bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing the impact of a digital coaching program for patients with cancer.
Authors: Srivastava Uma , Burton Stephen , Lewis M'Kayl , Patel Dhiren , Rasulnia Mazi
Published: September 2018

274

Background: Cancer pain is found in 64% of patients with metastatic disease which can lead to negative effect on patient’s functional status which can then lead to psychological distress.Cancer pain can significantly affects an individual’s quality of life extending into mood or mental health and physical health.3 Various studies have shown that coaching is a useful strategy to address cancer pain and pain management. The hypothesis was by providing patients with cancer the Pack Health digital coaching solution, would lead to a reduction of cancer pain and increase in mental health over a 12 week intervention. Methods: This was a prospective study conducted between January 1, 2017 and December 31, 2017. 78 patients with cancer opted into the study, giving consent, and received intervention over 12 weeks. Patients were given standard print information and tools for self-care management in addition to a personal health advisor, who was in weekly communication with the participant to provide support, motivation, additional education, and accountability. Patient reported outcomes were collected using validated instruments, and patient satisfaction was measured using the Net Promoter Score (NPS). Results: The group was 86% female, and the average age was 55 years. Though not statistically significant, patients with a cancer diagnosis saw marginal improvements across some domains after 12 weeks. These results included a 15% decrease in perceived pain, 10% fewer prescreen for depression, and 11% more getting the recommended 7-9 hours of sleep each night. The slight decrease seen on average in both the mental health (-0.19%) or physical health (-0.30%) from the PROMIS Global-10 scores did not rise to the level of statistical significance. An NPS score of 69 for the program indicated strong patient satisfaction. Conclusions: Preliminary results illustrate that intensive behavioral counseling intervention help patients achieve their goals related to their chronic condition. The program showed adherence to health is linked to an increase in healthy habits leading eventually to an increase in patient’s overall health.
Malnutrition screening: A screening tool for outpatient oncology patients, leveraging EMR data.
Authors: Mills Jeannine B. , Shapiro Alice C. , Spees Colleen , Trujillo Elaine , Cushman Elise , Stephens Natalie , Johnson Sarah , Wood Alexandra , Duffy Kimberly
Published: September 2018

275

Background: The provision of adequate nutritional care in outpatient cancer centers was the focus of a 2016 NAS Workshop, “Assessing Nutrition Care in Outpatient Oncology.” Here we report our internal project evaluating ongoing documentation of a malnutrition screening tool (MST) at 3 national cancer centers (CC). Methods: Screening scores from a validated 2 question MST scale were entered into the EMR. Questions probe for: 1) unintentional weight loss; and 2) eating poorly because of a decreased appetite. A score of ≥ 2 indicated nutrition risk. De-identified oncology clinic visit data were examined monthly to assess MST utilization and scores for radiation and medical oncology patients across the CC’s. Results: Approximately two-thirds (67%) of unique medical oncology patients that visited the CC’s had documented MST data with 9% (n = 144,129) scoring at nutritional risk. MST completion rates were higher in radiation oncology clinics secondary to staff education. Of those that had a valid MST score in radiation clinics, 13% (n = 23,202) of MST scores indicated nutritional risk. Conclusions: The MST is a valid malnutrition screening tool for outpatient oncology patients, yet this tool is not uniformly being utilized nationally. Consistent use of the MST in the electronic medical record and leveraging data on utilization are needed to inform staff compliance, consistency in care, future dietitian staffing patterns, cost/benefit analysis, and health outcomes for oncology patients. [Table: see text][Table: see text]
Implementation of a low-cost standardized handoff system (IPASS) in a pediatric hematology/oncology unit: Lessons from a low-middle income country.
Authors: Pariha Sheri , Saeed Sana , Qureshi Sonia , Altaf Sadaf
Published: September 2018

278

Background: Communication failure is the most common preventable cause of medical adverse event, and almost half of all sentinel events involve handoff failure. Inefficient handoff is labor intensive and time consuming, impacting the quality of patient care provided. A safe and efficient means of exchange of medical information between care teams via a standardized handoff system is essential, especially in high intensity fields such as Pediatric Hematology/Oncology. Methods: Pre-intervention, handoff entailed the physical handover of handwritten notes, carbon copied for various team members. A standardized electronic handoff tool (IPASS) was identified, and significantly modified to fit our needs, since we do not have a complete electronic medical record (EMR). Microsoft Sharepoint (Microsoft, Redmond, WA) was used to develop a tabulated online portal incorporating patient demographic, clinical and laboratory details with physician remarks. This allowed remote access, multiple simultaneous inputs, authenticated use and user-specific access control. Implementation included sensitizing residents to the IPASS template, hands-on training, weekly feedback from the residents, directly observed hand-off by the chief and/or senior resident. Following a four-week pilot this was expanded to other sub specialties, and a pre and post intervention survey was conducted to assess its impact. Results: Pre-implementation survey revealed 74% resident and 87% faculty dissatisfaction with the current handoff process. Weekly compliance audits after initial pilot demonstrated a 100% compliance. Post-Implementation results showed that the resident dissatisfaction has gone down to less than 5%. Conclusions: Implementation of an electronic handoff tool in the absence of an EMR with minimal resources is a major breakthrough and can be replicated in other low-resource settings. We successfully implemented IPASS without any added infrastructure cost. In the next phase of our project we will be measuring trends in reduction in medical errors since implementation.
Development of the CCRU kit squad: Centralization of biospecimen “kit” management.
Authors: Speers Vanessa
Published: September 2018

295

Background: Personalized medicine has resulted in a rapid increase in biospecimens collection. Each biospecimen collected requires supplies that are provided in the form of “kits”. The number of kit types per protocol ranges anywhere from 2-60, with an average of 30 different kit types per trial. Historically, each trials nurse has managed their own kits resulting in large amounts of nursing time being spent on kit management. Kits took up a large amount of space in clinical areas, including expired kits, and they were being managed in no standardized fashion. Due to rapidly increasing biospecimen volumes, existing methods of kit management were no longer feasible and the CCRU Kit Squad was developed. Methods: Over the course of 12-mos, an extensive assessment of current kit management practices were reviewed with all disease site groups, including workflows and quantities utilized. An e-commerce software platform was selected, and semi-customized to centralize online ordering and receiving of kits, and the creation of a central location was setup for kit storage and daily operations. On-boarding of each group included retrieving existing kits from each nurse, uploading kits to the software, training each nurse to use the software, setting up accounts with each respective vendor for deliveries and re-supply, and disposing of expired kits. Results: Disease site groups were transitioned to the CCRU Kit Squad stepwise from Oct 2016 to Dec 2017 (15-mos), which included 80 nurses, 16 disease site groups, and over 400 clinical trials. By the end of 2017, the average number of kits ordered per day, and per month were 33 and 1003, respectively. Conclusions: The CCRU Kit Squad developed a centralized online service for kit management, thereby reducing administrative burden on clinical trial nurses. It has streamlined the management of biospecimen kits, eliminated wasted space in clinical areas, and facilitated the selection of the right kit for the right test at the right time.
Improving start-up times in oncology clinical trials: An ASCO quality improvement project.
Authors: Byatt Leslie , Deutsch Kaylee , Dayao Zoneddy R.
Published: September 2018

297

Background: With the increasing complexity of clinical trials, the UNMCCC and NMCCA are seeing increased delays in study activation. Currently, the average time from protocol receipt to trial activation is 33 weeks. Creating strategies to shorten the timeline where the longest delays occur will expedite patient access to novel therapies and improve patient care. Aims: Define the average activation timelines; Identify the timeline where an intervention will make the most impact in shortening start-up time; Implement an intervention, beginning February 2018; Identify strategies to decrease the longest timeline by 50% by December 2018. Methods: Timelines of 81 clinical trials opened in 2017 were analyzed. Data showed that the longest timeline is IRB approval to activation (12 weeks) and identified this as the focus of intervention to decrease our overall activation time by 50% (6 weeks). Two focus group meetings with involved staff were organized and completed. Interventions were identified. The time to complete activation tasks cannot be shortened due to staffing resources. However, shifting these tasks forward in our timeline could decrease the time to activation by at least 6 weeks. A sponsor survey was created to identify logistical concerns earlier. Regulatory coordinators were provided an email template to request systems access early. Site initiation visits are scheduled earlier. Results: Our data shows that our interventions have had a strong positive impact on our timelines. Conclusions: Since implementation, we have seen an improvement in our study timeline. We will continue to track and analyze our timeline data to determine if these strategies are effective across trials with varying startup complexities.[Table: see text]
Practice transformation: Early impact of OCM on hospital admissions.
Authors: Mendenhall Molly , Bourbeau Brian , Dyehouse Karyn M. , Guinigundo Andrew S , Meyer-Smith Teresa , Waterhouse David Michael
Published: September 2018

30

Background: The purpose of the Oncology Care Model is to improve quality and reduce cost through practice transformation. A foundational tenant is to reduce avoidable ER visits and hospitalizations. In anticipation of being an OCM participant, we instituted a multidimensional campaign designed to meet these objectives. Methods: Prior Actions: Established phone triage unit. After-hours and weekend call. Instituted weekend urgent care. Year One: Improved education provided by nurse navigators and APPs prior to start of treatment (OCM Treatment Planning visit). Implemented triage pathways: 38 symptom and 27 follow-up pathways (modified COME HOME, Barbara McAneny, M.D.). Proactive symptoms follow-up calls to help circumvent emergent admissions. Increased APP staffing to provide blocked time slots for same day patient visits w/o schedule disruptions. Initiated “Call Us Early – Call Us First” campaign. Incorporated verbal and/or written instructions at all patient touch points, emphasizing patient’s responsibility to call before going to the emergency room. Results: Based on data from the Chronic Condition Warehouse, as provided by CMS, we were successful at reducing the acute care admissions rate by 16 percent. Conclusions: By implementing a cost efficient, reproducible, and scalable campaign targeting ER avoidance and hospitalizations, we were able to decrease hospital admissions. Reported Medicare savings amounted to nearly $798,000 in inpatient cost per quarter over 1,600 patients.[Table: see text]
Real-time assessment of resource utilization and subsequent cost analysis in cancer patients (pts) near the end of life (EOL).
Authors: McPherson Jordan P. , Patel Shiven B. , Igumnova Elena , Pettit Jacob , Ose Dominik , Haydell Tyler , Martineau Jim , Meropol Neal J. , Beck Anna Catherine
Published: September 2018

303

Background: Aggressive medical interventions and associated high costs of care for cancer pts near the EOL are common. Addressing this issue at the local level requires an accurate, automated process to merge real-time clinical EHR data with cost data for performance reporting. Methods: This was a single-center, observational cohort study of decedents treated with anticancer therapy (antiCT) in the last 6 months of life from January 2016 to October 2017. Pts were stratified by antiCT use in the last 30 days of life. The primary outcome measure was total cost of care. Secondary outcome measures (hospitalizations, ER and ICU utilization, antiCT use, and hospice referral) were obtained through Flatiron Health EHR-based automated data processing. Cost data were merged from the Value-Driven Outcomes analytics framework. Results: 650 pts were included. 228 (35.1%) received antiCT in the 30 days before death. Non-drug costs for pts who received antiCT in the last 30 days of life were higher than those who did not (p < 0.01, median 38X higher). A higher proportion of pts who received antiCT in the last 30 days of life had ≥1 ER visit (29.4% vs 9.5%, p < 0.01) and hospital admission (58.8% vs 27.3%, p < 0.01) during the last 30 days. In addition, more of these pts received ICU care (35.5% vs 11.4%, p < 0.01). AntiCT in the last 30 days was associated with shorter median time from first hospice referral to death (1.4 vs 4.7 weeks; IQR 0.7-2.0 vs 3.14-7.7 weeks, p < 0.01). Distribution of antiCT types administered to pts in the last 30 days versus those given antiCT > 30 days from the EOL was significantly different, with the most substantial difference seen in the proportion of pts receiving immunotherapy (20.2% vs 12.6%, p = 0.04). Conclusions: Real-time assessment of EOL outcomes shows antiCT in the last 30 days of life is associated with aggressive medical interventions and increased total cost of care. Future research should identify pts who are unlikely to benefit from aggressive care, and whether performance reporting to oncologists will reduce futile interventions near the EOL.
The Quality Oncology Practice Initiative program: Experience in Spain.
Authors: Lopez Rafael , Anton Antonio , Aranda Enrique , Carrato Alfredo , Constenla Manuel , Cruz Juan Jesús , Díaz Rubio Eduardo , Feyjoo Margarita , García Foncillas Jesús , Gascon Pedro , Guillem Vicente , Lugo Ilse , Camps Carlos
Published: September 2018

310

Background: Patient care quality is a discipline with enormous relevance in today’s healthcare. Quality Oncology Practice Initiative (QOPI) is a referral worldwide in quality for oncology practices. ECO Foundation is a collaboration of experts representing the major Spanish hospitals involved in the treatment of cancer patients. ECO reached an agreement with QOPI to involve Spanish hospitals in the QOPI program. Methods: Six rounds of data collection have taken place (Fall 2015 to Round 1 2018). Practices had to register online and submit data into the QOPI platform, and ECO Foundation offered all centers the necessary support. 17 Spanish hospitals have participated in the six rounds, and 7 of them have repeated participation. Core and Lung Cancer modules were completed. Results: During the six rounds, 1877 charts were submitted by the Spanish practices. In most of the rounds, the highest scores were: Pathology report confirming malignancy, Number of chemotherapy cycles documented, Patient consent for chemotherapy and 5 measures of the Lung Cancer module. The lowest scores were: Chemotherapy treatment summary provided to patient within 3 months of chemotherapy end, Chemotherapy treatment summary provided or communicated to practitioner(s) within 3 months of chemotherapy end, Smoking/tobacco use cessation counselling recommended to smokers/tobacco users in past year and Tobacco cessation counselling administered or patient referred in past year. The percentage of participating practices that presented results higher than 70% was successively 64%, 50%, 75% and 100% in the last three rounds. For the 7 hospitals that repeated participation, 3 reported an improvement of their global scores. Regarding QOPI Certification, three Spanish hospitals received this accreditation in September 2017 and one in June 2018. Conclusions: These preliminary results are a good starting point for the continued implementation of the QOPI program in Spain, thus providing a well-structured approach to analyze cancer care. ECO Foundation will continue pursuing excellence and quality with further activities like the QOPI Certification program and Quality Training Program, these being performed for the first time in Spain in 2017 and 2018 respectively.
Employing electronic health record data to predict risk of emergency department visits for new patients.
Authors: Daly Robert Michael , Gorenshteyn Dmitriy , Gazit Lior , Sokolowski Stefania , Nicholas Kevin , Perry Claire , Adams Lynn , Baldwin Abigail , Katzen Lauren L. , Chiu Yeneat O. , Reidy Diane Lauren , Simon Brett A , Perchick Wendy , Wagner Isaac
Published: September 2018

314

Background: Acute care accounts for half of cancer expenditures and is a measure of poor quality care. Identifying patients at high risk for ED visits enables institutions to target symptom management resources to those most likely to benefit. Risk stratification models developed to date have not been meaningfully employed in oncology, and there is a need for clinically relevant models to improve patient care. Methods: We established a predictive analytics framework for clinical use with attention to the modeling technique, clinician feedback, and application metrics. The model employs EHR data from initial visit to first antineoplastic administration for new patients at our institution from January 2014 to June 2017. The binary dependent variable is occurrence of an ED visit within the first 6 months of treatment. From over 1,400 data features, the model was refined to include 400 clinically relevant ones spanning demographics, pathology, clinician notes, labs, medications, and psychosocial information. Clinician review was performed to confirm EHR data input validity. The final regularized multivariate logistic regression model was chosen based on clinical and statistical significance. Parameter selection and model evaluation utilized the positive predictive value for the top 25% of observations ranked by model-determined risk. The final model was evaluated using a test set containing 20% of randomly held out data. The model was calibrated based on a 5-fold cross-validation scheme over the training set. Results: There are 5,752 antineoplastic starts in our training set, and 1,457 in our test set. The positive predictive value of this model for the top 25% riskiest new start antineoplastic patients is 0.53. The 400 clinically relevant features draw from multiple areas in the EHR. For example, those features found to increase risk include: combination chemotherapy, low albumin, social work needs, and opioid use, whereas those found to decrease risk include stage 1 disease, never smoker status, and oral antineoplastic therapy. Conclusions: We have constructed a framework to build a clinically relevant model. We are now piloting it to identify those likely to benefit from a home-based, digital symptom management intervention.
Performance on cancer quality measures: Ethnicity, insurance, and census division disparities.
Authors: Browner Amanda , Palis Bryan E. , Gay E. Greer , Mallin Katherine , McCabe Ryan M. , Facktor Matt , James Ted , Shulman Lawrence N.
Published: September 2018

34

Background: Since enactment of Healthy People 2000 (ODPHP.gov, nd), a focus has been to reduce disparity by achieving health equity across all people. We examined disparity for five cancer quality measures with high performance rates (PRs) ( > 85%). Methods: Five measures developed by the Commission on Cancer and endorsed by the National Quality Forum were evaluated for potential ethnicity, insurance, and Census Division disparities. Data from the National Cancer Database were used to examine hospital-level PRs on adjuvant chemotherapy for ER neg breast ca (MAC), hormone therapy for ER+ breast ca (HT), resection of at least 12 nodes in a colon resection (12RLN), and adjuvant chemotherapy for stage III colon ca (ACT) measures for patients diagnosed in 2015. Patients receiving radiation after breast conservation surgery (BCSRT) were diagnosed in 2014 to ensure complete treatment follow-up. Results: Significant disparities exist for all measures on ethnicity between non-Hispanic whites and Hispanics. The least variation of ethnicity occurred within 12RLN (non-significant). Variability within insurance was found most frequently with HT and BCSRT measures, not insured/Medicaid versus Medicare, and not insured/Medicaid versus Private respectively. Location disparity exists for all measures, with South Central states’ significantly lower PRs. Further investigation should focus on access, insurability, and delivery of care to better understand and eliminate disparities. Conclusions: Cancer quality measures, which show high performance nationally, show significant performance variability reflective of on-going disparities of care. [Table: see text]
Cancer survival outcomes in Ontario, Canada: Significant unexplained variation.
Authors: Brundage Michael Donald , Groome Patti , Hanna Timothy , Booth Christopher M. , Kong Weidong , Dyer Tina , Carter Brenda , Mackillop William J.
Published: September 2018

36

Background: Cancer-specific outcomes are critical for assessing quality of care, and are key quality indicators for cancer control programs. Previous analyses of Ontario (Canada) data show that regional survival differences at the Local Health Integrated Network (LHIN) level exist for relative survival, overall survival, cancer-specific survival (CSS), and mortality rates.We sought to describe: 5-year cancer-specific survival (5Y-CSS) rates among Ontario LHINs; the impact of adjusting for known patient factors; and 5Y-CSS rates among patients diagnosed at Ontario's 50 largest cancer diagnosing hospitals. Methods: Newly diagnosed cases (colorectal, lung, breast, or prostate cancer) were identified in the Ontario Cancer Registry. Records were linked to data from CIHI and Statistics Canada, to identify date of diagnosis, cause-specific vital status, diagnosing hospital, and other reported variables. Cox regression models were used, and all models were adjusted for age and sex. Results: N = 498,382 incident cases (2007-2013) were included. 5Y-CSS varied across LHINs for all patients combined (range 62%-72%; p < 0.0001). Considering colorectal cancer cases as illustrative (N = 57,927), 5Y-CSS varied among LHINs from 58.4%-66.4% (p < 0.0001). Further adjusting for socioeconomic and urban-rural status minimally reduced that variation. Limiting the analysis cohort to patients diagnosed in one of Ontario's 50 largest hospitals (N = 43,245), 5Y-CSS ranged from 52% to 72% (p < 0.0001) among hospitals, and from 55% to 63% (p < 0.0001) among the hospitals affiliated with regional cancer centres. Comparable findings were seen for patients diagnosed with lung, breast, or prostate cancer. Collaborative staging data were available for a subset of patients; 5Y-CSS within all stage III patients (N = 5,360) ranged from 72% to 87%. Conclusions: Important, highly significant differences in cancer survival outcomes exist across Ontario. These are of great interest to patients, health-care providers, system administrators, and policy makers, and are not explained by adjusting for the variables included in these analyses.
Expansion of high-quality specialized services: The gynecologic oncology experience in Ontario hospitals.
Authors: Gilbert Julie , Wheeler Sarah , D'Souza Junell , Irish Jonathan Crawford , Meertens Elaine , Simanovski Vicky , Matheson Garth
Published: September 2018

39

Background: In Ontario’s publicly funded cancer system, patient access to Gynecological Oncology (GyneOnc) care is threatened by growing demand, waiting times and need for lengthy patient travel. Cancer Care Ontario has published organizational standards that lay out the minimum clinical elements and infrastructure needed for a high quality program. Capacity planning and readiness assessments were used to guide GyneOnc expansion into non-academic regional cancer centres to alleviate system pressure. We evaluated early expansion activities to learn about critical factors and generate recommendations for future growth of this specialized oncology service. Methods: Capacity planning for new centres factored health human resources (HHR), patient volume and travel distances, ensuring that existing programs maintain critical mass. Evaluation included review of documents and readiness assessments related to the expansion projects undertaken to date. Interviews were done with GyneOncologists and administrators working at local and provincial levels to discover areas of risk, key factors for success, and recommended strategies for future expansion. Results: Gyne Onc programs need adequate resourcing (minimum 3 GyneOncs) to meet patient demand, support on-call and offer resilience to parental/medical leaves. Programs need engagement from other surgical and medical subspecialties, and clinical services (e.g. pathology, diagnostic imaging) for integrated, multidisciplinary care. Academic appointments, residencies, fellowships, and support for research provide links with universities, important for credibility. Endorsement by senior leadership - both management and clinical - is crucial. Organizational standards need specificity around the infrastructure and multidisciplinary environment needed for program success. Conclusions: HHR planning and readiness assessment are critical enablers in the expansion of specialized services like GyneOnc beyond academic centres. New programs need to consider the adequacy and appropriateness of staffing models, broad engagement of the clinical team, and linkages to academia, in order to ensure program sustainability and acceptability.
A descriptive analysis of clinician input and feedback into the CADTH pan-Canadian Oncology Drug Review process.
Authors: Trudeau Maureen E. , Mirabi Susan , Christiansen Kendra , Chan Kelvin K. , Chambers Alexandra , Haynes Adam E. , Mulla Sohail
Published: September 2018

42

Background: In Canada, through the pan-Canadian Oncology Drug Review (pCODR) process, CADTH conducts evaluations of clinical, economic, and patient evidence on cancer drugs to provide public reimbursement recommendations. The pCODR Expert Review Committee (pERC) makes these recommendations based on a drug’s overall clinical benefit, alignment with patient values, cost-effectiveness, and feasibility of adoption into the health system. Methods: In February 2016, pCODR launched a pilot process that allowed eligible clinicians (individually or as groups) not directly involved in the reviews to participate in the pCODR process, to provide: (1) input at the outset of a review; and, (2) feedback on the Initial Recommendation made by the pERC. Eligible clinicians are those who: (1) are actively practising physicians; (2) are members of a provincial cancer agency or similar body or a national cancer organization; and, (3) submit a declaration of conflict of interest. Results: As of March 31, 2018, 177 oncologists have registered to participate in the pCODR process. Of 43 submissions, 38 (88%) included clinician input. Fifteen submissions received individual input, and 33 received group input, the latter involving three to 13 clinicians or groups. Between April 2016 and March 2018, clinician input by tumour type was as follows: lung (n = 8), leukemia (n = 5), lymphoma (n = 5), gastrointestinal (n = 5), myeloma (n = 4), breast (n = 3), melanoma (n = 2), gynecological (n = 2), endocrine (n = 2), sarcoma (n = 1), and genitourinary (n = 1). Clinician input has answered several key questions, including current treatments, eligible patient populations, relevance to clinical practice, sequencing and priority of treatments, and companion diagnostic testing. Conclusions: Clinician engagement has provided value-added information on local issues from a practice perspective and insights into areas of unmet need. Continuous process improvement is important, however, and the pCODR program completed consultations in April 2018 to enhance clinician participation, proposing to: (1) customize the template that clinicians complete; and, (2) broaden the eligibility of clinicians to oncology pharmacists and oncology nurses.
Improving quality of cancer survivorship care: From framework to action.
Authors: Nekhlyudov Larissa , Mollica Michelle , Jacobsen Paul B. , Geiger Ann M.
Published: September 2018

49

Background: One decade after the Institute of Medicine report recommended the development of quality of cancer survivorship care measures, there remains little progress in achieving that goal. Our goal was to develop a framework for quality measurement and outline the next steps needed to drive research, policy and clinical care. Methods: We conducted a scoping review to identify quality domains and indicators for cancer survivorship care that included: (1) published cancer/cancer survivorship guidelines; (2) National Cancer Institute and Patient-Centered Outcomes Research Institute-funded cancer survivorship studies; (3) U.S. state Comprehensive Cancer Control Plans; (4) indicators developed by national quality organizations. We also reviewed published literature, specifically focusing on narrative and systematic reviews, commentaries/editorials and position papers addressing cancer survivorship care quality. We then conducted interviews with key experts in cancer survivorship and quality. Once the framework was developed, we convened a stakeholder meeting to outline actionable next steps. Results: Key domains focused on (1) cancer and its treatment, specifically prevention and surveillance of recurrences and second cancers as well as surveillance and management of physical and psychosocial effects and (2) primary health care needs such as management of multiple medical conditions and health promotion. Patient experience, communication, care coordination and health care delivery structure are critical domains in cancer survivorship care that must be measured. Lastly, domains included health care outcomes, such as utilization, costs, mortality and quality of life. Respective indicators and findings from stakeholder meeting will be presented at the Symposium. Conclusions: We developed a framework that will promote a systematic approach to (1) designing effective, evidence-based clinical care for cancer survivors in oncology and primary care settings, (2) expanding research initiatives to address identified gaps in quality measurement and (3) developing policy recommendations to encourage the implementation of standardized measures for quality improvement.
Performance of community-based lung cancer screening program in a region with a high rate of endemic histoplasmosis.
Authors: Bhandari Shruti , Tripathi Prashant Gyanendra , Pinkston Christina M , Kloecker Goetz H.
Published: September 2018

58

Background: Lung cancer screening (LCS) with Low dose computed-tomography (LDCT) has been recommended by USPSTF for high-risk population since 2013 largely based on 20% relative reduction in lung cancer mortality shown in National Lung Screening Trial (NLST). The success of NLST was related to its high adherence rate and thorough ascertainment of lung cancers and deaths. This study evaluated performance of lung cancer screening program in Histoplasmosis endemic community. Methods: Demographic and clinical information was collected through retrospective review on all patients in the lung cancer screening program of a Kentucky health system comprising 21 centers from 2016 and 2017. A positive LDCT screen is defined as Lung-RADS version 1.0 assessment categories 3 or 4. Results: A total of 4500 LDCT screens were performed in 2016 (39%) and 2017 (61%) with 49% adherence rate to repeat annual screen in 2017. Mean age of patients was 64 years, majority being females (54%) and current smokers (69%) with average 52-pack year smoking history. The rate of positive LDCT was 13.3% (600) varying based on initial (14.6%) vs annual (9.5%) screen. A total of 70 lung cancers were diagnosed among all positive LDCT screens (11.7%) with a false positive rate of 12%. Conclusions: Comparing to NLST results updated with Lung-RADS categories, baseline positive screens in our community are similar (14.6% vs 13.6%, p = 0.15) despite being a Histoplasmosis endemic region. Our higher rate of annual positive screens (9.5% vs 6%, p < 0.001) and false positive rate (12% vs 8%, p < 0.001) may be explained by poor adherence to annual screens and an inability to thoroughly ascertain lung cancer diagnosis in all patients due to lost to follow up. In community setting with < 50% adherence to annual screens compared to 95% adherence in NLST, it is unclear if LCS mortality benefit still holds and needs intervention to increase adherence to LCS.
Feasibility of a patient-reported outcomes quality-of-life instrument to improve care in underserved, ethnic minority patients with cancer.
Authors: Khera Nandita , Ramos Gilbert , Fruth Briant , Arslan Waqas , Komenaka Ian K. , Warsame Rahma M. , Northfelt Donald W. , Griffin Joan M. , Sloan Jeff A.
Published: September 2018

65

Background: We need better methods to understand the social determinants of health and integrate psychosocial and economic sequelae of cancer and its treatment into healthcare delivery for ethnoculturally diverse population. A Patient-Reported Outcomes Quality of Life (PROQOL) instrument has been developed to capture less commonly discussed patient concerns (Personal Relationships, Emotional health, Physical health, Cancer diagnosis and treatment, Money and Care planning) and improve patient-provider communication. We sought to adapt this instrument and pilot it in underserved, ethnically diverse solid tumor and hematological malignancies patients at Maricopa Integrated Health System (MIHS) in Phoenix, AZ. Methods: Two focus groups (FG) were conducted to understand patient perspectives of an adapted Spanish version of PROQOL. This version was then piloted among patients on active cancer treatment. Patients also completed a Linear Analog Scale Assessment (from 1-10) for quality of life (QOL) and its domains (higher scores indicate better QOL). Results: All participants in both FG (11/12 female) were Hispanics, with a median age of 53 years. Participants agreed that the domains covered in the PROQOL represented the most important psychosocial needs in their cancer continuum. No difficulty in understanding the individual domains or questions for delving deeper into each domain was noted. Median age of 34 pilot study participants (74% female) was 48 years, 79% were Hispanic, 10% were African Americans and median household income was $ 43,924 (range 23,002-98,382). 28/34 completed the Spanish version. Most common concerns were ‘Money’ (32%): difficulty paying medical bills and non-medical expenses and ‘Cancer Diagnosis, Treatment and Survivorship’ (32%): type of cancer and treatment concerns. Median overall QOL was 8 (range 3-10). Conclusions: PROQOL is feasible for systematic capture of patient concerns in underserved, ethnic minority cancer patients. A better understanding of these challenges can help design interventions to improve psychosocial and financial outcomes for the vulnerable groups and decrease disparities in care delivery.
Harnessing AI for health equity in oncology research and practice.
Authors: Urman Alexandra , Wang Ching-Kun , Dankwa-Mullan Irene , Scheinberg Ethan , Young Michael J.
Published: September 2018

67

Background: Recent advances in artificial intelligence (AI) carry underexplored practical and ethical implications for the practice of clinical oncology. As oncologic applications of AI proliferate, a framework for guiding their ethical implementations and equitable distribution will be crucial. Methods: We reviewed the current landscape of AI applications in oncology research and clinical practice by reviewing the current body of evidence in PubMed and Medline. Key ethical challenges and opportunities to address health equity are critically evaluated and highlighted. Ethical implications for patients, clinicians and society at large are delineated, with particular focus on the impact and ramifications of AI with respect to healthcare disparities and equity of oncology care delivery. Results: Growing concerns that AI may widen disparities in oncologic care by virtue of lack of affordability, inconsistent accessibility and biased machine-learning models are addressed. Although there is potential for AI to widen disparities in oncology care, using foresight in application, AI has the potential to (1) democratize access to specialized clinical knowledge, (2) improve the accuracy of predicting cancer susceptibility, recurrence and mortality, (3) prevent diagnostic errors in under-resourced settings, (4) minimize unintended bias and (5) enable access to tailored therapeutic options including clinical trials if appropriately deployed. Separately, AI can be harnessed to identify areas of underserved needs and optimize systems of health-information sharing and reimbursements as blockchain technology converges with AI. As AI advances it will have a larger presence in oncology research and clinical practice. Conclusions: A strategic framework integrating ethical standards and emphasizing equitable implementation can help ensure that the potential of AI to address disparities in oncology are maximally captured and its perils averted. Further work is being done on exploring these challenges and will be submitted as a manuscript.
Cancer history, health insurance coverage, and cost-related medication nonadherence and medication cost-coping strategies in the United States.
Authors: Zhao Jingxuan , Zheng Zhiyuan , Han Xuesong , Davidoff Amy J. , Banegas Matthew P. , Rai Ashish , Jemal Ahmedin , Yabroff K Robin
Published: September 2018

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Background: Policy makers, health care providers and patients are increasingly concerned about rising costs for prescription drugs and cost-related medication non-adherence (CRN). This study aims to evaluate the relationship between cancer history and CRN as well as cost-coping strategies, by health insurance coverage. Methods: We used the National Health Interview Survey data from 2013-2016 to identify adults age 18-64 with (n = 3 599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included a) CRN (skipping, taking less or delaying medication because of cost), and b) cost-coping strategies (requesting lower cost medication or using alternative therapies to save money). Separate multivariable logistic regressions were used to calculate the adjusted percentages of CRN and cost-coping strategies associated with cancer history, stratified by health insurance. Results: Cancer survivors reported higher percentages of CRN (14.5% vs. 12.1%, P < .001) and were slightly more likely to report using cost-coping strategies (24.4% vs. 22.8%, P = .060) compared with adults without a cancer history. The magnitude of differences in CRN by cancer history varied by insurance type (any private 10.2% vs. 8.6%, P = .034; public only 17.9% vs. 14.2%, P = .010; uninsured 41.0% vs. 33.2%, P = .064). Among the privately insured, the difference in CRN by cancer history was greatest among those enrolled in high deductible health plans (HDHP) without health saving accounts (HSA) (16.9% vs. 10.9%, P = .002). Regardless of cancer history, CRN and use of cost-coping strategies were highest for those uninsured, enrolled in HDHP and without HSA, and without prescription drugs coverage under their health plan (all P < .001). Conclusions: Cancer survivors are prone to CRN and more likely to use cost-coping strategies to minimize financial hardship. Expanding options for health insurance coverage and use of HSA, and prescription drug coverage may be effective strategies to address CRN.
A qualitative evaluation of barriers and facilitators to hepatocellular carcinoma care in North Carolina.
Authors: Ray Emily Miller , Teal Randall , Vu Maihan , Coffman Erin , Bell Mary Elizabeth , Carda-Auten Jessica , Sanoff Hanna Kelly
Published: September 2018

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Background: Hepatocellular carcinoma (HCC) is a common cause of cancer-related morbidity and mortality worldwide, yet many patients with HCC never receive cancer-directed therapy, for reasons that are not well documented. In order to tailor interventions to increase access to appropriate therapy, it is critical to understand the barriers and facilitators to access to care and receipt of treatment in HCC. Methods: This study includes 10 patients with HCC, within 6 months of diagnosis, identified through either the University of North Carolina (UNC) multidisciplinary HCC clinic or the UNC Rapid Case Ascertainment (RCA) Core which identifies cancer patients through registrars at local hospitals. Recruitment is ongoing with a target of 20 patients, expected to complete in July 2018. In-depth, semi-structured interviews were conducted by two qualitative researchers. Interviews were audiotaped, transcribed verbatim, and coded independently by two coders, using a common codebook. Coding discrepancies were reconciled by consensus. Results: Most participants described that they had been incidentally diagnosed with HCC during evaluation for another health issue. Key facilitators of care were: physician knowledge about HCC; clear, honest, and timely communication regarding test results, plan of care, and prognosis; access to transportation; strong social support; and financial support through friends, family, insurance, or charity care. Barriers to care included: lack of transportation; delays in receipt of information or in scheduling appointments; or poor communication with the medical team. Conclusions: This study identifies key facilitators and barriers to accessing care for HCC in North Carolina (NC). Further investigation of a broader sample of HCC patients is warranted, and the qualitative data from this study will be used to create a survey to be administered to all patients with incident HCC in NC. Ultimately, this information will serve as the basis for tailored interventions aimed at improving access to appropriate, life-prolonging care for patients with HCC.
Feasibility of medication coordination with lay navigators in outpatient oncology clinics.
Authors: Morgan Katherine P. , Sellers Jean B. , Muluneh Benyam , Carlson Megan , Wood William Allen , Shea Thomas C.
Published: September 2018

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Background: Significant obstacles exist with approval and payment of oncology medications for both the patient and pharmacy team. Our medication assistance program is supported by the clinical pharmacist (CP) and clinic staff. Many tasks are time consuming, interrupt patient care and may create medication access delays. Patients also need assistance with health insurance literacy and have minimal understanding of medication assistance resources. Lay navigators (LN) are volunteers who assist cancer patients overcome barriers to care. They are trained to work in tandem with clinical staff while linking patients to financial resources. A pilot was developed to determine the feasibility and value of integrating LN support within the pharmacy team. Methods: Four LN were integrated into oncology clinics. Tasks were assigned to the LN under the supervision of the CP. The LN documented tasks executed, entities and patients they communicated with and time spent on each encounter. Results: From April to June 2018, 4 LN were available 2 to 4 hours per week. The LN completed 46 interventions for 20 patients (Table 1). Average time spent on each intervention was 19 minutes. Over the 9-week pilot period the LN saved clinic staff a total of 10.87 hours. LN survey feedback was positive and 75% of the LN report confidence when communicating with patients about medication access. Conclusions: We have demonstrated that LN can be utilized as a pharmacy advocate for medication coordination in oncology clinics at our academic medical center. LN satisfaction was high and time savings allowed CP to focus on direct patient care. The model is cost effective and requires few resources other than financial toxicity training and supervision. Future steps will include determining financial impact, patient satisfaction and expansion into additional clinics.[Table: see text]
Tracking the clinical experience of women with metastatic breast cancer at an academic cancer center.
Authors: Ingram Stacey A. , Williams Courtney , Gilbert Aidan , Nappoe Stevie , Kenzik Kelly , Azuero Andres , Mennemeyer Stephen T. , Nipp Ryan David , Rocque Gabrielle Betty
Published: September 2018

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Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.