bluuebunny/crossref_metadata_2025 huggingface dataset:
Pre-COVID-19 food insecurity prevalence and risk factors in caregivers of pediatric cancer patients at a children’s cancer hospital.
Authors: Wells Stephanie J. , Brown Brandon Douglas , Mahadeo Kris Michael , Schadler Keri L. , Chandra Joya , Swartz Michael D. , Swartz Maria Chang
Published: October 2020

205

Background: Food insecurity (FI) affects 1 in 5 US households with children and is associated with malnutrition and poor diet quality in children. Malnutrition negatively impacts clinical trial outcomes, chemotherapy tolerance, and survival rate in cancer patients, who may be at higher FI risk given the financial toxicity of treatment. Thus, we aimed to assess FI prevalence and sociodemographics of pediatric patient caregivers at MD Anderson Cancer Center Children’s Cancer Hospital (MDACC-CCH) and to identify healthcare provider sociodemographics and FI practice considerations. Methods: We surveyed caregivers and providers at MDACC-CCH anonymously from December 2019 to January 2020. Caregiver surveys included sociodemographics and The Hunger Vital Sign FI screening tool. Oncologists and other providers were surveyed on FI-related practice considerations. Univariate relationships between known covariates and FI were explored using purposeful covariate selection and multivariable logistic regression to model variables associated with FI risk factors. Results: Baseline characteristics are listed in Table. Of 67 caregiver responses, 36% were positive for FI. Univariate analyses revealed that race, education level, spousal/child support, marital status, and household income were associated with FI status. Final logistic regression model indicated that race other than Non-Hispanic White and lower education level were positively associated with FI. Of 38 provider responses, 58% reported being knowledgeable about FI to some extent. No providers referred patients to community food access resources. Conclusions: In a small pilot study, FI is prevalent in families of pediatric cancer patients at MDACC-CCH and may be associated with race and education level. Further research is needed to assess the impact of the COVID-19 pandemic on FI in this population and to determine appropriate interventions and clinical pathways to improve FI status. [Table: see text]
Prospectively assessing risk of acute care utilization for patients with an active cancer diagnosis.
Authors: Csik Valerie Pracilio , Binder Adam , Li Michael , Handley Nathan
Published: October 2020

208

Background: Acute care utilization (ACU)--emergency department visits or hospitalizations--is common in patients with cancer. As many as 83% of all patients with cancer visit the emergency department annually; nearly three quarters of patients with advanced cancer are hospitalized in the year after diagnosis. Much of this ACU may be preventable. Identifying patients at risk for ACU using model-based approaches has shown potential for risk stratifying certain patient subgroups. However, a model applicable to any patient with an active cancer diagnosis is needed. We developed a real time clinical prediction model to assess risk for acute care utilization in patients with an active cancer diagnosis. Methods: We completed a retrospective cohort analysis of patients with an active cancer diagnosis (defined as at least one medical oncology encounter in a 12 month period) at one health system. Clinical factors with potential to impact disease progression and ACU were identified through a clinical review. Significant variables were defined by multivariate logistic regression. Risk of ACU was further characterized through the development of a point scoring system to define the upper decile of patients at highest risk. Results: We included 8,246 patient records in the analysis. Seven variables were determined to be statistically significant: An emergency department visit in the last 90 days, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, low hemoglobin, low albumin, and low absolute neutrophil count. The model produced an overall C-statistic of 0.726 Each significant variable was assigned a score of 0 or 1 (with the exception of ED visits, which were given one point for each visit, with three points maximum). Each patient received a total score, resulting from the summation of the individual variable scores. An evaluation of the distribution of points determined that 10% of the patients achieved a score of 2 or higher and contributed to 46% of ACU in the last 90 days. Patients receiving 0 points were defined as low risk (73% of patients contributing to 30% of ED/admissions). Patients receiving 1 point were deemed intermediate risk (17% of patients contributing to 24% of ED/admissions). Conclusions: Risk of acute care utilization for patients with an active cancer diagnosis can be prospectively assessed. This tool is currently integrated into our clinical practice and is updated every 14 days, or any time the chart is accessed. Assessment of efficacy is ongoing.
Moving palliative care upstream for patients diagnosed with head and neck cancers.
Authors: Day Tamara M
Published: October 2020

227

Background: Adults with cancer face complex treatment choices and symptom burden that impact their quality of life. Goals of palliative care (PC) are to reduce symptom burden and improve quality of life. Strong evidence exists that PC helps reduce symptom burden, decreases hospital utilization, and improve quality of life. Yet, PC remains underutilized, especially in the context of cancer care. Methods: This descriptive longitudinal study evaluated whether use of a psychosocial distress screening tool would help identify patients eligible for PC. A convenience sample of adults with diagnosis of head and neck cancers presenting to an otolaryngology clinic, located in the cancer center of a Midwestern academic health system, were screened for eligibility for PC referral. If eligible, the provider was notified and introduced PC to the patient. Upon acceptance, a PC referral was ordered. The project consisted of baseline (n = 61) and follow-up chart reviews (n = 60) of patients seen in clinic during over a 3-month period. Results: We found an increase in PC referrals from 14.6% at baseline to 30.8% in follow-up, a 227% increase. Psychosocial distress screenings increased from 5% at baseline to 45% in follow-up, an increase of 200%. Of patients who received a PC referral, 85.6% accepted. There were statistically significant differences found between the pre- and post-intervention groups for marital status, χ2 (3) = 9.67, ( p = .02); and cancer stage χ2 (4) = 21.35, ( p = .00) with increased referrals for married patients at higher cancer stages in the prospective group. Conclusions: This study has shown physicians maybe more likely to offer PC referrals based on cancer stages, and not based on psychosocial distress symptoms. Potential barriers to early referral to PC were identified and could serve as useful information for future studies.
Improving care for patients with stage III/IV NSCLC: Learnings for multidisciplinary teams from the ACCC National Quality Survey.
Authors: Salgia Ravi , Boehmer Leigh , Celestin Catherine , Yu Judy , Spigel David R.
Published: October 2020

228

Background: Refinement of the multidisciplinary team (MDT) approach continues to offer significant potential for improving the quality of non-small cell lung cancer (NSCLC) care and adherence to guideline-recommended protocols. This opportunity arises, in part, from insufficient characterization of MDT practice patterns and barriers to optimal care provision within U.S. cancer programs. The Association of Community Cancer Centers (ACCC), therefore, conducted a national survey to improve understanding on how patients with stage III/IV NSCLC were diagnosed and managed across different practice settings, with the aim of informing the design and execution of process-improvement plans to address identified barriers. Methods: ACCC convened an expert steering committee of multidisciplinary specialists, including oncologists, thoracic surgeons, pathologists, pulmonologists, and representation from patient advocacy, for a comprehensive, double-blind, web-based survey (January–April 2019) to obtain insights on cancer care delivery for patients with NSCLC in a diverse set of U.S. community cancer programs. Results: Of 1211 questionnaires, 639 responses affiliated to 160 unique cancer programs across 44 U.S. states were suitable for analysis. In total, 41% (n = 261) of respondents indicated that their cancer program did not have a thoracic multidisciplinary clinic. Nurse navigators (P = 0.03) and radiation oncologists (P = 0.04) were significantly more likely to engage in shared decision-making practices than other disciplines. The average time to first therapeutic intervention in newly diagnosed patients was 4 weeks (range = 1–10 weeks; n = 298). A significant negative correlation between frequency of tumor board meetings and time to complete disease staging (P = 0.03) was observed. The most challenging barriers to delivering high-quality NSCLC care are listed (Table). Conclusions: Multiple opportunities exist to improve the delivery and quality of care for patients with stage III/IV NSCLC, including reducing barriers to effective care coordination and patient education, screening, diagnosis and biomarker testing, and adherence to evolving standards of care. [Table: see text]
Identifying areas for quality improvement through outpatient mortality review.
Authors: Gococo-Benore Denise , Kase Adam McLain , Majeed Umair , Alhaj Moustafa Muhamad , Chen Ruqin , Battu Sree , Kilpatrick Molly , Robinson Maisha , Cowart Jennifer , Moreno-Aspitia Alvaro , Jones Jeremy Clifton , Ailawadhi Sikander , Sher Taimur , Advani Pooja Prem
Published: October 2020

230

Background: Inpatient mortality review is commonly used to improve patient care. Individual review of outpatient deaths is less common, yet 30-day mortality after hospital stay is an important quality metric. In this study, we sought to identify opportunities for care improvement by reviewing outpatient mortalities for cancer patients who died within 30 days of hospitalization. Methods: We identified 48 patients at Mayo Clinic Florida, with a hematologic (heme) or solid tumor (onc) cancer, who died within 30 days of an index hospital stay in 2018. We created a 32-question review survey to address quality of care around the hospital stay. The review team consisted of 1) heme or onc attendings, 2) heme/onc fellows, and 3) palliative care attendings. Each case was reviewed by one member of each of the 3 groups, split into heme or onc cases. Discrepancies in objective data points were resolved by the research team. Results: Of 143 surveys sent to 13 physicians (3 heme), 112 responses from 11 physicians (1 heme) for 47 patients were received. Twenty-one patients (45%) received cancer therapy within 30 days of death, and 23 (49%) were admitted >2 times in 2 months prior to death. For onc cases, attendings rated prognosis as discussed 83% of the time, vs 65% of fellows and 39% of palliative care; in heme cases, the attending rated prognosis as discussed 11% of the time, vs 86% of fellows and 50% of palliative care. In heme cases, the attending rated expected survival <3 months in 33% of cases vs 71% by fellows and 89% by palliative care; in onc cases, the reviews were more consistent (79% attending, 85% fellow, 93% palliative care). See Table for timing of prognosis discussions and palliative care involvement. Conclusions: The most common improvement opportunities identified by reviewing heme/onc patients who died within 30 days of a hospital stay included documented prognosis discussion and involvement of palliative care. Opportunities differed between heme and onc patients. Future directions include identifying and mitigating barriers that providers face in reaching these goals for their patients. [Table: see text]
Use of CARG toxicity tool to predict chemotherapy toxicity in older veterans to facilitate better treatment outcomes.
Authors: Chamarthy Srinivasu , Kumar Geetika
Published: October 2020

244

Background:
Traditionally the Eastern Cooperative Oncology Group (ECOG) performance status has been used to assess objective patient well- being and to determine whether geriatric patients can tolerate chemotherapy. Hurria and colleagues from The Cancer and Aging Research Group (CARG) developed a validated geriatric assessment model for adults > 65 yrs. to predict the risk of grade 3-5 chemotherapy toxicity in the treatment of solid tumors. The CARG score, ranging from scores of 0 to 19, incorporates measures of functional status such as fall history, hearing problems, physical capabilities, performance status as well as objective measures including age, gender, height, weight, cancer type, type and dose of chemotherapy, hemoglobin, and creatinine clearance.
Methods:
At the Dayton VA Medical Center, the utility of the CARG tool was studied in patients to predict chemotherapy tolerance for treatment naïve veterans age > 65 yrs. who were diagnosed with solid tumor malignancies excluding leukemias. CARG scores were stratified as low (score 0-5), intermediate (score 6-9) and high risk (score 10-19). The CARG toxicity score was compared with standard use of ECOG performance status alone to predict chemotherapy toxicity. Subsequent changes in chemotherapy dosage, treatment delays due to adverse effects as well as mortality rate after treatment were also monitored.
Results:
The study, which enrolled 20 patients over 1 year, revealed that out of 18 patients with ECOG 0-2, 94% had at least an intermediate CARG risk for chemotherapy toxicity and 50% were shown to have high CARG risk for chemotherapy toxicity. Of the 11 high-risk CARG patients in the study, 45% had chemotherapy intolerance. Of the 17 treated patients with calculated CARG toxicity risk 50% or higher, there was a 41% mortality rate.
Conclusions:
Geriatric assessment modalities are integral to predict chemotherapy toxicity in geriatric patients. These modalities should be part of routine assessment of geriatric cancer patients in order to adequately incorporate their functional status when calculating chemotherapy dosage as the solitary use of ECOG performance status appears to be inadequate for this purpose. The calculated CARG risk percentage may be a better predictor of mortality rate than the ECOG score.
Prognostic value of the “surprise question” among UPMC Hillman Cancer Center patients with select stage IV cancer diagnoses.
Authors: Gade Kristine , Spada Neal , Ormond Ellen , Bhatnagar Mamta , Guyette Maria , Brown Aaron , Cullison Kevin , Thomas Roby Antony
Published: October 2020

25

Background: The “Surprise Question” — Would I be surprised if this patient died in the next 12 months? — was developed to help clinicians predict when patients are nearing the end of life. Limited data has shown that the “Surprise Question” is modestly predictive of mortality (CMAJ 2017 Apr 3;189(13):E484-E493), though its performance seems to be superior among cancer patients (Palliat Med 2014 Jul;28(7):959-964). Via Oncology Pathways, a platform used by UPMC Hillman Cancer Center and other institutions nationwide to guide treatment decisions, asks physicians the “Surprise Question” when a new treatment plan is implemented for patients with metastatic cancer. We assessed the “Surprise Question’s” ability to predict survival among Hillman Cancer Center patients with select stage IV diagnoses. Methods: We queried the UPMC Hillman Cancer Center Registry Information and Reporting Services for cases of colorectal, non-small cell lung, prostate, pancreatic, and breast cancer with clinic visits between 1/1/2016 and 12/31/2017 and residence in Allegheny County, the primary referral base for the UPMC Hillman Cancer Center network’s flagship facility. Results: The “Surprise Question” was completed for 1,584 patients with metastatic disease of the 5,330 patients that were screened. “No” was the response for 891 patients (56.3%). Mortality at 12 months for patients for whom the answer to the “Surprise Question” was “no” was 63.1%, compared to 32.5% for patients for whom the answer was “yes” (P < 0.0001). The sensitivity of the “Surprise Question” was 71.4% (95% CI 69.0 – 73.8%), and the specificity was 58.7% (95% CI 56.3 – 61.0%). The positive predictive value was 63.1% (95% CI 60.9 – 65.2%) and negative predictive value 67.5% (64.8% – 70.2%). Finally, the positive likelihood ratio was 1.73 (95% CI 1.58 – 1.89) and negative likelihood ratio 0.49 (0.43 – 0.55). Conclusions: While a “no” response to the “Surprise Question” for UPMC oncology patients with select stage IV diagnoses was more likely to predict 12-month mortality than a “yes” response, the “Surprise Question” was only modestly predictive of 12-month mortality. Future work will focus on determining if there are patient populations for whom the “Surprise Question” is more predictive and assessing the ability of the “Surprise Question” to predict other clinical outcomes, such as ED visits and hospitalizations.
Creation of a telehealth task force to improve successful use of telehealth to maintain patient access during the COVID-19 pandemic.
Authors: Bhatia Avnish K , Waldman Lauren , Hunt Melissa , Leader Amy , Palidora Janene , Sabonjian Megan , Selvan Preethi , Shimada Ayaka , Worster Brooke , Garber Gregory D.
Published: October 2020

264

Background: In response to the COVID-19 National Emergency, the Sidney Kimmel Cancer Center (SKCC) medical oncology practice desired to greatly expand telehealth (TH) utilization to decrease patient risk while maintaining access to care. TH utilization requires resources (smart phones, internet) and there are disparities in digital media access in our patient population. A digital literacy survey performed at the SKCC in 2018 noted that 30% of patients used Android phones and > 60% of patients accessed the internet from a PC. Methods: In response to increased TH demand and need for support, the SKCC launched an oncology-dedicated Telehealth Task Force (TTF) to address barriers to TH access. The TTF team consisted of nine full-time individuals with digital and healthcare literacy to assist in telehealth and patient portal troubleshooting. Critical functions of TTF’s targeted patient solutions include; set-up and delivery of smartphones, creating email accounts, performing test visits, creating EHR patient portal accounts, real- time assistance during TH visits with implementation of this intervention beginning on April 3, 2020 with monitoring of patient interactions/touchpoints. Results: The SKCC medical oncology TTF noted increased interactions with patients immediately with a marked increase in the composite of medical oncology appointments completed by TH (51.0% in April 2020 compared to a prior level of 15.7% in March 2020). Additionally, there was a statistically significant increase in the proportion of patients have an active patient portal EHR account during this same period (14.6%; 95% CI, 12.3% to 16.9%; p < 0.0001). Oncology infusion treatment appointments remained relatively consistent over time. Conclusions: The SKCC medical oncology practice experienced an exponential rise in TH utilization during an uncertain public health crisis. Disparity in digital literacy and resources essential for successful TH use were quickly appreciated as potential barriers to access. The creation of a dedicated Telehealth Task Force was critical in maintain access to care for oncology patients given their vulnerability to infection. Further investigation of TH supports to improve TH use are warranted. [Table: see text]
Barriers to telehealth: The patient perspective.
Authors: Bodine Charles Douglas , Das Devika Govind , Haywood Karice , Khan Morgan
Published: October 2020

266

Background: During the COVID-19 pandemic, the need for telehealth has come to the forefront of healthcare. In the right clinical context, telehealth is an easy and effective way for providers to deliver high quality care, while also taking away barriers to care access such as clinic inconvenience, distance traveled, financial toxicity, etc. An abundance of data exists regarding the benefits and potential of telehealth, but most data is from the perspective of the provider. Unfortunately, there is little information regarding the patient’s perspective and satisfaction; and even less regarding accessibility issues in terms of technology and cultural perception of telehealth. We postulate that there is a need for individualized grass root level understanding of the population being served to make sure telehealth adoption is sustained and equitable. We are studying this using a rapid cycle improvement project using a Plan Do Study Act format (PDSA), with a cohort of veterans in a medical oncology clinic in Birmingham, AL. Methods: We spoke with a pilot cohort of 67 patients in the medical oncology clinic at the VA Medical Center in Birmingham, AL. Surveys were done on all patients prior to their initial telehealth visit. Patients first agreed to participate, and then answered a 6-question survey regarding their perception of telehealth, their willingness to participate, and their perceived barriers to participation. We then identified barriers to intervene upon, with the plan to engage senior VA Leadership for the same. Results: 67 medical oncology patients in the Birmingham VA between May 1 and May 31, 2020, agreed to participate in a survey prior to their first telehealth appointment. We found that of the 67 patients surveyed, only 48 (71.6%) had a video capable phone and only 41 (61.2%) had high-speed internet or data to support that call. Interestingly 25 patients (37%) did not feel they could access the video on their own phone. While this presented one barrier to telehealth, we also found that 11 patients (16.4%) would not want to participate in telehealth even if they had a video capable device. Conclusions: This data, while not exhaustive, clearly captures some unique barriers to telehealth that may not have been previously studied or understood. Hearing the voice of the patient is critical in developing culturally competent forms of telehealth delivery. We will use this data to implement interventions that not only provide access of technology for our patients but will also make sure to specifically address the cultural/socioeconomic barriers to this form of healthcare distribution and how to overcome those barriers.
Real-world outcomes among patients with epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer treated with EGFR tyrosine kinase inhibitors versus immunotherapy or chemotherapy in first-line setting.
Authors: Simmons Daniel , DerSarkissian Maral , Shenolikar Rahul , Wang Min-Jung , Lax Angela , Muthukumar Aruna , Laliberté François , Duh Mei Sheng
Published: October 2020

281

Background: While EGFR tyrosine kinase inhibitors (TKIs) are the NCCN-recommended first-line (1L) therapy for non-small cell lung cancer (NSCLC) patients (pts) with EGFR mutation (EGFRm), many pts initiate immunotherapy (IO) + chemotherapy (chemo) prior to receiving EGFRm test results. This study assessed clinical outcomes associated with initiating EGFR-TKI vs other therapies in stage IV EGFRm NSCLC. Methods: A retrospective study was conducted in adults with stage IV EGFRm NSCLC who initiated 1L EGFR-TKI, IO (+ chemo), or chemo alone from 5/2017-12/2018, using Flatiron Health Electronic Health Record data. Treatment patterns were characterized with respect to timing of EGFRm test results. Kaplan-Meier analysis and log-rank tests were used to evaluate the median duration of therapy (DoT) and time to next therapy (TTNT), as proxies for progression-free survival. Adjusted hazards ratios (HR) and 95% confidence intervals (CI) representing the effect of 1L therapy on the risk of discontinuing treatment or death (DoT) and the risk of initiating second-line therapy or death (TTNT) were reported from multivariable Cox proportional hazards models controlling for differences in demographics, smoking history, histology, cancer stage, ECOG score, NCI index, time from diagnosis to 1L initiation, and year of 1L initiation, across treatment arms. Results: Among 593 study pts, mean age was 67.5 years and 65.4% were female. EGFR-TKI was used as 1L therapy for 77.2% of pts (n=458), IO in 13.3% (n=79) and chemo in 9.4% (n=56). 7.2% of EGFR-TKI pts, 54.4% of IO pts, and 57.1% of chemo pts initiated 1L before receiving EGFRm test results. Compared to pts on IO and chemo, pts on EGFR-TKI had longer median DoT (EGFR-TKI: 8.7 months [mo]; IO: 4.8 mo; chemo: 3.0 mo, p<0.01) and median TTNT (EGFR-TKI: 12.3 mo; IO: 6.5 mo; chemo: 4.0 mo, p<0.01). Adjusted analyses showed that compared to pts on IO or chemo, pts on EGFR-TKI had significantly lower risk of discontinuing therapy or death (DoT) and initiating second-line therapy or death (TTNT) (Table). Conclusions: Substantial numbers of pts initiated IO + chemo in 1L and EGFR-TKI was associated with better clinical outcomes than IO + chemo, suggesting the importance of adhering to NCCN-recommended therapy for stage IV EGFRm NSCLC pts. [Table: see text]
Development and implementation of an evidence-based malignant hematology clinical pathway program.
Authors: Brahim Amanda , Vargas Madueno Fernando Manuel , Wilkinson Robert , Hardwick Melissa , Deutsch Yehuda Ethan , Sandoval-Sus Jose David , Fernandez Hugo Francisco
Published: October 2020

304

Background: Clinical pathways provide a means to maximize value-based care for cancer patients. They have been associated with decreased costs and outcome improvements. Our institution entered a transformative partnership with an NCI designated comprehensive cancer center for the treatment of hematologic malignancies. As part of the collaboration, a multidisciplinary task force was established to adapt clinical pathways within our system. Given the multiple new drug approvals for the treatment of Acute Myeloid Leukemia (AML), this was the first pathway created. Methods: The taskforce consisted of physicians, pharmacists, nurses, quality manager, and information technology staff. The group met weekly to draft algorithms in accordance with national guidelines, updated evidence and institutional preferences. Electronic Medical Record (EMR) treatment plans were reviewed in a secondary multidisciplinary workgroup and validated to ensure compliance with the AML pathway. When applicable, specific criteria for use were developed to aid in medication use optimization. The finalized pathway and treatment plans were presented and approved at our clinical standards committee meeting. A chart audit was performed one year after pathway implementation to assess adherence, with a goal of 80% or higher. The results were compared to an audit assessing adherence to best available clinical evidence for the year prior to implementation. Results: The group established a consensus on treatment, laboratory testing, and supportive care, including anti-emetic, anti-microbial, and tumor lysis syndrome (TLS) prophylaxis. Electronic order sets were created for bone marrow biopsies, transfusion support, TLS and febrile neutropenia. Thirty-two EMR treatment plans for AML were built and/or revised, while five were inactivated. A total of 88 patient charts were included in the pathway adherence audit (44 before and 44 after implementation). Pre and post pathway adherence was 64% and 89%, respectively (p=0.006). Deviations were categorized by type (table). Conclusions: AML pathway development and implementation resulted in standardization of treatment regimens, supportive care and higher adherence to institutional evidence based practices. [Table: see text]
Optimizing internal referrals within an academic breast oncology practice.
Authors: Carroll Jamie L , Amundson Stephanie L. , Haddad Tufia C. , Giridhar Karthik
Published: October 2020

48

Background: Improving new patient access to medical oncology clinics is a priority. Unlike external referrals which undergo a review process, internal referrals (from any Mayo department or community-based, affiliated health system) are scheduled directly. At times, these internal referrals lack necessary clinical information, or may be more appropriate for electronic consultation (e-consult). This impacts the patient experience, provider satisfaction, and access to new patient visits. A pilot program was implemented in the Medical Oncology breast clinic to review new internal referrals prior to scheduling. Methods: In 2018, all internally referred patients to Medical Oncology breast clinic were reviewed by an advanced practice provider in breast oncology. Electronic medical records were reviewed to collect diagnosis, pathology, radiology information and treatment to date. Internal referrals were either accepted directly to medical oncology breast clinic, triaged to an internal medicine clinic for workup of a new breast mass, converted to an e-consult, or declined as no medical oncology need was identified. Results: 52 patients were referred internally to Medical Oncology breast clinic. Of these, 29 (55.8%) were accepted directly as new consultations, 8 (15.4%) were triaged to the Internal Medicine clinic, 6 (11.5%) were converted to e-consults, and 6 (11.5%) were declined as not requiring breast medical oncology input. Of the 8 patients that started in the IM clinic, 6 eventually required Medical Oncology breast clinic consults for invasive breast cancers. The most common e-consult was for extending adjuvant endocrine therapy (3/6). 1/6 e-consults required a follow up consultation. The most common reason for declining a consult was no diagnosis of an invasive breast cancer (4/6). A total of 16/52 referrals (30.2%) did not require a breast oncology new consultation. Conclusions: Review of internal referrals improved the efficiency of new breast cancer medical oncology consultations. This review process has been implemented across the entire Medical Oncology practice.
Improving the efficiency of same-day ill calls.
Authors: Bociek Gregory , Wells Mary Huerter , Schuldt Teri , Farrell Tracy , Phillips Duncan
Published: October 2020

56

Background: Burnout is a syndrome whose manifestations include pervasive emotional and physical exhaustion, depersonalization, a lack of motivation and an inability to complete tasks efficiently. We sought to use quality improvement (QI) methodology to approach problems contributing to burnout and workplace stress in our oncology care team. Methods: Through a broad survey of cancer center team members, we identified the coordination of same-day outpatient visits for acutely ill oncology patients as a source of excessive stress for team members across various disciplines including case managers, infusion clinic nurses, advanced practice providers, and physicians. We used the Plan-Do-Study-Act (PDSA) framework to identify a feasible, appropriate intervention to reduce the time required to coordinate visits with the specific aim of reducing the time to schedule an ill patients by 25%. We generated a cause and effect diagram to map the elements involved in the ill call scheduling process, and used a priority/payoff matrix to evaluate possible countermeasures that could streamline the process by re-designing/improving the efficiency of the workflow for scheduling ill calls. Our initial workflow involved paging individual practitioners at three locations. The process led us to the creation of a HIPPA-compliant group text to simultaneously coordinate scheduling of an ill call among/between three campuses in a more collaborative/efficient manner. We tracked time from patient call to time of scheduled appointment pre- and post-test of change (Voalte group text). We also tracked quantity of phone calls required to arrange a visit and perceived frustration with the process. Results: After one PDSA cycle, we found case manager time required to arrange a visit had decreased by 21%, number of calls required by 59% and frustration with the process by 41%. Conclusions: While we did not meet our specific aim of decreasing scheduling time by 25%, we feel use of a QI approach led to an easily implemented, yet effective modification to streamline a previously inefficient and disruptive workflow. The use of QI methodology ensured we understood the baseline process and involved all stakeholders before implementing a change and also ensured we followed data to understand the impact of our intervention on team members. Viewing sources of burnout and workplace frustration through the lens of QI may lead to more consistently high-yield interventions than traditional wellness-based, administrative approaches.
Impact of oncology urgent care center on healthcare utilization.
Authors: Davella Christopher , Whooley Peter , Milano Emily , Egleston Brian L. , Edelman Martin , Helstrom James , Patrick Kenneth , Bauman Jessica Ruth
Published: October 2020

7

Background: Studies suggest that many Emergency Department (ED) visits and hospitalizations for cancer patients may be preventable. CMS has made changes to the hospital outpatient reporting program (OP-35) targeting ED visits and admissions in treatment patients for preventable conditions. Oncologic urgent care centers aim to streamline care for this population. Fox Chase Cancer Center (FCCC) developed an urgent care center called the Direct Referral Unit (DRU) in July 2011. We sought to assess the impact of the DRU on care utilization. Methods: We abstracted visits to our adjacent hospital (Jeanes) ED and the DRU from January 2014-June 2018. Visit rates represent the ratio of visits over the total number of patients with a clinic visit at FCCC per year. ED and DRU visits were associated with both a cancer and visit diagnosis per the International Classification of Disease (ICD). Patient demographics were abstracted. We also analyzed visit charges, inpatient admission and 30-day therapy utilization (chemotherapy, immunotherapy, radiation). Results: A total of 13,210 visits were analyzed including 5,789 ED visits and 7,421 DRU visits. Visits to the Jeanes ED increased over time. The average age of patients at time of first visit was 63 and visits were most common in females and Caucasians. Hispanic and African American (AA) patients were more likely to visit the ED compared to the DRU (OR: 7.54 and 1.30). Patients with GI (27%) and thoracic (15%) malignancies had the most visits. Commercial insurance use was most common (48%) followed by Medicare (34%) and Medicaid (16%). DRU use was most frequent on Mondays (22%), while ED use occurred the most on Sundays (17%). The most common DRU visit diagnoses in order of prevalence were dehydration, nausea/vomiting, abdominal pain, fever, shortness of breath, fatigue, diarrhea, cellulitis/rash, constipation and anemia. Inpatient admission rates were similar between the two settings (p=.8176). Patients on active cancer treatment more frequently presented to the DRU in comparison to the ED (p<.0001). The average charges were $2226.22 for a DRU visit vs. $10,253.44 for an ED visit. Conclusions: The increase in ED visits over time as well the more frequent ED use in Hispanic and AA patients both suggest a need for greater urgent care access. Many of the most common visit diagnoses to the DRU align with CMS’s list of preventable conditions, demonstrating the DRU’s success as a triage center targeting these conditions. DRU visits were associated with considerable cost savings, supporting the use of cancer urgent care centers as a cost-effective method to reduce acute care.
State-wide quality improvement addressing overutilization of neurokinin-1 receptor antagonists.
Authors: Mackler Emily R. , Procailo Kelly Marie , Bedard Louise , Griggs Jennifer J.
Published: October 2020

8

Background: The overuse of neurokinin-1 receptor antagonists (NK1-RAs) is a focus of quality measurement within the American Society of Clinical Oncology Quality Oncology Practice Initiative (ASCO-QOPI) and the American Board of Internal Medicine (ABIM) as a Choosing Wisely measure. The Michigan Oncology Quality Collaborative (MOQC) is a statewide collaborative with participation of nearly 100% of oncologists. The purpose of this project was to provide quality improvement practice support for deimplementation of NK1-RAs in the upfront prevention of chemotherapy- induced nausea and vomiting (CINV) for low and moderate emetic chemotherapy regimens (QOPI measure SMT28a) to less than 30% in practices across the State, with lower scores indicating better performance. Methods: In 2018, MOQC added the QOPI SMT28a measure as part of its standard quality measure module for collection by all MOQC practices. A quality improvement intervention was initiated that consisted of 1) baseline assessments of measure performance, prescriber knowledge and beliefs, and pre-populated antiemetic order sets, 2) reporting practice and state-level performance to MOQC practices, 3) state-wide CINV education, and 4) a value-based reimbursement (VBR) related to measure performance. Post-intervention performance was assessed with the Fall 2019 and Spring 2020 QOPI-measurement. Results: Responses from a survey assessing pre-populated antiemetic order sets (32/43, 74% response rate), 23% of practices had a pre-populated order set for NK1-RA and/or olanzapine in moderate emetic regimens. The post-education order set survey found that 48% of respondents (25/43, 54% response rate) either modified or were in the process of modifying their order sets. Conclusions: Deimplementation of unnecessary and low value antiemetics in patients receiving low- or moderate emetic chemotherapy was possible via a state-wide quality improvement program that involved performance reporting to practices, collaborative-wide education, modification of standing order sets, and VBR based on performance. [Table: see text]
Association of cancer history and medical financial hardship with mortality in the United States.
Authors: Yabroff K Robin , Han Xuesong , Song Weishan , Zhao Jingxuan , Jemal Ahmedin , Zheng Zhiyuan
Published: October 2020

86

Background: Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about its long-term health consequences. In this study, we examine the associations of cancer history, medical financial hardship and mortality in a large nationally representative sample. Methods: We identified cohorts of adults aged 18-64 years (n = 415,114) and 65-79 years (n = 73,571) from the 1997-2014 National Health Interview Survey (NHIS) and the NHIS Linked Mortality Files with vital status through December 31, 2015. Medical financial hardship was measured as problems affording care or delaying or forgoing any medical care due to cost in the past 12 months using survey questions consistently available in all NHIS years. Risk of mortality estimated with weighted Cox’s proportional hazards models with age as the time scale, controlling for the effects of sex, race/ethnicity, educational attainment, marital status, comorbid conditions, region, and survey year. Health insurance coverage was added separately to multivariable models. All estimates accounted for the complex survey design. Results: Among adults aged 18-64 years, 29.6% with and 21.3% without a cancer history reported financial hardship Among adults aged 65-79 years with and without a cancer history, the same percentage reported financial hardship: 11.1%. Among adults aged 18-64 years, cancer survivors with financial hardship had the highest adjusted mortality risk (hazard ratio [HR]: 2.14, 95% confidence interval [95CI]: 1.92-2.37); followed by cancer survivors without medical financial hardship (HR: 1.93, 95CI: 1.81-2.06); and adults without a cancer history with medical financial hardship (HR: 1.36; 95CI: 1.31-1.41) compared with adults with neither a cancer history nor financial hardship. Similar pattern was observed among adults aged 65-79 years: cancer survivors with (HR: 1.62, 95CI: 1.45-1.82) and without (HR: 1.34, 95CI: 1.28-1.24) medical financial hardship and adults without a cancer history with financial hardship (HR: 1.17, 95CI: 1.10-1.24) had elevated mortality risk. Further adjustment for health insurance coverage reduced the magnitude of association of financial hardship and mortality among adults 18-64 years, but further adjustment for insurance had little effect on mortality risk among those aged 65-79 years. Conclusions: Medical financial hardship was associated with increased risk of mortality among adults with and without a cancer history, highlighting the need for efforts to mitigate financial hardship in the United States.
Analysis of the Implementation of Telehealth Visits for Care of Patients With Cancer in Houston During the COVID-19 Pandemic
Authors: Darcourt Jorge G. , Aparicio Kalia , Dorsey Phillip M. , Ensor Joe E. , Zsigmond Eva M. , Wong Stephen T. , Ezeana Chika F. , Puppala Mamta , Heyne Kirk E. , Geyer Charles E. , Phillips Robert A. , Schwartz Roberta L. , Chang Jenny C.
Published: October 2020

PURPOSE:

The purpose of this study was to evaluate the use of telemedicine amid the SARS-CoV-2 pandemic in patients with cancer and assess barriers to its implementation.

PATIENTS AND METHODS:

Telehealth video visits, using the Houston Methodist MyChart platform, were offered to patients with cancer as an alternative to in-person visits. Reasons given by patients who declined to use video visits were documented, and demographic information was collected from all patients. Surveys were used to assess the levels of satisfaction of treating physicians and patients who agreed to video visits.

RESULTS:

Of 1,762 patients with cancer who were offered telehealth video visits, 1,477 (83.8%) participated. The patients who declined participation were older (67.7 v 60.2 years; P < .0001), lived in significantly lower-income areas ( P = .0021), and were less likely to have commercial insurance ( P < .0001) than patients who participated. Most participating patients (92.6%) were satisfied with telehealth video visits. A majority of physicians (65.2%) were also satisfied with its use, and 74% indicated that they would likely use telemedicine in the future. Primary concerns that physicians had in using this technology were inadequate patient interactions and acquisition of medical data, increased potential for missing significant clinical findings, decreased quality of care, and potential medical liability.

CONCLUSION:

Oncology/hematology patients and their physicians expressed high levels of satisfaction with the use of telehealth video visits. Despite recent advances in technology, there are still opportunities to improve the equal implementation of telemedicine for the medical care of vulnerable older, low-income, and underinsured patient populations.
Identity Politics, Criticism, and Self-Criticism
Authors: Lye Colleen
Published: October 2020

If one of French Maoism’s main contributions to the sixties’ cultural turn was a theory of the relative autonomy of ideology, one of US Maoism’s main contributions was identity politics. A product of the application of Mao’s theory of contradiction to US circumstances, identity politics also represented a reinvention of ideology critique by US Third World and Black feminist movements, though in this case directed to practical ends.
Kctd15 regulates nephron segment development by repressing Tfap2a activity
Authors: Chambers Brooke E. , Clark Eleanor G. , Gatz Allison E. , Wingert Rebecca A.
Published: October 2020

A functional vertebrate kidney relies on structural units called nephrons, which are epithelial tubules with a sequence of segments each expressing a distinct repertoire of solute transporters. The transcriptional codes driving regional specification, solute transporter program activation, and terminal differentiation of segment populations remain poorly understood. Here, we demonstrate that the KCTD15 paralogs, kctd15a and kctd15b, function in concert to restrict distal early (DE)/thick ascending limb (TAL) segment lineage assignment in the developing zebrafish pronephros by repressing Tfap2a activity. During renal ontogeny, expression of these factors co-localized with tfap2a in distal tubule precursors. kctd15 loss primed nephron cells to adopt distal fates by driving slc12a1, kcnj1a.1, and stc1 expression. These phenotypes were resultant of Tfap2a hyperactivity, where kctd15a/b-deficient embryos exhibited increased abundance of this transcription factor. Interestingly, tfap2a reciprocally promoted kctd15 transcription, unveiling a circuit of autoregulation operating in nephron progenitors. Concomitant kctd15b knockdown with tfap2a overexpression further expanded the DE population. Our study reveals that a transcription factor-repressor feedback module employs tight regulation of Tfap2a and Kctd15 kinetics to control nephron segment fate choice and differentiation during kidney development.
The Arp2/3 complex is critical for colonisation of the mouse skin by melanoblasts
Authors: Papalazarou Vassilis , Swaminathan Karthic , Jaber-Hijazi Farah , Spence Heather , Lahmann Ines , Nixon Colin , Salmeron-Sanchez Manuel , Arnold Hans-Henning , Rottner Klemens , Machesky Laura M.
Published: October 2020

The Arp2/3 complex is essential for the assembly of branched filamentous actin but its role in physiology and development is surprisingly little understood. Melanoblasts deriving from the neural crest migrate along the developing embryo and traverse the dermis to reach the epidermis colonising the skin and eventually homing within the hair follicles. We have previously established that Rac1 and Cdc42 direct melanoblast migration in vivo. We hypothesised that the Arp2/3 complex might be the main downstream effector of these small GTPases. Arp3 depletion in the melanocyte lineage results in severe pigmentation defects in dorsal and ventral regions of the mouse skin. Arp3 null melanoblasts demonstrate proliferation and migration defects and fail to elongate as their wild-type counterparts. Conditional deletion of Arp3 in primary melanocytes causes improper proliferation, spreading, migration and adhesion to extracellular matrix. Collectively, our results suggest that the Arp2/3 complex is absolutely indispensable in the melanocyte lineage in mouse development, and indicate a significant role in developmental processes that require tight regulation of actin-mediated motility.
Akkermansia muciniphila promotes type H vessel formation and bone fracture healing by reducing gut permeability and inflammation
Authors: Liu Jiang-Hua , Yue Tao , Luo Zhong-Wei , Cao Jia , Yan Zi-Qi , Jin Ling , Wan Teng-Fei , Shuai Ci-Jun , Wang Zheng-Guang , Zhou Yong , Xu Ran , Xie Hui
Published: October 2020

Improving revascularization is one of the major measures in fracture treatment. Moderate local inflammation triggers angiogenesis, whereas systemic inflammation hampers angiogenesis. Previous studies showed that Akkermansia muciniphila, a gut probiotic, ameliorates systemic inflammation by tightening the intestinal barrier. In this study, fractured mice intragastrically administrated with A. muciniphila were found to display better fracture healing than mice treated with vehicle. Notably, more preosteclasts positive for platelet-derived growth factor-BB (PDGF-BB) were induced by A. muciniphila at 2 weeks post fracture, coinciding with increased formation of type H vessels, a specific vessel subtype that couples angiogenesis and osteogenesis, and can be stimulated by PDGF-BB. Moreover, A. muciniphila treatment significantly reduced gut permeability and inflammation at the early stage. Dextran sulfate sodium (DSS) was used to disrupt the gut barrier to determine its role in fracture healing and whether A. muciniphila still can stimulate bone fracture healing. As expected, A. muciniphila evidently improved gut barrier, reduced inflammation and restored the impaired bone healing and angiogenesis in DSS-treated mice. Our results suggest that A. muciniphila reduces intestinal permeability and alleviates inflammation, which probably induces more PDGF-BB+ preosteoclasts and type H vessel formation in callus, thereby promoting fracture healing. This study provides the evidence for the involvement of type H vessels in fracture healing and suggests the potential of A. muciniphila as a promising strategy for bone healing.

This article has an associated First Person interview with the first author of the paper.