bluuebunny/crossref_metadata_2025 huggingface dataset:
The Canadian True NTH Initiative: A multisite intervention to improve the lives of men with prostate cancer.
Authors: Gilbert Julie , George Matthew M. , Huggins Elilzabeth D. , Rowlands Maureen E.
Published: February 2017

118

Background: The True NTH Initiative aims to improve the lives and experiences of men with prostate cancer, as well as those of their partners, family and caregivers. In Canada, Prostate Cancer Canada selected ten teams to develop, implement and evaluate evidence-informed programs focusing on decision support, clinical support, lifestyle management, education, social support, navigation and treatment follow-up. Project teams were encouraged to align their local evaluations with a common evaluation framework and a national evaluation plan was developed. The aim of this abstract is to share methodology and early results of a multi-level evaluation that will address a range of programs designed to improve the lives of men with prostate cancer. True NTH is funded globally by the Movember Foundation, and operates in Canada, USA, UK, Australia, New Zealand, Ireland and Singapore. Methods: Projects (Solutions) selected for the initiative had existing evidence for their efficacy. Project teams were responsible for designing the implementation of their Solution and an appropriate evaluation. Local and national evaluations used a recognized framework (RE-AIM) to systematically study the real world uptake of these interventions, focusing on questions of Reach, Effectiveness, Adoption, Implementation, and Maintenance. Project teams provide quarterly narrative updates and annual written reports with quantitative measures and narrative components. Key informant interviews with project leads will complete the final national evaluation. Results: To date, projects have generated learning across different provincial health systems, academic institutions and community settings. Teams have learned to address challenges of participant recruitment and project endorsement, and have begun to appreciate the benefits of collaboration. Teams have also reflected on the importance of engaging clinicians in the implementation of their Solutions for effective uptake and sustainability. Conclusions: The results of the ongoing multi-level evaluation continue to provide insight into real world implementation of evidence-informed programs and the critical factors that enable their effectiveness.
Development and implementation of competency-based orientation program for advanced practice providers at an academic cancer center.
Authors: Dougherty David W. , Berkhof Julie Ann , Hokula Cheryl , Kozlowski Julie , Galdys Jennifer , Zimmer Nicole
Published: February 2017

119

Background: Increased utilization of Advanced Practice Providers (APPs) has been identified as a means to increase oncology visit capacity and improve productivity. Many APPs have little experience in oncology or are new to the APP role. As a result, there is a need for a comprehensive, competency-based orientation and mentorship program to aid in this transition and ensure effective integration of APPs into the complex oncology environment. Methods: We developed and implemented a comprehensive, competency-based orientation and mentorship program for APPs hired into the Wilmot Cancer Institute. In addition to basic institutional orientation, APPs are assigned primary & secondary preceptors and complete a 12-week oncology-specific orientation that includes specific clinical activities relevant to their role. Oncology educational articles and lectures are provided and APPs meet weekly with preceptors to identify goals, accomplishments and improvement needs. Faculty mentors are assigned for additional oncology-specific and professional development, as well as oversight of chemotherapy ordering. If deficiencies are identified, APPs are provided an Individual Development Plan with milestones necessary for progression. Results: From January 2013 to July 2015, 16 APPs were hired and enrolled into the orientation program. 11 APPs had no prior oncology experience and 10 had no prior experience as an APP. 14 of 16 APPs (87.5%) successfully completed the orientation program. 2 APPs were placed on Individual Development Plans and subsequently did not complete the program. All 14 APPs successfully completing orientation have been retained in their position, leading to 100% retention rate for those completing the program since its inception. Conclusions: This framework for a comprehensive, competency-based orientation and mentorship program for APPs at an academic cancer center has improved our ability to successfully integrate APPs into the cancer care environment. In addition, APPs having difficulty transitioning or who are unable to complete the orientation were efficiently identified, leading to individualized improvement plans required for ongoing employment.
Code status documentation in the electronic medical record for patients with stage IV pancreatic cancer.
Authors: Kronenberg Daniel , Armstrong Janet M , Ma Joseph D. , Revta Carolyn , Roeland Eric
Published: February 2017

125

Background: Improving incidence of code status documentation in the electronic medical record (EMR) has been suggested a better guidance for clinical care compared with a traditional advance directive. We have previously reported that in the absence of a template in the EMR, code status documentation was 36% and inconsistent in patients with advanced cancer. Utilizing a different cohort of patients with metastatic pancreatic cancer, we examined the prevalence of EMR code status documentation. Methods: A retrospective analysis in patients with analytic metastatic pancreatic cancer (2008-2014) was conducted at a single, academic medical center. The primary objective was to determine prevalence of code status documentation in the EMR. Secondary objectives were to determine documentation author, location in the EMR, and time from documentation until death. Patients were identified from a tumor registry and code status documentation was identified in the scanned media, demographics tab, problem list, or using key search terms in the EMR. Results: 169 patients with stage IV pancreatic cancer were identified. Seventy-five percent (n = 127) had a code status documented. Of those with documented code status, 44.9% (n = 57) were full code/full care, 22.0% (n = 28) were DNR/comfort care, 18.9% (n = 24) were DNR/full care, 13.4% (n = 17) were DNR/not specified, and 0.8% (n = 1) was limited DNR/full code. EMR locations for code status documentation included: 71.7% (n = 91) discharge summary, 10.2% (n = 13) inpatient encounter, 10.2% (n = 13) history & physical, 6.3% (n = 8) media tab, 0.8% (n = 1) telephone encounter, and 0.8% (n = 1) admission note. Code status documentation was completed by hospitalists (42.5%, n = 54), medicine residents (21.3%, n = 27), and primary oncologists (4.7%, n = 6). Mean difference for date of code status documentation and death was 67±145 d. Conclusions: Code status documentation was higher for patients with metastatic pancreatic cancer compared to patients with advanced cancer from a previous study at our institution. Research is needed to determine if full code/full care is a default selection or a true representation of a patient’s wishes. Future efforts need to consider a standardized location for code status documentation in the EMR.
Geographic practice patterns in the selection of adjuvant dose dense (DD) chemotherapy among stage 1 breast cancer (BC) patients.
Authors: Hrushesky William J. , Baum Michael , Bennett Charles L. , Knopf Kevin , Huff Dinah Faith Q.
Published: February 2017

126

Background: Oncology Analytics (OA) reviewed drug pre-authorization requests amongst populations with similar demographic features. Small stage I, node-negative, margin-free BC may be treated by observation, hormone therapy or adjuvant chemotherapy. If chemo is used, either standard or DD schedules may be requested. Patient age, HER2 status, and ER expression affect the choice of treatment. Methods: We analyzed data from oncology drug preauthorization requests for BC protocols submitted by providers in FL, GA and TX from October 1, 2013 through September 30, 2015. Pearson chi-square was used to test for association at 95% CL. Risk was bifurcated by consideration of age, putative ER/PR status, and HER2 status. High-risk patients are those with putative ER/PR(-) status and/or Her2(+) status and/or younger than 50 years old. Results: Requests for standard and DD chemotherapy are related to the risk characteristics of the tumor. Oncologists in GA/TX prescribed a greater proportion of adjuvant chemotherapy for stage I BC patients than oncologists in FL (13.13% GA/TX vs 9.97% FL;p = 0.001). About 40% of all stage 1 chemotherapy requests are for dose-dense chemotherapy. Patients with high risk BC have a higher chance of getting dose dense chemotherapy than the low risk subgroup. FL oncologists have a higher likelihood of prescribing dose-dense chemotherapy than GA/TX oncologists (82% FL vs 65% TX p < 001) if the BC risk is high, whereas the opposite is true if the patient is low risk (8% FL vs 17% GA/TX, p = 0002). Conclusions: While these geographical differences may be random, it may also be relevant that OA has worked in Florida for six, Georgia and Texas for two years. This suggests that patients with low risk disease are less likely to get the more toxic DD therapy if OA is in a market for a longer period of time.
Utilizing an A3 project to improve assessment of oral chemotherapy adherence across a five-site enterprise.
Authors: Hepler Marjorie , Dunn Kathleen , Allen Debra Kay , Denny Diane , Markman Maurie
Published: February 2017

136

Background: Cancer Treatment Centers of America, Inc. (CTCA) is a national network of five hospitals that specialize in treating patients fighting complex or advanced-stage cancer. During the fall of 2013, two of the five centers began the pursuit of Quality Oncology Practice Initiative (QOPI) certification. A third site began QOPI certification the spring of 2014 and the remaining two sites followed suit the spring of 2015. This process brought attention to the patient population receiving oral chemotherapy and the importance of careful monitoring of those self-administering their cancer treatment regimens. In July of 2014, before the remaining two sites began the QOPI certification process, an A3 project was introduced to the enterprise, focusing on the assessment of patients’ toxicity and adherence to their oral chemotherapy regimen. The initial data suggested either a lack of documentation or missed opportunity for patient education with baseline performance data at 7.8% across the sites. Methods: Using A3 problem solving and education of care management teams at each site, a policy was composed and processes put in place to engage nursing in conducting follow up via telephone for those patients newly prescribed oral chemotherapy. This also included use of an acronym featured in the EHR to ensure appropriate documentation. Random chart reviews occurred monthly to monitor progress and to provide feedback to the nurses on proper documentation of assessment of adherence and toxicity. The goal was to attain a 60% composite score across the five centers with a score of 62% achieved, signifying a 694% improvement. Results: Once the patient received the oral chemotherapy, the care manager placed weekly calls to assess adherence and toxicities. Composite scores for fiscal year 2015 show a marked increase in the documentation of assessment of adherence in patients receiving oral chemotherapy. Conclusions: Involvement in problem solving and ongoing education of nursing regarding importance of assessment of adherence and toxicities of patients receiving oral chemotherapy significantly improves documentation ensuring high quality safe care. [Table: see text]
Improving screening and prophylaxis of Hepatitis B in immunosuppressed patients.
Authors: Ichiuji Mary Mitsuko , Rabrenovich Violeta , Baer David M. , Schottinger Joanne E.
Published: February 2017

139

Background: Kaiser Permanente (KP) is an integrated health care delivery system that provides clinical services to over 10 million members in nine states and the District of Columbia. Since 2007, KP oncology community collaborates at the national level to systematically improve safety and quality of care. Our improvements are accelerated by rapid adoption of evidence based protocols, leveraging of EMR and integration of quality improvement methods into clinical operations. Methods: KP created a team that included oncologists, hepatologists, rheumatologist, pharmacy, and quality improvement experts to evaluate safety of existing practice. Based on internal findings, we decided to focus on screening and prophylaxis of Hepatitis B in immunosuppressed patients. Hepatitis B primary infection can be self-limited with viral elimination and lasting immunity or can result in a state of chronic infection with persistent viremia. Hepatitis B can be reactivated with, or after withdrawal of, immune suppressive cancer therapy. Reactivation can result in clinical hepatitis, treatment interruptions, and not infrequently death from fulminant hepatitis. The goal of this initiative is to save lives (i.e. track % patients on chemotherapy who were not tested for Hepatitis B surface Antigen and Hepatitis B core Antibody and for those with a positive test, to determine if they received appropriate prophylaxis). Results: The multidisciplinary group initiated interventions: 1) Defined the patient safety measure of a rate of patients on anti-CD 20 therapies who had a Hepatitis B test prior to therapy; 2) Completed a baseline analyses and shared results with KP regions for appropriate actions; 3) Created an alert and incorporated into KP oncology/ rheumatology Beacon module; 4) Developed KP National screening and prophylaxis resource for hepatitis B in immunosuppressed patients; 5) Developed capacity for ongoing monitoring. Conclusions: We determined a need to educate clinicians and to standardize recommendations for screening and prophylaxis of Hepatitis B in patients receiving Anti-CD20 therapy. Changes were instituted in the Beacon protocols to check baseline labs. Ongoing surveillance using a safety net will be developed.
Economic evaluations of patient-navigation programs in cancer care.
Authors: Gerves-Pinquie Chloe , Girault Anne , Sicotte Claude , Minvielle Etienne
Published: February 2017

14

Background: Lack of coordination is challenging our health care systems. This is especially true in cancer care, which is based on multiple treatment alternatives and several types of patient-professional interactions. One recommendation is to develop patient navigation programs based on telemedicine in order to avoid costs that are due to under-coordination among providers and/or between patients and providers. The objective of our study was to identify the evidence on the economic impact of such programs in oncology, and to develop a methodological framework to conduct economic evaluations. Methods: We conducted a literature review, exploring articles indexed in Medline (2005-2015), and focusing on economic evaluations of navigation programs in oncology, with particular attention to the use of telemedicine. Results: Of the 14 studies included, nine were randomized controlled trials. Four studies adopted a societal perspective. Every study computed the direct costs of the program. Six studies included indirect costs in the total costs associated with the program, mainly based on patient productivity loss and travel cost. Only two papers included indirect costs associated with informal care. Two studies showed that patient navigation programs were less costly than standard care. Most of the total cost of patient navigation is attributable to direct medical costs (i.e. patient admission, diagnostic follow-up and medical intervention). Conclusions: More evidence is needed regarding the economic impact of navigation programs in oncology. This review provides some guidance for the design of economic evaluations. If these programs are funded through public resources, a societal perspective should be adopted since it covers the direct, indirect and intangible costs of the program. Furthermore, a key strategy will be to identify the most common situations of under-coordination occurring alongside the usual care pathway and measure avoidable costs. This advocates for an extended use of economic evaluations based on randomized controlled trials.
Effects of admission (adm) source, time, and provider on inpatient (inpt) oncology (onc) outcomes at the Cleveland Clinic Foundation (CCF).
Authors: Christopher Wee , Goodman Lindsey Martin , Rybicki Lisa A. , Montero Alberto J. , Estfan Bassam N. , Best Carolyn , Stevenson James
Published: February 2017

140

Background: The quality of care transfers is known to influence clinical outcomes. In an inpt onc setting at a major tertiary care referral center, patient (pt) adm originate from many different areas and times. A detailed evaluation of onc adm by source of transfer, admission time, and provider type, may identify opportunities to improve inpt clinical outcomes. Methods: We retrospectively reviewed all adm to the inpt solid tumor onc service from July - December 2014 from CCF regional hospital emergency departments (ED), outside hospital (OSH) ED, OSH inpt services, and CCF outpt clinics. Pts were excluded if the adm was planned or if admitted from the CCF Main Campus ED. Data collected included pt and encounter characteristics and provider type (house-staff or nocturnal hospitalist). Clinical outcomes, including activation of the adult medical emergency team (AMET), ICU transfers, length of stay (LOS), and in-hospital mortality were compared using chi-squared test; ECOG PS and LOS with the Kruskal-Wallis tests and Wilcoxon rank sum test. Results: A total of 413 unique pt admissions were reviewed. 213 were included after exclusion criteria were applied. The probability of AMET activation, mortality, and LOS differed by origin of transfer. Pts admitted from CCF regional EDs had the lowest median LOS and no deaths. OSH int transfers demonstrated significantly higher mortality vs other origins of transfer. Pts whose first orders were placed after 5pm had no significant differences in AMET activation, ICU transfers, LOS, or mortality vs daytime adm. There were no differences in adverse outcomes by the type of admitting provider. Conclusions: Onc inpts transferred from an outside healthcare setting were at highest risk for adverse outcomes (AMETs, increased LOS, and mortality) include those originating from OSH inpt services. Process and communication interventions focused on transfers from outside inpt facilities may improve safety and outcomes in this population. [Table: see text]
Safety of using escalated doses of enoxaparin prophylaxis in adults with acute lymphoblastic leukemia receiving asparaginase-based intensification therapy.
Authors: Sibai Hassan Abdulmaoula , Seki Jack Toshimine , Wang Tian , Saini Lalit , Stessman Andrew , Samuel Joseph , Sakurai Naoko , Schuh Andre C. , Yee Karen W. L. , Minden Mark D , Schimmer Aaron David , Gupta Vikas , Shanavas Mohamed , Brandwein Joseph M.
Published: February 2017

141

Background: Venous thromboembolism (VTE) is a known complication in adults receiving asparaginase (ASNase) for acute lymphoblastic leukemia (ALL). We previously reported a 27.3% VTE rate in patients (pts) receiving a modified Dana Farber Cancer Institute (DFCI).We report updated results using two different dosing of enoxaparin as primary VTE prophylaxis. Methods: 62 pts ALL in complete remission, who were treated with a weekly ASNase-based DFCI intensification phase for at least 7 cycles (21 weeks) and received prophylaxis with enoxaparin targeted to 1 mg/kg subcutaneously (SC) daily (escalated dose group), were evaluated . Results were compared to a similar group of 41 patients who had received enoxaparin 40 mg for patients weighing less than 80 kg, and 60 mg for those 80 kg and above (low-dose group), and to a similar group of 99 pts previously treated with the same DFCI protocol without anticoagulation prophylaxis. Results: The actual mean dose of enoxaparin in the low-dose prophylaxis group was 0.62 mg/kg, as compared to 0.88 mg/kg in the escalated dose group. There were no major bleeding complications observed in the prophylaxis groups. The minor bleeding rate in the entire prophylaxis cohort was 4.8% (5/103), and was similar between the low-dose and escalated dosing groups. The VTE entire cohort that received prophylaxis was 20% (21/103). The VTE rates for all groups as shown in the table. Conclusions: Overall use of prophylactic enoxaparin during intensification in adults with ALL receiving ASNase was safe; escalating the enoxaparin dose to 1 mg/kg, did not increase the number of bleeding events. There was a trend toward a lower rate of VTE using dose-escalated enoxaparin, particularly in patients weighing < 80 kg. [Table: see text]
Time stamps used to measure the patient's clinic experience.
Authors: Jensen Terry , Brown Roy , Riegel Gay , Wilfong Lalan S. , Hoverman John Russell
Published: February 2017

150

Background: In 2013, a patient reported satisfaction survey indicated 19% of patients waited 20-40 minutes, 8% 40-60 minutes and 4% over 1 hour. We initiated a project to objectively quantify the components of wait times to investigate opportunities for improvement. Methods: Utilizing existing technology in the practice management system, clinic staff use the Day List feature to capture time stamps as patients move through the clinic. We focused on provider appointments but these visits could also include business office, labs, infusion and diagnostics. It was important to define where the wait(s) occurred. The Time Stamp durations measured are as follows: Arrival to Depart – duration of each appointment; Arrival to site to Exam Start – duration of activity until ready to be seen by the provider, includes rooming, labs and business office activity. Used to compare to the patient satisfaction survey responses; Exam Start to Depart – the provider portion of the office visit, includes patient wait plus exam time. Three reports are generated: Time Stamp Error Report indicating the completeness of data collection; Average Wait Times Report with appointment counts by physician by site and average durations; Provider Wait Times Report with office visit counts, Wait Time Category counts ( < 10 min, 10-20, 20-40, 40-60, and > 1 hour ) and average durations. Results: There was a correlation calculation to the patient satisfaction survey of .779, with long wait times more likely to be underreported by patients. Site and physician data were available for review at site Quality Committees. The data can be used by the site to improve processes, such as lab and infusion room scheduling. Time stamps are used to communicate patient readiness for next steps in the office visit. The time stamps provide objective data to discuss patient complaints with staff. Conclusions: Patient wait times are a valued measure of patient satisfaction and quality. Full utilization of the Day List and supporting technology allows us to objectively monitor and improve this aspect of patient care. Table 1: Sample Provider Report [Table: see text]
Implementing value-based cancer care: A multidisciplinary approach to defining breast cancer outcomes.
Authors: Fayanju Oluwadamilola M. , Mayo Tinisha L. , Spinks Tracy E. , Lee Seohyun , Barcenas Carlos Hernando , Smith Benjamin D. , Giordano Sharon Hermes , Hwang Rosa F. , Ehlers Richard A. , Selber Jesse C. , Walters Ronald Stewart , Tripathy Debu , Hunt Kelly , Buchholz Thomas A. , Feeley Thomas W. , Kuerer Henry Mark
Published: February 2017

16

Background: Value in healthcare (patient-centered outcomes achieved per dollar spent) unifies performance improvement goals with health outcomes of importance to patients. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution. Methods: A review of the breast cancer literature was conducted on treatment options as well as expected outcomes and potential treatment complications. Patient perspective was obtained via focus groups. Multidisciplinary teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration, planned for spring 2016. Results: Outcomes were divided into 3 previously defined tiers (NEJM 2010; 363:2477-2481) that reflect the entire cycle of care (Table).Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria, specifications for reporting, and sources for data including the EHR and validated patient-reported outcome questionnaires (e.g., FACT-B+4) administered via our patient portal. Conclusions: A value-based approach to cancer care with transparently reported patient outcomes not only creates opportunity for performance improvement but also enables benchmarking within and across providers, healthcare systems, and even countries. Our value-based framework for breast cancer is the first of its kind in the United States, with a similar model being pursued internationally as well. [Table: see text]
Leveraging web-based interface systems with institutional databases to improve compliance with survivorship care plans.
Authors: Gilmore Katherine Ramsey , Chapman Patricia , Cleveland David , Lewis-Patterson Paula A. , Palos Guadalupe R. , Rodriguez Maria Alma
Published: February 2017

161

Background: ASCO’s Clinical Oncology Clinical Expert Statement on Cancer Survivorship Planning addressed the importance of using survivorship care plans (SCPs) to improve survivors’ care. Evolving information technology strategies, such as web-based systems, offer real-time reporting tools to track providers’ adherence for completion of SCPs. Our abstract reports on the creation of a web-based system to monitor survivors’ care. Methods: Ongoing audits of SCPs indicated broad variation in compliance rates with SCPs. The institutional benchmark for compliance was set at 90%. Yet, FY 2014 rates ranged from 7-97%, X= 84%. To address low or non-compliance rates, our institution selected a commercially available system as the IT intervention to improve compliance with SCPs. Core metrics identified were arrived appointments, missed appointments, completed SCPs, and transitions to survivorship status. To collect data, we used existing institutional databases with information on medical health, scheduled appointments, and other clinical documentation tools were used to collect data. Descriptive statistics were used to analyze and present data. Results: The current design of the Survivorship Performance Scorecard provided a centralized system for reporting data from 11 survivorship clinics. An exploratory review found 18 Passport templates across the 11 clinics, 188 OrderSets, and 986 scheduling codes were used in planning survivorship clinical services. Procedures for patient transition to survivorship clinics were defined in OrderSets, which were reviewed to identify appropriate fields for inclusion in the report. To ascertain compliance, procedures were developed to link arrived appointments with completed SCPs. Final reports will display all metrics by clinic, provider, and other patient level data. After the system goes live in late 2015, the systems benefits and shortfalls will be analyzed. Conclusions: This evolving tool offers a practice-based method for collecting data elements to monitor compliance with SCPs’ completion standards. Future work will focus on designing an alert system to inform providers when compliance rates are below the 90% compliance benchmark.
Oncologists’ opinions and experiences with electronic release of radiology and pathology results to patients.
Authors: Winget Marcy , Sheikhi Farnoosh , Rosenthal Eben Lloyd , Sharp Christopher , Buyyounouski Mark K. , Asch Steve
Published: February 2017

162

Background: There is an emerging standard to provide patients rapid electronic access to elements of their medical records,; this practice is controversial among practicing oncologists. Previous studies have primarily reported on patient access to physician notes and lab tests in primary care. In oncology, the emotional import and complexity of the results may be greater, particularly for staging imaging and biopsies. We report the opinions and experiences of oncologists after enabling patient access to radiology and pathology results for four months during which time finalized results were released upon physician action or after seven days. Methods: A brief survey was developed in REDCap and sent via email to all practicing oncologists at Stanford Cancer Center from the Medical Director. Six 5-point Likert scale items measured their experience and attitudes toward this practice. Results: 82/129 (64%) oncologists completed the survey. 51% were medical oncologists, 35% surgeons, and 14% radiation oncologists. 90% were aware of the patient access process and 64% said they had not changed their process of reviewing pathology/radiology results. Most (54%) responded that it is somewhat or very beneficial for patients to receive normal radiology/pathology results prior to discussing with a physician but 87% said it was somewhat or very harmful for patients to receive abnormal or confusing results prior to discussing with a physician. The minimum time oncologists reported as required to review and communicate results was 48 hours (35%) and 96% required less than 14 days. 49% said that release of radiology/pathology reports had had a somewhat or very negative impact on communication with their patients, though an almost equal number, 44%, replied that it had not affected the quality of their communication. Conclusions: Almost half of oncologists report sharing digital radiology and pathology records has had a negative impact on their communication with patients, particularly for abnormal results. Similar patient survey data would complement the physician perspective. Efforts are needed to bring better consensus amongst oncologists and patients on how to best communicate such results in a timely fashion.
Cervical screening reminder calls pilot: Utilizing EMRs to improve cancer screening.
Authors: Dhanji Zabin , Randall Aaron
Published: February 2017

163

Background: Cancer screening detects pre-cancerous changes, or cancer at an early stage when there is a better chance of treating it successfully. Research shows that that physician encouragement improves the odds of patients getting screened. Furthermore, systematic reviews demonstrate that efforts to encourage screening can be more effective through telephone reminders when compared to other methods of outreach. Electronic Medical Records (EMRs) are a powerful tool for the coordination, recording, monitoring and reporting of patient care in primary care. In Ontario, 80% of primary care providers (PCPs) have adopted EMRs within their practice. CCO developed the Cervical Screening Reminder Calls (CSRC) pilot to support PCPs in increasing their cervical cancer screening rates. The pilot consisted of two components. First, practice staff were trained to utilize their EMRs to identify eligible patients for cervical screening. Once identified, practice staff invited patients via telephone to get screened. Family Health Team’s (ANFHT) pilot implementation will be presented. Methods: Twelve primary care practices were recruited from across Ontario to participate in the four-month pilot. Each practice was assigned a CCO support person to guide them through the implementation. The practice teams completed the self-directed EMR training. They then generated lists of patients eligible for cervical screening based on CCO’s cancer screening guidelines and telephoned patients to book Pap test appointments. Results: Over the course of the pilot, 1593 (57%) of all eligible patients were reached and 71%, or 798, of them scheduled a Pap test. Overall, participating physicians saw an average 2% increase in their total cervical screening participation rates. Conclusions: From a spread and sustainability perspective, the pilot has provided valuable insights to inform future planning at CCO. The lessons learned have implications for the implementation of a broader range of quality improvement initiatives. Next steps will include the development of an implementation model that is ‘lower touch’ thus allowing for spread to a broader number of practices.
Using information technology to power an integrated, community-based oncology palliative care model.
Authors: Gill Dudley , Hertler Andrew Allan , Matthews Lianne , Carr RaeLynn
Published: February 2017

166

Background: There is a need to improve palliative care program access for patients with cancer. The identification of candidates for palliative care at the point of diagnose can improve care and reduce costs. This pilot program was launched in July 2015 by four stakeholders: Health plan; Regional palliative care provider; Community oncology practice; and Oncology quality management provider. Methods: Objectives are to increase patient satisfaction, reduce unnecessary utilization and costs. Data captured by information technology at the point-of-care are used to: Evaluate Diagnosis, Stage, Treatment Intent, Performance Status, and Line of Therapy criteria to identify patients with recurrent/metastatic disease who would potentially benefit from palliative care; Trigger a palliative care program referral; and Initiate the chemotherapy treatment preauthorization process. Retrospective analysis will evaluate: Patient (Concordance with goals & cultural preferences, Member quality of care at end-of-life, Length of stay on hospice, Death in place of patient’s preference), Hospital (Deaths in acute/facility ICU), and Clinical (Referrals to palliative care and hospice; Use of chemotherapy 2 weeks prior to death). Results: See table below. Conclusions: There is an opportunity to inform physicians and oncology practice mid-level staff about the differences between palliative and hospice care. Community-based supportive care services can prevent avoidable hospital admissions. There have been two instances where having a palliative care nurse visit patients at their homes prevented hospital emergency department admissions. Educating patients about the benefits of palliative care can be challenging. For example, a patient with recurrent/metastatic breast cancer, an ECOG status of 2 and who had received beyond 4th line treatment was not interested in the program. [Table: see text]
Recurrence risk perception and quality of life after treatment of breast cancer.
Authors: Hawley Sarah T. , Janz Nancy K. , Jagsi Reshma , Griffith Kent A. , Friese Christopher Ryan , Kurian Allison W. , Morrow Monica , Wallner Lauren P. , Katz Steven J.
Published: February 2017

175

Background: Many breast cancer patients overestimate their risk of distant recurrence after treatment. We explored risk perception in a large, diverse population of breast cancer patients with favorable prognosis and assessed associations between overestimation and quality of life (QoL). Methods: As part of the iCanCare Study, we surveyed a weighted random sample of newly diagnosed patients with early-stage breast cancer treated in 2013-14, identified through the population-based SEER registries of Los Angeles & Georgia about 3 months after surgical treatment (N = 2632, RR = 70%). Actual 10-year risk of distant recurrence after treatment was determined for women with DCIS (N = 502), and with low risk invasive (LRI: N = 520, Stg 1A, ER+HER2-, Gr 1-2). Women reported perceptions of their risk numerically between 0 – 100%, with values > 10% for DCIS and > 20% for LRI considered substantial overestimates. We assessed which patient and treatment factors were correlated with overestimation and report the bivariable associations between overestimation and the QoL measures of worry, distress, & PROMIS physical and mental health. Results: One third (36%) of DCIS and 25% of women with LRI breast cancer substantially overestimated their risk of distant recurrence. Overestimation of risk was significantly associated with lower education (p = 0.02), and marginally with lower acculturation (p = 0.08). DCIS patients were more likely to overestimate risk of distant recurrence than LRI patients (OR = 2.0, 95% CI: 1.4-2.7). Women who overestimated risk in both groups reported more worry about recurrence; 49% vs. 16% DCIS, p < 0.001 and 54% vs. 24% LRI, p < 0.001. These women more often had higher distress (0-10 scores, mean of 3.5 vs. 2.5 DCIS p < 0.001, and 3.9 vs. 2.2 for LRI, p < 0.0001) and had poor PROMIS physical (21% vs. 14% DCIS, p < 0.001; 34% vs. 16% LRI, p < 0.001) and mental health (13% vs. 11% DCIS, not significant; 21% vs. 7% LRI, p < 0.001) scores. Conclusions: Marked overestimation of risk after treatment was common, particularly among women with very low risk (DCIS). The strong association between risk overestimates and lower QoL suggests the need to address women’s perception of risk of distant recurrence after treatment of breast cancer. Funding: P01CA163233
Primary care physicians' endorsement of the importance of shared decision making in diverse cancer screening contexts.
Authors: Lafata Jennifer Elston , Brown Richard F. , Pignone Michael P. , Ratliff Scott , Shay Laura Aubree
Published: February 2017

179

Background: Despite widespread advocacy, shared decision making (SDM) is not routinely used in office-based cancer screening discussions. We describe primary care physicians’ (PCPs) endorsement of the importance of SDM in different cancer screening contexts. Methods: Between 3/15-5/15 we administered a mailed survey to PCPs randomly selected from the American Medical Association’s Master File. Using 5-point Likert scales, we report PCP’s ratings of the importance of SDM for 11 specific screening scenarios graded by the US Preventive Service Task Force (USPSTF), four specific to not screening elderly patients. Multivariable logistic regression, accounting for repeated observations, was used to estimate the association of physicians’ endorsement of SDM as ‘very important’ with (1) USPSTF grade A [highest endorsement] vs. others, and (2) if scenario pertained to not screening among the elderly. The model controlled for physician age, gender, race, specialty, medical school affiliation, practice size, and PCP’s internal/external motivation for SDM. Results: PCPs were on average 52 years of age, 38% female, and 69% white (N = 288). They were most likely to rate SDM as ‘very important’ for colorectal cancer (CRC) screening in adults aged 50-75 (69%), and least likely for CRC screening in adults aged > 85 (34%). Model results indicated PCPs were significantly (p < 0.01) more likely to endorse SDM as ‘very important’ for A-grade services compared to others, particularly D-grade services (OR = 0.63), and less likely to do so when decision was not to screen among elderly (OR = 0.45). PCPs with more internal motivation for SDM were more likely to endorse its importance (OR = 2.29), but no other physician characteristic was associated with SDM endorsement. Conclusions: The more PCPs internally value SDM, the more likely they are to endorse it as very important regardless of screening scenario. Yet, PCPs’ endorsement varied by USPSTF grade, being particularly low when screening was not recommended, especially when the decision pertained to screening not recommended among elderly patients.
Physician decisions related to maintenance therapy for advanced non-small cell lung cancer (NSCLC) in the United States (US).
Authors: Lane Suzanne , Goring Sarah , Mueller Kerstin , Hess Lisa M. , Oton Ana Belen , Muehlenbein Catherine , Zhu Yajun , Aggarwal Himani , Mohamed Mohamed K. , Levy Benjamin Philip , Winfree Katherine B.
Published: February 2017

182

Background: In 2006, maintenance therapy was added as a treatment guideline for patients with advanced non-squamous (nsq) NSCLC. This study aimed to identify patient- and disease-related factors that impact maintenance therapy decision making. Methods: An online discrete choice survey was administered to physicians currently managing patients with advanced nsq NSCLC in the US. Physicians viewed 12 patient profiles differing in levels of the following attributes: 1st line treatment response (complete, partial, stable, progression), adverse events during 1st line therapy (none, mild, moderate, severe), comorbidities (none, mild renal, severe renal, other), patient motivation/convenience (+/+, +/-, -/+, -/-), patient insurance co-pay rate (0, 5, 10, 20%), and age (45, 58, 68, 80 years). No specific maintenance treatments were stated. For each profile, physicians indicated if they would recommend maintenance therapy. Recommendations were analyzed using a mixed-effects logistic regression model. Odds ratios (ORs) were calculated to estimate the relative odds of a maintenance therapy recommendation for levels of each attribute. Results: The survey was completed by 100 physicians (81% male; mean years of experience: 15.4). The study design was balanced and orthogonal. Maintenance therapy was recommended for 75% of the profiles; 98% of physicians recommended maintenance therapy for at least 1 profile, with 26% recommending it for all profiles. The odds of recommending maintenance therapy were significantly lower when the patient profile included disease progression relative to stable response (OR: 0.17; p<0.01), severe renal impairment relative to no comorbidities (OR: 0.38; p<0.01), or low motivation/convenience relative to high motivation/convenience (OR: 0.25; p<0.01). The odds also decreased with increasing age (OR: 0.97 per year increase in age; p<0.01). Conclusions: Treatment response, age, motivation/convenience, and comorbidities were relevant factors for physicians when recommending maintenance therapy. Physicians report recommending maintenance even in the presence of less desirable patient and disease characteristics indicative of a real world setting.
Patient and clinician perspectives on treatment decision-making for African American men with prostate cancer.
Authors: Bickell Nina A. , Abramson Sarah , Walker Daniel , Sova Lindsey , Lin Jenny J , Fei Kezhen , Franco Rebeca , McAlearney Ann Scheck
Published: February 2017

186

Background: Prostate cancer is the most common cancer for men in the US, yet the burden of this disease falls disproportionately on African Americans (AAs). The disparity’s etiology is complex. Surgery and radiotherapy offer similar survival but historically have different rates of performance with younger and white men more likely to undergo surgery and AAs more likely to experience underuse. This study aims to examine treatment decision-making (TDM) processes for AA men from patient and physician perspectives. Methods: At 1 academic and 1 municipal urban hospital, pathology records and a tumor registry from 2007-2012 were used to identify 359 AA and 282 white men with locally advanced prostate cancer, a Gleason score of 7-10, and receipt of definitive treatment. 15/17 treating physicians of participating patients were interviewed. Underuse overall was 4%, AA had higher rate of underuse compared to whites (6% vs. 1% respectively, p = 0.0002). 14 patients with longer times between diagnosis and treatment were recruited for 4 focus groups & 2 interviews lasting 60-90 minutes eliciting perspectives on themes related to TDM. Transcripts were coded and analyzed using a grounded theory approach. Results: Preliminary analysis of patient interviews suggests that patients primarily base their treatment decisions on physician recommendations. Patients were often unaware of treatment side effects. However, some patients felt this deficit helped them decide to receive treatment, whereas if they had known about possible impotence and incontinence, they would have refused treatment. Physicians recognized that patient concerns about side effects were a critical TDM factor. Physicians attributed prolonged delays between diagnosis and treatment to waiting times for tests of possible tumor spread and medical comorbidities. Conclusions: Understanding decision making and care processes for AA men with local advanced prostate cancer is critical to reducing the treatment and outcome disparities in this population. This study identifies several patient and physician/system factors that contribute to this process. These data can help inform interventions to improve prostate cancer care for AA men.
A prospective assessment of the quality of multidisciplinary tumor boards in Mexico and its relationship with decision making.
Authors: Trejo rosales Raul Rogelio , Soto Perez De Celis Enrique , Baltazar-Avalos Edgar , Chavarri Guerra Yanin
Published: February 2017

188

Background: Multidisciplinary Tumor Boards (MDTB) allow the review of cases and have been associated with improved decision making and outcomes. There is limited information regarding the performance of MDTBs in developing countries. The aim of this study was to assess the quality of MDTBs and its relationship with decision making at an academic hospital in Mexico City. Methods: We used a validated tool (MTB-MODe) to prospectively assess the quality of MDTBs at our institution. MTB-MODe assigns a score of 1-5 to various aspects of case presentations at a MDTB, including the quality of the information presented and the performance of team members, which are then averaged to obtain a mean score. The scores of MTDBs which reached a decision were compared against those who failed to do so using Mann-Whitney U-test. Results: 100 cases presented at MDTBs between April and June 2015 were analyzed. Median patient age was 57 years (19 - 87). The most common diagnoses were hepatic (23%), breast (20%) and prostate cancer (15%). 50% of cases (n = 50) were localized. Mean MTB-MODe score was 3.27 (range 1.75-4.75), and a decision was reached in 83% of cases (n = 83). Cases in which a multidisciplinary decision was reached had a better MTB-MODe score than those without a decision (n = 17) (3.4 vs 2.8, p = 0.01). The ability of the MDTB to reach a decision was associated with the quality of case presentation (4.1 vs 3.2, p = 0.01), the presentation of comorbidities (3.5 vs 2.6, p = 0.006), better leadership of the coordinator (3.5 vs 2.5, p = 0.002) and better participation of team members (4.2 vs 2.9, p < 0.001). The patient’s point of view was discussed in only 8% of cases (n = 8), while psychosocial issues were only considered in 10% of cases (n = 10). Conclusions: We found that the quality of case presentations at MDTBs, and the performance of its members, are associated with the ability to reach multidisciplinary decisions. In contrast with reports from developed nations, we found that the patient’s point of view and psychosocial issues were not only largely ignored, but also irrelevant for decision making. The continuous evaluation and improvement of MDTBs is necessary for successful decision making in order to improve patient outcomes.