bluuebunny/crossref_metadata_2025 huggingface dataset:
Community-based dental evaluation program for hematopoietic cell transplantation.
Authors: Frustino Jennifer L. , Treister Nathaniel S. , Sonis Stephen T. , Woo Sook-Bin
Published: February 2017

143

Background: Conditioning regimens for hematopoietic cell transplantation (HCT) may result in profound neutropenia placing patients at risk for infection. Since the mouth is a common site of origin for infection and bacteremia, elimination of pre-existing oral and dental disease prior to HCT favorably impacts infection risk and attendant morbidities. While pre-HCT dental screening is highly desirable, the logistics of assuring that all HCT patients are comprehensively evaluated and appropriately managed is challenging. Dana-Farber/Brigham and Women’s Cancer Center (DFBWCC) implemented a community-based dental evaluation program (CBDEP) for all patients scheduled to undergo HCT which has proved to be effective, cost-efficient and patient-friendly. The objective of this presentation is to describe that program. Methods: We describe the CBDEP and evaluate volume trends and clinical and cost outcomes. As part of the HCT work-up, the patient is provided with education materials, evaluation guidelines and forms to be completed by the community dentist (CD). The patient is responsible for making a timely appointment with the CD who obtains a full series of radiographs and completes a comprehensive examination and treatment plan. The completed documents and radiographs are returned to DFBWCC and reviewed by the oral medicine specialist. The CD is contacted immediately with any discordance in the plan. A letter confirming the final treatment plan is sent to the CD and entered into the electronic medical record. Upon admission for HCT, the patient is evaluated bedside to ensure all work is completed and there are no new symptoms. Results: From 2009-2012 an average of 523 patients per year participated in the CBDEP, with an increasing trend due to growing HCT volume with 440 patients evaluated in 2009 and 563 in 2012. Once returned, evaluations were reviewed within 1-10 days. The average cost for examination, radiographs, scaling and prophylaxis was $255. The average cost rose to $453 if additional treatment was required. Conclusions: The CBDEP provides an efficient and effective model for clearance prior to HCT. This directly involves the patient and the CD, is inexpensive and easy to implement, and may reduce complications during HCT.
Developing a culturally and linguistically responsive survivorship care plan for breast cancer.
Authors: Ashing Kimlin Tan , Rosales Monica , Fulcher Gingi , Serrano Mayra , Weitzel Jeffrey N. , Paz Isaac Benjamin , Lai Lily L.
Published: February 2017

146

Background: African and Latina-American breast cancers patients (BCA) experience the greatest morbidity and mortality, suggesting a critical need for improved surveillance and quality care. The Institute of Medicine (IOM) and the Commission on Cancer (CoC) recommend that survivors receive personalized Treatment Summaries and Survivorship Care Plans (TSSCP) in order to facilitate best practice in clinical surveillance and follow-up care. This TSSCP template development study joined advocacy, scientific and medical communities to comprise a diverse advisory council (AC, N=38) to inform the development of the TSSCP-AA (African American) and TSSCP-S (Latino) templates targeting BCA. This abstract reports on the development, and presents the TSSCP-AA and TSSCP-S. Methods: The overall study was guided by the Shared Care and Psychooncology Models, and Contextual Model of Health Related Quality of Life. The AC provided input into the culturally relevant modifications of the American Society of Clinical Oncology (ASCO) TSSCP template to create the TSSCP-AA and TSSCP-S. Health care professionals enlisted from cancer centers and community hospitals (n=51) evaluated the TSSCP-AA and TSSCP-S templates on the following domains: content, clarity, utility, and cultural and socioecological responsiveness. Results: AC input revealed that the clinical (i.e., comorbidities) and cultural contexts (i.e., language, spirituality) must inform TS and SCP, respectively. Preliminary evaluation analyses documented that health professionals rated our TSSCP-AA and TSSCP-S templates as excellent to outstanding on content, clarity, utility, cultural responsiveness, and socioecological responsiveness (p<0.01). Conclusions: The evaluation results imply that the TSSCP-AA and TSSCP-S templates achieved cultural responsiveness with high acceptability and utility among professionals and survivors. We created both paper and electronic versions of theTSSCP-AA andTSSCP-S (English and bilingual English-Spanish formats) for providers to create individualized TSSCPs. Further, our TSSCP development approach can be adopted for TSSCP template development targeting ethnic/linguistic minority cancer survivors.
Patient-reported symptoms obtained through telephonic nursing services in an oncology disease management program.
Authors: Harrison Deb , Jameson Melissa , Espirito Janet L. , Harrell Robyn K. , Clayton Matthew , Abdullahpour Mitra , McQueen Jessica , Hoverman J. Russell
Published: February 2017

147

Background: Telephonic nursing (RN) outreach was provided as part of an oncology disease management program to provide symptom (sx) management education, assess patient-reported sxs during treatment (tx), and reduce acute care utilization. The Edmonton Symptom Assessment Scale (ESAS) was used to assess sx severity in patients (pts) receiving active chemotherapy. Methods: ESAS scores were obtained at scheduled intervals and documented in the electronic health record for eligible pts receiving chemotherapy between 6/2010-12/2012. Participation was voluntary. Pts were categorized according to cancer diagnosis (dx) and tx setting (early vs. advanced). Repeated measures logistic regression analysis was used to test for differences in ESAS scores between dx and tx settings. Results: 365 pts had 2,198 calls with ESAS scores. Mean age was 53 yrs, 67% female, 33% male. Pts were managed an average of 97 days and received on avg 6 calls/pt. The majority of pts had breast, colon, and non-small cell lung (NSCL) cancer (74%). Of these pts, the most frequent reported sx of any severity other than zero during post-tx calls were for mild/moderate tiredness, appetite, and pain. There was no evidence of a significant difference in the severity of sxs by tx setting in these cohorts; p=NS. One hundred and nine breast, colon, and NSCL pts (40%) received additional unscheduled calls based on sx scores or RN assessment. Outcomes related to acute care utilization are being evaluated. Conclusions: Pt reported sxs obtained through telephonic RN support demonstrated mild/moderate ESAS scores for mainly tiredness, appetite, and pain. This is lower than previously reported in different contexts. Regular RN contact as a supplement to clinic visits may help reduce sx severity. While the ESAS tool is traditionally used for palliative care, in this active tx setting it supported identification of sxs for referrals back to the practice with the goal to reinforce education and avoid acute care utilization. [Table: see text]
A population-based study examining the impact of a multidisciplinary rapid access clinic on utilization of initial treatment options for patients with localized prostate cancer.
Authors: Ho Clement K. , Ruether Joseph D. , Donnelly Bryan J , Kerba Marc
Published: February 2017

15

Background: Treatment decisions in localized prostate cancer (LPCa) are complicated by the variety of available options. A rapid access cancer clinic (RAC) has been unique to Calgary, Alberta (AB) since 2007. RAC offers multidisciplinary prostate cancer care by a urologist, medical oncologist, and radiation oncologist. It is hypothesized that treatment utilization data from decisions taken at RAC may serve to benchmark the appropriateness of treatment decisions on a population level. Objectives: To compare utilization rates for initial treatment of LPCa between AB and RAC. Methods: Records of patients with clinically LPCa in AB between 2007-9 were reviewed with ethics approval. Records were linked to the AB cancer registry database. Clinical, treatment and health services characteristics pertaining to patients attending RAC were compared to those managed elsewhere in AB. The primary endpoints were utilization rates by initial treatment; prostatectomy (P), radiotherapy (RT), hormone therapy (H), active surveillance (A). A logistics regression model was constructed to examine the influence of RAC on initial treatment decisions, while controlling for interactions and factors of interest. Results: 2,660 patients were diagnosed with LPCa. 375 presented to RAC. Utilization rates among RAC patients: P-60.3% (95%CI: 55.3-65.2), A-16%(12.3-19.7), RT-11.7%(8.5-15.0) and H-8.0%(CI:5.2-10.8). This compares to AB rates of P-47.2%(45.9-48.3), A-6.1%(15.2-17.0), RT-18.8%(17.9-19.7), and H-14.5%(13.6-15.4). On multivariate analysis, RAC was associated with a trend towards receiving RT (OR 1.6, p=0.097). Conclusions: A specialized clinic for LPCa may be associated with a higher likelihood of receiving radiotherapy as initial treatment compared to the prostate cancer population in Alberta.
Engaging new media to drive advance care planning.
Authors: Mulcahy Mary Frances , Gaitan Daniel M. , Belisomo Randi
Published: February 2017

153

Background: Though Congress enacted the Patient Self-Determination Act in 1991, only 18-36% of Americans have completed an advance directive. Less than half of severely ill patients had an advance directive in their medical record, only one in three with a chronic illness completed an advance directive, and studies suggest that two-thirds of physicians whose patients had advance directives were unaware of the existence of the documents. The Act required healthcare facilities to provide written information on rights to make treatment decisions and to make information available to patients who did not have an advance directive. There was a mandate directing HHS to conduct an awareness campaign about advance directives. The low acceptance of the directives demonstrates a failure to educate patients about their rights. Hypothesis: A patient-centered approach to end of life issues will generate better communication and result in greater acceptance of advance directives- achieving the goals of the Patient Self-Determination Act. Methods: A survey of 196 people showed that 67.7% felt that end of life issues were not covered enough in the media. We created a Newswire using WordPress and posted an average of three news stories weekly on topics pertaining to end of life. Posts were generated from existing media coverage and original reporting. The topics included culture, society, politics, healthcare, caregiving, law, advance care planning, hospice, and palliative care services. We tracked the number of views, the most viewed reports, monthly traffic and referral sources. We established Facebook, Twitter, and Pinterest accounts. We tracked followers, likes, re-tweets, pins, and shares. Results: From 8/2012 through 2/2013, the number of views increased from 566 to 2,452 with a peak of 3,809 in 11/2012. The most viewed day was 11/7/2012, the day following Election Day. The most viewed reports to date have been “Caregiver Discrimination Against LGBT Seniors,” “Psychedelic Drugs at the End of Life,” and “POLST Moving Forward in Illinois.” The referral sources in descending order are Facebook, Twitter, and Yahoo. Conclusions: We demonstrated that there is an interest in patient-centered topics pertaining to the end of life and that social media drives interest, education and conversation.
Effect of palliative care on aggressiveness of end-of-life care in patients with advanced colon cancer.
Authors: Reifer Hildebrand Jessica Ann , Bhan Renuka
Published: February 2017

168

Background: Recent studies have observed that starting Palliative Care (PC) soon after diagnosis for patients with advanced cancer improves quality of life, end of life (EOL) care, and possibly survival. Consequently, it has been recommended that combined standard oncology care and PC should be considered early in the course of illness for patients with advanced cancer. It has been posited that patients enrolled in early PC receive less aggressive care at the EOL and consequently spend fewer healthcare dollars. We sought to compare the aggressiveness of care received by those enrolled in early PC to those enrolled in late PC. Methods: A retrospective chart review of patients diagnosed with stage III or IIII colorectal cancer (CRC) at New Hanover Regional Medical Center between 2009 through 2011 was performed. Patients who were enrolled in PC within 30 days of diagnosis were compared to those enrolled later. Aggressiveness of care given during the last 30 days of life was assessed by: hospitalizations, ED visits, days spent in the ICU, chemotherapy received in the last 14 days of life, and death in the hospital. Results: 186 patients were identified for the study, and 89 met inclusion criteria. We found no significant difference in the aggressiveness of care received by those enrolled in early PC (46.7%) versus later PC (47.8%) (p = 1.00). In fact, almost half of all patients with advanced cancer received some form of aggressive care within the last 30 days of life. While those enrolled in late PC more frequently received chemotherapy, were admitted to the ICU, and died in the hospital, the differences were not statistically significant. Whether or not these differences account for cost savings in the early PC group has yet to be determined. Conclusions: Our study found that patients were just as likely to receive aggressive care at the EOL regardless of whether or not they were enrolled in early PC. This finding was unexpected given the goals and philosophy of PC groups. While early PC has been recommended as a quality care measure, patient and physician factors may limit its effectiveness. For example, patients, while receptive to certain aspects of PC, still desire a cure. Similarly, physicians feel compelled to treat patients aggressively.
Computer simulation and stochastic programming to reduce patient wait times in an outpatient infusion center.
Authors: Heiney Autumn , Potiris Spyros , Denton Brian T. , Cohn Amy , Friese Christopher Ryan
Published: February 2017

181

Background: As cancer treatment demand outpaces the capacity of outpatient facilities, providers are challenged to provide timely, cost-effective, safe, and patient-centered care. Reduction in patient wait times can help address these challenges through more efficient care delivery. Operations research techniques such as simulation and stochastic programming can inform more efficient patient scheduling. Methods: After 60 hours of observation by two students in one NCI-designated comprehensive cancer center's outpatient infusion center, 9 months of data from the electronic medical record and scheduling systems were used to calculate patient wait times, defined as the difference between scheduled time to begin infusion and actual time and actual administration time. After mapping the patient flow through the center, a computer simulation model was created to examine the effects on patient wait times and total hours of operation under different scheduling paradigms. To create different appointment schedules, both simple heuristic approaches and a more complex stochastic programming model were developed. These methods take into account the variability in infusion times. We generated 35 appointment schedules and evaluated their performance by running 100 replications for each one. Results: The baseline average patient wait time was 130.48 minutes (95% CI 122.38-138.68). Computer simulation results show that schedules generated by the stochastic programming model perform better than baseline and simple heuristics, reaching a 70% reduction in waiting times. Schedules that allocated patients with longer infusion times to earlier appointments resulted in both reduced average patient wait times and total hours of operation. Conclusions: Operations research techniques can improve care delivery in an outpatient infusion center. Based on our results from the computer simulation model, scheduling patients with longer infusion times earlier in the day results in shorter patient waiting times and total length of day of operations. Next steps include guideline development for appointment scheduling staff that attains maximal efficiency.
Implementing a comprehensive physician-communication-skills improvement initiative: The Cleveland Clinic experience.
Authors: Gilligan Timothy D. , Boissy Adrienne , Windover Amy , Crow Jessica
Published: February 2017

186

Background: Physician communication skills are associated with important outcomes, including medical results, treatment adherence, malpractice claims, patient safety, and physician satisfaction. Recently, patient satisfaction with physicain communication became a factor influencing Medicare reimbursement. In 2010, the Cleveland Clinic began building a physician communication training program to improve doctor communication skills. Methods: Following a literature review and a survey of communication skills programs at a variety of U.S. hospitals, we collaborated with the American Academy of Communication in Healthcare (AACH) to develop a full-day course based on Frankel and Stein’s Four Habits model. The model emphasizes skills related to initiating the encounter, eliciting the patient’s story, expressing empathy, educating the patient and collaboratively developing a plan. The course was designed to be taught by physicians and was highly experiential and skills based, making extensive use of role-play exercises. An AACH consultant trained 15 physicians to teach the course during several 7-day train-the-trainer courses. Results: Between September 2011 and May 2013, over 800 physicians took the course. It became very popular and has been consistently oversubscribed. For the first 450 physicians trained, we reviewed patient satisfaction survey scores for the 6 months before and after they took the course. For all 13 items on the Press Ganey ambulatory patient survey used, scores were higher after taking the course. For 7 of the 13, the difference was statistically significant (p values ranging from .003 to .044). Conclusions: Our experience with communication skills training indicates that such training can be well received by physicians if it is high quality. Key elements of our program that we believe contributed to its success are the following: it was developed by physicians for physicians; it is taught by physicians with substantial clinical practices so that the atmosphere is colleagues teaching colleagues; and it is skills based rather than cognitive in focus so that participants have tangible tools that they can use in their practice.
Identifying benchmarks for ASCO's “Choosing Wisely” measures that address low-value imaging in early-stage prostate and breast cancer.
Authors: Power Steve , Bitting Rhonda Lynn , Marcom P. Kelly , Kamal Arif
Published: February 2017

194

Background: ASCO has recently selected “Choosing Wisely” measures that identify physician health behaviors of low value in cancer care. Two of these measures address the use of advanced imaging for early stage disease. These measures aim to reduce imaging in patients at low risk for metastatic disease unless there is a clinical indication. To date, no evidence-based benchmarks for meeting these measures have been reported. Methods: We analyzed all patients from January 2010 to June 2012 at the Duke Cancer Institute (DCI), an NCI-designated, comprehensive cancer center. We investigated conformance to two Choosing Wisely measures: avoiding imaging for staging in early stage (ES) prostate cancer (PC) and ES breast cancer (BC). ES was defined by Choosing Wisely as Stage IIb or less for BC and Gleason <7 or PSA <10 ng/mL for PC. Advanced imaging was defined as bone scan, computed tomography (CT) scan, or positron emission tomography (PET) performed at the DCI within 60 days of cancer diagnosis. Descriptive statistics and chi-square were performed. Results: Total 1143 BC and 29 PC were identified. Median age was 58 and 61 years, respectively. 0% (0/29) of PC cases had advanced imaging. Within BC, 20.6% (235/1143) had at least one imaging procedure performed; 16.5% had two or more. Patients with imaging were more likely hormone receptor negative, triple negative, younger (<50), and higher stage (Stage IIb), (all p<0.0001). Of imaging performed in BC, 41% were CT only, 22% were PET or PET/CT, and 36% were bone scans. Ongoing chart abstractions are identifying clinical indications for the ordering of imaging and associated clinical consequences. Conclusions: We have established internal benchmarks for conformance to two Choosing Wisely measures. The lack of advanced imaging for low-risk PC patients demonstrates the feasibility of this measure even in a multi-disciplinary setting. Imaging in <25% low-risk BC patients suggests that these are performed for clinical rather than staging purposes. Further data sharing and comparisons are needed to establish oncology-wide benchmarks.
Measuring cost savings of process improvement.
Authors: Barboza Alexis , Rebello Elizabeth , Albright Heidi Wied , Dang Johnny , Jones Jennifer , Zhang Wei , Feeley Thomas W.
Published: February 2017

196

Background: The aim of the project was to use anesthesia providers in a cancer center to lead process improvements using time-driven activity-based costing (TDABC), a system of measuring process and capacity costs. Methods: The process improvement objectives were centered on eliminating unnecessary patient care processes and improving patient flow. Teams were tasked with planning, process mapping, improving processes, and measuring costs. Projects were done in four anesthesia sites: ambulatory surgery, bone marrow aspiration, pediatric CT and XRT, and cardiopulmonary areas. Results: Process mapping identified areas for improvement and costs before and after the improvement. The Table highlights four project areas’ average total cost and time savings per patient using TDABC methodology. Conclusions: TDABC is a costing methodology that measures the costs of care utilizing process maps. Anesthesia providers had front-line insight in improving process flow and found the process mapping useful to improve processes and measure the cost savings of the improvement. In each area there was improvement or no adverse effect on patient outcomes. This project demonstrates that TDABC illustrates inefficiencies and provides a method to evaluate the cost savings of process improvements. As cancer care reimbursement evolves, the ability to control costs while providing value-based care is essential. [Table: see text]
Implementation of a high-quality biospecimen program to support molecular medicine.
Authors: Morrill Susanne , Mandich Daniza , Cartun Richard , Salner Andrew L.
Published: February 2017

200

Background: The successful implementation of a tumor genomics program relies heavily upon the collection of high quality tumor tissue samples. Although there has been an evolution towards utilizing formalin-fixed paraffin embedded (FFPE) tissue, many research centers continue to rely upon frozen fresh tissue for these types of analyses. A comprehensive effort is required to supply high-volume and high-quality tissue for research. Most community hospitals, even with superb pathology departments, are not well suited to deliver consistent tissue samples without a concerted programmatic effort. As part of the NCI Community Cancer Centers Program (NCCCP), we undertook the development of such capability at our hospital. In addition, as a member of H. Lee Moffitt Cancer Center’s Total Cancer Care program, we received grant funding to help support this comprehensive effort. Our patients and clinicians expressed a strong desire to participate in this type of translational research. This project has been funded in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. Methods: We developed a comprehensive staffing model to implement this program, including a program coordinator, consenters, pathology assistant, lab aide, and data manager. We developed superb relationships with surgeons, interventional radiologists, pathologists and staffs to assure appropriate referrals and processes, and implemented quality checks as a standard. We developed relationships with Moffitt, The Cancer Genome Atlas, and other research efforts, which help provide funding. Results: We successfully implemented a program which resulted in high levels of patient and provider satisfaction, high numbers of fresh frozen and FFPE tissues (nearly 3,000 over 3 years), high quality pass rates, low ischemia time, and high satisfaction on the part of our research partners. We have incorporated best practices in our tissue handling protocols. Conclusions: We successfully implemented a comprehensive cancer genomics bio-specimen program utilizing dedicated staff, working with patients and clinicians closely, and assuring careful coordination of all efforts.
Tools to accurately identify veterans who undergo molecular diagnostic testing.
Authors: Kelley Michael J. , Lynch Julie Ann
Published: February 2017

201

Background: Yearly, 52,000 veterans are diagnosed with cancer. Minorities represent 18.5% (9,651) of these patients. The rapid and explosive growth of molecular diagnostics (MDx) has created challenges for large healthcare systems such as the Veterans Health Administration (VA) to integrate genomic data into the EMR. Yet, this is an important component of high quality cancer care. In 2011, the VA cancer registry (VACCR) began reporting molecular data. This presentation will describe one project to improve integration of genomics into the EMR and the VACCR. Methods: Using ICD diagnosis codes, we identified veterans diagnosed in 2011 with brain, breast, colon, gastrointestinal stromal, lung, and melanoma cancers. Administrative data was obtained to identify MDx testing. These data were then compared to random chart audits. Significant discrepancies between these sources of data prompted collaboration with national and proprietary reference labs (ARUP, LabCorp, Quest, Genomic Health) to obtain the volume of testing by each VAMC. These data were used to conduct targeted chart reviews to identify the location, processes of care, free and structured text information. These data informed the development of natural language processing (NLP) tools to automatically identify patients that underwent testing. Results: Laboratories had the most accurate source of data. Data from ARUP, Quest, and LabCorp identified a significantly higher volume of testing than reported by administrative data. Applying NLP tools to patients diagnosed with breast cancer identified 44 of the 116 tests ordered for the 21-gene risk score tests. Conclusions: Decision support systems are needed to link tumor SNOMED code to diagnostic testing. Until systems are developed, collaborations with reference labs may be an effective method for identifying molecular data. NLP tools may also serve as an adjunct method for capturing MDx tests ordered from smaller labs.
Implementing Lynch syndrome screening utilizing a community partnership.
Authors: Eichmeyer Jennifer N. , Burtelow Matthew , Carey Michael , Montgomery Paul , Graham Cynthia , Zuckerman Dan Sayam , Beck Thomas M.
Published: February 2017

203

Background: Lynch syndrome (LS) is an autosomal dominant condition associated with an 80% risk of colorectal cancer, a 60% risk of endometrial cancer, and additional risks for extra-colonic cancers. Amsterdam and Bethesda criteria can be used to identify patients who may be at risk. However, 25% of colon cancer and 65% of endometrial cancer patients with LS will be missed by using family history criteria alone. LS is caused by mutations in mismatch repair genes (MMR): MLH1, MSH2, MSH6, PMS2, and EPCAM. Tumor screening by immunohistochemistry (IHC) is available, and abnormal results can be flagged for more definitive genetic counseling and testing. Recommendations from the 2009 EGAPP (Evaluation of Genomic Applications in Practice and Prevention) Working Group concluded there is sufficient evidence to use this tumor testing for LS, and the screening would provide moderate population benefits. Cost effectiveness studies have shown universal screening detects nearly twice as many cases of LS and is < $25,000 per life year saved. Methods: St. Luke’s Mountain States Tumor Institute (MSTI) implemented these recommendations in 2012 using a unique strategy: collaborating with a community organization. The Brian Olson Foundation (BOF) strives to “prevent(ing) colon cancer through community outreach and education and saving lives by detecting colon cancer as early as possible.”These objectives were aligned with the MSTI screening program for LS in Idaho by using BOF funding to eliminate a financial burden to the patient for 12 months. Results: 204 specimens were screened for LS using IHC with the following results: 73% normal, 21% abnormal staining for MLH1/PMS2, and 6% abnormal staining for a single protein. Three families were confirmed to have LS after molecular genetic testing, and 6 families have genetic test results pending. Conclusions: Our system had IHC numbers consistent with national data, if not slightly higher. MSTI has elected to continue the program long-term. This kind of collaboration eased the change in practice such that LS screening could become a standard of care in Idaho.
Development of a cancer survivorship patient navigator program.
Authors: Salner Andrew L. , Walker Deborah , Dornelas Ellen
Published: February 2017

206

Background: Survivorship and navigation are component concepts within the continuum of integrated comprehensive cancer care. The focus of survivorship navigation is to provide strategies for a seamless transition for patients/family from acute cancer treatment to optimal post-treatment recovery, and to communicate those strategies with the patient’s health care providers. In addition, this visit may target a “teachable moment” where patients view health and lifestyle modifications as prioritized strategies for remaining cancer free. We developed a survivorship patient navigator program utilizing an APRN model, and performed pilot studies on its feasibility and effectiveness. This project has been funded in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. Methods: Our study, funded in part by a grant from the Livestrong Foundation and also through our collaborative work as an NCI Community Cancer Centers Program (NCCCP) site, examines whether the cancer treatment summary and survivorship care plan provided to the patient by a Survivorship Nurse Practitioner Navigator (SPN) will improve health and wellness from the patient’s perspective. The study obtained self-report data after a post treatment initial SPN visit and again 6 months later. It also explored enablers and barriers to successful program development. Results: Data analysis indicates that patients perceive they are receiving personalized and beneficial cancer care and are highly satisfied with the care plan provided. Barriers to establishing the program include: lack of MD understanding and acceptance, difficulty in obtaining treatment data from outside offices, limited staff resources, equipment costs, patient concern and buy-in for additional visit. Enablers include: MD champions, excellent communications to all team members, satisfied patients, CoC standards new in 2015 and ASCO QOPI measures, automation, sustainability, grant funding, philanthropy, and APRN visit charge. Conclusions: Survivorship is a key component of comprehensive cancer care. We have developed a sustainable model for program delivery, and our preliminary data supports enhancement of the patient experience.
Can racial and financial disparities be overcome in the surgical treatment of NSCLC?
Authors: Sasson Jordan R. , Schwartz Gary , Rehmani Sadiq , Moghaddas Hassan S , Almubarak Sarah , Evans Andrew , Becker Daniel Jacob , Levy Benjamin Philip , Nabong Andy , Rush Nadia , Bhora Faiz Y. , Connery Cliff P.
Published: February 2017

208

Background: Considerable data exists examining disparities in the treatment of non-small cell lung cancer (NSCLC) patients. Black patients, in particular those of lower socioeconomic status (SES), are less likely to receive appropriate care, including induction therapy and resection of surgically treatable lesions. We analyzed the outcomes of resection of NSCLC among a racially and financially diverse patient population at a large urban hospital network with a comprehensive thoracic oncology program. In this system, a patient navigation support team helped overcome barriers to preoperative preparation and multidisciplinary referral. Methods: A retrospective review of 345 patients who underwent lobectomy at our institution from 2002 - 2011 was performed. Data was retrieved from the Society of Thoracic Surgeons (STS) database and patient charts. Patient demographics, payor information and preoperative characteristics were noted. Postoperative complications, 30-day survival and 3-year survival were compared. Statistical analysis was performed using SPSS 17.0 (SPSS Inc, Chicago, IL). Chi-square test was used to compare categorical variables and Student's t-test was used to compare continuous variables. Results: Demographics of black and non-black patients were similar. There were more black patients within the Medicaid group than non-Medicaid (48.9% and 25.3%, p=0.001). Physiologic characteristics, risk factors and use of pre-operative RT and chemotherapy were similar. Post-operative complications were comparable in Medicaid vs. non-Medicaid (11.1% and 14.7%, p=0.524), however black patients had a lower rate of complications vs. non-black (6.1% and 17.4%, p=0.007). 3-year survival was similar in the black vs. non-black (82.3% and 78.6%, p=0.879) and Medicaid vs. non-Medicaid (66.7% and 78.8%, p=0.342) groups. Conclusions: We demonstrated equivalent surgical outcomes for NSCLC in addition to the similar use of induction therapy. Surprisingly, complications were lower in the black cohort. Our results reveal that appropriate treatment is being provided regardless of race or SES, and postulate that our system of preoperative patient support eliminates potential barriers to care.
Management of worry about recurrence in breast cancer survivors.
Authors: Shumway Dean Alden , Leinberger Rebecca , Griffith Kent A. , Zikmund-Fisher Brian , Hawley Sarah T. , Jagsi Reshma , Janz Nancy K.
Published: February 2017

21

Background: Worry about recurrence is a significant concern for breast cancer survivors. We explored physicians‘ confidence and practices in identifying and managing worry. Methods: We surveyed a random sample of 1,500 surgeons and medical oncologists drawn from the AMA Masterfile in 2012. Physician responses to questions regarding their confidence were stratified by practice specialty and compared using the Wilcoxon rank-sum test. Correlates of use of each strategy for managing worry were modeled using multiple variable logistic regression. Results: 896 physicians (59.7%) responded: 498 surgeons and 398 medical oncologists, of whom 85.5% saw breast cancer patients. 62% reported initiating discussions regarding worry about recurrence. Overall, medical oncologists reported more confidence than surgeons in their ability to present risk information to patients, identify survivors with high levels of worry, and help patients manage their worry (p<0.001). Of note, 40.2% of physicians reported low levels of confidence managing worries surrounding recurrence. Confidence presenting risk information was significantly associated with treatment volume, which was highest with >50 cases/year. Surgeons who routinely followed breast cancer survivors for >3 years reported higher confidence; no such correlation existed among medical oncologists, but >90% of this group routinely followed patients for >3 yrs. Female physicians were significantly more likely to report being able to identify survivors with high levels of worry. Practice in an academic setting demonstrated associations with increased confidence. Use of worry management strategies varied by specialty. Medical oncologists were more likely to prescribe medication, address concerns in detail themselves, or refer to a psychologist or social worker. Longer follow-up was associated with increased likelihood of physicians addressing concerns themselves. Conclusions: A sizeable minority of physicians lack confidence in their ability to identify and manage worry in cancer survivors. Medical oncologists and surgeons differ significantly in their approach to worry management, suggesting that greater attention toward this issue in training and continuing education may be warranted.
Lean implementation of electronic health records (EHR).
Authors: Reed Paula , Chan Albert , Colocci Natalia , Carter-West Virginia , Kunkel Matthew , Pierce Tina , Isle Mathew , Nguyen Diana , Roth Julie , Yu Peter Paul
Published: February 2017

211

Background: The Palo Alto Medical Foundation (PAMF), an integrated multispecialty physician group and one of five regions of Sutter Health in Northern California, is converting from an electronic chemotherapy ordering and administration system, Intellidose, to Epic Beacon to achieve full EHR integration. As chemotherapy workflows are complex with multiple interactions between providers and high potential for patient harm, we adopted a novel approach of incorporating Lean process improvement principles in advance of our Beacon deployment to improve the design of our software build and increase operational safety and efficiency. Methods: Two multi-disciplinary teams including oncologists, pharmacists, nurses, administrative and technical support staff were deployed; a Sutter Beacon team responsible for technical design and build of the Sutter Beacon standard and a second PAMF team to evaluate workflow variation among PAMF chemotherapy infusion centers, identify best practices, engage the Sutter Beacon Build team around system design and institute rapid cycle process improvement in partnership with the PAMF Lean Promotion Office. Results: Visio maps of current state workflows were constructed to reflect oncologist, pharmacy and nursing workflows from medication ordering to chemotherapy administration and billing submission. Two Rapid Process Improvement Workshops designed future state workflows and identified key areas requiring re-engineering. Lean rapid cycle improvement strategies will be leveraged to improve clinical workflows prior to Beacon implementation. To support the 40% of infusion treatments that are for non-oncology patients, a second process was designed as an important patient safety initiative to avoid discordant nursing administration workflows. Conclusions: Successful design, build and implementation of EHR require achieving consensus-driven work processes that maximize patient safety, eliminate workflow redundancies and maximizes the value-added component. It requires coordination between the EHR technical build team who design the system and the implementation team who integrate it with re-engineered workflows. Lean methodology provides the conceptual framework to achieve a successful EHR deployment.
Partnering to build a statewide cancer disparities program.
Authors: Murray Betty C. , Hogarty Lucinda H. , Latney Devon , Salner Andrew L.
Published: February 2017

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Background: People of color die from cancer in disproportionately higher rates than Caucasians. As an NCI Community Cancer Centers Program (NCCCP) network member, we utilized American Recovery and Reinvestment Act (ARRA) funding to develop a unique partnership. Hartford Hospital’s Helen and Harry Gray Cancer Center (GCC) has worked closely with our statewide comprehensive cancer control coalition, the Connecticut Cancer Partnership (CCP), to address racial and ethnic health disparities across the state of Connecticut. Methods: We provided a Disparities Project Coordinator (DPC) to work for the CCP as a loaned executive. In this role, the DPC leveraged GCC resources, shared best practices, convened and coordinated statewide activities, and provided oversight for statewide implementation of evidence-based disparities- related cancer projects. This project has been funded in whole or in part with Federal Funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. Results: The DPC worked within the CCP structure to inform decision-making, initiate educational activities, and spearhead innovative projects such as a disparities internship with local universities and the evidence-based Body and Soul program in churches. Beyond CCP integration, the DPC represents CCP and the GCC on key statewide bodies to influence and inform policy affecting racial and ethnic minorities. Conclusions: This unique partnership is an example of a successful private-public partnership that has resulted in increased minority involvement in the state coalition and creation of multiple key partnerships with private, non-profit and state agencies. The accomplishments of the DPC have resulted in sustainability for this position and the establishment of an effective partnership model to address cancer disparities in the state.
Oral anticancer medication: Does the patient understand?
Authors: Graham Donna M. , O'Shea Alan , Ismail Jeffri R. M. , Bambury Richard Martin , O'Keefe Margaret , Drake Catherine , Moylan Eugene J. , Power Derek Gerard , O'Reilly Seamus
Published: February 2017

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Background: Oral anti-cancer medication (OAM) prescribing is increasing. Safety and adherence issues surrounding OAM are causing a shift in the traditional roles and responsibilities of oncologists, nurses and pharmacists. This study aims to investigate patients’ perception of education and safety surrounding OAM use. Methods: Over a 6-month period an anonymous cross-sectional survey was offered to all patients (pts) attending for cancer treatment with OAM at Irish hospitals with cancer services in the South-West region. Data was prospectively analysed using standard statistical tools for non-parametric data. Results: A total of 172 surveys were distributed and 101 pts responded (59%). Of these, 53 (54%) were female. Median age was 62 (range 29-80 yrs). Diagnosis was colorectal cancer in 49 pts (48%), breast cancer in 13 (13%) and brain tumour in 12 (12%). Of treatments used, 85% were oral chemotherapy and 15% oral biological therapy. The most commonly used agent was capecitabine (61%). When commencing OAM, 17% of respondents felt they did not understand it. Understanding was improved by pt education by a doctor (p=0.03) or hospital-based nurse (p=0.04) and provision of information booklets (p=0.04). Pts were unaware of interactions in 30% of cases and 20% were not aware of any safety issues. Pts who had been given information leaflets were significantly more aware of safety including careful handling (p<0.001), storage conditions (p=0.02) and safe disposal (p<0.001). Pts attending nurse-led oral chemotherapy clinics (NOCC) were significantly more aware of safety issues (p=0.04). Of respondents, 1% reported taking too many tablets and 15% had forgotten to take OAM on ≥1 occasion. NOCC improved adherence (p=0.03). Conclusions: OAM, when indicated, is an option for selected pts who are compliant and educated about complications. This study highlights issues with pt education and safety awareness. To our knowledge the factors influencing this have not been previously explored. A significant proportion of our pts were sub-optimally educated regarding medication interactions, storage needs, handling and disposal precautions. Educational tools to aid healthcare professionals in pt instruction and NOCC significantly improve patient understanding.
Chemotherapy order review, activation, preparation, and administration redesign at a large academic cancer center.
Authors: Lennes Inga Tolin , Bohlen Nie , Rosato Erika , Fitzgerald Ellen , Cashavelly Barbara J. , Lafleur Katie , Ahmed Sami , Burke Debra , Ryan David P.
Published: February 2017

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Background: Chemotherapy medication errors are potentially catastrophic due to the small window of therapeutic index, high toxicity, and the compromised clinical status of most recipients. Although compliant with major guidelines for chemotherapy administration, MGH Cancer Center still experienced chemotherapy medication errors tracked in the safety reporting system. Analysis of the safety report data prompted the chemotherapy order review, activation, preparation and administration redesign project with two aims: 1) establish the standard for safety checks for chemotherapy order review, mixing, product verification and administration across all areas of adult chemotherapy infusion by April 2013 and 2) reduce to zero the number of chemotherapy related medication errors by January 2014. Methods: A multidisciplinary team including nursing, pharmacy, and physicians was convened and a problem statement, aim statement, project scope, boundaries and measures of success were delineated. Process maps of each chemotherapy administration area (four in total) were created in an iterative fashion via meetings with front line staff and administration. Cause and effect diagrams were created by small groups of staff members from each area and improvement projects were brainstormed and implemented by nursing directors. Error data from safety reports was compiled quarterly and shared with all workers. Results: A single gold standard for MGH Cancer Center chemotherapy order review, activation, preparation and administration was created for all areas that administer chemotherapy to adults. This redesign project has led to several spin off improvement projects including a medication error awareness project led by nursing and a new competency assessment for oncology nurses. The total number of medication related safety reports has decreased by 67%. The time since our last major chemotherapy administration error is 239 days and we are on track to meet our second project aim. Conclusions: This project employed quality improvement tools and practices to redesign and standardize chemotherapy administration and decrease safety reports related to chemotherapy errors by 67%.