bluuebunny/crossref_metadata_2025 huggingface dataset:
Avenues to integrate and improve care: Surgeon attitudes toward end-of-life care.
Authors: Bergman Jonathan , Lorenz Karl A. , Scales Charles D. , Ryan Gery , Saigal Christopher , Bennett Carol J. , Litwin Mark S.
Published: February 2017

16

Background: To examine urology trainees’ views about the quality and current practices of end-of-life care, and to explore strategies for improving integration and quality of care. Methods: We conducted semi-structured interviews with 20 urology trainees from four institutions in different regions of the United States. Stage of training ranged from intern to senior urologic oncology fellow; all were clinically active at busy academic institutions caring for many patients with advanced malignancies. Open-ended questions allowed participants to express themselves independently, and follow-up discussions explored their perception of current end-of-life practices, as well as avenues for future integration and improvement. We analyzed transcripts using a multi-stage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Results: Clinicians unanimously agreed that their patients do not currently receive ideal care and were unanimously interested in joining a team geared towards improving care at the end-of-life. They expressed a preference for a multidisciplinary team, although the precise role each wanted to play within the team varied. Better identification of depression, pain, and patient-centered goals to allow value-congruent care were high in priorities for improvement. Trainees sited the lack of an educational curriculum on end-of-life care as a barrier to improving care, and expressed a desire for formal education on this topic. Conclusions: Urology trainees do not think that current care at the end-of-life is ideal for patients, and are interested in participating as part of a multidisciplinary team to better care for these individuals. There was a unanimous consensus that end-of-life care should be formally taught to all intern and resident physicians, and care at the end-of-life must be integrated to pursue value-congruent care for each patient. In response to the information gathered, we built a web-based, interactive, self-directed learning module emphasizing high-quality end-of-life care, issues to address with patients during clinic visits, and integration of end-of-life care. We have also integrated palliative care into the team caring for our patients with advanced disease.
Standardizing quality breast cancer care throughout all New York university facilities.
Authors: Pavlick Anna C. , Schnabel Freya Ruth , Tiersten Amy , Volm Matthew , Wu Jennifer J. , Boester Cindy , Carroll William L.
Published: February 2017

160

Background: NYU physicians provide breast cancer care (BCC) at several locations throughout New York. The NYU Clinical Cancer Center (NYUCCC) is a private, university-based facility while Bellevue and Woodhull Hospitals are city hospitals. The diversity of BCC provided to patients (pts) in city hospitals can vary greatly from that of private centers and intra-center physician variability also diversifies care. This variability can impact on pt satisfaction and outcomes. Breast cancer (Br Ca) pts make up the greatest number of pts seen and treated at all NYU affiliated sites, therefore, a "Br Ca Quality of Care Program" will be incorporated into the electronic medical record (EMR) at all facilities. A treatment algorithm based on the pt’s stage and a simple "drop-down menus" will simplify use. It will encompass diagnostic imaging, pathology, biopsy procedures, surgery, radiation, chemo, and hormonal therapy as well as survivorship guidelines for maintaining wellness. Methods: Leaders of each Br Ca program have identified potential barriers to care and rectifiable issues. Algorithms and “drop down menus” in the EMR will be presented to the NYUCCC Br Ca physicians for feedback. This tool will then be refined and launched at NYUCCC. After evaluating this program at NYUCCC, the data will be presented to the all NYUCCC faculty. Achieving the city hospitals to adopt this EMR program will be the ultimate success and standardized quality care will be the result. Results: An assessment of the endpoints of physician adherence to guidelines, cost effectiveness and pt/provider satisfaction will be conducted 6 months later. Random audits of breast cancer pt charts will evaluate provider compliance. A cost analysis of this care will be done and compared to a random sampling of previously treated pt charts. Review and analysis of this data would be presented to the NYUCCC faculty, then programs launched at both city-hospitals. Conclusions: If the endpoints of quality standardized care, cost effectiveness and pt/provider satisfaction are met, incorporation of similar programs into other high volume oncologic disease entities seen at all NYU facilities would be developed.
Central reporting of human epidermal growth factor receptor-2 (HER2) status and adherence to testing and adjuvant trastuzumab treatment guidelines in Ontario.
Authors: Earle Craig , Ferrusi Ilia L. , Trudeau Maureen E. , Leighl Natasha B. , Pullenayegum Eleanor , Khong Hoa , Hoch Jeffrey , Marshall Deborah
Published: February 2017

166

Background: Quality monitoring pertaining to trastuzumab treatment requires knowledge of 1) HER2 status, 2) testing methods and sequence, and 3) treatment received. We examined the patterns of HER2 test documentation for early-stage breast cancer (ESBC) patients in Ontario and the adherence of practice patterns to Canadian HER2 testing consensus guidelines and adjuvant trastuzumab treatment guidelines from Cancer Care Ontario (CCO). Methods: Using tumor pathology reported centrally to the Ontario Cancer Registry (OCR) a population-based retrospective cohort of ESBC patients diagnosed in 2006 or 2007 was identified. We evaluated the use of subsequent HER2 fluorescence in situ hybridisation (FISH) after initial immunohistochemical testing, and predictors of trastuzumab use. HER2 test type, sequence, result(s) and status, tumour grade, and hormone receptor status were determined. Trastuzumab treatment was determined from linked drug funding records. Sociodemographic characteristics, prior surgical, radiation and anthracycline treatment, and comorbidity were also determined from administrative data sources. Logistic models estimated adjusted odds ratios for factors associated with guideline (non-)adherence. Results: A HER2 test was documented for 66% of the 13,396 patient cohort. HER2 equivocal tumors were more likely to be retested vs. positive: OR 116 (95% confidence interval [CI] 79, 169). Patients diagnosed with stage III disease had higher odds of having a FISH test vs. stage I (OR 1.5 [CI 1.1, 2.1]). HER2 status was the largest predictor of trastuzumab use, with HER2 equivocal, negative or unknown patients less likely to receive treatment than positive. Patients with advanced age (≥70y) had lower odds of trastuzumab treatment compared to younger patients (OR 0.48 [0.32, 0.73]). Higher tumor grade was associated with higher odds of treatment. Reporting, testing, and treatment all varied significantly by region. Conclusions: Despite limitations in centrally-reported tumour pathology at the time, the use of FISH testing and trastuzumab treatment in Ontario was largely consistent with guidelines, though practices vary across regions.
Robotic radiosurgery for the treatment of one to three brain metastases: A pragmatic application of cost-benefit analysis using willingness to pay.
Authors: Greenspoon Jeffrey Noah , Sharieff Waseem , Whitton Anthony , Whelan Timothy Joseph , Wright Jim R. , Sussman Jonathan , Gafni Amiram
Published: February 2017

17

Background: With the emergence of radiosurgery as a new radiotheraputic technique, health care decision makers are required to incorporate community need, cost and patient preferences when allocating radiosurgery resources. Conventional patient utility measures would not reflect short term preferences and would therefore not inform decision makers when allocating radiosurgery treatment units. The goal of this article is to demonstrate the feasibility of cost-benefit analysis to elicit the yearly net monetary benefit of robotic radiosurgery. Methods: To calculate the yearly incremental cost of robotic radiosurgery as compared to fixed-gantry radiosurgery we used direct local cost data. We assumed a standard 10 year replacement and 5% amortization rate. Decision boards summarizing the clinical scenario of brain metastases and the difference between robotic and fixed-gantry radiosurgery in terms of immobilization, comfort and treatment time were then presented to a sample of 18 participants. Participants who preferred robotic radiosurgery were randomly assigned to either a low ($1) or high ($5) starting point taxation based willingness-to-pay algorithm. Results: The yearly incremental cost of providing robotic radiosurgery was $99,177. The mean community yearly willingness-to pay for robotic radiosurgery was $2,300,000, p=0.03. The calculated yearly net societal benefit for robotic radiosurgery was $2,200,823. Among participants who preferred robotic radiosurgery there was no evidence of starting point bias, p=0.8. Conclusions: We have shown through this pilot study that it is feasible to perform cost-benefit analysis to evaluate new technologies in Radiation Oncology. Cost-benefit analysis offers an analytic method to evaluate local preferences and provide accountability when allocating limited healthcare resources.
Erlotinib and patterns of pharmacogenomic (PGx) testing.
Authors: De Souza Jonas A. , Gleason Patrick P. , Starner Catherine I. , Qiu Yang P.
Published: February 2017

182

Background: Erlotinib is an oral oncology drug that costs approximately $5,000 per month. Both the NCCN Guidelines (since March 2011) and ASCO (since April 2011) recommend PGx testing for tumor epidermal growth factor receptor (EGFR) mutation in patients with advanced non-small cell lung cancer prior to erlotinib use in the first line setting. Insight into early utilization patterns of PGx testing is crucial as new reimbursement methods, care models and evidence-based clinical pathways are developed. Methods: Using integrated medical and pharmaceutical data from four Blue Cross Blue Shield plans, we retrospectively identified members who received erlotinib between 01/2011 and 06/2011 and identified the date of the first erlotinib claim (index date). A new erlotinib user was defined as having no erlotinib claims filed in the prior 180 days. Among members who received erlotinib, medical claims were queried for the presence of ICD-9 codes for malignant neoplasm of trachea, bronchus and lung and for any current procedure terminology (CPT) code indicating PGx testing and other chemotherapy in the prior 24-month period and 1-month post the index date. Total paid amounts from all PGx test codes were obtained. The closest PGx testing date to the index date was used to calculate days between PGx testing and index date. Further analyses examining lines of therapy, monthly patterns of erlotinib usage and PGx testing pre- and post-guidelines recommendations, as well as a description of differences in utilized PGx CPT codes per individual patient, were performed. Results: Among 3,357,936 members insured, 125 (40 per million) received erlotinib, and 102 (81.6%) of those patients had a lung cancer diagnosis. Sixty (48%) were new erlotinib users, and 47 had a diagnosis of lung cancer. Of these, 36 (76.5%) had a PGx CPT code claim. The time between the PGx test and erlotinib start ranged from 4 days to 22 months. A total of $30,391 was spent on all PGx testing with an average of $844 per member tested. Conclusions: In a privately insured cohort of members who newly initiated erlotinib for lung cancer, 23.5% had no prior PGx testing. There is an opportunity for consensus guidelines, care management programs and a single PGx CPT code to possibly reduce variation regarding PGx testing patterns.
Reducing unnecessary testing on admission in autologous stem cell transplant (SCT) patients.
Authors: Glotzbecker Brett , Yolin-Raley Deborah , Close Sara , Soiffer Robert , Antin Joseph H. , Jacobson Joseph O. , Alyea Edwin
Published: February 2017

185

Background: Health care institutions are identifying strategies to reduce unnecessary testing, employ better utilization of resources, and decrease risk. At Dana-Farber Cancer Institute (DFCI), patients admitted for autologous SCT have standard testing, including CXR, completed within 42 days of hospital admission. Despite previous work-up, routine CXR is often ordered on admission. We questioned if this repeat CXR was clinically necessary. A retrospective review from 2010 showed that 69 of 130 (53%) asymptomatic SCT patients had CXR obtained on the day of admission. Two patients had findings of possible atelectasis vs. infiltrate on admission CXR. No further work up or antibiotics were initiated. After count recovery, one of the two patients had a chest CT for evaluation of fevers, showing only atelectasis. Based on these results, we aimed to reduce admission CXR without clinical indication to less than 5% by July 1, 2012. Methods: A multidisciplinary group was formed to map existing processes leading to admission CXR. Areas where previous standard testing were not readily available and areas of redundancy were identified. Changes to the EMR allowing easier access to pre-transplant results were made and a written and oral education program for PAs and nocturnists was created. Study Population: All elective patients admitted to the bone marrow transplant PA service (BMT-PA) for autologous SCT for multiple myeloma or lymphoma between 11/1/11-5/30/12. Results: The intervention (changing the EMR and establishing an education program) resulted in a reduction of admission CXR in asymptomatic patients from 53.3% to 5.5% (target 5.0%). During the study period, 144 patients were admitted to the BMT-PA service. Of those, 8 had CXR without indication. All CXR were ordered by Nocturnists, two prior to the intervention and six in the last four weeks of the observation period. Conclusions: The reduction of unnecessary CXR in asymptomatic SCT patients has had a considerable reduction in overall costs, nearly $58,000 to date, as well as reduced delays in initiating chemotherapy, radiation exposure, overall resource utilization, and patient inconvenience. Through this simple intervention, this reduction was easily obtained.
Evaluation of process control in radiation oncology treatment planning.
Authors: Wagner Henry , Singer Maria , Knipple Jamie , Aurand Amy , Repella Paulette , Ferenci Michele
Published: February 2017

186

Background: ROTP extends from simulation (SIM) through the start of treatment and constitutes a sequence of processes. Accurate implementation of each of these is essential for proper treatment. Prior guidelines had been proposed in our department for conformal treatment and intensity modulated radiation therapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT); these were often not met leading to dissatisfaction by staff and patients. To improve this we evaluated the current steps in ROTP in an effort to improve our process. Methods: We analyzed the records of 157 eligible patients who underwent CT simulation from 1/1/12 through 3/30/12, excluding patients treated for benign disease, brachytherapy, or patients who never started treatment. The departmental standard was for urgent cases to start within 4 days (d), non-IMRT cases to start in 5d and IMRT/VMAT/SBRT cases to start in 10d. We defined three intervals, from SIM to start of treatment, SIM to approval of the plan by the physician, and approval to treatment start. Results: The median interval between planning landmarks in work-days and the % exceeding planning standards plus 2 days are shown below. Almost half of cases exceeded departmental standards for timeliness of ROTP. Much of the variability occurred after the physician had approved the plan. Conclusions: To improve timeliness of ROTP we have introduced changes in our planning process: 1. Strict definition of urgent cases. 2. Assigning a start date at the time of simulation. 3. Case planning review by the Radiation Oncologist, dosimetrist (+/- Physicist) at SIM. 4. Daily review of task list by Chief of Physics and Department Chair. These changes have been implemented in our department and results of the first two months of their use will be presented. [Table: see text]
Categorization of measures of quality in radiation treatment.
Authors: Cao Jeffrey Quoc , Donaldson Holly , French John , Gillan Caitlin , Milosevic Michael , Lam Catarina , Dunscombe Peter
Published: February 2017

187

Background: The Canadian Partnership for Quality Radiotherapy (CPQR) has revised an outdated version of quality assurance (QA) guidelines for use in Canadian radiation treatment (RT) centres. This updated document contains concise, specific quality statements against which program structure and performance can be evaluated. Our objective was to review available international guidelines for quality in RT, categorize them according to a defined taxonomy, and inform a modified Delphi process for further evaluation of the guidelines. Methods: We identified 8 relevant standards documents issued by jurisdictions internationally. Taken together, 454 statements, or groups of statements, describing measures of quality were identified. These disparate quality statements were consolidated into a limited number of manageable groups using an appropriate classification scheme. A decision tree with two major categories was developed. Category 1 was based on the classification proposed by Donabedian as to whether the statement addressed a structure, process, outcome, or other. Category 2 addressed whether the statement referred to activities directed towards the organization, patients, staff, equipment/clinical processes, or other. Five reviewers assigned each of the 454 statements independently to one of these 20 (4 x 5) category decision tree endpoints. Results: A free marginal kappa analysis of agreement between the 5 reviewers in all 20 endpoints yielded a value of 0.38 which is fair agreement. Restricting analysis to Category 1, there is better agreement with a kappa of 0.54. Alternatively, 3 or more of the 5 reviewers agreed on their assignments 93% of the time for Category 1 and 76% for Categories 1 and 2. There were 290 statements with less than 100% agreement in Category 1 extracted for a second mapping using additional descriptive qualifiers. Subsequently, the overall free-marginal kappa increased to 0.71, considered substantial agreement. Conclusions: Kappa values varied among the 8 documents reviewed, possibly indicating differences in clarity of the descriptions. The 454 standards identified have been categorized and provide a manageable input to our ongoing effort to maintain appropriate, up-to-date Canadian quality guidelines for RT.
Primary care providers’ evaluation of survivorship care plans.
Authors: Mayer Deborah , Dittus Kim , Dulko Dorothy , Pace Clare , Sprague Brian , Gerstel Adrian , Davies Janine M. , Geller Berta , Hawkins Nikki
Published: February 2017

188

Background: Survivorship care represents a distinct phase of the cancer care and addresses surveillance, the physical and psychosocial sequelae of the cancer and treatment, and health promotion. Survivorship care plans (SCP) were recommended in the 2005 IOM From Cancer Patient to Cancer Survivor as a tool to address these issues and will be required by the Commission on Cancer in 2015. As part of two studies implementing SCP using the JourneyForward (JF-SCP) template, we evaluated primary care providers (PCP) perspective on their use. Methods: JF-SCP were developed and delivered to patients and PCP at the end of treatment. We collected information about usability, comprehension, barriers to use, and respondent demographics. Results: Of the 61 PCP who responded: 86% were physicians, 60% were women, had an average of 20 years in practice. PCP strongly agreed/agreed that SCP were easy to understand (95.7%), the right length (73.9%), addressed the right topics (95.7%), would be useful in talking with patients about survivorship plans (91.3%), would improve communication with oncologists (74.4%) and with patients (74.4%). Significant barriers interfering with the PCP providing follow-up care included: limited access to survivors as they stay with oncologists (59.5%), insufficient knowledge of issues (53.4%), inadequate recommendations from the oncologist (43.9%), lack of survivor care guidelines (42%), lack of time (38%), and poor reimbursement (16.6%). Specific suggestions about the JF-SCP included making it shorter and being clear about which provider was responsible for obtaining recommended testing. PCP commented on the importance of ongoing primary care provided throughout the cancer continuum. Conclusions: PCP reported ease of SCP use but did identify areas for improvement. Many PCP were frequently not included or did not stay involved with the cancer patient when being seen by oncologists. The SCP was viewed as a tool to facilitate communication with oncologists and patients.
Investigation of gastrointestinal stromal tumor (GIST) care management in GIST patients (pts) receiving short-term versus long-term imatinib (IM) adjuvant therapy: A chart review analysis.
Authors: Conley Anthony Paul , Guérin Annie , Sasane Medha , Gauthier Geneviève , Schwiep Frances , Keir Christopher Hunt , Wu Eric Q.
Published: February 2017

195

Background: Although optimal duration of adjuvant IM therapy in Kit+ GIST pts is unknown, the NCCN guidelines recommend treatment for ≥36 months in high-risk pts based on clinical trials showing reduced risk of recurrence and mortality in pts receiving long-term adjuvant IM. The objective of this study was to investigate clinicians’ recurrence risk assessment and GIST management in patients receiving adjuvant IM for short- (6-12 months) vs. long-term (≥24 months) in community practice. Methods: GIST-related and treatment characteristic information on adult pts with primary resectable Kit+ GIST initiating IM ≤84 days after surgery (short-term: 411 pts; long-term: 408 pts) was collected from 320 U.S. oncologists using an online data collection form. In addition, physician prescribing patterns and perception of risk assessment and IM duration were collected. Results: Indicators of risk (tumor size, mitotic count, and tumor location) were significantly associated with IM treatment duration. Tumor rupture status did not impact IM duration, except when unknown, in which case pts had longer IM duration. About 50% of pts had not been tested for Kit mutation; 31% of physicians reported that it would not have changed therapy/management or were not aware of how results should have impacted GIST management. Among short-term pts for whom physicians reported a reason for IM discontinuation, main reasons included non-severe adverse events, completion of the 1-year treatment scheduled, economic constraint/health plan coverage change, and pts’ preference. Overall, 77.8% of surveyed physicians reported that pt risk profile drove their decision of continuing IM over an extended period of time. However, in practice 39.9% of the short-term pts and 48.8% of the long-term pts had a high risk profile as assessed by Fletcher classification; suggesting a lack of consistency between treatment related opinions and practice. Conclusions: These observed discrepancies highlight the need for standardization of risk assessment practices and education among community oncologists and pts.
Impact of a multidisciplinary cancer care program and nurse navigation on pancreatic adenocarcinoma treatment.
Authors: McCahill Laurence E. , May Mary , Martinez Coralyn , Taylor Wendy K. , Davis Alan T.
Published: February 2017

200

Background: Treatment of pancreatic adenocarcinoma (PanCa) is complex and requires input from multiple physicians. We developed a unique gastrointestinal (GI) cancer program utilizing a multidisciplinary conference, a multidisciplinary clinic (MDC), a GI nurse navigator (NN) and continuous quality assessment with a nurse clinical auditor. The impact of this program, which requires significant additional resources, on adherence to evidence based cancer treatment for newly diagnosed PanCa patients is unknown. Methods: The GI (NN) interviews patients, coordinates staging and biopsies, physician visits and subsequent adjuvant care in the first year of diagnosis. A clinical quality specialist abstracted all treatment received (surgical, radiation, chemotherapy, palliative), and data was entered into a GI Quality database. Treatment received by patients in first year of diagnosis was compared to NCCN guidelines. Results: From January 2010 to April 2012, 68 patients with newly diagnosed PanCA were evaluated/treated. Overall compliance with NCCN treatment guidelines was 83.4%. Compliance was highest for stage I (almost all underwent surgical resection) and stage IV (none underwent surgery). Utilization of adjuvant therapies was 80% (16/20) for patients with stageI/II disease. Eight patients with stage I/II disease did not undergo surgery, due to comorbidities or disease progression. Conclusions: A novel GI cancer program utilizing a multispecialty MDC and a dedicated GI NN demonstrates very high compliance with evidence based therapy for first line treatment for PanCa patients. Although resource intensive, this level of adherence to evidence-based medicine is encouraging and higher than prior reports for PanCa. The relative contribution of the GI MDC clinic format versus the NN warrants further study. [Table: see text]
Adherence to head and neck cancer guidelines: Multidisciplinary conference recommendations and care delivered.
Authors: Nurgalieva Zhannat , Weber Randal S. , Lai Stephen Yenzen , Sturgis Erich M. , Beadle Beth Michelle , William William , Lewis Carol M.
Published: February 2017

202

Background: Adherence to clinical guidelines, such as those developed by the National Comprehensive Cancer Network (NCCN), can serve as a quality measure for delivered care. We aimed to determine NCCN guideline compliance of and concordance between multidisciplinary conference (MC) treatment recommendations and treatment received. Methods: A retrospective review of 71 consecutive previously untreated patients from 1/1 to 4/1/2006 evaluated whether MC recommendations were compliant with 2006 NCCN treatment guidelines, what treatment was actually provided, and whether this treatment was congruent with MC recommendations and/or adhered to 2006 NCCN guidelines. Results: TNM staging was documented in 94.4% of MC notes and treatment recommendations were documented for 98.6% of patients. Of enrolled patients, 53% had oropharyngeal cancer, 22.7% had oral cavity cancer, 18.2% had laryngeal cancer, and 6.1% had nasopharyngeal cancer. The mean age at presentation was 57.4 years. Forty-eight patients (72.7%) were men. MC recommendations were not compliant with NCCN guidelines in 7 (10.6%) patients. Reasons for non-compliance were recommended definitive radiation alone for T1/2N2 oropharyngeal cancer (3 patients), recommended over-use of induction chemotherapy (2 patients) or adjuvant therapy (1 patient), and incomplete documentation (1 patient). Actual treatment deviated from MC recommendations in 25 (38.5%) patients, although in 14 of these patients, treatment remained guideline-adherent. Actual treatment was not compliant with guidelines in 9 patients; 4 of these patients had treatment congruent with MC recommendations, which were not NCCN guideline-compliant. Reasons for guideline-discordance in the remaining patients were individual. Conclusions: Discordance with NCCN guidelines for head and neck cancer treatment planning and delivery was observed in this cohort; while some deviations were due to incomplete documentation, areas for improvement were identified. Further study is warranted to determine whether treatment deviating from NCCN guidelines impacts patient outcome.
The negative impact of prior reprimand on radiation therapists’ and dosimetrists’ comfort in reporting errors: Results from a national survey of more than 500 respondents.
Authors: Church Jessica A. , Adams Robert D. , Hendrix Laura H. , Holmes Jordan A. , Marks Lawrence B. , Chen Ronald C.
Published: February 2017

204

Background: The presence of a "just culture" is often noted to be critical in optimizing safety, since workers need to feel comfortable reporting errors. We performed a national survey of radiation therapists and medical dosimetrists to assess their comfort in reporting errors. We herein quantify the impact of workers’ perceptions of their workplace culture (based on prior experiences in reporting errors) on their comfort in reporting safety concerns. Methods: In 2011, a survey was mailed to 1,500 therapists and 528 dosimetrists assessing their comfort in reporting errors. The metric used to assess their perceptions of their workplace culture was if they had, or knew of staff who had been, reprimanded in the past for reporting errors. Comfort in reporting new errors among workers who have (vs. have not) experienced prior reprimand were compared using Fisher’s exact test. Results: Overall, 356 therapists from 47 states (24% response rate) and 190 dosimetrists from 35 States (36% response rate) responded to the survey. 16% of therapists and 5% of dosimetrists reported that they have been personally reprimanded for reporting an error. The proportion of workers comfortable reporting errors was lower among those with prior personal reprimand vs. those without such reprimand (47% vs. 90%, p<.0001). Similarly, 29% of therapists and 8% of dosimetrists reported that other staff members have been reprimanded for reporting, and these reprimands had a similar deterrent effect on reporting errors. On multivariate analysis, previous personal reprimand for reporting errors (OR 4.13, p=.001) and reprimand of other therapists/dosimetrists (OR 2.55, p=.03) were significantly associated with discomfort in error reporting. Conclusions: A sizable proportion of respondents in our study has been personally reprimanded or knows of staff in their facility reprimanded for reporting errors. Prior reprimand has a dramatic detrimental impact on workers’ comfort to report future concerns regarding safety. A potential opportunity for future improvement in radiation oncology treatment facilities is to encourage a culture that allows error reporting without fear of reprimand.
Capturing and addressing emotional well-being: Utilization of ASCO’s Quality Oncology Practice Initiative (QOPI) for performance improvement.
Authors: Hegedus Patricia D. , Bearden James D. , Grant Bruce
Published: February 2017

207

Background: Palmetto Hematology Oncology (PHO) is the medical oncology practice of Spartanburg Regional Healthcare System (SRHS) and has participated in QOPI since 2009 and earned QOPI certification in September 2011. Emotional well-being assessments and documentation of interventions were selected for a performance improvement project based on QOPI measures from Fall 2009. Methods: Several articles were identified supporting the use of the NCCN Distress Thermometer following a comprehensive literature search and approval was obtained for use. The NCCN Distress Thermometer was administered to all new patients through inclusion in “new patient” paperwork packets. Two physician offices within the practice were piloted with the physicians reviewing the patient reported assessments and documenting any required interventions. All completed NCCN Distress Thermometer forms were also reviewed by the medical social work team, and for scores > 3, interventions by phone or face-to-face were completed by them and documented in the patients’ electronic medical records. Results: Due to the success of the pilot efforts the assessment/intervention process for emotional well-being was expanded throughout the PHO practice, the Gibbs Infusion Center, and Radiation Oncology. The QOPI emotional well-being indicator revealed an increase from the Fall 2009 to Spring 2012 of 36.25% to 96.25%. Conversely, our compliance with intervention by the second office visit decreased from 94.44% to 69.44%, respectively. Conclusions: Although PHO’s scores for the emotional well-being assessment have dramatically improved with implementation of the process improvement initiative, opportunity remains for improving emotional well-being intervention documentation. This initiative highlighted the lack of psychiatric/psychological services available to PHO patients. References: NCCN Clinical Practice Guidelines in Oncology: Distress Management, Version 3.2012; Available at: http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf . QOPI The Quality Oncology Practice Initiative; Available at: http://qopi.asco.org/program .
Predictors of quality radiation therapy completion after breast-conserving surgery.
Authors: Powers Benjamin Daniel , Daly Maureen Patricia , Willis Alliric Isaac
Published: February 2017

210

Background: Quality radiation therapy completion (QRTC) is critical to quality breast conserving treatment (BCT). Our aim was to identify predictors of QRTC after BCT in an urban setting. Methods: Hospital Tumor Registry Data was collected for female BCT patients Stage I and II. Radiation therapy completion (RTC) was defined as 35 days or more of breast radiation. QRTC was defined as RTC of 35-49 days. Statistical analyses were performed with SPSS. Results: 346 patients were analyzed. Demographic data: Ethnicity: Black n=230 (66.5%), White n=63 (18.2%), Hispanic n=53 (15.3%); Age: < 50 years n=74 (21.4%), 50 – 64 years n=152 (43.9%), > 64 years n=120 (34.7%); Insurance: Medicare n=131 (37.9%), Private n=94 (27.2%), Medicaid n=121 (35.0%). Hispanics (60.4%) were more likely to have Medicaid versus blacks (33%) and whites (20.6%), p<0.001. Majority (52%) of patients live within 3 miles of treatment. More blacks (66.5%) live <3.0 miles than whites (7.9%) or Hispanics (41.5%), p<0.001. There was no significant difference in mean days of RTC by ethnicity (black 46.8, white 46.4, and Hispanic 48.1 days; p=0.75) or total RTC % (black 88.2%, white 97.9%, Hispanic 93.3%; p=0.09). However, a substantial difference was seen in QRTC % by ethnicity (black 51.8%, white 79.2%, Hispanic 57.8%; p=0.03) Multivariate logistic regression of failure to achieve QRTC found associations with black race (OR=2.67), Medicare (OR= 3.46), Medicaid (OR=2.19), and age <50 years (OR=4.13). Conclusions: This study demonstrates high overall % RTC; however, it identifies significant disparities in successful QRTC. Those at greatest risk of unsuccessful QRTC were younger, Medicare or Medicaid insured, and black ethnicity. Distance was not a significant factor in this urban population. Further studies should investigate the specific barriers that may contribute to disparities in QRCT among those at risk groups. [Table: see text]
Validation of electronic prostate cancer quality-of-care measures in the Veterans Health Administration (VHA).
Authors: Shelton Jeremy Bradford , Skolarus Ted A. , Malin Jennifer , Antonio Anna Liza M. , He Ren , Saigal Christopher
Published: February 2017

213

Background: Quality measures based on chart abstraction are the “gold-standard,” but the costs of measurement limit widespread adoption. Electronically specified measures (e-measures) promise to change this; however, the fidelity of electronic abstraction compared to chart abstraction is unknown. We sought to validate e-measure versions of VHA-developed prostate cancer quality of care measures. Methods: Quality measures were chart abstracted on 11,263 men in the VHA with incident prostate cancer in 2008. We identified and linked VHA cancer registry and administrative data for the same cohort. E-measures were specified iteratively and validated by comparing the sensitivity and specificity of measure denominators and numerators, and the overall pass rates to chart abstracted results. Results: 3 of 6 quality measures and 7 of 10 descriptive measures were successfully validated (see Table). Conclusions: The VHA’s electronic medical record environment and information technology infrastructure are sufficiently advanced to support valid e-measurement that is equivalent to that performed by chart abstraction. [Table: see text]
Monitoring acute care utilization (ACU) during adjuvant chemotherapy for early breast cancer (EBC) as a measure of quality.
Authors: Enright Katherine , Grunfeld Eva , Yun Lingsong , Moineddin Rahim , Dent Susan Faye , Eisen Andrea , Trudeau Maureen E. , Kaizer Leonard , Earle Craig , Krzyzanowska Monika K.
Published: February 2017

220

Background: Serious chemotherapy associated (CA) toxicities resulting in ACU are a concern when administering adjuvant chemotherapy for EBC. Monitoring ACU during adjuvant chemotherapy may serve as a measure of quality of cancer care delivery. We undertook a population based study of ACU in patients undergoing adjuvant chemotherapy for EBC compared with controls. Methods: All EBC patients diagnosed 01/07 – 12/09 in Ontario, Canada were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial healthcare databases. All patients received ≥1 cycle of adjuvant chemotherapy. EBC cases (n = 4,718) were matched to non-cancer controls (n = 4,718) on age and geographic location. ACUs (emergency room or hospitalizations) within 30 days of chemotherapy were identified. If the primary reason for visit was a common toxicity of chemotherapy, the visit was considered chemotherapy associated (CA). All cause and CA visits were compared between cases and controls. Logistic regression models were used to identify covariates associated with ACU. Results: ACU was significantly higher in EBC pts compared with controls for both all cause (42.1% vs. 9.1%, p<.001) and CA (30.7% vs. 2.4%, p<.001) visits. Fever was the most common CA toxicity (22.9% vs. 1.2%,p<.001). Taxanes were significantly associated with increased ACU compared with anthracycline only (see Table). Conclusions: Serious chemotherapy associated toxicity resulting in ACU is common among EBC patients receiving chemotherapy. Interventions aimed at mitigating CA toxicity, particularly with the use of taxanes may reduce ACUs and improve quality of care. [Table: see text]
Chemotherapy dose selection in a diverse sample of medically underserved women with breast cancer.
Authors: Griggs Jennifer J. , Sorbero Melony S. , Liu Yihang , Maly Rose C.
Published: February 2017

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Background: Black race, lower socioeconomic status, and obesity have been associated with reduced first cycle doses of adjuvant chemotherapy. There are no data on dosing patterns in Hispanics. The purpose of this study was to investigate chemotherapy dose selection among a diverse sample of patients treated for breast cancer through the Breast and Cervical Cancer Prevention Treatment Act (BCCPT) in the state of California from February 2003 to September 2005. Methods: Extensive medical record review of patients who received chemotherapy was performed. We calculated the first cycle dose ratio by dividing the actual doses of chemotherapy delivered by the expected doses. Expected doses were those in standard chemotherapy regimens. Bivariate and multivariate regression analyses were performed to identify clinical and non-clinical factors associated with dose reductions. Results: Among 658 patients with stages I to III breast cancer in the sample, 522 received chemotherapy. After exclusions, the final analytic sample included 403 women (122 non-Hispanic whites, 21 non-Hispanic blacks, 226 Hispanics, 28 Asians, and 6 of other races). Dose ratios < 0.9 were given to 57 patients (14%). In bivariate analyses, race/ethnicity (p=0.004), body mass index (p< 0.001), comorbidity (p< 0.001), and treatment at a non-academic site (p=0.015) were associated with a dose ratio < 0.9. Hispanics and Asians were least likely to have dose reductions. In multivariable analysis, only comorbidity (p=0.03), severe obesity (p=0.003), and being treated at a non-academic center (p=0.03) remained significantly associated with dose reductions. Race/ethnicity was no longer associated with dose selection. Conclusions: The majority of women diagnosed and treated through the BCCTP received high quality chemotherapy. Clinical factors (comorbidity and obesity) as well as site of care were associated with chemotherapy dose selection. The processes and resources in place at academic medical centers may account for the role of treatment site in quality of chemotherapy dose selection. Efforts to standardize dose selection across obesity status and treatment facilities are warranted.
Receipt of guideline-concordant treatment in elderly African American and Caucasian patients with prostate cancer.
Authors: Chen Ronald C. , Carpenter William Ruffin , Hendrix Laura H. , Wang Zhuang Andrew , Nielsen Matthew Edward , Godley Paul Alphonso
Published: February 2017

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Background: Clinical management of cancer patients according to published guidelines is an important quality indicator. Prior studies have demonstrated less aggressive treatments of elderly patients with breast and colorectal cancers, raising concern about potential undertreatment of elderly patients overall. The rate of guideline concordant management in elderly prostate cancer patients is unknown, and we examined this using the Surveillance, Epidemiologic and End Results (SEER)-Medicare linked database. Given that prostate cancer is often slow growing, we were especially interested in guideline concordance in patients with "high risk" (aggressive) prostate cancer. Methods: 15,154 Caucasian (CA) and 2,924 African American (AA) men diagnosed in 2004 to 2007 with localized prostate cancer, age 66 to 79, were included. We characterized the proportions of men who received management concordant with the National Comprehensive Cancer Network guidelines within 12 months of diagnosis. Logistic regression was used to examine the odds of receiving guideline-concordant management while accounting for race, comorbidity (NCI combined index), SEER region, and sociodemographic factors. Results: Guideline concordance was more than 80% for both CA and AA patients with low- or intermediate-risk disease. Among high-risk patients, only 63% of CA and 48% AA patients received guideline-concordant management, mostly due to no treatment or hormonal therapy alone, which offer no curative potential. Findings were almost identical in the subgroup of patients with little or no comorbidity, who have more than 10 year life expectancy on average. On multivariable analysis, AA race (OR .62, p<.001) and increasing age were associated with lower likelihood of guideline concordance for high-risk prostate cancer, but comorbidity was not. Conclusions: There is undertreatment of elderly but healthy patients with high-risk prostate cancer, the most aggressive form of this disease. Our results suggest a bias toward less aggressive treatment in elderly patients with less consideration for comorbidities or aggressiveness of cancer. Guideline concordance in elderly patients with aggressive prostate cancer is low.
Impact on mortality of increasing surgical volumes within hospitals after regionalization of thoracic surgery in Ontario, Canada.
Authors: Bendzsak Anna , Baxter Nancy N. , Darling Gail , Austin Peter , Urbach David R.
Published: February 2017

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Background: The causal direction of the volume-outcome relationship in surgery has not yet been established. Our objective was to study the effect of absolute hospital volume of anatomic lung resections and volume changes within hospitals on mortality, length of stay (LOS), readmission (RA), and post-discharge visits to the emergency room (ER visits), during a period of regionalization for lung surgery in Ontario, Canada, to test the theory of "practice makes perfect". Methods: For each anatomic lung resection in Ontario from 2004-2010 we determined the volume change within hospital as the difference in hospital operative volume between the year immediately prior to the date of surgery and year prior to that (Dvolume). We used generalized estimating equations and logistic regression, controlling for clustering within hospitals, to examine the effect of Dvolume, patient factors and year on operative mortality, RA and ER visits. Negative binomial regression was used for LOS. The absolute effect of volume, measured as the 12-month hospital volume prior to each procedure, on outcomes was also examined with the same models. Results: Higher hospital volumes were associated with significant improvements in mortality and length of stay, (for increases of 10 cases, mortality OR=0.98 [95%CI: 0.96-1.00] and LOS RR=0.98 [95% CI: 0.97-0.99]), but not for RA or ER visits. However, increases in within-hospital volume did not lead to changes in mortality (OR=1.00, 95% CI: 0.96-1.10), RA (OR=1.00, 95% CI: 0.99-1.00), or ER visits (OR=0.99, 95% CI: 0.98-1.00). Volume increases within hospitals did lead to small improvements in LOS (RR=0.996, 95% CI: 0.993-0.999). Conclusions: Increasing volumes within hospitals did not lead to improvements in mortality in our study, but did result in small improvements in LOS. The decrease in LOS was likely appropriate as it was not associated with changes in RA or ER visits. A volume-outcome relationship between absolute hospital volume and improved mortality was observed, but was not explained by increasing volumes within hospitals; thus practice did not make perfect for mortality.
Physician inter-annotator agreement in the Quality Oncology Practice Initiative (QOPI) manual abstraction task.
Authors: Warner Jeremy , Drews Reed
Published: February 2017

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Background: The Quality Oncology Practice Initiative (QOPI) relies upon the accuracy of manual abstraction of clinical data from paper-based and electronic medical records (EMR’s). While there is no “gold standard” to measure manual abstraction accuracy, measurement of inter-annotator agreement (IAA) is a commonly agreed-upon surrogate. We quantified the IAA of QOPI abstractions on a cohort of cancer patients treated at Beth Israel Deaconess Medical Center. Methods: The EMR charts of 49 patients (20 colorectal cancer; 18 breast cancer; 11 non-Hodgkin lymphoma) were abstracted by separate physician abstractors in the Fall 2010 and Fall 2011 QOPI abstraction rounds. The Fall 2011 abstractors were unaware that the charts had been previously abstracted. We analyzed data elements that were common to both rounds, had data entry for both rounds, and did not contain information expected to change after the Fall 2010 round. Cohen’s kappa (κ) was calculated for encoded data; raw levels of agreement and magnitude of discrepancies were calculated for numeric and dated data. IRB approval was obtained and all investigators completed appropriate human subjects research training. Results: 109 data elements with 2,035 paired entries met the above criteria; four narrative elements were not analyzed. Overall IAA for 1,496 coded entries was κ=0.75; median IAA for n=85 individual coded elements was κ=0.84 (interquartile range 0.30-1.00). Overall IAA for 421 dated entries was 73%; median IAA for n=17 individual dated elements was 67% (interquartile range 61-86%). The median discrepancy for the 113 discrepant dated entries was +6 days (range -217 to +391 days). Conclusions: This study establishes a baseline level of accuracy for a complex medical abstraction task with clear relevance for the oncology community. Despite the fact that all information was available in the EMR, there was disagreement for objective elements (e.g. cancer stage) as well as subjective elements (e.g. patient wellbeing). Given that the observed κ is considered only fair IAA, and that the rate of date discrepancy is high, caution is necessary in interpreting the results of QOPI and other manual abstractions of clinical oncology data.