bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of QOPI at Illinois CancerCare, P.C. (ILCC).
Authors: Howard Kendall , Heard Bridgette , Kumar Pankaj , Miller Laura M.
Published: February 2017

174

Background: ASCO’s Quality Oncology Practice Initiative (QOPI) is a practice based quality improvement program based on retrospective chart reviews. Data collection is performed twice a year. If scores meet a specified level, a practice may apply for certification. In order to achieve certification, a physician practice must meet minimum threshold scores in five areas including: Core, Symptom/Toxicity, Care at End of Life, Breast Cancer, Colon/Rectal Cancer and Non-Small Cell Lung Cancer. A QOPI on-site review is conducted after application. Once the application has been approved, the on-site review includes an audit of chemotherapy preparation and administration, patient education, treatment planning and the review of applicable policies. If acceptable, a 3 year certification is awarded to the practice. Methods: ILCC began QOPI participation in Fall 2011. For the first round, the scores were lower than the required minimum threshold certification score level requirements. The certification areas with lower than desirable scores included: Pain Score Assessed, Emotional Well Being Assessed and Colonoscopy within specified time frame. To improve scores, a committee was formed to identify improvements. Improvements included revising physician templates to include new areas and language. Physicians were also given the appropriate verbiage for assessing a patient’s Emotional Well Being, and employees also were engaged in our improvement efforts by addressing areas that needed to be asked in the first and second visits only. Results: All selected measures show improvement from Fall of 2011 to Spring of 2013. Pain addressed appropriately increased 59% (26% to 80%); patient emotional well being assessed increased 32% (19% to 51%), colonoscopy before or within 6 months of curative colorectal resection improved 35% (50%-86%). Our total certification score went from 72.05% to 87.99%, a 15% improvement. We applied for certification and became a QOPI certified practice in fall of 2012. Conclusions: QOPI is an effective program for evidence based quality improvement within oncology practices.
Unit redesign to improve safety, quality, and patient and nurse satisfaction.
Authors: Woodrum Theresa , Kneifl Missy , Aning Christina
Published: February 2017

179

Background: Increased emphases have been placed on hospital safety, and patient and nurse satisfaction in the competitive cancer care arena. The current climate demands critical attention to stakeholder input in cancer care delivery. Methods: Stakeholder (patients, families, nurses, physicians, and other members of the multidisciplinary care team) input directed efforts in an adult/pediatric oncology/hematology unit renovation. A true focus on stakeholder involvement was evident by uniting the patient advisory council from the cancer care service line, multidisciplinary staff, and unit-based shared governance structures to form the design team. Uniting multiple perspectives and eliciting design team ideas and recommendations ensured renovation plans remained focused on improved care delivery and processes. The design team discussed all aspects of renovation, including work flow, equipment/technology needs, safety and security, and family/child friendly spaces. A key feature of the renovation was the universal room concept, which meant that rooms needed to be adaptable to a cancer patient’s changing needs: from standard care to critical care. Stakeholder input was sought on as all aspects progressed as final decisions were made on aesthetics, family-focused amenities, work flow structures such as location of equipment and supplies, and patient safety features (especially in bathroom spaces). Results: Total falls decreased from 6.17 to 3.1 per 1,000/pt days and falls with injury decreased from 2.9 to 1.8 per 1,000/pt days. Improvements in patient satisfaction scores were seen in “overall room” scores increasing from 79.9 to 90.5 and “visitor /family” satisfaction increased from 87.9 to 92.1. Overall nursing satisfaction improved from 56.68 to 64.58 and job plans to remain on unit rose from 63-89. Conclusions: Avoiding a top-down, hierarchical decision-making process from conceptualization to realization resulted in measurable changes in patient safety and patient and staff satisfaction from pre- to post-renovation. This process can utilized to address the changing needs in cancer care.
Cancer center improvement through practice-based clinical leadership team infrastructure.
Authors: Coniglio Mary , Cunningham Regina , Gillespie Dawna
Published: February 2017

180

Background: A practice based clinical leadership team (PBCL) was created in the outpatient cancer center to identify, evaluate, and implement initiatives to improve safety, quality, and patient satisfaction. A quality leader facilitates the team which includes nursing, physician leaders, as well as subject matter experts from throughout the cancer service line. Methods: Key focus areas include data review/analysis, facilitating performance improvement teams to enhance patient satisfaction and patient safety; and to reduce variations in care. PBCL members participate in Performance Improvement in Action (PIIA) program that includes just-in-time process improvement training while completing projects in a 90-day period. The PIIA approach embeds quality/lean tools in the organization. The training provides structure, common terminology, and stresses the use of data to make decisions, relying on the voice of the customer and clear articulation of the problem statement before jumping to solutions. The methodology incorporates six sigma/lean tools and plan-do-check-act. Results: The PBCL structure has resulted in several specific improvement projects. The patient throughput project team implemented recommendations that increased the percentage of patients who arrived and completed lab tests before their scheduled appointment time by 36%. In addition, a simulation model was created which quantified a 28 minute reduction in total time in the department by increasing the number of patients seen independently by advanced practice providers and removing the room assignment constraint by assigning providers to a “pod of rooms” rather than a specified room(s). An infusion fast track program was implemented for selected medications to expedite patient throughput resulted in an 18 minute (52%) reduction of time in the department. Conclusions: Incorporating clinical leadership in a structured framework for quality improvement increases the buy-in to change while maintaining an objective, data driven approach. The team approach and use of performance metrics provides the opportunity to expedite pilot project testing while raising awareness of key metrics to inform of additional opportunities.
Breast cancer risk assessment: How risk models can “overdiagnose” risk.
Authors: Ozanne Elissa , Drohan Brian , Hughes Kevin S.
Published: February 2017

184

Background: Overdiagnosis is commonly defined as a diagnosis of "disease" which will never cause symptoms or death during a patient's lifetime. Similarly, overdiagnosis can also happen when individuals are given the diagnosis of being at risk for a disease, such as being at high-risk for developing breast cancer. Women can be given such a diagnosis by meeting a set of risk assessment criteria, which are often accompanied by recommended management strategies. We sought to identify the extent and consequences of overdiagnosis for individuals being at high risk for breast cancer using the American Cancer Society (ACS) guidelines for the appropriate use of Magnetic Resonance Imaging (MRI). Methods: We identified women who fit the ACS criteria in a population based sample at a community hospital. The ACS criteria mentions three risk assessment models for determining a woman’s risk, and these criteria were reviewed to determine the extent of possible overdiagnosis in this population. The expected resource utilization resulting from this overdiagnosis, and the impact on patient quality of life are extrapolated. Results: 5,894 women who received mammography screening at the study site were included. 342 (5.8%) of the women were diagnosed as high risk by at least one model. However, only 0.2% of the total study population were diagnosed as high risk by all three models. One model identified 330 (5.6%) to be at high risk, while the other two models identified many fewer eligible women (25, 0.4% and 54, 0.9% respectively). Conclusions: Using different models to evaluation the ACS criteria identifies very different populations, implying a large potential for overdiagnosis. Further, this overdiagnosis is likely to result in the outcome of screening too many women, incurring false positives and unnecessary resource utilization.
Decision regret following treatment for localized breast cancer: Is regret stable over time?
Authors: Martinez Kathryn Anne , Resnicow Ken , Hawley Sarah T.
Published: February 2017

19

Background: While studies suggest most women have little regret with their breast cancer treatment decisions, few (or no) studies have evaluated whether regret changes over time. Methods: Women diagnosed with breast cancer between August 2005 and May 2007 reported to the Detroit, Michigan, or Los Angeles County Surveillance Epidemiology and End Results (SEER) registry completed surveys at 9 months post diagnosis (time 1) and again approximately 4 years later (time 2). A decision regret scale (Brehaut, 2003) consisting of 5 items was completed at both time points. Item responses were summed to create a regret score at both 9 months and 4 years (scales of 5 to 25 points, with 25 being most regret). We used multivariable linear regression to examine change in regret from 9 months to 4 years. Independent variables included surgery type (breast conserving surgery, unilateral mastectomy, bilateral mastectomy), presence of invasive disease (yes/no), and recurrence status (yes/no) at follow-up. We included an interaction between surgery type and recurrence status. The model controlled for demographic and clinical factors. Results: The sample included 1,497 women. Mean decision regret at 9 months was 9.5 points and 10.1 points at 4 years (range 5-25) (NS). Two-thirds (64%) of respondents had breast conserving surgery, 26% had unilateral mastectomy, and 9% had bilateral mastectomy. We found no impact of surgery type on change in regret in the overall sample. However, among the, 86 (6%) women who recurred, those who underwent unilateral mastectomy reported significant reduction in decision regret over time relative to recurrent women who had breast conserving surgery (d= -6.76, p=0.024). Average change in regret among non-recurrent women was 0.52 points and was 2.7 points for women who recurred. Conclusions: Decision regret in breast cancer is generally stable over time, yet changes in regret appear to be associated with disease trajectory and treatment received. Our results suggest that more extensive treatment is associated with a reduction in regret only when women experience a recurrence. Understanding patients’ assessment of their decisions related to treatment may be useful for informing future decision making processes.
An interdisciplinary model for predicting patients at high risk for readmission amongst solid tumor oncology patients in a comprehensive cancer center.
Authors: Shinde Arvind , Nolen Ruth , Hein Marjorie Jen , Siccion Eduardo , Crocitto Laura E. , Kassab Tricia , Morse Denise , Leong Lucille A.
Published: February 2017

190

Background: Increasing emphasis is being placed on reducing hospital readmission (readm) rates. Reduction of hospital readm remains a challenge, especially among the oncology population. Identifying patients (pts) at increased risk can assist with developing targeted interventions. Methods: From 1/1/11 to 12/31/12, an interdisciplinary team consisting of medical oncologists, hospitalist physician and NP, QI specialist, and case manager prospectively reviewed the medical oncology inpatient census on a biweekly basis to identify pts at risk for readm. Pts with any of the following conditions were considered at high risk for readm: significant pain, wounds, intestinal obstruction, refractory neutropenia despite GCSF, elderly/frail, unstable housing, patient/family non-compliance, rapid cancer progression, refusal of appropriate hospice care, and stalled care plans. These criteria were based upon previous years’ anecdotal experience. Interdisciplinary interventions to address these conditions were identified and initiated. Results: 272 pts were assessed during these sessions. Each session took on average 60 minutes. 69 pts (25%) were deemed to have at least one high risk factor. Chart review revealed that 6 died in the hospital and 13 were discharged to hospice. No pts on hospice were readmitted. Of the remaining 50 high risk pts, 14 (28%) and 25 (50%) pts were readmitted within 14 days and 30 days, respectively. Conclusions: This interdisciplinary team model seems to have a fair predictive value in identifying pts at higher risk for readmission. However, it is time and labor intensive. Enrollment of appropriate high risk pts in hospice mitigates this risk. Given the current emphasis on decreasing readm and the increased cost/penalties associated with readm, the next step will be to pilot cost-effective interventions for pts with these high risk factors. Potential interventions which we have instituted include follow-up calls, social service referrals, intensive family/pt education, clinic appointments within 3 days of discharge, greater coordination with primary care physicians, and more effective hospice discussions. Supported by CA 62505.
Evaluation of oral chemotherapy prescribing at an outpatient oncology clinic.
Authors: Carro George W. , Brockstein Bruce , Hensing Thomas A. , Fleming Patrick Joseph , Gavin Shannon Maureen , Spath Wayne , Harper Abigail , Hui Wendy , Uhlig William J. , Hughes Brad
Published: February 2017

191

Background: Oral chemotherapy’s exponentially increasing role in the treatment of malignancies continues to pose unique challenges to oncology. The American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) drafted measures in the Chemotherapy Administration Safety Standards that help address some of these issues concerning oral chemotherapy. There is a lack of data describing the prescribing process for oral chemotherapy. In a retrospective chart review, prescriptions at a hospital-based outpatient oncology center were evaluated for completeness of prescribing and follow up measures. Methods: A retrospective chart review of ten oral chemotherapy medications from May 2012 to July 2012 was conducted. The primary outcome measure was compliance with ASCO and ONS Chemotherapy Administration Safety Standards. A secondary outcome was frequency of pharmacist interventions on oral chemotherapy prescriptions. Results: 412 prescriptions were evaluated. Prescriptions were graded on a scale from 1 to 8. One point was given for inclusion of each of the following: prescribing physician, patient name, drug name, dose, dosing methodology, quantity, refills, and accurate directions. Of all the prescriptions, 23% contained all aspects of a complete prescription. The most common reasons for point deductions were contradictory or unclear directions and allowing refills for oral chemotherapy which should not be refillable. Four percent of prescriptions had a documented pharmacist intervention. Conclusions: This study revealed areas for improvement in the prescribing process of oral chemotherapy. Targeting directions and refill fields within prescription templates will improve compliance with ASCO and ONS standards. This can be accomplished by implementing customized oral chemotherapy prescription templates within treatment plans in the electronic medical record system. Unlike chemotherapy administered in the clinic setting, oral chemotherapy prescriptions are not generally reviewed by oncology trained pharmacists. With the collaboration of medical and nursing staff, a new work flow was implemented which includes pharmacist review of electronic oral chemotherapy prescriptions.
Expectations of discipline representation on multidisciplinary treatment planning (MTP) teams.
Authors: Prabhu Das Irene , Mallin Katherine , Gay E. Greer , Rozjabek Heather , Fennell Mary L. , Stewart Andrew K. , Castro Kathleen M. , Clauser Steven
Published: February 2017

195

Background: The Commission on Cancer’s (CoC) standards require accredited cancer programs to utilize a multidisciplinary team approach for treatment planning. A recent CoC survey sought to characterize current multidisciplinary treatment planning (MTP) practice from the cancer programs’ perspective. Methods: The survey, administered to 1,261 programs, included items on team structure and process, case presentation, clinical trials and patient involvement. Each facility was designated to report on MTP for one cancer type: Breast, Gastrointestinal (GI), Lung, Head/Neck, Gynecologic (Gyn), Brain/Central Nervous System (CNS). A total of 797 (63%) facilities responded. Initial analyses highlight the disciplines expected to attend MTP meetings. Results: Forty-eight percent expected all core physician specialties (Medical Oncology, Radiation Oncology, Surgery and/or Surgical Oncology), to attend the initial case presentation. Respondents also expected affiliated specialists and professionals to attend initial case presentations, and included pathologists (90%), clinical trials nurses (46%), patient navigators (37%), primary care providers (20%), and genetic counselors (18%). Data analysis demonstrated significant variation in expected disciplinary attendance for select providers depending on type of cancer program, as illustrated below (Table). Analysis by cancer type showed that primary care physicians were expected to attend Lung MTP meetings at 25% of the facilities compared to Breast (15%). Genetic counselors were expected to attend MTP meetings for Breast (29%), Gyn (24%), and GI (18%). Additional analyses are ongoing. Conclusions: To improve cancer care quality, the CoC has put forward standards to foster multidisciplinary professional participation in the treatment of cancer care. Findings indicate expectations of attendance for key disciplines at MTP meetings vary by tumor–specific MTP and by type of cancer program. Key genetic markers for certain sites may also explain why genetic counselors are expected to attend. [Table: see text]
Improving utilization of patient portals through a multifaceted intervention strategy.
Authors: Higgins Patrick , Gillespie Dawna , Coniglio Mary , Guerra Carmen
Published: February 2017

205

Background: Healthcare’s paradigm shift is in full swing. Electronic medical record (EMR) systems are up and running across the country, creating the potential for a more interactive environment for patients. With Stage 2 of the Affordable Care Act’s Meaningful Use requirements approaching in 2014, health systems are being challenged to determine how to effectively engage with patients electronically. MyPennMedicine is the portal used at the Abramson Cancer Center, and its use has been incredibly low since its introduction in 2009. Methods: Our assessment focused on patient portal account activations, messaging volume, and follow-through. Baseline measurements of these variables were abysmal. We convened an inter-disciplinary team of stakeholders (including patients, physicians, nurses, IT, front desk, and marketing) to understand current barriers to portal use, and to develop innovative methods aimed at improving use of the tool. Our team cultivated a strategy that included system upgrades based on end-user feedback, provider education about the benefits of the portal, patient demonstrations, and improving the ease of patient sign-ups. Results: At baseline (February, 2013), we determined that only 13% (18/139) of patients who had been assigned a code to access the patient portal actually did so. Our response to patient requests via the portal was only 58% (216/374). Moreover, the average time it took providers and staff to complete patient requests was 17.1 hours. After our first round of interventions (May, 2013), the rate of account activation increased to 45% (110/244) and our response to patient requests increased to 73% (331/455). The average time to complete the requests actually increased to 21.3 hours perhaps as a result of the increased volume. Conclusions: EMRs will continue to change the way we engage with patients. The clinical significance of our increase in patient portal usage is yet to be fully appreciated. Our initial interventions have resulted in significant increases patient awareness and utilization as well as improved follow-through by clinicians and staff. Future directions include additional interventions focused on technological improvements and continued education and clinician support.
Stakeholder-informed “Choosing Wisely” implementation project in regional oncology clinics.
Authors: Kreizenbeck Karma L. , Stewart F. Marc , Lehman Constance , Carlos Timothy , Chen Eric Y. , Jensen Barbara , Rieke John W. , Greer Benjamin E. , Bredeson Chris , Putnam Kristie , Ramsey Scott David
Published: February 2017

207

Background: ASCO launched the Choosing Wisely campaign to reduce the use of interventions that lack evidence for their use in clinical cancer care. The recommendations have strong support, but lack an implementation plan. The objective of this project is to develop a stakeholder-informed process to improve adherence to ASCO Choosing Wisely within an experimental context. Methods: Participants include Medical Directors from 7 oncology clinics and 1 commercial insurer within the Puget Sound region, and the SEER Puget Sound Cancer Registry. The project consists of 3 phases (1) prioritization, (2) design, (3) implementation and monitoring. For phase 1, Medical Directors were surveyed via e-mail to prioritize the recommendations with the following criteria: importance for improving the value of cancer care; impact of adherence; urgency; and feasibility of implementing an intervention. Participants met via teleconference to discuss survey results, review regional utilization data, and design of interventions. Participants were surveyed again for a final ranking. In phase 2, participants discussed options for interventions and study designs. Results: Initially, the highest ranked recommendations were advanced imaging in staging of local stage prostate cancer, surveillance of local and regional stage breast cancer, and colony stimulating factor (CSF) use for low risk chemotherapy. After discussion, breast cancer surveillance and CSF prescribing ranked the highest. Participants requested utilization and cost-impact data from the health insurer for the top 2 choices. Conclusions: Using a transparent, multi-stakeholder process, it is feasible to implement programs to improve adherence to ASCO Choosing Wisely.
Ensuring evidence-based cancer medicine by influencing prescribing behavior.
Authors: Hrushesky William J. , Huff Dinah , Davis Sharon , Bobolts Laura Rose , Fishman Marc L. , Shimp William S. , Kogler Jurgen Wilhelm , Fishman Val , Walton Robert
Published: February 2017

212

Background: Oncology Analytics, Inc. (OA) promotes evidence-based, guidelines-compliant cancer therapeutic decision-making on behalf of healthcare payers. The OA web-based 1,300 protocol treatment request system screens several hundred applications each month. Evidence-based requests are automatically approvable within seconds (Auto); those needing medical director (MD) review, within hours (Non-Auto). Some 10% of all requests require real-time consultation between OA board-certified medical oncologists/hematologists and the prescribing cancer specialist. Three-quarters of these non-compliant residual requests are rescinded by the treating oncologist. The remainder are either approved because of additional information while about 1% are recommended for an adverse determination. Methods: We hypothesize that OA’s presence in a cancer market gradually improves the likelihood of evidence-based oncologist prescribing behavior. We tested this over 44 consecutive months of rapid growth, from May 2009 through December 2012, within a single southeastern US market. Since Auto requests are evidence- and guidelines-based, and Non-Auto requests are either not supported by evidence or have evidence support but with less toxic or less costly alternatives available, we reasoned that any sustained directional change in the ratio of Auto to Non-Auto represents a characteristic change in cancer specialist behavior over that span. The monthly ratios of Auto to Non-Auto were analyzed for trends by least squares and the slopes of each were contrasted by ANCOVA. Results: During the first six months, Auto-processed requests approximately equaled Non-Auto-processed request numbers, for a baseline ratio of one. Over the next 38 months, this ratio rose to approximately 1.4, meaning that 40% more requests were eventually approved automatically each month than those requiring MD review. The slopes of this relationship between Auto and Non-Auto approvals are statistically distinct (F = 43.34; p<0.001). Conclusions: This progressive quality improvement reflects malleability of cancer doctor prescribing behavior, results in substantial savings, occurs quickly, persists and grows over time.
Improving the care of acute lymphocytic leukemia (ALL) at a large county hospital.
Authors: Karuturi Meghan Sri , Yorio Jeffrey Thomas , Titus Annie , Pharr Stephenie Jeanette , Rieber Alyssa G.
Published: February 2017

213

Background: The treatment of ALL involves complex chemotherapy regimens that are difficult to deliver to underserved populations. Lyndon B. Johnson General Hospital (LBJGH) provides care to uninsured and underinsured patients in Harris County, the third largest county in the United States. Our goal is to achieve 80% adherence to National Comprehensive Cancer Network guidelines in the care of newly diagnosed ALL patients at LBJGH. Methods: The charts of 14 patients with newly diagnosed ALL were reviewed. Demographics, initial work-up (e.g., bone marrow biopsy and aspirate), type of treatment, adherence to scheduled treatment, use of supportive medications, outpatient follow-up, stem cell transplant referral and quality of provider documentation were collected. Areas of potential improvement were then identified using provider focus groups and Ishikowa Diagram. The project was approved by the MD Anderson Quality Improvement Assessment Board. Results: 12/14 patients were evaluable, having received their full course of care at LBJGH. The median age was 35, 9/12 (75%) were female and 9/12 (75%) were Hispanic. 6/11 (55%) cases expressed CD20 (CD20+) and 3/11 (27%) were Philadelphia chromosome positive (Ph+). All 12 patients received induction and consolidation therapy with the HyperCVAD regimen (cyclophosphamide/vincristine/doxorubicin/dexamethasone alternating with high-dose methotrexate/cytarabine). Bone marrow biopsy at time of diagnosis, use of a tyrosine kinase inhibitor for Ph+ ALL, and use of supportive medications occurred >80% of the time. Administration of outpatient chemotherapy, use of rituximab for CD20+ ALL, outpatient lab follow-up, intrathecal chemotherapy and appropriate referral for allogeneic transplant occurred 50-80% of the time. Provider documentation was appropriate <50% of the time. Conclusions: Based on these findings, we established a standard algorithm of care for ALL patients at LBJGH, enhanced provider education through the design and distribution of teaching tools, created a checklist to facilitate handoffs between providers and established expectations for documentation. In the future, we would also like to add a patient navigator to further improve coordination of care.
Leveraging the strengths of an academic health system to improve community cancer care.
Authors: Harse Kay M. , Wolf Terri P.
Published: February 2017

218

Background: To improve community cancer care quality, UC Davis Health System formed the UC Davis Cancer Care Network (CCN) to partner with select cancer centers in California to offer leading-edge care close to home. Hospital-based community cancer centers become affiliates of the UC Davis CCN through an evaluation process led by UC Davis. By synergizing the strengths of an academic health system and community-based oncology care, the network formalizes the commitment to collaboration with community providers. Methods: This quality model relies on a central university-based team interacting with affiliate sites to support them in their local missions. Affiliates progress through three phases of development of their cancer program. Each phase adds layers of quality to the organization. CCN staff members coordinate the phases: 1) Review and Develop Operations—site specific structures needed to be a comprehensive community cancer center; 2) Make Connections—within the network and the local community; 3) Become Self-Directed—identifying own needs and direction. The partnership attributes include: joint marketing, system synergies, certification assistance, coordinated service line development, dedicated personnel resources, on-site educational opportunities, and quality oversight. Results: Performance measurement includes: local market share, ACOS accreditation, adherence to national quality and patient satisfaction standards, assessment of community health needs and benefits, and enhancement of local capabilities (inpatient oncology unit, radiation, pathology, radiology, and surgical oncology services). Conclusions: This model demonstrates the benefit of partnering the strengths of an academic health system and community cancer programs to provide quality care.
Timely management of febrile neutropenia in children with cancer.
Authors: Vedi Aditi , Cohn Richard Jules , Pennington Victoria , O'Meara Matthew , Stark Kylie , Hunstead Paul , Londal Wendy , Adnum Kirsten , Senner Anne , Maurice Lucy , James Alan
Published: February 2017

220

Background: Sepsis is a major cause of morbidity and mortality in pediatric oncology patients, particularly during periods of neutropenia, which is a well-recognized complication of immunosuppressive therapy. The current international standard of care is recognized as rapid assessment and delivery of empiric antibiotics within one hour of onset of fever for all febrile and potentially neutropenic patients. Although pediatric oncology services are centralized to tertiary hospitals in Australia, peripheral referral centres regularly provide essential supportive care for this immunosuppressed group of patients close to home in a “shared-care” model. The objective of this study was to ensure delivery of empiric antibiotics to all children with fever and suspected neutropenia within one hour of presentation to tertiary and peripheral hospitals. Methods: The records of all oncology patients presenting to an emergency department over a 3-month period were reviewed and time to first antibiotic administration recorded. Potential causes of delay in commencement of antibiotics were identified through focus groups and a questionnaires involving patients, medical and nursing staff. These were evaluated to develop an algorithmic management guideline using current available consensus data, and the introduction of the practice change was supported by staff education. Follow-up data was collected at 12 and 60 months post intervention at the tertiary and peripheral hospitals. Results: The median time to empiric antibiotics was reduced from 180 minutes to 75 minutes at 12 months post intervention, and the results were sustained at 5 years, with the median time being 65 minutes. Conclusions: The introduction of the guideline has resulted in an improvement in practice, meeting international standards and sustained results at 5 years at both tertiary and peripheral hospitals. [Table: see text]
Enhancing your culture of safety and quality through practice accreditation.
Authors: Sinicki James , Heron Dwight Earl , Huq M. Saiful , Koen Martha , Bednarz Greg
Published: February 2017

227

Background: To strengthen the culture of quality and safety in an NCI-designated, multi-institution radiation oncology network by obtaining accreditation. Methods: Accreditation was sought by our geographic diverse, but integrated cancer center network made up of 20 radiation oncology sites. Accreditation standards were reviewed and compared to the current practices in place. Each site was internally audited for compliance to these measures and a process of education for any noncompliance instances. After submitting the application for accreditation, the process began with data collection from all locations, which included staffing levels, services provided, treatment and physics equipment used, beam data, as well as numerous pieces of documentation for quality reports and regulatory documents. Patient data was then submitted from each location for physician peer review followed by an onsite visit by a physicist and administrator. Results: After several internal site visits and respective multidisciplinary meetings with site physicists and managers, all locations underwent a thorough evaluation by an accrediting body. This third party found the quality and safety of the organization to meet the minimum standards set forth. All 20 sites were therefore given the stamp of approval and accredited. Conclusions: Preparing for accreditation and going through this process greatly strengthened each of our sites’ culture of safety and quality. It enabled all of our locations to do an in depth self-evaluation as a form of self regulation and continuous quality improvement. It was an opportunity to ensure that we not only had the appropriate quality practices in place, but could show through documentation that we, in fact, were a quality organization. The lessons we have learned from this experience can be used as a model for individual and network sites to pursue practice accreditation in an era of increasing emphasis on safety and quality in radiation oncology.
Hepatitis B reactivation in patients with lymphoma: A meta-analysis.
Authors: Mozessohn Lee , Chan Kelvin K. , Feld Jordan J. , Hicks Lisa K.
Published: February 2017

228

Background: Patients with hepatitis B virus (HBV) who are HBsAg+ are at risk of HBV reactivation if rituximab is administered in the absence of antiviral treatment. Recently, it has been reported that patients with so-called “resolved HBV infection”(HBsAg-/cAb+) may also be at risk; however, the degree of risk is not known. Methods: We performed a systematic review of the English and Chinese language literature in Medline (1996 to June week 3 2013) and Embase (1996 to 2013 week 26) using the MeSH terms “lymphoma” and “hepatitis B”. Eligible studies were limited to those reporting primary data on HBV reactivation rates in HBsAg-/cAb+ patients receiving rituximab. We excluded case series with less than 5 patients. Pooled estimates were calculated for HBV reactivation and the impact of HBsAb status on HBV reactivation rate was explored. We also examined reactivation in HBsAg+ patients receiving rituximab by performing a systematic review of the English language literature in PubMed (1997 to June 21, 2013) using the terms “hepatitis B virus”, “reactivation” and “lymphoma”. Results: Data from 550 HBsAg-/cAb+ patients in 12 studies were included. Using a standardized definition of HBV reactivation, (increase in HBV DNA from baseline or HBsAg seroreversion +/- ALT >3 x upper limit of normal), the pooled estimate for the risk of HBV reactivation in HBsAg-/cAb+ patients was 8.1% (I2 = 55%, P = 0.007). Significant heterogeneity was apparent. Exploratory analyses suggested that patients were less likely to reactivate if they were HBsAb+ (OR = 0.32; 95% CI 0.12-0.85, P = 0.0285). In HBsAg+ patients we meta-analyzed prospective, controlled studies. Without antiviral prophylaxis, the reactivation rate for HBsAg+ lymphoma patients was 51.0% (I2 = 0%, P = 0.93). Conclusions: Our meta-analyses confirm that there is a risk of HBV reactivation in HBsAg-/cAb+ patients exposed to rituximab. HBsAb+ patients may be at lower risk than those who are HBsAb-. However, heterogeneity in the risk estimates limits their generalizability. Without prophylaxis, significant reactivation in HBsAg+ patients exists. Large prospective studies are needed to clarify the risk of HBV reactivation in HBsAg-/cAb+ patients and to inform decisions about best practice.
Complementary and alternative medicine and other health behaviors.
Authors: Graham Donna M. , Espin-Garcia Osvaldo , Brown Catherine , Halytskyy Oleksandr , Mahler Mary , Pringle Dan , Eng Lawson , Niu Chongya , Lam Christine , Charow Rebecca , Villeneuve Jodie , Shani Ravi M. , Tiessen Kyoko , Howell Doris , Jones Jennifer M. , Alibhai Shabbir M.H. , Xu Wei , Liu Geoffrey
Published: February 2017

23

Background: Complementary and alternative medicine (CAM) use in patients with cancer has increased. A patient’s decision to seek CAM alongside conventional cancer treatment is complex. We evaluated whether patients who sought CAM were also more likely to engage in other healthy behaviours such as exercise, smoking cessation, alcohol reduction, and maintaining a healthy weight. Methods: As part of a larger survey of cancer survivors, 551 cancer patients across Princess Margaret Cancer Centre (Canada) were queried on clinico-demographic information, their use of CAM and other health-related behaviors (smoking, alcohol use, healthy weight, etc.). Multivariable logistic regression assessed each health behavior, adjusting for clinical factors associated with CAM use. Results: Females: 53%; median age: 54 years; Caucasian: 83%. Primary tumor sites: breast/gynecologic 22%; gastrointestinal/genitourinary 28%; hematologic 23%; lung/head and neck 12%. Following their cancer diagnosis, 43% used CAM. Being female (odds ratio=2.55, 95% CI [1.8-3.7], having higher education (2.08 [1.4-3.1]) or higher income (1.80 [1.2-2.7]), and having breast/gynaecological cancers (vs. all others; 2.82 [1.8-4.3]) were associated with greater CAM use. These factors served as adjustment variables for the analysis of behaviors. Behaviors associated with increased use of CAM included: use of CAM prior to diagnosis (10.6 [6.5-17.2]), participation in support groups (3.39 [2.1-5.6]), not being overweight or obese one year prior to diagnosis (1.82 [1.2-2.7]), and meeting Canadian physical activity guidelines either before diagnosis (1.80 [1.2-2.8]) or currently (1.70 [1.0-2.8]). No association was observed between CAM use and smoking status or cessation, alcohol intake or reduction, self-described diet habits prior to cancer diagnosis or dietary changes after diagnosis. Conclusions: Some behaviors such as baseline and current physical activity, participation in support groups, not being overweight, and prior use of CAM were each associated with greater CAM use. Smoking, alcohol and diet were not associated with CAM use. Improved understanding of the reasons for CAM use can an improve patient-physician communication, decision-making, and treatment planning.
Assessment of knowledge of vincristine toxicities in outpatient pediatric hematology/oncology nurses: An educational intervention.
Authors: Tishler David , Isenalumhe Leidy , Khazal Sajad , Mushrif Sujata , Rushing Teresa
Published: February 2017

231

Background: Vincristine (VCR) is a chemotherapeutic agent with a unique neurological side effect profile and is integral to the treatment of many pediatric hematological and solid malignancies. Side effects requiring VCR dose modification include peripheral neuropathies, intestinal ileus, cranial nerve abnormalities, hyponatremia and seizures. In our institution, orders for weekly VCR are written in advance by oncologists and administered by outpatient nurses independent of a provider physical examination. We sought to increase knowledge of VCR toxicities and improve pre-chemotherapy evaluation skills among outpatient Hematology/Oncology (Hem/Onc) nurses. Methods: A 23-question written quiz was given as a pre-test to 14 outpatient Hem/Onc nurses to assess their fund of knowledge regarding VCR toxicities. An educational intervention was then provided to the cohort as a lecture by a Hem/Onc fellow physician. The lecture was followed by the same quiz given as post-test to the nurses. Individual participant and group scores were tabulated comparing pre and post-test responses to assess improvement in identification and recognition of VCR toxicities. Results: 12/14 nurses demonstrated improvement in their fund of knowledge regarding VCR side effects (mean change in individual scores + 4.7). As a group, mean scores increased from 15.2 to 18/23 (the two-sample paired t-test was significant with a two-tailed p<0.005). Conclusions: An educational intervention significantly improved outpatient Hem/Onc nurses fund of knowledge regarding identification and evaluation of VCR toxicities. Future objectives include follow-up evaluation of retention of knowledge of VCR side effects and incorporating a VCR toxicity checklist into the electronic medical record outpatient nursing note.
Use of the Internet to connect radiation oncologists and medical oncologists with disease site-specific experts: 3-year outcomes of chartrounds.com.
Authors: Hardenbergh Patricia H. , Gehl Brigitta , Lyons-Mitchell Kimberly Anne
Published: February 2017

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Background: The purpose of this project is to improve the quality of cancer care by connecting disease site-specific experts with community oncologists through web-based technology. Methods: Chartrounds.com is a conferencing web-site developed to allow community oncologists to present real cases to disease site specialists in oncology on a scheduled basis. Chartrounds was developed initially for radiation oncologists and subsequently has expanded to include multidisciplinary tumor boards and medical oncology specific sessions. Presently 43 disease site expert oncologists including surgeons, medical oncologists and radiation oncologists from 38 academic institutions in the US host sessions. Feedback reports following the completion of each session were designed to assess the impact of the project. Results: Since its inception in December 2010, 43 disease site-specialists have lead 366 sessions, connecting 3,793 participating oncologists from all 50 US states and 24 countries.Broken down by specialty, 348 radiation oncology sessions have linked 3,632 participants, 14 medical oncology specific and multidisciplinary tumor board sessions have included 161 participants. On a 5 point Likert scale with 5 representing the greatest possible impact, the mean response to feedback questions is as follows: session quality: 4.7 for radiation oncology, 4.6 for multidisciplinary; time used effectively: 4.6 for radiation oncology, 4.5 for multidisciplinary; discussions relevant to daily practice: 4.6 for radiation oncology, 4.6 for multidisciplinary; session is likely to result in a change of practice: 4.0 for radiation oncology, 4.0 for multidisciplinary. Chartrounds sessions qualify for 1 CME credit and is approved for a practice quality improvement project by the American Board of Radiology. Conclusions: Chartrounds.com is impacting oncology practices which results in changes in community practice. Future directions of this project include providing chartrounds sessions for oncology nurses and providing a library of video recorded archived sessions. This work has been funded by the Improving Cancer Care Grant of the ASCO Conquer Cancer Foundation.
Adherence (adh) to and beliefs about oral anticancer medications (OAMs) in patients (pts) with metastatic renal cell carcinoma (mRCC).
Authors: Geynisman Daniel M. , Hlubocky Fay J. , Kocherginsky Masha , Stadler Walter Michael , Daugherty Christopher
Published: February 2017

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Background: Suboptimal adh to drugs is a problem in chronic diseases. In mRCC, OAMs are the mainstay of treatment (tx). Adh and its determinants in exclusively mRCC pts has not been studied in the US. This study aimed to evaluate adh to OAMs in mRCC pts, and describe pts understanding and beliefs about OAMs and their disease. Methods: Cross-sectional study of pts on OAMs for at least 60 days. Standardized assessment instruments used: Adh—MMAS-8 questionnaire (Q); beliefs and expectations regarding OAMs—Beliefs about Medicines Q (BMQ) and Brief-Illness Perception Q (IPQ); Quality of Life (QOL)—BSI-18, FKSI. Semi-structured interviews assessed financial burden, barriers to adh, understanding of prognosis and goals of therapy. Results: 52 pts interviewed with median age 65 (range 36-90), 73% male, 71% Caucasian, 40% college graduates. OAMs used: 38% sunitinib, 31% pazopanib, 21% everolimus, 8% axitinib. 1st line OAM tx: 46%; 2nd line tx: 33%; 3rd or beyond: 21%. MMAS-8: 10% low adheres, 25% intermediate, 65% high. Income: 35%<40K, 24%=40-60K, 41%>60K. Adh decreased as income increased across the 3 income levels from 82% to 67% to 45% (P=0.02). 13% reported financial difficulty paying for OAMs; 19% had ≥ $100/mo (0-500) out-of-pocket (OOP) cost. BMQ-N: 20 ± 4 (8-25); BMQ-C: 12 ± 4 (5-24). IPQ: 40 ± 12 (6-71). QOL: BSI 9 ± 8 (0-38); FKSI 43 ± 8 (21-60). No significant difference between adherers and non-adherers in regard to demographic, QOL, OOP costs or belief variables was noted. 29% reported not receiving counseling on taking OAMs. 59% believed mRCC is a chronic disease, 41% believed that their OAM can cure them and strongly agreed or agreed with “I expect to be free of cancer in the future.” 48% reported discussing prognosis with their MD. Conclusions: Self-reported adh to OAMs in mRCC is much better than in other chronic diseases, but not ideal. Surprisingly, adherence was negatively associated with income. Many pts felt mRCC was a chronic disease and over 40% believed they could be cured. Further research is needed addressing the development of an oncology-specific adh tool and defining an optimal adh benchmark for OAMs via prospective studies of self-reported adh, serum drug levels, and outcomes.