bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of myelosuppressive chemotherapy and colony-stimulating factor (CSF) prophylaxis: A longitudinal assessment of practices participating in the Centers for Medicare and Medicaid Services (CMS) oncology care model (OCM).
Authors: Weycker Derek , Hanau Ahuva , Lonshteyn Alex , Kim Christopher , Gawade Prasad L. , Bowers Charles
Published: September 2018

12

Background: The CMS OCM is a 5-year program (7/2016 – 6/2021) focused on improving oncology care by incentivizing practices via financial and performance accountability. Little is known about practices participating in the OCM and whether patterns of care have changed over time. Methods: We used a retrospective cohort with structured elements from national electronic health record dataset provided by Flatiron Health (1/2012-12/2017). Data were de-identified to prevent patient and provider re-identification. Study population included adults with breast, colorectal, lung, or ovarian cancer or non-Hodgkin lymphoma who received chemotherapy with intermediate/high-risk for febrile neutropenia (FN). Patient characteristics, treatment, and supportive care within OCM and non-OCM practices were evaluated overall and by calendar year. Results: Study population included 42,699 patients at 53 OCM practices, and 25,613 patients at 149 non-OCM practices. OCM practices were larger (mean: 806 vs. 172 patients); age (mean: 62 vs. 62 years), cancer type (breast cancer: 53% vs. 52%), chemotherapy (high FN-risk: 49% vs. 48%), and other characteristics were comparable between patients in OCM and non-OCM practices. Use of high (vs. intermediate) FN-risk chemotherapy in 2012, 2015, and 2017 was 48%, 50%, and 48% in OCM practices and 50%, 50%, and 48% in non-OCM practices. CSF prophylaxis use, while higher in OCM practices, decreased over time in both subgroups (OCM: 70% in 2012 to 65% in 2017; non-OCM: 63% in 2012 to 58% in 2017). Use of pegfilgrastim (vs. short-acting CSFs) was > 94% across years in OCM and non-OCM practices. Use of the on-body injector (vs. prefilled syringe) increased from 26% of pegfilgrastim use in 2015 to 73% in 2017 in OCM practices and from 16% to 63% in non-OCM practices. Conclusions: Although OCM practices are larger and more commonly use CSF prophylaxis than non-OCM practices, trends in use of high FN-risk chemotherapy and declining prophylactic support appear to be similar between subgroups. Additional research is needed to evaluate whether such changes impacted health outcomes.
Implementing prehabilitation as part of enhanced recovery after surgery (ERAS) efforts at a comprehensive cancer center: A team-based approach.
Authors: Ngo-Huang An , Fontillas Rhodora C. , Gupta Ekta , Sahai Sunil Kumar , Popovich Shannon , Andrabi Tayab , French Katy E.
Published: September 2018

137

Background: ERAS efforts across surgical specialties have been evolving since 2012. At MD Anderson Cancer Center (MDACC), surgical and anesthesia services have been participating in this movement. In 2017, anesthesia, surgical, internal medicine, physical medicine and rehabilitation (PM&R), and nutrition teams collaborated to pilot a prehabilitation clinical pathway. Our goal was to develop a preoperative pathway using validated screening tools to incorporate prehabilitation for patients preparing for cancer surgery. Methods: This pilot included patients with thoracic and gynecological cancers who were at least 3 weeks prior to surgery. They were screened using the validated FRAIL index (Morley) and the Centers for Disease Control and Prevention fall risk screening tool. (Questions below) All patients who scored > / = 2 were referred to the PM&R clinic. Each patient received an individualized prehabilitation program including exercise, nutrition, and underwent screening for mood impairments: Fatigue: Are you fatigued at rest or with activities of daily living?; Resistance: Do you have any difficulty walking up one flight of steps without stopping for rest?; Aerobic: Are you unable to walk at least one block at a brisk pace and without stopping for rest?; Illness: Do you have more than five illnesses?; Loss of weight: Have you had unintended weight loss of more than 5% of your weight in the past 6 months?; Have you fallen in the past year?; Do you feel unsteady when standing or walking?; Do you worry about falling? Results: 27 referrals were received. 21 patients seen by PM&R (six were not seen due to scheduling conflicts). Average age was 70 years, 38% male. Baseline functional status was below aged-related normal values. Mean values for functional tests include: 6 minute walk test distance was 301 meters, five-times sit-to-stand was 12.4 seconds, and dynamic gait index score was 20.1. Conclusions: Prehabilitation as part of the team-based approach in cancer care is becoming an important part of ERAS pathways. Screening surgical patients for functional issues and fall risk is vital as these patients require prehabilitation to optimize them prior to surgery.
Development of a nutrition-focused quality improvement program for new patients with cancer seen at the UTSW Simmons Comprehensive Cancer Center (SCCC) outpatient gastrointestinal (GI) oncology clinic.
Authors: Brown Timothy J , Wolfe Heather R , Hardy Shelli , Bhulani Nizar , Hong Christine , Khosama Leticia , Cheedella Naga , Hobbs Stephanie , Froehlich Thomas W. , Kamal Arif , Beg Muhammad Shaalan , Kazmi Syed Mohammad Ali
Published: September 2018

143

Background: Patients with GI malignancies suffer from weight loss, sarcopenia and malnutrition contributing to poor outcomes and reduced survival. Early nutritional intervention in at-risk patients by a clinical dietitian can prevent or delay the onset of malnutrition. In the GI Oncology clinic at the UTSW SCCC, the rate of documented nutritional plan by a clinical dietitian within first 90 days of new patient encounter was low. Methods: We aimed to increase the rate of a documented nutrition assessment by a clinical dietitian to 65% within 90 days of a new patient encounter. Baseline data from the electronic medical record were obtained from Sep 2017-Oct 2018. Group sessions were arranged to apply QI methodologies to determine steps to a documented nutritional plan by a clinical dietitian. Patient advocates were interviewed to assess patient perspective. Sequential PDSA cycles were planned to improve rates of nutritional plan documentation and data were obtained every 2 weeks. Results: At baseline, 41.1% of new patients in the two-month data collection period had documented nutrition plans within 90 days of their first appointment. Most of these patients were on intravenous chemotherapy. EMR-based nutrition assessments identified 17% of all new patients at risk of malnutrition. Multiple causes for low baseline rates of nutrition plans were discovered, including patient or family characteristics and needs, clinical dietitian resources, physician limitations, process flaws, as well as difficulty with the EMR. Patient-centered PDSA cycles directed toward patients, and clinical staff to increase the rate of documented nutritional plan are ongoing. After the first PDSA cycle, early 2-week assessment shows documented rate of nutritional plan of 28%. Authors expect it to increase with longer follow-up and subsequent PDSA cycles. Conclusions: Malnutrition in GI cancer is prevalent and under-recognized in routine clinical encounters. Addressing malnutrition is important aspect from patient perspective. We are continuing ongoing efforts to increase the rate of nutritional assessments in these patients.
Undertreated pain: Trends over time for older adults with and without cancer.
Authors: Presley Carolyn J , Kapo Jennifer , Wang Shi-Yi , Canavan Maureen , Sheinfeld Ella , Feder Shelli , Kent Erin , Davidoff Amy J.
Published: September 2018

15

Background: Concerns about the adequacy of pain management among older adults are increasing. We examined calendar year (CY) trends in prescription medication (Rx) use by older adults with and without cancer who reported pain interference with normal activities. Methods: Using the 2007-2012 SEER-Medicare Health Outcomes Survey (MHOS) database with a unique linkage to Part D prescription claims data, we selected MHOS participants with Part D coverage who were within 5 years of cancer diagnosis or without cancer history. We used Rx claims to characterize use of opioids, non-opioid analgesics, local anesthetics and anti-epileptics during the 90 days post survey. Participant reported pain-related activity limitations within the past 30 days (pain interference) were summarized as severe, moderate, or none. We applied multivariable logistic regression to determine associations of Rx use with CY, cancer status, and pain interference, controlling for socio-demographics, chronic conditions, plan type and Part D Low Income Subsidy. Adjusted outcome levels were predicted based on the regression coefficients. Results: In the total sample (N = 15,624), pain Rx was used by 30%, with 20% receiving opioids. Severe or moderate pain interference with activities was reported by 23% and 46%, respectively. Among respondents with cancer (N = 9,105), 49% reporting severe (28% moderate) pain interference received any pain Rx; 37% & 18% used opioids, respectively. For those without cancer, adjusted pain Rx use rates were significantly lower in all categories. Pain Rx increased over CY for cancer respondents with moderate pain (25% in 2008 to 31% in 2012; p = .017), but not for those reporting severe pain interference. In addition, pain Rx increased over CY for the cohort without cancer with no pain interference (11% in 2008 to 14% in 2012; p = .027). Conclusions: Despite increased focus on symptom management, the majority of older adults who experienced moderate or severe pain interference did not have Rx for pain management. Efforts to identify and target unmet supportive care needs for Medicare beneficiaries, with and without cancer, are necessary to further improve quality of life.
“Getting to Know You and Your Child” screening questionnaire: Results from a Chicago pediatric collaborative.
Authors: Suh Eugene , Owen Erika D , Reichek Jennifer , Roggenkamp Betty , Trosman Julia Rachel , Henderson Tara O. , Mittal Nupur , Dighe Dipti , Iqbal Asneha , Berardi Rosa , Choi Daniel K. , Pillay Smiley Natasha , Hesko Caroline , Canner Jason Andrew , Stewart Zayda , Sanford Stacy D. , Weldon Christine B.
Published: September 2018

163

Background: In 2012, a congressional symposium identified the need for services to address psychosocial issues of children with cancer. In 2013, the Institute of Medicine recommended supportive oncology services be initiated at cancer diagnosis. Chicago providers of pediatric cancer are collaborating to improve care for children with cancer and their families focusing on psychosocial stressors and quality of life. Methods: The collaborative conducted a structured review of tools: Psychosocial Assessment Tool (PAT), Social Work Assessment Tool (SWAT), National Comprehensive Cancer Network (NCCN) Problem List, and √IN; with input from providers on stressors throughout the care continuum. The resulting screening tool was created and piloted in English and Spanish at 7 pediatric cancer hospitals. Social workers (SW) informally reported assessment of its usefulness. Results: Parents (n = 85) completed “Getting to Know You and Your Child” screening tool which inquired about caregivers, siblings, child’s interests, school, SSI/SNAP, challenges, and cultural/religious preferences. Providers reported families found the tool useful “to think about support needs.” The tool assessed 12 psychosocial stressors; the mean per patient/family was 2.4 (range 0-11). Most frequent stressors included: lack of support from friends, family, community (29%), paying for food (26%), job flexibility (26%), paying for utilities (25%), medical costs (23%), emotional support for family (22%), school concerns (21%). All who reported temporary residence also reported difficulty paying for housing (p < 0.01). Ten SWs reported this screening tool generated new insight into family structures, identified stressors and informed resolution efforts. Provider recommended adjustments to the screening tool: simplify terms for siblings, hobbies and spiritual, add pet question. Conclusions: Pilot testing of a psychosocial screening tool for pediatric and adolescent oncology informed providers of patient/family needs in a standard manner. Six of the seven pilot sites are implementing this tool as a standard practice. Preliminary data suggests patients and providers find the screener easy to use and informative.
Initiation of family-centered bedside rounds at Phoenix Children's Hospital Center for Cancer and Blood Disorders.
Authors: Lee-Miller Cathy A , Connor Renee , Acosta Lynnette , Wetmore Cynthia
Published: September 2018

170

Background: There has been a national trend towards a family/patient-centered care model in an effort to achieve many goals: earlier discharges, enhanced collaboration and patient safety, and improved satisfaction among medical care teams, patients and families. While most of the services at Phoenix Children’s Hospital (PCH) utilized a family-centered rounding model, the hematology/oncology service used table rounds. In December 2017, the Center for Cancer and Blood Disorders (CCBD) initiated family-centered rounds (FCR) on the inpatient service. Methods: FCR participants include patient, parent(s), bedside nurse, clinical supervisor, residents, fellow, attending, nurse practitioners, pharmacist, dietitian and child life specialist. One unique aspect of our FCR model is using scheduled rounds, whereby each patient is allotted a specific length of time and each family is given a time range within which to expect the team. Patients are scheduled every 10 minutes and if more time is needed, the attending/fellow return later for discussion. Staying on a schedule allows for improved nursing workflow and for consulting teams and interpreters to join rounds for specific patients. Outcome measures include patient, family and employee satisfaction. Results: Patient satisfaction is measured using NRC Real-time electronic survey. Scores have increased from a baseline of 70% (Oct/Nov 2017) to 87.5% (April 2018) after the initiation of FCR. From a qualitative standpoint, families have expressed gratitude for the new rounding model. Staff have expressed increased satisfaction at the efficiency and thoroughness of communication on rounds and the multidisciplinary team allows for real-time collaboration. Conclusions: FCR have led to increases in patient satisfaction both quantitatively and qualitatively. Ongoing initiatives include adding family-centered night rounds and a more extensive evaluation of FCR’s impact on employee satisfaction, patient safety, length of stay and lower overall costs. We are continuously evaluating the structure and efficacy of FCR to achieve the best possible care for our patients.
Standardizing documentation and improving communication on an academic inpatient solid tumor oncology consult service.
Authors: Landry Chrystal Ann , Kessler Alaina J , Bhardwaj Aarti Sonia , Smith Cardinale B.
Published: September 2018

171

Background: As the number of patients living with cancer increases, a growing proportion of hospital inpatients will have an advanced cancer diagnosis. Data suggests that an unscheduled hospitalization for a patient with advanced cancer strongly predicts a median survival of less than 6 months. As hospitalists more frequently become the primary team taking care of admitted cancer patients, communication between a patient's oncologic care team and inpatient primary providers is crucial. We sought to implement and assess the impact of improved oncology consult documentation of patient prognosis on outcomes of advanced cancer patients admitted to our hospitalist medicine teaching services. Methods: We implemented an EMR-based oncology consult note template which required documentation of prognosis, potential future treatment options (if available), and advance care planning. We reviewed all patients with stage IV solid tumors admitted to the hospitalist teaching service for 8 weeks prior and 8 weeks post-template implementation for comparison. We utilized descriptive statistics and chi-squared testing as appropriate for analysis. Results: We evaluated 51 patients in the pre- and 36 patients in the post-intervention groups. Post-intervention, there was an improvement in documentation of prognosis (29.4% vs. 52.8%, p = 0.03), advanced care planning (37.2% vs. 83.3%, p < 0.0001), and in number of palliative care consults (58.8% vs. 83.3%, p = 0.02). On average, goals of care conversations occurred 2 days earlier in the post-intervention group (11 vs 9 days). Similarly, there was a decrease in inpatient chemotherapy administration (3 cases vs. 0), unit codes (2 vs. 0) and in-hospital death (23.5% vs. 11.1%). Conclusions: Creation of an oncology consult note template which incorporates current oncologic prognostic information improved documentation of prognosis and advance care planning as well as outcomes for advanced solid tumor oncology patients and enhanced inter-service communication. Based on these results, continued and targeted interventions are planned to further improve inter-service communication.
Lessons learned from implementing the first Alliance NCORP Research Base Cancer Care Delivery Research (CCDR) trial A191402CD.
Authors: Pacyna Joel E , Sloan Jeff A. , Kim Simon P. , Sedlacek Hillary , Tilburt Jon Charles
Published: September 2018

175

Background: Biomedical research focused on the experiences of cancer patients in care delivery has progressed remarkably in recent years, including the emergence of Cancer Care Delivery Research (CCDR) within the NCI Community Oncology Research Program (NCORP). CCDR is a relatively new mechanism with the NCORP to support protocols that test questions beyond standard clinical trials for treatment or symptom control interventions. CCDR leverages the NCORP infrastructure to develop and test care delivery interventions in community hospital settings and in settings serving underserved and minority populations. CCDR enables researchers to conduct care delivery studies in critical places and in niche populations. Methods: We will describe our experience coordinating the first Alliance NCORP Research Base Cancer CCDR trial. Our trial – a four arm, cluster-randomized trial of decision aids among sites capable of oversampling minority men with a diagnosis of early stage prostate cancer – was the first CCDR trial in the Alliance NCORP Research Base. We will describe the opportunities and challenges we encountered. Results: We implemented a CCDR protocol even as the oversight for CCDR was being worked out in parallel. Curating partnerships outside of established channels of clinical trials, engaging minority serving institutions, and engaging surgical practices like urology illustrate some of the challenges of implementing a care-delivery trial in a diverse multi-site network. Research staff must learn the art of mitigating the disruption of care delivery research procedures within clinics. Additionally, the researcher’s skills are drawn upon at multiple points— establishing relationships, advocating for flexibility in implementing rules, cheerleading, connecting dots, and directing traffic. Conclusions: Our “lessons learned” presentation will provide an experiential account that will inform aspiring care delivery researchers in their work and describe some of the emerging aspects of the institutional implementation of new initiatives in modern cooperative group research. Our presentation will also inform key stakeholders about how to best facilitate this type of research.
Assessing caregiver satisfaction with care on an acute palliative care unit.
Authors: Mak Ernie , Murphy-Kane Patricia , Zimmermann Camilla
Published: September 2018

180

Background: Accreditation Canada has adopted four main values for hospice, palliative, and end-of-life services: dignity and respect; information sharing; partnership and participation; and collaboration . These domains, as well as communication and joint decision-making, are important for satisfaction of caregivers for patients with cancer, and can be measured using the FAMCARE questionnaire. We aimed to assess satisfaction of caregivers for patient admitted to an acute palliative care unit at a comprehensive cancer center in Toronto, Canada. Methods: The FAMCARE questionnaire was administered by a trained volunteer to self-identified caregivers of patients who were admitted for more than five days on the acute palliative care unit. A short, anonymous demographic survey accompanied the FAMCARE questionnaire to gather information on relationship to patient, ethnicity, patient length of stay, and location of residence. The survey package either was completed in the presence of the volunteer, or was left to be completed by the caregiver alone and collected later by the volunteer. Results were reviewed regularly at the quality committee of the palliative care service. Results: From September 2014 to May 2018, 116 caregivers completed the questionnaire. Most caregivers were female (66%), identified as Canadian or Caucasian (56%), and lived in Toronto (66%). In all, 52% were spouses while 27% were children of the patient. Most patients had been admitted between a week and a month (68%). Care was rated as “Satisfied” or “Very satisfied” most of the time on all items (range 77-99%). The availability of nurses and doctors (99% satisfied/very satisfied) were rated highest. Information given about side effects (77%) and referral to specialists (84%) were rated lowest. Conclusions: Despite the nature of the acute palliative care unit, where patients admitted tend to be very ill with complex symptoms and psychosocial issues, caregiver satisfaction was high. Developing adequate support for the spouses of patients is important. Future research will examine whether caregivers of different ethnicities value different aspects of cancer care.
Factors influencing the use of electronic health record systems to provide follow-up care to cancer survivors.
Authors: Palos Guadalupe R. , Rodriguez Maria Alma , Lewis-Patterson Paula A. , Harris Rachel , Foxhall Lewis E.
Published: September 2018

182

Background: One of the expected benefits of electronic health records (EHRs) is their interoperability to remotely access and exchange clinical information across systems and clinicians. Cancer survivors’ treatment summaries (TSs) and care plans (CPs) are documents that can be electronically transferred from oncologists to primary care providers. We conducted a needs assessment to identify factors which influenced EHRs in meeting these expectations in rural and underserved primary care settings. Methods: Clinicians from 2 family practice health care systems, located in central and northeast Texas were surveyed. REDCap, a web-based system, was used to develop, manage, and distribute the survey to a convenience sample of clinical staff from both settings. Survey questions focused on respondents’ demographic and clinical practice characteristics, current experience with TSs and CPs, and type of EHR used. Results: A total of 26 surveys were included in this analysis. Respondents were primarily physicians (73%). Overall 61.5% reported that ≤ 25% of their patients were diagnosed with cancer or currently had cancer. A patient’s self-report was the primary method used by majority of respondents to determine if a patient had a history of cancer. 80.8% indicated they would be interested in learning more about the use and development of TSs and CPs. Barriers reported towards the use of EHRs to deliver TSs and CPs included: EHRs interference with workflow (60%); limited knowledge on how to develop TSs and CPs (48%), inadequate access to IT resources (48%), and inefficient EHR systems (44%). In these settings, EHRs used were: Epic (61.6%), Aria (30.8%), and Medit (7.7%). Respondents’ comments on EHRs weaknesses included: “the two systems…do not completely communicate with each other” or “no place where a cancer treatment summary or survivorship plan is documented”. Conclusions: Primary care providers identified limitations in EHR operability as a major barrier to retrieving health information required for TSs and CPs. Clinicians in rural or underserved regions may benefit from education and retraining in EHR systems.
Defining a patient-reported outcome measure (PROM) selection process: What criteria should be considered when choosing a PROM for routine symptom assessment in clinical practice?
Authors: Montgomery Nicole , Bartlett Susan J , Brundage Michael Donald , Bryant-Lukosius Denise , Howell Doris , Ismail Zahra , Krzyzanowska Monika K. , Moody Lesley , Snyder Claire Frances , Staley Liang Monica , Barbera Lisa
Published: September 2018

187

Background: PROMs capture the patient’s perspective on their health status and thus improve person-centred care. The Edmonton Symptom Assessment System has been the standard PROM used for all patients in Ontario. Recently, Cancer Care Ontario has chosen to expand the use of PROMs by adding cancer specific tools. The objective of this work was to develop a process to systematically evaluate and select PROMs for routine use in clinical practice. Methods: The development of the PROM selection process included several steps: 1) a literature scan to identify existing PROM selection guidelines and considerations; 2) development of clinically relevant criteria by a panel of methodological experts and patient advisors; and 3) use of a case study to test the process and identify gaps. In the case study, disease-site experts and patients were given the opportunity to review the PROMs and provide feedback. Results: The literature scan highlighted six resources endorsing three common considerations for PROM selection: symptom coverage, usability, and psychometric properties. The expert panel further developed criteria for each consideration. Symptom coverage criteria include percentage of prevalent, bothersome and expert endorsed symptoms addressed by the PROM. Usability criteria include: reference time-frame, scale, time to complete, scoring, plain language and translations. Psychometric criteria are: internal consistency, reliability, responsiveness, discrimination ability, meaningful change and translation validity. Each consideration is scored as weak, average or good based on how well the criteria are met. A summary matrix illustrates the overall assessment. In the case study, the selection process identified two top-performing PROMs; disease-specific patient focus groups were held to inform the final decision. Conclusions: This rigorous evaluation of candidate measures resulted in the selection of a PROM that was accepted by methodological experts, clinical advisors and patients. The case study demonstrated the value of disease-specific patient input on PROM selection.
Understanding health-related quality of life (HRQoL) in unresected stage III non-small cell lung cancer (NSCLC).
Authors: Ryan Kellie , Skinner Karen E , Fernandes Ancilla , Walker Mark S. , Pavilack Melissa , Punekar Rajeshwari S , VanderWalde Noam Avraham
Published: September 2018

189

Background: Despite curative treatment intent, most patients (pts) with unresected Stage III NSCLC progress to metastatic disease. Prior research has shown significant benefits on clinical outcomes when HRQoL is assessed in clinical care, but understanding is limited in Stage III NSCLC. Methods: A retrospective review of community oncology medical records was conducted to examine real-world clinical outcomes such as overall and progression-free survival. Eligible pts were adults diagnosed from 1/1/2011 to 3/1/2016 with unresected Stage III NSCLC. In a subset of patients with available data, HRQoL was assessed using the 86-item Patient Care Monitor (PCM), a patient reported measure. Linear mixed models (LMM) were used to assess the impact of pt characteristics and change in PCM scores associated with progression. Results: The main sample included 478 pts: mean [SD] age was 67 [10] years, 55% male, 72% Caucasian, and 71.1% initially treated with concurrent chemoradiation. HRQoL analysis included 167 pts. LMM showed significant worsening of Index scores for General Physical Symptoms, Treatment Side Effects, Despair, and Impaired Ambulation (p < 0.001) as well as Acute Distress (p = 0.044) at progression. Of the six symptoms analyzed, significant worsening of scores at progression occurred in pain, difficulty breathing, and fatigue (p < 0.001). HRQoL consistently worsened at progression, but the pattern of severity for Index scores varied when separately evaluated in the pre- and post-progression periods. Symptom patterns showed improvement for Treatment Side Effects, Acute Distress, and Despair during the pre-progression period, but worsened post-progression, an effect that exceeded the pre-progression improvement. Receipt of radiation and increasing age were associated with better overall HRQoL; HRQoL tended to be worse in pts with greater comorbidity burden and impaired performance status. Conclusions: Our study demonstrated a pattern of clinically meaningful worsening of HRQoL at progression, with pts reporting worsening physical symptoms and negative psychological states. The results also appear consistent with clinical expectations and show HRQoL benefit of radiation therapy.
Pilot study of iPad-based patient-reported outcomes at the MGH Cancer Center.
Authors: Parikh Aparna Raj , Soriano Margaret , Hochberg Ephraim P. , McLeish Courtney , Lennes Inga Tolin , Souza Elizabeth , Mulvey Therese Marie
Published: September 2018

190

Background: Patient reported outcomes (PROs) have been shown to improve outcomes in cancer patients in clinical trials and have also been shown to improve the patient experience, provide real-time access to patient reported symptoms and are increasingly used across disciplines. Given the importance of PROs, at the MGH Cancer Center, we implemented a pilot using iPADs to capture patient reported outcomes for patients receiving IV chemotherapy in the breast and lymphoma clinics as well all IV chemotherapy patients at one of the MGH satellite clinics where patients across all disease groups are seen. Methods: 12 measures from the PRO-CTCAE were selected to be applicable to all cancer patients. Working with the technology team and EPIC team at MGH the selected PROs were loaded into iPADs and are automatically assigned to patients receiving IV chemotherapy. Staff and clinicians were trained in the breast, lymphoma and satellite clinic. Patient who were receiving IV chemotherapy were assigned iPADs at check in. Patients completed the questionnaire and in real-time, the data was available in the EPIC chart. The objectives of the pilot were to assess the feasibility of collecting iPAD based PROs at the MGH Cancer Center. Results: In the 4-month pilot, there were 2,304 visit types that were eligible to receive an iPAD for PRO collection, 79% (N = 1,1816) patients were assigned an iPAD. Of the 1,816 patients assigned an iPAD, 65% (N = 1,173) patients completed the PROs, 4% (N = 36) partially completed the PROs. In terms of completion at the main disease specialty clinic vs the satellite, completion rates were higher at the satellite (77% vs 44%). During one week, we asked the front desk to record why patients did not complete the PROs-93 patients were assessed, 45% of patient refused the iPAD, in 28% of these patients the staff did not capture the reason and 22% were not given an iPAD. Conclusions: This pilot demonstrates the feasibility of collecting PROs in an oncology clinic for patients receiving IV chemotherapy. We plan to continue to improve the assignment of PROs to eligible patients, educate staff, providers and patients on the important of PROs and plan to expand to all the clinics at MGH Cancer Center and satellite centers.
Comparison of health utility values from EQ-5D-3L and EQ-5D-5L in patients with breast cancer in different health states.
Authors: Tse Tiffany , Yang Dongyang , Baek Justine , Liang Mindy , Skitch Amy , Brezden-Masley Christine , Brown M. Catherine , Torres Sofia , Xu Wei , Liu Geoffrey
Published: September 2018

197

Background: Recently, our group reported Canadian-derived EQ-5D-3L-derived health utility scores for over 20 different cancer sites (PMID: 27567613). However, more recently, a Canadian valuation set for EQ-5D-5L derived health utilities has been reported. As we switch from the 3L to 5L version, we need to evaluate whether the data can be analyzed together across versions, or whether the older cancer valuations need to be replicated. Methods: Breast cancer patients in three health states (primary breast cancer, locoregional recurrence of breast cancer, and metastatic breast cancer) were evaluated using EQ-5D-3L from 2014-2015 and EQ-5D-5L from 2016-2017. Mean (SD) values were compared. We opted not to compare the two versions in the same patients because of recall bias, so we compared two different sets of patients. Results: Of 387 breast cancer patients, 259 (67%) had completed the EQ-5D-5L, while 128 (33%) completed the EQ-5D-3L. The two groups had similar distributions for clinico-demographic data except for ethnicity, where there were more Asian patients in the 5L (22% vs 9%; p < 0.0074). When comparing EQ-5D-5L and EQ-5L-3L within health states, the EQ-5D-5L values were numerically higher for all three health states: for primary breast cancer (mean HUS(SD)/version: 0.85(0.11)/5L vs. 0.81(0.16)/3L) with a p-value of 0.028; locoregional recurrence (0.87(0.08)/5L vs. 0.85(0.20)/5L) with no available p-value due to the small sample size; metastatic disease (0.79(0.15)/5L vs. 0.78(0.13)/3L) with a p-value of 0.78. Histogram distributions appeared different between the two versions. There was greater separation and statistical significance between health states when using the 5L version when compared to the 3L version. The 5L version had a greater variation of values than the 3L, utilizing the entire spectrum of values from 0.0 to 1.0. Conclusions: Though the trends across health states were similar in EQ-5D-5L and EQ-5D-3L health states, values using the 5L were higher and distributions appeared different. There should be extreme caution if considering combining health utility values from 5L and 3L in Canadian breast cancer datasets.
Qualitative study to understand the emotional response to a metastatic diagnosis in castration-resistant prostate cancer.
Authors: Burbridge Claire , Randall Jason A , Symonds Tara , Lawson Joe , Dearden Lindsay , McQuarrie Kelly , Espina Byron M.
Published: September 2018

201

Background: To explore the emotional response of men with a recent metastatic Castration Resistant Prostate Cancer (mCRPC) diagnosis, emotional burden of monitoring their condition prior to additional treatment for metastasis (“watch and wait”), and emotional impact on caregivers. Methods: In-depth, qualitative, one-to-one interviews with 25 men with a recent diagnosis of mCRPC from the US (n = 4), France (n = 12) and Germany (n = 9). Additional interviews were conducted with 12 of the participants’ primary support person (PSP) - a friend/family member who provided support to the participants emotionally and/or in everyday tasks; US (n = 2), France (n = 8), Germany (n = 4). Interviews were audio-recorded, transcribed and thematic analyzed. Results: Participants were 54-85 years old; 88% retired; mean time since metastatic diagnosis was 7.5 months (seven were within 12 weeks of metastasis, all others within 24 months of metastasis); and 19 experienced pain related to their CRPC. Symptoms and impacts associated with mCRPC were consistent across countries. The most frequent symptoms (reported by ≥75%) were fatigue/tiredness, sexual dysfunction and pain. Metastasis had a negative emotional impact, participants reported fear of what happens next. Some explicitly associated certain symptoms/impacts with metastasis, such as localized pain, diarrhea, blood in stool, and increased impact of activities of daily living. 72% highlighted that metastatic diagnosis impacted their emotional state, experiencing worry, anxiety, fear, low mood/depression and shock, with increased burden on PSP and strain on relationships. 80% highlighted that monitoring PSA values was important, and ten discussed the emotional impact of this: fear and worry when rising; glad, happy, and excited when falling. Most participants (80%) reported that, if a medication had been available to them to delay metastasis, they would have taken it, even if asymptomatic. Conclusions: Metastatic diagnosis was associated with a worsening of symptoms and both physical and emotional impacts. Rising PSA levels prior to metastasis had a negative emotional impact. Most participants were willing to take a medication to delay metastasis.
The costs of breast cancer care: Patient-reported experiences and preferences for transparency.
Authors: Greenup Rachel Adams , Rushing Christel , Fish Laura , Hyslop Terry , Peppercorn Jeffrey M. , Wheeler Stephanie B. , Zafar Yousuf , Myers Evan , Hwang Eun-Sil Shelley
Published: September 2018

207

Background: Despite the recognized side effect of financial toxicity after cancer, treatment decisions for breast cancer rarely include the costs of care. We sought to determine women’s experiences with breast cancer treatment costs, and their preferences for cost transparency at diagnosis. Methods: Women ≥18 years old with a history of breast cancer completed an 88-question electronic survey based on validated or published items. Descriptive statistics and regression analysis were used. Results: In total, 607 women with stage 0-III breast cancer participated. Median age at diagnosis was 49.6 years. Median time from diagnosis was 6.7 years (range 0.1-37.1). The majority had private (70%) insurance or Medicare (25%), and reported an annual household income ≥$74,000. 43% reported considering costs in treatment decisions. Median reported out-of-pocket (OOP) costs were $3,500; 25% reported OOP costs ≥$8,000, 10% reported OOP costs ≥$18,000 and 5% reported OOP costs ≥$30,000. 15.5% reported significant to catastrophic financial burden. Bilateral mastectomy +/- reconstruction vs lumpectomy (OR 1.9, p 0.03), greater stage at diagnosis (stage 3 vs 0, OR 3.9, p < 0.01), and discussion of costs during the clinical encounter (OR 2.3, p < 0.01) were associated with a higher risk of financial harm. Women who reported discussing costs were more likely to be stage 2 or 3 (56% vs 40%, p = 0.02), less likely to be depressed (24% vs 30%, p = 0.03), and had less insurance coverage (trend p = 0.02) compared to those who did not. Older age (OR 0.95, p < 0.01), increasing household income (overall p < 0.001), better insurance coverage (OR 0.5, p < 0.001), and longer time since diagnosis (OR 0.65, p < 0.001) was associated with a decreased risk of financial harm. 78% of participants never discussed costs with their cancer team. 79% preferred cost transparency prior to embarking on care, and 40% preferred that doctors consider costs when making recommendations. Conclusions: Many women with breast cancer reported significant financial burden related to their care, and the vast majority preferred knowing costs at diagnosis. Cost transparency may improve the quality of preference-sensitive treatment decisions and reduce the risk of financial harm.
The effects of participation in an individualized exercise program under the supervision of health care professionals on cancer-related fatigue.
Authors: Megan Mary Elizabeth , Maul John Scott , Olson Lauren Ashley , Pogodzinski Jennifer Lynn , Singh Maharaj
Published: September 2018

208

Background: A majority of (80–100%) of patients with cancer report cancer-related fatigue. Physical activity has shown to be an effective intervention for cancer-related fatigue. The cancer rehabilitation team at Aurora Health Care’s Aurora Medical Center Grafton initiated the Exercise for Cancer Recovery Program (ECRP) in order to have a greater impact on the quality of life of their patients. ECRP was an individualized exercise program taking place in a group setting with other cancer survivors under the supervision of healthcare professionals. The program was open to patients with all types and stages of cancer, including patients in active treatment as well as those who completed treatment. The aim of the study was to determine if participation in ECRP reduces cancer-related fatigue. Methods: Upon referral and/or clearance from the patient’s oncologist/advanced practitioner, the patient was evaluated by a physical therapist and placed on an individualized exercise program. ECRP ran twice per week for an hour. Patients followed and filled out an exercise log. During each session, the supervising health care professionals circulated throughout the class, providing individual guidance as appropriate to ensure safe participation and motivation. Baseline data on fatigue was obtained for each patient upon the initial session and monthly thereafter using the Brief Fatigue Inventory Outcome Measurement tool (BFI) over a 12-month period dating from January to December 2017. Twenty-seven patients participated in ECRP. Not all patients attended all exercise sessions or completed BFI every month. The minimum fatigue score was determined and compared with the initial score utilizing a paired t-test and signed rank test. Results: Data was obtained and analyzed utilizing a paired t-test and a signed rank test to evaluate the significance of BFI scores obtained between the initial and minimum score. There was a significant reduction in the Total Brief Fatigue score (P-value < 0.001). Conclusions: An exercise program resulted in a significant reduction in cancer-related fatigue with improved patient outcomes and patient satisfaction.
National patient experience data and correlation with in-hospital adverse gynecologic cancer surgical outcomes.
Authors: Dottino Joseph , He Weiguo , Sun Charlotte C. , Zhao Hui , Lu Karen H. , Meyer Larissa
Published: September 2018

21

Background: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a patient experience and quality of care measure that impacts hospital reimbursement. HCAHPS data is made available to the public through Centers for Medicare and Medicaid. Given the potential implications for healthcare decision-making, this study sought to determine the utility of hospital-level data from the HCAHPS survey as a predictor of in-hospital postoperative outcomes in gynecologic cancer patients by creating a link with the Nationwide Inpatient Sample (NIS) database, an inpatient care database developed for the Healthcare Cost and Utilization Project (HCUP). Methods: 2009-2011 HCAHPS survey data was used to assign hospitals into terciles by scores. The NIS database was used to identify admissions for cancer-specific surgeries for patients with ovarian, uterine, and cervical cancers. Outcomes included complications, mortality, and prolonged length of stay. Mixed effects models compared correlation of outcomes and HCAHPS scores, after adjustment for patient-level and hospital-level variables. Results: 17,509 linked encounters in 651 hospitals across the U.S. were identified, with 51% uterine, 40% ovarian, and 9% cervical cancer surgical admissions. In-hospital mortality was less likely in hospitals in the highest vs. lowest tercile of summary HCAHPS scores (odds ratio (OR) 0.54, 95% CI: 0.31-0.94). While higher scores were not associated with overall postoperative complications, by complication subcategory, admissions in top tercile hospitals were less likely to have surgical complications (OR 0.82, 95% CI 0.69-0.98). No differences were found in risk of medical or nursing-related complications, or prolonged hospitalization (p > 0.05). Conclusions: For patients undergoing gynecologic oncology surgery, assessment of patient experience has limited correlation with in-hospital adverse surgical outcomes. Awareness of the limitations of HCAHPS survey data may better inform patients as consumers and highlights the importance for transparency of relevant quality measures.
Post-operative vital signs: How often is too often?
Authors: Filson Kristen , Atherholt Colleen , Simoes Meredith , DiPalma Michael , John Susheela , Reynolds Robin , McGovern Joanne
Published: September 2018

210

Background: Current protocol for post-operative patients admitted to medical-surgical/telemetry units from post anesthesia care units states vital signs are taken every 15 minutes for 1 hour, every 30 minutes for 2 hours and then, every 4 hours for 24 hours. To date, published evidence-based research regarding the frequency and duration of vital signs to safely monitor post-operative patients is limited. The goal is to determine best practice in post-operative vital sign monitoring to ensure safe patient care. The purpose of this review is to determine what frequency and duration of vital signs is required to identify a deviation greater than 20% of patient baseline to ensure safe post-operative monitoring of patients. Methods: A total of 742 post-operative patients’ charts were evaluated. A time frame in which vital signs deviated greater than 20% from patient baseline was established from the data collected. A chart was created depicting these results; listing the total deviations by individual vital sign and time frame. Results: Results show blood pressure and heart rate are the vital signs that have the greatest deviation from baseline followed by pulse-oximetry. Temperature deviations are widespread, while changes in respiratory rate are seen within the first hour. When looking at specific percentages, it was noted that 65% of the total patients reviewed had a 20% deviation from their baseline vital signs. Blood pressures made up 50% of those deviations, while heart rates made up 45%. A total of 27% of the deviations occurred 4-8 hours after admission, 13% of deviations occurred 8-12 hours after admission, 9% of deviations occurred 1.5 hours after admission, and 7% of deviations occurred 12-16 hours after admission. Conclusions: Based on these results, the best times to take post-operative vitals to ensure deviations are detected are: every 15 minutes for 30 minutes upon admission, 1.5 hours after admission, 4 hours after admission, and then every 4 hours for 20 hours. Findings indicate vital signs can safely be taken less frequently in post-operative patients admitted to medical-surgical/telemetry units.