bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of burn-out syndrome in oncology staff and its improvement through specific interventions.
Authors: Cunquero Tomas Alberto Jacobo , Ortega Inmaculada , Fernández Teresa , Lobo De Mena Miriam , Gil Raga Mireia , Iranzo Vega , Caballero Diaz Cristina , Gomez Ana , Blasco Ana , Camps Carlos
Published: October 2019

249

Background: Burn-Out Syndrome (BOS) is defined by: emotional and physical exhaustion; cynicism and depersonalization; and no personal nor professional fulfillment. With increasing incidence, it impacts negatively in the patient attention quality and the quality of institutional processes. Few experiences reported about its incidence and impact in Medical Oncology. Lack of resources for its diagnosis and management. Our objective was to determine the incidence of the BOS in our workers, analyze its causes and try to reduce in 20% the percentage of workers suffering or at risk of suffering BOS. Developed as a Quality Training Program (ASCO - ECO Foundation) project. Methods: 23 nurses/nurse-assistants Medical Oncology Department at University General Hospital of Valencia fulfilled anonymized questionnaire with personal details, GHQ-12 evaluation and Maslach index questions, at baseline and after intervention. Causes of BOS analyzed and process map and Ishikawa fish-bone scheme designed. Interventions carried in consequence. Results: 23 subjects, 87% women, 47 year-old median age. 14 nurses, 8 working in the clinic. 90% with more than 5 years of experience in Oncology. At baseline, 75% GHQ-12 good health. Maslech index: 70%, 45% and 55% in risk (medium+high) of BOS related to exhaustion, depersonalization or fulfillment, respectively. In exhaustion, 35% medium risk, 35% high risk of BOS. After priority-matrix development, ergonomy tips and self-improvement tools were identified as the adequate interventions to improve exhaustion risk. After ergonomy tips intervention, 90% GHQ-12 good health, 15% exhaustion medium risk, 50% exhaustion high risk, 65% at risk of BOS related to exhaustion. An improvement of 5% lowering the risk of suffering Burn-Out Syndrome among our workers was achieved Conclusions: BOS risk is complex due to answer subjectivity. We have healthier workers (GHQ-12), but although levels of exhaustion have decreased mildly, those who were already exhausted are worse than before (Maslach Index). Possible causes: renovation work on Clinic, labor instability, local holidays during project. Additional self-improvement tools sessions are now being held.
Developing and operationalizing a safety culture across a hematology/oncology ambulatory network.
Authors: Philip Tony , Gleason Karen , Paul Valadez Jenny , Guerrier Keasha , Abraham Sony
Published: October 2019

250

Background: The “Safety Belongs to Me” (SBTM) campaign is an initiative that evaluates safety systems utilized by the Medical Oncology ambulatory network. The SBTM project aims to identify, report, and resolve current and future safety risks by implementing weekly interdisciplinary conference calls across the network. In addition it deploys a highly reliable reporting structure for departmental stakeholders (i.e. Administration, Nursing Administration, Materials Operations, Laboratory, and Pharmacy.) Thereby increasing situational awareness, and prevention of complacency as it relates to patient and employee safety risks. Methods: Methodologies utilized include six sigma tools (Kano analysis, etc.) improvement science tools (PDSA, process maps, and driver diagrams), and surveys. These were used to illustrate how principles of process improvement can be utilized to provide an effective framework for systematic innovation in healthcare. Weekly safety calls were started March 2019 after clinical and administrative leadership completed IHI safety culture training. Results: Since implementation of weekly safety calls, an average 13.2 safety issues identified/week with 3.6 issues/week needing follow up for resolution. There has been an increasing trend in safety issues identified and decreasing trend in new safety issues for follow up. Conclusions: The development of a reporting platform augmented a pre-existing process to escalate safety concerns and events within the medical oncology network. This collaborative has facilitated a formalized safety culture that has increased the identification of both potential and existing safety concerns.
Normalizing the use of patient-provider agreement for opioid treatment within a cancer institute.
Authors: Cherenzia Katie , Begnoche Megan , Fenton Mary Anne
Published: October 2019

251

Background: Addressing the opioid epidemic can be challenging in a large academic cancer program and necessitates the need for a multidisciplinary approach for implementation of a successful program. The oncologist has a challenging role caring for patients with preexisting pain conditions, acute cancer-related pain, pain at the end of life and cancer survivors who live with cancer as a chronic condition after treatment. Methods: A structured program was developed to address the mounting pressure from many fronts related to the opioid epidemic including insurance companies, pharmacies, and the Department of Health. In April 2018, the Lifespan Cancer Institute implemented a system wide opioid program including patient education, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. The intent of the program is to implement safe processes to safe guard the patient and their family along with the providers. The patient-provider treatment agreement clearly describes the roles and responsibilities of both groups with a goal of reducing risks by improving education. Our responsibility is to provide optimal management while addressing patient concerns and maintaining patient safety. Results: The opioid program has been well received by both caregivers, patients and families. All are engaged in the embedded education process and fully appreciate the need to use opioids safely. The program has been helpful in managing patient expectations and focusing difficult conversations in cases of potential abuse. In April 2018, only 13% of patients prescribed an opioid had a signed patient-provider treatment agreement. As of April 2019, 75% of patients have a signed agreement. Conclusions: The transitioning of care for the patient with chronic pain after completion of active cancer treatment continues to be a focus of future initiatives. Patient satisfaction remains a top priority as the patient-provider agreement becomes a standard of care for all patients receiving opioids. As oncology healthcare providers, our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.
An initiative to improve mortality index in gynecologic oncology.
Authors: Taylor Jolyn Sharpe , Miller Jennifer F. , Ballard Edith K. , Blanco Tricia K. , Brown Karen L. , Byrd Corrine C. , Holloway Anita , Smith Arletta , Park Anne , Cain Katherine , Marten Claire , Finch Roshonda , Nguyen Van , Fleming Donna , Levenback Charles F. , Lu Karen H. , Schmeler Kathleen M.
Published: October 2019

256

Background: The mortality index (MI) is a quality metric that measures the ratio of actual mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on patient risks and comorbidities. A MI of < 1.0 represents that fewer patients die while admitted to the hospital than expected. Methods: We formed a multidisciplinary team that included Gynecologic Oncology (GO), Health Information Management, Clinical Informatics, Revenue Operations, Coding and Institutional Compliance experts. Our aim was to decrease the GO MI by 10% within a year. Quality Improvement Assessment Board approval was obtained. GO clinical providers were educated on proper documentation of patient comorbidities and severity of illness. Audits of the documentation were performed by the multidisciplinary team. GO patients perceived at high-risk of inpatient mortality were identified for additional review. All GO inpatient deaths were reviewed at the monthly GO Morbidity and Mortality conference and opportunities for avoidance of inpatient death were discussed. Plan-Do-Study-Act (PDSA) cycles were repeated with adjustments made to the review and education processes. Baseline (BL) 8/2017-7/2018 and interim post-intervention (PI) 11/2018-2/2019 outcomes were compared using the Mann Whitney U test. Results: The BL median number of inpatient deaths per month was 2 (range 0-7), with a median expected mortality of 2.96 (range 1.46-5.11), and a median MI of 0.84 (range 0-1.37). The PI median number of inpatient deaths per month was 2.5 (range 2-5), with a median expected mortality of 4.24 (range 3.77-5.06), and a median MI of 0.56 (range 0.53-1.27). The number of inpatient deaths per month was similar between groups (2 vs 2.5; p = 0.49) but the expected mortality increased from to 2.96 to 4.24 (p = 0.03). MI decreased by 33% between BL and PI (0.84 vs 0.56). Conclusions: Inpatient mortality is an important quality metric. Accurate measurement of expected mortality is critical and requires proper documentation. This can be improved through education, review and frequent assessment by PDSA cycles. Our preliminary results show improvement in accurate documentation and measurement of expected mortality resulting in a decrease in MI.
Unplanned hospital admission in patients receiving concurrent chemotherapy and radiation.
Authors: Damico Nicholas , Tiemeier Ellen , Krukowski Laura , Colo Lucy , Sydenstricker Christine Marie , Kraska Barbara , Dorth Jennifer Anne
Published: October 2019

258

Background: Concurrent chemotherapy and radiation therapy (CCRT) has become a curative treatment for many malignancies. Many patients are ultimately cured, but at the cost of significant acute toxicity. When severe, this can require unplanned hospitalization. More research is needed to better identify patients at risk for hospitalization and how to prevent it. Methods: As part of quality improvement at the Seidman Cancer Center, patients in the University Hospitals (UH) system who underwent CCRT were identified. A review was done to determine which patients experienced an unplanned admission in the UH system during their radiation course or within 30 days and the admission diagnosis. We recognized malnutrition and dehydration as causes for hospitalization that were preventable. Several interventions were then performed to reduce these admissions. The first was standardized nutrition screening that prompts earlier dietician referrals for patients at risk of malnutrition. We also instituted hydration assessments for patients beginning in the 3rd week of radiation. Patients found to be dehydrated were scheduled to receive intravenous (IV) fluids as an outpatient for the remainder of their treatment course. Admission rates for patients undergoing CCRT have been tracked as part of this initiative and are reported here. Results: From 7/2017 to 12/2018 we identified 303 patients who completed CCRT. 78 (26%) had an unplanned hospital admission during their treatment course or within 30 days of completing radiation. This included patients with primary head and neck, CNS, GI, lung, GYN, and GU malignancies for which admission rates were 36%, 32%, 23%, 29%, 19% and 8% respectively. 18 (23%) of these patients were admitted after completing the radiation course but within 30 days. The initial admission rate prior to intervention was 34%. This has since declined to 19% (table). Conclusions: Unplanned admission rates are high in patients who undergo CCRT across disease sites. Patients remain at risk following completion of radiation therapy for up to 30 days. Some admissions may be prevented by early dietician referrals and IV hydration.

[Table: see text]
Decreasing time to initiation of inpatient chemotherapy at LAC+USC medical center utilizing an admission checklist.
Authors: Patel Ronak , Chiu Victor , Spicer Darcy V.
Published: October 2019

262

Background: Delays in the initiation of chemotherapy for scheduled inpatient admissions cause excess lengths of stay and shift infusion start times to the evenings when hospital staffing is decreased. We sought to characterize delays in our admission process and assess the feasibility of using an admission checklist to shorten start times in a large academic safety-net hospital. Baseline data for scheduled chemotherapy admissions in July and August of 2017 (n = 25) showed a mean time to chemotherapy initiation of 14.6 hours and mean excess LOS was 0.7 midnights. Significant delays were identified in the time between ordering and resulting of pre-chemotherapy labs (average 2.6 hours), and the time required to obtain imaging to confirm peripheral-inserted central catheter (PICC) position (1.6 hours). Methods: We created a checklist of a standardized admission workflow for physicians, which included moving all pre-chemotherapy labs, pharmacy verification of chemotherapy regimen, and PICC imaging to the outpatient setting. We organized multiple staff in-services to introduce the admission workflow prior to implementation on May 1, 2018. We then performed a retrospective chart review of all scheduled inpatient chemotherapy admissions from May to August of 2018. Results: In the first 2 months after intervention, the mean time to chemotherapy initiation was 8.5 hrs, representing a 42% reduction. In the subsequent 2 months, the mean time to chemotherapy initiation was 11.6 hours, representing a 21% reduction from baseline. Mean excess LOS was 0.4 midnights and 0.5 midnights for those time periods, respectively. For the entire post-intervention group, 7 out of 26 patients obtained pre-chemotherapy labs in the outpatient setting. Conclusions: We observed an initial mean reduction of 6.1 hours in the time to start chemotherapy, as well as a reduction in mean excess length of stay with the introduction of a new admission workflow and admission checklist. We observed incomplete adoption of the checklist, and an increase in time to chemotherapy initiation after the first two months of implementation, suggesting that physician non-adherence represents a significant barrier to maintaining these reductions.
Improving implementation of standardized structured reporting: Development of an implementation toolkit.
Authors: Hermens Rosella , Swillens Julie Elisa Maria , Voorham Rinus , Nagtegaal Iris D.
Published: October 2019

265

Background: Although standardized structured reporting (SSR) usage is recommended in national and international evidence-based guidelines (warranting quality & safety), actual use varies widely in oncology related medical disciplines. Previous research showed multiple impeding factors regarding SSR-implementation. The aim of this study is to develop an implementation toolkit, based on the impeding factors found. Methods: We organized an expert meeting a. to explore experts’ opinions on the impeding factors found in a previous study; and b. to discuss possibilities for a tailored implementation toolkit. The expert-panel consisted of three pathologists, three multidisciplinary-team (MDT) members, three patient organization delegates, two delegates of the Dutch nationwide network and registry of histo- and cytopathology(PALGA), two delegates of the Netherlands Comprehensive Cancer Organization (IKNL), one PALGA-liaison, and one implementation expert. A literature study was performed to obtain evidence on the most effective implementation tools. All selected tools were included in an implementation toolkit. Results: The expert meeting and literature study yielded eight tools to be developed: 1. Two communication tools of both the benefits of SSR and of the development and updates of SSR-templates; 2. Consultation and simulation sessions with MDT-members to optimize the development and feedback process of the standardized structured reports and to increase familiarity with these reports; 3. A tailored e-learning for pathologists to increase the familiarity, knowledge and skills of SSR-usage; 4. IT-solutions, such as incorporation of speech recognition to improve the usability and content of both the SSR templates and the generated reports; 5. A sustainable feedback-system to support SSR-template usage; 6. Agenda setting success to encourage use of SSR. Conclusions: Experts proposed several tools to improve the implementation of SSR. The next step is to test this toolkit in a pilot study.
Can utilization of clinical pathways (CPs) effectively reduce drug spending (DS) within the Oncology Care Model (OCM)?
Authors: Hertler Andrew Allan , Khetarpal Rani , Wade James Lloyd , Bassin Ed , Chau Sang , Damarla Vijay Kumar
Published: October 2019

269

Background: It is well known that one of the biggest challenges in the OCM is being able to reduce DS. DS accounts for approximately 50% of episode costs within OCM. New Century Health (NCH) is well known for its value-based care CPs, with a history of successfully controlling DS and taking risk on behalf of commercial payors in oncology. Cancer Care Specialists of Illinois (CCSI), is a community-based oncology private practice spread throughout rural Illinois and is an OCM participant with 14 Medical Oncologists and 4 Mid-Level providers, 6 Radiation Oncologists, and 1 Urologic Oncologist. CCSI engaged NCH in a risk- based relationship to provide support and resources that will allow maximization of OCM episodic cost savings. This included utilization of NCH’s CPs. Methods: Starting in October 2017, CCSI utilized NCHs pathways for OCM attributed patients. NCH CPs were embedded in all CCSI physician computers for rapid access and reference decision making. All treatment plans were submitted in real time to NCH for CP adherence measurement. Analysis was conducted prior to implementation and on an ongoing daily & weekly basis to identify higher cost drugs or regimens. A joint CCSI/ NCH clinical data governance committee met bi-weekly to review CP performance metrics and drug utilization. The goal was to encourage treatment choices favoring both efficacy and value. Results: Post analysis revealed that over a 15-month period (Oct 2017 to Jan 2019), a 13.5% reduction in overall DS, which is equivalent to ~$250k per physician was achieved. This contributed to an overall reduction in total cost of care by 5% as compared to the OCM median. Post analysis also revealed an increase in pathway adherence from a baseline of 69% to 81% at the end of the measurement period. Conclusions: Reduction in DS is possible within a VBC model, through the use of value-based CPs. Important factors contributing to the reduction in DS include physician adherence rates, real time identification of high cost drugs/regimens, availability of immediate peer to peer discussion, rapid desktop access to a catalog of higher value alternate therapies, and continuous collaboration between CCSI and NCH through the governance committee.
Understanding the challenges for oncologists in predicting the end-of-life phase of care in cancer patients with advanced solid tumor diagnoses.
Authors: Lyss Aaron J. , Crouse Cheryl A. , Dickson Natalie R. , Patton Jeffrey , Waynick Christopher A. , Schleicher Stephen Matthew
Published: October 2019

281

Background: Early advanced care planning and palliative care improves outcomes during the end-of-life phase of care (EOL) for metastatic cancer patients. Identifying patients who are likely to transition to EOL is a necessary step to prioritize limited palliative care resources and is integral to success in value-based payment models. We analyzed whether physician documentation of prognosis in a clinical pathways system (CPS) could reliably predict when patients are nearing EOL for a large community oncology practice of more than 70 medical oncologists. Methods: Tennessee Oncology (TO) requires physicians to use CPS for all Medicare patients. CPS prompts physicians to answer the “prognostic question” “would you be surprised if this patient died in the next year?” for all OCM patients with advanced solid tumors at the beginning of treatment or at the time of a change in treatment plan. Prognostic question responses were compared to actual dates of death documented in the practice management system. Results: A total of 5,266 distinct patients were expected to trigger an OCM episode during 2017. The CPS prompted a response to the prognostic question for 1,228 (23%) of these OCM patients. There were 665 (54%) positive prognoses (expect patient to live more than 1 year) and 563 (46%) negative prognoses (expect patient to die within 1 year). Physicians documented accurate prognoses in 712 (58%) of cases. For patients with positive prognosis 557 (84%) were accurate. For patients with negative prognosis 155 (21.8%) were accurate. Conclusions: We found that for patients with terminal cancer, it is difficult for physicians to accurately predict prognosis. These findings support the importance of ASCO guidelines pertaining to patient access to palliative care during the entirety of cancer treatment for all patients with metastatic cancer.

[Table: see text]
Primary non-adherence to adjuvant endocrine therapy in older women with breast cancer.
Authors: Tchuente Vanina , Stern Donna , Prchal Jaroslav , Martin Judy , Tamblyn Robyn , Meguerditchian Ari N.
Published: October 2019

285

Background: Adjuvant endocrine therapy (AET) improves survival in hormone receptor positive breast cancer (HR+BC). Challenges with adherence to AET in seniors are well documented; however, there is limited knowledge on primary non-adherence (PNAD). PNAD is defined as non-initiation of a prescribed medication. Our aim is to characterize PNAD rates in women aged ≥ 65 with HR+BC and identify potential predictors, using real-time treatment information. Methods: Optimum is an e-health platform integrating real-time analysis of administrative claims data combined to patient-level clinical information on breast cancer. Optimum tracks care trajectories to identify deviations from best practice, using data from Quebec’s universal health insurance plan that covers all medical and pharmaceutical care. In this single-center feasibility study, we characterized PNAD as a non-initiation of AET within 10 days from the first prescription. Descriptive analyses were used to assess potential predictors. Results: Of the 57 patients enrolled, 9 were excluded due to lack of > 30 day follow up. In the remaining 48 patients, PNAD was 21 %. Baseline Charlson comorbidity index (0 vs 13 %), psychotropic drug use (20 % vs 26 %) and polypharmacy rate (10 % vs 11 %) were lower in PNAD patients, compared to primary-adherent patients. PNAD patients had larger average tumor size (1.8 cm vs 1.6 cm), more often overexpressing HER2NEU (10 % vs 3 %), more negative progesterone receptor (10 % vs 5 %). They also more often had lumpectomy (70 % vs 65 %), SLNB (70 % vs 58 %) and more frequent margin revisions (30 % vs 16 %). They more often received chemotherapy (30 % vs 0 %). At 30-day follow-up, 40 % of PNAD patients had not yet initiated AET. Conclusions: This study confirms the feasibility of combining real-time administrative data and patient-level clinical information to assess breast cancer quality care. PNAD in women with HR+BC was higher than expected. PNAD patients had less comorbidities and drug use, but more aggressive cancers and more often also had quality challenges with surgical care (margin revision). PNAD predictors can potentially be used to identify patients that may require additional support to optimize disease management.
Daily step counts to predict hospitalizations during concurrent chemoradiotherapy for solid tumors.
Authors: Izmailova Elena , Huang Chengrui , Cantor Matthew , Ellis Robert , Ohri Nitin
Published: October 2019

293

Background: Wearable activity trackers could be useful tools in cancer care. Potential gains include better selection of patients fit for aggressive treatment, improved evaluation of patients during treatment, and provision of enhanced supportive care for patients. In a pilot study, low daily step counts were associated with increased risk for hospital admission during concurrent chemoradiotherapy for solid tumors of the head/neck, lung, or gastrointestinal tract. Here we seek to refine those findings using a larger patient cohort. Methods: Study subjects wore a commercial fitness tracker during a course of concurrent chemoradiotherapy. Patient characteristics, daily step counts, and hospital admissions between the initiation and completion of radiotherapy were tabulated. EORTC QLQ-C30 questionnaires were completed weekly, and summary QoL (range: 0-100) for each subject and week were calculated. Cox regression models with time-dependent and time-fixed covariates were used to identify predictors of first hospital admission during the radiotherapy course. Results: 188 subjects from three trials met inclusion criteria. The most common cancer diagnoses were head and neck (31%), lung (28%), and a gastrointestinal (30%, most commonly rectal [10%] or esophageal [6%]). Median age was 61 (range: 27-90). Baseline ECOG performance status was 0 for 46% of subjects, 1 for 47%, and 2 for 7%. The median patient compliance of wearing activity trackers and contributing data was 98%; 38subjects (20%) were hospitalized during the radiotherapy course. Cox regression demonstrated a 36% reduction in the risk of hospitalization for every 1000 daily steps (averaged over the past 3 days; hazard ratio 0.62, 95% confidence interval 0.48-0.81, p=0.0005). Diagnosis, age, baseline performance status, and QoL score were not statistically significant predictors of hospitalization risk. Conclusions: Continuous activity monitoring with wearable devices during concurrent chemoradiotherapy is feasible. We have validated daily step counts as dynamic predictors of hospitalization risk during treatment. Interventional trials should leverage activity data to optimize supportive care during cancer therapy.
A physician engagement learning strategy to reduce care variation in breast cancer across a clinically integrated network.
Authors: Burgon Trever Bradley , Richards Jon M. , Nelson Carrie E. , Paculdo David R. , Tamondong-Lachica Diana , Liangco Wilfredo L. , Peabody John Williamson
Published: October 2019

30

Background: Advocate Physician Partners (APP) is a 5,000+ physician CIN associated with Advocate Aurora Health. APP wanted to standardize care among their 100+ medical oncologists who work in 20+ independent and employed practices. We approached standardization as a learning opportunity that could be best done through active engagement. Methods: From January 2016 to November 2017, we utilized the Clinical Performance and Value (CPVÒ) simulated patient platform to measure clinical practice and provide feedback across APP. Over six rounds, a total of 119 APP medical oncologists were scored against evidence-based work-up and treatment criteria. To determine if any of the learnings found on the CPVs translated into practice, we used registry and claims data on unnecessary imaging for early stage breast cancer. Results: In the simulated breast cancer patients, we found an overall improvement of 13.3% in primary diagnosis accuracy and 15.3% in treatment (p<0.001 for both). Preferred guideline-based hormonal therapy and chemotherapy similarly improved by 15.1% (p=0.018). To compare the CPV improvements with patient-level improvements, we looked specifically at unnecessary imaging and testing which declined overall by 35.7% (p=0.006); the associated costs fell by 31.3%. In early stage breast cancer, the CPV-measured use rates for CT or PET/CT (p=0.026) and other scans (p=0.012) decreased, showing better alignment with guidelines (see Table). When we analyzed the patient claims data, we found these showed similar declines in potentially unneeded breast cancer testing. Conclusions: Active learning, using CPV simulations, increased adherence to evidence-based practices, which translated into practice as evidenced by registry/claims data showing fewer unnecessary imaging in early stage breast cancer.

[Table: see text]
Structuring clinical pathways: Creating common language where there is none.
Authors: Hamilton Joanna M. , McNeil Debra , Milne Dana , Hayne Victoria , Holtz Laura , Jackman David Michael , Jacobson Joseph O. , Leblebjian Houry , Meserve Emily , Methot John , Wolfson Matthew , Tremonti Carole Kathleen
Published: October 2019

303

Background: Clinical pathways (PW) consist of Decision Criteria (DC) such as patient and disease characteristics, prior therapy, and genetic tests. Historical Dana-Farber Pathways (DFP) content was unstructured and maintained in static documents. This could lead to inconsistencies across and within PW, limits to the scope of DFP analytics, and potential discrepancies in clinical content. Methods: To transform DFP content into a digitally innovative structure the DFP team created a hierarchical Data Model (DM). The team compiled all unstructured DC in historical PW, organized them into parameters and attributes, and connected them to external ontologies (e.g., ICDO3) where appropriate. The team then applied the structured DC to historical PW to test comprehensiveness; and addressed any gaps identified in PW and the DM. Results: The DPF DM contains 32 parameters (e.g., Diagnosis) and 218 attributes (e.g., Group Stage) that can be combined to represent all 600+ pathway branch points. The comprehensiveness and nuance of the DM improves DFP’s specificity and clinical flexibility: The DM ensures that DFP gathers actionable data across all PW and creates common language that allows for disease-specific nuances; The DM rectifies gaps in historical PW, such as DC that were not mutually exclusive or conflated multiple clinical parameters; The DM creates complex DC to direct specific sub-groups of patients to the correct treatment path, even in cases where treatment recommendations differ within diagnostic groups. Conclusions: Structuring and standardizing PW content is a complex, time-intensive endeavor. However, this work addresses the challenges of managing clinical content and provides significant benefits for future PW development. A structured DM ensures PW are comprehensive, logical, and built on a framework of inter-operability standardization. A DM also allows DFP to connect with the EMR for auto-navigation, which streamlines provider workflow. The ongoing work required to build and maintain a structured PW DM is worth the result: rich actionable data that can illuminate and standardize practice patterns within and across diseases and institutions. It creates an insightful solution to broadly manage the cancer population.
Everyone needs robust analytics: Integrating medical ontologies into the Dana-Farber Pathways.
Authors: Milne Dana , Hamilton Joanna M. , McNeil Debra , Methot John , Jacobson Joseph O. , Tremonti Carole Kathleen , Jackman David Michael
Published: October 2019

304

Background: The majority of clinical data is unstructured. Medical ontologies standardize the language used to communicate diagnoses, symptoms, and procedures used in healthcare. Incorporating medical ontologies into the Dana-Farber Pathways (DFP) provides structure and removes ambiguity by creating definitions for each data point. This exercise was critical for the development of the DFP into a fully automated platform that optimizes clinician workflow, reduces clicks, and expands the potential for data analysis. Methods: The DFP data model was reviewed to identify value sets contained in an existing medical ontology. DFP required employing multiple ontologies, which was difficult, as many ontologies overlap (e.g., SNOMED, NCI, ICD-O-3, ICD-10) and none were developed for this intention. For example, the majority of DFP necessitate site/histology as a criterion for decision-making. In our Electronic Data Warehouse (EDW), site/histology are stored as free text, as ICD-O-3 codes from the cancer registry, and as ICD-10 codes from Epic. To obtain site/histology in a structured format, both ICD-O-3 and ICD-10 were needed. Ongoing maintenance of the linkages between ontologies and value sets is required as ontologies are updated and DFP are enhanced. Results: The relationship between the DFP value set and the SNOMED ontology was 1:1. However, other relationships were not equal or straightforward. Some ontology values were too detailed for DFP. These were either grouped together (e.g. tumor site) or just one value was chosen (e.g. drug class). Others didn’t contain all the values required by DFP (e.g. regimens). Conclusions: DFP requires structured data related to ontologies but not identical to and not limited by the scope of ontologies. Choosing medical ontologies utilized in an EDW facilitates the implementation of auto-navigation, which ultimately streamlines provider workflow. A structured data model connected to ontologies collects valid and clearly defined data to support robust analytics.

[Table: see text]
Untangling a web of Electronic Patient Reported Outcomes data to support quality improvement.
Authors: Davis Meggan , Winters Erik , Acomb Lisa , Palmgren Matt , McMillen Kerry K , Wong Tracy
Published: October 2019

311

Background: Adoption of Electronic Patient Reported Outcomes (ePROs) as part of clinical care is aided by the ability to respond to feedback and develop solutions founded on data. This requires access to usage, volume, response, and system performance data, yet with limited resources the infrastructure needed to store and analyze these data is often an afterthought. The Seattle Caner Care Alliance followed an iterative process to create dashboards featuring content-specific metrics while improving the underlying infrastructure of patient-generated data collected via the ePRO program. Methods: For each dashboard, the project team followed 7 steps: 1) Clarify the purpose. 2) Brainstorm requirements with content-specific stakeholders. 3) Create initial drafts for review, testing, and validation. 4) Validate that metrics are clear and provide value. 5) Update dashboards and review with stakeholders. 6) Perform technical clean-up and improvement to data infrastructure. 7) Iterate until all stakeholders approve. Results: 27 data tables were linked to create four content-specific dashboards: Overall Key Performance Indicators (KPI), an experimental dashboard, and responses to chemotherapy symptom and distress screening surveys. The KPI dashboard featured completion rate, adoption rate, survey and intervention volumes with the ability to filter by ePRO type, diagnosis, and intervention. The experimental dashboard allowed the project team to test data points, visualizations and methodologies before creating dashboards or updating data structures. Chemotherapy symptom and distress screening dashboards displayed interventions by symptom or concern, severity, referrals, and response distribution. Conclusions: Data collected via an ePRO program offers an opportunity for improvement during implementation and ongoing program development. An iterative approach to analyzing these data and creating dashboards that engaged stakeholders and focused on data quality was an effective way to untangle a complex web of patient-generated data and to support program improvement. Future ePRO implementation would benefit from the inclusion of a flexible data development approach as part of planning and design.
A structured algorithm for judicious use of antibody test in diagnosis of heparin-induced thrombocytopenia (HIT).
Authors: Swarup Sriman , Ball Somedeb , Sultan Anita , Adhikari Nimesh , Thein Kyaw Zin , Swarup Khatrina , Awasthi Sanjay , Tijani Lukman Aderoju
Published: October 2019

314

Background: HIT diagnosis combines 4T scoring & HIT antibodies (HIT-Ab) testing, with confirmatory serotonin release assay (SRA). Latex immunoturbidometric assay (LIA) shows promise in quick & accurate HIT diagnosis, compared to particle immunofiltration assay (PIFA). We designed a HIT workflow & replaced PIFA with LIA at our hospital, to improve 4T usage rates & HIT diagnosis accuracy in a cost-efficient manner. Methods: In phase I, patients (pts) charts with HIT-Ab (PIFA) ordered between Mar2017-Mar2018 were retrospectively reviewed. Three investigators independently calculated 4T & reviewed PIFA/SRA results, with any alternative anticoagulation (AC) used. In phase II, a new workflow on electronic health record incorporating 4T algorithm with HIT-Ab test order was implemented. Our lab replaced PIFA with LIA. In phase II, charts for pts with LIA results from Jan-Mar 2019 were reviewed. Results: In phase I, 170 pts had PIFA results & 5 such pts (0.02%) had 4T score documented in chart. Per investigators, 113 (66.4%) pts had 4T scores. PIFA showed 60% sensitivity & 50% specificity compared to SRA. 19 pts received AC (4 pts had low 4T with negative PIFA). In phase II, 40 pts with LIA tested, 4T scoring by ordering physicians improved to 100%. Per investigators, 42.5% pts had low 4T scores. Clinicians documented high 4T in 11 pts; investigators confirmed high 4T in 2 pts. AC was used in 5 pts (4 with intermediate-high 4T per investigators) Conclusions: Our study showed that incorporation of 4T scoring in HIT algorithm significantly reduced unnecessary ordering of HIT-Ab, with 100% compliance in 4T reporting. Use of AC was consistent with the level of probability by 4T. Further clinician education can help in reduction of up scoring of 4T noted in our results.

[Table: see text]
Building a population management informatics infrastructure for oncology care.
Authors: Lafata Jennifer Elston , Harris Stephen , Fasold Megan , Holdren Audrey , Sanoff Hanna Kelly
Published: October 2019

315

Background: While most primary care practices have informatics infrastructures to support population management, such infrastructures are not commonplace in oncology. Yet, value-based care requires that oncology practices be able to identify patients in real time, use risk stratification to target care efficiently, and monitor care quality to identify improvement opportunities. We describe an oncology informatics infrastructure development initiative in a large academic medical center. Methods: We convened a quality improvement team of administrators, analysts, clinicians, health services researchers and performance improvement staff. The team was sponsored by a senior leadership committee convened for a strategic planning initiative. We used PDSA cycles to develop and test ways to leverage data from an electronic health record (EHR) and billing system for oncology patient identification, risk stratification, and routine quality monitoring. We used clinician engagement, medical record review, and tumor registry comparisons to validate query strategies. Results: After considering different query strategies, we opted to identify patients via a new cancer treatment episode (as defined by a cancer diagnosis combined with evidence of pharmaceutical, radiation, and/or surgical treatment for cancer with no evidence of such treatment in the prior six months). This was done using diagnostic and procedural codes for chemo/immunotherapy and radiation treatment, and pathology reports and procedural codes for surgery. Using this approach, we identified over 7800 cancer treatment episodes within the health system in 2018. These episodes corresponded to 4178 chemo/immunotherapy, 1437 radiation, and 3440 surgical treatments. Quality monitoring has identified opportunities to enhance data capture, harmonize documentation processes across practitioners and practices, and initiate quality improvement efforts. Conclusions: Using data from the EHR and billing systems we are able to identify oncology patients as they initiate a cancer treatment episode. In so doing, we are able to track the quality of care delivered to oncology patients as they move across the care continuum from treatment to survivorship.
The impact of an electronic medical record alert on code status documentation for hospitalized patients with advanced cancer.
Authors: Switzer Benjamin , Jazieh Khalid , Bernstein Eden , Khan Mohammad , Harris David
Published: October 2019

319

Background: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Advanced care planning (ACP) in this population has exhibited improvements in quality, patient satisfaction, hospice utilization, rates of harm, and healthcare costs. We have sought to observe the changes in ACP documentation by Internal Medicine residents within a tertiary hospital’s inpatient oncology service following a mandatory caregiver training module and enterprise-wide modification in Epic, as well as identify self-reported barriers in code status documentation. Methods: Patients admitted to the Cleveland Clinic’s oncology service were retrospectively reviewed for 8 weeks before and after the implementation of an ACP caregiver training module and code-status best-practice-alert (BPA) into Epic. ACP documentation was assessed in admission notes and direct orders into Epic. In addition, Internal Medicine residents were surveyed on behaviors and perceived barriers contributing to code status documentation. Results: A total of 551 patients (181 pre and 370 post-BPA) were reviewed, exhibiting a 17.2% (44.2 to 61.4) increase of code status documentation in resident admission notes and a 17.6% (10.5 to 28.1) increase in code status orders by residents into patient Epic charts by the time of discharge. Observed 30, 60, and 90-day mortality rates from the day of admission were 18.2, 24.9, and 32%, respectively. The most common self-reported barrier to resident ACP documentation was “forgetting to discuss during the admission process”, and 58% of first-year residents admitted to feeling “uncomfortable” in orchestrating goals-of-care conversations. Conclusions: Resident ACP documentation continues to be suboptimal in the high-risk cohort of hospitalized advanced cancer patients. However, documentation rates appear to be positively influenced by large-scale and multimodal approaches. Further efforts to improve the current practice and culture of advanced directives and code status for the inpatient oncology patient population remains a crucial aspect in the quality and safety of our approach to patient care.
Enhancing the electronic health record to promote and measure adherence to breast cancer clinical pathways.
Authors: Geisel Lauren E. , Johnson Helen M. , Weil Andrew , Muzaffar Mahvish , Vohra Nasreen A. , DeAntonio Phyllis , Mulligan Katherine H. , Morey Chantel L. , Wong Jan H.
Published: October 2019

322

Background: Clinical pathways are widely accepted tools for improving the quality of cancer care. We developed and implemented, within the electronic health record (EHR), a standardized multidisciplinary breast cancer conference template comprised of NCCN clinical pathway elements, with triggers to promote adherence and measure compliance. Methods: The records of breast cancer patients diagnosed from January 2016 to December 2017 were reviewed. Baseline data on (1) the documentation of clinical stage prior to prospective presentation at multidisciplinary conference, (2) documentation of family history, and (3) functional breast imaging utilization were recorded. EHR enhancements developed throughout 2018 were implemented in January 2019. Post-implementation data were obtained via an EHR query of records from January 2019 to the present. Results: At baseline, 56.5% of new patients (n = 435) had a clinical stage documented appropriately (goal 100%). After the EHR enhancements went live, this rate increased to 76.9% (n = 78 new diagnoses), ranging from 40% for patients with metastatic disease to 85.7% for non-metastatic. Compared with baseline data, EHR-derived data from 149 multidisciplinary conference notes demonstrated relatively stable rates of compliance with the family history and imaging metrics: 94.3% to 93.9% (goal 100%), and 12.8% to 13.4% (goal ≤20%), respectively. In 2019, there were 128 instances of an EHR trigger prompting physicians to review the multidisciplinary conference recommendations. While 89.1% of users responded that they reviewed the note, only 42.1% of these clicked on the link to view it. Conclusions: The EHR is a powerful tool for incorporating clinical pathways into oncology providers’ daily workflow. Quality improvement data can be extracted rapidly and efficiently, which facilitates continuous QI. We observed a notable improvement in documentation of clinical staging prior to multidisciplinary conference after the implementation of the clinical pathways in the EHR. Our first report identified several areas for improvement, which will be the focus of subsequent PDSA cycles.
Multi-institution quality improvement in supportive oncology: Results of the Coleman Supportive Oncology Collaborative (CSOC).
Authors: Trosman Julia Rachel , Roggenkamp Betty , Khosla Paramjeet , Lillis Teresa , Martin Joanna , Pasquinelli Mary , Knightly Eileen , Lo Shelly S. , Bowman Anne , Chow Selina Lai-ming , Patel Urjeet , Berardi Rosa , Diaz Aidnag , Kircher Sheetal Mehta , Weldon Christine B.
Published: October 2019

33

Background: The Institute of Medicine and Commission on Cancer recommend systematic delivery of supportive oncology care for cancer patients. The CSOC is focused on quality improvement (QI) of supportive care across Chicago cancer centers (Weldon ASCO ’17). Supportive oncology includes distress, practical, family, physical, nutrition, pain, fatigue and care concerns. To support QI, cross-institution teams developed unique, relevant tools, methods, care delivery processes, patient handouts and online training. Methods: Ten centers (5 academic, 1 VA, 1 public, 2 safety net, 1 community) implemented supportive oncology screening and care delivery quality improvements. Centers collected data for relevant Quality Oncology Practice Initiative (QOPI) metrics. Analyses used simple frequencies and Fishers exact test. Results: Five of six QOPI measures were improved at statistically significant levels from 2014 to 2017, p < .00001. Improvements are more modest in 2016 & 2017 as 4 of the centers started this QI in 2017. Conclusions: The CSOC achieved significant improvements in supportive oncology screening and identifying and addressing patients’ needs and concerns. Additional work is needed to improve these measures to achieve the best quality of cancer care possible for every patient based on their needs and concerns.

[Table: see text]