bluuebunny/crossref_metadata_2025 huggingface dataset:
Chemotherapy use near end of life (EOL): Measuring real world benchmarks.
Authors: Kraut Joshua , Gippetti James , Peterson Dylan , Agarwala Vineeta , Revol Cindy , Fessele Kristen Lee , Abernethy Amy Pickar
Published: April 2017

228

Background: Use of anti-cancer therapies in the last 14-30 days of life may worsen patient outcomes and increase cost; accordingly, rate of chemotherapy use near EOL is an important quality measure. Contemporary benchmarks are needed, with transparent methods describing the cohort in which the measure is assessed, and criteria for calculation. Methods: Data on chemotherapy use, mortality, and cancer diagnosis was sourced from electronic health records (EHRs) of >8,000 patients seen between 2014-2016 at two large US academic centers, for whom dates of death were available. Death dates were sourced from the EHR and public records (e.g., obituaries). Patients were grouped by diagnosis using ICD-10 codes. Rates of infusional chemotherapy receipt within 14 or 30 days of death were calculated. Results: Across 10 tumor types, 3-7% of patients received chemotherapy within 14d of death, and 6-16% received it within 30d. Rates were stable from 2014-2016 and did not differ by cancer center. Rates were highest in diseases where patients may experience rapid clinical decline near EOL: in pancreatic and rectal cancer, 30d rates were 16% and 13%. The 30d rate was lowest (6%) in kidney cancer. When the cohort was restricted to only treated patients (who received >=5 chemotherapy administrations at the center), rates of chemotherapy use at EOL increased to 6-12% (14d) and 17-28% (30d). Conclusions: This study provides baseline estimates of current rates of EOL chemotherapy use at academic centers. Transparency in methodology is critical; for example, when the whole population of cancer patients seen at a center is considered, rates are low, but when the analysis is limited to patients who received chemotherapy there, rates nearly double. Further studies should focus on whether this quality measure is a meaningful driver of patient and health system outcomes. This work also demonstrates that it is possible to assess this metric across multiple centers; this approach could be easily scaled to all oncology practices integrated in a data sharing network. [Table: see text]
Lung cancer quality of care in Uruguay: First experience in a public hospital.
Authors: Palleiro Maria Clara Rodriguez , Rodriguez Virginia , Dominguez Viviana , Salisbury Siul , Rodriguez Alonzo , Delgado Lucia Beatriz , Cuello Toledo Mauricio
Published: April 2017

231

Background: Improvement in quality of cancer care is a strategic health objective for the Ministry of Health in Uruguay. Lung cancer is the first cancer in mortality in men and the third in women in our country, there are few reports from Latino America about quality of cancer care, in our knowledge this is the first in lung cancer. Methods: We audit a public reference center in oncology that receive about 8 percent of new cases in the country, our objective was to perform a first study in quality of cancer care in non-small cell lung cancer. We reviewed the compliance with a group of 14 indicators (six general and eight NSCLC specific) selected from literature and used in different quality programs. We performed a retrospective analysis of medical records from 408 new patients seen between January 2011 and July 2016. Results: The median age was 62 years, 72,8% were male and 27,2% females, 76,6% were stage III-IV and 23,6% were stage I-II. The median adherence rate to core indicators were 84,2 (69% to 100%). PS was recorded in 76% of cases. Pathology report was present in 71,8% and stage in 97% of medical records. NSCLC indicators had a lower adherence rate 29,8% (5% to 56,3%). 60% receive adjuvant therapy based in platins but only in 5% of patients receive cisplatin. Histologic subtype was informed in 42% of pathology samples and EGFR mutation test were performed in 56% of patient with non-squamous lung cancer. Patients were treated with chemotherapy or radiotherapy as first treatment in 65,4%, stage IV patients receive as first line platin based chemotherapy in 42,7% of cases . Time between diagnosis and first treatment initiation was 28 days and the time to symptoms initiation to diagnosis was 3 months. Conclusions: This auditory identify a high rate of compliance in general indicators, compliance with lung cancer specific quality indicators is heterogeneous. Time to diagnosis need special attention. This study identify a room to improve in lung cancer quality of care and establish a starting point to evaluate the impact of future improvement efforts.
Measuring experiences of patients with cancer with care: The SEER-CAHPS linked data resource.
Authors: Kent Erin , Lines Lisa M , Gaillot Sarah , Schussler Nicola C. , Halpern Michael , Mollica Michelle , Rincon Maria , Smith Ashley Wilder
Published: April 2017

238

Background: Care experience ratings are recognized as measures of quality. We introduce a new resource, SEER-CAHPS, linking cancer registry data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program with Medicare claims and the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Methods: The SEER-CAHPS data resource includes registry data from 1973-2011 (diagnosis, incidence, mortality, and sociodemographic data), Medicare CAHPS survey data from 1998-2013 (sociodemographic, health status, and care experience ratings), and Medicare fee-for-service (FFS) claims data from 2002-2013. SEER-CAHPS includes global ratings of overall care, personal doctor, specialist, health plan, and prescription drug plan and composite ratings of doctor communication, care coordination, getting needed care, and getting care quickly. The data also contain optional survey weights to account for the Medicare CAHPS sampling design. Results: Currently, SEER-CAHPS includes 205,339 individuals with a history of cancer documented in SEER (FFS: 26,802 with a survey before cancer diagnosis, and 55,231 with a survey after cancer diagnosis; Medicare Advantage [MA]: 57,227 with a survey before cancer diagnosis and 71,436 with a survey after cancer diagnosis). The database also includes 724,965 MCAHPS respondents without cancer in SEER regions (FFS: 282,592; MA: 447,358). The data provide insights on topics including experiences of cancer patients in their last year of life; experiences of cancer survivors; experiences of dually eligible (Medicare-Medicaid) cancer patients; and the associations of guideline-concordant follow-up care with patient experiences among people with colorectal cancer. We will demonstrate project sample-size estimation and present instructions for submitting data access applications. Conclusions: SEER-CAHPS provides population-based, cancer-specific data on patient experiences and associations with both health outcomes and healthcare utilization.
End-of-life healthcare utilization among Medicare beneficiaries with malignant brain tumors.
Authors: Dulaney Caleb , Dover Laura L , Williams Courtney , Jackson Bradford E. , Warren Paula , Fiveash John B. , Rocque Gabrielle Betty
Published: April 2017

244

Background: Patterns of end-of-life healthcare utilization for patients with primary and secondary malignant brain tumors (PMBT, SMBT) are poorly understood. The primary objective of this study was to compare end-of-life healthcare utilization and expenditures between patients with PMBT and SMBT. The secondary objective was to determine risk factors for low-quality healthcare utilization at the end-of-life. Methods: We analyzed Medicare administrative claims data for decedents with a diagnosis of PMBT or SMBT within a community cancer network in the southeastern US from 2012-2015. Outcomes included hospital-based care (ED visit, hospitalization, and ICU admission), cancer therapy (chemo- or radiotherapy), hospice care, and total cost to Medicare in the last 30 days of life. We performed regression analyses to determine risk factors for each of the outcomes. Results: 1323 patients had a diagnosis of PMBT (383) or SMBT (940). Patients with SMBT received more hospital-based care (57% v 49%, p < 0.01) and more cancer therapy (25% v 18%, p < 0.01) than those with PMBT. Male gender (RR 1.28, p = 0.03) and decreasing age (RR 1.09, p = 0.02) were risk factors for PMBT and SMBT hospital-based care, respectively. While the majority of PMBT (81%) and SMBT patients (78%) utilized hospice care, those with SMBT were more likely to enroll ≤ 3 days prior to death (10% v 5%, p < 0.01). Hospital-based care (RR 5.22, p < 0.01 (PMBT); RR 5.24, p < 0.01 (SMBT)), and non-white race (RR 1.59, p = 0.04 (PMBT); RR 1.56, p < 0.01 (SMBT)) were risk factors for no hospice utilization. Mean expenditures in the last 30 days of life were similar between PMBT and SMBT ($8592 v $9964). Hospital-based care increased the average cost by $16,303 (PMBT, p<0.001) and $13,132 (SMBT, p<0.001). Conclusions: Hospitalization at the end-of-life is common in patients with PMBT or SMBT and is associated with lower rates of hospice care and increased expenditure.
Uptake and effectiveness of FOLFIRINOX for advanced pancreas cancer: A population-based study.
Authors: Karim Safiya , Zhang-Salomons Jina , Biagi James Joseph , Asmis Tim , Booth Christopher M.
Published: April 2017

245

Background: While FOLFIRINOX is a standard treatment option for advanced pancreas cancer there is little data describing utilization and effectiveness in routine clinical practice. Here we report practice patterns and outcomes in the general population of Ontario, Canada. Methods: Using the Ontario Cancer Registry and New Drug Funding Program we identified all patients with pancreas cancer treated with palliative intent gemcitabine or FOLFIRINOX in Ontario during 2006-2014. FOLFIRINOX became available in Ontario’s single-payer health system in November 2011. Gemcitabine cases were classified as pre-FOLFIRINOX era (2006-2010) or post-FOLFIRINOX era (2011-2014). Cases treated with peri-operative chemotherapy were excluded. Comparisons of proportions between study groups were made using the chi-square test. Overall survival (OS) was measured from date of chemotherapy initiation. Results: During 2006-2014, 3826 patients in Ontario were treated with Gemcitabine (n=3042) or FOLFIRINOX (n=784) chemotherapy for advanced pancreas cancer. Uptake of FOLFIRINOX increased from 41% (206/505) of treated cases in 2012 to 56% (274/486) of treated cases in 2014. Among patients treated after 2011, median age was 69 and 63 years for Gemcitabine and FOLFIRINOX respectively (p<0.001). The proportion of treated cases who received FOLFIRINOX varied considerably across geographic regions (from 26% to 58%, p<0.001). Median number of FOLFIRINOX cycles delivered was 6 (median 10 cycles in pivotal RCT). Median OS of patients treated with Gemcitabine was 5.0 months in 2006-2010 and 4.8 months in 2011-2014. Median OS of FOLFIRINOX patients treated in 2011-2014 was 8.2 months (median 11.1 months in pivotal RCT). Conclusions: Use of FOLFIRINOX in the general population has increased since 2011 with a resulting decrease in use of Gemcitabine. However, outcomes achieved with FOLFIRINOX in Ontario demonstrate a substantial efficacy-effectiveness gap between survival in the pivotal clinical trial and survival in routine practice.
Disease complexity and economic burden on patients with colon cancer in the SEER-Medicare population.
Authors: Rodriguez Maria Alma , Cheng Lee , DeJesus Alma Yvette , Zhao Hui , Giordano Sharon Hermes
Published: April 2017

30

Background: The relatively high cost of cancer care is receiving national attention. Treating cancer includes not only managing this illness, but also the complications and exacerbation of the patients’ underlying comorbid conditions. The purpose of this study was to analyze how the charges for colon cancer care are affected by the complexity of the patients’ underlying health problems. Methods: We searched the Surveillance, Epidemiology, and End Results-Medicare database to identify patients diagnosed with colon cancer from 2009 through 2011. The estimated charges of the patients’ Medicare claims were stratified by survival time, disease stage, patient age, and comorbidity number. We defined patients’ 12 months of care as the 1 month immediately preceding cancer diagnosis plus the 11 months immediately following diagnosis. Results: We identified 10,822 patients newly diagnosed with colon cancer during the study period. Of those patients, one quarter died within 11 months after diagnosis. Treatment for early-stage cancer was significantly less expensive than treatment for advanced disease. For patients with early-stage disease, the charges for surgery, chemotherapy, and/or radiation therapy constituted a smaller contribution to the overall care charges. For patients with advanced-stage disease, the substantially higher overall care charges were largely due to charges for chemotherapy and/or biotherapy. Among patients with the same disease stage at diagnosis (except for patients stage IV disease), those with a survival time of less than 12 months incurred higher charges than those with a survival time of 12 months or more did. Regardless of disease stage, survival time, or age, patients with one and two or more comorbid conditions incurred statistically significant higher charges (7.0% and 29.7%, respectively) than those with no comorbid conditions. Conclusions: These findings demonstrate the important contribution of disease complexity among patients with cancer to the analysis of resource utilization. Using overall cancer care cost or reimbursement models that do not incorporate disease complexity may negatively affect hospitals that care for a high proportion of patients with complex conditions.
Establishing best practice recommendations for systemic treatment regimen development and maintenance.
Authors: Crespo Andrea , Redwood Erin , Vu Kathy , Kukreti Vishal
Published: April 2017

40

Background: A province-wide review of oncology regimens identified discrepancies in a number of regimens in systemic treatment computerized prescriber order entry (ST CPOE) systems. The potential patient harm from such discrepancies includes unnecessary toxicities and reduced treatment efficacy. The regimen review highlighted the need for a high-quality process to improve the safety of systemic treatment prescribing in Ontario. The objective of this work was to develop recommendations on best practices for the development and maintenance of oncology regimens. Methods: An expert multidisciplinary group of oncology clinicians and administrators was formed to review available literature and leverage their expertise to establish oncology-specific recommendations. These were then circulated to broader stakeholder groups for feedback and consensus. Results: Practical, consensus-based best practice recommendations for ST CPOE and pre-printed order regimen development and maintenance were created. Detailed processes for new regimen development are outlined in the table below. Moreover, broad areas of roles and responsibility, frequency of review, and sign-off were highlighted. This was repeated for regimen changes (not shown). Conclusions: There is a lack of guidance in the literature on best practices for oncology regimen development and maintenance. Careful analysis and application of the expertise of oncology professionals resulted in consensus-based best practice recommendations that will enable the advancement of safe, standardized, systemic treatment prescribing.[Table: see text]
Reducing overuse of colony-stimulating factors without compromising patient safety: Evidence from a decision-support enabled utilization management in patients with lung cancer receiving chemotherapy.
Authors: Adeboyeje Gboyega , Agiro Abiy , DeVries Andrea , Fisch Michael , Malin Jennifer L.
Published: April 2017

52

Background: Recent studies suggest significant overuse of colony-stimulating factors (CSFs) for the primary prevention of febrile neutropenia (FN) in patients with cancer receiving chemotherapy. Overtreatment with CSF increases costs without evidence of clinical benefit. We examined the impact of a decision-support tool to promote risk-appropriate CSF use in lung cancer. Methods: A retrospective cohort study design was used to analyze commercial claims data on lung cancer patients. The decision-support tool was implemented at participating oncology practices in staggered phases across 14 U.S states (from July 1, 2014 - November 1, 2014). Study population included adults with lung cancer who initiated chemotherapy from July 1, 2014 through March 30, 2015. Patients were assigned to case and control cohorts according to whether or not they resided in service areas where the tool had been implemented. Patients were followed up to 6 months after initiating chemotherapy in the pre- and post-implementation periods. The primary outcomes: CSF use and FN incidence rates were compared using difference-in-differences (DID) models; adjusting for baseline FN risk factors with generalized estimating equations. Results: The final study population included 3,470 patients (case: 1,857 and control: 1,613; overall mean age (SD), years: 65 (10)). There were no meaningful differences in FN risk factors at baseline between the cohorts. In adjusted results, CSF use decreased from 48.4% to 35.6% in the case compared to a change from 43.2% to 44.4% in control cohort (DID: -8.7% (95% CI: -14.65% to -2.67%), p - < 0.001) in the pre- and post-implementation periods. The rates of FN were consistent for both cohorts in each time period, with no statistical difference in trend for the case (2.8% to 4.3%) as compared with the control (3.1% to 5.1%) cohort (DID: -0.2% (95% CI: -0.63% to -0.33%), p – 0.953). Conclusions: These findings demonstrate the potential for decision-support tools to improve evidence-based guideline adherence and promote risk-appropriate CSF use in patients with lung cancer without adversely impacting patient safety.
Patient-reported outcomes (PROs) in testicular cancer survivors (TCS): Do unmet needs resolve with routine care?
Authors: Palmer Steven C , Vaughn David J. , Blauch Abigail N. , Pucci Donna A. , Jacobs Linda A.
Published: April 2017

56

Background: Unmet needs for intervention are common among cancer survivors, but may go unidentified and unaddressed in routine care, leading to poorer outcomes. PROs are becoming the standard of care at many treatment facilities and have been shown to be feasible and to potentially improve outcomes. However, communication of PROs to providers may be a necessary step in this process. We examined the prevalence and stability of unmet needs over a one-year time period in a sample of TCS to determine whether these resolve over time in routine care. As well, we examined the relationship of unmet needs to symptoms of anxiety and depression. Methods: Ninety-nine consecutive TCS were recruited from an ongoing survivorship clinic. Participants completed assessments of demographics, unmet needs, and anxiety and depression (HADS) prior to their visit and at a one year interval. To ensure routine care, providers were unaware of the results of unmet need screening. Results: Participants were primarily white (94%), early middle aged (M = 40 yrs), married (71%), and college educated (79%). Most participants were diagnosed with Stage I disease (73%) an average of 7 years previously. The number of unmet needs was generally low (M < 0.89) at both time points, but varied from 0-10 (SD = 1.8 over both time points). The number of unmet needs was significantly associated over the one year time period (r = 0.65), and unmet need for specific symptoms at time one was associated with unmet need at time two for fatigue, pain, insomnia, numbness, aching joints, difficulty with concentration, memory, anxiety, decreased sexual interest, and weight gain (all X2 > 8.12, all p < 0.05). Only muscle aches, depression, and body image were unstable over the one year period (all p > 0.05). Number of unmet needs was associated with increased symptoms of depression and anxiety at both time points (all r > 0.23 and < 0.50, all p < 05). Conclusions: Although unmet needs were fairly low, most failed to resolve over the one year time period in routine care, and greater unmet need was associated with more symptoms of depression and anxiety at both time points. The use of PROs may improve outcomes, but only if communicated to providers and acted upon in enhanced care.
Value of central line care teaching for families of pediatric oncology patients.
Authors: Wong Quiles Chris Ivette , Schwartz Marc A , Mahan Riley M , Billett Amy
Published: April 2017

60

Background: Pediatric oncology care depends on central lines (CLs) in both outpatient and inpatient settings. Although inpatient implementation of CL maintenance bundles has been achieved, little attention has focused on families who care for CLs at home. Families are expected to follow best practice, but most have no prior experience or medical background. We sought to understand the comfort level and knowledge of families caring for external CLs at home and the value of our program’s existing teaching strategies, prior to an improvement initiative. Methods: Families caring for children with new and existing external CLs at home from May 2015-May 2016 were eligible for a survey and approached during outpatient visits if their primary team agreed. Using Likert scales, families were asked to assess their current comfort level with CL care, evaluate existing teaching strategies (instructional sheets; hands-on teaching by program nurses, and by home health nurses), and comment on other potentially helpful strategies. Five content questions regarding CL care were included to evaluate knowledge. Results: 80 of 82 (97.6%) families approached completed the survey. 70% had a CL in place for > 60 days. 46.3% felt "very comfortable" performing CL care, 42.5% were "comfortable", and 11.2% were "sort of or not comfortable". Only 17.5% of families found instruction sheets indispensable. Hands-on teaching was indispensable for 51.3% of families; 1.3% responded that teaching was not performed. 27.5% of families found hands-on teaching by home health nurses indispensable, but 22.5% had not received this. 98% of content questions were answered correctly. Other helpful strategies concentrated on 3 themes: standardization of educational content, increased opportunity for hands-on practice, and cognitive aids (e.g. a checklist) for CL care. Conclusions: A minority of families feel the highest level of comfort with CL care at home even after months of experience. Improvement opportunities and gaps in CL care teaching strategies are prevalent. To help support families caring for CLs at home and ensure adherence to best practice, programs should engage families to better understand their needs and develop solutions to meet them.
Identifying cancer quality measurement gaps in the Choosing Wisely Initiative.
Authors: Corrigan Kelsey , Agarwal Sarvesh , Aksenov Leonid , Paul Alexandra , Sharif-Askary Banafsheh , Kamal Arif
Published: April 2017

7

Background: Cancer is a leading cause of morbidity in the US. Improvements in treatment strategies are rapidly transitioning many cancers into long-term, chronic illnesses, similar to heart failure, COPD, and diabetes. We compared the prevalence and focus of cancer and non-cancer quality measures within the Choosing Wisely Initiative to assess possible measure gaps. Methods: The Choosing Wisely Initiative is the most recognized public campaign to reduce low value services in health care. We identified all published Choosing Wisely measures from April 2012 to May 2016 and abstracted for target disease, care setting, type of care, and patient age. We calculated descriptive statistics and chi-squares for analysis. Results: 75 healthcare organizations submitted 461 total Choosing Wisely measures. Of these, 15% (71/461) involved cancer and 15% (68/461) involved non-cancer chronic illnesses, including heart disease, diabetes, COPD, asthma, stroke, and Alzheimer’s Disease; 70% (322/461) were “other”. Among measures, 30% (139/461) overlapped between cancer and non-cancer chronic illnesses. Among cancer measures, a minority (10/71; 14%) were submitted by ASCO. Prostate cancer (28%) and breast cancer (23%) were the two most addressed cancer diagnoses. Among cancer guidelines, 79% (66/84) targeted imaging, tests, and/or procedures, 12% (10/84) addressed treatment, 5% (4/84) addressed medications, and 5% (4/84) targeted prevention. This is similar to non-cancer chronic illnesses, which had 72% (60/83) of guidelines targeting imaging, tests, and/or procedures, 13% (11/83) of guidelines addressing treatment, 8% (7/83) addressed medications, and 6% (5/83) targeted prevention. In examining numbers of measures per prevalence of the diseases addressed, we found 71 guidelines for 14.4 million people for cancer and 68 guidelines for 152 million people with non-cancer chronic illnesses (p<0.001). Conclusions: Quality measures involving serious illness, including cancer, represent a minority of the Choosing Wisely measures. Existing quality measures emphasize diagnostics and procedures. Future measures should target the chronic illness aspects of cancer care, including prevention, survivorship, and palliative care.
Addressing the risk of infertility in young women with breast cancer (BC): A quality improvement (QI) intervention.
Authors: Smith Karen L. , Cheung Enoch , Thompson Beth , Jeter Stacie , Mull Jill , Ensminger Jennifer , Capano Mary , Klein Catherine , McTague Meghan , Christianson Mindy , Stearns Vered
Published: April 2017

72

Background: Many young women with early BC require systemic therapy (ST) which can result in ovarian damage leading to infertility. Fertility preservation (FP) can be performed prior to ST, however uptake is low. Data suggest oncology providers do not routinely discuss the risk of treatment related infertility (TRI) or FP with young women with BC. Methods: We created a QI protocol to ensure providers address fertility needs of young women with early BC. Non-pregnant women age 18-44 years with stage I-III BC who have not initiated ST are identified by screening clinic schedules. Clinicians are asked to follow a QI protocol requiring assessment of patients’ childbearing potential (CBP), risk for TRI and fertility goals (FG). If appropriate, FP is discussed and consultation with a fertility specialist arranged. A clinical team member completes a provider documentation form (PDF) summarizing the QI protocol steps accomplished. Results: Since implementation of the QI protocol, there have been 80 eligible women (mean age 38.6). At least one PDF was completed for 56 (70%), with the majority completed by breast surgeons. Among those with a completed PDF, 48 (86%) were of CBP, all but one of whom planned ST associated with a risk of infertility. According to the PDF, the risk of TRI was discussed in 34 (72%) while FG were assessed in 44 (94%), with 8 (18%) desiring fertility and 8 (18%) undecided about FG. Discussion of FP by the provider and/or a fertility specialist was documented in the PDF for 85% of those who desired fertility or who were undecided. In comparison to the PDF, discussion of FG was recorded in provider notes in 36 (45%) women with documentation in both provider notes and the PDF for 29 (36%). Provider notes documented discussion of FG in 94% of the women who desired fertility or who were undecided according to the PDF. Conclusions: Implementation of a QI protocol with required documentation ensures providers address fertility needs of young women with BC. Providers do not discuss the risk of TRI as frequently as assessing FG. Efforts are ongoing to increase completion rate of our PDF and to incorporate it into the electronic medical record. Follow-up regarding ST and uptake of FP in our cohort is ongoing.
Oncology beyond the hospital: 7 years taking care of cancer patients from the very begining until the last consequences.
Authors: Cunquero Tomas Alberto Jacobo , Avila Andrade Claudio Dario , Pep Ferri , Condori Farfan Lauren , Fernandez Diaz Amaya Belen , Shaheen Ihsan , Meri Abad Marina , Fernandez Adriana , Blasco Ana , Berrocal Alfonso , Safont Maria Jose , Caballero Cristina , Iranzo Vega , Godes Maria Jose , Camps Carlos
Published: April 2017

75

Background: Comprehensive and continuous care is esential for the correct management of cancer patients. To achieve this, specific programs for early diagnosis and long survivor care are needed. Since 2007, within the project “Oncology beyond the Hospital: Oncologic assistance at the Universitary General Hospital of Valencia”, the Oncologist Liaison was created. Methods: Two tracks were designed: High-resolution track for patients with suspicion of non-diagnosed cáncer; and Oncologist Liaison track, to organize the follow-up of cáncer long survivors. We present a descriptive and retrospective study by reviewing medical records of patients referred to the high-resolution diagnostic consultation; and long survivors followed up by the Oncologist Liaison from May 2007 to September 2015 (2016 data under review). Results: High-resolution track: 1,596 patients with suspected cancer were visited. The mean time between the primary care physician consultation and the oncologist visit was 4.32 days. Main reasons for consultation were: breast disease (25.4%), blood test disorders (16.4%), enlarged lymph nodes (11.1%) and radiological suspicion of tumor (12%). 424 cancers were diagnosed (26.5%) all having been studied in Oncologic Committee: 22.6% lung; 17% lung; 16.2% breast; 11.8% lymphomas; 12.5% superior dighestive tract; and19.8% miscelanea. Long-survivors track: 1406 patienst free from disease were referred for surveillance of recurrence and treatment sequelae: 44% breast; 20% gastrointestinal; 17% gynecological; 7% double neoplasia; 4% of lung cancer and other tumors, 8%. Conclusions: With the integration of the Oncologist Liaison in the continuum of care, we have achieved: Normalization of oncologic approach among patients and primary care physicians; implementation of a fast-track for patients with cancer suspicion: access to the oncologist in less tan a week; case study in the Oncologic Comittee in the following week; and consensus in diagnosis and treatment plan in each case. Ensure control over long-survivors.
Creating a radiation oncology oriented safety culture within a large oncology practice: Lessons learned.
Authors: Dubey Ajay , Bernard Jeff , Heintz Bret , Antes Kyle , Hartman Stacy , Taylor Bernard , Cheek Brennan Scott , Limmer Jeffrey , Wilfong Lalan S. , Hoverman John Russell
Published: April 2017

85

Background: Texas Oncology (TXO) is a dedicated oncology practice consisting of more than 400 physicians and 57 radiation oncologists at 52 sites of service. In order to enhance communications of the rad onc team, establish accountability by using metrics, and engage continuous improvement, we initiated a program to establish regional quality committees in each radiation oncology practice site. Methods: In 2015, the TXO leadership approved the formation of Regional Quality Committees (RQC) at each site. The key members of each RQC include a Physician Chair, a Physicist Co-Chair, Chief Therapist, Radiation Safety Officer, Dosimetrist, and Nurse. Meeting frequency was recommended monthly, but quarterly meetings were required. Meeting documentation reporting was required including a formal agenda, minutes for items discussed, and listing of attendees. Metrics with regard to RQC activities were reported and recorded beginning in 2016. The 2016 Action plan for the RQC at each site included documentation of timeout procedure, regular chart rounds, new patient conference, as well as a mortality and morbidity conference. Results: See table. Conclusions: Within 3 calendar quarters, a functional RQC was established in all 52 radiation oncology practice sites within TXO. Compliance with the action plan was high with regard to action items not requiring multiple physician participants (RQC committee, timeout, chart rounds, CQI projects, performance metrics). Compliance was lower in activities that required multiple physician participation. Verbal feedback was positive regarding the RQC program. Respecting time demands of physicians, education, and communication were identified as key success factors in the RQC program. [Table: see text]
National trends, outcomes, and costs of radiation therapy in the management of low- and high-intermediate risk endometrial carcinoma.
Authors: Suidan Rudy Sam , He Weiguo , Sun Charlotte C. , Zhao Hui , Smith Grace L. , Klopp Ann , Fleming Nicole D. , Lu Karen H. , Giordano Sharon Hermes , Meyer Larissa
Published: April 2017

9

Background: Our objective was to assess treatment patterns, outcomes, and costs for women with low- (LIR) and high-intermediate risk endometrial cancer (HIR) who are treated with and without adjuvant radiotherapy (RT). Methods: All pts with endometrioid endometrial cancer who underwent surgery from 2000 – 2011 were identified from the SEER – Medicare database. LIR was defined as G1-2 tumors with <50% myometrial invasion or G3 with no invasion. HIR was defined as G1-2 tumors with ≥50% or G3 with <50% invasion. Pts were categorized according to whether they received adjuvant RT (vaginal brachytherapy [VBT], external beam radiotherapy [EBRT], or both) or no RT. All costs incurred up to 6 months postoperatively were analyzed. Outcomes were compared using the χ2test and a Cox PH regression model. Multivariate analyses were performed on both survival and costs. Results: 10,842 pts were included, of which 70% were LIR and 30% were HIR. 9% of pts with LIR had RT, compared to 46% of those with HIR. Among all pts who underwent RT, the use of VBT increased from 25% in 2000 to 71% in 2011, while EBRT use declined from 41% to 18%, and concurrent VBT/EBRT declined from 34% to 11% (p<0.001). In the LIR group, there was no difference in 10-year overall survival (OS) between pts who had RT and those who did not (67% vs. 65%, multivariate HR 0.95, 95% CI 0.81 – 1.11). In the HIR group, pts who underwent RT had a significant increase in 10-year OS (60% vs. 47%, multivariate HR 0.75, 95% CI 0.67 – 0.85). Similar outcomes were noted on subgroup analysis stratifying by RT modality. RT was associated with an increased risk of gastrointestinal (7% vs. 4%, p<0.001), genitourinary (2% vs. 1%, p<0.001), and hematologic (16% vs. 12%, p<0.001) 2-year complications. Compared to pts who only had surgery, RT was associated with increased mean adjusted costs ($22.5k vs. $14.4k, p<0.001). Costs for pts receiving VBT, EBRT, and concurrent VBT/EBRT were $20.6k, $23.3k, and $26.5, respectively (p<0.001). Conclusions: RT was associated with improved OS in women with HIR, but not in the LIR cohort. RT also had significantly increased costs and a higher morbidity risk. In the absence of other risk factors, consideration of observation without RT in LIR may be reasonable.
Palliative care utilization in patients with newly diagnosed, incurable solid tumor malignancies: The experiences of an institution new to palliative care.
Authors: Bersabe Adrian REYES , Romain Joshua , Delacruz Wilfred P.
Published: April 2017

92

Background: Early palliative care (PC) referral can enhance quality of life (QOL) in patients with metastatic cancer and even improve overall survival in non-small cell lung cancer. Despite compelling data showing benefits of early integration of PC, barriers to care exist. Our institution recently established an outpatient PC service. To improve utilization of this new service we identified clinicians’ attitudes and barriers to PC, and provided education on the PC referral process. The effects of this intervention on PC utilization were assessed. Methods: We conducted a retrospective chart review of outpatient Hematology/Oncology (HO) referrals to identify patients referred for newly diagnosed, solid tumor malignancies with no curative options. Hospice referrals were excluded. We then formally surveyed clinicians participating in multi-disciplinary tumor boards to identify PC referral practices and attitudes/barriers to PC referrals. Education on PC and instruction on PC referral process were provided during this period. Post-intervention review of PC referrals over 4 months was conducted. Results: Prior to our intervention, of the 53 new consultations reviewed meeting study criteria only three (5.7%) patients were referred to PC. Our survey revealed that 66% (31/47) of oncology providers did not know the institution had onsite PC available and only eight (17%) knew how to place a referral. After education was provided, a second cohort revealed 24.1% (7/29) of patients were appropriately referred for early outpatient PC representing an 18.4% absolute increase. Conclusions: We significantly increased early PC referrals for HO patients with advanced or metastatic disease. However, other efforts to improve institutional awareness and change the culture of care to ensure that majority of these patients are appropriately referred. Longitudinal evaluation will further ensure that timely adjustments are made and that effects are permanent.
Outpatient hematologist and oncologist perceptions of inpatient continuity visits at an urban academic medical center.
Authors: Chen Christopher , DeGregorio Sara , Soriano Margaret , Lennes Inga Tolin , Thompson Ryan , Ferris Timothy
Published: April 2017

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Background: In 2012, in an effort to improve continuity between inpatient and outpatient care, Massachusetts General Hospital (MGH) began sending automated email notifications to outpatient physicians when patients with whom they have an established relationship are admitted to MGH. Physicians are allowed to bill internally for a “continuity visit” if they visit their patient during an inpatient stay. We sought to study MGH hematologist and oncologist perceptions of care continuity and the efficacy of this continuity visit program. Methods: In the summer of 2015, all MGH hematology and oncology attending physicians, regardless of whether they had previously billed for a continuity visit, were provided a small financial incentive to participate in an online survey. Ninety-one of 116 physicians responded to the survey (78%). Results: Of the respondents, 74% had previously billed for a continuity visit, although others may have performed continuity visits without formally billing for them. Ninety-six percent of respondents felt that continuity visits are either highly useful or moderately useful to their patients, namely because patients view continuity visits as an expression of interest in their well-being (90%) and/or as a welcome surprise (58%). Ninety-one percent of respondents felt that continuity visits are highly or moderately useful to the inpatient team, because they are able to informally share clinical insights that improve clinical care (71%) and/or answer questions or confirm the inpatient attending’s plan of care (79%). Furthermore, 72% of respondents felt that continuity visits improve their longitudinal relationship with their patients. Lastly, 84% of respondents expressed high or moderate satisfaction with making continuity visits. Conclusions: MGH hematologists and oncologists reported that visiting their hospitalized patients is useful to inpatient care teams and their patients. A small incentive payment may encourage such continuity visits. The next step is to evaluate whether continuity visits make a difference in clinical outcomes, such as patient experience, readmissions, and inpatient length-of-stay.
Clinical Pathways: Management of Quality and Cost in Oncology Networks in the Metastatic Colorectal Cancer Setting
Authors: Ellis Peter G. , O’Neil Bert H. , Earle Martin F. , McCutcheon Stephanie , Benson Hans , Krebs Melinda , Lokay Kathy , Barry Amanda
Published: April 2017

Purpose:

Via Pathways (clinical pathways for cancer) provide evidence-based guidance for specific patient presentations based on the merit of efficacy, then toxicity, and finally cost (if efficacy and toxicity are comparable). We evaluated the impact of a change to the guidance in the metastatic colorectal cancer (mCRC) setting across two large, integrated health networks.

Methods:

Cetuximab and panitumumab were determined to have equal efficacy in the treatment of mCRC with no significant difference in toxicity based on recent data from key clinical studies. A cost analysis using Centers for Medicare and Medicaid Services average sales data determined a cost advantage for panitumumab. A substitution of panitumumab for cetuximab in the clinical pathway for all mCRC lines of therapy was initiated as of August 2014.

Results:

In the preimplementation period, 86 (93.5%) and six (6.5%) treatment selections were for cetuximab and panitumumab, respectively. After the pathway change was implemented, 13 (18.1%) and 59 (81.9%) treatment selections were for cetuximab and panitumumab, respectively. The change in prescribing habits was rapidly altered by the pathway change. The estimated annualized cost savings for the two health networks resulting from the response to the pathway change was $711,021.

Conclusion:

This study demonstrates that clinical pathways can act as a tool to assist oncology practices in decreasing costs and quickly responding to changing treatment paradigms by providing clinicians with consensus-driven treatment recommendations that incorporate the most up-to-date clinical trial results, toxicity considerations, and regimen cost information.
Common Entrapment Neuropathies
Authors: Hobson-Webb Lisa D. , Juel Vern C.
Published: April 2017

Purpose of Review: This article addresses relevant peripheral neuroanatomy, clinical presentations, and diagnostic findings in common entrapment neuropathies involving the median, ulnar, radial, and fibular (peroneal) nerves.

Recent Findings: Entrapment neuropathies are a common issue in general neurology practice. Early diagnosis and effective management of entrapment mononeuropathies are essential in preserving limb function and maintaining patient quality of life. Median neuropathy at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, radial neuropathy at the spiral groove, and fibular neuropathy at the fibular head are among the most frequently encountered entrapment mononeuropathies. Electrodiagnostic studies and peripheral nerve ultrasound are employed to help confirm the clinical diagnosis of nerve compression or entrapment and to provide precise localization for nerve injury. Peripheral nerve ultrasound demonstrates nerve enlargement at or near sites of compression.

Summary: Entrapment neuropathies are commonly encountered in clinical practice. Accurate diagnosis and effective management require knowledge of peripheral neuroanatomy and recognition of key clinical symptoms and findings. Clinical diagnoses may be confirmed by diagnostic testing with electrodiagnostic studies and peripheral nerve ultrasound.
Waging war against pancreatic cancer: an interview with David Tuveson
Authors: Tuveson David
Published: April 2017

David Tuveson, Director of the Cancer Center at Cold Spring Harbor Laboratory, is a clinician-scientist with a longstanding interest in understanding and treating pancreatic cancer. Since developing the first mouse model of pancreatic cancer in 2002, the Tuveson lab has made a series of discoveries that shed light on the molecular drivers of this disease and provide promising therapeutic avenues for a malignancy that is notoriously challenging to treat. In collaboration with Hans Clevers, David developed the first pancreatic cancer organoids, which revolutionized the field by providing a powerful model system for basic discoveries and advancement of personalized medicine. Here, David talks to Ross Cagan about his path from chemistry student to world-renowned oncologist, highlighting how his colleagues, mentors and patient interactions shaped his research interests and unique approach to scientific discovery. As well as discussing the story behind some of his breakthroughs, he provides tips on running a lab and succeeding in or outside academia.
The Great Housing Boom of China
Authors: Chen Kaiji , Wen Yi
Published: April 2017

China’s housing prices have been growing nearly twice as fast as national income over the past decade, despite a high vacancy rate and a high rate of return to capital. This paper interprets China’s housing boom as a rational bubble emerging naturally from its economic transition. The bubble arises because high capital returns driven by resource reallocation are not sustainable in the long run. Rational expectations of a strong future demand for alternative stores of value can thus induce currently productive agents to speculate in the housing market. Our model can quantitatively account for China’s paradoxical housing boom. (JEL O16, O18, P24, P25, R21, R31)
Credit Relationships and Business Bankruptcy during the Great Depression
Authors: Hansen Mary Eschelbach , Ziebarth Nicolas L.
Published: April 2017

Credit relationships are sticky. Stickiness makes relationships beneficial to borrowers in times of their own distress but makes them potentially problematic when lenders themselves face hardship. To examine the role of credit relationships during a financial crisis, we exploit a natural experiment in Mississippi during the Great Depression that generated plausibly exogenous differences in financial distress for banks. Using new data drawn from the publications of the credit rating agency Dun & Bradstreet and from original bankruptcy filings, we show that financial distress increased business exit but did not increase the bankruptcy rate. Financial distress caused both banks and trade creditors to recalibrate their collections strategies, which is revealed by changes in the geographical distribution of the creditors of bankrupt businesses. (JEL G21, G24, G33, N12, N22, N82)
Examining the accuracy of visual diagnosis of tinea pedis and tinea unguium in aged care facilities
Authors: Goto T. , Nakagami G. , Takehara K. , Nakamura T. , Kawashima M. , Tsunemi Y. , Sanada H.
Published: April 2017

Objective:

The aim of this study was to examine the accuracy of visual diagnosis of tinea pedis (Athlete's foot) and tinea unguium (fungal nail infection), as well as to provide information on skin abnormalities that could help identify these diseases in aged care facilities (long-term care facilities (LTCFs) and nursing homes).

Method:

A multicentre, cross-sectional observational study was conducted in a LTCF and two nursing homes. A dermatologist observed the skin abnormalities in the participants' interdigital and plantar areas, to screen for tinea pedis, and in the participants' toenails, to screen for tinea unguium. If abnormalities were noted, samples such as scales or toenails were collected and examined using direct microscopy. The accuracy of the macroscopic observation for each skin abnormality was examined.

Results:

A total of 173 residents were recruited. The accuracy of clinical diagnosis using macroscopic observation was relatively low. The sensitivities and specificities for clinical diagnosis were 0.37 and 0.95 for tinea pedis in the interdigital areas, 0.47 and 0.94 for tinea pedis in the plantar areas, and 0.80 and 0.61 for tinea unguium in toenails, respectively. Scales in the plantar areas and discoloration of the toenails were more frequently observed in residents with tinea pedis and tinea unguium than in those without them.

Conclusion:

Several skin abnormalities were observed in the residents recruited in this study, but there was insufficient correlation with tinea pedis and tinea unguium to be used for screening.