bluuebunny/crossref_metadata_2025 huggingface dataset:
Using retrospective adverse event data to assess the impact of visitor management during a pandemic emergency plan at a community oncology practice.
Authors: Bilbrey Larry Edward , Dickson Natalie R.
Published: October 2020

146

Background: During the COVID-19 pandemic, our community oncology practice, with over 150 providers at 33 locations, incorporated infection control guidance from the CDC into our Pandemic Emergency Plan, including visitor restrictions at all locations. There was an increase in patient fall events in our clinics after visitor restrictions were implemented in March 2020, as there were fewer care-givers available in the clinics to assist patients. Methods: Using our adverse event reporting system, we abstracted and trended all safety events that involved patient falls from March 2019 through May 2020. We compared patient fall events during the period of visitor restriction (March-May 2020) to the same period in 2019, and to the 3 months preceding March 2020 and the implementation of COVID-19 restrictions. We report patient fall events per 1,000 patient visits. Results: Prior to COVID-19, patient fall events averaged .207 falls per 1,000 patient visits for March thru May 2019 and .137 falls per 1,000 patient visits for Dec 2019 thru Feb 2020. Following the implementation of visitor restrictions in March 2020, patient fall events increased to .271 per 1000 visits, with a vast upward trend resulting in .435 patient fall events per 1,000 visits in May of 2020 when the restrictions were tightened, more than double previous averages prior to COVID-19. Conclusions: Family members and care-givers play an important role in the patient’s care team. We are confident that the significant increase in patient falls in May 2020 is attributed to visitor restrictions. These findings support the vital role of family and care-givers in patient safety. They not only provide transportation, emotional support and information on patient health status, but assist with ADLs, ambulation and transfer needs during the patients’ visits to the clinics. Healthcare facilities are often under-resourced and under-staffed to fully address patients’ physical needs. Limiting care-givers during a pandemic may reduce the transmission of infection, but also may lead to other unexpected adverse events. Using these findings, we will be implementing standard fall prevention procedures. The practice’s emergency pandemic plan on visitor restrictions will also be amended to take this into account.
Healthy lifestyle challenges among older female cancer survivors.
Authors: Krok-Schoen Jessica L. , Pisegna Janell , Arthur Elizabeth , Ridgway Emily , Stephens Christian , Rosko Ashley Elizabeth
Published: October 2020

156

Background: Healthy lifestyles including consuming a healthy diet, being physically active, and maintaining a normal weight can improve prognosis and health-related quality of life (HRQoL) among cancer survivors. The largest proportion of cancer survivors are older adults (≥65 years), yet their lifestyle behaviors are understudied. This study examined the lifestyle behaviors (diet quality, physical activity, maintaining healthy weight) of older female cancer survivors and associations with HRQoL. Methods: Women aged 65 years or older, with all cancer subtypes and stages, who had completed primary cancer treatment (i.e., chemotherapy, surgery, radiation) within the past five years, were eligible to participate. Older female cancer survivors (n = 171) completed one-time surveys to assess HRQoL (RAND-36), unintentional weight loss, body mass index (BMI), diet quality (Diet History Questionnaire II), and physical activity. Demographic information and medical record data were also collected. Diet History Questionnaire II results were converted to Healthy Eating Index (HEI)-2015 scores. Descriptive analyses, correlations, and stepwise linear regressions were utilized. Results: The majority of the sample (median age = 74.50±8.43 years) were white (90%), married (54.7%), breast cancer survivors (67.7%), and completed at least a bachelor’s degree (54.7%). Physical and mental HRQoL of the sample were low; 41.94±10.50 and 48.47±7.18, respectively, out of 100. Physical activity was low; 75.3%, 54.2%, and 68.1% reported no strenuous, moderate, and mild physical activity, respectively. Mean BMI was 27.71±6.24 (overweight), with 64% of the participants being overweight or obese. Mean HEI-2015 scores were 66.54+10.0 out of 100 and below the cutoff score of 80, which represents a “good diet”. Participating in moderate physical activity was associated with higher physical HRQoL (β = 0.42, p = 0.004). Being older (β = 0.27, p = 0.025), white (β = 0.53, p < 0.001), and having higher HEI scores (β = 0.30, p = 0.011) was associated with higher mental HRQoL. Conclusions: Older female cancer survivors reported lifestyle challenges including poor diet quality, low levels of physical activity, and high rates of being overweight or obese, which were associated with HRQoL. Results indicate the need for tailored health interventions for older female cancer survivors regarding their lifestyle behaviors to improve prognosis and HRQoL.
Evaluating compliance of NCCN cancer and chemotherapy-induced anemia guidelines in a community healthcare setting.
Authors: Haber Jamie , Byrne Brian J.
Published: October 2020

16

Background: The National Comprehensive Cancer Network has released guidelines for management of cancer- and chemotherapy-induced anemia which are defined as Hb less than 11g/dL or a greater than 2g/dL decrease from baseline. The myelosuppressive effects of cancer, chemotherapy and associated treatments, can accumulate with each cycle leading to severe and worsening anemia. It is important to properly identify and treat anemia in cancer patients in a timely manner. This project evaluates the degree to which NCCN guidelines are followed within a multi-site community healthcare setting. Methods: Obtained patient medical records within Hartford Healthcare system in a 4 month period (Nov. 2019-Feb. 2020), who were started on new cancer chemotherapy treatment plans. Patients on single agent immunotherapy or hormone therapy only plans were excluded. Reviewed patient’s medical records to identify who met criteria for cancer- and chemotherapy-induced anemia and who received recommended work up and treatment based on NCCN guidelines. Age, sex, disease, renal function, and goals of treatment were also recorded. Results: A total of 869 patient records were obtained. 598 patients met the inclusion criteria. 452 patients (75.6%) met criteria for cancer- and chemotherapy-induced anemia. 235 patients (52%) had anemia appropriately documented in the physician medical record. 111 patients with anemia (24.6%) had an iron panel performed and 29 patients (6.4%) had a reticulocyte count resulted. For those eligible by NCCN criteria for anemia specific interventions 27 patients (40%) received appropriate iron supplementation, 95 patients (85.6%) received appropriate blood transfusions and 10 patients (7.7%) received appropriate EPO. Conclusions: It is apparent that based on NCCN guidelines, monitoring, evaluation, and treatment of anemia is not being appropriately performed in this healthcare setting. Based on this data a quality improvement project for proper documentation, workup, and treatment of anemia is being developed. [Table: see text]
Demographic, socioeconomic, and clinical factors associated with oncology patient experience in the Ontario cancer system.
Authors: Mahler Mary , Nicholls Brett , Chan Catherine , Nazeri-Rad Narges , Chan Kelvin K. , Singh Simron
Published: October 2020

160

Background: Your Voice Matters (YVM) is an electronic real time Patient Reported Experience Measure (PREM) collected on all adult patients accessing cancer services in Ontario by Cancer Care Ontario/Ontario Health. To our knowledge, this is the largest oncology PREM dataset worldwide. A total of 25 Items are assessed including care coordination, wait times, access to care and satisfaction with healthcare providers. We attempted to identify demographic, socioeconomic and disease factors that predict for a positive patient experience. Methods: Responses were collated from 18 individual cancer centers between Jan 2017 and Dec 2019. Each item was dichotomized into positive/negative experiences. Multivariable logistic regression was constructed for each of the 25 items. Results: Demographics are described in table. Males (OR=1.11, p=0.0032), genitourinary patients (OR=1.30, p=0.0031) and those receiving radiation (OR=1.39, p=<0.0001) were more likely to have a positive experience. Patients aged 18-39 (OR=0.74, p=<0.0001), receiving chemotherapy (OR=0.76, p=0.0002), and with central nervous system or lung cancer (OR= 0.56, p=<0.001; OR=0.79 p=0.0059, respectively) were more likely to have a negative experience. Lowest income patients were more likely to have a negative experience with healthcare providers (OR=0.83, p=0.0119) and patients from the highest immigration areas had a worse quality experience (OR=0.82, p=0.0029). Conclusions: Age, sex, disease site, visit type, income and immigration status significantly influence patients cancer care experience. This information helps promote equity and the use of PREM data to improve cancer care delivery. [Table: see text]
Using machine learning to identify older adults at high risk for hospitalization and mortality via the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE).
Authors: Xu Huiwen , Mohile Supriya Gupta , Flannery Marie Anne , Peppone Luke Joseph , Mohamed Mostafa , Ramsdale Erika E. , Patil Amita , Jonnalagadda Sahithi , Jamieson Leah , Vogel Victor G. , Katato Khalil , Hall Bianca , Mustian Karen Michelle , Culakova Eva
Published: October 2020

169

Background: PRO-CTCAE captures symptomatic adverse events (e.g. pain, fatigue) and may indicate poor treatment tolerability in older patients (pts) with advanced cancer. Using unsupervised machine learning which can detect unknown patterns in data, we aimed to evaluate if clusters identified based on PRO-CTCAE severity were associated with hospitalization and survival. Methods: We included pts randomized to the control arm of GAP 70+ (URCC 13059; PI: Mohile), which enrolled pts aged ≥70, with incurable solid tumors or lymphoma, and ≥1 geriatric assessment (GA) domain impairment starting a new treatment regimen. Measures included 24 PRO-CTCAE items (v1.0) with severity attributes (item 0-4; total score 0-96, higher score = greater severity). The unsupervised algorithm (K-means with Euclidean Distance) clustered pts at baseline based on similarities of severities of the 24 items. We examined if the clusters were associated with treatment-related hospitalization within 3 months and lower survival at 6 months using Logistic and Cox regressions. Results: Of the 369 control pts, 366 completed GA and PRO-CTCAE at baseline (mean age 77.2, 94.3% white, 30.9% with GI and 31.4% with lung cancer; mean number of impaired GA 4.4). By PRO-CTCAE, the most prevalent symptoms were fatigue (82.7%), pain (60.9%), and decreased appetite (58.7%). Greater GA impairment was associated with 20 PRO-CTCAE items (fatigue, pain, and decreased appetite having the strongest associations; all Pearson's r > 0.33). Three clusters were identified: Low Severity (51.4%); Moderate Severity (34.4%), and High Severity (14.2%). Mean total severity score was 6.9 (low), 16.9 (moderate), and 28.7 (high), respectively (p < 0.01). No difference in demographics was found among clusters. Percent of pts hospitalized were 21.3% (low), 36.5% (moderate), and 38.5% (high) (p < 0.01); survival rates were 81.9% (low), 71.4% (moderate), and 55.3% (high) (p < 0.01). Controlling for cancer type and GA, compared to pts in Low Severity cluster, pts in Moderate and High Severity were more likely to be hospitalized (odds ratio = 1.77, p = 0.03); pts in High Severity cluster were more likely to die (hazard ratio = 2.23, p = 0.01). Conclusions: Unsupervised machine learning was able to partition pts into different PRO-CTCAE severity clusters; pts with higher baseline severity were more likely to be hospitalized or die. PRO-CTCAE provides additional information to GA. Funding: R01CA177592, U01CA233167, UG1CA189961.
Influenza in hospitalized cancer patients: A propensity score matching analysis.
Authors: Li Jiarui , Zhang Dingding , Zhao Lin , Sun Zhao , Bai Chunmei
Published: October 2020

170

Background: Cancer patients are vulnerable to influenza viruses and are at great risk of developing related complications. However, few studies have assessed the impact of influenza infection among hospitalized cancer patients in the United States. Methods: We identified cancer-related hospitalizations from National Inpatient Sample between 2012 and 2014. A 1:1 propensity score matching analysis was conducted to compare the clinical outcomes between hospitalized cancer patients with and without influenza. Results: We identified 13,186,849 cancer-related hospitalizations, and 47,850 of them (0.36%) had a concomitant diagnosis of influenza. After propensity score matching, cancer patients with influenza had a higher mortality (5.4% vs. 4.2%; odds ratio [OR]: 1.3; 95% confidence interval [CI], 1.13 to 1.49; P < 0.001), longer length of stay (6.3 vs. 5.6 days; P < 0.001) but lower costs (14605.9 vs. 14625.5 dollars; P < 0.001) in hospital than those without influenza. In addition, patients with influenza had a higher incidence of pneumonia (18.4% vs. 13.2%; OR, 1.49; 95% CI, 1.37 to 1.62; P < 0.001), neutropenia (7.1% vs. 3.4%; OR, 2.18; 95% CI, 1.91 to 2.50; P < 0.001), sepsis (19.5% vs. 9.3%; OR, 2.36; 95% CI, 2.16 to 2.58; P < 0.001), dehydration (14.8% vs. 8.8%; OR, 1.80; 95% CI, 1.65 to 1.97; P < 0.001), and acute kidney injury (19.9% vs. 17.6%; OR, 1.16; 95% CI, 1.08 to 1.25; P < 0.001) than those without influenza. Conclusions: Influenza is associated with worse clinical outcomes among hospitalized cancer patients. Influenza vaccination is recommended in this population.
Perceptions of care coordination among older adult cancer survivors: A SEER-CAHPS study.
Authors: Mollica Michelle , Buckenmaier Susan S , Halpern Michael T. , McNeel Timothy S. , Weaver Sallie J. , Doose Michelle , Kent Erin E
Published: October 2020

178

Background: Care coordination represents deliberate efforts to harmonize and organize patient care activities. This study examined sociodemographic and clinical predictors of patient-reported care coordination among Medicare beneficiaries older than 65 with a history of cancer. Methods: This study utilized the Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data, including SEER cancer registry data, Medicare CAHPS patient experience surveys, and Medicare claims. We identified Medicare beneficiaries who completed a CAHPS survey within ten years after their most recent cancer diagnosis and reported visiting a personal doctor within six months before their survey (n = 14,646). Multivariable regression models examined associations between cancer survivor characteristics and care coordination, with higher scores indicating better coordination (scale of 0-100). Results: Residing in a rural area at time of diagnosis (1.2-points greater score than urban; p= 0.04) and reporting > 4 visits with a personal doctor within 6 months (3.0-points greater than 1-2 visits; p< 0.001) were significantly associated with higher care coordination scores. Older age ( p< 0.001) and seeing more specialists ( p= 0.006) were associated with significantly lower care coordination scores. Patients with melanoma (women: 5.2-point difference, p< 0.001; men: 2.8 points, p= 0.01) and breast cancer (women: 2.4 points; p< 0.001) also reported significantly lower care coordination scores than did men with prostate cancer (reference group). Conclusions: Adult cancer survivors who are older, have a history of breast, lung, or melanoma cancers, or see more specialists report worse care coordination. Future research should explore and address the multilevel influences that lead to worse care coordination for older adult cancer survivors.
A pilot study to increase adherence to ASCO Choosing Wisely recommendations for breast cancer surveillance at community clinics.
Authors: Kreizenbeck Karma L. , Wong Tracy , Jagels Barbara , Smith Julie C. , Irwin Blair Billings , Jensen Barbara , Egan Kathryn , Noble Heather , Ramsey Scott David
Published: October 2020

18

Background: ASCO 2012 Choosing Wisely recommends against serum tumor marker tests and advanced imaging for breast cancer survivors who are asymptomatic for recurrence. Our pilot aimed to measure and raise adherence to this recommendation through a patient video at regional community clinics. Methods: Eligibility for study included patients with 1+ long-term follow-up visit within 3 months of end of treatment in the pre- or post-intervention period: Clinic tumor registries were queried for stage I-IIIA breast cancer patients treated with curative intent. The intervention included 1) academic detailing for oncologists at a regular meeting and 2) a video about the recommendation shown to patients at end of active treatment. Surveillance data was manually abstracted. We define adherence as no asymptomatic tests in the first 13 months of surveillance. Results: Advanced imaging adherence was high before and after the intervention (99-100%). Tumor marker (TM) adherence is in the table. Six of seven providers with low (<60%) TM adherence before the intervention maintained low TM adherence after. One provider with low TM adherence and all 3 providers with moderate (60-90%) TM adherence increased to high TM adherence (>90%). TM adherence was better among patients who viewed the video (130 of 145, 90%) than those who did not (452 of 556, 81%) in the post-intervention period. The higher TM adherence among patients who viewed the video and the wide range in adherence among providers suggest that tumor marker use may be both patient- and provider-driven. Population characteristics may explain some of the variation in adherence. Conclusions: While adherence to recommendations regarding high-cost imaging was high, wide variation in tumor marker adherence among providers and high baseline adherence for advanced imaging suggests that interventions targeting surveillance testing may wish to focus primarily on tumor markers and provider outreach. [Table: see text]
A multicentered academic medical center experience of a simulated root cause analysis (RCA) for hematology/oncology fellows.
Authors: Wallace Danielle , Cochran Denise , Duff Jennifer Michelle , Close Julia Lee , Murphy Martina Cathryn , Patel Arpan
Published: October 2020

188

Background: Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Specifically, the ACGME requires trainee participation in interprofessional clinical patient safety activities, such as root cause analyses. These can be challenging to incorporate into busy schedules and are intimidating to some trainees, but simulated RCAs are a novel way to assure trainees gain important patient safety skills. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. Methods: The two-hour module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Seventeen fellows from two institutions completed pre- and post-session surveys regarding the experience. Results: There was a 47% increase in both the percentage of fellows who felt comfortable participating in live RCAs in the future, and in the number of fellows who felt comfortable with using the tools typically utilized in an RCA. 70.59% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event. Conclusions: Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills
The prevention of anticancer therapy extravasation events in the oncology clinic infusion patient: A quality improvement study.
Authors: Ciafre Lisa , Bigbee Matthew , Stallings Holley , Strom Chelsea , Reiser Patricia , Graham Emily , Lowery Raven , Scheerer Courtney , Haines Dana
Published: October 2020

192

Background: The Allegheny Health Network Cancer Institute (AHNCI) Medical Oncology is comprised of 19 infusion clinics located in the western Pennsylvania region. Safety quality assurance data revealed an extravasation rate of 0.12% for vesicant anticancer therapies. A literature review identified a benchmark for these extravasations to be 0.09% confirming that the AHNCI had an opportunity to improve patient safety. Methods: A multidisciplinary quality team with support from ASCO’s Quality Training Program was developed to decrease extravasation occurrences utilizing problem solving tools and PDSA methodology. A process flow map and cause and effect diagram revealed opportunities in the following categories: People–Lack of formal IV training resulting in care dependent on experiential knowledge only; Process–There is not a standardized process for IV starts; Plant–Supply standardization was non-existent. Offices and staff utilized the catheter of their choice with varying levels of technology for early detection of vein cannulation. The use of catheter stabilizing dressings or devices did not exist. Diagnostic data analysis revealed that a majority of extravasation events occurred peripherally in the forearm with a 24g, 0.75” catheter. Therefore, this quality team’s focus was on the prevention of peripheral extravasations. Gemba walk utilizing an observation tool identified that nurses often made decisions based on personal comfort rather than best practice. Process measures: Process Change #1: Standardize IV Catheters across the network to reduce variation and ensure that the chosen catheter’s manufacture technology includes early vein cannulation technology and to implement IV start kits with a securement dressing. Process Change#2: Educate nurses in vein assessment technique, catheter selection and insertion skill. Results: Allegheny Health Network Cancer Institute was able to decrease extravasation events from 0.12% to 0.02% due to the innovation of this quality improvement team by standardizing supplies and ensuring staff competency with peripheral IV insertion knowledge and skills. Conclusions: Validating a problem through data is essential–we can’t manage what we can’t measure.Validating a problem’s value through evidence is necessary (patient harm). Benchmarking must be supported with a high level of evidence. Eliminating variation improves investigative outcomes. Implementing process measures through best practice evidence and not hypothesis is essential.
Improving vaccine administration in patients with solid malignancies in the outpatient setting.
Authors: Alexander Mariam , Stuart Matthew , Galeas Jose Nahun , Browne Roy , McCarthy Jim , Packer Stuart H.
Published: October 2020

194

Background: Pneumococcal and influenza vaccinations are recommended for all patients with any malignancy in accordance with the Infectious Disease Society of America. Patients undergoing chemotherapy for solid tumors have a 40-50 fold higher risk for the development of invasive pneumococcal disease compared to healthy adults with a case fatality rate of 35% and should receive the sequential 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23). In the outpatient setting, lack of provider knowledge, complexity of the pneumococcal vaccine regimen and disruption in work-flow of a busy clinic can lead to low rates of administration. Towards this end, we conducted a quality project to improve administration of both pneumococcal and influenza vaccines by at least 50% at one of our outpatient oncology clinics at Montefiore Medical Center in Bronx, NY during a 4 month period. Methods: We first provided provider and nursing education with regard to safety and efficacy of the vaccines in both the clinic as well as the infusion setting. Nurses were then prompted to screen patients and offer the vaccines during intake prior to all infusions and clinic visits. We created bulk orders which allowed nurses greater control of releasing vaccine orders previously entered by the director of the clinic. We also posted “cheat-sheets” on optimal timing, safety and sequence of administration of the vaccines in every patient room and nursing station. After our first cycle, we identified that there was a delay in work-flow in the outpatient clinic with delivery of the vaccines to the clinic from the pharmacy. We therefore obtained a secure vaccine fridge that was placed at the nursing station, which allowed nurses easy access to the vaccines. Results: When vaccine administration during the 2018-2019 influenza season was compared to the 2019-2020 influenza season, we found that these interventions improved the administration of the influenza vaccine by 70%. There was a dramatic increase in the number of PCV-13 vaccines administered by 350% (more than 5-fold) and increase in PPVS-23 by 12.5%. No immediate adverse reactions during this cycle were reported to our nurse manager. Conclusions: A simple intervention of improved work-flow of vaccine administration and increased education of providers and nurses translated to a dramatic improvement in the administration of influenza and PCV-13 vaccines in a busy outpatient oncology clinic.
Geriatric assessment tool to assist physicians in providing patients with quality care in rural community oncology setting.
Authors: Montesano Mari , Fromwiller Venus , Sharma Shrida , Murphy Candice , Desai Amrita
Published: October 2020

200

Background: Currently in the USA, 60% of all cancers and 70% of cancer mortality occur s i n people aged 65 and older. However, there are significant gaps in knowledge of oncology treatment outcomes in the geriatric population. The Cancer and Aging Research Group developed a Comprehensive Geriatric Assessment (CGA) tool in 2 007 to assess the abilities of older patients to make judgments and carry out daily activities. The assessment was created to help doctors recognize issues in the geriatric population and develop comprehensive treatment plans with the aim to improve outcomes in this age group. The purpose of the study was to assess whether the CGA tool would be useful in the physician’s decision-making process and in making appropriate and timely patient referrals in a rural community oncology setting. Methods: Newly diagnosed cancer patients with non-hematological cancers above 65 years of age seeking care at the Columbia Memorial Hospital -OHSU Knight Cancer Collaborative during May to August of 2019 were consented and asked to take the CGA survey. A summary of the patient’s responses with the scores and a list of recommendations was provided to the physician at the time of the initial consultation. Along with this summary, a single question survey was given to the physician in order to assess whether the feedback was helpful in their treatment planning. Results: Of the 49 new patients seen at the CMH-OHSU Knight Cancer Collaborative who qualified to participate in the study 22 (44.8%) completed the survey,18 (36.7%) did not complete the survey, 5 (10%) did not come in for their clinic appointment, and 5 others were disqualified from the survey for other reasons. The results indicate that the survey tool aided the clinician in the majority (95%) of the cases to make overall assessments of their patient’s health and helped make management decisions. The results showed that more referrals were made to physical therapy & primary care clinics in patients who took the survey as compared to the patients who did not take the survey [14% vs 5%]. Conclusions: We conclude that the oncologists at our cancer center found that the CARG assessment tool is beneficial for physicians in their decision-making process while assessing an elderly patient and helped them provide timely and more comprehensive treatment care plan.
Development of a personalized follow-up care algorithm for Medicare breast cancer survivors.
Authors: Wheeler Stephanie B. , Spees Lisa , Biddell Caitlin B. , Rotter Jason , Trogdon Justin G. , Birken Sarah A. , Mayer Deborah
Published: October 2020

204

Background: The rapidly growing number of cancer survivors in the US have substantial healthcare needs requiring surveillance and care for the late and long-term effects of cancer treatment and comorbidities. Lacking a clear system of care, experts recommend a personalized approach to survivorship care. The objective of this study was to test a clinical prediction algorithm to distinguish low-complexity breast cancer survivors who may be suited to self-manage their survivorship care and be followed by their primary care provider (PCP) from survivors who require specialty care. Methods: We used the Surveillance and Epidemiology End Results (SEER) registry – Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to identify women diagnosed with stage 0-3 breast cancer between 2003 and 2011. Cross-validated random forest machine learning models separately estimated survivors’ independent risk of all-cause death, cancer-specific death, recurrence, or severe late effects within 3 years following treatment completion. The absence of these outcomes identified survivors as potentially eligible for self-management and PCP care. Predictors included measures of baseline health status and health care utilization, patient socio-demographic characteristics, cancer characteristics, and financial burden. Results: Among the 4,516 survivors in the primary cohort, 82% were white, and the mean (SD) age was 75.1 (7.8) years. Almost 50% were diagnosed with Stage I breast cancer, followed by 25.2% with Stage 2, 19.3% with Stage 0, and 5.6% with Stage III. Within the 3-year follow-up period, 372 (8.2%) survivors died (111 or 2.5% from cancer), 665 (14.7%) experienced recurrence, and 488 (10.8%) were hospitalized due to severe late effects. Predicting all-cause death resulted in 91.9% out-of-sample accuracy, a 37.6% improvement over an uninformed model. Important predictors across outcomes included age, geographic region, diagnosis year, financial burden, comorbidities, and cancer stage. Conclusions: Survivors requiring specialty care are characterized by higher comorbidity, lower educational attainment, and advanced age, suggesting that, in addition to cancer characteristics, personalized care pathways developed in response to our findings must account for social and contextual factors as well.
Reducing the wait time to initiate inpatient chemotherapy at Lyndon B. Johnson Hospital.
Authors: Wiele Andrew James , Nguyen Trung , Ononogbu Onyebuchi , Russo Kristyn-Mae , Le Phat , Patel Tejal Amar , Ma Hilary Y. , Rieber Alyssa G.
Published: October 2020

210

Background: Delays in initiating inpatient (inpt) chemotherapy (chemo) for planned admissions can decrease patient (pt) satisfaction and increase length of stay and healthcare costs. Our center, a community public teaching hospital, lacked clear standard operating procedures for scheduled chemo admissions, resulting in significant delays. We developed a process improvement initiative to reduce the pt wait time from admission to chemo administration (time to chemo [TTC]). Methods: A multidisciplinary team was formed to clarify workflows and identify root causes prolonging wait times for pts admitted to the inpt chemo unit. We implemented two Plan-Do-Study-Act (PDSA) cycles over a 6-month period. First, in early March, we collaborated with pharmacy and nursing to standardize the inpt chemo operating procedures and extend pharmacy’s evening hours for chemo preparation (prep) from 7pm to 9pm. Second, in early June, we implemented a Pre-admission Checklist that was visibly displayed in clinic for fellows to review with faculty, and began discussing pts scheduled for admission during the daily, multidisciplinary huddle that already occurred on the inpt chemo unit. Using the electronic medical record and available time stamps, baseline data was collected from November-December 2019, post-intervention data for PDSA cycle 1 was collected from March-April 2020, and data collection for PDSA cycle 2 is ongoing. Results: Root cause analysis identified late afternoon admissions and PICC line placements as two main sources for TTC delays. Hospital procedures also limited inpt PICC line placement between 8am-4pm and inpt chemo prep between 7am-7pm. Baseline data revealed 77.4% (24/31) of pts were admitted between 3pm-10pm, the median TTC was 20.4 hrs, and 6.5% (2/31) of pts had chemotherapy initiated within 12 hrs of admission (TTC < 12). Additionally, 56.5% (26/46) of pts had PICC lines placed during their admission, but 69.2% (18/26) of the pts with PICC lines were eligible for outpatient port placement according to institutional intravenous (IV) access guidelines. After PDSA cycle 1, median TTC decreased by 10% to 18.4 hrs, and 33.3% (5/15) of pts had TTC < 12. Conclusions: After standardizing inpt chemo procedures and extending chemo prep times, PDSA cycle 1 resulted in a 10% reduction in TTC and a 26.8% increase in the rate of TTC < 12. Although admission times cannot be controlled at this time, the impact of improving pre-admission planning, and specifically addressing IV access, for PDSA cycle 2 is currently being evaluated and will be reported at the time of abstract presentation.
Decreasing the number of authorization denials in an academic medical oncology practice.
Authors: Patel Monaliben , Bruno Debora S. , McCaulley Lauren , Srivastava Piyush
Published: October 2020

212

Background: Prior authorizations in medical oncology generate additional work and subsequent stress to providers, contributing to physician burnout. Denials of payments can also impact patient care and lead to loss of revenue for the institution. In 2018, first pass denial rates averaged 8.41% per month at our institution. Imaging/scans denials created the majority of this additional work for providers. We aimed to decrease the monthly first pass denial rate average of oncology scans by 25% by May 31, 2020. Methods: Following the creation of a process map of the current prior authorization process and a cause and effect diagram, we identified many factors that could not be controlled (i.e. Insurance company policies). We subsequently created a priority/pay-off-matrix using factors that we could control. Introducing standardized order template for oncology scans was identified as a high impact and feasible countermeasure. Plan-do-study-act cycles (PDSA) plan was developed using this countermeasure to achieve our aim. PDSA 1 included creating template for order entry, educating the nurse partners and advance practice providers (APPs). PDSA 2 included educating physicians and measuring the compliance rate of the template. PDSA 3 addressed the barriers for compliance and education on resources was provided. PDSA 4 included education of the prior authorization staff and reinforcement of template use. A sustainability plan created consisting of a designated RN liaison for review of peer-to-peer requests for oncology scans. Results: PDSA 1: 100% of the nurse partners and APPs were educated. PDSA2: 80% of physicians were educated and 32.8% compliance rate of template use. PDSA 3: 39.2% compliance. PDSA 4: 95% of the radiology prior authorization staff was educated. While our compliance rate for the standardized order template use did increase, we identified many other opportunities to improve the process. Unfortunately, due to COVID-19 pandemic outbreak, resources have been temporarily allocated to relief efforts and the sustainability plan continues to be a work in progress. Conclusions: Peer to peer requests for imaging/scans following authorization denials consume time and effort of providers contributing to burnout and potentially impacting patient care. While many factors cannot be controlled, standardizing ordering process and educating the involved personnel may decrease the number for peer to peer requests. ASCO’s quality training program process helped our institution identify a provider controlled barrier and helped standardize this approach.
Is inpatient chemotherapy overutilized?
Authors: Berger Natalie S , Petrone Giulia , Landry Chrystal Ann , Huang Hsin-hui , Smith Cardinale B.
Published: October 2020

215

Background: Inpatient palliative chemotherapy has been associated with more aggressive end of life care, reduced utilization of hospice services and decreased quality of life. The decision to administer chemotherapy in the inpatient setting is not always standardized which may lead to overutilization. Methods: We performed a retrospective chart review of all patients who received inpatient chemotherapy at an Academic center during the year 2016. Patients were stratified by solid tumor (ST) versus hematologic malignancies (HM) and assessed for the urgency of chemotherapy. We also evaluated response to treatment, death within 30 days of chemotherapy administration, and other qualitative and quantitative variables. We used descriptive statistics and odds ratios (OR) were estimated from logistic regression models. Results: We identified 141 patients; 47% HM. Select significant patient outcomes (p-value ≤0.05) are summarized in Table. At the time of admission, the majority of ST patients had stage 4 cancer (71%) with a poorer performance status (p= 0.0005) and were more often admitted due to symptoms related to their cancer (p<0.0001). HM patients were more likely to be directly admitted for chemotherapy (p<0.0001). Among ST patients, 29% received chemotherapy because the admission coincided with a non-urgent planned cycle compared to 11% of HM. Reason for inpatient chemotherapy was documented as urgent for 94% HM and 67% ST patients. ST patients were more likely to receive a palliative care consult (65% vs 24%; p<0.001) and to die within 30 days of index admission (15.8% vs 6.2%; p=0.019). In the adjusted analysis, the most important factor associated with urgent chemotherapy was the cancer type (OR: 8.25, 95% CI 2.13-31.97, p=0.002). Conclusions: Our study indicates that there is an overutilization of inpatient chemotherapy in ST patients as well as increased mortality within 30 days of inpatient chemotherapy administration compared to HM. The administration of inpatient chemotherapy can be avoided in many cases which can lead to improved quality of life and cost savings. Creation of a standardized algorithm on the appropriateness of inpatient chemotherapy may be a useful tool to guide decision making. [Table: see text]
Evaluation of Spanish hospitals participating in the Quality Oncology Practice Initiative program.
Authors: Lopez Rafael , Antón Antonio , Aranda Enrique , Carrato Alfredo , Constenla Manuel , Cruz-Hernández Juan J. , Díaz-Rubio Eduardo , Feyjóo Margarita , García-Foncillas Jesús , Gascón Pere , Guillem Vicente , Lugo Ilse , Camps Carlos
Published: October 2020

222

Background: Measuring and tracking quality of care is highly relevant in today’s healthcare. The Quality Oncology Practice Initiative (QOPI) program is a referral for evaluating oncology practices worldwide. The ECO Foundation (Excellence and Quality in Oncology), a collaboration of oncology experts from the major Spanish hospitals involved in cancer treatment, reached an agreement with ASCO (American Society of Clinical Oncology) to include Spanish hospitals in its QOPI program. Methods: We analyzed the results of the QOPI core module measures from 19 Spanish hospitals submitting their data in nine rounds (from Fall 2015 to Fall 2019). Results: Of the 19 hospitals, 15 participated more than once; none participated in all 9 rounds (2 hospitals participated in 8 rounds). The highest scores were for pathology report confirming malignancy, documenting plan of care for moderate/severe pain and chemotherapy dose, and chemotherapy administered to patients with metastatic solid tumor with performance status undocumented. Measures regarding a summary of chemotherapy treatment, tobacco use cessation counseling, and assessment of patient emotional well-being were among the lowest scored measures. Six of the 15 practices who participated repeatedly achieved a better score in their last round compared to their first. Overall, scores of Spanish hospitals improved from 67.79% in Fall 2015 to 68.91% in Fall 2019. Conclusions: This is the first study to evaluate QOPI scores in Spain; it showed that repeated participation enhances quality of care, although there is room for improvement. The ECO Foundation will continue supporting and engaging with practices to increase their participation in order to improve oncology care and implement strategies that address the areas for improvement.
Improving medication reconciliation in ambulatory cancer care.
Authors: Milley-Daigle Carissa , Dara Celina , Bouchard-Fortier Genevieve , Julius Anet , Kukreti Vishal , Mak Ernie , Morley Lyndon , Powis Melanie Lynn , Prince Rebecca M. , Bissonnette Jean-Pierre , Costello Judy , Espin-Garcia Osvaldo , Glinsky Victoria , Macedo Alyssa , Viswabandya Auro , Krzyzanowska Monika K.
Published: October 2020

224

Background: Adverse drug events are common in ambulatory oncology where care spans multiple providers and medication documentation is often poor. We undertook a QI project with the aim of having 30% of patients have a best possible medication history (BPMH) or medication reconciliation (MedRec) documented within 30 days of starting systemic therapy. Methods: An Electronic Medical record-Integrated Tool (EMITT) was developed to facilitate documentation. 2 Plan-Do-Study-Act (PDSA) cycles have been completed to date; PDSA 1 consisted of piloting EMITT in 3 clinics run by physician champions. PDSA 2 which consisted of expanding pharmacy support and addition of a 4th clinic was impacted by care changes related to COVID. The proportion of patients with BPMH/MedRec documented in EMITT was calculated monthly for each period (PDSA 1, PDSA 2 pre-COVID and PDSA 2 post-COVID). The balancing measure of time to complete an entry was evaluated through a time motion study. Results: Between 9/9/2019 and 31/5/2020, 9.4% (233/2488) of patients had BPMH/MedRec completed; Table shows proportion of patients by month. BPMH and MedRec were most frequently performed by pharmacists followed by pharmacy students and nurses. On average, it took 5.5 minutes to complete an entry (n = 10; median number of medications per patient = 12.3). Conclusions: BPMH was documented more often than MedRec. While some usage was sustained, the changes to care as a result of COVID-19 negatively impacted ambulatory medication reconciliation. Future PDSA cycles will involve engaging patients in MedRec and extending EMITT to all ambulatory cancer clinics where medication management is a major component of care. [Table: see text]
Providing uninterrupted oral oncolytic therapies during the COVID-19 pandemic.
Authors: Arrowsmith Edward , Mitchell Rachel L. , Taylor Jack L. , Schleicher Stephen Matthew , Dickson Natalie R. , McCullough Stacey ,   Tennessee Oncology
Published: October 2020

226

Background: Uninterrupted utilization of oral oncolytics is critical to maximizing safety and efficacy of cancer treatment. The COVID-19 pandemic presented numerous challenges to delivering a continuous and safe supply of oral oncolytics to patients with cancer including potential loss of insurance coverage, patient lost income making copays more difficult, remote pharmacy staffing difficulties, and logistical challenges in safely distributing drug to cancer patients. Tennessee Oncology has an in-house Specialty Pharmacy that utilizes home delivery of oral oncolytics while coordinating care with providers during changing patient situations. Methods: We analyzed patients who received an oral oncolytic from our pharmacy in two periods: January-May 2019 and January-May 2020. We compared the aggregate patient copay amounts during these periods, the number of patients who utilized copay assistance or foundational financial support. For insights on continuation we also assessed the medication possession ratios (MPR, the sum of the day’s supply for all fills of a given drug in a particular period divided by the number of days in that period) during these time periods for five of our most commonly dispensed drugs. Results: The aggregate patient copay was similar between the two time periods. A 22% increase in the utilization of copay cards indicated patient’s insurance coverage was sustained. We also observed a 12% increase in the number of patients utilizing foundation support for prescriptions filled. MPRs for five commonly dispensed oral oncolytics were unchanged during COVID-19. Conclusions: Our in-house specialty pharmacy maintained delivery of oral oncolytics during the COVID-19 pandemic. Patient cost share was contained by our pharmacy staff proactively utilizing copay cards for all eligible patients and diligently securing foundational grant support. The pharmacy interventions allowed for affordability, uninterrupted pharmacy operations, and consistent medication supply. This led to continued medication adherence. MPR for the 5 top dispensed medications was consistent in a year-on-year comparison. [Table: see text]
Synchronizing advance directives among patients across a health system.
Authors: Cervantez Sherri Rauenzahn , Hotakey Sadiyah , Hernandez Amanda , Warren Stephanie , Quintero Jennifer , Garcia Cesar
Published: October 2020

233

Background: Advance directives (ADs) are legal tools that direct treatment or decision making and appoint a surrogate decision-maker (health care proxy). The presence of ADs is associated with decreased rates of hospitalization, use of life-sustaining treatment, and deaths in a hospital setting. Additionally, completed ADs lead to increased use of hospice or palliative care, more positive family outcomes, improved quality of life for patients, and reduced costs for healthcare. Despite the benefits of advance care planning, only 18-36% of adults have completed advance care plans. The aims of our pilot study were to 1) implement a synchronized system for advance care planning across the UT Health San Antonio health system and 2) improve advance care planning rates in a primary care clinic and palliative oncology clinic. Methods: During a 10-month prospective period, system processes for advance care planning were reviewed with identification of three primary drivers for advance care plan completion: a) electronic/EMR processes, b) clinical workflows and training, and c) patient resources and education. As a result of this quality improvement initiative, standardized forms, resources, and processes for obtaining advance care plans were implemented in the selected clinics. Results: At baseline, the primary care clinic had 84/644 (13%) patients and the palliative oncology clinic had 25/336(7%) with completed advance care plans. With the implementation of a standardized process, 108 patients (23% increase in rate of completion) in the primary clinic and 56 patients (71% increase in rate of completion) in the palliative oncology setting completed advance care planning (ACP). Additionally, there was a 5-fold increase in billing of ACP CPT codes within the clinics during the first 6 months compared to the prior full year. Conclusions: While this quality improvement pilot initiative was limited to two clinics, the synchronized modifications suggest that the system changes could be expanded to other clinics in our UT health system to promote ACP discussions, completion of plans, and ultimately improved patient care.