bluuebunny/crossref_metadata_2025 huggingface dataset:
Novel use of an objective scoring rubric to guide inpatient chemotherapy stewardship.
Authors: Bhardwaj Aarti Sonia , Jain Priya , Hernandez Damaris Peralta , Handa Shivani , Petrone Giulia , Anderson Justine , Chowdhury Nobel , Yum Kendra , Kwon Deukwoo , Mato John , Berger Natalie S , Smith Cardinale B.
Published: September 2022

20

Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy is not reimbursed because of diagnosis-related group codes. We have previously reported inpatient chemotherapy and immunotherapy (IC) is associated with poorer outcomes for patients with advanced stage solid tumor (ST) vs hematologic malignancy (HM) patients. 1 We piloted the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of inpatient administration of costly therapies in patients especially at the end of life. Methods: Using an iterative process, an interdisciplinary group of physicians, nurses and pharmacists developed objective criteria of patient, cancer and treatment factors to guide chemotherapy stewardship. IC that is on formulary and being given as standard of care (i.e., induction of leukemia) are automatically approved. IC that is non-formulary requires evaluation using the developed criteria. Treatment factors include information on the level of existing evidence to support use: type and phase of trial, FDA and NCCN approvals. Patient factors include: performance status, line and goal of therapy. The scoring rubric positively weights regimens with strong levels of evidence or positive patient factors and negatively weights regimens with poor levels of evidence and adverse patient factors. Clinicians must complete the criteria via a form in RedCap. Upon completion, a score is automatically calculated by the tool and 2 disease specific physicians and a clinical pharmacist review for accuracy. If the threshold score is met, IC is approved for inpatient administration and if it is not met, IC is not approved for administration. Results: From January 2022 until May 2022 there have been 30 cases reviewed. 50% were ST requests and 50% were for HM requests. 20 cases (67%) were approved and 8 cases (26%) were not. Two cases were retracted by the requestor. This resulted in cost savings of $63,920. Table illustrates clinical outcomes and characteristics of the approved cases. Conclusions: This pilot illustrates that 67% of the time our cancer physicians chose the administration of inpatient chemotherapy that aligned with objective criteria which is reassuring and serves to validate the use of this tool. Alternatively, this objective rubric prevented inappropriate administration of chemotherapy 26% of the time. Our pilot indicates that there is a role for an objective tool for automated inpatient chemotherapy stewardship. Reference: Evaluation of inpatient chemotherapy among patients with cancer. Petrone G et al. JCO.2022.40.16_suppl.6566.[Table: see text]
Confirming Choosing Wisely: Inpatient thrombophilia testing.
Authors: Kovalenko Iuliia , Golubykh Konstantin , Cuevas Velazquez Adan Martin , Ammari Nadim , Malik Maidah , Sandhu Manpreet , Qurashi Hafiz , Saleem Tabinda , Atrash Anas , Komanduri Saketram , Wert Yijin , Lu Kit
Published: September 2022

22

Background: The American Society of Hematology (ASH) Choosing Wisely campaign have created thoughtful conversations between providers and patients in recommending care that is supported by evidence to reduce duplicative testing. However, some have raised concerns regarding the impact on patient care. We provide our institutional experience in exploring the clinical feasibility of the recommendation on reducing unnecessary inpatient thrombophilia testing. Methods: This was a retrospective review of patients admitted with a diagnosis of venous thromboembolism (VTE) across the 3 hospitals in Central PA from September 2021 to December 2021. Pregnancy was an exclusion criterion. Thrombophilia workup included tests for factor V Leiden mutation, activated protein C resistance, protein S activity, antithrombin deficiency, prothrombin gene mutation, anti-cardiolipin antibodies, dilute Russell viper venom time, lupus anticoagulant, anti-beta2-glycoprotein antibodies. The cost of testing was extrapolated by institutional hospital cost reports. Descriptive statistics included reporting the categorical variables as number and percent. The categorical variables were compared between groups with the use of Fisher’s exact test or the chi-square test. Results: During our study period, 310 patients had new VTE. Of those, 47.9% had pulmonary embolism, 33.7% upper or lower extremities deep vein thrombosis (DVT), 1.6% splanchnic DVT, 14.6% multiple DVTs, and 2.2% DVTs in other locations. The median age was 64. Provoked factors were found in 269 patients (86.7%) and 41 patients (13.2%) had unprovoked VTE. Overall, 33 out of 310 patients (10%) underwent thrombophilia workup with a total of 175 tests performed. More thrombophilia testing was ordered in unprovoked group (29.3% vs 7.8%, p = 0.0003) compared to provoked. There was no difference between the amount of inpatient hematology consults in both groups (33.83% vs 47.50%, p = 0.0920). Of the hematology consult, 19 out of 118 patients (16%) had thrombophilia testing recommended by hematologist. The cost of all tests ordered outside of hematology recommendation was $34,083 (avg $344 per person). Of the group that got tested regardless of provoking factors, there was no difference between hospital length of stay (2-12 days vs 3-12 days, p = 0.0665). Anticoagulation choice was also not affected by thrombophilia testing between the two groups. Conclusions: Our experience found that many thrombophilia work up were costly and did not impact quality patient care. Despite the relatively low frequency of inpatient workup (10%), eliminating testing could save our health system approximately $136,332 per year ($34,083 per quarter). Therefore, we support ASH’s campaign in reducing inpatient thrombophilia testing. We aim to work with our administration to provide education in reducing unnecessary testing.
Uptake in genetic testing in patients with pancreatic cancer with oncologist-driven testing protocol.
Authors: King Traci , Widick Page , Paredes Rodrigo , Klein Oliver , Krejdovsky Jill , Tung Nadine M. , Peters Mary Linton Bounetheau
Published: September 2022

33

Background: The objective was to compare the uptake of genetic testing in patients with pancreatic adenocarcinoma (PDAC) seen at a single center (1) before the 2019 NCCN recommendation of universal screening for genetic mutations in all new PDAC diagnoses, (2) after this change in guideline, and (3) after transitioning to an oncologist-driven genetic testing protocol. Methods: A retrospective review of patient records seen for a new PDAC diagnosis at BIDMC between May 2018-May 2022 was performed. Patients were categorized into three groups by date of visit: pre-guideline change (5/2018-4/2019), post-guideline change (5/2019-12/ 2020), and after implementation of an oncologist-driven testing protocol (12/ 2020-5/2022). The primary outcome was the differences in rates of testing between each time period. Results: An increase in rates of genetic testing occurred between each successive time period. Pre-guideline change, 22% of patients had testing sent, and this increased to 32% post-guideline. With the oncologist-driven testing, this increased to 73%. There was an increase in referrals for genetic testing from the pre- to post-guideline change time periods (42% to 61%). However, in both groups, the number of patients who completed testing was approximately half of those who were referred (23% and 34%, respectively). Conclusions: Our cancer center moved to oncologist-driven testing to increase uptake in the wake of a guideline change recommending universal testing of all PDAC patients. By this protocol, germ-line testing is sent by the medical oncologist at the initial multidisciplinary clinic visit, rather than following a consultation with our genetic counseling team. With this change, there was a dramatic increase in genetic testing (32% to 73%), thereby capturing approximately 10 additional patients with actionable pathogenic variants. However, this change necessitated additional resources in the multidisciplinary clinic and time from the oncologist to consent for testing. In addition, the expertise of cancer genetics counselors was not provided to all patients. We attempted to address the latter via selective referral after positive results. Despite these trade-offs, oncologist-driven testing successfully met the goal of increasing our adherence with guideline-based genetic testing of all PDAC patients.[Table: see text]
Oncologist and primary care provider attitudes towards shared care in patients with cancer with chronic medical comorbidities.
Authors: Simmons Kristen , Jotwani Aparna Chakravarti , Parker Colbert , Xiang Ellen , Lu Lee , Mims Martha P. , Badr Hoda
Published: September 2022

35

Background: Medical comorbidities pose challenges to the delivery of quality cancer care. Underserved cancer patients have the highest burden of chronic comorbidities, with increased risk for worse outcomes. Their health outcomes and care transitions might be improved by enhancing collaboration between oncologists and primary care providers (PCPs). Methods: This is a cross-sectional study of oncologists and PCPs in a large public safety-net hospital system in Houston, TX. Providers completed electronic surveys assessing demographics, attitudes, and satisfaction regarding the shared care of cancer patients with chronic comorbidities. Results: Eighteen oncologists (39% minority, 72% female) and 25 PCPs (23% minority, 77% female) completed the surveys. Independent samples t-tests revealed both oncologists and PCPs reported moderate levels of interprofessional collaboration, felt that existing processes to facilitate coordination of care were inadequate, and expressed moderate levels of dissatisfaction with the management of cancer patients with comorbidities within HHS (all p-values = n.s.). However, their attitudes toward care coordination differed significantly depending on the nature and timing of the care being provided. With regard to side effect management during cancer-directed therapy, 81% of PCPs preferred to co-manage side effects with oncologists, but 100% of oncologists preferred to be responsible for this activity (χ2= 23.08, p <.001). With regard to management of late-effects of cancer treatment, 40% of oncologists were either interested in co-managing late effects with PCPs or having PCPs be solely responsible for this activity. Conversely, 86% of PCPs preferred to co-manage late effects with oncologists (χ2= 26.74, p <.001). For cancer surveillance, oncologists and PCPs expressed interest in sharing responsibility depending on the patient’s risk for recurrence (χ2= 1.62, p =.30). Conclusions: Oncologists and PCPs were similarly dissatisfied with comorbidity management in cancer patients, but differed in their attitudes towards care coordination. Oncologists were more resistant to sharing responsibilities of toxicities during and after treatment. They were more accepting of PCPs assuming follow-up care for lower-risk patients. Further investigation is needed to determine specific areas of care coordination, barriers to provider collaboration, and knowledge and processes for effective shared care.
Levine Cancer Institute Financial Toxicity Control Program: Expanding the program to reduce fiscal vulnerability of patients.
Authors: Wayman Megan , Feild Donna , Goodnight Jennifer , Wise Jeffrey , Ford Ashley , Raghavan Derek
Published: September 2022

43

Background: It is well known that financial toxicity is becoming one of the most substantial problems encountered by patients receiving cancer care, and active solutions are required to address this (JCO Oncol. Pract., 2021, 17: e 1433-39). We have established a Financial Toxicity Tumor Board to address specific issues that cause out-of-pocket costs for patients and have saved more than $55 million per year in such costs to patients. A major contributor to patient-centric costs is denials from health insurance companies. We have developed an innovative, pharmacy technician program to assess and understand such denials and to avoid them proactively. Methods: Pharmacy technicians were inserted into an additional site’s treatment team to ensure appropriate prior authorizations were in place prior to patient infusion. Sequential and unselected data were collected over by the prior authorization technician. Medication denial reports generated by the financial clearance team were analyzed to identify issues that might be improved by changes in standard operating procedures in order to avoid recurrent concerns and these solutions were implemented. Results: The approach adopted by the LCI Financial Toxicity Tumor Board, with the use of additional pharmacy technicians to manage and preplan documentation, has resulted in a reduction of denials over a one-year period of from 16-18/month to 3-4/month with a concomitant additional saving to patients of $5,720,753. The expansion to an additional site over the evaluation period has preliminarily resulted in a 48% decrease in financial toxicity for patients as compared to the previous year. Conclusions: A reality of clinical practice is an ever-present fiscal tension between payers, patients and providers, with payers adopting increasingly complex rules and regulations to avoid payment of charges. When this occurs, patients inevitably sustain increased out-of-pocket charges and anxiety, contributing to the pattern of financial toxicity. The approach of using technical support staff to prospectively avoid insurance denials can be scaled universally to ensure that health insurance payers, while adhering to their defined rules and regulations, are held accountable for their contractual obligations.
Reducing the wastage of fresh frozen plasma in a hospital blood bank through the use of Six Sigma principles.
Authors: Hester Robert Harrison , Castillo Estella , Casteel Kelly , Natividad Lorenz , Aung Fleur M. , Martinez Fernando , Vadhan-Raj Saroj
Published: September 2022

45

Background: MD Anderson Cancer Center is one of the largest users of blood products in the United States, with approximately 3,600 units of blood (PRBCs) transfused per month, and over 500 units of fresh frozen plasma (FFP) transfused per month. The wastage of blood products has both financial and patient care implications, as well as implications to donors. Decreasing blood product wastage is an institutional priority in terms of both resource utilization and cost savings. Methods: Outside metrics for the waste of blood products published by the American Association of Blood Banks (AABB) were compared to current data on the percentage wastage of blood products for fiscal year 2020. A dedicated project team set an aim to reduce the wastage of FFP by 25% from Q4 2020 to Q3 2021. Using Six Sigma principles, a run chart was developed to track units FFP ordered and transfused from October 2020 – March 2021. Minitab software was used to calculate mean FFP ordered, the upper confidence interval, as well as 2 standard deviations above the mean to determine a new maximum FFP thaw level. Results: The historical FFP “thaw level” was 32 units of FFP thawed per day. From October 2020 – March 2021, the average number of FFP units ordered per day was 8. The upper confidence level was 32, and 2 standard deviations was 24 units. After identifying 3 data points that were “out of control” and unrepresentative of actual usage, these values were adjusted to 7.5 units and 19.5 units, respectively. Based on this data, the daily thaw level was adjusted from 32 units per day to 20 units per day on June 21st 2021. As of Q3 2021, this has resulted in a 40.7% decrease in the wastage of FFP. Conclusions: The application of Six Sigma principles was an effective way to identify variation in the ordering of fresh frozen plasma (FFP), and allowed for a sizeable reduction in the daily thaw level of this blood product. Post-intervention, there has been a dramatic decline in the wastage of FFP, resulting in cost savings for our institution and better stewardship of this scare resource.
Increasing advance directive completion within the 4R oncology model in patients with breast cancer prior to surgery in a racially diverse patient population.
Authors: Ossowski Stephanie , Lyon Liisa , Linehan Elizabeth Shurell , Gordon Nancy P. , Egorova Olga , Mark Becky , Beringer Kimberly , Abbe Thea , Shirazi Aida , Weldon Christine B. , Trosman Julia R. , Ravelo Arliene , Liu Raymond
Published: September 2022

54

Background: Advance directives (ADs) are an important part of life care planning in patients with cancer. There is a lack of effective interventions to increase AD rates in breast cancer patients prior to surgery. In this quality improvement project, we implemented an intervention for breast cancer patients receiving care in an integrated healthcare delivery system. 4R (Right Info / Right Care / Right Patient / Right Time) is a novel care planning and delivery model that enables the patient and oncology care team to manage complex time-sensitive care using a multi-modality 4R Care Sequence plan, coupled with follow-up workflows. Methods: We studied two groups of patients with newly diagnosed non-metastatic breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at one facility. The Usual Care (UC) cohort received care from 10/1/19 to 9/30/20. The 4R Intervention (4R) cohort received care from 10/1/20 to 9/30/21 using a 4R Care Sequence plan that included AD completion prior to surgery; those without an AD were referred for follow-up to a health educator to discuss AD completion. Bivariate analyses were used to compare the UC and 4R cohorts on demographics, NCCN thermometer distress scores, and AD completion rates. Results: Characteristics of age, gender, race/ethnicity, needing interpreter, Elixhauser Comorbidity Index, NCCN distress scores > 4, surgery type, grade, ER/PR/HER-2 status were similar in the UC (N = 140) and 4R cohorts (N = 141). AD completion prior to surgery was significantly higher for the 4R vs. UC cohort, both overall (15% vs 74%, p <.01), and for White, Black, and Asian/PI subgroups (Table). The Hispanic subgroups were too small to compare AD completion. AD completion did not significantly differ by higher vs. lower distress scores. Conclusions: Implementation of a 4R Care Sequence plan coupled with health educator follow-up can significantly increase rates of time-sensitive AD completion, regardless of patient distress score and patient race/ethnicity. Use of an effective standardized care delivery model like 4R can promote equitable care.[Table: see text]
Quality care for patients with tenosynovial giant cell tumor: A multidisciplinary quality improvement initiative.
Authors: Tap William D. , Pollack Seth , Carter Jeffrey D. , Heggen Cherilyn , McKinnon Kelly E.
Published: September 2022

56

Background: Tenosynovial giant cell tumor (TGCT) is a rare soft tissue sarcoma that is difficult to treat due to location, high risk of recurrence, and potential for significant morbidity. Recent approvals of novel systemic therapies provide new options for patients who may not be candidates for surgery. However, clinical teams may encounter challenges that inhibit prompt referral, quality of life assessment, and effective multidisciplinary care coordination between surgeons and oncologists. Methods: In September 2020, we surveyed multidisciplinary oncology health teams (n = 25) to assess gaps in TGCT diagnosis, clinical care, and multidisciplinary care coordination. To address identified gaps, teams participated in audit-feedback sessions to develop action plans for improvement. To better understand identified gaps, surveys and education were extended to a nationwide audience of providers caring for patients with TGCT (n = 553). Results: In the health teams survey, top challenges identified included differentiating among appropriate treatment management strategies (46%), coordinating care/transitions of care for patients with TGCT (25%), and making a proper TGCT diagnosis (13%). Confidence gaps echoed these challenges, with less than half of providers indicating high/very high confidence (5-point Likert scale) in their ability to distinguish between nodular and diffuse types of TGCT (47%), align treatment decisions with evidence-based guidelines (47%), and recognize and manage adverse events associated with novel therapies (47%). During audit-feedback sessions, teams developed action plans to improve collaboration between interprofessional teams, improve adverse event management, increase education for supportive care, and facilitate earlier referrals to medical oncologists. When healthcare providers nationwide were surveyed, only 13% reported high or very high confidence in differentiating available treatment options for TGCT. Additionally, the top challenges in coordination care for patients with TGCT included poor follow-up/monitoring for disease recurrence (23%), ineffective communication between multidisciplinary team members (20%), and lack of time for patient-centered measures (19%). Conclusions: These findings reveal important challenges in diagnosis, treatment, and multidisciplinary care of TGCT patients. The methods and findings from this study offer key opportunities for scalable interventions to improve care for patients with TGCT.
ONE Liver: A unique, multidisciplinary virtual tool for prospective review of complex liver tumors.
Authors: Chollet-Lipscomb Casey , Wolf Patrick , Bernhard Matthew R , Maduell Kelsey , Davidson Stacey , Bilbrey Larry Edward , Schleicher Stephen Matthew
Published: September 2022

59

Background: Primary and secondary malignancies involving the liver represent some of the most complex cases we see in oncology. These tumors often require multi-disciplinary decision making to determine the optimal treatment. For example, the treatment plan for hepatocellular carcinoma or colorectal cancer metastatic to the liver can often include one of several liver-directed therapy options for cure and/or palliation. Obtaining multiple opinions in an expedited and patient-centered way can be challenging for community oncologists, especially those serving a rural community. We opted to create a virtual tumor board with geographical reach across Tennessee for timely comprehensive evaluation of these patients at Tennessee Oncology (TO), a community oncology network spanning over 30 clinical sites of care. Methods: In January 2021, we created a multidisciplinary team containing specialists in medical oncology, radiation oncology, hepatology, radiology, interventional radiology, and hepatobiliary surgery. Medical oncologists at any TO clinic in Tennessee or Georgia could make referrals to the program within the Electronic Health Record (EHR). The team reviewed all submitted cases bi-weekly either virtually or at a centralized location. Referring providers were not required to attend the tumor boards to expand geographical reach. Recommendations were communicated back to the referring physician by both email and letters scanned into the EHR. Results: Between January 1, 2021 and May 1, 2022, a total of 154 referrals representing 126 unique patients were placed to the ONE Liver tumor board. Thirty-three physicians referred patients across 21 practice locations across the state. The top 3 diagnoses were: metastatic colorectal cancer (53), hepatocellular carcinoma (33), and primary biliary cancers (32). The most common first line recommendations were for therapy with Y-90 embolization, further imaging workup, continued systemic therapy and/or clinical trial evaluation, and stereotactic body radiation therapy. All patients were evaluated within 2 weeks of referral with most evaluated in less than 1 week. 60% of patients evaluated lived more than 25 miles from a tertiary medical center and 28% lived more than 50 miles out. Conclusions: This initiative successfully facilitated efficient and multi-disciplinary evaluation of patients with complex liver tumors living in rural areas. Tumor boards of this type might scale disease expertise across larger geographical locations than traditional in-person tumor boards.
Effects of establishing a multidisciplinary pancreatic cancer clinic on time-to-treatment.
Authors: Vaghjiani Raj , Sarkar Joy , Stiles Zachary , Pangelinan Jennifer , Iyer Renuka V. , Calvo Benjamin F. , Kukar Moshim , Hochwald Steven N. , Malik Nadia Karen , Fountzilas Christos , Alarcon Velasco Sylvia Vania , Cherkassky Leonid
Published: September 2022

61

Background: Despite recent advances, pancreatic cancer remains an exceedingly morbid disease. This is often attributed to the lack of effective screening tools and the consequent late presentation of patients. The best prognosis is reserved for patients with resectable tumors thus highlighting the importance of swift evaluation and the initiation of treatment following a diagnosis. Multidisciplinary clinics allow for the expedient evaluation of patients by different subspecialties in the same day. Methods: A newly designed, multidisciplinary workflow (MDC-multidisciplinary care clinic) for patients recently diagnosed with pancreatic adenocarcinoma was established at a single, tertiary-care comprehensive cancer center in September of 2021. Patients presenting to MDC undergo same day consultation by surgical oncology, medical oncology, receive genetics counseling and testing, nutrition counseling, and additional support services as indicated. Patients from a prospectively maintained database were compared from before (n = 14) and after (n = 30) implementation of the new workflow. Average time to provider consultation, port placement, and initiation of neoadjuvant chemotherapy were compared using student’s t-test. Results: After a biopsy diagnosis of pancreatic adenocarcinoma, the time interval from initial surgical consultation to initial medical oncology consultation improved from 7d to 1d ( p=.003) with the implementation of MDC. Over 90% of patients were seen on the same day after the MDC was established, compared to just 7% before. There was no difference in the time from initial biopsy diagnosis to initial surgical consultation, biopsy to initial medical oncology consultation, biopsy to port placement, or biopsy to chemotherapy initiation. Conclusions: In this early experience with a new pancreatic cancer multidisciplinary clinic, patients experienced improvements in time to subspecialty evaluation by nearly 7 days. Additionally, prospective data on oncologic outcomes and patient quality-of-care metrics are ongoing; however, this quality improvement effort has already reduced patient burdens in accessing timely care. Our continued efforts focus on further improving care coordination along the entire patient cancer care trajectory.
Association of clinic type with receipt of neoadjuvant therapy among patients with localized pancreatic cancer: Value of multidisciplinary clinic.
Authors: Pathak Priya , Hacker-Prietz Amy , Herman Joseph M. , Zheng Lei , He Jin , Narang Amol
Published: September 2022

63

Background: Patients with localized pancreatic adenocarcinoma (PDAC) generally benefit from multi-modality therapy, which may be best coordinated through a pancreas multi-disciplinary clinic (PMDC). Whether treatment practice patterns vary based on whether a patient was seen through PMDC versus individual specialty-specific clinics is unclear. Methods: Using institutional Pancreatic Cancer Registry, we identified patients who came to Johns Hopkins Hospital through either PMDC or one of the individual surgical, medical, or radiation oncology clinics for localized PDAC between 2018-2020 and eventually underwent resection. During this time, it was standard practice for borderline resectable (BRPC) patients to undergo at least 4 months of neoadjuvant chemotherapy, with or without radiation, before transitioning to exploration, while locally advanced (LAPC) patients were treated with 4-6 months of chemotherapy, followed by radiation, followed by potential exploration. The primary outcome was completion of neoadjuvant therapy as per the above stage-specific institutional standards. Multivariable analyses were performed to find association between PMDC visit and completion of neoadjuvant therapy, controlling for age, sex, race, stage, baseline performance status and type of chemotherapy. Results: A total of 240 patients met inclusion criteria. Of these, 157 (65.4%) had PMDC visits. Distribution of stage across the cohort included 81 (34.3%), 91 (38.5%), and 64 (27.1%) patients with resectable PDAC, BRPC and LAPC, respectively. Patients in the PMDC group received radiation therapy more commonly (59.7% vs 34.9%, p = 0.004), as compared to patients seen through individual specialty-specific clinics. Mean duration of chemotherapy was higher for patients seen through PMDC (4.4 (SD: 1.7) vs 3.9 (SD: 2.0) months) compared with individual clinics. Completion of neoadjuvant therapy per institutional stage-specific standards was seen in 46% (n = 24) of the patients visiting individual specialty-specific clinics compared to 71% (n = 85) of patients who were seen through PMDC (p = 0.002). The adjusted odds ratio of completion of neoadjuvant therapy per institutional standards for patients seen through PMDC visit was 3.35 times the odds for patients seen through individual clinics (95% CIs 1.46-7.07; p = 0.004). Of note, a higher proportion of patients who were seen through PMDC enrolled in a clinical trial (n = 26, 16.6%) compared with patients seen through individual clinics (n = 6; 7.2%) (p = 0.043). Conclusions: Provision of care through a multi-disciplinary clinic was associated with significantly higher odds of completing neoadjuvant therapy per institutional standards as compared to care through individual specialty-specific clinics. In addition, care through a PMDC may also be associated with increased trial enrollment.
The impact of seasonality with hierarchical condition category coding on Oncology Care Model performance for the U.S. Oncology Network.
Authors: Xiong Jennifer , Indurlal Puneeth , Ives Hope , Payne-De Bock Judi , Adams Chad , Abujamra Ramzi , Turnwald Brian , Staggs Stuart , Altieri Jason , Manjunath Rajini
Published: September 2022

66

Background: The Oncology Care Model (OCM) is a 6-month, episode-based, Medicare value-based care program, which rewards practices for decreasing the total cost of care (TCOC) compared to a trend adjusted predicted baseline called the benchmark price. The predicted baseline and trend factor are a function of 14 covariates in a generalized linear model with a log link and gamma distribution. Select non-cancer comorbidities, represented by a subset of Hierarchical Condition Category (HCC) flags assigned to the episode in the calendar year when the episode initiates, is a major covariate of the linear model. Patient episodes with one or more HCC flags are expected to have higher episode expenditures and receive a higher adjustment to the benchmark. Here, we seek to describe the seasonality of HCC flags and its impact on the benchmark for OCM episodes in The US Oncology Network (The Network). Methods: All eligible OCM episodes data from 14 practices in The Network participating in the OCM for performance periods (PP) 3-9 were analyzed to measure the average number of HCC flags per episode. The relative contribution of HCC flags to the benchmark was calculated by unraveling the linear model. The difference of the average HCC flags, benchmark, and relative contribution of HCC flags to the benchmark for episodes starting in different quarters of the calendar year were evaluated. Results: Average HCC flags for episodes showed a seasonal decline during each calendar year, with episodes initiating during the first quarter of a calendar year having 16.25% higher HCC flags, compared to those in the last quarter (1.93 vs 1.66 flags). The benchmark and the relative contribution of the HCC flags to the episode benchmark were lower in the last quarter of the year (4% and 16.5% respectively) compared to the first quarter. Episode expenditures did not show a similar seasonality pattern. Conclusions: The assignment of HCC flags based on the episode initiation date, leads to a seasonality effect on the average HCC flags and benchmark for episodes initiating in different parts of the calendar year. The seasonality results from a progressively abbreviated period available to assign HCC flags for episodes initiating later in the calendar year. We also hypothesize that the annual reporting requirement for HCC flags, and risk adjustment coding by professionals at the start of each new calendar year, contributes to this seasonality. The financial impact of seasonality on episodic value-based care model benchmarks necessitates a modified, non-seasonal approach to comorbidity-based risk adjustment.
Total cost of care of hematologic malignancy episodes versus target price under the Oncology Care Model.
Authors: Nguyen Jennifer , Walsh Karen , Maio Vittorio , Park Seojin , Patel Shivangi , Keith Scott W. , Handley Nathan , Csik Valerie Pracilio
Published: September 2022

67

Background: In 2016 the Center for Medicare & Medicaid Innovation developed the Oncology Care Model (OCM) in response to increasing cancer-attributable cost for medical services and prescription drugs. Under the OCM, practices are incentivized to provide higher quality and coordinated care through a dual payment model including a Monthly Enhanced Oncology Services (MEOS) payment and potential for performance-based payment (PBP), where PBPs are based on a practice’s total cost of care (TCOC) savings amount relative to a risk-adjusted target amount. On average, hematologic malignancies are burdened with higher costs than other cancer types. The objective of this study was to evaluate whether TCOC and target price were aligned in OCM hematologic malignancy episodes. Methods: This was a retrospective cross-sectional study using OCM claims data from an urban, academic, National Cancer Institute-designated cancer center. The analysis was conducted at the episode level from performance period 1 to 4 (time period: 7/1/2016 to 7/1/2018). A logistic regression with a generalized estimating equation (GEE) was used to assess the likelihood of episode characteristics and TCOC to exceed the target price. A linear regression with a GEE was used to evaluate the mean difference between TCOC and target price episodes. Results: Of the 516 episodes of hematologic malignancies included in the analysis, 55.2% were male and 26.9% were 70-74 years old. 283 episodes (54.8%) exceeded target price. Several parameters were found statistically significantly associated with the likelihood of exceeding and not exceeding target price (Table). Largest positive mean difference from target price was in episodes with Medicare Part D drug use ($24,344) and largest negative difference in radiation use (-$33,758). Conclusions: We found a substantial misalignment between TCOC and target price for hematologic malignancy episodes, with a majority of episodes exceeding target price. This study adds to the existing evidence on the lack of adequate adjustment to the OCM target price. As the OCM concludes, our findings identify areas of opportunity for consideration in future payment models, such as re-evaluating the target price methodology, inclusion of drug costs and adequate adjustment for select parameters (history of chemotherapy, novel therapy, and Part B and D expenditures).[Table: see text]
Physician knowledge and attitudes toward breast cancer screening strategies in transgender population.
Authors: Barragan-Carrillo Regina , Seidman Sorsby Alec , Cruz Mayte , Gonzalez-Lara Maria Fernanda , Chavarri Guerra Yanin
Published: September 2022

71

Background: Transgender people experience intersecting forms of marginalization and suffer significant healthcare disparities. There is evidence that healthcare providers are insufficiently equipped to provide adequate healthcare to this population. Hormone-replacement therapy for trans-women requires blockade of androgen production and estrogen supplementation, which increases the risk of breast cancer (BC) compared to cis-males. Also, trans-women without gender-affirming mastectomy should undergo BC screening (BCS). We seek to explore the knowledge and attitudes among physicians regarding current strategies for breast cancer screening in trans-women and men. Methods: We adapted an online 15-item survey exploring knowledge and attitudes among physicians on strategies for BCS in trans people. The first 6-items evaluated attitudes, and the last 9-items knowledge. We conducted a pilot phase to assess physicians' understanding before the final data collection and adjusted it after corrections. Participants were invited through social media and directly peer-to-peer in June 2022. Descriptive statistics and Chi-square test were used for statistical analysis using SPSS ver. 26. Results: A total of 165 participants completed the survey, 96 (58.2%) self-identified as male, 66 (40%) female, and 2 (1.2%) non-binary gender with a mean age of 30 years (23 – 60 years). Most participants were residents and fellows (70.3%), and 29.7% were attendings. Overall, only 7.3% of participants felt confident in their knowledge of BCS in trans-people, 55.2% felt that had an inadequate preparation regarding transgender health during medical school and 86.1 and 83% agreed that it should be thoroughly addressed during medical school and residency, respectively. Regarding knowledge, 10.9% recognized that BC risk is different between trans- and cis-women, 9.7% identified that trans-women had a lower BC risk, and 77% answered that transgender people have insufficient access to health services. Finally, as for specific BC screening strategies, only 49.1% correctly identified BCS strategies for trans-women, 61.2% correctly answered the recommended age to start BCS in trans-women, 40.6% the periodicity for BCS, and 63% identified the correct recommendation for BCS trans-men without a gender-affirming mastectomy. Conclusions: Current physician knowledge regarding BCS strategies in the transgender population is limited. Nonetheless, respondents identified transgender health as an area of opportunity that might be addressed with widespread information. These findings reinforce that education of healthcare providers is required to end health inequalities faced by this diverse group of patients.
Drivers of palliative care and hospice use among patients with advanced lung cancer.
Authors: Edmonds Megan C. , Jain Mayuri , Mazor Melissa , Morillo Jose , Augustin Marsha , Allen Olivia S. , Avril Amina , Smith Cardinale B.
Published: September 2022

79

Background: Despite rigorous evidence of improved quality of life and longer survival, disparities in the utilization and quality of palliative and hospice care persist for racial and ethnic minority (Black and Latinx) patients with advanced lung cancer. To better understand drivers of palliative care and hospice inequities, this study evaluated the impact of psychosocial factors (e.g., lung cancer beliefs) on palliative and hospice care utilization among minority patients with cancer. Methods: This was a prospective cohort study of 99 patients with advanced lung cancer recruited at the Mount Sinai Hospital. At enrollment, minority and non-minority patients were asked questions about their sociodemographic, clinical, and the following psychosocial factors: medical mistrust, lung cancer beliefs, palliative care and hospice beliefs. Palliative care and hospice care utilization was abstracted from patients’ medical records. Bivariate analysis examined the association between independent factors (e.g., sociodemographic, lung cancer beliefs) and outcomes of palliative care consult and hospice care use (yes vs. no). Results: Of the 99 enrolled participants, 55 (55%) were minorities with a mean age of 65 years. 42% completed a palliative care consult and 26% utilized hospice care (26%). Palliative care utilization was associated with more favorable beliefs toward palliative care (p = 0.022) and hospice (p = 0.005) and lower levels of medical mistrust (p = 0.007). Majority of the sample was not refered to palliative (50%) or hospice care (61%); however patients refered were more likely to utilize care (p < 0.001). Minority patients were more likely to receive a referral and schedule a palliative care consultation compared to non-minorities (p < 0.001). Self-reported minority status did not predict differences in hospice care use. Conclusions: Minority patients with lung cancer were more likely to receive a palliative care referral and specialty level consultation when compared to non-minority patients. Higher levels of mistrust were a driver of not receiving palliative care. Patient referrals appear to be an important leverage point to help mitigate disparities in palliative and hospice care use. Future work to understand factors associated with palliative care use and the impact on minority patients is needed.
System-level barriers and facilitators to cancer rehabilitation delivery for children with cancer.
Authors: Swartz Maria Chang , Kelly Donna M. , Schadler Keri L. , Andersen Clark R. , Wells Stephanie J. , Zhang Shiming , Rajan Alakh , Heaton Amy , Moody Karen
Published: September 2022

81

Background: Up to 20% of childhood cancer survivors suffer from a significant physical function impairment due to cancer or cancer treatment. Early intervention with Occupational Therapy (OT) and Physical Therapy (PT) increases engagement in personal care, leisure interests, school-based tasks, return to work, and prevents cognitive decline. Despite this, less than 30% of childhood cancer survivors receive PT services. To date, facilitators and barriers to implementing cancer rehabilitation (CR) for pediatric cancer survivors have not been adequately explored. Thus, the aim of this research was to identify system-level barriers and facilitators to CR delivery based on surveys completed by hospital administrators, oncology physicians, advanced practice providers, and OT/PT therapists. Methods: A cross-sectional method was employed. Three previously published cardiac rehabilitation delivery instruments specific for administrators, OT/PT therapists and clinical providers respectively were adapted to evaluate CR delivery. All surveys used a 5-point Likert-type response format (e.g., 1 = strongly disagree to 5 = strongly agree). Surveys ranged from 12 items (therapist survey) to 23 items (administrator survey). Questions pertained to knowledge, attitudes, and perceptions regarding CR. Results: A total of 20 administrators (mean age, 49.95 years old, 65% non-Hispanic White, 65% female), 20 providers (mean age, 43.4 years old, 71.4% non-Hispanic White, 67% female), and 20 therapists (mean age, 38.3 years old, 70% non-Hispanic white, 84% female) completed surveys. Administrators’ results indicated mid-range CR knowledge (median: 3.5; IQR 2,5), and all perceived CR as important or extremely important to outpatient care (median: 5; IQR 4,5). Limited insurance coverage and lack of space were the top barriers identified by administrators. Eighty percent of providers endorsed that clinical practice guidelines promote CR referral (median 4; IQR 4,5) and none reported being skeptical of CR benefits. Provider-identified barriers included an inconvenient referral process, lack of CR patient-education materials, and inadequate information on external CR resources. Therapists identified rate of absenteeism and referral rates as barriers to CR. Ninety percent of therapists reported hybrid CR delivery (supervised and unsupervised exercise) could facilitate CR participation (median 4; IQR 4,4). Conclusions: System-wide, there was adequate knowledge and positive perceptions and attitudes regarding CR. However, we identified multiple barriers presenting opportunities for multilevel interventions. These included: insurance coverage advocacy, streamlining referral processes to CR services, providing information on external CR programs, providing patient education materials, and leveraging hybrid CR delivery to optimize participation.
How granularity of data matters in understanding and accelerating racial diversity in U.S. clinical trials.
Authors: Bebi Ted , Horovitz Rachel , Blum Kevin , Buderi Robbie , Bourlon Pierre-Louis , Lamont Elizabeth W. , Chamberlain Stephanie , Melhem Fareed
Published: September 2022

88

Background: Historically, US clinical trials have been shown to recruit disproportionately large percentages of White patients, raising concerns about the generalizability of clinical trial results to underrepresented racial minority patient populations. Because of this, the FDA has recently reiterated its guidance stating that clinical trials need to reflect the demographic distribution of the US. In this research, we sought to understand how participation of Black patients varies by therapeutic area and geography within the US. Methods: Studying patient-level clinical trial data from an industry-leading historical clinical trial data repository of over 8 million patients from 27,000 clinical trials, we assessed the racial composition of US interventional trials across indications from 2010 to 2021 which encompassed 433,822 clinical trial participants across 2,997 trials. We also analyzed participants’ racial composition within the subset of trials from three distinct therapeutic areas (i.e., oncology n = 118,194, cardiovascular n = 12,281, central nervous system n = 35,533) and distinct sites over the same period. Results: The racial distribution of clinical trial participants in the US across all therapeutic areas was 78% White, 15% Black, and 3% Asian. Within the three distinct therapeutic areas, the proportion of Black clinical trial participants varied, with oncology trials reporting 8.5% Black participants, cardiovascular trials reporting 15.3% Black participants, and central nervous system trials reporting 19.9% Black participants. Black participation also varied within a therapeutic area, depending on the indication, as well as by site, with individual sites contributing differently to the racial diversity of trials. Conclusions: Our analysis shows that US interventional trials enroll 15% Black participants, appearing consistent with the 2020 US Census, which estimates that 14.6% of Americans are Black. However, more granular analyses at the level of therapeutic area, indication and site suggest substantial variation in Black participation in clinical trials including a gap in Black representation in oncology trials vs. US Census estimates. This research suggests that aggregate estimates of racial enrollment may mask dramatic variation by other factors like granularity of disease area and geographic location. The study of historic clinical trial data may yield useful insights for accelerating diverse representation in clinical trials.