bluuebunny/crossref_metadata_2025 huggingface dataset:
Experiences of patients with metastatic breast cancer: A qualitative study.
Authors: Hunter Natasha , English Sarah , Nguyen Vina , Vinayak Shaveta , Linden Hannah M. , Specht Jennifer M. , Gwin William R , Yung Rachel Lynn , Al Achkar Morhaf
Published: October 2023

346

Background: More than 150,000 women live with incurable metastatic breast cancer (MBC) in the U.S. today. Survival for patients with MBC has greatly improved over recent decades, but studies exploring aspects of breast cancer survivorship (quality of life, health outcomes, coping, etc.) disproportionately focus on patients with non-metastatic disease. In an effort to better serve patients with MBC at our large tertiary cancer center, we launched a project to understand the preferences, perceived barriers, and unmet needs of this unique population. Methods: We employed focus groups to qualitatively examine patients living with metastatic breast cancer at all points in their journey with advanced cancer. Two experienced patient advocates provided feedback on the protocol. We invited 37 patients with metastatic breast cancer to participate in focus groups of 2-4 subjects. A researcher moderated these recorded conversations, asking subjects to discuss their memories of being diagnosed with MBC, their everyday experience of living with MBC, and their hopes and fears as they look forward. Written transcripts of the studies are coded using the Atlas.ti qualitative research software with intercoder reliability calculated among three coders. Recurrent themes are identified and described. Results: 32 patients participated in 13 focus groups. The majority of patients were white (88%), with an average age of 59 (median 61). Median time since diagnosis with metastatic disease was 57 months (4.75 years). 84% of patients had estrogen-receptor positive MBC, 28% had HER2-positive MBC, and none had triple negative disease. Initial themes identified include a desire for more information about treatments (new drugs, clinical trials, symptom management), and about planning in the face of uncertainty (especially financial, but also regarding end-of-life challenges, relationship changes). Patients also commonly expressed a need for more connection to fellow patients who can provide guidance and support. Analysis of data and formulation of findings are still ongoing, and will be completed by the end of 2023. Publication is planned for early 2024. Conclusions: Metastatic breast cancer cancer survivors continue to have unmet physical, practical, emotional, and spiritual needs. These needs change throughout a patient’s journey. The knowledge gained from exploring these needs will inform projects and management changes designed to better serve our patients by adapting existing services and creating new ones.
Incorporating routine mental health assessment into survivorship.
Authors: Linendoll Nadine , Murphy-Banks Rachel , Fleisher Emma , Rodday Angie Mae , Parsons Susan K.
Published: October 2023

350

Background: Cancer survivors experience higher rates of mental health (MH) symptoms including anxiety and depression compared to the general population. To address this in our longitudinal survivorship clinic, the Patient-Reported Outcome Measurement Information System (PROMIS) Global health measure is routinely administered and reviewed at point-of-care with psychosocial status incorporated in survivorship care (SC) plans. The uncertainly and social isolation that occurred during the COVID-19 pandemic increased the risk of adverse MH outcomes. This study examines PROMIS Global MH subscale scores and discussions of MH prior to, during and following the pandemic. Methods: Patients who had at least one SC visit and a completed PROMIS-Global measure within 22 months prior to and after the Massachusetts COVID-19 state of emergency (SoE) (March 20, 2020-June 15, 2021) were evaluated. MH subscale scores were calculated using scoring algorithms. A paired t-test was used to compare scores from each time period. Patient characteristics were summarized from the clinic’s database. Clinician notes were analyzed to determine if MH discussions occurred. Results: All 41 patients had been diagnosed during childhood, adolescence, or young adulthood (median age of 12 years, range 0-36), with a median current age of 31 years (range 19-54). 61% were diagnosed with leukemia or lymphoma, 66% were female, 80% were White. Patients had been in the clinic from 0-7 years, with 15% of the initial visits occurring within the pre-SOE period. At time of entry into clinic 73% had a known late effect, 32% had a comorbidity and 29% had a known MH disorder. At some point in their SC, 41% of patients had been encouraged to pursue MH care. During the SoE, those with MH concerns were triaged for outreach; 78% of patients received virtual and/or in-person visits; PROMIS was not collected during virtual visits. Mean PROMIS-Global MH subscale scores were not statistically different by time period: 49.9 mean (9.3SD) pre vs 48.3 mean (10.1SD) post SoE (p=0.10) and did not differ from population norms. MH discussions occurred prior to (54%), during (53%) and following (49%) the SoE. Conclusions: Despite the additional barriers to providing care brought on by the pandemic, the MH tools in place supported quick identification of patients at risk and ongoing MH discussions. Consistent inclusion of MH assessment into SC should be encouraged as part of ongoing quality care, not only in response to the pandemic.
Integrative Oncology Leadership Collaborative (IOLC): Making tools (and a new PRO) for whole person cancer care to be routine and regular.
Authors: McManamon Alyssa Claire , Leyh Jenny , Jonas Wayne
Published: October 2023

355

Background: Nearly two-thirds (62%) of people with cancer want to know about non-tumor directed therapies such as exercise, nutrition counseling, massage, and meditation before starting conventional treatment, but only 33% of oncologists agree with that timeline, according to a 2022 online survey . In 2021-2022, Samueli Integrative Health Programs (now Healing Works Foundation) funded a two-year integrative oncology leadership collaborative (IOLC) with a goal to further whole person cancer care, also called integrative oncology. The IOLC adapted a new patient reported outcome (PRO), and patient education and workflow resources used in whole person primary care for use in cancer care. The Personal Health Inventory (PHI), a person-focused PRO intake tool to elicit “what matters”, was made oncology-specific and deployed at several centers including a VA Medical Center. The IOLC created or adapted additional resources, resulting in a set of open-source tools for use in mainstream oncology practice. Methods: 13 cancer care organizations met monthly in 90-min virtual format from April-Dec 2021. From Jan-Dec 2022 sessions were held twice monthly over 1-hr. Year One allowed group cohesion in discussion-based review of the current state of whole person cancer care and covered foundational topics to include guideline-based supportive care and group medical visits. IOLC members suggested changes to the primary care PHI along with development of new oncology-specific whole person care resources. In Year Two, IOLC members were encouraged to beta test the PHI and related-resources in their practice settings and a Patient Empowerment and Advocacy Collaborative (PAEC) was developed as part of the group to bring in direct patient experience. The oncology-specific PHI was trialed within the Dayton VA Whole Health Oncology clinic from Oct 2021-June 2023. It proved feasible for use at any stage of the cancer care experience in 25 intake encounters. Results: PHI oncology-specific adaptations included replacing “Healthy Days” with FACT-G7 and the Patient Dignity Question (PDQ). Nineteen “pocket guides” were created and posted free online to support whole person cancer care. The patient voice was expanded through the formation of the PAEC in Year Two, and the group led two joint sessions where advocates provided input on IOLC tools’ development. Conclusions: A group of cancer care professionals and patients, working together in a sponsored community of practice, created no-cost resources, including a new PRO called the PHI, to further whole person integrative cancer care. The PHI demonstrated feasibility in a veteran population with cancer and can be offered at any time in the oncology trajectory, from diagnosis to end of life, surviving to thriving. Next steps are to formally test these tools in various oncology practice settings.
The development of an ASCO-compliant, user-friendly electronic template to improve documentation and retrieval of advance care planning conversations: The approach of a community-based oncology practice.
Authors: Elia Giovanni , Sweeney Ann Marie
Published: October 2023

36

Background: Advance Care Planning (ACP) discussions are essential components of patient care. These conversations take place routinely in oncology settings, but their documentation is time consuming and difficult to extract. Methods: Blue Ridge Cancer Care (BRCC), is certified in the ASCO/COA APC4 pilot, planned to improve its documentation of ACP discussions, and took the initiative to create a succinct, user-friendly ACP template that could be documented electronically and easily extracted for data analysis. The ASCO requirements for ACP conversations were reviewed and applied to edit an ACP template created in compliance with the Joint Commission’s requirements for the advanced certification in Palliative Care. The new template was then presented to different groups of providers in the local practice and in the larger network that the practice is part of. Results: BRCC serves about 15,000 active patients a year, with 8, 000 new consults and a total of more than 70,000 visits. The documentation of ACP conversation at the beginning of the project was 76% (n=304). Over a period of 4 months (January-April 2023) the BRCC’s Quality Programs & Process Improvement team created the new ACP template and presented it at the monthly meeting of clinical providers in three different sites. The template was also presented at one of the monthly meetings of the US Oncology Palliative Care Team. Twenty-five feedbacks were collected. There were extensive conversations about the role of different level providers in performing and documenting the conversation, i.e. physicians, Advance Care Practice Providers (APP), social workers and Nurse Navigators. The feedback process resulted in 2 edits and 3 action plans. Interestingly, the compliance increased to 83% (n=622) during this period of time, likely due to increased awareness. The form will be implemented in the coming months and the report of the results will follow. Conclusions: The development of an efficient template to document ACP conversation requires extensive feedback from users, promotes insightful discussions and strengthens providers’ engagement to ensure sustainability.
Geriatric pre-surgical optimization in the NCORP (Alliance).
Authors: Finlayson Emily , Gunn Heather , Barber Anne , Lowenstein Lisa M. , Dohan Daniel Paul , Broering Jeanette M. , Dockter Travis , Tan Angelina D. , Dueck Amylou C. , Bailey Lisa , Chow Selina Lai-ming , Wills Rachel , Jatoi Aminah , Lee Eugene K. , Delacroix Scott Edward , Gills Jessie , Mulligan Charles , Hayseen Therese , Chang George J.
Published: October 2023

370

Background: Mounting evidence suggests tailored preparation targeting geriatric vulnerabilities can improve functional outcomes after major surgery in older adults. Although many surgeons express interest in surgical optimization of older patients, few practices have the time or expertise to deliver geriatric prehabilitation before surgery. This study investigated the effectiveness of OPTI-Surg, a frailty prehabilitation toolkit, for improving surgical outcomes. In this abstract, we report adherence to the OPTI-Surg toolkit in the intervention arm. Methods: Thoracic (T), gastrointestinal (GI), and urologic (GU) oncological surgery practices affiliated with NCI’s Community Oncology Research Program (NCORP) were randomized 1:1:1, stratified by practice type, to usual care (control), OPTI-Surg toolkit, or OPTI-Surg with an implementation coach. The toolkit was implemented at the practice level and consisted of the 12-item Edmonton Frail Scale (EFS) and guided recommendations for interventions including referrals directed at identified vulnerabilities. Eligible patients were ≥70 years old and undergoing curative intent surgery for T, Gl, or GU cancers. Results: From July 2019 to October 2021, 155 patients were enrolled in the OPTI-Surg intervention arm. The EFS was administered to 153 (98.7%) of the enrolled patients, 143 of whom went on to have surgery. Overall, 134 (93.7%) surgical patients had at least one deficit identified on the EFS assessment and 55 (41.0%) of these patients received a recommended referral intended to optimize surgical outcomes. Among the 55 patients who received referrals, 44 (80.0%) followed through on the referral. Individual deficit rates were highest for medication use, general health status, and functional performance, and referrals were most frequently made for deficits in continence and functional independence (Table). Conclusions: In the OPTI-Surg geriatric surgical optimization trial, implementation of the frailty screening with the EFS assessment was successful. Rates of recommended referrals for patients with identified deficits, however, were low. When referred, most patients followed through for targeted prehabilitation. Clinical trial information: NCT03857620 .[Table: see text]
Improving timely melphalan administration completion for recipients of autologous stem cell transplant.
Authors: Williams Michael , Mejaki Brittany , Atienza Sol , Aranda Renee , Graff Justin , Hamm Mark , Medlin Stephen
Published: October 2023

372

Background: Melphalan hydrochloride is a primary agent used in the conditioning regimen for autologous stem cell transplant indications including multiple myeloma and lymphoma. Brand Alkeran labelling indicates the drug concentration must not exceed 0.45 mg/mL and should be given over a minimum 15 minutes but infused in its entirety within 60 minutes from preparation. Caution is provided as data has shown a loss of potency by 1% every 10 minutes after melphalan dilution. Time and concentration constraints often require the dose being divided into two infusion bags with the option to Y-site. These limitations necessitated an optimized process to ensure melphalan completion within the 60-minute timeframe. Methods: Our institution began to formally audit melphalan administration data in November 2018 as part of a new program quality metric. A retrospective evaluation was performed which assessed the total time from melphalan dilution in a normal saline (NS) bag to melphalan infusion completion. The aim was to increase compliance within 60 minutes from 86.2% to 100%. We utilized the Plan-Do-Study-Act (PDSA) cycle method to address opportunities for improvement. PDSA 1 included staff education on the importance of timely administration; same-day audit forms were created to dissect any potential fallouts promptly. This form included documentation of the time from vial reconstitution to delivery to the pharmacist within the patient care unit. Secondary to re-evaluation of package insert verbiage and discussion with the manufacturer, we redefined the audit start time to be melphalan vial reconstitution instead of dilution in the infusion bag. PDSA 2 incorporated specific checkpoints for vial reconstitution (12 minutes) and bag delivery (20 minutes) and changed from concurrent to sequential bag administration. Results: A total 285 melphalan infusions were eligible for analysis (mean 1.91 bags per patient). Baseline data showed 86.2% of infusions completed within the 60-minute timeframe. Average time-to-completion was 50.2 minutes (N=73). PDSA 1 revealed 100% compliance of chemotherapy verification documentation and 97.9% infusion completion with an average time of 42.8 minutes (N=97). PDSA 2 resulted 99.1% compliance (one infusion fallout) and an average completion time of 41.2 minutes (N=115). Overall survival (OS) at 1-year for baseline, PDSA 1, and PDSA 2 groups was 94.7%, 95.9%, and 98.3% respectively ( p=0.66). Conclusions: The outcome measure average and mean time-to-completion improved from 86.2% to 99.1% and 50.2 to 41.2 minutes, respectively, secondary to process measure implementation despite the more stringent redefined vial dilution start time. A lone fallout of 62 minutes in PDSA 2 was triaged and determined to be due to unpredictable line complications. No significant differences in OS were observed. Ultimately, our process was optimized in terms of both compliance and efficiency.
Update of ongoing organizational partnership expanding ASCO Quality Training Program to oncology pharmacists.
Authors: Schwemm Ann , Morris Amy , Mackler Emily R. , Cunningham Gene , Eisinger Michael , Boring Brooke , Rockey Michelle L. , Hale Brittney , Guerrier Vedner , Keng Michael Kenneth
Published: October 2023

377

Background: Pharmacists have a recognized role in optimizing medication management and enhancing patient quality of care. The Hematology/Oncology Pharmacy Association (HOPA) partnered with American Society of Clinical Oncology (ASCO) Quality Training Program (QTP) to provide 1-day HOPA sponsored HOPA-ASCO QTP Workshops for HOPA members to enhance knowledge and skills related to oncology quality improvement (QI). The Workshop has been given annually from 2019-2022. Methods: The 1-day Workshop is a condensed overview of foundational quality improvement principles and methodologies consistent with ASCO’s QTP 6-month curriculum. These Workshops were tailored for HOPA members with examples specific to challenges routinely met by oncology pharmacists and leveraged prior HOPA-workshop participants to moderate breakout sessions. Surveys were formulated to assess knowledge pre- and post-participation as well as actionable efforts participants made given knowledge gained from the workshop. Results: A total of 124 HOPA members from 83 different oncology institutions have participated in the four workshops. With a 83% post-participation survey response rate, measures of knowledge and competency increased after participation. Knowledge increased an average of 3.3 points from 3.99 to 7.31 (1-10 scale) and competence increased an average of 3.1 points from 3.82 to 6.91. Ninety-nine percent of respondents were extremely or very likely to recommend someone to participate in the workshop, and 99% were extremely or very likely to continue using the skills gained in their practice. In the 3-month follow-up survey (41% response rate), 84% of respondents indicated they used the skills gained from the program somewhat, very or extremely often and 80% had or were planning to develop a QI project. Top reasons for participation were: content focused on cancer care, ASCO’s reputation, and the comprehensive training in the science of quality improvement. Seven participants completed the ASCO QTP 6-month course after participating in the Workshop. Conclusions: Consistent positive feedback from participants and aligned organizational priorities in improving the quality of care of cancer patients facilitates this continued organizational collaboration. Future workshops will consider feedback from participants to optimize the learning environment and program outcomes. This Workshop is the only quality improvement training program focused specifically on oncology pharmacists providing excellent training and education to HOPA members.
An evidence-based quality assessment tool for ovarian cancer care delivery.
Authors: Smeltzer Matthew , Black Destin , Blank Stephanie V. , Prescott Lauren S. , Effange Doreen , Senter Leigha , Yemelyanova Anna , Bires Jennifer , Plotkin Elana , Tacka Karen , Bupathi Manojkumar , Thaker Premal H. , Drescher Charles , Boehmer Leigh
Published: October 2023

384

Background: Ovarian cancer is the fifth leading cause of cancer death among women in the United States (US). Optimizing care for patients with ovarian cancer using a systematic, guideline-concordant approach improves outcomes. However, notable gaps persist for most patients with ovarian cancer in the US. Beginning in 2018, the Association of Community Cancer Centers (ACCC) implemented a quality improvement (QI) initiative in community and academic cancer centers to address care gaps. From this work, our expert steering committee published a quality document to inform evidence based ovarian cancer care delivery. Methods: In Phase II of this project we used the quality document to inform a qualitative baseline self-assessment and development of four six-month QI initiatives at cancer centers in the US. Based on this work, we developed a quality assessment tool to aid cancer centers in performing QI needs-assessments using the ovarian cancer quality document. The assessment tool applies evidence-based care recommendations in key areas identified by our multidisciplinary steering committee comprised of experts in ovarian cancer care. Results: The assessment tool includes a series of program-level questions and addresses seven key domains: 1. Care coordination and patient education, 2. Prevention and screening, 3. Diagnosis and initial management, 4. Treatment planning, 5. Disease surveillance, 6. Equity in care, and 7. Quality of life. Each domain has between two and seven key recommendations identified. Sites rate themselves on a four-point scale (1-unsatisfactory, 2-needs improvement, 3-acceptable, 4-good) for each key recommendation. Each key recommendation is given equal weight, and a combined score from 0-100 is calculated for each of the seven domains. The tool includes a macro-enabled spreadsheet that makes necessary calculations and provides an overall score, domain-specific sub-scores, and a list of key recommendations that received low ratings. The tool is to be used by clinical sites to self-assess the quality of ovarian cancer care currently provided at their cancer program and serves as a needs assessment. It is recommended that the site team performs the self-assessment in the context of a facilitated half-day multidisciplinary team meeting. After the self-assessment, sites are encouraged to develop QI initiatives to address the gaps identified using the format and structure we have previously described. Conclusions: The QI Assessment tool provides an important resource for cancer centers to conduct needs assessments in key areas of ovarian cancer care. The needs assessment can be used to inform the implementation of program-specific QI initiatives to elevate quality care delivery.
Safe and reliable inpatient chemotherapy administration: Impact of an ambulatory oncology pharmacist.
Authors: Yousef Mary , Li Melissa , Sengar Anjana , Lim Charles Henry
Published: October 2023

389

Background: Given their extensive adverse effect profiles, any errors involving chemotherapy medications are at high risk for causing patient harm. Analysis of inpatient chemotherapy related incidents at Trillium Health Partners, a Canadian academically-affiliated health system, between May 2019 and April 2021 revealed a number of key drivers for incidents. These included gaps in coordination of care, provider ordering practices and communication between different clinical teams. Methods: A dedicated inpatient oncology pharmacist role, staffed by an ambulatory care oncology pharmacist, was implemented from August 2021 - July 2022. The primary goal was to achieve a 50% reduction in inpatient incidents per 100 doses of chemotherapy by July 2022. Secondary goals included improving interdisciplinary communication and coordination of care between providers especially at transitions in care. Three data elements were collected: number and severity of incidents, types of pharmacist interventions and provider satisfaction. The clinical and organizational impact of the pharmacists interventions were assessed by a multidisciplinary team including an oncologist, a nurse and a pharmacist using the validated CLEO tool. Results: Incidents per 100 doses of administered inpatient chemotherapy decreased by 80%, with a significant shift from actual incidents to reportable circumstances. Chemotherapy coordination, chemotherapy dose adjustments and adapting orders for inpatient use were the most common pharmacist interventions. The interventions had major and moderate clinical impact and a positive organizational impact as assessed by the CLEO tool. Feedback through provider satisfaction surveys showed a 52% increase in satisfaction with the inpatient chemotherapy process. Qualitative feedback indicated the specialized oncology pharmacist role facilitated collaboration and improved communication and coordination of care between inpatient and ambulatory settings. In addition, the implementation of this role facilitated safe provision of inpatient chemotherapy on non-oncology inpatient units. Conclusions: Implementing a dedicated ambulatory oncology pharmacist in an inpatient setting facilitated safe administration of inpatient chemotherapy and improved multidisciplinary coordination, allowing for a seamless patient experience. This demonstrates the value of utilizing the niche outpatient clinical knowledge of oncology pharmacists, applied to inpatient roles to coordinate care in corresponding specialized inpatient populations. This model can be extrapolated to other cancer centers to maximize the utilization of specialized skills and knowledge leading to system-wide impact.[Table: see text]
Community reporting on cost and quality in Washington state: Lessons learned.
Authors: Kreizenbeck Karma L. , Fedorenko Catherine R. , Kestner Shannon , Sun Qin , Li Li , Wright Winona E , Shankaran Veena , Ramsey Scott David
Published: October 2023

39

Background: As part of an ongoing initiative to improve the quality and affordability of cancer care in WA state., the Hutchinson Institute for Cancer Outcomes Research (HICOR) releases open access reports showing cost and quality across several cancer care domains. Here, using the Agency for Healthcare Research and Quality’s (AHRQ) framework for quality reporting as a guide, we report processes, successes, challenges, and lessons learned. Methods: In 2014, HICOR began a transparent, inclusive, multi-stakeholder approach to identify priority metrics of oncology care quality and cost. Using a registry-claims database covering over 70% of cancer patients in WA state, HICOR constructed clinic-level adherence and episode costs for community-prioritized metrics. From 2018 to 2023, five reports were released. The 2018, 2019, and 2021 reports covered 4 domains (appropriate therapy, hospitalizations during chemotherapy, surveillance testing, and end-of-life care). The 2020 report compared quality measures between commercial and Medicaid-enrolled patients. The 2023 report expands the measure list to include biomarker and germline testing and timeliness of care. Between 2020 and 2022, HICOR reported on the impact of COVID-19 on cancer care in WA State. HICOR hosts an annual gathering of oncology practice leaders, payors, and patients to review findings, share best practices, and identify areas for regional research and quality improvement efforts. Results: HICOR’s processes relative to the AHRQ framework are summarized in the table. Conclusions: Community reporting of cancer cost and quality measure requires a flexible framework, balancing parsimony, relevance, and actionability of measures, transparency, and trust in methods, and providing multiple opportunities for feedback. Engaging the community in quality improvement research is critical but challenging due to unpredictability in funding. [Table: see text]
Utilizing a best practice advisory (BPA) to increase pneumocystis jirovecii pneumonia (PJP) prophylaxis prescribing for patients with cancer on high dose corticosteroids.
Authors: Spradlin Megan , Rhoads Sarah , Maloney James , Montague Brian , Wick Abraham , Ngov Li-Kheng , Norskog Sarah Samaya , Bowden Kasey , Graham Laura
Published: October 2023

391

Background: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that can cause severe respiratory infection in immunocompromised patients. Corticosteroid use is a common risk factor for developing PJP in non-human immunodeficiency virus (HIV) patients. Corticosteroids are commonly prescribed medications for cancer patients to help with symptom control from cancer treatment (e.g. nausea, vomiting, and pain) as well as for immunotherapy related adverse events. The risk of developing PJP is significantly increased for patients on prednisone equal to or greater than 20 mg per day x 1 month or equivalent. Steroid related PJP (srPJP) is associated with a 30-50% mortality in non-HIV patients. Methods: We conducted an IRB-approved retrospective chart review of individuals diagnosed with PJP at an academic medical center and 6 partner hospitals between 2016-2022. Patients were excluded if they had a diagnosis of HIV or prior hematopoietic stem cell transplant (HSCT). We then created a best practice advisory (BPA) built into the electronic health record to notify clinicians if a patient is at risk of developing srPJP based on their outpatient corticosteroid prescription. The BPA is triggered system-wide if a clinician signs an outpatient prescription for a prednisone or equivalent steroid dose of 20 mg or more for a duration of at least 3 weeks. The BPA will suggest PJP prophylaxis and link to an order for the clinician to select. Results: There were 96 identified cases of srPJP in non HIV/HSCT patients. None of these patients received antibiotic prophylaxis. Among these cases, 32 patients died from ARDS due to PJP, a mortality of 33.3%. 45% of identified cases were related to steroids prescribed for cancer management, and 68% of these received dexamethasone as the primary steroid. The BPA launched in April 2023 system wide across UC Health. Since launching the BPA in April 2023, it has been triggered 911 times with action taken by selecting an order for PJP prophylaxis 24.5% of the time. Conclusions: Despite the efficacy of prophylaxis, many patients at risk of developing srPJP do not receive prophylaxis. Since launching the BPA, preliminary data shows that the BPA has increased the orders placed for concurrent PJP prophylaxis. Further work must be done to determine if these orders for concurrent PJP prophylaxis were signed and if the BPA can increase PJP prophylaxis prescribing for patients on high dose corticosteroids and ultimately decrease srPJP cases and deaths.
Stomatitis in patients receiving EGFR-targeted therapy for non-small cell lung cancer: A population-based cohort study across the United States.
Authors: Lu Chuan , Ma Kevin Sheng-Kai , Hsieh Tina Y.J. , Chen Sheng-Yin
Published: October 2023

406

Background: As the standard therapy for non-small cell lung cancer (NSCLC) patients expressing epidermal growth factor receptor (EGFR) mutations, EGFR tyrosine kinase inhibitors (EGFR-TKIs) possess advanced potency and survival outcomes in clinical trials. However, little is known for stomatitis as a potential adverse event. This study aimed to assess the risk of stomatitis among patients initiating different EGFR-targeted therapy for NSCLC in a real-world study. Methods: Patients diagnosed with NSCLC and newly initiated EGFR-targeted therapy between 2008 and 2023 were included from 92 healthcare organizations across the U.S., then matched to non-users via propensity scores on age, comorbidities, metastatic status, and previous history of anticancer therapies. The primary outcome, stomatitis, was retrieved by ICD-9 or ICD-10 codes. The risk of stomatitis in association with EGFR-TKI was evaluated using regression models to obtain the odds ratio (OR) with 95% confidence intervals (CIs). Subgroup analyses were conducted to identify the EGFR-TKI agents that were associated with the risk of stomatitis. Results: A total of 22,225 EGFR-TKI initiators were included, including 719 on gefitinib, 16,404 on erlotinib, 1,864 on afatinib, and 5,300 on osimertinib. EGFR-TKIs initiators presented with a significantly increased risk of stomatitis compared to non-users (n= 445 vs 367; OR=1.22; 95% CI=1.058-1.399). Among all EGFR-TKIs, erlotinib (n=316; OR=1.56; 95% CI=1.394-1.739), afatinib (n=81; OR=3.49; 95% CI=2.794-4.365), and osimertinib (n=95; OR=1.40; 95% CI=1.139-1.711) were significantly associated with an increased risk of stomatitis before propensity score matching. The risk of EGFR-TKI-associated stomatitis in those treated with afatinib was validated after propensity score matching (OR=2.23; 95% CI=1.528-3.393). Conclusions: The present study demonstrated a significantly high risk of stomatitis in relation to EGFR-targeted therapy for NSCLC. Multidisciplinary care involving oral medicine specialists and dentists is needed for patients with lung cancer.
Optimizing discharge readiness to reduce health disparities for at-risk children with cancer in the Bronx.
Authors: Offenbacher Rachel , Parsons Susan K. , Weiser Daniel A.
Published: October 2023

407

Background: Transitions in care between hospital and home are overwhelming for patients and families, and often result in medical errors. Children with cancer are at an increased risk of adverse outcomes due to their immunocompromised state. Despite a robust therapeutic armamentarium, unfavorable outcomes secondary to disease- and treatment-related complications remain a challenge, and children with cancer are particularly vulnerable to these outcomes during transitions of care. At our institution, the pediatric oncology team noted that caregivers of patients with new pediatric cancer diagnoses often admitted to confusion regarding infection precautions, central venous catheter care, and medications when returning for follow up appointments. This experience is supported by data showing that caregivers of patients with leukemia feel subjectively unprepared to take care of patients after hospital discharge. The increasing prioritization of outpatient management in healthcare has shifted responsibility for identifying and managing emergencies and complications to caregivers. Methods: We initiated a comprehensive cancer-specific program through the use of quality improvement measures and four plan-do-study-act (PDSA) cycles to ensure consistency of healthcare provider-delivered education and improve caregiver knowledge of homecare instructions in a high-risk patient population. Results: Based on our recent publication, overall retention of key discharge information was greater in the intervention cohort compared to the non-intervention cohort (median total scores: 89 and 63, respectively; p=0.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=0.059), from 0.71 to 0.78 for signs of sepsis (p=0.65), from 0.57 to 1.00 for accurate choice of on-call number (p=0.004), and from 0.71 to 0.94 for antiemetic management (p=0.14). Conclusions: Our study demonstrated that standardized processes with a multi-disciplinary team and task allocation significantly improves ability of caregivers to retain important information after a new cancer diagnosis, with specific improvement in retention of fever guidelines and on-call contact instructions. During our intervention, it became clear that as team members change (residents changing cycle, oncologist going off service, nurses switching), having one point person is absolutely critical in ensuring discharge education continues. We anticipate that a dedicated patient navigator focused on consistent psychosocial screening and health literacy comprehension of key discharge details would lead to a marked improvement in cancer care delivery for children with cancer in the Bronx; specifically, discharge readiness, medication adherence, family satisfaction, and patient safety for children with cancer in the Bronx.
Incidence and treatment of checkpoint inhibitor induced immune related adverse events in the emergency department.
Authors: Duell Colin Harrison , Doherty Patrick , Pamer Hannah , Blazawski Jon
Published: October 2023

438

Background: Immune checkpoint inhibitors (ICPis) are currently indicated for the treatment of various types of cancers. Through inhibition of the cancer cell’s checkpoint mediated T-cell evasion, ICPis allow for sustained T-cell activation and proliferation, resulting in increased cancer cell death. However, due to increased activation and proliferation of cytotoxic T-cells, ICPis have been associated with a wide spectrum of adverse effects, known as immune related adverse effects (irAEs). Although recently updated, the 2018 NCCN and ASCO guidelines state that treatment is based on the location and severity of irAEs. In general, grade 3 toxicities warrant suspension of ICPis and initiation of high-dose corticosteroids. Corticosteroids should then be tapered over the course of at least 4-6 weeks. The diagnosis of an irAE is challenging, toxicities may be misdiagnosed as there is a diverse familiarity with ICPis and their associated irAEs. Subsequently, care may be delayed, and patients may not receive appropriate guideline directed care. Methods: This multi-center chart review included 7 hospitals within a large health system. Our electronic health record was utilized to compile a report of patients who had received ICPIs within 12 months of presentation to an ED within the health system between 9/1/2019 and 9/1/2022. Assessed outcomes included incidence and type of irAE, time between last ICPi dose and presentation to the ED, steroid used for treatment, time to steroid, treatment driver, and the action that deviated from the 2018 ASCO/NCCN guideline directed treatment if applicable. Results: Of the 241 patients receiving an ICPi, 26 (10.8%) experienced an irAE that prompted a visit to an ED within our health system. Guideline directed treatment of irAE(s) was followed 76.9% of the time, with the steroid dose being too low (15.4%) and the steroid taper occurring too quickly (7.7%) being the two reasons for discordant treatment. Treatment started a median of 1.1 after presentation to an ED, with colitis as the most prevalent irAE in 11 patients (42%) presenting. For all patients, there was an average of 20 days between the last ICPi dose and presentation to ED. The main steroid used was methylprednisolone (42%). Conclusions: The 10.8% of patients who experienced an irAE that prompted a visit to an ED within our health system is a lower rate than what has been described in the literature previously, where rates of presentation to an ED due to an irAE ranged from 25-37%. This could be due to previous data coming from before or shortly after the publication of ASCO and NCCN guidelines in 2018, or because our outpatient medical staff has become more aware of irAEs and their appropriate treatment. Limitations include this review was retrospective, no patients had an irAE that was refractory to steroids, and the study period being soon after national guidelines were published.
Intravenous hydration station in the chemotherapy infusion unit: A feasibility pilot study to improve efficiency, capacity, and wait times.
Authors: Feld Emily , Gabriel Danielle , Falbo Rosamaria , Wagner Keri , Kolb-Clark Sandra , Adams Lynn , Haughie Cheryl , OSullivan Maryellen , Reidy Diane , Zhi Iris
Published: October 2023

44

Background: Intravenous hydration (IVH) is frequently administered to oncology patients in outpatient chemotherapy infusion units. High demand for IVH often leads to capacity restraints in the chemotherapy infusion unit, negatively impacting the availability of infusion chairs for cancer-directed therapy, causing long wait times and patient dissatisfaction. This feasibility study aimed to expand the capacity for IVH and chemotherapy at a regional site of an academic medical center, through a dedicated hydration station outside of the conventional infusion chairs. Methods: A mobile space adjacent to a nurses’ station, within the chemotherapy infusion unit, was designated and converted to accommodate two patients simultaneously for IVH. Privacy screens separated this area from the rest of the infusion unit. Patients were directly scheduled into hydration station chairs. One nurse provided patient monitoring within the hydration station. The hydration rate was standardized to 1 liter per hour, subject to change at the discretion of treating physicians. Outcomes collected included the number of patients treated, total hours of hydration, wait times, and patient satisfaction, which was ascertained by a survey administered during February 2023 of the pilot phase. Results: Over a six-month period from December 2022 through May 2023, a total of 784 patients received IVH in the hydration station. This equates to 11 hours of IVH per day, and a cumulative total of 1,590 hours over the course of six months. The average wait time from check-in to starting IVH was 7 minutes. During the same period, the average wait time for chemotherapy was halved to 16 minutes. Among 28 patients who completed the satisfaction survey and had previously received IVH in a conventional infusion chair, 24 (86%) reported that the hydration station was either better or equivalent to their prior hydration experience. 23 (82%) patients reported a shorter or similar wait time compared to the conventional process. Overall, 84% were satisfied with their experience. Importantly, no patient safety issues were reported during the six-month period. Conclusions: IVH can be safely and effectively administered outside the conventional infusion chair, resulting in decreased wait times and high patient satisfaction. This IVH model increased the capacity for cancer-directed therapy in the chemotherapy infusion unit, with no reported safety issues. It is being standardized and implemented across other infusion units across our institution.
Identification of best practices for training in remote symptom monitoring using electronic patient-reported outcomes.
Authors: Dent D'Ambra , Ingram Stacey A. , Patterson Megan Brooke , Hildreth Keyonsis , Young Pierce Jennifer , McGowen Chelsea , Huang Chao-Hui Sylvia , Odom James Nicholas , Basch Ethan , Stover Angela M. , Howell Doris , Smith J.D. , Weiner Bryan J. , Rocque Gabrielle Betty
Published: October 2023

441

Background: As remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) is increasingly implemented as part of standard-of-care, practices must be prepared to train diverse clinical teams. Little is known about best practices for training multidisciplinary teams to engage effectively with ePROs. Methods: This quality improvement initiative evaluated a training approach for RSM using Plan Do Study Act (PDSA) cycles conducted in oncology practices at the University of Alabama at Birmingham (UAB). Multiple team members participated in training sessions over the duration of implementation scale-up. Training logs, field notes on barriers, and iterations to the training approach were updated using Excel spreadsheets. A recorded training session was utilized as an update to the training approach conducted via Zoom. Results: Overall, 145 providers (nurses, social workers, navigators, clinicians) were trained. Initial training (PDSA Cycle I) included a Zoom lecture for lay navigators, nurses, and physicians conducted by the physician lead, which included rationale for RSM, provider roles, and technical instruction. Barriers identified included limited knowledge retention and difficulty using ePRO technology in practice. In PDSA Cycle II, training included advanced practice providers. In addition, a nurse champion was added to the training team. Content was split into a lecture for rationale and roles (Zoom or in person, based on provider preference) and one on one hands on in-clinic training on technical aspects of ePRO delivery led by the training manager and nurse champion. While this approach increased engagement, provider turnover necessitating multiple trainings and low knowledge sustainment were barriers. In PDSA Cycle III, additional staff were trained including the intake team, nurse navigators, and social workers. The lecture was recorded for delivery by the training manager or independent viewing. In addition to the initial training, written standard operating procedures for providers, and check-ins or repeat sessions with participants were added for longitudinal engagement. Conclusions: Four key provider training elements were: (1) training more provider types to support the use of ePROs in clinical care delivery; (2) emphasizing in-person technical training by an individual with relevant experience; (3) using asynchronous materials to support both scalability and ongoing support; and (4) including additional sessions with longitudinal one-on-one provider training.
Innovation in cancer policy & health systems education during hematology-oncology (HO) fellowship training: Single center experience.
Authors: Hussaini S. M. Qasim , Chen Krista Y. , Donehower Ross C. , Marrone Kristen A.
Published: October 2023

446

Background: Cancer care delivery and outcomes in the US are influenced by a complex health system and regulatory environment. To our knowledge, a structured approach to education on these topics during HO training is lacking. We sought to evaluate baseline knowledge and establish a longitudinal curriculum aimed at educating HO trainees on cancer policy. Methods: First year HO trainees at Johns Hopkins were surveyed on their prior education related to affordability, social determinants of health, and oncologic drug development. Based on these results, a longitudinal curriculum with 10 didactic sessions led by invited content experts was developed and implemented into the 2022-23 academic year schedule. Impact of curriculum was evaluated through anonymous surveys at the beginning and end of each teaching session. Results: Pre-curricular intervention survey was completed by 12 fellows (100% response rate; 58% female, 41.6% White; 16.6% IMGs). All had treated patients that were uninsured (100%, n = 12), unable to afford care (100%, n = 12), or lacked stable housing, transportation, food and employment (100%, n = 12). Smaller number had counseled patients on clinical trial enrollment (50%, n = 6) or discussed trial endpoints (33%, n = 4). Systems education prior to fellowship varied by topic: social determinants of health (33%, n = 4), critical appraisal of clinical trials (33%, n = 4), oncologic care in low-resource settings (41.6%, n = 5), high-value care (66%, n = 8), health insurance (91%, n = 11). Pre and post-surveys demonstrated each teaching session was associated with a significant improvement in fellows’ confidence in understanding pre-set lecture objectives (Table; cumulative mean improvement 1.14 from “neutral” pre-intervention, to “agree” or “strongly agree” post-intervention). Conclusions: We demonstrate lack of education on practice-relevant systems topics in HO trainees at time of subspecialty education initiation. Our longitudinal systems education curriculum improved trainee awareness and understanding of these complex topics. Future efforts will build on this scalable curriculum utilizing trainee feedback and departmental buy-in with the goal of training an oncologic workforce better equipped to counsel patients, navigate structural barriers, and appraise evidence.[Table: see text]