bluuebunny/crossref_metadata_2025 huggingface dataset:
Early national dissemination of abiraterone and enzalutamide for advanced prostate cancer in Medicare Part D.
Authors: Caram Megan Veresh , Borza Tudor , Min Hye-Sung , Griggs Jennifer J. , Miller David Christopher , Hollenbeck Brent K. , Mukherjee Bhramar , Skolarus Ted A.
Published: April 2017

35

Background: Abiraterone and enzalutamide are oral medications approved by the Food & Drug Administration in 2011 and 2012 to treat men with advanced castration-resistant prostate cancer. Most men with advanced prostate cancer are over age 65 and thus eligible for Medicare Part D. We conducted a study to better understand the early dissemination of these drugs across the United States using national Medicare Part D data. Methods: We evaluated the number of prescriptions for abiraterone and enzalutamide by provider specialty and hospital referral region (HRR) using Medicare Part D and Dartmouth Atlas data. We categorized HRRs by abiraterone and enzalutamide prescriptions, adjusted for prostate cancer incidence, and examined factors associated with regional variation using multilevel regression models. Results: Among all providers who wrote prescriptions for abiraterone or enzalutamide in 2013 (n=2121), 87.5% were medical oncologists, 3.3% urologists, and 9.2% were listed as other provider specialties. Among those who prescribed either drug, 5% of providers were responsible for 75% of the claims for abiraterone, and 7% were responsible for 75% of the claims for enzalutamide. Some HRRs demonstrated low-prescribing rates despite average medical oncology and urology physician workforce density. Conclusions: The majority of prescriptions written for abiraterone and enzalutamide through Medicare Part D in 2013 were written by a minority of providers with marked regional variation across the United States. Better understanding the early national dissemination of these effective but expensive drugs can help inform strategies to optimize introduction of new, evidence-based advanced prostate cancer treatments.
Near miss or safety incident in patients treated with radiotherapy: What are the contributing factors?
Authors: Judy Greg D. , Mosaly Prithima , Mazur Lukasz M. , Tracton Gregg , Chera Bhishamjit S.
Published: April 2017

36

Background: To identify 1) factors that are associated with a near miss or safety incident (NMSI) in patients undergoing radiation therapy; 2) the most common root causes of NMSIs and their relationship with incident severity. Methods: We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with a NMSI (n=200; incident group) and a similar group of control patients (n=200) matched in time, without a NMSI. A root cause was determined for each incident. A univariate analysis was performed to determine which patient-, disease-, and treatment-specific factors were different between the incident and control groups. Next, multivariate logistic regression was used to determine the significant factors contributing to NMSIs. Multivariate logistic regression was used to determine the most common root causes of NMSIs and their relationship with incident severity. A p value of 0.05 was used to test the statistical significance. Results: NMSIs were associated with the following factors: i) head and neck treated sites versus other disease sites (OR 5.2, p=0.01), ii) image-guided intensity modulated radiotherapy (IGIMRT) versus other treatment modalities (OR 3, p=0.009); tumors staged as T2 more frequently had incidents versus other T stages (OR 3.3, p=0.004), and iv) daily imaging versus no imaging or weekly imaging (OR 7, p<0.001). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients (p<0.0001) and technical treatment delivery errors were most associated with a higher severity score (p=0.005). Conclusions: Several treatment- and disease-specific factors were found to be associated with a NMSI. These factors are similar to what has been previously reported by others. Overall, our results suggest that complexity (e.g., head and neck, IGIMRT, T2, and daily imaging) might be a contributing factor for a NMSI. This promotes an idea of developing a more dedicated and robust QA system for complex cases. Our study highlights the importance of a strong reporting system to support a safety culture and promote continuous learning and improvement efforts.
Significant and sustained reduction in chemotherapy errors though improvement science.
Authors: Weiss Brian D. , Scott Melissa , Demmel Kathleen , Perentesis John Peter , Kotagal Uma R , Walsh Kathleen
Published: April 2017

37

Background: The majority of children with cancer are now cured with highly complex chemotherapy regimens incorporating multiple drugs and demanding monitoring schedules. The risk for error is high and can occur at any stage in the process, from order generation through pharmacy formulation to bedside drug administration. Our objective is to describe a program to eliminate errors in chemotherapy use among children. Methods: To increase reporting of chemotherapy errors, we supplemented the hospital-reporting system with a new chemotherapy near-miss reporting system. Following the model for improvement, we then implemented several interventions, including a daily chemotherapy huddle, improvements to the preparation and delivery of intravenous therapy, headphones for clinicians ordering chemotherapy, and standards for chemotherapy administration throughout the hospital. Results: Twenty-two months into the project, we saw a centerline shift in our U Chart of chemotherapy errors that reached the patient from a baseline rate of 3.82/1,000 doses to 1.9/1,000 doses. This shift has been sustained for over 4 years. In Poisson regression analyses, we found an initial increase in error rates, followed by a significant decline in errors after 16 months of improvement work (p < 0.001). Conclusions: Following the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors which reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimized interruptions during ordering.
Readmission among patients with cancer who were discharged with hospice care.
Authors: Manzano Joanna-Grace Mayo , Barbo Andrea G. , Lin Heather Y. , Zhao Hui , Halm Josiah , Suarez-Almazor Maria E.
Published: April 2017

46

Background: Palliative and hospice care are appropriate recommendations for patients with high symptom burden and who are at end of life. Patients with cancer who are discharged to hospice care are less likely to be readmitted and this is expected. There remains a proportion of patients however, who rescind hospice after enrolling. We sought to describe this subgroup of patients and determine their readmission rate. Methods: This is a retrospective cohort study using administrative data of adult patients discharged from a non-surgical solid tumor service at The MD Anderson Cancer Center who were discharged to hospice care. Readmission was defined as any rehospitalization after discharge regardless of timing. Descriptive statistics are presented. Results: There were 1,452 discharge encounters with a disposition of hospice in our cohort with 50 resulting in readmission (readmission rate=3.4%). The mean age of patients who were readmitted was 59 years. Majority of the readmitted patients were female (60%), had a religious affiliation (83%), were English-speaking (85%), and were from Texas (94%). 54% of the patients who were readmitted were married versus 42% who were either single, divorced, widowed or separated. 42% had Medicare insurance, 44% had private insurance, 4% were indigent, and 10% were self-pay. 75% of the patients had metastatic disease at time of first presentation at MD Anderson. Conclusions: Transitioning to hospice care is a difficult decision for most patients and caregivers. Rescinding hospice after discharge to seek acute care in the hospital potentially reflects the difficult and daunting nature of this transition. Our study provides an insight into the characteristics of patients who are readmitted after hospice care has been initiated. More analysis is needed to determine if the characteristics described are associated with readmission in this population. Other factors such as those that are related to the caregiver, the patient’s symptom burden, or the care setting, may need to be investigated as well to have a better understanding of why patients decide to rescind hospice.
Evaluating the patient-centered quality of cancer survivorship care models.
Authors: Mead Holly , Pratt-Chapman Mandi , Cleary Sean , Raskin Sarah
Published: April 2017

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Background: With 15.5 million cancer survivors in the U.S., cancer is increasingly viewed as a chronic illness that requires systematic, coordinated care. Yet research has not determined what models of survivorship are most effective in providing high quality, patient-centered care. This study evaluates the quality of three models of cancer survivorship care using a newly developed patient-centered measure. Methods: We conducted a comparative effectiveness study with 32 cancer programs distributed across 3 distinct models of survivorship care: 1) Consultative Specialized Survivorship Clinic; 2) Longitudinal Specialized Survivorship Clinic; and 3) Oncology-Embedded Survivorship Clinic with Referrals. We developed the Patient-Prioritized Measure of High Quality Survivorship Care (PPM), a scale comprising 9 patient-prioritized components of survivorship care. We enrolled 991 survivors of breast, colorectal and prostate cancer across these programs and followed them over 6 months collecting self-reported data on quality of survivorship services. Results: Preliminary results suggest statistically significant differences across models of care for six PPM components. Model 1 is more likely than the other two models to provide a full spectrum of services (p=0.0001), mental health and social support (p<0.0001), and information and resources for patients in survivorship (p=0.0002). Model 2 is better than model 3 at providing a medical home (0.04), and outperforms both other models at coordinating care and transitions (p=0.0059). Both Models 1 and 2 are better than model 3 in ensuring productive patient-provider interactions (p=0.006). Conclusions: It appears that certain models of survivorship care are better at specific domains of patient-centered quality, suggesting cancer centers should consider their organizational context and their patients’ needs before committing to a particular model of care.
Improving care with portfolio of physician-led cancer quality measures at an academic center.
Authors: Porter Julie , Segura Smith Andrea , Winget Marcy , Rosenthal Eben Lloyd , Seshadri Sridhar Belavadi , Vetteth Yohan , Kiamanesh Eileen F , Badwe Amogh , Advani Ranjana H. , Buyyounouski Mark K. , Coutre Steven , Dorigo Oliver , Ganjoo Kristen N. , Johnston Laura J. , Recht Lawrence David , Shrager Joseph B , Skinner Eila C. , Swetter Susan M. , Visser Brendan C. , Blayney Douglas W.
Published: April 2017

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Background: Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the required manual data collection is slow and resource-intensive. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCP). Methods: CCP physician leaders (MD) identified two measures that were meaningful to their team and patients. The quality team worked with hospital and university analytics teams to develop metrics and reports. Hospital leadership provided financial incentives (FI) for each CCP if jointly set targets were met. Results: 16 metrics were identified and measured for 13 CCPs (Table). Measures spanned from new diagnosis (ND) through end of life or survivorship care, and were a mix of process and outcome measures. To build and manage metrics required 2 full-time equivalent data analysts and quality specialists over 12 months. CCP MDs received monthly reports for dissemination to their team. Almost all measures improved or maintained initial high levels (*). FI awards will be used for quality improvement, education, and team-building, as determined by CCP MDs. Conclusions: A successful quality reporting system with measured improvements takes considerable engagement and resources, including FI, data systems, and staff to build, manage, and improve measures. This may not be feasible or sustainable for centers in the current fiscal environment. [Table: see text]
Developing and evaluating new models of care in hematology.
Authors: Kouroukis Tom , Ratcliffe Jenna , Running Karen , Sussman Jonathan
Published: April 2017

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Background: The duration of care for patients with hematological malignancies (HM) from diagnosis to discharge can often be five years or longer, during which patients frequently visit their hematologist but may not maintain contact with their primary care physician (PCP). This can result in gaps in the care of non cancer health problems. A number of studies in solid tumors have highlighted the benefits of maintaining contact with the PCP however there has been little published on survivorship care in HM. Objective. Develop and evaluate models of care in hematology that facilitate transition to the PCP where appropriate. Methods: This study used a stepwise approach to inform the development and evaluation of care models. Models were developed using: a literature review; expert opinion; input from patient and PCP focus groups. The survivorship model (SM) was evaluated in a longitudinal, cohort of patients using validated patient surveys: Coordination of Cancer Care Questionnaire; Edmonton Symptom Assessment Scale; EQ5D-QoL. Results: Focus groups were conducted with 26 participants. Patients indicated they would be willing to engage with their PCP if primary care were more confident in their cancer care abilities, and if communication improved between specialty and PCP. PCPs felt care plans should be clear, concise and within their scope. Three new models of care were developed based on level of care need (survivorship, shared, engagement). The SM has been tested with 50 patients who have completed treatment and follow up. Survey results indicated the majority of SM patients: continued to feel well; reported high functioning; had seen their PCP since discharge; were satisfied with the coordination of their care. Fifteen PCPs responded to a follow up survey. PCPs were: satisfied with the SM care plan and aware of the repatriation process to specialty care, if needed. Conclusions: Patient involvement in model design was instrumental in the success of the project. PCPs reported that the tools developed in this pilot enhanced the care experience and provider collaboration. These findings warrant further testing of care models in a comparative study with this complex cancer population.
Quality of life after morphine treatment in patients with advanced and terminal cancer.
Authors: Alonso Tammy
Published: April 2017

54

Background: Life quality evaluation is the main indicator of the impact of palliative care, which has the objective of diminished suffering. It includes symptoms control and the satisfactions of patients and relatives. Opioids constitute a milestone in pain treatment. Present work is aimed to evaluate the secondary effects in oncological patients with bad prognosis treated with morphine at the Palliative Care Unit (PCU) of the National institute of Oncology and Radiobiology. Methods: The sample includes 72 cancer patients that arrive to the Palliative Care Unit of the National Institute of Oncology and Radiobiology of Cuba, from May 2015 to May 2016. It was characterized in terms of the demographic and clinical parameters. Severity of symptoms was evaluated using the Visual Analogue Scale (VAS). Pain was evaluated using Analogue Visual Scale. Morphine was administered subcutaneously. Incidence of adverse effects related to morphine administration and accuracy of moderate to severe pain was measured. Results: The age range was from 41 to 50 and females predominate. Gynecological cancers were the most frequent pathology. Most frequent adverse effects related to morphine administration were: constipation (35%), nauseas and vomiting (25%) and somnolence (22%). Despite of morphine myths that terrify many physicians and make them use this drug at the end of analgesic scale, in the present work was used in patients in clinical stage III (58.6 % of the 63.8 % survivors) with an effective pain control. Life quality, that includes mood, functional capacity, social interaction and recurrent symptoms, was improved. Conclusions: The use of morphine for pain relief in stage III oncological patients increases the quality of life of patients and relatives for a longer period of time.
Bringing the patient voice into quality assessment: National stakeholder perceptions of facilitators and barriers for the use of PROs as performance measures.
Authors: Stover Angela M. , Chung Arlene , Jansen Jennifer , Basch Ethan M.
Published: April 2017

61

Background: An emerging trend in quality improvement is to incorporate the patient voice into performance metrics for routine care delivery using patient-reported outcomes (PRO). For instance, patients may complete a questionnaire about how well their symptoms are controlled (e.g., nausea). High-quality care is then determined by adjusting scores and comparing similar practices on symptom control. However, stakeholder (clinicians, administrators, and researchers) perspectives of facilitators and barriers are not well characterized because PRO performance measures are an emerging concept. Methods: Key informant interviews were conducted with 35 stakeholders (9 medical oncology clinicians, 13 administrators, and 13 health services researchers) from 5 healthcare systems across the U.S. Interview guides were used to elicit perceptions of barriers, facilitators, and acceptability for using PROs as performance measures. Transcripts were content analyzed by stakeholder group using standard methodology. Results: Clinicians reported barriers that were structural (e.g., complexity of programming electronic health record [EHR] changes) and process-oriented (e.g., changing clinic workflow to accommodate PRO review and alerts). Clinicians noted concerns about appropriate adjustments to ensure fair quality comparisons across practices. Clinicians and administrators reported structural barriers such as reimbursement and staff training, and outcome barriers such as choosing symptoms that have clear treatment guidelines. Facilitators included dashboards to visually display results that are intuitive and easily accessible in the EHR. Researchers focused on standardization and selecting thresholds for symptom alerts. Conclusions: Clinicians, administrators, and researchers reported barriers to the integration of PROs as quality measures. These barriers are mainly structural- and process-oriented but generally did not focus on acceptability. Facilitators focused on presenting PRO scores in an easily interpretable and accessible way within the EHR. Results will inform multi-site feasibility testing of PROs as quality metrics.
Improving end-of-life care: Palliative care embedded in an outpatient oncology clinic.
Authors: Einstein David Johnson , DeSanto-Madeya Susan , Gregas Matt , Lynch Jessica A. , McDermott David F. , Buss Mary K.
Published: April 2017

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Background: Patients with advanced cancer benefit from early involvement of palliative care. Nonetheless, the ideal method of palliative care integration remains to be determined. Prior studies proposed automatic referral criteria and embedding palliative care teams within specialty clinics. Methods: We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic based on automatic referral criteria. Patients seen in this clinic on a specific day had access to the “embedded” model, whereas patients seen on two other days could access a separate palliative care clinic upon oncologist referral (usual care). We abstracted data from the medical records of 118 patients who were cared for in this oncology clinic and died during the 3 years following implementation of the embedded model. Results: Compared with those with access to usual care (n = 88), patients with access to the embedded model (n = 30) encountered palliative care as outpatients more often (p < 0.001) and twice as long before death (mean 223 versus 106 days, p = 0.001). Hospice enrollment rates were similar (p = 0.717) but duration was twice as long (mean 53.5 versus 25.3 days, p = 0.03), and enrollment greater than 7 days before death—a core Quality Oncology Practice Initiative metric—was significantly higher in the embedded model (OR 5.60, p = 0.034). Place of death (p = 0.505) and end-of-life chemotherapy (OR 0.361, p = 0.204) did not differ significantly. Conclusions: A model of embedded palliative care with automatic referral criteria, compared with usual practice, was associated with significant improvements in utilization and timing of palliative care and hospice.
Challenges, barriers, and keys to success for sustainable quality improvement in oncology: A focus group of oncology quality leaders.
Authors: Chiang Anne C. , Reeder-Hayes Katherine Elizabeth , McNiff Kristen K. , Evans Tracey L. , Lennes Inga Tolin , Eaton Erica , Kamal Arif
Published: April 2017

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Background: A sustainable, standardized approach for quality assessment and improvement is increasingly expected in oncology. This requires oncology leaders to identify processes and infrastructure to facilitate sustainable initiatives for practice refinement. To date, few summative reports of lessons learned, key success factors, and barriers to regular quality improvement have been reported. Methods: After IRB protocol approval, a focus group of 11 diverse physician oncology leaders was conducted, using a guide developed through multiple discussions by investigators. The physicians represented diverse organizations with community-based, private practice and academic settings. Data analysis of interview transcripts was performed iteratively, with a grounded theory approach with a method called “constant comparisons”, with related open and axial coding techniques. Transcripts were coded independently by two or three coders, and the resulting code lists integrated prior to final analysis. Differences in coding were resolved by consensus. Results: Overall, physician quality leaders discussed needs and barriers in 5 major domains: coordination of care, communication, finances, value, and quality improvement. Two major themes emerged: rapid change cycles in a dynamic landscape of practice--changing business models and care delivery, new expensive drugs, oral chemotherapy--and their respective unintended consequences on quality of care, e.g. financial toxicity for patients, misalignment of financial incentives and a quality agenda. Participants discussed responding to these changes and key factors in harnessing the practice model to deliver quality care. Conclusions: Cancer care delivery is rapidly evolving and undergoing intrinsic cycles of quality improvement. This project helps to inform systemic quality improvement efforts targeted towards oncology practices by identifying areas of concern and highlighting key factors to be addressed to achieve value, alignment and quality of care. Institutional culture and infrastructure including resources and incentives for quality improvement/measurement were identified as critical success factors.
Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.
Authors: Atiq Mohammad Omar , Ravilla Rahul , Kumar Ajay , Haider Sajjad , Tang Ji-Ling , Arnaoutakis Konstantinos , Motwani Pooja , Siegel Eric R , Sasapu Appalanaidu , Mahmoud Fade A. , Harrington Sarah Elizabeth
Published: April 2017

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Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]
Enhancing treatment planning workflow in radiation oncology.
Authors: Khudanyan Arpine , Jaboin Jerry Jeff , Agrimson Barb , Brown Simon , Laub Wolfram , Price Jo , Junell Stephanie , Hanson Jeff , Ryan Dorothy , Ruocco Jennifer , Thomas Charles R.
Published: April 2017

84

Background: The treatment planning process is the most impactful and complex aspect of radiation oncology care. In order to provide short turn around times from patient CT simulation to treatment plan QA, requires a level of strain and haste for multiple members of the treatment team. We evaluated 18 months of data to determine the percentage of Quality Assurance (QA) approvals of nonemergent complex plans (including 3D/IMRT/Arc/SBRT/SRS) that are not completed by 8:00a the day prior to a patient's first treatment appointment, and found that this occcurred on time 62% of the time. We utilized the ASCO Quality Training Process (QTP) process to brainstorm methods to enhance workflow, and create an action plan that would allow for small Plan-Do-Study-Act cycles to reach our ideal state of > 90% On Time Treatment Plan Delivery. Methods: We utilized LEAN tools from the ASCO QTP progam (June 2016 cycle). We created an Ishikawa diagram to determine the areas of greatest potential. We subsequently developed a highly detailed flow chart of our work processes. Then we utilized Mosaiq scripts to establish baselines for our process measures. Results: From our Ishikawa diagram, the initial most impact was in generate target volume contours after the CT simulation. Our first measure was to visually manage the CT simulation process. We established a computer based quality control list (QCL) to enhance the communication process, and provided a "reminder" at the time of simulation of the target contour delivery date. After collection of data points, there was a significant improvement in on time delivery (now 89%, and approaching the ideal state), as illustrated by our Run Chart, and a coincident decrease in variability between providers and cases was noted in this cohort. Conclusions: Our preliminary change effort is promising, but further data will enhance our findings. Our next steps are to collect an additional two weeks of data, and initiate another PDSA cycle with a new measure of automated reminders from the QCL system. In achieving our project goals and making it sustainable, we believe that we will be providing high quality, high value patient care, while enhancing the healthiness of the work environment for our staff.
Feasibility of lay cancer patient navigation in an academic medical center on unmet needs of cancer patients.
Authors: Wood William Allen , Sellers Jean B , Shea Thomas C. , Mayer Deborah
Published: April 2017

87

Background: Lay cancer patient navigators (LCPN) are volunteers from the community who assist cancer patients in overcoming barriers to receiving quality cancer care. LCPN can address issues such as. financial burden and psychosocial distress, and can reduce disparities in access to resources. There is little data regarding LCPN within academic medical centers. Methods: In 2013, 24 breast cancer patients at our center were surveyed to determine unmet needs. 82% reported feeling alone and 55% reported lack of awareness about available patient resources. These data supported the development of an LCPN program, in January 2015. Volunteers were provided with comprehensive training that focused on supportive communication, identification of barriers to care, and provision of available cancer resources to address unmet patient needs. Volunteers were integrated within clinical workflows to identify and interact with patients felt to potentially benefit from LCPN. Results: A total of 30 volunteer lay patient navigators were trained between January 2015 – June 2016. Of the 30, 14 elected to staff a weekly disease oriented clinic volunteering 3-4 hours per week. There have been 1,034 patient encounters with 484 encounters in new patients and 550 in repeat patients through June 2016. LCPN completed an encounter form after each patient visit. As a result of these encounters, referrals were provided to the following resources: patient and family resource center (74% ); community resource information (30%); financial counseling (27%); and social work (25%). LCPN report that they feel adequately trained to provide information and meet needs of cancer patients during these visits. Conclusions: We have developed an infrastructure to support an LCPN program within our academic medical center, and have found that this infrastructure facilitates provision of information to cancer patients that addresses their unmet needs. The model is cost-effective and requires few internal resources other than training and ongoing supervision. Future steps will include development of specific interventions to enhance the dissemination of this model throughout North Carolina.
Inpatient 100% mortality review at a NCI Comprehensive Cancer Center Hospital.
Authors: Jain Angela , Pendleton Delinda , Doyle Jamie , Barta Stefan K. , Hallman Mark A , Kloth Dwight D. , Patrick Kenneth , Ridge John A.
Published: April 2017

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Background: Fox Chase Cancer Center set about to identify opportunities to improve care (OIC) for cancer patients dying in the hospital. The team developed and tested a mortality review decision tree and paradigm that helped to identify OICs. Volunteer members of hospital staff representing most domains of patient care comprised the committee. Monthly meetings defined the review process, developed the form, initiated the program and refined the process as experience accumulated. Methods: Forms incorporated information from Temple University Hospital, Comprehensive Cancer Center Consortium for Quality Improvement(C4QI), and measures to be monitored by CMS. Deaths were considered “anticipated” or “unanticipated,” and with or without OIC. Issues in cases with OIC were recorded for each death. Level 1 review was completed by a research student or a member of the risk management team to organize clinical data. A level 2 review was then performed by a member of the committee and deaths were categorized. Level 3 review was undertaken at monthly meetings and action items determined. Results: From March 2014 to December 2015, 246 cases were reviewed. The elements were chosen for the level 1 & 2 review and collating objective data. Whether the patient was treated with curative intent, procedures were definitive or palliative, if chemotherapy, radiation or surgery were delivered, or if there was a complication within the last 2 weeks of life were recorded. Hospitalization features such as institution of palliative care, appropriate advanced directives, code status on admission and at death, and ICU admission were noted. Issues often arose when deaths were expected and predicted at admission. Increased need for inpatient palliative care teams and hospice support have been recognized. Better communication between patients, families, and oncologists should reduce hospitalization for patients whose death is imminent. Conclusions: Submitting 100% of inpatient deaths to formal mortality review discloses opportunities to improve care and allows focus on problems that occurred even when the patient’s death was expected.
A virtual tumor board-driven synaptic knowledge network.
Authors: Heifetz Laurence J. , Koppel Ahrin B. , Kaime Elaine Melissa , Palmer Daphne , Semrad Thomas John , Bervid Cathey , Potter Christina , Goodall Janet , Truscott Ann , Christensen Scott
Published: April 2017

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Background: In 2006, Tahoe Forest Hospital District—a 25-bed hospital in Truckee, CA, a mountain resort community one hour from regional and two hours from academic cancer services—designed and implemented an oncology program utilizing effective telecommunications with a committed academic partner, the UC Davis Comprehensive Cancer Center in Sacramento. Methods: The UC Davis Cancer Care Network was established with four remote cancer programs, enabling participation in daily virtual tumor boards, clinical trial enrollment, and quality assurance assistance. (Richard J. Bold, et. al., Virtual tumor boards: community-university collaboration to improve quality of care. Community Oncol 10(11):310-315, November 2013.; Laurence J. Heifetz, MD, et. al., A Model for Rural Oncology. J Oncol Pract, 7:168-171, May 2011.). An increasing number of patients were observed to in-migrate to Truckee from even more remote rural areas in the mountains. In 2013, the now Gene Upshaw Memorial Tahoe Forest Cancer Center developed four remote telemedicine clinics to allow even more physically distant patients the capacity to be followed locally. Results: Since we opened the remote telemedicine clinics, our Sullivan-Luallin patient satisfaction scores have averaged 4.82/5.00 for “overall satisfaction with the practice” and 4.90/5.00 for “recommending your provider to others”; our in-migration rate of patients from outside our primary catchment area increased from 43% to 52%: and clinical trial accrual rate averaged 10%. Conclusions: Reducing cancer health disparities is an ASCO mission. (cover, ASCO Connection, July 2014; Laurence J. Heifetz, MD. Country Docs with City Technology Can Address Rural Cancer Care Disparities. Oncol, 29(9):641-644, September 2015.). We believe this synaptic knowledge network effectively addresses that mission for rural communities. This model can be scaled in many configurations to address the inherent degradation of quality care as a function of physical distance to an academic center that rural doctors and patients deal with on a daily basis. The key is to insist on a cultural shift – Do something smart at lunch every day. Attend a virtual tumor board.
Identification of Lynch syndrome cohort in a hospital system.
Authors: Salner Andrew L. , Sekerak Richard , Yu Peter Paul
Published: April 2017

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Background: Lynch Syndrome (LS) is a genetically inherited autosomal dominant disease that is the result of germline mutations in mismatch repair (MMR) genes. LS is the most common cause of inherited colorectal cancer (CRC), causes cancer at a younger age, and increases other cancer risk (pancreas, endometrium). Thus, it is important to identify patients who have LS so that patients and affected family members can receive the proper surveillance and care. Hartford HealthCare Cancer Institute (HHCCI) has developed a standard of care to screen patients who may have LS by testing CRC specimens for loss of expression of MMR genes, as well as to refer all patients under 50 for counseling. The aim of this research project is to determine how well each of our healthcare system's five hospitals is meeting the standard. Methods: This retrospective study explored all cases of CRC at each of the five HHCCI hospitals from 2014-2015. Patients were identified from the Cancer Registry and data was extracted from patient charts, pathology and genetics reports. The study analyzed: age, gender, stage, presence of MMR testing, and genetics counseling and testing for MMR positive patients and patients under 50. Results: 423 CRC patients were diagnosed at HHC cancer centers, 45% male, 55% female, average age of 68.2. In total, HHCCI tested 81.3% of patients diagnosed with CRC in 2014-2015, ranging from 30.8 to 94.5% among the hospitals. 7.6% of patients had abnormal MMR results. Of patients with MMR+ results, 57.7% had genetic consult and 10 of the 15 consulted had a germline test. Seven patients (70%) tested positive for LS. Patients with LS were younger (average age 47.6), and the majority were male. Ten of 45 patients under 50 were referred for genetics consult (22%), with a range of 0-67% amongst the hospitals. Three were LS positive on testing. Conclusions: Clinicians on our GI cancer team assumed that the agreed upon standard of MMR testing in CRC and referral of younger patients for genetics counseling would result in 100% compliance. The study outcomes suggest a need for improved implementation strategies for CRC testing at HHCCI hospitals. Overall, the study demonstrates the importance and need of quality improvement measures to inform and improve patient care.
Impact of triggered palliative care consultation approaches on palliative care consult implementation in inpatient oncology.
Authors: Dimartino Lisa , Weiner Bryan J , Hanson Laura C , Weinberger Morris , Birken Sarah , Reeder-Hayes Katherine Elizabeth , Trogdon Justin G
Published: April 2017

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Background: Studies show palliative care (PC) delivered concurrently with cancer treatment improves outcomes, yet integration of PC with inpatient oncology is lacking. A promising approach to improve integration is a triggered palliative care consultation (TPCC), which is primarily based on clinical criteria (e.g. metastatic disease) and may include multiple strategies to support its use. This study evaluated the impact of two TPCC approaches on PC consult implementation (uptake and timeliness) in the solid tumor medical (MED) and gynecologic oncology (GYN) services at an academic medical center. Methods: MED TPCC used multiple strategies (chart review to identify eligible patients, training, clinician prompting); GYN TPCC used a single strategy (written guideline of clinical criteria for initiating a consult). PC consult information was obtained from medical charts and linked to all hospital encounter data for MED and GYN. The timeframe was 2010-2016 with TPCC onset in 2014 (GYN) and 2015 (MED). We compared PC consult implementation in GYN (single strategy) vs no strategy and MED (multiple strategies) vs GYN (single strategy). Difference-in-differences and modified Poisson regression was used to evaluate whether PC consult implementation differed after initiating strategies, adjusting for patient demographic and clinical characteristics. Results: Our sample included 5,873 MED and 3,889 GYN hospitalizations. Overall 8.8% of MED and 11.0% of GYN hospitalizations involved a PC consult. In regression analyses, use of a single strategy was associated with increased PC consult uptake vs no strategy (aRR: 1.45, p < .05), while use of multiple strategies was associated with increased PC consult uptake vs use of a single strategy (aRR: 2.34, p < .001). Across all comparisons, the strategies did not significantly impact PC consult timeliness. Conclusions: This study compared PC consult implementation across two inpatient oncology services and found a TPCC approach supported by multiple strategies had the greatest impact on uptake. Questions remain regarding which TPCC approach can most effectively achieve sustainability of uptake and PC consult timeliness in inpatient settings.
Effect of cancer nurse navigators (CNN) on physician engagement in multidisciplinary discussions prior to head and neck cancer treatment.
Authors: Werner Valerie , Barry-Weers Anne , Weese James Leighton , Corsten Martin
Published: April 2017

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Background: Aurora Health Care, a 15 hospital integrated system has recognized a multidisciplinary approach is the best practice for treatment of head and neck (H&N) cancers. We tested whether CNNs and system wide high definition video conferencing facilitates multidisciplinary collaboration in the treatment of H&N cancers. Methods: Baseline data identified the percent of newly diagnosed H&N cancer cases with prospective multidisciplinary discussion prior to initiation of treatment (Phase I). Then, performance improvement initiatives were identified to increase the percent of patients discussed during a multidisciplinary conference (MDC). The initiatives included: weekly review of all H&N cancer cases by a lead CNN found by Cancer Registry through EPATH; electronic communication from the CNN requesting physician presentation of their patients at the MDC; engagement of site-specific CNNs to schedule their provider’s patients for the MDC; collaboration with cancer registrars to place their site-specific patients with H&N cancer on their local or system MDC case list; follow-up with providers on patients not presented at MDC; and timely feedback (< 24 hours) to referring providers on recommendations for patients presented at MDC . After implementation of performance improvement initiatives, comparison data was obtained (Phase II) and analyzed utilizing a chi square test. Results: From January through September 2015 (Phase I) and October 2015 through June 2016 (Phase II), 75 and 102 H&N cancer cases were reviewed, respectively. A significant rise (p=0.005) in the percentage of patients being presented at an MDC occurred between phases I (77%, N=75) and II (93%, N=102). Conclusions: Through a coordinated process by CNNs, providers engaged in multidisciplinary discussions prior to the initiation of treatment. This increased engagement, changed practice patterns with patient assessment, aligned the institution with best practice guidelines and aided in therapy selection for the best possible patient outcomes.
Identifying genes for neurobehavioural traits in rodents: progress and pitfalls
Authors: Baud Amelie , Flint Jonathan
Published: April 2017

Identifying genes and pathways that contribute to differences in neurobehavioural traits is a key goal in psychiatric research. Despite considerable success in identifying quantitative trait loci (QTLs) associated with behaviour in laboratory rodents, pinpointing the causal variants and genes is more challenging. For a long time, the main obstacle was the size of QTLs, which could encompass tens if not hundreds of genes. However, recent studies have exploited mouse and rat resources that allow mapping of phenotypes to narrow intervals, encompassing only a few genes. Here, we review these studies, showcase the rodent resources they have used and highlight the insights into neurobehavioural traits provided to date. We discuss what we see as the biggest challenge in the field – translating QTLs into biological knowledge by experimentally validating and functionally characterizing candidate genes – and propose that the CRISPR/Cas genome-editing system holds the key to overcoming this obstacle. Finally, we challenge traditional views on inbred versus outbred resources in the light of recent resource and technology developments.
Algorithms for Generalized Clusterwise Linear Regression
Authors: Park Young Woong , Jiang Yan , Klabjan Diego , Williams Loren
Published: April 2017

Clusterwise linear regression (CLR), a clustering problem intertwined with regression, finds clusters of entities such that the overall sum of squared errors from regressions performed over these clusters is minimized, where each cluster may have different variances. We generalize the CLR problem by allowing each entity to have more than one observation and refer to this as generalized CLR. We propose an exact mathematical programming-based approach relying on column generation, a column generation–based heuristic algorithm that clusters predefined groups of entities, a metaheuristic genetic algorithm with adapted Lloyd’s algorithm for K-means clustering, a two-stage approach, and a modified algorithm of Späth [Späth (1979) Algorithm 39 clusterwise linear regression. Comput. 22(4):367–373] for solving generalized CLR. We examine the performance of our algorithms on a stock-keeping unit (SKU)-clustering problem employed in forecasting halo and cannibalization effects in promotions using real-world retail data from a large supermarket chain. In the SKU clustering problem, the retailer needs to cluster SKUs based on their seasonal effects in response to promotions. The seasonal effects result from regressions with predictors being promotion mechanisms and seasonal dummies performed over clusters generated. We compare the performance of all proposed algorithms for the SKU problem with real-world and synthetic data.

The online supplement is available at https://doi.org/10.1287/ijoc.2016.0729 .
When Waiting to See a Doctor Is Less Irritating: Understanding Patient Preferences and Choice Behavior in Appointment Scheduling
Authors: Liu Nan , Finkelstein Stacey R. , Kruk Margaret E. , Rosenthal David
Published: April 2017

This paper examines patient preferences and choice behavior in scheduling medical appointments. We conduct four discrete choice experiments on two distinct populations and identify several “operational” attributes (e.g., delay to care and choice of doctor) that affect patient choice. We observe an interesting gender effect with respect to how patients trade off speed (delay to care) and quality (doctor of choice), and demonstrate that risk attitudes mediate the impact of gender on the perception of speed and quality. Specifically, females (versus males) are more averse to not seeing their own doctor, and, when delay to care is relatively long, females perceive greater utility loss than males. As many operational strategies in outpatient care aim to improve the patient experience by making trade-offs between speed and quality, we make suggestions for when managers should intervene to improve their practice and how such interventions might look based on the patient mix and current delay level.

The online appendix is available at https://doi.org/10.1287/mnsc.2016.2704 .

This paper was accepted by Gad Allon, operations management.