bluuebunny/crossref_metadata_2025 huggingface dataset:
Storage, disposal, and utilization of opioids among cancer outpatients.
Authors: Reddy Akhila Sunkepally , De La Cruz Maxine Grace Jaucian , Rodriguez Eden Mae , Thames Jessica , Wu Jimin , Chisholm Gary B. , Liu Diane , Frisbee-Hume Susan , Cantu Hilda , Marin Alejandra , Gayle Vicki , Shinn Nancy , Xu Angela , Williams Janet L. , Yennurajalingam Sriram , Hui David , Bruera Eduardo
Published: February 2017

222

Background: Prescription opioid abuse is an epidemic in the US. Of the abusers, 75% obtain the opioid from a friend or relative, which may be related to improper opioid storage and disposal practices. Our aim was to determine patients’ practices of opioid use, storage, and disposal. Methods: We surveyed 300 cancer outpatients presenting to our Supportive Care Center who were receiving opioids for at least 1 month and collected information regarding opioid use, storage, and disposal along with patient characteristics and scores on Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire for alcoholism. Sharing or losing their opioids was defined as an unsafe use. Results: The median age of the patients was 57 years; 53% were female, 72% were white, and 63% were married. Most (89%) had advanced cancer, and lung cancer was the most common (22%). CAGE was positive in 19%, 9% had history of illicit drug use, and 36% lived with adult/young adult children. Of the 300 respondents, 19% stored opioids in the open, 69% kept opioids hidden but unlocked, and 9% locked their opioids. Patients with history of CAGE positivity (P=.007), illicit drug use (.0002), smoking (P=.03), and those living with adult children (P=.004) were more likely to keep their opioids locked. 66% were unaware of proper opioid disposal methods. 46% had unused opioids at home. 53% did not routinely dispose opioids, of whom 44% saved them for future use. 26% indulged in unsafe use by sharing (9%) or losing (17%) their opioids, and 44% informed their family and friends that they were on pain medications. 39% were unaware that their opioid could be fatal when taken by others. Compared with married patients, those who were never married [OR=2.92; 95% CI 1.48-5.77], separated [OR=11.38; 1.52-112.5], or divorced [OR=1.27; 0.55-2.91] had higher odds of unsafe use (P=.006). CAGE positivity (40% vs. 21%, P=.003) and illicit drug use (42% vs. 23%, P=.031) were also significant predictors of unsafe use. Conclusions: An alarming proportion of patients improperly and unsafely use, store, and dispose of opioids. Patient education by physicians/pharmacists and creation of more drug take back programs may reduce availability of prescription opioids for potential abuse. More research is needed in this area.
The frequency of falls in patients with advanced cancer followed in an outpatient palliative care center.
Authors: De la Cruz Maxine , Didwaniya Neha , Tanco Kimberson , Shin SeongHoon , Reddy Akhila Sunkepally , San Miguel Arregui Maria Teresa , Moreno Herlinda , Bruera Eduardo , Chisholm Gary B. , Williams Janet L.
Published: February 2017

225

Background: Falls are a concern in patients who are frail, have advance age or severe underlying medical condition as a significant cause of morbidity and reduced quality of life. It has been reported to occur in up to 50% of palliative care patients in different settings. Our aim was to determine the frequency of falls and identify its predictors and correlates in patients with advanced cancer. Methods: We reviewed 1,984 consecutive patients with advanced cancer seen in the outpatient supportive care center and determined the frequency of patient reported falls within the last month prior to the visit. Baseline patient characteristics, symptom severity scores in the Edmonton Symptom Assessment Scale (ESAS), medication use, functional status, and use of assistive devices were used to identify factors that are predictive of falls using backwards stepwise logistic regression. Results: 1,041 (52%) were female, 1,377 (69%) were non-Hispanic-white, 343 (17%) had peripheral neuropathy, 237 (12%) were on psychotropic medications, and 1,140 (58%) were on opioids. There were 211 (11%) patient reported falls. Presence of brain metastasis, use of assistive device, ECOG, ESAS depression, and weight prior to visit were significantly associated with patient reported falls in the multivariate model. Conclusions: One tenth of patients seen in the outpatient supportive care clinic reported falls. Our findings showing that falls to be associated with brain metastasis, assistive device, functional status, ESAS depression and weight are useful in stratifying high risk patients. They also show that certain medications deemed as risk factors in other populations were not associated with falls. [Table: see text]
Retrospective evaluation on safety concerns of adjuvant therapy for elderly breast cancer patients in a clinical setting.
Authors: Illarramendi Jose Juan , Illarramendi Jorge , De La Cruz Susana , Lainez Nuria , Salgado Esteban , Vera Ruth
Published: February 2017

232

Background: Safety concerns have an important role for the decision making of systemic adjuvant therapy in elderly frail breast cancer patients. These patients are not common in controlled clinical trials. Methods: Retrospective observational assessment of major events in a subgroup of elderly (>70 years) breast cancer patients who received adjuvant systemic therapy in a single center (2001-2011). Events were especially evaluated in case of a potential relation to antiestrogen therapy and chemotherapy. Results: 176 patients have been evaluated. Median age: 77.5 years (70-94). Median follow-up: 7.3 years (1-12,5). Most patients received hormone therapy with aromatase inhibitors (70 anastrozol, 43 letrozol, 2 exemestane) ot tamoxifen (41 p.). Some patients received adjuvant chemotherapy (41 p.) and trastuzumab (2 p.). Events found in this population included as follows: fractures (19 hip and/or pelvic, 19 arm, 5 leg, 7 vertebral), severe cognitive impairment (27), cardiac failure (23), ocular surgery for cataracts (15), joint and tendon surgery (10), cerebrovascular accidents (9), polymyalgia (4), second neoplasms (1 leukemia, 1 fallopian tube, 2 colon, 1 vulva, 1 uterus, 1 gastric, 1 bladder, 1 maxillary, 1 muultiple myeloma, 1 myelodysplastic syndrome), symptomatic arrythmia (11), cardiac ischemia (4), thromboembolic events (15), neutropenic fever (4) repeated urinary tract infections (9). Conclusions: Events with potential safety concerns are not uncommon in elderly breast cancer patients receiving adjuvant therapy and must be addressed in the treatment plans of these patients.
Informal decision support networks and treatment decisions for breast cancer.
Authors: Hawley Sarah T. , Janz Nancy K. , Juhasz Rose , Katz Steven J.
Published: February 2017

24

Background: Although nearly 80% of breast cancer patients have someone with them during surgical consultations, there is little research that examines the extent, nature, or impact of informal decision support persons (DSPs) such as partner/spouse, other family members, or friends on breast cancer treatment decision making. Methods: Two data sources were used: 1) A population based sample of patients recently diagnosed in 2006/7 in the Detroit and Los Angeles SEER catchment areas completed a survey 9 months (N=1837, 72% response rate); and 2) A pilot survey study of a convenience sample of 150 breast cancer patients at three clinical sites surveyed within 18 months that examined more details on the extent and nature of informal decision support networks, including: a) quantity and type of DSPs involved in their treatments, b) number of appointments attended by DSPs, and c) patient-reported satisfaction with DSP’s involvement in treatment decision making. Results: Both a spouse/partner and another family member were very important in treatment decision-making for 33% of patients; a spouse/partner alone was very important for 19%; a family member alone was very important for 13%. A spouse/partner or friends were not important in treatment decision making for 24% of patients. Only 19% of patients reported that a friend was very important in treatment decision making. Friends were much more frequently endorsed among patients with family involvement (45%) vs those without family involvement (5%). Latina patients significantly more often reported that the opinion of a family member was very important vs. other race/ethnic groups (71% vs. 39%, p<0.001). Patients in the pilot study reported an average of 2.67 DSPs were involved in locoregional decision making (SD = 2.57 ) vs. an average of 0.8 (SD=1.03) for involvement in systemic treatment decision making. Conclusions: Many breast cancer patients rely on some informal decision support, but there is a very wide variation in the extent and nature of this support. Further work is needed to understand how to best incorporate DSPs into the treatment decision process. Additional findings will be presented to further describe the impact of informal treatment decision support for women with breast cancer.
Systematic identification of metastatic population subsets for advance care planning (ACP) discussions: A scalable approach using electronic health record (EHR) technology.
Authors: Taniguchi Cynthia , Olson Kevin Donald , Harrison Deb , Hoverman J. Russell , Arlen Aimee Ginsburg , Mikan Sabrina Q. , Ash-Lee Susan
Published: February 2017

243

Background: Comprehensive cancer care embraces the concept of having timely discussions with patients about end of life care preferences regarding treatment interventions. Physicians and healthcare teams are frequently challenged with identifying patients who are clinically appropriate for these discussions and subsequent management of ACP work within the context of clinic resource capacity. A data extraction process is needed to systematically identify cancer population subsets for ACP based on clinical data elements maintained within an EHR database. Methods: Seven cancer center sites of service participated in a 90-day pilot study for delivering ACP services to discrete patient populations who it was believed would most benefit from ACP. Electronic methodology was developed and tested through the pilot process to systematically identify those patients having documented evidence of designated clinical criteria, including metastatic disease status. Metastatic status was determined using five clinical data elements. EHR technology enabled further targeting by cancer diagnoses and allowed this program to be scalable to individual practice capacity. Additional filtering capability was incorporated to exclude non-applicable patient records. Results: On a weekly basis, each pilot site received a report of eligible patients based on clinical criteria and practice-specific diagnoses. During the 90-day pilot period, sites collectively identified an average of 871 patients per week who met clinically-based selection criteria. Once a patient was identified, physicians were able to determine if the patient was appropriate for ACP introduction. The systematic patient identification process allowed ACP to be easily integrated into mainstream practice workflow. Conclusions: EHR technology is invaluable for strategically identifying cancer patient population subsets for clinically appropriate delivery of ACP services. Automated notification of eligible patients and the ability to filter the population enabled practices to engage the ACP process wholly within the scope of comprehensive cancer care delivery.
The Ontario oncology electronic medical record (EMR): The integration of end user and provincial needs.
Authors: Kukreti Vishal , Lankshear Sara , Manzon Arthur G. , Wolf Nancy , Habib Shafiq , Hertz Sherrie , Melamed Saul , Yardley Tim , Sarsfield Lisa
Published: February 2017

248

Background: The use of ambulatory electronic medical record (EMR) systems within oncology provides an opportunity for aligning provincial, local and end-user patient-centred quality indicators in the design, delivery and evaluation of clinical care and resource utilization. The aim of this provincial initiative is to define the “meaningful use” for the Oncology EMR by identifying the essential data elements and functional requirements required to facilitate integrated care, information standards (both local and provincial), and system integration needs. This paper presents the results of a provincial field study designed to determine end-user needs for information and quality metrics. Methods: Data collection included two separate onsite focus groups at each of the 13 regional cancer programs, with a focus on Clinical and Operational requirements. A total of 141 participants, representing physicians, interprofessional clinical team members, administrators and health information specialists were involved. An additional online survey was used for optimal engagement, with a total of 194 respondents, primarily nurses and physicians. Inclusion and exclusion criteria were developed to assist in coding and distillation of concepts generated. Results: A total of 1,598 ideas were generated (Clinical = 997, Operational = 601). Multiple rounds of content analysis were used to eliminate duplicates, identify common themes and distill the wealth of information down to the “vital few” discrete information requirements that should be included in the oncology EMR. At this time, 63 clinical and 55 operational concepts have been identified to support clinical care as well as operational planning and system evaluation. The online survey has helped define the data required for a Provincial Oncology Patient Profile within the EMR. Conclusions: The study employed significant consultation to merge end user and existing provincial quality measurement needs in order to define the Ontario Oncology EMR. A full spectrum of quality indicators identified through these processes will inform the future provincial priorities for information standards and quality monitoring that will be facilitated by a standardized EMR.
Implementation of EMR and effects on health care delivery.
Authors: Viana Nicacio Leonardo , Turner Nat , Weinberg Zach , Dulko Dorothy , Calkins Geoffrey , Shklarski Gil
Published: February 2017

250

Background: Electronic health records have potential to enhance health care safety and quality by enabling effective communication, Clinical Decision Support technology, and generation of structured data for analysis. Despite the fact that EHRs have been shown to improve health care processes, the rapid growth of technology used to support medical care has resulted in the creation of enormous volumes of data used to assess and manage healthcare delivery. Valuable data is often siloed in multiple IT systems or captured in free-text clinical notes and non-searchable documents (unstructured data) making it impossible to quickly develop and act on real-time longitudinal data. Methods: Flatiron (FI) operates a "big data" software platform that aggregates, cleans and structures deep clinical oncology data thus facilitating understanding of operational, clinical and financial analytics related to cancer care. The platform proposes to solve these fundamental data challenges, enabling a range of real-time quality measures. It is best understood as three related components: the first is the technical integration between FI and providers' IT and data systems. That integration serves as the plumbing through which data flows securely from the provider to FI. The second is FI’s structured database, which transforms raw clinical, operational, and billing data into clean, structured, longitudinal, real-time patient data. The third is the FI user interface portal, which is a web-based analytics tool that facilitates access to the continually updated structured database. Results: Over 10 institutions have partnered with FI to deploy the platform. The full integration of an institution can be achieved in 12 to 16 weeks with daily updates to the analytics after the initial phase. Over 15,000 patients are expected to be fully integrated in the next 3-6 months. Initial QOPI and other quality measures have been included and customizable dashboards linking charge databases with clinical outcomes have been created. Dashboards with quality metrics will be presented in the conference. Conclusions: Implementation of EMRs alone does not improve healthcare delivery. Data on colorectal cancer patients will be presented at the meeting.
How effective is telephonic case management of patients with cancer?
Authors: Wu Charlotte , Bannister Wade M. , Rosen Michael W. , Schumacker Pam , Rossof Arthur H.
Published: February 2017

254

Background: Case management offers the opportunity to improve quality of cancer care but the financial impact is largely unknown. Optum’s Cancer Support Program (CSP) provides patients and their caregivers with telephonic case management services which are focused on reducing emergency department visits and hospitalizations, and helping patients comply with treatments and more effectively manage symptoms related to their disease or to its treatment. This study evaluates the effectiveness of CSP primarily from financial perspectives. Methods: The study used a case control approach to compare participants and non-participants of the Optum CSP program. The propensity score method was applied to adjust for baseline differences between the two groups. The study population consisted of cancer patients (N=8,833) enrolled in commercial health plans through self-insured employers. The patients were referred to CSP between July 2009 and June 2011. Analyses were conducted for survivors and decedents separately to account for mortality bias. Outcomes of cost and hospice days were estimated with generalized linear models. Results: For program participants who were under active treatment and survived at least 6 months after referral, cancer-related medical cost per patient per month during the six months of follow up was reduced by 9.8% (95% confidence interval [3.7%, 15.6%], p-value 0.002), and almost 60% of the cost savings were from inpatient admissions. The decedent’s cost during the last 3 months of the life was reduced by 19.9% (95% confidence interval [2.8%, 34.1%], p-value 0.025), and more than 80% of the cost savings were from inpatient admissions. The average hospice days of all deceased CSP participants increased by 42.3%, (95% confidence interval [13.9%, 77.8%], p-value 0.002). Conclusions: We conclude the Optum CSP program is effective in reducing medical cost among both cancer survivors under active treatment and those who did not survive, while promoting hospice utilization during end-of-life.
A rapid method to estimate the value of genetic analysis of excised cancers: A comparison in the phase I setting.
Authors: Conter Henry Jacob , Kurzrock Razelle , Gopalakrishnan Vancheswaran , Zwelling Leonard A.
Published: February 2017

264

Background: There is great interest in delivering personalized phase I clinical trials for patients. The value of this strategy will be determined by the increased benefit of the testing against the testing’s associated increased costs. We developed and employed a rapid method for determining this value in a cohort of metastatic melanoma patients who participated in phase I clinical trials at M.D. Anderson Cancer Center. Methods: The clinical parameter of benefit used was time to treatment failure (TTF) and the charges were those accrued by patients during their participation on the trial. Charge data were extracted from the MD Anderson business database. Clinical and charge data were employed in a simulation to compare two strategies: testing all patients' tumor for genetic aberrations or not. Results: In the subcohort of patients (N = 103) that were reviewed for this analysis, patients who underwent molecular testing experienced an increase in TTF of 2 months (4.2 versus 2, p=0.1) compared to those not tested, but this was not the primary concern of this study. Rather, the charges and clinical data allowed for a calculation of the value of the testing. The incremental cost-effectiveness ratio (ICER) of genetic sequencing was $49,103 per failure-free month. Ninety-four percent of the this incremental cost was due to the cost of staying on the phase I trial, with only 6% due to the cost of the genetic testing. If the cost of the genetic test was zero, the incremental ICER would still over $46,000 per failure-free month. Probabilistic sensitivity analysis demonstrated that the untested strategy was predicted to be the most cost-effective strategy with a willingness-to-pay (WTP) under $52,000 per failure-free month. The sequencing of tumors becomes 85% likely to be the most acceptable strategy by a WTP threshold of $360,000 per failure free month. Conclusions: These data suggest that making molecular testing cost effective requires reducing the costs of clinical research. This methodology is a way to make a determination of value, as well as attributable costs, which we believe will have to be made for each individual clinical setting.
Readmissions following allogeneic hematopoietic stem cell transplantation.
Authors: Spring Laura , Li Shuli , Soiffer Robert , Alyea Edwin , Glotzbecker Brett
Published: February 2017

265

Background: Recent initiatives to improve patient safety and reduce healthcare costs have focused on preventing hospital readmissions. Historically, patients treated with allogeneic hematopoietic stem cell transplantation (HSCT) have high rates of hospital readmission. The purpose of this study was to identify the incidence and reasons for readmissions in allogeneic HSCT patients as well as associated risk factors for readmission. Methods: A retrospective review of patients receiving a myeloablative or reduced intensity conditioning (RIC) HSCT at Dana Farber/Brigham and Women’s Hospital between January 1, 2005 and December 31, 2010 was performed. Reasons for readmission, along with sociodemographic, disease, and transplant related variables were evaluated. Potential risk factors for readmission were determined by multivariate regression analysis. Results: A total of 1,097 HSCT patients were reviewed. In the myeloablative group, 130 of 495 (26.3%) patients were readmitted within 30 days of discharge, among whom the majority of patients (71.5%) had one readmission. For RICs, 105 of 602 (17.4%) patients were readmitted within 30 days, among whom 62.9% of patients had one readmission. In the myeloablative group, the most frequent reasons for readmission were infection or fever without identified source (40.7%) and graft versus host disease (GVHD) (23.7%). Similarly, the most common diagnoses at readmission in the RICs were infection or fever without source (54.9%) and GVHD (11.0%). In the RICs, a logistic regression model of the probability of being readmitted suggested active disease (OR 2.0, p=0.005), a mismatched donor (OR 2.4, p=0.029), infection during the index admission (OR 5.8, p<0.0001) and non-private insurance (OR 1.8, p=0.025) are significant factors for readmission within 30 days. Conclusions: Infection and fever without a source were the most common causes of readmission after HSCT. In the RIC group, multiple disease, transplant, and sociodemographic factors were associated with readmission. Better defining the risk factors for readmission in this population will allow for more transitional care resources to be focused on high risk patients.
Making the (business) case for outpatient and home-based palliative care for cancer patients.
Authors: Cassel Brian , Kerr Kathleen , Del Fabbro Egidio
Published: February 2017

266

Background: Randomized controlled trials by Temel (2010) and Brumley (2003, 2007) have demonstrated the positive clinical, psycho-social, and utilization impact of providing early clinic or home-based palliative care (PC) concurrently with standard disease-focused treatment. Despite clear benefits, the growth of outpatient PC has been constrained by lack of clarity about the “business case” for hospitals or health systems to develop and fund PC services outside the inpatient setting. Methods: We will present findings from Virginia Commonwealth University (VCU) that provide a compelling quantification of the risks for hospitals to continue “business as usual” in this changing environment. Our approach measures quality, quantity, and costs of care for patients with cancer over a period of 6-12 months prior to death. Performance on some of these measures impact revenues in the prevailing fee-for-service reimbursement model; others are utilized in national, public ratings of quality; and still others influence organizational ability to compete in the population health management model that rewards quality and efficiency over time. Results: We used these data to highlight VCU Health System’s exposure to financial risks to create a strong business case for outpatient palliative care in which patient-centered and hospital-centered outcomes are aligned. This approach elevated our proposal to be included in a broader strategic initiative by our health system to manage complex care more efficiently, and to manage population health more proactively. Our analytic approach was then replicated by a diverse group of California provider groups who adopted or adapted the VCU model to advance their community-based palliative care programs as part of the California Health Care Foundation’s “Palliative Care Action Community” initiative. Conclusions: Our analytic model and articulation of the business case for community-based palliative care can help others to create and sustain quality-driven, patient-centered, cost-effective PC programs in their own institutions.
Use of radiation pathways to drive standardization of evidence-based care across a large network.
Authors: Lokay Kathleen
Published: February 2017

27

Background: UPMC CancerCenter includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology, now marketed as Via Pathways. The program has served UPMC well for over eight years and is now a key foundation for UPMC’s overall healthcare reform strategy for accountable care. Methods: Radiation treatment algorithms for 90% of cancers were developed by committees of academic and community radiation, surgical, and medical oncologists, with current representation from multiple cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for contouring, planning and delivery are provided along with applicable citations. Clinical trials open at UPMC sites are also imbedded into the algorithms. Converting these algorithms into measureable decision support is accomplished with a web portal that presents the individual pathways status through the physician’s daily schedule. Results: Thirty-one (31) radiation oncologists at UPMC use Via Pathways in their daily practice. For the 12 months ended May 31, 2013, UPMC physicians confirmed a pathways status for 98% of their patient visits (n=9,400) and achieved an On Pathway rate of 95% for their 5,575 treatment decisions. All off pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC. Reasons for going off pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care. We continue to expand the scope of Via Pathways to include additional cancer types, surveillance protocols, and end of life prompts as well as surgical oncology pathways.
Application of a novel method weighing drug costs against survival in castrate-resistant prostate cancer cancer.
Authors: Guirgis Helmy M.
Published: February 2017

271

Background: In the last few years, 5 new anticancer drugs have been introduced for the treatment of castration-resistant prostate cancer (CRPC). The objective was to apply a simplified methodology of weighing drug costs against overall survival (OS) in CRPC. Methods: Estimated cost in United Sates (US) dollars of an entire treatment course of an evaluated drug was divided by previously reported median OS gain over control. An initial survey of 45 drugs demonstrated that the maximal cost/OS/day gain was $757. Accordingly, a scale of crude scores was constructed with a 0% assigned to a cost/OS gain greater than $1,000 and 100% to a cost/OS gain of $1. Value scores were calculated after adjusting for quality of life (QoL), adverse events (AEs), and specialized administration and preparation (AP). Results: The lowest cost/OS gain and highest value score were demonstrated by generic docetaxel. Enzalutamide in previously-treated and abiraterone in chemo-naïve and treated patients x 6 months showed cost/OS gain lower than that of docetaxel but significantly higher than cabazitaxel. Pricing of sipuleucel-T based on cost of the entire course partly accounted for its highest cost/OS and lowest scores. Extending abiraterone and enzalutamide treatment to 12 months increased cost/OS gain and decreased scores. Conclusions: Methodology was proposed to weigh drug cost against OS/day gain with and without adjustment for QoL, AEs, and AP. Results in CRPC tend to support use of docetaxel, abiraterone, and enzalutamide rather than cabazitaxel and sipuleucel-T. Varying drug indications and different populations within the CRPC spectrum preclude direct drug comparison.
Finding the value point in oncology care: Optimizing clinical quality.
Authors: McCrone Daniel , Tran Cecilia , Flocco Jessica , Gill Dudley
Published: February 2017

272

Background: New Century Health is an Oncology Care Management company. Evidence-based medicine is not a new trend, however, we believe that New Century Health has developed a way to quantify quality and cost outcomes based on our innovative approach to utilizing Clinical Pathways and Compendia. Methods: A retrospective clinical review was performed on 1,938 chemotherapy treatment requests (CTRs) withdrawn or recommended adverse determination (RAD), in calendar year 2012, for two national health insurance carriers. Financial impact associated with the clinical intervention was calculated at ASP +6%, net of confirmed resubmissions. Resubmissions are defined as those approved treatment requests received within one month of the original withdrawal/RAD for an alternative treatment resulting from the original withdrawal/RAD. Financial impact of gross administrative errors was mitigated through manual adjustments to the projected costs. Results: The average combined membership was 795,679; 5,731 unique patients had requests for chemotherapy treatment during 2012, generating 15,446 CTRs. Twelve point five (12.5) percent (1,938) of those were withdrawn/RAD resulting in a net impact of $15.1 million. Of the 1,938 withdrawn/RAD, 12.4% (241) resulted in increased quality with an associated increase in cost ($1.8M). Conclusions: New Century Health believes that cost effective treatment is a function of quality and not the ultimate goal at the expense of patient outcomes. Detailed retrospective case studies were performed on all of the requests that resulted in additional costs. New Century Health believes that in each case the quality of care or patient safety was significantly improved by our peer-to-peer clinical interventions. This is a patient-centric innovative approach to evidence-based medicine that embraces necessary cost increases in favor of clinical quality and patient safety.
How payment reform drives innovation in interventional oncology.
Authors: Steele Joseph Rodgers , Clarke Ryan Kristopher , Ninan Elizabeth Priya , Mahvash Armeen
Published: February 2017

276

Background: Innovation has transformed healthcare; however, our current fee-for-service payment system can actually stifle creativity. When procedures are streamlined, fewer CPT codes may be charged, resulting in lower total reimbursement. Payment reform is necessary not only to control costs, but also to support constructive innovation. We describe how an innovative, lower reimbursed, technique of catheter-directed cancer therapy failed widespread acceptance in spite of being faster, safer and cheaper than the standard of care. Methods: Retrospective patient review was performed using the radiology information system and electronic health record. Medicare Part A and Part B payments were obtained from the Hospital Outpatient Prospective Payment System (HOPPS) for Harris County, Texas, and disposable supply costs were obtained from Premier Group Purchasing Organization. Results: From May 2008 to May 2013, 292 Yttrium-90 hepatic radioembolization procedures were performed for primary and metastatic disease. Eighty patients received the innovated balloon occlusion technique. This technique resulted in less fluoroscopy dose to the patient, faster procedure times, similar clinical outcome and a disposable cost savings of $1,138.72. However, because numerous procedure steps were avoided, the total average per-patient reimbursement was decreased by $8,044.05. Conclusions: Innovation that simplifies a procedure frequently obviates process steps that correspond to specific CPT codes. Hence, in a fee-for-service payment system, a faster, safer and cheaper option may result in fewer CPT codes and lower reimbursement, a disincentive that slows adoption. Our experience resulted in lost profit of over $8,000 per case for a total exceeding $640,000. Not surprisingly, this technique has not been widely embraced since we described it nearly two years ago. Conversely, a bundled payment model would have resulted in better aligned incentives, increased profit, and cost savings shared by patients, providers, and payers.
Consensus development: Within general oncology practice, what constitutes high-quality palliative care delivery?
Authors: Bickel Kathleen Elizabeth , McNiff Kristen , Malin Jennifer , Abernethy Amy Pickar , Kurup Acheson Anupama , Shapiro Charles L. , Evans Tracey L. , Kamal Arif , Buss Mary K. , Lupu Dale , Broder Michael S. , Krzyzanowska Monika K.
Published: February 2017

280

Background: Multiple studies illustrate the benefits of combined palliative and standard cancer care, but oncology practices need guidance to fill existing gaps in delivering high quality palliative care (PC) to cancer patients. As a first step, ASCO and the American Academy of Hospice and Palliative Medicine (AAHPM) sought to develop a consensus definition of which PC aspects are within the purview of general adult oncology practice in the United States. Methods: An ASCO and AAHPM steering group used existing publications to define 9 domains of PC in oncology: Symptom Assessment and Management (A&M), Psychosocial A&M, Spiritual and Cultural A&M, Communication and Shared Decision-Making, Care Planning, Appropriate Palliative Care and Hospice Referral, Coordination and Continuity of Care, Carer Support, and End-of-Life Care. Within each domain, key PC activities were itemized and described (e.g. pain assessment using a standardized scale at every clinical encounter), totaling 966 activities. A 31-member multidisciplinary panel participated in a modified RAND Delphi process, rating each activity on a 9-point scale according to 3 constructs: importance, feasibility, and scope of practice. Composite scoring categorized activities as either reasonably within scope of oncology practice, uncertain, or typically not in scope. Results: The response rate for each round was 94%. Notable panelist concerns included the breadth of palliative care practice, the varied access that oncology practices have to PC resources, and the varied individual knowledge and comfort with specific activities. Despite multiple small ranking changes between surveys, only 41 activities changed in scope of practice category. Of 966 activities, 62% were ranked as reasonably within scope of oncology practice, 36% were uncertain, and 2% were typically not in scope. Conclusions: Despite the diverse range of PC activities, panelists strongly agreed that more than half were reasonably within the scope of adult medical oncology practice. These items provide a foundation for improving palliative care delivery within an oncology practice, with suggestions for future performance measures and quality improvement activities.
Measurement of mutation-specific survival as a real-time cancer care quality indicator.
Authors: Warner Jeremy , Wang Lucy L. , Burden Joseph , Carney Pam , Sobecki Scott , Levy Mia Alyce
Published: February 2017

30

Background: As targeted therapies become widespread in the treatment of cancer, tracking clinical effectiveness as a function of mutation status, outside of the research setting, is needed. We evaluated whether mutation-specific survival statistics could be derived in a completely automated fashion from electronic medical record data sources, for quality assurance and purposes preparatory to research. Methods: Patients with cancer mutation analysis obtained for clinical care at Vanderbilt University up to June 2013 were included. Informatics algorithms were developed to automatically extract tumor mutation status, cancer type, date of diagnosis, and date of death or date of last contact using multiple structured and unstructured clinical data sources including billing codes, narrative pathology reports, and the Social Security Death Index. Survival was modeled using Cox proportional hazards, stratified by mutation type; mutations occurring less than 10 times were aggregated into an “Other” category. Results: 2,636 out of 3,115,904 patients had sufficient data for inclusion. Date of death was recorded for 32% of patients; overall median follow-up was 19 months. The median mutation-specific survival for lung cancer and melanoma patients is shown in the Table. For lung cancer patients, EGFR mutation was associated with superior survival (HR 0.7, 95% CI 0.5-1, p = 0.05). For melanoma patients, GNAQ mutation was associated with inferior survival (HR 2.2, 95% CI 1.3-3.8, p = 0.006) whereas BRAF mutation was not statistically significant (p = 0.32). Conclusions: It is feasible to create survival curves based on cancer mutation status in a fully automated fashion for quality assurance and purposes preparatory to research. Further iterative improvements in the data extraction algorithms are continuing; updates will be presented. Future work will enable stratification by mutation subtype, treatment exposure, staging, and demographics. [Table: see text]
Patterns of referral to palliative care in clinical practice in patients with stage IV non-small cell lung cancer.
Authors: Karim Safiya , Ahmed Shahid
Published: February 2017

39

Background: Recent evidence has shown that patients with stage IV NSCLC benefit from early referral to palliative care (PC). In August 2010, a landmark randomized control trial revealed that patients with advanced NSCLC, who received early PC, had better quality of life, mood and survival (NEJM 2010; 363:733-42). Our study aimed to determine pattern of PC referral in clinical practice, in patients with stage IV NSCLC before and after the publication of the trial, and to assess factors correlated with PC referral. Methods: The study population was comprised of a cohort of patients with stage IV NSCLC, diagnosed between 2009 and 2011, and referred to the Saskatoon Cancer Center. Logistic regression models were used to assess factors correlated with PC referral. Kaplan Meier method was used to estimate survival. Cox regression analyses were used to determine factors correlated with survival. Results: 215 patients with median age of 68 yrs (range: 40-92) and M:F of 108:107 were identified. 101 (47%) patients had comorbid illness, 100 (47%) had ECOG performance status <2, 136 (63%) were married/common law and 161 (75%) had symptomatic disease. 126/251 (58%) were referred to PC. 70/118 (59%) diagnosed before Sep 2010 were referred to PC compared with 56/97 (58%) diagnosed after Sep 2010 (p=NS). The median time to PC referral from date of diagnosis was 51 days (inter-quartile range: 19-155). 33% patients were referred within 4 wks of diagnosis. Symptomatic disease (odd ratio [OR]=3.7, 95% CI =1.8-7.5), bone metastasis (OR = 3.0, 95% CI = 1.6-5.6), and brain metastasis (OR=2.2, 95% CI =1.1-4.5) were correlated with referral to PC. Median survival of whole cohort was 4 months (95% CI: 3.1-4.8). 2nd or 3rd line therapy (Hazard ratio [HR]= 0.54, 95% CI:0.34-0.87), non-smoking status (HR= 0.58, 95% CI:0.38-0.87), chemotherapy (HR 0.64, 95% CI:0.46-0.89), and lack of symptoms (HR=0.68, 95%CI:0.48-0.96) were correlated with better survival. Conclusions: Our study shows that publication of the landmark trial did not influence the pattern of referral to PC at our center. Symptomatic patients and those with metastasis to brain or bone were more often referred to PC. No survival benefit was seen in patients who were referred to PC.
Implementation of a statewide quality assessment program for rectal cancer.
Authors: Hendren Samantha K. , McKeown Ellen , Wong Sandra L. , Oerline Mary , Campbell Darrell A. , Birkmeyer Nancy J.
Published: February 2017

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Background: The quality of surgical care for rectal cancer (RC) has been extensively studied in Europe; however, efforts in the United States are limited by the lack of detail about surgical care in available registries. We describe a unique quality assessment program for RC designed within the Michigan Surgical Quality Collaborative (MSQC), a collaborative quality improvement organization that includes community and academic medical centers. Methods: 10 MSQC hospitals contributed to this retrospective cohort study (2007-2012). Experienced nurse reviewers were trained to abstract cancer surgery-specific data from hospital medical records and local tumor registries. Five RC surgery-specific quality measures were designed based on literature review and current guidelines: adequate lymph node (LN) procurement (>=12); use of mesorectal excision; rate of margin positivity; use of neoadjuvant therapy for clinical stage II/III; and sphincter preservation rate for mid/upper RC. Results: 353 RC cases were studied (333 radical surgery, 20 local surgery). Participating hospitals varied in size (5 <400 beds), teaching status (6 major teaching, 2 minor teaching, 2 non-teaching), and urban/rural location (9 urban). Challenges encountered in the data abstraction training process included overcoming technical jargon in pathology and operative reports. Regular conference calls, access to a specialist for questions, and modifications to definitions helped overcome difficulties; 9 of 10 abstractors scored >90% correct on test cases. Analysis reveals wide variation between hospitals on quality measures. 75% of cases had adequate LN procurement (range by hospital 64-100%); mesorectal excision was performed in 76% of cases (38-97%); 9% had positive margins (0-17%); 94% of clinical stage II/III cases had neoadjuvant therapy (67-100%); and 86% of eligible cases had sphincter preservation (62-100%). Conclusions: A program designed to provide salient feedback to surgeons regarding RC treatment is feasible, and reveals that high-quality processes of care are not consistently used. These data suggest opportunities for process improvement. The program will be disseminated statewide for prospective data feedback and quality assessment.
Improving immunization (imm) rates among oncology patients and health care providers (HCP) through a partnership of continuing medical education (CME) and quality improvement (QI) in an NCI-designated comprehensive cancer center.
Authors: Leong Lucille A. , Mendelsohn Mary , Bruno Ted , Kagan Jean , Saavedra Crystal J. , Scales Wendy , Morgan Robert
Published: February 2017

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Background: Onc pts are at increased risk of vaccine (vac)-preventable diseases and suffer worse sequelae. Regulatory requirements demand imm of patients and HCP. There is a large practice gap among clinicians in awareness of imm guidelines, of pt imm status, and of the high risk of transmission from HCP to immunocompromised pt. Methods: From May 2012 to June 2013 the City of Hope CME coordinated a team of MDs, QI specialists, infection control, IT, nursing, and pharmacy in a QI CME initiative to increase the imm rates of pt and HCP by education (ed) to clinicians, pt and families. Multiple ed platforms were used (live CME meetings, web-based content, point of care applications, visual cues, clinician longitudinal self-assessment surveys, systems-based support tools, patient handouts) with emphasis on MD-friendly platforms. Results: >350 HCP participated in CME events (59% MDs, 18% RN). Analysis of ed and clinical outcomes is from 4 areas. (1) Change in HCP attitudes through self-assessment surveys shows an increase in clinician knowledge of types and timing of imm, in use of system-based tools (standard orders, vac computerized manager), and in involvement of pts in imm history and ed. (2) There was an increase of doses of influenza vaccines in pts (Sept-March, 2010-11/ 2011-12/ 2012-13: 1129/1480(31% increase)/1838(24% increase). (3) Respiratory viral testing of pts was done to assess number of confirmed infections. (4) Influenza vac rates of hospital workers improved with the largest increase in the medical staff (65 to 76%). Conclusions: This interdisciplinary CME initiative to improve imm rates among onc pts involved ed activities and system-based changes. Improvements were seen in areas of HCP attitude, performance, and acceptance of their own vac. 24% of the medical staff remain unvaccinated, raising both ethical and compliance challenges to reach the 2020 90% goal of Joint Commission. A gap remains in HCP attitudes regarding their own vac which may not be amenable to analytical-based CME. Use of other decision-making/learning styles is necessary for further progress. CA62505 and Pfizer.
Process improvement in breast cancer care: Is mammography volume associated with a greater need for process improvement?
Authors: Francois Teena L. , Weldon Christine B. , Trosman Julia Rachel , Dupuy Danielle , Marcus Elizabeth A. , Roggenkamp Betty , Schink Julian C. , Ansell David , Murphy Anne Marie
Published: February 2017

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Background: Chicago black women are 62% more likely to die from breast cancer than white women. Previous data from 39 Chicago hospitals suggested significant variation in mammography quality (Chicago Breast Cancer Quality Consortium, 2010). We developed process improvement recommendations for sites that participated in our care process assessment (Weldon CB, et al, ASCO-Abstract-6120-2012). This study was funded through a generous grant from the Susan G. Komen for the Cure Foundation. We compared improvement needs between high and low patient volume institutions. Methods: Using Deming’s PDCA cycle for continuous improvement, we created care process improvement recommendations for 25 Chicago institutions with the patient base averaging more than 50% minority patients (20 community, 3 academic and 2 public hospitals). Low mammography volume (< 5,000 mammograms/ year) was reported by 12 of the 25 sites. Recommendations are based on analysis across sites, literature, and input from institution staff. Thematic and statistical analyses were performed using simple frequencies and Fisher's exact test. Results: Improvement recommendations are classified into nine areas (see Table). We found that 100% (12/12) of low mammography volume institutions have specific improvement needs in 6 or more process improvement areas, as compared to 23% (3/13) of the high mammography volume institutions (p value > 0.0001). Conclusions: Lower volume mammography sites have a larger need for breast cancer care process improvements. [Table: see text]