bluuebunny/crossref_metadata_2025 huggingface dataset:
Does 8-guage stereotactic core needle biopsy improve the accuracy over 11-gauge devices? Evaluation of pure DCIS on stereotactic biopsy and the rate of upstaging.
Authors: Halaharvi Deepa R. , Cripe Mark H.
Published: February 2017

97

Background: Ductal carcinoma in situ (DCIS) accounts for 25% of newly diagnosed breast cancers. Core needle biopsy (CNB) has replaced open surgical biopsy for mammographic calcifications. We compare our experience with 8-gauge vs. 11-gauge vacuum assisted core needle biopsy in pure DCIS. We hypothesize that the diagnosis of DCIS with use of an 8-gauge vacuum-assisted core needle will lead to a lower rate of upstaging to invasive cancer at definitive surgical excision compared to 11-gauge vacuum-assisted core needle biopsy. Methods: A retrospective study was performed evaluating all patients who underwent a stereotactic core needle biopsy at our institution for DCIS during 2008-2012.We then compared the upstaging rates between patients biopsied using 8 or 11-gauge biopsy devices. Results: A total of 580 patients underwent STCNB during 2008-2012 at our institution, there were 461 patients excluded as they did not meet inclusion criteria and 119 patients were included. The most common mammographic finding was calcifications in 104/119 (87.4%) and a mammographic mass in 15/119 (12.60%). Biopsy with the 11 gauge needle was utilized in 60 patients and 59 patients with 8-G needle. Factors associated with upstaging were using a smaller 11 gauge needle and a mass on imaging, higher grade and more than four cores obtained on biopsy. There was an upstaging rate of 17/60 (28%) in patients who underwent stereotactic biopsy using a11-gauge needle versus upstaging rate of 7/59 (11.8%) in patients who underwent stereotactic biopsy using 8 gauge needle. We obtained a statistically significant p-value of 0.025. Conclusions: This is one of the few studies comparing upstaging rates from pure DCIS on STCNB using 8 and 11-gauge stereotactic vacuum assisted needles. Our results show that there is a statistically significant decrease in upstaging of pure DCIS to invasive malignancy at excision using the larger 8-gauge needle devices. The clinical implication is that SLNB need not be performed secondary to the low upstaging rate. We recommend that all stereotactic core needle biopsies be performed using the 8-gauge needle devices, and that SLNB generally be omitted for DCIS.
Process mapping and time study to improve efficiency of HDR prostate brachytherapy.
Authors: Doyle Laura A. , Lockamy Virginia L. , Peng Cheng , Dicker Adam , Yu Yan , Den Robert Benjamin , Harrison Amy S.
Published: February 2017

103

Background: New technologies and procedures have the potential to improve outcomes; however, initial implementation is often associated with a steep learning curve, decreased efficiency, and patient safety implications. Since process mapping, checklists and external benchmarks have been proven to be useful quality improvement (QI) tools in health care, we sought to use these QI tools in a novel setting to decrease new procedure times without sacrificing the quality of care. Methods: Implementation of a real-time, ultrasound based prostate high-dose-rate brachytherapy procedure involved a multidisciplinary team composed of approximately 6-8 team members and numerous complex tasks. To characterize time spent on various aspects of the procedure and improve efficiency, our team developed a detailed process map including checklists and team debriefings. A benchmark was created based on an experienced institution which has performed >100 procedures annually. Times for key events, such as induction of general anesthesia, acquisition of first image, catheter insertion and completion of planning were recorded during each case. The process map was analyzed based on clinical tasks and treatment planning tasks. Results: The expert institution completed a procedure in 65 minutes. Over the course of ten cases at our institution, total procedure time ranged from 222-107 minutes. Implementation of the process map resulted in a reduction of total time by 52% (51% for clinical tasks and 65% for planning). Process improvements included changes to room layout, availability of supplies and identification of parallel processes. Improvement in efficiency was done without compromising quality as defined by dosimetric parameters. Conclusions: The implementation of a new procedure benefits from the integration and utilization of a process map. We were able to reduce procedure time significantly, which resulted in decreased time under general anesthesia, reduced risk of deep vein thrombosis and improved overall patient safety.
Quantitating the impact of satisfaction drivers on the chemotherapy patient experience: Employing MaxDiff survey analytics to identify key organizational strengths and potential enhancement opportunities.
Authors: Waterhouse David Michael , Ward Patrick J. , Dyehouse Karyn M. , Miller Robert , Schiano Richard
Published: February 2017

108

Background: Patient satisfaction surveys using Likert-style rating scales are subject to response, level, and dispersion bias. "MaxDiff" or "worst-best" scaling allows opportunity to determine and quantify the relative importance of satisfaction drivers. The focus of this conjoint survey was to assess satisfaction with factors related to the chemotherapy experience, while simultaneously defining the relative importance of these satisfaction drivers. Methods: Sequential chemotherapy pts at four independent office sites were offered an "in chair" electronic tablet survey. The 38 question survey instrument was adapted from the Community Oncology Alliance Oncology Medical Home (COA OMH) patient satisfaction survey. Sample size was calculated to allow maximum sensitivity for analysis of questions/attributes at a 90% confidence level. MaxDiff scaling (Sawtooth Software) was analyzed using hierarchal Bayes estimation. Comparisons were made between male/female pts, age, length of time as OHC pt, and office site; statistical significance was determined by the Mann-Whiney test. Results: In total, 297 pts of 320 pts (92.8%) responded; mean patient age was 61.7 yrs, 197 female/100male. MD and staff wait times, professional skills, concern and communication abilities weighed heavily in driving high satisfaction; whereas scheduling, availability of clinical trials, facilities, account, and pharmacy services had low influence. Wait times (higher importance/lower satisfaction) offered the highest enhancement opportunity for process improvement. Both genders had similar priorities for factors driving chemotherapy satisfaction. Wait time, staff and facility satisfaction differed slightly by office. No significant age or time differences were identified. Conclusions: The addition of MaxDiff scaling to conventional patient satisfaction surveys is novel, feasible and acceptable in the community oncology office setting, and can yield relevant, interpretable data. Results of this survey are currently being used to inform ongoing OHC process and quality improvement initiatives.
Enabling quality data reporting: National implementation of standardization pathology reporting.
Authors: Kwiatkowski Avril
Published: February 2017

122

Background: The Canadian Partnership Against Cancer (the Partnership) launched its Electronic Synoptic Pathology Reporting Initiative (ESPRI) to advance the implementation and promote the wide adoption of standardized synoptic pathology reporting tools in Canada. This presentation will highlight strategies to ensure successful implementation of this program across the Canadian health system as well as lessons learned. Methods: Upon consultation with clinical and system leaders, clear and measureable program targets (such as 90% completeness rates against mandatory elements of the College of American Pathology cancer protocols and disease-specific clinical indicators) were agreed upon. Thorough provincial planning to understand the variances across provincial current states, establish strategies and solidify plans was supported by the Partnership; followed by implementation of those plans. Key approaches to enable adoption and implementation include coordination of Pathologist and Vendor-led education sessions, establishment of clinical expert panels and assignment of Canadian representatives to the College of American Pathologists’ (CAP) Cancer Protocol Review Panels. The Partnership continues to collaborate with national/international standards organizations such as NAACCR, CAP, and Canada Health Infoway to support standards maintenance. Results: As a result of ESPRI, approximately 80% of Canadian pathologists will be reporting synoptically by 2017, across 7 of 10 provinces. It is expected that this will reflect approximately 25,000 reports per year for the five cancer types of focus (breast, colorectal, lung, prostate and endometrial) from about 950 pathologists. The Partnership, with CAP-ACP, has partnered with pathology communities from the US, UK, and Australasia to form the International Collaboration on Cancer Reporting (ICCR) to collaborate on internationally-harmonized core datasets for cancer pathology. Conclusions: Adoption of structured pathology reporting in Canada will enable better patient care, improve data quality, create efficiencies and enable interoperability. Through adoption and implementation efforts, this will impact patient care.
Avoidance of fulminant liver failure from hepatitis B reactivation with chemotherapy and immunotherapy: A value-based approach.
Authors: Knopf Kevin B. , Siegel Samantha , Bennett Charles L.
Published: February 2017

134

Background: Fulminant liver failure (FLF) is a potentially fatal complication of hepatitis B reactivation in patients who receive rituximab and cytotoxic chemotherapy. Often patients receiving these regimens are treated with curative intent (e.g. diffuse large cell Non Hodgkin’s lymphoma, adjuvant chemotherapy for breast cancer) and thus avoidance of this complication is desirable. The only known treatment for fulminant liver failure is orthotropic liver transplant. We have developed a cost-effective approach to avoiding FLF. Methods: NCCN recommends screening for hepatitis B serologies in any patient who is to receive Rituximab therapy. Review of the literature regarding fulminant liver failure and cytotoxic chemotherapy revealed that the regimens most strongly associated with reactivation of HepB and fulminant liver failure included doxorubicin and high dose of cyclophosphamide—we have targeted Hepatitis B screening to patients receiving these two chemotherapy drugs. We target patients either felt to have a high probability of occult hepatitis B are screened—these include patients who have had a blood transfusion in a foreign country, those with a transfusion more than 20 years ago, and those patients where Hepatitis B can be passed vertically—including first and second generation Asian American immigrants. Patients deemed at high risk are checked for Hepatitis B surface Antigen and Hepatitis B Core antibodies. No routine imaging is performed. Patients who are HepBSag or HepBCoreAb positive who are to receive high risk chemo/immunotherapy are then started on entecavir 0.5 mg/d two weeks before starting therapy and this is continued for 6 months after completion of therapy. Patients who are HepBAg- and HepBCab+ are monitored with HBV DNA levels monthly during therapy with initiation of entecavir if HBV DNA becomes detectable. Results: Patients receiving chemo/immunotherapy associated with Hep B reactivation can be safely identified and given prophylactgic entecavir treatment. Conclusions: We have created a value-driven cost effective approach to minimizing FLF in patients receiving chemo/immunotherapy. Cost estimates based on US pricing will be presented.
Improving the quality of care for patients receiving radiation therapy: Increasing the proportion of radiation treatment plans undergoing peer review in Ontario.
Authors: Reddeman Lindsay Elizabeth , Brundage Michael Donald , Foxcroft Sophie , Hart Margaret , Gutierrez Eric , Mendelsohn Marissa , Warde Padraig Richard
Published: February 2017

136

Background: Peer review of radiation treatment (RT) plans is recognized as an essential component of quality assurance programs in radiation medicine (Marks et al., 2013). The benefits of peer review include: (1) identifying errors that may compromise treatment outcomes, (2) enhancing safety by promoting standardization, and (3) promoting greater attention to detail in RT staff. Current state analysis conducted in 2011 identified considerable variation in the proportion of cases undergoing peer review across Ontario’s 14 cancer centres (Brundage et al., 2013). In 2012, Cancer Care Ontario launched an initiative to ensure all patients receiving radical/adjuvant radiotherapy have the benefit of peer review of their RT plans. Methods: A multi-professional project team was established to conduct site visits to promote peer review at the cancer centres. They also provided guidance on the organization of peer review rounds so that the activity could be incorporated into local workflows. The education, training, methods, and a centralized reporting infrastructure were developed in collaboration with centres over a one year ramp-up phase and patient-level data was available to the centres for audit purposes. The reporting infrastructure enabled reporting of (1) the proportion of cases peer reviewed and (2) the timing of peer review – prior to treatment, <25% dose delivered, >25% dose delivered. Results: Data for each centre is now a key quality metric and is publicly reported (see Cancer System Quality Index at http://www.csqi.on.ca/). The target for year-one of the project (2013-14) – the proportion of cases to be peer reviewed – was set at 50% with the intent that 100% of cases will be peer reviewed within the next two years. In the ramp-up year, the proportion of cases peer reviewed increased across all centres, though high variation still exists between centres. Conclusions: This initiative demonstrates that it is possible to substantially increase peer review activities on a jurisdictional basis. Key success factors include: a dedicated project team, buy-in and confidence in data quality from centres, investment in education and training, and commitment to public reporting.
Reducing the time from diagnosis to treatment of patients with stage II/III rectal cancer at a large county hospital.
Authors: Jacobs Ryan , Hoffmann Marc Steven , Leslie Lori Ann , Jackson Lymesia W. , Rieber Alyssa G. , Bhadkamkar Nishin Anil
Published: February 2017

141

Background: The treatment of stage II/III rectal cancer is complex and requires multidisciplinary collaboration. Delays in definitive treatment may increase morbidity and compromise outcomes. The goal was to reduce the time from pathologic diagnosis to initiation of treatment by 30% for patients with stage II/III rectal cancer at Lyndon B. Johnson General Hospital (LBJGH), which provides care to uninsured and underinsured patients in Harris County, TX. Methods: The charts of 32 patients with rectal cancer diagnosed between July 2012 and December 2013 were reviewed. Baseline data regarding diagnostic and treatment time points were collected. Potential areas for improvement were identified through analysis of the baseline data, affinity sorting, and fishbone diagrams. A multidisciplinary rectal cancer working group with all relevant administrative and subspecialty stakeholders was created to discuss potential interventions and implementation strategies. The project was approved by the MD Anderson Quality Improvement Assessment Board. Results: Twenty-four of the thirty-two patients reviewed had stage II/III rectal cancer and were eligible for multimodality therapy with curative intent. The median time from pathologic diagnosis to treatment initiation was 62 days. The referral process was identified as the greatest source of delays. The median times from diagnosis to medical oncology and radiation oncology referral were 15 and 32 days, respectively. The median time for eligibility verification and clinical review by Case Management was 13 days. Conclusions: Based on these findings, two primary interventions have been instituted: (1) A synchronized referral process that will result in simultaneous consultation of all involved subspecialty services (surgery, medical oncology, and radiation oncology) was created for patients with rectal cancer; (2) Redundancy in the clinical review process was eliminated by coordination between Case Management and the Medical Oncology Chief Fellow. In tandem, these interventions are projected to reduce the time from diagnosis to treatment by approximately 50% (from 62 to 29 days).
Predictors of positive test results in patients with cancer undergoing hepatitis B screening before chemotherapy.
Authors: Hwang Jessica , Lok Anna S.F. , Cantor Scott B. , Fisch Michael , Barbo Andrea G. , Lin Heather Y. , Suarez-Almazor Maria E.
Published: February 2017

143

Background: Optimal hepatitis B virus (HBV) screening strategies for patients with cancer awaiting chemotherapy are unknown. We aimed to identify predictors of HBV infection in a large cohort of patients with cancer who were systematically screened for HBV before chemotherapy. Methods: In this prospective observational study, patients with cancer at MD Anderson Cancer Center awaiting first administration of chemotherapy in an outpatient chemotherapy unit were identified and approached for HBV screening. Enrolled patients completed a CDC risk survey and had blood tests to screen for HBV (HBsAg, anti-HBc) and hepatitis C virus (anti-HCV) infection. We developed a logistic regression model to identify clinical predictors of either chronic (HBsAg+/anti-HBc+) or past (HBsAg-/anti-HBc+) HBV infection. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test. We present results from year 1 of our ongoing 2-year study. Results: From July 2013 to June 2014, 1176 patients (mean [SD] age, 58 [13] years) have completed the risk survey and HBV screening. Of these, 54% were women, 84% white, 9% black, 4% Asian, and nearly 11% Hispanic. Over 20% had a hematologic malignancy, 1% liver cancer, and 77% a solid tumor other than liver cancer. Almost 12% of patients were born outside the US. Three patients (0.26%) had chronic and 84 (7%) had past HBV infection. Among the latter, 9 patients were also anti-HCV+. Predictors (odds ratio [OR]; 95% CI) of having either HBsAg+ or anti-HBc+ result included black race (4; 2-7), Asian race (4; 2-9), birthplace outside the US (5; 3-10), and having lived with someone with HBV (3; 2-7). Patients who reported ever injecting drugs (OR 7; 2-24) or being a man currently having sex with another man (OR 42; 6-277), or who were anti-HCV+ (OR 5; 1-16) had high risk of HBsAg+ or anti-HBc+ result. Conclusions: Known HBV risk factors are predictive of chronic or past HBV infection in patients with cancer. These results can assist in the development and testing of risk-based screening strategies to enhance accurate and cost-effective identification of patients with HBV infection.
Implementation of pharmacy services in 22 oncology clinics.
Authors: Feldt Ashley , Godden Jennifer
Published: February 2017

145

Background: Our integrated health care system consisted of 15 hospitals and 159 clinics. Since 2011, 22 private practice oncology clinics transitioned to hospital-based clinics. This presented an opportunity to standardize safe and effective pharmacy services at these locations. Methods: Using patient volumes, system leaders determined six pharmacists would serve the 22 new clinics via telepharmacy. Baseline pharmacy services to be offered were prospective order verification, product checking and drug information dissemination. To prepare for the transition, over 25 physicians agreed to standardize electronic order sets and develop one formulary. Vial sizes were consolidated and a uniform way to prepare each chemotherapy agent was designated. Over 75 policies were reviewed and updated. Education was provided to all caregivers prior to the transition. Once baseline services were integrated, additional patient-focused services such as supportive care counseling, follow-up phone calls, medication reconciliation and chemotherapy education were offered. Results: Pharmacists verified over 66,000 physician-ordered chemotherapy prescriptions in 2013, intervening on about 6% by suggesting adjustments for potential organ dysfunction or toxicity. For the past year pharmacists counseled nearly 90 patients a month regarding their supportive care medications. Survey results revealed a consistent increase in overall understanding, although the sample size did not allow for statistical significance. In addition, pharmacists made about 25 follow-up phone calls to patients to assess control of nausea and vomiting, completed medication histories for about 10 patients new to chemotherapy and were consulted for about 5 chemotherapy teachings per month. Conclusions: Integration of pharmacy services in our oncology clinics has allowed for development of a streamlined and safe process for ordering and preparing chemotherapy. It also has increased patient access to pharmacists and education related to supportive care medications.
Improving quality of prostate cancer care in an integrated care delivery system.
Authors: Rabrenovich Violeta , Loo Ronald , Tamaddon Kirk
Published: February 2017

147

Background: Kaiser Permanente (KP) is an integrated care delivery system that provides clinical services to over 9 million members in nine states and the District of Columbia with the goal of providing high-quality and affordable health care to our patients. Over the last decade, the rapid adoption of prostate cancer (Pca) screening practice and technology have resulted in increased detection of Pca and helped identify opportunities for care improvement. KP initiated improvements of continuum of services provided to Pca patients. Methods: Transforming the care provided to Pca patients evolved into the first population-based cancer program that manages the entire continuum of care by taking advantage of our integrated health delivery system. Major accomplishments include appropriate Pca screening to prevent over-diagnosis (Prostate Cancer Screening), improved patient safety and claims reduction to prevent missed abnormal cancer screening (PSA Safety Net), comparative effectiveness of cancer treatment choices to improve quality, and benchmark outcomes in efficiency and clinical quality utilizing a new technology (Robotic Surgery). In addition, the program has achieved superior outcomes and value through innovative chemotherapy management for advanced disease (Lupron Management). Evidence-based medicine, research, analytics and continuous quality improvementare cornerstones of the program, while the pinnacle is our patients, who receive informed, shared decision making and equitable unbiased care. Results: We strongly believe that measures of how well our patients are living with Pca are as important as the cancer-specific survival measures; because of this, we established a prospective registry to measure quality of life for every newly diagnosed patient and stratified by all treatment types. This practice is being disseminated across the Program. Conclusions: By systematically stratifying this diverse population, we have been able to achieve efficient reliable care, and spread each successful process to other regions through collaboration with KP’s Interregional Chiefs of Urology.
Measuring alignment with evidence-informed practice in Ontario’s systemic treatment funding model.
Authors: Kaizer Leonard , Simanovski Vicky , Blais Irene , Lalonde Carlin , Tariq Huma , Lam Jennifer , Evans William K.
Published: February 2017

15

Background: A new systemic treatment funding model (STFM) was implemented in Ontario on April 1, 2014, transitioning from life-time per case funding to reimbursement based on evidence-informed episodes of care. The effectiveness of the model will be evaluated against key indicators including the percent of patients on evidence-informed regimens (PPEIR). Methods: Provincial Disease Site Group (DSG) experts reviewed all chemotherapy regimens administered in Ontario over the two years prior to implementation. Each DSG identified the treatment regimens to be STFM reimbursed, based on evidence of clinical benefit according to treatment intent (curative/adjuvant vs. palliative or both). A year of pre-implementation data will serve as a baseline to assess the impact of transition to the new funding model. Clinical and administrative stakeholders have received their baseline facility-level data and will receive monthly reports, including the PPEIR, to aid in identifying and resolving clinical practice and/or data quality issues post-implementation. Results: Of approximately 1,000 regimens reviewed by the DSGs, ~100 were deemed to be evidence informed for adjuvant/curative intent, ~325 for palliative intent, and ~90 for both intents. Overall, the 2013/14 baseline provincial PPEIR was 91.6% for 16,200 treatment courses given with adjuvant/curative intent while 93.2% of 56,800 patient-months of treatment with palliative intent were aligned with the proposed evidence informed definition. Significant variation in baseline PPEIR was seen for the 29 level 1-3 provincial treatment facilities (range = 71-99%) and for the 10 different disease sites. Conclusions: Knowledge of the PPEIR utilized increases understanding of practice at the system (provincial), regional, facility and disease site level and will provide opportunities for benchmarking and ongoing improvement in quality of care.
Creating infrastructure to manage the maintenance of certification part IV (MOC IV) program at an academic cancer center.
Authors: Donohue Caitlin C. , Porter Julie M. , Norden Andrew David , Dalby Carole Kathleen , Davidson Suzanne , Jacobson Joseph O.
Published: February 2017

160

Background: The American Board of Medical Specialties (ABMS) authorizes Portfolio Sponsor organizations to internally review and approve MOC IV quality improvement projects for their physicians. Dana-Farber Cancer Institute (DFCI) became the first cancer center Portfolio Sponsor in March 2013. We used the opportunity to create a central oversight and incentive structure for quality improvement projects. Methods: As part of the ABMS requirements, physicians must submit a project application, agree to meaningfully participate in a project, and personally reflect on the experience. DFCI must submit documentation of these completed requirements to the ABMS. Therefore, a multi-disciplinary team comprised of physicians, administrators, and information specialists created a user-friendly, online system to submit, track, and store MOC IV information. This web-based system is accessible via the DFCI intranet site and contains forms, feedback loops, automated emails, and reporting capabilities. Results: Three online workflows including a Project Application, a Participation Contract, and an Attestation and Personal Reflection were created. To begin the Application workflow, physicians submit an online application. A link to the application is sent to DFCI administrators with the option to return to the submitter or send the application to the Review Board. The Review Board has the option to request additional information from the submitter or approve the project to begin. Similar feedback loops are built into the other workflows as well. The submitted information is automatically saved and cataloged and can be easily queried for reporting purposes. By 2016, 25 DFCI physicians are due for board recertification and will need to earn MOC IV credit. These workflows will help this cohort and future cohorts of physicians submit information needed to earn credit. Conclusions: The physicians and administrators who have used the system enjoy the ‘save’ functionality which allows them to complete work over time, the automated emails informing them of when they have an assignment to complete, and the ease of completing web-based forms in lieu of paper-based forms.
Standardizing risk: Development of disease and regimen-specific side effect language to enhance consent and chemotherapy treatment plan.
Authors: Donohue Caitlin C. , Perry Laura , Bartel Sylvia , Elfiky Aymen , Kaymakcalan Marina Dusevic , Murphy Karen , Jacobson Joseph O. , Dalby Carole Kathleen
Published: February 2017

162

Background: The American Society of Clinical Oncology recommends the use of a synoptic Chemotherapy Treatment Plan (CTP) to define care including outlining anticipated side effects of chemotherapy. Dana-Farber Cancer Institute (DFCI) sought to improve their existing CTP template in the Electronic Medical Record (EMR) by standardizing side effect language. While DFCI’s existing CTP template contained a side effect section, it was burdensome, requiring clinicians to develop and list the risks for individual treatments. Side effect language varied in content and length, often inaccurately depicting the risks of treatment. DFCI created standardized, disease and regimen specific side effect templates, accessible within the EMR, in order to populate the side effects section of the CTP and consent. Methods: A multi-disciplinary team comprised of physicians, pharmacists, and administrators developed side effect language for chemotherapy regimens. Through research of published materials, a pharmacist wrote unique side effect language for each regimen, translated into a 6th grade reading level. The physicians reviewed the templates for accuracy and completeness making clinical edits to doses, schedules, and risks. Administrators assessed the language for readability using DFCI’s approved Risk Lay Language and built the side effect templates into the EMR. Clinicians access the templates in the CTP section of the EMR and populate the CTP with the appropriate disease and regimen-specific language. Results: There are 36 adult solid tumor disease categories at DFCI. Side effect profiles were developed for 27 (75%) of these categories. By fall 2014, 100% of the side effect profiles will be completed and available in the EMR. In total, 612 regimens will have specific side effect language written and built into the EMR as custom paragraphs. To date, 500 (82%) of the side effect profiles are in development. Conclusions: Building standardized disease and regimen specific side effect language provides patients and clinicians with an accurate depiction of the risks of treatment; subsequently ensuring proper patient education and elimination of provider documentation burden.
Development of Smilow's EPIC ambulatory dashboard and the impact on bar code scanning compliance at care centers.
Authors: Amport Stephanie Buia , Shomsky Lisa , Lyons Catherine A. , Sterling Roberta , Smith Mandeep , Beaulieu Nancy , Corjulo Diane , Adelson Kerin B. , Chiang Anne C.
Published: February 2017

166

Background: Barcode scanning of patient wristbands is a critical stop-gap to prevent administration errors. After EPIC go-live and the implementation of barcode scanning, we created 10 EPIC-based metric reports including scanning compliance. Prior to having reports, our clinical leadership relied on variable qualitative feedback on scanning rates. Our AIM was to reach 90% patient barcode scanning compliance by Feb, 2014 and 95% by Aug, 2014 across Smilow Cancer Hospital Care Centers of Yale-New Haven Hospital. Methods: To engage staff, we shared data on the importance of barcode scanning, compliance and related adverse event reports. Staff reported challenges with scanning patients. We engaged pharmacy leadership to rectify barcode mapping errors. Leadership shared the expectation that all patients would be scanned, that there would be spot checks to prevent workarounds, that staff would be accountable for their own performance and that of their peers, remediation plans for areas <90% compliant and use of a dashboard for employee and medication specific reports. Results: Monitoring, feedback, competition, and improved scanning equipment led to compliance increasing form 89% to 99%. Conclusions: Staff input, detailed reports and workflow review were needed for successful barcode scanning implementation. Staff knowledge that compliance was monitored, communicating improvement, and competition were required for incentive to change practice. Leaders encouraged a culture of safety by ensuring staff feedback was addressed and issues were resolved.Interdisciplinary teamwork between nursing, pharmacy, education and products was necessary to improve barcoding capability.EPIC-based metric reports can drive awareness of and improvement in quality metrics to ensure safe patient-care. [Table: see text]
An electronic prompt to improve hepatitis B virus screening prior to cancer treatment.
Authors: Hicks Lisa K. , Feld Jordan J. , Juan Joshua , Truong Judy , Zurawska Urszula , Giotis Angie , Chan Kelvin K.
Published: February 2017

169

Background: Hepatitis B virus (HBV) reactivation is a potentially fatal complication of cancer therapy that is almost entirely preventable. Despite this, HBV screening rates remain low at many centers. We evaluated the effectiveness of an electronic prompt on HBV screening rates and compared this strategy with education alone. Methods: An education session on HBV reactivation was delivered to all oncology staff at two large, academic oncology centers in the fall of 2010. At one center (study center) an electronic prompt was also introduced. The electronic prompt reminded physicians to screen for HBV when booking a new patient’s first chemotherapy and automatically trigged an electronic order for HBsAg if the physician assented. The prompt was not implemented at the second (control) center. The primary endpoint was the rate of HBV screening. Actual HBV screening rates were determined in both centers for 10 months prior to and for 12 months following the interventions. HBV screening rates were assessed and compared with process control charts (p-charts); 3-sigma limits were employed to define special cause variation. Results: 6,116 new patients received their first chemotherapy during the study period (2,095 study center; 4,021 control center). In the pre-prompt period, the screening rate was stable at 16% at the study center and 25% in the control center. In the prompt period, the screening rate increased to 62% at the study center and was unchanged at 25% in the control center. Special cause variation suggesting a non-random improvement in HBV screening rate was detected at the Study Center two months after the introduction of the electronic prompt. Conclusions: An electronic prompt increased the rate of HBV screening, however screening rates remained relatively low. Education sessions did not appear to improve the HBV screening rate.
The use of IT to improve practice quality within a radiation oncology program.
Authors: Varghese James , Giovinazzo Julia , Larsen Tessa , Medlam Gaylene , Moran Natasha , Murphy Julie , VergelDedios Dennis , Wang Yizhen
Published: February 2017

170

Background: Our centre has used ARIA as its oncology information system since 2005. Anecdotally, since 2008, dosimetrists have identified a high rate of replanned treatment plans. In 2010, a 2% replan rate was estimated however, it was felt that the results did not capture the true rework impact. A definition for replan was created to distinguish it from plan revisions and an attempt to standardize replan naming conventions was initiated. The replan workload was again raised as an issue in 2013 and an interdisciplinary review workgroup was formed with the objective to develop a process to capture workload more accurately. Methods: Rework was further categorized into replan, rework and revision. The nomenclature for the ARIA plan name data field was standardized to identify replans and plan revisions. In addition, rework task activities were created to identify the discipline initiating the rework. Embedding these changes into our process allowed for efficient and accurate workload data extraction. Results of monthly data analysis are shared with the dosimetrists and actionable items are sent to department heads for program engagement. Results: In March 2014, we achieved 100% compliance to the plan naming convention. Data showed 6% replan and 6.5% revision rates. Table 1 shows the rework numbers initiated by discipline. Conclusions: A paperless environment lends itself well to an organization’s ability to capture data. Our experience shows that if processes are designed to support and be supported by the information system, the input of data points can be embedded seamlessly and practically in the clinician’s workflow. This results in improved data capture where data becomes more meaningful, and can then be used for continuous quality improvement, operational decision-making and research projects, all of which can lead to practice improvements. [Table: see text]
Pathways clinical decision support for appropriate use of key biomarker.
Authors: Ellis Peter G. , Lokay Kathleen
Published: February 2017

172

Background: UPMC CancerCenter (UPMC) has utilized clinical pathways for almost ten years in an effort to ensure standardization to the evidence based care for its patients. UPMC oncologists participate in the various pathways disease committees that develop and maintain the pathways content and utilize the pathways through a web-based portal in their daily decision making and documentation. The pathways cover not only treatment recommendations but also guidance for work up such as recurrence risk tools (OncoType Dx) for node negative, HER2 negative, ER positive breast cancer who are candidates for chemotherapy. For patients with a low recurrence risk score, the pathways recommends hormonal therapy only, saving the patient both toxicities and costs of chemotherapy where appropriate. Methods: UPMC analyzed its use of chemotherapy in patients with a recurrence risk score of less than 19 through a retrospective review of physician-input data in its Via Pathways Portal for the twelve months ended May 31, 2014. During this time period, the Via Pathways recommended the recurrence risk test for node negative, HER2 negative, ER positive patients. For patients with a low risk score (less than 19), the Via Pathways recommended hormonal therapy only. For those low risk score patients receiving chemotherapy, the physician would document that an Off Pathway decision was being made, indicate the reason for going Off Pathway, and document the actual therapy delivered. Results: For the twelve months ended May 31, 2014, UPMC physicians documented 288 decisions for patient presentation of node negative, HER2 negative, ER positive patients with a recurrence risk score of less than 19. Of these decisions, 99% (n=284) were On Pathway for hormonal therapy. Of the remaining 1%, three (3) were for accrual to a clinical trial and one (1) was Off Pathway for chemotherapy. Conclusions: Pathways are a tool for promoting adherence to evidence based care by oncologists through the use of a point of care decision support system. Pathways have the potential to reduce costs and toxicities of treatment through the evidence based guidance developed by the pathways disease committees and the adherence to such guidance by oncologists utilizing the pathways decision support tool.
Tumor boards among physicians caring for lung and colorectal cancer patients.
Authors: Kehl Kenneth L. , Landrum Mary Beth , Kahn Katherine Leslie , Gray Stacy W. , Ko Clifford Y. , Chen Aileen B. , Keating Nancy Lynn
Published: February 2017

179

Background: Multidisciplinary tumor board meetings are an important part of cancer care, but few data are available about their benefits. We assessed the association of tumor board participation and structure with patient outcomes. Methods: We surveyed a population and health system-based cohort of patients with lung or colorectal cancer diagnosed in 2003-05 (N=9732) and their physicians (N=1601). We asked physicians how often they participated in tumor boards and whether those meetings served a treatment planning function, evaluated prior treatment decisions, reviewed only challenging cases, reviewed >1 cancer site, and/or served only as teaching sessions. Using logistic and Cox regression, we assessed associations of tumor board participation and tumor board features with patient clinical trial enrollment, receipt of guideline-concordant care, patient-reported quality, and survival. We adjusted for patient demographic and clinical characteristics and physician traits, including specialty. In this exploratory analysis, P values were not adjusted for multiple comparisons. Results: Patients treated by the 54% of physicians participating in tumor boards weekly (vs. less often/never) were more likely to enroll in clinical trials (OR 1.6, 95% CI 1.1-2.2). Patients of physicians whose meetings reviewed >1 cancer site had lower likelihood of trial enrollment (P=0.04) and, among patients with stage I/II non-small cell lung cancer (NSCLC), of curative-intent surgery (P<0.001). Patients with stage I NSCLC, extensive-stage small cell lung cancer (SCLC), or stage IV colorectal cancer had lower mortality if treated by physicians participating in tumor boards weekly (vs. less often/never, P<0.05). Stage I NSCLC patients whose physicians’ tumor boards reviewed >1 cancer site had higher mortality (P=0.04), as did patients with SCLC whose physicians’ tumor boards served only as teaching sessions (P=0.004 for limited SCLC, <0.001 for extensive SCLC). Conclusions: Frequent physician tumor board engagement was associated with patient clinical trial participation and lower mortality for colorectal, small cell lung, and early non-small cell lung cancer, diseases that may benefit from coordinated treatment delivery among specialists.
Use of imaging for staging of early breast cancer in two integrated health care systems.
Authors: Hahn Erin Elizabeth , Tang Tania , Lee Janet S. , Munoz-Plaza Corrine , Adesina Joyce O , Shen Ernest , Rowley Braden D. , Maeda Jared L , Mosen David M , Ruckdeschel John C. , Gould Michael K
Published: February 2017

184

Background: The initial ASCO “Top 5” list, created as part of the Choosing Wisely campaign, recommends against use of imaging for staging of early stage breast cancer in asymptomatic women at low risk for metastasis. The objective of this study was to measure and compare use of imaging for staging in two large integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was used for routine staging or for diagnostic purposes. Methods: We identified stage 0-IIB breast cancer patients diagnosed between January 1, 2010 and December 31, 2012 with first primary malignancy from tumor registries in three KP regions (Southern California, Northwest, and Mid-Atlantic) and IH. Using the KP and IH electronic health records, we identified use of imaging tests (PET, CT, bone scan) during the staging window (30 days prior to diagnosis up to initial surgery). We performed chart abstraction on a random sample of patients who received an imaging test to identify indication. Results: For the total sample of 10,014, mean age at diagnosis was 60 (range 22-99); with 21% stage 0, 47% stage I, 32% stage II. Overall, 8% of patients (792 patients) received at least one imaging test during the staging window, including 8% at KP and 6% at IH (p=0.0005). Chart abstraction (N=129) revealed that overall, almost half of all imaging tests (48%) were performed to evaluate a symptom, sign or prior imaging finding, including 55% at KP and 32% at IH. Conclusions: Use of imaging for staging of low-risk breast cancer was very low in both health care systems, with clinically trivial differences between them. Approximately half of imaging services were in response to a sign or symptom. Strategies to reduce use of imaging at staging for early stage breast cancer patients within these health care systems are unlikely to yield meaningful improvement. [Table: see text]
A breast analytics dashboard to allow near-real-time visualization of quality assurance data.
Authors: Levy Mia Alyce , Warner Jeremy , Sanders Neal , Carney Pam , Pratt Joy , Cobb Jared , Taylor Ariadne , Neuss Michael N.
Published: February 2017

186

Background: Quality metrics for internal use (e.g. quality improvement; quality assurance [QA/QI] activities) and external use (e.g. accreditation; national quality reporting) are currently primarily obtained through retrospective manual data abstraction on subsets of patients, at a majority of cancer centers. Real-time QA/QI of all patients is attractive but requires collection of electronic data from disparate clinical systems that are rarely fully interoperable. We developed a dashboard to aggregate relevant clinical information in near real-time for QA/QI visualizations. Methods: Tableau® software was used to visualize data from multiple clinical systems at Vanderbilt University Medical Center (VUMC). Custom extract, transform, and load (ETL) processes were developed to collect radiology, pathology, professional billing, and clinical data on a daily basis. An integrated dashboard was developed through an iterative process involving physicians, nurses, and software engineers. As a pilot project, data from all patients with an image-guided breast biopsy obtained at VUMC from 2009-2013 was visualized. Results: 4177 biopsies were included in the visualized cohort as of June 2014. 3,210 (77%) of the biopsies were preceded by a BiRADS 4 or 5 mammogram. The annual biopsy rate increased by 51% over the time period. Despite this increase in volume, the median number of weekdays from BiRADS 4 or 5 mammogram to image-guided biopsy was stable at 5 days over the time period. Prior diagnosis status, lesion class, procedure type, and imaging exam type were also included in the dashboard. Conclusions: This pilot project demonstrates the ability to visualize near real-time clinical data for QA/QI purposes. Tableau® is interactive, so that certain patterns (e.g. the distribution of number of days from screening mammogram to biopsy) can be explored at a granular level. This functionality also allows the user to investigate why 23% of patients had no apparent imaging before biopsy. Based on a perceived pattern of delayed biopsy in certain outliers, QI efforts at VUMC are underway to ensure timely biopsy. Interactive visual dashboards such as the one described present opportunities to rapidly cycle QA findings into QI actions.