bluuebunny/crossref_metadata_2025 huggingface dataset:
Value, balance, impact: Factors contributing to the exodus of medical oncologists from clinical care.
Authors: Dixit Niharika , Chism David D. , Wilky Breelyn A. , Speers Corey Wayne , Levit Laura A. , Kirkwood Margaret Kelsey , Morgante Jim D. , Mulvey Therese Marie
Published: October 2023

52

Background: A recent study of Medicare claims data suggested that 20% of oncologists left clinical roles in the last ten years. This exodus will add substantial indirect and direct costs to the healthcare system and reduce access to care. Understanding contributing factors can lead to solutions to this exodus. Methods: We performed a qualitative study of medical oncologists who recently left or self-identified as considering leaving clinical practice. Six focus groups were conducted from January and March 2023 with 26 oncologists. We used the whole-of-person workforce retention framework to inform the focus group guide. Focus groups were recorded and transcribed. Recordings were analyzed with open coding and grounded theory approach. Results: 26 participants participated in six focus groups: well-balanced for gender (14 male, 12 female), career stage (5 early, 14 mid, 7 late), practice setting (19 academic, 7 private practice), and predominantly urban (25) and one rural. Thematic saturation was achieved in these six focus groups, with 5 major themes identified: Value, Career development/impact, Burnout, Work life balance and Workload. Participants in all six focus groups reported feeling undervalued due to a lack of recognition for uncompensated effort, including education and clinical research, inadequate resources to provide clinical care, and/or mismatch of values. Symptoms of burnout, lack of work/life balance, and unsustainable workloads were present. Administrative tasks, documentation, electronic medical records, and prior authorization were not identified as significant contributors. Many respondents hoped to someday return to clinical care. Conclusions: Themes of value, balance, and personal impact in the field were identified as major reasons oncologists left or considered leaving clinical care roles. We found that burnout is a symptom of dysfunction in the healthcare system and not due to a lack of personal resiliency. Medical organizations like ASCO should focus on improving the workplace environments by helping sites to focus on valuing clinical care, education, research, and right-sizing oncology practices to support excellent cancer care and support medical oncology workforce.
Assessment of hospitalizations and cytopenia events among patients with extensive stage small cell lung cancer (ES-SCLC) receiving chemotherapy with trilaciclib.
Authors: Huang Huan , Tkacz Joseph , Moore Michelle , Lewing Benjamin , Huang Yecheng , Schinkel Jill , Parikh Ravi Bharat
Published: October 2023

531

Background: Prior studies have reported that that nearly 75% of patients receiving chemotherapy for small cell lung cancer present a hospitalization associated with myelosuppression. Trilaciclib is a myeloprotective agent indicated for use prior to chemotherapy in ES-SCLC. Given the relative recency in trilaciclib approval (2/12/2021), this study assessed real-world outcomes associated with trilaciclib among patients with ES-SCLC. Methods: This study was a retrospective analysis of adult ES-SCLC patients diagnosed between 2020 and 2023 using the 100% Medicare Fee-for-Service and MORE2 Registry claims databases. Eligible patients met literature-based criteria for ES-SCLC using International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes, received platinum/etoposide- or topotecan-based chemotherapy regimens after diagnosis, and were continuously enrolled ≥ 30 days preceding and following chemotherapy initiation. Patients were categorized into 2 mutually exclusive cohorts: 1) trilaciclib administered at chemotherapy initiation and with no granulocyte colony stimulating factor (G-CSF) received during chemotherapy, and 2) no trilaciclib administered during chemotherapy. Chi-square tests and student’s t-tests were used to assess statistically significant differences between groups on cytopenia events (based on the appearance of an ICD-10 diagnosis code) and all-cause hospitalizations during the post-index period. Data use agreements prohibit reporting of categorical outcomes of < 11 patients. Results: 132 trilaciclib (mean age 70.6, male 50.8%) and 12,305 non-trilaciclib patients (age 68.0, male 48.2%) were eligible for the study; median follow-up was 202 days. Compared to the non-trilaciclib cohort, patients receiving trilaciclib had a lower rate of hospitalizations per patient per month during follow-up (0.14±0.25 vs. 0.19±0.27; p <0.001). Within 90 days post-chemotherapy initiation, trilaciclib was associated with lower rates of hospitalization (21.2% vs. 32.4%; p <0.01) and febrile neutropenia (< 3% vs. 5.7%, p=0.01). Anemia (44.7% vs. 52.6%, p=0.07), neutropenia (9.1% vs. 14.9%, p=0.06) and thrombocytopenia (5.3% vs. 8.4%, p=0.2) were numerically lower for trilaciclib patients in the 90-day post-index period. Results were similar when the non-trilaciclib group was stratified by prophylactic G-CSF usage. Conclusions: This real-world study demonstrated that receiving trilaciclib prior to chemotherapy treatment was associated with a lower rates of hospitalizations and cytopenia events, suggesting trilaciclib may prevent adverse events associated with treatment for ES-SCLC.
Real-world comparative effectiveness and safety of pembrolizumab vs chemotherapy for previously untreated PD-L1≥50% metastatic non-small cell lung cancer.
Authors: Lu Brandon , Parmar Ambika , Luo Jin , Chan Kelvin K.
Published: October 2023

538

Background: In the randomized KEYNOTE-024 trial, pembrolizumab demonstrated robust efficacy in patients with PD-L1≥50% metastatic non-small cell lung cancer (mNSCLC) with median overall survival of (OS) of 26.3 months and 13.4 months in the pembrolizumab and chemotherapy groups, respectively (hazard ratio (HR)=0.62). However, it is unclear how well this efficacy translates to effectiveness in routine practice. Thus, we sought to assess the real-world effectiveness and safety of pembrolizumab for patients with previously untreated PD-L1≥50% mNSCLC compared to platinum-based chemotherapy. Methods: This was a population-based, retrospective cohort study of mNSCLC patients receiving first-line platinum-based chemotherapy (historical controls) from April 1, 2013, to January 17, 2018, or first-line pembrolizumab (cases) from January 17, 2018, to March 31, 2021, in Ontario, Canada. Baseline characteristics and outcomes were ascertained from linked administrative databases. The primary outcome was OS, assessed using Kaplan-Meier and Cox proportional hazards regression methods. Secondary safety outcomes included hospitalization, emergency department visits, specialist visits, and adverse events. To adjust for baseline differences, propensity-score matching was used to match the case and control cohorts (1:1). As a sensitivity analysis, we analyzed OS by histology subgroups (squamous versus non-squamous). Results: A total of 2,284 matched patients were included in our propensity score-matched cohort. The median OS in the pembrolizumab group (13.0 months, 95% confidence interval (CI): 11.8-14.6) was significantly longer than the chemotherapy group (9.2 months, 95% CI: 8.0-10.0), with a HR of 0.81 (95% CI: 0.71-0.92). Though pembrolizumab was also associated with improved OS in both patients with squamous (HR=0.77) and non-squamous histology (HR=0.81), pembrolizumab patients reported significantly more adverse events, specialist visits, and higher 1-year cumulative incidence of direct hospitalizations (11.5% vs 6.8%, p=0.0002). Conclusions: The results of this study confirm the survival benefit of pembrolizumab monotherapy for previously untreated mNSCLC patients with PD-L1≥50% in routine practice, though with increased toxicity and diminished benefit in the real world.
Enabling real-world cancer care quality surveillance and analytics through a novel population-based statewide linked database.
Authors: Spees Lisa P. , Albaneze Natasha , Baggett Christopher D. , Green Laura , Johnson Katie , Morris Hayley , Salas Ana I. , Olshan Andrew F , Wheeler Stephanie B.
Published: October 2023

545

Background: Population-based linked datasets are vital tools to generate real-world evidence (RWE) that can inform interventions and policies to improve cancer care quality and outcomes. The novel University of North Cancer Information & Population Health Resource (CIPHR) links statewide cancer registry data, public and private health insurance claims, and provider- and area-level data since 2003, representing more than 80% of North Carolina’s large, diverse cancer patient population. This scoping review included all articles that have used CIPHR data (N=44) to characterize the breadth of RWE generated and to identify further opportunities for population-based care quality surveillance. Methods: Articles published between 2012-2022 were categorized by cancer site(s) of focus, exposure variables, and outcomes examined across the cancer care continuum. For each article, notable results and conclusions were extracted and summarized, including statistically significant associations between patient-level factors (e.g., demographics, clinical variables, insurance type, distance to providers), provider-level factors (e.g., specialties, facility type, networks), system/policy-level factors and outcomes. Results: Of the 44 articles included, findings were reported across 23 unique cancer sites; 9 articles reported results aggregated across multiple cancer sites. Across the cancer care continuum, the majority of articles’ outcomes were categorized as focused on treatment and survivorship (n=25), with most examining treatment initiation and/or adherence (n=13). Other common outcomes included costs of care (n=8) and mortality/survival (n=8). Fewer articles focused on cancer screening (n=2), recurrence (n=1), long-term care use (n=1), or incidence (n=1). The cancer site most frequently examined was breast cancer (n=19), followed by colorectal (n=6), cervical (n=5), and uterine cancers (n=5). The majority of articles focused on racial/ethnic, rural/geographic, and socioeconomic inequities in care and outcomes, as well as multilevel predictors of observed trends. Conclusions: These findings demonstrate the value of creating and sustaining robust, longitudinal, population-based databases to facilitate the generation of RWE that can be used to monitor cancer care delivery trends, including cancer inequities that warrant intervention and policy attention. Lessons learned from more than a decade of analytics utilizing this unique data resource highlight opportunities to explore less frequently studied cancers and outcomes; motivate targeted implementation of equity-focused interventions and policies responding to trends; and inform development of similar resources in other states.
Development and evaluation of a data-driven virtual interdisciplinary workshop to facilitate communication and teamwork in ambulatory medical oncology settings.
Authors: Blok Amanda Constance , Costa Deena Kelly , Wright Nathan , Manojlovich Milisa , Friese Christopher Ryan
Published: October 2023

551

Background: While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. Our objective was to determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Methods: Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. Workshop content was tailored to address key findings from the patient and clinician survey data, including addressing quality, safety, teamwork, communication, and conflict issues. Results: 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team. Clinicians perceived a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by summative data, along participant suggestions for improvement for the Workshop and a desire for long-term partnership in quality improvement. Conclusions: The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable in an ambulatory oncology setting. The Workshop identified opportunities for individual- and system-level improvements in interdisciplinary clinical team communication. This promising strategy—incorporating clinic-specific data and communication techniques in a virtual interdisciplinary communication Workshop—requires replication in larger, more diverse practice samples.
Acceptance testing of a visual care navigation tool for patients, survivors, caregivers, nurses, and oncologists.
Authors: Daswani Samira , Lindquist Molly , Blayney Douglas W.
Published: October 2023

552

Background: Cancer patients and family caregivers often describe the experience as a treacherous hike without access to a map, relevant gear, and a guide. Without the necessary tools, individuals are often overwhelmed and unable to participate in shared decision-making. On average, oncologists have ~24 minutes per patient to communicate the condition and upcoming activities. Sometimes, they make hand-drawn visuals to explain the sequence, duration, and decision points of the experience. Despite these efforts, 97% of individuals rely on Google to learn about their condition, often furthering “Cancer Information Overload” and non-evidence-based activities. A team of cancer survivors, cartographers, and oncologists developed a proprietary platform with interactive cancer maps and self-management tools to navigate treatment better. We tested the interactive product demo through a series of qualitative interviews. Methods: A convenience sample of individuals in four categories underwent a 30-minute virtual structured interview with both parties and the cancer map visible to each other. Interviewees (INTs) included breast cancer patients under treatment (Tx), survivors (S) on either surveillance or anti-hormone therapy, informal caregivers (CG), and health care providers (HCP), either oncologists (ONC) or advanced practice providers (APP). After informed consent, INTs were shown the product and asked 8 questions, including 5 open-ended, 1 prioritization, and 2 scoring questions. Sample sizes were chosen to reach theoretical saturation. Results: We conducted 33 interviews between April 1 and June 5th, 2023. The results are shown in the table. The self-management tools that were identified to be most useful included: Digital appointment notebook, symptom tracker, medication tracker, insurance management, nutrition plans, and legal templates. Conclusions: Cartographically represented maps of the cancer journey and the self-management tools appear to be acceptable to patients, survivors, and caregivers. The platform is acceptable to HCPs and is not perceived to increase work or the burden of explanations. APPs found value in the platform to create efficiency and enable easier education of patients and caregivers. The interactive platform can be shared to explain the journey, treatment duration, and potential side effects.[Table: see text]
The impact of 4R Care Delivery Model on timing and sequence of bone density screening among patients with breast cancer.
Authors: Brookhart Carolyn , Weldon Christine B. , Trosman Julia R. , Zhu Zheng , Linehan Elizabeth Shurell , Lin Amy Ying Ju , Abbe Thea , Sakoda Lori C. , Gordon Nancy P. , Ravelo Arliene , Shirazi Aida , Kwan Marilyn L. , Liu Raymond
Published: October 2023

553

Background: Bone loss is common in patients with breast cancer and can impact treatment decisions related to endocrine therapy. Hence, bone density assessment prior to starting endocrine therapy is highly important, especially because endocrine therapy is the first line adjuvant treatment for patients with ER+ breast cancer. Implementing timely bone density assessment is challenging, particularly in the early care trajectory when there are many tests and procedures taking place. We conducted a care delivery optimization in a large health system to implement bone density testing and referral for bone health consultation prior to endocrine therapy. The optimization was conducted as part of implementing the 4R Oncology model (Right Info, Right Care, Right Patient, at the Right Time), a novel approach to improving patient-facing care planning, team-based delivery and patient self-management. Here we describe the impact of this intervention. Methods: A cohort of 278 women with breast cancer who were in the 4R intervention (the 4R cohort) was compared to a historical control cohort of 201 women who received care pre-4R. Demographic, bone health history, and oncologic care data were abstracted from chart review and clinical databases. The prevalence of bone loss and timing of bone density consultation request was compared between the 4R and historical control cohorts. Results: The age, race/ethnicity and rate of ER+ cancer were similar between cohorts. Patients in the 4R cohort were significantly more likely to have received a consultation for bone density screening prior to the start of endocrine therapy (see Table). They were also more likely to receive a bone density test result during their care (Table). These findings remained significant when data were restricted to those ≥ 50 years (as a proxy for postmenopausal status) and those with ER-positive breast cancer. The rates of osteopenia and osteoporosis were similar between the cohorts: control 47%, 24%; 4R cohort: 46%, 23% respectively (data not shown). Conclusions: Care optimization using the 4R Oncology Model was associated with a significant improvement in the timing of bone density testing before initiation of endocrine therapy. The 4R Oncology Model can lead to more informed decision making in adjuvant endocrine therapy for patients with breast cancer. Additional optimizations to improve the rates of bone density tests and referrals will be beneficial.[Table: see text]
VetConnect Cancer Navigator: Enhancing care for veterans with breast and gynecologic cancers.
Authors: Rasmussen Kelli M , Halwani Ahmad Sami , Patil Vikas , Morreall Deborah , Li Chunyang , Mcshinsky Richard , Burningham Zachary R. , Collins Sarah , Underwood Phelisa R. , Kelley Michael J. , Colonna Sarah Violet , Moss Haley
Published: October 2023

554

Background: With women becoming the fastest-growing group in the Veteran population, the prevalence of breast and gynecologic cancers among Veterans is a growing concern. Studies have demonstrated higher rates of breast cancer among Veterans compared to nonveterans. As the number of women Veterans continues to rise, an increased incidence of breast and gynecologic cancers is expected. Unfortunately, efficient identification of newly diagnosed cases among Veterans is often lacking, leading to delays in diagnosis and treatment. The Breast/Gynecological System of Excellence (BGSOE) aims to ensure that Veterans with breast and gynecologic cancers receive state-of-the-art, guideline-adherent care, whether within the VA system or at outside institutions. Methods: To address this issue, BGSOE stakeholders collaborated to develop a comprehensive care coordination infrastructure called the VetConnect Cancer Navigator. This tool not only identifies newly diagnosed cases of breast and/or gynecologic cancers, but also provides additional navigation support to Veterans who may be receiving their cancer care within the VA or other healthcare systems. The development process involved designing a user-friendly interface, extracting relevant data, and integrating advanced analytics to optimize user experience. Continuous evaluations, both formal and informal, were conducted to ensure optimal usability and workflow fitness. In January 2023, the VetConnect Cancer Navigator was launched as a pilot program at the Durham VA Medical Center. Results: From January 2021 to June 2023, a total of 5,519 Veterans were identified with newly diagnosed breast and/or gynecologic cancers throughout the entire nationwide VA system. Since the launch of the navigator at the Durham VA Medical Center pilot site, it has successfully identified 37 Veterans with newly diagnosed breast and/or gynecologic cancers. Of these cases, 27 patients have been contacted by the dedicated nurse navigator, 22 have completed an intake form, and 18 have agreed to enroll in the BGSOE navigation program. Conclusions: The VetConnect Cancer Navigator represents a pioneering approach to the design and implementation of health information technology tools. As demonstrated through the pilot site, the navigator facilitates innovative coordination and delivery of healthcare, specifically tailored to the need of the BGSOE program, this tool significantly enhances the quality of care provided to Veterans with breast and/or gynecologic cancers. Through improved care coordination and navigation support, the VetConnect Cancer Navigator plays a crucial role in ensuring Veterans receive optimal, guideline-based care regardless of their treatment location within or outside the VA system.
Telemedicine consultation between providers managing gynecologic cancers.
Authors: Shalowitz David I. , Wagi Cheyenne R. , Randazzo Aliza , Peluso Alexandra G. , Birken Sarah A.
Published: October 2023

556

Background: Gynecologic cancers are among the most prevalent cancers in women, yet many patients do not receive guideline-concordant care, in part due to lack of geographic access to gynecologic oncologists (Gyn Onc). Telemedical technology allows patients’ local physicians to consult with subspecialist Gyn Oncs, without burdening patients with unnecessary in-person visits. Providers’ acceptance of provider-to-provider telemedicine consultation for the management of gynecologic cancers is unknown. We aimed to gather feedback about experiences with referrals, communication, and openness to telemedical consultation between Gyn Oncs, gynecologists (Gyn) and medical oncologists (Med Onc). Methods: Gyn Onc, Gyn, and Med Onc physicians were recruited from practices serving rural patient populations to participate in semi-structured interviews. As implementation of telemedicine interventions is influenced by factors at multiple levels, the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) guided the interview. Questions focused on barriers and facilitators to provider-to-provider telemedicine consultation stemming from inner/outer settings and individual experiences. Interviews were conducted via WebEx, recorded, and transcribed. Two coders established analytic reliability with two transcripts and independently coded remaining interviews using a combined CFIR-TDF framework. Codes were analyzed and combined into salient themes. Results: We conducted 11 interviews (6 Gyn Onc, 3 Gyn, 2 Med Onc). We identified six themes (Table 1). Themes included hesitancy to adopt new methods of communication, frustration with existing methods, and potential gaps that could be filled by a cloud-based asynchronous platform. Conclusions: Providers experience burnout from communication and are hesitant to adopt a new platform. Providers note referrals with providers using different EHR systems is difficult, as they cannot share patient records easily and securely. Providers are open to adopting provider-to-provider telemedicine consultation if the system can be streamlined to share patient records easily.[Table: see text]
Improving operational efficiency via the novel use of an ePRO.
Authors: Kudel Ian , Ivey Camey , Curry Heather A. , Akar Nicola , Christianson Annette , Lucisano Jennifer
Published: October 2023

568

Background: A cloud-based, multifunction, bidirectional app that communicates real-time patient-reported cancer treatment symptom(s)/severity and clinical care team (CCT) recommendation(s) can lessen treatment burden. Additionally, it can be used creatively to enhance operational efficiency by replacing appointment scheduling via phone with a templated message sent using the secure communication feature. Methods: Four different datasets were analyzed for this multimethod study. In the first, an independent sample t-test was used to compare the time it took to review a patient record and contact them via phone with post-app implementation, which included the same review and scheduling an appointment by templated message using the app’s secure communication feature. Second, the tasked nurse was interviewed for 30 minutes to solicit her opinion regarding this new workflow. Third, a clinic survey assessing patient preference for communication (phone call vs. secure communication via app) was analyzed descriptively. Finally, patient satisfaction with the app was assessed by randomly asking users with active accounts for a minimum of 30 days, “How likely are you to recommend “the app” to another patient?”. Patients answered the question using an 11-point visual analog scale. Data collected over 180 days (downloaded June 21, 2023) were analyzed descriptively. Results: There was a significant difference in the time required for the nurse to schedule appointments (t=5.4, p<0.01); patient contact by app took much less time (n=89; M=7.1 minutes; SD=2.8) than pre-implementation phone calls (n=55; M=11.7 minutes; SD=6.0). During the interview, the nurse found that setting up the new workflow was “tricky and time-consuming...but benefits for both yourself and your patient completely outweigh the stress and the hard work it took you to get to that point“. Additionally, she noted increased efficiency, “It's most definitely made it easier to run the clinic. For instance, the nine patients yesterday...if I had done a phone clinic that would have taken me the whole morning, whereas it took me about an hour and a half, I think, to do those nine patients.” In her view, this new approach did not negatively impact patient care, “I don’t think doing it this way is compromising care in any way.” Third, the survey (n=66) indicated that, generally, patients found app-based communication better (n=35; 53.0%) than phone-based (n=13; 19.7%). Finally, patients’ (n=228) mean overall app satisfaction was 8.5 (SD=2.4); 65.4% rated it a 9 or 10. Conclusions: Novel use of an ePRO’s secure communication feature has – quantitatively and qualitatively – demonstrated greater operational efficiencies. Further, most patients favored this contact modality and rated the app highly.
Remote nurse triage and standardization of clinical pathway utilization.
Authors: Hoegger Blake , Davis Cassidy Rose , Bodenhorn Payne Calliope Constance , Ortega Lance , Patt Debra A.
Published: October 2023

574

Background: In March of 2022, Texas Oncology (community oncology practice) initiated a state-wide rollout for Remote Nurse Triage. This program implemented and standardized the utilization of Clinical Pathways within the Navigating Care system with a goal to decrease time to patient first call back, increase first touch resolution for patient-initiated contact, and increase patient satisfaction related to patient-initiated communication resolution. Methods: To determine an appropriate plan of action, a needs assessment was conducted to evaluate current pathway utilization, call volumes and patient satisfaction. Based on the findings of this assessment, triage nurses were trained to resolve incidents using standardized care pathways and standing orders within the Navigating Care System. This implementation was monitored on a weekly basis with metrics from Navigating Care and the Relatient dashboard and compared to the 12-month baseline data for 2 beta sites. Results: In the 12-month pilot, standardized pathway utilization increased from 1% pre-pilot to 78% post-pilot for clinical symptom management calls. With standardized pathways and better first touch resolution clinical calls decreased 8% overall from 4,302/month to 3,987/month while patient volumes (billable visits) increased 25%. Patient satisfaction scores, in relation to their phone experience and needs resolution, went up to 4.5/5 from 3.9/5. Symptom management resolution times also trended down since beginning the pilot. Conclusions: Standardizing the usage of clinical pathways by virtual triage nurses reduced clinical call volumes despite a positive growth in the number of billable visits at the pilot sites. This increase in pathway utilization also led to decreased time for symptom management resolution. Additionally, these measures resulted in an increased patient satisfaction related to patient-initiated communication.
A multisite initiative to increase medical oncologists’ utilization of clinical pathways in the selection of systemic cancer treatment.
Authors: Hough Katherine , Birkenbuel Aliki , Griffin John , Thompson Nancy , Grethlein Sara Jo
Published: October 2023

575

Background: The Swedish Cancer Institute (SCI) recognizes that quality cancer care is a systemwide commitment. In 2020, SCI implemented ClinicalPath (formerly Via Oncology). The ClinicalPath tool assists in the selection of systemic treatment protocols. The protocols balance considerations of clinical efficacy, safety, toxicities, and cost. National utilization rate for ClinicalPath ranges between 50-70%. In 2021, ClinicalPath monthly utilization by SCI medical oncologists was 56%. This initiative aimed to increase utilization of ClinicalPath by SCI Medical Oncologists, across the three main campuses, to above 70% by the end of 2022. Methods: The Plan Do Study Act framework was used. Utilization was defined as accessing the ClinicalPath tool. Utilization data was abstracted from an Epic Workbench Report that was filtered to reflect practicing SCI medical oncologists and the 25 diagnoses included in ClinicalPath. An introduction email and meeting request was sent to eight Medical Directors. A fishbone diagram was used to identify the potential causes of low utilization. PDSA 1 interventions included 1:1 meeting with each Medical Director to validate baseline data for cascading to their oncologists and encourage engagement. PDSA 2 included monthly “Quality Messages” with oncologists’ monthly utilization rate. In addition, a public recognition of “Most Improved Utilization” from Q1 to Q2 was done by the SCI Executive Medical Director. PDSA 3 focused on wide dissemination of the initiative through presentations that included a link to a “Tips & Tricks for ClinicalPath” video at SCI executive and department meetings. Public recognition of “Top Performers” from Q3 was published in the SCI newsletter. Results: The process measure of 1:1 meeting with Medical Directors was achieved at 100%. During PDSA 1 the outcome measure of monthly utilization rates improved to 71%. The 2nd PDSA cycle yielded a utilization rate of 84%. The 3rd PDSA cycle monthly utilization rate by the end of 2022 was 86%. At the most recent tracking into 2023, the utilization rate showed sustainability with achieved rates of 83%, 80%, 80% for Jan, Feb, March. Conclusions: Engaging the SCI Medical Directors and sharing individual performance data with the medical oncologists was a simple intervention yet yielded a significant improvement in their ClinicalPath utilization rates. Public recognition, along with addressing common barriers through education resulted in further improvement. This approach serves as a model for increasing utilization of a point of care clinical decision tool.
Quality metrics at scale: Deriving time to first cancer treatment from electronic health records.
Authors: Sondhi Arjun , Silver Heather , Jacob Alexandra , Bramwell Lindsay Gaido , Levine Jonathan , Dominic Erica , Geno Giselle , Xhaja Anisa , Rocque Gabrielle Betty
Published: October 2023

580

Background: Measurements of cancer care quality are critical for internal administration and participation in value-based care programs, towards the goal of improving patient outcomes. Data from electronic health records (EHRs) have the potential to allow for automatic computation of quality measures at a larger scale than manual chart review. This requires the creation of algorithms that process data and apply custom logic to define a clinically meaningful measurement. In this work, we describe the development and performance of an algorithm for deriving time from first primary oncologist visit to first cancer treatment using EHR data. Methods: This EHR-derived measure of time to first treatment (TTT) was implemented at an academic medical center for all patients who had a visit since 01/01/2011 and a cancer-related diagnosis code. We defined a patient’s primary oncologist as the first medical oncologist who they visited at least 5 times. These criteria were chosen to find the first provider at the site who the patient likely established care with and received treatment from. Then the patient’s TTT is computed as the number of days between their first visit date with this oncologist and the date of their first antineoplastic drug administration. Data on other treatment modalities, such as surgery and radiation therapy, were not available at the time of algorithm development. We allow for patients to receive their first treatment up to 60 days before their first visit to account for inpatient treatments before a primary outpatient oncologist is established. This algorithm’s performance was assessed through manual chart review among a sample of 38 patients. Results: Our algorithm correctly assigned 37 out of 38 patients (97.4%) to their primary oncologist, and computed the correct TTT for 28 out of 38 patients (73.4%). Incorrect TTT computations were mostly due to missingness of systemic therapy administrations in the structured EHR data; these were primarily for oral therapies. Conclusions: This work demonstrates the feasibility of measuring a patient’s TTT from structured EHR data alone. In particular, a patient’s initial visit with their primary oncologist can be derived with high accuracy. From this index date, the accuracy of the metric is dependent on the availability of structured treatment data. To further improve the EHR-derived metric, future work should incorporate other treatment modalities through structured data sources such as billing codes, and improve completeness of systemic therapy data in a scalable way, such as from natural language processing techniques.[Table: see text]
Enhancing cancer care: Leveraging technology for proactive psychosocial and social determinants of health screenings.
Authors: Liu Mark , Snow Alison , Bhardwaj Aarti Sonia , Terry Karen , Bressler Toby , Kreitman Jessica , Karpin Jordan , Mazor Melissa , Smith Cardinale B.
Published: October 2023

583

Background: Cancer diagnoses and their associated treatments cause many patients significant psychosocial distress. The psychological, social, spiritual, and financial burdens of cancer contribute to psychosocial distress throughout all stages of the cancer trajectory, with between 35-46% of patients reporting significant psychosocial distress. As such, the American College of Surgeons Commission on Cancer mandates psychosocial distress screening in cancer patients. Though this screening has been shown to reduce cancer related distress levels, barriers remain in sustained implementation. Additionally, even at locations with screening strategies in place, patient completion remains variable and inconsistent. To address these challenges, we created a customized screening tool, embedded in the electronic health record (EHR), that includes assessment for depression, social determinants of health (SDH) and spiritual care. Methods: The Quality of Life and Support (QOL&S) survey was created through an interdisciplinary review of evidence-based questions to proactively address supportive care needs for patients with cancer seen in the ambulatory setting. Survey questions, available in English and Spanish, were consolidated into a single survey, which was built into the EHR. Patients were prompted to complete the survey via the patient portal 7 days prior to their second medical oncology appointment, with a reminder sent if the survey was not yet completed 3 days before the appointment. Patients are automatically sent the survey again every 3 months. Based on responses, the survey automatically generated referrals to social work, chaplain and/or child life specialist. SDH responses are aggregated at a patient-level in a dedicated section of the patient’s chart. We used descriptive statistics to describe the rate of survey completion, patient demographics and referrals generated. Results: From June 22, 2022-May 31, 2023, 4,278 (37%) eligible patients have completed surveys. Among patients, the mean age is 59; 42% identify as White, 21% as Black; 89% have a primary language of English; 67% identify as Female, 33% as Male. Patients completed 75% of surveys prior to their appointment. Surveys completed by unique patients generated: 1,113 (26%) referrals to social work, 490 (11%) to chaplain and 82 (2%) to child life. Conclusions: Identification of those at risk of psychosocial distress enables practitioners to provide appropriate resources and alleviate the overall burden experienced by cancer patients. Using technology, we have increased completion of the screening tool while also reducing the reliance on staff to administer the survey. Future work includes expanding access to more languages, increasing patient response rates and identifying the highest SDH needs to develop meaningful interventions and programs.
Improving serious illness conversations in oncology: A machine learning approach that integrates natural language processing for mortality prediction.
Authors: Parchure Prathamesh , Vargas Marcos , Graham Livingston , Wang Min-heng , Gorbenko Ksenia O. , Mazumdar Madhu , Smith Cardinale B. , Kia Arash
Published: October 2023

590

Background: ML-based mortality prediction tools in oncology can optimize clinical decisions and prompt end-of-life care discussions. Patients with advanced cancer who have engaged in Goals of Care (GoC) conversations report improved quality of life and better care alignment. However, oncologists often have overly optimistic prognoses and miss timely GoC discussions. Clinical notes are a valuable source of information, but processing and extracting data from them is time-consuming and labor-intensive. To address this issue, we have developed a machine learning application that ingests clinical notes and structured data from electronic health records (EHRs) to generate a 180-day mortality risk, prompting oncologists for GoC conversations. Methods: A predictive machine learning model was developed using data from cancer patients aged 21 and above, diagnosed between January 2016 and December 2021. Data was collected from various sources, including cancer and death registry and the EHR. By analyzing structured and unstructured data from ambulatory progress notes, a clinical profile was created for each patient. The model utilized Spark-NLP for preprocessing, applying word2vec embedding and pre-trained NER models to extract information on diseases, symptoms, procedures, treatments, and medications. Feature engineering techniques were used to select the best NLP features, combined with structured data. The model was trained using 894 patients, employing Random Forest Classifier with 10-fold cross-validation, and tested on a separate set of 43,274 patients. Performance evaluation included ROC AUC, PR AUC, and F1 Score metrics. Results: After the fine tuning, the best model showed an AUC-ROC of 0.88 on the train set and 0.75 on the test set. At a threshold of 0.44, the model achieved a balanced performance with a sensitivity of 0.70 and specificity of 0.71 on the testing set. Conclusions: Our team pioneered the development of an automated multi-modality pipeline that combines unstructured real-world data with structured data, allowing for training and testing of a fusion model. This automation opens doors for scaling and dissemination, to enhance mortality prediction. Future works will involve qualitative analysis of implementation and acceptance in clinical practice.
Addressing challenges in telephone triage for outpatient oncology care: A data-centred digital routing solution.
Authors: Lovas Mike , Krzyzanowska Monika K. , Somji Faiza , Devonish Shayla , Spiro Grace , Truong Tran , Lane Kelly , Badzynski Adam , Wolf Susan , Tymoshyk Iryna , Macedo Alyssa , Dozois Graham , Bravo Ana , Julius Anet , Moody Lesley , Kooner Simranjit , Melwani Sheena , Berlin Alejandro
Published: October 2023

591

Background: As cancer care shifts to a predominately outpatient model, there is growing recognition that optimizing communication between patients and their care providers between scheduled visits can improve efficiency and patient outcomes. Princess Margaret Cancer Centre (PM), which sees over 80,000 patients annually, operates with many parallel telephone triage lines as the primary means of patients-provider communication. When a patient needs to contact their care team, they are instructed to leave a voicemail and wait for a response. In a high-volume setting this model presents many challenges to the patient experience, provider efficiency, and patient safety. The purpose of this pilot project was to design, implement, and assess the feasibility of a digital channel for patients to reach their care team. Methods: We used a human-centred design approach to develop a new digital triage service. First, we analyzed manually collected triage call data over a one-year period to understand the most common patient queries of the telephone triage service. Through co-design, a new digital-triage service was conceptualized and prototyped. Subsequently, we tested a data-centred digital routing algorithm for patient concerns and symptoms. To evaluate implementation and assess feasibility, we collected usage data, satisfaction surveys, and conducted staff shadowing and interviews. We used PDSA cycles to refine user experience and clinical workflows. Results: Patient adoption of digital triage increased continuously over 9 months, with volumes surpassing voicemail after four months: over the last four months digital triage has encompassed on average 63% of the total request volumes. The response rate to patient surveys was 21%. Patients indicated being very satisfied or satisfied (74.4%), neutral (6.7%), and dissatisfied or very dissatisfied (18.9%). Interviews with leading triage staff suggest the digital channel improves triage efficiency and redirecting/escalation by providing structured and complete patient queries. Conclusions: The pilot highlights the feasibility and acceptability of a digital-triage service in a comprehensive cancer care setting. By leveraging digital tools and real-time data, PM addressed the challenges of telephone triage, enabling a more efficient process to respond to patients’ needs, while demonstrating high adoption and patient satisfaction. Subsequent work will expand the use of digital triage to all disease sites across the cancer centre, and create foundational workflows and technology for proactive care models, such as Remote Patient Monitoring.
Outcomes of clinical pharmacist integration in a community oncology practice.
Authors: Sias Katie , Reyes-Gastelum David , Young Katie , Farris Karen B. , Schwartz Ashley , Wietzke Julie , Mackler Emily R.
Published: October 2023

61

Background: There is a need to optimize the education and follow-up of patients receiving oral anticancer agents (OAAs) and high emetic risk chemotherapy (HEC) due to toxicities and implications of non-adherence and decreased dose intensity. The purpose of this study was to compare outcomes before and after the integration of a clinical pharmacist in a community oncology practice. Prior to the pharmacist, patients receiving OAAs and intravenous (IV) HEC received education and symptom monitoring by a team of nurses. Methods: This single center, retrospective analysis was conducted with data from February 2020 – December 2022. Up to 200 patients in the pre- and post-intervention periods each were identified. Charts were eligible for abstraction if patients were newly prescribed an OAA or IV HEC regimen during the study period. The post-intervention period began after the pharmacist’s start in March 2021. Patients receiving endocrine therapy for breast cancer were excluded. The following data were abstracted: patient demographics, OAA and IV HEC medication, line of therapy, cancer diagnosis, prescribed date, start date, education date, follow-up visits, emergency department (ED) and hospitalizations, reason for ED/hospitalization, IV HEC dose adjustments, delays and discontinuations. Chi-square analyses compared pre and post time periods. Results: Abstraction was completed for 179 patients in the pre-intervention (n=61 IV HEC; n=118 OAA) and 162 patients in the post-intervention group (n=44 IV HEC; n=118 OAA). After the pharmacist was integrated into the practice, more patients in the OAA group received education prior to their OAA start and had their medication adherence assessed. In the IV HEC group, more patients received guideline concordant care with a 4-drug regimen (including olanzapine) and were more often able to remain on their prescribed dose and dosing interval in the group with pharmacist care. Other outcomes remained approximately the same across time periods. Conclusions: Embedded clinical pharmacist care improved patient outcomes, including improved rates of patient education, medication adherence assessment, and improved dose intensity. [Table: see text]