bluuebunny/crossref_metadata_2025 huggingface dataset:
Multisite quality improvement initiative to repair incomplete electronic medical record documentation as one contributor to provider burnout.
Authors: Russo Carolyn , Raney Lauren , McManaman Joanne , Elsaid Mohamed , Morgan Jennifer , Bowman Ronda Marie , Mohamed Ashraf Mahmoud
Published: October 2020

190

Background: Provider burnout is a challenge adversely affecting the quality, safety, and cost of health care. We measured burnout among pediatric oncology providers in the St. Jude Affiliate network and used a Plan-Do-Study-Act (PDSA) improvement cycle to address one of the factors contributing to burnout. Methods: Within the framework of the American Society of Clinical Oncology (ASCO) Thematic Quality Training Program (QTP) we sent the Mini Z 2.0 Survey to 47 pediatric oncology providers. Applying a fishbone diagram and Pareto chart we analyzed potential causes of provider burnout. Based on the analysis, we used a PDSA approach to address documentation of oral chemotherapy adherence for children with acute lymphoblastic leukemia to mitigate burnout among providers. Results: The burnout survey response rate was 44.6%. Burnout was identified in 42.9% of providers. Documentation in the electronic medical record (EMR) was cited as the second most common contributor to burnout, and it was this issue we chose to address based on a priority matrix. We improved the completeness of oral chemotherapy documentation from a baseline of 13% compliance to 87% compliance within 3 months. The improved compliance was achieved by standardizing the documentation process in the EMR for content and location. Conclusions: The EMR was one of the contributing factors in the burnout survey of the pediatric oncology providers in the St. Jude Affiliate network. A PDSA improvement model to improve clinical research documentation was successful in addressing one of several contributing factors to provider burnout.
The association between clinical trial (CT) participation, pharmaceutical costs, and savings performance in the Oncology Care Model (OCM).
Authors: Adelson Kerin B. , Canavan Maureen , Mun Sophia , Gross Cary Philip , Sinanis Naralys , Davidoff Amy J.
Published: October 2020

2

Background: The OCM is a Centers for Medicare and Medicaid Services (CMS) alternative payment model, which seeks to curb costs while improving care for patients receiving systemic cancer therapy. CMS models the expected spending target for each 6-month episode using historical, geographic and clinical factors, including CTr participation. We evaluated the relationship between CTr participation, drug costs and performance in the OCM. Methods: We used claims for OCM episodes attributed to the Yale Cancer Center between July 2016 and July 2018. We stratified episodes by CTr participation and used t-tests and chi-square tests to compare total cost, drug costs (Part B, Part D and novel cancer therapies) and whether observed episode costs were above or below CMS targets. Analyses were conducted for the total sample and among the most common cancer types. Results: Among 9,387 OCM episodes (5,270 unique patients), 815 (8.7%) episodes involved a CTr. Among non-CTr patients, the mean Medicare cost per episode ($32,909) was modestly higher than the mean episode spending target ($31,746; p < 0.001), while in the CTr group, the mean Medicare cost per episode ($36,590) was substantially lower than the mean episode spending target ($48,124 p < 0.001). CTr episode costs were more likely to be under spending targets than non-CTr episodes (66% vs 56%, p < 0.001) overall and in breast, lung, and myeloma cancers, although only statistically significant for lung cancer (76% CTr vs 48% non-CTr, p < .001). Overall, non-CTr had significantly higher mean Part D drug costs per episode ($8,441 vs $3,893, p < 0.001), which was also noted among patients with lung cancer, ovarian cancer and lymphoma. Non-CTr episodes were also associated with higher mean novel therapies cost ($5,736) compared with CTr patient episodes ($4,346, p = 0.013). When comparing the sum of all other expenditures, CTr episodes were significantly associated with higher non-pharmaceutical expenditures than non-CTr episodes ($20,940 vs. $13,323, p < 0.001) overall. Conclusions: Episodes with CTr participation out-performed non-CTr episodes in achieving savings relative to CMS spending targets. Savings were driven by lower drug costs for the CTr episodes, particularly in the categories of Part D and novel cancer therapies. This suggests that CTr enrollment shifts costs for expensive pharmaceuticals away from CMS and toward the CTr study sponsor. Further research should explore whether this finding is generalizable to other cancer centers and payment models.
Characteristics and outcomes of patients (pts) who developed immune-related adverse events (irAEs) with an initial presentation in the emergency department (ED).
Authors: Holstead Ryan , Kartolo Baskoro , Baetz Tara D.
Published: October 2020

201

Background: Management of irAEs due to immune checkpoint inhibitors (ICIs) requires a high degree of suspicion, and management of severe irAEs require timely initiation of corticosteroids (CS). This can be challenging in the ED, where providers may not be aware of an individual pt’s cancer treatment or its toxicities. Methods: We performed a retrospective single-center chart review for pts treated with ICIs in 2018 and 2019 who subsequently presented to ED. New irAEs with first presentation in ED were analyzed and pt outcomes were recorded. Descriptive statistics compared this population to irAEs identified in outpatient setting, as well as rates of ED utilization in pts on doublet ICI (dICI). Results: Of 351 evaluable pts treated with an ICI, 129 (37%) had at least one presentation to ED. Seventeen pts had a first presentation of a new irAE. These pts had received a median 2 cycles of ICI prior to presentation (interquartile range [IQR] 1-3) Twelve of these pts presented with generalized fatigue or pain, twelve required admission, 4 were admitted to intensive care within 30 days, and two died. Toxicities included hypophysitis (5), arthritis (2), colitis (2), myocarditis (2), neuritis (2), pneumonitis (2), adrenalitis (1), hepatitis (1). Median admission was 8.5 days (IQR 2-32), and median time to corticosteroids was 30.5 hours (range 4-269). Grade 3 or higher toxicity was more frequent in the ED pts compared to the total ICI pt population (70.5% vs. 32.2%). Pts on dICI (n = 41) had a higher rate of ED utilization (n = 23, 56.1%) and ED visits were more likely to be for first presentation of a new irAE (n = 7, 30.4% of dICI ED visits) compared to single-agent ICI regimens. Conclusions: Pts with irAEs that first present at the ED often have generalized symptoms, prolonged hospitalizations, and can have long delays to initiation of CS. Development of a protocolized approach for pts on ICI at the point of care in the ED may improve identification of irAEs, ‘door-to-steroid’ time, and patient outcomes.
Comparing cancer survivors' perceptions on lifestyle behaviors between adolescent-young adult (AYA) and middle-aged patients (pts).
Authors: Soberano Spencer , Eng Lawson , Chen RuiQi , Altesha Ashraf , Nagaratnam Subiksha , Rudolph-Naiberg Sarah , Chotai Simren , Wang Wanning , Lu Lin , Xu Wei , Hueniken Katrina , Brown Catherine , Liu Geoffrey
Published: October 2020

207

Background: Lifestyle behaviours such as smoking, physical activity, and alcohol consumption are important determinants of cancer survivorship. Previous studies have compared the lifestyle behaviours of elderly and middle-aged patients (pts), yet no studies have compared these behavioural perceptions between AYA (aged 18-39 years) to those of middle-aged pts (MA, 40-64 years). Methods: Cancer pts across various tumour types at a comprehensive cancer centre were surveyed with respect to their perceptions of how their well-being was affected by smoking, physical activity and alcohol consumption after diagnosis. Univariate logistic regression models evaluated factors associated with perceptions on the effect of various adverse lifestyle behaviours on health and well-being. Results: Of 200 AYA (57% female, 43% male) and 772 MA (56% female, 44% male) pts, a positive smoking history was reported by 33% of AYA and 48% of MA (P<0.001). At time of diagnosis, 55% of AYA and 59% of MA pts consumed alcohol, 16% of AYA and 16% of MA were ex-drinkers, and 28% of AYA and 25% of MA were never drinkers (P=0.62). Among AYA, 26% exercised compared to 20% in the MA group (P=0.19). The majority (72-92%) of pts perceived that smoking and lack of activity after cancer diagnosis negatively affected quality of life, survival chances, and fatigue; there were no significant differences between age groups. In contrast, both age cohorts displayed misperceptions about how alcohol affects health, which was characterized by perceiving neutral or beneficial influence on their overall well-being: Fifty-seven percent of MA pts had a borderline greater misperception versus 49% of AYA pts (P=0.06). Misperceptions regarding how alcohol affects survival were observed in 49% of AYA pts and 58% of MA pts (P=0.05). Misperception with respect to how alcohol affects fatigue was observed in 40% of AYA pts compared to 52% of MA pts (P=0.005). Furthermore, MA pts had 1.63 (95% CI 1.16–2.29) times the odds to have misperceptions regarding how alcohol affects fatigue, and 1.41 (95% CI 1.01–1.97) times the odds to have misperceptions on how alcohol affects survival compared to AYA pts. Conclusions: Both the AYA and MA population were not adequately informed about how alcohol affects cancer survivorship health; with more misperceptions in MA pts. Results from this study advocate for survivorship programs to implement emphasis on the deleterious effects of alcohol, with particular efforts tailored to the MA group.
Strategies for comprehensive implementation of survivorship care: A qualitative analysis of CoC-accredited cancer programs.
Authors: Hwang Soohyun , Bozkurt Burcu , Huson Tamara , Asad Sarah , Richardson Lauren , Ogbansiegbe Joseph , Viera Laura , Buse Caroline , Mayer Deborah , Shulman Lawrence N. , Birken Sarah A.
Published: October 2020

209

Background: The Commission on Cancer (CoC) seeks to promote comprehensive approaches to implementing survivorship programs among accredited cancer programs. In practice, cancer programs’ approaches range from cursory (e.g., developing care plans without robust services) to comprehensive (e.g., facilitating follow-up care). This study identified strategies that were unique to cancer programs with comprehensive approaches to implementing survivorship programs. Methods: We sampled 39 CoC-accredited cancer programs with approaches to survivorship program implementation ranging from cursory to comprehensive, as reported in CoC annual surveys. Within sampled cancer programs, we conducted in-depth semi-structured interviews with a total of 42 healthcare professionals (1-2/program). We identified strategies unique to cancer programs with comprehensive approaches by comparing them to cancer programs with cursory approaches. Results: Cancer programs with comprehensive approaches to implementing survivorship programs had formal committees with ample opportunities to evaluate the progress, revise roles, and acquire multiple stakeholders’ support. Keeping a good record system enabled these cancer programs to meet accreditation requirements and improve processes. Buy-in from upper management and key physicians was deemed crucial in leveraging cancer program resources. These programs also had clear roles with shared accountability among multidisciplinary groups. Like cancer programs with comprehensive approaches to implementing survivorship programs, many cancer programs with cursory approaches also had formal committees; however, cancer programs with cursory approaches lacked buy-in from key stakeholders, relying on few staff or a champion for implementation. Cancer programs with cursory approaches had limited resources, cumbersome processes, and team members with unclear roles. Conclusions: Cancer programs with comprehensive approaches to survivorship program implementation gained broad stakeholder buy-in and established clear team member roles with shared accountability. Study findings will inform more than 1500 CoC-accredited US cancer programs’ approaches to implementing survivorship programs. At the conference, we will have results from quantitative and measures validation companion studies.
Factors determining oncology on-call service utilization and implications for quality improvement.
Authors: Wronska Marta Wioleta , Braunstein Marc Justin , Islam Shahidul
Published: October 2020

213

Background: Most ambulatory oncology practices utilize an on-call service that is essential for continuity of cancer care after office hours, yet there is limited literature about the dynamics of this care delivery model and how to improve it from a quality standpoint. We hypothesize that patients with more advanced cancers are more likely to require the on-call service due to acute symptoms arising during their treatment, and that this information can be used to create a risk model to predict subsequent hospitalization. Methods: We performed a single-center, retrospective review of sequential overnight and weekend calls received by an oncology practice with 16 physicians over a 20-week period from January-May 2020. Calls were classified as being either urgent, requiring immediate attention, or non-urgent, which could be addressed during office hours. Data were summarized using descriptive statistics, continuous and categorical variables were compared using Wilcoxon rank-sum test and Fisher’s exact test, respectively. Multivariate analyses were estimated by logistic regression using the penalized maximum likelihood estimation method. Results: The data set included 236 consecutive calls among 176 patients, with 65% females and median age of 68 (range: 25-87). Of these, 185 calls (78.4%) were deemed urgent, among which 139 (75%) were symptom-related. Among the 202 calls (85%) from patients with cancer, 164 (81%) of them were urgent, mostly due to symptoms (82%). Of these urgent calls, 44 (27%) resulted in admission within 24 hours (P < 0.0001), primarily related to treatment toxicity or disease progression (81%). Patients with stage 4 cancers (42%) or hematologic malignancies (28%) were more likely to use the on-call service. There was no significant difference between call urgency and treatment regimen (P = 0.06). In a multivariable model, advanced age [OR = 1.03(1.0-1.07)] and urgent calls [OR = 33.1(2.7-401.0)] were independently associated with risk of hospitalization. Of note, there were no differences in admissions before or after the peak of the COVID-19 pandemic in New York City (P = 0.49). Conclusions: We identified an association between after-hours calls and more advanced malignancy, which was independent of treatment regimen. The majority of on-call issues were urgent and symptom-related, with advanced age and urgent calls being most likely to result in hospital admission. These results suggest that strategies can be developed to prevent hospitalizations in patients at higher-risk for adverse events based on a multivariable risk model.
The impact of social determinants on receipt of colonoscopy in an under-resourced hospital service area: A retrospective cohort study.
Authors: Dhahri Amina , Azargoon Sam , Gandhi Darshan , Barot Dhruvi , Goli Himan , Mahjoob Homayoon , Tegene Teshome , Ntiri Shana
Published: October 2020

216

Background: Although colorectal cancer (CRC) screening with colonoscopy reduces the risk of CRC mortality, screening rates remain low among African Americans and low social economic status (SES) patients. However, few studies have assessed CRC screening rates in under-resourced hospital service areas. Using a granular measure of socioeconomic deprivation (SED), we examined the association between social determinants and CRC screening. Methods: We conducted a retrospective cohort study from 2014-2019 to identify primary care patients referred for CRC screening with colonoscopy at an academic hospital system. Patients were assessed at annual visits for completion of colonoscopy. SED was assessed using the area deprivation index (ADI), a composite measure of 17 SED indicators including income, housing, education, and employment at the census block group level. Other social determinants analyzed were race and insurance status. Frequency and multivariable logistic regression were used for statistical analysis. Results: 1040 patients met CRC screening guidelines and were referred for colonoscopy. 136 (13.1%) underwent colonoscopy in the follow-up period. High and low SED made up 655 (63%) and 77 (7.4%) of patients, respectively. SED, race, age, and sex were not associated with higher screening rates. Uninsured patients had a lower rate of screening. After controlling for other social determinants, uninsured patients had the lowest odds of colonoscopy (OR 0.28; 95% CI, 0.08-0.92). Conclusions: In this under-resourced hospital service area, receipt of colonoscopy for CRC screening is significantly lower than previously reported. Furthermore, screening rates were persistently low across strata of SED, race and insurance status, with uninsured patients having the lowest odds of screening. These data suggest that in an under-resourced hospital service area with extensive SED, further research is needed to understand the role of social determinants and behavioral factors to address disparities in CRC screening with colonoscopy. [Table: see text]
Disparities between provider assessment and documentation of care needs in the care of adolescent and young adult patients with sarcoma.
Authors: McKay Grace Eileen , Parkes Amanda Marie
Published: October 2020

218

Background: Given the occurrence of cancer during a complex developmental time, adolescent and young adult (AYA) patients have unique psychosocial needs, necessitating supportive care guidelines including National Comprehensive Cancer Network (NCCN) AYA guidelines. We sought to assess compliance with NCCN AYA guidelines and compare to oncology provider identified AYA care needs. Methods: Retrospective chart review was performed on AYA patients (15-39 years) with sarcoma seen at least once in 2019 at the University of Wisconsin (UW), identifying documentation of discussions deemed critical per NCCN AYA guidelines. As per ASCO’s Quality Oncology Practice Initiative certification, we considered a threshold of 75% or higher to be compliant. Compliance was compared with an electronic survey of UW oncology providers regarding AYA patient needs, with items determined to have adequate resources if noted sufficient by >75% of providers. Results: We identified 43 AYA patients with sarcoma. As seen in table, <75% of patients had documentation regarding contraception, fertility, finances, genetics, social work referral and clinical trials indicating non-compliance. Surveys, completed by 38 oncology providers, showed significant discordance between provider’s perception of adequate access to resources and compliance on chart review. Conclusions: Disparities between oncology provider assessment of AYA care needs and lack of documentation of critical components of AYA patient care demonstrates the need for novel tools to evaluate AYA care needs beyond provider assessments. Care needs identified in our study will serve as the basis of an ongoing quality improvement project to better support AYA patients at UW. [Table: see text]
Defining and measuring quality cancer survivorship care: An environmental scan.
Authors: Ly Lena , Lisy Karolina , Clode Melanie , Kelly Helana , Jefford Michael
Published: October 2020

219

Background: It is recognised that current models of survivorship care are suboptimal and unsustainable. The landmark Institute of Medicine (IOM) report ‘From Cancer Patient to Cancer Survivor: Lost in Transition’ suggested four essential components of survivorship care: prevention of recurrent and new cancers; surveillance for recurrent or second cancers; intervention for consequences of cancer and its treatment, and coordinated care between health providers. The report also recommended “quality of survivorship care measures should be developed... and quality assurance programs implemented to monitor and improve the care that all survivors receive.” Nekhlyudov et al (JNCI 2019) built on the IOM’s recommendations to develop a quality of cancer survivorship care framework. We undertook an environmental scan to understand how quality survivorship care is conceptualised internationally, and what metrics are available. Methods: This scan comprised limited literature review, review of organisations’ websites, and expert consultation to source documents that described and measured quality survivorship care. Documents were assessed against the domains proposed by Nekhlyudov et al. Metrics were categorised as policy, process or outcome measures. Results: The search yielded 40 documents from six countries. There was agreement that quality survivorship care is founded on the IOM elements, expanded by Nekhlyudov et al. The review also noted risk stratification/personalised pathways of care and patient self-management as other elements of quality care. Many countries have proposed or implemented quality measures, with greater emphasis on processes over outcome assessments. Only the USA was found to have implemented policy measures. In the process domain, frequently reported metrics included completion of needs assessments and survivorship care plans, and adherence to recommended follow up guidelines. Regarding outcome measures, patient-reported outcomes and experiences were commonly proposed, however there was a lack of specific elements, or recommended instruments. Conclusions: There is broad agreement on what constitutes quality survivorship care internationally. Future work should consider policy or structural elements that support optimal care. Findings from this scan will inform a modified reactive Delphi study to establish consensus-based criteria for high quality survivorship care. Additional work should consider how to define and implement metrics of quality care, and how to use metrics to improve survivors’ outcomes.
Oral chemotherapy education: Hitting the mark?
Authors: Berry Jonathan L , Doolin Jim W , Diltz Garrett , Dechen Tenzin , Forbath Natalia , Zerillo Jessica A. , Shea Meghan
Published: October 2020

221

Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes process measures on oral chemotherapy education. Whether achievement of these measures has an impact on clinical outcomes and if an intervention to improve these measures can improve outcomes is not yet known. Methods: A retrospective analysis was conducted of patients initiated on oral chemotherapy in an academic medical center site and a community oncology practice between January 2016 and October 2019. The primary aim was to compare the time to emergency department (ED) within 90 days from initiation of oral chemotherapy of patients who met the QOPI process measure through an intervention of pharmacist-driven education with a comparison group of patients who had not received formal education. A secondary aim was to assess for a difference in oral chemotherapy medication persistence. Data were also analyzed by demographics, concurrent parenteral therapy, intent of therapy, and disease group. Results: 285 patients in the education group and 284 patients in the non-education group were analyzed. The education group had a higher proportion of patients with gastrointestinal and gynecologic cancers, and a lower proportion of patients with hematologic malignancies, compared to the non-education group. The education group also had a higher proportion of patients treated at the community practice compared to the non-education group. There was no statistical difference in median time-to-ED, with 49 days (IQR 37-74) in the education group and 59 days (IQR 41-60) in the non-education group (p=0.15). Conclusions: In patients receiving oral chemotherapy, pharmacist-driven education with improvement in QOPI process measures did not result in an improvement in time to ED. One factor contributing to this result may be that only 20% of patients required ED-level care within 90 days of starting oral We continue to collect data regarding medication persistence, which may be a more sensitive outcome measure. At this point, further work is needed to determine if achievement or modification of the QOPI oral chemotherapy process measures results in a clinically significant change in outcome. [Table: see text]
Barriers and facilitators to implementation of serial point-of-care hearing tests using a novel iPad-based audiometry in platinum chemotherapy-treated cancer patients (pts).
Authors: Soberano Spencer , Khan Khaleeq , Hueniken Katrina , Diekoloreoluwa Famoriyo Elyon , Soriano Joelle , Gill Sarfraz , Zhan Luna Jia , Shepherd Frances A. , Sacher Adrian G. , Bradbury Penelope Ann , Leighl Natasha B. , Bedard Philippe L. , Hansen Aaron Richard , Spreafico Anna , Xu Wei , Brown Catherine , Liu Geoffrey
Published: October 2020

223

Background: Platinum-based chemotherapy agents cause significant hearing loss in 40-80% of treated cancer pts. Lack of follow-up serial testing has created gaps in knowledge regarding hearing loss onset, progression, and possible recovery between treatment cycles. This study aims to determine barriers and facilitators to implementation of a tablet-based point-of-care hearing test, as a serial screening tool to address these knowledge gaps. Methods: From Jul 2019 to Mar 2020, 53 pts receiving high dose platinum agents were recruited from three clinics (Thoracic, head and neck, and testicular cancer) at a comprehensive cancer centre, to undergo serial audiometry testing. Baseline hearing tests, mid cycles (3,6, and 9 weeks), and post treatment tests (3,6,9,12, 19 and 24 months) were completed during the pts’ clinic appointments. Clinical research coordinators (CRCs) collected feedback from physicians, nurses, and pts to identify barriers and facilitators of implementing serial point-of-care hearing tests in these clinics. An inductive and iterative approach was used to identify themes. Implementation was tailored and mapped to the CIHR Knowledge to Action Framework (KTA). Results: Barriers: Logistical barriers included: locating quiet and accessible rooms to administer the test; pts being distracted or interrupted while completing the test; presence of family members adding to noise levels; concerns over the serial testing during treatment; length of each test; and clinic staff burden. Facilitators: User-friendly self-administered tests; increasing healthcare staff education and pt management. Adapting to the local context: Logistical barriers were resolved by CRCs designating quiet spaces for the study to occur, and meeting pts upon arrival to utilize their wait time. A ‘hearing test in progress’ sign put on exam room doors prevented interruptions. CRCs utilized the test’s ‘assisted mode’ feature to keep pts attentive and/or accelerate the process. Low noise level was emphasized to obtain accurate test results. Pt engagement in their test results facilitated retention in the study. Test length may be shortened in the future by omitting low frequency testing. Conclusions: Participants and stakeholders expressed support for in-clinic hearing tests and identified personal and systemic barriers to implementation. These findings suggest that implementation should focus on addressing concerns related to accessible rooms, pt time investment and overall clinic flow.
4R Care Delivery Program results: Impact of implementation metrics on patient self-management and 4R usefulness.
Authors: Trosman Julia Rachel , Weldon Christine B. , Makower Della F. , Rapkin Bruce D. , Perez Claudia Beth , Kulkarni Swati , Schaeffer Cathleen M. , Hoskins Kent , Gallagher Christopher , Lo Shelly S. , Grace-Louthen Cathy , Throckmorton Alyssa , Krueger Editha A. , Van Horn Jennifer , Reaves Brieyona Chardee , Ravelo Arliene , Yu Elaine , Schapira Lidia , Benson Al Bowen , Gradishar William John
Published: October 2020

225

Background: We previously proposed a 4R care delivery model that facilitates teamwork and patient self-management (pSM) in cancer care (NCI ASCO Teams Project, Trosman JOP 2016). 4R (Right Info / Care / Patient / Time) enables patient and care team to manage complex care with an innovative 4R Care Sequence. We tested 4R at 10 US sites in a stepwise mode 2016-2019. Methods: Step 1 included 1 academic and 2 nonacademic sites; step 2 included 3 academic and 4 nonacademic sites. Patients with stage 0-III breast cancer received 4R Sequences (4R Cohort). We surveyed 4R and historical control cohorts of patients treated at the same sites pre-4R. We assessed the impact of implementation metrics on usefulness of 4R to the 4R cohort and on improvement of pSM in 4R cohort vs historical control cohort. Results: Survey response rates: 63%, 422/670 (4R cohort); 47%, 466/992 (control cohort). Three of the five implementation metrics significantly impacted patient usefulness of 4R (Table). Patients at step 2 sites; sites with a systematic care process; and sites with small practices reported significantly higher 4R usefulness than patients in the comparison subgroup within respective metrics. 4R usefulness was not affected by practice setting or availability of patient navigators. pSM was significantly improved between control and 4R cohorts along all implementation metrics (p < .001), but the magnitude of incremental improvement between comparison subgroups varied across metrics (Table), with the largest increment associated with the program step metric. Conclusions: 4R is useful to patients across settings, with or without patient navigators. Stepwise design is effective in increasing 4R impact overtime. Future 4R Program will investigate an expanded array of implementation metrics and their influence on 4R outcomes. [Table: see text]
Reducing futile acute care services (ACS) for terminally ill cancer patients (Dignity Project).
Authors: Salama Hind , Al Mutairi Nashmia , Damlaj Moussab , Alolayan Ashwaq Aman Mohammed , Binahmed Ahmed , Salama Hagir , Tlayjeh Haytham , Lawrence Myer , Shehata Hussam , Al Shami Mona , Alkaiyat Mohammad , Jazieh Abdul-Rahman
Published: October 2020

23

Background: Patients with terminal diseases frequently undergo procedures and interventions that are futile and maybe detrimental to the patients’ quality of life. We conducted a quality improvement project aimed to reduce futile acute care services (ACS) for cancer patients treated with a palliative intent. Methods: A multidisciplinary team retrospectively reviewed the records of terminally ill cancer patients who died during in the hospital at our institution, King Abdulaziz Medical City, Riyadh, Saudi Arabia. We included all patients expired between November 2017 to May 2018. The review aimed to assess the magnitude of improper utilization of acute care services (ACS) such as: critical care response team (CCRT), cardio-pulmonary resuscitations (CPR) and admission to intensive care unit (ICU). A root cause analysis and process mapping were conducted to identify reasons for over utilization of these services. Timely documentation of goals of care was identified as a main reason for this problem. Then interventions were implemented to improve the practice. Post intervention data was captured and compared to the baseline data. Results: After delivery of staff education sessions and implementation of mandatory documentation of goals of care in the electronic healthcare record system, the timely documentation of goal of care for patients with palliative intent had significantly increased from 59% of cases in the baseline to 86% for the post intervention phase. As a result, admission to ICU decreased from 32% of cases in the pre intervention phase to 14% in the post intervention phase reducing monthly cost of admission to the ICU by 40% and estimated to be on average of $48,000 USD monthly ($576,000 USD annually). Conclusions: Our interventions resulted in improved documentation of the goal of care leading to decrease in the utilization of acute care services (ACS) including reduction of intensive care unit (ICU) admissions and cost. This outcome is even more relevant nowadays during COVID-19 pandemic and the pressure on critical care resources. Improvement is sustained by integrating the changes in the work process and electronic medical records.
Real-world practice patterns in follicular lymphoma (FL) care at community oncology centers.
Authors: Barr Paul M. , Patel Taral , Dela Cruz Servillano E. , Hussein Maen A. , Castine Michael J. , Farris Breanne Y , Crawford Rebecca R , Carter Jeffrey D. , Sapir Tamar
Published: October 2020

231

Background: Though FL generally has good outcomes, patients with high risk FL have poorer outcomes; proper risk stratification for early intervention has been shown to improve overall benefit in some patients. In a quality improvement (QI) initiative conducted in 4 community oncology systems, we assessed practice patterns involving prognostication and the integration of patient-disease-and treatment-related factors to improve decision-making for patients with FL. Methods: Between 10/17/2019 and 3/4/2020, we surveyed hematology/oncology health care professionals (HCP; N=59) to assess challenges, barriers, and self-reported performance of quality FL care. Electronic medical records (EMR) of 100 patients were audited for demographics, disease characteristics, risk stratification, treatment, and patient-centered metrics. To address suboptimal guideline-aligned care, teams participated in audit-feedback sessions to develop action plans for resolving identified gaps. Results: The EMR audit demonstrated low levels of documentation of staging, grade, and criteria required by risk stratification models (Table). Despite 92% of HCP indicating the use of risk stratification or prognostic models to determine treatment choice, only 23% of charts indicated use of a model for risk stratification. 55% of HCP indicated testing for t(14;18), though no patients had documented evidence of t(14;18) testing results. Survey findings indicated low confidence integrating patient-related factors to determine appropriate risk group (24%). Treatment choice was aligned with guidelines. In surveys, providers reported uncertainty about when to initiate treatment (13%), which treatments are most appropriate for each patient (23%), and engaging patients in shared decision-making (28%) as top barriers to care. During audit-feedback sessions, teams created action plans to improve documentation for variables of risk stratification, patient symptoms, molecular results, and shared decision-making. Further, teams identified the need for improved resources and personnel. Conclusions: These findings reveal important challenges to providing individualized FL care in community settings, such as documentation of clinically important metrics, care coordination, and engaging patients in shared decision-making. These gaps may inform future QI and implementation science initiatives. [Table: see text]
Patterns of care in ALK+ or ROS1+ non-small cell lung cancer (NSCLC) in community systems.
Authors: Levy Benjamin Philip , Farris Breanne Y , Crawford Rebecca R , Carter Jeffrey D. , Sapir Tamar
Published: October 2020

232

Background: For patients who have ALK or ROS1+ NSCLC, targeted therapies have greatly improved treatment options, though challenges personalizing care have hindered effective integration. In a quality improvement (QI) program conducted in 2 community oncology systems, practices involving the use of targeted therapies for NSCLC were assessed. Methods: Between 01-04/2020, retrospective EMR audits of 100 patients with ALK or ROS1+ NSCLC were analyzed for demographics, molecular testing, disease characteristics, treatment history, and shared decision-making (SDM). Surveys were administered to evaluate healthcare professionals’ (HCP; N = 47) challenges and barriers. HCP teams participated in audit-feedback sessions and developed action plans for resolving identified gaps. Results: 64% of HCPs indicated high confidence in utilizing molecular tests to inform treatment and properly sequencing targeted therapies; however, the EMR audit demonstrated challenges efficiently integrating guideline-aligned testing into practice. The mean time from diagnosis to molecular testing results was 22 days and documentation of testing for genetic aberrations other than ALK/ROS1 during work-up were low (Table). Delays in receiving molecular testing results may have presented challenges aligning treatment practices to guidelines as some patients were not receiving frontline targeted therapies (31% ALK+, 24% ROS1+). Additionally, EMR audits suggested sub-optimal use of distress screening (37%), tobacco counseling (38%), quality of life screening (60%), and engagement/documentation of various aspects of SDM (Table) for patient-centered care. Importantly, given the role internalized stigma can play in lung cancer, only 59% of those surveyed indicated that they routinely use tools to identify patients affected by stigma. During audit-feedback sessions, teams identified increased documentation, improved molecular testing/collaboration with pathology team, and provision of patient-centered care, including reduction of smoking-associated stigma as action items. Conclusions: These findings reveal important performance gaps in providing targeted and patient-centered treatment for NSCLC in community settings. These findings may be relevant for future QI programs. [Table: see text]
Quality indicators of colorectal cancer care in a public healthcare institution in Uruguay: Results from a retrospective population-based study.
Authors: Fontes Santiago , Cuello Mauricio , Marín-Jiménez Ana , Sánchez Juan Carlos , Berry Megan , Reyes Graciela , Requena Nicolás , Krygier Gabriel David
Published: October 2020

234

Background: There is an urgent need to assess quality of cancer care in Latin America, especially amongst the most prevalent tumors, such as colorectal cancer. The main aim of this study was to assess adherence to previously validated quality indicators (QIs) for colorectal cancer in the context of a public healthcare provider in Uruguay. Methods: Data regarding all colorectal cancers registered between January 1, 2008 and December 31, 2019 at the National Cancer Institute of Montevideo was collected through retrospective analysis of medical records. We used 12 QIs (4 diagnostic, 7 treatment,1 surveillance) validated in previous publications. Each QI was analyzed as a proportion (%) and compared to target values with 95% confidence interval. Results: A total of 808 colorectal cancers were identified; only 10.1% were diagnosed by screening, 87% were diagnosed after reporting symptoms and 29.5% underwent emergency surgery. A complete preoperative colonoscopy was performed in 47% of patients, 64% had a CT-TAP scan and 63% of locally advanced rectal cancers had staging MRI prior to definitive treatment. Surgical resection with tumor free margins was obtained in 97% of cases, and for 68% at least 12 lymph nodes were examined. Neoadjuvant radiotherapy plus chemotherapy as first therapeutic strategy was implemented in 79% of rectal cancers. High risk stage II and III colon cancer received adjuvant chemotherapy within 16 weeks of surgery in 72,9% of cases. Postoperative follow up with CEA was registered in 97% of our series. Most patients ≤ 75 years of age with metastatic unresectable colorectal cancer at diagnosis underwent first-line chemotherapy or bio-chemotherapy. A low level of adherence was identified in micro-satellite and RAS status testing, 16 and 22 patients respectively. Conclusions: This study is a pioneer study in Latin America. The standardization of QI definition to achieve interregional comparative goals remains an unmet need.Our data indicates there is much to improve in early diagnosis, preoperative staging, neoadjuvant therapy and molecular testing. QI indicators in surgery and adjuvant chemotherapy prescription are similar to those reported in international studies.
Implementing a ride share program for patient transportation home from a hospital admission.
Authors: Lightheart Erin , Kucharczuk Colleen
Published: October 2020

243

Background: This quality improvement project takes place within a large hospital, on a team that manages about 1700 oncology discharges per year. The hospital emphasizes the importance of discharging patients early in the day to encourage more efficient patient flow. On advanced medicine units within the hospital, 19% of discharge delays were reported as stemming from transportation issues related to family being delayed. Methods: A multidisciplinary group utilized a ride share company to implement a HIPPA compliant transportation program. Upon admission, each patient was screened for potential transportation barriers by a coordinator. Patients outside of a 35-mile drive from the hospital were excluded. Patients who expressed a concern about reliable transportation were offered enrollment. The patient completed a consent form, agreeing to be texted by the company with logistical information about their ride. At the end of the patient’s stay, the coordinator scheduled a “will call” ride within the vendor’s electronic system, which could then be activated by the patient via phone upon discharge. The coordinator tracked each patient’s barriers along with an estimated number of hours saved. Results: The average time saved per patient was 5.3 hours and, at peak, the average number of rides per month was 36. The estimated additional capacity created was 7.2 patients annually. About 14% of transportation barrier screenings resulted in a ride being scheduled. Of the patients that declined, 53% preferred to travel with family or friends, 28% were excluded due to distance, 10% were too ill to utilize the service, and 8% declined for other reasons. Conclusions: The intervention provided clear value to the institution and the patient, and the organization is now exploring a system-wide ride share transportation program. The team identified an untapped opportunity in using the program for admissions. Suggested patient populations for expansion include patients leaving the Emergency Department, those with fairly predictable lengths of stay, such as gastrointestinal surgery patients, and populations of relatively lower acuity since they are more likely to be well enough to get into their home without assistance. [Table: see text]
Care redesign of pelvic radiotherapy using Design Thinking: An enhanced quality improvement initiative.
Authors: Ho Cho Hao Francis , Tey Jeremy Chee Seong , Ooi Kiat Huat , Tan Teng Hwee , Leong Yiat Horng , Chia David
Published: October 2020

246

Background: Cone Beam Computed Tomography(CBCT) is the cornerstone of image guided radiotherapy(IGRT) which is an integral part of pelvic cancers like prostate cancer. Each pelvic radiotherapy (RT) session is preceded by a planned CBCT to ensure target localisation and organ at risk avoidance. When these criteria are not met, an unplanned CBCT is performed until the CBCT is satisfactory. Possible reasons for an unsatisfactory CBCT include an under filled bladder, distended rectum or prostate gland movement. Repeated unplanned CBCT results in unnecessary excess radiation for patients. We aimed to reduce the incidence of unplanned CBCT from a baseline of 21% to 9% over 5 months. Methods: We conducted the project using both conventional quality improvement methodology and the design thinking methodology. In the diagnostic phase up to March 2017, the baseline incidence of CBCT in patients receiving pelvic RT was 21%. We hypothesized that there were reversible factors leading to a higher incidence of unplanned CBCT and sought to identify and rectify these reversible factors to reduce the incidence of unplanned CBCT. Using human centred design, we designed a new process of performing a bladder ultrasound prior to CBCT to ensure a full bladder prior to RT using the steps empathy, define, ideation, prototype, testing, sharing. Results: A total of 97 patients that underwent pelvic radiotherapy were included in this study, 40 patients were pre intervention and 61 patients received the bladder ultrasound intervention implemented from April 2017 onwards. After intervention, incidence of unplanned decreased from 21% to 5.8%. A 2 sample t test was used to compare the unplanned CBCT pre and post intervention. We found the mean pre and post intervention difference in pooled mean incidence of unplanned CBCT to be significantly different by 13.3%. The reduction in unplanned CBCT translated to saving each patient on average equivalent to 3000 chest x rays worth of unnecessary radiation. Conclusions: Design Thinking is a feasible strategy in quality improvement. We report the first design thinking project in radiation oncology quality improvement. An automated ultrasound bladder is a feasible strategy to screen for bladder filling prior to each CBCT to reduce reliance on CBCT and also patient exposure to radiation in IGRT of pelvic cancers.
Impact of a built-in electronic medical record prompt on guideline-recommended prophylactic antiviral usage in patients with multiple myeloma receiving proteasome inhibitors.
Authors: Young Garrett , McCullough Stacey , Arrowsmith George , Lyss Aaron J. , Schleicher Stephen Matthew , Dickson Natalie R. , Arrowsmith Edward
Published: October 2020

248

Background: Guidelines support the use of prophylactic antivirals to prevent reactivation of herpes varicella in patients with multiple myeloma (MM) on proteasome inhibitors (PI). In our network of five oncology practices spanning over 100 clinic sites, one practice has a built-in prompt for acyclovir use in patients receiving a PI, while the other four practices do not. We used this natural experiment to determine the impact of this prompt on appropriate prophylactic antiviral usage in this patient population. Methods: We retrospectively identified all patients in our network with MM beginning a regimen containing a PI between 1/1/19 and 5/28/20. Of these patients, we identified those with documentation of a prescription for acyclovir or valacyclovir before or within 2 days of the first PI dose. We compared prophylactic usage across five practices. Practice 1 had built a prompt for the prescription of acyclovir in regimens containing bortezomib or carfilzomib within the electronic medical record (EMR) which both reminded physicians and nurses and simplified the prescribing process. No other practices had similar EMR prompts. Results: We identified 583 patients with MM who received a PI during the study period. Wide variation in rates of prophylactic antiviral usage existed across the five practices (range 21%-94%). The highest rate of prophylactic antiviral usage was practice 1 (94%). This was the only practice with a built-in EMR prompt for acyclovir usage in PI regimens. We found no association between use of prophylactic antivirals and individual provider-level volume of patients with MM. Conclusions: Use of prophylactic therapy is heterogeneous across practices. A comprehensive treatment plan containing a prompt in the EMR can markedly increase appropriate utilization. We plan to add an EMR prompt and analytics-driven reminders across our network to improve utilization of all guideline-recommend, orally administered prophylactic medications. [Table: see text]