bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of timing of goals of care discussion on hospitalization outcomes in metastatic cancer patients.
Authors: Emiloju Oluwadunni , Ford Jean G , Djibo Djeneba Audrey
Published: October 2019

219

Background: Cancer patients often require acute hospitalizations, and these hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals of care (GOC) discussions be initiated early for metastatic cancers. Discussing GOC during hospitalization can help reduce readmissions and improve patient satisfaction, by helping to ensure that patients receive goal-congruent care. We aim to examine the association between the timing of GOC discussion and the patient's length of stay and the time to hospital readmission. Methods: We conducted a retrospective review of medical records of patients with stage IV solid tumors who were hospitalized acutely between August 2017 and July 2018. We assessed demographics, timing of GOC discussion, use of palliative care services and hospital readmissions within 90 days. Chi-square tests were used to identify independent associations with having a GOC discussion; and anova was used for continuous variables. We used logistic regression to examine the association with a hospital readmission within 90 days, controlling for potential confounders. Results: The subjects were 26-92 years old and 40.6% were female. Only 46% (n = 112) of patients had a GOC discussion. Age, tumor site, and presenting complaint were not independently associated with having a GOC discussion (p > 0.05). Overall, 34% (n = 82) had a palliative care encounter. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (p < 0.05). Length of stay was positively correlated with having a GOC discussion. Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having any GOC discussion reduced the odds of an unplanned hospital readmission within 90 days by 79% [OR = 0.21, 95% confidence interval 0.12-0.37]. Conclusions: Among hospitalized patients with stage IV cancer, performing an early GOC discussion is associated with better hospitalization outcomes. It is therefore important to perform GOC discussion early when such patients are acutely hospitalized.
Navigating specialty pharmacies to get oral agents to patients in a timely manner.
Authors: Dorff Tanya B. , Mendelsohn Mary , Christian Amis , Kim Hoim
Published: October 2019

220

Background: Increasing numbers of oncology patients require oral therapies provided by specialty pharmacies. Our experience indicates patients receiving care in a facility without specialty pharmacy dispensing capabilities are at a disadvantage in receiving their medications in a timely manner. Methods: Metastatic prostate patients receiving oral hormonal therapies were identified for chart review. Findings indicated the median time to medication receipt by the patient was 25 days. Interviews with the team, staff and patients revealed that multiple factors contributed to the delays. Patient expectations were to receive prescribed agents within 7 days. Review of our Community Clinics, who employ a centralized process and have relationships with specialty pharmacies, indicated that medications were received by patients within a week. Successful interventions necessitated the patient partnering with the healthcare team to improve efficiencies and reduce time to drug delivery. Results: Delays were multifactorial and extremely difficult to ascertain from chart review. Reasons for delay were clearly noted in 19 out of 97 patient records out of which over 47% charts indicated the pre-approval process as the cause for the delay. Patients were educated regarding the specialty pharmacy process, the name of the prescribed drug and the pharmacy where the prescription was sent. The patient education sheet encouraged patients to become partners in the process and advised them to check with their insurance for their approved specialty pharmacy. If the approved pharmacy varied from the pharmacy initially chosen, patients were asked to notify the clinic staff to initiate a new prescription to the correct pharmacy. Patient response to the education sheet has been positive. Impact on median time to delivery is not yet known. Conclusions: Streamlining the authorization process of specialty pharmacies would benefit oncology patients, as we identified that most delays occur in specialty pharmacy processing. Healthcare facilities may consider increasing patient education or obtaining a specialty pharmacy dispensing license in order to minimize delays for oncology patients receiving oral oncology medications.
Living systematic reviews: A novel mechanism for improving efficiency and quality of evidence synthesis in oncology.
Authors: Riaz Irbaz Bin , Siddiqi Rabbia , Asghar Noureen , Cathcart-Rake Elizabeth Jane , Herasevich Vitaly , Montori Victor , Wang Zhen , Go Ronald S. , Rajkumar S. Vincent , Murad M. Hassan
Published: October 2019

241

Background: In a rapidly moving field, such as cancer immunotherapy, where immune checkpoint inhibitors (ICIs) are used across 14 different tumor types, patients may receive suboptimal treatment or even be harmed if information on toxicity is not readily translated for use in clinical practice. Every single systematic review and meta-analysis which attempted to summarize toxicity of immune checkpoint inhibitors (ICIs) quickly became outdated. A living systematic review, which is defined as a systematic review that is continually updated to incorporate relevant new evidence as it becomes available, is necessary in this situation. Methods: The process of creating a living systematic review started with the creation of a comprehensive search designed by a librarian experienced in systematic reviews in collaboration with the study’s principle investigator. Search was constantly updated every 3 months and evidence is synthesized in a series of steps (microtasks) using a combination of human and augmented intelligence. A complete infrastructure is being developed and it includes automated cumulative meta-analysis and an online reporting platform which will constantly update information for clinicians and patients in a live manner. Results: We screened 6746 studies during Sep 2018-March 2019 and identified 6746 studies and we were able to successfully maintain up-to-date toxicity estimates for immune mediated adverse events over this period while maintaining the rigor of a conventional systematic review. Eventually, we will integrate the steps of LSR into one, user-friendly, semi-automated format which can independently provide accurate estimates and feed into and support a living guidelines platform through shared Application Programing Interface (APIs). Conclusions: LSRs are feasible, efficient, and when fully developed can reduce redundancy and waste in medical research, improve the quality of evidence, reduce human effort and support living and dynamic guidelines to facilitate truly informed shared decision making.
Retrospective evaluation of clinical evidence submitted with off-label requests at a community-based oncology infusion center.
Authors: Stankowicz Matthew , Heyer David M.
Published: October 2019

254

Background: A systematic grading system was created to evaluate literature submitted with off-label requests to the Inova Schar Cancer Institute (ISCI) oncology P&T. Level of evidence (LOE) 1A, 1B, and 1C are granted immediate approval. LOE 2A, 2B, 2C require two members (MD and PharmD) to approve. LOE 3A, 3B, 3C require 3/4 (2MDs, 2PharmDs) members to approve. LOE no benefit (NB) is denied approval. Methods: Identified off-label requests for hematology/oncology patients from December 23, 2016 to January 2, 2019. Primary objective was retrospective evaluation of literature submitted using a systematic grading system through the oncology P&T. Secondary objective was to evaluate financial and clinical outcomes of off-label treatments, including compliance with Quality Oncology Practice Initiative measures. Future aim is to compare LOE and treatment outcomes pre- and post-implementation. Results: There were 73 off-label requests with 126 references submitted as supporting literature. The most frequently requested treatments were nivolumab (21.9%) and pembrolizumab (20.5%). The most common disease state was breast cancer. The LOE for the literature submitted was 1A (10.3%), 1B (23%), 1C (8.7%), 2A (9.5%), 2B (7.9%), 2C (4.8%), 3A (1.6%), 3B (7.1%), 3C (5.6%), and NB (21.4%). Sixty-six treatments were approved and 54 patients received at least one dose of off-label treatment. Thirty off-label requests were made based on molecular tumor board recommendations. Off-label treatment was discontinued for disease progression (29.6%), toxicity (25.9%), or death (14.8%). Three patients completed therapy and 11 received subsequent treatment after discontinuation of the off-label treatment. Average time from last treatment to death was 41.8 days (median 21, range 6-175). Eleven of 55 expired patients received hospice care prior to expiring. Most off-label treatments were approved by third party insurance (55.6%) while 37% were covered by manufacturer provided free drug and 7.4% were paid for by the ISCI Foundation. Conclusions: The standardized grading system for off-label treatments can be implemented to ensure safe and effective use of off-label treatments in oncology patients.
Improving quality of cancer care: Lessons learned from the journey towards QOPI Certification.
Authors: Abdelhafiez Nafisa , Alshami Mona Mohamed , Al-Kaiyat Mohammad Omar , Pasha Tabrez , Mutairi Nashmia , Gilmore Terry , Jahanzeb Mohammad , Jazieh Abdul Rahman
Published: October 2019

263

Background: To assess the quality of cancer care provided at our institution, we participated in Quality Oncology Practice Initiative (QOPI) of American Society of Clinical Oncology (ASCO). However, our initial two rounds revealed lower score than required for QOPI Certification. Our goal was to implement interventions based on lessons learned from the initial rounds. Methods: Prior to the third round and using plan-do-study-act (PDSA) cycles, we identified and worked on three processes: clarifying and enhancing the function of the team, optimizing communication and improving documentation. We created QOPI multi-disciplinary team to include more members from different disciplines. We enhanced the knowledge of the team regarding our electronic health records system (EHRS) by conducting educational sessions and nominating super users who are very competent in EHRS and peer-to-peer support was created. Members were entering data in group sessions with the help of super users. We established double check system for records to be reviewed by two team members before submission. communication was assured among team members through weekly in person meetings and with ASCO QOPI team via virtual meetings to address queries. Documentation was improved by creating newer templates that conform with QOPI requirements including chemotherapy treatment plan, end of treatment summary and documentation of treatment consent. Results: The implementation of these interventions over three PDSA cycles made noticeable improvement in the previously unmet standards resulting in a score that exceeded the benchmark in fall of 2017 (score of 93%). This made our practice eligible for on-site certification visit by ASCO QOPI surveyors on May 2018 to assess practice compliance with QOPI standards. After addressing the unmet standards from the visit, our center became the first QOPI Certified Center in the Middle East and Asia in October/2018. Conclusions: Our journey towards QOPI Certification highlights the importance of fundamental principles in health care: coordinated multidisciplinary team, effective communication and proper documentation that captures essential and critical items reflecting better quality of care.
Increasing screening for latent tuberculosis in patients with hematologic malignancy: A quality improvement project.
Authors: Veloce Nicole , Chan Maverick , Seemangal Julie , Zwolinski Andrea , Al Saleh Abdullah S , Garcia Luciana , Habib Laura Anne , Jayakar Jai , Kimpton Miriam , Batt Jane , Hicks Lisa K.
Published: October 2019

264

Background: Latent tuberculosis infection (LBTI) affects about one quarter of the world population. Treating LTBI is the most effective way of preventing active TB. Patients with hematologic malignancy (HM) and LTBI are at heightened risk (2-40 times baseline) of progressing to active TB. Universal TB screening is recommended for this population. In 2016, a patient receiving chemotherapy for myeloma at our center developed active TB. This triggered an intensive contact tracing investigation involving local public health units, infection control, and specialists. Over 800 patients had one or more exposures to the index case. No cases of secondary TB were identified; however, the contact tracing was resource intensive and stressful for patients and staff. This project aims to prevent future incidents by developing a standardized process for completing and documenting TBSTs, ensuring LTBIs are identified and managed prior to systemic therapy for HM. We aimed to complete and document TBSTs in ≥85% of patients starting systemic therapy for HM by Feb 2018. Methods: Baseline data was determined via retrospective review of 25 patients receiving chemotherapy for HM Jul-Nov 2017. An order set, work flow process map and standard operating procedure were created over a series of plan-do-study act cycles. TBST was added to a pre-existing “ready for treatment” checklist employed by pharmacists at our site. When pharmacists could find no record of a TBST result prior to treatment, the treating physician was notified. The go-live date was Aug 15, 2018. The impact of change was evaluated via chart review of patients who started chemotherapy for HM between Aug 27, 2018-Feb 27, 2019. Results: Prior to implementation of the standardized process, 3/25 patients (12%) had documentation of prior TBST. Following implementation of the standardized process, 14/30 patients (47%) had documentation of TBST prior to starting systemic therapy for HM. All 14 patients had negative TBSTs. Conclusions: Developing a standardized process for ordering, completing, and documenting TBST for patients starting systemic therapy for HM is feasible and effective. Additional revisions of the process are required to meet our target.
Improving quality through A.I.: Applying machine learning to predict unplanned hospitalizations after radiation.
Authors: Christopherson Kaitlin M. , Berlind Christopher G. , Ahern Christopher A. , Holmes Angela , Lindsay William David , Smith Benjamin D. , Das Prajnan , Smith Grace L.
Published: October 2019

271

Background: Unplanned hospitalizations may diminish quality of care among cancer patients receiving radiotherapy (RT). In patients undergoing RT for gastrointestinal (GI) cancers, we hypothesized that a machine learning approach would enable prediction of unplanned hospitalizations within 30 days of RT. Methods: We analyzed 836 abdominal (gastric, pancreatic, biliary, hepatic) and 514 pelvic (rectal, anal) courses of RT for GI cancers treated at our institution (3/2016—1/2019). Over 700 clinical/treatment variables and unplanned hospitalizations during or within 30 days after RT were mined from institutional databases. Using machine learning, we developed random forest (RF), gradient boosted decision trees (XGB), and logistic models for unplanned hospitalizations. Models were trained on 670 abdominal and 423 pelvic cases. Five-fold cross-validation (CV) was used to select model type and hyperparameters, using area under the ROC curve (AUC) to measure performance. The best model was validated on the subsequent 166 abdominal and 91 pelvic cases. AUC>0.70 was deemed clinically valid. Results: Among 1,350 cases, incidence of 30-day unplanned hospitalization was 12.3% (13.3% abdominal cohort; 10.7% pelvic cohort). Model CV AUCs are shown in table. The best models were XGB and RF for the abdominal and pelvic cohorts, respectively. Their validation testing AUCs are shown in table. For all models tested, lab values (e.g. potassium, lipoproteins, hemoglobin) prior to RT were significant predictors of unplanned hospitalizations. In the abdominal cohort, pancreatic primary and total RT dose were important. For the pelvic cohort, body mass index was important. Median healthcare costs from RT start - 30 days post-RT were $69,108 in non-hospitalized patients and $119,844 in hospitalized patients. Conclusions: In GI cancer patients undergoing RT, a machine learning model identified patients at risk of 30-day unplanned hospitalization. Predictive analytics may be a key tool to help providers identify high-risk patients and optimize interventions, while improving quality and value of care.

[Table: see text]
Launch of telemedicine in community oncology practice.
Authors: Blakely L. Johnetta , Dickson Natalie R. , Erter Jack William , Craig Carolyn , Bushart Holly , Stewart David , Darden Mary , Ripley Ann , Poole Stacey L , Frailey Susan , Patton Jeffrey
Published: October 2019

275

Background: Tennessee Oncology (TO) is a community medical, radiation and gynecology oncology practice with 90 physicians and 40 advanced practice providers (APPs) in 33 locations in Tennessee. TO participates in the Oncology Care Model (OCM), a CMMI experimental payment model to improve access, quality of care, patient experience and lower costs. Methods: To promote provider-patient communication to improve outcomes and lower healthcare costs, TO launched a telemedicine pilot. The pilot was designed to understand Tennessee’s rules and regulations, reimbursement policies for Medicare, Medicaid and commercial payers and technology requirements. As survivorship was aligned with clinical workflow, supported by existing technology and required minimal staff training, the Survivorship Program for OCM was selected as proof of concept for telemedicine. Education surrounding Survivorship is required as part of the OCM model. A portion of the MEOS payment was considered as reimbursement for this initiative. The goal was to increase the delivery and review of survivorship documents to eligible breast cancer patients using the telemedicine platform from 0% to 80%. Results: 4000 potential patients were eligible for survivorship visits within TO. The selection was narrowed to include only OCM patients with breast cancer. TO identified 4 APPs who were given special training. TO’s front office staff coordinated scheduling of the technology, provider and space available. There were 99 patients eligible for a Telemedicine visit. 36 patients completed a Telemedicine visit with 23 patients declining. 19 patients did not respond to requests for these visits. 10 patients completed surveys and were 100% satisfied with their visits. The APPs felt Telemedicine visits were more productive than in person visits. Conclusions: Telemedicine is an effective tool for delivery of health care. There are challenges that make this technology difficult to implement such as reimbursement and limitations to the use of technology in elderly. In our pilot we found that the APPs and patients found this to be an effective way of communication and delivery of care. In the future telemedicine could answer some of the shortages in health care delivery and could also improve coordination of care.
Evaluation of scheduled video visits for cancer care at the Sidney Kimmel Cancer Center at Thomas Jefferson University.
Authors: Handley Nathan , Binder Adam , Sabonjian Megan , Lopez Ana Maria
Published: October 2019

277

Background: Telehealth is currently undergoing exponential growth as a result of improved access through less costly, more portable, and better quality technology and through increased broadband internet proliferation. Telehealth has been shown to improve access and decrease costs while maintaining quality of care and high levels of patient satisfaction. One approach to telehealth is the video visit, in which audiovisual technology is used to connect patients and providers virtually. We implemented a pilot scheduled video visit program in a large academic cancer center (SKCC). Methods: Oncology clinical teams were trained in the use of JeffConnect, the video visit platform developed at our institution. Clinical teams were encouraged to utilize video visits in instances they deemed appropriate (i.e. post hospital follow-up, post-chemotherapy evaluations). All participating patients received a link to an evaluation following completion of the video visit. A subset of patients receiving more detailed survey questions. We reviewed evaluations occurring between 9/1/2016 and 3/31/2019. Results: Sixty-nine unique clinicians and 759 unique patients engaged in 865 completed telemedicine visits. For these, 118 surveys were completed and returned (14.03% of total visits), a similar response rate for other services. Average likelihood to recommend JeffConnect to a friend or colleague was 9.1 (scale 0-10). The majority of patients reported video visits saved them time (Figure 1) and money. For the subset of patients receiving the more detailed survey (n=30), average distance from SKCC at the time of the visit was 125 miles (range 10-963 miles, median 50) and average financial savings were $61.15 (range $8-$300, median $45). Conclusions: Scheduled cancer care video visits were feasible, resulted in high patient satisfaction, and saved patients time and money. Evaluating patient and clinician perceptions of the benefits of and barriers to telemedicine in greater detail is necessary for broader implementation. Patient-reported time saved by telemedicine.

[Table: see text]
Survivorship: Leveraging the EMR to better care.
Authors: Walde Amy , Bootle Emma
Published: October 2019

283

Background: UCHealth is a 10-hospital health system located on the Front Range of the Rocky Mountains. In 2018, UCHealth Cancer Care diagnosed or treated more than 8,400 analytic cases. In this presentation, we will discuss how we formulated a response to our organizational need for the creation of a Cancer Survivorship Program that not only met the ASCO QOPI & Commission on Cancer (CoC) Standards but also the needs of our patients. Methods: Our response plan included devising processes for the development and delivery of treatment summary care plans (TS/SCP). The development phase comprised the formation of UCHealth Cancer Care governance structure, creation of 22 disease specific templates containing the Institute of Medicine (IOM) / National Comprehensive Care Network (NCCN) recommended elements of survivorship care, Electronic Health Record (EHR) automation to increase efficiency and finally designing dashboard reports to identify eligible patients and capture compliance. The delivery phase consisted of securing dedicated resources, a communication plan and education for staff and providers regarding the benefits of a Cancer Survivorship program. Results: A jump in compliance from 7% in 2015 to 29% in 2018, demonstrates the success and impact of TS/SCPs at UCHealth. We will also discuss the 2019 work plan to achieve 50% compliance as required by the CoC. Conclusions: Leveraging the EHR is necessary when developing a Cancer Survivorship Program. UCHealth will provide examples of the treatment summary care plans, reference and reporting metrics to get other programs started on their journey.
Improving biobehavioral outcomes with progressive muscle relaxation in patients with advanced lung cancer.
Authors: Arrato Nicole A , Lo Stephen B. , Grogan Madison , Stec Nathan J. , Eastep Christine , Tenney Kathryn M. , Palmer Sara A. , Andersen Barbara L. , Presley Carolyn J
Published: October 2019

292

Background: Advanced lung cancer involves severe and distressing symptoms, especially anxiety, breathlessness, insomnia, and pain. Progressive muscle relaxation (PMR) is an empirically supported treatment for reducing stress and the emotional, cognitive, and physiological concomitants of anxiety. Methods: A quality improvement effort involved enhancing standard of care (SOC) by offering patients with newly diagnosed lung cancer one brief (20-minute) PMR session during a clinic visit for treatment determination. A static group comparison design was used. The PMR group ( n= 40) received PMR with pre (initial visit) and post (3-4 week follow-up) assessments of anxiety (Generalized Anxiety Disorder-7 Scale), breathlessness (American Thoracic Society for the Division of Lung Diseases Questionnaire), insomnia (Medical Outcomes Study Sleep Scale), and pain (Brief Pain Inventory). The static group ( n= 32) was assessed on one occasion only, during the 3-4 week follow-up visit. Pre/post analyses for the PMR group used paired samples t-tests. Linear regressions compared post data between the two groups. An alpha of .10 determined significance. Results: Analyses showed pre- to post-PMR differences in pain ( p= .036, d= .309) and breathlessness ( p= .084, d= .663), with null effects for anxiety ( p= .149, d= .178) and insomnia ( p= .811, d= .067). Controlling for performance status, smoking history, and toxicities, regression showed that the PMR group reported significantly less pain ( p= .046, b= 2.48). Conclusions: PMR effectively reduced symptoms of breathlessness and pain among patients with advanced lung cancer. Interventions based on the education and training of PMR may provide an improvement to SOC lung cancer treatment.
Centralizing mixing of infusion drugs: A process to comply with USP 797/800, improve efficiency, and reduce costs in a multisite oncology infusion practice.
Authors: Perry Manuel , Dolson Theresa , Lindros Gianna , Welyczko Courtney , Hines Scott
Published: October 2019

295

Background: In oncology practices with multiple infusion sites, compliance with USP 797/800 will be difficult to achieve due to increased building costs. Mixing oncology medications in a single-site referred to as “centralized mixing” is an attempt to comply with USP regulations as well to improve safety, quality and decrease costs. Methods: The centralized mixing process was initiated in June 2017 and required patients to have labs drawn 24-48 hours prior to infusion. If results were adequate, infusion nurses contacted the patient to review a symptom checklist to report findings which would preclude treatment. The next day, pharmacists began drug mixing at 6 am and distributed them by courier to five other practice sites by 10am. When patients arrived for treatment, they went directly to the infusion suite. A follow up visit was arranged mid-cycle to see their oncologist prior to the next scheduled infusion. If weekly infusions were required, then follow up visits were scheduled at the discretion of the oncologist. Results: Data from the fourth quarter of 2016 (prior to centralized mixing) was compared to the fourth quarter of 2018. Although physician total work RVUs increased from 12,198 to 16,254, labor costs decreased by $15,194. After implementation of centralized mixing, there were four fewer infusion nurse FTE’s while two registered pharmacists were hired. Labor costs per total work RVU decreased from $38.51 to $27.97 resulting in a quarterly savings of $42,790. Conclusions: Centralized mixing of oncology medication has reduced the cost per physician work RVU of administering chemotherapy by 27.3% and has lead to an annualized savings of $171,160. Increased infusion capacity and improved efficiency were due to streamlining the patient experience: there is no need to wait for drugs to be mixed, for lab results to return or to see their oncologist prior to treatment. The practice is now able to improve environmental safety with USP 797/800 at a single site, improve quality by limiting staff who mix chemotherapy to only two pharmacists, reduce training time for our infusion nurses by six weeks and to delay the need to build additional infusion suites.
Prediction of acute care service utilization for patients with hematologic malignancies.
Authors: Zu Kai , Greenwood Kristina , Lamori Joyce , Smith Besa , Smith Tyler C , Lee Alaina
Published: October 2019

312

Background: Improving the ability to predict which patients are at increased risk for acute care services subsequent to hospitalization can lead to more effective interventions and quality care. This study evaluated the performance of risk models to predict 30-day acute service utilization among adult inpatients with newly diagnosed hematologic malignancies. The study explored the impact of medical complications on potentially preventable service utilization, aligned with specifications for proposed measure OP-35 from the CMS Hospital Outpatient Quality Reporting Program. Methods: The study included 933 unique adult patients admitted to four acute care inpatient facilities within a non-profit community based healthcare system during calendar years 2012 to 2017. Risk models integrated a comprehensive set of data elements using clinical information from electronic medical records and facility oncology registries. Predictive models were constructed using a multivariable logistic regression, with calculation of standardized coefficients to rank order variables with the greatest impact on unplanned readmissions. Exploratory data mining techniques were conducted to augment classification of at-risk patients. Results: The mean age of study participants was 65 years and 55.1% were male. In order of prevalence, the types of hematologic malignancy were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days after the index hospitalization (lymphoma = 23.1%, myeloma = 22.1%, leukemia = 18.6%). Among the risk models, the most influential predictors included initial length of stay, severity of illness, and consult for social work. Overall, 56.6% of patients who were readmitted within 30 days of hospitalization presented with one or more symptoms associated with the CMS medical complication measure, including cytopenia, infection, negative hydration, and/or pain. Conclusions: Optimizing quality care in a value-based health care environment requires proactive approaches such as risk prediction models for identifying patients who can benefit most from care transition interventions.
Five-year longitudinal mammographic follow-up after breast cancer.
Authors: Bruce Laura , Kerns Jessica , Carter W. Bradford , Frazier Thomas G.
Published: October 2019

37

Background: Breast Cancer recurrences following radiation are seen in the first three to five years after treatment. As part of our Survivorship Program, annual screening mammography is a guideline following treatment with the exception of those patients who undergo bilateral mastectomy. To evaluate compliance with this guideline, we followed patients treated in 2012 for breast cancer at our institution, over the five-year period through 2017. Methods: A retrospective chart review of patients diagnosed with breast cancer in 2012 was conducted and annual mammography was assessed for compliance for a period of five-years. Compliance was defined as having annual mammography screening for five years, until recurrence or until death. Results: 252 patients were treated for Breast Cancer in 2012. Of these, 15 patients had follow-up elsewhere. 4 patients had metastatic disease at the time of diagnosis and were not included. 3 patients with male breast cancer had no mammographic follow-up. 5 patients had bilateral mastectomies and were excluded leaving 225 patients followed for compliance. Of the 225 evaluable patients, 134 (59.5%) were compliant with mammography. 126 (56.0%) had a full five years of follow-up and had no recurrent breast cancer. 158 (70.2%) had four years of follow-up. 168 patients (74.7%) had three years of follow-up. 178 (79.1%) had two years of follow-up. 190 (84.4%) had at least one year of follow-up. 14 (6.2%) died before the five year follow-up of causes not related to breast cancer. 7 (3.1%) developed metastatic disease during follow-up and no additional mammography was carried out. 7 had ipsilateral recurrence, 3 had contralateral recurrence (4.4%). Conclusions: In an upper-middle class population that is well insured and should be compliant, only 59.5% of eligible patients were compliant with mammography for five-years, until recurrence or death. Since almost 5% of patients in this cohort recurred in the breast, follow-up with annual mammography is critical. The Survivorship Care Plan (SCP) discussion with the patient is a strategy to address compliance with annual follow-up. Future studies are planned to re-evaluate compliance with annual mammography.
Integration of palliative care into the inpatient oncology service.
Authors: Waldstein Sasha , Smith Benjamin , Nunnink J. Chris
Published: October 2019

46

Background: Research has demonstrated that early palliative care involvement for patients with advanced cancer has multiple benefits, including improved symptom control/quality of life and reduced readmission rates. Based on this data, the American Society of Clinical Oncology (ASCO) has developed guidelines for early palliative care consultation. At the University of Vermont Medical Center, historically 40% of such patients were evaluated by palliative care during hospital admission. The purpose of this study was to better integrate palliative care into the oncology inpatient setting through the use of a standardized admission template. Methods: A specific oncology H&P template, with inclusion of a drop down menu of ASCO based criteria for palliative care consultation, was created. Providers were educated on template use, and data then were collected for oncology admissions from 2/1-8/31/2018 regarding template usage, if criteria was met for palliative care consultation, and whether consultation occurred. Additionally, 30 day post discharge ED visits and readmissions were recorded, extending data collection for this purpose to 9/30/2018. Results: There were 372 medical oncology admissions during the studied time period, with 284 individual patients. The template was used for 95 (26%) admissions. 267 of those patients admitted qualified for palliative care consultation and, of those in which the template was used, 72% had palliative care consulted versus 50% without the template (p= 0.0013). There was no statistically significant difference in readmission rates between those with palliative care consultation and without. Conclusions: Early palliative care consultation for patients with advanced malignancy has been shown to have multiple benefits on an individual and system-wide basis. It was shown in this study that, though the created template was used for a minority of admissions, with template use a significantly greater proportion of appropriate patients had palliative care consulted. This suggests that, with more widespread practice, this strategy could further promote inpatient palliative care involvement for appropriate oncology patients.
Pragmatic randomized trial of a distress screening program using an effectiveness-implementation hybrid design.
Authors: Hahn Erin Elizabeth , Munoz-Plaza Corrine E. , Pounds Dana , Lyons Lindsay Joe , Lee Janet S. , Shen Ernest , La Cava Shannon , Brasfield Farah , Durna Lara N. , Kwan Karen W. , Beard David B. , Ferreira Alexander , Schottinger Joanne E. , Mittman Brian S. , Gould Michael K.
Published: October 2019

5

Background: Implementation of guideline-recommended distress screening in oncology remains challenging. Evidence suggests that multicomponent care pathways to identify distress severity with algorithm-based referral and management are effective, yet testing of pragmatic implementation in community settings remains limited. We conducted a pragmatic randomized trial of a distress screening program in a large healthcare system to evaluate effectiveness and simultaneously examined implementation outcomes. Methods: We designed a highly pragmatic study per the Pragmatic-Explanatory Continuum Indicator Summary-2 with adaptive workflow design. Randomization was at the medical center level (N=6); eligible patients had a new diagnosis of breast cancer (no exclusions). Eligible patients were offered the distress screening program as part of usual care: PHQ-9 screening, algorithm-based scoring and referral, referral tracking, and audit and feedback of performance data. Control sites had access to the PHQ-9 and scoring algorithm. We compared number screened, distress severity, and referral. We conducted qualitative interviews with stakeholders on implementation barriers and facilitators. Results: We enrolled 1,436 eligible patients; 692 control, 744 intervention. Groups were similar in demographic and tumor characteristics (Table); 80% of patients completed screening at intervention sites vs <1% at control sites. Of those screened at intervention sites, 10% scored in the medium/high range indicating need for referral; 94% received an appropriate referral. We conducted 20 interviews; the program was found to be highly feasible and acceptable. Conclusions: Our pragmatic, adaptive approach resulted in the large majority of patients screened and appropriately referred with a high degree of acceptability and feasibility. Our results can promote more widespread, sustained adoption of effective distress screening programs. Clinical trial information: NCT02941614.

[Table: see text]
A trainee-led quality improvement project to improve rates of palliative care utilization in patients with advanced cancer.
Authors: Sedhom Ramy , Gupta Arjun , Shah Mirat , Marrone Kristen , Browner Ilene S. , Smith Thomas J.
Published: October 2019

51

Background: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. 1st year oncology fellows at our institution identified low rates of palliative care in their longitudinal clinic as an avenue for improvement. Methods: A Fellow-led multidisciplinary team aimed to increase palliative care utilization for patients with advanced cancer followed in first-year fellows’ clinic from baseline 11.5% (5/43 patients, Jul-Dec, '18) to 30% over a 4-mo period. Utilization was defined as evaluation in the outpatient palliative care clinic hosted in the cancer center. The team identified several barriers to referral: orders difficult to find in EMR, multiple consulting mechanisms (EMR, by phone, in person), EMR request not activating formal consult, no centralized scheduler to contact/confirm appointment, and poor awareness of team structure. PDSA cycles were implemented based on identified opportunities. Data were obtained from the EMR. Results: The PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and dissemination of process changes. The PDSA was implemented Jan-Apr '19. Rates of palliative care use increased from 11.5% pre-intervention to 43% (27/62 patients) post-intervention. In addition, median time to evaluation in palliative care clinic after placing a consult improved from 23 days (range, 10-60 days) to 12 days (range, 6-19 days). Conclusions: A multidisciplinary approach and classic QI methodology improved palliative care use for patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional support of efforts. Straightforward EMR interventions and ancillary staff use are effective in addressing under referrals.
Exploratory analysis of the cost of episodes of care in metastatic renal cell carcinoma in the United States.
Authors: Kangethe Anne , Polson Michael , Speicher Lindsay C. , Zheng Ying , Bhanegaonkar Abhijeet , Krulewicz Stan , Kim Ruth
Published: October 2019

55

Background: Treatment decisions in oncology care have financial implications. A shift in reimbursement from traditional fee-for-service models toward episode-based care sets the framework for assessing the value of therapies. The objective of this study was to determine episode-based total cost (medical and pharmacy) and resource utilization by therapy for patients with metastatic renal cell carcinoma (mRCC) using the Oncology Care Model methodology. Methods: Retrospective analysis of commercial claims data incurred between Jan 1, 2013 and Jun 30, 2018. Patients included had ≥1 claim with a diagnosis code of renal cell carcinoma (RCC), ≥2 claims for metastasis on or after initial RCC diagnosis date, evidence of any mRCC systemic therapy on or after initial mRCC diagnosis date, and continuous enrollment from ≥6 months before until ≥6 months after the index date and were ≥18 years old on the index date. Patients were classified by 1 of 6 therapy classes: tyrosine kinase inhibitors (TKIs) monotherapy, mechanistic target of rapamycin (mTOR) monotherapy, immuno-oncology (IO) monotherapy, other (e.g., interferon) monotherapy, changed therapy class (e.g., from TKI to mTOR), or traditional chemotherapy. Results: 606 commercially insured patients with mRCC met the inclusion criteria. Most received monotherapy, and 53% had ≥2 episodes. Specifically, 59% of TKI, 17% of mTOR, 28% of IO, 59% of other, 85% of changed therapy class, and 38% of chemotherapy patients had ≥2 episodes. IO patients had the longest average inpatient length of stay per episode (7 days; p = 0.0002). There were differences in total episode costs among each selected therapeutic class: TKI (n = 161; $61,417), mTOR (n = 30; $67,637), IO (n = 75; $92,082), other (n = 34; $98,877), changed therapy (n = 130; $84,480), and chemotherapy (n = 34; $55,743) (p < 0.0001). Conclusions: Differences in total episode costs exist in each monotherapy class used to treat mRCC, even in an episode-based structure. As healthcare financing shifts to alternative payment models, it is important to investigate overall episode cost of care for various therapies, as the cost for the individual drug may not accurately reflect the total episode value.
Why do payers refuse to fund "effective" therapies?
Authors: Conter Henry Jacob , Cheema Parneet Kaur
Published: October 2019

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Background: The pan-Canadian Oncology Drug Review (pCODR) provides funding recommendations to the provinces of Canada on Health Canada approved systemic therapies. Why would they recommend against funding drugs that meet regulatory standards? Methods: 136 reviews for 70 compounds were completed by pCODR from inception to January 1, 2019 were collected and data abstracted using a standardized form. For all submissions that received a negative recommendation, the Clinical Guidance Panel (CGP), Economic Guidance Panel (EGP), and Expert Review Committee (pERC) reports were examined to determine the underlying cause for rejection. Results: 32 (24%) of submissions received a negative recommendation. In all cases, this was due to concerns regarding the clinical effectiveness of the compound. Economic considerations were never cited as rational for rejection. 10 (32%) were submitted with supporting evidence from non-comparative phase 2 clinical data, and this level of evidence was cited as the basis for the recommendation. 4 (12%) supported by randomized phase 2 evidence were rejected in support of awaiting phase 3 trials in progress. 6 phase 2-based recommendations have since been overturned on re-submission with phase 3 data. Of the 18 (56%) rejected with phase 3 data, 4 had demonstrated an overall survival advantage over standard of care (range 1.5-3.8 months) that was deemed not clinically significant. 12 were rejected due to lack of confidence in surrogate end-points employed in the trial. 1 was rejected due to diminishing clinical benefit observed over time, and 1 was rejected due to data quality. The EGP calculated the median cost-effectiveness of the proposed indications to be $188,537/QALY (range 22,326-2,120,433), with a median cost increase of $47,529 (2,536-226,752) and life-years gained of 3.8 months (0.8-11). Conclusions: Regulatory approval does not translate to clinically meaningful effectiveness. Bodies that consider opportunity cost may have a higher threshold for minimum benefit than regulators.
Establishing a prostate cancer referral pathway between urology and medical oncology at Lyndon B. Johnson Hospital.
Authors: Wiele Andrew , Ajufo Helen , Gulvin Joshua Michael , Laccetti Andrew L. , Brown Sarah , Stapleton Leslie , Rizvi Sarah , Park Anne , Ma Hilary Y. , Rieber Alyssa G.
Published: October 2019

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Background: Treatment for biochemically recurrent (bcr) and metastatic prostate cancer (pc) is evolving, making multidisciplinary evaluation a critical need. Our center, a community public hospital, lacked clear referral criteria between the Urology (Uro) and Medical Oncology (Onc) clinics, resulting in inconsistent care. We aimed to improve multidisciplinary communication and the rate of patient (pt) referrals by establishing standardized referral criteria for pc pts between Uro and Onc. Methods: Referral criteria were based on the presence or concern for primary refractory, bcr, castrate resistant (cr), or metastatic pc, as established by the PCWG3 and RTOG-ASTRO Phoenix consensuses. Primary refractory pc was defined as a failure of the PSA to fall to undetectable levels after radical prostatectomy (rp). Bcr pc was defined as two consecutive PSA values ≥ 0.2ng/mL after rp, or a rise in PSA 2ng/mL above post-treatment nadir after radiation therapy. Cr pc was defined as radiographic (progressive measurable disease) or chemical (two rising PSA levels 6-12 weeks apart) progression despite castrate levels of testosterone (T), defined as a serum T < 50ng/dL. Metastatic pc was defined as the development of bone lesion(s), organ involvement, or lymphadenopathy above the bifurcation of common iliac vessels. The referral criteria were organized into a chart and visibly displayed, discussed during multidisciplinary meetings, and distributed during educational sessions with Uro Residents and Onc Fellows in January 2019. Referral rate was collected from July 2018 through December 2018, and collection of post-intervention referral rate is planned from January 2019 through June 2019. Results: Pre-intervention, 39% (23/59 pts) of the pts that met referral criteria were referred to Onc. Preliminary data from January through April 2019 demonstrated a referral rate of 60% (9/15 pts). Conclusions: In 4 months, our intervention improved the referral rate by 21%. These criteria continue to be reinforced during multidisciplinary meetings and more educational sessions are planned as new personnel establish in the clinics. Ultimately, more time and pts are required to determine the full impact of this project.