bluuebunny/crossref_metadata_2025 huggingface dataset:
Care coordination for oral oncolytics through pharmacy integration and cycle 1-day 1 documentation.
Authors: Peacock Nancy Walker , McCullough Stacey , Crumb Jared , Owens Leah , Kaufman Laura , Arrowsmith Edward , Patton Jeffrey , Taylor Jack L. , Lyss Aaron J. , Kelsey Carolyn J. , Senneke Kimberly , Frailley Susan A
Published: October 2019

260

Background: The growing number of oral oncolytic therapies (OOTs) necessitates a standardized EMR workflow that integrates pharmacy activities for dispense and patient management and standardizes cycle-1/day-1 (C1D1) documentation. Our practice’s treatment plans contain appropriately timed OOT follow-up activities including labs, physician follow-up visits, and pharmacy calls for toxicity and adherence checks, however complications in prescription fulfillment such as prior authorization, co-pay assistance, or inability of in-practice pharmacy to dispense limit the predictability of C1D1 dates of OOTs. Methods: An EMR query identified patients at a single clinic location of 5-medical oncologists (MDs) for whom oral oncolytic treatment plans were entered from January 1 to June 30, 2018. C1D1 date entered by the MD in the EMR was compared to the pharmacy processing system dispense date. Ten patients were identified, and 10% (1/10) had an accurate C1D1 documented within the EMR. As part of the ASCO Quality Training Program, to improve the accuracy of C1D1 documentation, a new workflow was implemented whereby: (1) a “hold” activity was added to new EMR treatment plans so that C1D1 remained pending until patients had received medication; (2) clinic checkout staff provided patients with information on the in-practice pharmacy and expectations for next steps; (3) pharmacists utilized existing reporting tools to identify newly entered treatment plans and transcribed orders into e-prescriptions sent to our practice pharmacy; (4) the pharmacy workflow ensued with pharmacy staff leading patient engagement, drug counseling; (5) pharmacists confirm C1D1, document within EMR (6) subsequent treatment plan activities were scheduled. Results: Following education and process changes within the clinic and pharmacy, accurate C1D1 documentation occurred in 90% (9/10) of patients initiating OOTs. Conclusions: Including pharmacy fulfillment time in EMR workflow can improve C1D1 documentation accuracy and associated management of OOTs. Education regarding roles and processes of prescribing MDs, pharmacy staff and clinic staff will be required to scale this process improvement throughout the organization.
Compliance of protocol-driven hepatitis B serological screening in patients receiving anti-CD20 monoclonal antibody therapy.
Authors: Schluenz Lauren , Jeffers Kate , Kalis Joseph
Published: October 2019

261

Background: The US Food and Drug Administration has issued a boxed warning for anti-CD20 monoclonal anti-bodies for the reactivation of Hepatitis B virus (HBV) infection. The National Comprehensive Cancer Network (NCCN) Non-Hodgkin Lymphoma and Infectious Diseases Society of America guidelines recommend routine serologic testing for all patients receiving anti-CD20 antibody therapy. NCCN specifies serologic screening of HBV surface antigen (HBsAg) and hepatitis B core antibody (HBcAb) should be completed prior to initiation of anti-CD20 therapy. In March 2018, UCHealth included HBV screening into the EHR oncology templates which include an anti-CD20 monoclonal antibody. The purpose of this study was to assess the impact of this template modification on compliance to guideline recommended screening for patients receiving anti-CD20 monoclonal antibody therapy. Methods: This was a retrospective chart review of patients who received an anti-CD20 monoclonal antibody for an oncologic indication between April 1, 2017 to November 30, 2017 (pre-template change) and April 1, 2018 to November 30, 2018 (post-template change) at any of the UCHealth Cancer Care and Hematology Centers. The primary objective was the composite compliance rate of HBsAg and HBcAb screening completed prior to receipt of treatment. Secondary objectives included compliance rate of each screening test, days between screening and treatment, screening for initial compared to relapse therapy, and rate of hepatitis C virus screening. Results: The addition HBV serologic screening to the EHR oncology templates containing an anti-CD20 agent improved screening compliance of HBsAg and HBcAb by 6.7% as a system (2017: 89.7% vs 2018: 96.4% [p = 0.133]). Secondary endpoints saw an increase in testing of each individual screening, testing for patients in the relapse setting, and HCV screening. Additionally, a reduction was seen in median days between screening and start of therapy (2017: 11 (4.5-30.3 IQR) vs 2018: 7 (2-14 IQR) [p = 0.008]). Conclusions: The addition of HBV serologic screening to EHR oncology templates increased compliance to guideline recommended screening for patients receiving anti-CD20 antibody therapy.
A multimodal, interprofessional training program on chemotherapy safety for nurses and pharmacists: Development and preliminary evaluation.
Authors: Friese Christopher Ryan , Aebersold Michelle L.
Published: October 2019

266

Background: Chemotherapy is a high-volume, high-risk clinical intervention that requires interprofessional clinical teams. With increased demand for chemotherapy, a record number of newly-approved drugs, and health system cuts to professional development, we sought to develop and deliver an evidence-based educational program for nurses and pharmacists on safe handling of hazardous drugs, management of oncology emergencies, extravasations, oral oncolytic therapy, and promoting clinical practice change. Methods: After mail and web-based recruitment activities, selected participants completed pre-workshop online modules. Live workshops included a blend of faculty-led interactive sessions and four simulations to reinforce content. Post-simulation debriefing sessions clarified concepts and identified participant action plans for clinical practice change. Attendees have access to lecture videos, handouts, resources, and a discussion board. Applying Kirkpatrick’s framework, we assessed participant confidence to meet program objectives before and after the workshop, a 27-item knowledge assessment before and after the workshop, and satisfaction with specific learning activities on a 5-point Likert scale. Results: To date, faculty have led two workshops. 266 nurses and 72 pharmacists applied and we accepted 77 (29%) and 30 (42%), respectively. Participants' change scores in confidence to meet program objectives increased from pre- to post-workshop (range 0.51-1.00). Knowledge scores increased between pre- and post- workshop (16.3 vs. 18.76, p < .01). Overall satisfaction was high across all content areas (range 4.76 - 4.98). Nearly all participants (n = 104, 97.2%) reported they were extremely satisfied with the program. Conclusions: An interprofessional education program with online modules, in-person interactive sessions, and simulation activities is a promising strategy to deliver chemotherapy safety content to practicing oncology nurses and pharmacists. Future efforts include recruiting a more diverse pool of participants, and expanding the program to include advanced practice providers.
Increasing compliance of an oral oncolytic program in a multi-location practice.
Authors: Patel Amita , Woerner Shannon , Flocco Tina , Carroll Rachel , Shander Ellen
Published: October 2019

267

Background: Over the past two decades the rise in number of oral oncolytics has significantly changed the landscape of cancer treatment. Although these medications offer patients the convenience of home administration, they pose different challenges. Two examples are adherence and education of associated toxicities. In an ongoing effort to provide quality cancer care, the Central Jersey Division of Regional Cancer Care Associates (CJD RCCA) has reconstructed its oral oncolytic program. Methods: In 2016 the CJD of RCCA developed an oral oncolytic program to educate patients on how to safely manage their medications. After the provider sent the prescription, a flowsheet is entered into the EMR, triggering the chemotherapy teaching session and appropriate follow up visits. During this visit patients are provided drug specific educational sheets which include lab monitoring, common adverse effects, and calendars to document adherence. Due to failure of entering flowsheets into the EMR, patients lost to scheduling while waiting for medication delivery, or patient refusal of teaching, compliance remained low. The program was modified to include running a daily report to identify all new oral oncolytic prescriptions. Schedulers are immediately calling patients to schedule a teaching session. A field in the EMR was created to document “patient refusal”. By making these improvements, CJD RCCA has increased compliance along with upholding quality care for patients receiving oral oncolytics. Results: Since re-structuring the program the RCCA CJD APNs have performed teaching on 124 of 172 (72%) patients from January to May of 2019. This is compared to only 79 of 144 (54%) in all of 2018. Of the patients identified in 2019 30 refused, 13 were completed by the physician, and 5 expired. This dramatic rise of 18% is largely due to running the daily oral oncolytic reports and entering the flowsheet into the EMR. Conclusions: Patient compliance has increased by identifying new patients and prompt enrollment into the program. It provides them the tools to safely navigate through treatment. At CJD RCCA, the oral oncolytic program is vital to ensuring positive clinical outcomes for these patients.
Achieving best possible cancer treatment outcomes in care pathways through benchmarking: ABC benchmarking.
Authors: Wind Anke , Bessems Maud , van Eekeren Ramon RJP , Wijburg Carl J , Wijn Rob P.W.F. , Mattson Johanna , Borges Marina , Abreu de Sousa Joaquim , Oliveira Jorge , Halamkova Jana , Svoboda Marek , van Harten Wim H
Published: October 2019

268

Background: Care pathways are used to manage quality in healthcare and concern the organization and standardization of care processes. By benchmarking care pathways, new knowledge is generated that can be utilized to optimize care pathways. A recent development in healthcare is the transformation from volume-based healthcare to value-based healthcare, which amongst others emphasizes the need for IPU (Integrated Practice Unit) development. The ABC-Benchmarking project is an international benchmarking project aiming to further develop the BENCH-CAN pathway benchmark, establish comparative scores on IPU development, and link outcome data to benchmark results. Methods: The 13 step benchmarking process as developed by Van Lent et al. was used. Indicators were primarily derived from the BENCH-CAN pathway benchmark format and secondary from expert opinion. An adapted Delphi method, in which clinical experts on breast and prostate cancer provided feedback in three rounds, was used to select the final set of indicators. The indicator sets containing structure, process and outcome indicators were piloted in 5 centers. Clinical outcome indicators were collected primarily through cancer registries. Site visits were performed to clarify additional questions based on the provided data and to grasp the context of the care pathway. Results: The final set contained 79 indicators for breast and 69 indicators for prostate cancer. Due to differences in registration and data availability of cancer registries not all data could be collected for all centers. Differences between cancer centers were found for example in the measurement of patient reported outcomes and status of the IPU. Aggregated and comparative data can be shown during the symposium. Conclusions: Further validating the pathway benchmark tool and adding more focus to IPU development and outcome indicators led to new knowledge on adding value for cancer patients. Examples given were optimizing care organized in care pathways for breast and prostate cancer patients. The results provided improvement opportunities for all centers. A study into patient involvement in pathway development, evaluation and improvement is also part of this project.
Treatment patterns and barriers involving the use of CDK4/6 inhibitors for women with HR+, HER2- breast cancer.
Authors: Tolaney Sara M. , O'Shaughnessy Joyce , Ackbarali Tariqa , Crawford Rebecca , Carter Jeffrey D. , Greene Laurence , Sapir Tamar
Published: October 2019

27

Background: For women with HR+, HER2- breast cancer, cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) can significantly improve outcomes. However, the most effective uses of CDK4/6i may be limited by barriers including a lack of systems-based pathways and education to guide individualized treatment. In a quality improvement program in 2 healthcare systems, we assessed baseline treatment patterns and barriers involving CDK4/6i use. Methods: Participants were 34 oncologists and team members. At baseline, we administered surveys to assess barriers to prescribing CDK4/6i and audited the EMRs of 100 women with HR+, HER2- breast cancer in each system. EMRs were audited for demographics; disease characteristics; and treatment history, monitoring, and shared decision-making (SDM) involving CDK4/6i. The teams participated in an audit-feedback session and developed action plans for resolving gaps. Results: Overall, 31% of the 200 women received a CDK4/6i, and 13% received a CDK4/6i as second-line therapy. More than 30% of women treated with a CDK4/6i had documentation of only Stage I/II disease. EMR audits revealed low rates of recommended electrolyte monitoring and ECGs (0%), liver function tests (LFT; 44%), and SDM (Table). Surveys were completed by 20 participants. Whereas 80% indicated being likely to recommend a CDK4/6i, they reported barriers of identifying eligible patients (35%) and monitoring for disease progression (45%). A moderate proportion of oncologists reported considering menopausal status (60%) and patient preferences (50%) in CDK4/6i decision-making. Participants developed action plans for improving EMR documentation for disease stage and protocols for monitoring progression. Conclusions: These baseline findings reveal gaps that may inform QI initiatives for promoting the appropriate use of CDK4/6i for women with HR+, HER2- breast cancer. Findings from baseline EMR audits (n = 200).

[Table: see text]
Hospitalization rates related to coordinated home healthcare services with a community oncology practice.
Authors: Sandbach John F. , Bachelor John , Larson Kimberly , Jordan Denize , Mullins Janet , Sheff Gregory
Published: October 2019

273

Background: Unplanned hospital admissions or hospital re-admissions in cancer patients after discharge cost in excess of 16 billion dollars. Oncology patients are a very high risk of hospitalization despite the involvement of a home healthcare agency. The 30-day medical oncology re-hospitalization rates are reported to be 21.6%. Unplanned hospitalization rates in selected oncology patients over a 12 month period have been reported to be as high as 58%. Methods: A large home health agency and a community based medical oncology practice created a delivery model referred to as the Advanced Community Care Model (ACCM). We are reporting our initial 14 month experience. The initial pilot involved three of the medical group’s six cancer centers. The ACCM created standing intervention orders regarding hydration, nausea/vomiting, central line management, antiemetic and diarrhea and a continuum of monthly management meetings with the agency and the practice. Navigation services by a designated RN were provided. Enhanced interventions with either telephone communication or home visits took place when deemed appropriate. Results: ACCM impacted 60-day hospitalization rates fell a baseline at 6 months into the program from 43% to 22% by the end of the 18 month pilot. Avoidable hospitalizations and re-hospitalizations related to N/V, pain, SOB and infection were less than 10%. The initial program has involved 310 unique patients. Conclusions: The reduction in the 60 day hospitalization rates and the low hospitalization and re-hospitalization rates related to pain control, infection, SOB and infection were below published national averages. The results were felt to be encouraging and the ACCM will be expanded to involve all 7 cancer centers in the practice.
Impact of community practice on providing in-patient oncology and hematology consults via telemedicine to remote rural hospital.
Authors: Dickson Natalie R. , Bilbrey Larry Edward , Joseph Mathew John , Matheny Janet A , Poole Stacey L , Patton Jeffrey
Published: October 2019

278

Background: A rural oncology/hematology clinic located a far distance from the local community hospital was not able to provide hospital consultation support. Collaboration between the practice and the hospital resulted in a telemedicine pilot study to provide oncology and hematology consults to in-patients using a telemedicine robot that connected patients to a hematologist/oncologist (heme/onc) over the internet. Methods: When an appropriate patient was identified at the hospital, a referring provider contacted the heme/onc for a consult. The heme/onc determined and relayed the appropriate time to schedule and perform the telemedicine consult. The referring provider arranged for hospital staff to deliver the telemedicine robot to the patient’s room at the scheduled time. The heme/onc reviewed clinical data in the hospital EMR and logged into the telemedicine robot to speak in consultation with the patient. Notes and orders were placed in the EMR. Out-patient follow-up at the oncology/hematology clinic was scheduled as needed. Supporting front-office and clinical workflows were developed, and policy and procedure established. Surveys were sent to patients and referring providers. Results: At baseline, hospital consults were not provided. In 2018, there were 27 oncology/hematology consults, of which 89% (24 of 27) were for malignancies. 52% (14 of 27) were seen in the clinic after discharge. To date 40 telemedicine consults have been completed. Patient and referring physician satisfaction are inconclusive due to low survey return. Conclusions: Telemedicine provides an effective means to provide specialty consultative support to rural hospitals by remote community providers. Despite the complexity and sensitive nature of oncology and hematology concerns, the technology has been embraced by referring providers and patients.
The effect of medical home enrollment on cardiometabolic medication adherence among Medicaid-insured cancer patients.
Authors: Spees Lisa , Wheeler Stephanie B. , Zhou Xi , Amin Krutika B , Baggett Chris , Lund Jennifer Leigh , Urick Ben , Farley Joel , Reeder-Hayes Katherine Elizabeth , Trogdon Justin G
Published: October 2019

279

Background: Medical homes, developed to increase care coordination among vulnerable patient populations, have been successful in improving outcomes of patients with multiple chronic comorbidities, but have not been evaluated among cancer survivors. We determined the impact of medical home enrollment on adherence to anti-diabetics, anti-lipidemics, and anti-hypertensives among Medicaid patients diagnosed with non-metastatic breast, colorectal, or lung cancer. Methods: Using linked cancer registry and claims data from North Carolina, we included Medicaid-insured adults diagnosed from 2004-2012 with breast, colorectal, or lung cancer who had at least one cardiometabolic condition (i.e., hyperlipidemia, hypertension, and diabetes mellitus). For each cardiometabolic condition, we measured medication adherence using ambulatory proportion of days covered (PDC). We examined the impact of medical home enrollment on PDC across the phases of cancer care (i.e., pre-cancer diagnosis, treatment, and survivorship phases) using a differences-in-differences model. All models adjusted for age, sex, race/ethnicity, dual enrollment, cancer type, comorbidity index, and number of cardiometabolic conditions. Results: We included, respectively, 765, 1079, and 1634 cancer patients with diabetes, hyperlipidemia, and hypertension. Overall, adherence to anti-lipidemics was lower than adherence to anti-diabetics and anti-hypertensives. In the pre-diagnosis phase, mean PDC across all cardiometabolic conditions was slightly lower for cancer patients enrolled in a medical home than those not enrolled in a medical home. However, medication adherence improved 3-5% in the treatment phase and 7% in the survivorship phase for cancer patients in a medical home compared to cancer patients not in a medical home during the pre-diagnosis phase. Conclusions: These results provide evidence that enrollment in a medical home can improve medication adherence, even among vulnerable cancer patients with complex health needs. The medical home model is an effective healthcare system intervention through which to provide better care coordination and improve patient outcomes.
Mixed-methods research to evaluate a novel patient-centered cancer care coordination instrument.
Authors: Okado Izumi , Cassel Kevin , Pagano Ian , Holcombe Randall F.
Published: October 2019

280

Background: Effective care coordination (CC) is a critical component of high-quality cancer care; however, efforts to improve cancer care coordination are hampered by limited patient-centered measures. This mixed-methods research reports on patients’ feedback and the utility of a novel care coordination instrument (CCI) designed to assess cancer care coordination. Methods: 7 focus group discussions were conducted with 68 cancer patients receiving active therapy to evaluate validity of the CCI. Subsequently, the CCI was modified and administered to additional 200 cancer patients derived from community-based private and hospital clinics. The CCI is a 29-item, multiple-choice questionnaire and includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between providers; during inpatient-to-ambulatory care transitions; during transitions across phases of care). Results: Qualitative analysis of focus group discussions demonstrated that the CCI has good face and content validity. Content analysis identified the following themes: Survey, Education/Knowledge, Navigator, Communication, Support, Access, Providers, and Team. Questions with unclear wording or high proportions of not applicable or missing responses were refined or removed. Results of the revised survey indicated that the CCI is able to distinguish patient- and practice characteristics associated with optimal/poor CC. Specifically, cancer types (leukemia, myeloma) and having a patient navigator predicted high overall patients’ ratings of CC ( p < .05). Marginally significant differences were found for practice setting ( p = .085). A multiple regression model with all predictors entered simultaneously revealed that the presence of a family/friend caregiver significantly predicted better CC ( p < .001); however, the benefits of a patient navigator were no longer significant. Conclusions: This study demonstrates the utility of the CCI for assessing patients’ perspectives of cancer CC. Use and integration of this instrument in oncology practices/clinics can identify areas of potential interventions for CC improvement and lead to a better quality of care.
Quality improvement of lung cancer patient selection using clinic-based spirometry.
Authors: Lam Tony Kin- Ming CL , Aggarwal Reenika , Stewart Erin L. , Hueniken Katrina , McGregor Maureen , Xu Wei , Schmidt Heidi , Kavanagh John , Liu Geoffrey
Published: October 2019

282

Background: Coordinating lung cancer screening requires risk assessment for patient selection. Optimal selection can reduce costs and improve efficiency of low dose computed tomography (LDCT) screening of lung cancer. This study evaluated clinic-based spirometry as a tool to improve patient selection for lung cancer screening. Methods: Eligibility criteria for three large LDCT screening studies were retrospectively applied to the highest risk patients enrolled in the Princess Margaret Lung Cancer Screening Program who had received clinic-based research spirometry. The three studies were: Danish Lung Cancer Screening Trial (DLST), National Lung Screening Trial (NLST), and the Ontario Lung Cancer Screening Program (OLCS). Lung cancer incidence was compared between those who would were included by the screening study eligibility criteria (Group I), those who were excluded by the eligibility criteria but demonstrated obstruction on spirometry (defined as a Forced Expiratory Volume in 1 Second % Predicted (FEV1%) < 90%) (Group II), and those who did not meet eligibility criteria and had no obstruction (FEV1% ≥90) (Group III). Results: The 321 highest risk participants of the screening program had a mean age of 65 years and were 39% male. The median number of pack years in this group was 39. After undergoing spirometry, this cohort was screened using LDCT for a median of 3.3 years (range 1–8.1 years). Under DLST criteria, Groups I and II had virtually identical lung cancer incidences detected by screening at 13.1% and 13.6% of the individuals screened, respectively; Group III had a substantially lower incidence at 6.3%. Results were similar by NLST criteria where the incidence of screen-detected lung cancer were 13.7% for Groups I, 11.1% for Group II, and 8.6% for Group III. Under OLCS criteria, these values were 13.4% (Group I), 13.5% (Group II), and 8.2% (Group III). Conclusions: Individuals who were excluded from LDCT screening because they lacked other clinical eligibility criteria, but had a FEV1 < 90%, had similar lung cancer incidence as patients who had met screening study eligibility criteria. Coordinating care for screening of at-risk individuals could be improved by incorporating spirometric tools.
Utilizing technology for malnutrition screening and referrals to nutrition services.
Authors: Franco Susan , Hanson Corrine , Woscyna Glenda , Wells Jana , McLarney Meghan
Published: October 2019

284

Background: The incidence of disease-related malnutrition in oncology patients ranges from 40-80%. This is the highest of all hospital patient groups. Malnutrition is associated with decreased quality of life, increased healthcare costs and intolerance to treatment. Screening for nutrition risk is often lacking in outpatient settings. Electronic health records could be utilized to improve the delivery of validated nutrition screening tools such as the Malnutrition Screening Tool (MST) in outpatient oncology settings. Methods: We designed a pilot project (Feb-July 2018) to administer the MST for outpatient oncology patients seen at the Fred and Pamela Buffett Cancer Center (FPBCC) using an electronic medical record system. “Best Practice Alerts” (BPAs) were used to notify the nursing staff of a patient with a screen that was positive for nutrition risk (MST score ≥3). The BPA recommended a referral to nutrition services; nursing staff could choose to “order” or “do not order" a Nutrition Consult. Results: A total of 2,672 patients received MST screening during the pilot. Out of these, 223 (8%) had a positive screen for nutrition risk; 197 of these were eligible for a nutrition services referral. A BPA “fired” 152 times out of 197 eligible patients (77%). Of the197 eligible patients, 58 (29%) were actually referred to nutrition services. Of these 58 referrals, 43 (74%) were triggered based on a BPA, while the remaining referrals were received outside of a BPA. BPAs failed to fire 45/197 times (23%). Conclusions: An EHR-based nutrition screening system to increase referrals in patients identified at nutrition risk in an outpatient oncology setting was effective for 29% of eligible patients. Barriers encountered included failures in technology as well as human factors. During the pilot it was discovered that the BPA was firing in a location in the chart where the nurse did not regularly work. There was not a consistent message as to the goals and outcomes during the pilot which resulted in lack of awareness by nurses to respond to the nutrition risk score. Utilizing an EHR-based nutrition screening tool is an effective way to identify patients at risk and refer them to appropriate resources in a timely and efficient way.
Tailoring implementation for a cancer self-management support intervention for patients starting chemotherapy.
Authors: Kirkby Ryan Lawrence , Howell Doris , Powis Melanie Lynn , Amernic Heidi , Moody Lesley , O'Brien Mary Ann , Rask Sara , Krzyzanowska Monika K.
Published: October 2019

287

Background: Multiple implementation strategies are described in the literature; however, there is limited consensus on how to best tailor implementation to organizational and clinician readiness. We undertook a mixed-methods evaluation to inform tailored implementation of self-management support (SMS) in ambulatory cancer care as the first phase of a pilot randomized trial of the intervention in patients starting chemotherapy. Methods: Validated surveys, focus groups and interviews were undertaken with key stakeholders (oncologists, nurses, allied health, and administrative leaders) in the lung, colorectal and lymphoma disease site groups at 3 regional cancer centres in Ontario, Canada. Median responses to individual survey questions were classified as an enabler, barrier or neutral based on predetermined cut-offs. Enablers and barriers were triangulated with qualitative data and mapped to the Consolidated Framework for Implementation Research domains. Implementation strategies to address barriers were identified using the Expert Recommendations for Implementing Change tool. Results: Survey respondents represented all stakeholder groups (n = 78; respondent rate = 50%). Minimal variation was noted across stakeholders and centres. Overall, respondents held positive beliefs about the value of SMS, were familiar with the principles of SMS and felt there was a tangible fit among the intervention, individual beliefs, and existing workflows. Suboptimal communication networks and access to information about the adoption of SMS, as well as a lack of organizational commitment to implementing the intervention were identified as key implementation barriers. Qualitative data reinforced quantitative findings, namely that stakeholders value SMS but were unsure if it would translate into reduced treatment toxicities. 46 implementation strategies were identified based on perceived barriers, of which 28 (61%) were common to all 3 centres. Conclusions: Stakeholders at cancer centres acknowledged that SMS is valuable, but potential barriers to integration of SMS into routine ambulatory practice exist. The impact of the tailored implementation plans will be evaluated as part of the trial.
Association between Charlson-Deyo Score and delay to colonoscopy in veterans subsequently diagnosed with colorectal cancer.
Authors: Khuc Thi , Jackson Christian
Published: October 2019

288

Background: Colorectal cancer (CRC) is the second most common cause of cancer deaths in the United States and expected to cause 51,020 deaths in 2019. Early detection with yearly fecal occult blood test (FOBT) has been proven to decrease CRC mortality. A 30-day delay from positive FOBT to colonoscopy is associated with increased risk of CRC. The Veterans Affairs Health System (VAHS) treats approximately 11% of CRCs in the United States. The effects of an aging population, physician shortage, and increased military personnel entering the VAHS may increase demands on VAHS resources. The primary aim of this study was to determine risk factors that caused delay to colonoscopy. Methods: We retrospectively reviewed records of 600 patients referred for colonoscopy from January 1999 to January 2009, who were subsequently diagnosed with CRC. Patients with a prior CRC diagnosis were excluded. The final study cohort consisted of 530 patients. We analyzed the relationship between 10 variables and delay in time from initial consultation to colonoscopy. Variables consisted of age, sex, race, ethnicity, CRC location, marital status, history of mental health diagnosis, tobacco use, substance abuse, Charlson/Deyo (C/D) score and season of referral for colonoscopy. A delay in time was defined as 30 days or greater. Logistic regression analysis adjusted for age, race, CRC location and C/D score. Results: A total of 87.17% of patients experienced a delay in time from initial consultation to colonoscopy. When analyzed with a predictive variable of delay to colonoscopy, C/D score of ≥ 2 versus 0, was associated with higher odds of delay in time to colonoscopy (OR = 2.18, p = 0.02). African American race and Hispanic ethnicity was associated with a higher odds of delay in time to colonoscopy, but was not statistically significant (OR = 1.47, p = 0.47, OR = 1.37, p = 0.48). Conclusions: Patients with a C/D score ≥ 2 were 218% more likely to have delay in time from initial consult to colonoscopy, resulting in a delayed CRC diagnosis. C/D score may be used to determine which patients should have more frequent reminders to schedule their colonoscopy to prevent delays in care. Randomized and prospective studies will need to be performed.
Novel clinical definitions for immune-related adverse events (irAEs): A QI intervention to improve accuracy in irAE diagnosis.
Authors: Brito Amanda , Grover Shilpa , Abdulnour Raja-Elie E , SINGH PRABHSIMRANJOT , Yenulevich Eric , Kehl Kenneth L. , Ni Jian , LeBoeuf Nicole R. , Jacobson Joseph O. , Rahma Osama E.
Published: October 2019

290

Background: Use of immunotherapy has increased exponentially with survival benefit in many malignancies. As a result, suspected irAEs are commonly encountered, but lack of a gold standard for diagnosis puts patients at risk. We describe preliminary results of a QI project to improve accuracy of irAE diagnosis. Methods: Specialists at our institution created algorithms to define the likelihood of immune-related hepatitis, colitis, and pneumonitis based on clinical data, diagnostic results, and treatment response. Records of patients admitted from June-November 2018 with possible irAE were retrospectively reviewed by an oncology provider and an immunotoxicity specialist. A web-based tool automated irAE likelihood from clinical data based on the aglorithms. Reviewers could agree or disagree with the result and share their clinical impression. We evaluated concordance between providers and between provider and algorithm. Results: Of 65 patients, most had non-small-cell lung cancer (29%), melanoma (15%), or breast cancer (9%) and were treated with pembrolizumab (48%), nivolumab (23%), or ipilimumab/nivolumab (22%). There were 4 irAE-related deaths and 40 patients (71%) discontinued therapy for presumed toxicity. After 14 cases were excluded due to incomplete information, algorithms were applied to the remaining 51 cases (19 colitis, 8 hepatitis, 24 pneumonitis). The algorithm generated the likelihood of an irAE in 63% of reviews. Overall agreement with the algorithm was 86% (84-100% for individual algorithms), Kappa 0.8 (0.7-1.0). Overall concordance between reviewers was 76% (75-88%), Kappa of 0.7 (0.6- 0.8). Conclusions: While algorithm definitions and provider impressions were fairly consistent, cases lacking a generated likelihood suggest that some clinical scenarios are not addressed. Different interpretation of clinical information or varying experience with irAEs may explain inter-reviewer discordance, which underscores the importance of applying a standardized approach to irAE diagnosis across settings and experience levels. In the next improvement cycle, the algorithm will be refined to broaden algorithm scope, clarify criteria, and improve accuracy.
Real world implementation of patient report outcomes: Sustainability constraints and impact on patients health outcomes.
Authors: Faria Rosana , Langleben Adrian , Kushneryk Ashley , Wilson Jennifer
Published: October 2019

291

Background: St Mary’s Hospital, an affiliated McGill Teaching University Hospital, receives ~700 new cancer patients yearly. In 2014-17, electronic PROs were implemented through the Improving Patient Experience and Health in Outcomes Collaborative in partnership with Cancer Care Ontario, granted by Canadian Partnership against Cancer and Rossy Cancer Network, as part of a PRO Canadian Initiative to improve the Patient Experience across Canada through standardized measurement of health-related outcomes for patients. Methods: The PROs measures included the Edmonton Symptom Assessment Scale (ESAS), additional measures for Fatigue, Anxiety, Depression, and Pain, the Social Difficulties Inventory-21 and Quality of Life. PRO-data was scored in real-time; nurses and patients received a printed summary report. Nurses were provided with an algorithm and instructions. Monthly Distress Screening Dashboard were generated with key indicators. In 2016, all patients receiving chemotherapy were assessed at each cycle of treatment. After project completion, due to nursing staff shortage, the frequency of screenings was reduced. Yearly Dashboard results were used to promote discussion with clinicians and address sustainability constraints of PROs in real-word oncology practice. Results: In 2016 1366 total screens completed ( 376 patients) and in 2018, 753 total screens (325 patients). This comparison indicates that a decrease in frequency of screenings resulted in an increase in symptom severity in all health-related outcomes. Physicians’ participation was proposed as mitigation plan to increase screening frequency. We propose to present a three year retrospectively cross analyzed patient data to examine symptom change over time, frequencies of screening, impact on patients’ health outcomes, overlapping sustainability constraints encountered and mitigation plans. Conclusions: Embedding the use of PRO into existing hospital structures requires constant review involving administrative, clinician and patient engagement.
Can we keep patients home? Decreasing hospitalizations in the oral chemotherapy patient.
Authors: Karlin Michelle Rene , Mikan Sabrina Q. , Wilfong Lalan S. , Books Holly
Published: October 2019

294

Background: The Oncology Care Model (OCM) pilot includes all types of cancer with an aim to test whether additional funding for enhanced services and financial incentives to improve quality and efficiency, could reduce Medicare spending while maintaining or improving quality for a broad array of cancer types. Patients taking oral chemotherapy are included in the OCM. Often these patients require hospitalization due to side effects,decreased access and ability to communicate with providers. Limited documented strategies exist showing how to decrease hospitalizations in patients with cancer. The aim of this study was to decrease the hospitalization rate of oral chemotherapy patients at five sites by improving access to care and communication via establishment of phone triage nursing management. Methods: The aim of this project was to reduce hospitalizations for oral chemotherapy patients being treated at home over an eight month period. The Model for Improvement served as the research framework and design for this improvement project. The model includes identifying, defining and diagnosing a problem, before developing solutions and implementing interventions that are anticipated to solve the identified issues. Plan, Do, Study, Act (PDSA) cycles were utilized to develop and test changes in support of the oral chemotherapy patients. Five clinical sites affiliated with a community oncology practice in Texas collaborated with a Patient Support Service (PSS) nursing call center. Results: Implementing the PSS center resulted in a lowered number of monthly hospitalizations over eight months in patients receiving outpatient oral chemotherapy as compared to monthly volume of hospitalizations over eight months before implementation while demonstrating positive patient satisfaction with the oral regimen. Conclusions: This quality initiative found that OCM patients receiving oral chemotherapy can be supported to remain in their homes while decreasing unnecessary hospitalizations through the establishment of a PSS center. Through support systems for out-patient oncology patients, outcomes can be improved, unnecessary hospitalizations decreased, patient satisfaction sustained, and overall cost of care reduced.
Applying quality improvement methodologies to decrease the time-to-activation of new clinical trials at an NCI-designated comprehensive cancer center.
Authors: Brown Timothy J , Williams Erin Fenske , Griffith Patrice , Rahimi Asal Shoushtari , Oilepo Rhonda , Hammers Hans J. , Laetsch Theodore Willis , Kurian Pamela , Currykosky Penny , Partridge Susan , Beg Muhammad Shaalan
Published: October 2019

296

Background: Initiating a new clinical trial is burdensome and complex. The time to activate a clinical trial can directly affect the ability to provide innovative, state-of-the-art care to patients. We sought to understand the process of activating an oncology clinical trial at a matrix National Cancer Institute-designated, comprehensive cancer center. Methods: A multidisciplinary team of stakeholders within the cancer center, university, and affiliate hospitals held a retreat to map out the process of activating a clinical trial from packet receipt to enrollment of the first patient. We applied classical QI and Six Sigma methodology to determine bottlenecks and redundancies in activating a clinical trial. During this process, particular attention was paid to time to pass through each step and perceived barriers and bottlenecks were identified through group discussions. The time to activation was measured from the day the trial packet was received until the time when the trial was open for enrollment. Results: The process map identified 66 steps with 12 decision points to activate a new clinical trial. The following two steps were instituted first: 1) allow parallel scientific committee and institutional review board (IRB) review and 2) allow the clinical research coordination committee to review protocols for feasibility and university interest separate from the IRB approval process. These changes resulted in a mean time-to-activation change from 194 days at baseline to 135 days after these changes were implemented. The committee continues to track the activation time and this frame work is used to identify additional improvement steps. Conclusions: By applying quality improvement methodologies and Six Sigma principles, we were able to redesign redundant aspects of the process of activating a clinical trial at a matrix comprehensive cancer center. This was associated with a reduction of time to activation of trials. More importantly, the process map provides a framework to maintain these gains and implement further changes.
Tumor board automation.
Authors: Zechmann Stephanie , Schreiner Susan
Published: October 2019

297

Background: Coordinating tumor boards is a complex resource intensive process. Nebraska Medicine has 16 oncology-based Tumor Boards weekly. Preparation included multiple emails between disciplines for each conference regarding case request, case reminders, agenda modification, final agendas and printing. Other tasks include recording of attendance, completion of staging sheets, tracking tumor board summaries, totaling cases presented, and completion of CoC summaries. A full time employee completed these tasks. Developing an efficient streamlined approach to managing tumor boards became critical. Methods: Standardized agenda templates and tumor board communication processes were created. Multiple email groups were developed per tumor board to allow for specificity and clarity for individuals within a targeted tumor group to reduce email traffic. Leveraged available technology within Microsoft Office 365 Suite at our organization. Microsoft Flow and SharePoint applications were selected to manage data information sharing and ease communication flow as well as provide immediate notification of agenda changes. SharePoint subsites were set up for each tumor board including: current agenda Excel file, archive agendas and summaries. Microsoft Flow turns repetitive tasks into multistep workflows. It makes decisions in workflow, running specific actions when certain conditions are met. Flow is used for automated emails for case requests, submission reminders, and final agendas to selected group of individuals including Imaging, Pathology, Physicians, Researchers and nurse. A condition was built in Flow for agenda modification. This auto-checks the agenda for updates and auto email notifies targeted individuals of updates. Results: Oncology Tumor Boards/Multi-Disciplinary Conference processes are automated with streamlined flow of communication, reduction in emails, better accommodation of late additions and greater number of patient presentations. This has improved patient care and reduction in employee time. Conclusions: Through exploration, collaboration and innovation, it is possible to automate tumor boards/MDC to create a seamless process, expand number of conferences and patient presentation while reducing resource utilization and staffing expense.
ASCO Research Community Forum: Impact on clinical research.
Authors: Waterhouse David Michael , Robert Nicholas J. , Kim Edward S. , Kurbegov Dax , Burris III Howard A. , Thompson Michael A. , Nowakowski Grzegorz S. , Hurley Patricia A. , Davis Courtney , Lilenbaum Rogerio
Published: October 2019

299

Background: In 2011, ASCO launched a forum for the oncology research community to facilitate and promote the implementation of quality clinical research. The ASCO Research Community Forum (RCF) was created to provide a solution-oriented venue for research sites to address common challenges with conducting clinical trials. It offers in-person and virtual forums and resources to learn and share best practices with peers on a variety of topics, including site quality assessment and improvement, research site operations, and clinical trial access and accrual. Methods: An assessment was performed to measure the ASCO RCF output and to gather information on its potential impact on the cancer community. Results: The ASCO RCF has provided an in-person venue for physicians and research administrators with a steady increase in attendance, from 52 attendees in 2012 to 159 in 2018. Multi-stakeholder meetings and manuscripts have promoted best practices and solutions to address challenges with implementing quality clinical trials. Tools and resources to facilitate best practices and quality improvement at trial sites have been accessed by a range of types of research sites from across the U.S. and internationally. Its web-based library of resources was accessed over 27,000 times in 2018, alone. An online forum was launched in 2019 to provide a new opportunity to connect and impact the research community. Conclusions: The ASCO RCF is a productive and esteemed resource for the cancer research community. In-person and virtual forums, along with practical tools, promote access and accrual to clinical trials by facilitating networking, developing solutions, and providing education and resources. The ASCO RCF impact has extended from community-based oncology practices to larger research networks and academic centers across the U.S. and internationally. Its efforts to promote and facilitate access to quality clinical trials align with the vision and mission of ASCO to conquer cancer through research, education, and promotion of the highest quality patient care.