bluuebunny/crossref_metadata_2025 huggingface dataset:
The Choosing Wisely Canada cancer initiative.
Authors: Mitera Gunita , Bezjak Andrea , Booth Christopher M. , Delouya Guila , Desbiens Christine , Earle Craig , Laing Kara E. , Latosinsky Steven , Camuso Natasha , Agent-Katwala Mary , Porter Geoff
Published: February 2017

5

Background: Choosing Wisely Canada is a campaign modelled after Choosing Wisely in the USA and aims, through a pan-Canadian cancer physician-based consensus process, to identify a list of low value or harmful cancer services/practices frequently used in Canada. The following describes the approach taken for this work related to cancer in Canada. Methods: A Task Force approach was used, facilitated by the Canadian Partnership Against Cancer (CPAC), and included representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: (1) identify potentially relevant items and a framework for their subsequent selection; (2) develop a long list; (3) refine and reduce the long list to a short list; and (4) select and endorse a final list of low value or harmful cancer practices. Phases 2–4 followed a framework-driven consensus process and used a series of electronic surveys and voting processes. Results: For Phase 1, 66 cancer relevant practices were initially identified. The framework for subsequent selection included: (1) the size of population to which the practice is relevant; (2) frequency of use in Canada; (3) cost; (4) evidence of low value/harm; and (5) potential for change in use of the practice. The long list (41 practices) was refined and reduced to a short list of 19 practices and a final list including 10 practices. Of these, 5 are completely new, and 3 are revisions/adaptations practices from USA Choosing Wisely. Of the 10 practices, 6 are involve multiple disease sites, while 4 practices are disease-site specific. One practice relates to diagnosis, 6 are treatment- focussed, 2 target surveillance/survivorship, while one practice spans the cancer continuum from diagnosis through survivorship. Conclusions: Through CPAC facilitation, the collective input and work of three professional oncology societies informed this initiative. The content of the final list will be officially released through Choosing Wisely Canada in October 2014, and will be fully revealed at the ASCO Quality Care Symposium.
A "continuously connected team support" model to facilitate high-quality gynecologic cancer care in rural and remote regions.
Authors: Silver David F. , Aukers Steven M. , Simon Melissa A.
Published: February 2017

51

Background: Quality gynecologic cancer care (GCC) in rural and remote regions (RRR) of the U.S. is limited by poor access to gynecologic oncology expertise (GOE). While a variety of telehealth programs in other specialties have enhanced healthcare in RRR, none have resulted in provision of the comprehensive medical and surgical services required to treat gynecologic cancer patients. We propose a model to improve access and quality for comprehensive GCC in RRR. Methods: PubMed, Medline, and Google searches identified and characterized: 1) core quality components of GCC models; 2) RRR lacking GOE; and 3) current models for delivering healthcare services in remote regions. A new model was developed addressing needs of RRR. Results: Characteristics observed in high-performing GCC models include: 1) gynecologic oncologists (GO) guide all aspects of GCC, 2) care is performed by high-volume providers (HVP), and 3) multidisciplinary provider teams (MDT) address all patient needs. Without equal access to GO, HVP, or MDT, patients in RRR do not share benefits of high-quality outcomes. Integrating components of successful telementoring models with identified high-quality characteristics of traditional GCC, our model is developed to address the comprehensive and ongoing unique GCC needs of RRR. This Continuously Connected Team Support (CCTS) model utilizes a semi-remote GO to facilitate quality GCC through mentorship and education of a local MDT, transforming it into a transdisciplinary team (TDT). Off-site activities include 24/7 availability via phone or HIPAA-compliant videoconferencing. The GO’s on-site activities include proctoring the TDT in surgeries, mentoring and educating in clinical conferences, and continuous quality improvement activities. Long-term, regular on-site and remote interactions with the local TDT makes CCTS unique in its commitment and service beyond that of itinerant surgeons, locum tenens, international surgical charity efforts or established telehealth programs. Conclusions: Deployment of CCTS in RRR offers an innovative solution for the facilitation of high-quality comprehensive GCC in RRR lacking GOE. Further outcomes research is warranted.
Population-based standardized symptom screening: Cancer Care Ontario’s Edmonton Symptom Assessment System and performance status initiatives.
Authors: Molloy Sean , Pereira Jose , Green Esther , Dudgeon Deborah Jane , Howell Doris , Krzyzanowska Monika K. , Mahase Wenonah , Tabing Reena , Urowitz Sara , Macdougall Laura
Published: February 2017

56

Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are: (a) promote the adoption of electronic symptom assessment using a standardized tool and (b) increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are to manage cancer symptoms through a patient reported measurement tool; improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and drive improvement through the adoption of an electronic symptom assessment platform The following aims were established for this work: (1) Aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month) (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores) (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan) and (4) aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success. (a.) Leadership at all levels of the system; (b.) clinical tools at the point of care; (c) engagement of patients in the design of care; (d) communications support to spread information to all stakeholders; and (e) using to data to drive performance improvement and accountability.
Transition of breast cancer (BC) survivors to primary care: Results of a Cancer Care Ontario (CCO) pilot project.
Authors: Sussman Jonathan , Grant Maria
Published: February 2017

58

Background: Emerging evidence indicates that the transition of well breast cancer survivors to primary care is safe and effective. Methods: Prospective longitudinal cohort study across 14 health regions in Ontario, Canada. Each region received $100 000 (CAN) to develop and implement a sustainable new model of survivorship care for BC survivors that involved transition from medical oncology-led practice. Each region had a designated lead, and support from primary care. Funding could be used to develop any aspect of the model including personnel support, development of communication materials and outcome measurement. A minimal dataset reporting requirement included a description of the program, documentation of transitioned BC survivors as well as standardized patient and provider experience feedback once transition completed. Results: All 14 health regions in Ontario participated and all developed a survivorship care plan and patient educational materials. The models developed included direct transition to primary care in 6 regions, a nurse-led transition clinic in 4 and a GP-led transition clinic in 4. To date, 3,418 BC survivors have transitioned. Of 676 BC respondents to date, 83% felt there was a clear plan for follow up and 87% felt adequately prepared for transition. Feedback from primary care providers demonstrated that many feel informed about intent of transition and understand their role in on-going follow-up care. Process outcomes such as re-referral back to cancer center and adherence to follow-up guidelines are currently underway. Conclusions: The wide scale transition of appropriate BC survivors to a primary setting appears feasible with high acceptability by patients and providers.
Treatment of stage IV NSCLC with chemotherapy in a community setting based on ECOG PS.
Authors: Singh Rahul , Saucier Jillian , Schreiber Andrew Michael
Published: February 2017

62

Background: ECOG Performance Status (PS) plays a pivotal role in the decision to treat patients with NSCLC Stage IV. The current ASCO guidelines for offering cytotoxic chemotherapy in stage IV NSCLC state that a PS of ≤2 can be considered for intravenous treatment. The goal of our retrospective evaluation was to evaluate treatment patterns based on ECOG PS in a community setting. Methods: An IRB-retrospective chart review of all stage IV NSCLC patients at our institution between 1/1/2008 and 1/1/2013 was conducted. A total of 150 patients with NSCLC and an ECOG of ≤2 were randomly selected and reviewed from the cancer registry (12 were excluded for undocumented ECOG PS status). 138 patients were included. The data was analyzed using X2 test of independence, Fisher’s exact, and students T-Test all run by SAS 9.1. Results: Of the 138 patients observed, 92 (66.7%) had an ECOG PS of 0, 16 (11.6%) were PS 1 and 30 (21.7%) were PS 2. There were no significant differences in ECOG PS based on race, gender or payer status. Patients with a PS of 2 received chemotherapy (N=1/30, p <0.0001) significantly less than those with PS 0-1 (N=54/108, p <0.0001). Those with PS 2 were more likely to have additional comorbidities as well (N=23/30, p<0.0001) versus patients with a PS 0 or 1. Chemotherapy was not offered to 76.7% of patients with a PS of 2 (N= 23/30, p <0.0001). Conclusions: In our community setting cytotoxic chemotherapy was offered significantly less in patients with ECOG PS of 2 compared to those with 0 and 1. While it is more likely that patients with better PS will be offered treatment, this significant difference reflects practice that differs from ASCO’s guidelines. It is suspected the disparity in offering treatment depending on the PS of 2 vs 0-1 likely was due to many cofounding variables as well as provider and patient preference. Another disparity noted was that of undocumented ECOG PS. As the system of healthcare is switching to an electronic based system one proposed theory would be to add the quality measure ECOG PS as an additional vital sign in an oncologist progress note, with a prompt to consider chemotherapy in patients with PS ≤2 and not to consider in PS 3 or 4. This could greatly benefit the medical oncologist in considering possible treatment.
Improving prophylactic growth factor (pGCSF) use in non-small cell lung cancer (NSCLC) patients (pts) receiving chemotherapy (CT) at the Cleveland Clinic Taussig Cancer Institute (TCI).
Authors: Goodman Lindsey Martin , Moeller Machelle , Dalby Carole Kathleen , Guthrie Amy E. , Earl Marc A. , Pennell Nathan A. , Shapiro Marc A. , Velcheti Vamsidhar , Ma Patrick C. , Stevenson James
Published: February 2017

83

Background: Per guidelines (ASCO, NCCN, EORTC), pGCSF is not recommended for pts receiving CT regimens with low risk (< 10%) for febrile neutropenia (FN). Inappropriate use of pGCSF increases pt morbidity and healthcare costs. In the current healthcare environment, it is critical to maximize value via alignment with accepted care standards and elimination of unnecessary costs. Methods: A multidisciplinary team was created to perform a quality improvement (QI) project under ASCO’s Quality Training Program. We reviewed all NSCLC pts at TCI who initiated a new CT regimen from April to November 2013. First-cycle pGCSF use was identified and deemed appropriate if prescribed for CT associated with high risk of FN (>20%) or intermediate risk (10-20%) if other risk factors for FN were present (age, gender, performance status, renal/hepatic function, prior treatment with radiation or CT, and pre-existing neutropenia, wounds, or infection). Use with low-risk CT was recorded as inappropriate. Results: 179 NSCLC pts received a new CT regimen during the specified time period. 22/90 pts (24%) treated with low-risk CT received pGCSF. Each pt received an average of 3 doses with 69 total doses administered. In all other instances pGCSF was prescribed in accordance with guidelines. Using QI strategies, we identified and implemented three PDSA cycles: education of NSCLC providers, development of TCI Consensus Guidelines for the use of pGCSF in NSCLC, and removal of standing pGCSF orders from low-risk CT regimens in the EMR. Cost analysis shows the potential to save 1.6 million dollars in charges over 1 year when pGCSF is not administered to NSCLC pts receiving low risk CT. Conclusions: pGCSF was excessively prescribed for NSCLC pts at a tertiary care academic medical center. Factors contributing to inappropriate pGCSF use included providers’ lack of familiarity with guidelines and the risk of FN for CT regimens as well as EMR CT templates with standing pGCSF. Appropriate pGCSF administration leads to significant cost savings without adverse impact on pt outcomes. Re-measurement is in progress and will be presented at the time of the meeting.
Implementation of code status discussion early in the course of treatment for oncology patients.
Authors: Faggen Meredith , Gilchrist Heather , Donohue Caitlin C. , Burke Reanne
Published: February 2017

88

Background: Having a code status discussion early in the treatment course of patients with advanced stage cancer is important to ensure that patients make decisions about life sustaining treatment in a non-urgent setting. There was not a standardized approach to addressing the code status of patients with stage IV cancer enrolled on the Supportive Oncology (SO) Pathway at Dana Farber Cancer Institute/South Shore. We addressed this problem by implementing a standardized method of documenting code status at or before the 3rd visit in patients with stage IV disease participating in our SO pathway. Methods: A process map highlighted that most patients with advanced cancer discussed their code status the day of hospice enrollment. A fishbone chart detailed the barriers to obtaining code status, and a priority pay-off matrix identified opportunities for improvement, including standardizing the process of the code status discussion and emphasizing the importance of the discussion early in the course of treatment. Physicians were educated on the importance of code status discussions and agreed that documentation should occur by the 3rd visit. Patients enrolled on the SO Pathway were tracked for the first three visits after initial referral to the pathway. We developed a script to assist physicians with code status discussions, which was placed on the encounter form at these visits. To measure the number of discussions, patient charts were reviewed on a weekly basis for documentation of code status. Results: Pre-intervention, during a 1 year period, only 14% (n=42) of patients enrolled on the SO pathway had a code status documented by the 3rd visit. After a 6 week implementation period, 70% (n=10) of patients enrolled on the SO Pathway had a code status documented in the chart by the 3rd visit. Conclusions: Substantial improvement in code status documentation was seen post-implementation of our intervention. We conclude that a script/reminder is a useful tool to prompt physicians to have a meaningful code status discussion in a non-urgent setting. This project has made the often difficult process of obtaining code status a more standardized process, and a more integral part of the culture at the Cancer Center.
Interventions to optimize the use of colony-stimulating factors.
Authors: Rathod Heena , Yoder Sol
Published: February 2017

92

Background: The Food and Drug Administration approved granulocyte colony-stimulating factors filgrastim (fil) and pegfilgrastim (peg) for use in the prevention of chemotherapy-induced neutropenia. The objective of this study was to characterize and optimize the current utilization of these costly colony-stimulating factors within a tertiary care health system. Methods: Data parameters and improvement measures were defined based on the current literature, national guidelines and institutional standards. Data was collected retrospectively by chart review and analyzed to develop interventions that would optimize fil/peg utilization. Existing policies and procedures were updated, and feedback and approval was obtained through collaborative groups. Improvement measurements will be reassessed post implementation of the proposed interventions. Results: Chart review yielded 156 fil/peg orders. The following observations and interventions were applied. All indications were determined appropriate per established oncology guidelines; however, 3 patients received an unwarranted fil/peg dose within a week of peg administration. An electronic alert was created to prevent administration of an additional fil dose if a recent peg dose had been administered. Of inpatient fil orders (n=38), 24% of weight-based dose rounding and 32% of predetermined discontinuation parameters were not compliant with the institutional standards. Fill electronic order entries were modified to automatically round doses based on patient weight. If an additional one-time absolute neutrophil count (ANC) discontinuation parameter was applied, it is anticipated that fil treatment duration could decrease in 30% of patients. The one-time ANC discontinuation parameter for fil was added. Conclusions: Although our system’s utilization of colony-stimulating factors was in compliance with national guidelines and institutional standards, opportunities for optimization were identified and targeted for improvement.
Effects of variation of sentinel lymph nodes submitted during breast cancer sugery: Analysis of practice variation and costs.
Authors: Barr Louis H. , Wu Meiling , Shao Yai-Ping Mimi , Zhu Xiang
Published: February 2017

94

Background: Routine node evaluation involves simple bivalving the node with slides made from the resultant surfaces. SLNs are more thoroughly evaluated with 2-3 mm slices and histologic evaluation of each slice, resulting in many more slides to review. These slides would often have immunohistochemical analysis adding to the time and cost. In early studies of SLN efficacy and accuracy, the mean number of nodes was between 2 and 3 per patient though with some variation. As the number of submitted SLNs increases, the concern of benefit of the procedure comes into question. This is a retrospective examination of all SLN procedures for the year 2012 to examine the variation in the number of SLNs submitted for focused pathologic evaluation. Variation in the number of nodes submitted by surgeon is determined along with the associated costs of the pathologic evaluation. In addition, intraoperative evaluation of lymph node status may be useful to allow for immediate axillary node dissection during the initial operation. Utilization of this procedure was also examined to determine ultimate correlation with permanent pathologic evaluation. Methods: Retrospective examination of all breast cancer patients >=18 yrs who underwent SLN procedures during 2012. Introperative evaluation of lymph node for metastatic disease was also examined for correlation with permanent pathologic result. Results: 259 cases among 21 surgeons had touch prep performed. True positive number: 29. True negative number: 224. False negative number: 6. Fasle negative rate (FNR): 17.14%. Cost Effectiveness Evaluation: CPT 88307 - surg path gross and micro level V. CPT 88342 - Immunohistochemistry. CPT 88333 - Touch Prep. Pathologist time: 30 minutes per case. Conclusions: There is significant variation among surgeons as to number of cases and number of nodes submitted. There is a significantly greater number of sentinel lymph nodes examined by the pathologist as compared to the number of nodes submitted by the surgeon. The frequency of outliers is infrequent, but when it occurs there is significant cost in terms of time and dollars. The false negative rate from pathological evaluation is under study for isolated tumor cells.
Process of standardizing time to follow-up when initiating oral chemotherapy.
Authors: Shea Meghan , Giampietro Donna , Lennes Inga Tolin , McDonnell Theresa Margaret , Bohlen Nie
Published: February 2017

95

Background: With the explosion of oral chemotherapy agents, cancer care is shifting from the hospital to the home. The many safeguards developed for parenteral chemotherapy have not translated to oral chemotherapy. Patients are responsible for adherence to complex medication regimens while managing the side effects of chemotherapy at home. Many clinicians at Massachusetts General Hospital (MGH) improvise systems to monitor patients on oral agents, and practices remain varied. The 2013 American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS) addressed standards for safe administration and management of oral chemotherapy, which served as the framework for improving follow up care at MGH. Methods: Theclinicians in the thoracic and gastroenterology disease centers were surveyed and selected standardization for the first follow up appointment after initiation of oral chemotherapy as a safety initiative. The team, which consisted of the thoracic clinicians, delineated a process map from writing the prescription for erlotinib or crizotinib to the follow up appointment, as well as identified barriers to ensuring a standardized time for follow up. A second survey established a consensus of a 28 day ceiling for time to first follow up for both oral agents. The aim was for 95% of patients to be seen within 28 days of initiating oral chemotherapy. An education campaign for providers regarding the standardized algorithm for time to follow up and a text template to incorporate in the clinic note was instituted. Results: Prior toan intervention, patients initiated on erlotinib or crizotinib were seen in follow up within 19 days (on average), and 82% reached the aim of within 28 days. A time frame for return to follow up was established as well as required documentation for initiation of each drug. Conclusions: The process of implementing standardized drug specific time to follow up highlighted a number of key lessons. It is crucial to evaluate and measure the current process prior to developing interventions. Support of local leadership and “buy in” from all clinicians and staff is essential to the success of the intervention. Additionally, a regular setting to discuss and present updates on the process improvement is vital.
Consistent tumor measurement reporting in serial CT scans: A pilot study.
Authors: Wolf Terri P. , Little Dana Ann , Christensen Scott , Perkins Natasha
Published: February 2017

99

Background: Oncologists in community cancer centers affiliated with the UC Davis Cancer Care Network reported quality concerns with inconsistently measured lesions on serial Computed Tomography (CT) scan reports. Radiologic imaging is an important tool in diagnosis, staging, and assessment of response to therapy in cancer treatment cancer. Accurate assessment of oncologic therapeutic efficacy is dependent on reliable radiology and report quality. The primary objective of this pilot study was to validate oncologist concerns about tumor measurement consistency in radiology reports through an audit. The secondary objective was to identify areas for quality improvement and establish process and time requirements for auditing. Two of four affiliated cancer centers (CC1 and CC2) were selected for a pilot assessment. Methods: CC1 and CC2 identified charts with CT scans in the audit timeframes. Auditors reviewed charts for serial CT scans and measureable disease in the audit date range and created a list of eligible charts. Auditors randomized the list and a sample of 61 (CC1) and 66 (CC2) charts were audited. Auditors reviewed CT orders, radiology reports for consistent lesion measurement, comparison to previous scan, addenda, service dates, radiology facilities, reading radiologist, and medical provider placing order. Results: This audit demonstrated deficiencies with lesion measurement consistency at both CC1 and CC2. At CC1 64% of radiology reports were consistently measured and at CC2 57% were consistently measured. Both CC1 and CC2 had identifiable areas for process and quality improvement. The audit required 86 hours at CC1 and 83 hours at CC2. The audit identified deficiencies in order clarity and information flow from the cancer center to the reading radiologist. At CC1 a radiologist reviewed the audited charts and reported an 85% concurrence with the auditors. A literature search did not provide benchmarks for measurement consistency in radiology reports. Conclusions: Oncologists complaints were verified regarding lesion measurement inconsistencies. This pilot demonstrated the need for quality oversight and implementation of standardized measurement (RECIST) criteria and tumor logs in the non-clinical trial environment.
Developing palliative care capacity in Colombia and Mexico.
Authors: Knaul Felicia Marie , LeBaron Virginia Townsend , Calderon Mariana , Arreola-Ornelas Hector , Bhadelia Afsan , Krakauer Eric Lewis , Leon Marta Ximena , Lohman Diederik , O'Farrill Karla Petersen , De Lima Liliana
Published: February 2017

103

Background: Access to pain relief and palliative care often is limited or absent in low-and-middle-income countries (LMICs). Consequently, millions of patients with cancer and other serious illnesses in LMICs suffer needlessly. Multiple stakeholders have joined efforts to enhance the delivery of palliative care, develop national plans, and advocate for improved policies and regulations in Colombia and Mexico with applications to other LMICs. Methods: In Mexico and Colombia, efforts to improve access to palliative care focus on regulatory frameworks, finance, delivery, research and capacity-building, as per World Health Organization recommendations. In Colombia, health and educational institutions have partnered with non-governmental organizations to advise the Ministry of Health (MOH) and Senate. In Mexico, a range of governmental, legislative and private institutions are developing a National Palliative Care Plan. Results: Colombia: Laws passed in 2010 and 2013 require palliative care be available for all cancer patients. The allowable length of opioid prescriptions has been extended from 10 to 30 days, strong opioids must be freely available, and the MOH requires at least 1 pharmacy per State be able to dispense opioids 24/7. Mexico: Amendments to the health law introduced palliative care and pain management as a right for people with terminal illness. The government plans a new digital system to make opioid prescribing more efficient and secure, and the pharmaceutical industry is developing systems for monitoring production and supply. Yet, in both countries, palliative care training is mandatory in less than 5% of medical schools and innovative materials are being developed to train practicing primary care personnel. Conclusions: To meet palliative care needs in LMICs, novel approaches are required to develop and implement national plans, train healthcare providers, educate government officials, and advocate for policies that improve equitable access. Exemplary work in Colombia and Mexico illustrate effective strategies to improve palliative care delivery in LMICs.
Implementing values-based advance care planning (ACP) in a community oncology network.
Authors: Taniguchi Cynthia , Neubauer Marcus A.
Published: February 2017

105

Background: Oncologists often embrace the concept of having discussions with patients regarding end-of-life care. Still, challenges remain with initiating these discussions early in the metastatic setting so that the full ACP process can be satisfied. A framework and infrastructure are needed to systematically initiate and promote the ACP process at a time when metastatic disease is identified and patients are better able to make thoughtful decisions regarding their future care. Methodology is needed for documenting and updating the ACP process within the patient’s health record. Methods: During a 15 month period, 32 independent sites of service within a nationwide community oncology network implemented an electronic health record (EHR)-based program for initiating ACP conversations with patients having a metastatic cancer diagnosis. Patients were identified for program engagement based on clinical criteria populated within the EHR. Identified patients received a brief introduction to ACP by the physician or other clinician and were encouraged to meet with a trained ACP Counselor to engage the full process. ACP Counselors provided guidance to the patient to discover and share personal values and goals for care. Values for care were documented within the EHR. Counselors provided appropriate patient education regarding code status and state-specific advance directives. At end-of-life, practices included hospice and death details within the EHR. Results: For metastatic patients (n = 29,389), ACP counseling was provided for 1,034 individuals (4%). Code status was visible in 3648 health records (12%) and patient values were included for 376 patients (1%). 2,206 patients (8%) transitioned to hospice care during the 14-month period. EHR-based infrastructure allowed for ongoing ACP visibility by the healthcare team. Conclusions: Use of an EHR-based ACP process demonstrates promising outcomes for realizing meaningful delivery of ACP. Essential components are patient identification early in the metastatic trajectory, assessment of patient values for care, thorough patient education regarding code status and advance directive documents, and full visibility of the ACP process within the health record.
Testing a model of caregiver satisfaction with hospice care in the cancer population.
Authors: MacKenzie Meredith A. , Buck Harleah G. , Meghani Salimah H. , Riegel Barbara
Published: February 2017

107

Background: Caregiver satisfaction with hospice care is a quality measure for hospice organizations and predicts caregiver and patient health, mortality and resource use. Yet contributing factors to caregiver satisfaction are poorly understood and there are no tested models of caregiver satisfaction in the literature to date. To fill this gap, our aim was to develop and test a model of caregiver satisfaction with hospice care in the cancer population. Methods: This was a retrospective cohort study of national data collected by the National Hospice and Palliative Care Organization (NHPCO) using the Family Evaluation of Hospice Care (FEHC) survey in 2011. We utilized a random sample of 1000 cancer caregivers (70,782 available). An initial theoretical model was developed which posited a relationship between demand (as measured by reported patient symptoms) and satisfaction, modified by caregiver internal and external resources. Structural equation modeling was used to test the model and adjustments made to improve model fit. Results: The final model fit the data well (LR=189.08, df=78; RMSEA=0.04; CFI=0.91; SRMR=0.03). Caregiver satisfaction was predicted by demand – higher perception of demand (more patient symptoms) reduces caregiver satisfaction. Patient age, caregiver race, education, relationship to the patient and length of hospice stay modify this relationship directly – black, non-spousal and more highly educated caregivers are less satisfied, along with caregivers of younger patients and those with shorter lengths of stay. Patient and caregiver age, caregiver sex and length of stay influence this relationship by altering caregiver perception of demand. Younger caregiver and patient age, being a female caregiver and longer length of stay increases caregiver demand, decreasing satisfaction. Note that length of stay works both for and against satisfaction. Conclusions: Caregiver satisfaction is a complex perception that depends on caregiver and patient characteristics, as well as hospice care received. Hospice care providers should consider screening caregiver-patient dyads for “high-risk” characteristics and providing additional supportive measures.
The value of advance care planning (ACP) in cancer critical care.
Authors: Portman Diane G. , Lancet Jeffrey E. , Fernandez Hugo Francisco
Published: February 2017

109

Background: Findings from previous research on the effect of advance directives (ADs) on patient outcomes have been mixed and are limited in the oncology population. A palliative care project in our Cancer Center’s ICU revealed patients with long length of stay (LOS) and ICU death without ADs in place. The Center’s Bone Marrow Transplant (BMT) program has implemented a protocol to obtain ADs pre-transplant. We sought to determine the presence and effect of ADs on end-of-life cost of care (COC) and LOS in critical care patients at our Center. Methods: We compared the 2013 COC and LOS of all ICU patients to the subset of patients for whom ICU care proved futile. The presence of ADs and DNR orders for expired ICU patients were matched to their respective COC and LOS. The COC of floor and ICU care were compared to determine potential cost savings from ICU avoidance. BMT-specific data was reviewed to establish the effect of early ADs on care and LOS. Results: Floor care proved to cost on average $2,000 less per day than ICU care. Thirty-eight percent of ICU patients had ADs. Only 41% of patients who expired in the ICU had an AD. If an AD was present, it was most likely to be a Living Will (LW) with DNR. The daily COC was highest for patients without ADs and lowest for those with LWs with DNR, despite a longer LOS in the LW/DNR group. In the BMT group, AD prevalence was 83% and resulted in earlier discussions about futility and shorter LOS. Conclusions: Obtaining timely ADs with DNR is likely to result in the lowest daily COC for critical patients. The greatest savings is likely to result from early ACP and ICU avoidance. Further study is needed to understand and overcome barriers to timely ACP implementation.
Advance care planning among seniors of a diverse city.
Authors: Belisomo Randi , Gaitan Daniel M. , Eisenstein Amy R. , Mulcahy Mary Frances
Published: February 2017

117

Background: Advance care planning (ACP) is a system of education, reflection and documentation of health care wishes. Respecting Choices has been successful in implementing ACP throughout Lacrosse County, WI (J Am Geriatr Soc 2010;58:1249–1255)..A single center study in Melbourne, AU, showed that ACP improves end of life (EOL) care, patient and family satisfaction, and reduces stress, anxiety, and depression in surviving relatives (BMJ 2010;340:c1345).We aim to quantify knowledge about ACP, interest in engaging in ACP, and barriers to effective ACP among the older adults of Chicago. The results will provide actionable items to implement an ACP program in a diverse city. Methods: 17 of the 22 City of Chicago senior centers participated in a survey and education forum “Starting the Conversation”. Participants provided demographic information, awareness and knowledge of EOL wishes and advance directives (AD). Data was tabulated and analyzed using descriptive statistics in IBM SPSS Statistics 22 Software. Results: 375 people completed the survey, the average age was 70+8, (range 41 to 93), 93.3% in English, and 6.7% in Spanish. Respondents live alone (44.5%), with a spouse (29.9%) or child (14.4%). 71% have thought about the medical care they would want at the EOL, 60% have discussed their EOL wishes with their loved ones, and 4% with their doctor. 60.5% do not know what an AD is, 25% have an AD, 76% know who would speak for them if they were unable, 58% have discussed their wishes with that person. Using neighborhood demographics, there was no difference in having an AD for predominately African American neighborhoods compared to others (33% and 27%). Respondents from lower income neighborhoods were less likely to think about medical care at the EOL (65% and 77%), less likely to have discussed EOL care (41% and 30% have not discussed EOL care) and less likely to have an AD (19% and 31%). Conclusions: ACP is underutilized in Chicago. The frequency of AD completion among Chicago seniors mirrors that of the US (Am J Public Health. 2013;103(6):e8-e10). Unlike other population studies, no difference was found among racial groups. Participants are aware of EOL wishes, are interested in engaging in these conversations, but lack the knowledge and collaboration of their healthcare team.
Patient-centered prescribing of medications for comorbid illness in older adults with advanced cancer: A qualitative study.
Authors: Tjia Jennifer , Gallagher Julia , Han Paul , Cutrona Sarah L , Mazor Kathleen
Published: February 2017

122

Background: Polypharmacy is common, burdensome, and potentially harmful in older adults with advanced cancer. According to the IOM, prescribing and coordination of chronic disease medication for these patients is suboptimal. We conducted a qualitative study with patients, caregivers, nurses, and physicians to better understand these issues. Methods: We used semi-structured interviews to explore participants’ views on medication management, care coordination, and communication for advanced cancer patients enrolled in 3 hospice agencies in New England. Eligible hospice patients were aged ≥ 65 yrs, had a diagnosis of cancer, and prescribed ≥5 medications. Family caregivers participated at the patient’s discretion. We also interviewed nurses and physicians to obtain an interdisciplinary perspective on medication coordination and communication. We used content analysis to identify emerging themes. Eighteen (18) patients (mean age 80 yrs [SD 10], 42% female) and 8 caregivers (mean age 63 yrs [SD 16.6], 88% female) were included, along with 10 nurses and 7 physicians from hospice, outpatient oncology and primary care settings. Results: Emerging themes revealed that patients and families were receptive to comprehensive medication reviews upon transition to hospice that assess the ongoing use of longstanding medications for comorbid illness. Effective framing for discussions included a focus on reducing harmful and non-essential medications; a less effective approach emphasized time to benefit (i.e. whether a medication is indicated for active symptom management vs prevention). Hospice nurses reported physician reluctance to discontinue medications, lack of physician confidence in their medication assessments, and lack of prescribing guidelines as barriers to optimizing prescribing. Conclusions: Patients enrolled in hospice for cancer and their families are willing to reassess the ongoing use of chronic medications for comorbid illness; information about medication harms and their impact on quality of life is considered particularly useful. Barriers to optimal prescribing include physician reluctance to discontinue medications and mistrust between providers.
Health services utilization and payments in patients with cancer pain: A comparison of intrathecal drug delivery versus conventional medical management.
Authors: Stearns Lisa , Janjan Nora Anita , Hinnenthal Jennifer A.
Published: February 2017

125

Background: The financial costs of cancer care are a burden to people diagnosed with cancer, their families, and society. This analysis compared health services utilization and cost in patients receiving either intrathecal drug delivery (IDD) or conventional medical management (CMM) for the treatment of cancer pain. Methods: Using retrospective administrative claims data, patients receiving either IDD or CMM were propensity score-matched 1:1 based on characteristics including, but not limited to, age, gender, cancer type, comorbid conditions, and health care utilization and cost during a six-month baseline period. Follow-up cost and utilization were subsequently compared for up to 12 months. Results: From a sample of 142 IDD patients and 3,188 CMM patients that met all inclusion/exclusion criteria, 73 matched pairs were obtained. Among the matched pairs, the average age was 52.6 years and 70.5% were female. The three most common cancers were leukemia/lymphoma (54.8%), digestive system cancer (40.4%) and breast cancer (24.0%). All patients were continuously enrolled at 2 months, 61% at 6 months, and 35.6% at 12 months; enrollment was not significantly different between groups. At two, six and twelve months follow-up, compared to CMM, IDD patients had a lower average number of inpatient (IP) hospitalizations (two months: 1.12 vs. 1.74 (p=0.0010); six months: 1.72 vs. 2.69 (p=0.0358); twelve months: 2.14 vs. 3.13 (p=0.1476)), and emergency department (ED) visits (two months: 0.47 vs. 1.36 (p<0.0001); six months: 0.98 vs. 2.38 (p=0.0049); 12 months: 1.59 vs. 3.17 (p=0.0611)). Including the cost of the IDD implant procedure, IDD still provided overall savings of $4,123 in IP hospital costs, $6,144 in outpatient hospital costs and $1,902 in ED costs at 12 months. Once all sites of services were considered, IDD saved $3,195 at 12 months relative to CMM. Conclusions: The goal of healthcare reform is to improve health outcomes through more effective therapies and avoid futile care. Through reduced hospital and ED visits, IDD improves health outcomes, and assists healthcare entities to meet current hospital readmission rate criteria and other quality standards.
Integration of oncology and palliative care (PC): A systematic review.
Authors: Hui David , Kim Yu Jung , Zhang Yi , Park Jichan , Strasser Florian , Cherny Nathan , Kaasa Stein , Davis Mellar P. , Bruera Eduardo
Published: February 2017

13

Background: Both ASCO and ESMO strongly endorse integrating oncology and PC; however, a global consensus on indicators of integration is currently lacking. To better understand what “integration” entails, we conducted a systematic review to identify articles addressing the clinical, education, and administrative indicators of integration. Methods: We searched Ovid MEDLINE and Ovid EMBase between 1948 to 2013 using the search terms “neoplasms”, “integration”, and “Palliative Care” or “Supportive Care”. Two researchers independently reviewed each citation for inclusion, and then extracted the indicators related to integration. The inter-rater agreement was high (kappa=0.96, P<0.001). Results: Our initial search identified 411 publications, and 97 were included in the final sample. 58 (60%) were review articles and 31 (32%) were original articles. The number of articles on integration increased significantly between 1991 and 2013 (P<0.001), with 63 (65%) articles published in 2010 or later. Among these articles, 30 (31%), 16 (16%), 15 (15%) and 8 (8%) articles, respectively, discussed the role of outpatient clinics, community care, PC units, and inpatient consultation teams in integration. 53 (55%) articles addressed various processes for integration, including routine symptom screening (N=16), interdisciplinary teams (N=16), guidelines (N=11), referral criteria (N=10), embedded clinics (N=5) and clinical care pathways (N=5). 31 (32%) mentioned “early” involvement of PC, 11 (11%) provided a specific timing, and 24 (25%) discussed referral criteria. 33 (34%) articles addressed educational strategies for integration, such as training programs (N=13), PC rotations (N=3), and continuing medical education (N=4). 14 (14%) articles described research indicators and 21 (22%) on administrative indicators. No articles specifically defined the term “integration” nor discussed standardized outcomes of integration. Conclusions: Integration was a heterogeneously defined concept. Our systematic review highlighted 40 clinical, educational, research and administrative indicators on integration. This study is part of an international effort to further develop refined and widely endorsed criteria for broad application.
Beyond SPIKES: Key principles to enhance communication in difficult conversations.
Authors: Farrell Tommie Wade , Reed Josh , Roffers Michael
Published: February 2017

138

Background: The SPIKES protocol for delivering bad news developed by Buckman et al. has been a standard since published. Though helpful those in practice understand that further training is needed for these difficult conversations and for those that follow when deciding on treatment options. What skills can be taught to prepare for these conversations? Methods: At our program Hospice/Palliative and Oncology fellows rotate with the hospital Supportive Care team. They are trained in Three Key Principles after training in the SPIKES protocol: EMOTIONAL ALIGNMENT: aligning team goals with the goals of the patient/family. This includes eliciting the goals of the patient, clarifying the basis of these goals and showing alignment. Example phrases: Tell me what your hopes are for your treatment. What do you feel will happen when you attempt this? Your desire to live as long as possible makes perfect sense. TRANSPARENCY: sharing the ambiguity inherent in care. This includes presenting all options of care, and the variability that exists with all options. Examples: We don't always know exactly what will happen with treatment, but if your goal is to live as long as possible this will possibly extend life by months. If your goal is to maximize time with family, a person may choose to use the services of the hospice team who focus on you being at home. CLARITY: clarifying misconceptions and ensuring that goals and treatment plans match. This includes asking for expectations of treatment, giving accurate expected outcomes, and using language that is clear. Examples: When we say that this treatment is palliative we mean that we don't expect that it will cure, but it may provide on average an extra few months. You have told me you hope to get stronger by doing this treatment. I need to tell you that typically this treatment does not make a person stronger and fatigue is actually a potential side effect. Results: Fellows find these principles helpful in discussing treatment options. They universally evaluate this skill set as being achievable and also report it enhances patient-physician relationships. Conclusions: Applying these key principles is a skill that can enhance communication when making treatment decisions in potentially terminal illness.