bluuebunny/crossref_metadata_2025 huggingface dataset:
Cancer patients’ and physicians’ preferences for decision making regarding pharmacogenomic testing (PGT).
Authors: Cuffe Sinead , Hon Henrique , Qiu Xin , Masroor Sohaib , De Souza Bradley , McFarlane Graham , Wong Chung-Kwun Amy , Tobros Kimberly , Azad Abul Kalam , Hasani Ekta , Rozanec Natalie , Leighl Natasha B. , Atehortua Nelson A. , Alibhai Shabbir M. H. , Xu Wei , Issa Amalia M. , Liu Geoffrey
Published: February 2017

13

Background: Pharmacogenomics is increasingly utilized in oncology; however, there is little knowledge concerning cancer patients’ or oncologists’ attitudes toward PGT decision-making in clinical practice. Methods: A broad cross-section of cancer patients were interviewed regarding their attitudes toward PGT using hypothetical time, efficacy and toxicity trade-off and willingness-to-pay scenarios (N=278) and/or quantitative choice-based conjoint analysis surveys (N=264); 64 cancer specialists/physicians in training were surveyed similarly. Results: Of patients participating in the trade-off scenario phase of study, >94% accepted chemotherapy, and of these, >98% wanted PGT that identifies a subset of patients either benefiting from chemotheraphy or who were at risk of severe toxicity. Patients were willing to pay between CAD $1,000-$1,900 for PGT and accept wait times for results of 2-3 weeks. Similar findings were observed in the conjoint phase of the study, with preferences for PGT starting to decline when the out-of-pocket costs reached CAD $500-$1,500, wait time for results exceeded 14 days, and when the prevalence of the genetic variant fell below 25%. Adjuvant patients’ acceptance of PGT was most influenced by cost (decision weight [DW]=41%) and prevalence of the genetic variant associated with lack of benefit from chemo (DW=26%). Metastatic patients were most influenced by cost (DW=49%) and wait times (DW=31%). More patients reported difficulty understanding conjoint surveys (14%) than trade-off scenarios (7%; p=0.01). 81% of patients wanted to be involved in decision-making regarding PGT; while 30% of physicians felt it should be a physician-only decision (p=0.006). However, 21% of patients and 5% of physicians admitted to not understanding PGT, while just 14% of physicians rated themselves as very knowledgeable regarding PGT. Conclusions: Cancer patients overwhelmingly accept and want to be involved in decision-making regarding PGT, to a greater extent than what physicians prefer. However, communication of PGT information was a potential barrier, as a considerable minority lacked the necessary knowledge to facilitate informed decision-making. Improved patient and physician education is necessary.
Sepsis in adult leukemia patients.
Authors: Garza Jan
Published: February 2017

133

Background: Sepsis is estimated to affect 16.8% of the cancer population with hematologic malignancies leading to significant mortality. The incidence may be higher in elderly leukemia patients with concurrent comorbidities. Results of case scenario questionnaires presented to leukemia nurses during a quality improvement project revealed a potential to increase recognition of systemic inflammatory response syndrome, commonly used to identify patients who are at high risk for sepsis, severe sepsis, and septic shock, by 20% among leukemia nurses. Earlier recognition of the systemic inflammatory response syndrome by clinicians is thought to possibly reduce the mortality among those with leukemia. The purpose of this poster is to present the pre-test/post-test results of an educational intervention aimed at increasing earlier recognition of SIRS and consequent sepsis, severe sepsis, and septic shock by 20% among 65 nurses on the leukemia units at a major cancer center. Methods: A multidisciplinary team Pharmacists from ICU and Leukemia and ICU MERIT Team-Leader, led by 2 APNs from ICU and Leukemia, developed and presented an educational program to nurses on the leukemia units to support proposed changes in practice. Pre-test and post-tests were used to determine nurses’ knowledge prior to and after the educational intervention. Results: Analysis of pre- and post-test scores revealed 61% increase in recognition of SIRS, sepsis, severe sepsis, and septic shock. There were no cases of systemic inflammatory response syndrome identified among the 29 leukemia patients by nurses prior to the intervention compared to 9 out of 16 post intervention. Conclusions: Education of nurses on leukemia units revealed an increase in their knowledge base and improvement in recognition of SIRS, sepsis, severe sepsis and septic shock. Implications for nursing include a need to incorporate this education to all nurses who are assigned to units caring for hematologic malignancies to include lymphoma, stem-cell transplant, and myeloma. Our quality improvement project showed the need for on-going healthcare provider education to recognize the symptoms early which may save lives and reduce costs of healthcare.
Avoidance of futile treatment and adverse events by using angiogenesis-specific imaging for early detection of disease progression in patients with first-line metastatic renal cell carcinoma.
Authors: Gruschkus Stephen K. , Bodnar Carolyn , Dhamane Amol , Shah Manan
Published: February 2017

134

Background: Although sunitinib is effective first-line therapy (1LT) for metastatic renal cell carcinoma (mRCC), ~20% of patients experience rapid progressive disease (PD). Traditional RECIST monitoring often does not detect PD until 90 days after 1LT initiation. Investigational angiogenesis-specific imaging (AI) may identify PD as early as 14 days post-1LT initiation, thus allowing a switch to a potentially more effective second-line therapy and avoiding unnecessary risk of AEs. This study’s goal was to quantify the potential reduction in futile 1LT length, AEs, and costs by using AI for early detection of PD. Methods: Decision modeling with a 90-day horizon evaluated a comparator arm using RECIST monitoring at 90 days and an intervention arm using AI at 14 days. Sunitinib costs were $21,250 for the comparator arm and $13,282 for the intervention arm. RECIST costs were $619 and AI costs were tested as a breakeven analysis. A literature review quantified AE rates associated with 1LT sunitinib and claims data were used to determine costs. Early PD detection was estimated based on a 20% rapid PD rate. Results: For AI sensitivity of 50% to predict rapid PD, a 38-day reduction in futile 1LT could be achieved per PD patient by using AI vs. RECIST (AI sensitivity of 75%/100% yielded 57/76 fewer days). The potential number of AEs avoided through early PD identification is shown below. Costs saved per 1,000 mRCC patients were $684,566 for AEs and $3,187,400 for futile 1LT. Based on these results, $3,872 per mRCC patient would be freed up for AI. Conclusions: Continuing 1LT after PD brings unnecessary risk of AEs and delays potentially effective 2nd-line therapy. Results of this study indicate that early PD identification using AI may improve quality of care by minimizing duration of futile 1LT and avoiding unnecessary AEs. [Table: see text]
Norris Cotton Cancer Center (NCCC) neuro-oncology glioma tumor quality improvement project.
Authors: Schlosser Evelyn , Fadul Camilo E. , Snide Jennifer , Homa Karen
Published: February 2017

137

Background: Glioma patients represent 30% of the primary brain tumor population at NCCC, and often require surgical intervention prior to medical management. In order to ensure coordinated, comprehensive and timely care, reliable referral to the neuro-oncology program is needed. Earlier quality improvement efforts identified 10 best practices designed to facilitate referral into the neuro-oncology program, though over the years these practices lapsed. A manual record review of 2010 cases revealed 43 glioma patients, of which compliance with best practices ranged from 29% to 93%, and none of the patients had all best practices when indicated. Additionally, the percentage of 9 out of the 10 best practices (excluding post-operative order sets) completed for all consecutive patients from January 2010 to May 2011 was 63%. Methods: A project was chartered by leadership and a multidisciplinary team was convened twice a month from May to October 2011. The team was organized into three groups (entry into the system, surgical, and post-op care, and continuing care) and assigned a coach with instructions to flowchart the current processes and identify factors that contributed to poor performance. The three process maps were then combined to create one system map by which the team brainstormed improvement ideas to pilot. Results: Concurrent review of the individual case-level data during the project team meetings was helpful in identifying process weaknesses as changes were being piloted. Performance of best practices improved significantly when measured several months following completion of the project; furthermore, best practices completed for consecutive patients from June 2011-May 2012 was 87%. Conclusions: The team was challenged to identify changes in process that were not dependent upon individual providers/staff members and that took advantage of a newly implemented electronic medical record. Manual chart abstraction was replaced by electronic data abstraction. Sustained measurement and reporting of performance is essential and has been incorporated into the Neuro-Oncology Tumor Board meetings on a quarterly basis.
Emerging development and use of clinical pathways to improve quality and standardize care in oncology.
Authors: Nash Colin , Williams Ken , Pirog Francesca , Mitchell Kristi
Published: February 2017

139

Background: Clinical pathways have emerged as a tool for payers to encourage provider adherence to evidence-based care. Avalere sought to understand how oncology pathway developers consider different types of evidence and physician input in designing pathways, and how the experiences of early programs may serve as an indicator for future implementation. Methods: Avalere conducted targeted white and grey literature searches to identify and analyze pathways used by oncology practice groups, provider networks, and major commercial payers. The research was augmented by informant interviews with representatives from leading organizations that have developed or implemented pathways. Results: Current pathways programs differ in their origins and objectives. Across these programs, Avalere identified findings in three key areas: Development: Developers consider efficacy of treatments first, followed by toxicity, and then cost. Many developers conduct an independent evidence review, while others leverage clinical practice guidelines. All developers solicit physician input on pathway design and updates; Use: Independent pathway developers partner with commercial insurers and large provider networks to design pathways with cost-saving components. Physicians are evaluated based on their adherence to the pathways, but are not held accountable for reporting or performance on NQF-endorsed quality measures; Impact: Cost savings in early programs are largely due to reduced toxicity-related medical costs, use of less expensive drugs, and lower total drug use. However, there is limited evidence on the impact of pathways on patient outcomes. Conclusions: There is variability across oncology pathway developers regarding their scope, granularity, and processes related to evaluating and incorporating evidence. If clinical programs demonstrate early cost reductions while improving patient outcomes, payers will likely attempt to expand pathways programs to new geographies and therapeutic areas. Existing practice patterns and previously implemented pathways programs will likely play heavily in determining which pathways are adopted in a given region, but national standardization is highly unlikely.
Natural language processing (NLP) of Internet conversations to evaluate prostate cancer (PC) patients’ perceptions of active surveillance (AS).
Authors: Mishra Mark Vikas , Bennett Michele , Vincent Armon , Lee Olivia T. , Lallas Costas D. , Trabulsi Edouard John , Gomella Leonard G. , Dicker Adam , Showalter Timothy Norman
Published: February 2017

14

Background: Less than 10% of qualifying PC patients receive primary management with AS. Qualitative research aimed at identifying patient acceptance of AS has been identified as a national health research priority. The primary objective of this study was to determine if NLP of anonymous internet conversations (ICs) could be utilized to identify unmet public needs regarding AS. Methods: After obtaining IRB approval, English-language ICs regarding PC treatment with AS from 2002-2012 were identified using a novel internet search methodology. Web spiders were developed to identify, mine, and gather content from the internet for ICs centered on AS. All ICs identified were screened programmatically to remove any not-on-topic ICs. Collection of ICs was not restricted to any specific geographic region of origin. NLP was used to evaluate content and perform a sentiment analysis. Conversations were scored as positive, negative, or neutral. A sentiment index (SI) was subsequently calculated according to the following formula to compare temporal trends in public sentiment towards AS: [(#Positive IC/#Total IC) – (#Negative IC/#Total IC) x 100]. Results: A total of 464 ICs were identified. Sentiment increased from -13 to +2 over the study period. The increase sentiment has been driven by increased patient emphasis on quality-of-life factors and endorsement of AS by national medical organizations. Unmet needs identified in these ICs include: a gap between quantitative data regarding long-term outcomes with AS versus conventional treatments, desire for treatment information from an unbiased specialist, and absence of public role models managed with AS. Conclusions: This study demonstrates the potential utility of NLP to analyze ICs in order to provide insight into patient preferences and decision-making. Based on our findings, we recommend that multidisciplinary clinics consider including an unbiased specialist to present treatment options and that future decision tools for AS include quantitative data regarding outcomes after AS, so that patients can make decisions with an amount of information that is more similar to the resources available regarding radiation or surgery.
Systems engineering in health care: Overview and examples from The University of Texas MD Anderson Cancer Center.
Authors: Jordan Victoria S.
Published: February 2017

140

Background: The University of Texas has six health institutions and Industrial and Systems Engineering faculty throughout university locations across the state. These academic medical centers, including MD Anderson Cancer Center, and schools of engineering, business, and medicine are partnering to implement Systems Engineering in healthcare throughout the UT system. The “systems approach to implementing Systems Engineering” is an opportunity to serve as a world-class model for collaboration across academic institutions for engineering, business, medicine, and healthcare organizations to implement Systems Engineering and systems thinking in healthcare. The objective of the collaboration is not just to produce successful projects, but to achieve transformational change. Methods: This presentation will provide an overview of Systems Engineering and provide examples of the different tools and strategies from the discipline including lean, six sigma, mathematical simulation, optimization and operations research, human factors, facility design layout, statistical process control, design of experiments, scheduling, supply chain and inventory management, staffing models, etc. Funding, leadership, training, and communication efforts associated with the effort will be reviewed including the grant application process for transformational efforts. (The implementation follows the PDSA process.) Results: Currently nine grants have been awarded in the UT system for implementing Systems Engineering. Results will be shared (in terms of cost savings and/or avoidance and patient satisfaction) from specific projects such as a lean effort in the Diagnostic Center and simulation models to schedule nurses in the OR and to determine resource requirements in the ICU. Conclusions: Systems Engineering is a valuable discipline that is relatively new to healthcare. Practicing clinical oncologists can increase efficiency, patient flow, and patient and physician satisfaction by applying Systems Engineering tools and strategies.
Quality improvement using lean methods to increase access and utilization of support services in younger breast cancer survivors.
Authors: Mayer Deborah , Gerstel Adrian , Taylor Kinley , Jackson Marianne , Shea Thomas C. , Rosenstein Donald , Marks Lawrence Bruce
Published: February 2017

143

Background: A variety of ‘structured support services’ (SS) are available to patients (e.g., genetics, fertility, counseling, physical functioning, nutrition). Many of these SS have value for breast cancer survivors (BCS) as they are often likely to face issues regarding genetic factors, fertility, parenting, relationships, work, and financial hard-ships. As part of an ongoing CDC-funded initiative, we report our preliminary findings regarding perceived needs and actual rates of use of these SS, and identified barriers to their use for BCS. Methods: We assessed the needs for and utilization of SS by 1) conducting a survey of younger breast cancer survivors; and 2) performed chart reviews for documentation of assessment and referral for each SS. To identify barriers to the receipt of SS we 1) conducted key informant interviews, and 2) performed extensive observations in the clinic to value-stream map the flow of the patient throughout the care process. Results: Survey results: Women (n= 59/283) responded with a mean age of 39 (range 19-46) at the time of diagnosis. The most common limitations to using SS included lack of information about SS (60%), distance from services (54%), and inconvenient times (51%). Chart results: We reviewed 57 charts from 2011 for assessment and referral for any SS. The lack of consistent documentation made it challenging to extract meaningful data. Observation and interview results: Common barriers to the receipt of SS include lack of patient and staff education about available services, lack of consistent referral mechanisms, heavy burden on the provider to make referral, and poor feedback loop between SS and provider. Conclusions: Patients and providers both perceive many challenges to the delivery of support services. We are applying lean processes to improve the delivery of consistent information about SS to patients and providers, to standardize methods to refer patients for them, and to provide feedback to providers, in order to improve the delivery of SS to BCS, therefore improving their quality of care.
Off-shift Administration operations improvement collaborative.
Authors: Hayes-Rodgers Angela , Revis Altrivice D.
Published: February 2017

144

Background: Off-Shift Administration (OSA) supports the senior leadership by overseeing clinical operations for both inpatient and outpatient areas at MD Anderson. Our team is responsible for resolving and/or managing issues that could impede patient care, particularly when unsuccessful at the departmental level. This project focuses on streamlining inpatient discharge activities. Data reports from December 2010 to February 2011 revealed that OSA received 1,923 assistance requests institution-wide of which 13% were case management related. A taskforce familiar with patient care and case management processes ultimately resolved to decrease the number of calls made to Off-Shift Administration requesting case management services by 50% by June 2011. Methods: The pilot period began March 1, 2011 and ended May 31, 2011. The earliest intervention was to re-route after hours case management requests directly to the case manager on-call. In the new process, the RN paged the case manager on-call directly who would then escalate calls to OSA as deemed necessary for internal support. A staff education plan complemented the intervention. The education plan entailed in-services with nursing staff, discharge planning teams and nurse leaders for each unit. Education by way of posters was delivered on select units. Piloted areas were also surveyed to assess their knowledge of case management processes and wait time experiences. Results: Outcomes were favorable. OSA experienced an 80% reduction in call volume from the piloted areas. Survey results showed educational efforts yielded a positive practice change and increased awareness of case management protocol. Survey results also revealed a 20-minute reduction in wait time for case management assistance. Certainly, of greatest benefit were the reduced wait times and more expedient patient care and customer service for staff. Conclusions: The project was successful and knowledge gained was be used to implement permanently and within all patient care settings. This project also serves as a useful paradigm of Clinical Operations’ improved ability to distinguish operational trends requiring attention, thereby increasing operational efficiency and customer satisfaction.
Caring for our deceased.
Authors: Tripp Kimberly , Hayes-Rodgers Angela , Revis Altrivice D.
Published: February 2017

145

Background: In spring 2010, Off-Shift Administration (OSA) at MD Anderson Cancer Center received a spike in inquiries from staff concerned about the lack of uniformity in processing patient deaths occurring on campus. Procedures were known within administration, but no formal policy existed to substantiate requirements. A core team from Medical Affairs, Nursing, and OSA joined forces to address deficiencies and enhance the quality of end-of-life care across the organization. The core team then assembled two multidisciplinary groups to contribute to outcomes. Specific project aims were to increase physician completion of a death note within one hour of death from 83% to 95% compliance by April 2011. Monitoring of the death note was selected because it is often the first action barrier that further hinders processing a patient death. Methods: Key activity was carried out from July 2010 to July 2011. The first working group met to consider all processes relevant to expirations and write a policy. A second convened to address needed updates to clinical documentation. CLN1084 Caring for the Deceased Policy was implemented in January 2011. Education to physicians occurred in March 2011 and to ancillary staff in July 2011. In-services were given and announcements were made in various institutional communiqué. Results: Results were tabulated following a randomized monthly audit of deceased inpatient medical records. Audit specifications included a) determining presence of a death note and b) verifying that the note was completed within one hour of pronouncement. A March 2011 audit revealed 100% compliance of death note completion within one hour of the death. After the target end date, the team continued to see a superior 96.6% compliance rate. Clinical and support staff alike have also expressed great appreciation for reference tools now available to guide activity following a death on campus. Conclusions: Monitoring for compliance will continue as deemed necessary. The policy will also be reviewed regularly to assure accuracy and ongoing compliance with state law and hospital requirements. Finally, the core group continues to consult with departments who express interest in outlining specific departmental procedures (Rotary House, Regional Care Centers, etc.) that align with policy.
The role of ACOs in accelerating high-quality care: Implications for prostate cancer.
Authors: Picarillo Grant , Jivani Natasha , Nash Colin , Mitchell Kristi
Published: February 2017

151

Background: Accountable Care Organizations (ACOs) seek to promote high quality, coordinated care by eliminating unnecessary procedures, sharing clinical information, and meeting quality targets. Of the 65 proposed quality measures outlined in the Medicare Shared Savings Program (MSSP), only two relate specifically to cancer care, calling into question how such models will accelerate high quality care in oncology. Prostate cancer offers an insightful case study as it is characterized by a lack of consensus around diagnosis and treatment and the involvement of several providers throughout the care continuum. Methods: As part of a multi-layered analysis to evaluate the impact of the ACO model on quality improvement and the management and treatment of prostate cancer, Avalere examined recent legislation (e.g., the Affordable Care Act, MSSP) to identify key characteristics of the model. Avalere then reviewed the potential impact of these characteristics in oncology by examining clinical guidelines and reviewing public statements by key opinion leaders. After identifying gaps specifically related to prostate cancer, Avalere categorized the characteristics into three groups based on their potential impact on prostate cancer care: high, moderate, and low. Results: Our analysis yielded the following categorization of the ACO characteristics: High Impact: Streamlined coordination of care between facilities and providers Focus on high-risk, high-cost populations Moderate Impact: Emphasis on preventative health Standardized use of outcomes-based quality measures Low Impact: Improved medication continuity Chronic disease management Shared savings incentives Conclusions: As providers involved in prostate cancer care explore the ACO concept, it will be critical to identify the characteristics with the greatest potential to improve the quality and coordination of care, and to incorporate these characteristics into the guideline recommendations influencing the standard of care. Our research indicates that prostate cancer guidelines should emphasize the low quality and high cost of fragmented care in this patient population and develop recommendations on proven methods of care coordination and quality improvement.
Transitioning chemotherapy administration from the inpatient setting: Creating bed capacity and improving the patient experience.
Authors: Cunningham Regina , Vozniak Michael , Wiley Kathleen , Kucharczuk Colleen , Swisher Brandi , Land Danielle , Tobin Robert , Holmes Marianna , Sullivan Mauri , Bell Tonita
Published: February 2017

152

Background: Administration of selected multiday chemotherapy regimens typically requires an inpatient stay at an academic quaternary care facility. A growing oncology population exceeding the capacity of oncology allocated beds led to occasional cancellation of patients scheduled for curative-intent treatment, necessitating a reevaluation of our processes. A multidisciplinary group formed to pilot a process by which certain regimens would be transitioned to the outpatient arena and others would be split, requiring only a portion of the regimen to be given inpatient. Methods: The utilization of a variety of quality improvement tools and processes determined the feasibility and safety of transitioning previously inpatient-based regimens to the outpatient setting and identified those regimens that were most appropriate to pilot. An evaluative ranking process identified high-dose cytarabine for treatment of acute myeloid leukemia and infusional cyclophosphamide for multiple myeloma as most appropriate to be home-based regimens. Phase II of the pilot involved developing a process for the administration of select rituximab-based regimens between the inpatient and outpatient setting, with tightly fitted communication to ensure seamless transitions in care. Patients receive rituximab in the ambulatory clinic and are then admitted to a reserved hospital bed for the remainder of the regimen. Results: Since pilot inception and abstract submission, 20 patients have either received their entire regimen as an outpatient or by using our split location process. Preliminary analyses reveal an increased bed capacity for acute patients and outside hospital referrals by preventing scheduled admissions and reducing overall length of stay for rituximab-based regimens. Survey responses from patients and families are overwhelmingly positive. Conclusions: Care delivery models must be continually evaluated to adapt to change in this dynamic health care era. Our pilot suggests beneficial outcomes for patients and health care systems alike. As an institution, we have seen the effects that integrated team communication and tighter care coordination have on patient care and outcomes.
Efficacy of oral ketamine against opioid-refractory cancer pain due to bone metastases: Four case reports.
Authors: Hagihara Takeshi
Published: February 2017

161

Background: The use of oral ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is reported to be effective against opioid-refractory cancer pain. Only a few studies have been performed worldwide so far, and in Japan we have more difficulty evaluating it, as the insurance doesn’t cover the application of ketamine to the tumor pain unlike in some other countries. Here we present the successful treatment of four patients with severe cancer-related pain due to bone metastases, by oral administration of ketamine. Methods: Inclusion criteria were cancer pain refractory to standard opiates. After institutional approval and informed patient consent were obtained, the treatment started with 40mg/day of oral ketamine. The ketamine regimen was adjusted individually based on analgesia and any adverse effects. Results: Self-reported pain significantly improved. In addition, serious adverse effects such as nightmares were not observed. In one case, epidural anesthesia became unnecessary. In another case, base and rescue opiates regimen can decreased. Conclusions: Ketamine is considered one of the World Health Organization essential drugs for the management of refractory pain. By oral administration of ketamine the quality of life can be improved, so we consider that further studies should be performed.
Bridging efforts to longitudinally improve and evaluate venous thromboembolism prophylaxis uptake in hospitalized cancer patients through interprofessional teamwork (BELIEVE IT): A study by Princess Margaret Cancer Centre.
Authors: Seki Jack Toshimine , Vather Triyu , Kukreti Vishal , Krzyzanowska Monika Karolina
Published: February 2017

170

Background: Thromboprophylaxis continues to be underutilized in hospitalized cancer patients despite the demonstrable risk of venous thromboembolism (VTE). Our study evaluated institutional VTE prophylaxis rates after devising a series of strategic interventions to longitudinally improve adherence rates over a period of eight years. Methods: Solid tumour patients admitted between 2004 and 2012 were selected as the primary study population for analysis. The bleeding risk associated with thromboprophylaxis was discernibly minimal. Guidelines were developed and formalized into an institutional thromboprophylaxis policy. Educational in-services were provided to physicians, nurses and pharmacists to review the most updated guidelines and tools added to encourage compliance to VTE prophylaxis. Support also arose from clinical members of the Cancer Quality Committee. An amalgamation of manual and electronic audit formats were undertaken to asses VTE prophylaxis rates prior to, and following strategy implementation. These audit formats either comprised of visiting inpatient units and examining anticoagulant orders on a per-patient basis, or viewing patient consensus reports and active anticoagulant orders electronically. Results: At the 2004 outset, 11 (19.3%) patients received appropriate pharmacological prophylaxis, and thus formed the baseline of our analysis. Post-2009 policy implementation and educational sessions, 46.5% of an eligible 185 inpatients were administered thromboprophylaxis. Following a two-year grace period to allow for policy acceptance, a series of three audits were conducted in 2011 for which an average prophylaxis rate of 62.3% resulted. In 2012, following awareness by clinicians of previous rates and rigorous strategy execution, a 96.7% rate was achieved and maintained five weeks thereafter. Conclusions: A reproducible 96.7% prophylaxis rate was the result of our cumulative eight-year efforts. A multidisciplinary approach is critical to improving thromboprophylaxis uptake rates and ensuring long-term sustainability of this outcome.
Safe chemotherapy: Clinicians driving technology and not the other way around.
Authors: Kukreti Vishal , Cosby Roxanne , Cheung Annie , Hamasoor Marie , Hertz Sherrie , Kaiser Leonard , Lankshear Sara
Published: February 2017

183

Background: Although information technology (IT) has the potential to improve the quality and safety of patient care, introduction into the clinical work flow may create unanticipated consequences. IT solutions such as computerized physician order entry (CPOE) are often designed and executed without end-user involvement. An evidence based guideline for systemic treatment (ST) CPOE was developed. The guideline looks at the features, functionalities and components of a ST CPOE system required to ensure safe and high-quality care. Methods: The guideline was developed by an interdisciplinary panel of physicians, nurses, pharmacists, methodologists, IT specialists, and human factors experts. A systematic review was conducted of the available clinical and technology literature and key informant interviews were conducted. Role-specific CPOE functionalities were process mapped for physicians, nurses and pharmacists. Two expert panels (i.e., clinical and supporting tools) were convened to review the information and provide feedback on guideline content. The guideline was also reviewed externally by content experts from provincial, national and international organizations. Results: The resulting evidence-based guideline focused on two distinct yet interconnected parts: clinical practice (e.g., error prevention, unanticipated consequences, impact on practice, clinical decision support), and technology requirements (e.g., usability features, system integration, effective alerts, audit logs, regimen building). The recommendations also highlight the importance of change management strategies and clinician engagement. Conclusions: This innovative guideline provides an approach to technology evaluation focusing on clinical practice needs driving IT solutions. Future research to help standardize design and usability of such systems is necessary. The non-vendor specific recommendations can be used as the foundation for evaluation of ST CPOE systems to reduce errors, improve safety, and support clinical practice. The application of the recommendations as an assessment of ST CPOE system guideline concordance will also be valuable.
The future delivery of oncology care: Thoughts on the impact of quality improvement, personalized medicine, and integrating interprofessional collaboration.
Authors: Robinson Caroline Osborne , Abdolrasulnia Maziar , Nevins Holder , Ruggiero John E.
Published: February 2017

19

Background: A significant thrust within recent innovation has been focused on improving the quality of diagnostics and system adherence to guidelines; equally important are attempts to improve patient-specific therapy plans, or personalized medicine. These two approaches—quality improvement and personalized medicine—have equally laudable goals toward improving cancer care and outcomes, yet have not been fully examined for their concomitant impacts, particularly among and within interprofessional teams, in which a mix of health care providers present varied foci within the oncology care delivery process. Methods: Twenty phone-based qualitative interviews were facilitated with community-based medical oncologists in active practice in July 2012. Transcripts of the interview sessions were examined through grounded qualitative analysis, and overall findings are presented. Results: Oncologists hold varied definitions of personalized medicine, yet share understanding of the central nature of the patient within personalized medicine care delivery. More varied are oncologists’ perceptions of the goals and value of implementation of quality improvement initiatives, which range from those focused on pragmatic concerns of the oncology clinic, such as patient flow, to the quality of clinical decision-making and outcomes. Oncologists value well-functioning and clearly defined roles within interprofessional teams within oncology practices, both among other clinicians and allied team members. However, functional and perceptional gaps remain in the practical application of quality improvement objectives within interprofessional teams and within the implementation of personalized oncology care delivery. Conclusions: This exploratory qualitative analysis approach provides grounded identification of practicing oncologists’ definitions of quality improvement, personalized medicine, interprofessional care delivery, and the practical interrelationships between these domains, enabling a framework for future research and quality initiatives.
De-adoption of epidermal growth factor receptor (EGFR) inhibitors following recommendations for KRAS testing to guide treatment of metastatic colorectal cancer (mCRC).
Authors: Dotan Efrat , Li Tianyu , Hall Michael J. , Meropol Neal J. , Beck Robert J. , Wong Yu-Ning
Published: February 2017

191

Background: KRAS mutation status is a predictive biomarker for resistance to EGFR antibodies among mCRC pts, and is recommended for use by ASCO and the FDA. Little is known about the uptake of clinical recommendations in oncology practice. We sought to study the effect of ASCO and FDA guidelines on the use of EGFR antibodies among a commercially insured population. Methods: The LifeLink Health Plan Claims Database (formerly the PharMetrics Patient-Centric Database) was used to create a cohort of >18 yo mCRC pts treated between 2004-2010. We identified treatment and diagnosis using ICD-9 or HCPCS (J) codes. We defined 1st-line therapy as any chemotherapy +/- bevacizumab given after the pt had a claim for mCRC, excluding pts treated with EGFR antibodies in the 1st line. 2nd-line therapy was defined as the initiation of a new chemotherapy agent (irinotecan/oxaliplatin) +/- EGFR antibody. We examined pts in two-month time intervals and calculated the fraction of pts in each interval who received EGFR antibody at any point beyond their 1st-line treatment. Chi 2 tests were used to compare treatment rates at the time points shown in the Table. Results: 5,099 pts received 2nd-line therapy of which 2,603 pts received an EGFR antibody. Median age was 61 years, with 57% males. 59% received an EGFR antibody as a single agent. The remainder received this in combination with one or more of the following agents: fluorouracil 13.5%, irinotecan 36.7%, oxaliplatin 3.9%, and bevacizumab 6.1%. Rates of EGFR antibody use are outlined in the Table. Conclusions: The utilization of EGFR antibodies for mCRC treatment decreased following the presentation of clinical trial data, publication of ASCO guidelines and FDA label change. These data suggest that oncologists respond rapidly to new evidence and professional guidelines, and readily accept the use of predictive biomarkers in clinical practice. [Table: see text]
Adherence to head and neck cancer guidelines: Setting the stage for continual quality improvement.
Authors: Nurgalieva Zhannat , Weber Randal S. , Lai Stephen Yenzen , Sturgis Erich M. , Beadle Beth Michelle , William William , Lewis Carol M.
Published: February 2017

193

Background: Adherence to clinical guidelines, such as those developed by the National Comprehensive Cancer Network (NCCN), can serve as a quality measure for delivered care. We aimed to assess multidisciplinary conference (MC) treatment recommendations’ adherence to NCCN head and neck cancer guidelines, while identifying potential areas for quality improvement. Methods: Patients presented with previously un-treated head and neck cancers are being prospectively accrued as they are presented at weekly MC. The charts of patients presented between 10/20/2011 and 6/31/2012 were retrospectively reviewed for clinical data leading up to MC to allow us to assess whether, based on the available information, the recommendations of conference are compliant with NCCN treatment guidelines. Results: We identified 231 eligible patients. TNM staging was documented in 90.9% of MC notes and treatment recommendations were documented for 93.5% of patients; the remainder of presented patients required further evaluation before a treatment plan could be determined. Of 196 enrolled patients, 53% had oropharyngeal cancer, 25% had oral cavity cancer, 18.4% had laryngeal cancer, and 3.6% had nasopharyngeal cancer. For the entire cohort, the mean age at presentation was 59.5 years. One hundred fifty nine patients (81.1%) were men. The recommendations of conference were compliant with NCCN treatment guidelines for 92.3% patients. The main reasons for non-compliance in 15 patients were treatment of T1/2N2 oropharyngeal cancer with definitive radiation alone (6 patients), incomplete documentation (4 patients), and recommended over-use of adjuvant therapy (3 patients) and induction chemotherapy (2 patients). Conclusions: NCCN guideline compliance can be used to evaluate the quality of head and neck cancer care. Although most cases involving deviation resulted from incomplete MC documentation, areas for improvement were identified. Further study is needed to evaluate how care that deviates from NCCN guidelines affects patient outcomes.
The impact of “significant others” on breast cancer patients’ treatment decision making.
Authors: May Suepattra G. , Rendle Katharine , Halley Meghan , Ventre Nicole , Kurian Allison W. , Yu Peter Paul
Published: February 2017

20

Background: Shared medical decision making (SDM) has been lauded by advocates for its potential to democratize the patient-physician relationship. However, the practice of SDM is still conceived of as largely a dyadic moment that exists between the patient and the physician. Few studies have looked at the role of significant others (spouses, partners, family members and friends) in decision making or considered how discussions and actions outside the consultation room affect a patient’s medical decisions. This prospective study investigated the impact of significant others on the decision making deliberations of newly diagnosed breast cancer patients. Methods: Forty-one newly diagnosed breast cancer patients were interviewed at four critical time points throughout treatment to explore how they deliberated decisions with both care providers and significant others. Surveys assessing HRQOL, role preferences and treatment satisfaction along with EHR abstraction augmented interview data. Grounded theory analysis was used to identify recurrent themes in the qualitative data, and survey data were analyzed using IBM SPSS Statistics 20. Results: Emergent themes from our analysis identified several factors that patients consider when faced with cancer treatment decisions, including 1) presentation of treatment options 2) patient or significant other conflict/concordance with care team recommendations 3) perceived risk of recurrence and 4) short and long term impact of treatment on daily life. Participants stressed the need for clinicians to view patients beyond diagnosis and recognize their larger care network as influential factors in their decision making. Conclusions: Our interviews highlight how the current healthcare delivery structure rarely acknowledges the circles of care that can exert influence on decision making. Lack of attention to non-clinical others can lead to sub-optimal medical decision making because these influences are not adequately understood by clinicians. Findings from this study suggest the need to enhance clinicians’ and researchers’ understanding of the influence of others in patients’ treatment decision making, enabling them to intervene in these practices.
Quantification of the impact of multifaceted improvements in patient safety culture: A case study from academic medical center radiation oncology department.
Authors: Chera Bhishamjit S. , Maszur Lukasz , Mosaly Prithima , Jackson Marianne , Taylor Kinely , Burkhardt Katharin , Chang Sha , LaChapelle Dana , Rockwell John , Miller Seth , Zagar Timothy , Jones Ellen , Church Jessica A. , Adams Robert D. , Marks Lawrence Bruce
Published: February 2017

205

Background: We have systematically been incorporating several safety initiatives (based on process-engineering and Lean methodologies) into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful metrics. Methods: The data from five quality improvement initiatives are presented. For each, data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using descriptive statistics and unpaired student t-test. Each initiative focused on a specific safety/process concern in our clinic. Results: 1) Workload levels for nurses assisting with brachytherapy were too high (NASA task load index scores >55-60, suggesting, “overwork”). Changes in work flow and procedure room layout reduced workload scores to more acceptable limits (<55). 2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range 1-11) times per patient treatment to a mean < 1 (range 0-3, p<0.001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (e.g., delayed, on time). 3) The rates of replans by dosimetrists was reduced from 11% in 2010 to 6% in 2011 though a more systematic pre-treatment peer review process. 4) Standardizing nursing/resident functions reduced patient wait times by ≈ 45% (14 min). 5) Standardizing pre-simulation instructions from the physician within the EMR reduced the number of patients experiencing delays on the simulator (from approximatley >50% to <10%). Conclusions: Process engineering and Lean methodologies can be successfully applied in an academic radiation oncology department to yield measurable improvements in operations likely improving quality/safety.