bluuebunny/crossref_metadata_2025 huggingface dataset:
Do advance directives predict receipt of palliative care? An evaluation of a single-institution in the Veterans Administration health care system.
Authors: Patel Manali I. , Bhattacharya Jay , Asch Steven M , Kahn James
Published: February 2017

203

Background: Cancer-related deaths are often preceded by high utilization of non-beneficial care that may contribute to poor quality of life, adverse symptoms, and high costs. Over the past several years, there is increased attention on palliative care to limit these challenges. Yet, rates of palliative care referral at the end of life remain low, and there are few studies that evaluate why. Our objective is to study whether one potentially important factor among patients with advanced cancer, advance directives, influence referral to palliative care among patients with advanced cancer. Methods: We conducted a retrospective chart review of all patients diagnosed with Stage III and IV cancers and treated at the Veterans Administration Palo Alto Healthcare System (VAPAHCS) in Fiscal Year 2012-2013. Chi-squared tests estimated differences in receipt of palliative care by individual- and clinical-factors. Logistic regression models estimated odds of receipt of palliative care after adjustment for individual and clinical factors). Results: There were 276 patients diagnosed with Stage III and IV cancer during the years of study. No records were excluded from analysis. Median age at diagnosis was 68; thoracic cancers were the most common (31%, p = 0.001). A minority of patients (45%) received palliative care or hospice. Rates of referral to palliative care and hospice were highest among patients with stage IV disease (p=0.003). In logistic regression models adjusted for individual and clinical factors only stage of disease predicted increased odds of palliative care and hospice referral. We could not reject the null hypothesis that presence of an advance directive increased palliative care or hospice treatment. Conclusions: Advance directives may be a useful tool to help patients transition to palliative care and hospice, however, we found no influence of advance directives on the receipt of these services in our VA facility. Future studies should evaluate other factors that predict receipt of high quality end-of-life care for patients with cancer.
Patient and physician factors associated with overuse and underuse of cancer screening: A factorial, cluster-randomized trial.
Authors: Talcott James Austin , Cassano Kelly A , Cohen Roy , Herzstein Jessica , Fowler Floyd Jackson , Balakrishnan Aparna , Osborne Michael P.
Published: February 2017

206

Background: Cancer screening, like other interventions, requires close patient-provider collaboration. By patient recall, key elements are often omitted from informed consent discussions. Most screening guideline compliance efforts focus on reducing underuse, but overuse is also harmful and may be influenced by distinct factors. Therefore, we are performing a prospective randomized trial of educational interventions to improve screening compliance for breast, cervical, colorectal, lung and prostate cancer at an urban academic medical center. Our hypothesis is that gender, age, prior screening experience, provider recommendations, anticipated benefit and distress, communication and informational support will affect compliance. Our primary data collection will be complete before the Symposium. Methods: We will enroll an age- and sex-stratified sample of 216 patients aged 40 to 89 years, 18 each treated by 12 primary care physicians at two affiliated hospitals, undergoing an annual physical examination in a cluster-randomized prospective trial of educational supports for screening. Screening guideline format (color-coding) and academic detailing will be randomly assigned independently. Patients and providers are surveyed immediately after the encounter to record their recollections of screening discussions and recommendations and their plans. Follow-up surveys at 3, 6 and 12 months assess concordance between expressed screening intentions and behaviors. Results: Pilot results indicate patient gender, age, anticipated screening-related distress and benefit, and prior screening experience affect screening recommendations and intentions. These factors vary by cancer. Patients recall less discussion than providers. Reasons not to screen are infrequently discussed. Conclusions: Cancer screening decisions are complex and vary by screening modality, patient and provider factors and communication. Improving underuse and overuse compliance may require distinct strategies. Screening overuse may be a “lower-stakes” environment to develop strategies to reduce overuse of cancer interventions of marginal or negative benefit, including treatment.
An interdisciplinary model of collaboration between medical staff (MS), hospital quality improvement (QI), and continuing medical education (CME) departments to promote education and practice changes in the prevention of venous thromboembolism (VTE) in cancer patients (pts).
Authors: Leong Lucille A. , Mendelsohn Mary , Saavedra Crystal J. , Morgan Robert
Published: February 2017

215

Background: Venous thromboembolism (VTE) is a leading cause of morbidity/mortality in cancer pts. VTE is increasing and is the second cause of death in cancer pts, behind only cancer itself. In 2010 of the 186 unique hospitalized cancer pts at our institution with VTE, 25% were medical and 75% surgical. Gaps in clinician knowledge/practice of VTE prevention were evident. Methods: A interdisciplinary approach across clinical and administrative specialties was undertaken, with collaboration between: medical/surgical oncologists, MS leaders, pharmacists, nursing, and hospital departments of QI, information technology, and CME, to educate a target group of 120 cancer clinicians in VTE prophylaxis. In 2/2013 - 2/2014 multiplatform educational initiatives were utilized to reach physicians, advance practice/ward nurses and pharmacists: didactic lectures, Key Opinion Leader visiting professorships, online vignettes, VTE FAQ emails from MS QI leaders, small group sessions, e-learning modules. System changes such as standardized VTE prophylaxis order sets tailored for each service and strategically placed visual cues were also used. Results: Almost 3 times as many unique learners participated in these activities as were targeted. Learner satisfaction, knowledge acquisition and competency were high. Compliance with use of standardized order sets improved from 65 to 95% among the MS. Claims by clinicians of pt contraindications to prophylaxis were audited and found valid. Despite these improvements, incidence of VTE has not dropped, reflecting a national trend. Conclusions: With intensive and interdisciplinary effort, progressin clinician knowledge and performance in VTE prophylaxis can be made. This effort required considerable input from physician champions (eg., surgical oncologists with overlapping roles of clinician, QI advocate, and departmental leader, and medical oncologists with roles of clinician, CME and MS leader). This is a promising model for other QI initiatives. Supported by Unihealth educational grant.
A clinical care pathway to improve the acute care of patients with glioma.
Authors: Riblet Natalie , Snide Jennifer , Schlosser Evelyn , Nalepinski David , Jalowiec Lanelle , Ronan Lara Kunschner , Mason Linda , Kennedy Nancy , Powers Sabrina , Cooney Tobi , Thorley Katherine , Fadul Camilo E.
Published: February 2017

217

Background: Gliomas account for nearly 80% of primary malignant brain tumors and are associated with poor survival. Developing clinical care pathways to ensure that patients receive coordinated, comprehensive and timely care may result in improved outcomes and patient satisfaction. Methods: A quality improvement (QI) project was chartered to improve the care provided to patients with glioma. A multidisciplinary team was convened and met weekly and then monthly from Feb 2013 – April 2014. Twenty best practice measures were identified from the literature. Using a Plan-Do-Study-Act framework, the team brainstormed and implemented various improvement interventions between Oct 2013 and Feb 2014. Statistical process control charts were used to evaluate progress. A dashboard of quality measures was generated to allow for ongoing reporting. Results: Retrospective data was available for 12 best practice measures; 6 of which could be abstracted from electronic medical records. Eight measures were not part of the current system of care. The baseline population consisted of 98 patients with gliomas. Review of their records suggested wide variation in performance, with compliance ranging from 30% to 100%. Unanticipated opportunities for improvement included a high proportion of outpatient falls (7%) and urinary tract infections (10%). The team hypothesized that lack of standardization in the current process may contribute to less-than-ideal performance. After implementing improvement interventions, the records of 19 consecutive patients with glioma were reviewed. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre QI-work; 78% post-QI work). There were no additional cases of urinary tract infections. Barriers to pathway development included difficulties with transforming manual measures into electronic data sets and accounting for portions of care that occurred at outside facilities. Updated outcomes will be presented. Conclusions: Creating evidence based clinical care pathways for addressing the acute care needs of patients with glioma is important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.
Effect of inpatient radiation delivery on length of stay and health care costs.
Authors: Pintova Sofya , Holcombe Randall F. , Blacksburg Seth , Friedlander Philip Adam
Published: February 2017

225

Background: Healthcare costs continue to rise. Identifying areas for healthcare utilization savings may be useful in reducing costs. The goal of this pilot study was to identify oncologic patients who remained in the hospital to receive radiotherapy treatment with the purpose of measuring length of stay (LOS) and charges associated with delivering inpatient radiation. Methods: Between July 1, 2013 and July 31, 2013 patients receiving inpatient radiation were identified. Actual LOS and end of acuity LOS were determined from the chart review. Expected LOS was calculated using the UHC database. Charges associated with actual LOS, end of acuity LOS and expected LOS were then reported. Comparisons of the actual and expected LOS were made between the radiation and non-radiation cohorts. Results: Seven patients were identified as remaining in the hospital to receive radiation treatment. There were 50 solid oncology patients admitted during July 2013 that did not receive radiation therapy. The seven patient cohort accounted in total for 281 days of hospitalization, with an average of 40.1 (+/-43.3) days per patient. The end of acuity LOS averaged 25.6 (+/-42.8) days per patient. The mean LOS attributed to radiation alone was 10.7 days. In contrast, the actual LOS for the 50 patients admitted to the solid tumor oncology service without radiation treatment, was 6.7 +/-4.9 days. The patients receiving radiation had a statistically significant longer actual LOS 40.1 vs 6.7 days (p<0.0001). The expected LOS for patients who received radiation was on average 7.7 days versus 5.2 days in the cohort that did not receive radiation, (p=0.0098). In the radiation cohort, the charges associated with the actual LOS per patient, end of acuity LOS per patient and expected LOS per patient were respectively $48,724, $34,089 and $10,028. The charges attributed to radiation alone amounted to $12,514 per patient. Conclusions: Delivery of radiation therapy during inpatient hospitalization extends LOS and contributes to higher healthcare costs. Methods to address this issue may result in cost savings.
Improving the quality of multidisciplinary care for head and neck cancer.
Authors: Lewis Carol M. , Nurgalieva Zhannat , Lai Stephen Yenzen , Weber Randal S.
Published: February 2017

232

Background: As specialty- and disease-specific treatment recommendations based on the best available evidence and/or expert consensus, clinical practice guidelines such as those set forth by the National Comprehensive Care Network (NCCN) establish the current standard of quality care; adherence to these guidelines can serve as a measure of the quality and effectiveness of care. We aimed to assess multidisciplinary conference (MC) treatment recommendations’ adherence to NCCN head and neck cancer guidelines, while identifying potential areas for quality improvement. Methods: Patients presented with previously untreated head and neck cancers are being prospectively accrued as they are presented at weekly MC. The charts of patients presented between 10/20/2011 and 10/20/2013 were reviewed for clinical data leading up to MC to allow us to assess whether, based on the available information, the recommendations of conference are compliant with NCCN treatment guidelines. Results: Of 556 enrolled patients, 49.1% had oropharyngeal cancer, 28.2% had oral cavity cancer, 19.3% had laryngeal cancer, and 3.4% had nasopharyngeal cancer. For the entire cohort, the mean age at presentation was 58.9 years (16.4 - 89.3). Four hundred forty three patients (79.7%) were men. The recommendations of conference were non-compliant with NCCN treatment guidelines for 6.2% patients (17/273) with oropharyngeal cancer, 13.4% patients with oral cavity cancer (21/157), 0.9% patients (1/107) with laryngeal cancer, and 15.8% patients (3/19) with nasopharyngeal cancer. The most common reasons for non-compliance were recommended treatment of N2 oropharyngeal disease with definitive radiation alone (13 patients) and recommended over-use of induction chemotherapy (14 patients). Conclusions: NCCN guideline compliance can be used to evaluate the quality of head and neck cancer care. We have identified areas for potential improvement within our institution. Further study is needed to evaluate how care that deviates from NCCN guidelines affects patient outcomes.
Development and implementation of a longitudinal quality assessment for community outreach programs.
Authors: Martins Yolanda , Gonzalez-Suarez Elizabeth , de Zengotita Luis , Contreras Magnolia , Levine Anne L
Published: February 2017

235

Background: Part of Dana-Farber Cancer Institute’s mission is to educate the community and raise awareness about the importance of cancer prevention, outreach, screening, early detection, clinical trials and survivorship. Development of a logic model and evaluation plan enables us to assess program quality and identify areas for improvement and future outreach. Methods: A forward logic, iterative approach was used to develop logic models for our community outreach programs. Models were reviewed by key stakeholders including program staff and management. These were used as the basis for a comprehensive logic model encompassing the common elements across all programs. Results: Seven logic models were developed to capture work in tobacco, sun safety, breast health, obesity prevention, community education programs, as well as comprehensive community benefits program model. We designed a developmental evaluation to allow for an assessment that could be adapted in a dynamic, ever-changing environment. This approach is also responsive to program growth and changes. It measures demographic information about our community participants, satisfaction with our programs, and strength of our community partnerships and compares these to internal benchmarks and state information. We can re-contact participants for on-going assessments and provide cross-sectional and longitudinal reports. RedCap freeware was used to create online versions of all tracking measures. Since (date) we have captured information from 119 community participants, most of whom are Black and Latino/a, and are representative of traditionally underserved minorities. Conclusions: Logic models and evaluation plans are integral components of community outreach programming. They ensure that effective, high-quality community outreach programming is being delivered, allow for the assessment of impact and assessment against program benchmarks. More importantly, they provide continuous information about areas for program growth and improvement.
Identification of quality care standards and development of indicators in oncology.
Authors: Camps-Herrero Carlos
Published: February 2017

239

Background: Continuous assessment of clinical practice is a fundamental strategy for improving quality care. The generation of indicators in the context of clinical practice standards is the key factor for its success. The purpose of this work is to identify and establish standards in medical care of patients with breast, lung and colon cancer and to develop their indicators. Methods: The project was performed in 4 cycles: (1) Identification of clinical care standards for patients with lung, colon and breast cancer through research for scientific evidence. It was structured in four stages: diagnosis and treatment for every cancer and organisation of palliative care services at the end of life, equal for all three groups. (2) Revision of standards by an expert group of 9 oncologists. (3) Selection of standards for the generation of the indicators using the Delphi method, modified by a panel of experts consisted of 39 oncologists. (4) Development of indicators for the selected standards. Results: During the first revision 98 recommendations and standards were approved and selected by the group of experts and presented to the second panel of experts. Finally through the Delphi method 50 standards were selected, applicable to national level. For each one of the 50 standards an indicator was formed, 10 indicators for the organisational stage, 10 for the palliative care and 10 indicators specific for the diagnosis and treatment of each one of the cancer groups (colon, breast and lung). Conclusions: A total of 50 indicators were generated as measurement of parameters related to the quality of clinical practice and the organisation of care for patients with breast, colon and lung cancer. Their use is fundamental in identifying areas for improvement that will allow the identification of future strategies of quality care.
Value proposition for colorectal cancer (CRC) screening (SC) in underinsured populations (UP).
Authors: Barzi Afsaneh , Sadeghi Sarmad
Published: February 2017

24

Background: SC for CRC is an effective preventive tool. In ASCO 2013 we reported that costs of SC are quickly offset by a reduction in the management costs of CRC rendering No Screening financially unsound. This is particularly relevant to the Medicaid and other UP where low reimbursements result in lower availability and inconsistent practice of SC creating an impediment to better outcomes and is a key part of outcome disparities. Methods: Twelve strategies (STs) and 1.4 million individuals were simulated to examine the role of participation (PA) in the SC on effectiveness and cost effectiveness of each SC ST. Individuals > 50 with average risk of CRC and 1/1 male to female ratio were followed for up to 35 years with SC stopped at 75. PA was increased by 10% increments between 20% and 80%. Results: Our results demonstrated that FOBT and colonoscopy (CS) are consistently cost effective STs independently of the level of PA. The incremental cost effectiveness ratios (ICER) of CS relative to FOBT remain flat as PA increases. The absolute difference in life years gained between FOBT and CS ranges from 0.014 to 0.30. Sensitivity analysis reveals that costs of FOBT can be increased before CS becomes more cost effective. Conclusions: Given the limitations of resources within provider networks primarily supported by Medicaid, FOBT can be deployed as the SC modality of choice and efforts maybe focused on increasing PA. To this end, Medicaid can potentially offer more competitive reimbursement rates for fecal testing, thereby incentivizing providers. This will improve quality as reflected in the outcomes and is more pragmatic in terms of resources it requires. [Table: see text]
Model of quality care indicators for patients with colorectal, lung, and breast cancer.
Authors: Diaz-Rubio Eduardo
Published: February 2017

241

Background: The care of an oncology patient is a complex process with important clinical, social and financial repercussions. The purpose of this work is to develop quality care indicators for the medical care of patients with cancer. It is fundamental that health organisations adopt such models based on quality standards with the intention to promote excellence in the care of cancer patients. Methods: Research for scientific evidence, revision and selection of standards using the Delphi method was employed and definition of indicators was established. Results: 50 quality indicators were created directed to: Organisation: Multidisciplinary committees; informed consent; patient security; elapsed time between diagnosis and treatment; tumour registry; treatment protocols. Colorectal cancer: Histopathology report and markers; chemotherapy for advanced/metastatic cancer; evaluation of staging of colorectal cancer; liver metastases; adjuvant chemotherapy; evaluation of history family; biological therapy and RAS gene mutation; radiotherapy; quality of surgical notes. Breast cancer: Histopathology report and markers; initial staging; hormonotherapy; other treatments; elapsed time between histological diagnosis and treatment and between surgery and adjuvant treatment; pre-operative assessment and conservative surgery focused on the armpit; access availability to initial radiological studies.Lung cancer: Histopathology report and markers; initial staging; elapsed time between histological diagnosis and treatment; concomitant chemoradiotherapy; evaluation of chemotherapy response; adjuvant chemotherapy; elapsed time till the completion of staging; surgery; chemotherapy with good functional status; adjuvant radiotherapy; concomitant chemoradiotherapy for small cell lung cancer. End of life: Organisation of palliative care; outpatient attention; identify patients; access to care; pain management; information availability; psycosociological support; constipation management; counselling of family after death. Conclusions: The indicators constitute a reference model based on standards in order to measure care quality and to compare achieved results among health institutions.
Adjuvant chemotherapy selection for stage I NSCLC 2011 through 2014 in the southeastern United States.
Authors: Mamgain Avinash , Huff Dinah Faith Q. , Bennett Charles L. , Shimp William S. , Baranwal Anmol , Bobolts Laura Rose , Armitage Melissa , Davis Sharon , Schorer Anna E. , Fishman Marc L. , Fishman Val , Walton Robert , Kogler Jurgen , Hrushesky William J.
Published: February 2017

248

Background: Among patients with early stage non-small cell lung cancer (NSCLC), appropriate use of adjuvant chemotherapy is an important determinant of survival. Existing level 1 data, which includes analysis of five cisplatin-based phase III trials (IALT, BLT, ALPI, ANITA, NCIC-CTG-JBR.10), two carboplatin-based phase III trials (CALGB 9633 and NATCH Trial), and two meta-analyses (LACE, MRC), demonstrate only cisplatin-based adjuvant chemotherapy regimens enhance overall patient survival. Most importantly, these studies also reveal that survival advantage from adjuvant chemotherapy does not extend to stage I patients, but only to stage II-IIIA patient subgroups. Unplanned a posteriori subset analyses indicate the possibility that certain stage I NSCLC with one or more "high risk" characteristics may benefit from cisplatin-based adjuvant chemotherapy. This hypothesis must be properly tested before it can be adopted. We, herein, hypothesize that many US stage I NSCLC patients are routinely treated in the adjuvant setting with regimens that have not demonstrated level one overall survival benefit. Methods: We examined chemotherapy request data for stage I & II NSCLC, submitted to a private health insurer by oncologists for the adjuvant treatment of NSCLC patients in the southeast US from January 2011 through May 2014. Results: Overall, 25% (67/264) of adjuvant chemotherapy requests were for stage I NSCLC patients (potential overuse). The frequency of these requests has increased over time: 17% in 2011, 20% in 2012, 30% in 2013, 34% in 2014. Four out of five of patients with stage I NSCLC (52/67) were given carboplatin-based regimens, while only one in five (19%, 13/67) received cisplatin-based regimens, and 3% (3/67) were pemetrexed-based regimens (potential misuse). Conclusions: High misuse and overuse rates of adjuvant chemotherapy for stage I NSCLC are observed among the privately insured populations of Florida, Texas and Georgia. Quality improvement initiatives in this patient population may be indicated to prevent potential harm from treatments advised against by ASCO, ESMO, NCIC, NCCN and UK guidelines.
Regional initiative to define, collect, and report value metrics in cancer care.
Authors: Kreizenbeck Karma L. , Hughes Erin E. , Stewart F. Marc , Brown Thomas David , Chen Eric Y. , Corman John M. , Curry Thomas , Glenn Michael , Lonergan Matt , Martins Renato , Rieke John , Saikaly Elie P. , Szalwinski Mark , Chauhan Rakesh T , Lyman Gary H. , Ramsey Scott David
Published: February 2017

25

Background: In the context of numerous national initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research, in partnership with local healthcare delivery organizations, patient advocacy groups, payers, and policymakers launched a regional, stakeholder-driven initiative to define 3-5 “value-based metrics” for cancer care for Washington State. Methods: Representatives from major cancer care delivery organizations, patient advocacy groups, payers, and policymakers were invited to participate in a day-long Value Summit. Attendees were tasked with identifying metrics that considered both costs and outcomes. Trained facilitators helped participants identify metrics for 9 domains: appropriate use of effective therapies, adherence to best practices, survival, comprehensive disease management, efficiency of care, hospice/palliative care, patient and family satisfaction with care, patient reported outcomes/preferences and safety. After the initial list was generated, attendees were then asked to rank the metrics on the basis of feasibility to collect, clinical relevance, ability to act on, meaningfulness to multiple stakeholders, and willingness to report statewide. Attendees were then asked to participate in 3 domain-specific facilitated breakout sessions to prioritize the top metrics for each domain. Breakout sessions reported top metrics for a final group prioritization exercise. Following the Summit, attendees provided feedback on the final rankings. The metrics were then presented at a Town Hall style meeting for public comment. Results: Over 70 participants, representing 20 different organizations, identified 750 unique metrics from 9 domains. The prioritization process yielded 3 areas of interest, with 2 specific metrics within each: end of life and palliative care (metric 1, metric 2); adherence to best practices (metric 3, metric 4); and coordinated and efficient care (metric 5, metric 6). Follow-up surveys of Summit attendees and the Town Hall forum showed widespread support for these metrics Conclusions: Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus around value metrics in cancer care.
Universal truths: Learning from the experience of cancer patients in Australia and England.
Authors: Lacey Karen , Schofield Penelope , Krishnasamy Meinir , Lethborg Carrie , Cashill Elizabeth , Thompson Eileen , Butty Jill , Mollo Adele , Morrone Assunta , Byrne Jenny , Bishop James F.
Published: February 2017

255

Background: Self-reported patient experience data is vital to the design of responsive and relevant health services. Annual Cancer Patient Experience Surveys in England (NHS-CPES) have been used to effectively guide and monitor improvements in patient experience. This study measured baseline cancer patient experience in member hospitals of the Victorian Comprehensive Cancer Centre in Australia, and benchmarked this with cancer patients in England. Methods: The NHS-CPES instrument and methodology was used. A paper-based questionnaire was mailed to 5,722 admitted patients aged >18 years with an eligible ICD-10 code. Australian results were compared to 71,793 patients in England from the 2011/12 NHS-CPES. Results: 37% (2,101) patients responded. Most patients rated their overall care as very good or excellent (91% Australia, 88% England). Having a named nurse specialist was a key predictor of experience. Patients with a specialist nurse were significantly more positive in 50 questions in Australia (77%) and 64 questions in England (98%) compared to patients without one. In both countries, patients with rarer cancers tended to be less positive than those with other cancer types. Australian patients with brain/central nervous system cancers and sarcomas gave the lowest score in 46 questions (71%). Patients with a disability or a long-term condition, and those from minority ethnic groups were also less positive. Relevant patient information was lacking; only 65% of patients in Australia and 77% in England were given understandable written information specific to their care, and a little over half received information about financial entitlements (58% Australia, 52% England). Conclusions: Cancer patient experience using the NHS-CPES has been successfully measured and compared across two different health systems. Findings in Australia are similar to those in England suggesting the same key issues affect all cancer patients. Important areas for quality improvement include the provision of tailored written patient information and the provision of named nurse specialists as part of the model of care. Acknowledgement: The authors thank Quality Health Limited for data analysis and the NHS for permitting use of the NHS-CPES.
Identifying patients at increased cancer risk: Validation of the Health Heritage risk assessment and decision support tool.
Authors: Baumgart Leigh A , Postula Kristen J , Hulick Peter J , Knaus William A
Published: February 2017

277

Background: Family history is critical to assess risk for cancer and inherited cancer syndromes. National Comprehensive Cancer Network (NCCN) guidelines are available to aid in identification and management of at-risk patients, but the guidelines are complex and ever-changing, hindering optimal use. This leads to under-recognition and mismanagement of high-risk patients. To address this need, we have developed and have fully implemented Health Heritage (HH), a web-based risk assessment and decision support tool. HH combines clinical data automatically extracted from a patient’s EHR with information entered by patients and shared between family members to provide personalized risk assessment and recommendations related to common cancers. This study aims to validate HH’s ability to properly identify patients who meet NCCN guidelines for a genetics evaluation and to stratify cancer risk. Methods: We performed a retrospective chart review of 100 patients seen at an adult genetics clinic in 2012. Relevant personal and family medical history and genetic test results were entered into HH. Independent of the HH assessment, each patient’s information was reviewed by a genetic counselor to assess fulfillment of NCCN guidelines for a genetics evaluation. A subset of records was reviewed to compare cancer risk stratification between HH and a medical geneticist. Results: 87 patients met NCCN guidelines for a genetics evaluation for breast/ovarian cancer, 2 for colorectal cancer, and 3 for multiple cancers; 8 patients did not meet guidelines. HH had a sensitivity of 98% and specificity of 88% in identifying patients who met these guidelines. For patients at increased risk for breast, ovarian, or colorectal cancer as determined by a medical geneticist, HH agreed 83%, 86%, and 75% of the time, respectively. Discordances were the result of both complex clinical situations better handled by the geneticist and also HH’s strict adherence to incorporating all information. Conclusions: Health Heritage is a highly sensitive tool for identifying at-risk patients appropriate for a genetics evaluation and its risk stratification is complementary in high risk settings requiring management recommendations.
Outcomes in cancer patients (pts) admitted to a surgical (SICU) or medical ICU (MICU) compared to a newly opened cancer specific ICU (HICU).
Authors: Stenehjem David D. , Bannon Meredith , Boltax Jonathan
Published: February 2017

279

Background: The University of Utah opened a cancer specific ICU (HICU) in 2011 admitting medical and surgical cancer pts. Prior to this, medical cancer pts were admitted to the MICU while the SICU admitted both and medical and surgical pts. The primary objective of this study was to compare the quality metrics of mortality and length of stay (LOS). Methods: Pts with a cancer diagnosis and admitted to the MICU or SICU from 2009-2011 or the HICU from 2011-2013 were evaluated. Pts were stratified by ICU type and the HICU was also analyzed by excluding post-operative pts (HICU-MED). Survival from admission, hospital and ICU mortality, and LOS was assessed. Results: A total of 1,375 pts were included with 259 (19%), 416 (30%), and 700 (51%) pts admitted to the MICU, SICU, and HICU, respectively. The median age was 62 years (range 18-91 years) and 57% (n = 787) were male; no significant differences in age (p = 0.1975) and sex (p = 0.7681) were observed between ICU’s. Cancer classification was oncology (65%, n = 888), hematology (32%, n = 435), and BMT (4%, n = 52). Of all pts admitted to the HICU, 44% (n = 308) were post-operative and excluded from HICU-MED (n = 392). See table for survival and LOS comparisons. Conclusions: No differences in overall survival and hospital morality (ICU and out-of-ICU) were observed comparing pts admitted to the HICU vs SICU and HICU-MED vs MICU. ICU-free days were significantly shorter resulting in shorter hospitalizations for the HICU vs SICU, which may have contributed to the reduced 30-day mortality in pts admitted to the HICU. [Table: see text]
Surgical interventions in cancer patients at the end of life: Experiences at an academic medical center.
Authors: Howie Lynn Jackson , Kamal Arif , Bhavsar Nrupen A , Power Steve , Mosca Paul J.
Published: February 2017

281

Background: Surgical quality measures look to reduce variation and improve outcomes. Procedure goals can range from cure to symptom improvement. Knowledge of procedures used in this population can inform quality metrics, ensure palliation is included and that metrics do not discourage interventions where benefits are other than traditional measures like mortality. Methods: Clinical and administrative data from 1,343 patients treated at an academic medical center from 2006 to 2013 were obtained. Using CPT codes, procedures were identified. Patients who underwent surgical procedures within 180 days of their death were then evaluated to determine the demographic, clinical and surgical characteristics of these cases. Patients <18 years of age and those with missing data were excluded from the analysis. Descriptive statistics were used to describe interventions among patients in the cohort. Results: From 2006 to 2010, 761 patients with cancer treated at an academic medical center had surgical procedures performed within the last 180 days of life. 38.8% of these patients were female, 82% were Caucasian, 15% were African-American, and 3% were other race. Median age was 67.9 years (interquartile range: 58.1 - 78.1). 158 had procedures performed ≤30 days of death, 295 ≤60 days of death, and 530 ≤120 days of death. The most frequent type of procedure performed ≤30 days from death were thoracic procedures including bronchoscopy, thoracentesis, mediastinoscopy and catheter placement for pleural fluid drainage (20.8%), ≤60 days of death 30.3% underwent thoracic procedures, and ≤120 days of death 24.5% underwent similar thoracic procedures. Conclusions: Surgical quality measures are thought to improve surgical outcomes. Evaluation of surgical data from a academic medical center demonstrates continued use interventional procedures in cancer patients within the last 6 months of life. This may in part be due to the symptom burden associated with these diseases. Further evaluation about the goals of interventional procedures in this patient population can inform the outcomes of primary interest in this population of patients who have high mortality due to their advanced disease.
Aggregating administrative and claims data from multiple payers to estimate population-based health outcomes: A validation study.
Authors: Kuo Tzy-Mey , Schenck Anna , Meyer Anne-Marie
Published: February 2017

285

Background: Health insurance claims data are increasingly used for estimating individual health outcomes. However, it is challenging to obtain population-based estimates because of difficulties obtaining and reconciling data from all insurance providers. With incomplete insurance data, methods are needed to estimate the entire insured population. Using multi-payer claims we demonstrate and validate a synthetic method to obtain county level morbidity estimates. Methods: We used data from the Integrated Cancer Information and Surveillance System (ICISS) data resource at the University of North Carolina (NC) at Chapel Hill. ICISS data represent a linked data resource comprised of beneficiaries enrolled in federal as well as private insurance plans and rich ecologic data; and represent 5.5 million unique individuals, about 55% of the NC population. Using specific ICD-9 diagnosis codes, claims data from 2008 were compared to state department of public health data. We computed county level hospitalization rates by summing data from three sub-groups: age 65 and older in the 100% Medicare sample, age younger than 65 in the 100% Medicaid sample, and age younger than 65 represented in the private payer data. For the privately insured population, we used census data to obtain estimates of the entire privately insured population and used the hospitalization rate from beneficiaries in ICISS data to estimate a numerator for the synthetic sample of privately insured beneficiaries. We used State Inpatient Data (SID) from NC County Data Book to validate our method. Results: Overall, our synthetic approach showed moderate to high validity with a Pearson correlation coefficient 0.77 for heart disease and 0.93 for flu or pneumonia. Our hospitalization estimates were slightly lower than the data from SID, because SID data include uninsured individuals and multiple hospitalizations for individuals. Conclusions: Our synthetic method can be useful in estimating population-based health outcomes using linked insurance claims data.
Is it time for quality time? Intensive medical oncology follow-up during treatment for esophageal adenocarcinoma.
Authors: Kothari Nishi , Shridhar Ravi , Hoffe Sarah E. , Meredith Kenneth L. , Fontaine Jacques , Fulp William J. , Almhanna Khaldoun
Published: February 2017

29

Background: Concurrent chemotherapy and radiation for esophageal cancer patients is morbid with many potential complications. The efficacy of intensive patient follow up by medical oncology during concurrent treatment was retrospectively evaluated at our cancer center. We hypothesized that weekly follow up would result in better compliance and less toxicity, leading to better outcomes. Methods: Patients with locally advanced esophageal adenocarcinoma referred to our cancer center for potentially curable neoadjuvant therapy were identified. Age, gender, radiation dose, weight loss, hospital admissions, and outcome were compared between patients who had intensive follow up and patients who did not. Wilcoxon Rank Sum Test and Chi-squared test, both exact tests using Monte Carlo estimation, were used to compare weekly follow-up status with continuous and categorical factors, respectively. Kaplan-Meier curves and Log-Rank tests were used for OS analysis, and a multivariable model was fit using Cox Proportional Hazard models. Results: 169 were patients eligible for analysis, including 154 men and median age of 66 years. 108 patients were seen weekly by medical oncology while on treatment. Groups had balanced baseline characteristics except for age; the weekly follow up patients were older (68 vs. 63 years, p=0.007). There was no difference in hospitalization rate (33% vs. 28%) or weight loss (4 kg vs. 4.7 kg) between groups. In multivariate analysis, advanced age and stage were associated with worsened OS. Weekly follow up did not lead to improved survival at 3 years (42% vs. 50%). Conclusions: This study is retrospective in nature, but to our knowledge it is the first of its kind to investigate the impact of intensive follow up during concurrent chemotherapy and radiation. Though we did not find improved outcome in patients who were seen weekly, a potential confounder is the older age of these patients. In addition, at our institution patients have close weekly follow up with radiation oncologists, dieticians and oncology nurses. While we were not able to substantiate our hypothesis that weekly follow up by medical oncology leads to improved outcomes, our preliminary findings merit further study.
Impact of physician visits on bone density testing in men with prostate cancer who receive androgen deprivation therapy.
Authors: Yong Candice , Onukwugha Ebere
Published: February 2017

291

Background: Clinical guidelines for men receiving androgen deprivation therapy (ADT) for prostate cancer (PC) recommend bone mineral density (BMD) monitoring. We examined physician visit patterns following ADT initiation and the implications for follow up BMD testing. Methods: We analyzed linked Surveillance, Epidemiology, and End Results (SEER) & Medicare data for men aged 65+ with incident non-metastatic PC diagnosed during 2007-2009 and receiving ADT for at least 6 months. We examined the proportion of men who visited the following physician types after ADT initiation: urologist, medical oncologist (MO), radiation oncologist (RO), and primary care physician (PCP). Physician contact was measured during 3 time periods: 3 months pre-ADT and 3 months post-ADT (P1); 3-6 months post-ADT (P2); and 6-9 months post-ADT (P3). Multivariable logistic regression models estimated the association between physician visits and BMD testing. Results: The sample included 4,631 men (median age: 75) with non-metastatic PC who received ADT over a median duration of 12 months. During follow-up, 12% received BMD testing, and median time from ADT initiation to BMD testing was 364 days. The proportion who visited any urologist, MO, RO, and PCP during P1 was 97%, 12%, 52%, and 71%. During P2, the proportions dropped to 69%, 9%, 19%, and 53%, respectively, and remained similar in P3. Physician visits during P1 were not associated with BMD testing. During P2, the adjusted odds ratio (95% CI) for BMD testing in men who saw a MO was 1.39 (1.04-1.86). During P3, the AOR (95% CI) was 1.52 (1.15-2.01) in men who saw a MO and 1.23 (1.02-1.49) in men who saw a PCP. Conclusions: In older PC men treated with ADT, physician contact was highest during ADT initiation and decreased over time. Continued contact with physicians following ADT initiation can be beneficial.
Investigating rates of CINV across settings of care in Medicare: A retrospective claims-based analysis.
Authors: Agatep Barnabie C , Faria Claudio , Knoth Russell L. , Chapman Richard H. , Inocencio Timothy J , Johnsrud Michael , Powers Annette
Published: February 2017

297

Background: Clinical practice may differ according to settings of care and may impact both the quality of care delivered and, ultimately, patient outcomes. This study describes the differences in chemotherapy-induced nausea and vomiting (CINV) rates between chemotherapy (CT) naïve Medicare cancer patients starting CT in a hospital outpatient (HOP) or community outpatient (COP) setting. Methods: Using the 5% Medicare Fee-for-Service standard analytic files, patients with a new claim of CT and ≥1 outpatient cancer diagnosis claim between 1/1/10 – 6/30/11 were identified. Patients with a previous inpatient cancer diagnosis, multi-day CT cycles or who switched CT relevant to emetogenic potential were excluded. CINV was defined using relevant claims-based ICD-9-CM diagnosis and procedure codes within days 2-7 of the first 8 single-day CT cycles or the first 6 months following the index CT claim. CINV events were evaluated descriptively and using regression models. Results: Medicare patients receiving CT in HOP (n=1,007) vs. COP (n=1,080) were similar in demographics such as age, race, and baseline healthcare costs. However, Medicare patients receiving CT in COP compared to those in HOP settings were more likely to be female (57.0% vs. 44.7%), breast cancer patients (27.6% vs. 16.0%), live in the South region (37.7% vs. 32.3%), have higher Charlson Comorbidity Index scores (mean 5.2 vs. 4.8) and receive moderately to highly emetogenic CT (44.1% vs. 36.0%) (all p<0.05). Overall, 13.9% had any CINV in the evaluation period. More CINV events per patient were reported among those in COP compared to those in HOP settings (0.43 vs 0.27, p <0.05). However, differences between settings of care were not shown to be significantly different in adjusted regression analyses (p=0.177). Conclusions: We found the population characteristics between Medicare patients treated with CT in HOP and COP to vary on a number of factors. However, after controlling for these differences, our results suggest the number of CINV events was similar across settings of care. Future research should further clarify how differences in quality of care for antiemesis between COP and HOP settings may impact the incidence of CINV events in this population.
Association between Oncotype DX and receipt of chemotherapy in early-stage breast cancer within the Medicare population from 2004 to 2007.
Authors: Dinan Michaela Ann , Mi Xiaojuan , Reed Shelby D. , Lyman Gary H. , Curtis Lesley H
Published: February 2017

309

Background: In 2004, the Oncotype DX (ODX) multigene assay became available to help guide physicians in their decision to recommend adjuvant chemotherapy in patients with early stage estrogen receptor (ER) positive breast cancer. ODX utilization within a non-academic, nationally representative breast cancer population has not been previously examined. Methods: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data of the association between ODX testing and receipt of chemotherapy in patients diagnosed with invasive, non-metastatic, ER-positive breast cancer between 2004 and 2007. Results: A total of 28,760 Medicare beneficiaries met study criteria. NCCN guidelines were used to stratify patients on the basis of clinical and pathologic features into low (<1 cm tumors, 24.4%), intermediate (≥ 1 cm tumors, 52.0%), and high (node positive, 23.7%) risk disease. In patients with low or intermediate risk disease, receipt of ODX was associated with increased chemotherapy utilization (13% vs. 1% and 19% vs. 8%, respectively; both P < 0.001), but not in high risk patients (30% vs. 39%, P= 0.34). Conclusions: Randomized trials have previously suggested the ability of ODX to decrease chemotherapy utilization. In this study, we observed increased chemotherapy utilization associated with receipt of ODX in patients with low and intermediate NCCN risk disease. Association between ODX and chemotherapy utilization in observational studies may be impacted by preferential administration of ODX testing to patients being considered for chemotherapy. [Table: see text]