bluuebunny/crossref_metadata_2025 huggingface dataset:
Oncology quality improvement as a cornerstone of the transition to accountable care.
Authors: Ruckdeschel John C. , Sause William T. , Belnap Tom , Jones Cory , Rowley Braden D.
Published: February 2017

141

Background: Accountable care is defined as moving the incentives for health care from a system that rewards volume and procedures to one that rewards improvements in the quality of care for a defined population. To prevent this process from deteriorating into solely a cost reduction exercise, physicians, and hospitals need to develop a valid, reproducible, and effective means of measuring quality and impacting behavior to reduce variation and improve quality of care. The Intermountain Healthcare Oncology Clinical Program’s (OCP) experience with Oncology Quality Improvement (OQI) offers several key lessons for enabling this process. Methods: OQI initiatives are developed by a multidisciplinary physician-based team tasked with directing standardization and ensuring optimal care delivery. The team uses clinical knowledge, peer-reviewed literature, and data from an enterprise data warehouse to develop goals. Performance is measured against a goal which focuses on variation between physicians and facilities. Individual physician data is compared to de-identified data of peers, facilities, and the system. A physician champion performs academic detailing for physician groups across the system and is critical to the success of the program. Results: Over the past decade, the OCP initiated over 30 projects designed to measure and improve quality of oncology care delivery. Breast cancer projects included breast conservation in surgical management, reducing axillary dissection for ductal carcinoma in situ and sentinel node biopsy rather than axillary dissection. The OCP also explored standardizing lymph node resection during colorectal cancer surgery and subsequently the utilization of adjuvant chemotherapy. Imaging based goals included improving mammography callback rates and using PET/CT during preoperative assessment of lung cancer. In most instances the process resulted in significant, sustainable OQI. Conclusions: The investment in program and clinician staff is significant, and the requirements and costs for a sophisticated data system are real. However, an OQI program can provide meaningful improvements in the quality of cancer care and is an important step to facilitate the transition to accountable care.
Improving quality of early breast cancer care with a predictive test for taxane response.
Authors: Bodnar Carolyn , Brown Ruth , Knopf Kevin B.
Published: February 2017

146

Background: Patients (pts) with high-risk early breast cancer (BC) frequently have adjuvant taxane (TAX) treatment, but only 22% experience benefits in disease-free survival and many experience toxicities which impact quality of life (QoL) and increase costs. Research is underway to develop biomarkers which predict TAX response and hence identify pts who will benefit from the regimen and pts who will not, avoiding futile treatment and associated toxicities. Methods: A predictive economic model estimated the potential avoided toxicities and related costs of testing 100 BC pts with a biomarker to guide therapy selection compared to no pretesting. The no biomarker test group all received AC-T (AC-T) (doxorubicin 60mg/m2, cyclophosphamide 600mg/m2, followed by weekly paclitaxel 80mg/m2) for 12 weeks ($572). The model included rates and costs of 3 associated side effects (average $2024/patient): neutropenia (14%), thrombocytopenia (1%), and peripheral neuropathy (1%). In comparison, all pts were biomarker tested ($950) pre-treatment initiation and only those with biomarker overexpression were treated with AC-T versus AC, accruing the appropriate related costs plus the biomarker test cost. The model assumed the biomarker test was 70% to 90% predictive of expression. Results: The model found the biomarker group identified 55 to 70 non-expressing pts who would likely not have an increased benefit from the addition of TAX. For this group, 55% to 70% of the 3 AE toxicities and the associated impacts on QoL would be avoided producing $110,505 to $142,078 cost offsets. Between $25,792 and $60,304 of treatment expenditures could be avoided and better used. Budget neutrality occurred when neutropenia rates were reduced to 7%. The biomarker group identified 30–45 expressing pts who likely would benefit from AC-T. Conclusions: Applying a biomarker test to identify BC pts likely to respond to TAX may improve quality of care, particularly for non-expressers who could avoid QoL decrements of futile therapy and instead be managed with a less toxic and more beneficial therapy. Further development of such a biomarker should assess all pt impacts and healthcare system costs for both biomarker-identified expressers and non-expressers.
Systematic improvement of SBRT dose gradients.
Authors: Gagnon Patrick James , Weintraub Sheri , Scott Amanda , Schofield Deborah , Kumar Tushar , Mulvey Therese M.
Published: February 2017

154

Background: Stereotactic body radiation therapy (SBRT) offers excellent local control for early stage lung cancer. SBRT utilizes high fractional doses of radiation in 5 or fewer treatments. Normal tissue risk is substantial necessitating steep dose gradients and conformal plans. The Radiation Therapy Oncology Group (RTOG) has established quality metrics for conformality and dose gradients for SBRT. The conformality ratio is the prescription isodose volume to the planning target volume (PTV). Dose falloff is represented by the ratio of the 50% prescription isodose volume to PTV volume (R50%). We evaluated our approach and identified a systematic method to improve our SBRT plans in a community cancer center setting. Methods: 26 lung nodules were treated with SBRT over 30 months at our institution. RTOG 0915 benchmarks were evaluated. Conformality ratios were excellent in all cases. Dose falloff was measured by the R50% and the 7 cases with the largest R50% were re-planned systematically. The technique included creation of a customized ring structure: PTV volume was multiplied by the maximum allowable ratio to establish an ideal 50% isodose volume and a 2 cm ring structure was created around this: the 50 IDV Ring. Intensity modulated radiation therapy (IMRT) optimization specified a max dose to the 50 IDV Ring of 50% of the prescription. Beam geometry and IMRT objectives were held constant from the initial plan. Results: Conformality ratios were maintained and were excellent in all cases. The 50 IDV Ring resulted in R50% improvements in 5 of 7 cases, 4 of which had at least a 15% improvement (15%, 20.6%, 19.2%, and 20.4%) and 1 of which had a 3.3% improvement. Two cases resulted in 1.8% and 0.5% increases in the ratio representing a small deterioration in dose falloff. Conclusions: A strategically designed ring structure can have an impact on dose falloff around a target volume resulting in improvements in dose gradients for SBRT plans. Whether this benchmark is clinically significant is uncertain but it does provide a useful metric for comparison and quality assurance of SBRT plans. A systematic approach to SBRT planning may help provide the highest possible therapeutic ratio in the setting of optimal beam geometry.
Toward proven and prioritized quality measures: Which ASCO QOPI and other supportive care measures associate with improved quality of life (QOL)?
Authors: Kamal Arif , Bull Janet , Abernethy Amy Pickar
Published: February 2017

165

Background: An expanding array of quality measures, including the Quality Oncology Practice Initiative (QOPI) metrics, is being developed for oncology. To date, evidence demonstrating the impact of each metric on outcomes, ultimately aiding in prioritization of individual measures, remains immature. We investigated the relationship between conformance with quality measures and higher patient QOL among cancer patients receiving palliative care. Methods: A comprehensive systematic review of PUBMED and the gray literature (1995-2012) identifed all described supportive care quality measures. Patients receiving palliative care in 4 community-based programs were entered into a longitudinal quality registry; analyses focused on cancer patients registered between 6/08-10/11. To find predictors of higher QOL, conformance cohorts were examined for demographic variables, performance status (measured by palliative performance scale, PPS) and provider estimation of prognosis and included in univariate and multivariate regression. Results: The systematic review yielded 303 quality measures. Of these, 18 measures, representing components of the ASCO QOPI, Hospice PEACE, and Cancer-ASSIST measure sets, were evaluable using registry data. 460 cancer patients were included. 60% of patients had weeks to 6 months expected prognosis. Among QOPI measures, conformance with two measures was significantly associated with better QOL: constipation assessment at time of narcotic prescription and emotional well-being assessment (both p<0.05). Other significant findings were conformance with screening of symptoms at first visit (p=0.017), timely treatment for uncontrolled dyspnea (p=0.005), and assessment of fatigue (p=0.007). In a multivariate model predicting higher QOL, measures involving emotional well-being assessment (OR 1.60; p=0.026) and screening of symptoms (OR 1.74, p=0.008) remained significant. Conclusions: Clinical care that conforms to quality measures reflecting regular symptom and emotional assessment is significantly associated with better patient experiences (QOL) and should be prioritized in quality assessment efforts.
Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study.
Authors: Gilmore James W. , Peacock Nancy Walker , Gu Anna , Szabo Stephen , Rammage Melissa , Sharpe Joyce , Haislip Sally , Perry Toni S. , Boozan Tim Lee , Meador Katherine , Cao Xiting , Burke Thomas A.
Published: February 2017

167

Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p<0.0001), primary cancer site (p<0.0001), practice site (p<0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]
Guideline-concordant surveillance and follow-up care among low-income patients with breast cancer: The role of primary care medical homes.
Authors: Wheeler Stephanie B. , Kohler Racquel Elizabeth , Goyal Ravi K. , Lich Kristen Hassmiller , Moore Alexis , Smith Timothy , Melvin Cathy , Reeder-Hayes Katherine Elizabeth , Domino Marisa E.
Published: February 2017

171

Background: Community Care of North Carolina (CCNC) initiated an innovative medical home (MH) program in the 1990s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes, but has not been evaluated in the context of cancer care. We sought to determine whether MH enrollment was associated with guideline-concordant surveillance and follow-up care among breast cancer survivors. Methods: Using state cancer registry records matched to Medicaid claims, we identified women ages 18-64 diagnosed with stage 0, I, or II breast cancer from 2003-2007 and tracked their CCNC enrollment. Using published American Society for Clinical Oncology breast cancer survivorship guidelines to define our outcomes, we employed multivariate logistic regressions to examine correlates of receipt of surveillance mammogram and at least two physical exams within 15 months post-diagnosis. Results: In total, 840 women were included in our sample. Approximately half were enrolled in a CCNC MH during the study period, 38% were enrolled for more than 7 months post-diagnosis. Enrollment in a MH for at least 7 months post-diagnosis was strongly associated with receiving guideline-recommended surveillance mammogram (p<0.01) and at least 2 physical exams (p<0.01) within 15 months post-diagnosis. Conclusions: Results suggest that MH enrollment is associated with higher quality breast cancer survivorship care among women insured by Medicaid. Given the growing population of cancer survivors and increased emphasis on primary care MH, more research is needed to explore how medical homes can enhance and ensure the provision of guideline-recommended care during cancer survivorship.
Socioeconomic and clinical factors associated with delayed initiation of adjuvant chemotherapy for stage III colon cancer.
Authors: Haynes Alex Bernard , Chiang Y. Sabrina , Boland Genevieve Marie , Xing Yan , Massarweh Nader N. , Chang George J. , You Y. Nancy , Feig Barry W. , Cormier Janice N.
Published: February 2017

173

Background: We have previously described an association between a greater than 8-week interval to initiation of adjuvant chemotherapy after resection of stage III adenocarcinoma of the colon and an approximately 20% increased risk of mortality. We sought to understand the factors that lead to delay in chemotherapy initiation. Methods: Patients who received adjuvant chemotherapy after resection of stage III colon cancer between 2003 and 2007 were identified from the National Cancer Data Base. Delayed chemotherapy was defined as the first date of chemotherapy administration being eight weeks or more after surgical resection. Comorbidity was categorized using the Charlson/Deyo index. Prolonged length of stay and unplanned readmission were used as surrogates for surgical complications. Multivariate logistic regression was performed to examine the associations between various clinical and socioeconomic variables and delay in the receipt of adjuvant chemotherapy. Results: 33,011 stage III colon cancer patients who received chemotherapy after surgery were identified. 8,036 (24.3%) initiated chemotherapy more than eight weeks after surgical resection. Unplanned readmission (OR 1.76, 95% CI 1.58-1.95), prolonged postoperative stay (OR 1.56, 95% CI 1.48-1.65), and comorbidity (OR 1.18, 95% CI 1.12-1.25) were all independent predictors of delay. Nonclinical factors, including African-American race (OR 1.34, 95% CI 1.24-1.45), lack of insurance (OR 1.63, 95% CI 1.43-1.87), and residence more than 100 miles from treating center (OR 1.23, 95% CI 1.01-1.51) were also independently associated with delayed chemotherapy. Conclusions: Delay in the initiation of adjuvant therapy for colon cancer beyond 8 weeks has previously been found to be an independent predictor of increased mortality. While some delays may result from patient frailty or postoperative complications, these data suggest that nonclinical factors may also contribute to delays. Increased focus on overcoming barriers to coordinated care should be prioritized to ensure that those patients who may benefit from adjuvant therapy receive it in a timely fashion to optimize survival advantages.
Effect of national recommendations on hepatitis B virus screening in a large U.S. cancer center.
Authors: Hwang Jessica , Fisch Michael , Lok Anna , Zhang Hong , Vierling John , Suarez-Almazor Maria
Published: February 2017

175

Background: National organizations recommend screening for hepatitis B virus (HBV) before chemotherapy but differ regarding which patients should be screened. We aimed to determine changes in screening rates at a cancer center after national recommendations were published between 2008 and 2010. Methods: We conducted a retrospective cohort study of HBV screening in cancer patients registered 1/2004 through 4/2011. Screening was defined as HBsAg and anti-HBc tests ordered around initial chemotherapy. We compared screening rates for 3 periods: before publication recommendations, during the period of publication of CDC, NCCN, AASLD, IOM, and ASCO recommendations, and after publication of recommendations. Logistic regression models were used to identify predictors of screening. Results: Of 139,981 new patients, 18,688 received chemotherapy, and 3,020 (16.2%) were screened. HBV screening rates increased over the 3 periods (14.8%, 18.2%, 19.9%; p<0.0001), but <19% of patients with HBV risk factors were screened. Among patients with hematologic malignancies, over 66% were screened during the entire study period, and odds of screening nearly doubled after publication of recommendations (p<0.0001). Less than 4% of patients with solid tumors were screened during the entire study period despite 70% increase in odds of screening after recommendations (p=0.003). Other predictors of screening included younger age, planned rituximab therapy, and known risk factors for HBV infection. Conclusions: HBV screening increased after publication of national recommendations, yet most patients with solid tumors or HBV risk factors remained unscreened. Efforts are needed to increase awareness of the importance of HBV screening prior to chemotherapy and antiviral prophylaxis to prevent HBV reactivation.
The effect of gaps in chemotherapy on survival in patients with high-risk stage II and stage III colon cancer.
Authors: Sada Yvonne , Duan Zhigang , El-Serag Hashem , Davila Jessica
Published: February 2017

180

Background: Current guidelines recommend six months of chemotherapy (CT) for stage III colon cancer and consideration for high-risk stage II colon cancer. No previous studies have examined the impact of CT gaps on survival. This retrospective study examines determinants of CT gaps and the effect of gaps on survival. Methods: Using national Surveillance, Epidemiology, and End Results registry-Medicare linked data, high-risk stage II and stage III colon cancer patients diagnosed between 2000-2007 who received surgery and CT were identified. CT duration and gaps were calculated. CT gap was defined as 30 to 90 days between two CT claims. Data on demographics, clinical factors (comorbidity, tumor grade), and treatment factors (time to CT initiation, toxicity, hospitalization) were collected. Multivariable regression was used to examine factors associated with gaps. Cox proportional hazards analysis examined the effect of gaps on risk of mortality. Results: 7,371 patients were identified. Median age was 75 (IQR: 71-79); 47% were male. Among all patients, 1,803 (24%) had a gap. 2,674 patients (36%) received 5 to 7 months of CT, of which 469 (18%) had a gap. Multivariable regression analysis showed that patients who were black (OR 1.3, 95% CI: 1.1-1.7), stage III (1.2, 1.0-1.3), had toxicity (1.3, 1.1-1.4), or had 3 to 4 months of CT (vs. 5-7 months, 2.6, 2.3-3.0) were more likely to have a gap, while patients with a more recent diagnosis in 2007(vs. 2000, 0.6, 0.5-0.8) were less likely to have a gap. 3-year cancer-specific survival was the same in all patients with CT gaps compared with no gaps (80%, 95% CI: 78%-82% vs. 81%, 95% CI: 80%-82%). Cox proportional hazard models showed that patients with gaps did not have increased risk of mortality (HR 0.99, 0.89-1.1) adjusting for patient and clinical factors. Among those who received 5 to 7 months of CT, 3-year survival was 8% lower in patients with gaps compared to those with no gaps (80%, 95% CI: 75%-83% vs. 88%, 95% CI: 87%-90%). Conclusions: Nearly 25% of high-risk stage II and III patients who received CT had a gap. CT gaps were associated with worse survival in patients who received 5 to 7 months of CT. Interventions to improve CT toxicity management and reduce gaps are needed to maximize the benefit of CT.
Skin cancer surveillance and malignancies in patients with chronic lymphocytic leukemia (CLL).
Authors: Mansfield Aaron Scott , Rabe Kari G. , Schwager Susan M. , Call Timothy , Brewer Jerry D. , Shanafelt Tait D.
Published: February 2017

184

Background: Patients with CLL are at higher risk of developing melanoma and other skin malignancies. The survival of patients with melanoma is worse, stage for stage, in patients with CLL than patients without. It is thought that early diagnosis of skin cancer is critical to improving survival in CLL patients. To promote early diagnosis and education on skin cancer prevention, the Mayo Clinic CLL group has recommended that CLL patients be referred for full body skin evaluation within 6 months of diagnosis. We sought to determine adherence to these guidelines by our group and identify prevalence of skin malignancies within 6 months of diagnosis. Methods: We identified patients who lived within 30 miles of Mayo Clinic who were diagnosed with CLL between 01/01/2004 and 01/01/2012 using the Mayo Clinic CLL database. Charts were reviewed for skin examinations, referrals to dermatology/primary care within 6 months of diagnosis of CLL, and diagnosis of a skin malignancy. Results: There were 107 patients newly diagnosed with CLL included in this study. Of the 79 patients who received their primary care at Mayo Clinic, 40 (51%) had a documented whole body skin exam by either a dermatologist or primary care provider within six months of diagnosis. Nine of these 40 patients (23% of examined patients; 8% overall cohort) had a skin malignancy: 2 patients had basal cell carcinomas, 6 patients had squamous cell carcinomas, and 1 patient had malignant melanoma. Prophylactic skin care recommendations could be documented for only 28 (26%) of patients. Conclusions: At least 8% of patients in this locally dwelling cohort with newly diagnosed CLL had a skin malignancy identified within six months of diagnosis (number needed to screen for 1 skin cancer: 13). Of patients referred to dermatology 23% had a skin malignancy (number needed to screen: 4.3). Referrals for screening skin examinations at diagnosis in patients with CLL could have an immediate impact for this at-risk population.
Compliance with established pneumonia core measures at MD Anderson Cancer Center in the emergency center.
Authors: Gonzalez Carmen E. , Johnson Tami N. , Kidin Lisa M. , Evans Scott , DeJesus Yvette , Rolston Kenneth V. I. , Walters Ronald Stewart
Published: February 2017

189

Background: Pneumonia is the major cause of death due to infectious diseases in the United States. In the cancer patient, pneumonia is the overall leading infectious cause of death. Pneumonia Core Measures (PCM) and Clinical Pathways are frequently used by healthcare organizations to ensure the delivery of high-quality care and pathogen-directed therapy. A multidisciplinary team was organized at the University of Texas MD Anderson Cancer Center (MDACC) Emergency Center (EC) into a Pneumonia Team to optimize care and to enhance compliance with current PCM. Methods: A retrospective review of EC patients during pneumonia season was completed. Results: Three areas for improvement in the EC were identified. The areas include lack of EC staff’s knowledge on PCM, lack of standardized order-sets for pathogen-directed treatment, and cancer patients presenting with pneumonia syndromes that fall outside established Community-Acquired Pneumonia (CAP) guidelines. The identified problems were addressed through three strategies: Intense EC staff education initially and yearly prior to pneumonia season (September-March). Microbiologic analysis of the pathogens responsible for the pneumonias in our unique cancer population at MDACC. Development and implementation of an institutional pneumonia algorithm and an order-set. The Pneumonia Team also identified a gap between our patient population and the current PCM. Pneumonia patients at MDACC EC are divided into two distinct groups, solid tumor and hematologic cancers. The microbiology analyzed in both groups is consistent with Healthcare-Associated Pneumonia (HCAP) and not CAP. Microbiology analysis identified gram positive, gram negative, fungal, viral and multi-drug resistant organisms. The initial analysis demonstrated that 87% of our patients met criteria for HCAP and only 12% met CAP. Based on this percentage, antibiotic selection for our CAP patients comprises a small portion of our total population. Conclusions: Our current algorithm and order-set optimize care and minimize variation to match our patient population. These findings provide important considerations for policy makers in regard to pneumonia measurements in a cancer setting.
Evaluating the impact of a clinical universal mismatch repair screening initiative.
Authors: Hall Michael J. , Martin Kathleen Q. , Rybak Christina , Cooper Harry S. , Gustafson Karen S. , Boyd Jeff , Daly Mary Beryl
Published: February 2017

194

Background: Immunohistochemistry (IHC)-based universal mismatch repair (UMMR) screening of incident colorectal (CRC) and endometrial (EC) tumors for deficient MMR (dMMR) associated with Lynch syndrome (LS) is supported by expert recommendations and is cost-effective. Heterogeneity in the approach to implementation of UMMR screening nationwide has been observed, suggesting knowledge gaps that could adversely impact anticipated outcomes. Studies of clinical UMMR screening can inform efforts to optimize implementation in the real world setting. Methods: In September 2011, Fox Chase Cancer Center (FCCC) began UMMR screening of incident (surgical) CRC/EC tumors. Providers were emailed a tailored UMMR Results letter intended to facilitate discussion of hereditary cancer risks and for distribution to patients. Content supported genetics consultation for an abnormal UMMR screen or for high-risk history (Hx) regardless of MMR status (i.e., personal Hx of any cancer; or 1st/2nd degree relative with a LS cancer and/or cancer <50). For comparison, clinical data on all CRC/EC surgical cases 3 months prior to implementation of UMMR screening were extracted from the medical record. Results: 55 surgeries for CRC/EC occurred in the 3 months pre-implementation (PRE) and 130 in the 9 months post-implementation (POST). 1 yr PRE and POST data will be presented at the 2012 Quality Symposium. Conclusions: The UMMR screening initiative greatly improved patient outcomes. Provider referral and documentation behavior was highly responsive to an abnormal screening result, but not high-risk cancer history alone. [Table: see text]
An IT-integrated, computer-based telephone system for monitoring patient-reported symptoms: Result of two trials.
Authors: Mooney Kathi , Beck Susan L. , Wong Bob , Dunson William A. , Wujcik Debra
Published: February 2017

2

Background: An automated remote monitoring system of patient reported symptoms was tested in two separate trials to determine if it improved unrelieved symptoms after outpatient chemotherapy. Methods: In Study 1,250 patients and Study 2,335 patients beginning a chemotherapy course were randomized to Telephone Care (TC) (n 129/174) or usual care (UC) (n 121/162). All called daily reporting presence, severity, and distress (0-10 scale) for 11 common symptoms. Those in the Study 1 TC group had reports of moderate to severe symptoms emailed to their oncologist and oncology nurse. Those in Study 2 TC group had similar moderate to severe symptom reports sent to a study Nurse Practitioner (NP) who responded by telephone utilizing evidence based guidelines to intensify symptom care. These patients also received automated tailored self-care messages based on their specific symptoms. Results: The majority of participants in both studies were white (91%; 84%) and female (76%; 77%). The mean age was 56 years, with breast cancer most common (40%; 45%). Mean study days were 45 (Study 1) and 73 (Study 2) with 66% and 87% call completion days respectively. Fatigue, pain, poor sleep, nausea and depressed mood were reported as moderate to severe by over 50% of patients in both studies. In Study 1 no difference was found in symptom severity between TC and UC. Oncology providers found the TC symptom alerts useful but rarely initiated symptom care intensification. In Study 2 the TC group mean symptom score was significantly lower than UC, p < .001. Poisson regression showed TC had fewer Severe symptom days than UC (est. means and SE) 3.16 (0.44) vs. 10.24 (1.84), p < .001; and fewer Moderate days 8.91 (1.04) vs. 19.06 (2.22), p < .001. TC had somewhat higher Mild days 19.85 (2.81) vs. 13.75 (1.85), p = .06; and more no symptom days 66.06 (3.82) vs 52.02 (4.15), p = .01. Conclusions: Remote monitoring of patient reported symptoms after chemotherapy is effective in identifying unrelieved symptoms. It can be used to track quality improvement as well as augment symptom care. Follow up to intensify symptom treatment utilizing guidelines is necessary to achieve significant reductions in symptom severity, distress and days of moderate or severe symptoms.
Quality improvement outcomes in an academic practice participating in ASCO’s Quality Oncology Practice Initiative (QOPI).
Authors: Fenton Mary Anne
Published: February 2017

206

Background: The ASCO QOPI is an instrument for community and academic practices to assess quality and adherence to guidelines in areas of treatment planning and goals, chemotherapy consent documentation, smoking cessation, symptom control, palliative care, and disease specific measures. Following data submission QOPI summary reports for the submitting practice and QOPI aggregate are available for review and comparison. Methods: The academic practice of Rhode Island Hospital Comprehensive Cancer Center has participated in QOPI since the fall of 2008. QOPI measure summary reports for our practice and comparison to the Academic Aggregate are reviewed by our physicians after each round of chart abstraction, measures are identified for improvement. Interventions include education on practice improvement and development of policy and procedures for implementation by our Quality Control Officer in compliance with hospital policies. Results: Presented is a summary of quality improvement interventions implemented. Additional areas of quality improvement have been identified based on QOPI data, and improvement plans are ongoing including treatment summaries for patient and primary care physicians, tools to assess patient emotional well being, documentation of family history and referral for genetic assessment. Conclusions: QOPI provides a platform for collection, analysis and comparison of quality measures. For the measures of formulating a pain plan the intervention was a reminder to document the plan. For the measure hospice enrollment, a reflection on our hospice enrollment has lead to an increase in referral to palliative care. The ASCO QOPI program is a tool for quality improvement, our Quality Control Officer was essential in implementation of our improvement projects. [Table: see text]
Physician order for scope of treatment (POST) in South Carolina (SC).
Authors: O’Rourke Mark Allen , Hudson Matthew F. , Craig Janet B. , Ropp John C. , Reeves Karen
Published: February 2017

21

Background: Physician Order for Life-Sustaining Treatment (POLST, www.POLST.org ) is a process and tool that translates patients’ goals of care into medical orders in a highly visible, portable way. Trained providers meet with seriously ill patients (or the surrogates) and discuss the available treatment options in light of their current condition, and help clarify the patient’s preferences. The physician then documents those preferences on a standardized medical order form, which travels with the patient if he or she changes settings of care. The POLST form is 1. a physician order, 2. signed by the patient, 3. after consultation with the physician, 4. facilitated by a person trained in advance care planning, 5. directed toward people with serious, chronic illness such that death in the next year would not be a surprise, 6. addressing the decision at a moment of medical crisis to a. hospitalize with full therapeutic intervention, or b. hospitalize with limited therapeutic intervention (such as no CPR), or c. provide supportive, palliative care in the present setting (home or nursing facility), 1. addressing further decisions such as feeding tube, parenteral (IV) hydration, or antibiotics, 2. documented in a widely publicized, recognized and understood form with a distinct pink color, and 3. accepted by EMS responders, hospices, nursing facilities, and hospitals across the state. Methods: The SC Coalition for the Care of the Seriously Ill is comprised of clinical and administrative leaders representing key statewide organizational partners, healthcare entities, and individuals. The Coalition proposes a template order for statewide integration to be called POST. The target population is persons with serious illness for whom death in the next year would “not be a surprise.” Results: Presently, the Coalition is working with state government to undertake a three-county pilot study of POST. Challenges include creating a legal framework, IRB approval, and education of providers and the public. Conclusions: POST may facilitate patient-centered advanced cancer care. Implementation of the POST in SC will require collaboration by stakeholders. Collaboration will require responsiveness to constituents’ concerns in order to facilitate patient-centered care.
Improving quality of pediatric oncology care via ASCO’s Quality Oncology Practice Initiative (QOPI) program.
Authors: Cooper Robert Michael , Abasolo Robin
Published: February 2017

212

Background: Pediatric oncologists strive to provide a high quality of care for their patients. American Society of Clinical Oncology (ASCO) developed the Quality Oncology Practice Initiative (QOPI) Program which serves to evaluate institution’s best oncology practices. The program evaluates Core Measures in Disease Modules and Domain Modules. The Disease Modules were not useful in a pediatric practice, however, the Core Measures and Domain Modules were appropriate for evaluating pediatric quality care. Methods: Kaiser Permanente Los Angeles Medical Center Pediatric Oncology participated in the QOPI Spring 2012 Collection. Thirty-five member charts were audited by a registered nurse case manager via the electronic medical record (EMR) for Symptom/Toxicity Management, Care at End of Life, and Core Measures modules over the course of six weeks. Results: Data results revealed areas that needed improvement at LAMC included oncologist’s documentation of chemotherapy treatment and consent, physician and nurse documentation of chemotherapy and disease education, documentation of oral chemotherapy adherence and documentation of fertility preservation. Only two pediatric end-of-life cases met requirements for abstraction during this round of audit. Chart audits were easily abstracted from EMR. The QOPI computer program was easy to use and concise with information and guidelines for measures to be abstracted. QOPI personnel were readily available for any problems or concerns. Conclusions: Participation in the ASCO QOPI Program can serve as a tool to help improve oncology institution’s best practices. The QOPI Program could further expand its disease modules to include more pediatric content such as acute leukemia and neuro-oncology. In addition, participation in this program offers 3-year certification for outpatient hematology-oncology practices (limited to internal medicine at this time) and could serve as your Part IV Maintenance of Certification (limited to internal medicine).
Variation in the use of intensity-modulated radiation therapy (IMRT) in the state of Michigan: 2005-2010.
Authors: Hayman James , Griffith Kent A. , Jagsi Reshma , Feng Mary Uan-Sian , Moran Jean M. , Piotrowski Tania L. , Pierce Lori J.
Published: February 2017

219

Background: Interest is growing in value in health care, defined as better outcomes at lower costs. A primary driver of cost in radiation oncology is the use of IMRT. We examined the patterns and correlates of use of IMRT across Michigan using publicly available data. Methods: As a certificate of need state, Michigan requires every radiation oncology facility to report yearly the number of external beam and IMRT treatments delivered. Data for 2005-2008 were obtained through a Freedom of Information Act request of the Michigan Department of Community Health, while 2009-2010 data were available at its website. Percentage of external beam treatments delivered using IMRT (IMRT%) was examined across centers over time and repeated-measures longitudinal linear regression was used to identify factors associated with use. Results: During 2005-2010, 48 to 65 centers reported data. Median IMRT% (range) rose steadily during the study period: 2005 16% (0-64); 2006 21% (0-57); 2007 27% (0-79); 2008 37% (7-85); 2009 41% (0-87) 2010 45% (7-100). There was also significant between-center variation (see table). Regression modeling demonstrated that IMRT% was associated with year (+6.7% per year, p<0.0001), facility type (+7.1% freestanding versus hospital, p<0.11), facility annual volume (+5.0% high volume: 7,000+ versus low: <7,000, p=0.01) and the interaction between year and volume (low volume +2.4% per year versus high volume p<0.02). The significant interaction between year and volume suggests that the greatest IMRT% growth was in low volume centers (6.7% per year versus 4.3% per year for high volume). Conclusions: IMRT utilization has grown steadily across Michigan between 2005 and 2010. There is significant variation in its use that appears to be related in part to facility characteristics. The newly established Michigan Radiation Oncology Quality Collaborative (MROQC) is beginning to explore the use of IMRT in patients with breast and lung cancer statewide to identify those groups of patients where improved outcomes may justify its higher cost. [Table: see text]
Assessment of follow-up decisions and care after BRCA testing.
Authors: Riaz Sara Sarwar , Ahsan Samira
Published: February 2017

22

Background: Inherited mutations in BRCA1/2 genes render high risk of development of breast and ovarian cancers in affected individuals. A spectrum of risk reducing strategies exists inclusive of preventive measures as clinical and radiographic surveillance, hormonal therapies and prophylactic surgeries. Baseline prognostic parameters direct decisions regarding adoption of each approach. Methods: We aimed to study the pattern of clinico-preventive inclination among deleterious mutation carriers, with and without personal history of malignancies. Our mode of intervention was a phone survey conducted to elicit pertinent information from individuals with high risk penetrance mutations and to assess their choice and bias toward each strategy, primarily designed to abate the oncogenic potential inherent to these mutations. Results: Analysis of subjective and sequential data revealed that 5 out of the 7 mutation carriers had a personal history of breast or ovarian cancer. All 5 of these subjects opted for prophylactic mastectomy while 4 of them underwent prophylactic oophorectomy, detecting one additional cancer. 2 of the individuals preferred surveillance as their preventive program while none of the subjects chose hormonal therapy. In terms of demographics and lifestyle, 3 patients claimed to had increased their level of physical activity, 4 modified their dietary habits and 2 incorporated vitamins and herbal supplements into their regimen. 6 of the subjects felt adequately supported while 1 individual relayed concerns regarding inadequate insurance coverage. None of the subjects felt their follow up decisions were influenced by their annual income or coverage plans. Conclusions: Decisions regarding adopting least to most aggressive measures are highly influenced by personal history of cancer shifting the focus from quality to quantity of life. Prophylactic mastectomy reduces the risk of contralateral breast cancer by 90% and oophorectomy by 50%. Estrogen and progestrogen receptors are infrequently expressed in BRCA related tumors rendering hormonal therapy less effective. Lifestyle modification and stringent surveillance are evolving areas of preventive oncology, however, their effectiveness remains to be elucidated.
Use of performance data to drive process change and improve patient wait time for chemotherapy treatment.
Authors: De Mendonca Ben , DeAngelis Carlo , Charbonneau Flay , Leung Tiffany , Trudeau Maureen E.
Published: February 2017

223

Background: The Odette Cancer Centre (OCC) manages more than 24,000 chemotherapy visits annually. The delivery process is complex and patients have significant wait times for treatment. The OCC was faced with improving this process with no data infrastructure to support continuous quality improvement. Methods: An electronic scheduling manager, Chemotherapy Appointment Reservation Manager (CHARM) was designed that includes workflow communication between pharmacy and nursing. A multidisciplinary team created a value stream map of the process. Rate limiting steps and key milestones in the delivery process were identified. CHARM timestamps stages in the chemotherapy process, from nurse approval to pharmacy verification, medication processing and medications received on the chemotherapy unit. Extracted data was used to create a weekly report to monitor key performance indicators (KPIs). Results: An analysis of six months of data led to the establishment of KPIs and targets. Our baseline targets were established as pharmacy turnaround time (AR) < 1 hour, pharmacy verification (HP)< 13 minutes, medication processing (PR) <45 minutes and chemotherapy ready (CR) +/- 30 minutes of the patient appointment time. Since April 2012, KPIs have been reported. Over a four month period (81 clinic days and 5,920 appointments) the median AR time was 1:02 (hh:min), HP was 00:12 and PR was 00:43. The KPI targets were met AR 46%, HP 52% and PR 51% and CR 29% of the time. The data infrastructure now drives the quality improvement initiatives. An early strategy implemented queuing theory, to process orders by appointment rather than approval time, resulting in no change in median AR time, but a decrease of seven minutes AR range. Conclusions: Quality improvement is hinged on measurement and evaluation. The OCC has successfully implemented a continuous quality improvement data infrastructure that monitors quality of ambulatory chemotherapy delivery. These data describe pharmacy and nursing processes. Further work to improve the delivery process and data infrastrucutre is ongoing.
Do patients participating in oncology clinical trials understand the informed consent form? A Brown University Oncology Research Group study.
Authors: Schumacher Andrew , Bartley Carolyn , Kaplan Anne , Murphy Benjamin , Safran Howard , Rosati Kayla , Wilson Donna
Published: February 2017

23

Background: The informed consent process is used to provide research participants information that includes the purpose and procedures of the research study, risks, benefits, potential alternatives and that participation is voluntary. The goal of informed consent to is to provide this information in language that is understandable to the research participant. The aim of this study is to evaluate whether research participants in adult hematology/oncology clinical trials understand the information presented during the informed consent process. Methods: Patients receiving active treatment on an oncology clinical trial that utilizes chemotherapy, radiation, targeted agents, biologic therapy or hormonal therapy were eligible to participate in this study. After informed consent was obtained, research participants are given a 14-question test. The questions evaluate whether patients understand the following elements on the informed consent related to their oncology treatment study: The purpose and procedures of the research study, risks, benefits, potential alternatives, research related injury compensation, study contact information, measures used to protect confidentiality, and that participation is voluntary. The possible answers to each question are disagree, unsure, and agree. Results: This study was initiated in June 2012. Eleven patients enrolled on this study within the first month. Participants include those on cooperative group studies, pharmaceutical industry trials and investigator initiated trials. The average length of the informed consent document exceeded 20 pages. An initial analysis of data is planned after the study has been open for six months. Conclusions: Informed consents are becoming increasingly lengthy and complex. Much of the language added is regulatory and legal in nature and used to protect the institutions conducting the research. This study will assess the readability of the informed consent and whether patients participating in oncology research trials understand the essential elements of the informed consent document. The first data analysis will be December 2012.
The value of a quality metric.
Authors: Hoverman J. Russell , Schwartz Jim R.
Published: February 2017

239

Background: The value of a quality metric is tied to improving outcomes or reducing costs while maintaining outcomes. In the last year ASCO/ONS Chemotherapy Safety metric 1F has changed from requiring current BLS (Basic Life Support) certification for all clinical personnel to requiring only one currently certified professional be present during chemotherapy administration (CA). For this study we evaluated the need for BLS training in outpatient chemotherapy delivery. Methods: Texas Oncology maintains a voluntary drug occurrence system, web-based and accessible at all sites. Occurrences with severity Grade 6 (transfer to a more intensive facility or temporary harm to patient) or higher (7 or 8) were collected for 2008-2ndq 2011. Use of BLS and AED and outcomes were tracked through chart review. Results: There were 188 instances of Grade 6 or higher events of which 5 involved BLS. There were no events where an AED was triggered. All 5 patients were transferred alive to a hospital. All events were drug reactions. During the same period there were 779, 805 CAs, 371,693 unique patients with 15,394,601 patient visits. Facility reports were also queried for 2010 with no additional events identified. Conclusions: 1) The need for BLS recertification is unproven in this setting. 2) AED triggering did not occur in this time frame, 3) Protocols for addressing severe drug reactions are of prime importance. 4) Quality metrics may or may not add value to a quality program and require validation. 5) The original BLS requirement was burdensome. 6) The incidence of true cardiac arrest in this setting is remarkably low.