bluuebunny/crossref_metadata_2025 huggingface dataset:
Triple-negative breast cancer treatment pattern and factors associated with its treatment in the United States: A population study using Central Cancer Registry data, 2013-2015.
Authors: Wu Manxia ,   CDC NPCR Working Group
Published: September 2018

24

Background: Large population-based studies on TNBC epidemiology and treatment pattern in the US were generally limited due to lack of routinely data collection on these biomarkers until recent years. This study examined and documented general treatment status and factors associated with the treatments among TNBC patients in the US. Methods: We used the latest released NPCR and SEER combined cancer registry data, which covers 100% of the US population. All women in the US with a primary invasive TNBC breast cancer diagnosed between 2013 and 2015 were included. First course treatment patterns by AJCC staging on TNBC were examined based on corresponding year’s NCCN guideline recommendations. Regression analysis were performed to identify factors associated with treatments. Results: There were 74,952 TNBC women included in the study. Ninety three percent of women with early stage of TNBC had surgery, and 35% women with mastectomy chose to undergo contralateral prophylactic mastectomy. Among stage I-III patients, those aged < 35, Non-Hispanic Asian Pacific Islander, living in other regions than northeast or metropolitan were more likely to have mastectomy compared to BCS. Radiation therapy were only received for 65% women with breast conserving surgery (BCS), which were less likely to be performed in non-Hispanic Black, Hispanic, and among those aged < 35 or > 70+. Chemotherapy were received for 75% of TNBC women, ranged from 63% (stage I) to 86% (stage III). Treatment variations among different demographic and geographic characteristics in chemotherapy were also observed. Conclusions: Overall, current treatment practice for TNBC in the US is generally concordance with the recommended breast cancer care except a relative low radiation therapy among BCS women. However, treatment disparities existed within the limited treatment options, and factors associated with the disparities also varied. More effective treatment options and treatment equality are warranted to improve overall care of this subtype.
Risk-adjusted prediction models using the specialty-specific head and neck reconstructive surgery NSQIP.
Authors: Tam Samantha , Dong Wenli , Martin Ira L , Adelman David Matthew , Weber Randal S. , Lewis Carol M.
Published: September 2018

240

Background: With increasing health care costs, risk-adjusted quality outcomes are essential. The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) is a robust perioperative risk-adjustment platform, but lacks capture of oncologic- and specialty-specific variables and has limited utility for risk adjustment in head and neck oncologic surgery. This study uses the specialty-specific Head and Neck-Reconstructive Surgery (HNSR) NSQIP to develop risk-adjusted models for patients undergoing head and neck oncologic surgery with reconstruction. Methods: Multiple logistic regression modelling using data from patients in the HNSR NSQIP between 8/2012-10/2016 identified predictors of postoperative morbidity. Final models were validated using a cohort of patients treated between 10/2016-12/2017. The concordance index (c-index) was used to evaluate the model performance. Results: The modelling cohort included 1095 patients and the validation cohort included 407. Models were created to predict probability of postoperative complications (presence of fistula, ventilator dependence > 48 hours, pneumonia, deep/superficial surgical site infection); presence of gastrostomy-jejunostomy (GJ), nasoenteric (NE), or tracheostomy tube at 30 days postoperatively; conversion from NE to GJ tube; unplanned return to the operating room; and length of stay > 7 days. Most discriminant models were those predicting presence of GJ tube (model c-index [MCI] = 0.91; validation c-index[VCI] = 0.93), NE tube (MCI= 0.83; VCI= 0.84), and conversion from NE to GJ tube (MCI= 0.86; VCI= 0.80). Prediction models were least discriminant for ventilator dependence (MCI= 0.63; VCI= 0.45), fistula (MCI= 0.58; VCI= 0.54), and unplanned return to the operating room (MCI= 0.59; VCI= 0.51). Conclusions: Reliable and discriminant risk prediction models were able to be created for a variety of perioperative complications incorporating oncologic- and specialty-specific variables in the HNSR NSQIP. These models help inform risk stratification strategies for patients undergoing head and neck reconstructive surgery and the development of a specialty-specific preoperative risk calculators.
Saline alone vs saline plus mannitol hydration for the prevention of acute cisplatin nephrotoxicity: A randomized trial.
Authors: Beeler Bradley , Delacruz Wilfred P. , Flynt Frederick L. , Terrazzino Sandra , Hullinger Naomi , Aden James , Byrd Tiffany , King Melissa M. , Nelson Douglas A.
Published: September 2018

242

Background: Cisplatin is a widely used chemotherapeutic in treating malignancies. A common side effects of cisplatin is kidney injury, or nephrotoxicity. This can be a reason for discontinuation of treatment. The majority of the cisplatin is removed from the body by urination. Mannitol is a compound that has been thought to help negate cisplatin-induced nephrotoxicity. Mannitol is a diuretic, causing increased amount of urination, enhancing excretion of cisplatin. Mmultiple studies that indirectly looked into the effect of mannitol in preventing kidney damage in patients receiving cisplatin. However, there are limited prospective data that evaluate the effect of mannitol in preventing cisplatin-induced nephrotoxicity. In this study, we determine the effects of pre-hydration with mannitol on reducing the risk of cisplatin-induced nephrotoxicity, as opposed to normal saline pre-hydration in patients receiving cisplatin. Methods: 50 patients eligible to receive chemotherapy with cisplatin chemotherapy were identified and randomized to receive 1L saline alone (A) or saline plus mannitol (B) before and after chemotherapy. (1) NS 1 Liter pre chemo- > chemo - > NS 1 Liter post chemo; (2) NS + Mannitol pre chemo - > chemo - > NS + Mannitol post chemo. Serum creatinine and BUN were drawn on days 1 (baseline), 5, and 14 Results: Renal function as measured by BUN/Cr ration, GFR, creatinine, and BUN between group (A) and (B) are similar at baseline (BL), day 1, 5, and 14. Cisplatin caused acute decline in renal function as determined by ser Cr, BUN to ser Cr ratio and GFR, however, the addition of mannitol to NS pre-hydration did not change the outcome. The decline in renal function is limited to grade 1 and most patients recover. Conclusions: Mannitol does not prevent acute nephrotoxicity in patients receiving cisplatin. This underscores the importance of adequate hydration in patients treated with cisplatin.[Table: see text]
Using the Risk Assessment Index (RAI) to predict 90-day mortality and hospital utilization in cancer patients at UPMC Hillman Cancer Center.
Authors: Garcia Christine Ann , Borrebach Jeffrey , Altieri Dunn Stefanie C , Bellon Johanna E , Ormond Ellen , Burgess Melissa Amber
Published: September 2018

243

Background: Patients with cancer vary considerably in health status and functional reserve. Identifying the most frail patients whom are at risk of treatment toxicity or death can be difficult. The Risk Assessment Index (RAI) is a validated tool used to assess frailty in patients prior to surgery. Thus, we aimed to investigate frailty assessment utilizing the RAI in cancer patients and its ability to predict hospital utilization and 90-day mortality. Methods: From 9/15/2017 to 1/31/2018, new patients with solid tumor malignancies at the UPMC Hillman Cancer Center completed the RAI. Age, cancer type and stage, and treatments were abstracted. ED visits, hospitalizations and mortality data were provided by the Wolff Center at UPMC. Mann-Whitney U and likelihood-ratio tests were performed comparing RAI, ED usage/hospitalizations, and mortality. Elective hospital admissions were excluded. Results: 273 patients completed the RAI. 58.6% of pts were male and average age was 62.7 (21-88), and the average RAI score was 39.9 (IQR 35-44). The most common cancer types were melanoma (22.7%), prostate (14.3%), and lung (11.4%). 43.6% of patients had stage IV cancer. Within 90 days after RAI, 51 patients (18.7%) experienced at least one unplanned ED visit or hospitalization, and 10 patients (3.7%) were deceased. Patients with an ED visit/hospitalization had an average RAI of 42 (IQR 37-46) compared to 39.4 (IQR 35-43) for patients without one: a 2.6-point difference (p = 0.008). 90-day mortalities had an average RAI score of 47.5 (IQR 42-53) compared to 39.6 (IQR 35-44) for non-mortalities: a 7.9-point difference (p = 0.003). Six of 242 (2.5%) patients without a hospitalization experienced mortality whereas 4 of 31 (12.9%) patients with a hospitalization experienced mortality (p = 0.017). Conclusions: This study shows that the RAI may be utilized to predict 90-day mortality in cancer patients. Patients at greatest risk of 90-day mortality were more likely to have unplanned hospitalizations. While there was a statistically significant difference in RAI scores between patients with and without unplanned ED visits/hospitalizations, this difference was too small to be clinically meaningful.
Quality improvement and safety curriculum for hematology/oncology fellows at Columbia University.
Authors: Accordino Melissa Kate , Heaney Mark L.
Published: September 2018

247

Background: It is imperative to provide Hem/Onc fellows with experiential training in quality improvement (QI) and patient safety methodology. Our objective was to design a curriculum that would provide experience in designing, implementing, and analyzing a QI/safety project with the ultimate aim of engagement in QI/safety efforts throughout their careers. Methods: The curriculum focused on experiential learning and was led by a faculty member with QI/safety methodology training who provided didactics and supervisory support of the projects. Fellows worked in groups (3-5 fellows) to implement a project. Plan-Do-Study-Act (PDSA) methodology was introduced early in the academic year and workshops continued over a one-year time period. At the year end, projects were presented at an institution-wide symposium. Two cohorts (2015-2016, 2017-2018) have completed the curriculum. Results: Program efficacy was measured in several ways. The QIKAT-R tool was administered prior to the curriculum in August 2015 (n = 12) and at completion June 2016 (n = 14). At baseline, the mean score was 3.97 (out of 9) which improved to 7.57 at completion. Comfort level with QI also increased by 42.9%. Annual ACGME survey questions pertaining to an institutional culture of patient safety increased from 88% (2015) to 100% (2016 and 2018) and participation in QI increased from 53% (2015) to 95% (2106) to 100% (2018). Further, fellows (n = 33) successfully completed nine projects which included: improvement of fertility preservation, improvement in the adequacy of bone marrow aspirates performed by fellows, increasing genetic counseling referrals in select patients with colorectal cancer, improvement in smoking cessation counseling, increasing timely chemotherapy order entry, and reduction of unnecessary heparin induced thrombocytopenia antibody testing. The curriculum is currently being adapted to other fellowship programs at Columbia. Conclusions: Our curriculum is an effective method to teach fellows at Columbia University Medical Center a skill set necessary to conduct successful QI/safety projects. PDSA methodology of small cycles of change can be used life-long to continuously assess and improve care quality and safety.
SAFE Initiative: A step closer to a positive safety culture and improved patient experience.
Authors: Walters Cherie , Byler Caitlin , Hyatt Melissa , Jreissaty Claudine , Joe Timisha , Thomas April , Mejicanos Jennefer , Smith Regina F. , Hassid Victor
Published: September 2018

249

Background: A positive safety culture is a major characteristic of a high reliability organization (HRO). At The University of Texas MD Anderson Cancer Center, safety is our leading service excellence standard, and because of this, creating a positive safety culture throughout the institution is a top priority. At MD Anderson Sugar Land, we sought to create, improve, and foster a culture of safety throughout all levels of our campus by implementing a new initiative. Methods: The Safe, Attentive, Focused, Engaged (SAFE™) initiative was conceptualized by our leadership team at MD Anderson Sugar Land to improve our safety culture. Improvements were measured by the number of reported safety events, the amount of employee engagement at our weekly safety meetings, and participation in and scores from MD Anderson’s institutional Culture of Safety survey. Results: The SAFE initiative was implemented in April 2017. During the 12 months before its implementation, the average monthly number of reported safety events for our campus was 7.17. During the 12 months after implementation, the average monthly number of reported safety events for our campus was 12.75, a 78% increase over the previous 12 months. An increase in the number of reported events is a key indicator of our move toward a more positive safety culture. Qualitatively, we saw a noticeable increase in attendance and participation in our weekly safety meetings. Furthermore, in February 2018, an institution-wide Culture of Safety survey was distributed, and MD Anderson Sugar Land had 100% participation compared with 87% across MD Anderson as a whole. MD Anderson Sugar Land scored above national benchmarks in 10 of the 14 domains surveyed. Conclusions: A positive safety culture is a requirement for health care organizations to be considered HROs. Identification of methods to achieve that goal can be challenging and time-consuming. At MD Anderson Sugar Land, we implemented an initiative that proved to have a meaningful impact on creating a positive safety culture. Limitations and challenges are continuously being identified, discussed, and addressed among our entire workforce with the goal of improving our culture of safety.
Evaluation and identification of protocols for safe and efficacious institutional administration of intravenous immune globulin in hypogammaglobulinemia associated with chronic lymphocytic leukemia, non-Hodgkin lymphoma, and multiple myeloma.
Authors: Feinsilber Doron , McCoy Cole , Hari Parameswaran , Foy Patrick C. , Narra Ravi , Fenske Timothy S , Shah Nirav Niranjan , Michaelis Laura Christian , Kollu Vidya , Mears Katrina Angela , Osinski Kristin , Froggatt Nancy , Atallah Ehab L. , Dhakal Binod
Published: September 2018

250

Background: Hematologic malignancies effect both humoral and cell-mediated immunity. We hypothesize that for patients with Chronic Lymphocytic Leukemia (CLL), Non-Hodgkins Lymphoma (NHL), and Multiple Myeloma (MM) outcomes improve with adherence to National Comprehensive Cancer Network (NCCN) guidelines for intravenous immunoglobulin (IVIG).Our objective is to understand resource allocation and implementation of IVIG in outpatient and inpatient settings. We identified a cohort of patients with hypogammaglobulinemia for assessing incidence of sepsis, outcomes, and resource use. We initiated this project by undertaking a large descriptive study of current IVIG use. Methods: A retrospective Institutional Review Board (IRB) approved data capture was conducted covering 2016-2018. Inclusion criteria involved those on an active chemotherapy plan, age > 18 years and diagnosis of CLL, NHL, or MM. IgA deficiency, anaphylaxis to IVIG, planned chemotherapy, inherited immunodeficiency, and thymic deficiency were excluded. We considered patients to be suitable for IVIG if IgG was < 500 mg/dL for CLL and MM and < 400 mg/dL in NHL. Outcomes, number of admissions, sepsis, ICU care, infectious etiology, and monthly IgG levels were examined. Results: A preliminary i2b2 data capture identified a cohort of 563 patients that yielded 12% with bacteremia, 21% with sepsis, and 23% with pneumonia of which 87% were admitted. 28% received IVIG during the 2-year period. Of the 563, 77% were hospitalized and 21% required ICU care. 54% of ICU patients received inpatient IVIG. All influenza and parainfluenza cases were inpatient. Final data analysis will yield greater detail in comparing inpatient to outpatient IVIG use. Conclusions: Large academic institutions appear to have significant variability in use of IVIG in patients with lymphopenia and hematologic malignancies. With this data, we plan to assess for patient-level outcomes based on adherence to NCCN guidelines as a way to enhance Physician Quality Reporting System (PQRS) standards by prioritizing outpatient use of IVIG.
Are we really good to go? Can we do better?
Authors: Magni Katie , Bagley Janet , Durney Jeffrey , Wolfberg Rachel A , Perna Melissa , Crifasi Richard ,   Good to Go Workgroup
Published: September 2018

251

Background: ASCO/ONS (2016) stated that health care continues to see errors regarding chemotherapy administration. ASHP (2015) recommends that institutions establish checkpoints to ensure that chemotherapy orders are correct. These critical safety checks involve stakeholders on the frontline. The institute uses the pharmacy intervention program to combat this critical need. Pharmacy interventions are reviewed monthly and defined as any medication order that pharmacy reviews and recognizes a discrepancy, requiring follow up. An interdisciplinary workgroup of pharmacists and nurses was established to address pharmacy interventions identified. Methods: The workgroup met over two months to revise the existing medication administration criteria and developed a standardized Good to Go worksheet. A mandatory training video was assigned to infusion nurses. The worksheets were piloted over three weeks and reviewed for completion and notes. Pharmacy interventions were collected prior to and during implementation to track compliance and improvement to patient safety. Nurses and pharmacists were identified as team members. Daily debriefing huddles were held during implementation with feedback incorporated and revisions made to the worksheet for the following day(s). This project was approved by the DFCI IRB as a Quality Improvement Project. Results: The pilot unit had a pharmacy intervention rate of 8.8 % for one week prior to implementation. During week one of the pilot the pharmacy interventions decreased to 4.1% and one month after pilot the rate was 4.6% and 4.7%. The most recent pharmacy interventions were communicated to staff. May data showed a further reduction to 2.8%. Nurses reported feeling better organized and more focused, while pharmacists report less phone calls to infusion. Statements from frontline staff and leadership including the positive results of the pilot were added to the training video. Conclusions: With the positive impact on patient safety, the Good to Go project will be implemented throughout the institute in the summer of 2018. Team members will include infusion nurses and pharmacists from all units. A standardized team approach to chemotherapy administration has the potential to minimize medication errors.
Surgical Universal euGlycemic Attainment during Recovery (SUGAR) Initiative.
Authors: Taylor Jolyn Sharpe , Cain Katherine , Earles Terri , Harris Melinda , James Deepthi , Hubbs Cheryl , Dottino Joseph , Stewart Katherine Ikard , McGrew Leon , Siebel Christine , Enbaya Ahmed , Iniesta Maria , Vachhani Shital , Lasala Javier , Thosani Sonali , Best Conor , Sahai Sunil Kumar , Schmeler Kathleen M. , Ramirez Pedro T , Meyer Larissa
Published: September 2018

252

Background: Surgical site infections (SSI) are infections of the surgical incision or organ space within 30 days of surgery and are associated with increased morbidity, mortality and healthcare expenditures. Diabetic patients undergoing laparotomy are at high risk. Prior studies have shown SSI reduction by avoiding hyperglycemia. The aim of our Quality Improvement (QI) initiative is to reduce the SSI rate among diabetic patients undergoing laparotomy by 40% within 2 years compared to the baseline (2/2015-8/2017) rate of 16%. Methods: We formed a multi-disciplinary QI team including physicians, nurses and advanced care providers from Gynecologic Oncology, Pharmacy, Nutrition, Endocrinology, Internal Medicine and Anesthesiology. The intervention began 2/2018 in our main center and 5 satellite sites including: screening gynecologic cancer patients undergoing laparotomy with hemoglobin A1C, intra-operative glucose monitoring with goal of < 180mg/dL, creation and use of a standardized basal-bolus insulin order set for post-operative care, and endocrine and nutritional consultation. The following variables were assessed: age, race, ethnicity, BMI, cancer type, comorbidities, smoking status, surgical procedure, receipt of antibiotic prophylaxis, hemoglobin A1C, post-operative glucose values, intervention compliance, intra-operative complications, post-operative complications including SSI, hospital readmissions, reoperation and mortality. Results: Since 2/2018, 39 gynecologic cancer patients have undergone laparotomy. Overall compliance with HgA1c screening is 64% (25/39), which has improved from 42% in 2/2018 to 70% in 3/2018 and 83% in 4/2018. Causes of non-compliance included unplanned conversion to laparotomy and need for additional education. Five of 39 (13%) patients were diabetic, including one newly diagnosed through this initiative. The post-intervention diabetic SSI rate is 0% (0/5) with all post-intervention glucose values < 180mg/dL. There have been no safety adverse events resulting in patient harm. Conclusions: Implementing a QI initiative to standardize management of diabetic patients undergoing surgery is both safe and feasible. Effectiveness data will continue to be collected.
Improving safety and adherence of oral chemotherapy.
Authors: Shahin George , Bersabe Adrian Reyes , Layman Clifton Patrick
Published: September 2018

253

Background: Oral chemotherapy (OC) has gained increasing popularity due to perceived advantages in convenience and toxicity profiles compared to conventional chemotherapy. Based on ASCO/ONS guidelines, we established standard operating procedures (SOPs) and a nurse-led oral chemotherapy clinic to guide the safe administration and monitoring of OC in our outpatient hematology/oncology clinic. Methods: A dedicated oral chemotherapy clinic led by a certified chemotherapy nurse was created to ensure standard metrics identified in the ASCO/ONS guidelines were met with each patient visit. Fifty-seven charts were randomly selected for a 3-month post intervention analysis. Results: The OC nurse identified toxicities in 17/57 (30%) of cases prompting notification of the ordering physician. This led to modifications in supportive medications in 9/17 (53%) of cases. Dose modifications occurred in 6/17 (35%). Informed consent documentation was available in only 36/57 (63%) charts. Necessary lab work was missing in 7/57 (12%) cases, prompting completion prior to OC release. An incorrect OC was dispensed by pharmacy in one case. Each visit took approximately 30 minutes from check-in to release of OC. All patients received OC education specific to their regimen. Conclusions: A dedicated visit with an OC nurse provided a vital means to ensure patient education, safe prescribing, proper dispensing, and monitoring of toxicities. Nursing identified the need for supportive care interventions and dose reductions in over 25% of charts which mitigated potential adverse events. Due to average time required for each patient encounter, we found this process to be unsustainable with increasing needs and limited resources. Thus, we revised our SOP to include a checklist of standard ASCO/ONS metrics. We also decreased the follow-up requirement for patients who did not require further intense monitoring after 6 months. Ongoing efforts will be made to ensure the effectiveness of this program. Future interventions will also capture cost effectiveness to establish a fair compensation model for reimbursement and justification of clinical support required to enforce current administration safety standards.
Developing a standardized process for oral chemotherapy management for neuro-oncology.
Authors: McGranahan Tresa , Gershon Megan , Pena Justine , Bains Chamnjot , Van Meter Margaret Elizabeth McCormick , Salas Sarah , Nagpal Seema
Published: September 2018

258

Background: Oral chemotherapies (OC) have transformed cancer care for millions of patients. While this has improved the patient experience, it presents significant challenges to safety of prescription, administration and side effect monitoring. While there are guidelines for documentation, there is not a best practices system for managing OC. This project identified areas of latent errors and implemented a standardized process for OC management. Methods: After review of the literature, we developed a process map for OC prescriptions at our institution. We then compared processes at three other neuro oncology clinics. We completed a hazard analysis and implemented several changes (see table). We identified binary measures in the medical record for every OC prescription that related to the process changes. Chart review of the 6 months prior to process change was used to create a baseline process mean for each variable. These same variables were monitored every 2 weeks after process change implementation using run charts. Successful process shift was defined as 7 consecutive 2-week averages that were continually on one side of the baseline process mean. Results: 5 months after process change was implemented, we had successfully reduced refills for OC and increased documentation of dose and dose calculation. There is a trend towards improvement in independently verified dose calculation and dedicated chemotherapy teaching visits, however these have not yet reached criteria for process change. Conclusions: This project used published studies, multi-institutional process mapping and hazard analysis to develop and implement a standardize process for OC. This process can be implemented for OC management in other oncology practices. [Table: see text]
Improving patient safety: Utilization of standardized radiation oncology simulation templates.
Authors: Everett Ashlyn S. , Blalock Ginna , Boggs Drexell Hunter
Published: September 2018

259

Background: Increasing patient volume and treatment complexity in the field of radiation oncology has resulted in increased number of errors possibly affecting patient safety. Effective methods of mitigating these errors include automation, computerization, simplification, and standardization. To improve quality of care and patient safety, our institution established consensus standardized treatment guidelines for each cancer site. However, physician orders for computed tomography (CT) simulation for radiation treatment planning continued to have extreme variability, with error rates of 31%. Therefore, a team was assembled to devise standardized orders to reduce error, improve patient safety, and improve quality of care in the CT simulation order process. Methods: For this study, we investigated 3 commonly treated sites at our institution: breast (14%), prostate (7%), and brain metastases treated with radiosurgery (14%). A standardized template CT simulation order was defined for each disease site using the consensus treatment guidelines. These orders were integrated into the electronic medical record (EMR) on March 5, 2018. To evaluate the efficacy of the intervention, CT simulation order data were queried for the two-month period before and after implementation of standardized template orders. Orders with variation from the treatment guidelines were counted to calculate error rates with and without standardized simulation orders. Results: In the two-months prior to implementation of the standardized order templates, 48 of 151 (31%) CT simulation orders for the three selected sites had variation from the consensus standardized orders. After implementation of the EMR standardized template, 17 of 129 simulation orders (13%) in the three selected sites had variations from the standard during this two-month period. Standardization of CT simulation orders using an EMR template reduced error rates from 31% to 13% (18% absolute reduction; 42% relative reduction). Conclusions: Simplification and standardization of CT simulation orders decreased error rates by 42%, thereby improving clinic efficiency and appropriate patient treatment.
Comparison of PCR/FISH testing and next generation sequencing (NGS) in molecular diagnosis of advanced-stage lung adenocarcinoma.
Authors: Whooley Peter , Guinee Donald , Mandelson Margaret T. , Hubka Michal , Kuppusamy Madhankumar , Chu Frank , Kirtland Steven H. , Rosales Joseph Grant F
Published: September 2018

262

Background: As the number of clinically actionable genetic markers for lung adenocarcinoma has increased, the need for accurate and timely identification of these markers has become paramount. In January 2018, our practice began systemically using NGS on all lung adenocarcinoma biopsy specimens. We compared NGS testing to our previous standard (PCR- and FISH-based assays) with regards to breadth of markers tested and time to diagnosis. Methods: We compared detection of mutations in EGFR, ALK, and ROS1 and time from resection or biopsy to test results in recently diagnosed patients from January-March 2018 with stage III/IV adenocarcinoma of the lung to similar patients diagnosed January-December 2016. Results: 63 patients were eligible for analysis: 17 patients in 2018 and 46 patients in 2016. Mean time to diagnosis was 13 days for EGFR, 16 days for ALK and 18 days for ROS1 in 2016, based on previous methods (PCR/FISH) compared to 27 days for EGFR, 26 days for ALK and 26 days for ROS1 in 2018 with NGS testing. Four of the 46 samples (8.6%) were found to have insufficient tissue using PCR/FISH, whereas 1 out of 17 (5.8%) samples were found to be insufficient with NGS testing. NGS testing returned up to 35 molecular markers, including those which might be targets for clinical trial therapy. Conclusions: The use of NGS testing increased the number of actionable molecular markers tested and appears to have resulted in an increase in the time taken to diagnose EGFR, ALK, and ROS1. The clinical significance of this time difference (i.e. time to treatment initiation) as well as ultimate cost of NGS compared to PCR/FISH remain to be determined. FIGURE 1: Time to diagnosis of molecular tests in lung adenocarcinoma stage III/IV using PCR/FISH from January through December 2016 and NGS from January through March 2018.[Table: see text]
Quality improvement interventions to reduce chemotherapy dose-modification ordering errors at a large academic medical center.
Authors: Soriano Margaret , Chang Anne , Galway Aralee , Listro Laura , Liu Evaline , McGuire Jessica , Mulvey Therese Marie , O'Donoghue Sheila , Parikh Aparna Raj , Rosato Erika , Ryan David P. , White Lawren , Woolwine Melissa Anne , Isakoff Steven J.
Published: September 2018

264

Background: Despite clear advantages of Electronic Health Records (EHR) systems for safe cancer chemotherapy administration, persistent opportunities exist to further reduce chemotherapy order errors. Unintended dose escalation orders of previously dose reduced chemotherapy were the most commonly reported “near-miss” medication safety events at our institution. This can lead to potential patient harm, delays in care, decreased patient satisfaction, reduced infusion room efficiency, and increased care team workload and decreased satisfaction. We sought to reduce chemotherapy order errors using interventions developed with process improvement techniques. Methods: Unintended dose escalation errors per month (the primary outcome measure) were identified through the hospital safety reporting system and by monitoring the EHR (EPIC) chemotherapy administration reports to identify dose escalations. All cases were confirmed with primary chart review. The pre-intervention baseline assessment period was 6/2017-11/2017, and the post intervention period was 12/2017-5/2018. Two interventions were selected: 1) Revision of the nursing chemotherapy checklist posted on all infusion room workstations for use prior to releasing chemotherapy orders; and 2) educating ordering providers and nurses about new EHR functionality to display prior and future chemotherapy orders. Statistical Process Control chart analysis was conducted with upper (UCL) and lower (LCL) control limits of 3 standard deviations. The primary aim was to reduce the number of chemotherapy errors by 50% in the post-intervention period. Results: The pre-intervention period averaged 3.83 chemotherapy ordering errors per month (UCL = 9.71, LCL = 0). The post-intervention period significantly reduced the average errors per month to 1.33 (UCL = 4.97, LCL = 0). The copy/forward feature in multi-day cycles was the most common source of unintended dose escalations. Conclusions: Implementation of the 2 interventions resulted in a 65% reduction of unintended dose modification errors. Based on successful results and positive staff feedback, we plan to roll out these interventions at additional satellite facilities.
An interprofessional pathway for patients initiating treatment with palbociclib: Optimization of toxicity monitoring.
Authors: Thawer Alia , Singh Susan , Boudreau Angela , Mackinnon Lori , Ng Lisa , Lawrence Shikha , Charbonneau Flay , Stinson Jordan , Slater Deana , Trudeau Maureen E. , Gandhi Sonal
Published: September 2018

268

Background: CDK 4/6 Inhibitors such as palbociclib in combination with hormonal therapy are considered the new standard of care for eligible advanced breast cancer patients with ER positive, HER2 negative disease. These agents have toxicities warranting standardized monitoring algorithms. Methods: An interprofessional pathway was created for palbociclib that identified key patient milestones and responsibilities of different care providers. Blood work (BW) parameters for dose interruption/reduction were specified, with a minimum absolute neutrophil count (ANC) of 1 as the threshold for continuing therapy. A retrospective chart audit was conducted to assess adherence to the biweekly BW and toxicity assessment pathway. Toxicity results were compared to the PALOMA-2 trial. Results: Consecutive patients were assessed between June 2016 and August 2017. Median follow up was 193 days. Twenty five patients before and 24 patients post algorithm implementation were included. Median age was 59, and 80% had >2 lines of prior systemic treatment. Dose reductions were observed in 57% of patients, 84% for neutropenia (Table 1). This is higher than documented in PALOMA-2. Instances where BW and clinic assessment were indicated and completed went from 43% to 69% and 32% to 67% respectively. Conclusions: Our study included heavily pre-treated patients and used an ANC treatment continuation threshold of 1 as opposed to 0.5; this might explain the increased incidence of neutropenia and dose modifications. This algorithm, with defined provider roles and patient milestones, appears feasible and effective in standardizing follow up and optimizing patient care.[Table: see text]
Creating an optimal care coordination model for patients with lung cancer on Medicaid.
Authors: Marbaugh Amy , Asfeldt Thomas , Kramar Amanda , Lucas Lorna
Published: September 2018

273

Background: The Association of Community Cancer Centers (ACCC) created an Optimal Care Coordination Model (OCCM), which provides a comprehensive self-assessment tool designed to orient cancer programs to achieving patient-centered, multidisciplinary care. The OCCM is designed to help cancer programs, regardless of resources, location, or population, improve care for lung cancer patients, especially those on Medicaid. Methods: An environmental scan was conducted in early 2016 with a focus on coordination of care after lung cancer diagnosis to improve experiences and outcomes for Medicaid beneficiaries. Five ACCC Cancer Program Members each hosted 2-day site visits in mid-2016. Interview sessions were conducted to explore effective practices and current care models for patients with lung cancer insured by Medicaid. Key problems in care coordination were identified, as well as local solutions that had been put in place to overcome these barriers. The NCI Community Cancer Centers Program’s (NCCCP) Multidisciplinary Care (MDC) Assessment Tool was the foundational template to create the OCCM. The MDC Tool included 7 assessment areas that were identified as impactful to establishing multidisciplinary care and includes a Level 1-5 evaluation matrix. Results: The beta version of the OCCM was created in early 2017. The number of Assessment Areas was expanded to better capture current care coordination philosophies; (1) Patient Access to Care; (2) Prospective Multidisciplinary Case Planning; (3) Financial, Transportation, and Housing; (4) Management of Comorbid Conditions; (5) Care Coordination; (6) Treatment Team Integration; (7) Electronic Health Records (EHR) and Patient Access to Information; (8) Survivorship Care; (9) Supportive Care; (10) Tobacco Cessation; (11) Clinical Trials; (12) Physician Engagement; (13) Quality Measurement and Improvement. Conclusions: Seven ACCC Cancer Program Members are currently validating the model by each implementing at least one program-specific quality improvement project focused on an Assessment Area over a 12-month time period. All programs are collecting extensive data to determine the extent their program improved within an assessment area. Final results will be available for dissemination in 2019.
Improving communication with referring oncologists (RO): Indiana University experience.
Authors: Hashemi-Sadraei Neda , Kalra Maitri , Gbolahan Olumide B. , Betbadal Anthony Michel , Grethlein Sara
Published: September 2018

276

Background: Poor communication between referring physicians and consultants can lead to disruptions in continuity of care, unnecessary testing, and iatrogenic complications. We sought to identify the barriers to effective communication between Indiana University Simon Cancer Center (IUSCC) oncologists and ROs. Methods: We retrospectively analyzed communication surrounding the visits of consecutive new oncology patients (pt) to IUSCC during Dec 2017 and Jan 2018. Demographics, diagnoses, RO’s information, and IUSCC physician’s information were recorded from the electronic medical record (EMR). ROs were contacted and a questionnaire was administered about timeliness, methods, and satisfaction with the communication. Results: A total of 110 new pt consultations were undertaken during the study period. There were 9 self-referrals, 69 interfacility referrals from the IU Health system, and 32 referrals by community RO. We were able to reach 27 community ROs, and their comments were included in the final analysis. RO interviews revealed that 78% had received notes (21 of 27 visits). Median time from pts’ clinic visit at IUSCC to ROs receiving a note was 2.5 days (range, 0-38 days). Five (25%) notes were received on the same day of consultation, and 10 (50%) were received within 2-7 days from pt visit. Of 18 traditionally dictated notes, 16 (89%) were received by ROs. Of 9 EMR typed notes, 5 (55%) were received by ROs. Only 62% of ROs received notes when their information was missing in the EMR. Based on feedback from ROs, effective communication was defined as communication within 7 days from pt visit. Ineffective communication was seen mostly on Mondays, followed by Fridays (75% and 50%, respectively). Conclusions: Effective communication was achieved in 75% of consultations. Effective communication was impacted by the day of the week, accuracy of RO information in the EMR, and the method of note documentation. Correcting ineffective communication can be explored through improvement of both human factors (ex.reinforcement of timely communication goals with physicians) and system factors (ex. Improving the accuracy of RO data in the EMR). Checklists, audits and other process analytics may help overcome the barriers identified.
Hospital variation in outcomes after surgery for prostate cancer.
Authors: Hassett Michael J. , Mossanen Matthew , Weng Shicheng , Cronin Angel M. , Uno Hajime , McNiff Kristen K.
Published: September 2018

28

Background: Surgery for prostate cancer can lead to adverse outcomes, such as incontinence and erectile dysfunction. Studies have identified hospital variation in survival after surgery for other types of cancer; few studies have assessed hospital variation in outcomes after prostate cancer surgery. We sought to characterize hospital variation in incontinence/erectile dysfunction (IED) and overall survival (OS) after prostate surgery. Methods: Using SEER-Medicare claims, we identified men > 65 years old who had surgery for prostate cancer from 2009-13, excluding those with metastatic disease, chemotherapy, or radiation therapy. We computed the difference in the number of days with claims for incontinence or erectile dysfunction in the year after versus the year before prostate surgery (IED score). Then, we assigned each patient to the hospital where prostate surgery was performed, and derived the mean IED score for hospitals that treated ≥10 patients (n = 239). Hierarchical linear and cox regression models were used to assess the association of patient, tumor, and hospital factors with the IED score and OS, respectively. The Kaplan-Meier method was used to estimate 3-year OS. Results: Among 10,850 Medicare-insured men with prostate cancer, the mean difference in claim-days for incontinence or erectile dysfunction during the year after versus before prostate surgery was +2.34 (standard deviation [SD] 3.72, minimum -18, maximum 54). After rescaling the IED score using a 0 (worst) to 100 (best) scale, the mean unadjusted hospital performance was 52.7 (SD 8.0). Controlling for other factors, hospital, NCI-cancer center designation (comprehensive vs. none), region in the US (south or west vs. northeast), and type of prostate surgery (open vs. not) were associated with a higher IED score. The mean 3-year OS across all hospitals was 98% (SD 3%). Conclusions: This claims-based analysis identified significant variation in incontinence/erectile dysfunction after prostate cancer surgery by hospital, but not by patient socio-demographic factors. The IED score may help identify opportunities to improve outcomes. Efforts to validate claims as indicators of patient-centric outcomes and to explore the reasons for hospital-level variation are needed.
Strategies for reducing grade 2 and 3 adverse events due to immunotherapy in a Spanish university hospital.
Authors: Gomez Ana , Gómez Solana Paloma , Ruiz Elena , Anton Antonio , Aranda Enrique , Camps Carlos , Constenla Manuel , Cruz Juan Jesús , Díaz Rubio Eduardo , Feyjoo Margarita , García Foncillas Jesús , Gascon Pedro , Guillem Vicente , Lopez Rafael , Lugo Ilse , Carrato Alfredo
Published: September 2018

288

Background: To develop an improvement project, the Lung Cancer Unit of Ramón y Cajal Hospital (Madrid) analyzed 45 patients treated with immunotherapy in 2017 and detected that 55% presented moderate-to-severe Adverse Events (AEs). Consequently, a specialized team from Ramon y Cajal Hospital and ECO Foundation proposed to identify improvement areas that reduce grade 2 (G2) and 3 (G3) AEs. ECO is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Methods: The team used as an instrument the American Society of Clinical Oncology (ASCO) Quality Training Program (QTP). A data collection process was conducted before attending the first out of three sessions of the QTP with the revision of medical records from lung cancer patients. The goal for the final QTP session in late-June 2018 was to reduce G2 and G3 AEs by 25%, by standardizing patient education sessions using ASCO guidelines for the management of immune-related AEs. Results: The data collected showed that G2 and G3 AEs had an impact on quality of care, specifically a treatment delay in 31% of patients, unscheduled visits in 19%, serious complications in 11% and patient dissatisfaction with the reporting system. The team created a cause and effect diagram, in which the most relevant causes were inadequate patient knowledge and a lack of communication with patients between visits, in addition to a Pareto chart, in which the more frequent AEs were asthenia, respiratory infection, cough, among others. A run chart of percentage of G2 and G3 AEs during 2017 displayed that G2 AEs were higher during January and August; and G3 AEs in February and December. The team, including patient advocates, prioritized the implementation of these short-term measures for patients: improvement of education, education follow-up, satisfaction questionnaire development and AE knowledge test. By mid-June 2018, new data will be collected to determine the effectivity of these measures. Conclusions: This improvement approach indicates the need to continue further quality projects in healthcare. Broader participation of Spanish hospitals in improvement initiatives will enhance the goal of a quality-oriented health care system.
Oral chemotherapy adherence tracking program implementation at a medically underserved comprehensive community cancer center.
Authors: Chandra Abhinav Binod , Sweigart Mary , Alvarez Angelic , Kumar Vivek
Published: September 2018

294

Background: The field of oncology has witnessed a significant increase in the number of oral antineoplastic agents over the last several years and their utilization is expected to grow. Several deficiencies in procedures for safe management and monitoring of oral chemotherapy regimens remain unaddressed. Rates of adherence to oral antineoplastic agents have varied in literature and not widely studied. There is paucity of data on impact of oral chemotherapy adherence to patient outcomes or emergency room visits. Methods: Baseline oral chemotherapy adherence was tracked in new oral treatment plans. This was supplemented with education of staff to run reports and increase chemotherapy tracking with special focus on education and follow ups. Over 9 month period, the oral chemotherapy tracking process was implemented with the goal of 80% tracking being achieved. Emergency room (ER) visits were calculated on patients having active oral chemotherapy care plans during a 3-month period before and after implementation of the program. Results: Reporting metric for compliance with oral tracking showed improvement from 5% completed reports to 84% completed reports over 9 months. The goal set to achieve 80% tracking was reached. The program was successfully implemented from January 2017 – September 2017. Prior to implementation of the program, over a 3-month period, 55 patients were receiving active oral chemotherapy care, with 56 encounters of ER visits by 30 patients related to their cancer. After successful implementation of the program and with consistent 80% chemotherapy tracking in place, we analyzed data for another 3-month period. During this 3-month period, 108 patients were receiving active oral chemotherapy, with 31 encounters of ER visits by 17 patients for their cancer. Conclusions: Implementation of a tracking program for oral chemotherapy led to 72% reduction in emergency room visits by patients on oral chemotherapy care plans. We were successfully able to implement an oral chemotherapy adherence tracking program in a medically underserved comprehensive community cancer program. A prospective study can further validate the findings of this study.