bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing invasive fungal infections in patients with acute myeloid leukemia receiving induction and re-induction chemotherapy at the University of Virginia Health System.
Authors: Naeem Mohammed Athar , Morris Amy , Murray Torey , Thomas Tanya , Degregory Kathlene , Cox-Hall Heather , Lewis Jessica D , Bal Anjali , Daniels Elizabeth , Keng Michael Kenneth
Published: April 2017

120

Background: At the University of Virginia Health System (UVaHS), antifungal prophylaxis was not routinely given to patients undergoing induction and re-induction chemotherapy for acute myeloid leukemia (AML) from 7/2011 to 9/2015. A retrospective chart review of 179 patient encounters identified a 19.7% rate of proven or probable invasive fungal infection (IFI); national averages for IFI are 8-10% in this population. Methods: To target an IFI rate of less than 10%, a multidisciplinary team comprised of oncology and infectious diseases physicians, clinical pharmacists, nurses, and information technology specialists was formed. Through participation in the 2016 ASCO Quality Training Program (QTP), the group developed current and ideal state process maps, a Pareto chart, and a priority matrix to determine an action plan. The group identified the most common problems contributing to IFI: inconsistent definition of IFI, no routine antifungal prophylaxis, and lack of education for the health care team. Results: From 9/2014 to 8/2016, the first PDSA cycle consisted of physicians ordering antifungal prophylaxis on an ad hoc basis, resulting in 11.7% IFI in 77 total patient encounters. During the second PDSA cycle starting in 8/2016, a clinical practice guideline standardized the definition of IFI and appropriate antifungal prophylaxis. Physicians, nurses, and pharmacists were educated on the new standard work. PDSA Cycle #2 is ongoing. As of 11/2016, zero of 8 patient encounters had an IFI. To ensure sustainability of the quality improvement study, monthly electronic medical record reports will capture guideline compliance, specifically the use of antifungal agents, and track future IFI. Future data will be statistically analyzed. Conclusions: Using quality improvement methods learned at ASCO QTP, a multidisciplinary team developed an action plan which to date has shown a clinically significant reduction in IFI; this outcome may lead to decreased hospital length of stay and improved patient quality of life. Further PDSA cycles are scheduled and continuous evaluation of the process is ongoing.
A needs-based curriculum for hematology/oncology mid-level providers.
Authors: Binder Adam , Odea Denise , Malone Adriana Kaczaraj
Published: April 2017

121

Background: Mid-level providers, both nurse practitioners and physician assistants have comprehensive clinical training, however, they do not undergo in depth sub-specialty training prior to working within a sub-specialty practice. In addition, at our institution, often they are not integrated into academic culture resulting in dissatisfaction with educational opportunities. As a result, we set out to develop a needs based curriculum in order to provide focused learning opportunities for our mid-level providers and improve their satisfaction with the educational environment. Methods: An initial survey was sent to all mid-level providers within the division of hematology and oncology at a single institution. The survey evaluated attendance to currently available lecture series, satisfaction with the educational environment, and an assessment on practitioner comfort level in managing 19 clinical conditions commonly seen in oncology patients. All responses were voluntary and anonymous. A lecture series was developed focusing on topics in which providers felt least comfortable. Follow up survey was to be conducted after 6 months and 1 year of the educational lecture series. Results: On average 11 providers attended each lecture. After 6 months of lectures, there was a suggestion that more practitioners were satisfied with educational opportunities at our institution (pre-intervention 0% (N = 15) satisfaction, at 6 months 43.75% (N = 7)). There was no suggested change in comfort level in managing the specific clinical conditions. Mid-level providers, in addition to attending the focused educational lecture series, were more likely to attend other educational lectures within the institution. Conclusions: At interim analysis, our educational intervention seems to have improved mid-level provider satisfaction with educational opportunities provided to them. In addition, there has been an unintended effect of improving their attendance at other lecture series offered, implying that they feel more integrated into the academic community. To date there is no suggestion that the curriculum is improving providers comfort level in managing the pre-defined clinical scenarios.
Harmonization of patient-reported outcomes into EHRs at four cancer hospital outpatient clinics for patient care and quality assessment.
Authors: Chung Arlene , Stover Angela M. , Wagner Lynne I. , LeBlanc Thomas William , Topalaglu Umit , Zafar Yousuf , Zullig Leah L. , Smeltzer Phil , Basch Ethan M.
Published: April 2017

129

Background: Patient-reported outcome (PRO) measures are well established in oncology trials but are not collected systematically during clinical care, to guide symptom management, or to assess quality. A growing body of evidence shows that collecting PROs during cancer care yields better clinical outcomes. Yet, little is known about best practices for PRO integration into electronic health record (EHR) workflows. We report on the first cross-institutional effort for PRO data harmonization across four CTSA-funded institutions (University of North Carolina at Chapel Hill, Wake Forest University, Duke University, Medical University of South Carolina). Methods: Through surveys, systematic stakeholder qualitative focus groups, a landscape analysis, and technical/workflow assessment, our cross-institutional team sought to: 1) determine a set of common PRO measures to be collected via patient portals tethered to EHRs across the 4 sites; 2) develop an implementation strategy for the collection of PROs via patient portal within clinical workflows; and 3) collect a common set of PROs in cancer clinical care. We also sought to develop the methodological steps to harmonize extracted PRO data across each site to each other and then to the PCORnet Common Data Model Common Measures for PROs across each site. Results: Across the four sites, each institution uses Epic Systems (EHR and patient portal) and had available a library of PRO questionnaires which included the PROMIS profile (29 items) and short forms, SF-20, RAND, PHQ-2, and PHQ-9. The study team developed a list of domains and the tools available within each domain for stakeholders to prioritize at each site. The proposed workflows take into consideration the use of these data within the clinical encounter. Pilots at each site to collect PROs are underway along with the methodological work for data extraction and harmonization and will be reported at the meeting. Conclusions: The collection of a common set of PROs across EHRs has important implications for improving individual patient’s symptoms and for enhancing the quality of cancer care. Complex workflows and technical barriers must be considered successful implementation.
Understanding the financial impact of beyond use date in a publicly funded cancer system.
Authors: Redwood Erin , Vu Kathy , Fung Ron , Han Heekyung , Teimoortagh Megan , Meertens Elaine , Forbes Leta , Kukreti Vishal , Santaera Daniella
Published: April 2017

13

Background: According to USP 797 and the National Association of Pharmacy Regulatory Authorities standards, the Beyond Use Date (BUD) based on sterility for single-dose vials is 6 hours, after which the contents must be discarded. In Ontario, centres have traditionally based BUD on stability data, not sterility data. This change presents concern about potential drug waste so an analysis was done to estimate the financial impact to the 76 systemic treatment facilities in Ontario. Methods: Using an administrative database that records the daily total dose of drugs administered by facility, annual drug waste cost was calculated using daily dose administered, cost per milligram, and available vial size(s) for 26 publicly funded drugs. Two different methods were used to determine the amount of drug waste. Method 1 used the largest vial size matched to the closest amount of drug required. Method 2 used the optimal vial size mix, when there are multiple vial sizes, to minimize wastage across all configurations of vial size. Some assumptions made include: 1) each facility had access to all available vial sizes, and 2) single-dose vial contents were true to the stated quantity as per the manufacturer. Results: The 10 facilities with the highest waste estimates are summarized in the table. The total waste estimates for all facilities are $25,927,861 (method 1) and $12,945,353 (method 2). Waste estimates were also calculated by drug, with rituximab, bevacizumab and pemetrexed having the highest waste costs. These drugs are only available in vials with a large range in size (100 and 500 mg), but could waste more than drugs with more size options or less variance between sizes. Conclusions: Assigning a BUD based on 6 hour sterility standards will have significant financial implications to facilities in Ontario. Development of mitigation strategies should be explored to provide guidance to Ontario and other jurisdictions on how to curtail the budget impact.[Table: see text]
Quality of information addressing treatment options for women with breast cancer on NCI cancer center websites.
Authors: Dulaney Caleb , Wakefield Daniel Victor , Rocque Gabrielle Betty , De Los Santos Jennifer F.
Published: April 2017

135

Background: The internet is increasingly utilized by cancer patients for information that may influence treatment decisions. National Cancer Institute (NCI)-designated cancer center websites and nationally recognized cancer research agencies are trusted sources of information, however little data exists regarding the quality of information on these sites. We evaluated the quality and accessibility of breast cancer treatment information on cancer center websites addressing therapeutic options. Methods: Websites of all NCI cancer centers, the NCI, and Susan G. Komen were reviewed. Quality was measured using 33 questions from three validated Breast Cancer Decision Quality Instruments (DQI). Two blinded reviewers determined if websites provided information to answer each question. Number of clicks to reach the breast-specific webpage, evaluation time, and Spanish and mobile accessibility were recorded. Kappa coefficient was used to measure inter-observer variability. Correlation between evaluation time and questions answered was measured using Pearson coefficient. Results: Of the 63 cancer center websites evaluated, 94% had breast cancer webpages reached in a median of 2 clicks. Average evaluation time was 11 minutes. 24% were Spanish accessible. 59% were mobile friendly. No site provided information that addressed all questions. The most informative cancer center site addressed 76% of questions. On average, 21% of questions were addressed per site. 16% of sites did not have sufficient information to answer any question. In comparison, the NCI and Komen sites covered higher proportions of questions than cancer center sites (85 and 88%). Inter-observer variability was fair to moderate (avg. Kappa 0.37). Evaluation time strongly correlated with number of questions answered (r = 0.75). Conclusions: NCI cancer center websites provided informative feedback for breast cancer patients across an average 21% of key knowledge points in a validated DQI. This information is less accessible to Spanish speaking patients and patients using mobile devices. Website improvements represent an opportunity to enhance knowledge that may improve shared decision making for women with breast cancer.
Routine physical function assessment through a Branching Logic Electronic Symptom Survey (BLESS) vs. the 32-combined item HAQ-DI + WHODAS (HW) survey: A quality improvement controlled trial.
Authors: Tam Emily , Chen Judy , Zhang Qihuang , Zheng Dennis , Tam Vivian , Li Yuchen , Tse Tiffany , Brown M Catherine , Xu Wei , Howell Doris , Liu Geoffrey , Hall Elizabeth
Published: April 2017

136

Background: Routine outpatient physical function assessment can improve quality of care by prioritizing supports for specific patients. However, conventional research surveys including the 32-combined item HAQ-DI + WHODAS (HW) may be burdensome to patients. To streamline this process, we have developed BLESS, an electronic patient reported outcomes software program that utilizes PRO-ECOG and EQ-5D-3L items to screen for physical dysfunction symptoms, with follow-up questions from HW; BLESS has been demonstrated to have high sensitivity and specificity for the complete HW survey. We compared completion times and patient acceptability of BLESS vs. HW. Methods: Adult oncology outpatients of all stages at Princess Margaret Cancer Centre were allocated prospectively and alternately to receive either BLESS or HW on touchscreen tablets. Completion times were recorded and a patient acceptability survey was administered. Results: Of 225 patients analyzed from breast (19%), GI (22%), GU (12%), gynecology (16%), head/neck (12%), skin (6%) and thoracic (13%) cancer clinics, 118 (52%) patients completed BLESS and 107 (47%) completed HW. Median age was 61 (range: 18-97) years; 60% were female, 68% were Caucasian, 44% were stage IV, and 57% were treated with a curative intent. There were no statistically significant differences in demographic and clinical characteristics between the arms analyzed. Median EQ-5D-3L utility was 0.83 (0.28-1.00), median HAQ-DI was 0.13 (0-3.00) and median WHODAS was 8.3% (0-83.3%). Compared to HW, BLESS resulted in a median completion time reduction of 3.9 minutes (32% decrease; p < 0.001). Although most patients in both arms did not find the survey time-consuming nor caused the clinic visit to be more difficult, a greater proportion of BLESS patients held a stronger conviction in their answers (p = 0.02 for both comparisons). Conclusions: In comparison to traditional research tools of HW for assessing physical function,BLESS was associated with shorter administration times and improved patient acceptability, rendering BLESS more suitable for routine clinical use.
Improving cancer treatment handoffs: Wilmot Cancer Institute’s (WCI) ASCO Quality Training Program experience.
Authors: Dougherty David W. , Scarsella Elizabeth , Clarke Tammy , Alvino Elizabeth , Rich Lynn , Goonan Sean , Mietus Karen , Wade Nathaniel , Alongi Alex , Bobry Melanie , Guancial Elizabeth A. , Blaney Margaret , Amport Stephanie Buia , Pandya Chintan
Published: April 2017

139

Background: Ineffective handoffs contribute to gaps in patient care and medication errors, jeopardizing patient safety and leading to poor quality of care. Ineffective handoffs accounted for 59% of reported medication events at WCI Infusion Center. The completion rate of WCI’s existing electronic medical record (EMR) based free text handoff note for patients treated with anti-cancer therapy on the same day as a clinic visit was 32%. The project aim is to create an effective EMR integrated treatment handoff tool and establish standard workflow processes to ensure optimal communication among WCI providers for improved patient safety and quality of care. Methods: We convened a multidisciplinary team to develop an efficient and safe treatment handoff tool. WCI nurses were surveyed to evaluate the baseline state of the handoff process. Tool development was performed over a series of phases, including creation of a project charter and aim statement, outlining current workflow process, identifying gaps and limitations in the process, identifying potential causes of ineffective hand-off and using a Pareto chart to prioritize them. Utilizing the Situation-Background-Assessment-Recommendation framework, an EMR-integrated handoff tool with standardized workflow process was developed, along with an educational plan for the tool. Results: 52% (N = 22/42) of nurses found the current handoff note to be ineffective at preventing errors and 48% (N = 20/42) identified incomplete or missing information as a significant factor for ineffective communication. Other barriers identified included poor note design, lack of standardization in workflow and variation in note use. During the 1 week implementation of the new handoff tool, the utilization rate was 100% (N = 32) with completion rate of 41% (13 of 32). Further data collection is ongoing and nursing perception of the new tool will be evaluated at 3 months. Conclusions: Multidisciplinary stakeholders’ guided development and implementation of an EMR-integrated treatment handoff tool to optimize the communication between cancer care providers during patient transition is associated with improvement in handoff tool utilization and communication.
Rate of use of NCCN “preferred” chemotherapy regimens for the treatment of HER2 positive breast cancer.
Authors: Gratias Eric J. , Rausa Margaret , Newcomer Lee N. , Andrews Kurt , Andrews Nick , Weininger Richard B.
Published: April 2017

163

Background: The National Comprehensive Cancer Network (NCCN) Guidelines represent a well-established standard of care for the treatment of HER2+ breast cancer patients. eviCore healthcare is a licensee of NCCN that uses the NCCN guidelines to support its proprietary chemotherapy management program. All regimens assigned NCCN Category of Evidence 1, 2A, or 2B are adherent treatments in the eviCore program. NCCN recommends many systemic treatment options for HER2+ breast cancer, and a limited group is designated by NCCN as “preferred” based on superior efficacy and/or safety. This study evaluated the frequency of NCCN-preferred regimen use by practicing oncologists in HER2+ breast cancer patients. Methods: Chemotherapy authorizations for all HER2+ breast cancer patients with ≥ 1 injectable drug from 4/1/2015-9/30/2016 for multiple payers were included; > 90% of authorizations occurred in United HealthCare members. Cases with incomplete data were excluded. 3685 fully evaluable cases were stratified by stage, ER/PR status, and NCCN-preferred vs. NCCN-recommended status. The frequency of NCCN-preferred regimen selection was calculated for each subgroup. Results: There were 2883 HER2+/ER+ and/or PR+ cases and 802 HER2+/ER-/PR- cases. The highest frequency of NCCN-preferred regimen use occurred in neoadjuvant chemotherapy for patients with Stage III HER2+/ER+ and/or PR+ disease, where 88% of 289 patients used an NCCN-preferred regimen. Metastatic HER2+ patients had a markedly lower rate of NCCN-preferred regimen use at 62% of 557 cases. Only 48% of 1096 patients with Stage I/II HER2+/ER+ and/or PR+ disease received NCCN-preferred regimens. Conclusions: Patients receiving neoadjuvant chemotherapy for HER2+ breast cancer receive NCCN-preferred regimens at significantly higher rates than patients receiving adjuvant chemotherapy or metastatic treatment. Less than half of patients receiving adjuvant chemotherapy are receiving NCCN-preferred regimens. Further study is needed to determine the reasons for low preferred regimen use and ways to optimize preferred regimen use in HER2+ breast cancer.
Pregnancy screening prior to chemotherapy initiation: A retrospective review.
Authors: Rogers Brittany Kayla , Kolarich Andrew , Markham Merry Jennifer
Published: April 2017

165

Background: ASCO’s Quality Oncology Practice Initiative (QOPI) sets site standards to promote excellence in oncology care. One standard is screening appropriate female patients for pregnancy prior to chemotherapy. However, no formal guidelines exist regarding pregnancy screening protocols or timing of screening. We believe that women are inconsistently being screened for pregnancy prior to chemotherapy. Methods: A retrospective chart review was conducted using the UF Health (UFH) tumor registry and electronic health record (Epic) to identify women ages 18-55 who received chemotherapy or endocrine therapy by a medical oncologist between January 1, 2012 and December 31, 2014. Exclusions were prior hysterectomy or tubal ligation, known pregnancy, or treatment outside of UFH. The following data was collected: age, race, diagnosis date, cancer type, pregnancy screening test (urine or blood β-HCG) and date, specialty of ordering provider, name of chemotherapy or endocrine agent, and participation in interventional clinical trial. Results: Our search identified 501 potentially eligible women. Of these, 204 were excluded, 96% due to prior hysterectomy or tubal ligation. Of the remaining 297 eligible women, 103 (35%) received pregnancy testing prior to chemotherapy. Three screening tests were positive of the 103 pregnancy tests ordered. Follow up testing revealed 2 were true positives and 1 was a false positive. Of the 103 pregnancy tests, 23 (22%) were ordered by medical oncology, 51 (50%) were ordered by a surgery or anesthesia, and 16 (16%) were ordered by emergency medicine. 48% of the pregnancy tests were performed within 14 days prior to treatment start date. Conclusions: At our institution, pregnancy screening rates in women of childbearing potential were just 35%, and less than half of the women who were screened received pregnancy testing within 14 days of treatment start. Based on this data, a quality improvement project has been initiated in the outpatient medical oncology clinic and infusion center to improve pregnancy screening in this population. [Table: see text]
Implementation of surgeon-initiated Oncotype DX ordering among patients with breast cancer to reduce chemotherapy wait times.
Authors: Losk Katya , Freedman Rachel A. , Lin Nancy U. , Golshan Mehra , Lester Susan , Pochebit Stephen , Natsuhara Kelsey , Camuso Kristen , King Tari A. , Bunnell Craig A.
Published: April 2017

166

Background: Oncotype DX testing in breast cancer is associated with delayed chemotherapy initiation, which may adversely impact clinical outcomes and patient satisfaction. We sought to reduce delays between surgery and adjuvant chemotherapy initiation among patients who undergo Oncotype DX testing by developing standard ordering criteria and modifying surgical oncology, medical oncology, and pathology workflows. Methods: We implemented ‘reflex’ Oncotype DX testing for any patient ≤ 65 with the following tumor characteristics: T1cN0 (grade 2-3), T2N0 (grade 1-2), or T1/T2N1 (grade 1-2). A new process was developed whereby once pathology review is complete surgeons communicate the results to medical oncologists in real-time and initiate requests for Oncotype DX when appropriate. Medical oncologists can order Oncotype for cases outside the criteria. A streamlined pathology system for receiving and processing Oncotype DX requests was also developed. We then examined 649 consecutive breast cancer patients who received postoperative Oncotype DX testing and measured time intervals between surgery date, Oncotype DX order date, Oncotype DX result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. Results: The interventions reduced the turnaround time (TAT) from surgery to Oncotype DX order and time to when the results were available by 7.7 days and 6.3 days, respectively. A 6.5 day decrease in the mean time from surgery to chemotherapy initiation was observed. The decrease in the standard deviation also suggests a reduction in process variation. Conclusions: Developing Oncotype DX testing criteria and implementing streamlined workflows among providers has led to a significant reduction in Oncotype DX ordering TAT and wait times to chemotherapy initiation. [Table: see text]
Improving hepatitis B screening prior to rituximab at a multispecialty urban hospital.
Authors: Nandagopal Lakshminarayanan , Paluri Ravi Kumar , Gleaton Barbara , De Idiaquez Diego Alonso , Nabell Lisle
Published: April 2017

176

Background: Rituximab(R) is a novel anti-CD20 monoclonal antibody used in multiple hematologic and rheumatologic diseases. Patients who are hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (HBcAb) positive are at risk for hepatitis-B reactivation with R-based treatments. Therefore, the VA’s medication use evaluation tracker recommends serological testing for HBsAg, HBsAb and HBcAb within 6 months prior to initiating R. We conducted a PDSA cycle to improve Hepatitis-B serological testing in patients receiving R at Birmingham VA medical center (BVAMC). Methods: For baseline evaluation, patients at BVAMC who were treated with R between 2004- march 2014 were retrospectively evaluated for HBV serology results 6 months prior to first treatment. Presence of all 4- HBsAg, HBsAb and HBcAb (IgM and total) was complete; absence of all 4 was ‘not done’ with remaining being incomplete. After conducting a RCA, 3 pharmacy-based interventions were implemented- 1) pharmacy education; 2) pharmacist autonomy to order hepatitis B serology eliminating physician dependence; 3) pharmacy reminders to health care providers to order HBV serology. We aimed to improve ‘complete’ screening rates to > 90% in the post-intervention period (april 2014-sep 2016). Results: In the pre-intervention group (n = 162), majority (81%) had hematologic indications and complete testing was performed in 38%, reminder being incomplete (13%) or not done (49%). Post-intervention (n = 86), majority (54%) had rheumatologic indications with complete testing in 71%, incomplete in 15% and not done in 14%. No Hepatitis B reactivations were identified in either study periods. Conclusions: Pre-intervention, ‘complete’ testing was performed in only one-third of patients and our intervention was effective in almost doubling screening rates. We also demonstrate increasing use of Rituximab in non-hematologic conditions and with second-generation anti-CD20 Ofatumumab and Obinutuzumab also requiring similar testing; our study could standardize Hep-B screening for these agents. A second PDSA cycle with a reflex ‘forcing-function’ EMR-based tool to decrease reliance on human factors is planned to meet the study goal of > 90%.
Clinical trials in Ontario’s quality-based funding model.
Authors: Forbes Leta , Evans William K. , Kais-Prial Thomas Eduard , Fung Ron , Lalonde Carlin , Hoskin Charlotte , Milgram Lisa , Cho Vanessa , Simanovski Vicky , Gavura Scott , Chan Kelvin K.
Published: April 2017

186

Background: Clinical trials (CTs) are a key component of a quality cancer care system. When funding for systemic therapy services in Ontario transitioned in 2014 from a one-time payment for new cases to bundled payments for specific care activities (consultation, therapy, well follow-up, supportive care), a policy was developed to address public funding for systemic therapy in CTs. Methods: Treatment facilities receive funding from the Systemic Treatment-Quality Based Program (ST-QBP) for treatment with evidence-informed regimens inclusive of inexpensive drug, preparation and delivery costs. Under the new CT policy, randomized CTs with a standard of care comparator arm receive funding for all arms of the trial from the ST-QBP for older inexpensive drugs and all treatment administration costs at the band level for the disease type and stage. Non-randomized CTs are funded at the level of best supportive care or other appropriate band level. CT costs over and above the standard of care must be negotiated with industry sponsors. New and expensive drugs in CTs may be funded through separate provincial drug reimbursement programs if used according to publicly approved funding indications. Weekly joint reviews of new CT submissions by staff of the ST-QBP and drug reimbursement programs ensures timely communication to investigators concerning policy alignment and public funding and addresses potential concerns with regard to downstream access to expensive drugs. Results: As of January 29, 2016, 121 CT applications have been assessed (Phase 0 = 1, Phase I = 26, Phase II = 31, Phase III = 39, Phase IV = 1 and Multi-Phase = 23). Almost all CTs are aligned with the new policy and were assessed in a timely fashion. Assessments are posted on Cancer Care Ontario’s website within 1 week of review to allow all Ontario investigators access to this information. Conclusions: A clear CT funding policy and timely reviews support patient and investigator access to new and innovative therapies within an evidence-informed public funding model in Ontario, Canada. [Table: see text]
Providing consistent patient education across the continuum of cancer care.
Authors: Hoff Becky , Tonne Heidi
Published: April 2017

187

Background: The need for consistent patient education across Cancer Care Services was identified while planning for the Fred and Pamela Buffett Cancer Center. Work began in November 2015 to validate if education provided by multiple providers in various settings was consistent and delivered a clear message to patients. A plan was developed to provide consistent education across the care continuum with the goal of enhancing patient experience, improving staff workflow and defining expectations for patient education. Methods: A survey to assess the current state of education was conducted. Participants in the survey included multidisciplinary team members from inpatient and ambulatory care settings. Five questions were asked about education consistency. Comments about the current and future state of education were encouraged. An audit of educational materials was completed and outdated resources eliminated. Results: 456 surveys were sent with 154 surveys completed (34% return rate). Five major themes emerged (documentation, role expectation, resource standardization/availability, handoff between departments and disciplines, and assessment of individual learning needs). The documentation in Electronic Medical Record was inconsistent and unable to easily assess learner progress. Role expectation was poorly defined with no consistent approach to education delivery. Resource standardization/availability had varying availability of education materials and staff unaware of resources. Handoff between departments and disciplines had inconsistent documentation and no established process to identify needs and barriers related to successful handoffs. Assessment of individual learning needs had unknown compliance in completing the Learning Questionnaire. A team was assembled to address the themes. A process map of patient education was created starting at the initial encounter through end of treatment. Staff was educated on their role, available resources, and documentation expectations. Conclusions: Conducting an evaluation of the patient education process allows for identification of improvement opportunities. This reduces patient confusion and increases trust. Patient satisfaction scores related to education have increased. This work enhanced the patient experience and helped prepare for a smooth transition of patient education initiatives into our new cancer center.
The impact of interruptions on physician workflow, productivity, and delivery of care.
Authors: Cheung Matthew C. , Trudeau Maureen E. , Mackay Helen , Naik Harsh , De Mendonca Ben , Eisen Andrea , Singh Simron
Published: April 2017

201

Background: Physician interruptions during clinic and non-clinic hours can lead to medical errors, provider fatigue, prolonged clinic times, reduced academic output and poor job satisfaction. Repetitive interruptions can hamper the ability of physicians to deliver high quality patient-centered care. This study aims to evaluate the type, frequency, duration and self-reported physician response interruptions physicians experience in clinic. Methods: A work observation study was conducted at the Odette Cancer Centre, Sunnybrook Health Sciences Centre in Toronto, Canada. In-clinic data were collected from September 22 to October 6, 2016 using time-motion analyses by shadowing multiple oncologists in clinic. Interruption data were collected and categorized as follows: type of interruption, length of interruption, reason for interruption and role of interrupter. Physicians were asked to record and track themselves regarding interruptions they experienced during non-clinic hours using the same criteria. Results: Over a 2-week period, 5 medical oncology clinics (median 4 hours (hrs) per clinic), were observed and tracked. The clinic physicians averaged 22 interruptions per block, equating to 6 interruptions/hr (one interruption every 10 minutes (mins)). Over the 5 sessions, 112 data points were collected totaling over 1 hr 48 mins of interrupted time. Interruptions averaged 80 seconds (range of 4 to 517) in length with a positive skewed distribution. This calculates to approximately 30 mins of cumulative interrupted time per clinic session. Most interruptions were under 4 mins in length (4.1 at 95th percentile). The type of interruption varied but was most commonly in-person (67), email (24) and text message (10). Conclusions: Interruptions account for approximately 30 mins of physician time during a 4-hour clinic. An assessment of the type and frequency of requests proved highly variable, creating inconsistent ways messages are delivered to physicians. Interruptions potentially impact on patient care and disrupt the workflow of the clinic. These data provide future directions for exploring efficient clinic workflows and establishing standardized means of communicating with physicians during clinic hours.
Understanding the landscape and challenges of end-of-life measurement among comprehensive cancer centers.
Authors: Morse Denise , Pendleton Delinda ,   C4QI
Published: April 2017

207

Background: Quality at the end of life is vitally important to providing patient and family centered care, however the measurement of end of life care is challenging. Numerous metrics have been fully endorsed by the NQF, however benchmark data is difficult to obtain and clinicians question the usability and reliability of these existing measures. Methods: The Comprehensive Cancer Center Consortium for Quality Improvement (C4QI) convened an End of Life workgroup comprised of members from 21 cancer centers across the country. The first task of the workgroup was to collate existing end of life metrics that are in the public domain. Once the measures were collated, a survey was sent out to the membership for feedback on current utilization of measures and obtain baseline data where available. Data was pulled using the Vizient Clinical Database to look at the ability to pull end of life data within the database. The organizations were able to compare data on ICU Utilization, Chemotherapy, Length of Stay, and Cost. Results: The results of the C4QI End of Life survey showed that there challenges exist with interpretation and analysis. Even within ASCO QOPI, each center had their own issues with capturing the same population of cases and including/excluding the same criteria. Although we had received ASCO QOPI results from numerous centers, the comparison between the centers proved to be not as accurate of a comparison as desired. The Vizient data on inpatient mortalities and discharges to hospice showed differences among centers. The data led to additional discussions about the additional data needs especially as it relates to outpatient data capture both at each individual center as well as at other centers, and the need for more clarifying information about hospital makeup. Conclusions: The C4QI End of Life workgroup has agreed to focus on Advance Directive, Management of Pain at the End of Life, Palliative Care Referrals, and Hospice Enrollment. These 4 areas are the first step towards measuring advance care planning and quality at the end of life. The project shows the challenges of metric analysis, data sharing and benchmarking that collaborative groups face especially around potentially charged topics like End of Life.
Patient-reported outcomes for performance measurement: Multi-institution challenges.
Authors: Barysauskas Constance , McNiff Kristen K. , Flaherty Stephen , Morba Mary Ellen , Spinks Tracy E. , Fisher Terry , Jagels Barbara , Martin Neil E.
Published: April 2017

211

Background: Patient-reported outcomes (PROs) are self-reported measures of a patient’s health or healthcare experience. PRO utilization is driven by the movement toward patient-centered care and emerging evidence which suggests patients (pts) more involved in their care experience better outcomes. The infrastructure to capture PROs is evolving and PROs are now used for performance measurement (PM). PRO-PMs assess the quality of healthcare for improvement and/or accountability; but implementation is challenging. Success of PRO-PM requires identification of pts, ongoing data collection and data aggregation across institutions. The Alliance of Dedicated Cancer Centers (ADCC) identified challenges of PRO use for PM. Methods: The validated tool, Expanded Prostate Cancer Index Composite, evaluating pt function and bother from treatment (trt), administered to new localized prostate pts at three independent cancer centers was retrospectively collected. Surveys administered before and after trt measured change from trt. Results: Institutions implementing PROs following local standards resulted in a high degree of variation. The aggregated data presented challenges in identifying eligible pt populations who received surveys before and after trt within a timeframe. We identified a pragmatic and meaningful pt population and survey implementation window. Pts were stratified by center and trt modality for analysis. Conclusions: The aggregation of dissimilar data sources led to the identification of institution implementation and data capture differences, however, the ADCC identified variation for PRO measure development. Clear guidance, policies and procedures are essential to ensure adequate homogeneity and reduced variability, to assure meaningful PM and reduce confounding by institution. [Table: see text]
Real-world concordance of clinical practice with ASCO and NCCN guidelines for EGFR/ALK testing in aNSCLC.
Authors: Ruggiero John E. , Rughani Jay , Neiman Josh , Swanson Steven , Revol Cindy , Green Robert J.
Published: April 2017

212

Background: Timely and appropriate biomarker testing guides evidence-based treatment decision-making in advanced non-small cell lung cancer (aNSCLC). American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommend that all treatment-eligible patients with non-squamous, or squamous histology in non-smokers undergo EGFR and ALK biomarker testing prior to initiating first line therapy. Genentech’s Learning and Clinical Integration team and Flatiron Health explored the frequency of EGFR/ALK testing and overall time between advanced disease diagnosis, results receipt and treatment initiation in clinical oncology practices. Methods: Structured and unstructured data were obtained from Flatiron’s electronic health record database. 6,991 patients from 166 clinics diagnosed after 1/1/14 with at least 2 visits before 8/31/15 were randomly selected from the Flatiron aNSCLC national cohort of > 25,000 patients. Dates of specimen collection, results receipt and treatment start were collected. Results: EGFR/ALK testing was conducted in 75% of non-squamous patients with wide variation across practices (< 20% to 100%). For squamous patients, 15% were tested overall, but with dramatic variation across practices (0% to 100%). For patients with a positive test result available prior to initiation of first line treatment, 79% of EGFR+ and 94% of ALK+ patients received the appropriate targeted therapy. However, for those patients tested after initiation of first line therapy, only 41% of EGFR+ and 65% of ALK+ patients received appropriate targeted first line therapy. EGFR/ALK tests results were received > 4 weeks from aNSCLC diagnosis in 32% and 34% of patients, respectively. Validation testing indicated that delays were attributed to non-lab factors, as test results were returned in < 2 weeks in 95% of cases. Conclusions: Wide variation in real-world practice illustrates the need to improve adherence to ASCO and NCCN biomarker testing guidelines. Educational intervention to improve quality of care in aNSCLC should focus on ensuring testing of almost all non-squamous patients, limiting testing to the non-smoking squamous cell population, and ensuring timely ordering of testing by clinicians.
Delays in access to palliative care services among cancer patients in South Texas.
Authors: Rauenzahn Sherri L. , Schmidt Susanne , Aduba Ifeoma , Ali Nazneen , Tenner Laura LaNiel
Published: April 2017

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Background: The growing support for integrated palliative and cancer care resulted in the American Society of Clinical Oncology’s new recommendation which states patients “with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment.” Unfortunately, timely access to palliative services remains an issue for cancer patients and centers. The aim of this project is to evaluate how socioeconomic factors impact palliative access for patients in South Texas. Methods: During a 6-month period, patients in oncology clinics completed the Edmonton Symptom Assessment System questionnaire. Scores reaching a predetermined threshold resulted in a provider alert to consider referral to palliative services. We examine time to initial palliative appointment after referral and compare time to visit based on location of palliative services determined by insurance coverage. Results: During our study period, providers referred 47 unique patients with 27 patients eligible to receive care at the University of Texas Medicine System (Group A) and 20 patients qualified for care at the University Hospital System providing services to under-insured and safety net patients (Group B). Of the 47 referred patients, 27 (57%) patients were offered an appointment and only 17 patients (36%) actually had a palliative care visit (13/27 (48%) Group A patients and 4/20 (20%) Group B patients). On average, Group B patients had 25.2 days longer wait times to palliative visits compared to Group A patients. Conclusions: This investigation revealed a discrepancy between referral and actual receipt of care. While this study is limited by a small sample, data suggests that under-insured oncology patients may have significantly different access to palliative services which may impact the quality of cancer care. [Table: see text]
Resource utilization and provider variation in the care of patients with stage IV non-small cell lung cancer six months before death.
Authors: Aakhus Erin , Berman Abigail T. , Crimins Neil , Gabriel Peter Edward , Braun Jennifer , Shulman Lawrence N. , Evans Tracey L.
Published: April 2017

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Background: Cost of care of cancer patients near the end of life is a focus for payers and others. The breakdown of costs during this period for patients with Stage IV non-small cell lung cancer (NSCLC) are shifting as therapeutic choices change. We measured and reported variation in utilization, by oncologist, aiming to improve standardization and reduce utilization while maintaining or increasing the quality of care. Methods: Within the University of Pennsylvania Health System (UPHS), we identified all deceased patients with Stage IV NSCLC with first contact of 1/3/2011 to date of death of 4/10/2016, at least 1 chemotherapy visit, and 6 months between first contact and death (N=175). We captured all inpatient and outpatient charges within 6 months of patient death. Results: The median gross total charge per patient was $209,637 (interquartile range, $121,517-$371,196), which consisted of 39% outpatient infusions, 23% radiation therapy, 18% inpatient medical admissions, 11% outpatient radiology, 4.5% professional charges, and <1% ED visits. Infusions of pemetrexed and bevacizumab accounted for 7.3% and 6.1% of the gross total charges, respectively. Only 13/175 (7.4%) of patients received infusions within 14 days of death. Primary oncologist was not found to be a significant driver of variation in total, outpatient, or inpatient gross charges per patient (p=0.097, 0.208, 0.297). However, we showed that professional charges and use of outpatient radiology differed by oncologist (p=0.039, 0.003). We also identified oncologist-driven differences in use of supportive care drugs pegfilgrastim, darbepoietin, and denosumab (p=0.002, <0.001, <0.001). We detected no differences in use of pemetrexed or bevacizumab (p=0.835, 0.521). The differences in number of infusion visits approached significance (p=0.058). Conclusions: Outpatient infusions and radiation therapy were the largest contributors to healthcare resource utilization in the care of Stage IV NSCLC patients in the last 6 months of life. Variation in utilization by primary oncologist was detected in professional charges, outpatient radiology, and the use of supportive care (but not chemotherapeutic) agents.
Quality indicators for cervical cancer care in Japan.
Authors: Watanabe Tomone , Kamitani Satoru , Iwamoto Momoko , Higashi Takahiro
Published: April 2017

219

Background: Although ensuring high-quality care has a central role in Japanese cancer policy, introduction of a system to evaluate quality is still underway. With the goal of establishing a sustainable measurement system, this study assesses adherence to quality indicators (QIs) as an index for evaluating the quality of care for cervical cancer patients in Japan. Methods: Ten measurable QIs were devised by an expert committee using the modified Delphi method. Adherence to each QI was calculated by using hospital cancer registry data of patients diagnosed during 2013 and claims data between October 1, 2012, and December 31, 2014. Using registry-linked claims data across 281 hospitals, we measured 3 QIs on treatment for CIN3, 3 QIs on stage III or IVA, and 1 QI on stage IVB, respectively. We also measured 1 QI on examination of cancer spread and 1 QI on brachytherapy. Results: Data for 11,925 cervical cancer patients were analyzed. Patients’ mean age was 45.4 years (SD: 15.1). Among the QIs, use of platinum-based chemotherapy among stage IVB patients (99.1%), total hysterectomy as the last treatment among intraepithelial adenocarcinoma patients over age 44 years (87.7%), and selection of cisplatin-based regimen for concurrent chemo-radiation therapy (CCRT) (81.2%) to stage III/IVA diseases marked high adherence. In contrast, evaluation with cystoscope or proctoscope among stage IVA patients (32.4%) and use of CCRT as the initial treatment for stage III or IVA patients (49.5%) had relatively low adherence. Conclusions: The observed variation in adherence to QIs could demonstrate the provision of unstandardized care across Japan. Feedback on the results and continued monitoring are necessary to improve the quality of cervical cancer care.