bluuebunny/crossref_metadata_2025 huggingface dataset:
Disruption of gut integrity and permeability contributes to enteritis in a fish-parasite model: a story told from serum metabolomics
Authors: Sitjà-Bobadilla Ariadna , Gil-Solsona Rubén , Estensoro Itziar , Piazzon M. Carla , Martos-Sitcha Juan Antonio , Picard-Sánchez Amparo , Fuentes Juan , Sancho Juan Vicente , Calduch-Giner Josep A. , Hernández Félix , Pérez-Sánchez Jaume
Published: October 2019

Background

In the animal production sector, enteritis is responsible for serious economic losses, and intestinal parasitism is a major stress factor leading to malnutrition and lowered performance and animal production efficiency. The effect of enteric parasites on the gut function of teleost fish, which represent the most ancient bony vertebrates, is far from being understood. The intestinal myxozoan parasite Enteromyxum leei dwells between gut epithelial cells and causes severe enteritis in gilthead sea bream (Sparus aurata), anorexia, cachexia, growth impairment, reduced marketability and increased mortality.

Methods

This study aimed to outline the gut failure in this fish-parasite model using a multifaceted approach and to find and validate non-lethal serum markers of gut barrier dysfunction. Intestinal integrity was studied in parasitized and non-parasitized fish by immunohistochemistry with specific markers for cellular adhesion (E-cadherin) and tight junctions (Tjp1 and Cldn3) and by functional studies of permeability (oral administration of FITC-dextran) and electrophysiology (Ussing chambers). Serum samples from parasitized and non-parasitized fish were analyzed using non-targeted metabolomics and some significantly altered metabolites were selected to be validated using commercial kits.

Results

The immunodetection of Tjp1 and Cldn3 was significantly lower in the intestine of parasitized fish, while no strong differences were found in E-cadherin. Parasitized fish showed a significant increase in paracellular uptake measured by FITC-dextran detection in serum. Electrophysiology showed a decrease in transepithelial resistance in infected animals, which showed a diarrheic profile. Serum metabolomics revealed 3702 ions, from which the differential expression of 20 identified compounds significantly separated control from infected groups in multivariate analyses. Of these compounds, serum inosine (decreased) and creatine (increased) were identified as relevant and validated with commercial kits.

Conclusions

The results demonstrate the disruption of tight junctions and the loss of gut barrier function, a metabolomic profile of absorption dysfunction and anorexia, which further outline the pathophysiological effects of E. leei.
The transition from university to work: what happens to mental health? A longitudinal study
Authors: Geirdal Amy Østertun , Nerdrum Per , Bonsaksen Tore
Published: October 2019

Background

When enrolled in university or college, students receive varying degrees of training in managing practical situations in the workplace. However, after graduation, the young professionals meet their responsibilities at work. The experience of the transition between education and work may connote a feeling of professional uncertainty and lack of coping, both of which are important factors related to young professionals’ mental health. The gap between the two areas of knowledge is frequently described as ‘practice shock’. Very few studies of mental health among students and young professional workers have used longitudinal designs. In the present study, we conducted a longitudinal investigation of change and stability in the levels of psychological distress among healthcare professionals, teachers, and social workers from the end of their study programs until 3 years into their subsequent professional lives. We also assessed the extent to which psychological distress at the end of the study program, sociodemographic characteristics, coping with the professional role, the psychosocial workplace environment, and experience of overall quality of life can predict psychological distress 3 years into their professional lives.

Methods

Psychological distress was measured using the General Health Questionnaire 12 (GHQ-12). A total of 773 students/young professionals participated at both the end of their study programs and 3 years into their professional lives. Group differences were examined by the chi-squared test, independent samplest-test, and one-way analysis of variance. McNemar’s test were applied to identify changes in the proportion of cases at the two time points. Linear and logistic regressions were employed to identify factors associated with GHQ-12 Likert scores and GHQ-12 case scores, respectively.

Results

Psychological distress was significantly reduced at 3 years for health professionals. Among the social workers and teachers, the change in psychological distress was not significant during the same period. Higher current quality of life contributed to lower psychological distress.

Conclusions

Our findings support assumptions about higher levels of mental health problems as students, with mental health improving as health professionals and social workers move into professional work.
Infertility knowledge and treatment beliefs among African American women in an urban community
Authors: Wiltshire Ashley , Brayboy Lynae M , Phillips Kiwita , Matthews Roland , Yan Fengxia , McCarthy-Keith Desiree
Published: October 2019

Background

To assess infertility knowledge and treatment beliefs among African American women in an urban community in Atlanta, Georgia.

Methods

This was a cross sectional study at a safety net hospital. A convenience sample of a total of 158 women receiving outpatient obstetrical or gynecologic care from March–April 2017 were recruited. Infertility knowledge and treatment beliefs were assessed using a previously applied and field-tested survey from the International Fertility Decision Making Study.

Results

The mean infertility knowledge score was 38.15% for total subjects. Those with a higher level of education (p < 0.0001) and those with paid employment (p = 0.01) had a significantly higher level of infertility knowledge. Those who had a history of infertility therapy were significantly more likely to agree with negative treatment beliefs (p = 0.01). There was no significant difference in infertility knowledge or treatment beliefs based on age, sexuality, parity or being pregnant at the time of survey completion.

Conclusions

African American women in our urban clinic setting seem to have a limited level of knowledge pertaining to infertility. Further research is needed to understand how differences in knowledge and beliefs translate into infertility care decision-making and future childbearing.
High prevalence of obesity in rheumatoid arthritis patients: association with disease activity, hypertension, dyslipidemia and diabetes, a multi-center study
Authors: de Resende Guimarães Maria Fernanda Brandão , Rodrigues Carlos Ewerton Maia , Gomes Kirla Wagner Poti , Machado Carla Jorge , Brenol Claiton Viegas , Krampe Susana Ferreira , de Andrade Nicole Pamplona Bueno , Kakehasi Adriana Maria
Published: October 2019

Introduction

Rheumatoid arthritis (RA) is a well-documented independent risk factor for cardiovascular disease. Obesity may provide an additional link between inflammation and accelerated atherosclerosis in RA.

Objective

To evaluate the association between obesity and disease parameters and cardiovascular risk factors in RA patients.

Method

Cross-sectional study of a cohort of RA patients from three Brazilian teaching hospitals. Information on demographics, clinical parameters and the presence of cardiovascular risk factors was collected. Blood pressure, weight, height and waist circumference (WC) were measured during the first consultation. Laboratory data were retrieved from medical records. Obesity was defined according to the NCEP/ATPIII and IDF guidelines. The prevalence of obesity was determined cross-sectionally. Disease activity was evaluated using the DAS28 system (remission < 2.6; low 2.6–3.1; moderate 3.2–5.0; high > 5.1).

Results

The sample consisted of 791 RA patients aged 54.7 ± 12.0 years, of whom 86.9% were women and 59.9% were Caucasian. The mean disease duration was 12.8 ± 8.9 years. Three quarters were rheumatoid factor-positive, the mean body mass index (BMI) was 27.1 ± 4.9, and the mean WC was 93.5 ± 12.5 cm. The observed risk factors included dyslipidemia (34.3%), type-2 diabetes (15%), hypertension (49.2%) and family history of premature cardiovascular disease (16.5%). BMI-defined obesity was highly prevalent (26.9%) and associated with age, hypertension and dyslipidemia. Increased WC was associated with diabetes, hypertension, dyslipidemia and disease activity. Conclusion: Obesity was highly prevalent in RA patients and associated with disease activity.
Inversion of downhole electrical measurements for proppant mapping using very fast simulated annealing
Authors: Zhang Peng , Shiriyev Javid , Sen Mrinal K. , Sharma Mukul M.
Published: October 2019

Proppant mapping is critical for optimizing fracture treatment design and improving wells’ productivity. An electrode-based resistivity tool concept was developed earlier for proppant mapping in cased-hole wells. An array of insulating gaps is installed and cemented in place as a permanent part of the casing string. The electrical measurements are performed by imposing a voltage across each insulating gap, one at a time, before and after hydraulic fracture operations. The voltages across other insulating gaps near the transmitter gap are recorded. The method relies on direct excitation of the casing, which is expected to overcome the severe limitations of induction tools in cased-hole wells. A forward model based on a finite volume method has been developed to simulate the tool’s response to one or multiple fractures. To enable the implementation of such a practical system in multistage fractured horizontal wells, a fast and robust inversion approach is required. To that end, we have developed a divide-and-conquer approach based on a global optimization algorithm very fast simulated annealing (VFSA). Specifically, the original inverse problem is divided into subproblems and each subproblem can be solved separately using VFSA. The results indicate that our approach can invert the data and output widths and radii of multiple fractures without requiring a large number of forward simulations. The robustness of the inverse solver is also tested by adding Gaussian noise to the synthetic data. We tested example cases that demonstrate that when up to 5% noise is introduced, VFSA still provides very accurate inversion results with moderate uncertainties. Inversion results with some more realistic conditions, e.g., tilted fractures, complex fractures, and so on, are also presented.
Surface-related multiple leakage extraction using local primary-and-multiple orthogonalization
Authors: Zhang Dong , Verschuur D. J. (Eric) , Qu Shan , Chen Yangkang
Published: October 2019

Accurate multiple removal remains an important step in seismic data processing sequences. Most multiple removal methods, such as surface-related multiple elimination (SRME), consist of a multiple prediction step and an adaptive subtraction step. Due to imperfect circumstances (e.g., coarse data sampling) or built-in assumptions (e.g., 2D method versus 3D data), multiple leakage is commonly observed in the results. More aggressive adaptive multiple subtraction can reduce the leakage problem, for example, by using small local windows and a long filter length, but at the risk of severely damaging the primaries due to overfitting. In contrast, conservative adaptive subtraction with large or global windows and a short filter length can preserve most primary energy while tending to have more multiple leakage because of underfitting. Assuming that the primaries and multiples do not correlate locally in the time-space domain, our solution to this problem is to extract the leaked multiples from the initially estimated primaries using local primary-and-multiple orthogonalization (LPMO) rather than restoring the damaged primaries. Our framework consists of two steps: an initial primary estimation step and a multiple leakage extraction step. The initial step corresponds to conservative SRME (or an equivalent method) that produces the initially estimated primary and multiple models. The second step is based on LPMO to retrieve the leaked multiples from the estimated primaries via a time- and space-varying weight function that is estimated from the local correlation of predicted multiples and residual multiples in the estimated primaries with the help of shaping regularization. In this way, we can obtain a better primary model that has much less leaked multiple energy and less primary damage at the same time. We find good performance of our framework via two synthetic data examples and one field data example.
Acadian detachment and wrench faults in central Pennsylvania: Implications for the Marcellus Shale reservoir integrity and gas productivity in the hinge of the Pennsylvania salient
Authors: Gao Dengliang , Roberts Emily , Geiger Connor , Sullivan Peter
Published: October 2019

High-quality 3D seismic data in Clearfield County, central Pennsylvania, reveal subsurface structural details of regional flat-top, box-shaped folds, convergent reverse faults, and cross-regional lineaments in the hinge of the Pennsylvanian salient. Cross-stratal variations in structural relief, bed curvature, and seismic facies indicate that the deformational intensity increases from below the Salina (Upper Silurian) to the Onondaga (Middle Devonian) and then decreases from the Onondaga to the Elk (Upper Devonian). The pre-Onondaga isochron thickness sees an increasing trend but the post-Onondaga isochron thickness sees a decreasing trend on the anticlinal axes. The seismically imaged subsurface structures are consistent with outcrop and topographic observations, wireline and formation microimager (FMI) logs, and gravity and magnetic intensity measurements. The Marcellus Shale (Middle Devonian) gas exploration and production data indicate that the operational activity and gas productivity drop significantly in Clearfield County and other counties in the hinge of the Pennsylvanian salient. We interpret that the regional folds and faults and cross-regional lineaments are detachment and wrench faults that were most likely caused by gravitational sliding above the Salina (salt) during the Acadian (Middle Devonian-Early Mississippian). We infer that the co-occurrence of the regional and the cross-regional faults, particularly the cross-regional wrench faults, might have had a significant impact on the Marcellus Shale reservoir integrity and gas productivity in the hinge of the Pennsylvania salient. These observations and interpretations demonstrate the dynamic interplay among tectonic deformation, syntectonic deposition, and shale gas retention, thus entailing significant geologic, economic, and environmental implications in the Appalachian Basin.
Absolute Improvements in Freedom From Distant Recurrence to Tailor Adjuvant Endocrine Therapies for Premenopausal Women: Results From TEXT and SOFT
Authors: Pagani Olivia , Francis Prudence A. , Fleming Gini F. , Walley Barbara A. , Viale Giuseppe , Colleoni Marco , Láng István , Gómez Henry L. , Tondini Carlo , Pinotti Graziella , Di Leo Angelo , Coates Alan S. , Goldhirsch Aron , Gelber Richard D. , Regan Meredith M. ,   for the SOFT and TEXT Investigators and International Breast Cancer Study Group
Published: October 2019

PURPOSE

The Tamoxifen and Exemestane Trial (TEXT)/Suppression of Ovarian Function Trial (SOFT) showed superior outcomes for premenopausal women with hormone receptor (HR)–positive breast cancer treated with adjuvant exemestane plus ovarian function suppression (OFS) or tamoxifen plus OFS versus tamoxifen alone. We previously reported the magnitude of absolute improvements in freedom from any recurrence across a continuous, composite measure of recurrence risk to tailor decision making. With longer follow-up, we now focus on distant recurrence.

METHODS

The TEXT/SOFT HR-positive/human epidermal growth factor receptor 2 (HER2)–negative analysis population included 4,891 women stratified by predetermined chemotherapy use. Kaplan-Meier estimates of 8-year freedom from distant recurrence were analyzed using subpopulation treatment effect pattern plot (STEPP) methodology across subpopulations defined by the continuous composite measure of recurrence risk. For each patient, the composite risk value was obtained from a Cox model that incorporated age; nodal status; tumor size; grade; and estrogen receptor, progesterone receptor, and Ki-67 labeling index expression levels.

RESULTS

The overall rate of 8-year freedom from distant recurrence was 91.1% and ranged from approximately 100% to 63% across lowest to highest composite risks. TEXT patients who received chemotherapy had an average absolute improvement with exemestane plus OFS versus tamoxifen plus OFS of 5.1%, and STEPP analysis showed improvements from less than 1% to more than 15% from lowest to highest composite risks. SOFT patients who remained premenopausal after chemotherapy had an average 5.2% absolute improvement with exemestane plus OFS versus tamoxifen and reached 10% across composite risks; for tamoxifen plus OFS versus tamoxifen, the maximum improvement was approximately 3.5%. Women who did not receive chemotherapy had a more than 97% rate of 8-year freedom from distant recurrence, and improvements with exemestane plus OFS ranged from 1% to 4%.

CONCLUSION

Premenopausal women with HR-positive/HER2-negative breast cancer and high recurrence risk, as defined by clinicopathologic characteristics, may experience a 10% to 15% absolute improvement in 8-year freedom from distant recurrence with exemestane plus OFS versus tamoxifen plus OFS or tamoxifen alone. The potential benefit of escalating endocrine therapy versus tamoxifen alone is minimal for those at low recurrence risk.
Financial toxicity among veterans with cancer.
Authors: Parikh Divya Ahuja , Ragavan Meera Vimala , Khateeb Sana , Patel Manali I.
Published: October 2019

103

Background: Financial toxicity of cancer care has not previously been studied within the Veterans Health Administration (VHA). The VHA provides health care for veterans in VA hospitals across the United States (US). It is a single-payer system and the largest integrated health system in the US and in this study we sought to assess financial toxicity experienced by veterans at a VA hospital. Methods: We asked veterans with oncology clinic visits at the VA Palo Alto to complete a survey that included an 11-item validated questionnaire called the COST tool. The COST tool calculates a score 0-44 with higher scores suggestive of higher financial toxicity. We also assessed demographic factors including gender, education, race, income, and insurance status as well as monthly out of pocket costs (OOPC) and suggested resources to reduce burden. We coded responses and calculated descriptive statistics with proportions. Results: A total of 84 veterans completed the survey and demographic factors are depicted in Table. Veterans were predominantly male (96%), high school or less educated (46%), white (61%), with annual income less than $50,000 (81%), and VA insurance (95%). The mean COST score was 21. The majority of veterans (63%) reported less than $100 of monthly OOPC and many (56%) reported transportation as a major expense and requested transportation resources. Conclusions: Financial toxicity is an unmet concern among veterans. Despite low monthly OOPC in the VHA single-payer system, financial toxicity as measured by the COST score at a VA hospital was as high as a nearby academic center. Transportation was the most significant expense and future studies should evaluate interventions to reduce the financial burden of transportation for veterans.

[Table: see text]
Lost productivity and time in patients with metastatic breast cancer receiving treatment.
Authors: Ingram Stacey A. , Williams Courtney , Gilbert Aidan , Lawhon Valerie , Davis Jasmine D. , Wan Clara , Dekle Kendal , Lowman Janel , Jones Jonathan , Rocque Gabrielle Betty
Published: October 2019

106

Background: Costs for cancer patients are not all monetary. For patients with limited life expectancy, such as metastatic breast cancer (MBC) patients, time spent in the hospital or clinic setting can become burdensome. The goal was to evaluate time spent on healthcare among patients receiving treatment for MBC. Methods: This survey-based, cross-sectional study included women ≥18 years with MBC who received treatment at two academic medical centers in Alabama from 2017-2019. Questions regarding employment status, MBC-related hours missed from work, and time spent on healthcare-related activities were used to quantify lost productivity and time. Descriptive statistics included means and standard deviations (SD) or medians and interquartile ranges (IQR) for continuous variables and frequencies for categorical variables. Effect sizes were calculated using Cohen’s d or Cramer’s V. Results: We surveyed 83 female MBC patients with a median age of 59 years (IQR 50-66). Among all respondents, 34% were African American, 41% held a college degree, and 52% had a household income of < $40,000. Patients spent a median 60 minutes (IQR 30-110) traveling from their home to clinic and a median 120 minutes (IQR 60-180) receiving care at a clinic visit. Though not statistically significant, modest differences were found for patients with differing insurance types in travel time. Patients with Medicare had the shortest travel time (median 45 minutes [IQR 30-75]) compared to Medicaid (60 minutes [IQR 60-80]) and private insurance (60 minutes [IQR 30-120]; d = .06).). Patients spent a median 30 minutes (IQR 0-60) on cancer care related activities outside of a clinic visit. Most patients were retired (31%); however, 15% worked full-time, 6% worked part-time, and 20% were on disability. For working women, a median of 8 hours (IQR 1-11) were missed from work in the week. Conclusions: This study highlights productivity losses uncaptured by current patient healthcare cost calculations. Further work is needed to identify and minimize these additional patient costs related to lost productivity during cancer treatment.
A cost-effectiveness analysis of primary prophylaxis (PP) versus secondary prophylaxis (SP) with biosimilar myeloid growth factors (MGFs) for preventing chemotherapy-induced febrile neutropenia (FN) in non-Hodgkin lymphoma (NHL) patients at intermediate risk.
Authors: Lyman Gary H. , Mezzio Dylan , Li Edward C. , Campbell Kim , Balu Sanjeev
Published: October 2019

107

Background: Historically, PP with a MGF was recommended in patients with a ≥40% risk for developing chemotherapy-induced FN, based on clinical and regimen-related factors. Previous economic studies provided evidence to lower the threshold to 20%, the current high-risk threshold listed by practice guidelines. Biosimilar MGFs, such as filgrastim-sndz or LA-EP2006 (a proposed pegfilgrastim biosimilar), offer an opportunity to evaluate whether it is cost-effective to further lower the threshold for intermediate-risk regimens (i.e., 10-20% FN risk). Methods: A Markov model was constructed to evaluate the total costs and clinical outcomes of biosimilar or reference MGFs when used as PP vs. SP in patients 55 years old with NHL receiving 6 cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with no additional FN risk factors. Model inputs, including MGF efficacy and acquisition costs, were estimated from publically available data and literature, as were FN hospitalization costs and clinical utilities. Incremental cost-effectiveness ratios (ICERs) were calculated for cost per FN event avoided, life-year saved (LYS), and quality-adjusted life-year (QALY) gained from a payer perspective within the United States. Deterministic and probabilistic sensitivity analyses were conducted. Results: Use of filgrastim-sndz as PP vs. SP provided an additional 0.130 QALYs (0.144 LYS) at an incremental cost of $5,999. The ICERs were $50,676, $41,761, and $46,207 for cost per FN event avoided, cost per LYS, and cost per QALY gained, respectively. Using LA-EP2006 as PP vs. SP provided an additional 0.166 QALYs (0.184 LYS) at an incremental cost of $17,648. The ICERs were $123,840, $95,963, and $106,265 for cost per FN event avoided, cost per LYS, and cost per QALY gained, respectively. Conclusions: Within NHL patients receiving R-CHOP at an intermediate risk for FN, PP with filgrastim-sndz and LA-EP2006 are cost-effective compared to their respective use as SP based on a cost-effectiveness threshold of $150,000/QALY.
Cost implications of growth in new cancer drugs in a comprehensive cancer center.
Authors: Venkatesan Sukanya Murali , Chaudhuri Anamika , Fraile Belen
Published: October 2019

112

Background: Rising costs of cancer therapies calls for strategizing towards sustainable care delivery models from a hospital planning, payer as well as policy-making perspective. This topic becomes increasingly significant as there is exponential growth of novel, high-cost immunotherapy drugs making it imperative for players to adopt and practice value-based oncology. Objective: This study aims to evaluate increasing trends in use of new and transformative cancer therapies, and associated drug costs in a comprehensive cancer center in Massachusetts. Methods: Study period was fiscal year (FY) 2015-2018. Utilization was defined by the number of patients receiving infusion and number of visits made by them to the center during the FY. Cost was defined as expense to hospital. Data source was hospital billing database. ASP (Average Sales Price) of drug was obtained from CMS website and was used as an indicator for cost per unit of the drug. Results: Top 10 drugs were identified based on total cost incurred in the study period and contributed to almost a third of center’s total cost. Over the three years, number of visits for these drugs grew up to 700% and treated patients grew up to 350%. Use of chemotherapy in isolation decreased from 35% of treated patients in FY15 to 26% in FY18, whereas its use in combination with immunotherapy increased from 22% in FY15 to 28% in FY18. Average drug cost to hospital per patient for the study period ranged as high as $120,000 (excluding non-drug treatment costs). Conclusions: While clinical value of the new cancer therapies is unquestionably significant, there is a dire need for policy-makers, providers and payers alike to pay continued attention towards its high cost implications as observed in this study and, continue striving towards establishing more sustainable pricing policies through alternative payment models.
Community oncologists' perceptions three years after the Oncology Care Model.
Authors: Kish Jonathan Karl , Yeh Ting-Chun , Gajra Ajeet , Smith Yolaine , Feinberg Bruce A.
Published: October 2019

113

Background: The Oncology Care Model (OCM) is a Medicare-sponsored delivery and payment innovation pilot under the broader concept of value-based care (VBC). OCM aims to provide better quality and coordinated cancer care at reduced cost. The OCM participants, 176 practices and 10 payers who provide care to nearly half of Medicare beneficiaries, entered into payment arrangements based on financial and performance accountability for episodes of care surrounding chemotherapy administration. We sought to understand the impact of OCM adoption on community physicians 3 years into the pilot. Methods: A live meeting in April 2019 convened a sample of US-based community oncologists to discuss “The OCM Experience”. Audience response survey methodology addressed: participation in OCM and/or related commercial programs, implementation, operation and perceptions of outcomes to patient care and practice. Results: Regarding VBC initiatives at the practices (n = 48) of 57 providers: 61% identified their practice participated in OCM, 31% in other commercial payer pathway program, and 17% in other commercial payer VBC reimbursement (not mutually exclusive). Regarding impact of OCM on improving access to care: 60% indicated having same-day appointments, 45% 24/7 HCP access, 22% weekend hours and 18% evening clinic hours. Regarding changes to patient care: 58% stated OCM driven initiatives reduced ER visits, 48% reduced hospitalizations, 62% increased palliative care referrals, and 54% increased hospice referrals. Regarding impact on practice: 41% felt an increased administrative burden with 50% hiring administrative staff, advanced practice providers, and patient navigators, but only 11% hiring physicians. The 13-component oncology care plan was reported by 53% as “not easy” to devise. The “most challenging” components included estimating total out of pocket expenses (61%) and creating a plan to address psychosocial needs (16%). 49% respondents found their practices’ OCM transformation meaningful and 46% found it not very/not at all meaningful. Conclusions: The impact of OCM/VBC transformation upon community oncologists and their practices appear to be quite profound, while the precise impact on their patients remains to be determined.
Cost implications of potentially avoidable hospitalizations among Oncology Care Model patients with prostate cancer.
Authors: Smith William H. , Parikh Anish B , Li Lihua , Sanderson Mark , Liu Mark , Mazumdar Madhu , Isola Luis M. , Dharmarajan Kavita Vyas
Published: October 2019

114

Background: Hospital-based care remains a major contributor to cost in oncology and thus represents an important cost-saving opportunity. We previously developed a rigorous two-stage consensus driven review process to identify potentially avoidable hospitalizations (PAHs) among oncology care model (OCM) patients with prostate cancer and reported a 28% rate of PAHs between 1/2012-6/2015. Our current objective was to estimate the magnitude of any expected cost savings generated if inpatient care from these PAHs were shifted to an acute care model in the outpatient setting. Methods: Costs for ambulatory acute care management among a separate but characteristically similar cohort of cancer patients were obtained from our institution’s recently established Oncology Care Unit (OCU), where acute clinical issues are managed in an enhanced ambulatory setting. We used an exact-matching algorithm to match previously identified PAHs to OCU visits based on strata of age (≤ 70 years vs. > 70 years), categorically defined chief complaint (infusion/transfusion, lab abnormalities, symptom control, and diagnostic work-up), and the presence of “systemic disease” (metastatic disease or hematologic malignancy). PAH costs obtained from OCM data were compared to costs from these matched OCU encounters. Results: We identified 89 acute care OCU visits occurring from 5/2017-12/2018, of which 48 were fully evaluable based on documentation. Twenty-five of our initial 28 PAHs (89%) matched to 29 OCU acute care visits. The mean inpatient cost among matched PAHs was $15,879 compared to $975 for matched OCU visits. Boot strapping within each match produced a mean estimated cost savings of $15,120 (95% CI $13,682 to $16,557) per PAH. We estimate this per event savings to yield an overall spending decrement of 5.7% for OCM prostate cancer episodes. Conclusions: PAHs contribute substantially to costs of care in oncology. Investment in specialized ambulatory acute care services for oncology patients could lead to meaningful cost savings by shifting avoidable inpatient care to the outpatient setting.
ICU utilization among oncology patients at the end of life.
Authors: Hong Jennifer , Kurian Christine , Minetola Jared , Csik Valerie Pracilio , Binder Adam
Published: October 2019

118

Background: Patients with advanced cancer have high rates of hospitalizations as a result of their oncologic care. Furthermore, these patients receive aggressive end of life care despite evidence that aggressive end of life care does not improves quality of life or outcomes for patients and is associated with worse bereavement adjustment for caregivers. The American Society of Clinical Oncology has endorsed several indicators of aggressive end of life care, but most striking is intensive care unit (ICU) admission within 30 days before death. Methods: Adult oncology patients who died within 30 days of hospitalization and/or admitted to the ICU from 10/2018-3/2019 at an academic medical center were evaluated. The cohort was identified using ICD-10 codes, EMR systems support, and manual chart review. Patient demographic data, cancer type, stage, line of therapy, code status, advanced care plan, prior admissions as well as other clinical characteristics were collected. Results: In total, 180 patients were included for analysis; 106 of which were admitted to the ICU. Of patients admitted to the ICU, 58 patients died (54.7%). Mean ECOG performance status was 1.24. Average number of admissions 3 and 6 months prior to death was 0.71 and 1.26. Thirty six percent of patients were on first or second-line chemotherapy. 41.37% of patients who died in the ICU had prolonged length of stay (>1 week). Only 34.48% were known to palliative care prior to admission and 12.06% of patients had advanced care plans in place at time of hospitalization. Palliative care was consulted on 32.75% of patients who died in the ICU. Ninety Three percent had their code status changed prior to death. Conclusions: Despite established recommendations to support otherwise, at our institution there continues to be high utilization of ICU care near the end of life. Previous admissions and ECOG status are poor predictors of death in this cohort. The majority of patients had relapsed and refractory disease. There was a low rate of advanced care planning or palliative care involvement prior to the patient’s hospitalization. Further interventions are underway to improve end of life planning in order to improve our quality of care.
Patients enrolled in clinical trials with Medicaid or no insurance and overall survival benefits from new interventions.
Authors: Unger Joseph M. , Blanke Charles David , LeBlanc Michael Leo , Barlow William E. , Hershman Dawn L.
Published: October 2019

119

Background: Very few new treatments tested in randomized phase III cancer clinical trials show an overall survival (OS) benefit. Understanding whether the benefits are consistent among all patient groups is critical for informing guideline care. However, within trials, there is limited power to examine demographic or insurance subsets, especially in under-represented groups. Here we systematically examine whether positive treatment effects apply to all demographic and insurance groups. Methods: We examined all SWOG treatment trials completed from 1985-2014, and pooled data from trials with a statistically significant (p < .05) OS benefit for the experimental treatment. We conducted multivariable Cox regression analyses adjusting for clinical risk level and stratifying by study-specific 2-year OS probability ( < 25% vs. 25-75% vs. > 75%). Interaction tests determined whether OS hazard ratios (HRs) differed by 5 prespecified factors including age ( < 65 vs. ≥65), race (black vs. other), sex, ethnicity (Hispanic vs. non-Hispanic), and insurance status in patients < 65 years (private insurance vs. Medicaid/no insurance). Results: We identified 16 trials, containing 9,328 patients, with statistically significantly better OS in the experimental arm. The OS HR did not differ by sex (p = .60), race (p = .68), or ethnicity (p = .66). However, patients ≥65 years had a smaller treatment benefit than patients < 65 (HR = 1.24 vs HR = 1.37, p = .03), and patients with Medicaid/no insurance had a smaller treatment benefit than private insurance patients (HR = 1.22 vs. HR = 1.70, p = .03). Conclusions: The magnitude of the OS benefit from experimental treatments may not be uniform among demographic and insurance status groups. Older age patients and those with suboptimal insurance are at greater risk of experiencing competing risks of death, which can reduce power to identify the benefits of new experimental therapies. Trial designs should account for the risk of non-cancer deaths in important patient groups. Future research should examine whether reduced treatment impact is due to a higher comorbid burden in older patients, and to worse adherence to protocol care in those with limited financial resources.
Improving patient access in radiation oncology from referral to consult.
Authors: Baracena Daphne , Jaboin Jerry Jeff , Bednar Michelle
Published: October 2019

122

Background: To increase patient access, Oregon Health & Science University set an institution-wide metric for ambulatory clinics to contact the patient within a specified time frame. For our study, we utilized targets of patient contact within three days from the date of referral and of scheduling and resolving referrals within six days. Since the reports for these metrics did not provide detailed reasons for the consult delays, we were unable to assess if these delays were due to pending patient action, provider recommendations, providers’ overbooked schedules, and/or an inefficient intake process. Methods: We targeted two providers’ schedules with the highest consult-to-treatment turnover and determined that 45% of consult delays were due to intake processing. The Department implemented two PDSA cycles: internal metrics were set for 97% of the patients to be contacted within three days and for 100% within six days; and a standardized workflow for the providers’ patient list was provided. Results: After the first PDSA cycle, patient contact within three days declined from 80% to 62% and within six days from 57% to 45%. However, the percent of patients scheduled within six days increased from 61% to 64%. After the second PDSA cycle, patient contact within three days increased to 70% and within six days to 68%. About 76% of referrals were scheduled within those six days. Conclusions: Although patient contact within three days declined from the baseline data for both PDSA cycles, we found that there was a gradual increase in patients being contacted and scheduled within six days, especially after the second PDSA cycle. Despite the progress observed, we did not hit our internal metrics and intend to launch an automated patient list to further improve intake processing.[Table: see text]
A population-based study of medical cannabis utilization in patients with cancer.
Authors: Karim Safiya , Bu Jingyu , Jess Ed , Cheung Winson Y. , Kerba Marc
Published: October 2019

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Background: Between 2014 and 2018, access to cannabis for medical purposes was regulated by Health Canada. Surveys have demonstrated that cancer patients use cannabis to manage symptoms and side effects. Medical cannabis utilization patterns in cancer patients under Canada’s regulatory framework have not been well-described. We aimed to determine the proportion of cancer patients who used medical cannabis, timing of use in relation to cancer treatment and sociodemographic factors predicting use. Methods: The Alberta Cancer Registry was used to identify all patients age ≥ 18 diagnosed with invasive cancer in the province from April 01, 2014 to December 31, 2016. These cases were linked to records from the College of Physicians and Surgeons of Alberta database which collects data on patients who received an authorization for medical cannabis. Authorization was used as a surrogate for medical cannabis utilization. Univariate and multivariate logistic regression models were constructed to determine factors associated with medical cannabis utilization. Results: We identified 41,889 patients between April 1, 2014 and December 31, 2016. Median age at cancer diagnosis was 65 and 50% were female. Among these patients, 1,070 (2.5%) used medical cannabis. Of these patients, 541 (51%) used medical cannabis within 1 year of diagnosis, 248 (52%) within one year of the start of systemic therapy and 128 (41%) within one year of the start of radiation therapy. On multivariate analysis, patients aged 18-29 (OR 12.4, 95% CI 7.8-19.7) and those receiving systemic therapy (OR 2.0, 95% CI 1.7-2.4) were more likely to use medical cannabis (p < 0.001). There were 171 unique physicians who authorized medical cannabis of which only 3.5% (6/171) were oncologists. Conclusions: A small proportion of cancer patients used medical cannabis under Health Canada’s regulatory framework. Utilization was associated with a cancer diagnosis and receiving treatment. Younger patients and those undergoing systemic treatment were predictors of medical cannabis use. Further study is required to understand utilization patterns after cannabis legalization and how to incorporate these findings into patient-centered cancer care.
Exploratory analysis of barriers and facilitators to cervical cancer care in rural Tamil Nadu, India.
Authors: Rajashekara Shruthi , Subramanian Malliga J , Rajaraman Swaminathan , Davila Jessica , Anandasabapathy Sharmila
Published: October 2019

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Background: Approximately 20% of cervical cancer deaths worldwide occur in India, most notably in rural areas. The key to addressing the cervical cancer epidemic is early detection and treatment of precancerous cervical lesions. Many studies that assess barriers to cervical cancer care in India focus on individual level factors, such as awareness and education. Given the disparities in cervical cancer in India, particularly between rural and urban settings, a comprehensive, multi-level approach to evaluating barriers and facilitators to care is needed. Methods: In December 2018, we used semi-structured interviews and direct observation of 15 community health workers, medical officers and gynecologic oncologists to explore the multi-level barriers and facilitators to cervical cancer care in rural Tamil Nadu. Data collection occurred within an existing organized cervical cancer screening program and was guided by the social-ecological model. Results: Barriers and facilitators to cervical cancer screening and treatment of precancerous lesions were identified at all levels of the social-ecological model. Barriers included fear of and travel distance to urban centers for treatment (individual), limited social support (interpersonal), lack of rural clinical facilities that provide treatment (organizational), competing community health initiatives (community), and lack of cohesive national screening and treatment guidelines (policy). Facilitators included travel distance to local screening services (individual), access to community health workers (interpersonal), institutional initiatives to increase screening access (organizational), mass awareness campaigns (community), and Tamil Nadu State priorities to improve cervical cancer care (policy). Conclusions: This assessment underscores the gap between cervical cancer screening and treatment in rural Tamil Nadu. This data will inform the development of a multi-faceted intervention, targeting all levels of the social-ecological model, to improve the linkage between cervical cancer screening and treatment for precancerous cervical lesions to decrease the burden of disease and mortality in India.
Oncologic services through Project Access and other safety net care coordination programs.
Authors: Hammock James Blake , Williams Courtney , Rocque Gabrielle Betty
Published: October 2019

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Background: Since the 1996 formation of Project Access, a nationwide program linking uninsured, low-income, or underserved patients to specialty care, the US has experienced a growth of third-party, safety net care coordination programs that provide sub-specialty care at no or reduced cost. These programs pre-negotiate with local physicians and hospitals to offer pro bono services to patients. Little is known about the provision of oncologic services within these programs. This study evaluated the current landscape of oncologic services within US safety net care coordination programs. Methods: This study reviewed websites via an online search from 04/22/19 - 04/28/19 using keywords “Project Access”, “healthcare”, and individual state names. The websites were reviewed for information on location, services offered, and patient eligibility criteria. Where online data on oncologic services was unavailable, individual programs were called on 05/08/19 for additional information. Five programs were unreachable by phone or e-mail. Results: Websites of 29 safety net care coordination programs in 22 states were identified, serving only approximately 40 counties. Online, one program highlighted "limited" access to oncologic care, while another offered chemotherapy at a reduced cost ($5000/round). When contacted by phone, 55% offered access to oncologic services and 48% assisted with chemotherapy costs. One program provided chemotherapy only if the cancer diagnosis was made after the patient was enrolled in their system. Virtually all programs who offered chemotherapy did so through affiliated large hospital systems. A commonly reported reason for lack of oncology care was a reluctance of oncologists to commit to potential long-term agreements of free care. Online, one program offered PET scans. By phone, 89% offered some imaging. Two programs (7%) explicitly required US citizenship for care. Conclusions: Third-party care coordination centers are increasing in number and provide a novel, and potentially unrecognized, approach to increasing oncology service access. Further research should identify barriers contributing to the relative lack of oncologic services in these programs compared to other specialties.
Characteristics, treatment patterns, and survival from three cohorts of advanced or metastatic cancer patients using health care claims data in the United States.
Authors: Beachler Daniel C , Lamy Francois-Xavier , Russo Leo J , Lanes Stephan , Dinh Jade , Taylor Devon H , Yin Ruihua , Jamal-Allial Aziza , Verpillat Patrice
Published: October 2019

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Background: Our main objective was to identify, in healthcare claims data, patients with advanced or metastatic: urothelial carcinoma (amUC), gastric cancer (amGC) and non-small cell lung cancer (amNSCLC) and to report on their characteristics, treatments, and survival rates using contemporaneous real-world data. Methods: This cohort study was conducted in the HealthCore Integrated Research Database (HIRD), from January 2010 to January 2018, which contains healthcare claims data from commercial health plans across the US (60 million lives). We applied algorithms, previously validated on registry data, to the HIRD to define 3 cohorts of advanced stage cancer. Cohort characteristics and treatment patterns were described. Patient vital status was captured through probabilistic linkage with the National Death Index (NDI) and survival was assessed using the Kaplan-Meier method. Results: Algorithms to predict advanced stage cancer resulted in the following cohorts: 1,501 amUC, 6,253 amGC and 38,451 amNSCLC cases. Most patients in each cohort were de novo advanced or metastatic, but subsets were diagnosed at early stage and progressed to advanced stage (ranging from 15.1% for amNSCLC to 23.1% for amUC). Patient characteristics, treatments and survival outcomes are described in Table 1. Not all received systemic treatment; Immune Checkpoint inhibitors (ICI) were used in 5.3%, 2.2% and 10.8% of treated amUC, amGC and amNSCLC patients, respectively. Conclusions: In these cohorts of advanced or metastatic cancer patients, median survival time was limited despite most receiving treatment: radiation, systemic therapy or surgery. Treatment with ICI was low despite recent data in amUC and amNSCLC.[Table: see text]