bluuebunny/crossref_metadata_2025 huggingface dataset:
Recommendations for improving digital health literacy in patients with cancer receiving care in the Deep South.
Authors: Hildreth Keyonsis , Henderson Nicole , Bourne Garrett , Azuero Andres , Chu Daniel I , Caston Nicole E. , Dent D'Ambra , Hardy Claudia M. , Herring Loretta , Ingram Stacey A. , McGowen Chelsea , Young Pierce Jennifer , Williams Courtney , Rocque Gabrielle Betty
Published: October 2023

202

Background: As technological advances are developed and implemented in healthcare, cancer patients with low digital health literacy may be at increased risk of health inequities. This study explored recommendations for improving digital health literacy related to electronic patient-reported outcome (ePRO) based remote symptom monitoring (RSM). Methods: This qualitative study, conducted December 2021-May 2023, included (1) patients with cancer and oncology providers from University of Alabama at Birmingham and University of South Alabama Mitchell Cancer Institute participating in RSM, and (2) community health workers (CHWs) who serve communities experiencing care access barriers across Alabama. Semi-structured interviews were conducted via phone, Zoom, or in-person. Recordings were transcribed and inductively content coded using Nvivo software for recurring themes and exemplary quotes by two independent coders. Results: Patients with cancer (n=19), providers (n=15), and community health workers (n=13) participated. Among patients and providers participating in RSM, recommendations included additional tech-focused training opportunities and in-person tech guidance. CHWs expanded upon this with four key recommendations involving provider-facing interventions. The first was to engage in communication-focused interventions that encourage use of lay language, developing cultural competency among providers, and “meeting patients where they are,” because as one CHW explained “if you don't actually understand the actual language, then you're never going to be able to really understand what's going on with your health.” A second recommendation was to focus on individual and community needs, such as lobbying to bring Wi-Fi to rural locations and developing subsidized cost programs for individuals who need them. CHWs then highlighted the existence of community partnerships and technology-focused training programs that largely go underutilized by local populations. Further developing these partnerships would also serve to emphasize the connection to the local community and legitimization of digital healthcare services. Finally, CHWs encouraged providers to emphasize to patients that technology in healthcare is a tool to facilitator greater connection and communication between patients and providers and that there is a “face behind the screen.” Conclusions: This study identifies key recommendations on how to address digital health literacy gaps and communicate the importance of the technologization of the American healthcare system to local communities in Alabama.
Transportation assistance in gynecologic oncology: A pilot study.
Authors: Smith Anna Jo Bodurtha , Powell Kristina , Doherty Meredith , Hinkle Stefanie , Bekelman Justin E. , Simpkins Fiona , Ko Emily Meichun
Published: October 2023

206

Background: Patients who experience transportation barriers to cancer care are less likely to receive optimal treatment and more likely to have delays in care. Our objective was to assess the prevalence of transportation barriers and the impact of a transportation intervention in gynecologic cancer care. Methods: We prospectively screen patients seen at new visits and at clinical trial enrollment in the 5 University of Pennsylvania gynecologic oncology practices for transportation barriers to cancer care. Patients who screen positive are referred to the intervention program, a ride-sharing service through RideHealth. Rides are available to and from clinic visits, to and from chemotherapy or radiation sessions, or to surgical procedures. There are no income or insurance restrictions on transportation assistance; per federal regulation, patients had to live within 40 miles of their oncology practice to receive transportation. Results: From June 2022 to April 2023, 1200 patients were screened. Of these, 34 screened positive for transportation barriers. All of those who screened positive accepted ride-sharing services. Two patients who screened positive were not eligible for ridesharing as they lived greater than 40 miles from our practices. Two patients who screened positive had transportation benefits available through their health insurance and were redirected to those services. We have provided 193 rides for 30 identified patients. The average length of ride was 9.2 miles (range 2.4-14), and the average cost per month was $1,200. Evaluation of clinical impact is ongoing. Conclusions: Transportation assistance is highly acceptable to patients and can facilitate access to cancer care.
Patient perspectives of the quality of preoperative education in surgical cancer care.
Authors: Jones Bayley A , Pisu Maria , Smith Burkely , Schoenberger Yu-Mei , Wang Lingling , Ivankova Nataliya V. , Richman Joshua , Chu Daniel I
Published: October 2023

207

Background: Preoperative education is an important component of surgical cancer care that has been shown to impact surgical outcomes. However, the quality of education varies, especially among patients with low health literacy (HL), which is prevalent among states in the Deep South. Low HL patients experience worse surgical outcomes, and variation in preoperative education further increases the disparity gap for this vulnerable patient population. We aimed to characterize patient perspectives of preoperative education by HL level among gastrointestinal cancer patients in the Deep South. Methods: Surveys were administered to colorectal, pancreatic, and esophageal cancer survivors in Alabama and Mississippi. Eligible participants had stage 1-3 cancer, were within 5 years of diagnosis, and had surgery as part of their cancer care. Participants were also administered the BRIEF survey, which is a validated four question survey measuring HL level. Patients with a score of 17 or higher were categorized as having adequate HL, while a score of 16 or less were categorized as having low HL. Fisher Exact or Chi Square tests were performed to examine significant differences between patients with low and adequate HL. Results: Of 272 survey respondents, the mean age was 63.17 (±11.57) and 151 (55.5%) were women. 92 (33.8%) had low HL and 174 (64.0%) had adequate HL. Compared to patients with adequate HL, patients with low HL reported lower rates of a health care provider in the surgeon’s clinic definitely giving them all the information needed about their surgery (80.9% versus 90.1%, p=0.07) and lower rates of their surgeon or other provider definitely talking to them about what to expect for surgery and recovery (76.4% versus 89.0%, p=0.03, respectively). Low and adequate HL patients reported similar rates of receiving instructions about getting ready for surgery (88.6% and 90.1%, p=0.66). However, 88.3% of low HL patients reported these instructions were easy to understand compared to 97.4% for adequate HL patients (p=0.001). Low and adequate HL patients reported similar rates of visual aids used during education (76.1% versus 78.2%, p=0.54, respectively), with low HL patients reporting slightly lower use of flyers/pamphlets with pictures (58.7% versus 60.3%, p=0.79) and drawings (40.2% versus 42.5%, p=0.72); similar use of models (9.8% versus 9.2%, p=0.86); and less frequent use of videos (7.6% versus 10.9%, p=0.39). Conclusions: Patient-reported disparities in preoperative education exist among surgical cancer patients with low health literacy. 1 in 5 patients with low HL did not think they received enough information prior to surgery and the information they received was difficult to understand. Overall, there was a low use of visual aids among this patient population. Future directions should aim to improve the quality of education for low HL, incorporating the use of visual aids.
Assessing the effectiveness of a learning collaborative to build capacity for community-based cancer survivorship navigation.
Authors: Hamlish Tamara , Holzman Castellands Talia , Papautsky Elizabeth Lerner , Hughes M. Courtney , Gonzales Elaine D
Published: October 2023

213

Background: Community-based patient navigation has emerged as a highly effective strategy to increase cancer screening and early diagnosis, particularly for underserved populations. This navigation typically ends at diagnosis, when patients transition to clinical care. However, clinical navigation offers limited assistance to connect survivors with a broad range of community resources and support services. Community-based survivorship navigators have the potential to bridge this gap. We implemented a virtual learning collaborative (VLC) to build community capacity to deliver breast cancer survivorship navigation. Our research assesses the impact of the VLC on participants' behaviors, self-efficacy, and barriers to navigation. Methods: We conducted an analysis of data from the Breast Cancer Survivorship Patient Navigator Virtual Learning Collaborative (VLC), a 14-week practice-based training for community health workers and patient navigators to address the needs of breast cancer survivors. Weekly 60-minute virtual learning sessions included a brief didactic, followed by participants’ presentation of de-identified client cases. A 27-item pre-post survey was used to assess changes in behaviors, self-efficacy, and barriers to navigation. Results: A total of 40 participants completed both the pre- and post-surveys. Participants were predominantly female (98%), White (55%) or Black (30%), and non-Hispanic (68%). The majority were affiliated with community-based organizations (50%), as well as health departments (19%), and hospitals/cancer centers (19%) serving urban (50%) and suburban (33%) communities. Survey results indicate an average increase of 24% in self-efficacy, with the greatest increase in ability to serve as a consultant to others on cancer survivorship (38%), link survivors to appropriate resources and services (32%), explain how clinical trials work (32%), and work with survivors to address their needs (32%). Reductions in barriers to navigation included limited knowledge of cancer and cancer treatment (33%) and awareness of survivorship resources and services (34%). We found no change in behaviors or other barriers to navigation. Conclusions: The results of this study indicate the effectiveness of the VLC to build community-based capacity to deliver breast cancer survivorship navigation through increased navigator self-efficacy. No changes in behaviors suggests that navigators provide survivorship support whether or not they have training, and points to a key opportunity to increase their knowledge of evidence-based information and resources. Results of this research provide evidence to support recognition of the critical role of community navigators and reimbursement to ensure high quality, consistent community-based care for cancer survivors.
Availability of family caregiver support in U.S. cancer centers.
Authors: Odom James Nicholas , Applebaum Allison J , Bakitas Marie , Bryant Tara , Currie Erin , Curry Kayleigh , Donovan Heidi AS , Fernandez Maria , Ferrell Betty R. , Gray Tamryn , Hendricks Bailey , Meier Diane E. , Nightingale Chandylen L , Reinhard Susan , Sannes Timothy S. , Sterba Katherine R. , Young Heather
Published: October 2023

218

Background: Family caregivers provide the majority of health care to the 18 million persons with cancer in the U.S. Yet despite providing complex medical and nursing care, a large proportion report no formal support or training. Recognizing this gap, many interventions to support cancer caregivers have been developed and tested over the past two decades and many have demonstrated effectiveness. However, there is little system-level data on whether U.S. cancer centers have adopted and implemented these interventions. We conducted the first national survey of Commission on Cancer (CoC)-accredited U.S. cancer centers to characterize the availability and types of family caregiver support programs. Methods: We conducted a mail and web-based survey of staff from CoC-accredited U.S. cancer centers regarding their family caregiver support programs (09/2021-03/2023). “Family caregiver programs” were defined as structured, planned, coordinated groups of activities and procedures aimed specifically at supporting family caregivers as part of usual care. Survey questions about 11 types of family caregiver programs (e.g., peer-mentoring, education classes, psychosocial programs) were developed after literature review, assessment of similar program evaluation surveys, and discussions among a 13-member national expert advisory committee. Results: Surveys were sent to potential respondents at 971 adult cancer centers and 238 were completed (response rate: 25%). Most cancer centers had at least 1 family caregiver program (178/238, 75.1%), which was most commonly “Information and Referral Services” (53.4%). Cancer centers with no programs were more likely to have smaller annual outpatient volumes (p<.05). Few centers had caregiver programs on: training in medical and/or nursing tasks (21.8%), caregiver self-care (20.3%), caregiver-specific distress screening (19.3%), peer mentoring (18.5%), and minor children caregiving for a parent (8.4%). Very few programs were developed from published evidence in a journal (7.9%). The top reason why cancer centers chose their programs was community members requesting the program (26.5%); only 11.8% chose their programs based on scientific evidence. Most programs were funded by the cancer center or hospital (58.0%) or by philanthropy (42.4%). Conclusions: While most U.S. cancer centers had some family caregiver programs, a quarter had none. Furthermore, the scope of programming was limited and rarely evidence-based, with few centers offering caregiver education and training. Implementation strategies are critically needed to foster uptake of evidence-based caregiver interventions.
Understanding the unique needs of African American/Black caregivers.
Authors: Cannady Rachel , Beckwitt Asher , Prince Sabiyha , Maxwell Danielle
Published: October 2023

220

Background: A lack of culturally responsive resources, systemic bias in the healthcare system, and a lack of understanding of culture means African American/Black (AAB) caregivers can face additional barriers to providing care. To address this enormous gap, the American Cancer Society (ACS) is leading the charge in the way support is delivered to AAB caregivers through qualitative inquiry to better understand their unique needs and challenges. Methods: Six focus groups with AAB caregivers (n=32) were conducted using the Zoom online platform to assess a) their perceptions of providing care to a person with cancer, b) their unmet needs, and c) their preferences for how best to meet their needs. NVivo 12 was used to store, code, query, and organize the data. Deductive codes were derived based on the research questions for the study. Data was also inductively coded to identify the categories and themes that emerged that did not fit into the research questions. Results: Participants were mostly female (90%), ≥ 55 years old (64%), employed full time (54%), and providing care to their mother with cancer (42%). The primary unmet need was related to their relationship with their loved one’s healthcare providers. Major themes identified: negative healthcare system perceptions, racism and discrimination, limited access to medication due to cost, provider insensitivity and dismissiveness, medical mistrust, and lack of informational resources. Caregivers highlighted the desire for timely information from the provider about the cancer diagnosis to better assist with treatment decisions. Early navigator involvement was also requested to assist them in advocating for the patient’s needs as well as their own. Conclusions: Caregivers are a critical part of the healthcare team. Providers should strive to deliver culturally competent care that acknowledges and respects the experiences, values, and beliefs of AAB caregivers. Themes that emerged from this study were used to develop topics for a 6-part ECHO Series aimed to address AAB caregiver needs at the system level. ACS will leverage these findings to develop information and resources targeted to AAB caregivers.
Engaging patient-family dyads to inform the development of a digital health intervention to support cancer caregivers.
Authors: Pozzar Rachel A. , Gray Tamryn , Underhill-Blazey Meghan , Nayak Manan , Ehrlich Olga , Haas Niina Mari , Enzinger Andrea Catherine , Hammer Marilyn J. , Berry Donna Lynn
Published: October 2023

221

Background: Shifts in cancer care from hospital to home have increased the burden on family caregivers of individuals with cancer. Cancer caregiving is demanding and associated with declines in caregivers’ physical and psychological well-being. Digital health interventions may improve caregiver well-being by supporting them to monitor patient symptoms, access social support, and communicate with patients’ care team members. Despite benefits to quality care, few digital health interventions have been developed or implemented to support cancer caregivers. The purpose of this study was to develop a web-based intervention (myCare2) focused on supporting caregivers and caregiver well-being. Methods: This multi-method study followed a user-centered design. Participants were recruited from two clinics within one NCI-designated cancer center. We conducted three focus groups with patients with hematologic or gastrointestinal cancers and their caregivers to identify needs and preferences and guide intervention development. Next, we developed a wireframe prototype of myCare2. We iteratively refined the prototype in response to feedback obtained in cognitive interviews with patient-caregiver dyads. Lastly, we built a functioning web-based prototype and conducted user tests with dyads. Focus groups, cognitive interviews, and user tests were audio recorded, transcribed, and analyzed using conventional content analysis. Results: Eight dyads participated in three focus groups. Caregivers reported feeling unprepared and viewed themselves as “head of logistics” for the patient. Caregivers expressed the desire for a tool to help them organize caregiver responsibilities, including medication management, daily schedules and appointments, symptom monitoring, nursing and medical tasks, self-care, and communication with clinicians and support networks. In cognitive interviews, four dyads reviewed and provided positive feedback on the wireframe prototype features that allow the caregiver to schedule tasks; report patient and caregiver concerns; track patient symptoms and medications; ask family and friends for support; share updates with support networks; and find local resources, classes, and events. Five dyads tested myCare2, providing positive and constructive feedback about the intervention layout and functionality. Conclusions: Growing evidence suggests digital health interventions can benefit caregivers managing cancer care at home. The myCare2 intervention is a web-based tool based on caregiver and patient feedback that was found helpful and acceptable. Future research should evaluate the feasibility of myCare2, measure its effects on caregiver and patient outcomes, and identify optimal implementation strategies for use in practice.
Cancer and asset inheritance at the end of life in the United States.
Authors: Hussaini S. M. Qasim , Rodarte Cecilia , Nicholas Lauren H.
Published: October 2023

225

Background: The cost of medical care in the United States is among the highest in the world and has risen in recent decades with trends toward greater cost-sharing from payors and higher out-of-pocket costs for individuals diagnosed with cancer. It is unclear if high healthcare expenses can also have a significant impact on the accumulation of wealth across generations, as families struggle to pay for medical care and may not have the financial resources to pass as inheritance or bequests. In this study, we investigated trends in asset inheritance following the death of a primary household member from cancer. Methods: We conducted a retrospective analysis of deaths among respondents in the Health and Retirement Study (HRS) through 2014. The HRS is a nationally representative, biennial and longitudinal survey of adults 50 and older and their spouses collected since 1992. We compared remaining estate size and familial bequests among those who died from cancer versus other causes of death using post-mortem interviews with next-of-kin proxy respondents. Results: Our sample included 10,196 deaths (mean age 78y) including 2752 cancer-related deaths (27.0%). Compared to those that died from non-cancer causes, those dying from cancer had higher OOP costs for doctor visits ($1244 vs $785; p < 0.05), and more often had not paid medical expenses (16.2% vs 9.7%; p < 0.05). Similar trends were noted for individuals that had a lifetime diagnosis of cancer. Higher rates of will completion were seen in patients with a history of cancer as well (p < 0.01). While higher homeownership at death was noted in this group compared to those without a history of cancer, those dying from cancer were less likely to sell their home or pass it as inheritance to a child, grandchild, or spouse. Unmarried/unpartnered respondents dying from cancer were also more likely to have reduced estate assets. Conclusions: We noted a striking loss of inheritance transfer resulting in reduced accumulation of generational wealth following death from cancer, or from a history of cancer in a household in the United States. These represent troubling findings and should inform an urgent need to prioritize policy-level solutions to reduce cost burden of receiving required care.
The impact of hospice on end-of-life expenditures and total cost of care in episodic value-based care models at a community oncology network.
Authors: Sharma Gunjan , Deepak Divya , Neeb Jessica , Garey Jody S. , Thomas Hope Ives , Mills Lydia , Payne-De Bock Judi , Wilfong Lalan S. , Indurlal Puneeth
Published: October 2023

228

Background: The Institute of Medicine highlighted that multiple care transitions and fragmented care delivery at the end-of-life (EOL) is a burden to patients and caregivers. Hospice care has been shown to deliver high-quality, coordinated, and comprehensive EOL care while reducing unneeded healthcare interventions and improving EOL patient experience (preference of place of death, type of EOL care). The impact of timely hospice care on Total Cost of Care (TCOC) in episodic value-based care (VBC) models and patient experience at the EOL is largely unknown. The Oncology Care Model (OCM) was a 6-year long Medicare VBC program that encouraged care transformation at Oncology practices to drive better quality of care and patient experience, while decreasing TCOC. We studied the impact of timely hospice enrollment on TCOC, EOL expenditures, and patient experience. Methods: We obtained episode level data for patients who died in an episode (decedents) during the 6-years of the OCM (July 2016 to June 2022), for 15 practices in The US Oncology Network (The Network) participating in the OCM, along with several expenditure, clinical and episodic characteristics. We evaluated utilization and experience outcomes for episodes with and without hospice. Results: Of the 26,074 decedents during the 6-year period of the OCM, 55% were enrolled in hospice for 3 or more days (Hsp), and 45% were not enrolled or enrolled in hospice for less than 3 days (NoHsp). Mean TCOC for Hsp episodes ($41,297, n = 14,240) was significantly lower (Mann Whitney U test, p-value < 0.0001, significance level = 0.01) than NoHsp ($47,601, n = 11,834) episodes. TCOC comparison by expense cohort results are provided in Table 1. Median duration of hospice for Hsp episodes was 9 days. Mean ICU and inpatient spend in last 30 days of life in NoHsp group was more than 2 times the spend in Hsp group. 44% of patients in NoHsp group died in a hospital or an ICU setting, whereas 97% of patients in Hsp group died at home or in a hospice setting. Conclusions: Patients enrolled in hospice for 3 or more days had lower EOL care expenditures, fewer acute care interventions, and died at home or in hospice. Timely and proactive enrollment in hospice and coordinated EOL care can improve patient experience, but also reduce EOL costs for the healthcare system and patients. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.[Table: see text]
Impacts of an outpatient palliative care team on the end-of-life care at a cancer center in Brazil.
Authors: Gomes Sarah Ananda , Silva Danielle , Bergerot Cristiane Decat , Sorice Flavia , Barreto Arantes Alexandra , Passarini Thais , Alvarenga Petrocchi Julia , de Paula Marcela , Melo Andreia Cristina De , Jácome Alexandre A. , Ferrari Bruno Lemos
Published: October 2023

231

Background: It has been demonstrated. that early palliative care improves the quality of life of cancer patients by reducing overtreatment at the end-of-life (EoL) and improving symptomatic control. However, there is a lack of research on the impact of palliative care on the EoL outcomes in developing countries. EoL cancer care varies widely and very few centers evaluate it systematically. Studies suggest that people often prefer dying at home, however, data also shows that most deaths in Latin America occur at hospitals. Methods: This study aimed to analyze the impact of cancer patients’ follow-up by an outpatient palliative care team (OPCT) on the EoL outcomes at a private Multicentric Cancer Center in Brazil. Data were retrospectively retrieved from electronic medical records of patients who were treated at a Brazilian Cancer Center and who died between January 2022 and December 2022. Adults with any type of cancer were considered eligible. The participants were divided into two groups: the OPCT group was followed up by a palliative care multidisciplinary team who regularly evaluated cancer patients during their treatments in an outpatient setting and the No-OPCT group followed up by oncologists with multidisciplinary teams as demanded. Univariate comparisons and multivariate analysis adjusted to the multivariate logistic regression model were performed and p<0.05 was deemed as statistically significant. Results: A total of 1980 patients were included in the study: OPCT (N=640) and No-OPCT (N=1340). Most of the patients in both groups were older than 65 years (61% vs 66%). The groups were well balanced concerning gender (women: 54% vs 46%), and TNM stage (stage IV: 87% vs 89%). Gastrointestinal and breast cancers were the most prevalent in both groups. The rate of home death was 20.2% in the OPCT group, compared to 10.6% in the No-OPCT group, meaning a 2 times greater chance of dying at home when the OPCT was provided (p<0.001). In multivariate analysis, follow-up by the OPCT was the strongest independent predictor of home death. Age, gender, and TNM stage did not influence the place of death. Conclusions: The current study suggests that an active palliative care program in an outpatient care institution, through early conversations about goals of care, prognostic awareness, and EoL preferences may potentially improve the EoL outcomes for patients with cancer, while also reinforcing the need of early referral for a palliative care team. Future studies and ongoing prospective studies in Brazil are needed to validate these findings and also to evaluate the impact of other variables, such as health support systems for home deaths.
Exploring factors and trends in place of death by cancer: A population-based study in Brazil.
Authors: Gomes Sarah Ananda , Da Silva Jesse Lopes , Moura Lívia Machado , de Albuquerque Lucas Zanetti , de Oliveira Livia Costa , Thuler Luiz Claudio Santos , de Melo Andréia Cristina
Published: October 2023

237

Background: Place of death serves as an indicator of the quality of end-of-life care. This study seeks to elucidate the place of deaths by cancer in Brazil, also identifying factors contributing to regional disparities in end-of-life settings. Methods: Using data obtained from the National Mortality Information System, this study extracted sociodemographic characteristics and the location of cancer deaths in Brazil from 2012 to 2021. The place of death was classified into hospital death, home death, and other settings (not shown). Results: A total of 2.165.643 deaths by cancer were included. Almost half of the cases were from Southeast (47.4%), while 22.0% were from Northeast, 19.0% from South and the minority from Central-west (6.5%) and North (5.0%) regions; remarkably, 73.3% of deaths occurred out of capitals. A downward trend was observed from 2012 to 2021 with a Relative Percent Difference (RPD) of -4,0. The frequency of deaths occurring at home in the Northeast region (26.6%) was found to be higher than the reference region, the Southeast (10.6%), RPD -22.2. Furthermore, Indigenous individuals showed a higher frequency of death at home (25.4%) compared to White ethnicity (14.2%), RPD -18.4. A clear inverse relation between in-hospital deaths and aging can be noted, as more at-home deaths are observed in the elderly (17.8%) compared to the young group (4.1%). Conclusions: Most cancer deaths in Brazil occur in hospitals. Death at home is related to pronounced regional differences, being higher in the North and Northeast, and may be related to advanced age, race and educational level.[Table: see text]
Economic burden in patients (pt) with CLL/SLL (CLL) who received ≥ 2 prior lines of therapy (LOT), including a Bruton tyrosine kinase inhibitor (BTKi): A SEER-Medicare analysis.
Authors: Awan Farrukh Tauseef , Yande Soham , Esterberg Lizzi , Nagar Saurabh P. , Goyal Ravi K. , Priyadarshini Masoom
Published: October 2023

24

Background: In third-line or later (3L+) CLL, there is no standard of care after failure of oral-targeted treatments (tx) (eg, BTKi, B-cell lymphoma 2 inhibitor [BCL2i]). There is limited real-world evidence on tx received and economic burden among pts with advanced CLL. Therefore, this study assessed tx patterns, health care resource utilization (HCRU), and costs in 3L+ Medicare-enrolled pts with CLL who received prior BTKi. Methods: A retrospective study was conducted using SEER data from 2010 to 2017 linked to Medicare claims data through 12/31/2019. Eligible pts had a CLL diagnosis, were ≥ 66 y of age at diagnosis, received ≥ 2 prior LOTs, including a BTKi, and initiated a subsequent LOT. Index date was defined as start of 3L+ tx after discontinuation of prior LOT containing a BTKi. Pts were continuously enrolled in Medicare parts A, B, and D ≥ 6 mo before and ≥ 1 mo after index date. Baseline pt characteristics, HCRU, and associated health care costs in the postindex period were summarized descriptively. HCRU and costs (adjusted to 2019 US dollars) were reported as mean CLL-related and all-cause per pt per month (PPPM). Results: Among 98 eligible pts with post-BTKi 3L+ CLL, mean age was 78 y; 54.1% were male. Pts had a median of 2 prior LOTs with median postindex follow-up of 12 mo. Mean Charlson Comorbidity Index score was 2.8. The top 3 index LOT txs received were chemotherapy with anti-CD20 monoclonal antibodies (mAb [19.4%]), anti-CD20 mAb monotherapy (19.4%), and BCL2i monotherapy (14.3%). In the postindex period, 90.8% of pts had ≥ 1 office visit; 63.3% had ≥ 1 inpatient admission with a mean length of stay of 7.6 d. All-cause mean PPPM HCRU was 2.3 office visits, 1.8 hospital outpatient visits, 0.02 skilled nursing facility (SNF) visits, 1.6 ancillary care visits, 0.2 emergency room (ER) visits, and 0.2 inpatient admissions. Total all-cause mean (standard deviation [SD]) PPPM cost was $12,679 ($15,123). The main drivers of total all-cause PPPM cost were inpatient admissions ($4891) followed by drugs ($4379), hospital outpatient ($2338), office visits ($412), ancillary care ($412), SNF ($140), and ER ($26). CLL-related HCRU and costs are shown in the Table. CLL-related PPPM costs accounted for 83% of total all-cause costs with a mean (SD) of $10,501 ($14,052). Conclusions: Our study demonstrated that Medicare-enrolled pts with 3L+ CLL who received prior BTKi experienced high economic burden (mean monthly cost of $12,679). Inpatient admissions and drugs were the largest cost drivers. Considering the survival in this population (median OS of 33.1 mo; Awan et al. Blood 2022), the lifetime economic burden to Medicare could be significant. [Table: see text]
Effect of removing an oncologist-directed behavioral nudge on sustaining rates of serious illness conversations: An interrupted time series analysis.
Authors: O'Keefe Ryan M , Wileyto E. Paul , Gabriel Peter Edward , Blumenthal Daniel , Tejada Sharon , Beidas Rinad S , Schnoll Robert , Bekelman Justin E. , Parikh Ravi Bharat , Takvorian Samuel U
Published: October 2023

242

Background: Behavorial economic nudges are increasingly used in oncology settings to encourage evidence-based practices, such as serious illness conversations (SIC). Prior work demonstrated the effectiveness of an oncologist-directed nudge identifying patients at high risk of 180-day mortality, which led to a 3-fold increase in SIC documentation. It is unknown whether such nudges must continue indefinitely to sustain effective behavior change, or whether clinician behavior change would persist in their absence. The objective of this analysis was to examine the effect of removing an oncologist-directed nudge on overall SIC rates. Methods: From 2019 to 2022, clinicians within our institution received a nudge consisting of weekly performance feedback on SIC completion and opt-out text messages identifying patients at high-risk of 180-day mortality based on a validated machine-learning algorithm. In March 2022, at the conclusion of clinical trial NCT04867850, this program ended. For this analysis, the population included adult patients seen by a medical oncologist at one of 11 practices between Sept 2021 and Sept 2022. Patient encounters with an SIC documented in the previous year were excluded, as well as those occurring during a washout period (March-April 2022). SICs were attributed to an encounter if documented within 30 days. The primary outcome was the number of SICs documented per 1000 patient encounters. We used linear probability models and an interrupted time series analysis at the patient-encounter level to analyze the association between nudge cessation and SIC rates. All analyses were unadjusted. Results: 111,459 encounters were included in the final analysis (56.9% prior to nudge cessation). Demographic data showed mean age 64.16 (SD 13.29), 57.02% female, 75.25% non-Hispanic white, 61.88% Medicare. There were 1,517 unique encounters with an SIC documented within 30 days (1.36%), with 1,030 pre-cessation (1.62%) and 487 post-cessation (1.01%). Rates of SICs were 15.3 per 1000 encounters in February 2022 (pre-cessation) vs. 9.7 in May 2022 (post-cessation), representing a 37% decline (Table). Unadjusted interrupted time series analyses showed a significant decrease in documented SICs per 1000 encounters (odds ratio 0.64, 95% CI 0.57 - 0.71). Conclusions: Removal of a clinician nudge was associated with a significant decline in SIC rates, suggesting a lack of sustained clinician behavior change without an ongoing behavioral nudge. Because nudges may be required indefinitely to promote evidence-based practices such as SICs, their design should be minimally intrusive and easily adaptable to evolving care standards. Adjusted analyses, marginal effects analysis, and time-to-event analyses are in progress.[Table: see text]
Simultaneous care clinic: A mono-institutional experience at an ESMO designated center for palliative care.
Authors: Stragliotto Silvia , Gallio Ivan , Cambi Caroline , Lo Mauro Leda , Moretto Valentina , Lorusso Marina , Scelzi Elvira , Ahcene-Djaballah Selma , Roma Anna , Frezzini Simona , Nardi Mariateresa , Feltrin Alessandra , Pasalic Mirsad , Salmaso Flavia , Gottardi Michele , Saieva Anna Maria , Formaglio Fabio , Zagonel Vittorina , Lonardi Sara
Published: October 2023

254

Background: Early palliative care has been shown to improve patient (pts) and caregiver satisfaction, symptom control, quality of end-of-life care, cost and in some cases survival in pts with advanced cancer. In accordance with ASCO, ESMO and AIOM guidelines a Simultaneous Care Clinic (SCC) was set up at Veneto Institute of Oncology (IOV) since 2014. In the Castelfranco Branch of the IOV, SCC started in January 2022. Methods: Data from all consecutive outpatient patients seen in SCC were retrieved from a prospectively maintained database.Data collected included cancer type, status of disease, performance status (PS), ongoing oncological treatment, nutritional evaluation, social evaluation, psychological evaluation, activation of home territorial and/or palliative care services,use of other health services after a first visit and place of death. At the first visit pts were evaluated with validated tools for symptom identification, Edmonton Symptom Assessment (ESAS), distress thermometer, Malnutrition Universal Screening Toll (MUST). Results: From January to December 2022seventy-four pts were evaluated by a multidisciplinary team and re-evaluated 2 months later in terms of improvement or stabilization of symptoms, appropriateness of intervention and outcome. All patients had a metastatic disease and were in active oncological treatment. The median age was 73 y and the most prevalent disease type was gastrointestinal cancers (48%). The median time from first SCC visit to death was 3.8 months; 32 pts are still alive. At the first visit symptom management measures were adopted. The median score for the distress thermometer was 5 with higher prevalence of physical problem. A higher prevalence on 7-10 ESAS score (26% of the pts) was found for pain, fatigue and lack of appetite. At the second visit, an improvement was observed: the median score for the distress thermometer was 4 and ESAS score was 7-10 in 18% of the pts. At first SCC visit, patients deemed in need of home care services were 17 (23%) and for these a formal request for Home Care services activation was sent to the Local Health Territorial Unit (Distretto ULSS). Conclusions: The SCC multidisciplinary assessment represents an organizational model effective in granting a global management of needs with the aim of improving the therapeutic path for patients and their caregivers.
Palliative prognostic index in end-of-life cancer care: A comparative study of different cut-off scores.
Authors: Elfaituri Muhammed Khaled , Khaled Ala , Faraj Hazem , Msherghi Ahmed
Published: October 2023

258

Background: Accurate prognostication of survival in terminally ill cancer patients, particularly those with a life expectancy of less than three weeks, is critical to palliative care. It facilitates tailored care and enhances communication with patients and their families. The Palliative Prognostic Index (PPI) is a commonly used approach. However, a comprehensive examination of PPI's utility and predictive accuracy remains largely unexplored, particularly at different cut-off scores, compared to other prognostic tests. This study aims to determine and compare the predictive utility of PPI (at cut-off scores >4, >5, and >6) in estimating survival of less than three weeks in terminally ill cancer patients. Methods: A systematic search of MEDLINE, Embase, and Cochrane databases was conducted until November 2022, focusing on studies evaluating the predictive utility of PPI and other prognostic tests for cancer patients with a survival prognosis of less than three weeks. Statistical analyses were carried out using R software (version 4.0.3) and the mada package, enabling the aggregation of sensitivity, specificity, false-positive rate estimates, diagnostic odds ratio, and both positive and negative Likelihood Ratios (LRs). All outcomes are reported with a 95% Confidence Interval (CI) and I2 statistic to measure heterogeneity among the studies. Results: The meta-analysis included 16 studies with 9,839 patients. At a PPI cut-off score >4, the pooled sensitivity was 83.3% (95% CI: 79.6-86.5%, I2=78.1%), specificity was 58.5% (95% CI: 52.4-64.4%, I2=83.6%), false-positive rate was 41.5% (95% CI: 35.6-47.6%), diagnostic odds ratio was 7.04 (95% CI: 4.95-9.98), positive LR was 2.01 (95% CI: 1.73-2.34), and negative LR was 0.29 (95% CI: 0.23-0.36). At a PPI cut-off score >5, the pooled sensitivity decreased to 65.9% (95% CI: 54-76%, I2=96.2%), but specificity increased to 70.2% (95% CI: 57-80.7%, I2=97.3%), false-positive rate was 29.8% (95% CI: 19.3-43%), diagnostic odds ratio was 4.54 (95% CI: 2.13-9.71), positive LR was 2.21 (95% CI: 1.43-3.42), and negative LR was 0.49 (95% CI: 0.34-0.70). At a PPI cut-off score >6, the pooled sensitivity was 68.6% (95% CI: 58.4-77.2%, I2=95%), specificity increased further to 79% (95% CI: 72.1-84.6%, I2=95.1%), false-positive rate was 21% (95% CI: 15.4-27.9%), diagnostic odds ratio was 8.24 (95% CI: 4.61-14.71), positive LR was 3.27 (95% CI: 2.36-4.55), and negative LR was 0.39 (95% CI: 0.29-0.54). Conclusions: This study evaluated the predictive utility of varying Palliative Prognostic Index (PPI) cut-off scores for short-term survival in terminally ill cancer patients, suggesting a higher cut-off score (>6) optimizes specificity and reduces false positives. Our findings offer practical insights for healthcare providers in tailoring PPI score selection and underscore the need for further research in diverse settings and populations.
Patient-generated outcomes, questions and concerns: Quantitative and open text methods and relationships with palliative care referrals in advanced ovarian cancer.
Authors: Berry Donna Lynn , Wolpin Seth , Pike Kenneth , Cho Susie , Goff Barbara Ann
Published: October 2023

259

Background: Remotely entered patient-reported outcomes, questions and concerns in an open-text format offer opportunity for communication to providers. However, is there a benefit beyond quantitative questionnaire items? The electronic Self-Report Assessment and Care (eSAC) was implemented for patients with advanced ovarian cancer undergoing treatment in ambulatory care at a Pacific Northwest tertiary care medical center and was shown to increase rates of palliative care referrals. The purpose of this study was to analyze open text entries along with quantitative symptom and quality of life reports exploring content consistency between the two reporting methods and palliative care (PC) referrals. Methods: Adult patients with advanced or recurrent ovarian cancer were invited to participate after an in-person clinic visit and complete a baseline report. Participants were prompted to complete a report 5 days prior to every clinic visit. Following completion of web-based symptom and quality of life issues (SQI) questionnaires, participants selected the two most bothersome SQI from a list of their moderate-to-severe level (MSL) responses. Just after, the participants saw, “If there is anything else you would like to discuss, or any questions you have for your care team, please type them in the box below.” Any MSL response to pain and/or quality of life items triggered a note to the provider on the summary report, “Based on this patient’s responses, a palliative care referral is recommended.” The one-page report, including all quantitative item responses and the text entries, was hand-delivered to the provider at each clinic visit. Text entries were analyzed for consistency with the quantitative bothersome SQI and frequencies of PC referrals were calculated. Results: A total of 134 enrolled and of the 120 participants submitting at least one report, 57 (48%) reported symptoms or quality of life issues at the MSL and made 108 text entries during the study. In 26 (24%) of the text entries, participants further discussed the two most bothersome MSL, 35 (32%) addressed one MSL and 47 (44%) entries addressed completely different issues. For those who provided no text entries and triggered the PC recommendation, only 5/21 (24%) received a referral. Those who created text entries and triggered were referred in 17/33 (52%) cases. Conclusions: The inconsistency and uniqueness between quantitative and text entry approaches to assessing SQI suggest that both methods are necessary for a comprehensive patient-generated report. Communication beyond quantitative scores may prompt the consideration of a PC referral.
Comparative cost-effectiveness analysis of oral agents for advanced EGFR mutated and ALK-positive non-small cell lung cancer.
Authors: Edwards Dali , Gim Gahyun , Kyi Kaitlin , Patel Kushal , Patel Arpan
Published: October 2023

26

Background: The cost of lung cancer treatment and accessibility to the first-line oral targeted therapies is a growing concern worldwide. However, the cost-effectiveness of guideline-directed treatments is not well studied. The aim of this study was to evaluate cost-effectiveness of advanced epidermal growth factor receptor (EGFR) mutated and anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC). Methods: We calculated the cost of each targeted therapies based on the progress free survival and overall survival as shown in the major studies that led to the therapy approval. The cost-effectiveness of a treatment was measured by its incremental cost-effectiveness ratio (ICER). Lower ICER values indicate better cost-effectiveness, as they represent a lower cost per unit of health benefit. We evaluated the total costs, incremental ICERs and quality-adjusted life years (QALYs) associated with different treatment options. Results: The yearly-cost analysis revealed that Osimertinib, an oral agent targeting EGFR mutations, is the most expensive option. With a total cost of $222,044.10 per year, Osimertinib surpasses the cost of other oral agents, including erlotinib ($113,171.90) and Afatinib ($147,204.50). The ICERs indicate that Osimertinib has a higher ICER compared to other oral agents. Specifically, the ICER for Osimertinib versus erlotinib is calculated at $62,779.22. For each additional QALY gained, the cost of Osimertinib exceeds that of erlotinib by $62,779.22. Despite its higher cost, Osimertinib may offer a greater improvement in QALYs, making it a justifiable choice. In the context of ALK-positive NSCLC, Alectinib compared to Brigatinib, Lorlatinib and Crizotinib, as well as Brigatinib compared to Lorlatinib, and Lorlatinib compared to Crizotinib, are the drugs with lower ICER values, indicating better cost-effectiveness. Alectinib emerges as the most cost-effective oral agent, followed by Ceritinib. While Brigatinib and Lorlatinib are more expensive, they may provide a greater improvement in QALYs. Crizotinib is found to be the least cost-effective agent. Conclusions: The cost-effectiveness analysis presented in this study highlights the economic considerations associated with oral agents. The findings indicate the higher costs of Osimertinib and certain ALK inhibitors, which need to be weighed against the potential improvements in QALYs. By considering both costs and effectiveness, healthcare decision-makers can optimize treatment strategies, allocate resources efficiently and improve patient outcomes.