bluuebunny/crossref_metadata_2025 huggingface dataset:
Network wide national and international radiation oncology accreditation program.
Authors: Kennedy Andrew S. , Wotring Tammy , Liu Zejian , Burris Howard A. , LeMaistre Charles F.
Published: February 2017

271

Background: Modern radiation oncology departments contain an extensive array of complex therapies and technologies. Adoption of new treatments and staff changes challenge each team in maintaining high levels of performance and standards. Fewer than 15% of US centers have independent certification of quality. We plan to achieve American College of Radiology (ACR) Accreditation for all USA and UK Radiation Oncology Centers of HCA. Methods: A GAP analysis tool was developed to enable each center to approach the ACR application with the coordinated and simultaneous efforts of all sections of the radiation oncology department. Data was prospectively gathered for each department, highlighting areas of strength and aspects that need focused attention to improve. A scale of 1-5 was assigned to each task regarding the initial and ongoing level of progress towards meeting the standard with documentation for each required. Our intent is for each of the 52 radiation oncology departments to achieve full ACR Accreditation in a timeframe of no more than 4.5 months from start of the GAP analysis. Results: One program was fully accredited when the program began in July 2013. Since then 6 have achieved full accreditation and 12 are in process with the GAP tool. Analyses of full GAP data are available from eight programs thus far. High achievement in compliance with ACR Standards (95-100% compliance) was found in policies monitoring complications, adverse reactions and ‘time out’ procedures. Areas needing improvement s (<80% compliance) included annual review of policies and procedures, physician peer review, formal treatment planning system QA and imaging equipment quality control. Our facility in London will be the first achieving ACR accreditation in the UK. Conclusions: Significant time savings, engagement of staff, and accreditation success has thus far been realized with the utilization of a GAP tool for radiation oncology program accreditation. Common deficiencies were identified across facilities and allowed sharing of successful corrective action plans. The success of the program in improving quality led to the adoption of the ACR program from our USA sites to our radiation oncology departments in the UK.
Policy and procedure manuals: Does existence imply standardization in practice?
Authors: Kapur Ajay , Barbee David , Cao Yijan , Jamshidi Abolghassem , Potters Louis
Published: February 2017

275

Background: Patient safety organizations recommend the use of policy and procedure manuals (PPM) to effectuate standards and guidelines in practice. In this work we explored inter-physicist variability in the interpretation of five established physics policies amongst physicists in our department. Methods: The policies for treatment planning, 2nd physics checks, 1st day physics checks, weekly chart checks and final physics checks were reviewed by members of the quality management team in our department. Specific definitive statements were extracted into a spreadsheet and provided to 11 physicists and 6 dosimetrists. The intent was to obtain individual responses on adherence to the statements and thereby assess the level of standardization in perception and practice amongst the staff using free-margin kappa statistics. The responses were limited to affirmation, rejection or non-applicability. A total of 732 responses were assessed. Results: Based on the Landis-and-Koch criteria for interpretation of kappa values, the consistency amongst the respondents varied from moderate (0.40-0.60) to good (0.60-0.80). The kappa scores for the statements assessed were 0.56 for treatment planning, 0.64 for second physics check, 0.70 for the first day physics check, 0.54 for the weekly physics check and 0.73 for the final physics check. Conclusions: Validating the effectiveness of PPMs by measuring uniformity in staff interpretation is an important step in establishing their effectiveness. Mere existence of a PPM may not be sufficient. This work demonstrated reasonable uniformity of interpretation of existing policies, but underscored the need for further improvement. The review of specific policy statements with weaker consensus may lead to more effective revisions and in-servicing to enhance clarity and reduce ambiguity, re-testable using the same approach. Absence of validation will tend to retain ambiguity, thereby rendering the policy not as effective as it could be.
Hepatocellular carcinoma and end-of-life care.
Authors: Hunter Natasha , Potosek Jamie Erin , Miksad Rebecca A.
Published: February 2017

278

Background: Patients with hepatocellular carcinoma (HCC) usually present with incurable tumors and advanced underlying liver disease. Although guidelines exist to assess the quality of end of life (EOL) care for cancer patients, little is known about EOL care for HCC patients. Due to the complexity and multidisciplinary nature of the disease, we hypothesized that EOL care for HCC patients differs from that delivered to other cancer patients and may be heterogenous based on patient characteristics and primary clinician specialty. Methods: We assessed EOL HCC care through medical chart review of 188 consecutive HCC patients treated at an academic tertiary care hospital who died between 2007 and 2013. Based on available data, EOL care and documentation was assessed per published guidelines. Patient, HCC and liver disease characteristics, cancer treatments, symptom burden, and EOL care and documentation was compared by provider specialty. The odds of receiving aggressive EOL care by provider specialty, patient characteristics, and documentation measures were calculated. Using data from the Dartmouth Atlas Project, we compared results with EOL data for cancer patients overall at our institution and nationally during a similar time frame. Results: Fewer HCC patients enrolled in hospice compared with cancer patients overall at our institution, and nationally (36%, 49% and 55%, respectively). In addition, HCC patients spent fewer days on hospice, spent more time in the hospital, and experienced more (and longer) intensive care unit admissions. Compared to those primarily cared for by other specialties, HCC patients seen by an oncologist were more likely to have goals of care (GOC) documentation and to enroll in hospice. Patients never seen by an oncologist were more likely to have a psychiatric illness. English as a non-primary language and code status documentation were among factors associated with more aggressive EOL care. Conclusions: At our institution, EOL care for HCC patients is more aggressive compared to cancer patients overall and nationally. The subset of HCC patients seen by oncology were more likely to meet EOL quality guidelines (GOC documentation and hospice enrollment). A better understanding of EOL practices for HCC may impact multidisciplinary care.
Variation in adherence to QOPI core measures based on tumor type.
Authors: Patel Sunil M. , Sarma Amit , Ip Mee-chung Puscilla , Sturdevant Laurie , Kian Leslie , Schaub Diane , Theriault Rachel Leigh , Nelson Douglas A. , Jasani Nikesh Ramesh , Fisch Michael
Published: February 2017

280

Background: QOPI measures fall into one of three categories: (1) core, (2) disease-specific (breast, colon, lung, non-Hodgkin lymphoma, gynecologic cancers), or (3) domain-specific (symptom control, end-of-life). For each data collection period (DCP), participating sites choose to submit data in at least one disease- or domain-specific module. Charts are identified and abstracted for the selected module(s) based on eligibility criteria. The same charts are also abstracted for core measures. Our group hypothesized that the case mix resulting from choice of module(s) would impact performance for a subset of core measures. Methods: The MD Anderson Regional Care Centers have participated in QOPI over nine DCPs from Fall 2009 to Spring 2014. Unexplained variation was identified in staging documentation (core measure 2) and chemotherapy intent documentation (core measure 10). For each DCP, QOPI chart-level data were reviewed. Adherence for each measure was tabulated and stratified by tumor type. Due to small sample sizes within each DCP, data were pooled and analyzed with descriptive statistics and chi-square testing. Results: Over nine DCPs, stage and chemotherapy intent were documented in 89.1% and 81.3% of charts, respectively. There was a significant association between tumor type and documentation of stage (χ2(4) = 30.4, N=727, p <.001) and chemotherapy intent (χ2(4) = 157.5, N=534, p <.001). Documentation of stage and chemotherapy intent was highest for breast (100%, 93.6%) and colorectal cancers (92.7%, 92.1%) and lowest for NHL (71.8% 32.8%). Conclusions: Observed variation in documentation of stage and chemotherapy intent was primarily due to tumor type. Reasons for this observation are myriad and likely include factors related to the providers, the practice, the measures, and differing complexity of tumor types. This variation in quality scores by tumor type (driven by module selection) could have significant implications in today’s pay for performance environment. [Table: see text]
Association between certificate of need (CON) legislation and radiotherapy use among elderly patients with early cancers: A population-based examination.
Authors: Falchook Aaron David , Chen Ronald C.
Published: February 2017

283

Background: High quality cancer care includes reducing overtreatment, a well-recognized problem for elderly patients with ductal carcinoma in situ (Stage 0) or Stage 1 breast cancer and low-risk prostate cancer. The federal Health Planning Resources Development Act of 1974 led to implementation of CON programs in multiple states. The stated purpose of CON is to facilitate coordinated health care services to reduce overall medical costs. We examined whether CON is associated with less radiotherapy (RT) use in elderly patients with Stage 0-1 breast cancer, and low-risk prostate cancer. Methods: We compared RT use in 6 Surveillance, Epidemiology and End Results (SEER) states with CON for radiotherapy vs. 6 states without CON for 1) men 65 years and older with low-risk prostate cancer, 2) women 70 years and older with Stage 0-1 breast cancer after lumpectomy. In both clinical scenarios, the use of RT is controversial. Patients diagnosed from 2004-2011 were included. Results: 40,267 men and 24,385 women were included. Radiotherapy use was higher in CON states: prostate cancer (64.3 vs. 56.0%, p<.001), and breast cancer (59.5% vs. 53.6%, p<.001) overall, and for each year studied (Table). RT use decreased from 2004 to 2011, but remains persistently higher in states with CON programs. On multivariate analysis controlling for age, race, stage and year, CON was associated with higher use in both prostate cancer (OR 1.46, p<.001) and breast cancer (OR 1.35, p<.001). Conclusions: There is more RT use in CON states for elderly patients who may not need this treatment for Stage 0-1 breast cancer and low-risk prostate cancer. This suggests that CON programs may not be effective in reducing overtreatment, an important quality of care issue in oncology. [Table: see text]
Effectiveness of cisplatin versus carboplatin-based doublet chemotherapy in elderly Medicare patients with advanced non-small cell lung cancer.
Authors: Lamont Elizabeth B. , Keating Nancy Lynn , Azzoli Christopher G. , Landrum Mary Beth
Published: February 2017

284

Background: There is some evidence that cisplatin-based chemotherapy doublet regimens are more efficacious than the less toxic carboplatin-based doublet regimens for advanced non-small cell lung cancer (NSCLC) but little evidence of effectiveness in elderly cancer patients treated in the usual care setting. We estimated differences in survival and post-treatment morbidity between first-line cisplatin-based and carboplatin-based doublet regimens in elderly Medicare patients with advanced NSCLC. Methods: We identified 13,406 elderly Medicare patients who were diagnosed with stage IV NSCLC between 1995-2009 in SEER regions and treated with either a cisplatin-based doublet chemotherapy regimen or a carboplatin-based doublet chemotherapy regimen in the subsequent six months. Using propensity score weighting, we balanced the two treatment cohorts with respect to observable attributes. We then estimated survival and toxicity according to treatment. Results: Overall patients treated with cisplatin-based doublets lived nearly two weeks longer on average than patients treated with carboplatin-based doublets (i.e., 7.4 months vs. 7.0 months, p=0.05) survival differences were not appreciated in subsets of patients with adenocarcinoma or squamous carcinoma. Patients treated with cisplatin-based doublets were slightly more likely than those patients treated with carboplatin-based doublets to be hospitalized (i.e., 42.9% vs 39.8%, p<0.01) and use intensive hospital-based care. Conclusions: Among elderly Medicare patients with advanced NSCLC, those treated with first line cisplatin-based doublet chemotherapy regimens lived slightly longer than those treated with carboplatin-based doublet regimens, but also utilized more hospital-based care following treatment. The difference in overall survival is not clinically significant, and does not appear to justify the added toxicity.
Understanding the impact of settings of care and the development of chemotherapy-induced nausea and vomiting within a population of commercially insured patients.
Authors: Inocencio Timothy J , Faria Claudio , Knoth Russell L. , Chapman Richard H. , Agatep Barnabie C , Johnsrud Michael , Powers Annette
Published: February 2017

298

Background: Research evaluating the impact of different clinical practice patterns according to settings of care and oncology patient outcomes is limited. This study describes chemotherapy-induced nausea and vomiting (CINV) rates in chemotherapy (CT) naïve cancer patients starting CT in a hospital outpatient (HOP) or community outpatient (COP) setting. Methods: Using the Optum Normative Health Information Database, patients with a new claim of CT and ≥1 outpatient cancer diagnosis claim between 1/1/06 – 6/30/12 were identified. Patients with previous inpatient cancer diagnoses, multi-day CT regimens or Medicare/Medicaid patients were excluded. CINV was defined using relevant claims-based ICD-9-CM diagnosis and procedure codes or a prescription claim for antiemetics within days 2-7 of 1st 8 CT cycles or 1st 6 months following the index CT claim. CINV events were evaluated descriptively and using regression models Results: Patients receiving CT in HOP vs. COP were similar in age. Patients receiving CT in COP vs. HOP setting were more likely to be female (78.7% vs. 62.8%), breast cancer patients (66.8% vs. 46.7%), live in the South region (49.7% vs. 44.1%) and have higher baseline healthcare costs (mean $24,950 vs. $24,629) (all p<0.05). Patients in the HOP vs. COP settings had higher Charlson Comorbidity Index scores (mean 3.9 vs. 3.3, p < 0.05). More CINV events were reported for patients in COP vs. those in HOP settings (p < 0.05) (Table). After adjusting for clinical and demographic factors, number of CINV events remained higher for COP vs. HOP settings. However, we were unable to control for antiemetic prophylaxis use or CT emetogenic potential, due to coding irregularities. Conclusions: Results suggest cancer patients starting CT in COP vs. HOP settings may have more CINV events. However, further analyses are needed to explore the impact of antiemetic prophylaxis use or CT emetogenic potential on CINV events between settings of care. [Table: see text]
Evaluate algorithms for identifying treatment patterns for patients with metastatic colorectal cancer using administrative claims data.
Authors: Zhong Yue , Kamalakar Rajesh , Asche Carl V , Anderson Sibyl , Seal Brian S.
Published: February 2017

299

Background: Administrative claims data are widely used to identify treatment patterns. However, as new drugs are brought to clinical practice, treatment regimens become more complicated for cancer patients receiving both chemotherapy and biologic agents. We evaluated the influence of using different treatment length algorithms on identification of treatment patterns for patients with metastatic colorectal cancer (mCRC). Methods: We identified patients aged 18 or older with at least one primary CRC diagnosis between 01/01/2008 and 03/31/2012 in the MarketScan databases. mCRC patients were included if claims indicated the presence of distant metastases (ICD-9-CM codes: 196.x, 197.0 to 197.4, 197.6 to 197.8, 198.x, and 199.0). All treatment claims were extracted and patients were followed for more than 6 months, until end of enrollment or study end date (03/01/2013). We identified all chemotherapy and/or biologic drugs given to a patient during 30, 60, or 90 days after initiation of treatment and compared differences in type and number of treatment lines (TLs). Results: A total of 2,046 mCRC patients received at least one TL. Using a 30-day cutoff period, 30% patients received 1 TL; 30% received 2 TLs; and 40% received ≥3 TLs. Results changed after using a 60-day cutoff period: 39% patients with 1 TL, 33% with 2 TLs, and 28% with ≥3 TLs. If using 90 days as a cutoff period, 44% received 1 TL; 35% received 2 TLs; and 22% received ≥3 TLs. For all cutoff periods, the most common first TL prescribed were FOLFOX +/- bevacizumab and 5-FU/LV. For patients receiving a second TL, FOLFOX was most frequently prescribed if using a 30-day or 60-day cutoff, while FOLFIRI/bevacizumab had a higher prescription rate with a 90-day cutoff. Regimens varied in third and fourth-line therapy using different cutoff periods and FOLFIRI +/- bevacizumab was more frequently used than other regimens. Conclusions: The cutoff period did not significantly influence treatment regimens detected for first and second TL. Using a 30-day cutoff period resulted in 30% patients with one TL and 40% with three or more TLs, while with a 90-day cutoff, 44% patients received one TL and only 22% received three or more TLs.
Performance of a low-dose computed tomography (LDCT) lung cancer screening program: Findings from a registry study.
Authors: Goulart Bernardo , Madtes David , Koepl Lisel , Karnopp Andrew , Nelson Judy Ann , Ramsey Scott David
Published: February 2017

304

Background: Many centers are establishing LDCT lung cancer screening programs after the 2013 grade B recommendation from the United States Preventive Services Task Force (USPSTF). Uncertainty remains regarding the extent to which new programs will adhere to recommended selection criteria, as well as screening program performance. We analyzed adherence to selection criteria, rate of positive screens, and prevalence of incidental findings in a single-center LDCT screening registry study. Methods: We established a prospective, longitudinal registry study of patients undergoing LDCT screening at the Seattle Cancer Care Alliance. Baseline data include socio-demographic characteristics and eligibility for LDCT screening. We conduct chart reviews at 6 and 12 months to determine screening results (based on NLST definitions); lung cancer diagnosis; and incidental findings. Results: From August 2012 to April 2014, 62 out of 105 (59%) screened patients enrolled in the registry. Mean age is 62 years; 38 (61%) are male; 52 (84%) are white; mean household income is $97,363; 31 (50%) are current smokers; and 39 (63%) have a smoking history ≥ 30 pack-years. A total of 28 (45%), 31 (50%), and 31 (50%) of patients were eligible for screening based on criteria used in the NLST or recommended by the NCCN or USPSTF guidelines, respectively. Sixteen patients (26%) were not eligible for screening based on any of these criteria. For fourteen (88%) of these patients, LDCT screening was ordered by a primary care provider as opposed to a lung cancer specialist. Initial screening results were positive in 7 (13%) patients, with 1 patient diagnosed with lung cancer. At least one incidental finding was reported in 40 (74%) patients, including cardiac and pulmonary abnormalities in 28 (70%) and 25 (63%) patients. Conclusions: About one quarter of patients undergoing LDCT screening do not meet recommended criteria, with primary care providers most commonly ordering the LDCT screen for these patients. Primary care provider education may improve adherence to screening guidelines. Incidental findings were more frequently reported than in the NLST; their impact on healthcare outcomes and costs deserves further investigation.
Chemotherapy use in the treatment of glioblastoma multiforme: Comparing patient characteristics using the National Cancer Data Base (NCDB).
Authors: Inserra Christopher J. , Khanal Nabin , Silberstein Peter T.
Published: February 2017

305

Background: Glioblastoma Multiforme (GBM) is the most common and most deadly type of human glioma. Nearly half of all gliomas are diagnosed as GBM at which point the median survival of patients is approximately one year and the two-year survival rates are approximately 10%. Current treatment options for GBM include surgical resection, external beam radiation, and oral temozolomide chemotherapy. However, the patterns of chemotherapy use in GBM as well as the patient characteristics that determine its use have yet to be investigated. Methods: This is a retrospective study of glioblastoma patients (n = 96,966, making this the largest trial ever on glioblastoma) diagnosed between 2000 and 2011 in the NCDB. The NCDB contains nearly 70% of new cancer cases diagnosed in the United States and consists of data from over 1,500 cancer programs across the country. A chi-squared test was used to determine any differences in the characteristics of patients who did or did not receive chemotherapy. Results: Patients who were younger than 70 years of age, male, white, had private/managed insurance, no comorbidities, household income greater than $49,000, were receiving radiation therapy, and diagnosed between 2004 and 2011 were significantly more likely to have received chemotherapy to treat glioblastoma (see Table). Conclusions: Understanding any potential barriers in the use of chemotherapy to treat glioblastoma can help improve its utilization among people of diverse socioeconomic backgrounds. [Table: see text]
Outcomes in stage I non-small cell lung cancer following the introduction of stereotactic body radiotherapy in Alberta, Canada.
Authors: Kerba Marc , Gabos Zsolt , Ghosh Sunita , Liu Hongwei , Lau Harold Y. , Roberts Barbara
Published: February 2017

306

Background: Stereotactic body radiotherapy (SBRT) is a treatment option for patients with Stage I (T1-T2N0M0) NSCLC (non-small cell lung cancer) who decline surgery or are medically inoperable. Case series suggest superior outcomes with lung SBRT compared to conventional radiotherapy and high local control rates. The primary study objective was to describe population outcomes in the initial management of stage 1 NSCLC patients including treatment utilization rates and survival. Methods: Clinical records of patients diagnosed with Stage 1 NSCLC who attended any SBRT clinic in Alberta between 2005 and 2011 were examined with REB approval. These cases were linked to the Alberta Cancer Registry and Provincial Health Administration databases. Clinical, treatment, pre-diagnosis 3M Aggregate Clinical Risk Grouping (ACRG3) scores as a proxy for prevailing patient comorbidity and health services characteristics pertaining to all cases of stage 1 NSCLC between 2005 and 2011 were determined. A cox regression model was constructed to examine the influence of these factors and their interactions on cancer outcomes. Results: 2,146 patients were diagnosed with stage 1 NSCLC. Median patient age was 72 and overall 43.0% of cases had a 1 year pre-treatment ACRG3 score of 10-49. Observed treatment utilization rates; surgery 63.4% (95%CI: 61.4-65.4), conventional RT 9.0% (7.9-10.3%), SBRT 3.6% (2.8-4.4%), chemotherapy 0.8% (0.5-1.4%) and no treatment 23.2% (21.4-25.0%). Median survival ranged from 69.6 months for surgery to 17.0 months if no active treatment was delivered. SBRT had survival outcomes superior to conventional radiotherapy: median survival of 39.4 vs. 23.5 months (p<0.001), despite more patients 69.9% vs 63.0% having an ACRG3-1y of 50 or higher. On multivariate analysis, while accounting for all modeled variables including ACRG3 pre-treatment and compared to patients receiving no active treatment, primary surgical intervention HR= 0.23 (95%C.I.:0.18-0.28) and SBRT HR=0.33 (0.21-0.51) remained most strongly associated with survival.No significant variable interactions (p<0.05) between treatment modality, patient age, pathology diagnosis and ACRG3 scores were demonstrated to impact on survival outcomes. Conclusions: Surgery for Stage I NSCLC patients is associated with the best overall survival. SBRT patients have improved survival over conventional radiotherapy. Improvements in population level outcomes may result from an increased utilization of SBRT in the non-surgical management of stage I lung cancer.
Surveillance imaging following colon cancer resection: Universal or risk-based?
Authors: Bailey Christina Edwards , Hu Chung-Yuan , Cuddy Amanda , You Y. Nancy , Chang George J.
Published: February 2017

307

Background: Current colon cancer surveillance guidelines recommend annual imaging for all patients following curative resection. The primary aim of this study is to evaluate variation in surveillance practices following colon cancer resection. Methods: A retrospective cohort study of patients ≥ 66 years old with stage I-III colon cancer that underwent surgical resection in the Surveillance, Epidemiology, and End Results-Medicare linked database (July 2001 through December 2007) with at least 3 years of follow-up was performed. Medicare claims for PET and CT scan of the chest, abdomen and pelvis performed after surgical resection were recorded and analyzed. In order to evaluate the use of definitive treatment (DT) for presumed recurrent disease, we identified patients who had undergone lung, liver, or colorectal resection during follow-up. Results: Of 22,544 patients who underwent primary resection of colon cancer, 13,753 (61.0%) underwent PET and/or CT after resection and 1,109 (4.52%) underwent at least 1 DT. The mean number of imaging performed for patients who did not undergo DT was 1.68. Within this group, the utilization of PET and/or CT varied by stage, with 14.1%, 22.4%, and 42.2% of patients with stage I, II, and III disease undergoing imaging, respectively. The most significant factor associated with PET and/or CT was tumor stage with an odds ratio of 1.86 (95% CI 1.70-2.02, P<0.001) for stage II disease and 4.56 (95% CI 4.17-4.99, P<0.001) for stage III disease compared to stage I disease. Additional factors significantly associated with PET and/or CT included year of diagnosis and SEER region. Among patients who did undergo DT, the mean number of PET and/or CT performed was 5.37 but the majority of imaging studies were performed 4 months prior to DT (mean 2.95). Conclusions: There is a high degree of variation in the use of surveillance imaging among elderly patients with localized colon cancer although some of this variation appears to be associated with stage at presentation. Our findings highlight discordance between clinical practice and surveillance guidelines. Further study is needed to understand the basis and appropriateness of clinical decision making that departs from guideline-based care.
Making the case for outpatient palliative care for cancer patients at a safety-net hospital.
Authors: Harris Heather A. , Kinderman Anne , Kerr Kathleen
Published: February 2017

310

Background: Prior research has shown that patients who receive earlier, outpatient palliative care (OP PC) have improved end-of-life care compared to patients who receive only inpatient palliative care (IP PC). We examined the need, expected impact and feasibility of providing OP PC to patients with cancer seen at our hospital, which offers IP PC but not OP PC. Methods: Retrospective cohort study of patients cared for at our urban, safety-net hospital who died of cancer between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns, contacts with our IP PC service, and cost of care in the final 6 months of life. Results: In the analysis period 403 patients died of cancer, 307 of whom were admitted to the hospital in the 6 months preceding death. On average patients were admitted 1.9 times, with 39% having multiple admissions. Average length of stay was 10.47 days. Nearly half of all patients were admitted to the hospital in the final month of life (181/403), and 21% of those (38/181) had multiple admissions. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. The IP PC service had contact with 178 patients; 44% of the entire decedent population and 58% of those who were hospitalized. In 60% of cases the initial contact with the PC team took place in the final month of life. We determined that 33% of patients had multiple inpatient and or outpatient encounters 90-180 days prior to death, pointing to an expected annual clinic volume of about 50 patients. Annual costs for staffing a clinic that could follow 50 patients for an average of 4 months were estimated at $88,290. We assumed that providing OP PC would reduce utilization of inpatient services by 40% (38 avoided admissions), with resulting avoided direct costs of $846,450. Conclusions: At our facility cancer patients often receive aggressive EOL care. Our IP PC team sees many of these patients, but most contacts occur days-weeks prior to death. Though many patients present very late in the course of illness, a substantial number have multiple health system contacts >3 months prior to death, and could be referred to an OP PC clinic.
Examining the use of PET scans in the diagnosis and management of non-small cell lung cancer patients.
Authors: Louzado Cheryl , DeCaria Kristen , Hernandez Jose , Rahal Rami , Niu Jin , Lockwood Gina , Bryant Heather E.
Published: February 2017

311

Background: PET Scans are increasingly used in the diagnosis and management of non-small cell lung cancer (NSCLC) patients. However, uptake of PET at provincial level is not well studied. This project, led by the Canadian Partnership Against Cancer, established processes and indicators to describe utilization of PET in patients with NSCLC. These indicators support the monitoring of uptake and highlight areas for quality improvement strategies at the national and provincial level. Methods: Cases of NSCLC, diagnosed in the study period of 2009-2011, were identified from cancer registries and linked to PET utilization data. PET scans were identified as indicated for diagnosis/staging or treatment response, based on the timing of scans relative to diagnosis and treatment dates. Scans conducted three months prior to and up to four months post-diagnosis but before start of treatment (surgery or radiation) were identified as diagnosis/staging. Scans conducted after the start of treatment to ten weeks post-treatment were identified as management and follow-up of treatment. Results: A total of 27,984 cases of NSCLC were identified. Preliminary analysis revealed that 8,947 (32.0%) of NSCLC patients had at least one PET scan. Some variation was seen in age, with those 18 to 69 years more likely to receive a scan than those 70 years and older. PET scan use was higher among stages I and II (52.3% to 50.6%) compared to stage IV (17.98%). A majority of PET scans were performed for diagnosing/staging NSCLC (91.1%). PET scans for diagnosis/staging were highest for patients with stage I (36.7%) followed by stage IV (24.6%). Conclusions: This study provided information on the current use of PET technology across Canada, allowing for identification of opportunities for increasing evidence-based use while decreasing extra-evidential use, and forming a baseline for future monitoring as evidence evolves.
Overutilization of IMRT/IGRT in treatment of rectal cancer: Cost implications of deviation from evidence-based practices.
Authors: Curry Heather A , Forastiere Arlene A. , Flood William A. , Whyler Elaine , Plastaras John Peter , Vapiwala Neha
Published: February 2017

34

Background: Current evidence-based guidelines for management of rectal cancer (RC) caution against routine use of IMRT and do not address the role of IGRT. To explore patterns of care and cost implications for treatment of RC in commercially insured patients, we assessed treatment requests submitted for preauthorization through eviti Connect. Methods: A proprietary web-based application enables oncology providers to obtain automated precertification for patients insured by payers across the US that use the platform. All requests for pelvic radiation for treatment of RC submitted from 6/1/11-5/31/14 were reviewed. Treatment delivery costs for 3D CRT + weekly port films and for IMRT + IGRT were calculated based on average reimbursement rates from 3 payers for a typical course of 50.4 Gy/28 fractions. Results: A total of 195 cases for treatment of RC were submitted. At submission, 50.3% (98/195) of cases met evidence based standards and received automated preauthorization; 49.7% required treatment justification. Ninety-eight percent of deviations involved use of IMRT and/or IGRT. Upon review, 34.9% (68/195) had a medical rationale for the variance. Justification for IMRT/IGRT use included treatment volumes comparable to anal cancer, inadequate bowel displacement by routine techniques, and obesity. Fifteen percent (29/195) contained unwarranted deviations. In 23/29 cases peer to peer discussion resulted in the provider altering the plan to be compliant. Providers did not agree to changes in the other 6 cases. Cost for a course of 3D CRT + weekly port films was $6,591 vs. $32,292 for IMRT + daily IGRT. For these 195 cases, the estimated cost of overutilization of IMRT/IGRT was $745,000 ($25,700 X 29). Conclusions: Despite lack of endorsement by consensus group guidelines, IMRT and IGRT were prescribed for treatment of RC in nearly 50% of cases. Case review and peer to peer discussion clarified the rationale for treatment deviations from guidelines and allowed providers to bring plans into compliance with evidence based practices, reducing inappropriate use of IMRT/IGRT from 15% to 3%. Reduction in unwarranted use of high cost technologies can improve quality and yield significant cost savings.
Treatment, mortality, and health care costs in a U.S. cohort of indolent non-Hodgkin lymphoma patients with relapsed or refractory disease.
Authors: Meyer Nicole , Song Xue , Gregory Stephanie A. , Ramsey Scott David
Published: February 2017

35

Background: Indolent non-Hodgkin lymphomas (iNHL) have relapsing courses after initial therapy. For those who relapse, the response duration to subsequent lines of therapy shortens with time, eventually becoming refractory. Using a large national claims database, this study examined the treatment, mortality and healthcare costs of iNHL patients who relapse after initial therapy. Methods: Patients newly diagnosed with iNHL (i.e., follicular lymphoma, small lymphocytic lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma) during 2004-2013 were identified from the Truven Health MarketScan Commercial and Medicare claims databases. Relapsed or refractory disease (R/R) was defined as those patients relapsing/not responding within 6 months on any combination of alkylating agents (AA) and rituximab (R) as evidenced by having claims indicating a change in treatment. Patients were followed from the start of the new treatment (index date) until death or end of data. Healthcare costs were adjusted to 2013 dollars. Results: Among a total of 254,067 iNHL patients, 1,483 (1.4%) met study criteria for R/R. The average age was 63 (SD 13) and 61% were male. Common comorbidities were: lipometabolic disorders (44%), hypertension (40%), diabetes mellitus (17%), chronic pulmonary disease (15%), cerebrovascular disease (7%) and renal disease (6%). The most common first line regimens were rituximab, cyclophosphamide, doxorubicin and vincristine ± prednisone/ dexamethasone (22%). The mean duration of first-line and second-line therapy was 230 (SD 401) and 369 (SD 544) days, respectively. Among the 45% patients with mortality information, the median survival time from R/R was 5.3 months (mean 16.4, SD 17.7). During the follow up period from the initial date of R/R, the mean annual total medical cost was $170,179 (SD $250,376): 62% outpatient, 34% inpatient and 4% outpatient pharmacy. Conclusions: Patients with R/R iNHL represented a relatively small fraction of all iNHL patients, but had high mortality rate and incurred substantial medical cost.
Quality and value implications of NCCN-compliant use of maintenance rituximab for patients with low-grade NHL.
Authors: Huff Dinah Faith Q. , Bennett Charles L. , Shimp William S. , Baranwal Anmol , Mamgain Avinash , Fishman Marc L. , Davis Sharon , Kogler Jurgen , Schorer Anna E. , Bobolts Laura Rose , Armitage Melissa , Hrushesky William J.
Published: February 2017

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Background: Rituximab maintenance for indolent, incurable non-Hodgkin lymphoma (NHL) remains controversial. NCCN supports maintenance rituximab for a span of up to two years as an alternative to watchful waiting following induction therapy. At least a dozen scientific papers have been published describing rituximab maintenance results; none has demonstrated overall survival benefit. The strongest data support comes from the PRIMA phase III trial which showed an increased PFS but no survival advantage. Increased toxicity, however, is clear and can be serious. Reports of progressive multifocal leukoencephalopathy, a rapidly fatal neurodegenerative disease, should be of especial concern to patients whose disease course can span many years. Oncology Analytics (OA) enhances cancer care quality and value by providing oncology decision-support to providers in SE USA. We hypothesized that the use of maintenance rituximab in this area of the country produces profound cost and real risk for a highly uncertain benefit to this population. Methods: We reviewed all requests for rituximab maintenance for low-grade NHL submitted by oncology practices to a major health insurer in one US region from Jul 2009-May 2014. We calculated the cumulative cost for blanket approval of such requests and the savings associated with our decision-support discussions of this questionable but NCCN-compliant practice. Results: 470 requests for maintenance rituximab for low-grade NHL were initiated within this 59-month span. The proportion of maintenance rituximab requests relative to the total chemotherapy requests decreased consistently over time, from 4.5% in the first six months of OA involvement in 2009, down to 1.5% in May 2014. The annual cost of rituximab maintenance, which depends on the dose schedule, ranges from about $30,000 to $40,000 per year. Additionally, we discovered many rituximab maintenance requests for durations exceeding two years without evidence-based support, most of which were rescinded after OA intervention. Conclusions: Ongoing OA intervention reduces risk of toxicity and enhances the quality and value of cancer care for these patients.
The financial burden of rehabilitation: Variation in clinician charges and implications for patient financial liability.
Authors: Pergolotti Mackenzi , Lavery Jessica A. , Reeve Bryce B. , Dusetzina Stacie
Published: February 2017

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Background: Occupational and Physical therapies (OT/PT) are effective treatments to decrease disability and functional status. Few studies have examined the variations in the cost of outpatient OT/PT. For adults with cancer, the added financial burden of cancer rehabilitation is unknown. The study objectives were to (1) describe the variation in patient financial burden for the most commonly used OT/PT services by the provider type (either OT or PT) and State; and (2) determine the impact of therapy caps on the price of service provided among Medicare beneficiaries. Methods: This retrospective, population-based study used the Medicare Provider Utilization and Payment Data Public Use File (PUF), released in April 2014 by the Center for Medicare and Medicaid Services (CMS) to examine variations in care by level of insurance (uninsured, insured and reimbursed), between providers and across states with descriptive statistics. We also examined the impact of the therapy cap on number of visits allowed and the proposed reduction of the therapy cap dollar amount on services use and patient out-of-pocket liability. Results: 3,663 (9.2%) OT’s and 36,247 (90.8%) PT’s were included. Differences between provider’s charges were minimal. Wisconsin, Illinois, Tennessee and Texas had the most inflated charges, respectively, for OT and PT. 12-14 visits plus evaluation are covered under 2012 therapy cap, and the amount of visits would be cut to 7-9 with the MedPAC cap. Conclusions: This study suggests there is wide variation between the potential patient liability for the price of OT/PT based on service provided, state received and insurance coverage. For older adults with cancer who need OT/PT services, this will be an additional cost to their care. Patients without insurance pay a premium for OT/PT services.
Lessons learned from a cancer center-specific federal quality reporting program.
Authors: Flaherty Stephen , Morse Denise , Spinks Tracy , Berger Sara , Kidin Lisa M. , Ross Thomas W.
Published: February 2017

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Background: As part of the Affordable Care Act (ACA) of 2010, the Prospective Payment System-Exempt Cancer Hospital Quality Reporting (PCHQR) Program was created for 11 cancer centers. PCHQR includes an initial set of 5 measures mandated for federal reporting and expanded to include 18 measures for subsequent program years. The Alliance of Dedicated Cancer Centers (ADCC) formed in 1983 to include and represent the interests of the same 11 centers. As a small and previously organized group, we have been able to collaborate closely throughout implementation of PCHQR to understand, evaluate, and offer feedback on the program. Methods: The ADCC began sharing and reviewing data on mandated measures upon the release of the ACA in 2010. Numerator and denominator data for measures are manually uploaded from each center to a common master file bi-annually. In December 2013, ADCC hospitals formally began sharing feedback on concordant and non-concordant cases through email, bi-annual in person meetings, and monthly teleconferences. Results: Through sharing feedback on data submission with each other, CMS, and CMS contractors the ADCC learned the following lessons: 1- Limitations exist in the submission of our current data sets, (e.g. inability to accurately capture all scenarios that lead to appropriate delays in treatment). 2- Process of care measures are topped out with aggregated values above 95% for multiple consecutive quarters. 3- 4 of the existing measures and multiple forthcoming measures have case selection criteria creating sample sizes of little comparative value or statistical significance. 4- Tertiary care centers share many unique treatment patterns affecting compliance (e.g. lag time from referral to diagnosis, high percentage of patients on clinical trials). 5- Subject matter experts embedded at the 11 centers are critical for measure development/ refinement (e.g. Tumor Registrars, ICP’s). 6- CMS, CMS contractors, and affected hospitals must establish effective communication channels. Conclusions: Our early experiences indicate it is challenging to apply broad national measures to the ADCC hospitals. The 11 centers seek to continually improve upon this mandate and advance clinical practices.
Building a provider network based on quality: The Moffitt Oncology Network initiative.
Authors: Kubal Timothy Edward , Letson Douglas D. , Fields Karen K. , Levine Richard M. , Andrews Charles F. , Hamm John Turner , Lachica Diana , Shimkhada Riti , Peabody John W.
Published: February 2017

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Background: Before entering into risk bearing contracts with payors, ACOs are challenged to find a basis for forming partnerships. Specialty ACO networks, in particular, must find ways to provide a common, high standard of care among a typically varied set of partners. The Moffitt Oncology Network (MON) Initiative demonstrates a possible solution to forming a value based ACO network across a broad geographical area that is based upon using clinical pathways. Methods: Moffitt Cancer Center (MCC) has developed more than 24 different disease specific pathways. The MCC pathways translate evidence-based guidelines into personalized cancer care throughout the continuum of care from evaluation to treatment. MCC is using these pathways with other hospital systems and physician groups throughout the MON. To enhance the use of pathways in the MON, MCC uses Clinical Performance and Value (CPV) Vignettes. CPV’s, are virtual patient cases related to the specific clinical pathways. The report herein is on pathway implementation in several disease areas (breast, lung and gastrointestinal (GI) cancers) across multiple sites: Lehigh Valley Hospital (Pennsylvania), Norton Cancer Institute (Kentucky), and Space Coast Cancer Center (Florida). Results: Pathway based clinical care was measured at baseline using CPVs across disease and site (Table). A total of 67 breast cancer providers took 131 breast cancer vignettes; 35 lung cancer providers took 104 lung cancer vignettes; and to date 27 GI cancer providers have taken 54 GI vignettes. There is statistically significant variation in performance among providers and between sites. This is manifest in pathway-specified areas of work-up, diagnosis, and treatment. Conclusions: Fostering adoption of clinical pathways is a practical objective that can help guide the formation of an ACO oncology network. This may be useful for forming specialty ACOs that establish a standard of care and set the stage for adopting new payment models with payors. [Table: see text]