bluuebunny/crossref_metadata_2025 huggingface dataset:
Ibrutinib + durvalumab (MEDI4736) in patients (pts) with relapsed or refractory (R/R) pancreatic adenocarcinoma (PAC): A phase Ib/II multicenter study.
Authors: Borazanci Erkut Hasan , Hong David S. , Gutierrez Martin , Rasco Drew W. , Reid Tony R. , Veeder Michael H. , Tawashi Ahmed , Lin Jennifer , Dimery Isaiah W.
Published: February 2017

TPS484

Background: PAC is an aggressive disease characterized by poor prognosis and is inadequately treated with available therapies. Ibrutinib is a first-in-class, oral inhibitor of Bruton’s tyrosine kinase (BTK) that was shown to inhibit mast cell degranulation in the PAC tumor microenvironment with subsequent inhibition of tumor cell proliferation, angiogenesis, and collagen deposition (Chang, 2011; Masso-Valles, 2015). Durvalumab, a human IgG1 monoclonal antibody (mAb), binds PD-L1 with high affinity and prevents interaction with PD-1 and CD80 (IC50values of 0.1 nM and 0.04 nM, respectively), facilitating antitumor T-cell responses (Stewart, 2015). Ibrutinib + anti-PD-L1 mAbs inhibited tumor cell growth and led to enhanced anti-tumor immune responses in mouse models (Sagiv-Barfi, 2015). This trial (PCYC-1135; NCT02403271) evaluates the safety and efficacy of ibrutinib + durvalumab in pts with PAC, breast cancer, and non-small cell lung cancer. Study details presented here focus on the cohort of pts with PAC. Methods: Key inclusion criteria include pathologically confirmed PAC, R/R disease (failed ≥ 1 prior systemic therapy), stage III-IV disease, ≥ 1 measurable lesion by RECIST 1.1 criteria, and adequate hematologic, renal, hepatic function. Key exclusion criteria include any history of central nervous system involvement; prior treatment with ibrutinib/BTK inhibitor or treatment with antibodies targeting PD-1, PD-L1, PD-L2, CD137, or CTLA-4; history of allogeneic organ transplant; or treatment with a strong cytochrome P450 3A inhibitor. Primary objectives are safety, tolerability, and efficacy of the combination; secondary objectives include pharmacokinetics and pharmacodynamic assessments of the combination. The phase 1b portion will assess the dose-limiting toxicities (DLTs) and determine the recommended phase 2 dose (RP2D). Ibrutinib will be administered at the standard dose with the potential for dose level reductions if DLTs occur in combination with durvalumab. After RP2D determination, enrollment in phase 2 will occur until a total of 130-160 pts (across all 3 disease cohorts) are treated. Enrollment for phase 1b began in March 2015. Clinical trial information: NCT02403271.
Bridging community and academic cancer centers using nurse navigation.
Authors: Miller Eleanor
Published: February 2017

102

Background: The Penn Cancer Network was formed in the early 1990’s to bridge a connection between the community oncology setting and The University of Pennsylvania, an academic medical center. Aspects of the network contracts include cancer program assessment and development, accreditation preparation, and most recently dedicated access to cancer care via the network nurse navigator. This poster emphasizes the impact of a network nurse navigator has as a highly sought link between health systems, providers and patients to streamline patient referrals, with a formal process evolving over time. Methods: The establishment, growth and success of the referral process can be attributed to multiple efforts on behalf of the nurse navigator and administration, including but not limited to strong relationship development among nurse navigators and administrators at the hospitals and a formalized process developed by the nurse navigators using an online portal for referrals directly to the nurse navigator. Metrics are also maintained to demonstrate clinical and financial outcomes. Results: Since the establishment of a dedicated nurse navigator in 2010, referrals have increased year over year and two hospitals have since joined Penn Medicine, in part due to these strong relationships. Systematic chart reviews and data analysis have been completed annually to present to administration, with hundreds of patients being referred annually for second opinions, complex surgeries or clinical trials. A comprehensive financial analysis has been done to demonstrate the impact of these patient referrals on the health system, increasing annually. Conclusions: Access to the network nurse navigator has been emphasized as a major advantage to being a network hospital. A nurse navigator is well positioned to triage to subspecialties, assess patient and provider needs, and be knowledgeable in the operations of both systems. Data analysis has been paramount in demonstrating the impact of this program, both clinically and financially. This process could be done for formal network relationships or informal, but it certainly builds a great pattern to improve patient’s access to care.
Bringing provincial improvements to oral chemotherapy prescribing through co-ordinated regional initiatives.
Authors: Simanovski Vicky , Ahmad Noor , Kaizer Leonard , Redwood Erin , Vu Kathy , Fox Colleen , Meertens Elaine , Krzyzanowska Monika K.
Published: February 2017

107

Background: Oral chemotherapy delivery is complex, making safe medication practices a high priority. Cancer Care Ontario, the provincial government agency responsible for continually improving cancer services in Ontario, undertook a jurisdiction-wide quality improvement initiative to ensure that all oral chemotherapy drugs are prescribed using Computerized Prescriber Order Entry (CPOE) or standardized Pre-printed Orders (PPO). The initiative was further enabled by changes to the provincial funding approach that flows facility funding for oral chemotherapy delivery. Methods: All 35 facilities prescribing chemotherapy in Ontario across 14 regions implemented strategies to work towards the common aim of reducing handwritten/verbal oral chemotherapy prescribing to zero by June 30th, 2015. Baseline audits were completed between Sept-Nov 2014; repeat audits were performed between Mar-May 2015. Each facility reported the number of patients that received an oral chemotherapy prescription, and the method of prescribing. Results: At baseline, 30% of audited prescriptions across the province were handwritten or verbal, which decreased to 9% by June 2015. Improvements were seen in thirteen of the 14 regions. Thirteen out of 35 facilities met the aim of 0 handwritten/verbal orders, with an additional 16 facilities seeing an improvement. Alignment with funding mechanisms, an early physician engagement strategy, and education of key stakeholders on CPOE systems were identified as key enablers to implementation. Conclusions: Though the goal of zero handwritten/verbal prescriptions was not met by all facilities, the initiative encouraged a change in implementing safe prescribing practices for oral chemotherapy. Further audits will assess that the gain was sustained and that the provincial goal is achieved. This initiative is part of a larger strategy to standardize care for systemic treatment patients and promote a culture of safety in hospitals. [Table: see text]
Pathway map development as an approach to identifying priority areas for quality improvement in Ontario.
Authors: Mackay Helen , Soobrian Jasmin , Murphy Joan , Elit Lorraine , Milosevic Michael F. , Gollnow Angelika , Ross Jillian , Holloway Claire ,   Cancer Care Ontario (CCO) Cervical Care Pathway Working Group
Published: February 2017

108

Background: Disease Pathway Management (DPM) is the unifying approach to the way in which Cancer Care Ontario (CCO) sets priorities for cancer control, plans cancer services and improves the quality of care in Ontario. In 2014 DPM began developing a cervical cancer pathway map (CCPM) to map the patient journey along the cervical cancer care continuum. Objective: to report on the CPPM development process as a tool to identify key priorities for cervical cancer management in Ontario. Methods: DPM convened a multidisciplinary/multi-stakeholder cervical cancer working group with regional and specialty representation from across Ontario. Over 12 months, 33 individuals participated in an in-person meeting and monthly teleconferences. The CCPM was drafted using guidelines developed by CCO’s Program in Evidence Based Care (PEBC) and considering clinical guidance documents from several jurisdictions. Throughout the development process the team were asked to discuss and reach consensus on key priorities for improving care. Results: Twenty-two priority areas were identified across the continuum in: prevention, diagnosis, treatment, follow-up and survivorship. Opportunities were identified for: development/endorsement of evidence based guidelines; patient-centered approaches to screening; quality improvement; survivorship; drug funding implementation and a CPPM Knowledge Translation strategy. Potentially actionable items were aligned with relevant internal and external stakeholders including organized screening programs, the PEBC, provincial drug reimbursement programs and other quality improvement teams within CCO. Conclusions: The process of bringing multidisciplinary experts together in order to develop the CPPM successfully identified key priorities across the spectrum of care in Ontario and allowed identification of potential opportunities for quality improvement, development of practice guidelines and new models of care. In turn, the CCPM provides a patient-centred disease focused framework from which stakeholders can approach and evaluate new initiatives in the context of the cervical cancer continuum.
Optimizing the collection and reporting of wait time data.
Authors: Bedford Colleen , Langer Deanna , Kaan Melissa , Norton Jonathan , Ho Brian , Thomas Ann , Dobranowski Julian
Published: February 2017

121

Background: Wait times for critical interventional radiology (IR) procedures have long been reported as barriers to access for cancer patients. Wait times have been difficult to measure in the province of Ontario as no mechanisms exist to capture IR data. Three individual programs at Cancer Care Ontario (CCO) began collection of CT-guided biopsies wait time data, with nuances dependent on program area of focus. The Cancer Imaging Program collects appointment availability for lung biopsies through a monthly email survey. The Diagnostic Assessment Program collects patient-level lung biopsy data at select facilities in the province. The Access to Care program collects patient-level data from facilities that perform CT biopsies, but the data is not specific to lung biopsies. To streamline data collection processes and provide a comprehensive report for the province, the three programs are collaborating to validate current data sets and optimize data collection. Methods: A four phase approach has been developed to prepare for the ongoing comprehensive report: Planning – identify target audience, timelines, and data; Data Validation – three step evaluation to compare data sets; Test Report – consultation of draft report with clinical experts; and Evaluation – lessons learned from steps one to three to prepare for ongoing report. Results: This initiative allows each program to: Critically assess the components of their respective datasets; Cross-validate data for consistency or alignment; and Frame the clinically relevant data components to support and inform decision making and reporting processes. Through this process, efficiencies are gained by streamlining data collection and ensuring alignment between program areas. The collaborative approach ensures the business needs of each program are protected in the final product. Furthermore, this process will allow decision makers at CCO to analyze various methods of wait time data collection and aid in methodology decisions of future collections. Conclusions: The final product of this initiative will provide physicians and decision makers throughout Ontario with robust data to understand what is happening in their hospitals. The report will also facilitate impact analysis of interventions to reduce wait times.
Clinical specialist radiation therapists (CSRT): Creating capacity while improving quality of care.
Authors: Lockhart Elizabeth , Ang Michelle , Zychla Laura , Bak Kate , Nagata Lynne , Beglaryan Hasmik , Ross Jillian , Husain Asad , Simniceanu Carina , Gutierrez Eric , Warde Padraig Richard , Harnett Nicole
Published: February 2017

124

Background: Ontario’s cancer system faces many challenges, including a rising incidence of cancer, aging population, increasingly complex cancer treatment, and health human resource (HHR) constraints. In response, Cancer Care Ontario and the Ontario Ministry of Health and Long Term Care collaborated on a project to assess whether a new advanced practice radiation therapist role – the ‘Clinical Specialist Radiation Therapist’ (CSRT) – could enhance access to high quality, innovative care by optimizing the use of HHR. Methods: This innovative model of care aims to enable radiation therapists with advanced training and accreditation (CSRTs) to assume responsibility for certain activities traditionally performed by radiation oncologists (ROs) while maintaining and improving the quality, accessibility and efficiency of radiotherapy (RT) for patients. To assess CSRTs’ impacts standardized metrics, including efficiency (access, wait times (WTs), team function) and quality (new/enhanced services, patient experience) measures, were used. Results: Currently there are 24 CSRTs in 9 of 14 regional cancer centres. 2014/15 data demonstrated that CSRTs can improve the efficiency of referral processes and clinic operations, decrease WTs, and increase capacity (2-28 additional patients seen in clinic/month). Optimized team function and time savings (5-66 RO hours/month) have been achieved through CSRTs’ assumption of certain patient assessment and treatment planning activities. Efficiencies have improved patient experience by facilitating quicker, more coordinated flow through the RT process, and greater continuity of care. Further, CSRTs have enhanced access to high quality RT, through > 75 innovative initiatives (rapid access clinics, telemedicine consults). Conclusions: The CSRT role demonstrates how innovative models of care can improve patient access to high quality cancer care. With 24 CSRTs implemented, opportunities for analysis of factors which facilitate achievement of maximal impact and position sustainability exist. Such investigations could inform the refinement and further implementation of CSRTs in Ontario and other jurisdictions, improving patients’ access to RT more broadly.
Timeliness of care delivery for lung cancer patients in a vertically integrated health care system.
Authors: Cooper Robert Michael , Hahn Erin Elizabeth
Published: February 2017

127

Background: A Kaiser Permanente Southern California (KPSC) organizational goal is to achieve optimal timeliness of cancer care delivery. The purpose of this report is to present a process used for a multi-disciplinary physician led performance improvement exercise at the at the Los Angeles Medical Center and share initial learnings. Methods: A CME approved Performance Improvement (PI) program to examine timeliness of care delivery for newly diagnosed patients with lung cancer was created for physicians. The multi-disciplinary core group met for 6 three hour blocks of time to process map the patient centered flow. The physicians evaluated current practice, developed a future state and made structural changes. The group focused on two time intervals: time from suspicion of malignancy until pathology resulted, and time from pathology until the start of treatment. Results: Initial learnings included, that the work was meaningful as shown by physicians using their dedicated education time and consistency of participation; an electronic medical record was useful for the initial process mapping and ongoing monitoring; patient flow is complex and patients followed many different paths to diagnosis and treatment. Participating in this project benefitted team building, improved understanding of the challenges throughout the system, enhanced empathy for their colleagues and patients, and educated physicians about performance improvement methodology. Preliminary review of timeliness of care delivery shows improvements in timeliness at the two time points both during the year of instituting a PI program and with the first interventions. Conclusions: A physician led multi-disciplinary approach to review of timeliness of care delivery is feasible and productive.
Early experience with Puerto Rico: Effective use management of bone agents.
Authors: Wurtz Kenneth , Huff Dinah Faith Q. , Feliciano Lourdes , Bennett Charles L. , Knopf Kevin , Hrushesky William J. , DiMarco Anna , Baum Michael
Published: February 2017

130

Background: Oncology Analytics is a cancer care decision support group recently entering the Puerto Rican cancer care marketplace. Bone agents are used in metastatic cancer management to delay the progression of lytic bone metastases. These agents are also used for the treatment of demonstrated osteoporosis with bone densitometry (DEXA scan). Oncology Analytics has found these agents are sometimes used in the absence of lytic metastases or osteoporosis. When this is discussed with treating physicians, practice patterns promptly improve. Beginning our work: The following work focuses entirely upon use among patients with bone mets. There is modest use of bone agents for bone mets among PR oncologists. A statistically significant decreasing and sustained trend in the inappropriate utilization of bone agents and especially the use of denosumab in the PR market is closely associated with recent initiation of OA decision support. Methods: We analyzed data from oncology drug preauthorization requests for bone modifying agents for the management of metastatic bone disease submitted by providers to payers serving in Puerto Rico from Jan 1, 2015 through September 30, 2015. Results: Within the 9 months, non-compliant zoledronic acid use diminished by one-third; pamidronate by 40%; and denosumab use was decreased by 75%. Quarterly dynamics demonstrates a statistically significant downward trend in the unnecessary use of these agents among PR oncologists (p,0.05). Conclusions: Oncology Analytics presence in a new market enhances cancer care quality and cancer care value quickly, while at the same time conserving substantial resources.
Multidisciplinary process improvement to optimize oral chemotherapy safety.
Authors: Amport Stephanie Buia , Adelson Kerin B. , Fradkin Monica , Havriliak Renee , Harrison Michelle Renee , Abdelghany Osama , Kregling Stephanie , Wright Jessica , Morrow Bret , Sterling Roberta , Smith Mandeep , Esposito Frank , Stutsky Martha , Miller LeeAnn , Lilenbaum Rogerio , Lyons Catherine A. , Chiang Anne C. , Cohen Howard
Published: February 2017

134

Background: The rapid development of oral chemotherapy agents brings unique challenges. These drugs must be treated with the same vigilance as parenteral chemotherapy. The oral chemotherapy system is not optimized or integrated across our hospital. A quality assessment survey identified the need for a better means to monitor and improve oral chemotherapy patient outcomes. Methods: Patient and staff satisfaction with the current process was measured. A chartered multidisciplinary task force reviewed existing practice and developed a program to identify patients, ensure drug access, standardize prescription and consent, ensure on-going clinical support including patient education, regimen specific adherence monitoring, toxicity assessment and address patient concerns. Current state process mapping and gap analysis identified eighty-seven points where care could break down. A risk mitigating model was developed to include clinically reviewed electronic orders, nursing and pharmacist order review, specialty pharmacy, Medication Assistance Program (MAP) to assist with access and co-payment, patient education, day 5 and 21 pharmacist to patient phone calls, multidisciplinary flow sheet documentation, EMR report to track patients and outcomes and standardized patient education and provider training. The implementation team addresses process challenges identified via clinical team feedback e.g. therapy delays and implements fixes. Results: See table below. Specialty pharmacy revenue is directed to supporting non-profit clinical care at a time when revenue sources are being cut. MAP co-pay support exceeds $2.3 million. Conclusions: A patient-centered multidisciplinary care model integrating clinical, operational, financial and technology resources optimized care. Our improvement approach created opportunities for collaboration between pharmacists, physicians and nurses and can be adapted for many settings. [Table: see text]
Enhancing a culture of patient safety in an oncologic hospital setting.
Authors: Worthington Nicole , Bristow Shannon
Published: February 2017

135

Background: Patient safety is a priority for all hospitals and staff members. With approx. 1:10 hospitalized patients experiencing an adverse event1, healthcare lags behind other industries with regards to safety. Oncology patients have an increased risk of adverse events due to an immunocompromised status, coupled with complex treatments. Cancer Treatment Centers of America at Eastern Regional Medical Center (ERMC) recognized the need to heighten patient safety while maintaining a positive patient experience. Methods: ERMC participates in the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture to assess employee’s perception of the organization’s patient safety, conducted every 18-24 months. The most recent survey was conducted between May 11 - June 1, 2015. Interventions to enhance safety culture from 2013 to 2015 survey results included: daily safety check-ins for all hospital departments for both day and night shifts; sharing safety stories before routine meetings; leadership rounding; and enhanced transparency of safety events that occurred throughout the hospital. Routine in-servicing was also completed to educate staff members on reportable safety events for Pennsylvania and foster ongoing discussions about patient safety. Results: Survey response rate experienced a 236% increase from 2013 to 2015 (218 to 628 responses respectively). Of the 12 patient safety composites, 11 showed an increase in scores from 2013 to 2015, the outlier being “overall perceptions of patient safety” composite score which dropped by two percentage points. Furthermore, ERMC was above the national benchmark in all 12 patient safety composite categories for the 2015 survey. Conclusions: The ERMC staff considers safety a priority, as evidenced by the increase in AHRQ survey scores from 2013 to 2015. Perceptions of safety throughout the system have increased with the initiation of several safety projects. Based on raw comments from the AHRQ culture of safety survey, more work is needed to involve non-clinical staff in hospital safety. Moving forward, ERMC will investigate innovative solutions to involve all staff, clinical and non-clinical alike, to be engaged in patient safety.
Moving towards hospital and radiation oncology EMR integration: Results of an institutional survey.
Authors: Solanki Abhishek Ashok , Surucu Murat , Kaczmarz Barbara , McCoo Teresita , Roeske John , Small William
Published: February 2017

152

Background: We are working to electronically integrate our radiation oncology EMR and our hospital EMR to improve communication and facilitate patient care. To guide integration, we surveyed providers and support staff at our academic cancer center to identify the important encounters/documents and how well these are currently communicated. Methods: We sent an email survey to 182 MDs, nurses, and administrative staff at our cancer center. Respondents identified their role in the patient care team, and rated how important several radiation oncology-specific encounters/documents from “not important at all” to “extremely important” and rated the accessibility of these encounters/documents from “not at all accessible” to “exceptionally accessible.” Encounters/documents are listed in the table. Descriptive statistics were then performed to identify opportunities to improve communication. Results: There were 32 responses to our survey from staff outside of our department, including 18 physicians, 2 APN/PAs, 8 nurses, 2 nutritionists, 1 receptionist, and 1 social worker. Of the physicians, there were 8 medical oncologists, 2 neurosurgeons, 5 urologists, 1 breast surgeon, 1 gynecologic oncologist, and 1 reconstructive surgeon. The table describes the number of respondents who felt the encounter/document was “moderately,” “very,” or “extremely important”, and within this group of respondents, what percent thought each item was “very” or “exceptionally accessible.” Conclusions: We prioritized the importance of encounters/documents for integration between EMRs and identified deficiencies in communication. We will use the results of this study to guide our electronic integration of our two EMR systems. We will repeat the survey after integration is complete to identify improvement. [Table: see text]
Survival as a measure of quality of cancer care and advances in therapy: Lessons learned from analyses of the National Cancer Data Base (NCDB).
Authors: Shulman Lawrence N. , Palis Bryan E. , McCabe Ryan M. , Gay E. Greer , Mallin Katherine , Loomis Ashley , Winchester David P , McKellar Daniel P.
Published: February 2017

173

Background: Many quality metrics of cancer care are process measures, based on whether a patient received recommended treatment for diagnosis and stage of their disease. Survival is dependent on patient characteristics, disease specifics, and care received (surgery, systemic therapies, radiation). Some argue survival is the ultimate measure of cancer care quality. Survival calculated from registry data may be a better indication of the real effects of new therapies as it contains a broad representation of patients who may not meet the eligibility criteria for clinical trials. Methods: The NCDB is composed of registry data from approximately 1,500 hospital based cancer programs, and includes stage, demographic data, co-morbidities, treatments, and vital status. Survival analyses were derived from NCDB data for all stages of breast cancer, non-small cell lung cancer (NSCLC), and pancreatic cancer. These diseases were selected because breast cancer has a high survival rate, whereas NSCLC and pancreatic cancer are diseases with a poor prognosis, but recent advances may have improved survival. Un-adjusted and risk adjusted survival were analyzed by socioeconomic, tumor, and hospital factors including stage, comorbidities, diagnosis year (to assess new treatment trends), and type of institution (academic, comprehensive community, and community cancer programs). Results: Results for these diseases and variables noted will be presented. Whereas better un-adjusted survival rates were often seen at academic cancer programs, differences disappeared after risk-adjustment. Improved survival was seen in more recent years, probably representing new treatment effects, though gains were modest and stage dependent. Conclusions: Measuring survival across hospitals and regions is critical to understanding the state of cancer treatment nationally and the effect of quality and therapy advances on patients across a variety of clinical settings. Methodologic challenges in analyzing and interpreting survival data must be realized, and continued innovation in the collection and analysis of data is needed.
Patient preferences for provider roles in collaborative breast cancer survivorship care.
Authors: Wallner Lauren P. , Abrahamse Paul , Friese Christopher Ryan , Katz Steven J. , Hawley Sarah T.
Published: February 2017

184

Background: Prior studies have exploredbarriers to collaborative cancer care and suggest a need for greater clarity about clinician roles. However, little is known about patient’s preferences and expectations for which clinicians handle various aspects of care after primary cancer treatment. Methods: A weighted random sample of newly diagnosed breast cancer patients in the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (expected final N = 2600, 70% current response rate). Patient preferences for which clinician handles the following aspects of care after treatment were ascertained: follow-up mammograms, screening for other cancers, general preventive care, treatment of comorbidities, physical symptoms, emotional symptoms, and reassurance about their breast cancer. Response categories included primary care clinician (PCP), cancer doctors, either or both. The associations between patient demographic and clinical factors with preferences for clinician roles were assessed using multinomial logistic regression. Results: In a preliminary sample (N = 1038), the majority of women preferred to see oncologists for mammograms (63%), other cancer screening (67%) and reassurance about their cancer (75%) and PCPs for general preventive care (80%), comorbid care (85%) and emotional symptoms (67%). Black women (vs. White) were more likely to prefer to see both clinicians for mammograms (OR: 3.7, 95%CI: 2.5, 5.5), screening for other cancers (OR: 2.1, 95%CI: 1.3, 3.2), reassurance about their cancer (OR: 2.1, 95%CI: 1.3, 3.2), and general preventive care (OR: 4.0, 95%CI: 2.1, 7.8). Black and Hispanic women were more likely to prefer to see both for comorbidity care (Black OR: 3.2, 95%CI: 1.6, 6.3; Hispanic OR: 2.6, 95%CI: 1.1, 6.3). Less than a high school education was also associated with a preference for seeing both clinicians for comorbidity care. Conclusions: While patients report clear preferences for which clinicians handle various aspects of their collaborative survivorship care, variation exists by race and education. Targeting these patients to clarify clinician roles may be particularly effective in interventions to improve collaborative cancer care.
Lung cancer screening knowledge and beliefs among primary care providers and pulmonologists.
Authors: Marsh Katie , Greenwood-Hickman Mikael Anne , Jones Laura , Rivera M. Patricia , Bowling J. Michael , Molina Paul , Maygarden Susan , Birchard Katherine , Reuland Dan , Henderson Louise
Published: February 2017

191

Background: In response to the National Lung Screening Trial’s findings, numerous professional organizations have published guidelines recommending annual lung cancer (LC) screening with low dose computed tomography (LDCT) for eligible patients. In the wake of these guidelines, we sought to assess LC screening practices and beliefs among providers at a large academic medical center. Methods: In 2015, we surveyed 54 physicians and 9 residents in pulmonology (27% response rate) and 86 physicians and 100 residents in family/internal medicine (39% response rate). The 23 question Qualtrics survey focused on beliefs and knowledge about LC screening recommendations, guidelines, and practices. Results: Survey respondents in both groups were mostly White non-Hispanic clinicians with a mean age of 40 (range 28-67). Pulmonology respondents were mostly male (69%) and family/internal medicine respondents were mostly female (53%). The pulmonology group was more likely than family/internal medicine to believe that LC screening is beneficial for patients (p < 0.0001) and cost effective (p = 0.02). Over 76% of the pulmonology group reported ordering a LDCT for an asymptomatic patient in the past 12 months compared to 41% in the family/internal medicine group (p = 0.012). Additionally, 76% in pulmonology were aware of the American College of Chest Physicians recommendations versus 38% in family/internal medicine (p = 0.02). The majority of both groups agreed that an electronic prompt would increase the likelihood of referring a patient for LC screening. While both groups agreed that a LC screening registry would benefit the quality of patient care (100% pulmonology; 65% family/internal medicine; p = 0.02) and make them more likely to refer patients to a LC screening program (88%; 54%; p = 0.04), a significantly larger majority of the pulmonology group held these beliefs. Conclusions: Pulmonology respondents had more knowledge of guidelines and more favorable opinions of LC screening than family/internal medicine respondents. Our findings suggest future studies should focus on educating providers about recommendations and understanding why the family/internal medicine group is less likely to refer patients for LC screening.
Standardizing architecture and governance of radiology clinical checklist development.
Authors: Bedford Colleen , Jain Priyanka , Langer Deanna , Kwan David , Dobranowski Julian
Published: February 2017

193

Background: To improve quality of radiology reporting, Cancer Care Ontario’s (CCO) Cancer Imaging Program established synoptic radiology reporting as a priority area. Program goals are to implement standardized radiology reports across the province, improving communication between referring and interpreting physicians and providing a standardized foundation for staging data collection and population health research. Although there are libraries of structured radiology clinical checklists, development methodologies quality vary. To support ongoing development and provide a framework to assess existing checklists, the program developed and published two white papers. Methods: To ensure checklists are consistent in format, the first white paper provides guidance on ‘architecture’ (high-level elements) of a cancer imaging report. To ensure the content of adopted checklists are based on high-quality evidence, the second white paper focuses on clinical checklist development governance. Both white papers were developed in consultation with multidisciplinary expert panels assembled by CCO and underwent peer review prior to being made available. Results: The architecture white paper outlines the minimum mandatory elements for cancer imaging reports. The elements to be included in these reports are: demographics, relevant clinical information, body of the report, and impression. This paper provides specific guidance for expert panels in the development of new clinical checklists as well as criteria for reviewing existing checklists. The governance white paper provides a clear methodology for a systematic approach to clinical checklist development for synoptic radiology. Included are recommendations on the constitution of the clinical expert panels, the level of evidence needed to support checklist items, external review of the checklist, and periodic checklist maintenance. Conclusions: CCO has developed two white papers that serve as a guide for both CCO and external parties in the creation of high-quality clinical checklists. Improved standardization of the structure and development approach for clinical checklists facilitates both in-house development and adoption of third party checklists.
Measuring adherence to a Choosing Wisely recommendation in a regional oncology clinic.
Authors: Egan Kathryn S. , Lyman Gary H. , Kreizenbeck Karma L. , Fedorenko Catherine R. , Alfiler April , Noble Heather , Kusnir-Wong Tracy , Mohedano Ada , Stewart F. Marc , Greer Benjamin E. , Ramsey Scott David
Published: February 2017

196

Background: Natural language processing (NLP) has the potential to significantly ease the burden of manual abstraction of unstructured electronic text when measuring adherence to national guidelines. We incorporated NLP into standard data processing techniques such as manual abstraction and database queries in order to more efficiently evaluate a regional oncology clinic’s adherence to ASCO’s Choosing Wisely colony stimulating factor (CSF) recommendation using clinical, billing, and cancer registry data. Methods: Database queries on the clinic’s cancer registry yielded the study population of patients with stage II-IV breast, non-small cell lung (NSCL), and colorectal cancer. We manually abstracted chemotherapy regimens from paper prescription records. CSF orders were collected through queries on the clinic’s facility billing data, when available; otherwise through a custom NLP program and manual abstraction of the electronic medical record. The NLP program was designed to identify clinical note text containing CSF information, which was then manually abstracted. Results: Out of 31,725 clinical notes for the eligible population, the NLP program identified 1,487 clinical notes with CSF-related language, effectively reducing the number of notes requiring abstraction by up to 95%. Between 1/1/2012-12/31/2014, adherence to the ASCO CW CSF recommendation at the regional oncology clinic was 89% for a population of 322 patients. Conclusions: NLP significantly reduced the burden of manual abstraction by singling out relevant clinical text for abstractors. Abstraction is often necessary due to the complexity of data collection tasks or the use of paper records. However, NLP is a valuable addition to the suite of data processing techniques traditionally used to measure adherence to national guidelines.
Development of a radiation oncology-specific prospective data registry for clinical research and quality improvement: A clinical workflow-based solution.
Authors: Chen Allen M. , Wang Pin-Chieh , Verittupong Darlene , Shao Weber , McCloskey Susan Ann , Basehart Vincent , Steinberg Michael L. , Kupelian Patrick
Published: February 2017

197

Background: The computerized ‘paperless’ medical recording system has transformed the modern health information system and serves as an idea platform for cancer registry development, particularly in a specialty like radiation oncology, where technological advances generate unprecedented amounts of data. Methods: From May 2011 to May 2015, physicians prospectively inputted data on patients seen during consultation in the Department of Radiation Oncology at UCLA. Using a customized interface established between an in-house registry and a commercially-available, hospital-based electronic medical record system (Epic Systems, Inc. Verona, WI), a parcel was created for data deposition, which was also linked to the Aria Treatment Planning Station (Varian Medical Systems, Inc., Palo Alto, CA). This registry was designed to assimilate into routine physician work-flow and was based on the completion of tabular entries, which were templated by disease sites. The total number of data fields per disease site ranged from 9 to 73 (median, 21). Results: A total of 7,646 patients were logged into the registry. Primary disease sites were prostate (N = 1,247), breast (N = 1157), head/neck (N = 726), central nervous system (N = 638), lung (N = 439), brain metastasis (N = 349), gastrointestinal (N = 238), gynecologic (N = 234), other (N = 2,618). The mean data capture completion rate by physicians was 55% (range, 32 to 65%); however, this rate did not differentiate between true incomplete (data available but not collected), versus data that was either unavailable, not required, or not applicable. A total of 46 independent, investigator-initiated research studies have been undertaken using queries supported by the registry from multiple access points, 8 of which were published in peer-reviewed journals. Conclusions: The development of a radiation oncology-specific registry not only enhanced research efficiency and facilitated quality assurance, but also fostered data reuse and promoted self-education by producing quality information to guide clinical practice. Our next steps include the integration of patient-reported outcomes through radiation oncology-specific surverys, the documentation of cost of delivery of care of specific treatment pathways, and the implementation of data collection processes in the community.
Understanding efficiency of chemotherapy delivery for planned chemotherapy admission at Columbia University Medical Center.
Authors: Accordino Melissa Kate , Wright Jason Dennis , Vasan Sowmya , Neugut Alfred I. , Hu Jim , Hershman Dawn L.
Published: February 2017

206

Background: Delays in administration of planned in-patient chemotherapy can lead to prolonged length of stay (LOS), resulting in increased cost and risk of nosocomial infections and other complications. Methods: We conducted a retrospective analysis of cancer patients admitted to Columbia University Medical Center, a tertiary care center, for planned chemotherapy from January 1, 2014 through December 31, 2014. Eligible patients were identified as cancer patients (via ICD9 codes) who were admitted directly to the inpatient hematology/oncology service with intravenous chemotherapy orders submitted within 24 hours of the admission. Patients were excluded if they received oral, non-formulary, intrathecal, or high dose methotrexate therapy. For each admission, the duration of time from admission to infusion start time was recorded. We evaluated patients who were admitted to the Intensive care unit (ICU) separately. Chart review and provider interviews were conducted on a subset of patients. Results: Over 12 months, 314 unique hospital admissions involving 162 patients were included in the analysis. The median time from admission to chemotherapy infusion start was 15.8 hours (mean 31.5, IQR 3.1-41.0 hours). Of the 314 unique admissions, 299 (95.2%) did not require ICU involvement during their hospitalization. Of these patients, median admission to chemotherapy infusion start time was 15.5 hours (mean 29.9, IQR 2.9-38.9 hours). Chart review and provider interview were conducted for 22 patient admissions. In this subset, median time from admission to chemotherapy start was 13.6 hours. Top reasons for delays were: order modifications for lab abnormalities, lack of chemotherapy consent, and delay in chemotherapy delivery to inpatient units. Conclusions: In cancer patients admitted for planned chemotherapy we found a significant delay between hospital admission and infusion start time. Inefficiencies in this process are likely multifactorial on the patient, provider, and systems level, however our data suggests that they may be modifiable. Interventions devoted to reducing the time may decrease LOS, reduce cost, improve patient satisfaction, and reduce risk of complications.
Improving care quality for patients with soft tissue and bone sarcoma by establishing a national virtual tumor board and electronic consultation platform.
Authors: Pan Minggui , Fang Andrew , Kavanagh Maihgan , Kim Brian , Lee Jason D , McCormick Craig , Morse Lee Jae , Nag Subir , Nybbaken Grant , Peng Peter , Schwartz Corey M. , Song Joseph , Taggart Denah Renee , Yu Jeanette Cu
Published: February 2017

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Background: Bone and soft tissue sarcomas are relatively uncommon and their management is extremely complex requiring coordinated multidisciplinary expertise for optimal care. Because Kaiser Permanente operates across many geographic regions in the country, in-person tumor board is not practical. Methods: The Kaiser Permanente Northern California medical oncology team has developed a system-based virtual tumor board (VTB) and electronic consultation (EC) platform comprised of experts from several key disciplines including musculoskeletal/surgical oncology, musculoskeletal radiology, pathology, radiation oncology, brachytherapy, medical adult and pediatric oncology. The VTB and EC cases are physician referral-based. The VTB occurs once every two weeks via video conferencing reviewing imaging studies and pathology while EC is available for more urgent cases whenever requested. This platform is available to Kaiser Permanente physicians in Northern and Southern California and other states including Hawaii, Mid-Atlantic, Northwest, Colorado, and Georgia. We conducted a survey targeting referring physicians to assess the value of this service platform in improving sarcoma care. Results: From March 2013 to October 2015, approximately 500 cases have been referred to the VTB and EC. Approximately 2/3 of the cases were referred to the VTB and 1/3 to the EC. The cases include a vast spectrum of bone and soft tissue sarcoma cases that were either newly diagnosed or at the time of relapse or progression. The physician survey on the quality and utilization of this sarcoma platform provided very positive feedback, with 100% responses stating that VTB and EC improved patient care and their confidence in managing patients with sarcoma, 90% stating VTB and EC changed their management to a certain extent. Approximately 90% responders rated VTB and EC very to extremely helpful. Conclusions: We conclude that a system-based VTB and EC can provide an excellent platform for improving quality of care and physician confidence in managing patients with bone and soft tissue sarcoma in an integrated healthcare system.
Implementation of a new patient health questionnaire into standard practice in outpatient cancer clinics to improve patient care and quality of treatment.
Authors: Estey Kathryn , Brown Catherine , Perez-Cosio Andrea , Gill Gursharan , Liang Mindy , Liu Geoffrey
Published: February 2017

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Background: Patient socio-demographic, lifestyle, and risk factor information at the Princess Margaret Cancer Centre (PM) is routinely collected for clinical purposes. The only standardized patient information presently being gathered in the outpatient cancer clinics at the PM is symptom management data, which is linked directly into the electronic medical records. Collecting and recording additional data can improve the quality of patient care, help identify risk factors, and guide treatment options. Our aim was to determine the feasibility of collecting this additional information in a clinical setting. Methods: This pilot cohort study was implemented in the thoracic outpatient oncology clinic at the PM. It involved developing a questionnaire utilizing literature sources, expert review, and pilot testing. Adult cancer patients completed the questionnaire and a complementary acceptability survey during their first clinic visit. Results: 170 patients with thoracic tumours, primarily lung cancer, took part in the feasibility study. Of these, 51% were female, 67% were Caucasian, and the median age was 65 (range 32 to 88) years old. The acceptability survey demonstrated that: 76% of respondents found that the questionnaire did not make their clinic visit more difficult, 68% found that it asked the right questions, 79% thought the questionnaire contained pertinent information for their doctor and other healthcare providers to know, and 51% found that it was time consuming to complete. Conclusions: This study determined that it is feasible to implement a standardized questionnaire that gathers patient socio-demographic, lifestyle, and risk factor information in routine clinical cancer care. Since half of the study population found the questionnaire time consuming to complete it should be administered prior to patient visits, in an electronic format, and with greater explanation/education. The next phase is converting the questionnaire into an electronic version, which aligns with the preferences of study participants and will allow the information to be more easily accessible by clinicians/researchers.