bluuebunny/crossref_metadata_2025 huggingface dataset:
Pathways Between Combat Stress and Physical Health Among Portuguese War Veterans
Authors: Ferrajão Paulo Correia
Published: April 2017

In this study, I explored the experience of both physical and psychological chronic illnesses among a sample of Portuguese war veterans. Twenty suffered from chronic posttraumatic stress disorder (PTSD; unrecovered) and 20 had remission from PTSD (recovered), and all participants suffered from a chronic physician-diagnosed medical disorder. Two semistructured interviews were conducted. Analysis of the interviews was conducted using the Thematic and Categorical Analysis. Unrecovered participants reported higher moral injury, discrepancy between pre- and postwar identity, medication side effects, and lower repertoire of coping strategies, and verbalized that treatment care plan triggers posttraumatic symptoms. Recovered participants reported stronger moral repair, sense of continuity between pre- and postwar identity, and wider repertoire of coping strategies, well-being. Veterans’ adjustment to chronic physician-diagnosed medical disorders is related to the accommodation of war traumatic experiences within existing self-schemas to restore a sense of continuity between veterans’ pre- and postwar identity.
Domestic Violence Counseling in Rural Northern China: Gender, Social Harmony, and Human Rights
Authors: Xie Lijia , Eyre Stephen L. , Barker Judith
Published: April 2017

Domestic violence (DV) affects over a third of Chinese women in a relationship. Focusing on ethnographic data from six staff members and six DV survivors at a rural, state-affiliated women’s center in China in 2010, this article relies on Henrietta Moore’s notion of the poststructuralist gendered subject to examine how the staff draw on discourses about gender and social harmony in persuading women to stay in their marriages, rather than on human rights discourses that emphasize survivor safety. It shows that DV survivors are frequently sent back to dangerous homes where their health is placed at risk.
The Influence of Legislative Reappointment on State Supreme Court Decision-Making
Authors: Gray Thomas
Published: April 2017

Most state supreme court justices have time-bound terms that require them to be reappointed or reelected after a certain amount of time. In three American states, South Carolina, Vermont, and Virginia, the legislature has the sole power to retain justices. Legislatures, and their specialized judiciary committees, are well positioned to monitor judicial behavior and can reject retention for justices who are unacceptable. This turns the legislature's oversight authority into influence over policy making by justices who still need to be reappointed to additional terms. But some justices (co-partisans) are insulated from this influence by their connections to the majority party, which substantially increases the likelihood of their retention. I show that, between 1995 and 2014, justices appointed by the minority party who were eligible for a new term voted more in line with the preferences of their legislature than those who were no longer eligible for a new term due to mandatory or voluntary retirement. No similar effect is found among appointees of the majority party. To support my argument that it is the legislature's reappointment authority that gives them this power, I conduct a placebo test to show that governors in these states enjoy no comparable influence on reappointment-seeking justices. This legislative influence represents a substantial limitation on judicial independence.
Cardiovascular Risk Reduction is Important for Improving Patient and Graft Survival After Ligation and Bypass Surgery for Popliteal Artery Aneurysm
Authors: Dattani N. , Ali M. , Aber A. , Kannan R. Yap , Choke E. C. , Bown M. J. , Sayers R. D. , Davies R. S.
Published: April 2017

Objectives:

To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival.

Materials and Methods:

A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively.

Results:

Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively.

Conclusion:

This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.
Joint variable stiffness of musculoskeletal leg mechanism for quadruped robot
Authors: Lei Jingtao , Zhu Jianmin , Xie Ping , Tokhi MO
Published: April 2017

When the quadruped robot is in locomotion such as jumping and running with higher speed, there is non-continuous contact force between the foot and the environment inevitably. In order to achieve the flexible force interaction of the bionic legs with the environment, it is necessary to analyze the joint angular stiffness of the bionic leg. In this article, based on the designing principles of the bionics, light-weighted, and flexible, a kind of musculoskeletal bionic leg mechanism driven by pneumatic artificial muscles is presented by inspiring from the biological cheetah anatomy and physiology muscle distribution. The kinematics of the bionic leg is analyzed to obtain the Jacobian matrix. In order to achieve high-speed jumping and soft landing of the bionic leg, a kind of foot stiffness model is presented by analyzing the foot elastic potential energy caused by the contact force. The mapping relationship between the joint stiffness matrix and the foot stiffness matrix is obtained by the Jacobian matrix. Then, the dynamics of the bionic leg is analyzed to determine the relationship between the joint angular stiffness and the pneumatic artificial muscle gas pressure. Finally, the experiment on controlling the pneumatic artificial muscles gas pressure for tracking the joint angular stiffness of the bionic leg is conducted. By regulating the pneumatic artificial muscle gas pressure, the needed pneumatic artificial muscle gas pressure that could meet the desired foot stiffness ellipse model can be determined. The study will pay a theoretical foundation for controlling the pneumatic artificial muscles to achieve the high-speed locomotion of the bionic leg.
Modified wavelets–based algorithm for nonlinear delay differential equations of fractional order
Authors: Asad Iqbal Muhammad , Shakeel Muhammad , Mohyud-Din Syed Tauseef , Rafiq Muhammad
Published: April 2017

Most of the physical phenomena located around us are nonlinear in nature and their solutions are of great significance for scientists and engineers. In order to have a better representation of these physical phenomena, fractional calculus is developed. Some of these nonlinear physical models can be represented in the form of delay differential equations of fractional order. In this article, a new method named Gegenbauer Wavelets Steps Method is proposed using Gegenbauer polynomials and method of steps for solving nonlinear fractional delay differential equations. Method of steps is used to convert the fractional nonlinear fractional delay differential equation into a fractional nonlinear differential equation and then Gegenbauer wavelet method is applied at each iteration of fractional differential equation to find the solution. To check the accuracy and efficiency of the proposed method, the proposed method is implemented on different nonlinear fractional delay differential equations including singular-type problems also.
‘Don’t Even Think About Bringing That to School’: New Brunswick students’ understandings of ethnic diversity
Authors: Hamm Lyle , Peck Carla L , Sears Alan
Published: April 2017

Canada is a country with a long history of substantial ethnocultural diversity. Questions about the reasonable accommodation of immigrant groups, the preservation of official language minority rights, and the fostering of Aboriginal rights permeate political and social discourse in Canada. Effective citizenship requires people who understand the subtle differences between and among groups in Canada, and are able to wrestle intelligently and respectfully with difficult questions inherent in these issues. This article reports on a study designed to map the conceptions of ethnic diversity held by grade 6 students in the eastern Canadian province of New Brunswick with a particular focus on the three areas outlined above. Overall, students demonstrated quite superficial understandings of ethnic diversity being able to identify some practices and beliefs as ‘cultural’, but with little knowledge of specific cultural groups or practices or the role of language as a vehicle for cultural enhancement and preservation.
Theoretical and practical investigation into the use of a bio-inspired “click” mechanism for the flight motor of a micro air vehicle
Authors: Tang Bin , Meng Xia , Zhang Fuliang , Brennan Michael J , Lau Gih-Keong , Wang Zheng , Feng Liyan
Published: April 2017

Recently, flapping wing micro air vehicles have received great attention with the drive to make smaller and smaller devices. This paper describes a theoretical investigation and subsequent practical implementation of a specific type of flight motor structure for this type of micro air vehicle that uses a “click” mechanism to improve mechanical efficiency. Diptera, which may use the mechanism, are the inspiration for this work. It builds on previous research into the “click” mechanism, which has been studied both from the biological and engineering points of view. It is difficult to capture the important fine details using a simple analytical model; hence, a multi-body dynamic software is used to model the device and to aid the design of a large-scale prototype. Force–deflection curves of the structure and the displacement response are obtained numerically and experimentally. The experimental and numerical results compare reasonably well, enabling the model to be used for further development and potential miniaturization of the flight motor structure. In a practical device, asymmetry occurs in the up- and down-stroke. The effects of this asymmetry are compared with previous results from analytical models. It is found that asymmetry offers a marginal improvement.
The effect of humeral polyethylene insert constraint on reverse shoulder arthroplasty biomechanics
Authors: Abdulla Irfan , Langohr Daniel G , Giles Joshua W. , Johnson James A. , Athwal George S.
Published: April 2017

Background

There is little information on the effects of altering reverse shoulder arthroplasty (RSA) polyethylene constraint on joint load, load angle and deltoid force. The present biomechanical study aimed to investigate the effects of changing RSA polyethylene constraint on joint load, load angle, deltoid force and range of motion.

Methods

A custom RSA implant capable of measuring forces across the joint with varying polyethylene constraint was tested in six cadaveric shoulders. Standard-, low- and high-constraint (retentive) polyethylene liners were tested, and joint kinematics, loads and muscle forces were recorded.

Results

When polyethylene constraint was altered, joint load and load angle during active abduction were not affected significantly ( p > 0.19). Additionally, the force required by the deltoid for active abduction was not affected significantly by cup constraint ( p = 0.144). Interestingly, active abduction range of motion was also not affected significantly by changes in cup constraint ( p > 0.45).

Conclusions

Altering polyethylene cup constraint in RSA to enhance stability does not significantly alter resultant joint loads and deltoid forces. Surprisingly, terminal abduction range of motion was also not significantly different with varying cup constraint, indicating that terminal impingement may be tuberosity related rather than polyethylene.
New sacrificial cladding system for the reduction of blast damage in reinforced concrete structures
Authors: Codina Ramón , Ambrosini Daniel , de Borbón Fernanda
Published: April 2017

Over the past few decades, explosive devices have become the weapon of choice for many terrorist attacks. In some of these attacks, large amounts of explosives are detonated within a short distance of building structures. It has been shown that current design methods are inadequate for the prevention of progressive collapse. The protection of key elements, such as columns, is necessary to prevent this catastrophic response sufficiently. This article discusses the performance of a new sacrificial cladding that protects reinforced concrete members under blast loading. It consists of reinforced resin panels with an insulation layer. For comparison purposes, two reinforced concrete members were previously experimentally studied, a reinforced concrete column without protection and reinforced concrete column with classical steel jacketing. It can be observed from the experimental results that the new sacrificial cladding achieves an important reduction in damage and displacements.
The publicness of an urban space for cultural consumption: The case of Pingjiang Road in Suzhou
Authors: Yu Hongmei
Published: April 2017

The advent of globalization and digital media compels us to reexamine the blurring and fluidity of the boundaries between public and private spaces. The construction of urban spaces for consumption is, arguably, compressing city’s public spaces. But various space-use activities, some of which are aided by digital media, may have the potentials in cultivating the public capacity of such consumption spaces. Through this lens, this article takes the historic street of Pingjiang Road in Suzhou, China, as a case to explore how in the age of digital media and globalization, such urban spaces revived for historic and cultural consumption may exhibit potential capacity for publicity or the publicness of an urban space. Through this case study, this article aims to show the tensions as well as potentials for publicity arising from the boundary fluidity in similar urban spaces.
Systemic therapy in the curative treatment of head and neck squamous cell cancer: A systematic review
Authors: Winquist Eric , Agbassi Chika , Meyers Brandon M. , Yoo John , Chan Kelvin K. W. ,   the Head and Neck Disease Site Group
Published: April 2017

Objective

To review the available evidence and make recommendations regarding use of systemically administered drugs in combination or in sequence with radiation (RT) and/or surgery for cure and/or organ preservation in patients with locally advanced nonmetastatic (Stage III to IVB) squamous cell carcinoma of the head and neck (LASCCHN).

Method

Recognizing the Meta-analysis of Chemotherapy in Head and Neck Cancer (MACH-NC) group reports have de facto guided practice since 2000, we searched for systematic reviews in the MEDLINE, EMBASE and Cochrane Database of Systematic Reviews published from January 2000 to February 2015 in reference to 4 research questions. A search was also conducted for randomized trials (RCTs) up to February 2015 not included in the meta-analyses.

Result

The MACH-NC reports, 5 additional meta-analyses, and 30 RCTs not included by MACH-NC were identified. For chemotherapy, MACH-NC findings showing improved overall survival with concomitant chemoRT did not require modification. High-dose cisplatin was most commonly studied. We confirmed this benefit with cisplatin monotherapy in patients treated with with postoperative concurrent chemoRT. Other than cetuximab, no targeted agents and radiosensitizers studied in RCTs were shown effective. TPF induction chemotherapy was superior to PF for tumor response and larynx preservation but not survival. Larynx preservation was reported with both CRT and induction chemotherapy approaches.

Conclusion

ChemoRT with cisplatin at least 40 mg/m2 per week given as radical or postoperative adjuvant remains a standard treatment approach for LASCCHN that improves overall survival but increases toxicity. 5-FU plus platinum is supported by less data but may be a reasonable alternative for patients unsuitable for cisplatin. Of note, stratification of outcomes by HPV-status was not available but outcomes for oropharynx cancer appeared similar to other subsites in chemoRT RCTs. No RCTs have yet demonstrated superiority or non-inferiority of cetuximab-RT to CRT. In view of this, cetuximab-RT is suggested only for patients not candidates for CRT. Taxane-based triplet induction chemotherapy is superior to doublets for rapid tumour downsizing and for larynx preservation, but does not improve overall survival and should be used with primary G-CSF prophylaxis. Further investigation of induction approaches for larynx preservation may be warranted.
Upper Paleocene ultramafic igneous rocks offshore mid-Norway: Reinterpretation of the Vestbrona Formation as a sill complex
Authors: Hafeez Amer , Planke Sverre , Jerram Dougal A. , Millett John M. , Maharjan Dwarika , Prestvik Tore
Published: April 2017

Continental breakup between northwest Europe and Greenland (approximately 56 Ma) was associated with widespread magmatism. Silica undersaturated alkaline porphyritic igneous rocks of a similar age have previously been dredged near the mid-Norwegian coast. These igneous rocks of the Vestbrona Formation have previously been interpreted as either igneous plugs or volcanic flows. New 3D seismic data indicate that relatively small sill complexes are abundant in the same region. In total, 36 sills with a size of [Formula: see text] have been mapped. In addition, 10 seismic horizons were interpreted and tied to nearby wells to obtain a robust stratigraphic framework. The sills mainly intrude Cretaceous and Paleocene sequences; however, one sill is also identified in the pre-Cretaceous sequences. The sills locally form erosional remnants on the seabed due to massive uplifting and erosion of the continental margin. Vintage igneous and sedimentary dredge samples have been reanalyzed, including petrography, geochemistry (X-ray fluorescence [XRF], X-ray diffraction [XRD]), biostratigraphy, and Ar-Ar geochronology. The new Ar-Ar data suggest that the sills are 1–2 Ma older than breakup (approximately 57–58 Ma). Furthermore, the biostratigraphy and petrography of two sediment samples suggest that the samples were collected from near in situ subcrops and not of an ice rafted origin. The sediment samples are of Danian age and are strongly metamorphosed, most likely by contact metamorphism resulting from heating during sill emplacement. The newly identified sills have implications for the petroleum prospectivity of the study area including source rock maturation within thermal aureoles and the long-term alteration of fluid migration pathways.
Maternal Cancer During Pregnancy and Risks of Stillbirth and Infant Mortality
Authors: Lu Donghao , Ludvigsson Jonas F. , Smedby Karin E. , Fall Katja , Valdimarsdóttir Unnur , Cnattingius Sven , Fang Fang
Published: April 2017

Purpose

To examine whether maternal cancer during pregnancy is associated with increased risks of stillbirth and infant mortality.

Methods

On the basis of nationwide health registers, we conducted a study of 3,947,215 singleton births in Sweden from 1973 through 2012. Exposure was defined as maternal cancer diagnosed during pregnancy (number of births = 984) or during the year after pregnancy (number of births = 2,723). We calculated incidence rate ratios (IRRs) for stillbirth and infant mortality, comparing exposed births to unexposed births. Small-for-gestational-age (SGA) and preterm births were examined as secondary outcomes.

Results

Maternal cancer diagnosed during pregnancy was positively associated with stillbirth (IRR, 2.5; 95% CI, 1.2 to 5.0), mainly stillbirths assessed as SGA (IRR, 4.9; 95% CI, 2.2 to 11.0), and with preterm SGA births (relative risk 3.0; 95% CI, 2.1 to 4.4). Positive associations of maternal cancer diagnosed during pregnancy or the year after pregnancy were noted for both neonatal mortality (deaths within 0 to 27 days; IRR, 2.7; 95% CI, 1.3 to 5.6 and IRR, 2.0; 95% CI, 1.2 to 3.2, respectively) and preterm birth (IRR, 5.8; 95% CI, 5.3 to 6.5 and IRR, 1.6; 95% CI, 1.4 to 1.8, respectively). The positive association with preterm birth was due to iatrogenic instead of spontaneous preterm birth. Preterm birth explained 89% of the association of maternal cancer during pregnancy with neonatal mortality.

Conclusion

Maternal cancer during pregnancy is associated with increased risks of rare but fatal outcomes, including stillbirth and neonatal mortality. This may be due to conditions associated with fetal growth restriction and iatrogenic preterm birth. Careful monitoring of fetal growth and cautious decision making on preterm delivery should therefore be reinforced.
Risk of Second Cancer in Hodgkin Lymphoma Survivors and Influence of Family History
Authors: Sud Amit , Thomsen Hauke , Sundquist Kristina , Houlston Richard S. , Hemminki Kari
Published: April 2017

Purpose

Although advances in Hodgkin lymphoma (HL) treatment have led to improved disease-free survival, this has been accompanied by an increased risk of second cancers. We sought to quantify the second cancer risks and to investigate the impact of family history.

Patients and Methods

Using the Swedish Family-Cancer Project Database, we identified 9,522 individuals with primary HL diagnosed between 1965 and 2012. We calculated standardized incidence ratios and cumulative incidence of second cancer in HL survivors and compared the standardized incidence ratios of lung, breast, colorectal, and all second cancers in HL survivors with and without a site-specific family history of cancer. Interactions between family history of cancer and HL treatment were evaluated under additive and multiplicative models.

Results

Overall, the risk of a second cancer in HL survivors was increased 2.39-fold (95% CI, 2.29 to 2.53). The 30-year cumulative incidence of breast cancer in women diagnosed with HL at younger than 35 years of age was 13.8%. We observed no significant difference in cancer risk over successive time periods. The risk of all second cancers was 1.3-fold higher for HL survivors with a first-degree relative with cancer ( P < .001), with 3.3-fold, 2.1-fold, and 1.8-fold differences shown for lung, colorectal, and breast cancers, respectively. Moreover, a greater than additive interaction between family history of lung cancer and HL treatment was shown ( P = .03).

Conclusion

HL survivorship is associated with a substantive risk of a second cancer. Notably, the risk is higher in individuals with a family history of cancer. This information should be used to inform risk-adapted therapy and to assist in screening to reduce long-term morbidity and mortality in patients with HL.
Preparing for bundled payments in urology: Defining episodes, evaluating variations in care, and demonstrating improved value.
Authors: Skinner Eila C. , Tang Ning , Stevenson Kerri , Guo David , Hu Jui-Shan , Hendershott Joan , Krishna Purnima
Published: April 2017

11

Background: As payors introduce APMs, there is little guidance on how episodes will be defined in subspecialty areas. We set out to define clinically relevant episodes of care, develop standardized approachs toward reducing variations in care, and implement evidence-based standardized care pathways. We chose two urologic cancer procedures- Radical Cystectomy and Robotic Radical Prostatectomy. Methods: Episode timeframes were defined: Radical Cystectomy (14 days prior, index hospitalization, 90 days post) and RALP (30 days prior, index hospitalization, 30 days post). To identify variations in care, we compared evidence-based guidelines with practice patterns, analyzed episode and index hospitalization direct costs for various surgeons, and reviewed the utilization of high cost supplies and drugs. Length of stay (LOS), readmissions, complications, and acuity were benchmarked against comparable academic medical centers. Faculty, trainees, APPs, and staff collaborated to develop care pathways, modify workflows and EPIC order sets to reduce variation, improve outcomes, and increase efficiency. Results: Variation in care was reflected in wide standard deviations in episode direct costs. Six months after implementing care pathways, we achieved the following: RALP average cost per episode decreased by 15%. Standard deviation in episode direct costs decreased by 77%. The percentage of patients with 1-day LOS increased from 21% to 67%. The medical surgical supply costs during hospitalization decreased by 22.5%. Standard deviation in episode direct costs for Radical Cystectomy decreased by 27%. Readmissions to SHC decreased from 15.6% to 12.5%. The percentage of patients with less than 6-day LOS increased from 46% to 66%. Conclusions: Across two episodes, our care redesign efforts had actualized direct cost savings of $692,000 annually. As we prepare for future APMs, similar multidisciplinary approaches can be applied to other areas to reduce costs and improve quality of care.
A quality improvement initiative to reduce low-value red blood cell transfusions in hospitalized oncology patients.
Authors: Wong Tiffany , Dubin Perry Harris , Davenport Michael , Bass Geoffrey D , Myers Jennifer , Wagner Jason
Published: April 2017

116

Background: Red blood cell (RBC) transfusions are costly, a limited resource, and pose serious medical risk. While most disciplines now transfuse sparingly, hospitalized oncology patients at our institution are often transfused liberally. We conducted a QI initiative to reduce practice variation by adopting a standardized restrictive transfusion strategy. Methods: We performed a retrospective analysis of the total number of pre-transfusion hemoglobin-adjusted RBC transfusions from 02/2015 to 08/2015. Patients with severe gastrointestinal bleeding and acute coronary syndrome were excluded. Extensive feedback from providers was solicited and a comprehensive review of the evidence was performed to understand the process driving existing practices. This information and a root cause analysis were presented to key members of Oncology leadership to gain consensus on a RBC transfusion algorithm. The final algorithm recommended transfusing to a Hg goal of 8 g/dL if the platelet count was ≤ 50K; otherwise the Hg goal was 7 g/dL. We defined low-value RBC transfusions as a transfusion occurring outside the parameters of this algorithm. A multifaceted educational campaign comprising in-person meetings and web-based postings was launched to target ward nurses, advanced practitioners, residents, and attending physicians. RBC transfusions were then tracked to monitor adherence to the algorithm. Results: Analysis of the current process using QI methods found that RBC transfusion practices are most influenced by uncertainty of best practice and variation in attending preference. After the implementation of a RBC transfusion algorithm, the overall number of low-value RBC transfusions decreased from 29.6% to 19.7% (p < 0.001). This reduction was most marked in patients with platelet counts > 50K where there was a reduction from 78.7% to 55.6% (p < 0.001). A 9.9% overall reduction corresponds to roughly 520 fewer RBC transfusions per year, which suggests an annual estimated cost savings of $520,000. Conclusions: By using a standardized QI framework, we were able to successfully decrease variation in practice that results in low-value RBC transfusions in hospitalized oncology patients.
Quality, clinician and information technology (IT) partnership for metric reporting.
Authors: Segura Smith Andrea , Porter Julie , Badwe Amogh , Kiamanesh Eileen F , Blayney Douglas W.
Published: April 2017

128

Background: Reporting of physician defined quality metrics, using manual data abstraction, is labor intensive and not always timely. We developed a multidisciplinary team to develop a metric reporting system. Methods: The Senior Quality Consultant (SQC) partnered with the Research Data Analyst using data extracted from the electronic data warehouse, Bone Marrow Transplant Registry, Cancer Registry, Aria (Varian, Palo Alto) and Epic (Verona, WI) and the Social Security Death index. The Plan, Do, Check Act model was used to guide the team. Results: Fourteen metrics were developed in a seven-month period. Sample of metrics: Blood Marrow Transplant patient referral to Survivorship by Day 100; Genetic counseling referral for ovarian cancer; Cytogenetic testing of acute leukemia, myeloma; Chemotherapy in the last two weeks of life; Hospice enrollment at death; > 10 radiation fractions for bone metastases palliation. Conclusions: The PDCA model created a shared framework for metric development. Standard definitions were developed and applied to promote consistent design. 72% (10/14) of the metrics are on a reporting system for automated data extraction and reporting. The limitation of the project is negative results are reviewed manually by the SQC because not all data elements are discrete and may require review of items (ex. progress notes or media). [Table: see text]
Cancer patients' answers to surveys: Incorporation into the electronic health record (EHR) can decrease manual data entry and increase patient-centered information.
Authors: French Katy E. , Feeley Thomas W. , Andrabi Tayab A. , Guzman Alexis B. , Calhoun John D.
Published: April 2017

130

Background: Delivery of value-based cancer care has centered on the use of EHR’s and how these applications can document health information, including patient reported outcomes (PRO’s), (1-4). Survey information must be incorporated into the medical record with minimal staff intervention. Our institution, and many cancer centers are currently using “EPIC” as their EHR platform. Although this is a data driven platform, and data can be extracted and reported as desired, certain things need to be done prior to going live in order to ensure this occurs. Surveys must be built using standardized “smart data elements” (SDE’s). If patient data is gathered, but not integrated correctly into the EHR, one will find themselves manually entering data. The goal is to allow patients to answer questions about their health history 1 time, validate answers, incorporate into the EHR, and report data. Methods: We engaged our technology team prior to “go-live” to build patient survey questionnaires. 40 survey questions, were mapped to 72 specific EHR/“EPIC” SDE’s. The SDE’s included cancer diagnoses and past medical history. Patients received and completed the electronic survey via the patient portal. Clinic providers validated patient answers from the surveys and the information was incorporated into the EHR. Results: Patient entered survey data collected, documented, and reported within the EHR. Decreased data entry by providers, efficiently incorporating the patient cancer diagnosis and medical history into the EHR. Data collected for review/reporting/research as needed. Conclusions: EHR’s can gather specific/discrete patient data to benefit both patients and providers. Cancer patients can participate in providing health information easily incorporated and documented by the provider. Data can be updated as needed, and used for patient reported outcomes (PRO’s) and other research endeavors. EHR’s should enhance care by allowing providers to spend more face to face time with patients and providing data that is most important to patients from which they may make informed decisions about their health care.
Monitoring inbaskets with feedback to providers enhances the timeliness of patient care.
Authors: Adelson Kerin B. , Trant Amelia Anne , Strait Michael , Kaplan Rory , Dest Vanna , Roshka Adam , Lyons Catherine A. , Vest Kevin A. , Steffen Tessa , Lilenbaum Rogerio
Published: April 2017

132

Background: The adoption of Electronic Health Records (EHRs) has changed the workflow for providers. The “inBasket” feature supplants telephone and email communications, replaces paper results review and has become the way to track incomplete encounters. Failure to promptly complete medical records leads to unread notes and impairs multidisciplinary communication. Also, unclosed encounters lead to potential penalties and uncollected fees. One benefit of the inBasket, is that it can be monitored. Methods: We created a report that tracked EPIC inBasket activities by provider including numbers of open charts, unchecked results, phone calls, incomplete dictations and orders needing cosign. The report shows the number and length of time each activity has been delinquent. In December 2015 we began emailing automated reports to all providers with their monthly results. In January 2016 we began an enforcement process for providers with >50 open charts: 30 days to complete charts or practice would be closed to new patients; if >50 remained after 30 days providers had 60 days before complete suspension from practice. We modeled the financial impact of chart closure by creating a weighted average by payor of fees collected per visit. For charts that would have been delinquent beyond payor filing deadlines this represents actual increased revenue. For charts that would have eventually been closed before the filing deadline this represents earlier revenue capture. Results: See table. Conclusions: Inbasket monitoring with structured feedback to providers led to improvement in the number of open charts, the focus of corrective action. We did not see consistent improvements in the other inbasket metrics. Future work will involve a similar approach to all inBasket metrics. Closing charts also has a significant financial impact; we estimate that $483,049 in fees that could have been lost due to exceeding payor deadlines became collectable. [Table: see text]
Developing and piloting an electronic telephone triage application.
Authors: Ellis Peter G. , Rushford Justin S. , Krebs Melinda , Carlisle Christine , Ford Colleen F. , Nikolajski Peggy , Reidmiller Carol , Stewart Leslie , Barry Amanda
Published: April 2017

137

Background: With the shift of cancer care to the outpatient setting, telephone triage is a vital part of today’s oncology practice. UPMC CancerCenter (UPMC) desires to streamline the current telephone triage process across its 31 outpatient clinics. UPMC and Via Oncology collaborated to develop and pilot a prototype of an electronic telephone triage application. The key components of the prototype were defined as decision support, EHR integration, reporting, and workflow management. Methods: A prototype application, Symptom Manager (SM), was developed and piloted with 4 nurses at 3 outpatient clinics. Front office staff registered inbound calls in SM, which populated a phone triage queue. The nurse was prompted to enter information about the call. Decision support materials were displayed for reference, including algorithms for symptom assessment, adjudication, and treatment. The output was a structured summary of the encounter that was copied to the patient’s chart. From the queue, the nurse was also prompted to make outbound calls for symptom reassessment. A feedback session with the nurse users and institution leadership was held following the pilot. Results: A total of 235 inbound calls were captured in the application, of which 74 (31.5%) were symptom-related. Additional data fields collected during the pilot included symptom, adjudication, time elapsed for callback, and symptom status at follow up. The ability to extract and report on data of this type was viewed as valuable for quality and process improvement. The nurse users praised SM’s ease of use, but prototype performance issues shortened the pilot. They indicated that the standardized documentation increased efficiency. Requests for future enhancements included deeper EHR integration and additional fields for data capture. Conclusions: This pilot provided the feedback necessary to develop the latest version of SM which begins roll out across UPMC in November 2016 and includes EMR integration. An update on the software and additional data captured during the pilot will be provided at presentation.
Creating a multi-payer provider database for cancer outcomes research.
Authors: Meyer Anne-Marie , Barkhurst David , Meyer Adrian , Shai Saray , Trogdon Justin G , Mucha Peter
Published: April 2017

138

Background: Cancer care is multi-disciplinary in nature and relationships between healthcare providers may potentially influence outcomes. Yet understanding how patient care or outcomes are affected by these relationships has been hindered by the paucity of temporal and multi-relational data on physicians. We demonstrate a method for uniquely identifying and linking providers across multiple databases longitudinally. Methods: We identified unique, individual healthcare providers in Medicare, Medicaid, and private payer data in North Carolina (NC) from 2003-2014. In order to link the providers between the different identifiers (e.g., NPI, UPIN, etc.), five provider data sets were obtained. These databases included the National Plan and Provider Enumeration System (NPPES), the Medicare Physician Identification and Eligibility Records (MPIER), the NC State Medicaid provider file, private payer provider files and the NC medical license file. Identification and linking was performed using a novel approach leveraging relational database tools in Oracle and then verified via a second approach applying network analysis in Python. Sub-set validation was performed using claims from cancer cohorts in NC with continuous enrollment in multiple payers. Results: There was significant variation in data quality as well as temporal and geographic overlap between datasets. Linking across all data resulted in a Cartesian product of over 50 billion combinations. This was overcome by aligning provider identifiers under unique combinations of matching variables (given name, last name, zip code and specialty). From all five datasets, approximately 158,000 unique physicians were identified. In subset validation, the NPI and UPIN matches agreed 99-100% with the 2008 Medicare professional claims in a cohort of NC cancer patients. The NPI and private provider ID matches agreed between 73-79% of the time for those cancer patients with claims aligned in both payers. However, only about 30% of the Medicaid provider IDs were individually attributable and matched. Conclusions: Providers can be uniquely identified and matched across disparate databases enabling us to measure and contrast provider networks and their variation across payers and systems.
Development of an oncology-specific instrument to measure care coordination.
Authors: Holcombe Randall F. , Cortese Marisa , Zinghini Isabelle , Mahida Rupali , Draluk Dinah , Ru Meng , Winkel Gary
Published: April 2017

148

Background: Care coordination (CC) has been identified by the IOM as critically important for the delivery of quality medical care. Coordination of care is especially important in oncology due to multiple encounters, many physicians, significant toxicities and several care transition points. Standard patient satisfaction surveys do not accurately measure CC and there are few instruments to measure a patient’s perspective of CC directly. In this project, multiple PDSA cycles were utilized with oncology patients to develop a Care Coordination Instrument (CCI) that was then used to compare the level of CC in two distinct practices. Methods: Survey questions were initially prepared by the research team after review of existing literature, submitted to oncology RNs, NPs and MDs and then modified based on their feedback. A new survey was then administered to 30 patients. This was again modified to eliminate or improve questions that were confusing to patients. A third survey instrument was developed and administered to an additional 30 patients. Statistical analysis identified that several questions were too structured leading to many “not applicable” responses. These were changed to a more conceptual framework. The survey was then administered to 30 patients in the myeloma practice and 30 in the GI oncology practice. Results: The CCI included questions from 4 areas of coordination (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care) and 3 domains (Communication, Operational, Navigation). The GI oncology practice scored significantly better than the myeloma practice on the communication and navigation domains (p < 0.01). There was no significant difference in the operational domain. Conclusions: Testing to date suggests that the CCI is a useful instrument in measuring an oncology patient’s perception of CC. For two distinct practices, significant differences in the delivery of CC were identified. Further refinement is necessary to modify or eliminate questions with high levels of missing data due to non-responsiveness. Separate sub-scores across domains help identify specific targets for quality improvement interventions.
What are the health care costs for chronic lymphocytic leukemia?
Authors: Matasar Matthew J. , DaCosta Byfield Stacey , Blauer-Peterson Cori , Montez Melissa , Reyes Carolina , Masaquel Anthony
Published: April 2017

15

Background: New drugs for chronic lymphocytic leukemia (CLL) have recently been approved, including oral therapies. We examined total health care costs, including drug and patient out-of-pocket (OOP) costs, in patients (pts) initiating CLL treatment. Methods: This retrospective studyused a U.S. health insurance claims database. Adult commercially insured and Medicare Advantage pts from 5/2013 - 6/2015, with ≥2 medical claims for CLL were included. Pts required ≥1 claim for NCCN-recommended systemic cancer therapy. Pts were categorized based on first-line of therapy. Aggregate costs during a fixed 9-month follow-up period (treatment switch or discontinuation were possible) were investigated. Mean and standard deviation (SD) of total healthcare costs, regimen costs, and pt OOP regimen costs are presented. Results: A total of 707 CLL pts met all study criteria during the study period; 40% were commercially insured and 60% had Medicare Advantage. Mean age was 70 years (SD 11). Some of the most common regimens received included Bendamustine+Rituximab (BR) (N=186), Ibrutinib (Ibr) (N=101), Fludarabine, Cyclophosphamide, and Rituximab (FCR) (N=62), and Obinutuzumab +/- Chlorambucil (Ob+/-Chl) (N=51). Mean length of therapy varied by regimen; BR 4.2 months (m) (SD 2.7), Ibr 6.7m (SD 4.8), FCR 4.7m (SD 2.1), and Ob±Chl 4.0m (SD 2.1). The table shows aggregate costs among pts with ≥ 9 months follow-up. Ob±Chl had lower costs compared to other cohorts. Ibr had the highest drug costs. Conclusions: While the study has limited follow-up, Ob+/-Cl had the lowest drug and total costs. Oral therapy with Ibr had the highest drug and OOP costs compared to those associated with a prescribed fixed number of cycles. The magnitude of the difference between orals and infusions is expected to be greater with a longer follow-up and is a consideration in patient treatment decision-making in CLL.[Table: see text]
Identifying latent factors in the Living With Cancer (LWC) patient-reported outcomes (PRO) tool for patients with advanced malignancies.
Authors: Paramanathan Dhakshila , Khoury Raya , Bunce Mikele , Patel Sharmi Narendra , Arunajadai Srikesh , DeVincenzo Victoria , Kaur Sukhi , Pe Benito Ruth , Goldberg Stuart L. , Choi Kelly
Published: April 2017

150

Background: End-of-Life Care (EOLC) discussions are frequently delayed past the time of usefulness, resulting in cancer patients (pts) receiving aggressive, expensive, non-desired care. The “Living with Cancer” project has developed a 7-item, 5-level Likert scale PRO tool that evaluates, from the pt perspective, their concerns regarding performance status, pain, family/financial burden, and depression during their cancer journey. The instrument was shown to correlate well with the oncologist’s opinion of appropriateness to continue treatment and might be useful as a quality metric in guiding timing of EOLC discussions (J Palliative Med 2016). Methods: The LWC PRO was administered to 1302 pts with advanced malignancies receiving care by Regional Cancer Care Associates (NJ) between Sept 2015 and Aug 2016, with confirmation of life status in Sept 2016. Exploratory factor analysis was conducted on the LWC instrument to identify latent constructs (factors) contributing to the item scores. The data set was deemed suitable for factor analysis based on standard statistical tests, including Bartlett’s test (p < 0.001). Results: A 3-factor model comprised of factors (1) Global functioning (using 5/7 items), (2) Financial toxicity (1/7 items), and (3) Depression (1/7 items) was fitted to the data using maximum likelihood and promax rotation (p = 0.043). Factor scores were compared between the cohort of 133 pts who expired within 3 months of completing their final survey and the 1124 who remained alive after 3 months. The mean global functioning score was significantly greater (worse) in the expired cohort (p < 0.001), suggesting the PRO description of distress correlated with survival. Financial toxicity and depression factor scores did not correlate with survival. Conclusions: The 7-item LWC PRO instrument contains 5 items defined by a global functioning factor that discriminates based on 3-month overall survival. This finding adds further evidence that the 7-item PRO tool can be used to time EOLC discussions with the aim to ensure better correlation between pts’ treatment desires and delivered care. LWC may also serve as a quality metric evaluating timing of EOLC discussions.