy.
Authors: Fuld Nasso Shelley , Porter Laura Diane , McNiff Landrum Kristen K.
Published: September 2021

204

Background: Patient advocates share their time and experience to improve cancer research, care, and support. Advocacy can be rewarding and empowering, and survivors and caregivers express a variety of reasons for engaging in advocacy. Yet, advocacy can also come with mental and emotional costs. Challenges include the grief of losing friends to cancer, the related “survivors’ guilt”, and the burden of repeatedly reliving their experience. The National Coalition for Cancer Survivorship (NCCS) conducted a survey to better understand the experience of patient advocates, and actions that organizations can take to recognize and support advocates. Methods: NCCS convened two focus groups with 10 advocates (the “working group”) to understand factors that contribute to advocates feeling rewarded or burned out from advocacy. We reviewed the transcripts to identify themes and reviewed the literature. We developed a survey and included a validated, non-proprietary, single-item burnout measure used for health care professionals. We built the survey online and tested with select working group members. We disseminated the survey to NCCS’ advocacy network, and working group members shared with their networks. Results: As of June 1, we received 176 responses, with the survey will open for another week. The initial data show that the vast majority of respondents find their advocacy work rewarding (97%), empowering (93%), and a positive impact on their lives (96%). At the same time, 29.5% of respondents indicated they have symptoms of burnout, including emotional and physical exhaustion. Respondents report that their advocacy work results in exhaustion (50.7%), sadness (41.1%), and anxiousness (28.7%). More than a third (36.7%) said that grief makes it hard to maintain their work as advocates. A majority manage the demands of their advocacy work by practicing self-care (66.6%) and using coping strategies (62.5%). Advocates shared the specific practices and strategies they used. Less than half (42.5%) said they set boundaries between their advocacy work and their personal life. The final analysis of the survey data will be complete by the end of June 2021. Conclusions: The phrase, “Nothing about us, without us,” has guided the inclusion of patient and caregiver voices in the design of research, care delivery, research grant review, quality measurement, and other aspects of cancer care and cancer research. Yet organizations that ask for the mental and emotional labor of advocates, including patient organizations, researchers, health care professionals, government institutions, and pharmaceutical companies, should understand the costs to advocates and how to best support them. As one respondent said, “Perhaps organizations could set the stage for this work by openly validating the toll that cancer itself takes, and acknowledge that advocacy takes energy and commitment, which may not always be possible to sustain in the face of ongoing treatment or other life complications.”
An evaluation of patient workflow in hematology clinics at a university hospital referred for the workup of monoclonal gammopathy of undetermined significance (MGUS).
Authors: Kumar Swarup , Kulkarni Radhika B , Ozcan Gonca , Tipirneni Asha , Vankina Ritika , Baker W. Jeffrey
Published: September 2021

207

Background: Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant condition that can be a precursor to multiple myeloma and lymphoproliferative disorders. There exists no best practice for the workup of MGUS, despite the number of patients diagnosed every year. We evaluated the workup of MGUS patients at a University Hospital Hematology clinic before and after implementation of an algorithm based on the Mayo Clinic Risk Stratification Model. Methods: This was a single-center IRB-approved retrospective study. Charts of 132 patients referred for MGUS were reviewed across two groups (A: June 2019 -May 2020 and B: June-Dec 2020). Use of the Mayo Clinic Risk Stratification Model for MGUS was implemented in May 2020. Data regarding initial work up, bone marrow studies and imaging were collected. Statistical analyses were performed using R software for computing (4.0.4). Results: Patient demographics and those who did not need further work up per the algorithm are summarized in table. All 86 new (100%) referrals had an initial CBC, creatinine, calcium, SPEP, and IFE while 7(8.1%) did not have an FLC assay. 43(50%) patients had a 24-hour urine protein electrophoresis. 65.1% (56/86) [group A: 26; group B: 30] met the criteria for no extended workup; 39.3% of these (22/56) underwent imaging while 7.1% (4/56) underwent bone marrow exam. After implementation of the algorithm, the number of patients who underwent imaging studies decreased from 50% (13/26) to 30% (9/30). Skeletal survey was the most ordered imaging modality (90.1%,20/22). Conclusions: Our study highlights the overutilization of imaging studies in low-risk MGUS patients. Approximately 50% of patients with MGUS are low risk with a lifetime risk of progression being less than 2%. In these patients avoiding extensive testing will minimize costs without adversely affecting clinical outcomes. We recommend a dedicated MGUS clinic to improve workup and monitoring of these patients. [Table: see text]
Implementation of a mortality risk predictive analytics model.
Authors: Broussard Stephanie Broadnax , Hoverman John Russell , Wilfong Lalan S. , Mikan Sabrina Q. , Books Holly , Ortega Lance , Jensen Terry Lynn , Toth Sara , Vo Duc
Published: September 2021

211

Background: Improving the quality of End of Life (EOL) care continues to be a challenge. Enhanced prognostic awareness is critical for all members of the clinical team. In December 2020, The McKesson Advance Care Planning Enrollment eXtended (APEX) mortality risk predictive analytics model was implemented to improve prognostic awareness in OCM population and improve the timing of initiation of end of life care. (See ASCO 2021 abstract #1560). Methods: The APEX tool was provided in collaboration with the McKesson/US Oncology network analytics team. A process was established for dissemination of the report information. In the pilot, 12 practice locations with varying community landscapes, socio-cultural dynamics, and site clinical personnel resources were selected. At each site clinical leads and physician champions were selected. Education was provided on the tool, prognostic variables, and appropriate interventions. Biweekly, each site was provided a list of stratified patients based on their risk of mortality within the next 90 days. Patients that were identified as “very high” or “high” risk were reviewed by the clinical teams and discussed in routine huddles. Physicians and teams reported their planned interventions before and after mortality risk identification. Results: In the pilot, 105 patients were identified as very high or high risk. Reported interventions included the option to continue treatment, ACP Discussion, hospice referral/enrollment, palliative care referral, or continue close monitoring. Prior to the report, 14 identified patients were admitted to hospice and 30 patients had 1 or more advance directives documented. For 26 patients, treatment changes occurred including hospice enrollment, reduction in chemotherapy dosage, change in regimen, or initiating intensive monitoring. 23 patients indicated on the report expired in the interim between generation of the report and receipt by the clinic. No changes in treatment were made in 22 patients. There was physician reported disagreement with the mortality risk assessment in 4 patients. Conclusions: We describe implementation of a mortality predictive model in our practice. The care teams found the tool useful to identify patients at high risk of mortality. Interventions were varied and we will track the outcomes based on intervention. We are using the information from the pilot to continue refining the tool and implementation.
Results of a multistate, multi-institution implementation of a multidisciplinary cancer conference quality measurement tool.
Authors: Simpson Lijo , Mathew Anju , Wojciechowski Robert , Hill Irina
Published: September 2021

212

Background: The 2006 ASCO and the ESMO consensus statement on quality cancer care defined the delivery of multimodality treatment by a multidisciplinary team of appropriately skilled health professionals as an essential component of quality cancer care. Furthermore, MDCs have demonstrated improved survival in breast, head and neck, ovarian and colorectal cancers. Despite these advantages, health care systems struggle to implement and sustain MDCs due to the heavy burden imposed by the required work processes. We report on the large-scale utilization of a propriety quality measurement platform OncoLens to run MDCs across the country. Methods: Technology quality metrics were collected from the ongoing daily usage of the platform including cancer characteristics, care team utilization metrics, average attendance, quality metrics collected for accreditation and clinical trials matching on the OncoLens platform. Results: The virtual platform was accessible to around 8000 providers across the United States. In 2020, 13771 cases were discussed. Attendance of the required specialties for high quality care of Medical Oncology, Radiation Oncology, Surgery, Pathology and Radiology was attained, with the average conference attendance being 14. Race/ethnicity data on the cases revealed White (9197, 67%), Black (1817,13%), Hispanic (363,3%) and Other (2356,17%). Optional quality metrics were collected during discussions for CoC, NAPBC and NAPRC accreditation. These included NCCN guidelines discussed, Staging discussed, clinical trials discussed, Genetics discussion, palliative care discussion, rehabilitation services, reproductive counselling discussed, psychosocial counselling discussed, nutritional counselling discussed, reconstructive surgery discussion, tobacco cessation discussion across General and Site-specific conferences. Most of the case presentations were prospective. This format does enable cancer programs to collect quality metrics around Cancer program accreditation by the American College of Surgeons. 66% of patients discussed potentially matched to clinical trials during the discussion. Conclusions: A technology platform can assist cancer programs to collect quality metrics around cancer care. This gives them the ability to run data driven quality programs targeting specific quality metrics. Hispanics have a lower percentage of cases presented at MDC compared to other race/ethnicities. It is possible to have high quality discussions and attain metrics for Commission on Cancer accreditation utilizing a virtual platform.
Rate of venous thromboembolism in gynecologic patients on an ERAS pathway.
Authors: Taylor Jolyn Sharpe , Iniesta-Donate Maria , Cain Katherine , Lasala Javier , Mena Gabriel , Zorilla Vaca Andres S. , Meyer Larissa , Ramirez Pedro T.
Published: September 2021

214

Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.
Understanding mortality among hematology oncology patients identified from hospital administrative data.
Authors: Paracha Munizay , Parekh Anish , Sheikh Ayesha Rizwan , Nwabudike Stanley Madu , Fikre Tsion , Ko Naomi Yu
Published: September 2021

215

Background: Hospital administrative data has large ramifications for quality of care and quality improvement projects. Unexpected inpatient mortality among patients with a hematology/oncology (H/O) diagnostic related group (DRG) is not widely studied and reported. We sought to investigate the unexpected inpatient mortality rate among cancer patients who were admitted to a large, urban, tertiary care safety net teaching hospital. Methods: We obtained the hospital’s adjusted mortality rate and evaluated the subset of specific observed/expected deaths ratio (O/E) of patients with a primary H/O diagnosis. We reviewed each case that was identified as an unexpected inpatient mortality from 2016 to 2018. A chart abstraction tool was designed for data abstraction that included demographics, location of admission, comorbid conditions, if mortality was expected, if documentation was reflective of the severity of the illness. Two independent reviewers abstracted each chart. A third reviewer assessed each case to make a final determination regarding expected mortality based on medical complexity and if documentation was reflective of severity of illness. Results: On review of the inpatient mortality data, the O/E for the H/O diagnostic related group (DRG) from Vizient was 1.14. Twenty two cases were identified as having an unexpected death. Among those cases, 23% of patients were transferred from an outside hospital, and 23% of patients did not have a known cancer diagnosis on admission. In the majority of cases, initial documentation did not accurately reflect severity of illness and/or specialists in hematology or oncology were not consulted at time of diagnosis. We noted the majority of patients were not followed by a hematologist/oncologist within the hospital system (63.6%). In 55% of patients, the cause of death was acute respiratory failure, and 14% of patients had an Advance Directive/DNAR in the chart prior to admission. Delayed antibiotics in febrile neutropenia and a missed blood transfusion reaction were among causes of unexpected deaths. Conclusions: Hospital generated data reported that mortality among H/O patients was greater than projected, however careful chart review of each case demonstrated a significant number of cases that were expected but the severity of illness was not documented properly to account for the death. Templates for proper documentation using the Vizient mortality variables is a key area to lower unexpected inpatient mortality.
Sustaining safety and delivery of oral chemotherapy utilizing lean methodology.
Authors: Hoffmann Marc Steven , Neiberger Adam , Solis Gloria , Johnson Marshall , Fernandez Debbie
Published: September 2021

218

Background: An oral chemotherapy safety event in 2017 prompted analysis of related workflows utilizing lean quality improvement methodology. Three kaizen workshops utilizing lean methodology with primary objectives to 1) develop safety standards for oral chemotherapy as rigorous as those for intravenous chemotherapy; 2) improve efficiency; and 3) design workflows that enable data collection and process control were conducted. Since 2017, our goal has been to sustain developed workflows to ensure oral chemotherapy patients have the right oral chemotherapy agent, at the right dose, at the right time, with independent and efficient safety checks by all care providers. Methods: After multidisciplinary teams participated in three kaizen workshops to develop workflows, education plans were developed and results were incorporated into the lean management system. The lean production method of Training Within Industry (TWI) was used to train physician, nursing, and pharmacy teams to the workflows. Results were communicated to key stakeholders weekly to monitor progress on workflow creation, spread, and process metrics designed to signal defects in the workflow. When processes were deemed ‘out of control,’ clinical team members provided regular and targeted interventions. Safety data were collected and correlated to surrogate outcomes for long-term impact assessment. Results: Interventions resulted in the following outcomes: 62 consecutive weeks with 99% reduction in oral chemotherapy defects reaching pharmacy. 86 consecutive weeks with 51% error reduction processing oral chemotherapy though a single EMR workflow. 57 consecutive weeks with 62% error reduction processing oral chemotherapy though a single EMR workflow. No serious safety events have occurred since 2017. Conclusions: Comprehensive quality improvement in our oral chemotherapy process has resulted in sustained safety, efficiency, and a data collection to signal when process defects occur. Multidisciplinary teams utilizing established lean methodology were critical to success.
Response-guided treatment optimization in the I-SPY2 trial.
Authors: Olunuga Ebunoluwa , Gibbs Jessica E. , Li Wen , Venters Sara , Delson Amy , DeMichele Angela , Isaacs Claudine , Hylton Nola M. , Rocque Gabrielle Betty , Esserman Laura
Published: September 2021

222

Background: As new tools for prognostic prediction and assessment of treatment response in breast cancer are developed, there is growing interest in treatment optimization strategies to reduce toxic therapy or add additional therapy as needed. The I-SPY 2 trial utilizes a new predictive tool “PreRCB,” which includes mid-treatment MRI and core biopsy responses, to identify patients likely to have a pCR (pathologic complete response) who can de-implement, or forgo, standard-of-care anthracycline-based chemotherapy (AC) after treatment with a taxane + investigational agent. This study assesses initial de-implementation eligibility and selection within the I-SPY2 trial. Methods: All patients enrolled in I-SPY2 since September of 2020 (when the preRCB protocol was first introduced to the trial) who completed the first treatment regimen were evaluated. Patients were only considered for de-implementation of AC if the mid-treatment biopsy was routed to site clinical pathology for review for residual invasive disease. In these patients, preRCB was determined to be predictive of pCR if there was 1) no invasive cancer on the core biopsy and 2) MRI findings met subtype-specific functional tumor volume criteria. Patients meeting criteria for predicted pCR could be offered the option to go directly to surgery by their provider, foregoing pre-operative AC, with the option to receive AC post-operatively should the surgical specimen reveal residual disease. The following outcomes (n,%) were descriptively evaluated: patients participating in I-SPY2, sites with at least one patient evaluated for de-implementation using pre-RCB, patients eligible for de-implementation, patients with surgical RCB assessment, and patients who de-implemented chemotherapy. Results: From September 2020 – May 2021, 145 patients were eligible for analysis. 9/20 (45%) sites with eligible I-SPY patients had at least one patient considered for preRCB assessment. Only 46 patients (32%) had clinical reads on their biopsies, as required for preRCB evaluation. Of these, 48% (14/29) of patients met both MRI and pathology criteria to de-implement AC. However, only seven (50%) of these patients chose to proceed to surgery without preoperative AC. Of those who did not have a predicted pCR using preRBC criteria, 87.5% (28/32) received AC as recommended by the protocol and 12.5% (4/32) did not receive preoperative AC. Conclusions: These pilot results demonstrate slow uptake of this strategy by patients and clinicians. We are currently interviewing patients and physicians to identify and assess facilitators and barriers for patients and physicians to pursue response-guided treatment regimes. Understanding these motivations will create the opportunity to engage site, providers, and patients to engage in research optimizing chemotherapy treatment. Clinical trial information: NCT01042379.
Risk factors for ED visits and admissions during outpatient chemotherapy in head and neck cancer.
Authors: Shukla Navika , Saraswathula Anirudh , Khan Saad A. , Divi Vasu
Published: September 2021

223

Background: Despite the recent introduction of the CMS metric, OP-35, which tracks 30-day inpatient admissions and ED visits after outpatient chemotherapy administration, the risk factors driving acute care utilization (ACU) in the head and neck cancer treatment setting are not yet well understood. Further characterization of these risk factors could allow for improved care quality and reduce preventable inpatient and ED admissions. Methods: This was a retrospective cohort study utilizing the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked cancer registry-claims database. The study cohort consisted of patients aged 66 years or older diagnosed with head and neck cancer between 2004-2015 who received outpatient chemotherapy within the first two years after diagnosis. Multivariable logistic regression modeling was utilized to characterize the risk factors associated with an inpatient or ED admission within 30 days after receiving chemotherapy. Results: Of the 2,236 eligible patients, 735 (32.9%) had at least one inpatient or ED admission within 30 days of receiving outpatient chemotherapy. On multivariable analysis, cancer of the oral cavity [odds ratio (OR) 1.43; 95% confidence interval (CI) 1.04-1.96] and oropharynx/hypopharynx [OR 1.34; 95% CI 1.06-1.70] were associated with an increased odds of ACU. Other factors associated with ACU included NCI comorbidity index [OR 1.10; 95% CI 1.03-1.18], prior ACU [OR 1.06; 95% CI 1.02-1.09], second cycle of chemotherapy relative to the first cycle [OR 0.38, 95% CI 0.29-0.50], and third or greater cycle of chemotherapy [OR 0.17; 95% CI 0.13-0.21]. Certain chemotherapeutic agents also modified risk: use of an angiogenesis inhibitor [OR 0.18; 95% CI 0.06-0.45], alkylating agent [OR 1.24; 95% 1.01-1.53], plant alkaloid [OR 1.63; 95% CI 1.25-2.10], or antimetabolite [OR 2.69; 95% CI 1.78-4.09]. The most common admission diagnosis was pain (n = 243; 33.1%) followed by dehydration (n = 167; 22.7%). Conclusions: Multiple clinical variables modify risk of acute care utilization after outpatient chemotherapy in the head and neck cancer setting, providing several potential avenues of intervention for providers.
Decreasing inpatient chemotherapy initiation delays at Memorial Regional Hospital.
Authors: Vulfovich Michel , Salzberg Matthew Philip , Louis-Jeune Marie , Pham Khang , King Kelly , Jacques Jessica , Lanier Ulonda , Morris Amy
Published: September 2021

225

Background: Between June and December 2019, hematology-oncology patients admitted for elective chemotherapy at Memorial Regional Hospital had a median delay of 10 hours to initiate chemotherapy infusion from time of admission. This contributes to increased cost to the healthcare system and patient dissatisfaction. By September 2020, elective inpatient median time from admission to chemotherapy initiation at Memorial Regional Hospital will be reduced by 20%. Methods: Multidisciplinary team formed to evaluate the time from admission to initiation of chemotherapy for patients who are electively admitted for chemotherapy in 8 Central based on time stamps available in the electronic health records. Patients electively admitted by a non MCI oncologist were excluded. Data collections included time stamp between each process from admission to administration of 1st chemotherapy. Longest time lapse between each process was counted as an occurrence/contributor to delay. Top 80% contributors identified from Pareto chart allowed team to identify countermeasures. Priority Matrix of implementation in PDSA cycle based on highest impact and ease of implementation. Statistical process control chart was developed. Results: (see table). Conclusions: PDSA Cycle 1, obtaining labs 24-48 hours prior to admission, resulted in a 10% reduction in chemotherapy initiation time. PDSA Cycle 2, enhancing “ok to treat” communication, resulted in a further reduction of time to treatment. The combination of PDSA Cycle 1 & 2 resulted in a 40% reduction in time to chemotherapy initiation, exceeding the planned aim of 20%. Balance measures reflected no reduction in the mean number of overnight stays between baseline and PDSA Cycle 2 (4 nights) that could contribute to a decreased cost. Results and recommendations to adopt at all inpatient oncology departments within the healthcare system will be presented to leadership for support. Data automation through collaborative efforts with information technology is in process to assist with continuous monitoring. Future state, the quality improvement tools gained from ASCO QTP will be utilized to evaluate and improve workflow issues in the outpatient oncology setting. Nationally recognized organizations are encouraged to propose a benchmark for admission time to first chemotherapy administration based on the evaluation of current available data. Additional studies are needed to evaluate chemotherapy treatment delays in other settings.[Table: see text]
Suboptimal clinician awareness of appropriate NTRK fusion testing and TRK inhibitor use in solid tumors.
Authors: Topping Ryan P. , Marcello Krista , Fagan Terrence , Quill Timothy A. , Bauer Todd Michael , Drilon Alexander E. , Demetri George D.
Published: September 2021

229

Background: Since late 2018, 2 TRK inhibitors—larotrectinib and entrectinib—have been approved by the EMA and FDA for treating patients with advanced solid tumors harboring an NTRK fusion and progressive disease or no therapeutic alternatives. It is recommended that testing for NTRK fusions occur as early as possible after a diagnosis of advanced disease in patients with solid tumors to inform potential use of TRK inhibitors. Methods: Between April 2018 and April 2021, we conducted multiple live and online educational activities for oncology healthcare professionals (HCPs) on NTRK fusion testing and/or TRK inhibitor treatment for varied solid tumors. Each activity included polling questions designed to assess HCP knowledge and practice patterns. In this analysis, we assessed HCP responses to these questions to evaluate awareness of expert recommendations on NTRK fusion testing and the selection of TRK inhibitor therapy for appropriate patients. Results: In 6 live and online activities with data from April 2018 to April 2021, 29% of HCPs (n = 844) indicated that they ordered molecular profiling to test for NTRK fusions in all solid tumors in their current practice. Of note, low rates of testing were reported in TRK inhibitor/ NTRK testing-focused activities throughout this time period, with no significant increase over time. In assessing different patient cases across 8 activities where experts recommended TRK inhibitor therapy as optimal, many HCPs did not select a TRK inhibitor, with considerable variance by tumor type (Table). *For all cases, experts selected larotrectinib and/or entrectinib as optimal treatment. †HCP respondents. GBM, glioblastoma; GI, gastrointestinal; MSI-H, microsatellite instability-high; PD, progressive disease; PTC, papillary thyroid cancer.Conclusions: The rate of broad testing for NTRK fusions across patients with solid tumors remains low, and many HCPs lack awareness of when to consider a TRK inhibitor. Educational activities designed to address these deficiencies would be of clear benefit to HCPs treating patients with advanced solid tumors. A detailed analysis of HCP trends will be presented.[Table: see text]
Improving management of hypersensitivity reactions: A BC Cancer-Victoria quality improvement initiative.
Authors: Rauw Jennifer Marie , Parimi Sunil , Anderson Helen , Hinada Pamela , Abrahams Bethina , Hennessy Katie
Published: September 2021

230

Background: Hypersensitivity reactions (HSR) are a documented, predictable side effect of multiple chemotherapy agents. Reactions negatively affect the patient experience, increase the amount of chair time, nursing and physician resources, may result in the omission of a potentially effective cancer management tool from a patient’s treatment plan and could potentially result in death. BC Cancer is a Health Care Organization with 6 cancer centres across British Columbia, Canada. Guideline(GL)s have been developed at BC Cancer to support clinicians to manage reactions acutely and reduce the risk of reactions with subsequent cycles. A recent audit identified that the GLs were not always being followed at the Victoria Centre. Our goal was to encourage physician and nursing staff to follow GLs, which we hypothesized would result in decreased rates of HSR. Methods: Our aim was to decrease HSR to < 5% of doses delivered within 1 year at BC Cancer-Victoria. We engaged stakeholders (nursing, physicians, pharmacy, clerical staff and administration). Our change ideas improved adherence to GLs by focusing on: physician attendance and documentation, written orders for rescue medication, and rate of infusion of the chemotherapy drug rechallenge. Our interventions included: two physician-education sessions, one nursing education session, daily huddles, pre-printed order development for management of the reaction (PPOA) and prophylaxis for subsequent cycles (PPOB), and a modified clinic flow. All interventions were introduced and underwent modifications through PDSA cycles. Our family of measures were: Outcome: number of reactions, percent of reactions per dose given. Process: percent of PPO use per reaction, physician attendance and notes dictated per reaction. Balancing: physician and nursing satisfaction. We analyzed the data using quality improvement run charts and control charts. Results: After the start of our initiative, our total number of reactions displayed special cause variation, and a shift in the baseline from a mean of 11.27 HSR per month to 7.526. This change was reflected in the percentage of reactions per doses given which fell from 3.1% to 1.9%. Average percentage of dictated notes per reaction increased from 55% to 64%. Physician attendance per reaction also showed special cause variation with the average increasing from 57% to 90%. PPOA and PPOB use both increased over time. Nursing and Physician satisfaction data will also be presented. Conclusions: Our successful initiative has resulted in HSR management which more closely reflects GLs, including increased physician attendance and notes, and clear consistent written orders detailed on PPO A and B. This has led to decreased HSRs at our site, resulting in decreased resource use and increased patient safety and quality. This has provincial implications as there is the potential to spread this initiative to other BC Cancer sites.
Improving the completion rate of outpatient stool-based colon cancer screening during a global pandemic.
Authors: Aung Ye , Scherer Christian , Gdowski Andrew , Cubas Doris , Horton Alexandra , Saghir Nabeel , Sadler Holli
Published: September 2021

238

Background: Colon Cancer Screening is an important intervention to reduce the morbidity and mortality of colorectal cancer. In particular, stool based screening tests help to increase the availability of screening especially amidst a global pandemic. However stool based screening is limited by patient return rates of FIT/iFOBT tests. Here at the Austin Outpatient VA we sought to improve the FIT test return rate of patients in our resident clinic by at least 20%. Methods: We did a root cause analysis as to why iFOBT/FIT were not being returned, particularly during the height of the pandemic when most visits were virtual. With help from the VA data core we generated a list of 76 patients during a period from 2/3/2020-7/7/2020 who had not returned an ordered FIT/iFOBT test in >30 days. We called these patients to identify the reasons why they did not return their test. Results: We were able to reach (44/76) patients and discovered that only (12/44) 27.3% of patients contacted had received a FIT test. Of our patients-reached 33/44 of them asked for a new FIT test to be sent to them and ultimately (21/44) patients contacted returned and completed their FIT test successfully with 3 tests being positive and referred to diagnostic colonoscopy. This resulted in an improvement in return rate of ̃47% of all patients ultimately contacted. Conclusions: Through a meeting of stakeholders including nurses and resident physicians we discovered in our EMR, that the order to send out a FIT test does not automatically alert a nurse nor does it automatically mail out or send out a FIT test. We discovered there was not a standardized process in place to facilitate communication between physicians ordering tests and nurses, thus FIT/FOBT tests were not being sent. We are currently working on a process to standardize the FIT test ordering process to improve communication between physicians and nurses. We are developing a better order set that reminds providers to alert and message nurses prior to ordering the FIT/iFOBT test. We are also educating Residents about the FIT/FOBT ordering process. With future PDSA cycles we should be able to improve the robustness and reliability of our outpatient colon cancer screening process through improved inter-professional communication.
Analysis of reasons for Emergency Department (ED) visits and subsequent hospital admissions in patients with solid malignancies: A retrospective study from a cancer center in rural Maine.
Authors: Patwari Anannya , Bhatlapenumarthi Vineel , Brann Courtney , Waldrip Jackson , Caruso Victoria , Hatch Abigail , Curtis Adam , Chodkiewicz Catherine
Published: September 2021

241

Background: Reducing ED visits in patients with cancer is cost saving and is particularly relevant during the COVID pandemic. We aim to identify patterns of ED visits among various cancer patients and reduce preventable ED visits and hospital admissions. Methods: We analyzed the number of ED visits and hospital admissions that occurred in patients with breast, lung, and Gastrointestinal (GI) cancers between July12019 and October31 2020 including demographics, stage, treatment type preceding the month of ED visit, reason, time of the day, day of the week the visit occurred. Results: 308 patients had 519 ED visits, 111 breast cancer patients had 184, 102 lung cancer patients had 186 and 95 GI cancer patients had 149 ED visits. 38% had > 1 visit. 51%, (37% breast, 60% Lung and 58 % GI cancer) had stage 4 disease at the time of visit. There were no visits in the month of May 2020. 275 (53%) visits required hospital admissions, 60% of ED visits in lung cancer, 54% in GI and 46 % in breast cancer patients required hospitalization. Most common reason for ED visits in breast cancer patients was fall/injury (20%), with median age of 71 years, none were cancer/ chemotherapy induced. Among lung and GI cancer patients respiratory (24%) and GI related (24%) symptoms were the most common reasons respectively, majority were cancer/chemotherapy related. Most common symptoms requiring hospital admissions were respiratory 21%, GI 18%, cardiac 12%. 11% and 9% of ED visits were due to fall/injury and cancer related pain, of these 3.6% and 9% resulted in hospital admissions respectively. Lung and GI cancer patients were more likely to be referred to the ED from the oncologist office (23%) than breast cancer patients (11%). Conclusions: Reasons for ED visits vary by tumor types and some may be preventable. Fall/injury in breast cancer patients and cancer related pain in lung and GI cancer patients were frequent reasons for preventable ED visits. In lung and GI cancer patients, cancer/chemotherapy related respiratory, GI symptoms are felt to be less avoidable since they may be related to disease progression or presenting symptoms. We have initiated several strategies such as ‘’systematic physical therapy assessment’’ of our breast cancer patients over age 70 to reduce ED visits due to fall/injury. We are developing strategies to involve palliative care early to reduce the number of ED visits related to cancer related pain We now have “call us first campaign” to assess and intervene before going to ED since most visits occurred during working hours.[Table: see text]
Variable implementation of optimal therapeutic strategies in metastatic colorectal cancer: Reviewing rates of liver resection and triplet chemotherapy across Australian hospitals as potential quality indicators.
Authors: Dunn Catherine , Gately Lucy , Tie Jeanne , Nott Louise M. , Lee Belinda , Mendis Shehara Ramyalini , Shapiro Jeremy David , Wong Vanessa , Burge Matthew E. , Wong Rachel , Kosmider Suzanne , Lee Margaret , Jennens Ross , Gibbs Peter
Published: September 2021

248

Background: Quality indicators (QI) are essential to monitor the efficacy of cancer care and to guide quality improvement, however many are derived from ‘expert consensus’ and are not validated against outcomes. Moreover, the majority of oncological QI are defined in the surgical setting, with only a paucity of QI for the treatment of metastatic disease. We aimed to define and validate novel QI for metastatic colorectal cancer (mCRC) based on therapeutic approaches associated with a proven survival benefit. Methods: Data was analysed from TRACC, a multisite Australian registry collecting prospective demographic, tumour, treatment and outcome data for mCRC. We identified all patients diagnosed across 11 hospitals and explored variation by site with regards to patient and tumour characteristics, first-line chemotherapy administration and resection of oligometastatic disease. Log-rank testing and Kaplan-Meier curves compare overall survival (OS) between sites, and Pearson correlation was used to assess associations with each QI. Results: We examined data from 3132 patients diagnosed with mCRC between July 2009 – April 2021. Median age was 66 years (range 62 – 71 years by site), ECOG 0-1 81% (range 69 – 96% by site), and Charlson Comorbidity Index ≤2 43% (33 – 59% by site). Multivariate analysis confirmed association of known adverse prognostic factors with inferior OS (poor ECOG, right sided primary, KRAS or BRAF mutation, all p <0.05). Median OS for entire cohort was 26.2 months (95%CI 24.9 – 27.3 months), and varied by hospital site from 20.1 – 36.1 months (p<0.001). Of the QI evaluated, rate of triplet chemotherapy (FOLFOXIRI) administration (2.8 – 13.2% by site) was very strongly correlated with OS (R2 = 0.851), rate of liver resection (9.8 – 23.2% by site) was moderately correlated (R2 = 0.523), and rates of active treatment with first-line chemotherapy (63 - 90% by site) were weakly correlated (R2 = 0.209). Other proposed QI such as rates of lung metastases resection or chemotherapy administration in the elderly showed significant variation by site, but did not correlate with survival. Conclusions: There is significant variation in OS for patients with mCRC in these Australian hospitals, with major differences in treatment approaches. Treatment strategies known to improve survival outcomes, such as triplet FOLFOXIRI chemotherapy and resection of liver metastases, may be potential QI to benchmark and track quality improvement over time. Further analysis will determine the impact of baseline patient populations between sites, and to correlate these QI with other quality measures.
Hematology/oncology utilization of advance care planning services.
Authors: Dickson Natalie R. , Hirschorn Allison , Bourbeau Brian , Thomas Christian A. , Thebarge Stephanie , Srivastava Piyush , Soliman Pamela T. , Levanduski Heather
Published: September 2021

25

Background: In 2016, Medicare added coverage for advance care planning (ACP) services (CPT codes 99497 and 99498). ASCO’s Coverage and Reimbursement Steering Group sought to explore and quantify whether these codes are regularly utilized by hematology and oncology physicians, and to provide guidance on administrative best practices for successful reimbursement. Methods: We analyzed utilization of care management services using Physician/Supplier Procedure Summary (2016-2019) and Medicare Provider Utilization and Payment Data: Physician and other Supplier PUF CY2018 (PUF) files, available on data.cms.gov. Data files are limited to lines representing services to at least 11 unique Medicare beneficiaries; otherwise, Medicare imputes a blank value. Total ACP services submitted to Medicare and the total services denied were calculated for each year using the combination of Hematology, Hematology/Oncology, and Medical Oncology (collectively Hematology/Oncology) specialties, as well as for all specialties. Within Hematology/Oncology, we also pulled physician-level data for 6,335 physicians who had billed Medicare for at least 500 office or hospital outpatient evaluation and management services in 2018. Totals for codes 99497 and 99498 were calculated per physician, providing a distribution of volume. Results: Specialty utilization of ACP services has increased each year, from 708,183 submitted services in 2016 to 2,043,767 in 2019. Hematology/Oncology utilization increased from 2016 to 2017, followed by declines in volume for 2018 and 2019. Among 6,355 hematology/oncology physicians submitting at least 500 office or hospital outpatient evaluation and management visits, 145 billed Medicare at least 11 ACP services in either a facility or non-facility setting. Advance Care Planning Services (99497 and 99498) billed to Medicare in 2016-2019. Conclusions: Though Advance Care Planning is an integral part of cancer care, the codes are not frequently reported to Medicare as a separate service. This may be due to lack of awareness or understanding of the codes, and uncertainty as to how to implement the services into the workflow of the practice. To increase utilization and ensure appropriate reporting of ACP, Oncologists and Oncology practices would benefit from coding and reporting education, and well as guidance on administrative processes to successfully manage ACP services. ASCO's Coverage and Reimbursement Steering Group has developed a practice administration and reimbursement guide for publication on asco.org.[Table: see text]