bluuebunny/crossref_metadata_2025 huggingface dataset:
Measuring the impact of chemotherapy cost discussions between patients and providers at the time of prescribing.
Authors: Kelly Ronan Joseph , Forde Patrick M. , Bagheri Ashley , Ahn Jenny , Forastiere Arlene A. , Frick Kevin D. , Rosner Gary L. , Dy Sydney Morss , Smith Thomas J.
Published: February 2017

257

Background: In 2007, the ASCO Cost of Care Task Force was established to deal with the soaring costs of cancer treatment in the United States. One of the key recommendations was that the cost of chemotherapy should be introduced into the patient-physician discussion from the outset. It is unknown if these discussions are occurring in academic Institutions and what if any is the impact on the doctor/patient relationship. Methods: The National Comprehensive Cancer Network (NCCN) Guidelines and the Eviti advisor platform were jointly used in an academic oncology center during the patient/doctor consultation to demonstrate treatment options to patients and display the costs at the time of prescribing to providers and patients alike. Questionnaires measured oncology providers attitudes to cost discussions and assessed physician satisfaction with the shared decision making process when costs are introduced into the patient/doctor relationship. Patients were interviewed before and after their doctor consultation to measure their satisfaction with the process using modifications of the shared decision making scale, satisfaction with decision scale and decisional conflict scale. Basic descriptive statistics were applied. Results: Only 5/18 oncologists (28%) reported feeling comfortable discussing costs with patients and just one (6%) admitted to regularly asking patients about financial difficulties. The majority (83%) of doctors reported that the NCCN guidelines should contain cost information. Seventy-one patients (42 females, 29 males) with metastatic breast (27%), lung (49%), and colorectal cancer (24%) have been interviewed. Interestingly, 70% of patients responded that no health care professional has ever discussed costs with them despite 57/71 (80%) rating this as very important information. The majority of patients (75%) had no negative feelings to hearing cost information. Only 4% admitted to developing significant negative feelings. Conclusions: In an era of rising co-pays, patients want cost of treatment discussions and these do not lead to negative feelings in the majority of patients. Additional training to prepare clinicians for how to discuss costs with their patients is needed.
Physician data review to reduce cost per case and ALOS.
Authors: Schreiner Susan , Franco Theresa
Published: February 2017

268

Background: Reducing costs in health care is critical due to declining reimbursement. Physicians are often unaware of how their practices affect the cost of patient care and may have difficulty in making changes. The leadership of the Cancer Service Line believed a more targeted approach in sharing data would improve physician understanding and engagement to assist in greater standardization and cost reduction. Methods: An education and communication strategy was developed that involves the leadership of each specialty section of oncology. A dashboard was created with metrics such as clinic visits, surgical volume, cost per case, average length of stay, and net income. The data is presented in monthly, quarterly and annual time frames with trends to highlight progress and identify areas for improvement. Monthly meetings are conducted with key stakeholders to obtain critical feedback. Results: Consistent data has increased physician understanding of clinical businesses the business is doing and has prompted them to optimize clinical schedules and improve operational efficiencies. Outpatient and inpatient data regarding cost per case, ancillary costs, pharmaceutical usage, blood product utilization, and drug exchanges has driven practice changes. The ALOS is at almost an entire day below benchmarks and direct cost per case is at budgeted target. Standardization has occurred in the use of blood products and there has been an intentional shift of some interventions to the outpatient arena. Conclusions: The implementation of a robust education and communication strategy have resulted in active engagement and participation of physicians, significant practice changes in cancer care and heightened understanding of the relationship of practice to cost. A dashboard that trends relevant metrics shared at regular intervals with key providers impact the cost of cancer services without affecting the quality.
A systematic literature review of the impact of 5-HT3RA use on health care utilization in patients with chemotherapy-induced nausea and vomiting in the United States.
Authors: Broder Michael S. , Faria Claudio , Powers Annette , Sunderji Jehangeer , Cherepanov Dasha
Published: February 2017

269

Background: Uncontrolled chemotherapy-induced nausea and vomiting (CINV) can lead to nutrient depletion, diminished function, disruption of chemotherapy, and increased costs. Standard antiemetic therapy includes 5-HT3RAs for CINV prophylaxis, with palonosetron recommended in National Comprehensive Cancer Network (NCCN), Multinational Association of Supportive Care in Cancer (MASCC), and ASCO guidelines as the preferred 5-HT3RA for CINV prophylaxis with MEC. There is evidence that using 5-HT3RAs can reduce costs but no comprehensive review of the evidence is available. Methods: We searched MEDLINE, National Institute for Health Research (NIHR), Centre for Reviews and Dissemination (CRD databases, 4 conferences (Academy of Managed Care Pharmacy, ASCO, International Society for Pharmacoeconomics and Outcomes Research, MASCC), and bibliographies of included articles. We queried Medical Subject Headings (MeSH) and key terms: “ondansetron,” “granisetron,” “palonosetron,” “dolasetron mesylate,” “costs,” “cost analysis,” and “economics.” Included records reported data on cost/utilization (rescue medication, outpatient/inpatient services) related to 5-HT3RA use for CINV in English, in human subjects, and published after 1997. Results: Of the 433 identified records, the 16 reporting utilization in the US were reviewed (excluded: 29 duplicates, 388 off-topic records). Studies varied significantly in designs, patients, 5-HT3RA regimens, and definition of outcomes. Twelve studies reported rescue medication use for CINV in patients using different 5-HT3RAs. In 5 studies, fewer patients treated with palonosetron required rescue medication versus ondansetron users (56% vs. 61%, 28% vs. 83%, 14% vs. 24%, 8% vs. 11%, 6% vs. 11%); 2 studies found palonosetron users had fewer outpatient services versus ondansetron users (5% vs. 10%, 8% vs. 10%). Four studies, with a variety of patients and outcomes, reported fewer patients treated with palonosetron versus ondansetron or other 5-HT3RAs used inpatient care (e.g., 0.2% vs. 0.4%, 16% vs. 23%, 7% vs. 10%, 0% vs. 5%), while 2 studies reported similar use (1% vs. 1%, 0% vs. 0%). Conclusions: CINV prophylaxis with palonosetron is generally associated with lower use of rescue medications, outpatient and inpatient services compared to ondansetron or other 5-HT3RAs. Use of palonosetron as a standard treatment may lead to reduced utilization of rescue medications and healthcare services for CINV and subsequent cost savings.
Risk factors for the development of chemotherapy-related hospitalization (CRH) in patients treated with palliative intent: Results of a 9-year nested case control study.
Authors: Kansagra Ankit J , Brooks Gabriel , Gao Jenny Hong , Jamali Layli , Kundi Meenakshi , Saini Neeraj , Stankiewicz Rosemary , Rao Sowmya R , Linden Erica Ann , Jacobson Joseph O.
Published: February 2017

3

Background: Palliative chemotherapy is aimed at improving quality of life and increasing life expectancy, without curative intent. Toxicity during palliative treatment defeats the goal of care and increases healthcare cost. We describe the predictors of CRHs among cancer patients treated for palliative intent at a community cancer center. Methods: We conducted a nested case-control study of adult cancer patients who received chemotherapy from Jan 03 to Dec 11. Utilizing a pharmacy database we identified patients who had received chemotherapy for palliative intent. For quality measures cancer center prospectively collects data on all the patients who developed CRH, which was used to identify cases. Hospitalizations were classified as CRH, disease-related or unrelated by a multidisciplinary panel. We frequency matched 2 controls to per case on lines of their chemotherapy treatment (3 groups). We obtained odds ratios (OR) and 95% confidence intervals (CI) from a multivariable logistic regression model on this set of 199 cases and 398 controls to identify predictors of CRH. A two-sided p-value of 0.05 was used for all measures of statistical significance. Results: During the selected period 6,850 patients received chemotherapy, 2,559 (37.3%) for palliative intent. 230 (9%) of 2,559 developed CRH. 76.5 % of CRH happened during the first 3 cycles of chemotherapy, and the mean length of stay was 5 days. Significant predictors on multivariable regression were ECOG score (p = .03), Charlson score (p= .0018), cancer site (p <.006,) abnormal creatinine (p <.0001) and low albumin (p < .007). Conclusions: The results of this mature study demonstrate that patients treated with palliative chemotherapy have a substantial risk of severe hospital-requiring toxicity resulting in morbidity and cost. The finding that risk of severe toxicity is increased among patients with poor PS, multiple comorbidities and renal insufficiency suggests that some events may be avoidable. Furthermore, identified risk factors will enable the development and testing of a predictive model which could be used to identify patients at high risk of CRH prior treatment initiation.
Implementing an oncology-specific health care IT portal to enhance patient-provider communication.
Authors: Patt Debra A. , Trageser Jennifer , Howard Jeffrey A. , Rush Max , Heiman Cara , Yalamanchili Rajesh , Lodder Daniel , Neiman Julie , Khang Hk , Langer Lucy R. , Schwartz Rowena , Ahmad Asif
Published: February 2017

31

Background: Our large network of oncology practices (PRs) launched a health IT (HIT) patient portal (PP) to improve patient (PT) access to clinical information (CI) and serve as a platform to enhance PR-to-PT communication (C). Methods: A team of HIT specialists and oncologists engaged in development of the PP to develop a platform to facilitate PR-to-PT C, satisfy meaningful use (MU) requirements, and have brand identification (ID) for PRs. Workflow planning for implementation was conducted including ID and education of key participants at PRs. Educational signage was posted at PRs during initiation partnered with information at check-in at clinic visits to inform PTs about PP benefits and registration steps. After consent was obtained, pts were invited by email to the PP and could access their PP and view and download their secure CI. A review of support calls from both PR personnel and pts highlighted opportunities for enhanced PP engagement. Enrollment (E) was captured monthly. Results: From April 2012 to June 2013 more than 34,000 pts have enrolled in the PP across over 47 PRs (Table). In addition, inclusion of the PR brand and removing extraneous data capture during E are critical to success. Comparing E data from April 2012 to April 2013 after increased PR brand ID and reduction of pt validation changes were implemented, there was an increase of 13% of opened Is and 22% increase in Es. Conclusions: By engaging a development team, and strategically planning content dissemination and education around initiation, implementation of the PP was widely utilized throughout the PRs. By monitoring adoption rates and capturing the PT feedback, incremental enhancements can positively affect PT engagement with PRs. This functional mechanism can now serve as a platform to facilitate C between PRs and PTs, fulfill MU requirements, and plan future dissemination of educational content. [Table: see text]
Bridging to survivorship in breast cancer: How BMI weighs in.
Authors: Espirito Janet L. , Turnwald Brian , Harrell Robyn K. , Bhowmik Debajyoti , Denduluri Neelima , Brooks Barry Don , Hoverman J. Russell , Patt Debra A.
Published: February 2017

32

Background: Obesity and depression complicate survivorship in early stage breast cancer (BC) by having a direct impact on survival and morbidity among patients (pts) who complete treatment (tx). The prevalence of obesity after BC tx in the community and concordance with BC tx type is poorly described, but important as we characterize risks of tx and optimize goals for survivorship care planning. Methods: We queried the electronic health record (EHR), iKnowMed, from a large network of community oncology practices for pts diagnosed with stage I-III BC from 2007-2010 with at least 5 office visits and follow up through 11-2012 for our retrospective study. We excluded pts who developed metastatic disease or died. We stratified pts by chemotherapy (CT) utilization (yes/no), hormone receptor (HR) status, age, and documented body mass index (BMI) at first office visit and annually. We evaluated changes in BMI characteristics by tx cohort. Results: We identified 8,506 pts with a documented BMI at first office visit and 1, 2, and 3 years (yrs) thereafter. 4,369 (51% of the total) pts received adjuvant CT and 4,137 (49%) did not. 6,897 pts (81%) were HR positive. Baseline BMI between tx cohorts were similar, though the prevalence of overweight (31%) and overweight or obese (68%) is high. Percent change of BMI at 3 yrs varied significantly between T cohorts (p<0.01) with greater rise among the cohorts who received CT in comparison to those who did not. Pts receiving CT were 46% more likely to have a 5 point or more increase in BMI at 3 yrs compared to pts that did not receive CT (OR 1.46, CI[1.08-1.96]). A stronger association for BMI increase of at least 0.5 points at 3 yrs (OR 1.53, CI [1.4-1.7]) was also observed amongst pts who received CT compared to those that did not. HR positive pts were less likely than HR negative or unknown pts to increase their BMI by at least 0.5 points (OR 0.84, p<0.01), but there was no difference at detecting a difference of 5 points in BMI (OR 0.88, p=0.49). Conclusions: With 3 yrs of follow up, overweight and obese status is remarkably common among BC survivors in the community and appears to be more prevalent after CT tx. Determinants of obesity require further study and point to necessary intervention to improve the health of early stage BC pts.
Bridging to survivorship in breast cancer: Learning how treatment impacts mental health among early-stage breast cancer survivors.
Authors: Patt Debra A. , Espirito Janet L. , Harrell Robyn K. , Turnwald Brian , Bhowmik Debajyoti , Brooks Barry Don , Denduluri Neelima , Hoverman J. Russell
Published: February 2017

33

Background: Depression (D) and anxiety (A) complicate survivorship in breast cancer (BC) patients (pts). The prevalence of D and A after BC treatment (Tx) in the community and concordance with BC Tx type is poorly described, but vitally important to characterize risks of Tx and optimize support for BC pts and goals for survivorship care planning. Methods: We queried the electronic health record (EHR), iKnowMed, from a a large network of community oncology practices for pts treated with stage I-III breast cancer from 2007-2010 with at least 5 visits and follow up through 2012 for our retrospective study. We excluded pts who developed metastatic disease or died. We stratified pts by chemotherapy (CT) utilization (yes/no),hormone receptor (HR) status, age, and documented body mass index (BMI) at diagnosis, and post diagnosis development of D (y/n), A (y/n) or utilization of venlafaxine (E) like antidepressants (Ads), non-E like Ads or anti-A medications within the study period. Time to onset of A or D was analyzed using Cox proportional hazard methodology. Results: We identified 8,506 patients with a documented BMI at 1, 2, and 3 years (yrs) post diagnosis. 4,369 (51%) of patients received adjuvant CT and 4,137 (49%) did not. Baseline characteristics were similar between tx groups, and active D or A was low at the time of dx, but as a whole rose to 41% during the study period. Pts with pre-existing D or A at the time of diagnosis were excluded. CT increases the risk of D or A (HR: 1.23, CI: 1.15-1.33). HR+ status also increases the risk of D or A (HR: 1.21, CI:1.11-1.32). Age conveyed a small diminished risk of D or A (HR: 0.98, CI: 0.98-0.99) while baseline BMI conveyed a small increased risk (HR: 1.02, CI 1.01-1.3). When excluding E like compounds that are often used to treat hot flashes in BC pts, CT was still found to have an increased risk of D or A (HR: 1.28, CI: 1.18-1.39), and HR+ was still associated with higher risk of D or A as well (HR: 1.11, CI: 1.01-1.22). Conclusions: Mental health disorders such as D and A are common among BC survivors, and more prevalent among BC survivors who received CT and have HR+ disease. This warrants further investigation on how to evaluate and support the mental health needs of BC survivors.
Design, implementation, and assessment of a metrics management system for quality improvement studies.
Authors: Samedy Patrick
Published: February 2017

34

Background: Research and quality improvement studies often involve an extensive amount of manual review of medical records. The effective management of this process is critical to the consistent, accurate, and cost effective collection and timely dissemination of quality data. Methods: The purpose of this paper is to introduce “OpenQA”, a data management tool designed specifically to help organize, track, and communicate data related to quality improvement studies. OpenQA is designed with ease of chart abstraction, efficiency of data collection, and data transparency as a goal, while providing reporting that support a range of activities related to data management tasks common to hospital quality management departments. The basic method behind OpenQA is to: (1) Provide a centralized online repository for measure related metadata; (2) automatically identify retrospective and prospective encounters that meet specified study inclusion/exclusion criteria; (3) extract key details from structured and unstructured data sources and then combine them to help quality auditors make compliance decisions; (4) provide a workflow engine that supports work lists, alerting and a feedback mechanism for metric stakeholders; (5) provide audit tracking to enable measurability of data collection efforts. Results: Favorable effects were realized post implementation across all measures of performance despite an increase in case volume. Results indicate a decrease in median audit turnaround time, defined as the time between the patient encounter and a decision is made by the auditor, by 23 days (85%). Results also indicate a decrease in the audit reporting turnaround time, defined as the time between the patient encounter and the compliance decision is made and reported. Both reductions were significant at a p value of < 0.05. Conclusions: We suggest that a tool designed to help streamline and standardize the quality improvement data collection process may offer the advantage of minimizing the resource utilization associated with data collection while improving data integrity and shortening the feedback loop.
Prevalence and predictors of online patient access to electronic medical records among patients with cancer.
Authors: Laccetti Andrew L , Yan Jingsheng , Cai Jennifer , Gates Samantha , Xie Yang , Lee Simon Craddock , Gerber David E.
Published: February 2017

35

Background: Although the impact of patient access to health records and providers has not been well studied in cancer populations, these applications are now widely employed at cancer centers nationwide. Understanding implications of this practice in cancer patients is critical as patient-reported symptoms may be more likely to represent medical emergencies and test results may be more likely to represent major clinical developments. Methods: Retrospective analysis of enrollment in and use of MyChart, an internet-based patient portal for the EPIC electronic medical record, among patients seen at the Harold C. Simmons Cancer Center at UT Southwestern Medical Center. Predictors of MyChart use were analyzed through univariate and multivariate regression models. Results: A total of 6,495 patients enrolled in MyChart (2006-2012). Mean age was 60 ± 13 years, and 67% were female. The number of patients enrolling per year increased more than five-fold - 181 in 2006 to 1,146 in 2012. The total number of MyChart log-ins was 707,746. Per patient, median total log-ins was 57 (range 1-10,347). In a multivariate model, increased MyChart use was associated with male gender (p=0.01) and with cancer type (p<0.001), with highest rates among patients with genitourinary and upper aerodigestive malignancies. The most common MyChart activities were review of laboratory and radiology results (35%), communicating with providers (34%) [including messaging (29%) and medical advice request (5%)], and appointment scheduling/canceling (18%). Eighty-nine percent of log-ins occurred Monday-Friday. Login-times were 8a-5p (72%), 5p-11p (17%), and 11p-8a (11%). Approximately 32% of messaging (40% of medical advice requests) occurred outside clinic hours. Conclusions: Patient use of an internet-based patient health portal at an NCI-designated cancer center increased dramatically in recent years. The most common activities were viewing of test results and messaging with providers. A substantial proportion of messaging, particularly advice requests, occurred outside clinic hours. Further study of this technology is needed to understand its impact on patient safety, patient/provider satisfaction, and quality of care.
Improving code status documentation as a marker of advanced care planning at an outpatient academic cancer center: A pilot project.
Authors: Ranganathan Anjana , Sauerbaum James J. , Green Katie , Sheaffer Heather , Coniglio Mary , Evans Tracey L.
Published: February 2017

38

Background: Advanced care planning can significantly impact the quality of end of life care. Readily accessible documentation of goals of care for patients (pts) known to have a high morbidity and mortality provides a concrete means for practitioners to discuss and guide advanced care planning. We previously reported a surprisingly small proportion of established pts in our oncology clinic with a documented code status (CS), and undertook a pilot project aimed at improving this rate. Methods: Query of the outpatient electronic medical record (EMR) at the Abramson Cancer Center for established pts revealed an average of 2% with a documented CS. Our pilot study focused on 8 providers in thoracic and gastrointestinal oncology. We established provider agreement on the importance of CS documentation, and analyzed the mechanisms in place for documentation. We educated providers on the method of documentation, raised visibility and importance of advanced directives, implemented a system of normalizing conversations for all new pts, reported weekly to providers on upcoming established pts without documentation and provided monthly report cards, indicating provider rates within the pilot group. Results: Prior to intervention, a median of 499-established pts per month were seen by our pilot group. A median of 50 pts (10%) had a documented CS with documentation rates by provider ranging from 0 – 91%. 5 of 8 providers had no established pts with a documented CS. After intervention, a median of 494-established pts per month were seen by the same group. A median of 197 pts (40%) (p < 0.05) had a documented CS with provider rates ranging from 26 – 94%. All providers had documented a CS on at least some of their established pts; improvements ranged from an increase of 0 to 26%, to an increase of 1 to 43%. Conclusions: Previously, at our institution, only a small minority of established patients with an oncologic diagnosis had documentation of CS in the readily available EMR. Our pilot study resulted in a statistically significant increase in the documentation rates for all providers over a 2-month period. We have yet to analyze the clinical significance of this, with attention to quality and cost of end of life care.
Assessment of accuracy of data obtained from patient-reported questionnaire (PRQ) compared to electronic patient records (EPR) in patients with lung cancer.
Authors: Palepu Prakruthi R. , Brown Catherine , Joshi Gautam , Epsin-Garcia Osvaldo , Eng Lawson , Ramanna Jayalakshmi , Hon Henrique , Momin Salma , Pringle Dan , Cuffe Sinead , Waddell Thomas K. , Keshavjee Shaf , Darling Gail Elizabeth , Yasufuku Kazuhiro , de Perrot Marc , Pierre Andrew , Cypel Marcelo , Xu Wei , Liu Geoffrey
Published: February 2017

40

Background: Cigarette smoking, alcohol consumption and co-morbidities are important determinants of health in lung cancer patients. The gold standard for obtaining accurate data is PRQ. The purpose of this study is to ascertain the accuracy of abstracting health-related behaviour data from retrospective chart review compared to data directly obtained from PRQ in a lung cancer patient population. Methods: 731 lung cancer patients completed a PRQ related to lifetime tobacco use, alcohol consumption and co-morbidity. Relevant smoking, alcohol and co-morbidity data was collected independently from EPR. Results: Ever/never status for smoking showed almost perfect agreement (k=0.95) between PRQ and EPR and surpassed all other health behavioural measures and co-morbidity agreement values. Both the sensitivity and specificity were high (0.94 and 0.99 respectively). The calculation of pack-years from EPR and PRQ showed substantial agreement (k=0.77); However, categorizing the smoking status into current/ former / never, resulted in moderate agreement (k=0.46). Alcohol ever/ never status agreement was moderate (0.43) with high sensitivity (0.90) but low specificity (0.50). Agreement for co-morbidities varied by condition showing moderate to substantial agreement for hypertension (K=0.57), heart attack (K=0.80) and diabetes (K=0.76) while fair to slight agreement (K<0.4) was seen in the others. Specificity was 0.86 or higher for co-morbidity conditions and was consistently higher than the sensitivity. Conclusions: EPR may be used as a reliable surrogate to PRQ in determining ever/never smoking status and lifetime smoking exposure. Evaluation of current/former/never smoking status and alcohol consumption is best determined by PRQ. Diabetes, hypertension and heart attack are more accurately reported in the PRQ than other co-morbidities. Patients tend to report absence of a medical condition more accurately than the presence of it. Missing EPR data related to smoking pack years, alcohol consumption and lung co-morbidities is concerning and suggests more synoptic reporting by physicians would improve opportunities for research.
The six IOM quality aims in practice: A multidisciplinary assessment of the scope and focus of quality activities in oncology.
Authors: Hurwitz Mark , Harrison Amy , Doyle Laura , Bar-Ad Voichita , Smyles John , Siglin Joshua , Munro Susan , Itri Alisa , Wilson Kathleen , DeGregorio Nicholas , Clancy Daniel , Lowther Ann , Dicker Adam
Published: February 2017

44

Background: Strategies to address quality have evolved through adaptation of best practices, need to address institutional priorities, and mandates from accreditation organizations. Therefore evolution of QA/QI practice has been mostly reactive in nature. In the IOM report “The Quality Chasm” 6 key quality aims were identified: safety, timeliness efficacy, equitability, patient centeredness, and efficiency. To date however, a comprehensive assessment of the relationship of quality activities in oncology to these aims has not previously been reported. We hypothesized that there is variability in focus and scope of quality related activities in oncology as they pertain to the IOM key quality aims. Methods: Multidisciplinary quality activities in our department were identified by our quality committee. For each activity, 10 committee members individually identified in their opinion which of the 6 IOM quality aims were addressed by that activity and ranked in order the relative focus of each identified aim per activity. The percentage of respondents associating an aim to an activity and relative focus score per activity (1-6 with 1 representing the primary focus) were tabulated. Results: Imbalance with emphasis on safety was noted. Average relative focus scores linking the six quality aims to each quality activity are shown in the Table. Conclusions: Review of department quality activities revealed imbalances in focus on the IOM quality aims. While there is relative emphasis on safety as expected, opportunities exist for development of activities focused on other quality aims including timeliness and equitability. [Table: see text]
Are patients' needs being met after hours? An evaluation of phone calls made after hours for patients with thoracic malignancies.
Authors: Patel Manali I. , Moore David , Milstein Arnold , Wakelee Heather A. , Blayney Douglas W.
Published: February 2017

46

Background: Understanding phone calls patients make after hours is important as it represents opportunities to provide improved care. Furthermore, better understanding of after-hours calls can help to influence reductions in healthcare spending. Therefore, we sought to evaluate the nature of after-hours calls to the thoracic oncology clinic. Methods: The study is a retrospective analysis of 4 months of phone calls made to the Stanford Cancer Institute during weekends and hours of 5pm-8am on weekdays. On-call physicians documented complaint, age, gender, and advice given. Phone calls were excluded from analysis if there were missing information. Differences in proportions were analyzed by Fisher's exact test. A two-sided p value <0.05 was considered significant. Results: There were 271 phone calls made after-hours by patients with lung cancer however after exclusions, there were 215 calls for analysis. The majority of phone calls occurred between 5pm-11pm (n = 57; 173%) followed by daytime calls during the weekend (n = 37; 17%). A majority of phone calls were made by the patient (50%) with a slightly lower proportion made by family members (46%). The majority of patients who called were in their 50’s (29%) and female (54%). A high proportion of patients called for more than one complaint (30%) although almost all patients complained of more than one symptom on review of systems (95%). The main symptoms patients called for were cough (28%) and shortness of breath (27%). Of the phone calls, 62% (133) were referred to the emergency room. Of those patients referred to the emergency department, 77% (103/133) resulted in an admission. Conclusions: Most after-hours phone calls from patients with lung cancer are related to symptoms. A large proportion of patients who were referred to the emergency department subsequently required an admission. Analyses of call content, and of events leading to the after hours calls might help predict hospital admission in this group of patients, and will inform development of proactive interventions to improve the quality of care, patient-centered outcomes, and value.
Reducing breast cancer chemotherapy treatment delays by improving the transition from surgical to medical oncology.
Authors: Losk Katya , Kadish Sarah , Golshan Mehra , Lin Nancy , Hirshfield-Bartek Judith , Cutone Linda , Bunnell Craig A. , Weingart Saul
Published: February 2017

51

Background: Delayed chemotherapy is associated with adverse clinical outcomes for breast cancer patients. Few studies have examined the processes of care within administrative staff and providers’ control that might affect the timeliness of breast cancer care. Coordinating transitions of care from surgical to medical oncology to eliminate variation is essential in ensuring timely chemotherapy for patients after surgery. This study evaluated the time of transition from surgery to medical oncology when administrative change of practice was implemented. Methods: We studied 192 consecutive breast cancer patients who received adjuvant chemotherapy. The interval between last definitive surgery and initiation of chemotherapy was calculated by integrating billing and scheduling data. Using process improvement methods a multidisciplinary team identified the opportunity to reduce delays in care coordination by scheduling the surgery, surgical post-op appointment, and medical oncology follow-up appointments simultaneously. Furthermore, responsibility for scheduling the medical oncology follow-up appointment was shifted and standardized from medical to surgical oncology administrative staff. Criteria for acceptable timeliness of appointments and escalation pathways for when provider availability was limited were established. The intervention targeted patients whose initial consultation with a breast surgeon and medical oncologist occurred on the same day, the standard practice at our institution. Results: Implementation of the interventions decreased the time from surgery to chemotherapy by six days. The standard deviation also declined, suggesting that the intervention reduced process variability. Conclusions: Standardizing administrative practices between breast surgery and medical oncology has led to a significant decrease in the time from last definitive surgery to initiation of chemotherapy and in the variability of that delay. [Table: see text]
Positive reactions of hospital staff to feedback by specialists.
Authors: Nakamoto Nana , Nakamura Fumiaki , Higashi Takahiro , Amano Asuka , Fukuchi Misato , Hirayasu Masako , Higa Hatsue , Asato Kuniko , Shimada Yasuhiro , Yoshikawa Takaki , Ono Hiroyuki , Tanaka Shinji , Ishiguro Megumi , Masuda Masato
Published: February 2017

57

Background: Although cancer is the leading cause of death in Japan, systematic quality monitoring of cancer care has not been established. In an attempt to explore such systems, we measured the quality of cancer care in several facilities through chart reviews by tumor registrars. The subsequent step is the provision of effective feedback of these results to the practicing physicians and other health professionals for further improvement. However, the receptiveness of lead practicing physicians may be debatable. Methods: We measured 23 quality indicators (QIs) (10 indicators for stomach cancer and 13 for colorectal cancer) in 10 designated cancer hospitals between 2010 and 2011. The staff who worked in these hospitals could see results of the measured QIs on web pages. All three designated cancer hospitals and one large general hospital in Okinawa Prefecture participated in feedback meetings. A feedback meeting was held in each of the four hospitals for one hour each. The feedback meeting consisted of three parts: general explanation of the measured QIs by the researcher, feedback regarding results of each indicator by the panels, and discussions. At the end of the meeting, participants answered a questionnaire regarding the meeting. Results: Of the 190 hospital staff who participated in the meeting (52 were medical doctors, 21 were nurse, 15 were other medical staff, and 102 were medical clerks), 142 (75%) answered the questionnaire. Majority of the responses were supportive of the quality measurement and feedback activities: 85% of the participants understood results of the measured QIs and 94% replied that the feedback methods were good. In addition, 86% answered that they would recommend other hospitals to participate if there was an opportunity. Among the physicians who participated, 89% answered that results of the measured QIs would influence their practices and 95% answered that data abstraction by tumor registrars was appropriate. Conclusions: Feedback by the panels who established QIs was favorably perceived by the hospital staff and could influence the attitude of physicians regarding current practices.
Fertility preservation cost and use: Results from the LIVESTRONG survey.
Authors: Rechis Ruth , Nutt Stephanie , Bann Carla
Published: February 2017

59

Background: Each year nearly 70,000 adolescents and young adults (AYAs) are diagnosed with cancer. Recently, steps have been taken to address infertility, which is an important issue experienced by AYAs. For example, ASCO QOPI includes fertility standards and Walgreens and the LIVESTRONG Foundation provide financial assistance for fertility preservation medications. To better understand the current state of fertility preservation, eight questions on this topic were included on the LIVESTRONG Survey. Methods: From June to December 2012, LIVESTRONG conducted an online survey (N = 6,313). Analysis here includes the 1,333 AYA respondents who were diagnosed since 2002. Results: Only 24% of respondents (42% of males, 12% of females) indicated they took steps to preserve their fertility before beginning treatment. Top reasons for not preserving their fertility were not receiving information about options (19%) and/or information about the risks to their fertility (14%). For the AYAs who did preserve their fertility, the median amount spent on fertility expenses was between $1,000 and $2,499 (Table) with males spending significantly less than females (p < 0.001). Mostly commonly, males used sperm banking (97%) while females used egg and embryo banking (each 35%). The majority all who attempted to become pregnant were successful (58% and 68% respectively). Conclusions: Results from this analysis indicate that few survivors took steps to preserve their fertility before starting treatment. Yet for those who were interested in preserving their fertility and starting a family, the majority of individuals were successful. Many individuals reported not preserving their fertility due to a lack of information or resources. While a relatively small number of survivors will have fertility concerns, this is an important quality of life issue for those who do. [Table: see text]
Pragmatic approach to quality metrics development in cancer.
Authors: Chung Donna , Dwarakanath Aniruddha , Williams Charlotte , Pritchard-Jones Kathy , Mountford James , Mayer Astrid
Published: February 2017

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Background: London Cancer aims to use transparency of service and quality measures to drive improvement in cancer care in North and East London and surrounding areas, serving our population of 3.5m people. Whilst the on-going implementation of the National Outcome and Service Dataset for UK is expected to take 18 months we have chosen to develop quality measures with the teams accountable to deliver the service by using available data from a variety of existent sources and illustrate this in value scorecards tracking the patient pathway. Methods: Building on an engagement exercise with patients, clinicians and charities in 2011 to identify which outcomes mattered most to patients, a small set of key pathways metrics was identified for each site specific cancer pathway board to monitor their progress in implementing integrated cancer care. Metrics were selected only if (a) clinically useful, in line with the current work plan and improvement effort; (b) accessible on a recurrent basis and requiring minimal manual effort; (c) facilitate the understanding of the patient pathway; (d) align with London Cancer objectives in improving survival, patient experience, and access to innovation and clinical trials. Pathway boards were invited to contribute with the intention to provide a pathway metrics value scorecards on a quarterly basis. Results: The first set pathway metrics scorecards, with 31 metrics, were published by June 2013. Key items include adherence to established best practice (16), data completeness (6), survival (3), pathway efficiency (3), and patient experience (3). Conclusions: Pathway metrics are reported at a system level, reflecting the care for our local population, against measures that are important to them and will allow visibility of success. Whilst current pathway metric development is limited by the availability of meaningful data we aim to build on the existing metrics in an iterative fashion. For this we are working with stakeholders to improve data quality.
City of Hope's referring physician communication process improvement initiative.
Authors: Alvarnas Joseph C. , Avanessian Priscilla , Wakabayashi Mark Tsuneo , Kassab Tricia , Levine Alexandra M.
Published: February 2017

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Background: City of Hope’s (COH) Performance Excellence Program (PEP), a physician incentive program aimed at improving quality and process outcomes, identified the need to establish a process for strengthening COH’s relationship with referring physicians. Methods: Working in collaboration with New Patient Services, Marketing, and physicians across multiple disciplines, we implemented a manual process of copying information in all H and Ps/Admit Notes, discharge summaries, consultation notes, and operative reports to referring MDs if the COH MD had not done so. The PEP team is also in the process of establishing a specific COH referral MD line that would allow for priority queuing and a real-time warm transfer to the MD/ MD’s office. Marketing of the number will be conducted through a standard thank-you cover letter sent by every COH MD upon initial consultation of patient, as well as through a newly revamped physician website. The implementation of a Health Information Exchange is also in progress. Results: Overall satisfaction on COHs ability to communicate increased from 23% to 30%. Number of 10 or more updates received from COH increased from 0% to 17%. Those who referred 20% of their patient volume increased from 15% to 20% while those who only referred 1-5% decreased from 69% to 30%. Conclusions: Through the multiple strategies and joint efforts across disciplines, COH has strengthened its relationship with referring MDs and increased its referral volume. [Table: see text]
Streamlining federally mandated quality metric reporting in cancer care.
Authors: Kidin Lisa M. , Walters Ronald Stewart , Browning Doug , Taylor Sarah H , Jordan Victoria S.
Published: February 2017

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Background: Public reporting has been an established process for non-PPS exempt hospitals since the inception of the Core Measures in 2001; however, Cancer Centers were not subject to public reporting and had no standardized established formal mechanism to collect, analyze and report clinical quality data until the Affordable Care Act (ACA) of 2010. The first three Clinical Process/Oncology Care Measures must be submitted through the American College of Surgeons Rapid Quality Reporting (RQRS) system. Since registries are designed to provide a retrospective snapshot of the patient population during the first four months of the disease process, the change to longitudinal data collection, while critical for intervention in time to improve concordance, is extremely difficult for cancer centers with large volumes and complex cases. Our institution created a collaborative interdisciplinary model utilizing quality management nurses to support and enhance the submission process by utilizing an early identification and intervention process. Methods: Prior to implementation, the average submission time for the initial three oncology specific metrics was eight months due to the significant effort to determine the analytic population based on our volume of patients. In addition, many patients receive treatments outside the facility with little or no documentation that often resulted in the inability to determine metric concordance. Results: The new process identified patients at two months and created a robust follow up and validation process utilizing a model to ensure evidence based care is provided across the continuum. This enabled monthly submission to RQRS at the end of three months and leveraged the system to ensure that patients had the appropriate therapy documented in the system. This process shortened the submission time to less than half and initial projections indicate increased overall compliance. Conclusions: We enhanced the process of submission for federally mandated measures to RQRS by initiating early identification and follow up. This significantly impacted our ability to accurately represent the high quality care provided at our institution and provide documented concordance with national quality measures.
Use of pharmacist integration in oncology clinics to identify and resolve moderate to major drug-drug interactions.
Authors: Seki Jack Toshimine , Hughsam Matthew , Krzyzanowska Monika , Lo Aaron , Ng Pamela , Sridhar Srikala S. , Tsang Dominic , Kukreti Vishal
Published: February 2017

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Background: Medication reconciliation (MR) in outpatient clinics has been under-evaluated. We postulated that cancer patients would benefit from MR done by a pharmacist as these patients have many care providers, many medications, and are at high risk of drug-drug interactions (DDIs). Hence, we conducted a quality initiative evaluating the role of a pharmacist in the ambulatory clinics. Methods: One pharmacist prospectively rotated amongst four oncology clinics four days a week from June 3 to September 18, 2008. The pharmacist performed MR, and as a consultant developed therapeutic plans related to drug therapeutic problems (DTPs) including adverse reactions and DDIs. Patient medication lists were retrospectively analyzed using Micromedex and DDIs were categorized by frequency, severity and evidence level. A monthly survey (Likert scale) evaluating pharmacist contributions to each clinic team was completed by physicians and nurses. Results: A total of 158 patients were seen in 227 patient visits. The pharmacist identified 141 DTPs in 60 patients across 74 visits. The most frequently observed were no drug for a medical problem (51.1%), dose too low (12.8%), wrong drug (9.9%), and adverse drug reactions (9.2%). In response, 174 therapeutic plans were made. The most frequently recommended actions were drug added (40.8%), dose changed (13.2%), drug discontinued (9.2%), and interval/duration changed (7.5%). A total of 414 DDIs were identified in 110 patients, across 149 patient visits. On average, 2.62 DDIs were reported per patient, and 1.82 DDIs per visit. By severity, 139 (33.6%) major, 258 (62.3%) moderate, 16 (3.9%) minor and 1 (0.2%) contraindicated DDIs were documented. By level of evidence, 46 (11.1%) DDIs were excellent, and 236 (57%) were good. Survey results showed that doctors and nurses agreed/strongly agreed that pharmacist presence was valuable. The most useful contributions identified were consultation regarding DDIs, adverse drug effects, and medication efficacy decisions. Conclusions: DDI rates are high and most are moderate or major in severity. There is a clear benefit from the integration of a pharmacist to the clinics with an improvement in patient safety and quality of care.