bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing administrative burden through the use of IT tools.
Authors: Rothacker Andrew , Glass Katherine
Published: October 2019

300

Background: With the increasing cost of healthcare, providers have been tasked with increasing efficiencies. While the Electronic Medical Record (EMR) is a great tool for managing the patient at the time of their appointment, it can be difficult to utilize that information outside of and prior to the appointment. We recognized the need for better reporting to enable the end users to spend less time in front of a screen and more time with their patients. The need for better, more efficient data was evident. Simple data extracts from the EMR were not working. Methods: The operations analysts attended weekly huddles, shadowed clinicians, and immersed themselves in the data to better understand what is required from the reports. Multiple patient databases were created, along with dashboards, using a visual software package to display patient information. Information is then filtered into the dashboard for reporting, examples include: the patient’s appointments, treatment length, treatment location, and any other pertinent information that is needed. The reports are then automated to provide users a report with a specific snapshot of the patients coming to the clinic the following day/week. End users are then able to take the reports provided to them automatically and plan their time accordingly. Results: The reports are used daily/weekly (depending on the need of the report) by clinical and non-clinical teams. By leveraging appointment data from the back end of the EMR and the visual software package, end users no longer need to spend time combing through the EMR to identify future appointments. Information is tailored to their specific needs, which may be different from a clinical team to a non-clinical team. While it is difficult to quantify the exact value each report provides, one specific example for the Art & Music Therapy team is saving end users an estimated 4 hours per day, extrapolating out to 1,040 hours per year and freeing them up to provide better service to their patients. Conclusions: Combining appointment data and data visualization and automation tools allows teams to review the necessary information more efficiently. By reducing the manual burden of searching through the EMR, end users are able to free up their time and spend more time with the patient.
Evaluation of an NCCN guideline-based weight management pathway on weight loss in female breast cancer patients.
Authors: Hansra Damien Mikael , Ahn Eugene R , Schoeber Nathan , Cargile Jennifer , Johnson Anita , Alvarez Ricardo H.
Published: October 2019

301

Background: Obesity is a risk factor for many breast cancer (BC) subtypes & is associated w/ inferior BC outcomes. Here, we investigate the effect of a NCCN based intervention on weight loss (WL) in BC pts. Methods: Prospective study using WL guidelines adapted from NCCN Survivorship (V. 2.2017). Data collected: demographics, clinical, cardiovascular risk factors (CVD), weight, height, body fat%. Stats: 1 sample T-Test w/ 2 tail p-value & 95% CI used to calculate change in weight from baseline to 3 & 6 months (mo) using hypothetical mean of 0. Inclusions: Female BC pts, stage 0-III, OW (BMI > 25mg/m2) or OB (BMI > 30kg/m2). Exclusions: No BC, stage IV, not OW/OB, lost to follow up (f/u), non-compliance, death, or recurrent disease. Intervention: BMI assessed at baseline at initial visit where pt received 20 minute OB counseling by oncologist (ONC). Pts include NEW pts (treatment & surgery naïve) & F/U pts (pts finished definitive treatment in survivorship). ONC counseling included pt education on OB & cancer outcomes & CVD risk. Initially, pts referred to physical therapy (PT) for exercise program & dietician (DT) for nutrition counseling. Pts visit PT & DT q 3 mo. ONC counseling provided periodically during scheduled visits. Results: 70 pts enrolled 10/26/2017 – 10/8/2018. Median pt age = 56 yrs (37-87). Menopausal status: 25/70 (36%) pre menopause vs. 45/70 (64%) post menopause. Race: 29/70 Caucasian (41%), 41/70 (59%) African American, 0/70 (0%) other. Ethnicity: 2/70 (3%) Latin vs. 68/70 (97%) non-Latin. Avg. BMI = 34 kg/m2 (26-54). Avg. weight = 90 kg (61-143). Stage: 0 = 7/70 (10%) , I = 26/70 (37%), II = 21/70 (30%), III = 16/70 (23%). Receptors: 12/70 (17%) triple negative, 13/70 (19%) Her-2+, 49/70 (70%) ER/PR+. CVD risk factors & body fat% shown separately. Mean WL for the 70 pts (NEW + F/U, N = 70) = -0.7 kg @ 3 mo. (p = 0.08), 95%CI (-1.510- +0.101); mean WL = -0.7 kg @ 6 mo. (p = 0.16), 95%CI (-1.703-+0.295). Mean WL for NEW pts, (N = 52) lost -0.9 kg @ 3 mo. (p = 0.0467), 95%CI (-1.809- -0.014). New pts lost -0.7 kg @ 6 mo. (p = 0.21), 95% CI (-1.868 - +0.440). Conclusions: Implementation of the NCCN guidelines + ONC counseling as part of a WL program mitigates weight gain @ 3 & 6 mo in all OW & OB BC pts & induced significant weight loss in NEW pts @ 3 mo.
Maintaining clinical pathways: What does it really take?
Authors: McNeil Debra , Hamilton Joanna M. , Meserve Emily , Hayne Victoria , Holtz Laura , Wolfson Matthew , Milne Dana , Jackman David Michael , Leblebjian Houry , Jacobson Joseph O. , Tremonti Carole Kathleen
Published: October 2019

305

Background: Building pathways to support clinical decision making is one step, maintaining them is a mountain. Dana-Farber Cancer Institute has built 34 medical oncology (MO) pathways (PWs) and 27 radiation oncology (RO) PWs. These PWs are managed by 28 lead MDs, 8 pharmacists, 6 project managers (PMs), 1 data analyst and 1 coordinator. Once PWs are built, attention shifts to platform and content maintenance. Methods: Maintaining PW clinical and informatics content is complicated and laborious. It requires collaboration amongst clinical and non-clinical experts; these resources form the PW team. PW content is updated quarterly or semi-annually, based on the pace of scientific change in a disease. These review meetings serve as a forum for physicians to review, discuss and revise content. Infrastructure support is provided by the PW team. Supporting the meeting requires a pre-meeting, the formal review meeting, a post meeting, and extensive revisions and content validation along the way. To prepare, PW performance data and emerging relevant evidence is reviewed with the lead MD to establish the meeting agenda. In both MO and RO the PW team is responsible for all content management. Results: We reviewed 6 months of data (2/18-7/18) and analyzed the hours and cost to maintain the pathway portfolio. Conclusions: PW maintenance is costly therefore labor efficiency is critical to overall success. There are 4 strategies for success: building trust; MD engagement; data; and program coordination. The MD/PM relationship is the foundation and consistency is key. MD engagement is crucial; having an influential lead MD sets the tone for the disease center overall. Establishing clear expectations and frequent check-ins keeps the lead MD engaged. Actionable, frequent, and transparent data reports give MDs feedback on their practice patterns. The coordinator is a central point of contact and ensures programmatic execution and success. Though PW maintenance is resource intensive, it facilitates standardized decision-making for the dissemination of cutting-edge cancer care.

[Table: see text]
Quality improvements in palliative radiotherapy at end of life: The FutRE Study.
Authors: Goutam Siddhartha , Stosky Jordan Mark , Wu Jackson S.Y. , Fairchild Alysa M. , Kerba Marc
Published: October 2019

306

Background: Palliative radiation therapy (RT) is offered to patients with cancer for symptom management. RT planning and delivery is resource intensive. Benefits may take weeks to develop. Palliative RT at the end of life may not be completed due to patient and disease factors. RT courses that are not completed may indicate a need for improved patient selection for RT and choice of RT prescription, minimizing the likelihood of delivering futile treatment. Methods: The FUTile Radiotherapy at End of life survey was implemented in the electronic RT workspace across Alberta in 2018. Radiation oncologists (ROs) were tasked with survey completion, at the time of palliative RT prescription approval, as part of their workflow on domains pertaining to patient and treatment decision-making. This survey data was linked to the cancer registry and date of death. Data association were examined among patients completing RT within 90 days of death for the accuracy of oncologist’s provided survival prognostication estimates, number of RT fractions prescribed, number of RT fractions completed, prescribing physician, including disease factors and treatment intent. Results were explored using descriptive statistics and tests of associations (STATA 11.1) Results: 1963 RT surveys were included in our analysis. Prescribing ROs overestimated patient survival 67% of the time, by a mean of 145 days, and underestimated survival 12% of the time by a mean of 109 days. Multi-fraction RT (1403 courses) was more frequently prescribed over single fraction (SF) RT (560 courses)(one-sample t-test, p≤0.001). SF treatments were more likely to be completed than MF treatments (RR = 10.3, 95% CI = [4.85, 21.7], p < 0.0001). Treatments were less likely to be completed when survival was overestimated by 6 or more months and were over twice as likely to be completed than when patient survival was underestimated (RR = 2.6, 95% CI = [1.04, 6.50], p = 0.04). Conclusions: Survival among end of life patients is overestimated by ROs prescribing palliative MF RT treatments.
Effect of digital tumor board solutions on “failure-to-discuss” rates for patient cases during tumor boards.
Authors: Fowler Donna , Sheets Lincoln R , Prime Matthew S , Guo Chaohui , Siadimas Athanasios , Levy Yariv Z , Hammer Richard D
Published: October 2019

308

Background: A multidisciplinary tumor board (MTB) provides an interdisciplinary approach for decision-making in cancer care. Efficient conduction of MTBs is importantfor optimal patient management. It is, however, often observed that prepared patient cases are not discussed during tumor boards due to limited time or incomplete information, which could cause delaytocaredecisions and/or the initiation of treatments. It remains unknown whether digital technologies canreduce the rate of failure to discuss during MTBs. Methods: A prospective cohort study was undertaken to evaluate the preparation & conduction of MTBs pre- & post-implementation of the NAVIFY Tumor Board (NTB) solution at Missouri University Health Care (MU), including the Ear, Nose & Throat (ENT) MTB. The NTB is a cloud-based workflow product, integrated with the hospital EMR, that aggregates and displays relevant clinical information. NTB was introduced to theMUENT MTB on Oct 10, 2018. Results: Pre-NTB implementation, data was collected from 42 ENT MTBs. A total of 551 patient cases were prepared for MTBs, but only 423 patient cases were discussed. This was an average “failure-to-discuss” rate of 19.4% per meeting (SD = 15.6%). After NTB implementation, data was collected from 7 MTBs where a total of 70 patient cases were prepared and discussed. There were no instances of failure to discuss, and as such, was significantlyreduced after the implementation of NTB (Mann-Whitney U test, p = 0.0004). The average number of patient cases discussed per meeting pre- and post-NTB implementation did not change (Mann-Whitney U test, p > 0.1) and meeting duration was the same. Conclusions: Introduction of the NTB did not change the weekly number of cases discussed, but did significantly reduce the failure to discuss rates for ENT MTB cases. Reducing failure to discuss rates could decrease the overall time to clinical decision and the initiation of treatment, which could potentially improve patient outcomes. Additional studies are needed to examine the impact of digital solutions on the quality of clinical care.
Adherence to breast cancer treatment guidelines according to pathogenic variants in cancer susceptibility genes in a population-based cohort.
Authors: Katz Steven J. , Morrow Monica , Kurian Allison W.
Published: October 2019

34

Background: Increasing use of germline genetic testing may have unintended consequences on breast cancer treatment. We do not know whether treatment deviates from guidelines for women with pathogenic variants (PV) in cancer susceptibility genes. Methods: SEER data for all women aged ≥20 years, diagnosed with breast cancer in 2014-15 and reported to Georgia and California registries (N=77,588) by December 1, 2016 were linked to germline genetic testing results from 4 laboratories that did nearly all clinical testing. We examined first course of therapy of stage <IV patients who linked to a genetic test: bilateral mastectomy (BLM) in candidates for surgery (unilateral, stages 0-III); post-lumpectomy radiation in those with an indication (all but age ≥70, stage I, hormone receptor (HR)-positive and HER2-negative); and chemotherapy in those without definitive indication (stage I-II, HR-positive, HER2-negative and 21-gene recurrence score <30). We report the percent treated based on multivariable modeling, adjusted for age, race, stage, grade, insurance and socioeconomic status. Results: The table shows that 9% of patients who linked to a genetic test result had a PV (N=1,283). Compared to women with negative results, those with BRCA1/2 PVs were more likely to receive BLM, more likely to receive chemotherapy without definitive indication, and less likely to receive indicated radiation as initial treatment. Lower-magnitude effects were seen with other PVs but not variants of uncertain significance (VUS). Conclusions: In a population-based setting, women with PVs in BRCA1/2 or other cancer susceptibility genes may have higher risk of receiving locoregional and systemic treatment that does not follow guidelines.

[Table: see text]
Oncologist decision drivers in stage III non-small cell lung cancer: Outcomes of a web-based survey.
Authors: Yagui-Beltran Adam , Ryan Kellie , Boron Marnie L. , Cotarla Ion , Spinner Daryl S. , Faulkner Eric C. , Carroll Marissa C. , Shah Surbhi , Cullen Shawna L.
Published: October 2019

35

Background: Clinical guidelines seek to optimize patient care. We investigated how oncologists manage stage III non-small cell lung cancer (NSCLC) patients from diagnosis through treatment decision-making and drivers impacting guideline adherence. Methods: A sample of US medical oncologists (n=150) participated in a 38-question, 25-min web-based quantitative survey in January 2019. Participation required at least 3 yrs in practice and 3 stage III NSCLC patients treated in the prior 6-mo period. Results: Surveyed oncologists (82% community; 18% academic), on average, had 15 yrs of clinical experience and treated 20 stage III NSCLC patients in the prior 6 mos. Time from first treatment decision to initiation averaged >2–4 wks in 31% and >4 wks in 20% of patients, respectively. Oncologists recommend definitive concurrent chemoradiation therapy (cCRT) in 48% of unresectable stage III NSCLC patients. Reasons for not recommending cCRT include patient unlikely to tolerate cCRT (64% of oncologists), presence of a targetable mutation (41%), patient inability to travel consistently to receive treatment/inconvenient dosing (41%), and patient cost/affordability (34%). Eighteen percent of unresectable stage III NSCLC patients decline recommended cCRT. Fifty-five percent of patients who receive cCRT go on to receive consolidation immunotherapy (IO). Insurance challenges led to oncologists not recommending consolidation IO in 19% of patients. In the 85% of oncologists who conduct EGFR or PD-L1 testing, positive EGFR or negative PD-L1 tests are reasons for not recommending consolidation IO in 27% of patients (12% and 15%, respectively). Over half (55%) of unresectable stage III NSCLC patients who receive definitive cCRT also receive consolidation chemotherapy, which is no longer recommended in guidelines. Patients receiving consolidation CT were less likely to receive consolidation IO than the overall cohort of patients receiving cCRT (42% vs. 55%). Conclusions: Oncologists reported important variances in guidelines and standards of care related to the stage III NSCLC patient treatment journey. While some deviations from both are expected, there may be areas of focus for quality improvement initiatives.
Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?
Authors: Weldon Christine B. , Trosman Julia Rachel , Makower Della F. , Rapkin Bruce D. , Bozier Moreen , Knightly Eileen , Schaeffer Cathleen M. , Hoskins Kent , Gallagher Christopher , Lo Shelly S. , Grace-Louthen Cathy , Throckmorton Alyssa , Vanderwalde Lindi , Krueger Editha A. , Van Horn Jennifer , Schapira Lidia , Santa-Maria Cesar Augusto , Ravelo Arliene , Benson Al Bowen , Gradishar William John
Published: October 2019

36

Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N = 105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N = 190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p = .02) and dental visit (100%, 6/6 vs. 20%, 1/5, p = .02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work.

[Table: see text]
Assessing advance directive (AD) completion rate in inpatient hematology unit.
Authors: Ananthula Aneesha , Konda Manojna , Makhoul Issam , Moore Heather C , Sasapu Appalanaidu
Published: October 2019

42

Background: Advance Directive (AD) completion is particularly more important in patients with cancer given the higher mortality associated with the diagnoses as well as the treatments that patients receive. In reality AD discussion and completion rate is influenced by patient characteristics and disease status. We undertook a Quality improvement project to improve AD discussion and completion in inpatient hematology unit at our institution. Methods: Plan-Do-Study-Act (PDSA) methodology was used and the team consisted of residents and case managers. Each morning electronic medical record (EMR) was reviewed and new patients admitted to hematology unit were identified for a period of 1 month. Patients without an AD on file were educated by a designated resident and were given forms to file AD. Based on the patient’s willingness, the case manager was alerted with daily communication email to follow-up and assist in completion and filing of AD into EMRs. Results: AD on discharge on a randomly chosen pre-intervention month was 6.97% which improved to 42% post intervention. Conclusions: Compared to Oncology patients, Hematology patients have a lower rate of AD completion in general. Hematology patients are usually younger, have a higher chance of achieving remission, and usually have improved survival with stem cell transplant due to which AD discussion does not happen very often. The notion of having AD discussion only for patients with poor prognosis should change and must be offered to everyone. We found an improvement in AD filing rate by increasing physician involvement and streamlining the process with designated roles. It is the responsibility of physicians to discuss Advance Care Planning (ACP) with their patients and readdress them at appropriate intervals as disease status can change.

[Table: see text]
Assessment of compliance with USPSTF lung cancer screening guidelines among resident primary care physicians in a university residency program.
Authors: Lopetegui-Lia Nerea , Jafri Syed Imran , Kumar Manish , Sama Shashank , Vredenburgh James J.
Published: October 2019

43

Background: Lung cancer remains the leading cause of morbidity and mortality, with a predicted 1.8 million deaths worldwide yearly. The United States Preventive Services Task Force (USPSTF) recommends screening for lung cancer with Low Dose Computed Tomography (LDCT) for all genres of age 55 to 80 with a 30 pack-year smoking history, current smokers or have quit within the past 15 years. Early detection has shown to reduce mortality. Only 4% of eligible patients in the US actually undergo lung cancer screening. Methods: A retrospective review of data was performed amongst the University of Connecticut Internal Medicine Residents acting as PCPs at a Clinic in Hartford, CT, USA. Results: 369 medical charts were reviewed. 115 patients (31.1%) met the USPSTF criteria for screening. 5.7% had an appropriately ordered LDCT scan. 2.71% had a LDCT completed and 2.98% had LDCT scheduled but pending or cancelled. 4 patients with smoking history who did not meet USPSTF criteria but had a LDCT due to clinical suspicion for lung cancer. Approximately 11% of patients had chronic obstructive pulmonary disease (COPD) or emphysema and asthma. 5 patients had a first degree relative with history of lung cancer. 6 patients had lung cancer, 3 of which had metastatic lung cancer at the time of diagnosis and are deceased. Conclusions: Lung cancer screening amongst resident PCP is insufficient. The results obtained were lower than the national average. This is likely due to newer trainees focusing less in prevention/screening and more on managing chronic medical conditions. Patients that attend resident PCP clinics in the US are typically of lower socio-economic status, less insurance coverage or uninsured and with a lower level of education. LDCT orders that were cancelled were likely because insurers declined it. Patients not realizing the importance of screening could also be contributing. It is unclear if lung disease or family history attributes a higher risk of developing lung cancer. In conclusion, educating resident PCPs and patients on lung cancer screening, as well as evaluating the reasons for cancelling LDCT could help ensure high quality care.
Pharmacist-driven oral oncolytic medication education and consent.
Authors: Tawfik Bernard , Bowles Harmony , Dayao Zoneddy R. , Lauer Richard C. , Abernathy Janet
Published: October 2019

44

Background: The number and type of oral oncolytic therapy in oncology is expanding rapidly. Oral oncolytics have serious side effect potential and patient education has been shown to reduce adverse events. Pharmacist driven interventions have been shown to safety and adherence. The University of New Mexico Comprehensive Cancer Center (UNM CCC) initiated and then improved upon a pharmacist driven patient education and consent process for oral oncolytic therapy. Methods: A pharmacist driven education and consent process was initiated at UNM CCC and monitored from August 2016 to October 2018. The intervention initially used a message generated by an order in the Electronic Medical Record (EMR) to alert the pharmacist of new oral oncolytic prescriptions. Initial uptake by providers was low so education regarding this order was presented to providers. Outpatient pharmacy staff were instructed not to release first fill oral oncolytic prescriptions without notifying the pharmacist educator. Lastly, hematology and oncology fellows notified the pharmacist educator of patients discharged directly from the hospital with a new oncolytic prescription. The metric measured was the percent of patients on oral oncolytic therapy who were educated and consented by the pharmacist for oral oncolytic medications filled at UNM CCC. Statistical analysis included run charts with 95% Confidence Intervals and t-tests with two tails, assuming unequal variation between groups and an alpha of 0.05. Results: The initial monthly education and consent rate was 17.9% followed by 45.5% the following month. This quickly grew to an average of 87.0% (95% CI 55.7-118.2) for the subsequent 15 months which achieved control. Additional changes were made as part of the PDSA cycle which increased the education rate to 95.7% (95% CI 84.4-107.1). These two periods were statistically significantly different (p = 0.0025). Conclusions: A pharmacist driven program for education and consent upon initiation of oral oncolytics is possible and can successfully educate the majority of patients. Future expansions of this program will include ensuring patient adherence and educating patients who fill oral oncolytics outside UNM CCC.
Impact of palliative care consultation on end-of-life care measures: A retrospective analysis of patients in the Oncology Care Model.
Authors: Greidinger Alison , Vershvovsky Maria , Lapinsky Evan , Rhoades Alison , Leader Amy , Maio Vittorio , Minetola Jared , Walsh Karen , Csik Valerie Pracilio , Rhoades Ruben
Published: October 2019

45

Background: Despite a 2016 ASCO recommendation that patients with advanced cancer receive dedicated palliative care (PC) services, many patients are not referred and continue to receive chemotherapy and utilize high-acuity services near the end of life (EOL). Studies suggest that early PC involvement is associated with lower spending, acute care utilization, and chemotherapy administration at the EOL. The Sidney Kimmel Cancer Center participates in the Oncology Care Model (OCM), a CMS episode-based alternative payment model promoting high-value care. Using OCM-generated data, we evaluated the effect of PC visits on EOL outcomes. Methods: We identified OCM patients with episodes starting April 1, 2016-July 1, 2018 with GI and head & neck malignancies who had died, and determined whether patients who saw a PC provider had greater documentation of a code status (CS) before death, as well as lower spending and utilization of chemotherapy or acute care in the last 30 days of life. CMS spending data and dates of death were derived from OCM quarterly feedback, while all other data was compiled via chart review. CS was recorded at the start of the episode and at the time of death. Results: The study included 126 patients (median age 66 years), of whom 38% had a PC visit. 24% had only an inpatient (IP) PC consult, 6% only an outpatient (OP) visit, and 9% both IP & OP visits. More patients who saw PC had an initial CS documented (85%, vs 46% for no PC), and had a greater proportional increase in CS documentation before death (96% vs 53%). Despite similar rates at baseline, the final CS was significantly more likely to be “Do Not Resuscitate/Intubate” (DNR/DNI) among PC patients (79%, vs 28% for no PC). An initial CS of DNR/DNI was associated with lower mean ICU and total non-hospice spending in the last 30 days of life. Conclusions: This retrospective study in OCM patients found that PC intervention is associated with improved documentation of a CS and higher rates of DNR/DNI documentation before death. There is an association between an initial DNR/DNI CS and lower acute care spending. This data suggests a beneficial effect of early PC on utilization at the EOL in advanced cancer patients.
Clinical and financial outcomes in cancer patients with integration of specialty palliative care versus standard oncology care.
Authors: Gaster Sam , Arneson Francine , Rojas-Espaillat Luis Alexander , Hruby Nathan , Perrenoud Mari
Published: October 2019

47

Background: Evidence suggests that integrating palliative care into usual oncology care benefits patients with advanced cancer and their caregivers (Ferrell et al., 2017). We evaluated patients with an advanced cancer diagnosis with concurrent palliative care versus standard oncology care to determine how both clinical and financial outcomes differ in our cancer center. Methods: We conducted a retrospective analysis on 340 deceased cancer patients who attended an office visit at a medical/gynecologic oncology clinic between January 2018 and February 2019. Patients who received concurrent palliative care as well as patients that received usual oncologic care were included. Data available in the electronic health record (EHR) were abstracted to quantify patient and practice level data. We compared differences in advance care planning (ACP) documentation, DNR designation, hospice enrollment prior to death, chemotherapy in the last 14 days of life, and health care utilization and cost. Results: Forty-nine patients received a specialty palliative care consultation concurrent with their cancer care. Compared to their counterparts, patients who received a specialty palliative care consultation were more likely to have a completed advanced care plan (57% v 16%, p < .05), have a DNR designation (29% v 4%, p < .05) in the EHR, to enroll in hospice prior to death (78% v 50%, p < .05), and at an earlier time (Mdiff = 14 days, p = .05). Patients who received a specialty palliative care consultation were also less likely to receive chemotherapy in the last 14 days of life (2% v 7%) and end-of-life acute care utilization was lower in patients with a specialty palliative care consultation, including ED visits (50% v 67%) and hospitalizations (20% v 59%), but these results were not statistically significant. Median per patient per month (PPPM) total cost of care was higher pre-consult ($9,307) versus post-consult ($6,088; Diff = -$3,219), but this result was statistically non-significant. Conclusions: These results provide additional support for advantage of concurrent specialty palliative care in patients with advanced cancer versus standard oncologic care.
Primary care comprehensive medication reviews in cancer patients with comorbid conditions.
Authors: Mackler Emily R. , Thompson Amy , Azar Michelle , Farris Karen B.
Published: October 2019

48

Background: Management of comorbidities is an important component of cancer care and may impact treatment toxicities, effectiveness, and survival. The purpose of this pilot study was to explore patient characteristics and interventions from a comprehensive medication review (CMR) in cancer patients with select comorbidities. Methods: Adult patients who received both active cancer treatment and primary care at Michigan Medicine with comorbid conditions of diabetes (DM), hypertension, chronic (HTN), heart failure (HF), depression, and/or anxiety, completed an intake survey and had a CMR done by primary care clinical pharmacists. Medication recommendations were reviewed with PCPs, implemented in follow-up visits, and documented in the electronic medical record. When needed, patients were referred to pharmacists for DM and/or HTN management using collaborative practice agreements. Results: Of the 96 eligible patients, 81% had solid tumor cancers (31% metastatic) while 19% had a hematologic cancer. Patients were 39% male, 34% ≥70 years, and 70% Caucasian. Comorbid conditions included DM (20%), HTN (61%), HF (6%), and depression/anxiety (45%). To date, pharmacists have seen 31 patients, and changes to medication profiles were made in 84% of patients. Almost 1 in 4 patients (23%) were referred for disease management. Patient intake surveys were obtained for 28 of the 31 patients. Over 1 in 5 (21%) reported their most bothersome symptom to be pain or neuropathy. Of the 2 patients reporting low social support, they also reported low confidence in symptom self-management. When asked to rate the hassle with frequent doctor appointments, 1 patient indicated a value of 4 or higher (5-point scale, where 5 = high) with the majority selecting no or little hassle. Conclusions: Primary care pharmacists have an opportunity to improve the coordination of care and enhance clinical outcomes in patients with cancer and comorbid conditions, as 23% of patients required additional chronic disease management. Furthermore, patients having lower social support may require additional services to ensure their needs are met.
Integration of pathology within the multidisciplinary cancer care team.
Authors: Plotkin Elana , Allen Timothy Craig , Brown Sandra , Gutman Pablo , Herndon Dana , Nowak Jan A. , Martin Jeremiah , Mohamed Mohamed , Gandee Marianne , Lucas Lorna
Published: October 2019

49

Background: In an era of precision medicine the role of pathology in the diagnosis/management of cancer is evolving. Pathologists are positioned at the intersection of multiple points along the cancer care continuum. Starting at diagnosis pathologists provide expert interpretation and may recommend biomarker testing to guide treatment decisions. Methods: ACCC joined with partners AMP, ASCP, and CAP administered a survey in June 2018. 659 responses were received from a multidisciplinary group and a variety of cancer program settings. Results: Respondents reported that breakdowns in communication are most likely to occur when selecting and ordering biomarker tests (78%) and when reporting the results of the tests (34%). The top 5 challenges reported were coverage/reimbursement, insufficient quantity of material, turnaround time, test selection/ordering, and communication across the multidisciplinary team. There were sizable gaps in regular ordering of NGS among those with 1 tumor board (28%), 2-3 tumor boards (42%) and 4+ tumor boards (64%). Current use of liquid biopsy remains low with the majority (52%) reporting that clinicians rarely order ctDNA testing (12% “routinely”). Time to receiving test results varied with 58% reporting 5-10 business days, 19% reporting <5 business days and 24% >10 business days. 43% indicated pathologists are authorized to order all types of cancer biomarker tests. 56% have molecular pathologists on staff, 24% have a cancer genetics team. 62% report pathology has access to all inpatient records (38% outpatient records). Conclusions: Programs viewed as having integrated pathology participation feature pathologists leading institutional biomarker testing protocols, active participation at tumor boards and standardized reflexive testing pathways that reduce waste & turnaround time. Full integration is a critical piece to ensure patients receive appropriate and timely care.
Cross training of APPs on inpatient oncology units as a safe and cost-effective model.
Authors: Koniarczyk Heather , Tackitt Helen
Published: October 2019

56

Background: Oncology Advanced Practice Providers (APPs) have not been optimally trained to care for each other’s sub specialty of patients. In times of high census and/or short staffing, inpatient APPs are left to care for and manage high volumes of acutely ill patients. This is concerning for patient safety, burning out as well as dissatisfactions when vacation and meetings are denied because there is no backup coverage available. Methods: In order to minimize the use of overtime pay, physician moonlighting pay and additional positions in times of short staffing, we proposed to cross train experienced APPs to see if the staffing needs could be met. The disease groups consisted of transplant, leukemia and lymphoma. Each disease group has a lead APP involved in the strategic planning and implementation process. They were instrumental in working through and identifying risks and benefits of this training plan and were the first to be trained, as to lead by example. Buy in from APPs was achieved by promoting the flexibility of scheduling that would result from having more coverage. Some were also motivated to add to their skill set by learning how to care for a new disease group. Results: The APPs felt comfortable taking patients after around 2 training shifts. They felt the patients were more alike than different and the workflow for most job duties were identical, and enjoyed working with fellow oncology APPs they hadn’t interacted much with. Cross training was proposed to add a financial benefit to our institution. Key metrics we monitored were productivity and supplemental pay. The financial savings from avoiding supplemental overtime or fellow moonlighting wages for 2018 was $8,540, and $14,640 for quarter1 2019. The APPs had no decrease in productivity to date, and no decrease in quality metrics and no adverse events related. Conclusions: Cross training as a means to reduce short staffing financial burdens while advancing the scope of practice of APPs is a safe and possible alternative to adding positions, or paying overtime/moonlighting pay. Training of cross covering APPs was not overall a major constraint. Buy-in from leadership as well as APPs is instrumental in not only initiating a cross training program, but maintaining it as well.
Pilot study to assess a pharmacist- and medication navigator-led intervention of oral anticancer medication (OAM) adherence.
Authors: Lin Mingqian , Hackenyos Douglas W. , Parsons Susan K. , Rodday Angie Mae , Murphy-Banks Rachel , Weidner Ruth Ann , Savidge Nicole
Published: October 2019

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Background: While advances in OAM make treatment more convenient for patients, OAM must be taken and handled correctly. Studies show gaps in patients’ knowledge of taking/handling OAM, suboptimal adherence, and worse outcomes. A prior study at our institution showed low patient understanding of OAM taking (30%) and handling (15%). Other pharmacist (RPh)- or nurse-led interventions have included patient education, short-term follow-up, and reminder tools. No studies have examined multisession interventions co-led by an RPh and medication navigator (MN). This ongoing pilot study assesses the feasibility of such an intervention, its impact on patients’ understanding and adherence, and patient acceptability. Methods: Patients at our institution met with an RPh and MN for an education and teach-back session at OAM initiation (T1). Patients were given a Drug Information Sheet and Medication Calendar as educational tools. Patients were then invited to enroll in a multisession intervention, including an RPh-led re-education at the first refill (T3) and MN-led boosters (T2, T4). At each session, teach-back responses were recorded and participants completed study measures and evaluations. Preliminary results on T1 and T2 are presented. Results: To date, 37 (95%) patients enrolled at T1 and 33 completed the MN-led booster a week later (T2). At T1 and T2, 85% of participants demonstrated sufficient understanding of OAM taking and handling. However, despite high levels of self-reported adherence, 48% lacked knowledge about when or where to get a refill. At T1 (32%) and T2 (60%), of patients raised issues that were not previously shared with their clinical team. Patients were highly satisfied with the intervention and found the education session, booster, and educational tools useful. Conclusions: While data collection is ongoing, preliminary results suggest this intervention is feasible, enhances patient understanding and adherence to their medications, and is acceptable to patients undergoing OAM treatment. Integration of RPh and MN into oncology teams can enhance care delivery and provide timely assistance for OAM-related issues, providing insight into future models of care.
Implementation of an enhanced recovery program framework in medical oncology.
Authors: Campbell Brittany C , Ong Yvette , Eska Jarrod , Mathai Sharon , Mendez Noel , Olanigan Maroof , Varghese Susy , Waits Mark , George Marina C.
Published: October 2019

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Background: Enhanced recovery programs (ERPs) apply multi-modal approaches to manage symptoms, decrease complications, and reduce length of stay (LOS). Widely adopted in surgical settings, there is limited evidence of their implementation in non-surgical patient cohorts. An ERP was implemented in a medical oncology population at a National Cancer Institute-designated comprehensive cancer center. The aim of this quality improvement initiative was to evaluate the implementation of an enhanced recovery framework and determine feasibility in medical oncology. Methods: Enhanced recovery in medical oncology (ERMO) was implemented using Plan, Do, Study, Act methodology. Implementation included introduction of integrative medicine, opioid sparing alternatives, fluid and nutrition management, and functional mobility. Outcome measures included symptom distress as measured by the Edmonton Symptom Assessment Scale (ESAS), return to intended oncologic therapy (RIOT), LOS, and opioid use, evaluated from January 2017 through April 2018. Results: A total of 50 patients were evaluated during the program implementation, and compared with 49 control patients retrospectively reviewed prior to ERMO implementation. Average LOS for ERMO patients was 7.3 days compared to 5.5 days for the control group. Time to RIOT averaged 18.9 days for control patients (n = 30) versus 20.8 days for ERMO patients (n = 17). Nineteen patients (38%) had a reduction in morphine equivalent daily dose (MEDD) from admission to discharge, with an average MEDD of 328.47 milligrams per patient. Conclusions: ERMO as a framework is feasible. The patient reported outcomes such as ESAS and RIOT, and barriers to implementation, including participant engagement and patient pain management perceptions, should be evaluated in the context of larger clinical trials.
Evaluating the early impact of adding a financial counselor to an Oncology Care Model pilot program.
Authors: Liang Margaret , Summerlin Sarah S. , Rocque Gabrielle Betty , Salter Terri , Wiersma Mark , Huh Warner King
Published: October 2019

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Background: The Oncology Care Model (OCM) emphasizes the importance of patient costs. Our practice identified a need for patient financial counseling (Plan) and added a financial counselor to the care team (Do). Our objective is to describe the financial counseling process and evaluate (Study) the impact of adding a financial counselor to address financial burden among cancer patients. Methods: New treatment orders trigger a task to the financial counselor who mails a letter including personalized insurance benefit information (i.e., deductible, out of pocket maximum, amount met to date), estimated out of pocket cost for prescribed chemotherapy regimen, and additional financial resources. The health care team can also place referrals for identified needs. Data on patient characteristics, referral patterns, and services delivered was abstracted from the electronic medical record. Results: The financial counselor contacted 157 cancer patients from 4/2018-4/2019, including 134 (85%) OCM patients. The average age was 68 years old (range 22-91); 93 (59%) patients were female; 39 (25%) patients identified as black. Out of 32 patients with documented income, the average annual household income was $25,000. Most patients had Medicare Part D coverage (67/73, 92%) and secondary insurance (59/77, 77%). The financial counselor contacted patients by mail (52/77, 68%), phone (13/77, 17%), in-person at clinic (7/77, 9%), e-mail (1/77, 1%), or using multiple methods (4/77, 5%). Actions taken included mailing insurance benefit and estimated out of pocket cost letters (60/72, 83%), referring to social workers or lay navigators (5/72, 7%), or reviewing insurance benefits (4/72, 6%). Co-pay applications through foundation grants were submitted by the financial counselor for 27 patients of which most (23/27, 85%) were approved. Conclusions: Financial counselors provide diverse services to cancer patients to reduce financial burden, including to patients without secondary insurance who were noted to have additional financial needs. Patient satisfaction surveys and accounting for the dollar amount returned to patients and the health system represent next steps for our new program (Act).
"Cancer Life ReiMagined:" The CaLM model of whole-person cancer care.
Authors: Schear Rebekkah , Eckhardt S. Gail , Kvale Elizabeth Ann , Richardson Robin , Jones Barbara L.
Published: October 2019

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Background: Despite advances in cancer treatment, the orientation of our health system does not address the whole cancer patient or support the wellbeing of the heart, soul, and mind. We launched the CaLM Model of Whole Person Cancer Care, an oncology medical home approach that integrates high acuity, sub-specialty clinical cancer care with comprehensive, ongoing supportive care. The CaLM Model operationalizes the six components in the conceptual framework set forth in the NASEM’s 2013 report. Delivering High-Quality Cancer Care. Methods: Beginning December 2018, we piloted a “flipped” ambulatory care model in GYN and GI oncology delivering daily care through a subset of providers, the SWAT Team: a palliative NP, med onc NP, clinical social worker, and navigator. The SWAT Team triages all physical and social needs. As opposed to anchoring care with the oncologist and referring the patient out to social services, the SWAT team anchors care and the oncologist plugs in for treatment planning. The CaLM Model also utilizes coordinated, interdisciplinary care including financial and fertility navigation, nutrition, genetic counseling, pharmacy, and psychiatry, to manage the patient’s needs via a team-based approach by assessing and addressing the patient’s needs according to their values and preferences. We designed a new clinical and psychosocial assessment tool and patient-facing care plan; launched a Multi-Disciplinary “whole-person” case review process with all interdisciplinary providers and measured patient reported outcomes using the FACT-G, PHQ, GAD, and MD Anderson Symptom Inventory at baseline (initial visit) and every clinical visit. Measured at initial visit and every 6 months. Results: Early data show that the CaLM Model reduces patient symptom burden while improving quality of life. Conclusions: The CaLM Model is an efficient use of resources, compared to a traditional oncologist-focused model of cancer care. Further research is underway to assess cost benefit to the system, the patient and the payers. Ultimately, the CaLM Model may shift the paradigm of cancer care by demonstrating the feasibility and effectiveness of a patient-centered model of care delivery that builds a foundation for a value-based payment model.