bluuebunny/crossref_metadata_2025 huggingface dataset:
Examining potential cancer care disparities in an equal access system: Quality of colorectal cancer care (CRC) in the Veterans Affairs (VA) health care system.
Authors: Zullig Leah L. , Carpenter William Ruffin , Abbott David H. , Provenzale Dawn T. , Weinberger Morris , Reeve Bryce B. , Jackson George L.
Published: February 2017

229

Background: Racial disparities in cancer treatment and outcomes are a substantial problem nationally. The Veterans Affairs (VA) health system is nationwide, with goals of being equal access and delivering high-quality care; however, the presence or extent of racial disparities in CRC treatment and outcomes within the VA is poorly understood. We examined the relationship between race and receipt of National Comprehensive Cancer Network guideline-concordant CRC care in the VA. Methods: We identified 2,896 patients diagnosed with incident CRC between October 1, 2003 and March 31, 2006 from 128 VAMCs. We included white and black patients with invasive, non-metastatic disease, known comorbidity status, age, and marital status. Multivariable logistic regression examined the association between race and receipt of guideline-concordant care (CT scan, preoperative CEA, clear surgical margins, referral to medical oncology for stages II to III; receipt of 5FU-based adjuvant chemotherapy for stage III; receipt of surveillance colonoscopy for stages I-III). Explanatory variables included demographic and disease characteristics. Results: In the final sample of 2,022 men, mean age at diagnosis was 68 years; 85% were white, 52%, married, and 38% lived in the South. Stage was evenly distributed. No significant racial differences existed for most guidelines. Compared to blacks, whites were more likely to undergo surveillance colonoscopy 6 to 18 months following surgery (OR=1.32, 95% CI 1.01-1.73, p=0.04) and marginally more likely to be referred to medical oncology (OR=1.46, 95% CI 1.00-2.13, p=0.05). Patients who were 75 years or older at diagnosis (p<0.01) or with cardiovascular-related comorbidities (OR=0.65, 95% CI 0.50-0.89, p=0.01) were less likely to be referred to a medical oncologist than their younger, healthier counterparts. Conclusions: In general, the VA provides high quality, equal access cancer care; however, there may be room for improvement.
Claims/utilization-based intensity of end-of-life (EOL) cancer care in integrated health systems (IHS).
Authors: Loggers Elizabeth , Fishman Paul Arthur , Ramaprasan Arvind , Earle Craig
Published: February 2017

230

Background: Little is known about the intensity of EOL cancer care for patients within IHS or those under 65 years of age. This study assessed achievement of National Quality Forum (NQF) benchmarks for EOL cancer care among IHS enrollees aged >20 at death. Methods: Using methods described by Earle, we identified IHS enrollees whose cause of death was cancer (not diagnosed at death or via autopsy) per tumor registry data between 2000-2008. Using claims/utilization data we identified individuals who received chemotherapy (chemo) in the last 14 days of life (C, benchmark (B): <10%) or a new chemo regimen in the last 30 days of life (NC, B<2%); had >1 emergency department visit (ER, B<4%):) or hospitalization (H, B<4%) in the last 30 days of life; died in hospital (HD, B: <17%), were not admitted to hospice (NH, B: <45%), or where admitted to hospice in the last 3 days of life (SH, B: <8%). The percentages were then compared to previously established fee-for-service (FFS) Medicare benchmarks. Results: At death, 4,924 IHS cancer patients were >65 years of age, 3,478 were <65. For those >65, benchmarks were achieved for chemo in the last 14 days of life (5%), death in an acute care hospital (16%), and hospice stay <3 days (4%). For those aged 21-64 years of age at death, benchmarks were achieved for chemo in the last 14 days of life (7%) and hospice stay <3 days (4%). Benchmarks were not achieved in either group for new chemo regimens, ER visits, or hospitalizations in the last 30 days of life or hospice admissions. Conclusions: Most NQF benchmarks for EOL cancer care were not achieved, particularly among the young. Future research should update FFS benchmarks based on current utilization and clarify benchmarks for those <65. Final presentation will include results from at least 2 other IHS. [Table: see text]
Chemotherapy use during the last 30 days of life in patients with cancer.
Authors: Rodriguez Maria Alma , DeJesus Yvette , Cheng Lee
Published: February 2017

231

Background: Treatment options are increasingly available to patients with advanced cancer. Appropriately timed cession of chemotherapy is a quality-of-care measure in the Quality Oncology Practice Initiative of the American Society of Clinical Oncology. To gain insight into whether communication about end-of-life (EOL) issues might need to be improved, we analyzed chemotherapy use during the 30 days at the EOL (EOLCx) among patients at large cancer center. We also analyzed the presence of electronic DNR (eDNR) orders at the time of death in hospital as a surrogate indicator of EOL discussions. Methods: We reviewed the records of cancer patients (age≥18 years) who received their care at The University of Texas MD Anderson Cancer Center and died between December 2010 and May 2012. Logistic regression was used to measure associations of EOLCx and age, gender, ethnicity, comorbidities, cancer type, and cancer progression. Results: A total of 7,399 patients met the inclusion criteria. The median age was 64 years; 46% were female and 18% had hematologic malignancies (HM). 996 patients (14%) received EOLCx, and of these, 554 died in the hospital (7%, 554/7,399). Of those who died in the hospital, 93% had eDNR orders (no difference between solid tumors [ST] and HM). The EOLCx was higher for patients who died in the hospital than for those who died elsewhere (44% vs 7%) and higher for patients with HM than for those with ST (38% vs 8%). EOLCx was more common in patients with ST with metastases, HM without relapse, and HM with relapse than in those with ST without metastases [odds ratios (ORs), 3.3, 13.9, and 32.8, respectively; all p<0.05]. EOLCx was less common in older patients (≥65 years) than younger patients (OR, 0.6; p<0.05) and was more common in patients with comorbidities than in those without (OR, 1.3; p<0.05) and in patients who were not black or Hispanic than in white patients (OR, 1.6; p<0.05). No difference of EOLCx between genders was found. Conclusions: EOLCx was more common in patients with HM with or without relapse than in patients with ST. Most patients had eDNR orders at the time of death in hospital. The results suggest that communication about prognosis and advanced planning about the goals of medical care is becoming critical part in overall oncologic care plan.
Using QOPI metrics for physician incentive compensation.
Authors: Makari-Judson Grace , Wrenn Tamara , Mertens Wilson C. , Josephson Gordon , Stewart James A.
Published: February 2017

241

Background: Physician incentive or variable compensation (VC) models are typically based on work relative value units (wRVU). Baystate Medical Practices (BMP), a group of over 450 practitioners, is evaluating a division based pilot program for VC that, while it includes wRVUs, also includes other important performance metrics. QOPI is emerging nationally as a comprehensive method for assessing quality across oncology practices. We describe the use of QOPI measures as part of a financial incentive plan for a hospital-based oncology division. Methods: A nine member QOPI certified Oncology Division participated in a pilot VC plan with group specific targets selected based on prior below average performance. 20 overall weighting percent (10% weight per category) of the overall VC framework was linked to success in two QOPI categories; “completion of treatment summaries (RxS) within 90 days of end of chemo” and “assessment of patients’ emotional well being by second office visit.” Three tiers of achievement were set for each goal. For RxS completion, Tiers I, II and III were defined as completion of 15, 25, and 40% of charts respectively as measured by an internal audit. For assessment of patient emotional well being tiers were at the 75th, 80th, and 85th percentiles of national QOPI participants. A formula combining VC goals into year-end VC payout was driven by three levels of percent base salary: 8, 12, and 24% respectively. The probability of achievement of each goal was expected to be 90, 50, and 10% respectively. Educational discussions with BMP leadership were held to teach about QOPI validity in the oncology community. Results: BMP fiscal year ends September 30, thus final numbers are pending. With systems based improvements, Tier I achievement for emotional well being and Tier II achievement for RxS completion is expected. The division is interested in using different QOPI measures for VC next year with the goal of continuous improvement in QOPI scores. Conclusions: QOPI metrics can be used as a quality incentive for oncologists in the setting of a VC plan. Non-oncologists can appreciate the strength of QOPI as a quality tool. With time, the combination of a QOPI program through ASCO and use of various QOPI metrics can drive continuous improvement in an oncology group.
Access to palliative care before death among patients treated at a comprehensive cancer center.
Authors: Hui David , Kim Sun Hyun , Kwon Jung Hye , Tanco Kimberson Cochien , Zhang Tao , Kang Jung Hun , Rhondali Wadih , Chisholm Gary B. , Bruera Eduardo
Published: February 2017

25

Background: Palliative care (PC) access is a critical component of quality cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually received PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center, and the predictors of PC referral. Methods: We reviewed the charts ofconsecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center and died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death using univariate and multivariate logistic regression. Results: A total of 366/816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range (0.5-4.2) and the median number of medical team encounters before PC was 20 (6-45). In multivariate analysis, older age, being married, and specific cancer types (gynecology, lung and head and neck) were significantly associated with a PC referral (Table). Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between advanced cancer diagnosis and PC consultation (median 16 months), the shortest interval between PC consultation and death (median 0.4 month), and one of the largest number of medical team encounters (median 38) before PC. Conclusions: We found that a majority of cancer patients at our cancer center did not access PC before they die. PC referral occurs late in the disease process with many missed opportunities for referral. Further effort is needed to improve quality of end-of-life care. [Table: see text]
Using a pathways process to ensure measurable evidence-based standardized care in a large cancer network.
Authors: Ellis Peter G. , Lokay Kathleen
Published: February 2017

252

Background: UPMC CancerCenter includes 40 sites of services in a 100 mile radius in Western Pennsylvania. Consistency and quality of care are critical to such a diverse network. In addition, the UPMC mission includes accrual to clinical trials. To meet these challenges, UPMC developed the Via Oncology Pathways. The program has served UPMC well for over seven years to date and is now a key foundation for UPMC’s overall healthcare reform strategy for quality and accountable care. Methods: Treatment algorithms were developed for 90% of cancer types by establishing committees of academic and community specialists. These committees interpret the literature and define the most efficacious, least toxic, and economically efficient treatment regimens appropriate for highly specific disease presentations (e.g., node +, er-, her2 +, PS 0-1). Clinical trials are also imbedded into the algorithms. Quarterly, these algorithms are reviewed by the committees to assess relevance, review network feedback, add newly available trials and address emerging data. Equally important to clinical content is its presentation to the practicing physician in a manner that allows real time usage and adds value to physician workflow. This is accomplished with a web portal that presents the individual pathways status through the physician’s daily schedule. Results: Over 120 oncologists at UPMC use Via Oncology Pathways in their daily practice. In 2011, UPMC physicians confirmed a pathways status for 94% of their patient visits (195,000) and achieved an On Pathway rate of 82% for their 18,000 treatment decisions. The database also includes patient presentations, reasons for going off pathway and reasons for not accruing to clinical trial. Lower hospitalization rates and mandated adoption of personalized medicine were also observed. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to improving the quality and cost effectiveness of cancer care by enhancing physician decision-making, standardizing care and ensuring access to evidence-based personalized medicine. We continue to expand the scope of our pathways to include diagnostic studies, surveillance protocols and end of life prompts.
Identification, categorization, and mapping of indicators used by JACIE-accredited stem cell transplantation programs to assess distribution and coverage of processes.
Authors: Olivia Caunday , Odette Agulles , Eoin McGrath , Fabienne Empereur , Jean Francois Stoltz , Christian Chabannon
Published: February 2017

255

Background: More than 145 European hematopoietic stem cell transplantation (HSCT) programs received JACIE accreditation since 2000, demonstrating compliance with FACT-JACIE international standards. The association of JACIE with improved patient outcome was recently documented. Conditions in which quality management systems were introduced and actual benefits remain to be fully evaluated. Methods: The study explores one aspect of quality management: introduction and use of indicators. Through a questionnaire sent to JACIE accredited centers, we aimed at identifying indicators (name, domain of application, category, longevity, and general description), understanding how they were set in place, whether or not similar indicators were used by different programs, and whether all of the HSCT processes were monitored. The survey was first sent to 14 French accredited HSCT centers and next to 68 other programs in 11 European countries. Categorization was double-checked against published criteria. Results: The response rate was 40% (32 programs). 293 indicators were collected, including 224 (76%) that were introduced during the preparatory phase of JACIE accreditation. Indicators were associated with the following processes measurement, analysis and improvement (54/293 or 18%); donor collection (49/293 or 16%); processing and storage of cell therapy products (37 /293 or 12.5%), administration of HPC (67/293 or 23%). Mapping reveals an uneven distribution of indicators across the different sub-processes that contribute to this highly-specialized medical procedure. Moreover, we found that only 101/293 indicators (34%) comply with the rules for implementation of a quality indicator, as defined by the FDX 50-171 standard. Conclusions: This suggests that risks to donors/recipients are unevenly monitored, leaving critical medical steps with low levels of monitoring.
Patterns and predictors of chemotherapy and trastuzumab use for early-stage breast cancer in Kaiser Permanente Northern California, 2004-2007.
Authors: Kurian Allison W. , Lichtensztajn Daphne , Keegan Theresa H.M. , Leung Rita W. , Shema Sarah J. , Hershman Dawn L. , Kushi Lawrence H. , Habel Laurel A. , Kolevska Tatjana , Caan Bette Jane , Gomez Scarlett Lin
Published: February 2017

256

Background: Chemotherapy regimens for early-stage breast cancer have been extensively tested by randomized clinical trials, and specified by evidence based-practice guidelines. However, little is known about the translation of trial results and guidelines to oncology practice. Methods: We extracted individual-level data on chemotherapy administration from the electronic medical records of Kaiser Permanente Northern California (KPNC), a pre-paid integrated health-care delivery system serving 29% of the local population. We linked data to the California Cancer Registry, incorporating demographic and tumor factors, and performed multivariable logistic regression analyses on the receipt of specific chemotherapy regimens. Results: We identified 6,178 women diagnosed with stage I to III breast cancer at KPNC during 2004 to 2007; 2,735 (44.3%) received at least one chemotherapy infusion at KPNC within 18 months of diagnosis. Factors associated with receiving chemotherapy, and specifically receiving anthracyclines, taxanes, and/or trastuzumab, included young age, large tumor size, involved lymph nodes, hormone receptor-negative or HER2/neu-positive tumors, and high tumor grade; comorbid conditions were inversely associated with chemotherapy use (heart disease for anthracyclines, neuropathy for taxanes). We observed less chemotherapy use by unmarried women, less anthracycline and taxane use by low-socioeconomic status (SES) non-Hispanic whites, and more anthracycline use by high-SES Asian/Pacific Islanders (versus high-SES non-Hispanic whites). Concordance with relevant measures of the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) was highest among younger women with larger, higher grade tumors. Conclusions: In this health care organization with essentially equal access, we discovered that chemotherapy use was concordant with practice guidelines, yet may vary according to socio-demographic factors. These findings may inform efforts to optimize treatment, and guide studies of quality in breast cancer care.
From evidence to impact: Determining the vital few indicators for systemic treatment computerized prescriber order entry systems (ST CPOE).
Authors: Lankshear Sara , Theriault Marc , Cheung Annie , Hertz Sherrie , Kaiser Leonard , Kukreti Vishal
Published: February 2017

258

Background: It is important to demonstrate that delivery systems contribute to patient outcomes. Quality indicators provide a quantitative, evidence based (EB) foundation for clinicians, organizations, researchers, and administrators to monitor and evaluate performance of these systems. Technologies, such as ST CPOE systems are costly, impact clinician practice and therefore, would benefit from accountability through quality measures. The process for the identification of EB indicators for measuring the impacts of ST CPOE systems is described. Methods: The indicators were developed alongside the ST CPOE Best Practice Guideline. A multi-phased approach included the development of a conceptual framework, defining quality dimensions, literature review, environmental scans, and key informant interviews. An initial list of indicators was identified and aligned with the relevant quality dimensions (i.e. safety, effectiveness, efficiency, integration). A Modified Delphi methodology, involving internal and external content experts in oncology practice, technology, informatics, and human factors, was undertaken to obtain consensus on the vital few. Results: Three rounds of Modified Delphi exercises were conducted with the initial list of 118 indicators. 15 clinical practice indicators (CPI) were deemed as relevant for overall evaluation and research purposes specific to ST CPOE systems. Within this group, four indicators were identified as being valuable for reporting quality monitoring at the organizational, regional and provincial levels. In addition to CPI, 74 system functionality (e.g. usability, alert features, system integration) indicators were identified. Conclusions: Through engagement of experts and evidence review, we have identified a set of quality indicators for ST CPOE systems which will facilitate appropriate evaluation of systems and implementation processes. Operationalizing these indicators for automatic data flow through is planned in a large geographic area.
Compliance to select quality measures in a non-QOPI subspecialty academic practice: A pilot quality improvement initiative.
Authors: Reichert Sonia , DeGregorio Paola , Bilotti Lauren , Ulysse Fabienne , Sung Max , Holcombe Randall F.
Published: February 2017

261

Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes core, disease and domain-specific quality measures. QOPI Certification requires an overall score of 72.62% in 24 core and 80% in adjuvant quality measures. There are currently 137 oncology practices with only 10 in New York State having achieved QOPI certification. At Mount Sinai Medical Center (MSMC), the large hematology and oncology practice is subdivided into disease-specific groups functioning semi-autonomously. The practice is not QOPI certified. With no prior measures of quality adherence in the overall or subspecialty groups we aimed to determine the baseline compliance to QOPI disease specific measures. Methods: All colorectal patient charts seen in the GI oncology group at MSMC over a four-month period from February 2012 to May 2012 were retrospectively reviewed. The team included two GI oncology physicians, one physician assistant and one registered nurse. Each member was assigned roles to meet the defined quality measures prior to project initiation. A separate auditor reviewed medical records during the study period. 17 quality measures were evaluated including 10 core and one adjuvant colorectal disease-specific measure. Results: The average compliance with the QOPI measures tested was 96%, 98%, 92%, and 97% (February to May respectively). The measures with the lowest compliance were not required for certification but included for internal review after recent practice changes. Despite the high compliance rate, compliance for an individual patient in all 17 categories was achieved in only 48% of patients. Conclusions: This study highlights that adherence to quality benchmarks in a disease-specific subset of a larger oncology program can be achieved by identifying staff, assigning roles and defining practice structure. The GI Oncology group attained a level of compliance with quality measures that would result in QOPI certification if maintained practice-wide. This study serves as the basis for a larger internal audit of quality measures across other subspecialty disease-specific areas of hematology and oncology at MSMC.
Method of biopsy and sample quality for genetic mutation testing in advanced non-small cell lung cancer in a community hospital.
Authors: Hrinczenko Borys , Subramonia-Iyer Subramony
Published: February 2017

271

Background: Mutated EGFR gene testing transformed the care of NSCLC. ASCO now recommends EGFR mutation testing for NSCLC (April 2011); however, no studies to assess quality of biopsy samples and adequacy for mutation testing have been done outside a trial setting. Methods: A retrospective chart review to identify patients diagnosed with NSCLC at a community hospital during 2010. A pathologist reviewed the quality of archivedbiopsy samples for histological diagnosis and adequacy for EGFR mutation testing based on ASCO criteria. Results: In 2010, 64 cases of NSCLC were diagnosed and 18 patients had definitive surgery, 46 did not. Histological subtypes: squamous - 28 (44%), adenocarcinoma - 23 (36%), bronchoalveolar - 3 (5%), adeno with mixed bronchoalveolar - 2 (3%), large cell - 3 (5%), and large cell neuroendocrine - 2 (3%). Staging: stage I, II, III, IV - 18 (28%), 2 (3%), 13 (20%), 23 (36%). Biopsy material: transbronchial needle biopsy in 23 (36%), CT-guided biopsy in 13 (20%), surgery in 18 (28%), other - 10 (15%). Specimen review: 3 samples (5%) were designated as large cell carcinoma without squamous or adeno specification. 46/64 (72%) were adequate for mutation analysis; 18 (28%) were not. Among adenoca., 19/28 (68%) were adequate samples, but 9 (32%) were not. Among the 46 patients who had advanced or metastatic disease, 28 (60%) had sufficient samples, 18 (40%) did not. Among advanced adenoca. patients, the proportion without adequate sample was 9/18 (50%). Route of biopsy: 4/23 transbronchial biopsies (17%), 8/13 CT-guided biopsies (62%) and 6/10 from other sites (60%) were inadequate (p = 0.01). Conclusions: Nearly one-third of all NSCLC cases, including half of advanced adenoca., yielded poor quality specimens from the first biopsy for EGFR mutation analysis. 5% of samples lacked definitive histology. CT-guided transthoracic biopsies were at least twice as likely to yield poorer quality specimens compared to transbronchial biopsies. Poor quality tumor sampling may preclude mutation testing thus denying beneficial and less toxic therapy. Quality of tumor specimens needs to be improved in the future by the development of appropriate strategies by multidisciplinary lung cancer teams.
Coordination and timeliness of care by insurance status in a gastrointestinal (GI) multidisciplinary care (MDC) program.
Authors: McCahill Laurence E. , Kokko Jamie , Davis Alan T. , Taylor Wendy K. , Martinez Coralyn , May Mary
Published: February 2017

272

Background: Patients with newly diagnosed GI cancers require diagnostic studies and evaluations by physicians that may delay initiation of cancer care. Uninsured populations are particularly vulnerable. A Nurse Navigator (NN) can help decrease barriers and improve timeliness of care. This study aims to compare timeliness of cancer care received by patients referred to a GI MDC Program by the patient’s insurance status at the time of referral. Methods: Patients referred to the GI MDC are assigned a NN who evaluates medical history, diagnostic studies, and coordinates further testing and physician evaluations. Timeliness measures assessing milestones in cancer care initiation are collected prospectively. Descriptive statistics are presented and average times for measures are compared by insurance status (insured vs. uninsured) using t-tests, chi-square tests, and the Fisher’s Exact test. Results: 366 patients were evaluated between January 2010 and June 2012. 70% (255/366) were for new cancer diagnoses. Median age of cancer patients was 64 years (range 29-94), 63.1% of patients were male, and 94.1% of patients had insurance. Major cancer diagnosis types were colon/rectal (19.2%), esophageal/gastric (25.1%), hepatobiliary (12.8%) and pancreatic/ampullary/duodenal (35.7%) and 1.6% other. The table describes timeliness and care coordination measures by insurance status. Conclusions: Uninsured cancer patients in our health system appear to receive care in a timely fashion which does not differ from patients with insurance. The impact of a dedicated GI NN in avoiding disparate care for uninsured warrants further study. [Table: see text]
Average breast cancer stage in patients with various insurances and incomes.
Authors: Haroon Sehr
Published: February 2017

278

Background: Worsening global economy is increasing uninsured vs. other insurance (private, medicare, Medicaid, VA). Average stage of breast cancer is likely higher in uninsured vs. other insurance. Methods: Individuals diagnosed with breast cancer (diagnosed 2000- 2009) were reported to the National Cancer Database (NCDB). Variables of insurance status (uninsured, private, Medicaid, Medicare, and VA), stage of diagnosis (0:carcinoma in situ- 4:metastatic disease), and income level (<$28k, $28k-32,999, $33k-38,999, $39k-48,999, $49k+) were analyzed. Results: From 2000-2009, the privately insured percentage decreased by 39.4%, with 134.3% increase in Medicaid insured. Average stage in uninsured was 1.8, statistically significant compared to 1.2 for privately insured, and 1.5 for Medicare. This was untrue of VA and Medicaid insured. Significant differences exist between uninsured and Privately insured for every income. At $28K/yr, average stage of breast cancer was 1.9 in uninsured,1.5 in privately insured. When income >49K/yr, average stage was 1.7 in uninsured, 1.3 in privately insured, while VA insured remained 1.4. Conclusions: Uninsured patients had worse stage than privately insured. For private and Medicare insured, increasing income correlated significantly to earlier stage of diagnosis4, which was untrue for uninsured, VA, and Medicaid insured. Highest stage was in lowest income uninsured, whereas lowest stage was in highest income, privately insured. Income did not effect average stage of VA. [Table: see text]
Statistical methods as a problem-solving strategy in health care.
Authors: Schaub Diane , Terrell James
Published: February 2017

279

Background: Clinical personnel in healthcare are being challenged to improve quality and increase productivity in order to lower healthcare costs in the United States. With the effort to become more cost conscious, there is an ever increasing need to analyze processes and make them more efficient. The complexity of these processes and the data associated with them require more complex analysis and more sophisticated statistical tools. Unfortunately the statistical training of many health care employees is not adequate for the more complex tools and processes. Methods: At the University of Texas MD Anderson Cancer Center, we use Minitab software, widely used in the manufacturing sector, as our primary statistical analysis software. It is on this platform that the Office of Performance Improvement is creating training courses to assist in raising the statistical literacy level of clinical employees. This software is fairly easy to use, and contains tools for visualizing data such as control charts and box plots, as well as performing multivariable analysis such as regression or ANOVA (Analysis of Variance). Results: Early adopters of the methodology to utilize statistical tools in process improvement studies has been extremely positive. They enjoy being able to quantify their improvement results, document them, and share them with others. Conclusions: Process Improvement leaders need to improve their skills in several areas of statistical methodology. Specifically, they should be able to select the correct graphic to show the critical information in their data, they should be able to select the proper tools and perform analysis to interpret the data, and they should have a technical vocabulary to share and communicate their key learning with others. Minitab is a widely accepted software package for process improvement here at MD Anderson Cancer Center. There are many other very good software packages on the market but it is helpful for support, teaching, and consistency if an institution settles on a package as a basic standard.
Ongoing professional practice evaluation implementation within STATIT.
Authors: Shi Weiming
Published: February 2017

283

Background: The OPPE allows the organization to identify professional practice trends that impact quality of care and patient safety. The intent of the standard is that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis, to allow them to take steps to improve performance on a more timely basis. Methods: Infrastructure development. We assigned people for data integration, technical support and metric development. The manager of Clinical Decision Support serve as the administrative coordinator to the program managed the progress of implementation. Leadership Support. To implement the STATIT for OPPE in any hospital, executive leadership support is required to secure funding and resources for the program as well as to support the quality improvement initiatives undertaken that will affect current policies and a wide range of personnel. The early support for the OPPE STATIT came from hospital’s administrative leadership and Performance Improvement leadership. Committed OPPE STATIT implementation team. The basic OPPE STATIT team, consisting of a Manager of Clinical Decision Support, two IT people, and ten Informatics Analysts, requires additional personnel such as departmental Quality Officer with differing expertise for indicator development. Results: All of medical knowledge, patient care activity, and system based indicators plus departmental specific cancer care indicators can be reviewed and any outliers can be drilled down for analysis by division head, department chair and quality officer and signed off on a six-month basis. All individual providers also are able to review his/her performance quality and peers’ comparison. Conclusions: The MIDAS + Statit Physican Profile & Review (PPR) solution is a Web-based system that allows medical providers easy access performance dashboards, which contain up-to-the-moment performance data, annual and interim reviews and drill down to patient level data. The information is necessary to align medical staff with key strategic objectives across the organization. It provides the statistical analysis of patient care quality and safety and opportunities of improvement.
The rapid quality reporting system: Assessing and improving the quality of cancer care with a prospective clinical performance tracking and reporting system.
Authors: McNamara Erica J. , Stewart Andrew , Gay E. Greer , Banasiak James , Palis Bryan E. , Edge Stephen B.
Published: February 2017

286

Background: The Rapid Quality Reporting System (RQRS), developed by The Commission on Cancer of The American College of Surgeons, allows accredited cancer programs to prospectively monitor adherence to five National Quality Forum endorsed quality of care metrics for breast (BC) and colon (CC) cancer. This study assesses differences in performance rates by patient populations and demonstrates the impact a prospective clinical performance tracking system can have in impacting care. Methods: RQRS tracks and measures compliance with the following measures: Radiation therapy within one year of diagnosis (dx) for women <70 receiving breast conserving surgery for BC (BCS/RT); hormone therapy within one year of dx for AJCC T1c, N0M0, or stage II or II; hormone receptor positive BC (HT); multi-agent chemotherapy within four months of dx; age < 70; hormone receptor negative BC (MAC); adjuvant chemotherapy within four months of dx; age <80; AJCC stage III CC (ACT); pathologic examination of ≥12 regional lymph nodes for surgically resected CC (12RLN). 64,129 RQRS measure eligible cases diagnosed from 2006 to 2010 from 64 RQRS beta test centers were assessed. Performances rates, before and after implementing the RQRS beta test, were compared by patient demographics. Results: Between 2006 to 2010, compliance rates increased significantly for all five measures, ranging from a 16% increase for MAC to 36% for HT. Prior to RQRS participation, BCS/RT, HT and ACT compliance was significantly lower in patients of other races cf. to white and black; for MAC, other races were lower cf. to white. By 2010 a difference by race remained only in BCS/RT. Payer status and age also impact care. Private insurance cases were more likely to receive compliant care for BCS/RT, MAC and 12RLN; with Medicare for HT (p<.05). Age impacted HT (<40 less likely) and ACT (70-79 less likely cf. to 40-49) (p<.05). Conclusions: Increased performance rates show a system which promotes the ability to track patients in real clinical time can improve quality of care. By using RQRS to prospectively monitor expected adjuvant care, programs can proactively intervene and address potential issues that could impede delivery of timely standard of care.
The use of technology to improve the delivery process of ambulatory chemotherapy at the Odette Cancer Centre (OCC).
Authors: Trudeau Maureen E. , Sousa Philomena , Beattie Kathy , Fitzgerald Thane , Leung Michael Jung Chu , Cheung Matthew C. , Singh Simron , De Mendonca Ben
Published: February 2017

290

Background: The OCC manages over 24,000 chemotherapy patient visits/year. Over time the number of patients, complexity of treatment and staffing requirements increase. Barriers to efficient delivery of chemotherapy include: same day (as clinic visit) treatment, missing MD orders, manual appointment scheduling and poor communication between chemo nurses and pharmacists during drug preparation. These issues were addressed by (1) non-same day chemotherapy, (2) MD orders expected day prior to treatment, (3) development of two web-based tools for chemotherapy scheduling and communication. Methods: Two independent process reviews were undertaken confirming system inefficiencies. The move to non-same day chemotherapy was implemented. An electronic Chemotherapy Appointment Reservation Manager (CHARM) was developed and linked to the computerized physician order entry (CPOE) system, and reminders were sent to MDs with outstanding orders 72, 48, and 24 hours pre-chemotherapy. The tool was developed to facilitate staff communication during chemotherapy preparation. Data relating to each process improvement was collected pre- and post-implementation. Results: Over 300 of the more than 400 chemotherapy regimens were reviewed for nurse assessment, medication preparation, and in-chair infusion times, with the results used to build the algorithms for CHARM. With the move to non-same day chemotherapy over 80% of patients are treated on a non-clinic day compared with 40% pre-implementation. With CHARM the average number of patients booked/day went from 68 to 100, a 47% increase. Currently, 90% of physician orders are entered by 2pm the day before treatment. Use of the communication tool resulted in an 89% reduction in phone calls between the nurses and pharmacy. 36% of patients started treatment +/- 30 min of scheduled time in both time peroids. Conclusions: OCC introduced several innovative approaches to improving the safe delivery of chemotherapy to cancer patients. Patient volumes have increased while communication around care delivery has improved. The approach allows ongoing research and development to improve workflow and communication.
Development of an electronic point-of-care quality monitoring system for palliative care.
Authors: Kamal Arif , Bull Janet , Abernethy Amy Pickar
Published: February 2017

291

Background: Most current quality monitoring programs involve retrospective, manual data collection. These are inherently limited by accuracy issues and do not integrate well with national efforts to integrate electronic data documentation in all parts of medical practice. We aimed to build and test a prospective system for continuous quality monitoring in palliative care. Methods: Within a four-organization, academic/community quality consortium, we first conducted a focus group to inventory characteristics of an effective system. Then, with an interdisciplinary team of providers informatics, data security, and software programmers, we created an electronic solution for quality data collection and reporting. A usability study with think-aloud protocols followed using twenty providers and two mock cases across paper, laptop, and tablet computer platforms. Finally, a feasibility test assessing satisfaction, burden, and logistical issues was conducted. Results: Identified priorities for a proposed system were: 1. Use of information technology (IT); 2. Point-of-care use; and 3. Immediate, provider-level reporting on quality conformance. A previous systematic review of quality measures informed the development of a 92 item dataset comprised of variables drawn from validated clinical instruments and aligned with the National Consensus Project quality domains. To foster electronic, point-of-care data capture, the Quality Data Collection Tool (QDACT) user interface was then developed. Use at point-of-care in community-based palliative care settings can inform 82% (125) of identified relevant quality measures; a color-code reminder system provides immediate conformance feedback. The usability study demonstrated high satisfaction with electronic platforms, less than 15 minutes for completion, and a low error rate. Feasibility testing across 572 patient encounters demonstrated high acceptability and further improvements to the user interface. Feedback from an additional cycle of feasibility testing will inform further changes. Conclusions: Electronic systems that can integrate point-of-care quality monitoring and clinical assessments are buildable and usable in palliative care.
Clinical decision support tools to improve quality and practice efficiency across a large network of oncology practices.
Authors: Patt Debra A. , Nubie Madeline , Kazzaz Denise R. , Arlen Aimee , Sitarik Mark A. , Ahmad Asif , Busby Leslie T. , Beveridge Roy
Published: February 2017

294

Background: Electronic health records (EHR) provide opportunities for quality enhancements at various points in care. It can support electronic orders, meaningful use, progress notes, medication and allergy data, electronic prescribing, and vital-signs tracking. Clinical decision support tools (CDST) can facilitate high-quality performance and practice efficiency. These enhancements reduce error, improve quality, and drive practice efficiency. The oncology specific EHR (IKnowMed) incorporates CDST including physician driven level 1 pathways prescribing, chemotherapy regimen order entry, dose calculation, supportive care drugs, and guidelines for safe prescribing. Methods: To understand scope and utilization of CDSTs within a large network of individual oncology practices we characterized (qualitatively and quantitatively) common modalities in our EHR (iKnowMed). Treatment regimens were populated by the network collaborative-care committee. Physicians selected regimens pre-populated w/doses and pre-medications. Antiemetic regimens were pre-populated for emetagenic potential of the chemotherapy regimen. Results: Across the US Oncology Network, 952 physicians used the EHR to deliver services over a 5-month period. During that time, 69,448 cancer treatment regimens were ordered, pre-populated by drug, dose and pre-medications; and 68,268 chemotherapy regimens were pre-populated with antiemetic therapy to mirror emetagenic potential. Conclusions: By enhancing the EHR to include CDSTs, treatment and appropriate antiemetic regimens can be pre-populated across a large network of individual oncology practices that have aligned together using common IT and CDST to drive quality care for their patients. The network is using technology to enhance quality and efficiency in practice.
An automated system for insuring monitoring of myelosuppression in patients receiving self-administered oral chemotherapy.
Authors: Morrell Robert , Tooze Janet , Harmon Michele , Carter Annette , Detroye Alisha , Lesser Glenn Jay
Published: February 2017

296

Background: Protracted outpatient oral chemotherapy regimens have created new challenges for monitoring patients for toxicity. Unlike IV chemotherapy which guarantees clinician access to the patient before proceeding with therapy, oral agents can continue to be taken despite missed follow-up visits and lab draws. After observing patients return from unrecognized lapses in monitoring with severe myelosuppression, we sought to retrospectively measure risks and to prospectively test a software-based monitoring system designed to flag and notify team members of missed lab monitoring. Methods: We evaluated 117 patients who had received a standard 42-day continuous course of oral temozolomide as therapy for newly diagnosed primary malignant brain tumors to assess monitoring compliance, as well as adverse events. Standard practice is to obtain a weekly CBC with differential and platelets during the 6 weeks of concurrent chemoradiation. Grade 3 or higher hematologic events were observed in 9 (7.7%) patients. Gaps in monitoring were defined as no testing for 10 days or more, and were classified as minor (10-12 days) and major (13-27 days). Results: 34 (29.1%) patients had one or more gaps during treatment; 19 (16.2%) had majors and 18 (15.4%) had minors. 2 of the patients with gaps in coverage exhibited grade 3 or 4 myelosuppression upon their return to monitoring. We have currently monitored 36 patients prospectively with prototype software designed to email staff whenever a patient was not monitored for 7 days or had scheduled visits too far in the future. The software uses data downloaded from the electronic medical record (12,889 labs, [908 pertinent], 441 visits) and was effective in finding patients that missed labs or did not get properly scheduled visits. Five such mistakes were detected and 4 were corrected based on the system flag. Problems encountered were mainly false positives associated with entry of chemotherapy stop dates. Conclusions: Monitoring failures pose risks to patients receiving oral chemotherapy and traditional medical information systems make detection of missing data difficult. Systems such as ours are simple to build and could be integrated with most EMR systems.
The power of knowledge: Sharing patient test results electronically to improve quality of care.
Authors: Kaan Melissa , LeMar Jason , Gilbert Julie , Rae Erin , Sampson Anna , Meertens Elaine , Melamed Saul , Sarsfield Lisa , Kimball Jon , Hassam Shazmin , Matheson Garth
Published: February 2017

305

Background: For many patients going through the cancer diagnosis journey, the time from suspicion to diagnosis or rule-out can be a confusing and anxious time. To better support patients during this time, Cancer Care Ontario (CCO) is supporting Diagnostic Assessment Programs (DAPs) and the web-based tool known as the Diagnostic Assessment Program–Electronic Pathway Solution (DAP-EPS). DAPs consist of multi-disciplinary healthcare teams who provide diagnostic and supportive care services in a patient-focused environment, improving access to care and the patient experience. DAPs help manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis and part of this support involves providing access to personal health information through the DAP-EPS. This work was undertaken to determine the best approach to sharing test results with patients, including the type of test results that should be released and the most effective method for sharing these results with patients, from both the patient and provider perspective. Methods: The exploratory project involved conducting key informant interviews with individuals who had been involved with implementing similar patient portals, a targeted literature review, and a series of engagement sessions with physicians to measure the clinical response to this new strategy. Results: Initial discussions with patients and nurses yielded a strong endorsement for releasing all results, with no time delay. Key Informant interviews yielded similar results from the majority of the hospital contacts consulted. The environmental scan did not suggest that releasing results was associated with any adverse patient or provider effects. The physician engagement sessions generated both positive and negative feedback but overall, doctors were comfortable releasing all results, provided there was a delay built into the system. Conclusions: The release of diagnostic test results is seen as a valuable component of quality of care from the perspective of informing and empowering the patient. As the DAP-EPS moves forward with this initiative, the DAP program will continue to monitor the impact that the release of results has on both patients and providers.