bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing the true nature of unplanned cancer care.
Authors: Tamang Suzanne , Patel Manali I. , Finlayson Sam , Chen Xuemei , Kuznetsov Julie Lawrence , Blayney Douglas W. , Shah Nigam
Published: February 2017

183

Background: Unplanned care can result in poor outcomes that are potentially preventable. The design of effective interventions to improve outcomes for cancer patients requires a better understanding of the true nature of unplanned care. Although cancer care teams document each patient’s care trajectory in detailed free-text notes, care outcomes are typically measured from structured patient record data and do not contain key information necessary for quality improvement efforts, such as the etiology of emergent events, or events that occur at outside facilities. To inform clinical effectiveness work at Stanford’s Cancer Institute, we describe our application of text-mining to improve the assessment of post-diagnosis morbidity outcomes. Methods: We conducted a retrospective study of unplanned care among 3,318 patients with a new diagnosis of breast, gastrointestinal, or thoracic cancer during 2010-13. Using a validated framework for clinical text-mining, we analyzed 308,000 notes for two tasks. First, we extract information on external unplanned events that are documented by providers. Second, we profile symptom mentions in Emergency Department (ED) notes. Results: For all cancer patients, text-mining detected over 400 unplanned events (93% PPV) at outside facilities, resulting in patient rates of 5% in the first 30 days, and 11% up to one year post-diagnosis. Among breast cancer patients, the top three symptoms reported in ED notes are pain (89%), nausea (37%) and fever (18%). Pain is consistently the most prevalent symptom up to one year after diagnosis, other symptoms exhibit more dynamic trends; wound related disorders and nausea are more prevalent among ED admissions in the first three months, whereas fever, cognitive impairment and mental health issues become more prevalent among admissions after the first three months of cancer care. Conclusions: The application of text-mining methods can improve the quantification of morbidity outcomes by improving the estimation of unplanned care rates and by providing continued learning for symptom-driven interventions to mitigate preventable emergent care. Although additional information gaps in care trajectories may continue to exist, text-mining can aid in assessing the true nature of unplanned care.
Developing and evaluating composite measures of cancer care quality.
Authors: Samuel Cleo A , Landrum Mary Beth , Zaslavsky Alan M , Lorenz Karl A. , Keating Nancy Lynn
Published: February 2017

187

Background: Composite measures are useful for distilling quality data into summary scores; yet, there has been limited use of composite measures for cancer care quality measurement. We compared multiple approaches for generating composite measures of cancer care quality and evaluated how well composite measures summarize dimensions of cancer care and predict survival. Methods: We computed hospital-level rates for 13 colorectal, lung, and prostate cancer process measures for care delivered in 59 Veterans Affairs (VA) hospitals between 2001-2004. We generated 3 sets of composite measures: 3 cancer-specific composites (colorectal, lung, prostate), 3 care-modality-specific composites (diagnosis, surgery, non-surgical treatment), and 4 empirical-factor domain composites based on an exploratory factor analysis. We assessed correlations among all composite measures and estimated separate Cox proportional hazards models predicting all-cause survival for colon, rectal, non-small cell lung, and small cell lung cancers as a function of composite scores, controlling for patient clinical and demographic characteristics. Results: Four factors emerged from the factor analysis and accounted for 68.7% of the total variation in the cancer care measures. The factor domains included a combination of cancer-specific factors for "colorectal early diagnosis" and "prostate treatment" and care-modality-specific factors for "surgical treatment" and "non-surgical treatment.” We observed strong correlations (r) among composite measures comprised of similar process measures (r=.58 to 1.00, p<.0001), but not among composite measures reflecting different care dimensions. Across the different approaches, few composite measures were associated with survival. Conclusions: Each of the composite measure approaches examined reflected different aspects of cancer care quality, with the empirical-factor domains reflecting a combination of cancer-specific and modality-specific care domains. However, there was little evidence pointing to a single best approach for cancer care composite measurement. Weak associations across different care domains suggest that low- and high-quality cancer care delivery may coexist within VA hospitals.
Evaluation of radiation oncology workflows to optimize efficiency and ensure sufficient time for quality assurance testing.
Authors: Weintraub Sheri , Schofield Deborah , Scott Amanda , Carnes Samuel , Vinson Desiree , Kumar Tushar , Gagnon Patrick James , Herrick Beth , Ventura Deborah , Astle Lindsay , Mulvey Therese M. , Andrade Urszula
Published: February 2017

193

Background: Radiation treatment plan development involves many people throughout the various stages of the planning process. Delays at any point can result in compressed timeframes for final checks which can thereby threaten the quality and safety of the plan. We have used six sigma tools to establish goals, monitor delays, and to provide a framework for efficiency improvement. Methods: A team of physicians, physicists, dosimetrists, and therapists established time goals and broke the planning workflow into critical to quality elements. It was determined that contouring tasks shall be completed within 2 days of simulation and treatment plans shall be ready for final checks a minimum of 4 or 8 business hours prior to treatment (for 2-5 days or > 5 days from simulation to treatment respectively). Emergent patients were excluded. Time measurements were calculated based on plan upload time and the patient’s scheduled start time. Delayed starts were accounted for to ensure that improved compliance was not at the expense of such delays. Six sigma methodology was used to perform a failure modes and effects analysis and to identify the most significant workflow challenges. Results: Baseline data involving 34 patients was collected. Only 73.5% of these patients complied with the established time goals. From the six sigma process, it was determined that physicians’ schedules were a major contributor to compliance failures. Enhancements were made in physician scheduling and communication with staff. Over the following 6 months, 129 additional patients were evaluated and 89.1% were in compliance with the set time goals. This was a statistically significant improvement (P-test, p=.052). Delayed patient starts made up 5.9% of the baseline data and 6.2% of the 129 additional patients. There was no significant change in these delays (Fisher’s exact test, p=1.000). Conclusions: Our findings validate the employment of six sigma practice in improving workflow. Continued efforts will be employed to ensure consistent quality improvement.
Getting quality data back to frontline providers.
Authors: Barry-Weers Anne , Huibregtse Carol , Ihde Sue , Bjegovich-Weidman Marija , Weese James L.
Published: February 2017

196

Background: Oncology quality performance metrics may be improved by establishing a coordinated process for getting data back to providers. However, establishing ownership of quality metric data can be a challenge, especially in a large, integrated health system. Methods: Aurora Cancer Care’s team developed quality charters and a coordinated process for its 15-hospital, integrated health system that outlines a course of action for metric selection, data distribution, peer review and development of process improvement plans. A weighted tool was developed and implemented to prioritize measure selection. The weighted tool described and scored each quality measure against its performance improvement opportunity, ease in data collection, national benchmarks, regulatory and reimbursement impact, value to the patient and consideration of the resources required to implement change. The final score was used to prioritize and select measures. The System Multidisciplinary Disease-Specific Quality Subcommittees established quality measures. Abstraction began, outliers were reviewed and results were disseminated to the System Cancer Leadership Council as well as the 15 hospitals via the Regional Cancer Quality Subcommittees (RCQS). The RCQS chairs and quality directors meet quarterly with the system quality liaison to ensure the communication of data back to the front-line providers. Results: We found a rise in the percentages of invasive rectal cancers diagnosed with endorectal ultrasound or magnetic resonance imaging (no stage IV) (2012: 76%, 2013: 84%) and treated with total mesorectal excision (no stage IV) (2012: 72%, 2013: 87%). In addition, increases in the examination of at least 12 regional lymph nodes for invasive colorectal cancer (2012: 93%, 2013: 98%; p<0.05) and partial, rather than total, nephrectomy for renal cancer patients with T1a tumors (2012: 71%, 2013: 95%; p<0.05) were statistically significant. Conclusions: Though our coordinated process to get quality data back to providers continues to evolve, our front-line providers have shown greater enthusiasm for the data, engaged in behavior modification and become more accountable with process improvement plans that are integral to establishing the best patient outcomes.
Effect of physical activity (PA) perceptions in cancer survivors on PA behaviors: Helping health care providers improve patient communication.
Authors: Naik Hiten , Liu Geoffrey , Qiu Xin , Pringle Dan , Brown Catherine , Eng Lawson , Mahler Mary , Hon Henrique , Tiessen Kyoko , Thai Henry , Ho Valerie , Gonos Christina , Charow Rebecca , Pat Vivien , Irwin Margaret , Herzog Lindsay , Ho Anthea , Jones Jennifer M. , Xu Wei , Howell Doris
Published: February 2017

201

Background: While engagement in PA can lessen fatigue, improve quality of life (QOL) and/or improve survival in cancer survivors, to what extent patients are aware of this and how it affects their behavior is unclear. Methods: 1,244 adult cancer survivors across disease sites and stages (mostly curative) at the Princess Margaret Cancer Centre (PMCC) were surveyed about their perceptions of PA, the barriers that prevent them from being physically active, and their level of PA currently. Multivariable logistic regression evaluated the associations between clinical and socio-demographic factors on these perceptions and current activity levels. Analyses were adjusted for performance status and important covariates. Results: Cancer survivors were surveyed at a median of 26 months after diagnosis. 16% had breast, 12% GI, 26% gyne/GU, 14% head and neck, 6% lung and 19% hematologic cancers. 55% of survivors reported being physically active. Overall, 76% believed PA could lessen their fatigue, 91% reported PA could improve their QOL, and 89% felt PA could improve their 5-year survival. Common barriers to PA were: being too ill (41%), too tired (33%), too busy (29%) and having too many home responsibilities (28%). Older patients were more likely to believe that PA would not improve their fatigue (p=0.005) and not improve their 5-year survival (p=0.001). Lower household income was associated with belief in lack of benefit of PA on fatigue (p=0.0001) or QOL (p=0.02). Not perceiving benefit of PA on fatigue, QOL, or survival was associated with substantially lower levels of PA (p<0.01; each comparison), as was being older and having a lower income (p=<0.01, each comparison). Conclusions: Older patients (even those with good performance status) and those coming from a lower socioeconomic status were more likely to have negative perceptions of the effect of PA on major cancer outcomes, resulting in lower PA levels. At PMCC, we are using this information to shape how we communicate with our patients in our survivorship program to help them with their decision-making on PA.
Determining optimal first-line chemotherapy for good and intermediate prognosis testicular germ cell tumors using decision analysis.
Authors: Vanderburg Sky Breeden , Frazier A. Lindsay , Kim Jane
Published: February 2017

209

Background: Since 80-90% of testicular germ cell tumors (GCTs) are cured after first line therapy alone, minimizing toxicity should be an important consideration in the initial treatment decision between cisplatin and carboplatin. Cisplatin has been shown to be superior in 5-year disease-free survival, but cisplatin use confers a higher risk of key long-term toxicities. This study aims to quantify this trade-off between disease-free survival and toxicities using decision analysis. Methods: We developed a mathematical decision-analytic model that simulates competing strategies of initial treatment with cisplatin or carboplatin in terms of treatment response, long-term toxicity, and mortality associated with first, second, and third line therapies for patients with good and intermediate prognosis testicular GCTs and a median age of 20 years at diagnosis. Treatment toxicities included ototoxicity, neurotoxicity, and nephrotoxicity. Monthly probabilities were weighted means derived from a systematic review of total follow-up data reported in seminal clinical trials. The model projected life expectancies for each strategy. Sensitivity analysis was conducted to examine the impact of uncertain inputs and assumptions. Results: The life expectancies at diagnosis for cisplatin and carboplatin strategies were 436.1 months (36.3 years) and 663.2 months (55.3 years) respectively. Sensitivity analyses revealed life expectancy figures largely dependent on the risk of nephrotoxicity occurrence from first line therapy and death from nephrotoxicity. Unless these base monthly probabilities were reduced by 87% and 99% respectively, carboplatin consistently yielded higher life expectancy than cisplatin. Conclusions: Under the current model, first line carboplatin therapy yields longer life expectancy than cisplatin, but this difference is highly sensitive to variables concerning nephrotoxicity. These preliminary results suggest that first line carboplatin therapy could yield higher life expectancy, though this result may be mediated by inclusion of other factors in future analyses, including updated estimates of mortality from nephrotoxicity or other toxicities.
Refining the clinical trials assessment of infrastructure matrix tool.
Authors: Weiner Bryan , Teal Randall , Dimond Eileen P. , Good Marjorie J. , Carrigan Angela , St. Germain Diane C. , Denicoff Andrea , McCaskill-Stevens Worta J. , Dempsey Kandie , Zon Robin , Grubbs Stephen S.
Published: February 2017

230

Background: Many community cancer research programs aim to exceed Good Clinical Practices. To support such efforts, the National Cancer Institute and collaborators began developing the Clinical Trials Assessment of Infrastructure Matrix (CT AIM) Tool in 2008. CT AIM’s 3 levels of exemplary performance span 11 infrastructure attributes. 2013’s revisions focused on interpretability, usability, and measurability. Methods: Tool input was obtained at national research meetings. Also, 4 Principal Investigator-Program Administrator (PI/PA) pairs from NCI-funded community cancer programs with varied demographics (eg, size, population) underwent cognitive interviews. Aggregated responses and a major-themes summary led to tool revisions. Next a web-based version was piloted with 4 more PI/PA pairs. The frequency/distribution of responses within pairs was assessed. The revised tool was then field-tested with 9 more PIs and scoring method feedback was collected; the tool was further revised. Results: Per community input and cognitive interviews: (1) “best practice” designation was replaced with “assessment of infrastructure”, (2) attributes were reordered based on perceived importance, (3) terms and cumulativeness of levels were clarified. Receiving 0 “don’t understand”s indicated improvement in clarity. 64% of “don’t know” responses were from respondents at the same program and 5 were from the biospecimen research attribute, indicating the information is difficult for programs to obtain. PI/PA responses varied 36% of the time, of which 70% involved a 1-level difference in response, indicating variation in responses by program role. 2 questions generated inconsistent responses from all 4 pairs, indicating possible further revisions. Average scoring was more accurate and sensitive to incremental program improvements. Conclusions: Broad community input, cognitive interviews, and piloting improved the tool’s clarity. Program leaders are encouraged to use CT AIM with research team members to enhance site infrastructure. CT AIM is useful for quality improvement, benchmarking research performance, progress reporting, and communicating program needs with institutional leaders. NCI Contract No. HHSN261200800001E
Using algorithms to standardize peripheral stem cell mobilization and collection.
Authors: Jourdan Dawn , Schmit Pokorny Kim
Published: February 2017

233

Background: Review of peripheral stem cell (PSC) collection data showed a significant practice variation in the number of collections, minimum and target dose of PSC collected, and the use of plerixafor for mobilization of PSC. In addition, the peripheral blood CD34 test was not used to determine the start of collections. At this institution, approximately 100 adult patients collect PSC per year with a mean of 3 (range 1-10) collections per patient. Cost per patient varied from $9,800 to $74,600. Methods: Patients planned to undergo an autologous PSC transplant, 18 years and older, were included. Three years of historical data was analyzed and pilot algorithms developed. Algorithms identified when to start and stop collecting, if and when to start plerixafor, and when to re-evaluate the mobilization method. The use of the peripheral blood CD34 test was implemented. The minimum CD34 cell dose was standardized and the target dose was lowered. The entire collection process was reviewed and additional efficiencies were identified. Results: Analysis of 42 patients’ collections January 2013 through July 2013 revealed that the majority of patients (86%, n=36) were able to achieve the target CD34 dose in 3 or fewer collections (mean = 1.5, range = 1-4). The algorithms were followed in 41/42 patients. The patients’ engraftment and length of stay were similar to historical data suggesting that the minimum and target CD34 dose is acceptable. Work flow changes associated with the use of the peripheral CD34 test didn’t produce any negative impact on the departments involved. The initial collection cost decreased by approximately $2,000 and each additional collection decreased by approximately $800. The average cost savings per patient was $9,500. The actual total cost savings over a six month period was $303,204. The mean total number of collections per patient decreased from 3 to 1.5. Conclusions: Standardization of practice can result in significant cost savings. Using an expensive drug (plerixafor) in well-defined situations makes good clinical and economic sense. Reviewing processes also identifies additional opportunities in which to make positive changes.
Assessing the utility of a patient-reported screener question to detect fatigue symptoms: Improving the quality of systematic symptom measurement in clinical practice.
Authors: Tomasini Pascale , Brown Catherine , Vennettilli Ashlee , Zarrin Aein , Dobriyal Aditi , Chen Linda , Mirshams Maryam , Patel Deval , Irwin Margaret , Ho Valerie , Ho Anthea , Pat Vivien , Solomon Hannah , Thai Henry , Mahler Mary , Xu Wei , Howell Doris , Liu Geoffrey
Published: February 2017

236

Background: In Ontario, there is a concerted effort to screen all cancer outpatients for clinically significant symptoms at every visit, without causing undue burden on the patient. Although fatigue symptoms are common in cancer patients, severe fatigue may require clinical intervention. To reduce reporting fatigue, we evaluated the use of a single item screener question to detect severe fatigue, as defined through the FACT-Fatigue Scale (FACT-F), with the goal of reducing patient reporting burden. Methods: 316 Princess Margaret Cancer Centre outpatients across a wide range of cancers at all phases of therapies and disease stages were asked to report fatigue symptoms using the FACT-F. The ability of one screener question “I feel fatigued” to detect severe fatigue symptoms in any of the six other fatigue-related questions was evaluated. Using the presence of any severe fatigue symptom as the reference, sensitivity (Se) and specificity (Sp) of the screener question was determined. Results: Median age was 59 (19-91) years; 45% were male. The prevalence of significant, severe fatigue-related symptoms for the six individual questions covering various fatigue domains ranged from 4% to 7%. 12% of patients exhibited at least one severe symptom on FACT-F (prevalence). Defining a positive screen as “quite a bit” or “very much” fatigued, with 16% prevalence, the screener question was able to correctly identify any severe symptom 81% of the time (Se) and was able to rule out any severe symptoms 92% of the time (Sp). Conclusions: The use of a screener question to accurately detect patient symptoms provide patients with the ability to be involved in their care without being overly burdened in the process. At the meeting we will provide updated results on 500 patients, the potential modifying role of clinico-demographic factors, and results of the performance two additional screener questions on fatigue. While patient-reported outcomes are widely used in research, they may also be a practical and acceptable means to accurately detect clinically important symptoms in the clinic.
Unplanned visits to hospital emergency for oropharynx patients undergoing radiation therapy in Ontario.
Authors: Gutierrez Eric , Foster Nicoda , Lockhart Elizabeth , Comrie Rebecca , Stiff Jennifer , Anas Rebecca , Warde Padraig Richard
Published: February 2017

267

Background: Radiation therapy (RT) with or without concurrent chemotherapy is the standard of care for patients with oropharyngeal cancer. The acute toxicity of treatment is well recognized and highlights the need for a multidisciplinary approach to management. In 2009, a Head and Neck Organizational Guideline was published by Cancer Care Ontario (CCO) which emphasizes the need for a multidisciplinary team approach of surgical, medical and radiation oncologists; supportive care professionals, including speech language pathologists, dieticians, social workers; and others to support the care of this population. In order to assess the availability of appropriate supportive care for this patient group, the percentage of patients who visited an Emergency Department (ED) during their course of RT and the causes for these visits were assessed. Methods: Patients with a diagnosis of oropharyngeal cancer receiving radical RT in Ontario (10 Cancer Centres) between the period of April 1, 2011 and March 31, 2013 were identified from CCO’s Activity Level Reporting ( ALR ) database. These patients were then linked to the National Ambulatory Care Reporting System ( NACRS ) administrative dataset from the Canadian Institute for Health Information ( CIHI ) which allowed identification of patients that visited ED during their course of RT as well the reasons for the visits. Data on the use of concurrent chemotherapy was not available. Results: Over the two year period, 885 patients in Ontario had radical RT (+ concurrent chemotherapy) for oropharyngeal cancer of which 261 (29.5%) visited an ED at least once during their treatment (range of 22% to 36% across the 10 centres). The main reasons for the ED visits were dehydration and neutropenia, although coding for reason of visit was incomplete in 16% of cases. Conclusions: The high proportion of patients attending an ED while receiving daily RT would suggest that the supportive care needs of this population are not being regularly met. Further work is necessary to understand the reasons for ED visits in this group of patients and the substantial variation seen between centres would suggest this metric may be useful as a new quality of care indicator.
Clinical pathways and quality metrics.
Authors: Ellis Peter G. , Lokay Kathleen
Published: February 2017

273

Background: UPMC CancerCenter (UPMC) participates in a number of nationally recognized quality programs and strives to maximize quality through continuous improvement of the quality measures endorsed by these programs. Clinical pathways are potential aid in driving quality improvement through decision support and measurement. Methods: When deficiencies are identified, UPMC’s quality team develops improvement strategies including working with its pathways vendor (Via Oncology) on the placement of key decision support prompts and required data fields within its physician-facing pathways portal. Gaps in data completeness have also been identified as an opportunity to use pathways for more complete data collection during chart abstraction as well as interim reporting. Results: Due to the success above, UPMC continues to actively engage with pathways as a tool to drive adherence to and capture complete data for quality measures. If release of the UPMC data is approved by the quality measurement organization(s), UPMC will share the results of its quality measures in the full poster. Conclusions: Pathways are a tool for promoting adherence to quality measures by oncologists through the use of a point of care decision support system. Pathways are also a source of reporting quality measures across all patients in time period which allows for interim measurements and proactive identification of improvement areas. [Table: see text]
Monitoring treatment wait times for cancer patients in Japan.
Authors: Watanabe Yukiko , Iwamoto Momoko , Higashi Takahiro
Published: February 2017

289

Background: Treatment wait times for cancer patients is among the key performance indicators of cancer policy in Japan, but has never been measured across a large number of patients. We aimed to measure treatment wait times for cancer patients across a large number of hospitals in Japan using health claims data. Methods: We developed a database of claims data (Jan 2011 - Dec 2012) linked to 2011 hospital-based cancer registry data of breast, cervical, colorectal, liver, lung, prostate and stomach cancer patients from 126 designated cancer hospitals in Japan. Treatment wait time was defined as the number of days between the date of diagnosis (the date on which a pathological test or imaging exam that contributed the most to the diagnosis was performed) and initiation of treatment. Dates of diagnostic tests, therapeutic procedures, and chemotherapy (chemo) administration were obtained from health claims data. We calculated wait times by cancer type, treatment, and stage, and investigated if these factors were significantly associated with wait times even after adjusting for age using multiple linear regression. Results: Among 44,102 cancer patients who received cancer treatment, the median wait time was 31 days (IQR=18-50) for all patients, and 32, 42, 31, 22, 22, 55 and 31 days for breast, cervical, colon, liver, lung, prostate and stomach cancer patients, respectively. Wait times were longer for surgery (36 days) compared to radiation (22 days) and chemo (21 days), and shorter for later stage patients: 48, 36, 35, 23, and 14 days for stages 0, I, II, III, and IV, respectively. Cancer type, treatment type, and stages were all independently and significantly associated with treatment wait times even after adjusting for age (p<0.05). Conclusions: This is the first study to investigate treatment wait times across a large number of cancer hospitals in Japan. Treatment wait times were particularly longer for cervical and prostate cancer patients. While the effect of prolonged treatment wait times on clinical outcomes is unknown, longer treatment wait time increases the psychosocial stresses of cancer patients. Continuous monitoring and feedback of study findings to hospitals are required for improvements in the future.
Eribulin treatment patterns in patients with and without prior anthracycline use.
Authors: McBride Ali , Faria Claudio , Li Xuan , Powers Annette
Published: February 2017

292

Background: Eribulin mesylate is indicated for patients with metastatic breast cancer after treatment with ≥2 prior chemotherapeutic regimens for metastatic disease. Prior therapy should have included an anthracycline and a taxane. Evidence examining the effects of prior exposure to anthracyclines on eribulin therapy is limited. The purpose of this study was to compare demographic characteristics and treatment patterns for anthracycline-experienced patients vs. anthracycline-naïve patients treated with eribulin. Methods: A retrospective analysis using electronic medical record (EMR) data from 1/1/08 to 3/1/14 was conducted. Chemotherapy drugs were identified by the treatment name field in the EMR. Index date was defined as the first eribulin treatment. Patients with ≥2 eribulin administrations, continuous eligibility including a 6 month pre-period prior to the index date, and no treatment gaps more than 6 months were included. Patients were stratified into an anthracycline experienced cohort (treated prior to eribulin therapy) or without anthracycline cohort (never treated with this drug class prior to eribulin therapy). Demographics (gender, age, receptor status) and treatment characteristics (number and days of eribulin therapy) were compared between the cohorts. Results: 190 patients received eribulin; 46 (24%) with prior anthracycline use, 144 (76%) without. The majority of patients were female (87% for prior anthracycline, 97% without), and the average age of both groups was 59 yrs. Most patients were HR+/HER2- (56% overall; 70% for prior anthracycline, 51% for without), followed by TNBC (29% overall; 24% prior anthracycline, 31% without). Some patients had been treated previously with trastuzumab (15% overall; 7% for prior anthracycline, 17% for without). The number of eribulin administrations did not differ significantly between cohorts (8.2 administrations for anthracycline vs. 9.6 without, p=0.268). Likewise the number of days of therapy did not differ significantly (88.1 days for prior anthracycline vs. 104 without, p=0.369). Conclusions: There was no significant difference detected for prior anthracycline use impacting the number of eribulin administrations or days of therapy.
Comparative effectiveness of first-line chemotherapies in advanced non-small cell lung cancer.
Authors: Chang Jennifer T. , Spence Michele M. , Hui Rita L. , Schottinger Joanne E. , Rashid Nazia , Millares Mirta
Published: February 2017

293

Background: There is a variety of chemotherapy regimens used as first-line treatment in advanced non-small cell lung cancer (NSCLC). Few studies have used real-world data to compare the clinical outcomes associated with different chemotherapy combinations. The study objective was to compare overall survival between chemotherapy regimens used for patients with advanced NSCLC in an integrated healthcare system. Methods: This retrospective cohort analysis included patients age 18 or older from Northern and Southern California Kaiser Permanente with a diagnosis of Stage IIIB/IV NSCLC identified in the cancer registry. First chemotherapy date occurred from January 2008 through September 2012 with at least 6 months of follow up to March 31, 2013. Overall survival was measured as the number of months from initial chemotherapy until death, end of enrollment or March 31, 2013. Chemotherapy regimens were categorized into five mutually exclusive groups: pemetrexed-based, pemetrexed + bevacizumab, bevacizumab-based, platinum doublets and singlets. Survival was compared between the five groups using Cox proportional hazard models, adjusting for age, gender, race, region, stage, histology, days from diagnosis to initial chemotherapy and Diagnostic Cost Group (DxCG) risk score. The analysis was performed for all age groups and by age over and under 65. Results: Among 1,989 adults, those that received singlet chemotherapy were at significantly increased risk of mortality compared to doublets (HR 1.23; 95% CI 1.02-1.49). Patients younger than 65 who had received pemetrexed + bevacizumab regimens were at significantly reduced risk of mortality (HR 0.58; 95% CI 0.35-0.95) when compared to platinum doublets. Among patients over 65, there were no significant differences in survival between the chemotherapy regimens. Conclusions: Adult patients with advanced NSCLC who are younger than 65 years old have improved survival after receiving pemetrexed + bevacizumab chemotherapy regimens compared to platinum doublet regimens. No survival differences were found between regimens in patients over the age of 65.
Treatment sequencing patterns of novel agents in patients with prostate cancer.
Authors: Malangone Elisabetta , Foley Kathleen A. , Wilson Kathleen , Varker Helen , Binder Alison , McKenzie R. Scott , Ellis Lorie
Published: February 2017

296

Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend chemotherapy, immunotherapy or anti-androgen therapies for the treatment of advanced castration-resistant prostate cancer (CRPC). This study evaluated treatment sequencing of recently approved agents for CRPC [abiraterone (ABI), enzalutamide (ENZ), docetaxel (DOC), cabazitaxel (CAB), or sipuleucel-T (SIP)] among men with PC. Methods: This retrospective, observational study evaluated adult men with PC in the MarketScan Oncology EMR database, which includes data from over 900 contributing oncologists from over 100 community practices. Inclusion required a diagnosis of PC (ICD-9-CM diagnosis code 185) from 07/01/2011-03/31/2014, no treatment with ABI, ENZ, DOC, CAB, or SIP prior to 09/01/2012, no other primary cancers, and six months of medical record history prior to index date. The index date was the date of first prescription of ABI, ENZ, DOC, CAB or SIP between 09/01/2012 and 03/31/2014. First-, second- and subsequent-line treatments were evaluated prior to end of data availability or end of study. Results: In total, 812 PC patients were identified; mean age was 75 years and 68% had recorded metastasis. A single line of therapy was observed for 544 patients (67%). ABI was the most common first-line treatment (443; 55%), followed by DOC (167; 21%), ENZ (113; 14%), SIP (82; 10%) and CAB (7; 1%). A second line of therapy occurred in 268 patients (33%) and third line in 8%. The table below describes first-line and the two most common second-line therapies for those moving on to second-line. Conclusions: Of the five agents of interest, ABI was the most commonly prescribed first-line medication for advanced PC in this patient cohort. First-line DOC was more common than first-line CAB or SIP. Further studies with longer follow-up and other treatments are warranted. [Table: see text]
Understanding variation in the timeliness of diagnosis of cancer in symptomatic patients.
Authors: Lyratzopoulos Georgios
Published: February 2017

301

Background: Diagnosing cancer promptly in symptomatic patients is a priority for healthcare systems worldwide, but little is known about how initiatives can be targeted to patients at greater risk. Methods: UK data on the number of consultations with a family doctor before specialist referral (‘pre-referral consultations’); the time interval from presentation to referral (‘primary care interval’); and stage at diagnosis, were analysed using multivariable regression models. Results: Both patient experience (41,299 patients, 24 cancers) and clinical audit (13,031 patients, 18 cancers) data indicated wide variation in two correlated measures* of the difficulty of suspecting the diagnosis of cancer once the patient had presented to their family doctor. For example, >30% of patients with multiple myeloma, pancreatic and lung cancer experienced three or more pre-referral consultations; in contrast, this was true for <10% of patients with breast cancer and melanoma (p<0.001). Adjusting for diagnostic case-mix, younger and ethnic minority patients, and women, were more likely to experience three or more pre-referral consultations. Data from 88,657 patients (10 cancers) suggested socio-demographic disparities in stage at diagnosis for some only cancers: For patients with melanoma, breast and endometrial cancer, lower socioeconomic status was associated with higher risk of advanced stage at diagnosis and for, these three cancers, the same was true for older age. Conclusions: Different diagnostic intervals vary widely by cancer diagnosis and patient characteristics. Notable disparities in stage at diagnosis are apparent for ‘easy-to-suspect’ cancers (which are associated with minimal delay post-presentation), strongly implicating psychosocial patient factors as the source of these disparities. These findings can help to appropriately target early diagnosis policy initiatives and future research to patients at greater risk of prolonged diagnostic intervals. *Number of pre-referral consultations with a primary care physician and length of primary care interval (Spearman’s r=0.70).
Hospital size and demographics associated with HCAHPS and implications for hospital value-based purchasing (HVBP).
Authors: McFarland Daniel Curtis , Ornstein Katherine , Holcombe Randall F.
Published: February 2017

38

Background: Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) scores appear to be lower in densely populated areas and for urban academic medical centers (AMC). These patient satisfaction scores contribute to CMS reimbursement. We hypothesized that demographics and hospital factors such as size were significant determinants of HCAHPS. Methods: HCAHPS, hospital bed, and county demographics were obtained from the Hospital Compare, American Hospital Directory, and US Census Bureau websites, respectively. An aggregate positive score was created for each hospital. Multivariate regression modeling was performed for the aggregate positive score and all ten dimensions of HCAHPS. Standardized partial regression coefficients were used to assess strengths of postulated predictors (Table). A predictive formula based on the 4 strongest predictors was developed. An adjustment model corrected for demographic and hospital factors. Hospitals were rescored using this model to generate an adjusted score (WIPSAS – weighted individual patient satisfaction score). HCAHPS hospital ranking was compared to WIPSAS ranking for all NY State hospitals. HCAHPS were obtained from 3,192 hospitals and demographic data collected from 3,144 counties. Results: ‘Hospital beds’ and ‘non-English speaking’ were the strongest negative predictors while ‘% Bachelor’s’ and ‘white alone’ were the strongest positive predictors of HCAHPS. The adjusted r2 was.22 for the model and.155 for the predictive formula. WIPSAS altered the ranking in NY State. The adjusted ranking moved 3 AMCs into the top ten (prior #42, #43, #46). Conclusions: Demographic and hospital factors influence HCAHPS. Adjusted scores may be more representative of a hospital’s actual performance. CMS should utilize WIPSAS adjusted scores in order to more fairly calculate HVBP reimbursements. [Table: see text]
Clinician assessment of potentially avoidable hospitalization in patients with cancer.
Authors: Brooks Gabriel , Uno Hajime , Jacobson Joseph O. , Schrag Deborah
Published: February 2017

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Background: In patients with advanced cancer, acute hospitalization accounts for nearly half of all medical spending. Prior research has suggested that many hospitalizations in cancer patients are potentially avoidable, however the perspectives of clinicians directly involved in patient care are not known. Methods: We studied hospital admissions to an inpatient medical oncology service among patients with solid tumor malignancies. For each hospitalization, we interviewed three clinicians from the medical team: the outpatient medical oncologist, the inpatient attending oncologist, and the inpatient resident physician or physician assistant. Respondents were asked to identify whether or not each hospitalization was potentially avoidable (‘probably’ or ‘definitely’ avoidable vs. ‘definitely not’ or ‘probably not’ avoidable). The primary outcome was the proportion of hospitalizations identified as potentially avoidable by two or more of the three clinicians. Results: Complete clinician interview data were collected for 103 of 132 eligible hospitalizations (78%). The median age at hospitalization was 64 years, and 79% of hospitalized patients had metastatic cancer. The most common cancer sites were the lung, breast, and colorectum. 18% of hospitalizations were rated as potentially avoidable by the outpatient oncologist, 28% by the inpatient oncologist, and 30% by the inpatient resident or physician assistant. 24 hospitalizations (23%) were identified as potentially avoidable by two or more clinicians, but only 2% were identified as potentially avoidable by all three clinicians. Hospitalizations were more likely to be perceived as potentially avoidable when psychosocial factors contributed to the reason for hospital admission (OR 2.9, 95% CI 1.2-7.3). Median length of stay was shorter for potentially avoidable hospitalizations (2 vs. 4 days), but rates of death and readmission within 90 days did not significantly differ following potentially avoidable vs. other hospitalizations. Conclusions: A substantial proportion of hospitalizations in patients with cancer are perceived as potentially avoidable by clinicians who are directly involved in patient care.
Impact of radiotherapy practice structure on prostate cancer treatment and outcomes.
Authors: Hoffman Karen Elizabeth , Huo Jinhai , Giordano Sharon Hermes , Smith Benjamin D.
Published: February 2017

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Background: Traditionally men with prostate cancer were treated in clinics created, managed and overseen by radiation oncologists. Urology-owned “integrated” practices emerged in the 2000s. Proponents of integrated (INT) practices argue they improve quality-of-care by fostering multidisciplinary care while detractors argue they decrease quality-of care because they employ only one or two radiation oncologists which limits quality-assurance peer review. We compared radiation techniques and treatment toxicity for men who received radiation therapy (RT) in INT and non-INT practices. Methods: Men 66 years and older diagnosed with prostate cancer from 2006 to 2009 were obtained from the Texas Cancer Registry. Cancer-directed therapy, comorbid medical conditions and late treatment toxicity (diagnosis or procedure codes for toxicity 12 or more months after diagnosis) were determined from linked Medicare claims. Practice type was classified based on practice location of the treating radiation oncologist. Chi-square statistics compared categorical variables. Cox proportional hazards models evaluated predictors of toxicity. Results: External beam RT (> 20 fractions) was administered to 781 men in INT and 3,257 men in non-INT practices. Median follow up was 44 months. Men treated in INT practices lived in counties with higher income (p<0.001). There was no difference in patient age (p=0.55) or comorbidity (p=0.88) between practice types. Men treated in INT practices were more likely to receive intensity-modulated RT (98% vs. 82%, p<0.001) and image-guided RT (73% vs. 23%, p<0.001). Androgen deprivation therapy use was similar between practice types (p=0.36). Adjusting for patient and tumor characteristics, there was no difference in risk of late gastrointestinal (p=0.52), urinary (incontinence, p=0.10; other p=0.28), or erectile (p=0.28) toxicity between practice types. Conclusions: Men treated in INT practices were more likely to receive intensity-modulated RT and image-guided RT for their prostate cancer. Risk of late gastrointestinal, urinary and sexual side effects for men who received radiotherapy in INT practices was similar to risk of late side effects for men who received radiotherapy in non-INT practices.
Baseline evaluation of the patient-centered oncology care model.
Authors: Tirodkar Manasi A. , Scholle Sarah Hudson
Published: February 2017

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Background: The patient-centered medical home (PCMH) model of care is being widely adopted as a way to provide accessible, proactive, coordinated care and self-care through primary care practices. During active treatment for cancer, the oncology practice is often the primary setting supporting the patient and coordinating cancer treatment. For this project, we are implementing a Patient-centered Oncology Care model in five oncology practices and evaluating the impact on cost, quality, and patient experiences. Methods: To determine the structures and processes present in the practices at baseline, we conducted a self-assessment on the standards, followed with an on-site “audit” for compliance with the standards. To get a sense for organizational culture and motivation to change, we conducted site visits which included interviews with providers, staff and patients and observation of clinical encounters and workflow. Results: Among the highest priority structures and processes, the most common were telephone triage, symptom management, advance care planning, and the use of evidence-based guidelines. The least common were patient/family orientation, availability of same day appointments, discussion and documentation of goals of therapy, symptom assessment, and tracking of appointments. All of the practices had made patient-centered care a priority and staff were motivated to change. There was variation in the way providers and the care team used health information technology during clinical workflow. There was also variation in which staff coordinated care for patients and whether or not financial counseling was offered. All of the practices stated that they needed to work on implementing survivorship care planning, shared decision-making, and patient engagement in quality improvement and practice transformation Conclusions: The pilot oncology practices have many structures and processes in common. However, there is little standardization within practices in the way these processes are established and documented. Practices vary in how they are implementing patient-centered care processes. However, with motivation to change, staff and providers are actively engaged in the transformation process.