bluuebunny/crossref_metadata_2025 huggingface dataset:
The role, use, and nuances of clinical data systems in oncology quality improvement.
Authors: Belnap Thomas W. , Sause William T. , Rowley Braden D. , Jones Cory , Ruckdeschel John C.
Published: February 2017

135

Background: Data is essential to achieve meaningful quality improvement. A variety of commercial products are currently available for sophisticated data collection. However, data systems alone are not sufficient to improve quality. Additional resources are required in order to leverage electronic clinical data for meaningful improvement. This abstract outlines the necessary requirements and available methods for data-based oncology quality improvement using the experience of Intermountain Healthcare. Methods: The organizational components required for quality improvement are complex. Successful quality improvement begins with project feasibility, data availability and clinical leadership. Clinical processes are reviewed, data accuracy and availability are confirmed and clinical goals are established. Data collection, validation, and analysis are standardized across multiple facilities and providers. Data must be analyzed and presented in a way that clearly illustrates differences in current performance compared to quality goals, should be tracked over time to ensure real and sustainable progress, and must be combined with other improvement strategies to maximize impact. Results: Once quality reports are generated, a physician champion presents them to clinical staff along with education materials, national guidelines and current evidence from peer-reviewed literature. Clinicians are presented with individualized data comparing their personal performance to de-identified performance of their peers, the facility and the system. Providers are given updated data on a regular basis, the data system is monitored for outliers and the need for subsequent interventions, and additional metrics are tracked to ensure process changes don’t negatively impact quality in other areas. Conclusions: Oncology quality improvement requires both clinical and data infrastructure. Electronic clinical data systems are essential for quality improvement, but are not sufficient by themselves. Additional resources are required to capture, extract, validate and analyze clinical data. Appropriate use of these resources transforms existing electronic data systems into a powerful quality improvement tool.
Understanding the drivers of cancer care at the regional, state, and local levels.
Authors: Williams Ken , Donovan Sarah , Fitall Eleanor , McBride Tilithia
Published: February 2017

142

Background: Regional, state, and local variations in cancer care necessitate a more thorough understanding of the key drivers of quality at these levels. In this study, Avalere sought to understand how local quality and health information technology (HIT) infrastructures may influence the quality of care to which a cancer patient has access. Methods: Avalere conducted an analysis of the primary influencers of quality and value in each state, cataloguing over 500 public and private quality improvement organizations, including payers; employer groups; and hospitals and alternative care delivery models, such as accountable care organizations and patient-centered medical homes, among others. Recognizing the critical role that health information technology (HIT) plays in underpinning quality improvement efforts, Avalere also catalogued the primary HIT organizations in each state. From this, Avalere conducted a sub-analysis of those initiatives with a specific focus on cancer care to determine how the number of cancer-related initiatives relates to the sophistication of a region’s or state’s quality and HIT sophistication. Results: Avalere found that the sophistication of the quality and HIT infrastructures varied widely from state-to-state and region-to-region, with some areas being significantly less developed than others. Similarly, the number of cancer-related quality initiatives also varied widely, with fewer initiatives found in areas with less sophisticated quality and HIT infrastructures. In addition, major urban areas tend to have significantly more sophisticated infrastructures—and an associated higher number of cancer-related initiatives—than non-urban areas, regardless of regional or state quality or HIT trends, more generally. Conclusions: While national quality improvement efforts receive the most media attention and funding, patient care, including cancer care, is delivered at the local level. As such, in order to improve the quality and value of care cancer patients receive, it is imperative to understand and improve local quality and HIT infrastructures and the barriers to quality associated therewith. This is particularly important in locales without major urban access, such as found in large parts of the Midwest and West.
Impact of early engagement of patients with clinical trial information in a system-based multidisciplinary breast cancer clinic on clinical trial enrollment.
Authors: Pan Minggui , Lee Anita T. C. , Seaward Samantha A. , Ilano Aaron , House Karen , Duran Esther , DuLong Mark , Kavanagh Maihgan
Published: February 2017

149

Background: Cancer clinical trial enrollment is low at approximately 3% in the U.S., and there is an urgent need for improvement. Informing patients clinical trial information early at their initial appointment after the diagnosis of cancer may improve clinical trial enrollment. To this goal, we have developed a system-based multidisciplinary breast cancer clinic (MDBCC) that evaluates all newly diagnosed breast cancer cases and discuss with all patients eligible clinical trials at their initial appointment. Methods: Our MDBCC team consists of a medical and radiation oncologist, breast surgeon, mammographer, pathologist, geneticist, and breast cancer coordinators, who review all newly diagnosed cases in the tumor board (multidisciplinary breast cancer tumor board) prior to patient’s MDBCC appointment. During the MDBCC visit, each individual patient meets separately with a medical oncologist, a radiation oncologist, and a surgeon to discuss their treatment options. Eligible clinical trials are discussed and presented to patients with informed consent. Clinical trial nurses are dedicated for patients to call and meet for further discussion on the eligible trials after the MDBCC visit. Results: The average annual clinical trial enrollment for breast cancer was 9 cases (approximately 3%) between 2000 and 2006 prior to initiating the MDBCC, improved to 53 (approximately 17%) between 2007 and 2011 after the MDBCC was formed. The enrollment into the NSABP and SWOG trials accounts for the large portion of the accrual. Conclusions: Early engagement of patients with clinical trial information in a system-based MDBCC for all newly diagnosed breast cancer patients dramatically improves clinical trial enrollment.
Improving quality of care and reducing costs with angiogenesis-specific imaging tests in metastatic breast cancer.
Authors: Bodnar Carolyn , Paramore L. Clark , Knopf Kevin B.
Published: February 2017

150

Background: Anti-angiogenesis (AA) drugs (e.g., bevacizumab) are expensive and their clinical benefit in metastatic breast cancer (MBC) has been challenged. Healthcare reform and financial pressures prioritize programs which improve patient quality of care and reduce costs of unnecessary care. Angiogenesis-specific imaging tests (A-IT) under development have potential to offer earlier, accurate determination of response. For A-IT-identified responders, AA treatment would be continued. For patients identified as non-responders, futile AA treatment and associated toxicities can be avoided and alternative therapies initiated. Methods: A decision-tree model was developed to estimate the impact of A-IT from determination of AA therapy eligibility through to disease progression. Key decision nodes were presence/absence of A-IT (assessing change in biomarker expression across 2 PET/CT scans: at AA eligibility, then after one cycle of AA), A-IT sensitivity/specificity (SE/SP) and clinician adherence to test results (tied to belief that results are valid enough to stop AA therapy). Key model inputs (and base case values): 1) median time to progression (TTP) for current MBC patients on AA therapies (9.5 months); 2) median TTP for A-IT identified responders (13 months); 3) costs of bevacizumab, one cycle ($5,200); 4) percentage of AA patients with hemorrhage (4%); 5) costs of hemorrhaging, per event ($14,694); 6) per patient costs for A-IT ($6,000); 7) estimated SE/SP of A-IT – 95%/75%; and 8) clinician adherence to test results (75%). Results: Based on a cohort of 100 MBC patients, use of A-IT results in 29 patients avoiding futile AA therapy with a saving of $460,000, versus a scenario where A-IT was not used. One-way threshold sensitivity analysis shows A-IT is cost-saving if SP >62% or when clinician adherence is ≥63%; results are not sensitive to AA hemorrhage rate. Conclusions: Use of A-IT could improve quality of care by optimizing AA therapy, i.e., by identifying responders who will experience survival benefit and non-responders who can avoid futile therapy and toxicity risks. Significant cost savings may be possible as a result of early determination of response to AA drugs.
Quality improvement research in oncology: A bibliometric analysis.
Authors: Haq Samir Mohamed , Todd Knox H.
Published: February 2017

159

Background: As part of the Affordable Care Act of 2010, the U.S. government has established a “National Strategy for Quality Improvement in Health Care,” with the goal of implementing evidence-based research into practice. The quantity of oncology research devoted to quality improvement is uncertain. We use the percentage of quality improvement articles in the oncology literature as a proxy metric to gauge the importance given to quality improvement in oncology. Methods: A MEDLINE literature search was performed on July 14, 2012. We approximated the number of articles published in the field of oncology using a PubMed search with the MeSH (Medical Subject Headings) term “neoplasm” or keywords “neoplasm,” “cancer,” or “oncology.” Results were limited to English language and publication dates between July 2010 and June 2012. From this data, the number of articles concerning quality improvement was approximated using the MeSH term “quality improvement” or keywords “quality improvement.” Results: Of approximately 246,000 English language, oncology-related articles published in the last two years, 314 focused on “quality improvement.” The topic of quality improvement comprised only 0.1% of the oncology literature over this period. Conclusions: Using bibliometric analysis, it appears that research on quality improvement in oncology is infrequent. Quality improvement research has been found effective in other fields and requires increased emphasis by the oncology research community. To improve the quality of care in oncology, evidence-based research in the field of quality improvement should increase.
Use of survivorship care plans to re-engineer breast cancer follow-up.
Authors: Makari-Judson Grace , Hubbard Sandra , Wrenn Tamara
Published: February 2017

162

Background: Use of survivorship care plans (SCPs) was recommended by the IOM in 2005, but benefits are a subject of ongoing debate. ASCO’s Cost of Cancer Care Task Force cited use of unnecessary imaging and tumor markers in breast cancer follow up amongst the “top five” list to improve quality. Communication with breast cancer survivors about guideline based post-treatment follow-up may be improved with SCPs, however few studies have addressed measurable outcomes. We describe use of SCPs to coordinate follow-up care in a multidisciplinary practice. Methods: In 2009, our breast surgeons, medical oncologists, and nurse practitioners agreed upon guidelines for follow up of breast cancer patients, developed a Survivorship Care Program to follow active treatment and implemented use of SCPs. Prior to 2009, follow up was partly determined at physician discretion and partly patient-driven, often with both medical and surgical providers seeing patients within short spans of time. To improve access to two part-time breast surgeons, guidelines were established to shift follow-up to medical oncologists and nurse practitioners. After diagnosis, patients were given comprehensive SCPs, which included recommended follow-up visits and testing. Wait times and numbers of new surgical patients were measured before and after use of SCPs. Results: Implementation of SCPs occurred during 2009; data from time periods two years before and after SCPs is listed below. Wait times were measured from call to first appointment. New patients included both benign and malignant breast disease. Conclusions: SCPs were useful in re-engineering follow-up habits of clinicians, adding value to each visit and gaining acceptance from established patients regarding recommended surveillance. Patients expressed that uncertainty experienced at the end of active treatment is mitigated by remaining in an environment that can be easily transitioned back to other clinical services. SCPs contributed to reduced wait times and increase in volume of new patients seen by breast surgeons. Future studies should assess contribution of SCPs to reducing unnecessary tests and improving compliance with ASCO guidelines. [Table: see text]
Feasibility of screening hospitalized patients for palliative care.
Authors: Glare Paul A. , Plakovic Kathy , Schloms Anna , Egan Barbara , Saltz Leonard
Published: February 2017

176

Background: The National Comprehensive Cancer Network (NCCN) Palliative Care (PC) Guideline recommends screening all oncology patients for PC, and to call a consult when the referral criteria are met. There are no data on the feasibility or impact of following this recommendation. Methods: Design: Prospective observational study. From 11/1/10 to 1/31/11, floor nurses screened all admissions under the two teams (“Team A” and “Team B”) of the Gastrointestinal Oncology (GIO) service at Memorial Sloan-Kettering Cancer Center. Team A patients were also evaluated by the referral criteria. Endpoints: Patients screened ‘positive’ if they had any of the clinical situations nominated in the Guideline. A PC consult was triggered on Team A patients who met the referral criteria. Team B patients got PC consults based on clinical judgment. Outcomes: screening rates, nursing satisfaction survey, clinical and operational metrics. Results: 90% (228 of 254) admissions were screened, typically taking < 5 minutes. Both teams’ patients were seriously ill (Table 1a), and it is no surprise 75% (170 of 228) screened positive and that 68% (60 of 87) of screen-positive Team A patients met the referral criteria. Screening generated more consults on Team A than Team B (47 vs. 15 p<0.0001), and they were referred earlier (Table 1b). Nurses (response rate 50%) rated screening as quick and simple but not very helpful. Conclusions: Screening for PC was feasible and sustainable, increasing access to specialist services. The value to a comprehensive cancer center of markedly increasing PC consults through implementation of guidelines needs to be evaluated in well-designed trials. [Table: see text]
Use of a Pan-Canadian indicator to measure treatment rates relative to evidence-based guidelines for rectal cancer.
Authors: Forte Tonia , Klein-Geltink Julie , Rahal Rami , Lockwood Gina , Bryant Heather E. ,   in collaboration with the System Performance Steering Committee and Technical Working Group
Published: February 2017

177

Background: As part of the Canadian Partnership Against Cancer’s (CPAC) System Performance initiative, indicators measuring treatment practice patterns across the country are now available, offering the ability to compare against evidence-based guidelines. We report on the percentage of patients with stage II and III rectal cancer receiving pre-operative radiation treatment (RT) based on an analysis of Canadian administrative data. A retrospective chart review was conducted to examine reasons for non-treatment with RT, set performance targets, and inform quality improvements. Methods: Data on the percentage of stage II and III rectal cancer cases receiving preoperative RT were obtained from five provincial cancer registries using a standardized methodology for 2,854 cases diagnosed between 2007 and 2008, with 2009 data soon to be available. A retrospective chart review was conducted in five provinces on a random sample of 383 patients diagnosed in 2008 to examine reasons for non-referral and non-treatment. Results: Based on administrative data, an average of 45% of cases received RT preceding surgical resection for stage II or III rectal cancer, ranging from 36% to 48% across provinces. Preoperative RT rates were similar for men and women, but were lower in older patients. From 2007 to 2008, the percentage of patients receiving pre-operative RT increased in all provinces. Results from the chart review showed that, of those who did not receive preoperative RT, 33% were not referred by a surgeon to an oncologist. The most common documented reasons for non-referral were co-morbidities (26%) and patient choice (7%). Among patients referred to an oncologist, 42% were treated with preoperative RT, 30% were treated with post-operative RT and 28% received no treatment. Among those receiving no treatment, 29% were seen only by a medical oncologist, and 18% were not treated due to patient choice. Conclusions: Findings are being used to develop national targets for treatment rates and, working with national oncologist associations, to develop quality improvement strategies, including patient education efforts to promote informed decisions on treatment options.
Chemotherapy safe handling and safe labeling guideline concordance evaluation: A Canadian experience.
Authors: Vu Kathy , Hertz Sherrie , Green Esther , Kaizer Leonard , Trudeau Maureen E. , Simanovski Vicky , Lischka Andrea
Published: February 2017

179

Background: The safe delivery of chemotherapy is of utmost importance to patients, health care providers and systems administrators. Cancer Care Ontario and the Program for Evidence-Based Care published two guidelines addressing issues of chemotherapy safety: Safe Handling of Parenteral Cytotoxics (Safe Handling) in 2007 and Key Components of Chemotherapy Labeling (Safe Labeling) in 2009. Concordance with the two documents was evaluated across systemic treatment hospitals in Ontario in order to direct quality improvement initiatives. Methods: Since 2009, concordance with Safe Handling has been assessed annually by self-reported questionnaire as part of the regular provincial performance review process. In 2011, concordance with Safe Labeling was assessed by submission and scoring of five standardized chemotherapy labels demonstrating core and additional criteria. Core criteria included patient and drug information, administration information, as well as adherence to other guidelines related to abbreviations and units of measurement. Individualized regional scorecards were compiled highlighting areas of discordance and then used to develop improvement plans. Results: As of October 2011, 98% of Ontario hospitals providing chemotherapy had updated policies and procedures in place for the safe handling of cytotoxics, significantly improved compared to a baseline of 77% in 2009. Baseline evaluation of Safe Labeling performed in 2011 showed a provincial average of 64% concordance for core criteria and 63% for additional criteria. Regionally, concordance scores ranged from 55% to 80% for core criteria and 38% to 75% for additional criteria. Conclusions: Concordance with safety practice guidelines has the potential to improve significantly with continued measurement and performance management. A baseline assessment serves to identify areas for quality and process improvements. Continued evaluation of guideline concordance is necessary in order to achieve the desired target rate for the province.
Implementing patient-centered care: Challenges in community oncology.
Authors: Clifford Kathleen , Tallen Colleen , Davis Mary Helen , Griess Tamara , Zuckerman Dan Sayam , Padgett Lynne
Published: February 2017

192

Background: The newest Commission on Cancer (CoC) standards focus on patient-centered care across the cancer continuum and include palliative care (PC) and psychosocial care (PS). Little is published regarding the challenges of implementing these standards in community oncology settings. To help examine the integration of PC and PS and to identify barriers and best practices, an assessment was conducted by sites selected to take part in the National Cancer Institutes’ Community Cancer Centers Project (NCCCP). Methods: The NCCCP’s goals to improve quality of care and reduce healthcare disparities included goals for expansion of PC and PS services. Volunteers formed workgroups using monthly teleconferences to share best practices and resources. A questionnaire based on the National Quality Forum (NQF) preferred practices was completed (January-April 2012) by 22 of 29 sites. Results: All respondents have inpatient PC available, 65% in the outpatient setting; 39% described PC as an integral part of their cancer program. All have designated outpatient staff providing symptom management and rehabilitation services. Nurse practitioners and physician assistants are used at 78% of the centers. Interdisciplinary staff includes pharmacists and dietitians; integrative/complementary medicine is found in 57% of the centers. All have integrated PS services: social workers are available in 91% of sites, 30% have psychiatrists, and 30% have psychologists. Most perform psychosocial screening using the NCCN Distress Management tool; 74% have standardized processes. Spiritual support is present in 70% of programs, sexual counseling services in 26%. The majority provides bereavement support. 48% have an outpatient advanced directive program. Inpatient hospice beds are available in 52% of the institutions and 22% own a hospice. Conclusions: Challenges remain with implementation of psychosocial screening and care. Programs to address sexual counseling and advanced directives are lacking. Additional efforts are needed to integrate PC services across the cancer continuum. Project funded with federal funds from the NCI, Contract No. HHSN261200800001E.
Treatment patterns of castration-resistant prostate cancer: A retrospective claims database analysis.
Authors: Burton Tanya , Teitelbaum April H. , Bui Cat N. , Spalding James Robert
Published: February 2017

198

Background: Prostate cancer is the most commonly diagnosed malignancy among men in the US; mortality rates are highest among those with castration-resistant prostate cancer (CRPC). Observational data on CRPC are limited. This study examined CRPC treatment patterns relative to NCCN guidelines in a large US health plan. Methods: This was a retrospective claims database analysis of commercial and Medicare Advantage enrollees with evidence of prostate cancer (ICD-9: 185.xx) between 07/01/06 – 03/31/11. CRPC patients were then identified based on prostate-specific antigen (PSA) progression (≥2 PSA increases based on ≥3 PSA values) and/or use of chemotherapy: docetaxel (DOC), mitoxantrone (MIT), estramustine (EST), or cabazitaxel (CAB). The CRPC index date was the first date of PSA progression or chemotherapy. Patients were continuously enrolled for 6 months before (baseline) and ≥6 months after the index date until 09/30/2011 or until death, if sooner (follow-up). Results: A total of 1651 patients met the CRPC selection criteria. Mean (SD) age was 70 ± 9 years, 1085 (66%) received DOC on the index date, and 467 (28%) died during follow-up. A third of patients with DOC received additional CRPC therapy during follow-up: 160 (15%) received MIT, EST, or CAB, and 239 (22%) received a secondary hormonal therapy (SHT: antiandrogens, aminoglutethimide, GnRH/LHRH antagonists, estrogen, or abiraterone acetate). Among 566 patients without DOC, 99 (17%) received a different chemotherapy (MIT = 45; EST = 52; CAB = 2), and 178 (31%) received a SHT. More than half 311 (55%) without DOC did not receive any other CRPC therapy during follow-up, of which 40 (13%) received bone-directed therapy (BDT: denosumab = 0; bisphosphonates = 27; radiation = 13). Conclusions: Consistent with NCCN guidelines, DOC was the most commonly used therapy. However, two-thirds of patients with DOC and over half of patients without DOC did not receive additional CRPC therapy after the index date. In addition, only 13% of patients with no CRPC therapy received any follow-up BDT. Additional research is warranted to understand whether clinical rationale, patient preference, or access to care may have resulted in patients not receiving additional therapy.
Chronic hepatitis B virus screening prior to rituximab: A quality improvement project.
Authors: Mahajan Raina , Jang Sekwon
Published: February 2017

199

Background: Patients’ with chronic hepatitis B (HBV) are at risk for HBV reactivation and liver failure with initiation of rituximab therapy. HBV testing prior to rituximab for patients with non-Hodgkin lymphoma was a quality measure for the American Society of Clinical Oncology’s Quality Oncology Practice Initiative in Spring 2011. Methods: We assessed the pre-intervention HBV screening rate retrospectively from July 2009 to July 2011. Patient demographics, pathology, regimen, and prescriber were abstracted from the electronic medical record. Screening was complete if serum HBVsurface antigen was checked within 3 months prior to rituximab. A quality improvement (QI) intervention was initiated and all prescribers were informed of the screening rate in December 2011. Post-intervention, patients who received rituximab from January 2012 to July 2012 were identified and the same data was abstracted. HBV screening rates across categories pre and post-intervention were analyzed with Fisher’s exact test and multivariate logistic regression analysis. Results: A total of 146 patients (127 pre-intervention, 19 post-intervention) were included. There were more male and rituximab combination therapy in the post-intervention group. The HBV screening rate increased from 59% to 90% (p<0.01) after our QI project. In univariate analysis, factors associated with HBV screening were (1) prior treatment with rituximab (no: 72% vs. yes: 46%, p<0.01), (2) treatment regimen (rituximab alone: 68% vs. combination: 42%, <0.01) and (3) prescriber (full time: 69% vs. part time: 7%, <0.01) In multivariate logistic regression analysis, the odds of HBV screening increased 4.8 times in the post-intervention group compared to pre-intervention group although this was statistically not significant (p=0.07). Prior rituximab (Odds Ratio (OR) 0.4, 95%CI 0.2-0.9), combination regimen (OR 3.2, 95% CI 1.5-7.2), and full-time prescriber (OR 25.1, 95% CI 2.8-255.4) were statistically significant for HBV screening. Conclusions: The HBV screening rate improved after QI intervention although statistically insignificant in multivariate analysis. We identified characteristics associated with low screening rates which will guide future QI strategy.
Predictors of failure to perform pelvic peritoneal cytology in endometrial cancer staging surgery.
Authors: Lopez-Acevedo Micael , Zhang Chelsea , Secord Angeles Alvarez , Lee Paula S. , Havrilesky Laura Jean , Berchuck Andrew
Published: February 2017

201

Background: The Federation of Gynecology and Obstetrics (FIGO) staging system and the National Comprehensive Cancer Network (NCCN) guidelines for endometrial cancer recommend performing pelvic peritoneal cytology to look for the presence of cancer cells in the peritoneal cavity in patients who are undergoing surgical staging of apparent non-metastatic disease. About 10% of cases have positive cytology and this information is used in formulating plans for adjuvant therapy. However, adherence to the guidelines recommending that cytology be performed is not universal. In this study, we sought to identify factors associated with failure to perform pelvic peritoneal cytology at the time of endometrial cancer staging surgery. Methods: We performed a retrospective study of women with FIGO stage I/II endometrial adenocarcinoma who underwent endometrial cancer staging surgery at our institution from 1993-2007. Predictors of failure to perform cytology that were investigated included: surgeon, presence of adhesions, intraoperative blood loss and conversion from laparoscopy to laparotomy. Results: Among 1,112 cases, peritoneal cytology was not performed in 76 (6.8%). In 30 cases cytology was not performed for valid reasons including 15 in which the surgery was performed vaginally, 10 in which the diagnosis of endometrial cancer was not known prior to surgery and 5 in which gross evidence of stage III/IV disease was found at surgery. Of the remaining 46 cases, 11 (23.9%) had surgery that was converted from laparoscopy to laparotomy, 16 (34.8%) had dense pelvic adhesions and 40 (87.0%) had an estimated blood loss greater than 100 ml. The frequency of these and other risk factors will be compared to that seen in a matched cohort of patients who did have pelvic peritoneal cytology performed. Conclusions: Our analysis will investigate predictors of failure to perform pelvic peritoneal cytology. Increased awareness of these factors has the potential to improve compliance with this accepted procedure that plays a role in planning adjuvant therapy for early stage endometrial cancer.
Driving performance improvement using ASCO’s Quality Oncology Practice Initiative (QOPI).
Authors: Darland Shelby , Burnham Christa , Camilo Nicolas , Beck Thomas M. , Zuckerman Dan Sayam
Published: February 2017

203

Background: Defining and quantifying quality care is a challenge for cancer care providers. Since 2007 St. Luke’s Mountain States Tumor Institute (MSTI) has been participating in QOPI and was one of 23 practices that received the inaugural QOPI Certification in June 2010. The goal of participation is to benchmark MSTI’s performance with oncology practices across the nation and identify areas for improvement that are recognized as national quality standards. Methods: After each round of QOPI data abstraction, physician and administrative leadership selected measures with the greatest opportunity for improvement. Monthly chart audits for each measure were completed and the results were shared with individual staff to increase education and accountability. In Spring 2010, the education assessment in MSTI’s Electronic Medical Record (EMR) was redesigned to facilitate efficient documentation and data collection of smoking cessation counseling. In July 2011, the performance improvement (PI) team created “Quality Checklists (QCL)” in MSTI’s EMR for three different QOPI measures: i) signed chemotherapy consent, ii) smoking cessation counseling, and iii) assessment of emotional well-being. To ensure signed chemotherapy consent, one QCL included a reminder sent by the primary nurse or secretary to the chemotherapy infusion nurses. To ensure smoking cessation counseling and assessment of emotional well-being by social work, the other QCL included an alert sent by the new patient representative to the primary nurse and social worker. Results: Signed chemotherapy consent improved from 10% (n=229) in 2007 to 100% (n=117) in 2012. Smoking cessation counseling improved from 13% (n=40) in 2007 to 93% (n=272) in 2012. Assessment of emotional well-being improved from 78% (n=302) in 2007 to 95% (n=120) in 2012. Of the patients that had problems with emotional well-being, 73% (n=55) in 2007 had their problems addressed and 95% (n=41) in 2012. Conclusions: QOPI has provided MSTI with the initiatives and benchmarks to quantify quality cancer care. By combining participation in QOPI and ongoing PI data collection, analysis, and action plan implementation MSTI has enjoyed marked improvements in quality.
The effect of care at NCI comprehensive cancer centers on disparities in outcome in adolescents and young adults (AYAs) with cancer.
Authors: Wolfson Julie Anna , Sun Can-Lan , Kim Heeyoung , Kang Tongjun , Bhatia Smita
Published: February 2017

217

Background: AYAs (15-39y at diagnosis) with cancer have not seen the survival improvement evidenced by younger and older age groups with similar diagnoses, leaving an AYA Gap. While treatment on pediatric protocols is associated with superior survival in 15-21y, impact of site of care on survival for vulnerable AYA subpopulations (race/ethnicity) between 22-39y at diagnosis remains unstudied. Methods: Utilizing a cohort of 10,602 AYAs newly diagnosed between 22-39y with lymphoma, leukemia, brain tumors, melanoma, thyroid and GU cancers, and reported to the Los Angeles County cancer registry between 1998 and 2008, we aimed to determine the impact of receiving care at NCI Comprehensive Cancer Centers (NCICCC) on overall survival for AYAs, and disparities in survival by race/ethnicity. We further aimed to understand the role of SES and insurance status in accessing care at NCICCC. Multivariable analyses included race/ethnicity, age at diagnosis, SES, insurance status, primary cancer diagnosis and diagnosis year in the model. Results: A total of 904 (9%) patients received treatment at the 3 NCICCC (City of Hope, Jonsson Cancer Center, and Norris Cancer Center) in LA County. Ten-year overall survival (10y OS) was significantly worse for patients treated at non-NCICCC (81%) when compared with those treated at NCICCC (83%, p=0.02). Also, 10y OS was worse for African Americans (AA) (68%) vs. non-Hispanic whites (86%, p<0.0001). Multivariable analysis adjusting for SES, insurance status, diagnosis and diagnosis year revealed that AA (HR=1.5, p=0.0001) were at an increased risk of death. Among patients treated at NCICCC, the difference in risk of death due to race (HR=0.9, p=0.84) was abrogated. However, among patients treated at non-NCICCC, these differences in outcome persisted (HR=1.48, p<0.0001). Independent of SES, insurance and tumor factors, AA (OR=0.44, p<0.001) were less likely to use NCICCC. Conclusions: Population-based data reveal that receipt of care at an NCICCC abrogates the inferior outcome observed among AA with cancer. AA are less likely to use NCICCC for treatment. Barriers to accessing care at NCICCC are currently being explored.
Frequency of physician misconceptions that may drive underuse of radiotherapy (RT) in patients with breast cancer.
Authors: Zhou Jessica , Hawley Sarah T. , Zikmund-Fisher Brian , Janz Nancy K. , Griffith Kent A. , Sabel Michael S. , Griggs Jennifer J. , Katz Steven J. , Jagsi Reshma
Published: February 2017

237

Background: Registry studies suggest underuse of RT for breast cancer, especially after mastectomy. Because radiation oncology is referral-based, knowledge and attitudes of upstream providers may influence patients’ RT decisions, including whether they even consider it. Methods: We surveyed a random sample of 750 medical oncologists (MO) and 750 surgeons (S) drawn from the AMA Masterfile in 2012; 895 responded. We analyzed responses to scenarios in which RT should be considered from the 766 (403 S, 363 MO) who had seen breast cancer patients in the past year. Results: Mean age was 52; 36% worked in a practice with an academic affiliation. 84% of MO and 64% of S saw more than 10 breast cancer patients in the previous year (p<0.001). 44% participated in multidisciplinary breast clinics. In a 45 yo T1cN0 ER+/PR+/HER2- patient receiving lumpectomy and tamoxifen, half of respondents substantially underestimated the 10-year risk of locoregional recurrence without RT. 19% of MO and 38% of S did not know that guidelines recommend RT in that case, but reassuringly, almost all would refer the patient to radiation oncology (97%). Referral to radiation oncology was less common for node-positive patients after mastectomy; however, in a T1cN1 patient with 2/20 nodes s/p mastectomy (in whom guidelines state that RT should be strongly considered), only 53% of MO and 34% of S recommend RT; 29% of MO and 43% of S would not refer to radiation oncology. If 4/20 nodes were involved (where RT is clearly guideline-recommended), 94% of MO but only 79% of S would recommend RT, and 9% of S would not refer to radiation oncology. The majority (53% of MO, 68% of S) substantially underestimated the risk of LRR in a patient with pN2 disease after mastectomy without RT. Fewer than half knew that the EBCTCG meta-analysis revealed a survival benefit from RT after lumpectomy (45%) or mastectomy (47% of MO, 32% of S, p<0.001). Only 66% of MO and 54% of S recognized the 10-year risk of RT-induced second malignancy to be <1%. Conclusions: Many MO and S who treat breast cancer patients have misconceptions relevant to RT decision-making. Educational interventions targeted towards referring providers may improve the quality of care received by breast cancer patients.
Uncertainty in the management of thyroid cancer.
Authors: Haymart Megan , Banerjee Mousumi , Yang Di , Stewart Andrew , Sisson James , Koenig Ronald J. , Doherty Gerard M. , Griggs Jennifer J.
Published: February 2017

238

Background: Little is known about treatment practices in thyroid cancer, a cancer that is increasing in incidence. We sought to identify aspects of thyroid cancer management that have the greatest variation and thereby uncertainty in management. Methods: We surveyed 944 physicians involved in thyroid cancer care from 251 hospitals affiliated with the U.S. National Cancer Database. Using vignettes and additional survey items, physicians were asked questions in the following four domains: thyroid surgery, radioactive iodine use, thyroid hormone replacement post-surgery, and long-term thyroid cancer management. To identify aspects of thyroid cancer management with the greatest uncertainty, we calculated the ratio of observed variation to hypothetical maximum variation under the assumed distribution of the response. Ratios closer to 1 indicate greater uncertainty. Results: There is large uncertainty in multiple aspects of thyroid cancer management, including the role of central lymph node dissections, the role of pretreatment scans before radioactive iodine treatment, and all aspects of long-term thyroid cancer management, including applications of ultrasound and radioactive iodine scans. For the management of small thyroid cancers, uncertainty exist in all domains, including optimal extent of surgery and the role of both radioactive iodine treatment and suppressive doses of thyroid hormone replacement. Conclusions: We identified areas of uncertainty in thyroid cancer management. Since both a lack of data and a lack of acceptance of the existing data may be contributing to the variation demonstrated, to improve the management of thyroid cancer there is a need for more research and more research dissemination.
Social disparities in perceived coordination of care and use of chemotherapy among patients with stage III colorectal cancer.
Authors: Morris Arden M. , Griggs Jennifer J. , Davis Rachel , Banerjee Mousumi , Abrahamse Paul , Ward Kevin , Kato Ikuko , Hawley Sarah T.
Published: February 2017

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Background: Our prior work demonstrated low uptake of chemotherapy among advanced stage rectal cancer patients and significantly lower uptake among minorities. Underuse of chemotherapy is associated with decreased survival. In this analysis, we hypothesized that health system factors such as inadequate coordination of care contribute to under-use of chemotherapy among minority and low socioeconomic status (SES) patients. Methods: We performed a population-based survey of all stage III colorectal cancer patients diagnosed in the State of Georgia and Metropolitan Detroit SEER catchment areas. Our outcomes of interest were perceived care coordination and self-reported use of chemotherapy. Independent variables included clinical and demographic factors. We used chi square analyses to assess associations between patient characteristics, coordination of care, and use of chemotherapy. Multiple linear regression examined relationships between SES, coordination of care, and use of chemotherapy after adjusting for age, sex, and comorbidity. Results: In preliminary analyses, 215 patients have completed the survey (initial response rate of 60%). To date, most participants have reported good-to-excellent coordination of care (mean=4.3 on scale of 1-5), and care coordination did not differ by clinical or demographic factors. Those who perceived better care coordination were more likely to receive chemotherapy (p<0.001). Respondents with high school education or less had significantly lower uptake of chemotherapy relative to their counterparts (71% vs. 89%, p=0.005), and this difference was significant even when adjusting for coordination of care. Conclusions: SES, in particular education level, was associated with both coordination of care and with receipt of chemotherapy. If these findings are confirmed in our larger sample, we will be able to identify targets for health system intervention and improvement.
Use of diagnostic testing for patients with early-stage breast cancer in a multi-hospital quality collaborative in Michigan.
Authors: Breslin Tara M. , Kubus James , Ali Haythem Y. , Singh T. Trevor , Adams Paul T. , Applewhite Angela , Mehringer Ann M. , Silver Samuel M.
Published: February 2017

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Background: In 2012, ASCO identified five opportunities to improve the quality of cancer care and reduce costs. Two of these recommendations focused on limiting use of advanced diagnostic imaging with computed tomography (CT), Positron Emission Tomography (PET), and radionuclide bone scans (BS) at diagnosis and during surveillance for women with early stage breast cancer with a low risk of metastasis. We describe the use of diagnostic imaging among patients with early stage breast cancer treated at hospitals in Michigan. Methods: The Michigan Breast Oncology Quality Initiative is a collaboration between Michigan hospitals, the University of Michigan Comprehensive Cancer Center, and the National Comprehensive Cancer Network (NCCN). This collaborative collects longitudinal demographic, staging, treatment, and follow up data using the NCCN Breast Outcomes Database platform. We analyzed use of advanced diagnostic testing with CT, PET, BS and contrast it with use of traditional imaging (mammography/ultrasound) at diagnosis and during follow up in patients with stage 0, I, II breast cancer between 1998 to 2009. Patients who died or recurred were excluded. Results: The cohort included 7,632 patients (19.6% stage 0, 48.1% stage I, 32.3% stage II) treated at 17 hospitals. Use of traditional imaging was documented in nearly 100% of patients at diagnosis and throughout the follow up period. With respect to advanced diagnostic imaging, 20.3 % underwent CT, 4.7% underwent PET, and 11.6% underwent BS at diagnosis. Advanced testing use decreased over time (Table). Conclusions: Despite published guidelines, which recommend against their routine use, advanced diagnostic imaging use was prevalent among patients treated for early breast cancer at MiBOQI hospitals. Education efforts should target physicians and patients on the lack of proven benefit and potential risks of using advanced diagnostic imaging in this population. [Table: see text]
Development of quality indicators for treatment of ductal carcinoma in situ (DCIS) of the breast using a multidisciplinary Delphi process.
Authors: Quan May Lynn , Ghali William , Craighead Peter S. , Bryant Heather E.
Published: February 2017

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Background: Ductal carcinoma in situ (DCIS) of the breast accounts for ~30% of new breast cancer diagnoses. Measuring quality of DCIS treatment is problematic due to its distinctively different clinical behaviour from invasive breast carcinoma, where standard outcomes such as mortality are not relevant. Therefore, we sought to develop clinically relevant quality indicators to evaluate treatment of DCIS. Methods: A Delphi consensus process was undertaken using a multidisciplinary panel of nine clinical and methodologic experts from Ontario, Alberta, and British Columbia. Panel members were nominated based on membership in provincial breast tumour site groups. Four criteria for a good quality indicator were used; the indicator measures a treatment that benefits the patient, there is support from scientific literature or professional consensus for benefit; the indicator is under control of the health care provider, the indicator is extractable from the medical record. Candidate indicators were identified from published clinical practice guidelines in North America. Three iterations of ratings using Likert scale rankings were utilized to identify final quality indicators, which were then prioritized. Results: A total of 10 candidate indicators were identified from four clinical practice guidelines encompassing the diagnosis, surgery and adjuvant treatment components of DCIS. A total of eight indicators were identified and prioritized (Table). Conclusions: We successfully developed practical quality indicators for evaluating the treatment of DCIS, which can be used in any jurisdiction to measure key performance benchmarks and identify variations in care warranting intervention or improvement. [Table: see text]
The oncology palliative care matrix: A community-derived evaluation tool for constructing oncology palliative care programs.
Authors: Padgett Lynne
Published: February 2017

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Background: While the Institute of Medicine and the Center to Advance Palliative Care have provided the impetus for many cancer centers to build palliative care programs, guidance regarding the “nuts and bolts” of program development is lacking. The Oncology Palliative Care Matrix (OPCM) is a unique self-assessment tool designed to facilitate both program evaluation and planning for provision of oncology palliative care. Methods: The National Cancer Institute Community Cancer Centers Program (NCCCP) Palliative Care Working Group developed the OPCM to assess palliative care capacity. The tool covers 17 components associated with quality palliative care delivery (e.g., staff training, patient identification, advanced care planning, attention to spiritual care). All NCCCP sites (16 enrolled in 2007, 14 enrolled in 2010) completed the matrix in 2010 evaluating their capacity with respect to each of these domains at the following time points: baseline (entry to the NCCCP program), 2 years after NCCCP enrollment (2007 sites only), and the upcoming year (goals for the future). Results: At baseline, matrix responses reflected variability in service capacity across the 17 domains. Reported capacity for specific palliative care components improved for the 2007 sites after 2 years in NCCCP; all sites identified ‘reach’ goals for the coming year. For example, at baseline, 63% of 2007 sites and 50% of 2010 sites referred only patients at end-of-life or with advanced disease and severe symptoms for palliative care services. However, after 2 years in NCCCP, 44% of 2007 sites still referred only these patients, while 56% made referrals to palliative care for patients at all cancer stages and/or as needed during post-treatment. Further, 100% of 2007 sites and 86% of 2010 sites aspired to this expanded referral capacity in the future. Conclusions: The OPCM shows utility in the community setting for self-assessment of capacity and strategic planning to improve quality palliative care delivery. It also highlights that some components of quality care may be easier to achieve/improve (e.g., referral for palliative care) than others (e.g., regular symptom assessment, palliative care staff support).