bluuebunny/crossref_metadata_2025 huggingface dataset:
Training staff in a virtual unit.
Authors: Rawlinson Traci , Bartholet Todd , Tonne Heidi
Published: September 2018

119

Background: Nebraska Medicine, a 600 bed academic medical center, had 24 inpatient oncology beds. In order to grow the oncology population, planning for the Fred and Pamela Buffett Cancer Center began. The new center would include 108 inpatient beds on four units: acute, specialty, progressive, and intensive levels of care. A year in advance, plans were initiated to onboard newly hired nurses of various clinical backgrounds with the goal of creating a competent, cohesive health care team. Despite challenges of a nursing shortage in a competitive market and construction of the facility underway, the oncology leadership team developed innovative ways to orient the large number of new staff. Collaboration with existing inpatient units throughout the organization was instrumental in achieving this goal. Methods: The oncology leadership team developed a process to deploy nursing staff into a variety of inpatient units throughout the organization. A partnership was established involving inpatient managers and hospital educators to track progress and learning needs of each individual during the orientation process. Key components were consistent communication between the leadership teams, and ensuring exposure to the relevant oncology patients, procedures and providers. To provide additional support, an existing Oncology Nurse Fellowship program was adapted and utilized to educate on the holistic care of oncology patients. Day in the life scenarios were developed to expose staff to the new space. Lead Nurses for each inpatient unit received additional development training. Team building exercises and staff meetings contributed to creating positive working relationships. Results: A year later 73 nurses and 48 patient care technicians (PCT), along with the inter-professional team, were prepared to competently and holistically care for patients upon opening of the cancer center. Collaboration with 14 units, including the hospital float pool, yielded impressive results. 84 nurses participated in the Oncology Nurse Fellowship program and 62 PCT’s attended Oncology 101, a specific training for PCTs. Conclusions: Through collaboration and innovation, it is possible to orient clinical staff to create a competent, cohesive team before a physical nursing unit exists.
Quality assessment of tumor boards across an academic and community cancer network.
Authors: Roberts Daniel Aaron , Stuver Robert , Schillevoort Igor , Zerillo Jessica A.
Published: September 2018

122

Background: Cancer tumor boards (TB), or multidisciplinary team meetings are standard of care in oncology care worldwide. Specific components are described by the American College of Surgeon's Commission on Cancer Program. Most data show consistent improvement in outcomes including a change in diagnostic findings, treatment, and possibly improved survival with TBs. Methods: We adapted a performance assessment tool based on a validated survey implemented in the United Kingdom. An initial survey aimed at assessing tumor board structure and design was sent to 21 TB leaders, and subsequently a tumor board quality assessment survey was sent to 175 participants throughout an academic and community network. The quality assessment survey required participants to identify an answer on a 5-point Likert scale in the categories of "very poor, poor, average, good, and very good". Results: TB leaders representing 16 of 21 (response rate 76%) TBs responded to the structure/design survey. Twelve TBs were from the academic center and included diseases such as Gynecologic Oncology, Cutaneous Oncology, Genitourinary Oncology, and Sarcoma, while four were from community sites. TB leaders indicated that 55% of TBs did not receive CME credit and 60% did not document their recommendations. One hundred eleven TB participants of 175 (response rate 63%) responded to the quality assessment survey. Participants identified the following strengths: 1) all relevant subspecialties present for meetings, 2) respectful teamwork and culture, and 3) operating on an organized agenda. Areas for improvement included: 1) inconsistent tumor board recommendation documentation and 2) post-meeting coordination of care. Results were reviewed with network and cancer center leadership as well as with the Cancer Committee. Conclusions: We assessed our own tumor boards across our cancer network by utilizing an adapted version of a validated TB performance measurement tool for the first time in the United States. Through this assessment we identified key areas for improvement including the need for obtaining CME credit for TB attendance, and developed a policy, process, and template for documenting TB recommendations in an easily accessible centralized location.
Development of a financial navigation program to ease the burden of financial toxicity.
Authors: Monak Melissa , Rodgers Georgina T. , Bell Kimberly , Whitt Antoinette , Gamble Shontia , Jones Laron , Mason Tamara , Lewis Ni'Ema
Published: September 2018

124

Background: Due to the rising cost of cancer care, even well-insured patients are at risk for financial toxicity. Cancer treatment costs can be challenging for patients and families because of increasing deductibles, increasing premiums and frequent co-payments. At Cleveland Clinic Cancer Centers, our goal is to identify patients at risk for financial distress and help ease the financial stress and hardship associated with cancer care. Methods: The Financial Navigator (FN) role was created in 2016 to complete benefits investigations to determine covered services and minimize the patient’s out of pocket expenses. We are participants in the Oncology Care Model and are expected to provide and document the estimated out-of-pocket costs in the patient’s medical record. Navigators conduct telephone outreach calls with treatment patients to educate them on their benefits. The FN also assists with applications on copay assistance and free drug options. Finally, the FN will connect patients with resources for premium assistance and household expenses when copay assistance isn’t an option. The FN team has grown to 7 FTE’s since 2016. Results: Since 2016 the dollar amount approved through copay assistance applications has increased by 65%, the free drug value received increased by 62%, and YTD 2018 data shows that we have surpassed all of 2017 in what we collected towards patient out of pockets from copay assistance programs. We have also been able to comply with the out of pocket expense metric for OCM, not only for our Medicare patients, but for all of our treatment patients and compliance has risen from 44% in December 2017 to 98% in April 2018. Conclusions: In conclusion our Navigators have built relationships with Social Workers, Care Coordinators, and community services that are available to patients. This added benefit helps patients with non-medical financial stressors. The team can connect patients to organizations that can assist with household utilities, childcare concerns, food concerns, and mortgages. Utilization of the FN role has helped the healthcare team and patients to identify ways to mitigate the costs of care and distress related to financial concerns.
Chemotherapy wait times in a network of pediatric oncology clinics.
Authors: Russo Carolyn Lucille , Morgan Jennifer , Elsaid Mohamed
Published: September 2018

127

Background: Optimizing care delivery is a satisfier for patients and providers alike. Inadequate clinic flow may also drive up costs, as staff are more likely to utilize overtime hours. We noted in our network of outpatient pediatric oncology clinics that the lowest scores in patient satisfaction surveys were the category of waiting time in the chemotherapy area. We aimed to reduce wait time in the chemotherapy area for patients receiving outpatient, lab-dependent, intravenous push chemotherapy by 5% within 9 months. Methods: A team consisting of a nurse team leader and core members (physician, nurse and pharmacist) from affiliate clinics in 3 states (AL, MO, OK) obtained baseline data over 2 weeks. Data included 1) patient arrival time, 2) lab collection time, 3) lab result time, 4) chemotherapy order time, 5) chemotherapy delivery time to clinic, 6) chemotherapy administration time. Each clinic created their individual process map and cause/effect diagram. Additional measures collected were patient satisfaction scores, parent and staff surveys before and after the intervention. Each clinic site met weekly and the network of the 3 clinics met monthly to review all results. Using the baseline data, each clinic identified points in care where interventions could reduce chemotherapy wait time based on reviewing their own and other clinics’ data. Interventions included moving lab collection earlier in the visit, additional pharmacy staff to deliver chemotherapy and placing an electronic monitor to alert providers when lab resulted. Results: Within 4 months of the interventions all sites had a reduction in chemotherapy wait times (Site A 144m-pre, 134m-post; Site B 163m-pre, 140m-post; Site C 137m-pre, 116m-post). Parent and staff surveys are in process. Conclusions: Each clinic was able to reduce chemotherapy times using different interventions depending on their internal process, moreover each clinic learned how to improve from each other’s processes.
Creating value: Institution of outpatient infusional EPOCH-based chemotherapy at a safety-net hospital.
Authors: Gupta Arjun , Hon Mary C. , Keshvani Neil , Marley Eileen M. , Johnson David H. , Sadeghi Navid , Li Hsiao Ching
Published: September 2018

128

Background: EPOCH-based chemotherapy regimens are traditionally administered inpatient because they include a continuous 96-hour infusion. These admissions are costly, and disruptive to patients’ lives. We transitioned EPOCH-based chemotherapy regimens to an ambulatory infusion model at our safety-net hospital (Parkland Health and Hospital System, Dallas, TX), where patients visit the infusion center daily for 5 days. Methods: Guidelines for chemotherapy administration and educational materials were developed through a multidisciplinary collaboration with physicians, nursing, and pharmacy. Data were collected through chart review and the finance department. Project costs included purchase of portable infusion pumps and increasing outpatient infusion clinic capacity. Patient satisfaction with home infusions compared to hospitalization was measured on a Likert-type scale via direct-to-patient survey. Results: From 1/30/2017 through 1/30/2018, a total of 87 cycles of EPOCH-based chemotherapy were administered to 23 unique patients. 61 (70%) of these cycles were administered in the outpatient setting to 18 unique patients. There was a 58% reduction in drug costs in the outpatient setting due to lower drug acquisition cost. An estimated 336 days of hospital stay were avoided. There were no inappropriate prophylactic antimicrobial prescriptions and daily blood draws in the outpatient setting. 88% of survey responders reported > 3 (scale, 1 to 5) on a Likert-type scale for both overall experience with home infusions, and likelihood they would use home infusions again. No chemotherapy spills or extravasation occurred; 1 cycle was complicated by pump failure where chemotherapy was given at a slower rate than intended. Conclusions: Multiday EPOCH-based regimens were successfully and safely administered in an ambulatory setting at our safety net urban hospital. Patients reported satisfaction with the experience, and received less unnecessary interventions in the outpatient setting. Significant cost savings from avoided hospitalization and decreased drug acquisition cost were demonstrated.
Navigation models in diverse outpatient settings: Shared themes, challenges, and opportunities.
Authors: Greenwood Narcessa Gail-Rosales , Taniguchi Cynthia B. , Sheldrick Amy , Hurley Leslie
Published: September 2018

134

Background: Navigation has been recognized by the Centers for Medicare and Medicaid Services (CMS) as a component of quality oncology care. This discussion highlights progress of Nurse Navigation implementation within 3 US Oncology Network practices. A team-based approach optimizing patient care coordination and providing enhanced services has been identified. Study practices demonstrate common navigation goals and desired outcomes, despite variations in practice size, dissimilar workflows, and unclear best-practice guidelines for navigation in the outpatient setting. Methods: The US Oncology Network formed a committee to study and develop evidence-based nurse navigation processes for recommendation to the greater Network. The committee includes 6 members, each a lead Oncology Nurse Navigator, practicing in different US geographical regions. Preliminary steps were to seek evidence-based support through: Existing models for Oncology Nurse Navigation that are adaptable for the community setting Best-practice in navigation recommendations from esteemed professional organizations Challenges and solutions identified and implemented Scope of practice for the Nurse Navigator in a community setting Performance metrics targeting effective, value-driven navigation Results: Focusing on scientific Nursing Process, study practices provided navigation services to 3762 patients. Gaps in navigation processes were identified, as well as barriers throughout the continuum of care. Scope of Practice for the community-based Nurse Navigator was defined. Navigation framework was established to include patient/family education, psychosocial interventions, referral outsourcing, and patient advocacy. A formal job description was created for the role of the Oncology Nurse Navigator. The Interdisciplinary Care Team Conference Standard was finalized to support coordination of care. Conclusions: Work remains to define, implement, and test effective navigational models to support challenges of patients receiving care in the outpatient setting. Benefits resulting from Nurse Navigation processes are emerging as healthcare trends advance quality of care while decreasing total cost of care.
A physical assessment tool to evaluate functional status compared to ECOG scores in cancer outpatients.
Authors: Crandell Catherine Elizabeth , Quinn Sarah Elizabeth , Wingard Christopher Jon , Imel Reid , Penney Jarek , Swartz Kevin , Weiss Jessica , Wilson Joshua , Flynn Joseph M. , Hamm John Turner
Published: September 2018

135

Background: Individuals with cancer may experience loss of function, disability and fatigue. There is interest in team-based functional and physical assessment as part of a comprehensive oncology care plan. The Bellarmine Norton Assessment Tool (BNAT) was developed to provide an objective physical assessment tool for interprofessional use. The purpose of this study was to evaluate the BNAT and correlate its outcomes with ECOG scores across groups diagnosed with pancreatic (P), breast (B) and lung (L) cancers. Methods: The BNAT was developed by the Bellarmine University Physical Therapy Program utilizing validated physical assessment tests. It consists of 1 subjective question about physical activity frequency followed by 4 objective tests: 2-Minute Step Test (2MST), 30 Sec Sit-to-Stand, Timed Arm Curl (TAC) and Timed Up and Go. The ECOG was administered by attending oncologists during the same visit as BNAT testing. 18 participants were identified 6 in each of the diagnosis groups from a recruitment cohort of 57. The avg. age for P was 68.8±9 yrs 4♀,2♂; B 71.5±15.8 yrs 6♀; L 65.0±12.4 yrs 3♀,3♂. Results: The combined mean ± SD ECOG score was 1.2±1.0 (range 0-3) while the combined BNAT score was 15.4±6.5 (range 7-29). Mean BNAT score by diagnosis: P 16.6±7.4; B 13.0±5.5; & L 18.3±5.7. Spearman correlation analysis of BNAT and ECOG scores revealed a significant (p = 0.0001) negative correlation of agreement (r = -0.79). Both B and L cancers had significant (p < 0.05) correlation of agreement (B r = -0.71 & L r = -0.88). TAC correlation to ECOG was strongest in L group (r = -0.86), but 2MST was strongest for P group (r = -0.62). There was a reciprocal relationship of slopes between TAC and 2MST based on diagnosis. L steepest slope in TAC (-6.2 with deviation from 0, p = 0.014) while P had steepest slope with 2MST (-13.1). Slope for B group consistently fell between the 2 other diagnoses. Conclusions: There was a strong linear relationship of BNAT, TAC & 2MST to ECOG scores across the 3 cohorts of diagnoses. The BNAT subcomponents have varying degrees of contribution to the total that can be attributed to diagnosis-related functional deficits, thus giving providers information to determine appropriate care.
Identifying delays in care for patients with NSCLC using value-stream mapping.
Authors: Cummings Chad W. , Habecker Becky , Tullio Katherine , Rothacker Andrew , Pennell Nathan A. , Videtic Gregory M.M. , Raymond Daniel , Mazzone Peter J. , Ibsen Alison
Published: September 2018

136

Background: Value-Stream Mapping (VSM) was employed to evaluate non-value added activities focused on minimizing time between pathological diagnosis and first treatment (Time-To-Treat or TTT). Objective is to identify unnecessary delays in care for NSLC patients treated at a large academic medical center. Methods: A total of 253 patient records were examined between 1/15/2015 and 7/19/2016 and divided into stages: Stage I (Non-Surgical), Stage I-II (Surgical), Stage III, and Stage IV. Selection criteria required a min. of 50 patients/stage, including internally and externally diagnosed patients. A VSM was developed for each stage. Spreadsheets were used to detail dates and sequences of events, including consults, E&M visits, imaging, procedures, and testing. Results: Overall TTT results by stage (median days) are as follows: Stage I (Non-Surgical) = 46 days (n = 55), Stage I-II (Surgical) = 35 days, n = 50), Stage III = 34 days (n = 71), Stage IV = 19 days (n = 77). Consults were reviewed among 4 specialties (Med/Onc, Rad/Onc, Surgical, Pulmonary), revealing Pulmonary Consults most common regardless of stage, 38%, 40%, 49%, 29%, respectively. It was found consults among specialties were rarely coordinated (stage III: 11/70 patients had consults same day between 2 specialties). Bronchoscopy procedures were most common method of Dx; sampling (n = 60, all stages) revealed MD orders are placed within 1 median day for each stage (15% ≥ 5days), but lead time to procedure ranged 7-12 median days depending on stage. Comorbidities for surgical patients (n = 46) were reviewed and found TTT delays correlates with number of comorbidities and FEV1 test results. Interventions included weekly, multi-disciplinary identification and review of patients across the 4 specialties, development of a TTT visual dashboard, and creation of communication standards across specialties. Conclusions: A VSM will identify areas where excessive delays occur. Opportunities exist to combine activities (same-day appointments/consults), reduce delays between activities, and/or improve communication. Decision-making can be accelerated when time between events (consults, staging, procedures, and tests) is minimized, regardless of diagnosis origin.
Optimizing the use of trimethoprim-sulfamethoxazole for prevention of PCP and opportunistic infections in allogeneic hematopoietic cell transplant recipients.
Authors: Baneman Emily , Kim Nina , Rana Meenakshi , Renteria Anne Sigrid , Steinberg Amir S. , Jakubowski Rita M. , Yum Kendra , Saunders Patricia , Jacobs Samantha
Published: September 2018

138

Background: Trimethoprim-sulfamethoxazole (TMP-SMX) is preferred for prevention of Pneumocystis pneumonia (PCP), toxoplasmosis and other opportunistic infections after allogeneic hematopoietic cell transplantation (HCT), but it is often withheld due to potential adverse events (AE). From July 2016-June 2017 we observed that 31% of allogeneic HCT recipients at our hospital were prescribed TMP-SMX throughout the high risk period (day +30-180). Therefore, we developed an intervention to explore reasons for such a low prescription rate and to optimize TMP-SMX use. Methods: Our institution’s HCT practice guidelines were revised to include indications for TMP-SMX and alternative agents for PCP and Toxoplasma prophylaxis and specific clinical and laboratory criteria for withholding TMP-SMX. Education on the guidelines was provided to transplant clinicians. Outpatient encounters were prospectively audited from January to April 2018. Providers received real-time feedback with recommendations in accordance with our guidelines prior to patients’ visits. Results: We reviewed 321 outpatient encounters among 112 patients. Seventy-six (68%) patients were on TMP-SMX prophylaxis at the first reviewed encounter. Cytopenias were the most common reason for withholding TMP-SMX, occurring in 50 (57%) encounters, followed by elevated liver function tests (LFTs) (13.6%), hyperkalemia (3.4%), elevated creatinine (3.4%), rash or hypersensitivity (3.4%), and unknown/other (22%) . In 73 encounters in which patients received alternative or no PCP prophylaxis, we recommended changing to TMP-SMX. This intervention was accepted in 15 patients, 11(73%) of whom tolerated TMP-SMX well. In the remaining four patients, TMP-SMX was subsequently discontinued due to unrelated AE (N = 3) and possible TMP-SMX-associated elevated LFTs (N = 1). Conclusions: Provider education and real-time feedback led to increased utilization of TMP-SMX for prevention of PCP and other opportunistic infections in HCT recipients without an increase in TMP-SMX-related adverse effects. Further study is needed to understand the low clinician acceptance rate of the intervention.
Strategies supporting reduced hospitalization rates in a successful OCM practice.
Authors: Mendenhall Molly , Sheldrick Amy , Dyehouse Karyn M. , Guinigundo Andrew S , Waterhouse David Michael
Published: September 2018

139

Background: Team-based implementation of care is a foundational tenant to reducing avoidable ER visits and hospitalizations. This care strategy supports the OCM mission of improving quality and reducing cost through practice transformation. Methods: Comprehensive care team: Physician, Advanced Practice Provider, Nurse Navigator, Financial Navigator, Phone Triage Nurse; Consistent Message: “Call Us Early – Call Us First” campaign. Verbal and written instructions at all staff member touch points, emphasizing patient responsibility to call before going to the hospital; Supporting infrastructure: 2-hour teaching visit with the entire care team prior to all new treatments; Triage Phone Unit, COME HOME (Barbara McAneny, M.D.) triage pathways – 38 symptom and 27 symptom f/u pathways modified; Blocked time-slots at all offices for same-day APP triage appts; Proactive ER and hosp f/u calls. Results: 2017 phone triage data: 9,841 total symptoms calls. 2,476 same day visits. 338 ER saves. 67 ER f/u calls (Nov/Dec 17’ only). OCM pt survey scores improved and internal Netpromoter scores remained stable. Conclusions: A comprehensive team-based patient navigation strategy, supported by consistent “Call Us First” messaging, symptom pathways and same-day patient access, resulted in decreased hospitalization without commensurate increases in ER visits or 24hr observation stays. Pt satisfaction was not impacted negatively. [Table: see text]
Assessing the appropriate utilization of the palliative care service by the Carol and Ray Neag Comprehensive Cancer Center at UConn Health.
Authors: Stoute Trena , Loschiavo Sarah , Hook Karen
Published: September 2018

144

Background: The American Society of Clinical Oncology recommends initiation of palliative care concurrently with active treatment within 8 weeks of advanced cancer diagnoses. We studied the referral practice in our institution. Methods: We reviewed charts of all outpatients seen between June and November 2017 with a diagnosis of leukemia or breast, thoracic, head and neck, pancreas, and prostate malignancies. Data collection included: diagnosis, stage, age, race, gender, deceased/alive, lines of therapy, referral to palliative care, time to referral, reason for referral, time from referral to death, referring provider, inpatient/outpatient, follow up visits, hospitalizations, time from chemotherapy to death, referral for services, social worker referral, and insurance type. Patients with incomplete records were excluded. Fisher’s exact test and Wilcoxon rank-sum test were used to compare groups. Results: Of the 174 eligible patients, 49 (28%) were referred to Palliative Care. Only 22% of patients were referred within 8 weeks of diagnosis. The most common reason for referral was pain management; with the least common being goals of care. Women were more likely to be referred than men, 38% vs 22% (p = 0.035). The mean [SD] age was 63.9[14.7] years. By stage, 96% of patients had stage IV disease and the only stage III patients were those with lung cancer. Amongst stage IV cancers, breast and lung cancer had the highest referral rate, each 50%, with prostate cancer having the lowest at 5% (p < 0.001); despite prostate cancer being the most common diagnosis. There were more referrals to hospice (24% vs 6%; p = 0.002) and home palliative care (16% vs 1%; p < 0.001) in the group referred. The mean [SD] time (weeks) from last chemotherapy to death was shorter in the group referred 6.51[4.19] vs. 16.3 [11.29] (p = 0.037). There was no difference in referral rates to home care (p = 0.192), based on insurance type (p = 0.683) or race (p = 0.647). Conclusions: Referral rates in this analysis did not achieve the recommended guideline standards. Additional educational interventions are planned to identify and overcome barriers to referral.
Cancer survivorship care plans time and effort.
Authors: Begnoche Megan , Higel-Mcgovern Camille , Szymanski Tara , Korber Susan F. , Fenton Mary Anne
Published: September 2018

146

Background: The Lifespan Cancer Institute (LCI) is one program based at three hospitals in the Lifespan healthcare system, a main teaching affiliate of Brown Medical School. All sites are ASCO QOPI certified. In 2017, 1,742 patients from radiation, surgical, and medical oncology were diagnosed and/or treated for cancer. The Commission on Cancer guidelines specify patients with a new diagnosis of cancer treated with curative intent receive a survivorship care plan (SCP) within one year of diagnosis extended to 18 months for those receiving hormone therapy. Methods: The LCI Quality team is a multidisciplinary group comprised of nursing, leadership, physicians, midlevel providers, administrative assistants, and tumor registry staff. Our Quality Improvement Project for 2017 was generation and distribution of survivorship care plans to 50% of eligible patients. Our project underwent 5 plan/do/study/act cycles (PDSA). Prior to the intervention only 271 care plans were prepared and delivered for 2016 diagnoses. Results: For the total 2017 diagnoses, 843 eligible patients were treated within the LCI (medical and radiation oncology). Survivorship Care plans completed by midlevel providers were generated and distributed to 100% of LCI patients during January -April 2018 (244 in total), a 37% increase compared to the same timeframe, one year previous. The electronic medical record provides tools for SCP preparation including auto population of demographics and chemotherapy plan. Staging, radiation, and surgery are manually entered. On average, each SCP required 1 hour to complete for approximately 244 hours of midlevel provider time for January -April 2018. This abstract’s time and effort does not include the time for patient calls, survivorship visits or administrative monitoring. Conclusions: Survivorship care plans provide patients and primary care providers a summary of the treatment plan and recommendations for follow up/survivorship goals in transitions of care. Significant time and effort is required to generate an individual SCP therefore the goal should be to increase electronic efficiencies within the medical record, and focus on the clinically relevant patient population who are most likely to survive 5 years and be impacted by diagnosis and treatment.
Implementation of a regional structure across an oncology collaborative quality initiative and the impact on physician engagement.
Authors: Beusterien Samkeliso , Bedard Louise , Griggs Jennifer J.
Published: September 2018

149

Background: The Michigan Oncology Quality Consortium (MOQC) is a statewide collaborative quality initiative (CQI) sponsored by Blue Cross/Blue Shield of Michigan. The consortium uses Quality Oncology Practice Initiative (QOPI) measures to identify gaps in care and opportunities to improve quality. Data are collected on patients regardless of payer. MOQC includes nearly 90% of eligible medical oncologists (n = 364) in Michigan. We describe physician engagement within MOQC and quality improvement efforts after implementation of a regional structure in the CQI. Methods: The MOQC regional structure was introduced in Spring 2017. Forty-eight practices self-selected into 6 regions roughly by geographic location. Beginning in Spring 2017, a physician from each practice was required to attend both the Spring and Fall Regional Meetings and encouraged to bring an additional representative (e.g. administrative leader) from their practice. Regional meetings were facilitated by the MOQC Coordinating Center. Within each region, practices selected to work on one measure from a finite set of QOPI measures. and shared best practices gleaned from their quality improvement work, according to the Plan-Do-Study-Act cycle of quality improvement. We report on our primary outcome, the change in physician engagement, defined as attendance at biannual MOQC meetings (distinct from the Regional Meetings), before and after the introduction of the regional structure. Results: Provider engagement, measured by attendance at the biannual meetings increased from an average of 17.3 physicians in the 3 years before the introduction of the regional structure, to 33 physicians in the first meeting, and 22 physicians in the second meeting after the introduction of the regional structure. Conclusions: Implementation of a regional structure increased provider engagement, and provided a systematic approach to the launching of quality improvement efforts in an oncology CQI. Engaging providers at the regional level, which incorporates cultural aspects of geographically similar practices, may provide opportunities not otherwise recognized in larger consortia.
Pharmacy contributions to improving care and sustaining change in a comprehensive cancer center.
Authors: Brown Megan , Crosby David L. , Howe Megan H. , Dragnev Konstantin H.
Published: September 2018

150

Background: Delivery of care in an outpatient hematology/oncology clinic is complex and requires the coordination of numerous services for timely and efficient treatment of patients. The Norris Cotton Cancer Center in Lebanon, NH, began a comprehensive assessment of clinic and infusion operations in 2012 and developed a system-wide initiative to address inconsistent performance in infusion, clinic and pharmacy services. Methods: Cancer center staff and leadership were trained on lean six-sigma methodology to initiate system-wide improvements through targeted project work. We collaborated with quality improvement experts and our analytics team to obtain and analyze data from our EMR. Then we established process measures for all operational areas and a key performance indicator (KPI) for hem/onc infusion: “on time performance.” The pharmacy contributed to on-time performance by focusing improvement initiatives on turn-around time (TAT) for clinical reviews and order verification, TAT for drug preparation, and initiating a process for pre-making chemotherapy. Results: "On-time performance” was initially defined as the percentage of patients whose first medication began within 45 minutes of their scheduled infusion start time. The baseline of 63% in 2012 was improved to 86% in 2018. Through sustained process improvement work and concerted efforts to further improve the patient experience and utilization of resources, an interdisciplinary team targeted a 15 minute on-time performance measurement; this baseline of 28% was improved to 47% in less than a year. In 2012 the pharmacy set a goal of reviewing and verifying orders within 30 minutes, and completing drug preparation within 45 minutes of order verification. The baseline percentage of orders reviewed within 30 minutes was 47% and this increased to 93% in 2018. Our baseline percentage of doses prepared within 45 minutes was 37% and the current median time for drug preparation across all orders is 45 minutes. The pharmacy currently pre-makes approximately 11% of doses. Conclusions: The cancer center pharmacy increased efficiency and improved on-time performance in delivery of care by using data-driven continuous improvement methods.
Design and implementation of a predictive risk model to improve oncology patient management.
Authors: Young Garrett , Church Whitney , Roper Ashley , Hoy Tiffany
Published: September 2018

154

Background: Methods to identify cancer patients that are likely to seek inpatient care for conditions that can be treated in the outpatient setting are not well defined. In light of the rise in value-based care programs, there is increased pressure on oncology providers to decrease costs of care while continuing to achieve high-quality outcomes. One way this can be achieved is by decreasing avoidable, high-cost utilization through population management. We sought to investigate the feasibility of creating a model to predict which patients were more likely to utilize emergency department (ED) and inpatient hospital (IP) services as well as the impact such a model may have on patient management. Methods: For a sample of 1093 patients, historical information was gathered across four domains: Cancer-specific Attributes, Comorbidity Burden, Social Factors, and Utilization History. This data set was then used to design a predictive model which assigned a numerical “acuity” score to each patient. Patients were ranked by numerical score, and their subsequent ED and IP utilization was measured. The developed model was then tested on an independent set of 591 patients to assess broader validity. After development, the predictive model was built into a tool for use in patient management by a team of nurse care managers. Results: Of the 100 highest-ranking patients in the training sample, 29% had at least one future hospitalization and 33% had at least one future ED visit, compared to 13% and 19% in the entire sample, respectively. In the validation sample, 11% of the 100 highest-ranking patients had at least one future hospitalization and 20% had at least one future ED visit, compared to 5% and 13% in the entire sample, respectively. Before model deployment, an average of 39 follow-up touchpoints were completed for high-risk patients per month. In the 6 months after deployment, the average rose to 171 touchpoints per month, an increase of 335%. Conclusions: Models can be developed to proactively identify cancer patients at higher risk of utilizing ED and inpatient hospital services. Implementation of such a model can also increase targeted outreach and communication with patients at greater risk of utilizing high-cost services.
Standardizing and optimizing institutional-level documentation in the electronic medical record era.
Authors: Moreno Amy Catherine , Choi Seungtaek , Colbert Lauren Elizabeth , Farooqi Ahsan , Umberson Katie , Korah Bobby , Herman Joseph M.
Published: September 2018

155

Background: Although electronic medical records (EMR) offer numerous potential benefits, there are significant challenges to balance high quality patient care and clinical efficiency with the rising demands of required documentation. Our objective was to propose and implement a strategy to standardize and optimize EMR documentation. Methods: An EMR taskforce was created within our institution’s radiation oncology (RO) department consisting of representatives of the clinical staff and EMR coders. To optimize clinical documentation, disease-site specific consult templates were created using EMR standard data elements and personalized drop down menus (Smartlists). Meetings were held with the billing department for template review and with the analytics team to begin automated data extraction into research databases. Quality metrics such as the average number of clinic visits billed at levels 4 or 5 (B45) and the average number of hours per visit (AHV) were compared in different clinics within a 6-month pre- and post- template implementation time period. Results: Within 3 months of establishing the taskforce, 32 RO disease-specific templates were created and distributed for usage in clinic. Optimized template features include consistent cancer staging, standardized oncologic history entry, usage of macros for patients’ symptoms for multiple provider verification, imbedded disease-specific protocol list to improve patient screening and enrollment, and multiple Smartlists for common treatment recommendations. In the GI Clinic, B45 increased from 49.3 to 61.4 per month and similar trends were seen in the Thoracic Clinic (B45, 51.4 to 85.2 per month). The AHV decreased in both the GI (21 to 10 hours) and Thoracic (22 to 13 hours) clinics, showing a significant added value to use of standard documentation. Conclusions: EMR systems can be challenging to navigate; however, they also present a unique opportunity to optimize clinical and research efficiency if used properly. The implementation of standard documentation in our department led to significant improvement in clinical efficiency. Further efforts are being made to adopt these changes on an institutional-wide level.
Role of effective care plans in reducing admissions for sickle cell patients.
Authors: Ahmed Bilawal , Day Tami , Hirner Cara , Trendle Michael , Heidt Jonathan , Singh Sindhu
Published: September 2018

156

Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization’s ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management and a reduction in hospital admissions. Methods: Baseline data collected from November 2014 through December 2016 indicated that 108 SCD patients accounted for 195 inpatient hospital admissions, and 40% of all 30-day readmissions for the Hematology-Oncology service line. Further, the average length of stay for patients admitted for SCD crisis was 6.8 days per stay. Medical Director, Oncology Unit Manager, and Performance Improvement Professional collaborated with the ED Medical Director and representatives to develop a disease-specific acute care plan for our adult SCD patient population. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets in within the organization’s electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement in the 30-day readmission rate among the SCD patient population, from 40% to 3%. Further, use the SCD care plans helped reduce the average length of stay for patients admitted with SCD crisis from 6.8 days to 3 days. More importantly, we have been able to sustain this improvement over time. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans are key to reducing ED and hospital utilization among patients with SCD, and reducing the average length of stay for SCD patients who require hospitalization for disease management.
Methods for alerting clinicians to concerning symptom questionnaire responses during cancer care: Approaches from two randomized trials (STAR, AFT-39 PRO-TECT).
Authors: Stover Angela M. , Henson Sydney , Deal Allison Mary , Stricker Carrie Tompkins , Hammelef Karen Joan , Bennett Antonia Vickery , Carr Philip M , Jansen Jennifer , Kottschade Lisa A. , Dueck Amylou C. , Basch Ethan M.
Published: September 2018

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Background: There is limited research on methods for alerting clinicians to concerning patient-reported outcome (PRO) responses and how often PROs trigger alerts to nurses during cancer care. Methods: In two randomized trials, adults with advanced cancer receiving chemotherapy were enrolled. Participants were randomized to usual care vs. weekly PROs completed between visits (with automated feedback to nurses). PRO responses in the intervention arm triggered automated email alerts to nurses for frequent, severe, or worsening symptoms in the last 7 days. Alert thresholds for PROs were chosen a priori but were unique to each study. The “Symptom Tracking and Reporting” (STAR) trial was conducted at one academic medical center. The “PROs to Enhance Cancer Treatment” (PRO-TECT [AFT-39]) cluster-randomized trial is being conducted in > 30 community practices. Results: In STAR, 766 patients participated (58% female, 38% ages ≥65, 17% minority, 28% ≤high school). 441 participants were randomized to the intervention arm, where 1,431/84,212 items (2%) triggered a concerning symptom alert, during 1,070/8,498 weeks (13%). Frequent alerts were for fatigue (62%), pain (32%), and appetite (16%). In PRO-TECT (AFT-39), 300 patients have been enrolled (58% female, 49% ages ≥65, 8% minority, 47% ≤high school) out of 1,000. 146 participants have been randomized to the intervention arm, where 1,422/24,739 items (6%) triggered an alert, during 824/2249 weeks (37%). Common alerts were for pain (48%), physical function (35%), and diarrhea (15%). PRO-TECT provided clinical decision support with alerts. Conclusions: In two randomized trials in advanced cancer, PROs collected during care delivery enabled tailored treatment based on issues identified on PROs. Pain, physical function, appetite, and diarrhea commonly triggered alerts for concerning symptoms. Early PRO-TECT results are showing a trend for higher weekly alert rates for concerning symptoms (37% vs. 13% in STAR), which may indicate that the PRO intervention will be even more effective in community practices. Results assist in addressing logistical considerations for implementing PROs into routine care. Clinical trial information: NCT03249090.
Choice of radioactive iodine treatment for thyroid cancer: Results from a population-based survey.
Authors: Wallner Lauren P. , Reyes-Gastelum David , Hamilton Ann S , Ward Kevin C. , Hawley Sarah T. , Haymart Megan Rist
Published: September 2018

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Background: For many patients with differentiated thyroid cancer, use of radioactive iodine (RAI) does not improve survival or reduce recurrence risks. Yet, most patients continue to receive RAI suggesting the need for a better understanding of patient perspectives regarding RAI decision making. Methods: All eligible sequentially diagnosed patients with thyroid cancer in 2014-15 from the Georgia and Los Angeles SEER registries were surveyed (N = 2097, current response rate: 63%). Patients with intermediate risk thyroid cancer where selective RAI use is recommended were included in this analysis (N = 1357). Patients were asked whether or not they felt they had a choice to receive RAI (yes/no), how strongly their physician recommended initial RAI treatment (5 point Likert responses: Strongly against RAI--Strongly recommended RAI), whether they received RAI (yes/no), how satisfied they were with their RAI decision (5-pt Likert-type scale), categorized as more (score ≥4) vs. less satisfied. Multivariable logistic regression was used to assess 1) association between patient characteristics and perception of no RAI choice, 2) perception of no RAI choice with receipt of RAI and 3) perception of no RAI choice with decision satisfaction. Results: In this sample,over half (57%) of the respondents perceived they did not have a RAI choice, and the majority of them (76%) received RAI. The odds of perceiving no RAI choice was greater among Hispanic and Asian patients (Hispanic OR: 1.4, 95%CI: 1.0, 1.9, Asian OR: 1.9, 95%CI: 1.2, 2.9), and those whose physician strongly recommended RAI (OR: 1.9, 95%CI: 1.4, 2.6). Patients who perceived they did not have a RAI choice were more likely to receive RAI (Adjusted OR: 3.2, 95%CI: 2.1, 4.9) and report lower decision satisfaction (Adjusted OR: 2.7, 95%CI: 1.9, 3.7). Conclusions: Many patients in whom selective RAI use is recommended, particularly those of more vulnerable groups, did not feel they had a choice about whether or not to receive RAI. Patients who perceived they did not have a RAI choice were more likely to receive RAI and report lower decision satisfaction, suggesting a need for more shared treatment decision making to reduce overtreatment.
Essential elements of caregiver support in gynecologic oncology.
Authors: Hand Lauren , Campbell Grace , Hagan Teresa , Lee Young Ji , Belcher Sarah M. , Roberge Mary , Donovan Heidi AS
Published: September 2018

160

Background: Caregivers are instrumental to the health and well-being of gynecologic cancer patients and can be deeply affected by the demands of caregiving. Our aims were to increase awareness of the unmet needs of family caregivers of women with gynecologic cancers and provide recommendations for essential elements of support needed by caregivers to ensure that family caregivers are recognized and supported as key members of the patients’ care teams. Methods: Over the course of a year, a 16-person steering committee and 40 stakeholders, including caregivers, patients, and clinicians, participated in a modified Delphi approach to assemble, review and prioritize a set of essential elements for caregiver support. The process culminated in a multi-disciplinary research roundtable. Stakeholders prioritized caregiver needs and discussed, brainstormed and prioritized essential support services necessary to meet those needs, using three rounds of consensus-building activities. Basic descriptive statistics were performed to feed means and rankings back to stakeholders prior to each round. Results: Stakeholders prioritized the top three needs of caregivers as: 1) to obtain information about their loved one’s cancer (M = 4.18, SD = 4.33), 2) how to provide support and comfort to their loved one (M = 3.18, SD = 3.92) and 3) how to maintain their own emotional health and well-being (M = 2.94, SD = 3.90). Fifteen Essential Elements of Support to address the needs of caregivers of women with gynecologic cancers were identified. These ranged from supports that are immediately actionable (e.g., information for the caregiver on managing the patient’s symptoms, skilled-care training, a point-person to help navigate the system) to more aspirational supports (e.g., integrative services focused on the health and well-being of the caregiver). Conclusions: Caregivers are an integral part of cancer care, though their needs are inconsistently addressed by the care team. In order to provide comprehensive quality care, clinicians and healthcare systems should strive to provide caregivers with the Essential Elements of Support identified in this study and continue to build a healthcare system incorporating caregivers’ needs.