bluuebunny/crossref_metadata_2025 huggingface dataset:
Integrating a simple screening tool in the electronic medical record to standardize patient needs identification process.
Authors: Williams Valaree , Caspar-Clark Audrey , Niznan Neal , Cammy Rebecca
Published: February 2017

156

Background: Unidentified psychosocial and nutrition needs can impede a patient’s quality of life during cancer treatment. Nutritional, social, and logistical patient needs may be overlooked without a standardized identification process. With the increasing use of the electronic medical record (EMR), simple screening tools to identify psychosocial needs and nutritional concerns can be implemented. Methods: The University of Pennsylvania’s Department of Radiation Oncology integrated a simple six-question “yes” or “no” response screen directly into the nursing assessment in the EMR to quickly and easily trigger high-risk patient referrals to social work and nutrition services. The screen identifies multiple patient needs (i.e. home supports, weight loss) in a formalized approach across distinct time periods in the treatment course. Staff collected data on new patient encounters and the subsequent referral source (i.e. screen, physician). Results: For social work, 24.5% of the new patient referrals from July 2013 – February 2014 were triggered via the screening tool in the EMR. While it is not clear from this data that overall referrals to social work increased due to the screening tool, it can be inferred that these patients were identified earlier in the treatment trajectory for supportive services. For nutrition services, 51.2% of new patient referrals were triggered via the screening tool. A comparison of data prior to the implementation of the screen in January 2012 showed a 78% increase in nutrition referrals triggered by the screen. Conclusions: This method facilitates quick intervention and fosters better communication among staff. The screen allows the staff to readdress psychosocial and nutrition impact symptoms on a regular basis and provide appropriate interventions along the continuum of care. The screen also reduces the subjectivity of medical staff referrals and is an additional measure to identify oncology patients who would otherwise be overlooked. Lastly, the screening tool in the EMR denotes a targeted intervention and contributes to the establishment of a supportive patient relationship.
Defining user needs for an electronic tool to improve chemotherapy-related toxicity management.
Authors: Prince Rebecca M. , Parente Laura , Soung Yee Anthony , Powis Melanie , Enright Katherine , Gandhi Sonal , Grunfeld Eva , Haq Rashida , Husain Amna , Krzyzanowska Monika K.
Published: February 2017

157

Background: Cancer drugs are associated with toxicities which can negatively impact patients’ (pts) quality of life, outcomes and increase acute care use (ACU). There is increasing interest in leveraging technology to solve clinical problems in healthcare. We hypothesized that an electronic tool (toxicity module) targeting management of chemotherapy toxicities could decrease ACU by facilitating more effective symptom management. Methods: Participatory design methodology consisting of end user needs assessment through ethnographic field study (shadowing and in-depth interviews) and focus groups was used to inform design of an interactive prototype toxicity module. Oncology pts and their caregivers, and health care providers (HCPs) including oncologists, oncology nurses and primary care providers were included in all stages of development. Contemporaneous notes were taken during ethnography while focus groups were also audio recorded. Thematic analysis through ideation sessions and time-of-day exercises allowed identification of overarching issues. Results: Eight pts and 8 HCPs participated in the ethnographic field study. Two focus groups, one with 7 pts, one with 4 HCPs were held. Most themes were common to both pts and HCPs; gaps and barriers in the current system, need for decision aids, improved HCP communication and options in care delivery, and access to credible information delivered in a timely, secure manner and integrated into existing systems. Additionally, pts further identified missed opportunities, care not meeting their needs, feeling overwhelmed and anxious and wanting to be more empowered; HCPs identified accountability as an issue. These themes informed development of a prototype for a web-based toxicity management tool, which has served the purpose of defining user needs for symptom tracking, self-management advice, and timely communication with an oncology provider. Iterative evaluation over 2 rounds of usability testing is currently underway. Conclusions: An electronic tool that integrates just-in-time self-management advice and oncology provider support into routine care may address some of the gaps identified in the current system for managing chemotherapy toxicity.
Developing and implementing EMR functionality to improve oral chemotherapy outcomes.
Authors: Hensing Thomas A. , Brockstein Bruce , Carro George W. , Hullett Ashton Marie , Hughes Brad , Spath Wayne , Huginnie Sharon
Published: February 2017

159

Background: Approval of new oral anticancer agents (OAA) continues to rise, accounting for 75% of new oncology drugs approved so far in 2015. OAA prescriptions generated at our institution demonstrate similar growth, as the prescription volume for OAA is approximately 200% greater than it was 8 years ago. Challenges of OAA, including safe prescribing, monitoring toxicities, and assessing adherence, continue to be an obstacle to providing quality care. In recognition of these challenges, our institution employed the electronic medical record (EMR) to develop tools to enhance safe prescribing, monitoring, and follow up for patients receiving OAA. Methods: Comprehensive, regimen-specific, OAA protocols were built in the EMR using the American Society of Clinical Oncology’s Quality Oncology Practice Initiative criteria as a guide. Protocols included OAA prescriptions, laboratory tests, monitoring communications, supportive care medications, plan for follow up, and a monitoring order. The monitoring order, dated 7 to 10 days after the start of each cycle, was utilized to identify patients for follow up, and as a documentation tool. During follow up calls, pharmacists provided education, addressed adherence and toxicities, and communicated findings to team members. The initial analysis focused on six of the most commonly prescribed OAA agents at our institution. Results: Cycle 1 follow up calls were placed for 115 new start OAA patients. Over half of the patients (56.5%) required an intervention (ex: symptom management, alerting the medical team, counseling). Eleven patients had barriers to adherence (ex: confusion, incorrect technique, cost, obtaining insurance coverage, and toxicity). Overall, 98% of patients verbalized appropriate adherence. There were 191 subsequent follow up efforts, after the cycle 1 follow up call, which resulted in 39 interventions (20%). Conclusions: OAA requires the same intensive monitoring and follow up as IV chemotherapy, but is more difficult to provide given the nature of administration of these medications. Utilizing the EMR to develop prescribing and monitoring tools can help address these challenges by providing a means for enhanced documentation and follow up.
HICOR IQ: Developing a regional oncology metric reporting platform.
Authors: Fedorenko Catherine R. , Kreizenbeck Karma L. , Sadot Avital , Piehler Britt , Murray Jessi , Gersch Michael , Lyman Gary H. , Ramsey Scott David
Published: February 2017

165

Background: The Hutchinson Institute for Cancer Outcomes Research (HICOR) has adopted a multi-stakeholder approach to identify and prioritize metrics to characterize oncology care in the Western Washington. In March 2015, HICOR released a beta version of an oncology informatics platform, named HICOR IQ, which allows regional payers, providers and patient advocates to view and interact with community-prioritized metrics. Methods: Surveillance, Epidemiology, and End Results (SEER) records for patients diagnosed with cancer in Western Washington state between January 1, 2007 and May 31, 2014 were linked with enrollment and claims from two regional commercial insurance plans. Algorithms were developed to characterize the 2012 ASCO Choosing Wisely (CW) recommendations in the claims-registry database. HICOR partnered with LabKey Software to develop a regional metric reporting platform. Results: The beta version of HICOR IQ displays regional results for the CW recommendations, then allow users to customize the reports by stratifying and/or filtering by different demographic (age, race, gender), clinical (cancer site, stage) and provider (clinic volume) characteristics. In addition, de-identified clinic specific adherence can be plotted to show variation in care throughout the region. A convenience sample of oncology clinic leaders was asked to review and comment on the beta-version. Primary suggestions were as follows: Display clinic-identifying information based on logged in user; Expand the flexibility of the tool to allow for user-created metrics; Keep the tool intuitive and easy to use; Protect the data and identity of patients. Future development of the tool will take an iterative process to allow for continued user feedback. The next planned version of HICOR IQ will incorporate user feedback by displaying clinic-identifying information based on the user and expanding the reporting of regional metrics. Conclusions: It is feasible to create a tool that reports regional adherence rates to oncology metrics. An iterative process that incorporates user feedback is an important step to build a tool that is adopted by the community.
Real-world treatment patterns, health care resource utilization (HRU), and costs among patients with Waldenstrom macroglobulinemia (WM) initiating therapy.
Authors: Schenkel Brad , Ellis Lorie , Korrer Stephanie , Byfield Stacey DaCosta
Published: February 2017

17

Background: WM is a rare, indolent B-cell lymphoma with 1000 to 1500 new cases diagnosed annually in the US. The disease is incurable with current therapy. Prior to January 2015 when ibrutinib was approved by the US FDA for WM, there were no therapies approved in this indication. This study describes initial systemic anti-cancer therapy (SACT) and HRU among WM patients (pts). Methods: A retrospective study using a large, national US claims database from 1/2007-10/2013 was conducted. Adult WM pts ( ≥ 2 claims for WM) with ≥ 1 claim for SACT were identified; the first SACT claim date was the index date. Pts were required to have a WM diagnosis within 3 months (m) prior to the index date and be continuously enrolled (CE) in the health plan for 12m pre- and ≥ 6m post-index date. Pregnant pts and those with SACT in the pre-index period were excluded. The first line of therapy (LOT1) period was examined; the LOT started at index date and the regimen included all drugs received within 60 days. The LOT ended at the earliest of, start of a new drug, ≥ 60-day gap in receipt of initial drug regimen, death or CE end. All-cause HRU and costs during LOT1 were examined. Results: There were 161 WM pts identified. 66% of pts were ≥ 65 yrs (mean age 69), 55% were male, and by insurance type, 49% were Medicare Advantage pts vs. 51% commercially insured. Mean total follow-up time was 23m, and mean duration of LOT1 was 4.7m. The top 4 most common LOT1 regimens accounted for 71% of patients: Rituximab (R) only (39%); bortezomib+ R (14%); bendamustine+ R (9%) and cyclophosphamide+ R (9%). No other regimens identified accounted for more than 4% of pts. Overall, 96% and 81% of pts had ≥ 1 office or hospital outpatient visit with mean per patient per month (PPPM) visits of 3.55 (standard deviation, SD = 2.41) and 2.60 (SD = 3.06), respectively. Approximately 25% and 21% had ≥ 1 ER visit or inpatient stay with mean PPPM visits of 0.11 (SD = 0.24) and 0.06 (SD = 0.16), respectively. Total mean PPPM healthcare costs during LOT1 was $13,589 (SD = $13,404). Conclusions: HRU and costs were high among WM pts initiating SACT. Future studies should examine whether differences in LOT1 regimen choice are associated with differences in cost and outcomes.
Utilizing a case management system to reduce the response time for symptom management calls in a high-volume practice.
Authors: Dickson Natalie R. , Bilbrey Larry Edward
Published: February 2017

170

Background: A five physician, three nurse practitioner,community oncology clinic experiences high call volumes (average 352 daily), many of which are related to side-effects of chemo/biotherapy and health related issues. A study was completed to decrease the time for a patient symptom management call to be addressed and concluded. Methods: Initial primary data were collected over a four month period (April-August 2015) using the phone system and the Electronic Health Record (EHR) reporting capabilities, by cross-referencing the caller-ID data with the EHR patient demographics data; only documented symptom management calls within the EHR were included. Twenty-nine percent (202 of 691) of symptom management calls were identified for the sample. Secondary data were collected prospectively using a handwritten call log completed by triage nursing, detailing the purpose of every call routed to triage nursing. Changes were made in the daily telephone call process to include a full-time operator, additional triage nursing staff, and implementation of a structured case management system. Follow-up primary and secondary data were collected for six weeks (August-September 2015) utilizing the case management system. Of the calls routed to triage nursing, 100% were captured in the case management system; call response time and call purpose were recorded. Results: During the initial primary data collection, a baseline of 48% of symptom management calls being addressed within 2 hours was established. Staffing changes resulted in an improvement to 68%, and an additional improvement to 73% after implementation of the case management system. Secondary data collection at baseline showed that 35% of calls were inappropriately routed to triage nursing; this improved to under 1% after implementation of the case management system. Conclusions: The reallocation of staff to concentrate on patient call processes, and the use of a case management system, significantly improved symptom management call response time. The implementation of a case management system nearly eliminated all inappropriate calls routed to triage nursing.
Brentuximab vedotin in relapsed/refractory Hodgkin lymphoma following autologous stem cell transplant: A cost-effectiveness analysis updated with 5-year follow-up data from the pivotal trial.
Authors: Parker Christopher , Kay Gemma , Ma Esprit , Woods Beth , Eaton James , Sajosi Peter , Engstrom Andreas , Selby Ross , Benson Eugene , Teasell Jeremy , Richhariya Akshara , Briggs Andrew , Bonthapally Vijayveer
Published: February 2017

19

Background: In 2015, the Scottish Medicines Consortium (SMC) made a positive recommandation for brentuximab vedotin (BV) in patients with relapsed or refractory (R/R) Hodgkin lymphoma (HL) who have received autologous stem cell transplantation (ASCT) based on 3-year follow-up data from the pivotal phase 2 single-arm trial (SG035-0003; NCT00848926). At 3-years, the incremental cost-effectiveness ratio (ICER) for brentuximab vedotin compared with chemotherapy +/- radiotherapy (C/R) was £43,731 per quality-adjusted life year (QALY). This study re-evaluated the cost-effectiveness analysis with 5-year follow-up data from the pivotal trial. Methods: A partitioned survival model was developed using a Scottish health system perspective over a lifetime time-horizon. Three health states were evaluated: progression-free survival (PFS), post-progression survival, and death. The relevant comparators were C/R, or C/R with intent to allogeneic stem cell transplantation. Clinical outcomes (PFS and overall survival [OS]) for BV were estimated based on data from the pivotal trial in 102 patients. A naïve comparison with the specified comparators was conducted using published survival data. ICERs were calculated with measures of the clinical outcomes, direct costs and QALYs. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the model. Results: The 5-year follow-up data reduced the base case ICER for BV from £43,731 to £38,769 per QALY versus C/R and increased the probability of cost-effectiveness. The variation in ICER for BV generated by the deterministic sensitivity analyses was also reduced resulting from reduced uncertainty in the estimation of long term clinical outcomes. Conclusions: This update has strengthened the cost-effectiveness evidence for BV in patients with R/R HL post-ASCT. The 5-year follow-up has reduced the uncertainty in the long term outcomes and reduced the ICER, which is low in comparison to other treatments for orphan diseases approved by UK agencies. BV may therefore represent a cost-effective treatment option for this patient group.
Brentuximab vedotin (BV) consolidation post-autologous stem cell transplant (ASCT) in patients (pts) with Hodgkin lymphoma (HL) at risk of residual disease: Number needed to treat (NNT) analysis.
Authors: Gautam Ashish , Huebner Dirk , Zhu Yanyan , Ma Esprit , Lee Shih-Yuan , Zagadailov Erin , Teasell Jeremy , Richhariya Akshara , Bonthapally Vijayveer
Published: February 2017

20

Background: AETHERA (NCT01100502) is a randomized Phase 3 study of BV and best supportive care (BSC) vs placebo (PBO) and BSC in the treatment of pts at risk of residual HL post-ASCT. BV consolidation therapy post-ASCT significantly improved progression-free survival (PFS) by independent review vs PBO (HR = 0.57, P = 0.001) and was FDA approved. Most common grade ≥ 3 adverse events were neutropenia (29% BV vs 10% PBO) and peripheral sensory neuropathy (10% vs 1%). The aim of this study was to determine the NNT with BV to avoid 1 additional event, disease progression/death. Methods: The NNT with BV was calculated as the inverse of the absolute risk reduction (ARR); ARR was the PFS event rate per investigator (INV) assessment in the PBO arm minus the event rate in the BV arm of the AETHERA trial. The AETHERA trial recruited pts ≥ 18 yrs at risk of residual HL post-ASCT defined by ≥ 1 of: history of refractory HL; relapse/progression < 12 months after frontline therapy; extranodal involvement at time of pre-ASCT relapse. Pts were randomized to receive BV 1.8 mg/kg or PBO on day 1 of each 21-day cycle, for up to 16 cycles/disease progression. Results: 329 pts (median age 32 yrs [range 18–76]; 53% male) received BV (n = 165) or PBO (n = 164). Fewer PFS events per INV analysis were experienced by pts in the BV arm vs PBO arm. The NNT with BV to prevent a disease progression/death ranged from 4.08 (95% CI 2.94, 6.96) to 7.79 pts (95% CI 5.05, 16.4) over 48 months (Table). At 24 months (time majority of pts have progressed post-ASCT), the NNT to prevent a disease progression/death was 4.92 pts (95% CI 3.29, 10.39). Conclusions: AETHERA data suggest that, at various time points, 1 in every 5–8 pts treated with BV consolidation therapy will benefit by avoiding disease progression/death. This further demonstrates BV’s clinical benefit in the post-ASCT consolidation setting. Clinical trial information: NCT01100502. [Table: see text]
Outcome analysis of breast cancer patients treated with cardiotoxic agents in the community setting: A single-institution experience.
Authors: Khelfa Yousef , Mansour Munthir , Gress Todd W. , Tirona Maria R. B. Tria
Published: February 2017

213

Background: Anthracyclines and anti-Her-2 targeted therapy are commonly used effective breast cancer treatments. They are known to decrease Left Ventricular Ejection Fraction (LVEF), which may increase patients’ morbidity and mortality. There is currently no consensus on post treatment cardiac follow-up. Recent observations suggested that ACEI and B blocker drugs could have cardioprotective effects. We conducted a retrospective study to assess patients’ cardiac outcome using post-treatment LVEF follow-up and effect of ACEI and B blocker on cardiac outcome for breast cancer patients who received cardiotoxic agents in our institution. Methods: We reviewed 155 charts of non-metastatic breast cancer patients between 2000-2008, who received anthracyclines and/or anti-Her-2 targeted therapy. Patients were stratified into groups A (anthracycline), B (trastuzumab) and C (anthracycline+trastuzumab). Results: Patients’ median age was 52.5 years. Six patients had coronary artery disease and 45 received radiation to the left breast. After a median follow-up of 93 months, only 3 of 155 (2%) patients developed symptoms of congestive heart failure. One hundred twenty patients had pre-treatment LVEF evaluation, while only 31 patients had pre and post LVEF evaluation. Mean LVEF difference was -7.89, - 9.01, -9 and -6.08 for all patients, group A, group B and group C, respectively. Thirty patients were on ACEI, 7 of them had LVEF follow-up with mean difference of -6.86. Thirty patients were on B blocker, 7 of them had LVEF follow-up with mean difference of -15. Because of the small size of the groups who had LVEF follow-up, no statistical difference can be detected. Conclusions: Our patient population showed very low incidence of clinically significant cardiac events in relation to anthracycline and anti-her-2 directed therapy after a median follow-up of 93 months. However, further follow is required to assess cardiac outcome that may affect quality of life and survival later in life. In this regard, our institution is establishing a dedicated cardio-oncology service to closely monitor patients who have been treated with cardiotoxic agents and provide early cardiac management if needed.
A quality improvement project to increase compliance with indicated prechemotherapy pneumococcal vaccination.
Authors: Delacruz Wilfred P. , Terrazzino Sandra , Haney Brian R.
Published: February 2017

218

Background: Severe pneumonia is associated with high morbidity and mortality in cancer patients. The most common pathogen is S. pneumoniae, responsible for 2/3 of pneumonia-related deaths. Current guidelines recommend routine use of 13-valent (Prevnar 13) and 23-valent (PPSV23) pneumococcal vaccine for immunocompromised patients (cancer patients). Of the 110 patients younger than 65 years old who started chemotherapy in our clinic from July 2013 to June 2014, only seven patients received the pneumonia vaccine through our clinic. We conducted a quality improvement (QI) project to improve compliance of pneumonia vaccination in patients who will start on chemotherapy in our outpatient clinic. Methods: We reviewed the current guidelines for pneumonia vaccinations in cancer patients with our physicians and encouraged them to prescribe the pneumonia vaccination to their patients prior to therapy. In addition to educating the primary provider, we took a multidisciplinary approach and recruited our clinic nurse practitioner who meets all patients for chemotherapy teaching to prescribe the vaccine to patients less than 65. Results: Of the 90 patients (median age 60, 20-86) who started chemotherapy during the study period, 58 were less than 65 years old of which three patients were already vaccinated prior to their diagnosis. Twenty five (45.5%) patients were vaccinated through our QI project. We have improved our compliance with pneumonia vaccination guidelines by 39%. Conclusions: We have improved compliance of pneumonia vaccination in cancer patients starting chemotherapy in our clinic through a QI project. We found that screening and intervention are best accomplished by a single person who is able to see all patients. This practice is now being conducted as standard of care in our clinic.
Shared decision-making in chronic lymphocytic leukemia: Preferences and perceptions of patients, providers, and navigators.
Authors: Rocque Gabrielle Betty , Van Laar Emily , Borate Uma , Halilova Karina I. , Peters Pamela M. , Jackson Bradford E. , Pisu Maria , Butler Thomas Wayne , Davis Randall S. , Mehta Amitkumar , Acemgil Aras , Knight Sara J. , Safford Monika M.
Published: February 2017

221

Background: In recent years, new treatments for chronic lymphocytic leukemia (CLL) with excellent response rates and varying toxicity profiles have emerged. In the setting of multiple available options, shared decision-making is critical. Developing strategies to enhance shared decision-making requires better understanding of how patients and providers make treatment decisions. Methods: Patients with CLL and health care providers within the University of Alabama at Birmingham Health System Cancer Community Network were to assess how treatment decisions are made. Results: Forty-four patients with CLL completed telephone-based surveys. The median age was 69 years old. Thirty percent had completed ≤12 years of education, 20% had some college education. Seventy-three percent of patients preferred an active or shared role in decision-making (27% preferring to make decision, 23% making decision with physician input, and 45% a shared role). Only 2% of patients preferred the doctor select the treatment. Despite >50% preferring an active role, only 20.5% perceived having an active role (Table 1). Thirty-three lay patient navigators, 26 oncologists, and 28 nurses (RN)/advanced care providers (ACP) completed web-based surveys. Navigators and nurses perceived a greater patient role in decision-making than physicians, who perceived that decisions were most often shared. Conclusions: Patients and providers have differing perceptions of their roles in decision-making in CLL treatment. Patients desire higher levels of participation in decision-making than they perceive that they receive, suggesting an opportunity for education of patients and providers to improve shared decision-making. [Table: see text]
Better utilization of neutropenic precautions and adherence to guidelines to improve cost effectiveness and patient convenience.
Authors: Raufi Ali Mehmood , Attraplsi Shada , Lebowicz Yehuda Z.
Published: February 2017

227

Background: Cancer patient are generally immunocompromised and are at increased risk of infections once absolute neutrophils count is less than 500. The aim of the study to evaluate the inpatient utilization of a standardized neutropenic precautions in cancer patients admitted with febrile neutropenia. Methods: From Jan 2010 to May 2015, established cancer patients were included in this retrospective study who were admitted in Cabel Huntington hospital, Huntington, WV with a diagnosis of febrile neutropenia and were placed on Neutropenic precautions (NP). We analyzed if NP were discontinued once patient is stable and no longer neutropenic during hospital stay. Results: A total of 159 cancer patients with admitting diagnosis of febrile neutropenia were identified. 107 out of 159 (67%) patients had solid malignancies while 33% had hematologic malignancies. Median age was 61 (Range of 20-88 years). 69 patients were male while 90 patients were female. Median duration of Neutropenic precautions (NP) was 4 (Mean 5.69 and range: 1-35). NP were appropriately discontinued in 30% of patients during hospital stay however approximately 70% of patients continued to be on NP even after neutropenia resolved (48 vs 111 patients). Median duration of unnecessary NP was 3 with a mean of 3.87 and range of 1-18 days. Conclusions: Better utilization of Neutropenic precautions and adherence to guidelines will improve overall cost effectiveness as well as patient convenience by avoiding unnecessary restriction.
Integrating Lean Six Sigma in the daily operations of an ICU to achieve safe, quality patient care.
Authors: Marquis Ann , Magurn Jacqueline , McGovern Joanne , Jetter Michelle , Beadling Sarah , Gregoire Dorothy
Published: February 2017

230

Background: Developing and maintaining a culture of safety and quality in delivering patient care is critical in the intensive care unit (ICU) especially an oncology ICU. Incorporating the Lean Six Sigma program into daily operations of the ICU achieves, simplifies, and sustains continuous improvement in the delivery of safe quality patient care. This program engages the ICU team through visual management of quality, safety, and budget indicators including medication scanning, falls, sharps exposure, infection prevention including blood stream, catheter, hospital and ventilator acquired pneumonias, venous embolism prevention, and staffing compliance. Methods: The initiative focused on stakeholder development to increase professional certifications, improve engagement through development and implementation of educational events, and enhance participation in monthly journal club. Discussion of evidence-based research projects aligned each shift with data, metrics, and outcomes. Cost containment through charge capture, reduction in wasted supplies, and appropriate level of care order was implemented. With the support of Lean Six Sigma, the lean daily management board came to life each shift. Results: Outcomes included medication scanning rates increasing from 94% to 99.5%. Hospital acquired infection and pressure ulcer rates remained 0%. Venous thromboembolism prophylaxis rates increased form 77% to 100%. Staffing compliance increased from 90% to 100%. The number of chemotherapy certified nurses increased from 56% to 71%. The number of nurses with specialty certification improved from 28% to 47%. Stakeholders engaged in 32 professional educational events, and 12 journal clubs were led by the ICU nurses. Product charge capture began at $0 ending in an average of $1342 per month from 0% charge capture to 100% charge capture each month. Conclusions: Team alignment around daily production, patient flow, and staff development enables real-time problem solving around the daily issues of safety, quality, productivity, and stakeholder development. In this oncology critical care unit it has not only enhanced daily communication but every twelve hour shift engagement as well.
Understanding disease progression and treatment patterns in metastatic breast, colorectal, and lung cancer: Implications for evaluating value and quality of care.
Authors: Engel-Nitz Nicole M. , Byfield Stacey DaCosta , Bancroft Timothy , Anderson Amy J , Reyes Carolina M. , Ravelo Arliene , Ogale Sarika , Matasar Matthew J. , Chen May C.
Published: February 2017

24

Background: Impact of strategies for evaluating value and quality of cancer care may vary for patients with metastatic tumors, particularly for strategies considering lines of treatment therapy as distinct events. To aid in evaluating the value and quality of care in patients’ overall trajectory of disease, this study examined disease progression, mortality, hospice, and treatment patterns in patients (pts) with metastatic breast (mBC), lung (mLC), and colorectal cancers (mCRC). Methods: Included were commercially insured and Medicare Advantage adults from a large US health plan administrative claims database (2007-2014); pts had ≥ 2 claims for BC, CRC, or LC, and ≥ 2 claims for metastases. Index date was defined as the first post-metastatic systemic anti-cancer therapy (TX). Health plan enrollment for 6 mo pre- and post-index date was required; pts with < 6 mo of follow-up due to death were included. Pts with other primary cancers were excluded. A line of therapy (LOT) algorithm was developed and outcomes assessed over a variable follow-up. Progressive disease (PD) was defined as: start of a new LOT, where 1) previous LOT duration > 60 days, and 2) ≥ 1 imaging/lab test occurred between previous LOT and new LOT; receipt of hospice care; or death. Results: Among 7070 mBC, 4767 mCRC and 6994 mLC patients, 73%, 72%, and 84% respectively progressed during the study period (incidence rates: 7, 7, and 13 per 10-pt-years). Mean (median) time in months to PD was 9.5 (6.5) for mBC, 9.0 (7.0) for mCRC and 6.3 (5.0) for mLC. For all cancers, median number of LOT over 1 year was 2, with means of 1.8 (mBC), 1.7 (mCRC), and 1.7 (mLC). Compared to patients without PD, patients with PD had shorter LOT1. Mortality was highest among mLC patients (50%) compared to mCRC (27%) and mBC (22%), with rates per 100-pt-years of 50, 16, and 11 respectively. Hospice rates varied by tumor type. Conclusions: The high level of progression and use of multiple lines of therapy in the metastatic setting suggests a need to delay progression with effective treatments for breast, lung, and colorectal cancers. The value and quality of cancer care should be evaluated across the entire span of patients’ disease.
Elective chemotherapy admissions: An opportunity to improve wait times.
Authors: Meyerholz Samantha , Dowling Mary E.
Published: February 2017

240

Background: Chemotherapy wait times are a well-recognized challenge facing cancer hospitals. Recent publications have stated that not only do wait times affect patients but they increase costs and consume hospital resources. Wait times lead to longer lengths of stay and require additional staff attention. Reducing chemotherapy treatment wait times has long been a priority of Sloan Kettering, with this study focusing on inpatient chemo processes. During October and November of 2014, 6 current state observations were performed in chemo nursing verification, chemo pharmacy and an inpatient chemo unit. Metrics measured included submission of electronic chemo orders, blood work availability, clearing for treatment, PICC line placement, bed availability and drug transport. All system components were analyzed from both a clinical and industrial engineering perspective. Future state analysis was conducted from December 2014 through April of 2015. Process improvement techniques including direct observation, process mapping, waste analysis and time studies were used to assess workflow. Methods: Prior to implementing performance improvement interventions, baseline data was compiled. 12% of electronic chemo orders were submitted 24 hours prior to admission, 36% of the time blood work was not available within 72 hours prior to patient arrival, 46% of treatments experienced pending delays due to ‘Proceed to Treat’ order, 0% of PICC lines were placed prior to admission, 34% of patients were discharged before 2pm and time for drug delivery averaged 1 hour and 47 minutes. The average time from patient admission to first chemotherapy treatment was 9.7 hours. Results: Following the rollout of a newly designed pilot unit in January 2015, data was collected for 192 chemo admissions in February through April of 2015. The use of electronic chemo orders rose to 84%, blood work was available 60% of the time, pending orders reduced to 0%, PICC placement occurred prior to day of admission 98% of the time, 46% of patients discharged before 2pm and drug delivery was reduced to 0 minutes. The time from admission to chemo treatment was reduced to 2.1 hours. Conclusions: The amount of patients treated after day of admission reduced from 17% to 8%, saving 18 patient days.
Panc Support Project (PSP): Evaluating the integration of palliative care into a pancreatic cancer program at a comprehensive cancer center.
Authors: Makoff Eve , Shinde Arvind Manohar , Tuli Richard , Hendifar Andrew Eugene
Published: February 2017

241

Background: Pancreatic adenocarcinoma is the 4th leading cause of cancer death in the US. It is predicted to become the 2nd leading cause by 2030. Advanced disease at diagnosis is common. Fewer than 20% of patients having long-term disease control. Given the high prevalence of physical and psychosocial needs, a quality initiative that embedded a PC physician in a pancreatic cancer program was initiated. Methods: From June 2015-October 2015, all stage III/IV pancreatic adenocarcinoma patients were referred for palliative consultation. * The PC physician was introduced as a supportive care medicine provider; a part of the comprehensive pancreas cancer program. *Other resources (ie RN, SW, Chaplain, RD) deployed as indicated *Patients seen initially and at least every 2 months * ESAS, PHQ2, and spiritual screens performed regularly * Data collected regarding symptom trajectory, resource utilization; and timing/place of death. Results: N=17. Conclusions: PSP demonstrated the ability of a PC provider to be effectively accepted and integrated into a pancreas program. Results suggest a benefit in the standardization of symptom screening/ intervention, and a possible favorable impact on healthcare resource utilization. Outcomes will continue to be tracked and compared with patients in the larger cancer community. Further study is indicated to assess the scalability and impact of this model of integrated care. [Table: see text]
Evaluation of leukocytosis: Benign or malignant.
Authors: Bowhay-Carnes Elizabeth Ann , Lee Shuko , Datta Paromita
Published: February 2017

245

Background: Hematologists frequently evaluate patients with leukocytosis to differentiate between benign and malignant causes. The objective of this quality improvement project was to identify risk factors for malignant leukocytosis. Methods: A retrospective analysis of 1,330 consults in ALM VA Outpatient Hematology Clinic between 1/1/2011 and 2/22/2015 was performed. 147 patients referred for evaluation of leukocytosis were included in this study. The following data was collected: sex, age, race, ethnicity, BMI, tobacco use, total WBC, tempo of leukocytosis (constant vs intermittent), Hg level, plt count, ANC, ALC, AMC, AEC, ABC, laboratory tests performed during work-up, final diagnosis (primary hematologic malignancy vs secondary causes). 35 patients (24%) with a diagnosis of primary hematologic malignancy were compared with 112 patients (76%) with secondary causes and the relative risk of a primary hematology malignancy related to various risk factors was calculated. Results: See Table. Conclusions: Statistically significant independent risk factors for the presence of a primary hematologic malignancy as the cause of leukocytosis were identified. There was no increased risk based on race, ethnicity, BMI, AMC, or AEC. By identifying risk factors for malignant leukocytosis, we have created and implemented an algorithm outlining clinically appropriate and cost-effective laboratory evaluation for patients with leukocytosis.[Table: see text]
Publication of quality improvement in medical oncology: A descriptive numerical summary from a scoping review.
Authors: Dharmakulaseelan Laavanya , Franco Bryan B. , Cheung Matthew C. , Haynes Adam E. , Wong Brian M. , Singh Simron
Published: February 2017

251

Background: Quality improvement (QI) is becoming a professional expectation and essential to medical oncology practice. A study of medical oncologists found that most QI interventions are not published, suggesting barriers to knowledge dissemination. We aim to describe the authors, settings of QI interventions, and publishing journals of scholarly QI literature. Methods: We conducted a scoping review using Arksey and O'Malley's framework. A search of MEDLINE and EMBASE databases found 48,186 unique English citations from January 2001 to August 2014. Two independent reviewers were responsible for screening the search results and 270 studies were included. Characteristics of first authors, settings of QI interventions, and publishing journals were charted. We used online search engines to find institutional profiles to obtain author and institutional information. A descriptive numerical summary analysis was used to summarize and report the results. Results: The number of QI publications has increased over time, with 60 between 2001 and 2006 and 199 from 2007 to 2013. The majority of first authors are clinicians (65%), of which 59% are physicians, 31% are nurses, and 5% are pharmacists. Furthermore, 27% of first authors are primarily researchers whereas 5% are solely administrators. In addition to professional degrees, having an advanced degree was common amongst clinicians (48% of physicians, 85% of nurses, 44% of pharmacists). Forty-four percent of interventions were conducted in settings affiliated with an academic institution, as opposed to community-based settings. Only 9% of articles were published in a quality of care focused journal. Conclusions: Our scoping review found that most first authors of QI interventions are clinicians, many with an advanced degree in academic settings (rather than community-based settings where most patients receive care). The lack of studies published in quality of care focused journals may result in lost opportunities for knowledge transfer. These findings suggest that more effective knowledge dissemination and increased support for QI studies are needed to further the science of quality and ultimately improve quality of care.
Understanding patterns of genetic risk evaluation (GRE) referral and uptake in patients (pts) with epithelial ovarian cancer (EOC).
Authors: Cao Yu , Morgan Robert , Leong Lucille A.
Published: February 2017

254

Background: EOC is the most common cause of gynecologic cancer death and fifth leading cause in women. ~20% cases are due to identifiable genetic risk (BRCA1/2 in 15%, Lynch syndrome 2%, other germline mutations 6%). Since 2013, National Comprehensive Cancer Network (NCCN) guidelines recommend all women with EOC be referred for GRE, to optimize risk stratification, genetic testing decisions, clinical management, with goal to reduce mortality. Yet physicians under-refer and pts under-utilize genetic services. Identifying clinically meaningful quality metrics and associated adherence is critical to improving cancer care. We aimed to characterize patterns of GRE referral and uptake in pts with EOC. Methods: Completed GRE was tracked in pts with EOC 2009-2015, using City of Hope (COH) cancer registry and genetics appointments system. Targeted chart review was done for pts identified as without GRE completion in 2014 (18 cases), 2015 (2 cases). Results: 91/191 (48%) analytic pts with EOC from 2009-15 registry data were identified with completed GRE. Targeted chart review of non-adherent cases: 2015: 1/2 pts did not complete GRE (at COH primarily for surgery). 2014: 7/18 pts documented with completed GRE; Pareto chart was constructed for 11 unaccounted non-adherent pts: see Table. Conclusions: 2014-15 GRE completion rate (68%) suggests a higher GRE referral rate, above that reported in literature (<35%). In 2014, 75% pts seen by medical oncology had documented reasons for not completing GRE; 2/11 pts who did not complete GRE lacked a documented reason (see chart). Inability to track paper referrals (used prior to 2014) limited analysis. Promoting multidisciplinary educational interventions for specific audiences, collaboration between community and COH referring physicians, studying physician perceptions of GRE risks/benefits/barriers, EHR enhancements (e.g. creating a GRE check-off item, or documentation aids), and pt-centered assessment of GRE awareness and utilization may improve adherence with NCCN guidelines to 100% (CA33572). [Table: see text]
Analysis of the results of implementation of a pregnancy screening policy at a comprehensive cancer center.
Authors: Trowbridge Gloria , Cleveland David , DeJesus Alma Yvette , Cheng Lee , Wagar Elizabeth Ann , Levenback Charles F. , Rodriguez Maria Alma
Published: February 2017

256

Background: Institutional implementation of a standard pregnancy screening policy for women will enhance the safe and timely delivery of treatment throughout the care continuum. In 2012, we developed and implemented an initial policy on pregnancy screening test (PST). The policy indicated that all providers should fully discuss with their female patients of child bearing potential regarding the potential risks of cancer treatment on fertility and the adverse effects on the fetus. The providers should also discuss the contraceptive options with female patients and their partners prior to diagnostic studies and/or treatment. In 2015, we revised the initial policy to further clarify timeframe for PST and clinical indicators and also developed an algorithm to support this best practice. We assessed practice changes as a result of the policy changes regarding PST at our institution. Methods: A retrospective data review was conducted to assess the number of PST over a 5 year period at The University of Texas MD Anderson Cancer Center. The timeframe includes both baseline and post-implementation policy and reflects annual changes from fiscal year (FY) 2010 to 2015. The pregnancy test was defined as measuring human chorionic gonadotropin (hCG) level in a urine sample. Results: We observed a significant increase in PSTs over time among female patients between ages 10 to 55 years. Over 5 years, there were 23,793 urine pregnancy tests performed. The number of urine pregnancy tests performed per FY were as shown on table below (trend test, p< 0.01). The percentage of PST performed among age groups (years): 1.8% of 10 to 15, 11.6% of 16 to 25, 22.3% of 26 to 35, 34.7% of 36 to 45, and 29.5% of 46-55 years old. Conclusions: Wedemonstrated that developing a standard institutional policy on pregnancy screening tests with further enhancements contributed to a significant increase in the number of PSTs performed over 5 years at our comprehensive cancer center. The majority of PSTs were conducted among female patient between the ages of 26 and 55. [Table: see text]
Measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare survey items between non-Hispanic whites and Asians.
Authors: Hays Ron D. , Chawla Neetu , Kent Erin E. , Arora Neeraj K.
Published: February 2017

259

Background: Asians report worse experiences with care than Whites. This could be due to true differences in care received, expectations about care, or survey response styles. To examine measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare survey items between Whites and Asians. Methods: We conducted multiple group confirmatory factor analyses to evaluate measurement equivalence of CAHPS Medicare survey data between White and Asian Medicare beneficiaries for three CAHPS reporting composites (communication with personal doctor, access to care, plan customer service) and global ratings of care using pooled CAHPS data from 2007-2011. Responses were obtained from non-Hispanic whites (n = 1,326,410) and Asians (n = 40,672). The median age for whites was 70, with 24% 80 or older, and 70 for Asians, with 23% 80 or older. Fifty-eight percent of the whites and 56% of the Asians were female. Results: A model without group-specific estimates fit the data as well as a model that included 12 group-specific estimates suggested by Lagrange multiplier tests (Comparative Fit Index = 0.922, Root Mean Square Error of Approximation = 0.064). Three of the 12 group-specific estimates consisted of 7 factor loadings, 3 measured variable errors, and 2 item intercepts. Six of the factor loadings were larger for Asians than for whites. Conclusions: This study provides general support for measurement equivalence in response to the CAHPS Medicare survey composites (communication, access, customer service) and global ratings between White and Asian respondents, supporting comparison of care experiences for the two groups.