bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of advanced imaging and biomarker tests for post-treatment surveillance in early-stage breast cancer survivors.
Authors: Hahn Erin E. , Mody Kaizeen C. , Jacobson Amy Ann , Ganz Patricia A.
Published: February 2017

168

Background: The American Society of Clinical Oncology (ASCO) released a “Top Five” list of opportunities to improve the quality of cancer care. #4 focused on post-treatment surveillance in breast cancer patients treated with curative intent. The ASCO guideline on breast cancer follow up advises against using advanced imaging and biomarkers in this setting. We undertook an examination of the patterns of follow-up care for breast cancer survivors treated at an academic medical center to evaluate use of non-recommended services. Methods: Claims data and medical records were reviewed and abstracted for early stage (0-IIIA) breast cancer survivors starting one year post diagnosis, with an average of 5 years of follow-up data. A trained abstractor classified imaging tests as diagnostic/surveillance based on medical record content. A 10% random sample was abstracted by a second abstractor and compared for concordance. Descriptive statistics were generated for patient demographic and medical characteristics, and proportions for receipt of non-recommended services, including if imaging procedures were performed for diagnostic/surveillance purposes. Multivariate logistic regression modeling was used to determine factors associated with receiving non-recommended services. Results: Records were available for 258 patients. The mean age was 62 (SD 13), mean time since diagnosis was 6 years (SD 2), 66% were stage 0/1. 35% received at least one abdominal CT, 31% at least one chest CT, 20% at least one PET, 30% at least one bone scan. Of these services, 90 abdominal CT scans (47%), 131 chest CT scans (65%), 77 PET scans (90%), and 29 bone scans (26%) were classified as surveillance. 80% received CEA and/or CA 27.29 tests; 8% received CA 15-3 tests. Logistic regression revealed no consistent association of medical, demographic, or provider factors with receiving non-recommended services. Conclusions: Use of non-recommended services for surveillance occurs frequently among early stage survivors. Providers in this academic center had no personal financial incentive for ordering these services. There are opportunities to increase use of guideline concordant post-treatment care for breast cancer survivors.
Adherence to guidelines for adjuvant chemotherapy (AC) use in stage II colon cancer (CC).
Authors: Cheung Winson Y. , Lim Howard John , Renouf Daniel John , Woods Ryan , Speers Caroline
Published: February 2017

169

Background: Treatment guidelines suggest that AC may be considered inpatients (pts) with "high risk" stage II CC, defined by the presence of >/=1 poor prognostic features, such as obstruction or perforation, T4 stage, <12 lymph nodes retrieved, positive resection margins, and lymphovascular or perineural invasion. However, survival benefits associated with AC use in high risk pts remain largely unproven. Therefore, current recommendations are primarily driven by consensus rather than by evidence. Our aims were to examine population-based concordance with current guidelines for AC use in stage II CC and to explore the relationship between AC use and survival in high- vs. low-risk pts. Methods: All pts diagnosed with stage II CC in British Columbia from 1999 to 2008 and evaluated at 1 of 5 regional cancer centers were reviewed. Kaplan-Meier and Cox regression methods were used to correlate high- vs. low-risk status as well as receipt of AC with relapse-free (RFS), disease specific (DSS), and overall survival (OS). Results: We identified 1,697 stage II CC pts: 1,236 (73%) high risk and 461 (27%) low risk among whom only 363 (29%) and 61 (13%) received AC, respectively. Individuals with high risk features who received guideline-concordant AC were younger (median 62 vs. 72 years, p<0.001) and had better performance status (ECOG 0/1 47% vs. 34%, p=0.02). In the high-risk group, AC was associated with improved 5-year OS, but not with RFS or DSS. After adjusting for confounders, an OS advantage from AC persisted for high-risk pts (HR 0.67, 95 CI 0.52-0.86, p=0.002), but no significant RFS or DSS benefits were seen (HR 0.76, 95 CI 0.58-0.99, p=0.05 and HR 0.75, 95 CI 0.55-1.02, p=0.11, respectively). Subgroup analyses showed that only individuals with T4 lesions had improved RFS (HR 0.63, 95 CI 0.42-0.95, p=0.03), DSS (HR 0.59, 95 CI 0.37-0.93, p=0.02), and OS (HR 0.50, 95 CI 0.33-0.77, p=0.002). Conclusions: In this population-based cohort of stage II CC patients, less than one-third of high risk patients received guideline-concordant AC. Consistent survival benefits were only seen in those with T4 lesions, suggesting a very limited role for AC. Guidelines that are mainly consensus-driven and associated with minimal survival benefits have poor uptake.
Rates of bone mineral density measurement in men with prostate cancer starting androgen deprivation therapy.
Authors: Suarez-Almazor Maria , Peddi Prashanth , Luo Ruili , Nguyen Hoang , Elting Linda S.
Published: February 2017

174

Background: Men with prostate cancer on androgen deprivation therapy (ADT) are at risk for accelerated bone loss and osteoporotic fractures. Current National Comprehensive Cancer Network (NCCN) guidelines recommend dual-energy X-ray absorptiometry (DXA) scan for risk assessment when starting ADT. Our objective was to determine if DXA scans were performed prior or soon after ADT initiation among men with prostate cancer. Methods: In this claims-based database linkage study, men with prostate cancer were identified fromthe Texas Cancer Registry between 2006-2007 and their records were linked with Medicare databases parts A, B and D to identify claims for ADT using generic names, predefined J codes and ICD codes. Part D claims are currently available for years 2007 and 2008. DXA claims were obtained using CPT/HCPS codes from Medicare part A and part B. Patients were considered to have undergone a DXA exam, useful as a baseline screening test for ADT therapy if a claim could be identified within 2 years before starting ADT therapy, or 6 months afterwards. Multivariate logistic regression models were performed to examine determinants of DXA use. Results: 1,647 men 65 years and older were included in the study. A total of 144 (8.3%) had a DXA scan obtained within 2 years and 6 months after initiation of ADT. Age older than 75 years, history of prior bisphosphonate usage and residence in the metropolitan area were statistically significantly associated with higher likelihood of obtaining DXA. Race, gender, median income, high school percentage, number of ADT claims, and type of ADT used were not associated with DXA usage. Conclusions: Despite the importance of osteoporosis screening, men with prostate cancer and Medicare insurance, in the state of Texas, had very low DXA utilization rates prior, or soon after, the initiation of ADT. Further research is needed to identify barriers to adherence to recommendations for the evaluation of bone health in patients with prostate cancer.
Compliance with NCCN guidelines in the management of extra-abdominal soft tissue sarcoma across the United States.
Authors: Wasif Nabil , Bagaria Sanjay Prakash , Ashman Jonathan Ben , Beauchamp Chritsopher P. , Gray Richard J.
Published: February 2017

178

Background: Soft tissue sarcoma is a rare disease requiring multidisciplinary care for effective treatment. The National Comprehensive Cancer Network has developed guidelines for surgical resection and adjuvant therapy based on best available evidence. We sought to examine variance from these guidelines in treatment across the United States. Methods: The Surveillance, Epidemiology and End Results cancer registry was queried to identify patients undergoing surgery for extra-abdominal soft tissue sarcoma from 2004-2009. Coded variables signifying radical excision (RE) and the use of radiation therapy (RT) were correlated with stage of the primary tumor. Patients with metastatic disease, unknown size and unknown grade were excluded. Results: A total of 5,600 patients were identified with a median age of 61. Median tumor size was 8cm and most tumors were high grade (57% G3). Stage specific breakdown was as follows; Stage I 24%, Stage II 37% and Stage III 39%. Overall, 54% of patients underwent RE and 50% received RT, mostly in the post-operative setting (83%). The amputation rate was 4%. Although routine radiation therapy is not recommended for Stage IA and IB patients, 24% still underwent RT, whereas only 49% of Stage I patients were noted to have undergone a RE. Even though routine RT is recommended for Stage II and III tumors, 42% of patients did not undergo any RT, and only 58% underwent RE. On multivariate analysis predictors of RE were age <50 (OR 1.3, 95% CI 1.1-1.6), lower extremity tumor (OR 2.2, 95% CI 1.6- 2.8), Stage III, (OR 2.1, 95% CI 1.7- 2.6), and white race (OR 1.4, 95% CI 1.2- 1.8). Variance from guidelines was seen in 64% of patients. Conclusions: Significant heterogeneity and variation in the contemporary treatment for soft tissue sarcoma in the United States exists. Although low rates of RE may be related to coding discrepancies, rates as low as 54% are still a cause for concern. Overuse, and more importantly, underuse of RT is seen for a significant proportion of patients. If these trends are confirmed by further study, more effort will have to be directed towards compliance with appropriate treatment recommendations, perhaps by regionalizing sarcoma care.
Does a quality-of-care problem exist? Cancer Care Ontario practice pattern data and the recommendations of two lung cancer practice guidelines.
Authors: Brouwers Melissa C. , Makarski Julie
Published: February 2017

190

Background: Practice-pattern data, evidence-based knowledge and transfer, and performance management strategies define Cancer Care Ontario’s quality improvement strategy. Knowledge products, such as practice guidelines, are intended to provide recommendations for practice, based on best available evidence, to improve quality of care and reduce variation in practice. Review of 2010-2011 Cancer System Quality Index (CSQI) data revealed complex practice patterns in treatment of non-small cell lung cancer patients with stages II and IIIa resected and stages IIIa and IIIb non-resected disease in Ontario. A multi-method study was initiated to understand the patterns, to identify if a quality of care problem exists and to propose improvements moving forward. Methods: Surgeons, medical oncologists and radiation oncologists from Ontario were invited to participate in a survey consisting of 6 areas of inquiry. A grounded theory approach was used to guide key informant interviews of purposively sampled clinicians and administrators. A more in-depth analysis of the CSQI data was planned. Results: Clinicians responding to survey provided positive assessments of PG recommendations and evidentiary base; perceptions of practice patterns were less problematic than hypothesized; estimates of benchmarks were highly variable; and assessments of barriers to recommendation implementation included slow referral process, lack of organization support and patients seen in practice not reflected in the evidence. From the interviews, 5 themes emerged: unique patient, unique physician, family, clinical team, and clinical evidence. Further analysis of CSQI data was not possible given limitations related to data collection. Conclusions: A perceived quality of care problem initiated this study. Concerns centred on significant proportion of patients receiving no treatment; modest percentage of patients receiving treatment that aligned with PG recommendations; and regional variation within each of the clinical care options. Our data show that defining a quality of care problem is significantly more complex than consideration of practice patterns alone.
Prospective synoptic template recording to assess for compliance of care with NCCN guidelines for breast cancer.
Authors: Adegboyega Titilayo , Landercasper Jeffrey , Linebarger Jared , Johnson Jeanne , Dietrich Leah L. , Driscoll Collin , Andersen Jeremiah , Go Ronald S. , Vang Choua , Marcou Kristen , Hudak Jane
Published: February 2017

197

Background: There is a wide variation of compliance with National Comprehensive Cancer Network (NCCN) guidelines for diagnosis and treatment. Overutilization of preoperative testing and underutilization of adjuvant treatments have been documented. The former is associated with higher costs of care; the latter with poor patient outcomes. Prior reports of adherence to NCCN Guidelines contain methodological limitations due to lack of contemporary review and incomplete listing of reasons for non-compliance. This limits the “real time” analysis of breast cancer quality and delays action plans to address quality and cost issues of care. Methods: NCCN Guideline compliance was recorded prospectively by use of electronic synoptic templates for all newly diagnosed breast cancer patients treated at a single institution between January 2010 and December 2011. A retrospective review of the synoptic templates was then conducted. Accuracy of the synoptic auditing method was assessed as well as NCCN compliance and reasons for non-compliance. Results: A total of 312 new breast cancer patients who underwent surgery as initial treatment were identified. Compliance with NCCN Guidelines for preoperative testing, breast surgery and lymph node surgery was 98% (306/312), 99.7% (311/312) and 93% (290/312) respectively. Reasons for non-compliance include patient refusal, comorbidities, advanced age and overutilization of systemic imaging. There was 100% compliance to College of American Pathologist (CAP) molecular profile documentation for all breast cancer cases. There were two discrepancies noted between the prospective template reporting and medical record review. The average time needed to populate data into synoptic templates was less than 2 minutes per patient. Conclusions: Prospective auditing of adherence to NCCN Guidelines with electronic synoptic templates is accurate and time efficient. High compliance rates with NCCN Guidelines were demonstrated. Electronic synoptic NCCN templates potentially facilitate early recognition of quality gaps in compliance and provide a framework for peer performance comparison.
Utilizing QOPI in the quality improvement efforts of the NCI Community Cancer Centers Program (NCCCP).
Authors: Siegel Robert D. , Stallings Holley , Bryant Donna M. , Kadlubek Pamela , Borowski Laurel , Castro Kathleen M. , Clauser Steven B. ,   NCI Community Cancer Centers Program
Published: February 2017

208

Background: The NCCCP is a network of community based institutions from New England to Hawaii funded by the NCI. Quality of care is a priority of the NCCCP with participation in ASCO’s Quality Oncology Practice Initiative (QOPI) playing a fundamental role. QOPI provides a process for quality assessment but we have also used it as a measure of quality improvement (QI) network-wide. Using QOPI methodology, we have analyzed our performance twice a year in an effort to enhance our implementation of quality indicators relevant to program aims. Methods: A data sharing agreement allows individual practice QOPI data to be electronically sent to the NCI where it is aggregated with the other NCCCP QOPI participants. Data are presented via webinar within the network using a variety of QI strategies. For example, blinded site performance distributions are benchmarked against NCCCP national averages on specific indicators. High performing practices voluntarily present their QI initiatives and best practices to the network. The NCCCP Quality of Care Subcommittee then selects QI projects and areas to focus quality improvement efforts. Results: In Spring 2012, 44 practices affiliated with 25 NCCCP sites participated in QOPI, a consistent pattern since Fall 2010. The table below describes the percent compliance with certain QOPI measures for the NCCCP aggregate over time. Selected measures were perceived as having had suboptimal compliance in Fall 2010. Conclusions: QOPI is an effective tool for assessing quality within a network and for measuring quality improvement efforts. Best practices from within the network can be leveraged and disseminated to enhance the quality of cancer care. This methodology facilitates quality initiatives despite the logistical challenges of working with practices across the country. [Table: see text]
Peer-review of radiation treatment planning in a provincial radiation oncology program: A survey of current practice.
Authors: McGowan Thomas S. , Foxcroft Sophie , Brundage Michael Donald , Sharpe Michael , Gutierrez Eric , Warde Padraig Richard
Published: February 2017

211

Background: The use of peer-review activities in oncology is not well described as a quality improvement process. We sought to describe current patterns of practice of radiation oncology peer-review across a large Provincial Cancer program and to identifiy barriers to its use. Methods: Ontario cancer centres were surveyed. Survey item responses were typically scored using a 10-point Likert scale. The survey was administered electronically with follow-up reminders as required. The use of free-text for comments elaborating on responses was encouraged. Results: Fourteen (100%) centres responded. All rated the importance of peer-review as at least 8/10 (10=extremely important). Detection of medical error and improvement of planning processes were the highest-rated benefits of peer-review (each median 9/10). Four centres (29%) conducted peer-review in more than 80% of cases treated with curative intent; six (43%) peer-reviewed at least 50% of curative cases. Five centres (36%) reported “always” or “almost always” conducting peer-review prior to the initiation of treatment. Variation was seen in which aspects of a case were typically reviewed (e.g., GTV “almost always” reviewed in 67%; contouring of organs at risk in 50%). Five centres (46% of those with regular peer-review) reported that 5% to 9% of peer-reviewed cases were flagged as requiring a change, whereas 3 centres (27%) reported that < 2% of peer-reviewed cases required a change to be made. Five centres (36%) recorded the outcomes of peer-review on the medical record. Thirteen centres (93%) planned to expand peer-review activities; the two factors rated as most limiting to expanding peer-review were a critical mass of radiation oncologists (median score 6/10), and prioritization of peer review by the program overall (median 5/10). Conclusions: Peer review in radiation oncology practices it is now widely used as a quality assurance activity in Ontario, identifies changes to improve quality in the individual case, and improves departmental process. The development of guidelines and standards for peer-review activities, coupled with effective knowledge translation activities are recommended.
Targeted agent use in patients with cancer at the end of life.
Authors: Hui David , Karuturi Meghan Sri , Tanco Kimberson Cochien , Kwon Jung Hye , Kim Sun Hyun , Zhang Tao , Kang Jung Hun , Chisholm Gary B. , Bruera Eduardo
Published: February 2017

215

Background: Chemotherapy use at the end of life is considered an indicator of poor quality of care. The use of targeted agent has not been well characterized. In this study, we determined the frequency and predictors of targeted therapy use in the last 30 days of life. Methods: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents. Results: 816 patients were included: average age 62 (range 21 to 97), female 48% and White 61%. The median interval between the last treatment and death was 47 (interquartile range 21 to 97) days for targeted agents and 57 (26 to 118) days for chemotherapeutic agents. 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy within the last 30 days of life. 43 (5%) patients received targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n=25), bevacizumab (n=20) and rituximab (n=11). In multivariate analysis, younger age, hematologic, and lung malignancies were associated with increased targeted agent use in the last 30 days of life (Table). Conclusions: Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed. [Table: see text]
Patient safety in Danish cancer care: Results from complementary studies.
Authors: Knudsen Janne Lehmann , Lipzack Henriette , Sperling Cecilie , Sandager Mette
Published: February 2017

216

Background: Cancer care has been a top political priority in Danish health care for the past 12 years, but there has been no specific attention towards patient safety. During the past three years, the Danish Cancer Society has carried out several studies, and in 2011 a National working group with all central stakeholders was established together with the Multidisciplinary Cancer Groups. The aim is to provide an overview of safety hazards during the cancer journey based on four different studies addressing the perspective of the health care professionals as well as the patients, and to outline the challenges in the monitoring safety in cancer based on these. Methods: Data from four studies will be presented: (1) 2,429 cancer related adverse event reports from the national Danish Patient Safety Database; (2) retrospective chart review identifying harm in 572 patient records in five inpatients cancer settings using the Global Trigger Tool; (3) errors experienced by 4,262 patients participating in a nationwide survey addressing needs and experiences with healthcare from first contact until completion of primary treatment; (4) errors experienced by the same group of patients during follow-up and rehabilitation two years after diagnosis. Results: The hazards measured varies from according to the methods used; The cancer specific AE reports were primarily related to medication, clinical, process documentation, and clinical administration. Physical harm using GTT was identified in 28% of admissions related to clinical processes, infections, and medication. 10% of the patient reported errors during contact with GP, 15% during diagnostic at hospital and 25 % during treatment. Delay, insufficient information, medication errors, and logistic errors were the most dominant errors. The results adressing patient experienced errors during follow-up and rehablitation are being analyzed. Conclusions: There are specific and serious safety challenges in cancer care and systematic monitoring is needed. Asking the patients add new knowledge. There is a need for critical evaluation of which methods to use for measuring.
Impact of a cancer management program.
Authors: Hoverman J. Russell , Klein Ira , Harrison Deb , Hayes Jad , Garey Jody S. , Nelson Greg C. , Sipala Maria , Houldin Scott , Ciaglo John , Taniguchi Cynthia , Jameson Melissa , Abdullahpour Mitra , McQueen Jessica , Verrilli Diana K. , Beveridge Roy
Published: February 2017

227

Background: US Oncology, Inc., Texas Oncology (TxO) and Aetna are engaged in a pilot program, Innovent Oncology (IOP) to evaluate clinical and financial impacts of Pathways (PW), a nursing call intervention for chemotherapy patients (pt support services-PSS), and an advance care planning (ACP) initiative. We report quality initiatives, PW compliance and ACP, from the program at 18 months, and IP and ER admits at 12 months. Methods: Eligible Aetna pts with PW diagnoses, treated by TxO were enrolled. PW compliance was tracked. PSS calls occurred at regular intervals during chemotherapy. Symptoms, quality of life, and depression were screened each call with referrals to TxO as needed for management. ACP was initiated in month 2 of IOP. To support IOP, a leadership team comprising physicians, pharmacists and nurses was established. IP,ER data on predefined subgroups were compared to diagnosis-adjusted rates from the baseline prior year. Results: The program enrolled 184 patients from June 1, 2010 – Decembe 30, 2011 with 278 regimens ordered. Pathway adherence improved from 67% to 75%. 81% enrolled in PSS; of these, 83% were introduced to ACP, with 11% (n=16) completing a full ACP discussion. PSS made 906 calls to pts and assessed pain at 80% of contacts. IP, ER utilization rates after 12 months of IOP are reported (see Table). Conclusions: This is a preliminary evaluation with small numbers. Results suggest cancer patients can be identified pre-treatment; a proactive nurse call system is feasible and well received; a symptom assessment tool can be systematically implemented, communication on ACP initiated; and a pathways program enhanced. A reduction of ER visits by 39.8%, IP admits by 16.5 %, and inpatient days/member by 35.9% are very promising trends. A bootstrap shows 97% of scenarios with IP utilization reduction, and 96% with ER utilization reduction. [Table: see text]
Patient-centered wait time measurement in Ontario.
Authors: Kaizer Leonard , Krzyzanowska Monika Karolina , Hertz Sherrie , Srigley John , Dobranowski Julian , Irish Jonathan , Warde Padraig Richard , Gao Julia
Published: February 2017

233

Background: Since 2005, a concerted effort to measure and manage access to chemotherapy services in Ontario has resulted in a significant reduction in several specific wait time intervals (referral for medical oncology consultation and medical oncology consultation to first treatment). To identify other opportunities to improve access, a comprehensive analysis of the all-inclusive wait times from cancer diagnosis to the start of adjuvant chemotherapy for patients with early stage colon, breast, and lung cancer (patient centered wait time) has been undertaken. Methods: The study cohort comprised all Ontario patients who received adjuvant chemotherapy in 2009 for early stage colon, breast, and lung cancers. The Ontario Cancer Registry, linked to several administrative healthcare databases in Ontario, was used to identify the cohort and variables of interest. Wait time from diagnosis of cancer to the initiation of adjuvant chemotherapy was measured and separated into segments based on the dates of diagnosis (D), surgery (S), referral to medical oncology (R), medical oncology consultation (C), and first adjuvant chemotherapy treatment (T), and each was analyzed for variation at a regional and institutional level. The times from surgery to pathology sign-out (TTPR) and for peripherally inserted central catheter (PICC) acquisition were also studied in a subset of cases. Results: In 2009, 86% of patients with stage III colon cancer, 80% of patients with stage I to III breast cancer and 63% of patients with stage II lung cancer who received adjuvant chemotherapy started their treatment within 120 days of diagnosis. There was significantly better performance and less regional variation for colon cancer patients (82-93%) than for breast cancer patients (63-90%). For the whole cohort of breast cancer patients, the median total time from diagnosis to adjuvant chemotherapy was 81 days with the following segmental breakdown D-S (30 days), S-R (19 days), R-C (16 days), and C-T (16 days). The mean TTPR for colon cancer patients was 11.6 days and PICC insertion was < 7 days in 92% of patients. Conclusions: A number of opportunities for process improvement were identified, including shortening the pathology reporting interval and the timing for initiating referral to a medical oncologist.
Measuring adverse event rates in oncology inpatients using trigger tools: An assessment of measurement properties.
Authors: Mattsson Thea Otto , Brixen Kim , Knudsen Janne Lehmann , Herrstedt Jorn
Published: February 2017

235

Background: The Institute for Healthcare Improvement developed the Global Trigger Tool (GTT) for measuring harm rates over time in 2006. Few studies have been published on the measurement properties of GTT and no studies have assessed the value of adding specific modules to the generic GTT. We, therefore, aimed to determine inter-rater reliability, and to evaluate the effect of interrater variation on the reliability of the generic GTT to detect adverse event rates over time. Furthermore to evaluate the effect of adding an oncology specific module to the generic GTT on number and category of adverse events (AEs) identified. Methods: A retrospective chart review was performed by two teams consisting of two primary reviewers. One team used the general GTT, and the other used an oncology specific GTT (GTTO); consisting of the general GTT module plus an additional oncology module. A random sample of 10 charts was selected every two weeks between all discharged patients from a Department of Oncology in 2010. n=240. All charts were reviewed by both teams using standard GTT methods and measures. AEs per 1,000 admission days and AEs per 100 admissions where used to draw Statistical process control (SPC) charts for evaluation of the patient safety process. Inter-rater variability between review teams was assessed calculating the Kappa Cohen coefficient using data from the identical general GTT module. Results: Reliability between the two teams of reviewers to identify an AE was moderate [K=0.45]. A comparison of SPC charts, using the results from the identical general module, showed that moderate agreement gave rise to different conclusions on the patient safety process between teams. Comparing GTT with GTTO we found no significant difference (CI 95% [0.06-0.08]) in number of identified AEs and an equal distribution of the events on harm categories. GTT and GTTO identified 56 and 57 AEs respectively. Conclusions: Moderate agreement between review teams gave rise to different conclusions on the patient safety process suggesting limited use of the GTT to track harm rates over time. Addition of an oncology specific module showed no significant effect on the total number or distribution of AEs on harm categories.
An analytic framework for capturing trends in utilization, costs, and quality metrics in cancer patients’ last 6 months of life.
Authors: Cassel Brian , Skoro Nevena , Kerr Kathleen , Shickle Lisa , Del Fabbro Egidio , Coyne Patrick J.
Published: February 2017

240

Background: Increasingly, reimbursement models are shifting to bundled payments and pay-for-performance models. While cancer care is often profitable for hospitals in the fee for service model, it is important to monitor outcomes that could influence reimbursement, such as 30-day readmissions; possible indicators of poor quality, such as 30-day mortality admissions; and to utilize longitudinal measures of costs and revenues. Methods: We evaluated trends in the outpatient and inpatient care at an academic cancer center for patients across their last 6 months of life. All-payor hospital claims data were linked to Social Security Death Index data to determine patients’ date of death even if they did not die in-hospital. All utilization at our center was analyzed for the 3,128 cancer patients who died between January 2009 and June 2011. Results: Admissions increased over the final six months, with sharp increases in ICU and total bed days in the final three months. 31% of admissions were 30-day re-admissions; 40% had a negative net margin; and all (1,178) in the final month were 30-day mortality admissions. 63% of hospice referrals occur in the final month. Conclusions: With each month this hospital is increasingly exposed to the risks of 30-day mortality and 30-day readmissions. Are the escalating costs and risks justified in terms of outcomes or quality? These findings reinforce the need for care practices that ensure that care is aligned with patient and family preferences, and that alternate care options are available and presented to patients and families in a timely fashion. [Table: see text]
Analysis of stage of melanoma diagnosis in relation to insurance type and income as an indicator of early/late diagnosis.
Authors: Lamie Peter Makram , Sikora Asia , Silberstein Peter T.
Published: February 2017

243

Background: This study compares the average stage of diagnosis for melanoma by insurance status and household income. This is the largest such study for melanoma to date. Methods: Using the National Cancer Database (NCDB) we examined 299,214 patients with melanoma between 2000 and 2009 at 1,408 hospitals. The relationship of average stage of diagnosis is compared across insurance types and by income for 293,438 patients. Results: The VAH patient population had the lowest average stage of diagnosis (0.89) with the Medicaid population exhibiting the highest (1.87, p<0.0001). The VAH was lower than Tricare which had an average diagnosis of 1.11 (p<0.0001), private insurance 1.20 (p<0.0001), Medicare 1.34 (p<0.0001), and uninsured 1.70 (p<0.0001). The lowest rate of stage IV was private insurance (3.31%), with Tricare at 3.67% (p<0.0001), VAH 4.46% (p<0.0001), Medicare 5.74% (p<0.01), uninsured 10.12% (p<0.0001), and the highest rate was among Medicaid (14.35%, p<0.0001). The highest income category (≥$49K) had the lowest average stage at diagnosis of 1.16 compared to $39K to $48K (1.28, p<0.0001), $33K to $38K (1.35, p<0.0001), $28K to $32K (1.40, p<0.0001), and the lowest income group (<$28K) had the highest average stage of diagnosis (1.46, p<0.0001). The rate of Stage IV diagnosis increased from the highest income group (3.68%), followed by $39K to $48K (4.69%, p<0.0001), $33K to $38K (5.17%, p<0.0001), $28K to $32K (5.89%, p<0.0001), and less than $28K (6.92%, p<0.0001). Conclusions: Overall, VAH patients, higher income patients and patients with private insurance were diagnosed with earlier stage melanoma as compared to those with no insurance and Medicaid, who were more frequently diagnosed with stage IV disease. The VAH provision of high quality care, particularly preventative care, can result in improved patient outcomes such as cancer survival (Landrum et al, 2012). Reference: Landrum MB, Keating NL, Lamont EB, et al. Survival of Older Patients with Cancer in the Veterans Health Administration versus Fee-for-Service Medicare. Journal of Clinical Oncology, April 2012, 30(10): 1072-1079.
Staging documentation accuracy and adherence to workup and treatment guidelines: The M. D. Anderson Regional Care Center experience.
Authors: Sarma Amitabha , Patel Sunil M. , Sturdevant Laurie , Ip Mee-chung Puscilla , Hundley Carol L. , Kian Leslie , Simeone William , Fisch Michael
Published: February 2017

244

Background: MD Anderson Cancer (MDACC) disease-specific faculty experts have developed institutional guidelines for diagnostic workup and treatment of common tumor types. The institution has four Regional Care Centers in suburban Houston staffed by a total of 10general medical oncologists. The primary intent of this project was to measure the accuracy of staging documentation and adherence to guidelines. The secondary intent was to improve documentation and guideline adherence by regularly reporting results directly to the involved physicians. Methods: Between July 2009 and April 2012, charts for all new medical oncology visits for patients with breast, non-small cell lung, or colon cancer for whom no previous medical oncology plan had been implemented were reviewed by a team of quality nurses on a weekly basis. Source documents were analyzed for (a) adherence to MDACC diagnostic workup guidelines (n=782); (b) accuracy of both TNM and AJCC staging documentation (n=782); and (c) adherence to MDACC treatment guidelines (n=731). On a monthly basis, a graph with rates over time of guideline adherence and accuracy of staging documentation was provided to each general oncologist. Results: The adherence rate to MDACC diagnostic workup guidelines was 79%. The agreement rate for accurate documentation of both TNM and AJCC stage was 72%. The adherence rate to MDACC treatment guidelines was 94%. Providing monthly reports of individual results to each physician did not lead to an increase in the rates of adherence of accurate staging documentation. Analysis comparing all Regional Care Center medical oncologists (not provided to the involved physicians) showed significant variation in rates for all three categories. Conclusions: Providing MDACC Regional Care Center general medical oncologists with simple graphs over time reflecting guideline adherence and accuracy of documentation did not lead to any improvement on those measures. More creative interventions to improve performance in these realms will need to be explored.
Quality of systemic cancer therapy in routine care: What are we measuring?
Authors: Shen Shixin (Cindy) , Krzyzanowska Monika K.
Published: February 2017

249

Background: While clinical trials provide efficacy and early safety information regarding systemic cancer therapy (ST), most cancer patients who receive ST are treated outside clinical trials. We performed a systematic review of studies that have evaluated the quality of ST in routine practice to summarize the literature and define knowledge gaps across five quality domains – access, treatment delivery, toxicity, safety and outcome. Methods: We searched MEDLINE using a combination of terms pertaining to ST, such as “chemotherapy” with keywords related to healthcare quality for articles published in English from January 1, 2000 to December 31, 2010. Articles were included if they were based on original studies that examined quality of ST among adult patients from a population perspective (defined as multiple institutions). Study information was abstracted using a standardized form. Summary statistics were used to describe the results. Results: Our search identified 179 articles. The number of studies published each year increased over time from nine studies in 2000 to 30 in 2010. Most studies were conducted in the United States (58%) in either colorectal (31%) or breast cancers (27%) and focused on adjuvant intent cytotoxic chemotherapy (81%). Majority of the studies retrospectively (92%) identified patients from cancer registries (83%) and used either billing data (64%) or information in the registry itself (27%) for treatment identification. 66% of the studies evaluated a single quality domain, whereas the remaining articles assessed two or more domains. No study was found that examined safety from a population perspective. Access was the most frequently evaluated domain (77%) whereas treatment delivery was the least examined (12%). Treatment toxicity and outcome were evaluated in 21% and 31% of studies, respectively. Among studies that assessed outcome of ST, most evaluated patient specific outcomes such as survival (93%) although a few (13%) examined system level outcomes such as cost. Conclusions: Majority of studies evaluating quality of ST have focused on access to cytotoxic chemotherapy in early stage disease. Further studies focusing on other aspects of quality and in different clinical settings are needed.
Causes of chemotherapy infusion delays: Results of a time study in an academic cancer clinic in the community.
Authors: Altomare Ivy , Moss Lisa , Kamal Arif , Sutton Linda
Published: February 2017

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Background: Chemotherapy administration is a complex process involving several steps and checkpoints. Any of these can improve or delay efficiency in patients receiving timely care. We conducted a time study auditing delays to the start of chemo infusion to determine the main causes of treatment delays and identify areas for improvement. Methods: Within the Duke Oncology Network (DON), an outreach network assisting rural cancer clinics with clinical operations, we identified one site for the study. A DON nurse practitioner and chemotherapy nurse analyzed records from 157 patients who received intravenous (IV) chemotherapy from January to March of 2011. We collected data on timepoints from administrative schedules, nurses’ infusion records and faxes to and from the lab and pharmacy, and median times and ranges were calculated. Results: Causes of chemotherapy infusion delays can be investigated through usual patient and operational documentation. Clear and accurate data could be obtained regarding patient arrival times, time seated in infusion chair, time IV access was obtained, times labs were sent/resulted, times chemotherapy drugs were requested/received and times infusions were started. The longest delays generally involved the earlier steps, including from arrival to treatment start (see Table). Surprisingly, a thorough search did not find any literature-based benchmarks for comparison. Conclusions: It is logistically feasible and clinically helpful to conduct a time study of chemotherapy infusion delays by compiling data from timepoints available in infusion records, admin notations and faxed reports. Interestingly, in our study lab and pharmacy turnaround times were not the main cause of delays as initially expected, nor were MD visits. We identified concrete areas for improvement and will use this data to design a plan for administrators, nurses and clinicians to reduce delays to infusion start by 50%. [Table: see text]
Measuring and reporting on system performance across the Canadian cancer control continuum.
Authors: Rahal Rami , Forte Tonia , Klein-Geltink Julie , Lockwood Gina , Sandoval Carolyn , Bryant Heather E. ,   in collaboration with the System Performance Steering Committee and Technical Working Group
Published: February 2017

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Background: The Canadian Partnership Against Cancer’s System Performance initiative is a national, collaborative effort, aimed at reporting pan-Canadian system performance indicators across the cancer control continuum to inform system-wide quality improvements. Methods: This work involved prioritizing indicator development to address quality and cancer continuum dimensions, defining and adopting standardized methodologies, and collecting validated, comparable data from provincial and national sources. Results have been disseminated though a number of general and special topic reports and have been used by policy makers and planners to identify and interpret gaps, variations, and trends to inform quality improvement strategies. An independent evaluation of the impact of this work was conducted in 2012. Results: The Reports, published annually since 2009, include a broad range of performance indicators on prevention, screening, diagnosis and treatment, research, patient experience, survivorship, supportive care, and long-term outcomes. Results show notable differences in performance by province, age and gender, geography (urban/rural), and socio-economic status, including significant variations in clinical practice patterns and concordance with evidence-based surgical, radiation, and systemic therapy guidelines. These are examined along with population risk factors, screening rates, and wait times, to assess relationships with outcome measures, including patient reported outcomes. Special studies, including chart reviews, have been conducted to explain variations, set performance targets, and to help focus quality improvement efforts. The impact evaluation identified substantial uptake of system performance information across the country and a range of specific initiatives informed by the work. Conclusions: This work represents one of the most comprehensive efforts of its kind involving all provincial and national jurisdictions in the sharing and dissemination of standardized performance results, the development of evidence-based national performance targets, and coordinated efforts to use this information to inform system-wide quality improvements in cancer control.
Assessment of the effectiveness of a prechemotherapy teaching session: A Brown University Oncology Group study.
Authors: Connell Nathan , Mega Anthony E. , Castillo Jorge J. , Fenton Mary Anne , Bartley Carolyn , Kaplan Anne , Murphy Benjamin , Iannuccilli Jenna , Stobie Lindsey , Touloumtzis Currie , Schumacher Andrew , Korber Susan , Faricy-Anderson Katherine E. , Bakalarski Pamela , Sikov William M. , Safran Howard , Thomas Anthony George , Isdale Debora , Rosati Kayla
Published: February 2017

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Background: Pre-chemotherapy teaching sessions, often coordinated by nursing personnel, are an opportunity to educate patients on treatment side effects, schedule, medications for toxicities such as nausea, and how to contact the oncology team if adverse events develop. Our institution provides a structured 60-minute nurse-coordinated pre-chemotherapy teaching session. The aims of this study were to evaluate whether pre-chemotherapy teaching sessions improve patient knowledge, preparedness, and anxiety in relation to chemotherapy. Methods: Patients were offered the opportunity to participate in the study after their medical oncologist had reviewed their treatment regimen. After informed consent was obtained, participants were administered a 10-question survey assessing knowledge of treatment adverse effects, treatment schedule, management of complications, accessing their medical team, and patient anxiety. Subjects then participated in a pre-chemotherapy teaching session with an oncology nurse. The survey was readministered when patients returned on day 1, cycle 1 of treatment and on day 1, cycle 2. The questionnaire used a 1 to 4 rating scale (1=no knowledge, 2= minimally informed, 3= reasonably informed, 4= well informed). A pre-defined mean change of 1 on the rating scale was considered to be clinically significant. Paired one-sided t-tests were performed to evaluate the mean change in groups between each of the three surveys. p values <0.05 were considered statistically significant. Results: At the time of analysis, 78 patients had completed a pre-chemotherapy teaching session and all three surveys. After participating in a teaching session, there was an increase in patient’s perceived knowledge of side effects (mean score 2.3 vs. 3.5, p<0.001), knowledge of the treatment schedule (mean score 2.4 vs. 3.5, p<0.001) and medications to prevent nausea (mean score of 1.4 vs. 3.1, p <0.001). There was also a statistically significant reduction in patient anxiety in relation to treatment, p< 0.001. Conclusions: These results show that a nurse-coordinated, pre-chemotherapy teaching session increases patient knowledge and reduces anxiety regarding their upcoming treatment.