bluuebunny/crossref_metadata_2025 huggingface dataset:
Inpatient hospitalization costs associated with nausea and vomiting among patients with cancer.
Authors: Roeland Eric , Nipp Ryan David , Ruddy Kathryn Jean , Binder Gary , Bailey William L. , Amari Diana T. , Kanakamedala Hemanth , Navari Rudolph M.
Published: November 2018

112

Background: Reducing hospitalizations for chemotherapy-related toxicities represents an opportunity to improve both the quality and cost of cancer treatment. Nausea and vomiting (NV) account for almost 10% of “avoidable” toxicity-related post-chemotherapy hospitalizations (2016 Medicare data). We sought to evaluate the event cost of NV-related hospitalizations among patients with cancer from a US payer perspective. Methods: From a large US claims database (Truven MarketScan), we identified hospitalizations with NV as the primary diagnosis and cancer as a secondary diagnosis (01/2011-06/2017). This method increases specificity for NV as the principal hospitalization factor, while underreporting the prevalence of NV as a contributory factor. To determine event costs, we evaluated hospital and other reimbursement during the hospitalization. To explore subgroup differences, we stratified results by tumor type, payer type, admission route, receipt of highly emetogenic chemotherapy (HEC; 2017 definition includes carboplatin AUC ≥4) and antiemetic prophylaxis. We adjusted all costs to 2017 US dollars. Results: Among 918,192 hospitalizations involving cancer, we identified 80,995 with both NV and a cancer diagnosis code. Of these, 5,293 had NV as the primary diagnosis and 62 lacked cost data. Patients (mean age = 57.7±16.2) were 67% female. Median hospital length of stay was 4 days and mean cost per hospitalization was $15,085. Non-Medicare admissions (82%) had a higher mean cost vs. Medicare ($15,737 vs. $12,111, p < 0.01). We found < $1,000 difference between the highest and lowest cost per hospitalization among the 6 most common tumor types. We found the 65% of patients with a chemotherapy claim ≤30 days prior to hospitalization had costs of $13,882 per event. Among the 45% of chemotherapies that were HEC, > 50% lacked an NK1 receptor antagonist as prophylaxis. Conclusions: The average cost of NV-related hospitalizations among patients with cancer exceeds $15,000 per event, highlighting the need to effectively address this symptom. Roughly half the hospitalizations involved HEC, with over half of those patients not receiving guideline-based antiemetic prophylaxis.
The implementation of a palliative care intervention during induction chemotherapy for patients with acute myeloid leukemia (AML) at a community cancer institute.
Authors: Lattanzio-Hale Annamaria , McNaughton Caitlyn , Wilson Wendy , Nelson-Przywara Heather , Balepur Shyam S. , Jupin Peter , Ryan Miriam , Sivendran Shanthi
Published: November 2018

113

Background: Patients with hematologic malignancies are referred to palliative care less than patients with solid tumor malignancies. Clinical trials are underway at academic centers exploring early inpatient palliative care for patients newly diagnosed with AML receiving induction chemotherapy. Feasibility of such interventions have not been studied in a community setting. We structured a multi-faceted intervention for our community hematology and palliative team on the benefits of early palliative care in hematologic malignancies with the aim to increase utilization. Methods: In 2017, 24% of patients with AML admitted to Lancaster General Hospital for induction chemotherapy received an inpatient palliative consultation. Needs assessment performed on the hematology and palliative teams demonstrated a need for integration of palliative care into clinical pathways, automatic triggers for consultation, a need for increased education on AML, and creation of standard elements in inpatient consultations. Results: In the spring of 2018, we integrated palliative care into institutional AML clinical pathways such that all patients receive inpatient palliative consultation within 72 hours of admission. A consultation trigger was placed within the admission order set and is currently being incorporated into the chemotherapy treatment protocol. An educational program on AML was created and presented by the hematology team to the inpatient palliative team. This intervention included creation of minimum standards for inpatient palliative consultation including provider assessment within 72 hours of referral, two visits per week by a provider and a minimum of one visit by the interdisciplinary team during admission with a focus on symptom management, psychosocial assessments, and advanced care planning. Conclusions: We have demonstrated feasibility of creating standards for early palliative care intervention in AML patients with collaboration from the hematology and palliative teams. Next steps will include assessing whether these interventions increase uptake of palliative care utilization and specific patient outcomes.
Use of palliative care among patients with metastatic breast cancer at a safety net hospital.
Authors: Bushan Sita , Li Hsiao Ching , Syed Samira K. , Unni Nisha , Sadeghi Navid
Published: November 2018

117

Background: Palliative Care (PC) has been shown to improve quality of life in lung cancer patients, and ASCO recommends it as an adjunct to standard oncologic care. Data regarding the use of PC in other cancers and in disadvantaged populations is scant. We studied the patterns of use of PC in patients with metastatic breast cancer (MBC) at a safety net hospital. Methods: Electronic health records (EHR) of 234 patients who were diagnosed with MBC from 2010 to 2016 at Parkland Health and Hospital System (PHHS) were reviewed, and data on demographics, diagnostics, treatments, and palliative care elements were collected. Results: 105 of 234 (44.8%) patients with MBC were referred to PC, either as outpatients, inpatients, or both. The average time from the first visit with medical oncology to placement of an outpatient referral to PC was 390 days. Of the 79 patients with outpatient referrals to palliative care, we have hormone receptor status on 50. 12 of these patients had triple negative breast cancer; 30 had hormone receptor positive breast cancer. 77 (32% of all patients) patients had formal documentation of advanced directives (AD) in the EHR. Of these, 69 (89.6%) had seen PC. 133 patients have died, and 37 (27.8% of expired patients) died at the Parkland Hospital. Among the 96 patients who did not die in the hospital, 73 (76%) patients had some discussion of hospice prior to death. Conclusions: Less than half of patients with MBC at PHHS were referred to PC, and among those who are, referrals are placed late in the disease course, on average, more than one year after the first medical oncology visit. Lack of a sustained relationship with PC results in truncated goals of care discussions. As a result, most patients do not have formal documentation of AD in the EHR. Furthermore, they do not benefit from discussions with PC that could guide the management of their malignancy while they still have therapeutic options. Instead, patients discuss hospice with their providers toward the end of life, only when they are no longer candidates for cancer directed therapies. Although the use of PC resources at PHHS does not meet clinical guidelines, it is consistent with data from other studies showing inadequate use of PC resources among patients with advanced cancer.
Refining the TEACHH model: Towards improved clinical utility in the modern era.
Authors: Krishnan Monica Shalini , Hertan Lauren Michelle , Chen Yu-Hui , Nichipor Alexandra , Khouj Yaseer Mohammed , Zaslowe-Dude Cierra , Balboni Tracy A.
Published: November 2018

128

Background: The TEACHH model was previously developed to predict life expectancy in patients with metastatic cancer receiving palliative radiation. However, the model was developed prior to the immunotherapy era and limited in its clinical utility due to broad ranges of survival in each prognostic group. The aim of this project is to refine the TEACHH model to improve its clinical utility in a modern cohort. Methods: We retrospectively reviewed the charts of patients seen in consultation for palliative radiation at two tertiary centers and 4 community satellite practices from 7/1/2015 – 12/31/2016. Cox proportional hazards regression was used to construct a prediction model for overall survival (OS), with a goal of predicting the probability of surviving to the clinically relevant timepoints of 2 months, 6 months, and 1 year. The model was stratified by consult location (tertiary vs. community). Results: A total of 744 patients were included in this analysis. The final model included: 1) Gender (Male HR 1.35, 95% CI 1.11 – 1.64) 2) ECOG PS (ECOG 1 HR 1.63, 95% CI 1.20 – 2.22, ECOG 2 HR 2.59, 95% CI 1.86 – 3.60, ECOG 3/4 HR 4.12, 95% CI 2.84 – 5.98) 3) Consultation type (Inpatient HR 1.87, 95% CI 1.40 – 2.49) 4) Primary histology 5) Number of metastases 6) Number of prior palliative chemotherapy courses. Due to interactions between primary histology and number of metastases as well as primary histology and number of prior palliative chemotherapy courses, hazard ratios for these variables are shown in Table 1. Conclusions: Our final refined TEACHH model includes 6 variables to predict OS. We hypothesize that its increased complexity will increase its sensitivity and we will validate the model in a separate patient cohort. A web-based calculator will then be created to facilitate easy use of the model. Hazard ratios of variables with significant interactions. [Table: see text]
How family caregivers assist with upstream health care decision making by community-dwelling persons with advanced cancer: A qualitative study.
Authors: Dionne-Odom J Nicholas , Ejem Deborah , Wells Rachel , Barnato Amber , Taylor Richard , Rocque Gabrielle Betty , Turkman Yasemin E. , Ramsey Thomas , Kenny Matthew , Ivankova Nataliya , Bakitas Marie , Martin Michelle Y.
Published: November 2018

13

Background: In the palliative care context, the family caregiver role in patients’ healthcare decision-making has focused on being a surrogate decision-maker at end of life. Less is known about family caregiver’s role in supporting upstream patient decision-making in advanced cancer. Methods: Qualitative descriptive study consisting of one-on-one, semi-structured interviews with persons with metastatic cancer and their family caregivers. We elicited family members’ perspectives on how they assist their relatives with any current and prospective healthcare decisions. Transcribed interviews were analyzed using a thematic analysis approach. Co-investigators reviewed and refined themes. Results: Caregivers (n = 20) averaged 56 years of age and were mostly female (95%), White (85%), and the patient’s partner/spouse (70%). Patients (n = 18) averaged 58 years of age and were mostly male (67%) in “fair” or “poor” health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients’ decision-making were: 1) seeking information about the cancer, its trajectory, and different treatments options; 2) identifying treatment and disease decision points, including decisions about seeking emergent care; 3) ensuring family members have a common understanding of the patient’s plan of care; 4) initiating and facilitating conversations with patients about coping, values, beliefs, and “what if” scenarios about current and potential future health states and treatments; 5) implementing choices (e.g., providing transportation) and addressing “spillover” decisions (e.g., work arrangements) resulting from medical treatment choices; and 6) making upstream healthcare decisions on behalf of patients who preferred to have decisions made by their family caregivers. Conclusions: These data highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early palliative care decision support interventions for family caregivers.
AMTRA: An ambulatory and tailored symptom management and intervention system in patients with cancer initiating treatment.
Authors: Rasschaert Marika Anna , De Keersmaecker Sven , Vandenborne Kathleen , Vulsteke Christof , Dias Stefanie , Verschaeve Vincent , Vuylsteke Peter , Peeters Marc
Published: November 2018

142

Background: The purpose of this non-randomized prospective cohort analysis was to implement and validate a tailored symptom management and intervention system, which integrates tailored education and advice for improving symptom self-management among cancer patients. We hypothesized that improved symptom self-management allows for early symptom control, better compliance, better dose intensity and reduce the necessity for extra visits / ER-visits. Methods: Patients initiating systemic therapy for malignant disease used a pre-programmed device in order to register compliance (in case of oral treatment), 12 clinical symptoms and 2 biometrics (weight and temperature). These real time data were collected onto a central platform, stratified according to different grades based on the PRO Common Terminology Criteria for Adverse Events (PRO-CTCAE ); and processed by an algorithm to render personalized advise when necessary. In case of severe (≥ Gr III) toxicity a dedicated nurse would intervene. Our primary outcome was symptom burden assessed via patient report tool. Secondary outcomes included relative dose intensity. Results: 168 Cancer patients were recruited from June 1st 2017 to December 31st 2017 across 4 sites, 76 men and 92 women. The median age 63 years (range 23-88 yr). 8275 Registrations were analyzed, pain was most frequently scored and loss of appetite was the most frequent gr III PROM. 108 patients scored toxicities (1413) requiring follow up or intervention by a dedicated nurse; resulting in 99 extra interventions: 34 extra consultations and 15 hospitalizations. Supportive treatment was adapted in 2, supportive advice given in 40 and in 12 instances no registration of the action was retrieved. Conclusions: The ambulatory follow up of patients with anti-cancer treatment appears feasible and reliable. Further effort to provide at home symptom management is warranted and requires both a logistic framework, as well as continuous education of motivated caregivers and patients. Evaluation on dose intensity and compliance of treatment will follow.
Frontline oncology care team primary palliative symptom guideline education, the oncology care model, and emergency department visits.
Authors: McInnes Susan , Carrino Cheryl M , Shoemaker Laura
Published: November 2018

143

Background: The Oncology Care Model (OCM) is a novel 5-year quality-based Oncology payment and care delivery program established by the Centers for Medicare & Medicaid Service in 2016. OCM prioritizes high-quality, coordinated care for patients undergoing chemotherapy (chemo pts.) Participating centers provide augmented services to enhance care and meet quality goals. Challenging symptoms (sxs) are common among chemo pts and may lead to hospitalization and decreased quality of life. Specialist palliative care teams are not able to see all chemo pts with active sxs. Front line oncology care teams (FLC) need education on primary palliative sx management. Methods: Cleveland Clinic Taussig Cancer Institute is one of 181 practices voluntarily participating in OCM. Locations include main campus and 5 regional cancer offices with 100 oncologists caring for about 4,000 chemotherapy patients annually. Our OCM team engaged Oncology (Onc) and Palliative Medicine (PM) providers to standardize sx management. Education was provided to FLC of all disciplines. Electronic record analytics were used to determine emergency department (ED) utilization. Results: A multidisciplinary team of Onc and PM experts developed guidelines for 4 common sxs (chemotherapy-induced neuropathy, persistent cancer pain, nausea/vomiting and constipation. Guidelines were approved by key Onc and PM staff and made available to all providers online. There were 4 educational sessions for FLCs to all sites in 2017. Urgent sx outpatient appointment slots were created in oncology offices to address uncontrolled sx. From Dec 2017 to May 2018, ED visits for all cancer patients at main campus decreased from 500/month to 453/month (9.4%.) Reductions in ED visits were also seen at 2 hospitals adjacent to regional cancer centers (16% and 6%.) Conclusions: OCM participation provided an opportunity to improve care quality at our institution. Primary palliative sx guidelines were successfully developed by an interdisciplinary team and disseminated to FLC. Urgent sx management appointments were made available in oncology offices. These interventions coincided with a reduction in ED visits for all cancer patients.
Employing electronic health record data to predict risk of ED visits for new patients.
Authors: Daly Robert Michael , Gorenshteyn Dmitriy , Gazit Lior , Sokolowski Stefania , Nicholas Kevin , Perry Claire , Adams Lynn , Baldwin Abigail , Katzen Lauren L. , Chiu Yeneat O. , Reidy Diane Lauren , Simon Brett A , Perchick Wendy , Wagner Isaac
Published: November 2018

144

Background: Acute care accounts for half of cancer expenditures and is a measure of poor quality care. Identifying patients at high risk for ED visits enables institutions to target symptom management resources to those most likely to benefit. Risk stratification models developed to date have not been meaningfully employed in oncology, and there is a need for clinically relevant models to improve patient care. Methods: We established a predictive analytics framework for clinical use with attention to the modeling technique, clinician feedback, and application metrics. The model employs EHR data from initial visit to first antineoplastic administration for new patients at our institution from January 2014 to June 2017. The binary dependent variable is occurrence of an ED visit within the first 6 months of treatment. From over 1,400 data features, the model was refined to include 400 clinically relevant ones spanning demographics, pathology, clinician notes, labs, medications, and psychosocial information. Clinician review was performed to confirm EHR data input validity. The final regularized multivariate logistic regression model was chosen based on clinical and statistical significance. Parameter selection and model evaluation utilized the positive predictive value for the top 25% of observations ranked by model-determined risk. The final model was evaluated using a test set containing 20% of randomly held out data. The model was calibrated based on a 5-fold cross-validation scheme over the training set. Results: There are 5,752 antineoplastic starts in our training set, and 1,457 in our test set. The positive predictive value of this model for the top 25% riskiest new start antineoplastic patients is 0.53. The 400 clinically relevant features draw from multiple areas in the EHR. For example, those features found to increase risk include: combination chemotherapy, low albumin, social work needs, and opioid use, whereas those found to decrease risk include stage 1 disease, never smoker status, and oral antineoplastic therapy. Conclusions: We have constructed a framework to build a clinically relevant model. We are now piloting it to identify those likely to benefit from a home-based, digital symptom management intervention.
iOS data app for supportive care in cancer.
Authors: Butler Thomas Wayne , Najera Lucas
Published: November 2018

148

Background: Providers in oncology must optimize time to serve as many patients as possible daily with the caveat that patient outcomes and satisfaction is paramount. However, a paucity of tools are available to evaluate efficiency. An objective analysis of productivity and patient flow would optimize staff utilization, resulting in an increase in quality and economics of patient care. Methods: Patient flow in a supportive care clinic was recorded manually to delineate patient flow and staff productivity. This method provided baseline data for analysis. An iOS app was then created which can be adjusted to gather data and measure the flow in the clinic prompting patients to complete a questionnaire in the waiting room. The application stores the weather and driving distances to determine how these possibly correlate with efficiency. Additional data points were identified to trend staffing schedules and patient flow. Data inputs include diseases, characteristics, family dynamics and other clinical demographics for analysis and deliverables received. Results: The application generates reports for any variable collected, with a predefined daily report to compute the total relative value units (RVU) of the visit, the total cost and RVUs distribution by provider and/or staff. A percent profit or loss illustrates “value” created by individual objects and staff. The application interprets changes in efficiency over time. In the preliminary results we found direct intervention with the patient and record taking to be the primary deterrent to efficiency and having adequate oncology nursing staffing was most conducive with physician wait times varying significantly with changes in oncology staffing. Conclusions: This tool is unique in producing a cost-effective tool to evaluate daily patient flow and staff utilization. It has future applicability in dynamic analysis of how symptom burden and barriers to care in cancer patients effects the economics of a supportive care clinic. This production of real time information will provide data to improve efficiency, outcomes of care. We plan a pilot study in the supportive care clinic to further evaluate this tool and its benefit to optimizing flow, and enhance cost-effective, patient-centered allocation of resources in supportive care.
RELAX: An immersion virtual reality relaxation intervention for quality of life improvement in cancer patients.
Authors: Gordon Erlinda Maria , Li Bryan M , Liu Seiya , Chawla Sant P , Liu Seiji M , Liu Stephen M
Published: November 2018

152

Background: Interventions that reduce symptom distress and enhance positive feelings are crucial for improving quality of life and, conceivably, overall survival of cancer patients. One remedy is the immersive virtual reality relaxation (VR-R) environment/s to inspire an emotion-focused coping mechanism in cancer patients. Herein, we report on our experience with the use of this VR-R intervention in normal volunteers and cancer patient volunteers. Methods: Fifty cancer patient volunteers underwent VR-R training and used the VR-R environment/s for 5 - 30 minutes. VR-R is a software-based simulation, which allows an individual to be placed inside an experience, hearing and interacting with stimuli that correspond with visual images of an artificial world. The VR equipment consists of the Oculus Rift Head Mounted Display (HMD) that enables play of an interactive scenario or game that patients can experience from a first-person perspective (i.e., upon entering the interactive scenario, participants are transported into a virtual, 3D world). After the immersion VR-R intervention, patients reported on their experience during the VR-R intervention by answering a QoL questionnaire created by IFGCURE/Cancer Center of Southern California/Sarcoma Oncology Center. Results: Eight of 50 (16%) patients experienced mild motion sickness as the only adverse event associated with its use. Table 1 shows the emotions that patients reportedly experienced during VR-R intervention. Conclusions: Taken together, the data support the premise that VR-R intervention is safe and may be efficacious in improving symptom distress and quality of life of cancer patients. A phase 1/2 study is planned to evaluate the safety and efficacy of the VR-R intervention in improving quality of life in a larger number of cancer patients. [Table: see text]
Social isolation: Impact on treatment and survival in patients with advanced cancer.
Authors: Moore Sara , Leung Bonnie , Bates Alan , Ho Cheryl
Published: November 2018

156

Background: Social relationships are an important determinant of health, with impacts on morbidity and mortality in the general population. The influence of social isolation in patients with metastatic cancer is less clear, as are the potential mechanisms of its effect. We sought to examine patient-reported social support in a large unselected population, and explore the impact on outcome. Methods: A retrospective review was completed of all patients with metastatic cancer referred to BC Cancer from 2011-2016 who completed a psychological screen within six months of diagnosis. Social isolation was defined as a positive response to any of five questions about social support: live alone, recently lost spouse/partner, no regular contact with friends/relatives, no one to assist with IADLs, no emotional support. An isolation score was calculated as the number of positive responses. The primary outcome was overall survival (OS). Results: 7,699 patients were included in the study. Baseline characteristics: median age 68, 57% male, 60% received systemic therapy, primary tumor site 4% breast / 37% lung / 28% GI / 13% GU / 18% other. 5191 (67%) patients reported no isolation, and 2,538 (33%) were socially isolated. Patients with social isolation were more likely older (median age 70 vs. 67), female (50% vs. 40%), ECOG ≥2 (34% vs. 30%), and receive no systemic therapy (46% vs. 35%). Median OS was inferior in socially isolated patients at 10.1 m compared to those with no isolation at 13.5 m (p<0.001). In a multivariate model including age, sex, ECOG, systemic therapy, and primary tumor site, the impact of social isolation on OS remained significant (HR 1.06, p=0.04). In an exploratory analysis, increasing levels of social isolation were correlated with reduced systemic therapy uptake (score 0=65% received systemic therapy, 1=56%, 2=53%, 3=47%, ≥4=43%, p<0.001). Conclusions: Socially isolated patients with metastatic cancer have inferior survival, which may be influenced by the reduced use of systemic therapy. Increasing patient social support should be explored as a means to improve the uptake of systemic therapy and its benefits on survival in patients with advanced cancer.
Spirituality, religiosity, and burnout in Latin American palliative care health care professionals (LAPC).
Authors: Delgado-Guay Marvin Omar , Reyes Donoso Maria M , Lopez Saca Mario , Riveros Rios Miriam Elisa , Colautti Norma , Espín Gónzalez Ismariel I , Pastrana Tania
Published: November 2018

164

Background: Spirituality (S) and religiosity (R) are essential in delivering Quality Palliative Care(PC). There's limited literature regarding Latin American clinicians’ spiritual and religious characteristics, or how these shape their clinical engagement and presence of burnout. Methods: To describe the frequency, intensity and importance of S and R and burnout on the LAPC's practice. From 6/1-12/31, 2017, a crossectional study using an anonymous/voluntary Online Survey was provided to active members of ALCP. We collected and analyzed data regarding demographics, role of S, R, and burnout. Results: 221/353 members from 20 Latin American Countries participated, RR:63%. Median age 47(SD+/-12), 75% were women. 40% Catholic. 58% were physicians, 19% nurses, 12% psychology, and other 12%. The median time of working in PC was 9 years (+/-7). LAPC considered themselves spiritual(median:8/10, range 0-10) and religious (5, 0-10). LAPC considered S/R very important in their lives (9/10, 0-10 and 6/10, 0-10), respectively. LAPC reported that S/R was a source of strength/comfort (9/10, SD+/-2), helped them to cope with their problems (8/10,+/-3), and helped them to keep their quality of life in a stressful work environment (8/10,+/-4). 60% LAPC felt energized and 86% reported not feeling exhausted after taking care of patients who are dying. This is associated with being spiritual (p=0.003) and its importance in life (p=0.025). 86% reported strongly/somewhat agreed with: "I feel called to take care of patients who are dying", this was associated with being spiritual (p=0.044). 31/221(14%) reported being burned out. No significant difference among gender, profession, age, years in PC, or importance of S/R. Having higher (34%) versus not (11%) experience emotional exhaustion after caring of the dying were more likely to report burnout (p<0.000). Those who felt emotionally energized after caring for the dying were less likely to report burnout (p=0.010). Conclusions: Most of LAPC considered themselves spiritual/religious, which has an important role in life and helped them to cope. Low percentage reported presence of burnout. The "call" and feeling energized caring for the dying are associated with less burnout.
Development and evaluation of an innovative creative arts program on a tertiary palliative care unit.
Authors: Nekolaichuk Cheryl , Crowe Kim , Ellerby Trevor , Emery-Thom Bette , Enfield Christine , Killoran Sheila , Muller Viki
Published: November 2018

167

Background: The use of creative arts in palliative care is a unique psychosocial-spiritual intervention, yet there are limited evaluation studies of these programs. The purpose of this presentation is to describe the development and evaluation of a creative arts program, entitled “Tile Tales,” on a 20-bed tertiary palliative care unit. Methods: The “Tile Tales” program encourages the creative exploration of emotions, values and beliefs through the creation of a visual expression on a ceramic tile, with an accompanying story. In this second phase of a three-phase evaluation, participants (18 years or older) were asked to complete a survey at the end of their experience. Results: Over a two-year period (January, 2016 – December, 2017), 40 tiles were completed by 52 participants. Children under 18 years (n = 16) were excluded from further analysis. Twenty-one of 36 adult participants (58%) completed surveys, consisting of family members (n = 9, 43%), patients (n = 6, 28.5%) and staff (n = 6, 28.5%). Participants rated their experience as very meaningful (M 4.8, SD 0.5, scale 0-5). The three highest average impact scores (scale 0-5) were: raising spirits (M 4.9, SC 0.3), expression of feelings (M 4.6, SD .6) and working through grief (M 4.6, SD 0.7). Qualitative comments included themes of gratitude, leaving a legacy, meaning and connecting with others. Conclusions: This innovative creative arts program benefited patients, family and staff, in the expression of emotions and sharing personal stories. These findings will assist with improving program delivery and future planning of the creative arts in palliative care.
Survivorship care plan visits: Mixed methods analysis of patient surveys.
Authors: Garces Natalie , Goto Daisuke , Farhangfar Carol J. , Eaton Tara
Published: November 2018

174

Background: Survivorship Care Plans (SCPs) are endorsed by cancer advocacy groups and required for accreditation, yet benefits are unclear. The purpose of this quality initiative was to assess the benefit of SCPs. Methods: From June 2015 to September 2017, survivors who had a SCP visit were surveyed to report their understanding of key survivorship topics pre/post visit; the most valuable information learned and plans to use the information. Descriptive statistics and qualitative analysis were performed. Subgroup analysis was performed for age, insurance, marital status, and race. Wilcoxon signed-rank test computed statistical significance. Results: Of 794 surveys, 657 (83%) were complete and evaluable. Surveys were collected from breast (436 [66%]), lung (45 [7%]), colorectal (33 [5%]), head and neck (25 [4%]), melanoma (24 [4%]), endometrial and ovarian (20 each [3%]), and other (54 (8%) cancer survivors. Statistically significant ( p<0.05) improvements in all questions (Table 1) were noted across nearly all disease sites. Exceptions were endometrial, head and neck, and melanoma, which already had > 75% answering “completely understand” for selected questions pre- SCP visit. Subgroup analysis found no significant differences. Self-management was a theme in the “other” insurance status subgroup (14) qualitative analysis. Four (36%) indicated an interest in information about programs to improve healthy behaviors. Conclusions: There was major positive impact of the SCP visit on patient-reported understanding of all survivorship topics. Providers may benefit from focusing SCP discussion on areas the survivor reports as “some” or “no” understanding pre- SCP visit. Providers should connect survivors to resources to support self-identified needs. [Table: see text]
Using implementation science to initiate survivorship care plan practice change.
Authors: Goracke Olguin Betty , Benes Lindsay L.
Published: November 2018

175

Background: Failure to address coordination of cancer survivorship care can result in physical disability, emotional distress, and increased health care costs. The Institute of Medicine (IOM) recommended Survivorship Care Plans (SCPs) to improve care coordination among cancer survivors. Despite evidence supporting SCPs there remains limited implementation of SCPs. The use of implementation science, frameworks, and strategies that address contextual and process factors, could improve use of SCPs in oncology clinics (Selove et al., 2016). Methods: This innovation used the Quality Implementation Framework (QIF) (Meyers, Durlak, & Wandersman, 2012) to guide implementation. The QIF outlines steps and strategies for four phases of implementation; initial considerations regarding the host setting, creating a structure for implementation, ongoing structure once implementation begins, and improving future application. Results: During the project period (January 29, 2018 through April 23, 2018), 17 SCP visits were conducted; all 17 patients completed study surveys. In response to, “My health care providers work together as a team to ensure that my needs are met,” 65% reported strongly agree, 29% reported agree, 5% reported disagree, and 0% reported strongly disagree. When asked “My health care providers have informed me of what my follow-up care should be” 65% reported strongly agree and 35% reported agree. Of the 17 PCP surveys mailed, four were returned. In response to “For this patient the SCP helps me coordinate follow-up care,” three PCPs responded “agree.” When asked “For this patient, the SCP helps me provide better care,” three responded “strongly agree.” One PCP reported neutral feelings toward both statements. All PCPs reported SCP helped them better understand cancer treatment given and side effects. Conclusions: Successful SCP implementation, replicating outcomes of trials supporting SCPs, is attributable to the use of implementation science. Results from this project demonstrated SCPs achieved care coordination and patient satisfaction. SCPs enhanced PCPs’ understanding of cancer treatment and side effects which could increase likelihood PCPs discuss survivorship issues, as demonstrated in literature.
TIRED: A randomised controlled trial evaluating efficacy of cognitive behavior therapy and graded exercise therapy in severely fatigue patients with advanced cancer.
Authors: Poort Hanneke , Peters Marlies , Van Der Graaf Winette T.A. , Nieuwkerk Pythia , Van de Wouw Agnes W , Nijhuis-van der Sanden Maria , Bleijenberg Gijs , Verhagen Stans , Knoop Hans
Published: November 2018

183

Background: Patients with advanced, metastatic cancer frequently suffer from severe fatigue. We assessed the effect of cognitive behavioral therapy (CBT) and graded exercise therapy (GET) on fatigue during cancer treatment with palliative intent. Methods: This randomized study took place between Jan 1, 2013 and Sep 1, 2017 at Radboud University Medical Center (Nijmegen, Netherlands). We enrolled adult patients from nine medical oncology clinics. Eligible patients had advanced cancer and reported severe fatigue (Checklist Individual Strength, subscale fatigue severity [CIS fatigue] ≥ 35) during cancer treatment. Participants were randomized to CBT, GET, or usual care (1:1:1 ratio, using a computer-generated sequence, stratified by study site and minimized for sex). We measured fatigue (CIS fatigue and European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30 [EORTC-QLQ-C30] fatigue), quality of life, emotional functioning, physical functioning (all by EORTC-QLQ-C30), and functional impairments (Sickness Impact Profile [SIP8]) at baseline, 14, 18, and 26 weeks. The primary outcome was CIS fatigue at 14 weeks; secondary outcomes included scores for the aforementioned scales. We registered the trial with TrialRegister.nl (NTR3812). Results: 134 participants completed baseline measures (46 CBT, 42 GET, 46 usual care); 126 completed assessment at 14 weeks. There was a significant difference in CIS fatigue scores between CBT and usual care (-7.22, 97.5% CI -12.73 to -1.72; p = .003, d= 0.72), but no significant difference between GET and usual care (-4.70, -10.24 to 0.85, p = .057, d= 0.44). Secondary outcomes showed significant differences for EORTC-QLQ-C30 fatigue (-13.05 [95% CI -22.12 to -3.97]; p = 0.005), quality of life (10.15 [2.37 to 17.93]; p = 0.11), and physical functioning (7.10 [0.48 to 13.72]; p = 0.036), but not for emotional functioning or SIP8 functional impairments (p's > 0.05). There were no significant differences in secondary outcomes between GET and usual care. Conclusions: The findings support CBT for severe fatigue in patients with advanced cancer during treatment. Clinical trial information: NTR3812.
Opioid dose reduction and pain control with medical cannabis.
Authors: Bulbul Ajaz , Mino Emilio Araujo , Khorsand-Sahbaie Masoud , Lentkowski Lisa
Published: November 2018

189

Background: The use of medical cannabis (MC) for palliation of symptoms is on the rise in cancer and rheumatological patients. Whether there is a potential for opioid dose reduction (ODR) and or quality of life improvements (QOL) is unclear. Methods: A retrospective cohort was evaluated to understand the pattern of care and QOL outcomes with MC use across rural multidisciplinary practices in New Mexico. MC use (> 1 mo.), EMR interrogation, urine toxicology screening were used to identify patients. QOL questionnaire included a graded pain scale. Morphine equivalent (ME) dose was used to estimate changes in opioid dose. ODR was defined as any reduction of baseline opioid dose. A chi-square was performed to evaluate associations. Results: A total of 133 patients were identified between Jan 2017- May 2017. (M/F) 65/68; median age of 53 (range 20 - 84). Nineteen percent (25/133) had a cancer diagnosis. Pain score improved in 80 % of patients with cancer and in 75% (64/89) of non-cancer patients (x2 0.24 p = 0.62). ODR was achieved in 41% (54/133) of all patients on MC. Of these, 63% (34/54) had a 25% ODR and 37% (20/54) had 26% or more ODR (x2 12.8 p = 0.002). In cancer patients, a 25% ODR was achieved in 73% (x2 0.51 p = 0.771). All patients (15/15) using MC and high dose opioid (morphine equivalent ≥ 50 mg/day) had some ODR. Co-adjuvant NSAIDs with MC improved pain score in 67% of all cases vs 33% among non-NSAID cohort (x2 10.7 p = 0.001). ODR was achieved in 32% of patients with active depression vs 68% of patients without (x2 0.044 p = 0.83). Conclusions: In this rural cohort, MC use led to ODR in 41% of all patients. Depression was a negative predictor of ODR. NSAID use facilitated ODR. It will be important to assess MC toxicity before considering this intervention. This study did not include toxicity data due to the retrospective nature of this study and its inherent limitations. Prospective data are needed to confirm these findings.
Disparities in length of goals of care conversations between oncologists and patients with advanced cancer.
Authors: Smith Cardinale B. , Pintova Sofya , Adelson Kerin B. , Gonsky Jason Parker , Egorova Natalia , Bickell Nina A.
Published: November 2018

19

Background: Studies show minority patients have inadequate discussions about treatment, prognosis, and goals of care (GoC) which translate into substandard treatment, worse quality of life, and poorer survival than whites. However, there is a paucity of data on the quality of communication among minority patients with advanced cancer. We studied factors impacting the oncologists’ time spent during GoC discussion visits with their minority and non-minority patients. Methods: At community, academic, municipal, and rural hospitals, we recruited and randomized solid tumor oncologists and their newly diagnosed advanced cancer patients with <2-year prognosis to participate in a RCT, testing a coaching model of communication skills training. Patients were surveyed after post-imaging visits. These visits were audiotaped and median encounter time recorded. We define GoC discussions as patients report that their doctor talked about preferences for cancer treatment and clarified things most important to them given their illness. Comparisons were made using non-parametric tests. We used mix-effect models for risk adjustment. Results: For 22 randomized oncologists in the study,142 post-imaging encounters were audiotaped. Of these, 38% were non-Hispanic White, 32% non-Hispanic Black and 19% Hispanic. The median face to face time oncologists spent during a GoC encounter with an advanced cancer minority patient was 12 minutes compared to 17 minutes for non-minorities (p=0.002). Median encounter times varied between the four sites, ranging from 10 minutes to 18 minutes, p=0.009. For visits that took place after progression of disease, duration of visit was 18 minutes versus 13 minutes if there were no progression, p=0.007. After controlling for clustering of the patients within the hospitals and progression of disease, time spent with minority patients remained less than with non-minority patients (15 min vs. 18 min, p=0.02). Conclusions: Oncologists' time spent conducting GoC conversations with minority cancer patients is significantly less than with non-minority patients. Evaluating factors that contribute to this disparity is critically important to ensure minority patients receive high-quality cancer care. Clinical trial information: NCT02374255.
Switching endocrine therapy in breast cancer as a strategy for musculoskeletal symptoms, tolerance, and adherence.
Authors: Kibirova Albina , Hall Samantha , Miah Abdul , Salkeni Mohamad Adham
Published: November 2018

192

Background: Adverse effects of endocrine therapy (ET), especially musculoskeletal symptoms (MSS), represent the major cause of treatment discontinuation in breast cancer (BC) patients, resulting in increased risk of recurrence. Aromatase inhibitors (AI), the mainstay of ET, are associated with a high incidence of MSS such as arthralgia and myalgia. The hypothesis of whether switching ET subclass improves adherence and symptoms was tested. Methods: We conducted a retrospective single site chart review of female patients with nonmetastatic BC, who were seen at Cancer Clinic from January to June of 2017. All patients received AI as a first choice of adjuvant ET; those with disease recurrence while on ET were excluded. We collected data on baseline health, adherence and discontinuation rate, as well as whether switching to a different ET agent (another AI or tamoxifen) was attempted. The subsequent compliance and symptomatology after switching were assessed. Results: 483 eligible patients were identified and divided into 4 groups based upon adherence: 354 (73.3%) were found to be compliant with AI without interruption, 109 (22.5%) switched to a different ET and remained compliant (≥ 1 switch), 16 (3.3%) eventually discontinued ET despite attempting ≥ 1 switch, and 5 patients (1.0%) stopped treatment without a switch. On comparison of the different groups, patients who permanently discontinued ET were more likely to be elderly and have preexisting musculoskeletal condition. MSS was found to be the single most common cause for AI intolerance (105 patients, 81.4%). The median time to switch was 6.3 months (0.3-63.9). Among the compliant switchers, most needed only 1 switch (79) but there were patients who required 2 or 3 switches (23 and 6, respectively). Majority of patients switched from anastrozole to exemestane (84, 51.8%). Significant improvement in symptoms after the switch was reported by 73.3% of patients. Conclusions: Switching between different ET subclasses is an effective treatment strategy to alleviate side effects and enhance adherence to ET. A higher compliance rate of 95.8% was observed in our study compared to a national average estimated at < 80%.
Examination of the Screener and Opioid Assessment for Patients with Pain-Short Form (SOAPP-SF) in an oncology palliative medicine clinic.
Authors: Greiner Rebecca , Boselli Danielle , Salib Mariam , Patel Jai Narendra
Published: November 2018

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Background: The National Comprehensive Cancer Network states opioids can be used to treat cancer pain and prescribers should identify patients at risk for opioid misuse; research in this area is limited. In the non-cancer population, SOAPP-SF is a validated tool to predict aberrant drug behavior; a score of ≥ 4 (out of 20) is considered high risk. We performed a retrospective observational study to determine the utility of the SOAPP in identifying opioid misuse in the oncology population as measured by a non-compliant toxicology screen. Methods: Consecutive consults seen during a 6-month period completed the 5-question SOAPP-SF and Edmonton Symptom Assessment System (ESAS) form. Toxicology screens assessed non-compliance (i.e., absence of prescribed medications and/or presence of non-prescribed or illegal substances). Logistic regression models estimated the associations of composite and individual SOAPP-SF scores and ESAS symptom scores with non-compliant screens. Threshold analysis were conducted to identify an optimal SOAPP-SF cutoff. Results: Of 192 consults, 64 patients providing SOAPP-SF score and toxicology screen were evaluable. Mean age was 59 ± 9.8 years: 56% were female, 34% and 62% were African American and Caucasian respectively. Median SOAPP-SF score was 2 (range: [0, 12]). Non-compliant screens were observed in 31% of patients. The area under the curve (AUC) was 0.65. The validated SOAPP-SF cutoff score of ≥ 4 was associated with a sensitivity and specificity of 0.43 and 0.79, respectively (p = 0.082). Sensitivity (0.76) and specificity (0.72) were maximized at a cutoff score of ≥ 3 (p < 0.001). When evaluated individually, the SOAPP-SF question about smoking habit was associated with a non-compliant screen (p = 0.020). Increased ESAS pain scores were associated with SOAPP-SF score ≥ 3 (p = 0.013). Conclusions: SOAPP-SF can identify oncology patients at risk for opioid misuse. Preliminary analyses suggest a more appropriate threshold of identification is a score of ≥ 3 not ≥ 4. Future work will increase numbers of evaluable patients and examine other factors associated with opioid misuse.