bluuebunny/crossref_metadata_2025 huggingface dataset:
Customization of electronic health record (EHR) to implement meaningful use for quality improvement (QI).
Authors: Miller Laura M. , Heard Bridgette , Howard Kendall , Kumar Pankaj
Published: February 2017

246

Background: Meaningful Use is a government program that encourages providers to use an electronic health record (EHR) for QI. The goals of MU are to have complete and accurate information in the patient’s electronic record and share that information with other care providers to improve the quality of patient care and avoid duplication of services. The MU program is divided into 3 stages. Providers can earn incentive bonuses for successfully reporting on MU criteria set forth by CMS. There are incentive bonuses for each year until 2015 when penalties for non-reporting are assessed. Stage I has 20 criteria to report on with thresholds for 11 of the criteria. In stage II and III those thresholds will increase. When using an EHR, user efficiency is particularly important. Our goal was to collect MU data by facilitating efficient workflow and taking the documentation burden off the providers. Methods: We identified the MU criteria that required data collection. Some criteria required one time patient data; others involved collecting data at each patient visit. Committees were formed. Processes and responsible staff were identified. We customized features in our EHR to maximize efficiency for the staff collecting the data. We used reports to audit compliance with data collection. Results: We successfully met and reported all 20 Meaningful Use criteria for 16 providers in 2012 and are on track to meet all criteria again in 2013. 11 criteria had measureable thresholds. The average threshold for the 11 measures is 54.5%; our average for the 16 providers for those 11 measures is 86.8%. We collected $288,000 in incentive money for 2013. Since most of the data collection is done by staff, physician documentation is minimal. Conclusions: Customization of EHR allowed us to collect MU data efficiently, obtain the financial incentive in 2012 and helped us get ready for stage II of data collection.
Utilizing a “navigation app” to ensure quality and consistency of oncology patient navigation.
Authors: Sheaffer Heather
Published: February 2017

251

Background: Measuring the impact of the patient navigator has presented an on-going challenge since the inception of patient navigation in 1990. The Oncology Navigation team initially relied upon a spreadsheet to record data later utilized to evaluate the quality of the program however the spreadsheet did not meet the needs of the navigators nor of those who attempted to make sense of the voluminous data collected. This abstract offers an overview of the creation and implementation of a Navigation App to record the navigation workflow-ensuring quality and consistency in practice. Methods: The Navigation App is a web-based platform serving as the framework into which navigation data is entered. The customized version allows the collection of data specific to the metrics of interest to navigation including: care coordination, triage, reinforcement of the care plan and appointment scheduling. The App was designed as a means of evaluating the quality of the navigation process but also serves as a useful tool in organizing the navigators’ daily workflow. Results: The creation and implementation of a Navigation App has illuminated the complexity of the role of the navigator by recording both quantitative and qualitative data. The App allows the navigators to collect “real-time” data detailing their daily workflow with patients, families and providers. The navigators were quickly able master the App and significantly reduce the time needed to record data from hours to minutes each month. Entering data into the App concurrently also allows for instantaneous evaluation of productivity and quality. Finally, the App has proved to be a valuable tool for navigators in organizing their daily workflow and in prioritizing patient and provider needs. Conclusions: A web-based Navigation App can serve as an invaluable tool in driving quality patient navigation. The App not only serves as a means of recording data but also as an organizational tool to maximize productivity, quality and consistency of navigation. Utilizing a web-based application as opposed to a spreadsheet allows both navigators and administrators to track workflows in “real time” to ensure the highest quality of service to cancer patients, families and providers.
Developing a virtual collaborative to facilitate palliative care and quality improvement learning in oncology.
Authors: Kamal Arif , McNiff Kristen , Prestrud Ann A. , Lupu Dale , Gavigan Molly , Zafar Yousuf , Schilsky Richard L. , Abernethy Amy Pickar
Published: February 2017

252

Background: Despite a strong evidence base and increasing calls for integration, oncologists find it difficult to deliver primary palliative care concurrent with standard oncology care. Solutions that promote practical integration of palliative care in oncology are needed. In an AHRQ-funded pilot, ASCO and the American Academy of Hospice and Palliative Medicine are developing the Virtual Learning Collaborative (VLC) to develop and test a scalable model for quality improvement and dissemination of best practices in palliative care within the oncology setting. Methods: The VLC will be a web-based learning and collaboration system built upon existing ASCO technology resources. We will select at least 25 oncology practices to participate in regular, facilitated learning sessions, collaborative discussions, and sharing of best practices. The VLC will equip each practice with the knowledge, tools, and coaching to select, test, and adopt a quality improvement intervention relevant to their own palliative care needs. Development of the VLC is ongoing; oncology practices begin participation in Spring 2014. Results: We will assess the VLC using protocol-driven evaluation methods common to technology development, quality improvement, implementation science, and educational initiatives. VLC usability, feasibility, and acceptability will be assessed through surveys of participating practices and focus groups. Longitudinal changes in conformance to palliative care metrics will be assessed using ASCO’s Quality Oncology Practice Initiative (QOPI) system. We will use mixed qualitative and quantitative evaluation methods to assess ongoing changes in clinician knowledge and self-efficacy in applying palliative care principles. Conclusions: We aim to develop and test a novel method for facilitating quality improvement and palliative care learning in oncology. Through this pilot, we will refine the VLC for implementation in the greater oncology community. Ultimately, this effort supports other ASCO and AAHPM quality improvement initiatives focused on clinician education and dissemination of best practices.
Creation and implementation of a corporate compliance program (CCP): The Illinois CancerCare (ILCC) experience.
Authors: Heard Bridgette , Howard Kendall , Miller Laura M. , Kumar Pankaj
Published: February 2017

256

Background: In 2000, Office of Inspector General (OIG) provided guidance for physician practices in the adoption of corporate compliance program (CCP). The notice provided a basic outline that would allow organizations to detect, prevent and possibly report potential fraud and abuse as it relates to federal health care payers. Insurance payers, e.g., United, Healthcare, and Humana, are also requiring organizations to institute CCP for reimbursement. As health care reform evolves there is will be a greater need for an alliance between providers and payers as each are increasingly held accountable for their actions related to ethical behavior in documentation, billing and coding, HIPAA, improper inducements, kickbacks, financial conflicts of interest, in addition to other areas. Methods: The Illinois CancerCare (ILCC) is one of the largest private oncology practice in Midwest. We implemented the components outlined by OIG by completing the following tasks: identifying and empowering a compliance officer; identifying high-risk areas; developing policies and standards for major processes that might lead to fraud, waste, or abuse; developing a training program for all physicians, NPs, and employees; creating and implementing an auditing and monitoring program; developing investigation and remediation standards; and establishing committees for oversight. Results: The entire process took 18 months to be fully functional. We have developed a plan that is completely complaint and meets all the criteria as required and our personnel have been trained. Conclusions: In future most large practices in the United States will likely be required to have a CCP. It is complicated and includes multistep processes. In the end, implementing a CCP allows organizations to show their desire to be a quality organization with internal monitors to ensure they are participating in federal health care programs using ethical standards.
Cost-minimization analysis of pemetrexed/carboplatin with maintenance pemetrexed (PemC) versus paclitaxel/carboplatin/bevacizumab with maintenance bevacizumab (PCB) in nonsquamous non-small cell lung cancer (NS-NSCLC).
Authors: Graham Christopher N. , Knox Hediyyih N. , Winfree Katherine B. , Hess Lisa M. , Liu Jingyi , Ortuzar Waldo Feliu , Zinner Ralph
Published: February 2017

263

Background: The PRONOUNCE trial was a phase III, randomized, open-label U.S. study comparing pemetrexed (PemC) with bevacizumab (PCB) in the treatment of advanced chemo-naive nonsquamous non-small cell lung cancer (NS-NSCLC). The primary endpoint of improved PFS without grade 4 toxicity for PemC over PCB was not met. There were no differences in PFS or OS. This analysis was conducted to estimate differences in costs of treatment and related patient care between the groups to inform evidence-based treatment decision making. Methods: A cost-minimization analysis was performed using data from the PRONOUNCE trial and publically available U.S. unit costs. Drug costs modeled included induction, maintenance, and subsequent therapies. Other estimated medical costs were drug administration, concomitant medications, and treatment of grade 3/4 toxicities. A probabilistic sensitivity analysis (PSA) was conducted to model joint uncertainty associated with model parameters. Results: The average cost of treatment with PemC was $4,689 less than PCB ($30,334 vs $35,024). Drug acquisition and administration costs were less in all modeled settings (induction, maintenance, and subsequent lines) for PemC. Costs associated with concomitant medications and grade 3/4 toxicities were similar ($13,286 vs $13,738). PemC was cost saving in 99% of 10,000 PSA iterations. Conclusions: Based on the PRONOUNCE trial and model results, PemC may present a similarly effective but less costly treatment option for patients in the United States compared with PCB. While treatment decision making should consider the overall safety profile and patient preferences, this study provides estimates of the costs of treatment of these two therapeutic options. The analysis was based on clinical trial data; therefore, the results may not be generalizable to all patients. [Table: see text]
The financial burden of unexpected hospitalizations for childhood cancer patients and their families.
Authors: Kirchhoff Anne C. , Warner Echo L. , Fluchel Mark
Published: February 2017

267

Background: Complications of therapy, such as infection, pain, or dehydration, may cause financial stress for childhood cancer patients due to unexpected hospitalizations. Treatment for childhood cancer is typically provided at tertiary health care centers, requiring rural patients to travel long distances for care. We evaluated the perceived financial burden of unanticipated hospitalizations, insurance, and rurality on childhood cancer patients and their families. Methods: A single-site, cross-sectional survey of primary caretakers of childhood cancer patients was performed from July 2010-July 2012. Eligible patients were treated at a pediatric cancer hospital, diagnosed age ≤21 years and were ≤5 years from diagnosis (N=310). Financial burden was rated on a visual analog scale of 0-100. Multivariable linear regression models were used to calculate coefficients and 95% Confidence Intervals (CI) of financial burden by number of unexpected hospitalizations (0, 1-4, ≥5) and time since diagnosis. Results: The average age at diagnosis was 7.0 (SD 5.6) years. The most common diagnosis was leukemia (47.4%). The mean number of unexpected hospitalizations was 4.2 (SD 7.3). Patients did not differ on number of unexpected hospitalizations by current age, gender, race/ethnicity, or household income. In multivariable analyses, patients 1-5 years past diagnosis with ≥5 unexpected hospitalizations reported financial burden was 22.6 (95% CI 6.2-39.1, p=0.007) points higher than those with no hospitalization and 13.7 (95% CI 2.8-23.6 p=0.007) points higher than those with 1-4 hospitalizations. Patients <1 year from diagnosis did not differ. While type of insurance (public vs. private) did not impact burden, rural patients reported 15.0 (95% CI 6.8-23.2, p<0.001) points higher financial burden than urban patients. Conclusions: A high number of unexpected hospitalizations and rural residence were associated with greater financial burden for families of childhood cancer patients. Efforts to reduce unexpected admissions by managing side effects in outpatient visits, utilizing home health nurses and collaborating with local primary care physicians for remote patients could help ease the financial burden.
Younger survivors' insurance concerns.
Authors: Rechis Ruth , Nutt Stephanie , Bann Carla , Squiers Linda
Published: February 2017

277

Background: Each year approximately 70,000 adolescents and young adults (AYAs) are diagnosed with cancer—many of whom will experience insurance issues. While the Affordable Care Act (ACA) is intended to address many insurance issues, cancer survivors are dealing with these issues now. Methods: From June to December 2012, LIVESTRONG conducted an online survey modeled after the Medical Expenditure Panel Survey (MEPS) Cancer Survivorship Supplement to understand the practical concerns of survivors, including insurance issues. Analyses here includes 1,209 AYA respondents compared to 3,557 respondents diagnosed over the age 40. Results: Overwhelmingly, participants in this survey had insurance at some point since diagnosis (94%), yet AYAs were significantly less likely to have had insurance (p<.001). AYAs were significantly more likely to have experienced issues with insurance (Table), but both groups were unlikely to have received help for negative effects due to insurance (AYA = 30%; non-AYAs=25%). In terms of help seeking, AYAs were significantly more likely to have received help from family members (p<.001). Both groups indicated a number of reasons for not seeking help for insurance issues - most frequently citing "I have addressed this on my own” (18%) and “I tried to receive help but was unsuccessful” (17%). Conclusions: Results from this study indicate there are many issues related to insurance coverage for survivors, which in most cases were significantly more impactful for AYA survivors. Additionally, there are many challenges survivors face in terms of getting their insurance needs met. Finally, it’s important to consider the full implications of what it means for AYAs to be reliant on family members – for both the survivor and their family. The AYA period often denotes a time that individuals are trying to separate from family, yet cancer may make this separation considerably more challenging. While ACA is intended to address some of these issues, cancer survivors are dealing with insurance issues now, and we should consider how to address these issues more quickly. [Table: see text]
Improving the rate of influenza vaccination in pediatric patients with cancer.
Authors: Freedman Jason Lawrence , Reilly Anne F. , Bailey L. Charles
Published: February 2017

49

Background: Pediatric patients with cancer are at increased risk of influenza, with high mortality, morbidity, and delay of cancer therapy. CDC guidelines support yearly vaccination in these patients. In prior years at our center, only 53-56% of pediatric cancer patients received at least one dose of the vaccine. Our objective was to increase the rates of influenza vaccination in pediatric cancer patients through a multi-faceted QI initiative. Methods: Five interventions were instituted concomitantly, in eligible patients (>6 months old, >100 days from BMT if applicable, and within 1 year of chemotherapy) over a 6-month period (9/1/12 to 3/31/13). 1) Family education: provision of influenza/vaccine handouts to families in clinic waiting rooms; 2) Health informatics intervention: via electronic health records, generation of daily lists of patients due for doses with automated email lists to triage and nurses; 3) Clinical process interventions: standardization of triage process to identify patients needing vaccination and provision of colored wristbands to such patients alerting providers to order the vaccine, or document refusals, during the encounter; 4) Inpatient orders: influenza vaccine order built into computerized physician admission order set to trigger vaccination upon discharge; and 5) Provider education: printed materials and tutorials for staff at conferences on proper screening of patients, vaccine ordering/dose, and correct documenting of refusals/contraindications. These processes were iteratively refined over the 6-month timeframe. Results: Influenza immunization rates increased by 20% after the changes were implemented; this was seen across all tumor subgroups. Overall, 74% of patients received at least one dose as compared with 52% in the prior year. 61% of patients were fully immunized (vs. 42% in 2011-12). Immunizations were deferred due to allergy/refusal in 8% of patients (vs. 7% in 2011-12). Consequently, only 18% of eligible patients were unimmunized as compared to 41% in the prior year. Conclusions: Technology, education, and clinical process changes led to a successful increase in influenza vaccination rates. Ongoing efforts will target subgroups with lowest overall rates of immunization.
Augmenting state cancer registry data for quality-of-care assessment: A Georgia-based application to evaluate receipt of adjuvant therapies for breast cancer and colorectal cancer.
Authors: Lipscomb Joseph , Ward Kevin C. , Adams Kathleen , Joski Peter , Roblin Douglas , Gillespie Theresa Wicklin , Li Juan
Published: February 2017

5

Background: The value of linking population-based cancer registry data with insurance claims files to assess quality of care has been demonstrated in numerous studies, including those using NCI’s linked SEER-Medicare database, covering patients age 65+ in fee-for-service plans, and studies linking registry data with Medicaid, private insurance, or managed care data covering the under-65 population. We describe a prototype program linking registry data with multiple data sources to assess quality of care for at-risk populations in a defined geographical area. Methods: Data exchange agreements were executed among the investigative site (Emory University), Georgia state government, and the claims data sources/vendors. We linked Georgia Cancer Registry (GCR) records for 1999-2005 incident cases of breast and colorectal cancer with enrollment and medical services records from Medicare, Medicaid, Kaiser Permanente of Georgia, and the State Health Benefit Plan (SHBP) which covers all state workers and dependents. Following data quality checks, algorithms based on National Quality Forum (NQF) endorsed breast and colorectal cancer quality measures were applied to each linked data set to assess performance. Results: The linked data sets included 60% of all breast and colorectal cancer cases in the GCR over the study period. Quality measure performance rates varied notably across payers. For example, the percent of Stage III colon cancer patients meeting the NQF standard for adjuvant chemotherapy in the linked GCR-Medicaid, GCR-Kaiser, and GCR-SHBP data were, respectively, 75%, 92%, and 92% (p<0.05). The rates for breast cancer patients meeting standards for adjuvant chemotherapy were 86%, 84%, and 87% (p=NS), respectively. Patients in the linked GCR-Medicare data (all age 65+) generally had lower performance rates for each NQF measure. Conclusions: Linking state cancer registry data with multiple public and private sources of administrative data is technically feasible, and may represent a viable strategy for building a national cancer data system for quality improvement, as recommended in 1999 by the Institute of Medicine.
Development and implementation of communities of practice at Cancer Care Ontario (CCO).
Authors: Mendelsohn Marissa , Breen Stephen , D'Souza David , Foxcroft Sophie , Fyles Anthony W. , Gutierrez Eric , Kim Joon-Hyung J. , Lockhart Elizabeth , Murray Elizabeth , Ravi Ananth , Sankreacha Raxa , Scott Dani , Zaza Khaled , Warde Padraig Richard
Published: February 2017

58

Background: A “Community of Practice” (CoP) has been defined as a group of people who share a passion for something they do and learn to improve as they translate knowledge and interact together. Methods: The primary goal of the Radiation Treatment Program (RTP) at CCO is to improve the quality of care delivered to Ontario patients receiving radiation treatment. We identified variations in practice in the 14 Regional Cancer Centers (RCC) in Ontario and facilitated the development of 3 CoPs to share best practices and standardize care where appropriate. Through this initiative, two multidisciplinary [Radiation Oncologists, Physicists and Radiation Therapists (MRT(T)s)] CoPs have been established in Head and Neck (H&N) and Gynecological (GYN) Cancers and one discipline-specific CoP has been started in Radiation Treatment External Beam Delivery involving MRT(T)s alone . During initial meetings of each CoP key variations in practice affecting quality of care were identified. Results: Each CoP has developed recommendation documents for improving care: H&N Cancer – Nomenclature for anatomic structures in treatment volumes and Evaluation of Intensity Modulated treatment Plans; GYN Cancer – Imaging strategies for Intracavitary Brachytherapy of Cervical Cancer; Treatment Delivery – Protocol Development Toolkit and Image Guided Radiation Therapy Education Checklist. These recommendation documents are currently being piloted in each RCC with a view to standardizing care across the province. Conclusions: These CoP initiatives have enabled the development of recommendation reports by front-line staff to ensure evidence-based, high-quality radiation treatment to improve the safety and quality of care for all cancer patients across a jurisdiction of 13M people.
Evaluating the role of palliative care consultations in patients with advanced gastrointestinal cancers.
Authors: Paris Julia , Du Qingling , Morrison R. Sean
Published: February 2017

6

Background: Though research shows that patients with terminal illnesses prefer to die at home, over 60% of patients with advanced cancer are hospitalized in the last month of life. Additionally, less than half of these patients receive any form of hospice care at the end of life, despite its demonstrated potential to improve quality of care. Inpatient palliative care (PC) consultations may serve as a bridge from hospitalization to receiving the kind of end-of-life care that patients prefer. Tumors of the gastrointestinal (GI) system include some of the most common and deadliest cancers and these patients can benefit from PC services, especially when the disease has reached an advanced stage. Our objective was to compare the effectiveness of inpatient PC consultations vs. usual care on post-discharge outcomes in patients with advanced GI cancers. Methods: 202 adults with advanced GI cancers admitted to 5 US hospitals were followed prospectively through hospitalization and 6 months post-discharge. 82 patients received a palliative care consult during hospitalization. Propensity scores were used to match treated to control patients, with exposure to a palliative care consult as the intervention. Outcome measures included: referral to hospice, subsequent ER visit, hospital readmission, and place of death. Results: Significantly more patients in the treatment group were referred to hospice upon hospital discharge (38% vs. 8%, p=0.000). 70 patients died in the 6-month follow-up period. Receiving a PC consult increased the odds of dying at home 3-fold (OR=2.9, p=0.046, 95% CI 1.02-8.44) and decreased the odds of dying in a hospital by 85% (OR=0.159, p=0.002, 95% CI 0.05-0.52). At 2 and 6 months post-discharge, significantly more patients in the treatment group were receiving hospice services at death (75% vs. 18%, p=0.001 and 82% vs. 24%, p=0.000 respectively). There were no significant differences between the two groups regarding hospital readmission and ER visits post-discharge. Conclusions: PC consults for patients with advanced GI cancers was associated with increased referral to hospice, decreased likelihood of dying in a hospital and increased likelihood of dying at home.
Evaluating adherence to off-label policy at an academic outpatient cancer center and assessing reimbursement of high-cost drugs.
Authors: Blouin Gayle C. , Chio Christine , Kim E. Bridget , Ryan David P.
Published: February 2017

61

Background: An off-label policy was developed at Massachusetts General Hospital for drugs used in oncology to 1) ensure high quality standards across the cancer center, 2) promote safe and effective care and 3) demonstrate fiscal responsibility and accountability for drug costs. The purpose of this study is to evaluate adherence to the off-label policy around use of chemotherapy/biologics in outpatient oncology. The impact on pharmacy resources will also be evaluated. A secondary objective is to assess reimbursement of high cost drugs. Methods: A retrospective analysis was performed on all off-label requests submitted from May 1, 2012 through January, 2013 to evaluate adherence to policy. The following criteria were assessed: 1) submission at least 3 days in advance of scheduled treatment, 2) reference provided, 3) approval by clinical director and pharmacy, 4) order written as “Exception order,” and 5) reimbursement of high cost drugs without NCCN support (category 1 or 2A). Drugs evaluated for reimbursement included: bevacizumab, cetuximab, albumin-bound paclitaxel, rituximab, trastuzumab, liposomal doxorubicin, ipilimumab, brentuximab, bendamustine, and bortezomib. Data were also collected from electronic order entry reports, eMARs and hospital billing systems. Results: A total of 83 off-label requests were submitted and reviewed over study period. The majority of requests were written as “Exception orders” representing 2.1% of overall cycle 1 orders. Ninety-eight percent of requests were approved; 40% of requests fully met off-label policy criteria; 28% of requests were submitted without 3-day advance notification; of these, 57% were requested on day of scheduled treatment; 30% of requests were submitted without a reference. Thirty-three claims were evaluated for reimbursement; 91% were paid. Bevacizumab (n=22) was the most commonly requested high cost drug. Conclusions: Providers are generally adhering to the off-label policy. Opportunity exists to improve full adherence. This will ensure adequate time for pharmacy and finance review and avoid unnecessary delays in patient care. The majority of claims for high cost drugs were paid.
Improving quality of cancer care by rapid adoption of new scientific evidence.
Authors: Schottinger Joanne , Rabrenovich Violeta , Campen David , Fredriks Dean
Published: February 2017

62

Background: The goal of the Kaiser Permanente (KP) Cancer Care Program is to provide patient-centered, evidence-based, safe care for all KP oncology patients. Multiple processes and information technology tools support KP’s clinicians in delivering the best care to our patients. Prior to 2008, chemotherapy ordering and administration across KP was paper-based, and the standardization of chemotherapy regimens was driven by prescribers’ preferences. KP Oncologists used more than 1,400 chemotherapy protocols. Pharmacy had varying systems for dosing alerts, and reliable chemotherapy administration data was not available for clinical quality improvement. Methods: By 2012, all KP regions had implemented the KP HealthConnect Beacon (KPHCB) system, which incorporates chemotherapy ordering, alerting, verifying, dispensing, and administration in ambulatory and inpatient settings. Important outcomes of the KPHCB implementation include: 1) our success in gaining agreements on standardization of chemotherapy protocols across the Program, and 2) implementation of a rapid process for adoption of new scientific evidence. Our approach includes an evaluation of the quality of the relevant scientific literature and an assessment of a particular treatment. The KP multidisciplinary team discusses and integrates the scientific evidence and clinical expertise of KP clinicians into KPHCB chemotherapy protocols. The new evidence-based protocols with supporting literature references are imbedded as a web link at the end of the each protocol and are available to clinicians within days following the publishing of new evidence. Results: An example of a rapid dissemination and adoption of evidence is the 2010 Pfizer’s and FDA’s announcement that the sale of Mylotarg would be voluntarily discontinued due to a fatal liver veno-occlusive disease. Within 48 hours, we identified 12 patients who received Mylotarg in 2010, and the treating oncologists were individually contacted and provided with the new information to discuss with patients, as appropriate. Conclusions: The benefits of KP’s rapid adoption of new evidence methodology are reaching over 40,000 cancer patients, receiving over 250,000 chemotherapy treatments annually.
Clinical process analysis: Embedding performance improvement skills for measurable and sustainable change.
Authors: Hayes Beverly A , Barnes Courtney , Aranzamendez Gina , Kaufman Laurie , Haywood Valerie , Rohe Duke
Published: February 2017

67

Background: The Clinical Process Analysis methodology, based on Time Driven Activity Based Costing (Kaplan), aligns data reporting with frontline processes to drive improvement in clinical quality and financial performance. After the completion of 6 ambulatory centers (with 6 in progress), the program evolved to include a Performance Improvement (PI) Phase. The goal: embed PI skills in all clinical operations; provide resources for PI project initiation, facilitation, and sustainability; and continue collaboration with MD Anderson Cancer Center process owners through measurable improvement in safety, timeliness, effectiveness, efficiency, equity and patient-centeredness. (IOM 2001). Methods: The center and the CPA Team utilize institutional dashboards and multiple data resources to establish the project scope. The scope is converted to a Blueprint which outlines a timeline of the project, a list of required resources, and center-specific data. The CPA Team interviews frontline staff, clinical leadership and financial teams to create a current state process flow chart. Opportunities for Improvement (OFI), operational and clinical variations, cycle times and other management reporting metrics are included on the charts, as well as patient experience audio, as gathered by an MD Anderson marketing team. OFIs are evaluated, categorized, and prioritized by clinical leadership, and the CPA Team works with the center’s designated PI team to develop and implement Quick Fixes, PDSA and more extensive projects. Results: In 6 completed ambulatory centers in FY13: 176 Opportunities for Improvement, $936,463 Savings. Summary reports provide direct labor costs and estimated times, per resource type, for center activities. Per MDs, managers, staff and financial experts, other uses for process flow charts include: tracking patient flow; resource utilization; customer satisfaction; patient education; and on-boarding staff. Conclusions: In FY14, the CPA Program will focus on patient access in 15 centers, gathering data to identify trends and common themes to implement Best Practices across the institution.
Sharing hope: Preserving fertility through partnership.
Authors: Rechis Ruth , Eargle Emily , Arvey Sarah R. , Nutt Stephanie , Koenings Ashley , Hemingway Bree
Published: February 2017

69

Background: Each year about 70,000 individuals aged 15-39 are diagnosed with cancer. Unfortunately, essential cancer treatments often negatively impact an individual’s fertility. The average cost of fertility preservation ranges upwards of $12,000 for women and $1,500 for men and most insurance companies typically do not cover pre-treatment fertility preservation. Not only do these individuals experience a life-threatening cancer diagnosis, they are also faced with the possibility of not having children of their own in the future. The LIVESTRONG Foundation’s Fertile Hope Program provides educational information and timely pre-treatment financial assistance to cancer survivors whose medical treatments present the risk of infertility. Female participants receive the medication at no cost through the Foundation’s partnership with EMD Serono, and all survivors can receive at least a 25% discount, on preservation services at the more than 350 partnering fertility clinics. Methods: LIVESTRONG Navigators implementing this program track all interactions on an ongoing basis. Additionally, in 2012, clients who had been approved for the program within the last 12 months and those who had been approved two or more years ago received an online survey (N=200 and 105 respondents respectively). Results: In 2012, 3,353 individuals (1,537 men and 1,816 women) saved a total of $12,542,114 through this program. Survey respondents indicated that they value the speed of the process and the opportunity to preserve their fertility. Interestingly, respondents noted that they learned about the program through a reproductive doctor, but they learned about fertility-related issues through an oncologist. Finally, respondents indicated that 14 babies have been born as a result of this program. Conclusions: This program has made a unique and measurable change to improve the quality of life of survivors. By providing information and support as well as reducing costs, survivors have the potential to fulfill their aspirations to bear a biological child. Ensuring that providers who share information about fertility-related issues are informed about these types of programs could help to ensure all interested survivors have access to discounted, timely fertility preservation.
Quality assurance governance and implementation in cancer pathology: A national survey of Canada.
Authors: Mitera Gunita , Srigley John , Geldenhuys Laurette , Trotter Martin , Magee Fergall , Ravinsky Esther , McLachlin Meg , Banerjee Diponkar , Têtu Bernard , Carter Beverley , Rahmeh Tarek , Henderson Rosemary
Published: February 2017

73

Background: Robust quality assurance (QA) programs incorporating both technical and interpretive aspects of QA are integral to accurate pathology diagnosis and quality of care a cancer patient receives. Programs and governance addressing technical pathology quality have been well developed in Canada and internationally. The extent of interpretive pathology QA implementation across Canada remains unknown. The objective of this study was to document the current landscape for pathology QA in Canada. Methods: An environmental scan was conducted to determine the types and extent of current large institution and provincial-level pathology QA programs in place across Canada. An electronic survey was administered to key stakeholders and senior decision makers in cancer pathology. Targeted interviews were conducted with pathology leaders in each province to verify survey results, deliberate and resolve ambiguous responses. Results were presented to all survey respondents as a feedback mechanism. Results: 9/10 provinces currently have a professional group representing pathologists. 10/10 provinces currently have a technical QA program. Of these, 2/10 provinces are governed through Accreditation Canada, 3/10 provinces are governed through the Ontario Laboratory Accreditation Program and the remaining 5/10 provinces are governed by separate provincially-led programs. For interpretive pathology QA, 2/10 provinces have a coordinated provincial interpretive QA program, 5/10 provinces do not have provincial coordination, and have plans to implement one, and 3/10 provinces do not have a provincially coordinated interpretive QA program in place, nor are they planning to develop one. Conclusions: This is the first study to document the provincial landscape for pathology QA in Canada. Large pan-Canadian variations remain for level of integration and future plans to develop and integrate interpretive pathology QA programs within provinces. Next steps should include the development of a pan-Canadian recommendations framework for interpretive pathology QA to help guide senior decision-makers in implementing such quality programs provincially.
Clinical characteristics and outcomes of advanced cancer patients referred to outpatient supportive care who missed their appointment.
Authors: Delgado-Guay Marvin Omar , Tanzi Silvia , San Miguel Arregui Maria Teresa , Chisholm Gary B. , Williams Janet L. , Allo Julio , Bruera Eduardo
Published: February 2017

79

Background: Supportive Care Outpatient Clinics (SCOC) offer comprehensive care and symptom management to patients with advanced cancer (AdCa). Missed appointments (MA) are important source of problems to patient care and clinic operations. But there are no studies on the clinical outcomes of patients who fail to show for consultation. Methods: We determined the frequency of MA, including clinical and demographic data, and reviewed clinic appointment records for 218 consecutive kept (KA) and 218 MA for distinct patients referred to SCOC from January to December 2011. Results: 218/1,352(16%) AdCa who were referred to our SCOC, missed their appointment. Median age was 57 years (interquartile range 49-67). The mean(range) time between referral and appointment was 7.4 days(0-71) for KA vs. 9.1 days(0-89) for MA (p=0.0062). Age, gender, marital status, and cancer types or stages, and reasons for referral to SCOC were not significantly different between MA and KA patients. The reasons for MA were: admission to the hospital 17/218(8%), death 4/218(2%), appointment with primary oncologist 37/218(18%), other appointments 19/218(9%), visits to emergency room(ER) 9/218(9%), and unknown 111/218(54%). MA patients visited more the ER at 2 weeks 16/214(7%) vs. 5/217(2%), p=0.01, and 4 weeks 17/205(8%) vs. 8/217(4%), p=0.06. Median survival for MA patients was 177 days (range:127-215) vs. 253 days (range:192-347) for KA patients (p=0.013). Multivariate analysis showed that MA were associated to the time between referral and scheduled appointment (OR: 1.026/day, p=0.03), referral from targeted therapy services (OR:2.177, p=0.004), living at Texas/Louisiana regions (OR;2.345, p=0.002), having advanced directives (OR:0.154, P<0.0001), and being referred for symptom control(OR:0.024, p=0.0003). Conclusions: AdCa with MA have worse survival and increased ER utilization. We identified AdCa at higher risk for MA who should undergo more aggressive follow up. More research on MA prevention is needed.
Patient-specific quality assurance measurements for VMAT treatments: Do we really catch errors?
Authors: Laub Wolfram , Thomas Charles R.
Published: February 2017

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Background: Patient-specific quality assurance measurements are time consuming and Gamma pass/fail criteria are often picked based on typical criteria used for IMRT QA measurements in the past. The questions needs to be asked if with these criteria QA plans could still show clinically significant deviations from the treatment plan calculated and how we should be doing QA for treatment delivery of complex treatment plans. In our study DICOM files of clinical Rapidarc plans were modified with in-house developed software to mimic leaf alignment errors and gravitation shifts. The Octavius 2D-ARRAY (PTW-Freiburg) and the Delta4 device (Scandidos) were used to investigate the effect of the simulated errors on the passing rate of quality assurance results. The manipulated Rapidarc plans were recalculated on patient CT scans in Eclipse. Methods: Three different types of errors were simulated and applied to five prostate (two arcs), three 2-arc head and neck cases and three 3-arc head and neck cases. The MLC modifications were: (1) both MLC banks are opened by 0.25mm, 0.50mm and 1.00mm in opposing directions resulting in larger fields, (2) both MLC banks are closed by 0.10mm, 0.25mm and 0.50mm, (3) both MLC banks are shifted in the same direction for lateral gantry angles to simulate effects of gravitational forces onto the leaves by 1mm, 2mm and 3mm, (4) 25%, 50% 70% and 100% of all active leaves are shifted by 3mm as in (3). QA evaluations were performed according to a gamma-index criterion of 3mm and 3% as well as 2mm and 2%. Results: All unmodified plans and the majority of the plans with the smallest modification pass the gamma-index criterion of 2%/2mm with >90%. After that the passing rate drops below 90%. For the largest modifications passing rates were typically below 85%. The Delta4 is generally more sensitive and the passing rate for modified plans drops below 90% earlier and more drastically. With the standard criteria (3mm, 3%) even the largest modifications would satisfy a >90% passing rate. Conclusions: A stricter gamma-index (2mm, 2%) is necessary in order to detect MLC positional errors and a passing rate of >90% should be expected. Clinical pass/fail criteria need to be developed.
Pathways impact on chemotherapy administration before death.
Authors: Neubauer Marcus A. , Garey Jody S. , Turnwald Brian , Howell Josh , Harrell Robyn K. , Hayes Jad , Bhowmik Debajyoti , Hoverman J. Russell , Brooks Barry Don
Published: February 2017

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Background: Continuing IV chemotherapy (chemo) in patients (pts) with advanced cancer near death does not extend survival or improve quality, but does increase costs. Pathways (PW) programs have compared treatment (tx) costs but have not evaluated the impact on chemo given near death. The primary goal is to evaluate IV chemo administered in the last 14 and 30 days of life in pts treated On vs. Off-PW. Methods: Eligibility: in US Oncology’s (USO) iKnowMed (iKM) EHR 7/1/09-6/30/12; diagnosis (dx) of breast, colon, NSCLC, SCLC or pancreas cancer; >/=3 visits to a USO clinic; assessed for Level I PW compliance in the last 12 mths of life; and a date of death. IV chemo received in the last year of life was assessed. Pts were defined On-PW if all tx was On-PW or if pts did not receive IV chemo 12 mths before death (best supportive care). Pts were Off-PW if any tx received was Off-PW. PW-status, age, sex, dx, and last line of therapy (LOT) received were assessed. Multivariate logistic regression analysis was used to assess if PW status predicted likelihood of chemo within 14 and 30 days of death. Results: 12,551 pts met inclusion criteria. PW status was independently associated with chemo 14 and 30 days before death. Pts treated Off-PW had 2-fold higher odds of receiving IV chemo within 14, 30 days of death vs. pts treated On-PW (OR: 2; 95% CI: 1.8-2.3, OR: 2.2, 95% CI: 2-2.4), see Table. Findings were similar for each dx. Tx for pts On-PW vs Off-PW showed lower mean last LOT overall (1 vs. 2) and by dx. Conclusions: Pts On-PW were less likely to receive IV chemo within 14 and 30 days of death and had fewer LOT. This suggests adherence to Level I PWs is associated with improved quality metrics. [Table: see text]
Assessing patient values first: Creating a platform for advance care planning (ACP) in the adult oncology population.
Authors: Mikan Sabrina Q. , Taniguchi Cynthia , Hoverman J. Russell , Ash-Lee Susan , Harrison Deb , Olson Kevin Donald , Arlen Aimee
Published: February 2017

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Background: Patients, families and healthcare providers can be apprehensive about having end-of-life (EOL) conversations. However, asking patients about personal values regarding their healthcare goals may create a platform for more in depth conversations. A quantitative instrument to assess patient values and ACP readiness was developed and validated to complement a process for identifying patients appropriate for ACP. Methods: Recruitment was conducted at seven cancer center sites in The US Oncology Network over a 90-day pilot study period. Of 871 identified patients, 301 Texas Oncology patients engaged in ACP. A cross-sectional descriptive design was used in 301 metastatic cancer patients. Sixty-three participants completed the questionnaire. The 13-item instrument was created after an extensive literature review regarding EOL choices and interventions using a 5-point Likert scale. Descriptive statistics were examined, in addition to analysis of the relationships between items using Pearson’s r correlations. Results: Participants were primarily female (59%) and Caucasian (95%); with a mean age of 66 years. Sixty-eight percent reported it "Very Important" to be told they were dying. There was a significant association between willingness to discuss feelings about dying and being told by their physician when dying, (r= 0.373, p<0.01). Sixty-two percent reported it "Very Important" to be able to choose their EOL care location. EOL care location and level of burden for caregivers were significantly associated (r= 0.315, p<0.05). Also, 76% reported being able to select the person who makes EOL decisions for them as "Very Important." Conclusions: Recent studies have shown the importance of assessment of patient healthcare values in the metastatic oncology population. The values and readiness instrument allows healthcare providers to understand the patient’s wishes early in the course of care. ACP can be guided through review of the validated instrument in the adult metastatic population. This provides appropriate weight to both sides of the care equation and is a major step toward creating patient-centered care. Further development of the instrument is needed in this population.