bluuebunny/crossref_metadata_2025 huggingface dataset:
Diffuse large B-cell lymphoma: A single-institution experience of patient outcomes.
Authors: Chan Ryan James , Gupta Rasna , Kanjeekal Sindu Mary , Jarrar Mohammed , Kay Amin , Mathews John , Woldie Indryas Lemma , Hamm Caroline M.
Published: February 2017

271

Background: The Windsor Regional Cancer Program (WRCP) was determined to have consistently been a top performer in time to treatment of diffuse large B cell lymphoma in this Canadian province (http://www.csqi.on.ca/by_type_of_cancer/lymphoma/lymphoma_treatment/). We endeavored to determine whether faster time to diagnosis and treatment for diffuse large B-cell lymphoma (DLBCL) influenced the IPI score (International Prognostic Score), thereby predicting an improved clinical outcome in these presenting patients. Methods: The WRCP services a catchment area of 650,000 people. A retrospective chart review was conducted for patients diagnosed with DLBCL at the Windsor Regional Cancer Program (WRCP) between 2006-2012. Information collected included the five factors for scoring by the International Prognostic Index (IPI) – age, performance status, LDH, stage, and number of extranodal sites – chemotherapy regimen, relapses, existence of second malignancies, cause of death, and dates of diagnosis, last follow-up, and death. We analyzed the relationship between prognostic factors and these clinical outcomes, and also compared the IPI scores for this cohort of patients against a similar population in another Canadian province, British Columbia. Results: It is established that compared to other cancer centres in Ontario, the WRCP is consistently reporting a shorter diagnosis to treatment metric when compared to their counterparts in Ontario, Canada. When compared to historical Canadian data, presenting IPI scores for DLBCL patients were lower on average for patients treated at the WRCP than those reported in British Columbia, Canada by Sehn et al. [Sehn, L. H., et al. (2007). The revised International Prognostic Index is a better predictor of outcome than the standard IPI for patients with diffuse large B-cell lymphoma treated with R-CHOP. Blood, 109(5), 1857-1861.]. Conclusions: A lower presenting IPI score is known to be correlated improved lymphoma related outcome. With attention to the metric of diagnosis to treatment < 30 days for diffuse large B cell lymphoma, we expect an improved lymphoma related outcome for our patients. We recommend ongoing attention to this metric, in order to improve outcomes for our patients.
Current landscape of prostate cancer quality measures in the United States.
Authors: Flanders Scott C , Fitall Eleanor , Jagun Dayo , Mitchell Kristi , Francis Peter St. John , Tang Hong , Song Kyung Min
Published: February 2017

273

Background: Prostate cancer (PCa) is the leading cancer for men in the United States (US) and identified by the Centers for Medicare & Medicaid Services (CMS) as one of the top 20 high-impact Medicare conditions experienced by beneficiaries. Thus, there is increasing focus by stakeholders to measure and achieve high-value, quality care in PCa. However, quality measurement is particularly difficult in oncology. Our aim was to assess the current landscape of PCa quality measures (QMs) in the US. Methods: Published literature and online resources from the past 5 years were reviewed to identify PCa QMs and general oncology QMs relevant to PCa. PCa QMs were categorized using a “continuum of care” framework across 5 stages: 1) symptom assessment and screening; 2) diagnosis and risk stratification; 3) initial treatment; 4) monitoring and additional treatment; and 5) advanced- or late-stage care. Finally, PCa QMs were evaluated for their type (eg. process, outcomes), and use by CMS. Results: We identified 16 PCa-specific QMs and 20 general oncology QMs relevant to PCa. The majority of PCa QMs were developed by the American Medical Association–Physician Consortium for Performance Improvements (6 measures) and the Michigan Urological Surgery Improvement Collaborative (6 measures). There are 3 QMs for symptom assessment and screening, 5 QMs for diagnosis and risk stratification, 6 QMs for initial treatment, 2 QMs for monitoring and additional treatment, and 0 QMs for advanced- or late-stage care. Fourteen PCa QMs focus on process of care, but only 2 PCa QMs address outcomes. Nine PCa QMs are part of CMS quality improvement programs, 6 of which are reportable through the Michigan Urological Surgery Improvement Collaborative. Three new PCa QMs are under consideration by CMS. Conclusions: We found few PCa QMs that capture outcomes of patient experience or care, and no PCa-specific QMs available for advanced disease and late-stage care, demonstrating a need to better define quality in this setting. Opportunities to increase the focus on innovative, real-world data-generation strategies, such as PCa disease registries that collect clinical outcomes, patient preferences, and comorbidities, may inform stakeholder development and adoption of new QMs in the US.
Regional engagement to define, report, and use quality metrics to improve palliative care in oncology.
Authors: Stickney Kristine , Kreizenbeck Karma , Fedorenko Catherine R. , Goulart Bernardo , Shankaran Veena , Curtis J. Randall , Lyman Gary H. , Mera Csaba , Smith Bruce , Ramsey Scott David
Published: February 2017

282

Background: Palliative care in oncology encompasses a wide array of care, and optimal performance metrics remain uncertain. To address this issue we held a regional meeting that included patient advocates, clinicians, private and public payers and researchers to identify quality indicators for palliative care, discuss palliative care (PC) quality measurement in the region, review preliminary results and metrics for PC, and identify opportunities to improve care. Methods: Regional experts facilitated discussions. Data was presented from a regional insurance claims-cancer registry linked database. Participants were asked to: discuss and prioritize interventions to improve palliative care in oncology and create metric dashboards for healthcare providers. Results: Oncology-specific recommendations for interventions: early and continuous palliative care discussions from diagnosis through EOL; training existing care team on palliative care conversations, through standard certification programs; pair patients with an experienced patient/patient advocate; educate caregivers, patients and providers respectively on how to communicate about PC and care choices; and patient navigation to manage symptoms of advanced cancer. Feedback on prioritization of palliative care/EOL metrics: see Table. Conclusions: A multi-stakeholder approach can be effective for developing metrics and interventions to improve palliative care by providing an understanding of the information needs of the community. [Table: see text]
The impact of immigration status on cancer outcomes in Ontario, Canada.
Authors: Cheung Matthew C. , Earle Craig , Fischer Hadas , Camacho Ximena , Saskin Refik , Shah Baiju , Austin Peter , Singh Simron
Published: February 2017

285

Background: In the delivery of cancer care, barriers to access could potentially result in inferior outcomes and survival. Although a relationship has been demonstrated between disadvantaged socio-economic status and mortality, the impact of immigration on outcomes is less clear. Methods: Administrative databases were linked to create a cohort of all incident cases of colorectal, lung, prostate, head/neck, breast and hematologic malignancies from Jan 2000 to Dec 2012 in Ontario, Canada. Cases were defined according to immigration status and followed from diagnosis until death (or cancer-specific death). Cox proportional hazards models were constructed to study the impact of immigration status on survival after adjusting for relevant variables. Additional adjusted models studied the relationship of time since immigration on mortality. Results: During the study period, 11,485 cancer cases were diagnosed in recent immigrants (0-10 years in Canada), 17,844 cases in non-recent immigrants (11-25 years), and 416,118 cases in non-immigrants. Following adjustment for relevant predictors by Cox regression, survival was improved for recent immigrants (HR 0.843; 95% CI 0.814-0.873) and non-recent immigrants (HR 0.902; 95% CI 0.876-0.928) compared to non-immigrants. Cancer-specific survival was also better for recent immigrants (HR 0.857; 95% CI 0.823-0.893) and non-recent immigrants (HR 0.907; 95% CI 0.875-0.94) compared to non-immigrants. Amongst immigrants, each year from the original landing in Canada was associated with increased mortality (HR 1.004; 1.000-1.009) and a trend to increased cancer-specific mortality (HR 1.005; 0.999-1.010) that was not statistically significant. Immigrants from all WHO world regions were found to have similar reductions in mortality and cancer-specific mortality. Conclusions: Immigrants to Canada demonstrate a “healthy immigrant” effect, with lower mortality compared to Canadian-born individuals. This benefit appears to diminish over time, as the health of immigrants potentially converges with the Canadian norm. Potential contributors to the benefit include self-selection for immigration, health requirements for entrance, and differences in disease distribution related to ethnicity.
Investigating racial disparities in use of NK1 receptor antagonists to prevent chemotherapy-induced nausea and vomiting among breast cancer patients.
Authors: Check Devon , Reeder-Hayes Katherine Elizabeth , Basch Ethan M. , Zullig Leah L. , Weinberger Morris , Dusetzina Stacie
Published: February 2017

292

Background: Chemotherapy-induced nausea and vomiting (CINV) is a major concern for cancer patients and, if uncontrolled, it can have serious implications for patients’ treatment outcomes, including quality of life. Guidelines recommend the use of an NK1 receptor antagonist to prevent CINV among patients beginning chemotherapy with a high risk of causing the side effect. However, barriers to use of oral NK1s (i.e., aprepitant) exist. In many cases, patients are required to fill a prescription for aprepitant at their home pharmacy. As well, the drug is expensive, costing over $500 under Medicare Part D, and patients may be responsible for a large portion of that cost. These barriers may contribute to racial disparities as they disproportionately affect minority patients. Methods: We used 2006-2012 SEER-Medicare data to evaluate the use of NK1s among black and white women initiating adjuvant chemotherapy with an anthracylcline and cyclophosphamide for early-stage breast cancer. NK1 use during the first chemotherapy cycle was measured using Medicare Part D and Part B claims. We used modified Poisson regression to assess the relationship between race and (1) any NK1 use, (2) oral NK1 (aprepitant) use, and (3) intravenous NK1 (fosaprepitant) use. We report adjusted risk ratios (aRR) and 95% confidence intervals (CI). Results: Of 1,015 eligible women (911 white; 104 black), 38% of white and 28% of black women received any NK1 at the start of their chemotherapy regimen. In adjusted analyses, black women were 30% less likely than white women to receive any NK1 (aRR black vs. white: 0.70, 95% CI: 0.52-0.94). This disparity was driven by a 44% gap in orally administered NK1s (aprepitant) (aRR: 0.56 95% CI: 0.35-0.89). We did not observe disparities in intravenous fosaprepitant use (aRR: 0.77, 95% CI: 0.46-1.28, NS). After controlling for variables related to socioeconomic status, disparities in NK1 and aprepitant use were reduced but not eliminated. Conclusions: Our study found racial disparities in women’s use of oral NK1s for the prevention of CINV. These disparities may be partly explained by racial differences in women’s ability to afford the medication.
Comparative effectiveness of early-line nab-paclitaxel (nab-P) versus eribulin in patients (pts) with metastatic breast cancer (MBC): A U.S. real-world analysis.
Authors: Braiteh Fadi S. , Parisi Monika , Ni Quanhong , Park Si yeon , Faria Claudio
Published: February 2017

293

Background: In a phase III study in MBC, nab-P demonstrated anti-tumor activity across lines of therapy. Eribulin is indicated for the treatment (Tx) of MBC in pts who have previously received ≥ 2 chemotherapeutic regimens. This analysis evaluated Tx patterns and effectiveness of nab-P and eribulin in pts with MBC in a real-world community-based setting. Methods: A retrospective cohort study was performed using fully de-identified data from a US electronic medical record platform of 1300 community oncology physicians. The analysis included women aged ≥ 18 years with MBC who started on nab-P or eribulin monotherapy as 1L or 2L Tx from 12/4/10 to 10/6/14 (≥ 1 cycle of nab-P or eribulin required). The primary objective was to examine duration of Tx (DOT, including time to Tx discontinuation [TTD]; censored if last administration > 30 days from the last date in the database) and time to next Tx (TTNT; day 1 from drug 1 to drug 2). Incidence of adverse events (AEs) and supportive care used during Tx were also examined. Results: Pt characteristics were similar between groups. Mean age was 59 years. Most pts had hormone receptor + (62%), HER2− (82%) disease, and 1L therapy (60%). More pts received nab-P vs eribulin. Slightly more pts receiving nab-P vs eribulin were treated in 1L (63% vs 55%). DOT, TTNT, and TTD were significantly longer in the nab-P vs eribulin group (Table). Thrombocytopenia and anemia were numerically lower in the nab-P vs eribulin group (P = 0.11 for each). Nausea/vomiting was less common with eribulin vs nab-P (P = 0.009). Granulocyte-colony stimulating factor, hydrating agents, and antiemetics were used less often in pts receiving nab-P (P < 0.01 for each). Conclusions: DOT, TTNT, and TTD were significantly longer for pts treated with nab-P vs eribulin. Moreover, pts receiving nab-P experienced fewer hematologic AEs and utilized fewer doses of supportive care. [Table: see text]
Choosing Wisely in oncology: Screening for a new primary cancer in patients with metastatic disease.
Authors: Singh Simron , Lipscombe Lorraine , Fischer Hadas , Tinmouth Jill , Austin Peter , Fung Kinwah , Cheung Matthew C.
Published: February 2017

295

Background: The Choosing Wisely Canada (CWC) campaign aims to start conversations about unnecessary treatments and procedures in order to improve quality of care. In particular, the CWC campaign in cancer seeks to reduce interventions that are not supported by evidence and contribute to unnecessary rising costs of cancer care. We sought to document the performance of cancer screening for a new primary cancer in patients with existing metastatic cancer (CWC statement #2). Methods: We used population-based administrative health care databases from Ontario, Canada held at the Institute for Clinical Evaluative Sciences (ICES). The cohort included all adult residents of Ontario of eligible screening age (age 50 or older) diagnosed with incident, stage 4 (metastatic) colorectal cancer (CRC), lung, breast, or prostate cancer between January 1, 2007 and December 31, 2012. We examined screening tests for CRC and breast cancer in the first 1 and 3 years after diagnosis of an unrelated cancer. Given the high mortality rate in this population, screening rates were calculated using the cumulative incidence function which takes into account the competing risk of death or the occurrence of the cancer for which the patient was being screened (prior to being screened). Results: Among the 20,992 patients with stage 4 lung, breast, or prostate cancer, CRC screening within 1 year of cancer diagnosis occurred in 2.8%, 6.1%, and 13.0%, respectively. Within 3 years of diagnosis, screening rates were 3.9%, 11.9%, and 26.9%, respectively. Among the 10,034 women with metastatic CRC or lung cancer, breast cancer screening within 1 year of cancer diagnosis occurred in 8.0% and 8.7% of women, respectively. Within 3 years of diagnosis, screening rates were13.1% and 10.2%, respectively. Screening rates were higher in patients age 50-74 than those ≥75 years. Conclusions: Our findings indicate that up to one quarter of patients with metastatic cancer receive subsequent screening tests for other cancers, which are unnecessary as these patients are unlikely to benefit. Further studies are warranted to examine resource implications, potential patient and societal harms, and the future impact of the CWC campaign on this practice.
Breast cancer patient functional status and comorbidities and their impact on treatment aggressiveness: A population-based study.
Authors: Pearlstein Kevin A. , Basak Ramsankar , Chen Ronald C.
Published: February 2017

306

Background: The ASCO Choosing Wisely Campaign and other published guidelines recommend avoidance of aggressive treatments in early-stage cancer patients with limited life expectancy. However, patients with more advanced cancers are likely to benefit from aggressive treatment. The population-based SEER-MHOS (Medicare Health Outcomes Survey) provides unique data to allow assessment of aggressiveness of cancer treatment by cancer stage and patient frailty. Methods: MHOS includes patient-reported functional deficits in a sample of Medicare beneficiaries, and has been linked with SEER data which provide diagnostic and treatment data. This analysis included 2605 patients diagnosed with non-metastatic breast cancer from 1999-2006 who had pretreatment frailty data  which was calculated using a validated index based on age, comorbidity, and functional deficit. Each patient was classified as healthy, intermediate, or frail. Treatment aggressiveness was examined for each group. Results: Comorbidity and functional deficits were very common. For example, 11% had chronic lung disease, 17% diabetes, 52% low back pain, 50% reported difficulty walking several blocks, and 11% difficulty bathing. Almost all individuals with localized and regional breast cancers had surgery (Table 1). However, frail patients with localized cancers were less likely to receive post-lumpectomy radiotherapy (RT, p < .001); frail patients with regional cancers were less likely to receive post-mastectomy RT (p = .02). A sizable proportion of healthy patients (25-32%) do not receive post-lumpectomy RT. Conclusions: Comorbidities and functional status limitations are common in Medicare breast cancer patients. There appears to be an underutilization of adjuvant RT in healthy breast cancer patients, and use is less in frail patients. [Table: see text]
Disparity in early mortality among racial groups with multiple myeloma in the United States: A National Cancer Data Base study of 108,352 patients.
Authors: Gonsalves Wilson I. , Bartley Adam C , Go Ronald S.
Published: February 2017

311

Background: Previous population-based studies have shown variations in disease incidence and overall survival (OS) among multiple myeloma (MM) patients (pts) from different ethnic and racial backgrounds. However, the impact of race and ethnicity on early mortality (EM) or death in the first year after the diagnosis of MM is less well known. Methods: Pts with MM diagnosed from 2000-2011 were identified in the NCDB. We obtained data associated with socio-demographics, type and location of care facility, as well as the use of autologous stem cell transplant (ASCT) as an initial treatment option. Two cohorts were created based on the use of ASCT: 1) The group who received an upfront ASCT and 2) Pts who were 75 years or older who are unlikely to have ever received an ASCT. The rate of early mortality (EM) was estimated using the 1-year OS and assessed for all pts based on racial/ethnic background and the use of ASCT in their therapy. Results: There were a total of 108,352 pts who were included in this analysis. The median age of this cohort was 65 years (Range: 20 – 90). Of these 58,223 (54%) were male. The racial distributions of these cohorts were as follows: 78,589 (73%) White non-Hispanic (WNH), 21,292 (20%) Black non-Hispanic (BNH), 1,943 (2%) Asian Pacific-Islander (API), 293 (< 1%) Native-American (NA) and 6,235 (5%) Hispanics-any race (HIS). The estimated 1-yr OS (95% CI) was 71% (71 – 72) for WNH, 74% (73 – 74) for BNH, 77% (75 – 79) for API, 73% (68 – 78) for NA and 75% (74 – 76) for HIS. Amongst patients who received an upfront ASCT, the estimated 1-yr OS (95% CI) was 97% (97 – 98) for WNH (Reference), 98% (97 – 98) for BNH (P = 0.99), 99% (99 – 100) for API (P = 0.96) and 98% (97 – 99) for HIS (P = 0.99). Whereas amongst pts who likely never received an ASCT (75 years or older), the estimated 1-yr OS (95% CI) was 55% (54 – 56) WNH (Reference), 57% (56 – 59) for BNH (P = 0.03), 62% (58 – 67) for API (P = 0.02), 55% (43 – 72) for NA (P = 0.99) and 55% (52 – 58) for HIS (P = 0.99). Conclusions: In general, WNHs have a worse 1-yr OS compared to BNH and API. However, this disparity appears significant only among pts unlikely to get an ASCT. Further studies are required to identify explanations for such disparate outcomes based on race and use of ASCT.
Acute hospitalizations in cancer patients treated with definitive radiotherapy: A retrospective cohort study with implications for an urgent care clinic.
Authors: Berman Abigail T. , Gabriel Peter Edward , Owen Daniel , Xu Melody Ju , Simone Charles B. , Plastaras John Peter , Christodouleas John Paul , Hwang Wei-Ting , Vapiwala Neha
Published: February 2017

312

Background: Reasons for hospitalizations in patients undergoing curative-intent radiotherapy (RT) have not been well characterized previously. Implementation of urgent cancer care clinics could decrease rates of hospitalization, but the reasons for acute visits must be better understood. This retrospective cohort study investigates emergency department (ED) visits or admissions in patients treated with definitive RT. Methods: Under an IRB-approved protocol, the cohort was defined as all consecutive patients >=18 yo who began RT (RTSTART) between 7/1/11 and 12/31/13 for nonmetastatic disease with curative intent. An acute encounter was defined as an ED visit or inpatient admission during RT or 30 days after the conclusion of RT (30DA). Results: A total of 1852 unique RT courses from 1823 patients were identified, within which there were 666 RT unique courses (657 patients) who had at least one acute encounter. There were 1006 acute encounters, comprising 287 ER and 719 inpatient visits. The number of admissions per RT course ranged from 1 to 9, with <13% with >3. The mean difference between post- and pre-RT ECOG performance status was greater for patients with acute encounters than those without (0.47 vs. 0.06). For those admitted, the median days from RTSTART to admission were 36 (0-81) and 68.2% received concurrent chemotherapy. Conclusions: In this large analysis from a single quaternary cancer center,over one-third of patients receiving curative-intent RT had an acute encounter, a high percentage of whom received chemotherapy. Further investigations are needed to classify which admissions were unanticipated, which in turn would guide design of urgent cancer care centers for RT patients and improve quality of care. [Table: see text]
The effect of obesity on operating room (OR) utilization in breast surgery.
Authors: Dunderdale Julie , Jovanovic Borko , Kulkarni Swati
Published: February 2017

36

Background: More than one-third of adults in the United States are obese. Studies have shown that obesity-related comorbidities increase health care costs, but the effect of obesity on operating room utilization has not been completely evaluated. The purpose of our study was to examine how operative time (OPT) for common procedures in breast surgery is affected by patient weight. We expected that weight affected OPT more so for extensive procedures, such as axillary lymph node dissection (ALND) and mastectomy, than for minimally invasive procedures, such as lumpectomy and sentinel lymph node biopsy (SLNB). Methods: OPT and weight for ten breast surgeries were analyzed from the American College of Surgeons 2010 National Surgical Quality Improvement Project database. Only women were included, and those who underwent additional procedures or had incomplete data were excluded. Patients were divided into three groups based on their weight (<135 lbs, 135-199 lbs, and ≥200 lbs). Using the two-sample t-test, OPT for the procedures was compared among the lowest and highest weight categories. We specifically looked at lumpectomy, lumpectomy plus SLNB, ALND, mastectomy, and modified radical mastectomy (MRM). Results: In all, 16,077 patients were included in the analysis. When the lowest and highest weight groups (<135 lbs and ≥200 lbs) were compared for all procedures, a significant difference of 13 min was seen (p<0.0001). For these same groups, a significant, but not relevant for scheduling, difference in OPT was noted for lumpectomy alone (37 vs. 41 min, p<0.0001) and lumpectomy plus SLNB (71 vs. 80 min, p<0.0001). However, weight affected ALND and mastectomy more drastically. The difference for lumpectomy plus ALND was 22 min (93 vs. 115 min, p=0.0004), while the differences for simple mastectomy and mastectomy plus SLNB were 24 min (89 vs. 113 min, p<0.0001) and 23 min (102 vs. 125 min, p<0.0001), respectively. In addition, the difference for MRM was 22 min (104 vs. 126 min, p<0.0001). Conclusions: Patient weight does significantly affect OPT for lumpectomy and SLNB, but the difference is much greater for ALND, mastectomy, and MRM. Therefore, when scheduling more extensive procedures for obese patients, additional time should be allotted to improve OR utilization.
Achieving the triple aim in cancer care through a tri-part research collaboration.
Authors: Patel Manali I. , Ramirez David , Nguyen Andrew , Hagan Caroline , Asch Steven M , Agajanian Hilda H. , Agajanian Richy , Milstein Arnold , Blayney Douglas W.
Published: February 2017

52

Background: Curbing rising cancer care costs require models that safely lower expenditures and improve experience and outcomes. We developed a care delivery model integrating lay health workers to address early goals of care and symptoms (JOP 2015). We then created a research-collaboration with a health plan (which paid for care and processed claims), a contracted oncology group (which implemented the model), and a university research center (which designed the intervention and conducted the evaluation) to test effects on patient satisfaction, utilization, and costs. Methods: All patients newly diagnosed with cancer, referred to the contracted oncology group, and who were beneficiaries of the health plan from 11/17/13 through 9/30/15 were enrolled. We analyzed descriptive statistics and pre-intervention and 5-month post-intervention surveys to assess satisfaction with care and decision-making. Results: There were a total of 412 patients with cancer enrolled over the study period. The mean age of enrollees was 76 years; 53% were women. The mean risk adjustment score was 2.5 (www.CMS.gov). Gastrointestinal malignancies were the highest proportion of cancer diagnoses (26%) followed by breast (23%) and genitourinary cancers (13%). Thirty-one percent of patients were diagnosed with stage IV disease; 22% with stage I; 18% with stages II and III; and 10% with unknown stage. Twenty-two percent of patients died during the study period. In comparison to pre-intervention surveys, there were statistically significant improvements in overall mental and emotional health (p < 0.05) and improvements in satisfaction with care and decision-making (p < 0.05). Conclusions: Research collaborations can help to rapidly implement and test novel strategies of care delivery. These collaborations are needed to align stakeholder priorities to improve cancer care and reduce healthcare spending. Our collaboration demonstrates the feasibility of an all-stakeholder approach to designing and implementing innovative high-value cancer care delivery strategies. Our early findings demonstrate improvements in patient emotional and mental health and satisfaction with care and decision-making.
Data-driven quality improvement in an oncology patient-centered medical home.
Authors: Sprandio John David , Lowry Maureen , Flounders Brian , Tofani Susan Higman
Published: February 2017

54

Background: In a 2012 abstract, Data driven transformation for an Oncology Patient-Centered Medical Home, Consultants in Medical Oncology (CMOH) demonstrated that standardized processes and enhanced IT capabilities (IRIS software app) provided a rapid learning system for the practice. Iris aggregated data became the basis for Quality Improvement Projects (QIPs) allowing CMOH to continue to improve in quality and cost measures. Deviation from performance trend is readily identifiable, providing operational direction. Methods: A review of 2012 data identified an increase in the rate of hospitalizations, initiating a QIP. We identified inconsistent processes in Telephone Triage Symptom Management at one of the three practice locations. It was determined that symptom calls in the early to mid afternoon were being directed to the ER, and a higher percentage of these evaluations resulted in admissions. Steps to restructure roles and internal processes and reinforced training followed, resulting in improvement. Results: After analysis of site specific performance, we centralized Telephone Triage services to reduce variability in execution. We addressed staffing issues, streamlined nursing and physician education around Triage related processes, revised algorithms, and improved education materials to enhance patient engagement. This resulted in resetting our trend in ER utilization and admissions, increasing the number of calls into the telephone triage service, increasing the percentage of symptoms managed at home and decreasing the number of office visits within 24 hours. Conclusions: Aggregated real-time data provides the tools to rapidly identify opportunities for improvement and conduct QIPs to enhance the quality and value of delivered services. Supportive software apps like Iris are foundational for practice transformation to future value-based cancer care models. [Table: see text]
Impact of a best practice alert on transfusion practices for solid tumor oncology patients.
Authors: Buck Ryan , Wachsberg Kelley , Weaver Charlotta , Dombrowski Lyndsey , Ma Madeleine , Lee Jungwha , O'Leary Kevin
Published: February 2017

57

Background: Recent evidence supports a restrictive transfusion strategy in the majority of hospitalized patients, though transfusion practices for oncology patients remain highly variable. We evaluated whether use of a best practice alert for solid tumor oncology inpatients would result in more restrictive transfusion practices and impact patient outcomes. Methods: We conducted a retrospective, historical control analysis at a large academic hospital in Chicago, IL. We compared transfusion utilization among solid tumor oncology patients before and after implementation of a transfusion alert. Patients with active bleeding, hematologic malignancies and those undergoing surgical procedures were excluded. A best practice alert with clinical decision support encouraging use of a restrictive transfusion strategy (Hgb < 7 g/dL) was implemented 6/14 with phase-in completed by 9/14. We abstracted PRE intervention medical records of patients hospitalized from 5/1/13 to 4/30/14 and POST intervention records from 9/1/14 to 8/31/15. Readmission rates, incidence of ICU transfer and inpatient mortality were also compared using multiple linear regression. Outcomes were adjusted for age, gender, race, BMI, smoking status and Charlson comorbidity index. Results: 1296 total patients were included in the analysis (PRE, n = 685; POST, n = 611). There were no differences in age, gender, BMI or Charlson comorbidity index among cohorts, although the PRE cohort included more Caucasians (60.2% vs. 46.8%, p < 0.0001) and smokers (6.0% vs. 2.5%, p = 0.002). Packed red blood cells transfused per 100 patient-days were significantly lower in the POST-intervention cohort (3.8 vs. 6.4, p = 0.01). The POST-intervention cohort also had fewer 30-day emergency department visits (3.3% vs. 5.1%, p = 0.03). There were no significant differences in rates of 30-day readmission (34.6 % vs. 37.3%, p = 0.19), ICU transfer (0.5% vs. 1.1%, p = 0.08) or inpatient mortality (1.7% vs. 1.8%, p = 0.96). Conclusions: Implementation of a best practice alert among solid tumor oncology patients effectively reduced utilization of packed red blood cells without affecting patient outcomes.
Quality of life (QoL) by response: An interim analysis of patients (pts) with squamous (SCC) NSCLC treated with nab-paclitaxel/carboplatin (nab-P/C) induction therapy in the phase III ABOUND.sqm study.
Authors: Langer Corey J. , Hirsh Vera , Amiri Katayoun , Ko Amy , Knoble Jeanna L. , Johnson Melissa Lynne , Jotte Robert M. , McCleod Michael , Ong Teng Jin , Page Ray D. , Spigel David R. , West Howard Jack
Published: February 2017

63

Background: The correlation of radiological response and pt-reported outcomes (PROs) in advanced NSCLC remains underreported. This interim analysis evaluated QoL by response (RECIST v1.1) in SCC NSCLC pts treated with nab-P/C during the induction part of the ABOUND.sqm study. Methods: In the ongoing phase III ABOUND.sqm study, pts with advanced SCC NSCLC are treated with first-line nab-P 100 mg/m2 d 1, 8, 15 and C AUC 6 mg•min/mL d 1 (21-d cycles) for 4 cycles (induction). Pts not progressing are randomized 2:1 to maintenance nab-P 100 mg/m2d 1 and 8 of each 21-d cycle + best supportive care (BSC) or BSC alone until progression. The primary endpoint is PFS from randomization to maintenance. QoL, an exploratory endpoint, was assessed with predefined PRO instruments, LCSS and EQ-5D-5L, on d 1 of each cycle. Pts with a radiological CR/ PR are considered responders (R) in this analysis (57% of evaluable pts). As the study is ongoing, this pre-planned analysis included QoL and tumor response data that were reported up to the cutoff date. Results: Baseline (BL) characteristics were similar for Rs (n = 73) and non-Rs (n = 55). Over 80% of pts completed BL + ≥ 1 post-BL PRO assessments. For LCSS, average total score and symptom burden index improved during induction chemotherapy; a higher percentage of Rs vs non-Rs had clinically meaningful improvements (≥ 10 mm [VAS]) from BL in composite LCSS cough, shortness of breath, & hemoptysis (56% vs 38%). Of pts reporting BL EQ-5D-5L dimension problem(s), a higher percentage of Rs vs non-Rs reported complete resolution at least once during treatment (Table). Conclusions: These results indicate that Rs and non-Rs maintained/improved QoL during induction therapy with nab-P/C. Rs appeared to have greater improvements in LCSS and EQ-5D-5L. Radiological response translates into meaningful QoL improvement. Clinical trial information: NCT02027428. [Table: see text]
Engaging patients with their self-reported symptom outcomes trended data.
Authors: Hartman Scott , Denny Diane , Greene Carmon , Hannaford Morgan , Markman Maurie
Published: February 2017

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Background: Cancer Treatment Centers of America, Inc. (CTCA) is a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients’ perceived symptom burden for real-time clinical intervention. Patients take a baseline SIT assessment at new patient intake and are eligible to take the SIT every 21 days. The SIT is comprised of the M.D. Anderson Symptom Inventory tool, a validated assessment instrument, along with additional questions and a free text box that were created by CTCA. The SIT became an integral part of patient care at CTCA beginning in 2012. Recognizing the value of the SIT data in real time patient intervention, a project was undertaken to engage the patient with his/her results and facilitate dialogue with his/her care team. Methods: Upon completing the SIT, patients were provided with their Symptoms-At-a-Glance (SAG) report, which is a graphical representation of trended outcomes of their SIT data, along with education on how to interpret the document. Patients were encouraged to review the SAG with their care team as a communication facilitation tool promoting open dialog on those symptoms identified as the most severe and or frequent. Pre and post evaluations of the process were completed via a brief questionnaire for patients and staff to evaluate efficacy of the exchange. Results: A total of 272 patients completed the SIT during the initial 30 days. 80.5% of patients utilized the SAG report during their Medical Oncology appointments and/or took their report with them for subsequent reference. Utilization of the SAG report by interdisciplinary teams for patient intervention showed an increase of 103%. Patients responded favorably to the project and reported that the SAG is a valuable tool which will be shared with their primary care physician and used to update family members. Conclusions: The project was successful in creating improved integration of the SIT outcomes and driving more focused and complete discussions between patients and their providers on a wide spectrum of quality of life issues.
What is the health-related quality of life for women with metastatic breast cancer?
Authors: Lalla Deepa , Tevaarwerk Amye , Goertz Hans-Peter , Smith Mary Lou , Bajaj Preeti S. , Railey Elda , Reyes Carolina
Published: February 2017

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Background: Metastatic breast cancer (MBC) and its treatments can have a significant impact on patients’ health-related quality of life (HRQoL) and daily functioning. To better assess the impact of MBC on HRQoL, we conducted an online survey among women with MBC. Methods: We developed and administered a cross-sectional, web-based survey, and invited registered members of three advocacy groups currently living with MBC to participate. Respondents completed an informed consent and completed assessments on symptom burden using an overall QOL question (1 item), the MD Anderson Symptom Inventory Survey (MDASI), activities of daily living (ADLs, Rotterdam Scale), and impacts on work productivity. Results: We received 1285 complete responses to the survey. Over half the respondents were between 40-49yrs (37%) or 30-39 yrs (26%). The majority were white (87.7%), well-educated (70.7% had a bachelor’s degree or higher), and working at the time of the survey (55%), with private health insurance (63%). After diagnosis with MBC, most patients had received endocrine therapy (44.2% aromatase inhibitors, 27.3% fulvestrant). The most common chemotherapy agents received after diagnosis with MBC were capecitabine (30.1%) and docetaxel (26.9%). The overall mean HRQoL score was 74 (0-100, higher is better). Mean respondent-reported MDASI scores for symptom severity (SS) and symptom interference (SI) were 4.2 and 4.5 (0-10, higher is worse). Mean Rotterdam scale scores to assess ADLs were 23.7 (0-32, higher better). On average, working women with MBC missed 9.3 hours of work in the past 7 days due to their MBC. As symptom burden increased, respondents reported a lower ability to perform ADLs (p < 0.0001) and lower overall HRQoL (p < 0.0001). The ability to perform ADLs decreased with increase in the total number of agents received (p < 0.0001) and time since diagnosis (p < 0.0001). Conclusions: This survey provides valuable insights into health status, ability to perform ADLs, and lost productivity among patients with MBC. Future analyses will present results by tumor subtypes and drug treatments received.
Does oncology patient-reported healthcare experience vary by site of care (SOC)?
Authors: Drzayich Jankus Dana , Casebeer Adrianne Waldman , Hopson Sari , Dye Joseph , Tao Zhuliang , Howe Andrew M. , Stemkowski Stephen , Patton Jeffrey , Small Art , Masaquel Anthony
Published: February 2017

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Background: Patients with cancer are increasingly receiving chemotherapy infusions in a hospital outpatient (HO) as compared to the physician practice setting (PO). Previous research has focused on SOC differences in economic measures, such as healthcare costs, in commercially insured populations. This study investigates SOC differences in patients’ reported healthcare experience for a mostly Medicare population. Methods: A convenience sample of 2,604 Humana members with cancer of the breast, lung, colon/rectum or NHL/CLL and treated in 2014 received a survey by mail to capture patient reported healthcare experiences. We implemented the Consumer Assessment of Health Care Providers and Systems (CAHPS) for Cancer Care survey’s 5 domains (“affective” communication, shared decision making, patient self-management, exchanging information and access to care and information) and ad hoc travel and wait time questions. Average composite scores for each CAHPS domain were weighted and adjusted by age and health status (1 = excellent - 5 = poor). Differences in responses were tested using chi-square and t-tests. Results: The response rate was 25.0% (N = 651). Survey respondents were mostly female (75.0%) and Medicare beneficiaries (87.9%) with a mean age of 68.7. HO patients reported slightly worse health status than PO patients (2.9 vs 3.0, p= 0.028) CAHPS for cancer domain scores indicated a similar patient perceived experience across all domains except for access to care and information (1-3 scale): HO = 2.6 vs PO = 2.5, p= 0.007. This difference was driven mainly by items related to contacting the health care team for certain symptoms and after hours care. More HO patients traveled > 30 minutes for treatment (39.0% vs 25.9%, p= 0.004) and reported wait times > 15 minutes (72.2% vs 63.8%, p= .054). Patient perceived acceptability of these travel and wait times were similar (HO: 61.9% vs PO: 66.7%, p= .782 and HO: 60.4% vs PO: 63.1%, p= .919). Conclusions: Analysis of the new CAHPS for cancer care survey showed comparable patient perceived experiences by site of care. However, access to the health care team for certain symptoms and after hours care was better for HO patients, though HO patients also had longer travel and waiting time.
Patient uptake and satisfaction with advanced genomic technologies offered through an employee benefit program.
Authors: Kieran Shannon M. , Knickelbein Kelly Z. , Goldstein Julie , Riordan Sara , Billings Paul
Published: February 2017

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Background: Access to advanced genomic technologies for the diagnosis and treatment of cancer is important. As part of an employee benefit program, we offered genomic technologies, such as somatic tumor and inherited germline genetic testing, as well as clinical trial information, medical second opinions, and genetic counseling, as appropriate, to enrollees with cancer. Genetic counselors served as cancer navigators through the process. The study aimed to assess uptake of the services offered and satisfaction with the program. Methods: Established benefit enrollment criteria included a diagnosis of cancer and company status (employee, spouse, dependent child). All data and communications were tracked in an online Patient Resource Management (PRM) system. Data was pulled directly from the PRM system logs. To measure satisfaction, participants were asked to complete an anonymous exit survey following completion of the program. Results: The data set included 131 individuals who inquired about program services. Eighty of the 131 (61%) met criteria and enrolled. Thirty-six of the 80 (45%) had complete data available for analysis. Cancer types varied but mostly included breast, colon, lung, leukemia and lymphoma. The table below shows the specific service uptake rates for the cohort. Seven participants completed the exit survey and all responded that the information gained from the program was useful and that the program increased satisfaction with their employer. Conclusions: Patients with cancer do not always have access to genomic technologies, nor understand the technology applications for their prognosis and treatment. Our experience in developing this program is that enrollees were interested in pursuing services that supported the use of genomic technologies, and satisfaction was high amongst those that provided feedback. Overall, the program directly engaged participants in their care and empowered them through education provided by genetic counselor navigators in ways that are not typically available in most cancer care settings. [Table: see text]
Transitions in care and reduction in discharge errors.
Authors: Fenton Mary Anne , Szyamnski Tara , Begnoche Megan , Chase Carol , Moreau Michelle , Barnett Jessica
Published: February 2017

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Background: Patients are often overwhelmed at the time of hospital discharge and focus on home rather than the discharge process. Fragmented communication and lack of planning between the hospital team, patient, family and primary oncologist can lead to frustration and delays in implementation of palliative or curative therapies and potential hospital readmission when the plan of care is not followed in a timely manner. Our goal is to avoid medication errors, delays in implementation of a care plan and reemergence of symptoms or new symptoms as a result of a suboptimal discharge transition. Methods: A multidisciplinary care transition team including phone nurses, social workers, pharmacists, physicians, nursing leadership and a palliative care practitioner meet monthly to review and refine discharge transitions. Our intervention is a proactive phone call, by specially trained ambulatory oncology nurses, to patients within 1-2 business days after discharge from the inpatient Hematology Oncology service. The nurse asks consistent questions to address common issues in the discharge transition including review of symptoms, understanding of discharge medications, confirmation of new medication initiation, side effects, coping, and next appointment with the oncologist. The nurse reinforces the ambulatory nurse phone line and availability of same day sick visits. Results: Preliminary discharge phone call results from the nurses’ interventions include clarification of discharge medications, interventions when a patient had not obtained the ordered medication including antibiotics, referrals for same day sick visits, referrals to social work for emotional and financial distress, education on medications or side effect management, and follow-up appointments. The average time for the post discharge call is 13 minutes. Conclusions: Our follow up discharge intervention by the oncology nurse has shown many patients are uncertain of medications and follow-up even when provided with detailed discharge paperwork and medication reconciliation. A proactive discharge phone call may help resolve these issues and prevent future readmissions. A six month summary of our intervention will be presented.