bluuebunny/crossref_metadata_2025 huggingface dataset:
“It’s important to me”: A qualitative analysis of shared decision-making and patient preferences in early-stage breast cancer patients.
Authors: Lawhon Valerie , England Rebecca , Wallace Audrey S. , Williams Courtney , Ingram Stacey A. , Gilbert Aidan , Rocque Gabrielle Betty
Published: October 2019

227

Background: Shared decision-making (SDM) occurs when both patient and provider are involved in the treatment decision-making process. SDM allows patients to understand the pros and cons of different treatments while also helping them select the one that aligns with their care goals when multiple options are available. This qualitative study sought to understand different factors that influence early-stage breast cancer (EBC) patients’ approach in selecting treatment. Methods: This cross-sectional study included women with stage I-III EBC receiving treatment at the University of Alabama at Birmingham from 2017-2018. To understand SDM preferences, patients completed the Control Preferences Scale and a short demographic questionnaire. To understand patient’s values when choosing treatment, semi-structured interviews were conducted to capture patient preferences for making treatment decisions, including surgery, radiation, or systemic treatments. Interviews were audio-recorded, transcribed, and analyzed using NVivo. Two coders analyzed transcripts using a constant comparative method to identify major themes related to decision-making preferences. Results: Amongst the 33 women, the majority of patients (52%) desired shared responsibility in treatment decisions. 52% of patients were age 75+ and 48% of patients were age 65-74, with an average age of 74 (4.2 SD). 21% of patients were African American and 79% were Caucasian. Interviews revealed 19 recurrent treatment decision-making themes, including effectiveness, disease prognosis, physician and others’ opinions, side effects, logistics, personal responsibilites, ability to accomplish daily activities or larger goals, and spirituality. EBC patient preferences varied widely in regards to treatment decision-making. Conclusions: The variety of themes identified in the analysis indicate that there is a large amount of variability to what preferences are most crucial to patients. Providers should consider individual patient needs and desires rather than using a “one size fits all” approach when making treatment decisions. Findings from this study could aid in future SDM implementations.
“I had already made up my mind.” The impact of prior experience and health care perceptions on decision making in women with early-stage breast cancer.
Authors: England Rebecca , Lawhon Valerie , Wallace Audrey S. , Ingram Stacey A. , Williams Courtney , Rocque Gabrielle Betty
Published: October 2019

228

Background: Shared decision-making (SDM) occurs when informed patients partner with their oncologists to incorporate personal preferences into treatment. Even before engaging with an oncologist about treatment options, patients may have personal experiences or knowledge of other’s experiences with breast cancer that frame their decision-making. This study sought to understand how prior experiences and knowledge drive preferences in early stage breast cancer treatment approaches. Methods: This qualitative study included early stage breast cancer (BC) patients at an academic medical center in the Deep South. Women age ≥18 with an AJCC stage I-III BC diagnosis were invited to complete semi-structured interviews with a trained interviewer. Interviews were audio-recorded, transcribed, and analyzed by two independent coders utilizing a constant comparative method from an a priori conceptual model based on the Ottawa Framework. Major themes and exemplary quotes related to decision-making preferences were extracted. Results: Women (n = 33) interviewed were an average age of 74 (4.2 SD), and 19% of participants were African American. Many women were given the option to omit treatments, such as chemotherapy or radiation therapy, based on hormone receptor status and axillary node involvement. Major themes related to a desire for more treatment were past experiences with family members having cancer or an impression that additional treatment would be more effective. For women that opted out of treatments, prior knowledge of potential physical side effects from friends, family, and other cancer survivors were cited as a major deterrent. Perceptions of low recurrence risk also influenced desire to forgo treatments. Conclusions: Women presenting with early stage BC had varied healthcare experiences, which resulted in preconceived ideas about receiving breast cancer treatments. Consideration of these themes may aid physicians’ ability to address individual concerns to further personalize patient care, thus enhancing the patient-physician partnership. These findings will ultimately assist in improving patient engagement in SDM.
Characteristics associated with hospitalization for patients with cancer receiving chemotherapy who present to the emergency department (ED).
Authors: Nipp Ryan David , Azoba Chinenye , Vyas Austin , Kay Paul , Fuh Charn-Xin , Wang Irene , Mai Minh , Soriano Margaret , Mulvey Therese Marie
Published: October 2019

23

Background: Patients with cancer receiving chemotherapy often present to the ED and require hospitalization to manage acute issues. However, little work has sought to understand characteristics associated with hospitalizations for patients with cancer receiving chemotherapy who present to the ED. Methods: As part of a quality improvement initiative, we reviewed ED visits within 30-days of patients receiving intravenous chemotherapy at Massachusetts General Hospital from October 2017-January 2018. We used descriptive statistics to compare sociodemographic and clinical factors for hospitalized and non-hospitalized patients. We used logistic regression to explore variables independently associated with being hospitalized. We also compared death rates within 6 months between groups. Results: We identified 500 ED visits during our study period, which resulted in 350 (70.0%) hospitalizations. Hospitalized and non-hospitalized patients did not differ by age (mean 64.1 vs 63.4, P = 0.61), sex (48.9% vs 51.3% female, P = 0.61), or presence of metastatic disease (71.1% vs 68.7%, P = 0.59). Hospitalized patients were more likely to have gastrointestinal (25.7% vs 20.7%) and lung (14.0% vs 11.3%) cancer; less likely to have breast cancer (7.4% vs 16.7%, P < 0.01). Hospitalized patients were more likely to come to the ED on a Thursday (15.7% vs 6.7%); less likely to come on a Wednesday (10.3% vs 19.3%, P < 0.01). On logistic regression, factors associated with higher likelihood of being hospitalized included white race (OR = 1.84, P = 0.03), and presenting with fever/cold symptoms (OR = 2.64, P < 0.01), fatigue (OR = 2.15, P = 0.04), or dyspnea (OR = 2.29, P = 0.04). Death rates within 6 months were higher for the hospitalized patients (50.0% vs 18.7%, P < 0.01). Conclusions: Patients with cancer who visited the ED within 30-days of receiving intravenous chemotherapy often require hospitalization. We identified factors associated with higher likelihood of hospitalization, including patient characteristics, presenting symptoms, and the day of the week. Our findings should inform future efforts to enhance care delivery and outcomes for patients with cancer receiving chemotherapy.
Psychological safety and near miss events in radiation oncology.
Authors: Kundu Palak , Jung Olivia , Rose Kathy , Khaothiemsang Chonlawan , Agazaryan Nzhde , Edmondson Amy , Steinberg Michael L. , Raldow Ann C.
Published: October 2019

231

Background: Near miss events, defined as harm averted due to chance, are learning opportunities in radiation oncology. Psychological safety is a feature of a learning environment characterized by interpersonal risk taking. We examine the effects of near miss type and psychological safety on reporting near miss events to an incident learning system. We posit that submission likelihood will differ based on near miss types and psychological safety. Methods: We administered a survey assessing psychological safety to members of a radiation oncology department. We then presented six events for a patient with a pacemaker (PM), which requires cardiac clearance before radiation: process-based (harm averted by systematic PM check); good catch (harm averted by incidental PM check); “could” event (harm averted by chance PM absence); “almost” event (positive PM status, but no sequelae); hit (positive PM status, subsequent arrhythmia); and control (no PM, checked PM status, no sequelae). Subjects ranked each event on submission likelihood (1 = most likely, 7 = least likely), scored events based on submission likelihood by others (1 = least likely, 7 = most likely), and rated event success (1 = failure, 7 = success). ANOVA was used to assess differences in mean rank, submission likelihood, and success ratings. Regression was used to assess the relationship between psychological safety and submission likelihood. Results: The survey yielded 95 out of 127 responses (75%). Mean ranks (p < 0.0001), submission likelihood (p = .042), and success ratings (p < 0.001) differed by near miss type; psychological safety predicted likelihood of submitting the different near miss types (Table 1). 14 respondents (15%) would mind if an incident was submitted about them, while 43 respondents (45%) assume others would mind if an incident was reported related to the others (score > 4). Conclusions: Near miss events proximal to a negative outcome are more likely to be reported, though this effect may be mediated by psychological safety.

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Root cause analysis: A framework using principles of high reliability.
Authors: Denny, DBA Diane , Shinners Caitlyn , Hepler Marjorie
Published: October 2019

233

Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to errors. A network of hospitals and outpatient centers recognized an opportunity to enhance and standardize our approach to root cause analyses (RCAs). As leaders, we have an imperative to prevent issues that can result in a safety event; yet we have an even greater moral obligation to correct causes once an event occurs to prevent it from happening again. Methods: A framework was established to prevent recurrence through a focus upon root solutions. Recognizing that human error is not the cause of the failure but a symptom, the goal is to understand why it made sense for individuals to do what they did by reconstructing the world in which they found themselves at the time of the event. The includes: 1) training staff on high reliability; 2) assigning an executive to remove barriers; 3) creating a charter; 4) conducting 1:1 interviews; 5) deploying tools (such as sequence of event diagramming, validation and verification of raw data, human error type classification; individual/system failure and event/causal factor charting); 6) transporting findings; and 7) action planning with controls. A 3-meeting model was embraced. Results: As of April 2019, 9 events have been investigated. Event types include: infusion hours/splitting orders, incorrect lab order, retained object, wrong patient medication administration, patient brachytherapy underdosing, wrong site delayed treatment, rapid response call delay, and delay in care for extravasation. The 12-month rolling average serious safety event rate per 10,000 patient days decreased from 1.93 to 1.33 since implementation. With 6 months experience under the enhanced framework, plans also exist to monitor events from similar root causes as a success measure. Summaries allowing this level of analyses include event description, immediate actions, proximate versus root causes, and corrective actions. Conclusions: The capacity to learn from experience is essential to patient safety. Adherence to the framework ensures movement beyond proximate to root causes. It is a means to spread knowledge using proven tools based upon principles of high reliability.
Transforming a cancer center into a high reliability organization.
Authors: Pavlick Anna C. , Duffy Fray Kathleen C. , Rabinovich Annette C. , Wertheimer Benjamin C.
Published: October 2019

234

Background: The goals of a high reliability organization (HRO) are to eliminate preventable harm and streamline processes to maximize efficiency. The NYU Langone Medical Center embarked upon transforming the entire organization into an HRO. Educating the staff of the NYU Perlmutter Clinical Cancer Center (NYUPCCC) about the principles of HRO and a stepwise rollout began in March 2018. Methods: All cancer center employees were provided with an anonymous survey designed to assess culture, teamwork and burnout. Response rate to the survey was 83%. The survey evaluated 8 areas: improvement readiness, local leadership, teamwork climate, safety climate, decision making, burnout climate, personal burnout and emotional recovery. Three areas of opportunity were identified: teamwork and communication, discussing and correcting errors and participation in decision-making. Implementation and onboarding of the NYUPCCC occurred in 3 phases due to the physical layout of the center. Infusion floors were paired with physician floors that utilized them. Three “aims” for each floor were proposed with one aim being an overlapping aim that would require collaboration between the treatment and physician floors. Weekly “huddles” at a white board occur at a defined time and is led by a different staff member each week. This 15-minute gathering of all floor staff allows for an open exchange of ideas, verbalization of new areas of improvement and staff acknowledgement who provided a service above and beyond expectations. Initiatives and results will be presented. Results: This initiative had a positive impact on culture, improved staff-wide communication, improved physician efficacy and decreased patient wait times through the utilization of staff generated ideas and processes. It identified the need for better physician engagement. It also identified a data collection challenge so that information could be gathered in real time and metrics analyzed promptly. Conclusions: Transforming the NYUPCCC into an HRO identified opportunities for staff to encourage a culture of acceptance, foster teamwork, enhance overall cancer center communication and streamline processes to maximize patient safety and overall system efficiency.
Association of electronic medical record (EMR) QTc alerts with higher mortality within 10 days for patients with blood, lung, GI, and soft tissue cancer.
Authors: Bleiberg Benjamin Aaron , Xie Donglu , Lightfoot Tammy , Reisch Joan , Khan Saad A.
Published: October 2019

235

Background: Patients with cancer receive many prescriptions associated with QTc interval prolongation. Prognostic implications of drug-induced QTc interactions are unknown. EMR's regularly generate QTc-alerts but their significance or impact is not known. Methods: Using the UTSW tumor registry we identified 14,731 adult cancer patients from 2005-2018 for whom the EMR had generated 16,797 unique alerts for potential QTc drug interactions. We collected patient cancer details, demographics and specific drugs prescribed. After a QTc alert, timing of patient death within a < 365 day period was recorded and analyzed. Prior studies have defined death within 10 days as acute mortality that may be related to QTc prolongation-associated factors. We compared actual deaths that occurred ≤10 days from a QTc alert to expected deaths based on the null hypothesis that deaths ≤10 days were evenly distributed by cancer primary site and would be proportionate to the number of patients in each group; data were analyzed by chi-squared goodness of fit testing. Results: The number of ACTUAL deaths ≤10 days compared to those EXPECTED by the null model varied significantly by cancer site (Table). No mortality differences were noted based on patient demographics, age at first alert, ethnicity, or race. Conclusions: There is a significant association between EMR QTc alerts and higher than expected acute mortality for some cancers, but not universally. In lung, breast, and GI cancer patients who died <365 days of a QTc alert, > 15% died within 10 days of a QTc alert. EMR generated QTc alerts may identify cancer patients who are at imminent risk of death in some cancers but may represent distractions in other types of cancers.

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Developing clinical indicators to effectively monitor a large network of radiation oncology practices.
Authors: Frey Seth D. , Hoffman Karen E. , Jhingran Anuja , McAleer Mary Frances , Minsky Bruce D. , Kirsner Steve , Arora Gurpreet , Zaebst Denise , Robinson Ivy , Roberts Terence , Patel Ashish Bharat , Olson Michael Ray , Gabel Molly , Bolukbasi Yasemin , Llorente Manolo , de Carvalho Icaro Thiago , Ghafar Robert , Koong Albert , Herman Joseph M. , Kuban Deborah A.
Published: October 2019

236

Background: The MD Anderson Cancer Network includes 29 distinct Radiation Oncology facilities spread across metropolitan Houston area locations, national partnerships, and international affiliates. Standard performance indicators (PIs) were developed to monitor the quality and safety of radiation treatment at these facilities spread across the globe. Methods: Stakeholders from Radiation Oncology nursing, dosimetry, physics, radiation therapy, and clinical operations identified PIs that measure safe, efficient, and effective radiation oncology care. PIs are collected monthly from each facility and are reported in a scorecard that includes performance goals. The appropriateness and effectiveness of the PIs are reviewed annually to determine if PIs need to be added, removed, or revised. Results: As the network expanded, scorecard use expanded from 11 facilities in 2013 to 29 facilities in 2019. Select PIs are summarized in the table. Scorecard composition has evolved over time. PIs such as completion of simulation orders and treatment planning directives were removed once consistently reaching 100% after improved monitoring, process improvements, and implementation of hard stops. The scorecard has been especially useful when onboarding new facilities, as evidenced by PIs increasingly meeting performance thresholds in the first year after joining the network. For example, one facility increased PI compliance from 61% to 100% the first year after joining the network. Conclusions: It is feasible to develop and implement a performance indicator scorecard across a large radiation oncology network. The scorecard permits timely assessment of quality indicators, provides oversight, and is effective in stabilizing operations at newly on-boarded radiation oncology practices.

[Table: see text]
Developing a cancer-specific trigger tool to identify adverse events using administrative data.
Authors: Weingart Saul N. , Koethe Benjamin , Nelson Jason , Yaghi Omar , Kent David M. , Hassett Michael J. , Lipitz-Snyderman Allison
Published: October 2019

238

Background: “Trigger tools” identify complications of care and potential patient safety hazards. However, attempts to create triggers that flag treatment-related complications in oncology have been largely unsuccessful. To address this problem, the authors built a set of claims-based oncology-specific triggers based on a promising pilot study conducted at Memorial Sloan-Kettering Cancer Center. Methods: We selected subjects from the OptumLabs data warehouse, a repository of > 160 million de-identified patients drawn from commercial claims. The cohort included patients with breast, colorectal, lung, and prostate cancer undergoing an initial course of cancer-directed therapy from 2008-14. Using ICD and CPT codes, we defined 16 oncology-specific triggers drawn from the pilot study, all with PPVs ≥50%. Triggers included events such as neutropenic fever, abnormal serum potassium or bicarbonate, and initiation of therapeutic anticoagulation. To distinguish treatment-related complications from other comorbidities, we required a logical and temporal relationship between a treatment and the associated trigger. We tabulated the prevalence of cancer triggers by cancer type and metastatic status during a one-year follow up period and created multivariate logistic regression models to examine the association of triggered cases with one-year mortality. Results: The cohort comprised 369,354 unique subjects including 29% with metastatic disease. The prevalence of triggered events was greatest among non-metastatic patients with lung (33%) and colorectal (21%) cancers, and among those with metastatic disease. The most common triggers included abnormal chemistry tests, blood transfusions, hypoxemia, and chest CT following radiation therapy. The mortality rate was substantially higher among patients with at least one trigger compared to patients with none. Experiencing at least one cancer-specific trigger increased the one-year risk of death by 1.69 (95% CI 1.28-2.24). Conclusions: Oncology-specific triggers provide researchers a promising method for studying patient safety in cancer care.
Guideline adherence and the strategy of chemotherapy dose reduction in metastatic colorectal cancer: A multicenter oncology practice experience.
Authors: Orji Chinelo C. , Brown Carolyn M. , Hoverman J. Russell , Richards Kristin M.
Published: October 2019

24

Background: Current American Society of Clinical Oncology (ASCO) guidelines recommend prophylactic use of colony stimulating factors (CSF) for prevention of febrile neutropenia among cancer patients. ASCO also recommends chemotherapy dose reduction as a viable alternative to CSF administration, which may result in cost savings to patients and payers, but adherence to these guidelines has been less than ideal. The objectives of this study were i.) to determine the prevalence and prescribing patterns of CSF and dose reduction in metastatic colorectal cancer patients and ii.) to evaluate the impact of a program initiative on CSF prescribing patterns and on compliance to ASCO guidelines. Methods: In this retrospective study, we utilized data from the electronic health records of metastatic colorectal cancer patients who received care at a multi-center oncology practice network during two time periods: July 2013 to December 2014 and July to December 2017. In 2016, a site-wide program initiative that involved educational materials, appropriate non-use recommendations and prior authorization was introduced in the oncology practice network with an aim of reducing CSF overutilization. Descriptive statistics and chi squared tests were employed to explore CSF utilization across patient age, gender, disease, year of diagnosis, febrile neutropenia risk, line of therapy and duration of treatment. Results: There were 3426 chemotherapy regimens corresponding to 2968 patients. There was a total of 3095 CSF administrations and the CSF administered was pegfilgrastim. There were 343 (10%) CSF users. Among subjects who had data on dose reduction (N = 508), 58.7% received dose reduction. CSF use was significantly lower in the post-period, compared to the pre-period (p < 0.0001). Compliance to guidelines was significantly higher in the post-period, compared to the pre-period (p < 0.0001). Conclusions: Our results demonstrate that program initiatives have the potential to positively impact CSF prescription patterns. These findings could help prescribers adopt a cost-effective approach for this population, leading to enhanced clinical practice and value-based care.
A quality improvement initiative for reducing morning hypoglycemia in children undergoing treatment for acute lymphoblastic leukemia.
Authors: Mohamed Ashraf Mahmoud , Bolen Christine Marie , Morgan Jennifer , Rice Patricia , Speas Meredith , Russo Carolyn
Published: October 2019

240

Background: Hypoglycemia has been observed in children receiving Acute Lymphoblastic Leukemia (ALL) therapy. It affects patients’ outcome. The current quality initiative was piloted at two of the St Jude affiliate clinics. Each month about 10% of children with ALL develop hypoglycemia in those two clinics. Methods: Data was collected for the eight months prior to intervention. Root Cause Analysis (RCA) using fish bone diagram, and Pareto chart to find out the most likely causes of hypoglycemia. Prolonged hours of fasting for procedures, giving 6MP at night on empty stomach, seem to further prolong hours of fasting, and lack of awareness of the new 6MP administration guidelines were the top likely causes. Interventions based on RCA: Developed Hypoglycemia educational brochure addressing causes and prevention of hypoglycemia for care givers followed by knowledge assessment tool, in addition two educational sessions for staff. Plan, Do, Study, Act (PDSA) was used to guide implementation. 4 PDSA cycles were done. Results: Combined monthly average number of ALL patients seen in both centers was 43 (range 38-51) patients with monthly average of 94 (range 71-141) blood glucose samples drawn from them. Process Measure 1: % care givers received hypoglycemia education after 1st cycle was 16.3% which increased to 88% after PDSA cycle # 4. Process Measure 2: % of caregivers scored above 75% in the knowledge of morning hypoglycemia after education were 78%. Outcome Measure: At the end of intervention the average monthly patients with hypoglycemia decreased from 9.4% to 7.8% representing 17% reduction. Hypoglycemic episodes dropped from 6% to 4.2%, showing 30% reduction in hypoglycemic episodes. More reduction in hypoglycemic episodes was observed in clinic 1 (68%) compared to 22% reduction in clinic 2. Conclusions: Using quality improvement methodology in implementing hypoglycemia education led to drop in hypoglycemia episodes among children on ALL therapy. Despite using similar approach, yet one of the two clinics showed higher improvement compared to the other. This may reflect the possible impact of local institutional factors on implementation.
The impact of depression in cancer patients on healthcare utilization.
Authors: Ye Star , Gilbert Aidan , Huang Chao-Hui , Rocque Gabrielle Betty
Published: October 2019

243

Background: The Oncology Care Model (OCM) has set several initiatives to improve payment and care delivery in the Medicare patient population, including screening for depression in cancer patients. We evaluated the prevalence of depression in OCM patients and the relationship between depression and healthcare utilization. Methods: This cross-sectional study used patient-reported outcome (PRO) surveys administered in the outpatient setting as part of OCM at the University of Alabama at Birmingham (UAB). Depression scores and Eastern Cooperative Oncology Group performance status were obtained from PRO surveys. Moderate to severe depression was defined as a score ≥10 on the Patient Health Questionnaire 2/9 (PHQ-2/9). Sex, marital status, phase of care, race, disease aggressiveness (stage, progression, cancer type), number of emergency department (ED) visits and inpatient admissions within a 3-month period from survey completion were abstracted from the electronic health record. The relationship between depression and hospital visits was assessed using rate ratios and 95% confidence limits from Poisson regression models adjusting for clinical and demographic characteristics. Results: Of 856 patients surveyed, 68% of patients were female, and 27% of patients were non-Caucasian. Notably, almost 14% of patients had moderate to severe depression (PHQ-2/9≥10). The cancer-specific prevalence of at least moderate depression was 2% in breast, 1% in gastrointestinal, 2% in genitourinary, 5% in gynecologic, and 2% in hematologic cancers. In adjusted models, the inpatient admission and ED visit rate in the 3 months following PRO survey completion did not differ by depression category (RR: 1.22; CI: 0.93-1.61). Conclusions: Over 13% of cancer patients report clinically significant depression during routine screening, which highlights the continued need for outpatient counseling and behavioral services. Although rates of inpatient admissions and ED visits were not impacted by the presence of depression, further analysis is needed to evaluate the impact of treating depression on healthcare utilization over time.
Universal hepatitis B screening in a high risk community.
Authors: Abraham Ivy , Mccullough Jane , Golick Janet , Cadman Kasandra , Cirignani Gay , Sta Maria Megan , Maynard Vera , Nelson Lupe , Nishimura Susan , Oremovich Elizabeth , Palma Lydia , Valero LeeAnn , Walker Maria , Zubel Stacey , Cuellar Sandra , Chacra Wadih , Venepalli Neeta K.
Published: October 2019

244

Background: 2015 ASCO guidelines for Hepatitis B (HBV) screening in patients (pts) receiving chemotherapy recommend a risk-adaptive strategy considering patient and treatment-specific factors. The University of Illinois Cancer Center (UICC) is an academic center with largely underserved, minority and socioeconomically disadvantaged pts. UICC implemented a universal HBV screening policy in 2016. We aimed to increase HBV screening from 60% to 95% over 18 months. Methods: A multidisciplinary team of oncologists, hepatologists, fellows, nurses and pharmacists created an ideal process map for universal HBV screening in all pts starting chemotherapy outlining screening parameters, laboratory tests required and follow-up for positive screens. Four Plan-Do-Study-Act cycles were tested. Interim analysis was done targeting specific providers for additional education. Results of screening were analyzed by chart review. Results: A total of 589 treatment-naive pts were screened for HBV between Aug 2017 and Feb 2019. Educational sessions were held for nurses, pharmacists and fellows to review ideal process maps between Jan and March 2018. 0% of pts had insurance denials for HBV screening coverage. Screening rates improved from 65% in Aug 2017 to 100% in Feb 2019. Positive HBV screen rate was 3% (N = 18) and all were new diagnoses. 61% (N = 11) of positive screens had no risk factors for HBV exposure and would not have met risk adaptive criteria for screening. 27% (N = 3) of positive screens without prior risk factors were initiated on prophylactic ART. 50% (N = 9) of all new HBV diagnoses initiated prophylactic ART to prevent reactivation, while 50% received active surveillance on chemotherapy. 0% of pts on active surveillance developed reactivation. Conclusions: Implementing and sustaining a universal HBV screening program was feasible and effective in identifying pts at risk for reactivation in a high risk population. 61% of positive screens lacked traditional risk factors. Risk-adaptive screening may miss cases in diverse populations where HBV is not endemic, precluding appropriate management. Further evaluation will include expanding screening to inpatient chemotherapy starts and cost-benefit analysis of universal screening in this unique population.
A proactive approach to assess system safety in clinical operations at a comprehensive cancer center.
Authors: Durney Jeffrey , Wong Lawrence , Breaud Alan H. , Cedro Laura , Rowell Shannon , Harvey Caroline , Szabatura Audrea H , Kadish Sarah , Frank David , Lane Sharon , Lakhani Hakim , Bartel Sylvia
Published: October 2019

245

Background: Traditional approaches to improve safety in clinical operations focus on reacting to adverse events and intervening at the process level to prevent recurrence. A need exists to proactively explore safety at the system level and evaluate human factors that lead to errors. We developed and piloted a system safety assessment methodology to identify vulnerabilities in the Research Pharmacy at Dana-Farber Cancer Institute. Methods: We developed an interview tool based on the human factors analysis and classification system (HFACS) to obtain staff member perspectives on safety vulnerabilities. Detailed process maps were created for safety critical processes. Policies, procedures, and job aids were evaluated for effectiveness at preventing errors. Interfaces between the Research Pharmacy and other areas were studied to identify potential expectation misalignment. These elements formed a comprehensive methodology to proactively assess safety threats. Results: Based on our application of the assessment methodology, 16 system safety vulnerability themes were identified (table below) and 44 recommendations were generated to address them. From the recommendations, 26 improvement projects were proposed to prevent the occurrence of safety events. To date, 15 projects addressing 13 safety vulnerabilities have been initiated. Conclusions: Vulnerabilities uncovered through our methodology can inform the development of projects to proactively reduce risk and improve system resiliency in any clinical setting. Preliminary data indicate longer average days between safety events in the Research Pharmacy as projects triggered by the assessment are implemented. Further analysis is underway.

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Medication reconciliation practices in ambulatory cancer care across Canada.
Authors: Mak Ernie , Powis Melanie Lynn , Dara Celina , Bouchard-Fortier Genevieve , Kukreti Vishal , Stuart-McEwan Terri , Dave Hemangi , Kirkby Ryan Lawrence , Bissonnette Jean-Pierre , Glinsky Victoria , Howell Doris , Julius Anet , Macedo Alyssa , Morley Lyndon , Krzyzanowska Monika K.
Published: October 2019

248

Background: Substantial work has been done to implement medication reconciliation (MedRec) in the inpatient setting to reduce medical errors and drug discrepancies. However, this work has not extended to the ambulatory cancer setting, where care spans multiple providers and responsibility remains unclear. We undertook an environmental scan to understand current MedRec practices in ambulatory cancer care across Canada. Methods: Semi-structured telephone interviews were conducted with stakeholders from institutions across Canada during a 2-month period in 2019. Questionnaires were pre-circulated to participants to guide discussions. Questions probed participants on processes, policies, roles and responsibilities, definitions of target populations, information sources, and barriers and facilitators. Results: 21 of the 23 stakeholders contacted were interviewed, representing 9 of 10 Provinces. Most institutions had a process in place for collecting best possible medication history (BPMH; 81%); however, considerable variation in practice was noted and full MedRec was uncommon. Of those institutions with a process, BPMH was most often undertaken by a pharmacist or pharmacy tech (53%) using a comprehensive Provincial drug information system (65%) as a starting point, and targeted patients initiating systemic therapy (59%). Few institutions (22%) routinely collected performance measures evaluating the process or outcomes. Lack of resources (physical, human and financial), high patient volumes, and access to medication records from external institutions and community pharmacies were identified as significant barriers to routinely collecting BPMH. Understanding the value added, clinician buy-in, and patient education regarding the importance of bringing medication to the clinic were identified as facilitators. Leveraging patients to more actively participate in collection and maintenance of their own medication records was identified as an area for future work. Conclusions: While most centres were doing BPMH in some patients, MedRec was uncommon in the ambulatory cancer setting. Results indicate a lack of consensus regarding best practices for medication management in ambulatory cancer care.
Neoadjuvant chemoradiation (NCRT) for esophageal (EC) or gastroesophageal junction cancer (GEJC): A Canadian single institution real-world experience using the CROSS trial regimen.
Authors: Khalid Sidra , Hopman Wilma M. , Preti Beatrice , Tomiak Anna T. , Virik Kiran
Published: October 2019

25

Background: NCRT followed by surgery per the CROSS trial regimen is an accepted standard of care in the treatment of EC and GEJC. When treatments are used in the real-world setting, there are often patient, treatment and potential outcome differences compared to the original clinical trial. The study aim was to assess the real-world application and outcomes of the CROSS trial protocol. Methods: A retrospective chart review was undertaken of 83 patients (pts) with EC or GEJC who were treated from June 2012 to June 2018 with CRT. 65 pts were with NCRT intent to proceed to surgery. Pts’ demographics, clinical, pathological, treatment and surgical characteristics were assessed and exploratory analyses were conducted to review these factors and outcomes. Analyses included Chi-square, t-tests and Kaplan-Meier. Results: For pts who underwent NCRT (n = 65): median age was 68 yrs (range 52-80), male 79%, adenocarcinoma 82%, median (m) tumor length 5 cm, GERD 43%, clinical stage II/III 95%, and BMI > 30 in 37%. 80% completed CRT with RT ≥ 41.4 Gy; of these 88% had ≥ 50.4 Gy. Delay/interruption in chemotherapy occurred in 46% and in RT 37%. Pts who underwent surgery were younger (p = 0.04) and weighed more (p = 0.05). mOS was 37 months (M) v 14 M in those who started CRT ≤ 8 weeks (w) from diagnosis v > 8 w (p = 0.10). The median time from CRT to surgery was 8.9 w. 40 pts had surgery with a complete response in 38% and a R0 resection in 98%. Postoperative major and minor complications occurred in 67%. Those < 75 yrs v ≥ 75 yrs had a mOS of 32 M v 15 M respectively (log rank p = 0.46). 25 pts did not get surgery; 28% was due to death/progression. Pts who proceeded to surgery had a mOS of 35 M v 12 M in pts who did not go to surgery (log rank p = 0.002). Further correlative outcome data will be presented. Conclusions: Real-world data in our center showed patient, tumor and treatment differences compared to the CROSS trial protocol. Despite the broadening of eligibility and treatment criteria, survival in a single institution setting is maintained with trimodality therapy compared to NCRT alone. Real-world data is of value in the assessment of therapeutic validity of clinical trial data.
Standardization of the inpatient oncology signout process.
Authors: Parikh Anish B , Aronson Elizabeth , Steinberg Amir S. , Smith Cardinale B.
Published: October 2019

253

Background: Provider handoffs are prone to medical errors which in turn impact patient outcomes. Standardized signout tools have helped address this issue, however not in oncology. Methods: A pre-intervention survey (S1) was used to evaluate the current inpatient signout process and identify flaws by querying inpatient hematology/oncology fellows, attendings, nurse practitioners, and physician assistants. This data informed the development of a standardized electronic signout tool which was subsequently piloted on our bone marrow transplant unit. A post-intervention survey (S2) is currently evaluating the impact of this tool. Results: Of S1 respondents (54%, 71/131), 75% felt the signout process needs improvement, largely due to outdated (70%) or incomplete (24%) information and general disorganization (49%). Nearly half felt the signout contains too much (28%) or too little (18%) information. 18% felt that patient care had been compromised or delayed due to poor signout. Items requested for inclusion in the signout tool by more than half of respondents included patient identifiers, health care proxy, code status/goals of care, active issues summary, cancer details and treatment history, and a to-do list. Full S1 results are shown in Table; S2 results are pending. Conclusions: Use of a standardized, electronic signout tool can further enhance the inpatient handoff process in terms of safety and efficiency.

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Developing a standardized approach to cancer medication-related infusion reaction prevention and management in Ontario.
Authors: Crespo Andrea , Gallo-Hershberg Daniela , Enright Katherine , Kukreti Vishal , Martelli Lorraine , DeAngelis Carlo , Granic Anna , Mothersill Charmaine , Rashid Ferid , Spasic Lily , Young Leslie , Yu Jason , McBain Sarah , Forbes Leta Marie
Published: October 2019

255

Background: Cancer medication-related infusion reactions (CMIRs) can lead to treatment delays, switching to less optimal therapy, or discontinuation. Variation in the prevention, management and reporting of CMIRs was identified as a quality and safety gap by Ontario clinicians. This initiative aimed to facilitate a standardized approach to CMIRs in Ontario through the development of user-friendly health-care provider and patient resources. Methods: A multidisciplinary working group of 15 oncology clinicians (oncologists, pharmacists, nurses, administrators) with experience in the management of CMIRs reviewed available literature on CMIR assessment, prevention and management. Recommendations were based on best available evidence and group consensus when only low-level evidence was available. Final guideline content was reviewed and validated by external experts. Complementary patient information was created based on best practices in health literacy and input from patient education experts, patients and caregivers. A mechanism for system-wide reporting to track CMIRs was explored. Results: A CMIR clinical practice guideline was created. Definitions, risk factors, prophylaxis strategies, an acute management algorithm and desensitization protocols are described. A CMIR severity grading system was proposed. A toolkit was developed and contains a table outlining risk factors, mechanism, incidence, symptoms, onset, prophylaxis, acute management and re-challenge by specific drug and a tool for calculating a three-bag 12-step desensitization. Patient-friendly information was also created. A new data element for collection of CMIR incidence and severity was added to the provincial Activity Level Reporting (ALR) data set to track CMIR trends. Conclusions: A review of current evidence and expertise from oncology clinicians resulted in an evidence-informed, consensus-based guideline. This guideline and the accompanying resources can help to facilitate safe and standardized prevention and management of CMIRs across Ontario. The collection of system-wide CMIR data based on the proposed grading system will inform future quality and safety improvement initiatives.
A standardized workflow to improve the consent process among patients initiating an oral anticancer drug.
Authors: Brown Jessica S. , Hershman Dawn L. , O'Neil Daniel , Brafman Lois , Fuentes Deborah A. , Graafland Laura , Law Cynthia , Trivedi Meghna S. , Kalinsky Kevin , Crew Katherine D. , Accordino Melissa Kate
Published: October 2019

259

Background: The American Society of Clinical Oncology and The Oncology Nursing Society’s guidelines recommend that consent be obtained and patient education provided prior to oral anticancer drug (OACD) initiation. The aim of this quality improvement project was to improve documentation rates of consent and education prior to OACD initiation in an outpatient breast oncology clinic. Methods: Plan-Do-Study-Act (PDSA) methodology was used to identify the root causes of inadequate OACD documentation; and to evaluate a standardized OACD workflow that included a multidisciplinary (physician, nurse practitioner [NP], and administrative staff) checklist on the disposition sheet and standardized patient education material, used in the Columbia University Irving Medical Center Breast Oncology Clinic. New OACD prescriptions were identified in the electronic health record (EHR) from 2/1/18-4/1/18 (pre-intervention) and 6/5/18-8/17/18 (post-intervention). Documentation of consent and education were evaluated by EHR review. Consent (yes/no) was determined by physician documentation in either the corresponding clinic note or scanned consent form, and education (yes/no) was determined by NP documentation in the education section of the clinic note. Documentation rates were compared pre- and post-intervention. Results: Pre-intervention, 19 patients received a new OACD, and 0 (0%) had documentation of consent or patient education. Root cause analysis revealed the driver of inadequate documentation was the inability to identify patients with a new OACD prescription at the time of their clinic visit. After implementation of the OACD workflow, 23 patients initiated a new OACD, 15 (65.0%) had documentation of consent and 7 (30.0%) had OACD education documented in the EHR. Conclusions: After the first PDSA cycle, documentation of consent and education improved from baseline. However, improvement in both metrics are still needed. Patient volume, staff changes, and the format of the OACD checklist may have limited the efficacy of this intervention. In the next PDSA cycle, the consent process will be linked to the required OACD pre-approval process to further increase OACD documentation.
Time to treatment for lung cancer patients at an urban safety net institution.
Authors: Narra Kalyani , Lu Yan , Ghabach Bassam , Ojha Rohit P.
Published: October 2019

26

Background: Lung cancers are rapidly fatal, but no guidelines currently exist in the US for the optimal time between symptomatic presentation and treatment. A recent study from multiple institutions estimated a median of 52 days from symptomatic presentation to treatment, but this estimate was based on patient self-report and the study under-represented settings that provide care to patients with socioeconomic barriers to care that could affect time to treatment. Therefore, we aimed to assess time to treatment for lung cancer patients at an urban safety-net institution. Methods: We used institutional registry data from the JPS Center for Cancer Care (Fort Worth, TX), an accredited Comprehensive Community Cancer Program. Eligible patients were aged ≥18 years and had a pathological diagnosis of lung cancer between January 1, 2018 and December 31, 2018. We estimated the median overall and stage-specific time from abnormal imaging (chest X-ray or CT scan) to initiation of treatment, which were documented in medical records. Results: Our study population comprised 75 lung cancer patients. The majority of patients who received treatment ( n=46) were aged 55–64 years (54%), female (52%), and racial/ethnic minorities (54%). The overall median time to treatment was 81 days (interquartile range [IQR]=48–111) which varied by stage: stage I=108 (IQR=92–140), stage II=123 (IQR=111–134), stage III=85 (IQR=45, 102), stage IV=59 (IQR=39–72). In particular, the median time from ordering chemotherapy to start was 22 days (IQR= 13–30). Conclusions: Time to treatment for lung cancer patients at our institution is substantially longer than reported in the literature, which may partially reflect the patient population but warrants interventions (e.g. enhanced care coordination) to reduce this interval. Nevertheless, without an optimal time to treatment that is associated with improved outcomes among lung cancer patients, we and other institutions lack a meaningful benchmark.