bluuebunny/crossref_metadata_2025 huggingface dataset:
International Study Group of Pancreatic Surgery Definitions for Postpancreatectomy Complications: Applicability at a High-Volume Center
Authors: Dusch N. , Lietzmann A. , Barthels F. , Niedergethmann M. , Rückert F. , Wilhelm T. J.
Published: April 2017

Introduction:

The perioperative morbidity following pancreas surgery remains high due to various specific complications: postoperative pancreatic fistula, postpancreatectomy hemorrhage, and delayed gastric emptying. The International Study Group of Pancreatic Surgery has defined these complications. The aim of this study is to evaluate the clinical applicability, to validate the International Study Group of Pancreatic Surgery definition, and to evaluate the postoperative morbidity.

Methods:

Between 2004 and 2014, 769 patients underwent resection. Data were collected in a prospective database. Univariate examination was performed using the χ2-test. Continuous data were tested with the Mann–Whitney U-test. Student’s t-tests and Fisher’s exact tests were performed.

Results:

A total of 542 patients were included in this study. In all, 91 (16.8%) patients developed postoperative pancreatic fistula, 69 of them clinically relevant grades B and C postoperative pancreatic fistula. Grades B and C postoperative pancreatic fistulas were significantly associated with a longer hospital stay. The postoperative pancreatic fistula grade significantly correlated with re-operation. Totally, 32 (5.9%) patients developed postpancreatectomy hemorrhage. Postpancreatectomy hemorrhage grade was significantly associated with re-operation and 30-day mortality. In all, 14 of 19 patients with grade C postpancreatectomy hemorrhage (73.7%) were re-operated; 3 had a simultaneous postoperative pancreatic fistula C. Grade B postpancreatectomy hemorrhage significantly prolonged hospital stay. Grade C postpancreatectomy hemorrhage significantly prolonged intensive care unit stay. Grade C postpancreatectomy hemorrhage led to longer intensive care unit stay but a shorter hospital stay. Delayed gastric emptying occurred in 131 (24.2%) patients. The delayed gastric emptying grade was significantly associated with re-operation. Nine of the re-operated patients had a simultaneous postoperative pancreatic fistula C. Grades A, B, and C delayed gastric emptying were associated with prolonged hospital- and intensive care unit stay.

Conclusion:

Delayed gastric emptying is the most common specific complication after pancreas resection, followed by postoperative pancreatic fistula and postpancreatectomy hemorrhage. The International Study Group of Pancreatic Surgery definitions are well applicable in clinical routine and the different grades correlate well with severity of clinical condition, length of hospital or intensive care unit stay, and mortality. Their widespread use can contribute to a more reproducible and reliable comparison of surgical outcomes in pancreas surgery.
Multimodal structural health monitoring based on active and passive sensing
Authors: Nasrollahi Amir , Deng Wen , Ma Zhaoyun , Rizzo Piervincenzo
Published: April 2017

We present a structural health monitoring system based on the simultaneous use of passive and active sensing. The passive approach is based on acoustic emission, whereas the active approach uses the electromechanical impedance and the guided ultrasonic wave methods. As all these methods can be deployed with the use of wafer-type piezoelectric transducers bonded or embedded to the structure of interest, this article describes a unified structural health monitoring system where acoustic emission, electromechanical impedance, and guided ultrasonic wave are integrated in the same hardware/software unit. We assess the feasibility of this multimodal monitoring in a large flat aluminum plate instrumented with six transducers. Acoustic emission events are simulated by exciting a tone burst or by using the conventional pencil lead break test, and the detected signals are processed with a source localization algorithm to identify the position of the source. For the active sensing, damage is simulated by adding a small mass to the plate: the raw waveforms are processed with a delay-and-sum algorithm to create an image of the plate, whereas the electrical admittance of each transducer is analyzed using the statistical index of the root-mean-square deviation. The results presented in this article show that the proposed system is robust, mitigates the weaknesses of each method considered individually, and can be developed further to address the challenges associated with the structural health monitoring of complex structures.
Using neighborhood observation to support public housing tenants’ empowerment
Authors: Coulombe Simon , Radziszewski Stephanie , Morin Paul , Leloup Xavier , Bohémier Hélène , Houle Janie
Published: April 2017

Although public housing is often described as a negative and stigmatized environment, tenants living in such an environment can cultivate a positive sense of community, which enhances their individual and collective well-being. The present study describes the second phase of an action research, aiming to facilitate the empowerment of public housing tenants acting as peer-researchers. Following a Photovoice phase, this second phase focuses on the development and first implementation of a participatory observation method as a tool for evaluating tenants' collective environment fit. A group of nine tenants contributed to develop and later completed an observation grid. The observations were then discussed in decision-making sessions. The participatory observation method proved useful in supporting tenants in their reflection process, promoting the depiction of a nuanced portrait of their residential environment while also prioritizing capacity building. Results are currently used to inform an action phase in which tenants are taking increasingly more power. Triangulating the results from multiple sites is needed to establish more firmly the added-value of this observation method in a larger action research project. Key challenges and lessons learned are described in a reflective section, sharing experiential knowledge with researchers that consider using a similar method.
Antegrade vs Crossover Femoral Artery Access in the Endovascular Treatment of Isolated Below-the-Knee Lesions in Patients With Critical Limb Ischemia
Authors: Li Yukun , Esmail Ali , Donas Konstantinos P. , Pitoulias Georgios , Torsello Giovanni , Bisdas Theodosios , Michelagnoli Stefano , Troisi Nicola
Published: April 2017

Purpose: To evaluate the safety and effectiveness of antegrade vs crossover femoral artery access in the endovascular treatment of isolated below-the-knee (BTK) lesions in patients with critical limb ischemia (CLI). Methods: Between January 2014 and December 2015, 224 high-risk patients (mean age 75.8±9.8 years; 151 men) with CLI underwent infragenicular interventions on 292 crural vessels in 3 European vascular centers. All patients had isolated TransAtlantic Inter-Society Consensus (TASC) C (n=26) or D (n=198) BTK lesions. Primary endpoints were freedom from access-related complications and technical success comparing the antegrade vs crossover access groups. Results: Balloon angioplasty was the most used treatment modality (169 vessels, 75.4%). The technical success rate was 88.4% in the entire cohort and 88.0% in the antegrade group vs 90.4% in the crossover group (p>0.99). In all patients, the technical success rate was higher for stenotic lesions (100%) vs occlusions (85.5%, p=0.002) and in patients with TASC C BTK lesions (100%) vs TASC D (86.9%, p=0.033). The overall freedom from access-related complications was 97.8%: 99% in the antegrade group and 90.6% in the crossover group (p=0.022). Larger sheath size (5/6-F vs 4-F) was associated with a significantly higher risk for access-related complications (7.1% vs 1.1%, respectively; p=0.047). Conclusion: The present multicenter study showed high technical success and a low incidence of access-related complications in the treatment of isolated BTK lesions using either antegrade or crossover femoral access. The antegrade approach with the use of a 4-F system seems to have a significantly lower rate of access-related complications.
Peer Mentoring as Social Capital for Latina/o College Students at a Hispanic-Serving Institution
Authors: Moschetti Roxanne V. , Plunkett Scott W. , Efrat Rafi , Yomtov Dani
Published: April 2017

An evaluation was conducted on a university peer mentoring program for Latina/o college students (mostly freshmen and first generation) at a Hispanic-Serving Institution. Data were collected across 3 years from 458 Latina/o students with mentors and 86 Latina/o students without mentors (Year 3). Quantitative and qualitative data indicated mentees viewed peer mentors as social capital (e.g., emotional and academic support). Mentees reported increased university integration and connection at posttest, significantly greater than nonmentored students.
Temporary Break or Permanent Departure? Rethinking What It Means to Quit EVE Online
Authors: Bergstrom Kelly
Published: April 2017

To date, much of the research about massively multiplayer online games (MMOGs) and the people who play them has focused on studies of current players. Comparatively, little is known about why players quit. Rather than assuming MMOG play begins and ends with personal interest, this article uses a leisure studies framework to account for barriers and participation to play. Drawing on survey responses from 133 former EVE Online players, this article demonstrates that quitting is not a strict binary where one moves from playing to not playing. Furthermore, quitting in the context of MMOGs is not always a definitive act as some players will leave and then return to a particular game numerous times. Ultimately, this article argues that the voices of former players are an underattended demographic that can add further insights allowing game scholars to better understand why players gravitate toward particular games and not others.
An emergency exits choice preference model based on characteristics of individual diversity
Authors: Li Zhihong
Published: April 2017

Previously compute models usually applied the assumption that people would adopt the shortest route to escape, or be given fixed destination. But the diversity of characteristics mean everyone has an individual determination based on optimal utility including distance, crowding level, and personalized cognition. We focused on the correlation between individual feature and their initial exits strategy in crowded places. By carrying out a questionnaire survey about individual characteristics, spatial cognition, and personalized decision in a market, we found that each pedestrian held different preferences and probabilities of choosing a particular exit for evacuation due to diversity of social background. An emergency exits choice preference model was proposed to analyze escape behavior and to determine the initial preference. The model could balance the influence of differentiated cognition of various pedestrians against the practical evacuating state and surroundings. And also, it could predict the destinations choosing probability in emergency. The result showed the evacuation duration, maximum density, and highest density were more optimal. Applying this model, the pedestrians’ averaged density of exits decreased obviously. Stampede risk was significantly reduced. We expected to make a step that the pedestrian behavior simulation will advance on integrating the human social behavior from theoretical precision.
Lateral motion of the endless flat belt in a two-pulley belt system
Authors: Han Fenglin , He Ruibo , Yan Hongzhi , Xiong Feng
Published: April 2017

An analytical model of the lateral motion of the endless belt in a two-pulley belt system is proposed. This model can be used to forecast the transient and steady lateral motion of the belt when the tilted angle of the steering pulley is time-variant and it is valuable in the design and assessment of belt lateral position controllers. The responses of the belt to variations in the tilted angle of the steering pulley according to a piecewise step function are solved using the delay differential equation solver dde23 in MATLAB. The validity of the model is confirmed by experiments. The simulation and experimental results show that the belt tends to move to the side with a shorter center distance. In the steady phase of the step responses, the lateral belt velocities at different positions tend to be coincident with each other. A closed-form expression of the steady belt lateral velocity is derived. The expression shows the steady belt lateral velocity is proportional to the input tilted angle and the belt speed, and it increases with an increase in the center distance and the pre-load tension and a decrease in the radius of the pulleys and the belt bending stiffness.
Block diagonal dominant remotely operated vehicle model simulation using decentralized model predictive control
Authors: Lin Weipeng , Chin Cheng Siong
Published: April 2017

Model predictive control on a highly coupled open-frame remotely operated vehicle system subjected to uncertain disturbances has always been a challenge. A decentralized model predictive control uses a design scaling to balance the interactions between the loops to achieve a block diagonal dominant remotely operated vehicle model is used. The numerical stability of the model predictive control algorithm improves despite the sensitivity of the control parameters on the output performance. The model predictive control gives a better two-error norm performance and more tuning options to control the velocity and position output as compared to other design scaling methods and other controllers such as proportional–integral–derivative, fuzzy logic, sliding mode, and proportional–integral plus proportional cascaded control when subjected to underwater current disturbance.
How should I fixate the subscapularis in total shoulder arthroplasty? A systematic review of pertinent subscapularis repair biomechanics
Authors: Schrock John B. , Kraeutler Matthew J. , Crellin Charles T. , McCarty Eric C. , Bravman Jonathan T.
Published: April 2017

Background

The present study aimed to review the biomechanical outcomes of subscapularis repair techniques during total shoulder arthroplasty (TSA) to assist in clinical decision making.

Methods

A systematic review of multiple databases was performed by searching PubMed, Scopus, Cochrane Library, Google Scholar, and all databases within EBSCOhost to find biomechanical studies of subscapularis repair techniques in cadaveric models of TSA.

Results

Nine studies met the inclusion criteria. In the majority of studies, lesser tuberosity osteotomy (LTO) techniques had greater load to failure and less cyclic displacement compared to subscapularis tenotomy or peel methods. LTO repairs with sutures wrapped around the humeral stem demonstrated superior biomechanical outcomes compared to techniques using only a tension band. In terms of load to failure, the strongest repair of any study was a dual-row fleck LTO using four sutures wrapped around the stem.

Conclusions

Several cadaveric studies have shown superior biomechanical outcomes with LTO techniques compared to tenotomy. In the majority of studies, the strongest subscapularis repair technique in terms of biomechanical outcomes is a compression LTO. Using three or more sutures wrapped around the implant and the addition of a tension suture may increase the biomechanical strength of the LTO repair.
A case of epilepsy in multiple sclerosis: Three-dimensional double inversion recovery sequences revealed cortical dysplasia
Authors: Zimatore Domenico S , Trentadue Mirko , Castellaro Marco , Ferlisi Monica , Piovan Enrico , Calabrese Massimiliano
Published: April 2017

In epileptic patients with multiple sclerosis (MS), cortical lesions have been suggested to cause seizures. In brain magnetic resonance imaging (MRI), double inversion recovery (DIR) sequences are generally used to evaluate MS cortical disease burden. We present the case of a woman, diagnosed with MS, suffering from drug-resistant partial seizures initially attributed to MS. The patient underwent many MRI exams, but only by means of high-resolution three-dimensional DIR sequences was a focal cortical dysplasia discovered. The MRI findings and FDG-PET/CT supported the diagnosis. This case recommends the use of DIR sequences both in patients with suspect epileptogenic lesions not detected with routine MRI protocols and in epileptic patient with MS, before ascribing seizures to MS.
“Boomeranging” and Delinquent Behavior in Emerging Adulthood
Authors: Hill Jessica M. , Bosick Stacey J.
Published: April 2017

Role change is a central feature of the transition to adulthood. These transitions are not always linear. It is unclear whether “boomeranging” back into dependent roles is problematic to later life outcomes or represents healthy role exploration. Using a person-centered approach, we explore whether role dependence (remaining in dependent roles), role progression (movement into independent roles), or role boomeranging (moving from independent to dependent roles) clusters within individuals, using a sample of Dutch emerging adults. Three distinct classes emerged. The “experimenter” class was characterized by low progression into independent roles. These participants experimented with employment, education, and relationships but experienced highest levels of boomeranging compared to other classes (“early independents” and “achievement-focused singles”). Experimenters were most likely to be involved in delinquency. We discuss the low levels of boomeranging found in our young sample and whether the experimenter’s pattern of role change signals a pathway to continued instability into adulthood.
Testosterone Replacement Therapy and Risk of Favorable and Aggressive Prostate Cancer
Authors: Loeb Stacy , Folkvaljon Yasin , Damber Jan-Erik , Alukal Joseph , Lambe Mats , Stattin Pär
Published: April 2017

Purpose

The association between exposure to testosterone replacement therapy (TRT) and prostate cancer risk is controversial. The objective was to examine this association through nationwide, population-based registry data.

Methods

We performed a nested case-control study in the National Prostate Cancer Register of Sweden, which includes all 38,570 prostate cancer cases diagnosed from 2009 to 2012, and 192,838 age-matched men free of prostate cancer. Multivariable conditional logistic regression was used to examine associations between TRT and risk of prostate cancer (overall, favorable, and aggressive).

Results

Two hundred eighty-four patients with prostate cancer (1%) and 1,378 control cases (1%) filled prescriptions for TRT. In multivariable analysis, no association was found between TRT and overall prostate cancer risk (odds ratio [OR], 1.03; 95% CI, 0.90 to 1.17). However, patients who received TRT had more favorable-risk prostate cancer (OR, 1.35; 95% CI, 1.16 to 1.56) and a lower risk of aggressive prostate cancer (OR, 0.50; 95% CI, 0.37 to 0.67). The increase in favorable-risk prostate cancer was already observed within the first year of TRT (OR, 1.61; 95% CI, 1.10 to 2.34), whereas the lower risk of aggressive disease was observed after > 1 year of TRT (OR, 0.44; 95% CI, 0.32 to 0.61). After adjusting for previous biopsy findings as an indicator of diagnostic activity, TRT remained significantly associated with more favorable-risk prostate cancer and lower risk of aggressive prostate cancer.

Conclusion

The early increase in favorable-risk prostate cancer among patients who received TRT suggests a detection bias, whereas the decrease in risk of aggressive prostate cancer is a novel finding that warrants further investigation.
Vasectomy and Prostate Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC)
Authors: Smith Karl , Byrne  , Castaño Jose Maria , Chirlaque Maria Dolores , Lilja Hans , Agudo Antonio , Ardanaz Eva , Rodríguez-Barranco Miguel , Boeing Heiner , Kaaks Rudolf , Khaw Kay-Tee , Larrañaga Nerea , Navarro Carmen , Olsen Anja , Overvad Kim , Perez-Cornago Aurora , Rohrmann Sabine , Sánchez Maria José , Tjønneland Anne , Tsilidis Konstantinos K. , Johansson Mattias , Riboli Elio , Key Timothy J. , Travis Ruth C.
Published: April 2017

Purpose

Vasectomy is a commonly used form of male sterilization, and some studies have suggested that it may be associated with an increased risk of prostate cancer, including more aggressive forms of the disease. We investigated the prospective association of vasectomy with prostate cancer in a large European cohort, with a focus on high-grade and advanced-stage tumors, and death due to prostate cancer.

Patients and Methods

A total of 84,753 men from the European Prospective Investigation into Cancer and Nutrition (EPIC), aged 35 to 79 years, provided information on vasectomy status (15% with vasectomy) at recruitment and were followed for incidence of prostate cancer and death. We estimated the association of vasectomy with prostate cancer risk overall, by tumor subtype, and for death due to prostate cancer, using multivariable-adjusted Cox proportional hazards models.

Results

During an average follow-up of 15.4 years, 4,377 men were diagnosed with prostate cancer, including 641 who had undergone a vasectomy. Vasectomy was not associated with prostate cancer risk (hazard ratio [HR], 1.05; 95% CI, 0.96 to 1.15), and no evidence for heterogeneity in the association was observed by stage of disease or years since vasectomy. There was some evidence of heterogeneity by tumor grade ( P = .02), with an increased risk for low-intermediate grade (HR, 1.14; 95% CI, 1.01 to 1.29) but not high-grade prostate cancer (HR, 0.83; 95% CI, 0.64 to 1.07). Vasectomy was not associated with death due to prostate cancer (HR, 0.88; 95% CI, 0.68 to 1.12).

Conclusion

These findings from a large European prospective study show no elevated risk for overall, high-grade or advanced-stage prostate cancer, or death due to prostate cancer in men who have undergone a vasectomy compared with men who have not.
Idarubicin Dose Escalation During Consolidation Therapy for Adult Acute Myeloid Leukemia
Authors: Bradstock Kenneth F. , Link Emma , Di Iulio Juliana , Szer Jeff , Marlton Paula , Wei Andrew H. , Enno Arno , Schwarer Anthony , Lewis Ian D. , D’Rozario James , Coyle Luke , Cull Gavin , Campbell Phillip , Leahy Michael F. , Hahn Uwe , Cannell Paul , Tiley Campbell , Lowenthal Ray M. , Moore John , Cartwright Kimberly , Cunningham Ilona , Taper John , Grigg Andrew , Roberts Andrew W. , Benson Warwick , Hertzberg Mark , Deveridge Sandra , Rowlings Philip , Mills Anthony K. , Gill Devinder , Bardy Peter , Campbell Lynda , Seymour John F. ,   on behalf of the Australasian Leukaemia & Lymphoma Group
Published: April 2017

Purpose

Higher doses of the anthracycline daunorubicin during induction therapy for acute myeloid leukemia (AML) have been shown to improve remission rates and survival. We hypothesized that improvements in outcomes in adult AML may be further achieved by increased anthracycline dose during consolidation therapy.

Patients and Methods

Patients with AML in complete remission after induction therapy were randomly assigned to receive two cycles of consolidation therapy with cytarabine 100 mg/m2 daily for 5 days, etoposide 75 mg/m2 daily for 5 days, and idarubicin 9 mg/m2 daily for either 2 or 3 days (standard and intensive arms, respectively). The primary end point was leukemia-free survival (LFS).

Results

Two hundred ninety-three patients 16 to 60 years of age, excluding those with core binding factor AML and acute promyelocytic leukemia, were randomly assigned to treatment groups (146 to the standard arm and 147 to the intensive arm). Both groups were balanced for age, karyotypic risk, and FLT3–internal tandem duplication and NPM1 gene mutations. One hundred twenty patients in the standard arm (82%) and 95 patients in the intensive arm (65%) completed planned consolidation ( P < .001). Durations of severe neutropenia and thrombocytopenia were prolonged in the intensive arm, but there were no differences in serious nonhematological toxicities. With a median follow-up of 5.3 years (range, 0.6 to 9.9 years), there was a statistically significant improvement in LFS in the intensive arm compared with the standard arm (3-year LFS, 47% [95% CI, 40% to 56%] v 35% [95% CI, 28% to 44%]; P = .045). At 5 years, the overall survival rate was 57% in the intensive arm and 47% in the standard arm ( P = .092). There was no evidence of selective benefit of intensive consolidation within the cytogenetic or FLT3–internal tandem duplication and NPM1 gene mutation subgroups.

Conclusion

An increased cumulative dose of idarubicin during consolidation therapy for adult AML resulted in improved LFS, without increased nonhematologic toxicity.
An evaluation of the breast cancer Well Follow-up Care Initiative using administrative databases: A new model of analysis.
Authors: Mittmann Nicole , Earle Craig , Beglaryan Hasmik , Liu Ning , Gilbert Julie , Rahman Farah , Seung Soo Jin , LeBlanc Dominique , De Rossi Stefanie , Liberty Jacqueline , Zwicker Victoria , Sussman Jonathan
Published: April 2017

1

Background: Cancer Care Ontario (CCO) implemented the Well Follow-up Care Initiative (WFCI) to transition low-risk breast cancer (BC) survivors from oncologist to primary care providers. The objective of this work was to compare both the health system resources utilized and their associated costs, among women in the WFCI (cases) and women who were not transitioned (controls). Methods: Cases were linked to provincial administrative databases and matched to a control group based on year of diagnosis, cancer stage, age, comorbidity, income, geographic area of residence, and prior health system use. Health system resource utilization (physician, hospitalization, diagnostics, medication, and homecare) was ascertained per group. The annual mean and median costs (CAD 2014) per patient were determined. Annualized incremental costs between cases and controls were estimated using generalized estimating equations, accounting for matched pairs. Results: Results are based on 2,324 cases and 2,324 controls (mean age 64.4 and 64.9 years, respectively). During an average of 2.5 years of follow-up since the transition date, there were significant differences between the two groups for mean annual visits per patient with a medical oncologist (0.4 vs. 1.3, p<0.001) and radiation oncologist (0.2 vs. 0.4, p<0.001). There was no significant difference in mean annual family physician visits per patient (7.4 vs. 7.9, p=0.082). The intervention group had fewer inpatient hospitalizations (75.6% vs. 79.9%) and cancer clinic visits (84.9% vs. 94.0%). While there was a higher number of mammograms for cases compared to controls, other diagnostic tests (bone scan, CT, MRI, ultrasound, and x-rays) were done less frequently. The model was associated with a 39.3% reduction in mean annual costs ($6,575 among cases and $10,832 among controls) and a 22.1% reduction in median annual costs ($2,261 among cases and $2,903 among controls). Conclusions: Transitioning BC survivors to primary care was associated with fewer health system resources and had a lower annual mean cost per patient than women who were not transitioned.
Qualitative themes underlying potentially avoidable terminal oncology ICU hospitalizations.
Authors: Daly Robert Michael , Hantel Andrew , Polite Blase N.
Published: April 2017

101

Background: ICU admissions in the last 30 days of life is a quality measure endorsed by the National Quality Forum. Our prior research has demonstrated that nearly half of terminal oncology ICU hospitalizations are potentially avoidable. Methods: This was a retrospective care series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. Using a standardized assessment tool, an oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months prior to hospitalization until death and made a clinical determination of avoidability. Two investigators, blinded to the specialty of the reviewer, used a grounded theory approach to extract clinical themes associated with avoidability from the reviewers’ assessments. Results: The primary themes for avoidability identified and percent by specialty were as follows: failure to initiate appropriate advance care planning in the outpatient setting (68% oncologists, 55% intensivists, 65% hospitalists), failure to integrate understanding of limited prognosis from underlying cancer within the context of acute hospitalization (23% oncologists, 24% intensivists, 26% hospitalists), failure of clinical management (6% oncologists, 21% intensivists, 6% hospitalists), failure to recognize futility of outside hospital transfer (3% oncologists, 0% intensivists, 0% hospitalists), and failure of care coordination (0% oncologists, 0% intensivists, 3% hospitalists). A failure to educate and integrate surrogates into timely medical decision making was a prominent secondary theme for oncologists (22%), intensivists (18%), and hospitalists (29%). Conclusions: The themes identified suggest potential interventions to prevent avoidable terminal oncology ICU hospitalizations, including improved advance care planning in the outpatient setting, inpatient multidisciplinary communication to gain a better understanding of the patient’s underlying malignancy within the context of the acute hospitalization and prevent failures in clinical management, and better education and integration of surrogates in medical decision making.
No news, bad news? A deeper examination of the correlation between patient functional status and level of postoperative telephone communication with the surgical team.
Authors: Baksh Adrienne Nicole Hawkins , Shahrokni Armin
Published: April 2017

102

Background: In attempts to improve outcomes for and survival of geriatric oncology patients, studies have demonstrated the utility of phone communication as a tool for post-operative care. However, very little data is available to determine if this method of care is reaching the most vulnerable patients. The purpose of this study is to compare patient-surgical team phone communication for geriatric cancer patients of higher and lower preoperative functional status. Methods: This is a retrospective review of data from an internal geriatric assessment questionnaire and phone log data as recorded in the EHR at a single institution. Patients were stratified into two groups: those who had at least one recorded postoperative care phone call (PC) and those with no postoperative care phone call (NPC). Quantitative analysis of the data was performed, assessing the correlation between preoperative functional status and patient-surgical service communication in the first 30 postoperative days. Results: NPC group patients were more likely to be amongst the more frail patients, with lower preoperative functional status and a higher level of distress. Specifically, patients in the NPC group were more likely to be dependent for ADLs (61.0% vs. 50.8%, P = 0.013) and IADLs (59.6% VS. 44.7%, P = 0.001), and have a lower Karnofsky Performance Scale score (46.2% vs. 39.1%, P = 0.048) and also reported a higher level of distress (4.5 vs. 4.00, P = 0.001). There was a trend toward more cognitive impairment among the NPC group compared to the PC group (18.2% vs. 12.1%, P = 0.058). Conclusions: Our study highlights a disparity in the utilization of patient-surgical team phone calls as a method for postoperative care for more frail patients. Despite significant number of phone calls initiated during the postoperative period, mainly by surgical nurses, frail and distressed patients are more likely not to participate in a call. Future studies of postoperative phone communication with geriatric oncology patients should assess the utility of this tool for more frail patients and seek measures that will increase access and participation among this population.
Methodology and results of a pain-assessment process for patients receiving radiation therapy treatment.
Authors: McDuffie Angela , Harris Eleanor Elizabeth , Proctor Anita , Potter Leann , Barnes Timothy , Holloman Michael , Naves James
Published: April 2017

105

Background: Patients receiving radiation therapy treatment often exhibit pain as a consequence of their cancer or treatment, and is a major factor affecting the patient’s quality of life and functional status. Accreditation standards require pain to be assessed and managed, which are key components in successful implementation of a radiation therapy plan of care. Multifactorial causes for cancer pain, the subjective nature of pain assessment, and the protracted nature of radiation delivery make it necessary to routinely evaluate patient pain using quantifiable metrics. These evaluations can then be used to develop and evaluate effectiveness of interventional strategies. Methods: Internal “spot check” chart review in early 2015 showed deficits in 16 of 37 charts (43.2%) reviewed for pain assessments, revealing documentation well below the required threshold (95%). As a result, the Department of Radiation Therapy revised the process for the accepted 10-point intensity scale to evaluate patient pain. This revised process included staff re-education, workflow adjustments, and nursing evaluation prior to, during, and the end of the radiation treatment course using a standardized pain scale form. Documentation was accomplished by means of vital sign template encounter tool used by Nursing at the time of initial consult, for weekly on-treatment visits (OTVs), and end of treatment (EOT) encounter. Results: Data were monitored for the period of April-June 2015 and reported as a continuous quality improvement (CQI) activity to the department’s Quality Committee. Amassed data showed a total of 186 unduplicated patients were treated during this period, and 181 (97.3%) were assessed for pain. Conclusions: Ongoing monitoring is an important strategy to assure complete evaluation, treatment and outcomes of patient pain while receiving radiation treatment. A clearly defined and quantifiable process is important to facilitate monitoring and ongoing pain management. Improvements in consistency of pain assessment and management promote enhanced focus on patient pain and contribute to delivery of care, and patient quality of life and performance status.
Should Cancer Centers start their own specialty pharmacy? Quality and economic data from the oral chemotherapy program at Smilow Cancer Hospital and Yale New Haven Health System.
Authors: Adelson Kerin B. , Stutsky Martha , Fradkin Monica , Harrison Michelle Renee , Abdelghany Osama , Morrow Bret , Smith Mandeep , Havriliak Renee , Kregling Stephanie , Lyons Catherine A. , Chiang Anne C. , Cohen Howard
Published: April 2017

108

Background: Recent focus has shown that oral chemotherapy is high risk for medical error. Our QOPI certification process identified that oral oncologic processes were marked by: lack of documentation in the EMR, patients receiving refills from third party pharmacies after prescription discontinuation, incorrect self-administration of medications due to lack of education, delivery delays, high copays, and underuse of available patient assistance programs. Methods: A multidisciplinary task force developed a program to expedite drug access, standardize consent, and ensure clinical support including education, adherence and toxicity monitoring. We expanded an existing health-system pharmacy to provide specialty services. Treatment protocols were created for every oral oncologic drug, which are routed to a clinical oncology pharmacist and the specialty pharmacy. Nursing and pharmacist verify all orders. Medication Assistance Program for copay support. Day 1, 5 and 21 pharmacist to patient calls. Multidisciplinary flow sheet documentation. Results: Today, 80% of our patients receive medication within 72 hours. Specialty pharmacists monitor toxicity even for patients whose prescriptions are filled by other pharmacies. Pharmacists have prevented more than 400 prescription errors. Today, monthly revenue before cost for the oral chemotherapy program is nearly than $4 million. The total revenue since initiation in February 2015 is over $44 million, yielding an approximately $9 million margin after costs. Funding through the medication assistance program exceeded $1 million thus far in 2016, with an average of 140 patients receiving assistance each month. Conclusions: A patient-centered multidisciplinary model integrating clinical, operational, financial, and IT resources optimized care for patients receiving oral oncologic therapy. This project transferred revenue from for-profit third party pharmacies to our non-profit health system, and revenue is used to provide enhanced education, monitoring, and patient assistance. Our collaborative improvement model can be adapted to many practice settings.
Hematology and oncology patient perceptions of inpatient care coordination at an urban academic teaching center.
Authors: Chen Christopher , DeGregorio Sara , Soriano Margaret , Lennes Inga Tolin , Thompson Ryan , Ferris Timothy
Published: April 2017

109

Background: Outpatient doctors increasingly defer inpatient care to hospital-based physicians. At academic medical centers, inpatient care coordination is further complicated by frequent handoffs between resident teams. Breaks in inpatient care continuity may disproportionately affect hematology and oncology patients, given their often complicated longitudinal histories and specialized problems. We sought to understand hematology and oncology patient perceptions of inpatient care coordination at Massachusetts General Hospital (MGH). Methods: Between July 2014 and June 2015, patients admitted to any MGH service were randomly selected to complete a survey about their perception of inpatient care coordination. In total, 1,783 patients responded. Of these, 158 were admitted to hematology or oncology. Hematology and oncology patient responses were compared to all MGH patient responses using chi-squared analysis, with p values less than or equal to 0.05 used as the threshold for statistical significance. Responses reflect the percentage of patients who chose the “top box” option. Results: Compared to all MGH patients, hematology and oncology patients were significantly more likely to recognize a clearly identified doctor responsible for their care while in the hospital (85% vs 74%, p = 0.003) and to perceive the presence of a responding clinician at all times (79% vs 66%, p = 0.001). Hematology/oncology patients were also much more likely to report seeing their longitudinal MGH doctors while admitted (77% vs 57%, p < 0.001). However, despite more frequent in-person visits by outpatient physicians, significantly fewer hematology/oncology patients reported perceiving that their outpatient doctor receives discharge information (47% vs 64%, p = 0.005). Conclusions: MGH hematology and oncology patients reported stronger inpatient care coordination and higher frequency of outpatient physician visits than MGH patients overall. Nevertheless, patients perceived less frequent coordination of discharge information with outpatient physicians. More research is needed to understand whether patient perceptions of care coordination correlates with clinical and utilization outcomes.
Implementation to optimization: A tailored, data-driven approach to improve provider efficiency in using the electronic medical record.
Authors: Kadish Sarah , Mayer Erica L. , Jackman David Michael , Pomerantz Mark , Brady Lauren , Dimitriadis Audra , Cleveland Jessica , Wagner Andrew J.
Published: April 2017

123

Background: The increasing use of Electronic Medical Records (EMR) has been coupled with a growing focus on physician dissatisfaction. A recent study revealed physicians spend twice as much time working on the EMR and related tasks as they spend with patients. Physicians also spent time at night on EMR-related work. Nine months after the implementation of a new EMR at Dana-Farber Cancer Institute, providers expressed frustration with the EMR burden. Following three group training sessions, providers requested individualized training. We sought to enhance efficiency in clinical review, documentation, placing orders and to reduce after hour use. Methods: Each provider was sent their EMR system usage by time of day and activity. Providers were also surveyed to elicit content for training and to gauge confidence. Prior to training, a trainer reviewed the survey results and system usage data. System usage data and a post training survey were utilized to quantify changes against baseline. Results: A total of 114 MDs, 37 NPs and 8 PAs completed training. Providers reported an increase in confidence across all activities. Almost all providers (98%) agreed the training enhanced their efficiency. Overall confidence rose from 58% to 94% strongly agree or agree post training. Overall time in system (TIS) per appointment and TIS reviewing a patient’s chart significantly improved. TIS spent on documentation, placing orders, or after hours did not significantly change. Conclusions: A tailored data-driven training approach improved overall efficiency and confidence. While changes to TIS were not significant across all activities or reduce after hour usage, ongoing training may continue to improve these measures. [Table: see text]
Optimizing formulary decisions.
Authors: Conter Henry Jacob
Published: April 2017

14

Background: As medication prices rise, the sustainability of health care systems has been increasingly questioned. Health technology assessment (HTA) could be employed to maximize value when budgets are limited. Methods: The pan-Canadian Oncology Drug Review (pCODR) is an evidence-based, cancer drug review process that guides formulary decision-making. As of 10/30/16, data from all 93 reviews and economic guidances were abstracted for price of medication, total health care cost per patient, cost-utility provided by the submitter, and the re-analysis by pCODR. Regression analysis was employed to identify correlations. Expected use of therapy was estimated employing mortality data from the Canadian Cancer Society. An optimal formulary was then developed, with value for money as the primary concern. Results: Of the 93 reviews, 11 were not finalized, 3 were withdrawn, and 1 was suspended. 4 reviews were excluded since the base-case was ambiguous. Of included reviews, 13% were recommended for funding, 66% were recommended conditional on improved cost-effectiveness, and 22% were rejected. The median drug price per 28-day cycle was $7,567 (range $2,800-$18,435), with no annual difference from 2012-2016 (p=0.49). The median best-estimate of cost-utility was $188,537/QALY (IQR $127,399/QALY) with a median net increase in health system cost of $66,069/patient (IQR $90,466). The median difference between pCODR’s best estimate and the submitter’s was $61,240/QALY (IQR $73,656/QALY). The submitter’s estimate of cost effectiveness was correlated with pCODRs assessment (R² = 0.65, p<0.01). Cost per 28-day cycle was a weak predictor of value (R² = 0.01, p<0.01), and not of health system cost (R² = 0.17, p=0.11). In the Canadian context, funding all efficacious medications would require a total of $5.91 billion producing 31,705 QALYs, annually. Funding the system with $1.12 billion for new medicines by first-come-first-served principle, yields 5,966 QALYs over 16 drugs, annually. By prioritizing based on value, $1 billion allows for funding of 22 drugs producing 9,665 QALYs, annually. $2 billion would increase annual QALYs to 15,792 over 26 drugs. Conclusions: Price of medications should not be used as a heuristic for value. An optimized formulary requires practical deployment of HTA.
Decision support networks of women newly diagnosed with breast cancer.
Authors: Wallner Lauren P. , Li Yun , McLeod Chandler , Hamilton Ann S. , Ward Kevin C. , An Lawrence C. , Janz Nancy K. , Katz Steven J. , Hawley Sarah T.
Published: April 2017

157

Background: Prior studies suggest that women often involve a network of family and friends in their cancer treatment decision making, yet very little is known about the size and characteristics of these decision support networks and whether their involvement leads to high-quality breast cancer treatment decisions. Methods: A weighted random sample of patients newly diagnosed with breast cancer in 2014-15 as reported to the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (N = 2,502, 70% response rate). Network size was estimated by asking women to list up to 3 of the most important decision support people (DSP) who helped them make their locoregional therapy decisions. Decision deliberation was measured using 4-items assessing degree to which patients thought through the decision, with higher scores reflecting more deliberative breast cancer treatment decisions. We compared the size of the network (0-3+ people) across patient-level characteristics and estimated the adjusted mean deliberation scores across levels of network size using multivariable linear regression. Results: Of the 2,502 women included in this analysis, 51% reported having at least 3 DSPs, 20% reported 2, 18% reported 1, and 10% reported not having any DSPs. Among women who were not partnered (N = 961), 51% had 3 DSPs, 18% had 2, 16% had 1 and 16% had 0 DSPs. Of the DSPs that the respondents identified, the majority were children (30%), followed by partners/spouses (23%), friends (15%), siblings (10%), other family members (6%), and parents (5%). Married/partnered women (p < 0.001), those younger than 45 years old (p < 0.001), those with more than 1 comorbidity (p < 0.001), and black women (p = 0.02) were all more likely to report larger networks on average. Larger support networks were associated with more deliberative surgical decisions (p < 0.001). Conclusions: In this population-based sample, the majority of women engaged DSPs in their treatment decision making and for non-partnered patients, DSPs still played a key role in decision making. Larger size decision support networks were associated with higher quality decisions, underscoring the importance of efforts to identify and engage DSPs in the breast cancer decision making process.