bluuebunny/crossref_metadata_2025 huggingface dataset:
Multidisciplinary cancer teams and utilization of resources for metastatic breast cancer (MBC): A landscape analysis.
Authors: Plotkin Elana , Gandee Marianne , Lucas Lorna
Published: October 2019

186

Background: An estimated 250k Americans are currently living with MBC. While breast cancer is a high-profile disease receiving significant public funding, patients with metastatic breast cancer face unique challenges. ACCC seeks to expand the conversation to address gaps between early & metastatic disease and improve the management of MBC in the community setting. Communication challenges that cancer care teams face with MBC patients include: using a tailored and thoughtful approach, balancing hope and realism, patient engagement during conversations, incorporating principles of shared decision making, patient financial concerns, and family/caregiver involvement. Methods: An environmental scan was completed of nationally available resources. A survey on MBC Communication strategies was administered in a variety of oncology provider settings from Dec. 2018-Jan 2019. Results: Patient psychosocial needs were identified as the top challenge for working with MBC patients vs. Stage 1-3. 57% reported difficulty managing patient expectations, 55% reported patient financial concerns. While 66% of cancer programs offer a general breast cancer support group, only 27% offer a Stage 4 group. 59% of respondents rely on casual conversations with patients to assess what they want, only 34% ask patients to define what quality of life would mean for them. 33% document goals in the EMR. Over 150 free resources specific to MBC were categorized from diagnosis through hospice, resulting in a curated online library that clinicians can use with their patients. Conclusions: This patient population should be given specialized care to address their unique diagnosis and improve communications with their care team. The ACCC Resource Library gives both low and highly resourced programs access to more supportive care tailored to metastatic breast cancer.
Comparing clinician- and patient-rated performance status and association with psychosocial status in advanced genitourinary cancer.
Authors: Bergerot Cristiane Decat , Bergerot Paulo Gustavo , Philip Errol James , Hsu Joann , Dizman Nazli , Salgia Meghan , Battle Dena , Vaishampayan Ulka N. , Loscalzo Matthew J. , Dale William , Pal Sumanta K.
Published: October 2019

195

Background: Assessing patient-reported outcomes (PROs) is a critical element of comprehensive cancer care. Performance status (PS) is a widely used clinical measure to assess patients’ general well-being and, in clinical trials, provide insight into patients’ quality of life (QOL). This study compared PS as reported by clinicians and by patients, and explored whether associations between PS, QOL and psychological symptoms differed by patient or provider. Methods: This cross-sectional survey study enrolled patients with metastatic genitourinary cancers at a single institution. Patients completed measures assessing their PS (self-reported version of the Eastern Cooperative Oncology Group, ECOG), QOL (FACT-G) and psychiatric symptoms (PROMIS-Anxiety and Depression). Clinical data, including ECOG PS by physician rating, was extracted from medical records. Multivariate analysis was used to determine the association between PFS, QOL and psychological symptoms. Results: A total of 83 patients were enrolled. Median age was 67 (range, 31-91), 74% were male and 74% were married. Patients were diagnosed with advanced renal cell carcinoma (RCC; 54%), urothelial cancer (UC; 23%), or prostate cancer (PC; 23%) and were predominantly receiving first (39%) or second line (25%) therapy. Physicians were more likely to classify patients as ECOG PS 0 as compared to patients themselves (90% versus 63%, P = 0.01). Worse ECOG PS by patient-report was significantly associated with poorer psychosocial outcomes, including increased anxiety and decreased social well-being (P = 0.001 for each). In contrast, there was no association between physician-reported PS and these outcomes. Conclusions: This is the first study comparing PS as reported by clinicians and patients. Physicians appeared to overestimate ECOG PS when compared to patient self-rating, and this may have a downstream impact on the accuracy of PS for other psychosocial outcomes. This has potential implications for clinical trials in which PS is used for eligibility/stratification. This phenomenon will be examined prospectively in an upcoming SWOG trial in advanced RCC.
Distress screening in cancer survivorship.
Authors: Brockway-Marchello Julia P. , Theroux Haley Hines , Piccolino Sophia Tsesmelis , Yang Qiuchen , Smith Cardinale B.
Published: October 2019

197

Background: Cancer survivors have physical, psychosocial, emotional and financial needs that vary in prevalence and may differ from needs of patients on active cancer treatment. Distress screening is mandated for cancer program accreditation and identifies, addresses and monitors the needs of patients. There is a paucity of data on the clinical application of distress screening among survivors. We used a validated distress screening tool to conduct a needs assessment of cancer survivors in the solid oncology clinic. Methods: The Cancer Support Source Distress Screening tool is an 18-item questionnaire given to patients on their 2nd and every 3 month medical oncology clinic visit to assess depression and distress. We merged patient survey data (patients completing ≥ 2) with the cancer registry to identify cancer survivors from July 2015 to October 2018. We performed bivariate and multivariate analysis evaluating change in depression and distress scores over time. Results: 92 patients were identified. The table indicates changes in depression and distress scores by cancer. Depression scores improved for most cancer types with an improvement in distress scores across all cancers. Emotional/mental health, communication, provider relationship, system of care, body image and social support were associated with significant changes in survivorship concern. We are completing a multivariate analysis controlling for sociodemographic factors to evaluate change in depression and distress scores across the survivorship trajectory. Conclusions: A distress screening survey may be a useful tool in assessing the unmet needs of cancer survivors. Identifying prevalent domains of survivorship issues can highlight areas of greatest perceived need and can guide quality improvement initiatives within a cancer program.

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Determining the influence of patient-perceived curability on advance care planning in patients with cancer.
Authors: Pywell Cameron , Gilbert Aidan , Charles Rachel , Ye Star , Rocque Gabrielle Betty
Published: October 2019

198

Background: Advance Care Planning (ACP) allows patients to express their wishes regarding medical interventions when they are no longer able to make decisions. We hypothesized that among cancer patients treated at the University of Alabama at Birmingham (UAB), those who perceived their disease to be incurable were more likely to have an ACP. Methods: This cross-sectional study utilized data from patient reported outcome (PRO) surveys administered at the UAB outpatient oncology clinic. PRO responses included Eastern Cooperative Oncology Group (ECOG) performance status, perceived curability, and ACP status. Clinical and demographic information abstracted from the electronic health record included sex, stage, disease progression, phase of care (treatment: diagnosis to 1 year; survivorship: 1 year to 6 months before death; end of life: 6 months prior to death), diagnosis date, race, and marital status. The association between perceived curability and ACP was evaluated using likelihood ratios (LR) and 95% confidence intervals (CI) from generalized linear models with a log link and Poisson distribution with robust variance estimates adjusting for sex, race, stage, phase of care, ECOG, and marital status. Results: We analyzed PRO responses from 818 patients with a variety of different cancers. The majority of patients were female (68%), white (74%), were married (61%), had an early stage (0/I/II/III) cancer with no progression (56%), and had an ECOG of 0 or 1 (74%). Gynecologic (30%) and hematologic (28%) were the most common malignancies. The majority of patients were in the treatment (46%) or survivorship (48%) phase of care. Most patients did not have an ACP (59%). The majority of patients believed that their cancer was curable (61%). In adjusted models, there was no difference in ACP status between those believing their cancer was curable versus incurable (LR: 0.97, CI: 0.77-1.23). Conclusions: The absence of difference in ACP with respect to perceived curability suggests that patients’ completion of ACP depends on other factors, which may be more patient-specific rather than disease-specific. Our data reinforce the importance of addressing ACP for all patients.
Experiences of pediatric lymphoma patients undergoing treatment in Malawi across all PROMIS-25 domains.
Authors: Ellis Grace K , Reeve Bryce B , Itimu Salama , Salima Ande , Banda Grace , Manda Agness , Manthalu Olivia , Seguin Ryan , Gopal Satish , Westmoreland Katherine D
Published: October 2019

203

Background: Health-related quality of life (HRQoL) is an important outcome in cancer care and research, but such data from sub-Saharan Africa are scant. We translated and validated the Pediatric Patient-Reported Outcome Measurement Information System (PROMIS)-25 questionnaire for use in Malawi. Methods: We administered the Pediatric PROMIS-25 at baseline, mid-treatment, treatment completion, and follow-up to pediatric lymphoma patients receiving care in Lilongwe. Domain scores were transformed into PROMIS T-scores. Differences in follow-up and baseline values were calculated and compared to published minimally important difference (MID) estimates of 3 points. Results: Eighty-one questionnaires were completed at diagnosis, 41 at mid-treatment, 24 at treatment completion, and 25 at follow-up [Table]. At baseline, 57 (70%) were male, median age was 11 (IQR 9-13), and 50 (62%) reported Pain Intensity ≥8. Mobility, Anxiety, Depressive Symptoms, and Pain Interference improved during treatment, but seemed to worsen at treatment completion. At follow-up, substantial improvements in HRQoL were reported [Table]. Conclusions: Despite poor HRQoL at baseline, improvements in all measured domains exceeded accepted MID thresholds. This suggests treatment led to meaningful improvements in HRQoL, but high mortality in data may reflect a survivor effect. Incorporating serial HRQoL assessments in emerging cancer programs in sub-Saharan Africa should be a regional priority. HRQoL T-scores during care, median (IQR). Lower Mobility and Peer Relationship scores reflect worse functioning; higher symptom scores reflect worse symptom burden.

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Use of remote symptom monitoring with breast cancer survivors using patient reported outcome measures through Epic Mychart.
Authors: Terstriep Shelby A. , Wacker James , Quinlan Charissa , Pochardt Kiara , Basch Ethan M.
Published: October 2019

208

Background: Electronic patient-reported outcome (PRO) monitoring has been found to improve quality of life and overall survival in patients with metastatic cancer patients during active treatment. There has been limited data using PROs to enhance clinical outcomes in cancer survivorship. This pilot study of breast cancer survivors assessed utilization and satisfaction of proactive PRO symptom and adherence monitoring through an EHR patient portal (EPIC MyChart). Methods: Eighty breast cancer survivors who had completed surgery, chemotherapy, and/or radiation and received a survivorship care plan were randomized 1:1 either to usual care or PRO monitoring. The PRO group received questions from the NIH PROMIS toolkit through EPIC MyChart monthly between visits for 6 months. The triage nurse received an EPIC Inbasket alert if the survivor reported moderate to severe symptoms, had not taken their medication(s), or reported they would like to speak to a nurse. Participants in the control group were assessed for sadness, anxiety and satisfaction with provider communication at their usual follow visits. Results: Of 239 surveys sent out, 214 (90%) were completed. Eighty-five (36%) surveys triggered Inbasket alerts to the nurse. The most common nursing response to alerts was calling the patient for counseling/education. Compared to control, the PRO monitoring group exhibited no difference in satisfaction at 3 months, but had significantly higher scores at 6 months for satisfaction with communication (P=0.005) and monitoring (P=0.002). Anxiety scores did not differ between groups. Conclusions: Remote electronic monitoring of symptoms and adherence through the EHR bet was feasible with high completion rates, improved satisfaction, and did not increase anxiety in breast cancer survivors. Follow up work is assessing PRO monitoring to improve efficiency of following cancer survivors, and implementation of survivorship care plans.
Improving patient experience in health care and oncology: A scoping review.
Authors: Grendarova Petra , Yannitsos Demetra Hariklea , Vaska Marcus , Barbera Lisa Catherine
Published: October 2019

209

Background: Patient-reported experience measures (PREMs) gather information directly from patients and capture their perspectives on their health care. Deficiencies identified by PREMs can lead to quality improvement (QI) interventions. The purpose of this review was to identify published and unpublished evidence on initiatives aimed to improve patient experience, to identify their areas of application and their overall impact on patient experience. Methods: We conducted a systematic literature review using MEDLINE (Ovid), EBM Reviews, HealthStar, PsycINFO, PubMed, PubMed Central, CINAHL, MEDLINE (Ebsco), Psychology & Behavioral Sciences, TRIP Database, EMBASE and Web of Science databases and several sources of grey literature. Inclusion criteria required the studies to evaluate an intervention or a systematic change aimed to improve patient experience and measured by a specific PREM. The search was limited to English language reports published between 1998 and 2018. Of the initial 780 articles, 318 were included in abstract reviews. 304 abstracts were excluded leaving 44 records for full text review. Results: 21 records were included in the final analysis (20 journal articles and 1 web report). Publication dates ranged between 2007 and 2018 in the USA, UK, Norway, Denmark, Belgium and Bangladesh. There were 8 QI initiatives, 6 randomized studies, 1 non-randomized trial, 3 mixed methods, 2 repeated cross-sectional studies and 1 national patient experience model. Areas of focus included hospital care, surgery, internal medicine, primary care and oncology. Nine studies had programmatic interventions and 12 had specific interventions. All specific interventions reported positive effects. Outcomes were variable in programmatic interventions, including 5 studies reporting positive effects, 3 neutral and 1 mixed effects. Conclusions: The effect of specific interventions aimed to improve patient experience is positive. There is limited data on the effect of programmatic initiatives and the factors that drive the improvement in patient experience. Such initiatives are needed to understand their impact on patient experience and person-centered care.
Utilizaton of patient reported outcomes measures (PROM) to characterize symptom burden and adherence associated with oral oncolytic therapy.
Authors: Mackler Emily R. , Weis Taylor , Procailo Kelly Marie , Marshall Vincent D. , Farris Karen B.
Published: October 2019

210

Background: The use of patient reported outcome measures (PROMs) to monitor cancer treatment tolerability has been shown to positively impact outcomes. The purpose of this study was to characterize the incidence and severity of side effects, patient self-management confidence, and medication adherence in patients receiving oral oncolytic therapy. Methods: This multicenter, cross-sectional, observational study was conducted across 6 Michigan oncology practices from July 2016-December 2018. Patients were eligible to complete PROMs during the course of their treatment if they were receiving an oral oncolytic medication (excluding endocrine therapy). Results: There were a total of 2252 PROMs completed in 695 patients. Patients were 48% female, a median age of 69 years, and most commonly receiving treatment with capecitabine (18%), palbociclib (10%), and lenalidomide (9%). 54% of PROMs had at least one Edmonton Symptom Assessment Scale (ESAS) symptom rated as moderate or severe. Patients indicated the presence of a most bothersome symptom (MBS) in 35% of PROMs. Most common MBSs were fatigue (26%), pain (16%), constitutional symptoms other than fatigue (15%), and nausea/vomiting (14%). Non-adherence was reported in 20% of PROMs. ESAS symptoms rated as moderate or severe, the presence of a MBS, and lower confidence scores all correlated with medication non-adherence. Conclusions: Patients taking oral oncolytics for their cancer treatment experience a high symptom burden with more than 50% experiencing a moderate to severe symptom. Optimizing symptom management and providing patient education that increases patient confidence in self-management may improve medication adherence and patient outcomes.
Feasibility and design of a cloud-based digital platform in patients with advanced cancer.
Authors: Generalova Olga , Roy Mohana , Hall Evan Thomas , Velazquez Brianna , Shah Sumit , Fardeen Touran , Cunanan Kristen , San Pedro-Salcedo Melanie , Wakelee Heather A. , Neal Joel W. , Padda Sukhmani Kaur , Das Millie , Fan Alice C. , Srinivas Sandy , Fisher George A. , Haraldsdottir Sigurdis , Johnson Tyler Paul , Chu Gilbert , McMillan Alex , Ramchandran Kavitha
Published: October 2019

211

Background: Patient reported outcomes (PROs) allow for systematic and more continuous capture of the patient experience. PROs have been associated with improved symptom management and quality of life in patients with advanced cancer; however how to do this in a real world setting is not thoroughly described. We sought to provide a description of the implementation and feasibility of a digital PRO application in patients with advanced cancer at one academic center. Methods: This is an ongoing randomized trial, comparing digital PRO intervention vs standard of care, in advanced cancer patients from three oncology groups (thoracic, gastrointestinal, genitourinary). Prior to trial initiation, a lead in period to test workflows was conducted, as well as key stakeholder interviews to optimize engagement with the platform. Clinical team members (e.g. nurses, advanced practice providers) were critical to the workflows developed, thus operational leadership buy-in was required. We were unable to integrate our PRO platform with our digital EHR. Regular sponsor meetings addressed technical concerns and patient/provider feedback. Processes were tailored for each disease group to handle varying degrees of symptoms (mild, moderate and severe). Patient and clinician satisfaction and qualitative feedback was collected. We defined feasibility as > 70% questionnaire completion on the platform. Results: There are 64 patients on the intervention arm and 64 on the control arm. Of eligible patients, 93% (128/138) enrolled in the study. During the study period, 447 digital symptom questionnaires were sent by the platform, of which 333 were completed (74%). The majority of clinicians (82%, n = 18) and patients (85%, n = 64) felt neutral or positive when asked if the tool was easy to use. Approximately half of clinicians (45%, n = 10) and patients (46%, n = 36) would probably or definitely recommend the platform. Conclusions: Web-based PRO reporting for patients with advanced cancer is feasible. Clinicians and patients found the platform both acceptable and easy to use. Future directions include integration with our EHR, expansion across disease groups and other centers, and creation of workflows that are integrated into routine clinical practice.
Patient experiences of care in localized prostate cancer.
Authors: Mollica Michelle , Lines Lisa M , McNeel Timothy S. , Negoita Serban , Gaillot Sarah , Elliott Marc , Halpern Michael T. , Smith Ashley Wilder , Siembida Elizabeth , Kent Erin E
Published: October 2019

215

Background: Over 161,000 new prostate cancer patients diagnosed annually, with 75% diagnosed at early stages. Limited evidence exists supporting choice of treatment (including radical prostatectomy, radiation therapy, hormonal therapy, active surveillance or watchful waiting) for localized prostate cancer. Treatments have varying side effects associated with impaired functional status and health-related quality of life. Patient care experiences are important quality indicators, but research examining patient experiences by prostate cancer treatment is limited. The purpose of this study was to examine the association between treatment received (surgery, radiation, or no treatment) and CAHPS ratings of overall care over the prior six months. Methods: This study used data from SEER-CAHPS, which links Surveillance, Epidemiology, and End Results (SEER) data with Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey and Medicare claims data. Medicare Fee-for-Service beneficiaries ≥65 years with a National Comprehensive Cancer Network (NCCN) low- or intermediate-risk prostate cancer diagnosis were assigned to surgery only, radiation only, and no treatment received groups for analysis. The outcome variable was a CAHPS rating of overall care (0 = worst; 10 = best). The analysis adjusted for case mix and other cancer-specific variables. Results: The final cohort included 507 prostate cancer survivors (surgery n = 109 [21%]; radiation n = 197 [39%]; no treatment n = 201 [40%]). Respondents who received radiation rated their overall care higher than those not receiving treatment (adjusted mean 8.9 vs 8.3; p= 0.02). Ratings did not differ significantly between the surgery and no treatment groups. Conclusions: This study represents a first look at patient experiences among localized prostate cancer survivors receiving surgery, radiation, or no treatment. It is not clear whether those who did not receive treatment chose active surveillance or watchful waiting, or whether they did not have access to care, which could have affected results. Future research should explore associations between receipt of treatment and patient care experiences in an adequately powered sample to inform future interventions.
Palliative care impact on symptom burden.
Authors: Dunn Kathleen , Hannaford Morgan , Hartman Scott , Denny, DBA Diane , Holder MD Timothy
Published: October 2019

217

Background: A national network of five hospitals piloted the use of a patient reported outcomes tool as a means for referring patients to the palliative care program. An externally validated assessment tool that captures patients’ perceived symptom burden from baseline and every 21 days was used as means of identifying patients who might benefit from referral if they met the following criteria: six or > symptoms from 27 increasing in severity by two points or > since their last assessment and determined as having any stage cancer with metastatic disease, stage 3 not in remission, or stage 4 and not already enrolled in palliative care. The data generated from the pre and post referral assessments to the palliative care program was then used to measure the impact of the program on symptom burden for this group versus those patients referred to palliative care but electing not to engage. Methods: The patient population, identified as patients who took the assessment during a selected three-month period, was reviewed to identify two groups: those who were referred through the SIT process and subsequently joined the palliative care program, and those who were referred to palliative care but chose not to attend the appointment. Results were then reviewed for both groups for a six-month period, comparing the scores from the patients’ initial assessment and their subsequent assessment. The data from both groups was compared to identify changes in scores by symptom and overall average symptom scores and the cohorts reviewed for similarities and differences (age, gender, cancer type). Results: Out of the 27 symptoms the cohort electing to utilize palliative care had higher pre-referral scores than the comparison group; and their symptoms improved at a rate greater than those not seeking palliative care. The symptoms in which the greatest impact was experienced included: activity, appetite, drowsiness, sense of family, hope, mood, and sexual interest. Conclusions: Interventions from the Palliative Care program had a positive impact on symptom burden in comparison to the group that was referred for services but did not enter the program.
Increasing fertility preservation counseling prior to chemotherapy.
Authors: Schwartz Candice , Seifter Ari , Abraham Ivy , Lopes Caitlin , Woo Emily , Venepalli Neeta K. , Chowdhery Rozina A.
Published: October 2019

225

Background: The 2018 ASCO Guidelines recommend that physicians document discussions about fertility with all female patients < 49 years old at the time of cancer diagnosis. Patients interested in fertility preservation (FP) should be referred to Reproductive Endocrinology and Infertility (REI) prior to chemotherapy. Retrospective review of oncology patients at our academic medical center over 6 months found that 33% of females < 49 years old had FP discussion documented. We aimed to increase FP discussions and help expedite referrals to REI from 33% to 75% within 5 months. Methods: All new chemotherapy orders were reviewed weekly. Female patients between ages 18-49 were identified and charts were abstracted for the following: age, race, diagnosis, stage, type and line of chemotherapy, and FP discussion. If FP was not discussed, the physician was contacted in real time via email to address FP with the patient and document the discussion. Charts were reviewed 2-4 weeks later to determine if FP was documented. To better understand barriers to FP documentation, fellows and attendings were surveyed to target future interventions. Results: From Dec. 2018 to Apr. 2019, 6/27 (22%) patients had documented discussions of FP. Post intervention, this number increased to 17/27 (63%) with one referral to REI. Intent of chemotherapy was curative in 56% of patients, and 67% were receiving their first line of chemotherapy. 2/15 (13%) patients receiving curative treatment and 4/12 (33%) patients receiving palliative chemotherapy had documentation of FP, both of which increased with intervention to 8/15 (53%) and 9/12 (75%), respectively. Conclusions: Our intervention successfully increased FP discussion from 33% to 63%, but we did not meet our goal of 75%. Per our survey results, the most common barriers to FP discussion were time constraints, inexperience discussing FP, and perception of prohibitive cost to the patient. We are designing our next intervention to address provider inexperience with FP discussion. This will include education regarding the financial aspects of REI and discussion of the new Oncofertility law in Illinois (HB2617), which ensures insurance coverage for oncofertility as of Jan 2019.
Patient beliefs and behaviors concerning clinical trials for blood cancers: Outcomes from live-online education.
Authors: Roc Anne , Turell Wendy , Demairo Karen
Published: October 2019

226

Background: Finding a clinical trial can be overwhelming for patients and caregivers, generating more questions than answers. The Leukemia & Lymphoma Society (LLS) and PlatformQ Health produced a live-online education activity for patients and caregivers to elevate knowledge of clinical trials and competency discussing the topic with their healthcare providers (HCPs). Methods: A 1-hour web-based education launched on April 18, 2018 and made available on-demand for 18 months on www.cancercoachlive.com and www.LLS.org . Topics included the role and benefits of clinical trials for blood cancers, when it is a viable option, and LLS resources. The program featured a MD, LLS clinical trial navigator, patient and caregiver as speakers, and patient-friendly graphics, videos, slides, interactive polling, and live Q&A. Knowledge questions were administered at 3 time points (pre-, immediate post-, 2 mos. post). Responses from these questions, live polls and Q&A were analyzed to determine engagement, lessons learned, and continuing gaps. McNemar test compared matched pair responses (pre/post & pre/2 mos.). Effect size was computed using Cohen’s d. Results: As of May 2019, 1,040 learners participated in the education. At 2 mos. follow-up, 63% reported feeling more in control of their health care decisions, 47% stated they were more willing to participate in a clinical trial, 42% reported the education had a positive impact on communication with their HCPs about clinical trials, and 31% stated their health-related behavior had improved (n = 107, 103, 111, 103). 65 qualitative written entries were shared by learners as examples of feeling more “in control” of their health care decisions. Data from 4 knowledge questions all showed improvements over baseline at both posttest points, with an average pre to post effect size of d = 0.349. Conclusions: Education on clinical trials for patients and caregivers affected by blood cancers, including breaking down barriers of misinformation and fear, can lead to changes in understanding of the benefits and trustworthiness of clinical trials. Interactive live-online education can be a strong tool in reaching patients and caregivers who could benefit from clinical trials.
Goals of care discussion and hospice enrollment.
Authors: Gustafson Annika , Sharma Mallika , Wong Tracy , Eaton Keith D.
Published: October 2019

229

Background: When asked, many people wish to die at home. Yet, more than one third of cancer patients with poor prognosis die in hospital. Enrollment in hospice care is associated with reduced receipt of high-intensity care toward the end of life. Hospice is palliative care tailored to patients in the last 6 months of life. The ability to collect, organize, analyze and report documented Goals of Care (GOC) conversation data and the relationship to hospice enrollment is challenging. Seattle Cancer Care Alliance (SCCA) created a process to establish a sample baseline of documented GOC discussions, the healthcare setting in which they took place, and how this relates to hospice enrollment. Methods: We selected a sample of 50 decedent charts. Patients were verified as period of 6 months from date of death, documenting provider type, care setting that documented discussion took place and chart search terms. Results: Our sample consisted of 50 adult solid tumor cancer patients who died between March-May 2018. Using an SCCA created GOC discussion definition adapted from Ariadne Labs Serious Illness Care program, we found that 52% of patients had a GOC discussion in the last 6 months of life and of these, 92% discussed hospice with a provider, 77% received a hospice referral and 62% enrolled in hospice. 48% of our decedent sample did not have a GOC discussion. 46% had a hospice discussion of whom 100% enrolled in hospice. 46% received a hospice referral. 54% of patients did not discuss hospice of whom 30% enrolled in hospice. In looking at which providers talked with patients about hospice and in what care setting, we found that 44% discussed hospice with outpatient medical oncologist, 10% discussed hospice with an outpatient provider, 16% had a discussion while inpatient, and 30% had no hospice discussion at all. Conclusions: The majority of GOC discussions happened in the outpatient setting with medical oncologists. Many patients never had a discussion about hospice with their provider. Patients were most likely to enroll in hospice when it was specifically discussed, regardless of whether a GOC discussion took place.
The impact of interdisciplinary shared medical appointments in newly diagnosed early-stage melanoma patients: The Cleveland Clinic experience.
Authors: Switzer Benjamin , Savage David J , Parikh Rujul , Song Jung Min , Stanek Carolyn , Yurco Ann , Funchain Pauline , Marcus Joel Daniel
Published: October 2019

230

Background: Shared Medical Appointments (SMA) serve as a unique means of improving outcomes and patient satisfaction while reducing clinic wait times and healthcare costs. Early-stage melanoma survivors may benefit from a targeted SMA. This cohort exhibits high rates of psychosocial distress, with up to 30% warranting clinical intervention (Kasparian, 2013). Additionally,numerically more melanoma deaths are related to thin ( < 1mm) melanomas than those with thick ( > 4mm) on presentation (Whitehall et al, 2015). We hypothesized that an SMA targeting early-stage melanoma patients may reducepsychologic fear and stress, as well as improve patients’ melanoma-related knowledge and adherence to their individualized care plans. Methods: The Cleveland Clinic’s Early Stage Melanoma Survivorship SMA interdisciplinary care team focused on crucial survivorship and prevention techniques, in addition to targeting modifiable behaviors for patients to collaboratively explore (format introduced ASCO Quality 2018, abst 69). A retrospective chart review assessed for demographics, participation rates, changes in depression scores, follow-up show-rates, and post-SMA survey results. Results: Of 477 early stage melanoma patients seen during the time of SMA implementation (6/2018-4/2019), only 91 (19.1%) attended oncology follow-up appointments, and 34 (7.1%) participated in an SMA. Participants expressed high rates of satisfaction and improvement in melanoma-related knowledge, whileexhibiting a > 92% show rate in subsequent oncologic and dermatologic medical appointments compared to 74% and 73%, respectively, in the non-SMA group. No significant improvement in depression and anxiety scoring was noted in SMA vs. non-SMA groups. SMA attendance was notably higher in younger (mean age 56 vs 61) and female (56% vs 30%) patient cohorts without appreciable differences in social history, marital status, or socioeconomic region. Conclusions: Survivorship SMAs for early stage melanoma patients appear to exhibit high rates of patient satisfaction, improvement in clinical knowledge, and adherence to routine dermatology and oncology follow-up appointments.
Emergency department surge and overcrowding: An interdisciplinary solution for an institutional issue.
Authors: Gaeta Susan , Edwards Toni , Bourenane Sorayah , Gonzalez Carmen E. , McFarland Karen , Milling Danielle
Published: October 2019

242

Background: Emergency Department (ED) surges at MD Anderson Cancer Center (MDACC) lead to overcrowding, safety risks, privacy concerns, staff burnout, and adverse events associated with delays in care, including death. In 2015, the ED Interdisciplinary Quality & Safety Committee (EDIQSC) at MDACC was developed to review and address safety events. We report on the preliminary results of a quality improvement project with a long-term goal of developing a systematic solution of proactively responding to ED surge and overcrowding (EDSO). Methods: First, EDIQSC reviewed the current literature regarding EDSO. Subsequently an ED Surge and ED Overcrowding Committee (EDSOC) was established to identify solutions to address patient safety risks and improve patient experience in the ED. Results: Literature review showed that NEDOCS (Weiss, SJ et al) was the best scoring tool to calculate ED Overcrowding levels. EDSOC’s weekly meetings facilitated by the Office of Performance Improvement (OPI) explored factors related to EDSO via FMEA a quality improvement tool that proactively evaluate process associated risks. In addition, the following immediate solutions were implemented in the ED: daily status reporting by ED to institutional leaders, a “fast-track” care area implementation, senior executive rounding during ED Surge, electronic medical record (EMR) configuration for high census accommodation, continuous ED Nursing Leadership unit needs assessment, and prioritization of needs based on hospital throughput. Additional interventions in current development include a real-time EMR dashboard accurately reflecting ED capacity, and a NEDOCS guided interdisciplinary operational action plan. Conclusions: ED Surge & Overcrowding is a complex issue with various external and internal contributing factors that cannot be solved with one approach. It is a dynamic, interdisciplinary system that requires vigilant planning, assessment of downstream change effects, stakeholder agility and continuous risk anticipation. EDSOC continues these efforts in an attempt to develop and implement a comprehensive, interdisciplinary tool to direct institutional operations during times of ED Surge & Overcrowding.
Improving pregnancy screening prior to chemo: An institutional approach.
Authors: Rogers Brittany Kayla , Markham Merry Jennifer
Published: October 2019

252

Background: Screening appropriate female patients of childbearing potential for pregnancy prior to cancer therapy is crucial, but who and when to screen is unclear. Prior institutional data revealed low screening rates (35% of eligible women, with medical oncology performing 7% of screening) and less than half within two weeks of treatment. A QI intervention was implemented in the outpatient infusion center by adding screening to the infusion nurses’ (IC RN) pre-chemo checklist. If a patient was deemed eligible for screening, the RN could utilize a standing order for a urine pregnancy test. Following intervention, screening rates for medical oncologists improved but remained low (30.6%). Methods: A second PDSA cycle was initiated by surveying medical oncologists and IC RNs on screening practices and perceived barriers. Results: Survey response rates were 42.8% (9/21) for IC RNs, 53.3% (8/15) for oncologists. 50% of oncologists felt the screening age should be 18-50 vs. 37.5% for 18-45 vs. 12.5% for 18-55. 50% of medical oncologists felt that screening should occur the same day of chemo. Only 12.5% of oncologists reported "always" verifying a negative test prior to chemo, with 37.5% verifying "most", 25% “half", and 25% verifying "some” of the time. 62.5% of oncologists felt menopause should be an exclusion. 100% of IC RNs felt a negative test should be obtained the same day. 87.5% of IC RNs "always" confirm a negative test before chemo. Most IC RNs felt menopause should an exclusion (75%) and this would not increase IC RNs’ workload (87.5%). The barriers for screening are reported below. Conclusions: This survey was useful to identify barriers in our pregnancy screening QI initiative. Clearly defining patients (age 18-50), time frame for screening (same day) and excluding for menopause are manageable changes to decrease nurse workload and increase rates closer to our goal of 80%. Modification of the IC RN checklist will occur based on these results.

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Impact of early release of oral investigational prescriptions on safety and efficiency at a comprehensive cancer center.
Authors: Breaud Alan H. , Szabatura Audrea H , Cedro Laura , Shanedling Anna , Lakhani Hakim , Caparrotta Caryn , Mazeika Teresa , Rompelman Garrett , Gallant Amy , Do Khanh Tu , Bartel Sylvia
Published: October 2019

257

Background: At Dana-Farber Cancer Institute (DFCI), timing of order release to the pharmacy is a contributing factor to safety and processing concerns for oral investigational medications. Day-of release can lead to delayed delivery to the patient, creating a risk of missing timed specific protocol data collection, and rushed critical pharmacy safety checks, an issue raised in a comprehensive proactive systems safety risk assessment. We conducted a pilot project aimed at improving the safety and efficiency of oral investigational medication processing within the pharmacy by releasing prescription orders at least 24 hours in advance of a patient’s appointment. Methods: A team of pharmacists, nurses, process improvement professionals, and a physician designed a pilot project where the prescriber released oral investigational prescriptions, from 9 selected research protocols, at least 24 hours before a patient’s appointment. From 11/2/2018-3/1/2019, we used manual timestamp data to compare prescription processing times for prescriptions released at least 24 hours in advance (“released early”) to prescriptions released less than 24-hours in advance (“not released early”). Qualitative feedback was obtained to assess pilot impact on prescription processing safety. Results: As shown in the table below, prescription processing time on day of patient appointment for prescriptions released early was shorter, on average, compared to those not released early (p < 0.05). Due to orders being released early, pharmacy staff noted feeling less pressure during prescription checks and a better ability to proactively assess inventory and prescription issues. Conclusions: Releasing oral investigational prescriptions early reduced the prescription processing time and increased time available for safety checks. Expanding this workflow change to all investigational medication orders can increase the safety and efficiency of prescription processing at DFCI.

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Implementation and uptake of an interactive virtual online tumor board across NCI-Cancer Centers.
Authors: Kalra Maitri , McCann Kelly Elizabeth , Karuturi Meghan Sri , Alvarez Jean , Parkes Amanda Marie , Wesolowski Robert , Wei Mei , Mougalian Sarah Schellhorn , Durm Greg Andrew , Qin Angel , Trivedi Meghna S. , Armaghani Avan J. , Wilson Frederick Hugh , Iams Wade Thomas , Cecchini Michael , Turk Anita Ahmed , Soliman Hatem Hussein , Tripathy Debu , Housri Samir , Housri Nadine ,   The Mednet NCI Tumor Board Project Collaborators
Published: October 2019

272

Background: Expert knowledge is often shared among academic oncologists at tumor boards (TBs) at National Cancer Institute Designated Cancer Centers (NCI-CCs), but not documented or made accessible to community oncologists. Using an oncologist-only question and answer (Q&A) website, we sought to disseminate expert insights from TBs at NCI-CCs to provide educational benefit to the oncology community. Methods: A process was designed with faculty at 11 NCI-CCs to document and share discussions from TBs focused on areas of clinical complexity and practice variation on theMednet.org, an interactive Q&A website of over 8,700 US oncologists. One faculty member from each TB was selected as a site leader. She or he distilled discussions about patient management from the TB into a question that addressed the clinical situation being discussed. After the question was posted, faculty at the participating NCI-CCs were asked to answer the question on theMednet. Answers were peer reviewed, indexed, stored and disseminated via email newsletters to registered oncologists. Community engagement was measured by Q&A page views, upvotes of Q&A, and poll participation. Results: A total of 15 Breast, Thoracic, and Gastrointestinal programs from 11 NCI-CCs participated. Between 12/2016 and 5/2019, faculty highlighted 146 questions from their TBs. Q&A were viewed 43,291 times by 3,585 oncologists including 2,264 community oncologists. One hundred and eighty-four answers are posted by 56 academic physicians and peer reviewed by 76 academic physicians. One hundred and eighty-five publications were cited. Community oncologists upvoted Q&A 808 times and voted in 45 polls related to the questions 1,667 times. Viewership of NCI-CC Q&A increased by 419% over time. Q&A were repeatedly searched and viewed, with 90% of all TB Q&A viewed every month. Conclusions: Via the online Q&A theMednet platform, NCI-CC providers effectively made expert knowledge easily accessible to community oncologists across the US. Timely access to evidence based recommendations from expert faculty can inform future practice choices in the community.

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Implementation of a post discharge video visit telehealth initiative.
Authors: Burdette Samantha , Handley Nathan , Birchmeier Katlin , Basu Mallick Atrayee , Filicko Joanne , Binder Adam
Published: October 2019

274

Background: Telehealth is increasingly used as a means to influence four domains of healthcare: access, cost, experience, and effectiveness. The medical oncology service at Thomas Jefferson University implemented a post-discharge video visit program for all patients discharged from the Advanced Practice Provider (APP) service following scheduled inpatient chemotherapy. Data were collected to assess clinical interventions that occurred. Barriers to participation in the visits were also assessed. Methods: All patients on the APP service were screened for eligibility for a post discharge video visit. Patients who were eligible (requirements: reliable internet connection, access to a smart device, active patient portal account, English language speaker) had video visits scheduled prior to discharge. Data regarding the visits (including patient demographics, eligibility, patient interest, and interventions performed) were recorded. Results: One hundred forty nine admissions were included in the analysis. Sixty (40.27%) resulted in the scheduling of a post discharge video visit; 37 (61.67%) of these visits were completed. Medication reconciliation/education occurred in 22 encounters (59.46%); symptom management occurred in 17 encounters (45.95%).The most common reason for not completing a visit was the patient not answering the video visit call (17 encounters (73.91%)). Of the 89 encounters in which patients were ineligible or declined, technological barriers were the most common reason for not participating (29.21%), followed by disinterest (17.10%) and non-English speaking (16.85%). Conclusions: While significant barriers to implementation of post-discharge video visits exist, when visits did occur, frequent interventions occurred. Further research to understand and alleviate barriers to telehealth implementation are merited. Care must be taken to avoid creating disparities among patient populations.