bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing ED visits by “closing the loop” for symptomatic patients.
Authors: Arrowsmith Edward , Suits Lenes , Anz Bertrand Marquess , Geren Gina , Vasta Leslie , Lyss Aaron J.
Published: October 2019

100

Background: Improving the value provided to patients and payers in our system of cancer care relies on reduction of avoidable hospital and emergency department (ED) utilization. Furthermore, recent payer pressures on community oncology practices (COPs) have resulted in an increased focus on improving care coordination (CC) under strict resource constraints. As part of the ASCO Quality Training Program, we tested several low-cost CC interventions, leveraging workflow redesign, already employed care team members, and technology already implemented, to reduce ED visits (EDV) in a single large COP clinic where more than 3,200 cancer patients were treated during 2016. Methods: Baseline EDV rates were obtained through nurse chart review during Jan.-Jun. 2016. The following CC interventions were implemented: Initiated after hours call process with access to EMR and patient access to bidirectional real-time messaging with care team members; Implemented new in-office process to “close the loop” on patient evaluations by creating follow up guidelines for symptomatic telephone triage and in-clinic patient evaluations; Implemented a standard 48 hour follow up process for all EDV and hospital admissions; Increased patient awareness of telephone triage services during and after clinic hours by: augmenting new patient education by staff, developing a magnetic reminder to call the office for non-emergent and emergency situations, and instructions for use of afterhours call system. Nurse chart reviews were conducted throughout implementation to observe effects of new CC processes on EDV. Results: We observed a 30% reduction in EDV from baseline measurement. No new FTEs added and no new technology licenses acquired for this initiative. Conclusions: Low-cost CC interventions can be implemented in COPs to avoid ED utilization. Limitations of this analysis included manual chart abstraction that could not account for EDV outside the partnering health system, illustrating data access for hospital utilization remains a major challenge for quality improvement efforts for COPs. Additional challenges have been experienced in expanding these process improvements from a single large clinic to the broader Tennessee Oncology network of more than 30 clinics.
Implementation of the quality training program in Spain.
Authors: Lopez Rafael , Anton Antonio , Aranda Enrique , Carrato Alfredo , Constenla Manuel , Cruz Juan Jesús , Diaz-Rubio Eduardo , Feyjoo Margarita , Garcia-Foncillas Jesus , Gascon Pedro , Guillem Vicente , Lugo Ilse , Camps Carlos
Published: October 2019

11

Background: The ECO Foundation is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Since 2015, ECO has been collaborating with ASCO (American Society of Clinical Oncology) in quality initiatives in cancer care, like the QOPI (Quality Oncology Practice Initiative) program and the QOPI Certification Program (QCP). The Quality Training Program (QTP) is a 6-month course with 3 in-person learning sessions that prepares oncology teams to design, implement and lead successful quality improvement activities in their practices. In 2018, ECO reached a new agreement with ASCO to implement this program in Spain. Methods: The QTP was developed in Spain by ECO in collaboration with ASCO, following the same methodology and contents of ASCO’s program. The first session was carried out in October 2018, with 12 Spanish teams participating with diverse quality improvement projects. The program counted with ASCO and ECO faculty, constituted by experts in the quality and oncology field. Results: Each QTP Spanish team counted with 2-3 representatives from their hospitals and developed an improvement project, following the methodology of the course, including a problem statement, process map, cause and effect diagram, diagnostic data, aim statement, measures, baseline data, priority/pay-off matrix of possible changes/interventions, change data, next steps/plan for sustainability, among others. The projects were mainly focused on the waiting time reduction in the Emergency Area and from the patient’s visit to the oncologist until treatment administration, burnout reduction on oncology professionals, improvement of the identification and management of complications for cancer patients receiving immunotherapy, improvement of the uniformity in the medical records registry, among others. QTP participants presented their projects’ results on the third and last session of the program in April 2019 with positive outcomes. Conclusions: The QTP’s quality improvement approach allows Spanish teams and the ECO Foundation to enhance the goal of a quality-oriented health care system. ECO will continue pursuing excellence and quality with further initiatives like the QOPI program, the QCP and the QTP.
Impact of brain metastases on end-of-life health care utilization.
Authors: Ray Emily Miller , Dunham Lisette , Reeder-Hayes Katherine Elizabeth , Sanoff Hanna Kelly
Published: October 2019

116

Background: Patients with brain metastases (BMets) represent a subset of cancer patients who may experience high costs and frequent healthcare utilization. This study aims to assess whether patients with BMets have higher likelihood of healthcare utilization at the end of life (EOL) compared to other patients with metastatic cancer. Methods: Using the Cancer Information and Population Health Resource, linking North Carolina Medicare, Medicaid, and private payer claims with state cancer registry data, we conducted an observational cohort study of decedents with metastatic melanoma, renal cell carcinoma, breast cancer, or lung cancer (diagnosed 2003-2014) with or without BMets. Multivariate logistic regression, adjusting for demographics, cancer type, systemic treatment, comorbidity, frailty, and hospice use, was used to examine the impact of BMets on use of the emergency department (ED), hospital, and intensive care unit (ICU) in the 30 days prior to death. Results: Patients with BMets are hospitalized at EOL more often than patients without BMets (44% vs 38%, p < 0.001), but experience no difference in ED or ICU use. BMets patients receiving systemic treatment were particularly high risk for hospital and ICU use (odds ratios in Table). Black race and Charlson comorbidity score 3+ increased risk of hospitalization and ICU use. Utilization did not vary by cancer type. Hospice care significantly reduced all utilization. Conclusions: Patients with BMets are high risk for hospitalization at the end of life. Further study is needed to determine if targeted health system interventions can decrease hospitalizations in this patient group.

[Table: see text]
Expanding access to genetic evaluations in a large community oncology practice through a collaborative service delivery model.
Authors: Patel Gayle , Nichols Trisha , Bunnell Ann , Principe Kate , Sandbach John F. , Toth Sara , White Monica , Long Christine L. , Jones Megan , Sperl Ryan , Wilfong Lalan S.
Published: October 2019

123

Background: Identifying individuals with inherited cancer susceptibility is critical to cancer treatment and prevention in patients and families. While the identification and management of inherited susceptibility to cancer is the standard of care, genetic testing rates are low; 1.2 million women with breast and/or ovarian cancer who qualify have yet to undergo genetic testing (Childers et al 2017). The Genetic Risk Evaluation and Testing Program (GREAT) formed to improve access to genetic evaluations and testing in Texas Oncology, a large, state-wide community oncology practice. Methods: The GREAT program is a collaborative service delivery model, utilizing 4 certified genetic counselors (CGC) to lead advanced practice providers and physicians in offering pre and post-test evaluations to oncology patients in their own community. Training involves 8-12 weeks of didactic lectures, precepting, and ongoing education and support. GREAT-trained providers then offer comprehensive genetic evaluations and testing to established oncology patients as well as at-risk individuals from the surrounding community. Results: The GREAT program has trained 72 providers at 52 cancer centers. Rates of genetic evaluations increased each year from 2012 to 2018. Overall findings: 19,129 unique patients received an evaluation; 17,305 genetic tests were completed; 2,597 pathogenic/likely pathogenic variants (P/VLP) have been identified. Conclusions: Despite guidelines recommending genetic evaluations for hereditary cancer syndromes, most patients are not receiving this service. A hybrid service delivery model utilizing regional CGCs to train providers in community oncology offices can significantly increase access to genetic services. The model described is an effective and expansive mechanism for the delivery of high-quality cancer genetics care. The GREAT program plans to hire additional CGCs to train more providers across Texas Oncology with the goal of expanding access. [Table: see text]
Utilizing volunteer, nonclinical navigators (NCN) as extenders of the breast nurse navigator (BNN) to provide patient education and support.
Authors: Koutlas Judy B , Mascarenhas Debra C
Published: October 2019

128

Background: The role of the BNN during the treatment phase of the care continuum involves educating patients and families and assisting them with overcoming barriers to care by linking them to appropriate resources. Our BNN provides education to approximately 15 new patients per month. Additional navigation services are provided to 114 patients per month with an annual caseload of 580. The caseload volume limits the number of patients she can see in one day. With our existing volunteer NCN program, we decided to conduct a 3-month pilot project utilizing NCN in our breast clinic to provide navigation services while the BNN was on medical leave. Methods: Three NCN were trained by BNN to provide breast navigation services. Each NCN received a minimum of 10 hours of training, which included education regarding breast cancer, common barriers to care, and resources. The BNN created a navigation tool indicating the education to be provided at diagnosis, pre-and post-surgery, and systemic therapy. NCN provided education by utilizing videos and written materials. Patient medical questions were deferred to nursing staff and physicians. BNN provided training and resource guide to aide NCN to identify and link patients with appropriate resources and support staff. Results: NCN provided services to 78 patients including approximately 10 new patients per month. A total of 24 surveys were completed by healthcare team and patients. Results revealed 94% of patients agreed/strongly agreed NCN helped them feel better and reduced fears, 100% reported helpfulness in linking to resources and support programs, and 50% viewed a video and reported better understanding. Healthcare team overwhelmingly reported the emotional support provided was beneficial and that NCN were helpful in providing resources and recommended continuing. Conclusions: NCN are effective in providing additional navigation services. Our breast navigation program had a 29% increase in new patient encounters and 27% increase in returning patient encounters compared to the previous year prior to the addition of NCN. We plan to expand this model into other multidisciplinary clinics.
Small cell lung cancer: Sociodemographic factors in patients’ decisions for treatment.
Authors: Ho Thanh P. , Duma Narjust , Durani Urshila , Funni Shealeigh , Inselman Jonathan , Molina Julian R. , Mansfield Aaron Scott
Published: October 2019

144

Background: Small cell lung cancer (SCLC) is highly responsive to cytotoxic therapy and can be cured in early stages of disease. In this setting, disparities in patient refusal despite provider recommendations are unknown. Methods: All incident limited stage (LS)-SCLC cases from the National Cancer Database were identified from 2004 to 2014. Logistic regression was used to determine factors associated with treatment refusal. Results: 65,664 patients (pts) were identified with LS-SCLC: 44% male, median age 68 years. 3.4% of pts refused radiation and 3.8% refused chemotherapy. The proportion of chemotherapy refusal increased over the study period: 3% in 2004-2006 compared to 5.4% in 2013-2014 [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.55-2.01]; this was not observed for radiation. In multivariate analysis, women were more likely to refuse radiation (OR 1.18, 95% CI 1.06-1.32) and chemotherapy (OR 1.30, 95% CI 1.19-1.43) than men. Women who accepted treatment had higher overall survival compared to those who refused radiation (19.8 vs 5.2 months) or chemotherapy (17.4 vs 3.9 months) (both p < 0.001). Hispanic, Black, and Asian pts were not more likely to refuse treatment than White pts. Older pts were more likely to refuse radiation (OR 1.09 per year, 95% CI 1.08-1.09) and chemotherapy (OR 1.10 per year, 95% CI 1.09-1.11). Charlson comorbidity index (CCI) of 2 was associated with more frequent treatment refusal compared to CCI of 0 (radiation OR 1.96, 95% CI 1.68-2.30; chemotherapy OR 1.54, 95% CI 1.34-1.76). Medicaid as primary insurance predicted a higher risk of refusal compared to private insurance for radiation (OR 2.36, 95% CI 1.81-3.07) and chemotherapy (OR 2.23, 95% CI 1.78-2.80). Treatment at an academic facility predicted a lower risk of radiation refusal (OR 0.71, 95% CI 0.59-0.84) but not chemotherapy refusal. Conclusions: Female sex, comorbidities, and Medicaid insurance were predictors of treatment refusal in LS-SCLC, suggesting that socioeconomic and sex disparities may affect treatment decisions in this life-threatening disease. Further research to identify reasons for refusal via patient and provider interviews can improve care of vulnerable populations with potentially curable cancer.
Cancer-related suicide in the United States, 1999-2015.
Authors: Han Xuesong , Zhao Jingxuan , Ma Jiemin , Yabroff K Robin , Jemal Ahmedin
Published: October 2019

148

Background: Cancer patients have an elevated risk of suicide given the prevalent psychological distress, treatment side effects, and uncontrolled pain. This study aims to examine temporal trends in cancer-related suicide in the US during the past two decades in view of progress in psycho-oncology care and symptom control for cancer patients in the country. Methods: Cancer-related suicide was defined as deaths with suicide as the underlying cause and cancer as a contributing cause in the US Multiple Cause of Death Data. We first calculated annual age-standardized cancer-related suicide rates and overall suicide rates from 1999 to 2015. Then, we fitted the log-transformed age-standardized rates to Joinpoint regression models to calculate the annual percentage change (APC) by demographic factors and overall. Results: Among 599,786 suicides in the US from 1999 to 2015, 5,559 were cancer-related. Seventy-three percent of the cancer-related suicides were committed by firearm and 14% were by poisoning. The age-standardized cancer-related suicide rate per 100,000 persons decreased from 0.17 in 1999 to 0.12 in 2015, with an APC of -2.5% (95% CI: -3.3%, -1.7%). In contrast, the age-standardized overall suicide rate per 10,000 persons increased from 13.22 in 1999 to 16.73 in 2015, with APC of 0.9% (95% CI: 0.4%, 1.3%) from 1999 to 2006 and 2.0% (95% CI: 1.7%, 2.2%) from 2006 to 2015. The decline in cancer-related suicide rate was largest among male (APC = -3.1%, 95% CI: -3.9%, -2.3%), 65-74-year-olds (APC = -3.1%, 95% CI: -4.2%, -2.0%), in the South (APC = -4.0%, 95% CI: -5.8%, -2.3%), and in urban area (APC = -3.0%, 95% CI: -4.2%, -1.7%). Conclusions: Despite the continuous increasing overall suicide rates in the US during the past two decades, cancer-related suicide has been decreasing, suggesting an evolving role of psycho-oncology care and symptom control during this period. Well-designed prospective studies are warranted to identify cancer patients at high-risk of suicide and to develop effective care intervention.
Impact of rurality versus neighborhood deprivation on stage at diagnosis and survival: A regional analysis.
Authors: Panattoni Laura Elizabeth , Fedorenko Catherine R. , Sun Qin , Li Li , Kreizenbeck Karma L. , Ramsey Scott David
Published: October 2019

158

Background: Evidence that rural residents compared to urban residents are more likely to be diagnosed at later stages and have worse survival outcomes has prompted recent policy initiatives by ASCO to address the rural cancer care gap. However, rural residents are generally poorer, potentially confounding the cause of these disparities. This study examined the impact of rurality, travel time to oncologist (TTO), and neighborhood deprivation (ND) on stage of diagnosis and 3-year survival in a regional setting. Methods: Cancer registry records for patients in Western Washington were linked with claims from regional commercial insurers, Medicare, and Medicaid at time of diagnosis. The study included adult patients with solid tumors diagnosed between 2012-2014. Rurality was sourced from the Rural-Urban Commuting Area Codes (RUCAs): Metro, Metro with Commute, Micropolitan, Small Town/Rural. ND was measured by the census block Area Deprivation Index from 1 (least) to 10 (most) deprived; TTO from Google Maps (minutes). Multinomial logistic regression measured stage at diagnosis (local, regional, distant). Cox survival models were stratified by insurance type. We adjusted all models for age, gender, race, marital status, cancer type and grade, and hierarchical condition categories. Results: The table below lists the effect size of rurality, TTO, and ND on the outcomes where significant (p<0.05). Conclusions: In Washington State, neighborhood deprivation, not rurality, was largely associated with later stage at diagnosis and poorer survival. Regional stakeholders need to carefully examine the local sources of cancer care disparities to effectively target interventions.[Table: see text]
Using an ePRO tool to help meet quality metrics in a clinical oncology practice.
Authors: Buzaglo Joanne S. , Stepanski Edward , Joiner Mary , Taylor Deb , Tankersley Cynthia , Vanderwalde Ari M. , Schwartzberg Lee S.
Published: October 2019

171

Background: ASCO has implemented the Quality Oncology Practice Initiative (QOPI), a certification program established to evaluate oncology practice performance. However, practices often lack the necessary resources to meet the required standards and fulfill required metric reporting. The study purpose was to document the effectiveness of using an electronic Patient Reported Outcome (ePRO) system to facilitate compliance with two QOPI standards: pain assessment and depression screening. Methods: This study used a retrospective, observational design with ePRO and clinical data collected via the Patient Care Monitor (PCM), a web-based ePRO system linked to electronic medical record data. All study data were collected as part of routine clinical care at a community oncology practice during a 4-month interval (1/1–4/26/19). Patients at an initial oncology clinic visit completed the PCM Core Symptom survey and the PHQ2/PHQ9 to screen for pain and depression respectively via a handheld e-tablet. Results: Overall, 10,449 patients completed the PCM survey (mean age 63; 30% male/70% female; 62% White, 34% Black). Cancer type was known for 53% of all patients (22% breast, 9% hematologic, 4% lung, 5% colorectal, 3% prostate, 11% other types). Fifteen percent of patients (n = 1584) met the pain threshold (scored 7 or above on a 0-10 scale) that signaled an alert to the physician for further evaluation. About 3% of patients (n = 413) skipped the pain question on the PCM Core Symptom survey. With respect to depression, 5% (n = 559) reported a PHQ2 threshold level that triggered the remaining PHQ9 items. Among those at higher risk for depression, 16% (n = 92) met criteria for moderate to severe depression warranting further clinical evaluation and the PCM signaled a real-time alert to the physician in advance of the patient consultation. Approximately 4% (n = 413) skipped the PHQ2. Conclusions: This study demonstrates that using an ePRO system is an effective way to screen for pain and depression and can be used to: 1) monitor symptoms to enhance physician-patient communication during the consultation; 2) provide an audit trail for QOPI metric reporting. Overall, an ePRO system contributes to creating a culture of excellence at community oncology practices.
Structured handoff communication between affiliated health care sites.
Authors: Helmig Sara , Burlison Jonathan , Morgan Jennifer , Russo Carolyn
Published: October 2019

182

Background: The affiliate program at St. Jude Children’s Research Hospital (St. Jude) allows more children access to pediatric oncology care closer to the patient’s home. Currently 8 clinics, located throughout the Southeast and the Midwest, are affiliated with St. Jude and contribute 35% of patients enrolled in St. Jude clinical trials. Handoffs and transitions of care are common weak points in health care provider communication as patients move between sites. Failures in communication led to inefficiencies in care, patient dissatisfaction, and near-miss events. Ensuring that the information exchanged during the patient transition is efficient and complete will benefit patient safety and trust. With no consistent pattern of communication between St. Jude and affiliate clinics, we aimed to develop and implement a standardized communication tool to be used with each patient transition between different health care sites. Methods: Each team of providers (St. Jude and affiliate clinics) created individual flow diagrams to define the current state of communication when patients were transitioning between remote sites. Using fishbone diagrams each team identified the barriers to effective communication. Common barriers were incomplete communication and synthesis by the receiver. Results: We developed a communication bundle. Using IPASS methodology (a communication bundle developed for inpatient handoffs between resident physicians) we designed a standardized mnemonic, SMART (S-summary of plan; M-medications/roadmap; A-action plan; R-return visit date; T-transfer confirmation) for a patient transition between different health care sites. The communication bundle was transmitted by secure email. The time to send or receive the communication bundle was < 10 minutes. We measured % usage of the completed tool prior to transition, staff satisfaction, and number of errors. The SMART bundle was used 80% of the time and improved staff satisfaction. No errors have been identified. Conclusions: Closed loop, high-reliability communication can be accomplished between geographically remote health care sites using a standardized communication tool, which is transmitted electronically.
Partnering with patients and caregivers to improve systemic treatment regimen information.
Authors: Crespo Andrea , Amernic Heidi , McBain Sarah , Lakhani Nita , Gallo-Hershberg Daniela , Cheung Annie , Ng Jessica , Salama Sarah , Vu Kathy , Forbes Leta Marie
Published: October 2019

185

Background: Cancer Care Ontario’s Drug Formulary is a web-based drug information resource. Patient information is currently provided as single-drug information sheets, with a limited number of multi-drug regimen information sheets (RIS) for breast and lung cancer treatments. Patients identified a need to create additional, high-quality, “user-friendly” RIS. Objectives of this project were to 1) engage patients and caregivers in RIS redesign; 2) evaluate the original vs a redesigned model RIS; and 3) use the model RIS template to create additional RIS across disease sites. Methods: The project team included a patient and family advisor (PFA) and clinical and research experts. This was a qualitative study between August 2017 to May 2019. A focus group (FG) was conducted with 5 PFAs to identify and prioritize drug information needs. A model RIS was designed, incorporating FG input and health literacy best practices. RIS were evaluated through blinded comparative cognitive interviews with 13 PFAs, to assess RIS for usability, understandability and content relevance. Evaluation informed iterative revisions. RIS were also evaluated by clinical and education experts using the Patient Education Materials Assessment Tool (PEMAT). An RIS style guide was developed to inform the creation of future RIS. Ethics approval was obtained from the University of Toronto. Results: The FG prioritized information on regimen details, Dos and Don’ts while on treatment, drug interactions, side effects and contact information. Guidance was provided on simplifying language, highlighting important information and aesthetics. Cognitive interviews consistently reported preference for model RIS over original RIS in most domains. PEMAT scores for original versus model RIS were 64% and 94% respectively (for understandability) and 60% and 82% respectively (for actionability). To date, the style guide has informed the creation of RIS for 10 high-use regimens. Conclusions: PFA and clinician co-design along with health literacy best practices informed measurable improvements in RIS. The style guide will enable the future creation and ongoing evaluation of high-quality RIS to enhance the cancer treatment experience for patients and caregivers.
Analgesic requirement as a predictor of mortality to guide ceilings of care discussions for oncology patients in the emergency room.
Authors: Paxton-Hall Fiona , Lwin Zarnie , Chan Bryan Anthony , Lukin William , Williams Julian , Greenslade Jaimi , Kermond Anna
Published: October 2019

188

Background: Discussing an oncology patient’s ceiling of care in the emergency room (ER) is a high-stakes and time-pressured challenge. Discussions and consensus for ceilings are warranted when patients are acutely unwell with sepsis. We explored whether daily oral morphine equivalent (OME) was predictive of outcome and could therefore assist in ceiling of care decision making or advanced resuscitation planning (ARP). Methods: Oncology patients presenting with infection or sepsis to a quaternary hospital ER between October 2008 and April 2011 were included. Hospital electronic databases and medical records were manually reviewed to extract data on patient demographics, OME at time of presentation to ER, illness severity (SOFA scores), whether patients had a pre-existing formalised ARP vs acute ARP documented within the ER and 90-day mortality from ER presentation. Descriptive statistics were reported. Results: A total of 91 patients were identified with median age 64 years, 60% were male, 62% were undergoing palliative-intent treatment and 70% were receiving first-line chemotherapy. There were 54 patients taking no analgesia (OME 0) and 37 patients with an OME > 0. Of the 37 patients with OME > 0, 6 patients (16.2%) had an ARP documented in the ER. A further 14 patients with OME > 0 had an ARP documented at some point during their admission. The median total SOFA scores for patients with OME > 0 was 3 and OME of 0 was also 3. The 90- day mortality from ER presentation was higher for patients with an OME > 0 compared to those with an OME of 0 (Chi-square = 5.02, p = 0.03). There were 15/37 patients (40.5%) with an OME > 0 who were deceased within 90 days compared with 10/54 patients (18.5%) with an OME of 0. Conclusions: Patients with higher OME use at ER presentation had poorer outcomes and this may be useful to guide clinicians in ceilings of care decisions. Daily OME should signal a need for timely, formalised advanced care planning with patients and their treating oncologists.
Improving advance directive documentation in the electronic medical records at a comprehensive community cancer center.
Authors: Wood Kevin C. , Santana-Joseph Sobeida , Spitzer Ayelet , Power Steve , Casper Ephraim S.
Published: October 2019

191

Background: Advance directives (AD) are critical to understanding a patient’s wishes should they be unable to communicate. Lacking these documents may lead to decreased knowledge regarding end-of-life wishes, and hinder end-of-life care. Having an AD uploaded into the electronic medical record (EMR) ensures these documents are available to all providers. This project sought to improve, from a cohort of patients with documented discussions regarding ADs, the proportion with the document in the EMR. At Valley-Mount Sinai Comprehensive Cancer Care, baseline data analysis shows only 20% of clinic patients for whom an AD was documented had an AD uploaded to their EMR. Methods: This project was created through the ASCO Quality Training Program and sought to increase the proportion of AD’s in patient’s EMR's. The current workflow of obtaining AD's at Valley-Mount Sinai was first identified. In our setting, the medical assistant (MA) asks new patient if they have an AD and uploads the AD into the chart if available. Following a structured cause and effect exercise, two Plan-Do-Study-Act (PDSA) cycles were prioritized. The first, beginning 10/15/18, required that the new patient nurse navigator discuss the value of AD’s with the patient when scheduling initial visits. The second PDSA, completed 11/12/18 for the MA’s, was an educational session reviewing AD’s and how to discuss them. Results: Pre- and post-intervention data is depicted in the Table. At baseline, 20% of the 114 patients with existing AD discussions had these documents uploaded into their EMR. After PDSA-2, 37.1% of the 78 patient cohort had an AD uploaded. Conclusions: Through clinical education and revising the current process, this project increased uploading AD’s into EMR’s from 20% to 37.1%. This demonstrates that small but effective interventions can increase the proportion of patients with AD’s in their charts. Future PDSA’s will focus on patient and RN education to further improve these numbers.

[Table: see text]
Patient and caregiver benefit-risk preferences for non-metastatic castration-resistant prostate cancer treatment (nmCRPC).
Authors: Srinivas Sandy , Mohamed Ateesha F. , Appukkuttan Sreevalsa , Botteman Marc , Ng Xinyi , Joshi Namita , Tsai Jui-Hua , Fang Jarjieh , Waldeck Adrian Reg , Simmons Stacey J.
Published: October 2019

196

Background: Second-generation androgen receptor inhibitors (SGARIs) have been recently approved for the management of nmCRPC based on documented improvements in metastasis-free survival. We used a discrete choice experiment (DCE) to examine how nmCRPC patients (pts) and caregivers perceive the benefits versus risks of SGARIs. Methods: nmCRPC pts and caregivers were invited to complete an online DCE survey of 14 treatment choice questions, each comparing 2 hypothetical medication profiles varying in terms of 5 safety attributes (frequency or severity of adverse events [AEs]: fatigue, skin rash, cognitive problems, serious falls, and serious fractures) and 2 efficacy attributes (duration of overall survival [OS] and time to pain progression). These attributes were selected based on in-depth qualitative interviews with pts, caregivers, and physicians. We used random parameters logit models to estimate preference weights and relative importance scores for each attribute. Results: 143 nmCRPC pts and 149 caregivers were included in the analysis. Both pts and caregivers viewed safety attributes in the following decreasing order of importance: fractures, falls, cognitive problems, fatigue, and rash. Compared to a reduction in rash severity from moderate to none, a similar reduction in cognitive problems severity was considered nearly as important by patients but twice as important by caregivers. On average, pts were willing to trade 5.8 and 4.0 months of OS to reduce the risks of serious fractures and falls, respectively, from 3% to 0%; the corresponding figures caregivers were willing to trade were 6.6 and 5.4 months of OS. Of note, 8.4% of pts and 14.8% of caregivers consistently chose the treatment profile with the lowest fall or fracture risk, regardless of the other attributes' values. Conclusions: nmCRPC pts and caregivers preferred treatments with lower AE burdens and were willing to trade substantial amounts of OS to avoid AEs. They viewed the reduction of fractures, falls, and cognitive problems as most important. In this relatively asymptomatic population, carefully balancing risks and benefits when selecting SGARI treatments is important to optimizing quality of survival.
Provider perceptions of the social work role in oncologic pain management.
Authors: Ralli Claire , Bailiff Michelle , Fields-Burdick Crystal , Gajewski Kali , Garza Tara , Larson Nora , Mills Lydia
Published: October 2019

214

Background: Best practices of cancer care delivery have shifted from medical models to interdisciplinary approaches aimed at holistic care. The social work profession has advanced itself by gaining competence in psycho-oncology, advance care planning, biopsychosocial assessment and intervention, and pain management. While Masters prepared Social Workers (MSW) are widely recognized as experts in most of these areas, it appears that they are underutilized in pain management. This study will examine provider and nursing perceptions about social work expertise and whether those perceptions may limit utilization of social work in multidisciplinary management of cancer pain. Methods: While review of psycho-oncology literature supports the role of social work in pain management, this was not clearly indicated within the medical oncology domain. A survey was created to ascertain the perception of the MSW role in pain management as a supplement to pharmacologic and medically-based care when identifying and treating multidimensional pain. The survey was completed by Physicians, Advanced Practice Providers, and Nurses in outpatient oncology practices in The US Oncology Network. Results: 139 medical professionals responded. As hypothesized, 88% reported they were comfortable with MSWs conducting Advance Care Planning, while 61% reported being comfortable with MSWs educating patients and families about pain management during palliative/end of life care. 95% believed unmet emotional, social, spiritual and existential needs can present as physiological pain, however only 55% indicated they would include Licensed Clinical Social Workers to provide therapeutic interventions as part of pain management. Conclusions: Under half of survey participants reported an understanding of the scope of social work practice, which aligns with the lack of awareness and under-utilization of social work as a vital contributor in oncologic pain management. MSWs have training in evidence-based interventions such as CBT, guided imagery, mindfulness and biofeedback techniques which may diminish the experience of pain. Further research is recommended to identify strategies to promote and integrate social work into multidisciplinary pain management.
Survey results from a patient’s perspective during a phase I/research clinic visit.
Authors: Beltran Stefanie Valeria , MacIntyre Jessica , Tejera Dalissa , Merchan Jaime R. , Watts Justin M.
Published: October 2019

216

Background: The University of Miami’s Phase I Program is South Florida’s only academic Phase I center dedicated to drug development for cancer patients. On April 2018, Sylvester Comprehensive Cancer Center opened the Phase I/Experimental Therapeutics (ET) Clinic dedicated to research patients enrolled in Phase I clinical trials and established a multi-disciplinary care team. As Phase I clinical trials are evolving, it is necessary to improve on the patient experience as it pertains to research care. Methods: Using a Likert-type scale, dual language survey (English and Spanish), patients were asked 11 questions about the Phase I/ET Clinic visit ranging from the beginning of their Phase I clinical trial enrollment all the way to provider care during the visit. The survey was conducted from January 2019-April 2019 through a secure, HIPAA compliant online Research Electronic Data Capture software (REDCap). Results: Of the 30 patients that were approached, 26 responded (Renal 26.9%, Myelofibrosis 19.2%, Bladder 15.4%, Head and Neck 7.7%, Acute Myeloid Leukemia 15.4%, Myelodysplastic Syndrome 7.7%, and Other 7.7%). Our results found that 100% of research patients would recommend a Phase I clinical trial to another participant. In addition, 96.2% of patients felt there was continuation of their care through their clinical trial process. As a note, 19.2% of patients positively recognized a Phase I provider including Nurse Practitioners (NPs) and physicians. Of these 19.2% of patients, 50% praised an NP in the free text area of the survey. Lastly, 42.3% of patients positively mentioned the team support received in the Phase I Clinic in the free text area of the survey. Conclusions: Our conclusion based on survey results show that having committed providers and clinic space for research patients on a Phase I clinical trial provided an overall positive and personalized experience. Additionally, the survey reflects on how patients are more inclined to refer to a clinical trial due to a good experience. Future directions should look at developing a similar clinic for all phases of research considering the exceptional patient feedback emphasizing on provider care.
Patient and physician perceptions: Importance and documentation of patient priorities in treatment planning and decision-making.
Authors: Miller-Sonet Ellen , Rocque Gabrielle Betty
Published: October 2019

224

Background: The National Academies of Medicine prioritizes patient’s needs, values, and preferences when patient’s and care teams make treatment decisions. However, the collection of this patient information is not part of the formal clinical intake process, nor are pertinent questions included in EHR templates. Methods: Surveys were conducted of cancer patients and cancer physicians to understand perceptions on whether patients’ quality of life priorities (e.g work, hobbies, key events, household responsibilities) are discussed, documented and reflected in treatment plans. Physicians were recruited via a market research panel. Patients were recruited from the Cancer Care data base via an email request to complete an online survey. Results: From February to October, 2018, 310 cancer patients and 109 cancer physicians completed surveys. Cancer patients were mostly female, 91% had been diagnosed in the last year, 61% had breast cancer, and 55% were stage 1 or 2. Among physicians, 88% self-identified as trained in oncology, 33% practice at academic centers, 51% in community practices, 34% from the Northeast, 21% the Southeast, and 25% the Midwest. Most patients (62%) said it was very/extremely important their doctor know their priorities. Most physicians (66%) report they most of the time/always know patients’ personal quality of life priorities before finalizing treatment plans, and 62% say this information has a large/major impact on recommendations. However, only 40% of patients report having this conversation before treatment started. Although 76% of doctors said they discussed what is important to patients most of the time or always, only 60% report it is documented, usually in the social history or notes fields. Only 36% of patients are sure this information is entered into their medical record. Conclusions: Cancer patients want their doctors to know what is important to them, and physicians agree. However, documentation is often relegated to narrative notes fields in the EHR. Considering the key role patients’ priorities should play in treatment planning, there need to be standardized collection tools so this information can be timely collected and shared.
Radiation Oncology Incident Learning System (RO-ILS): Increasing stakeholder participation for safety and quality improvement.
Authors: Nelson Carl , Roy Lori Ann , Wallace H. James
Published: October 2019

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Background: RO-ILS was launched in 2014 and is free, web-based and in more than 500 U.S. radiation facilities. After RO-ILS was implemented at University of Vermont Medical Center (UVMMC), reporting of radiation incidents decreased and participation by radiation staff was limited. To improve incident reporting and participation, RO-ILS was relaunched for all radiation staff members at UVMMC with emphasis on improved system access and education on RO-ILS programmatic goals. Methods: Prior to RO-ILS, safety/quality incidents at UVMMC were submitted by radiation therapists, dosimetrists and physics staff on paper forms and reviewed monthly by the Radiation Quality Committee. After implementation of RO-ILS in 2016, RO-ILS incidents were reviewed by the UVMMC RO-ILS administrators with no formalized staff feedback. Due to decreasing staff submissions, RO-ILS relaunched September 2018 with increased training, scheduled submission review to radiation staff and identification of department champions. Results: Between April 2014 and May 2019, 270 radiation incidents were reported. Prior to RO-ILS, a median 8 incidents were reported per quarter but decreased to 6 per quarter after RO-ILS. After RO-ILS relaunch, median reported incidents increased to 42 per quarter. Radiation “Near Miss” events pre RO-ILS, post RO-ILS and with RO-ILS relaunch were reduced from 78% to 34% to 9%, while “Operational/Process Improvement” submissions increased from 17% pre RO-ILS to 49% post RO-ILS to 81% after relaunch. After RO-ILS relaunch, staff participation expanded to physicians, nursing and administrative staff for the first time, and physician participation increased from 0 to 50%. Conclusions: Following implementation of RO-ILS at UVMMC, radiation incident reporting initially decreased and the proportion of “Near Miss” reports decreased. After relaunch of RO-ILS, there was substantial increase in incident reporting involving all staff. As RO-ILS evolves at UVMMC, there is continued decrease in near misses and greater emphasis on “Process Improvement”. Continued education, reporting and feedback from RO-ILS submissions is recommended to maintain this high staff participation level.
Preventing complications: Hepatitis B screening in cancer patients undergoing systemic therapy.
Authors: Prince Rebecca M. , Krzyzanowska Monika K. , Glinsky Victoria , Wong David K , Macedo Alyssa
Published: October 2019

237

Background: Chemotherapy is a risk factor for HBV reactivation in pts with cancer and chronic HBV. Anti-viral prophylaxis can prevent reactivation but requires identification of infected pts. Many guidelines recommend universal HBV screening prior to cytotoxic/immunosuppressive-therapy, but lack of screening is common globally. A serious safety event and high prevalence of pts from HBV endemic regions receiving treatment at our institution led to a quality improvement project to increase HBV screening prior to chemotherapy. We aimed to increase HBV screening in pts starting systemic therapy at Princess Margaret by 100% by February 28, 2019. Methods: Starting April 2017, an interrupted time series study was undertaken. Baseline HBV screening rate was 43%. Diagnostics including interviews, process mapping and root cause analysis were performed. Interventions to address identified root causes were implemented including specifying required HBV tests, tips for ordering HBV tests, provision of electronic Hepatology referral form, a safety alert email, grand rounds presentation of serious safety event, including HBV screening rate in departmental monthly quality emails and Divisional meetings and adding positive HBV results to the laboratory alerting system. The main outcome measure was the proportion of pts starting systemic therapy screened for HBV. Process measures included correct test ordering, number of Hepatology referrals was a balancing measure. Results were analysed with statistical process control charts. Results: From April 2017-Feb 2019, 5604 pts commenced systemic therapy. Interventions were modified iteratively as the project progressed. HBV screening rate improved from 43 to 79% (84% improvement). Incidence of chronic HBV was routinely above the Canadian average ( > 2%). The percent of correctly ordered screening tests fell from 48 to 33% (31% worsening), while the volume of Hepatology referrals remained manageable (1.5 pts/week). Conclusions: Our Quality Improvement project led to a significant improvement in HBV screening prior to systemic therapy. Further interventions are planned to achieve our target improvement of 100%.
Safety culture interventions in cancer care: A systematic review.
Authors: Le Dan , Lim Charles Henry , Fazelzad Rouhi , Krzyzanowska Monika K.
Published: October 2019

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Background: Creation of a culture of safety in healthcare organizations is fundamentally important to patient safety. However, there is limited guidance on how to effectively promote a culture of safety in healthcare settings including in oncology. We performed a systematic review to identify interventions or strategies to promote safety culture in cancer care. Methods: Medical Subject Headings and text words for “safety culture” and “cancer care” were combined to conduct structured searches in MEDLINE, EMBASE, CDSR, CINAHL, Cochrane CENTRAL, Epub Ahead of Print & In-Process, PsycINFO, Scopus, and Web of Science databases, for peer-reviewed articles published between 1999 and 2017. Articles were included if they described an intervention or strategy to promote safety culture in an oncology setting, and quantitative outcomes were reported. Study quality was assessed using the ROBINS-I risk of bias tool. Results: We screened 21,572 studies, of which 46 underwent full-text review, and 19 met the inclusion criteria. Studies described interventions in radiation oncology (15 articles), medical oncology (3), and general oncology (1) settings in either North America (15) or Europe (4). The most common experimental designs were interrupted time series (10) or before-and-after comparisons (6), and were of either moderate (89%) or severe (11%) risk of bias. Interventions varied but could be broadly categorized as incident learning systems (8), quality improvement programs (7), provider education programs (2), a provider scheduling system (1), and a patient safety champion intervention (1). While 89% of studies reported improvement in safety culture, there was substantial heterogeneity in evaluated outcomes. Most assessed provider outcomes such as number of reported adverse events (11) or Agency for Healthcare Research and Quality Safety Culture survey results (7). Conclusions: Despite a growing evidence base to identify interventions to promote safety culture in cancer care, definitive recommendations were difficult to make due to heterogeneity in study designs and outcomes. Given the importance of safety culture in cancer care, additional high-quality studies and standardization of outcome measures are needed.