bluuebunny/crossref_metadata_2025 huggingface dataset:
Lung cancer screening on YouTube: Difficulty of finding balanced information.
Authors: Alban Juan , Alban Luis Felipe , Khanal Amit , Feldman Lawrence Eric
Published: April 2017

162

Background: Lung cancer (LC) is the leading cause of cancer mortality in the US, the ACS estimates upwards of 220,000 new cases will be diagnosed this year. Recently, the Center for Medicare/Medicaid Services (CMS) agreed to cover LC screening with low-dose CT for patients however, CMS requires prior documentation of a shared-decision making (SDM) visit between the patient and the referring clinician to inform them about risks of screening. LC Screening programs have begun to use YouTube for patient recruitment, education and marketing of screening. The objective of this study is to shed light on the role of YouTube in lung cancer screening in terms of guidelines, screening options, target population, steps after screening, and risks and benefits of screening. Methods: We searched YouTube.com to identify videos dealing with lung screening using the keywords: lung cancer screening. Videos without sound, uploaded before 2009, longer than 20 minutes, duplicates and videos in a language other than English were excluded. This method yielded 124 videos that fit criteria. Videos were coded for inclusion of LC screening process, risks and benefits of screening, screening guidelines, risk factors for LC, and treatment options after LC diagnosis. Results: 124 videos had a cumulative 262753 views. 38.7% of the videos included no mention of CMS guidelines. Only 30% included any mention of the risks associated with screening; 14% mentioned false positives, 12% radiation; 4% anxiety associated with screening though 92% of all videos sampled were intended for patients. 91% of videos explained the benefits associated with cancer screening however, only 26% explained the actual process of screening. The majority of videos were created by medical institutions (66%). No videos sampled included false information. Conclusions: While most videos highlighted the benefits of LC screening, YouTube can’t serve as a replacement for SDM visits due to inadequate discussion of risks of screening. A substantially low number of videos (30%) discussed the risks of lung cancer screening. Given the high rate of false positives, radiation and anxiety associated with screening, patients need to be made aware of these risks so they can make an informed decision.
Cancer screening, patient characteristics, and shared decision making (SDM): A complicated equation.
Authors: Talcott James Austin , Bezuhly Maureen , Aharanoff Gina , Seiden Danielle , Osborne Michael P. , Chadha Manjeet
Published: April 2017

164

Background: SDM may vary by patient and clinical decision. In a randomized trial of physician (MD) educational interventions to improve cancer screening guideline compliance, we studied patient (PT) and MD recall of discussions and factors that affected recall. Methods: In a cluster-randomized trial of educational supports for MDs, we are enrolling an age- (30-89 years) and sex-stratified sample of 216 PTs who underwent a physical examination at 2 urban hospitals, 18 for each of 12 primary care MDs. Screening guideline formatting (color-coding) and academic detailing were randomly assigned in a 2x2 design. Immediate post-encounter surveys recorded PT and MD recall of screening discussions. Results: The first 174 participants were diverse (63% white) and highly educated (77% college degree). PTs and MDs differed in recall of screening discussions, and the differences varied by screening test. When MDs reported a colorectal cancer (CRC) screening discussion, 21% of PTs did not; 20% of MDs disagreed when PTs reported the discussion. The discrepancies were greater for prostate specific antigen (PSA) screening, 29% and 29%, respectively, but much less for mammograms (MAM), 8% and 5%, respectively. Recall of the MD recommendation also differed: 15% of PTs disagreed when their MD reported it, and 33% of MDs when their PT reported it. For PSA, disagreement was 26% and 33%, respectively, and for MAM, disagreement was 17% and 10%, respectively. Overall, agreement between all PTs and MDs on whether screening was recommended was fair for CRC, PSA and MAM: kappa = 0.33, 0.34 and 0.29, respectively. Older PT age ( > 70) sharply eroded agreement on recalled CRC and PSA recommendations (kappa = -0.02 and -0.03, respectively) but much higher for MAM (kappa = 0.39). Recall concordance improved when elements of SDM were recalled. For CRC, kappa rose from -0.12 to 0.52 if the MD recalled any MDM element. Conclusions: In a highly educated, diverse PT population, PTs and MDs surveyed immediately after their encounter often disagreed on what had occurred in screening discussions. Disagreement was greater for CRC and PSA vs. MAM, greater for older PTs but improved when SDM was recalled. Clinical trial information: NCT02430948.
Feasibility of collecting routine information for clinical and research purposes via electronic format questionnaire.
Authors: Li Yuchen , Brown M Catherine , Estey Kathryn , Gill Gursharan , Liang Mindy , Perez Andrea Cosio , Borean Michael , Shani Kishan , Bradbury Penelope Ann , Shepherd Frances A. , Leighl Natasha B. , Howell Doris , Liu Geoffrey
Published: April 2017

167

Background: Patient demographics, lifestyle factors, and past medical history enable clinicians to optimize care plans, and be useful for health services research. Unfortunately, these data are often recorded inconsistently in the medical chart. In 2015, we tested a paper-form questionnaire to collect such data systematically in the outpatient setting. This current study assessed the feasibility (applicability, acceptability, practicality) of administering the questionnaire via electronic format (iPad). Objectives: To examine whether the electronic format of the questionnaire was (1) applicable (reliable and complete data); (2) acceptable to patients; and (3) practical for clinic utilization. Methods: New adult cancer patients visiting the thoracic cancer clinic at Princess Margaret Cancer Centre in summer, 2016 were asked to complete a Patient Health Questionnaire via iPad devices. This questionnaire was developed through trial testing in addition to literature review, expert opinion, and prior paper-based testing. Results: In 62 new patients (57% male, mean age 66 years old), this electronic questionnaire took on average 25 minutes to complete. The electronic questionnaire was applicable (89% completed the questionnaire, reliable data) and acceptable (69% were happy to complete, 69% found questionnaire useful, 61% thought it asked the right questions, 71% did not think it made clinic visits more difficult). For practicality, although the data were easily interpretable by clinicians, 48% of patients failed to complete the questionnaire before they were seen by their clinicians. Conclusions: Though feasible to collect electronically standardized demographics, lifestyle, and past medical history routinely, timeliness was an issue. Earlier arrival times or completion at home may be necessary to improve clinical utility of the questionnaire.
Timeliness to treatment in patients with lung cancer at UVA Cancer Center.
Authors: Tola Geda , Spencer Hannah E , Hall Richard Delmar , Horton Bethany J , Gentzler Ryan D.
Published: April 2017

169

Background: The current standard of care for lung cancer patients recommends initiation of treatment within 30 days of diagnosis; however, the effects of delayed treatment on prognosis have not been determined. Furthermore, it is unclear what factors lead to delayed care. Longer treatment delays have been associated with decreased survival outcomes in other cancers, but such associations have not been established for lung cancer. This study analyzed lung cancer patients at UVa Cancer Center to identify the factors associated with delayed treatment and the effect of this delay on overall survival outcomes. Methods: Lung cancer patients diagnosed from 2011 to 2014 were retrospectively analyzed using UVA Cancer Registry data. Two outcomes, diagnosis to treatment time interval, and overall survival were modeled. Multivariate analysis was used to identify the variables that affected timely care. Statistical tests were used to determine whether there were significant differences in overall survival between patients who received timely and delayed care. Results: 917 patients met the criteria for analysis. Most were stage I (47.5%) and received surgery as first line of treatment (57.7%). Median age was 66 years. The median treatment interval for this cohort was 32 days. Stage at diagnosis was major determinant for time to treatment (p = 0.0197), with stage IV patients being treated in shorter intervals (median 28 days) and stage III patients the longest (34 days). Treatment delay was not associated with overall survival (p-value 0.952) however, other covariates such as insurance type, primary treatment type and stage were (p-values < 0.0001, < 0.0001, < 0.0001). Conclusions: Complex multidisciplinary care can lead to delays in treatment. Stage and type of primary treatment type were determinants of treatment delays and should be recognized as obstacles to timely treatment. Although delays were not associated with survival in our study, further investigation to determine the impact of delays on symptoms, quality of life, and performance status is warranted.
Real-world palbociclib dosing patterns and potential wastage associated with dose modifications among post-menopausal women with HR-positive/HER2-negative metastatic breast cancer (mBC).
Authors: Li Nanxin , Du Ella X. , Chu Lihao , Peeples Miranda , Xie Jipan , Barghout Victoria E. , Tang Derek H.
Published: April 2017

17

Background: CDK4/6 inhibitor palbociclib is recently approved for the treatment of HR+/HER2- mBC and its treatment patterns have not been thoroughly understood. This study described real-world palbociclib dosing patterns in the US. Methods: Postmenopausal women with HR+/HER2- mBC who initiated palbociclib-based therapy (date of initiation was defined as index date) between 02/03/2015 (palbociclib approval date) and 02/29/2016 (end of data) were identified from Symphony Source Lx database. Patients were required to have continuous quarterly medical/pharmacy activity for 1 year prior to and 6 months after the index date. Dose decrease or increase (collectively, dose modification) was defined as a change of daily dose of >=25 mg compared to the last dose. Dose interruption was defined as a treatment gap within 60 days before restarting the treatment as the last dose. Kaplan-Meier analyses were conducted to assess dose decrease rate and dose decrease/interruption rate within one year from the index date. The proportion of patients with and days of overlap in fills during dose modification were assessed. The costs of potential palbociclib wastage related to dose modification were estimated by applying the wholesale acquisition costs (as of Oct 2016) to the number of overlapping days of supply between two adjacent fills. Results: A total of 1,242 patients initiated palbociclib-based therapy in line 1 through 4 for mBC (mean age=62.7 years, median follow-up time=8.7 months). Across line 1 to 4, dose decrease rates were 31.9%-33.7%, and dose decrease/interruption rates were 63.5%-80.9%. A total of 411 (33.1%) patients had dose modification, among whom 203 patients (49.4%) experienced an overlap in prescription fills during dose modification with an average overlap of 12.3 (SD=10.6) days per patient, resulting in costs of potential wastage for $4,556 (SD=$3,920) per patient. Conclusions: This real-world study showed most patients initiating palbociclib-based therapy had dose modification or interruption over a median follow-up of 8.7 months. Half of the patients experiencing dose modifications were associated with potential wastage.
Investigating associations between health-related quality of life and endocrine therapy under-utilization in women with early-stage breast cancer.
Authors: Pinheiro Laura C , Wheeler Stephanie B. , Reeder-Hayes Katherine Elizabeth , Samuel Cleo A. , Olshan Andrew F , Reeve Bryce B.
Published: April 2017

170

Background: Endocrine therapy under-utilization puts women at increased risk for breast cancer recurrence. The objective of this study was to determine if health-related quality of life (HRQOL) was significantly associated with under-utilization. Methods: Data came from the third phase of the population-based Carolina Breast Cancer Study. We included 1,599 women with hormone receptor positive disease aged 20-74 years. HRQOL was measured using the Functional Assessment of Cancer Therapy for Breast Cancer, on average, 5-months post-diagnosis. HRQOL domains included physical, functional, social, emotional, and spiritual well-being and breast cancer concerns. HRQOL subgroups were derived using latent profile analysis. Under-utilization was defined as not initiating or adhering to endocrine therapy by 36-months post-diagnosis. Multivariable logit models estimated adjusted odds ratios (aOR) between HRQOL subgroups and under-utilization. The subgroup with the best HRQOL scores across domains was the reference category. Chemotherapy and race-stratified models were estimated, separately. Results: Initiation analyses included 953 women with hormone receptor positive breast cancer who had not begun endocrine therapy by their 5-month survey, of whom 154 never initiated. Adherence analyses included 1,114 initiators, of whom 211 were non-adherent. HRQOL was not significantly associated with non-initiation except among non-chemotherapy users, with membership in the poorest subgroup associated with an increased odds of non-initiation (aOR 5.5; 1.7-17.4). Membership the two poorest HRQOL subgroups was associated with non-adherence (aOR 2.2; 1.2-4.0 and aOR1.9; 1.1-3.6), respectively. Membership in the poorest HRQOL subgroup was associated with non-adherence among non-chemotherapy users (aOR 2.1; 1.2-5.1). Conclusions: Our results suggest that women with poor HRQOL during active treatment may be at increased risk for under-utilization. Focusing on HRQOL, a modifiable factor, may improve targeting of future interventions early in the breast cancer continuum to improve endocrine therapy initiation, adherence, and breast cancer recurrence.
How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project.
Authors: Weldon Christine B. , Trosman Julia Rachel , Perez Claudia B. , Kulkarni Swati , Khan Seema Ahsan , Hansen Nora , Nelson Valerie , Stein Jennifer , Simon Melissa A. , Strauss Jonathan Blake , Espino Sasa M. , Bunce Mikele , Pan Wayne , Friedewald Sarah M. , Gradishar William John
Published: April 2017

171

Background: The “NCI ASCO Teams” Project emphasized management of interdependent cancer care across specialties as crucial to teamwork, yet a considerable challenge (Taplin JOP 2015). Interdependent care requires well-managed timing and sequencing of events across specialties. We developed the 4R model (Right Information / Care / Patient / Time) to manage interdependent care and facilitate teamwork (Trosman JOP 2016). 4R is being implemented at 3 centers: academic, community and safety net. Pre-implementation, we identified guideline recommended interdependent care whose timing / sequencing is challenging, developed relevant adherence metrics and gathered current state data. Methods: Interviews with 42 clinicians across breast cancer (BC) specialties at the 3 sites, using theme analysis to identify challenging interdependent care. Guidelines and literature were used to define adherence metrics. Clinical data were reviewed for 162 Stage I-III patients at 3 sites to measure adherence. Results: We identified 7 interdependent BC care events for which timing / sequencing is a challenge - Table. Adherence ranged from 0% to 100%, and was < = 50% for 6 of the 7 care events. Preoperative BRCA 1/2 results and neoadjuvant consult showed highest adherence, yet were most frequently noted as a challenge: interviewees reported substantial ad-hoc efforts applied to managing timeliness of these events. Conclusions: Identified challenges and adherence gaps support the need for the 4R implementation for systematic, consistent and timely delivery of interdependent care. Established metrics will allow pre / post 4R implementation comparison and may inform broader adoption of the 4R model. [Table: see text]
Measuring quality in cancer care: Utilizing a clinical decision support system to assess pathway adherence.
Authors: Patt Debra A. , Howell Josh , Neubauer Marcus A. , He Bo , Garey Jody S.
Published: April 2017

172

Background: Quality-based programs depend on clinical data documentation for reporting, treatment planning, and measuring pathways (PW) compliance. Adherence to treatment PW reduces variability and costs of care. Clinical decision support systems (CDSS) are tools embedded in the EHR to capture assessable data: stage, biomarkers, line of therapy, etc. With such data, CDSS can measure and report on clinical quality improvement programs like PW adherence, assessable data and exception reporting. Methods: A retrospective cohort study from Jan 1, 2014 - May 30, 2016 measured the impact of an integrated CDSS assessing compliance to PW and exception reporting across 9 independent oncology practices over a 9 month period. Assessable data, PW adherence, and exception reporting were tracked in 4 month intervals pre and post CDSS intervention by practice and physician. A one month wash out period was included post CDSS implementation. Overall rates of positivity, assessable data, and exception reporting were compared pre and post intervention using the Chi-square test. To account for the effect of time on the intervention, a segmented regression analysis was performed to analyze weekly rates of positivity pre and post intervention. Results: 9 practices, 633 physicians, and 30,666 treatment regimens were included. The weekly adherence rate increased by 7.2% after intervention (p = 0.005) across the group. Assessable data capture significantly improved across the cohort OR 6.79 (5.64-8.16) and individually for most practices. Physicians adherent to PW 75% of the time increased post intervention collectively, OR 1.83 (1.44-2.31), and individually. Exception reporting improved from 29% to 99% (p<0.0001). Conclusions: Across a cohort of community oncology practices rates of assessable data, PW adherence, and exception reporting improved after implementation of an integrated CDSS. Effective CDSSs are a critical component of quality improvement programs and may be used to improve data capture, increase adherence to PW and overall contribute to quality cancer care delivery. [Table: see text]
Oncology pharmacist opportunities: Closing the gap in quality care.
Authors: Hough Shannon , Vulaj Vera , Farris Karen B , Mackler Emily R.
Published: April 2017

174

Background: The quality of care provided to oncology patients is beginning to be linked to hospital and practice payment models. Oncology pharmacy specialists are well trained to deliver high-quality oncology care, with a focus on the appropriate utilization and monitoring of medication therapy, patient education and collaboration with other healthcare team members. The extent to which the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) metrics identify specific areas in which pharmacists may enhance care is not known. These findings are important because Centers for Medicare and Medicaid Services designate QOPI as a Qualified Clinical Data Registry (QCDR) and over 1000 US-based oncology practices submit quality data to it. Methods: We reviewed all QOPI measures for potential oncology pharmacist involvement. We utilized a summary of services provided by board-certified oncology pharmacists to identify which services would best fit the care described by the selected QOPI measures. Three individuals identified the areas where pharmacists could contribute and consensus was reached. Metrics were only scored positively for pharmacist impact if they could be obtained via the pharmacist as the primary team member responsible for meeting the measure. Results: Two hundred QOPI quality measures from Fall 2016 were reviewed and 177 were analyzed. Potential areas of pharmacist impact were identified in 67 (38%) of the included metrics. These measures fell within 11 of the 13 possible categories of the service summary. A total of 147 services were identified for the 67 actionable metrics. Patient counseling and education (28%), symptom management and supportive care (23%), chemotherapy adjustment (10%), and participation in protocol-based care (10%) comprised services that most commonly contributed to the ASCO QOPI measure performance. Conclusions: Multiple opportunities exist for pharmacists to directly impact the quality metrics that are measured by the service summary. Focusing new services and patient care activities to address validated quality metrics is a natural next step in the care that oncology clinical pharmacists provide to patients.
Evaluating the efficacy of an advanced practice provider symptom management telephone triage program in reducing ED visits and “avoidable” admissions of oncology patients.
Authors: Hirigoyen Jorge , Kalman Leonard A. , Szymanski Jill , Lazo Carmen , Espinosa Christopher , Malespin Amy
Published: April 2017

177

Background: One of the biggest challenges for oncology patients is timely access to care. The inability to provide the right care for the right patient at the right time many times result in overuse of Emergency Departments (ED) to receive oncology care. Approximately 77% of oncology patients have an ER visit, and 63.2% of visits result in hospital admission (Mayer et al., 2011). Furthermore, the average cancer patient receiving chemotherapy has at least one hospital admission and two ED visits per year (Klodziej, et al., 2011). Establishing a “triage” program that attempts to avoid “avoidable” admissions can reduce unnecessary ED visits and associated inpatient care, therefore improving health outcomes while reducing costs. Methods: A quality improvement value-based care (VBC) initiative to prevent ED visits and avoid “avoidable” admissions, via an “Express Symptom Management Hotline” (ESMH) was created. ESMH provides oncology patients with direct and rapid phone access to an oncology Advanced Practice Provider (APP) who can appropriately triage a patient that is in need of acute symptom management. A patient can be managed over the telephone, with a clinic visit, and/or with other outpatient oncology same day services. A next day follow up call for triaged ensures that there was appropriate management. Telephone triage, associated early intervention by an APP for cancer related symptoms and a next day follow-up call will reduce ED visits and avoid “avoidable” admissions. Results: Among the 294 calls that were received from oncology patients for acute symptoms during a 12 week trial period, only 14 led to patients requiring ED services. All 14 ED visits required an admission. Conclusions: Telephone triage by APP’s via an ESMH can effectively manage oncology patients’ symptoms by providing early outpatient interventions. Such an ESMH helps avoid “avoidable” admissions, leading to improved health outcomes while reducing costs. [Table: see text]
Delays in treatment for colorectal cancer patients in an NCI-designated cancer center serving a Hispanic majority community.
Authors: Wangjam Tamna , Rauenzahn Sherri L. , Iruku Praveena , Lindauer Stephanie Purkat , Butler Matthew James , Hung Annie , Yarta Kinan , Jones Jessica Trevino , Konkel Brandon , McCracken Andrew , Patel Sukeshi R.
Published: April 2017

178

Background: Timeliness of cancer treatment is an important aspect of health care quality. Colorectal cancer (CRC) care requires the coordinated multidisciplinary effort of various aspects of the health care system, which can lead to delays between initial diagnoses to definitive therapy. Little is known about the time from diagnosis to cancer-directed treatment, neither about the factors that cause delays or its effect on patient outcomes. Delays to curative surgery beyond 12 weeks are associated with increased mortality in CRC. Longer time to adjuvant chemotherapy is associated with worse survival among patients with resected CRC. The objective of our study is to identify delays in initiation of CRC treatment and its causative factors. Methods: We retrospectively reviewed the medical records of colorectal cancer patients who were either initially diagnosed or had initial surgical resection at University Hospital and had further treatment at Cancer Therapy and Research Center, between 7/1/2010 and 12/22/2014. Data were collected on patient and disease characteristics, treatment timelines and outcomes, till pre-specified data cut-off date of 8/1/16. Results: Of 256 patients treated for CRC, 59 % were males, 59 % Hispanic, and 34 % were uninsured. Most had non-metastatic disease (70%). 72 % were still alive at the time of data cut-off. The median time from diagnosis to treatment (TDT) was 21 days, with 60 % between 0-30 days and 59 % between 31-89 days. Median time from first treatment to first progression or recurrence was 12 months (range 0.9- 42 mos.). Median overall survival (OS) was 17 months (0.1- 51 months). There were no statistically significant difference between the progression or recurrence free survival and OS in patients with TDT <30 days, 30-89 days and >90 days. Compared to non-Hispanics, Hispanic patients were more likely to have a TDT of 31-89 days (31% vs 37%, p= 0.0003) and >/= 90 days (3% vs 7%, p= 0.0001). Conclusions: Hispanic patients were more likely to have a longer time from diagnosis to treatment compared to non-Hispanic patients. The various factors for such disparities in health care quality and their effect on survival needs to be explored further.
The implementation of a streamlined process for biomarker testing in medical oncology.
Authors: Dharmakulaseelan Laavanya , Jorden Tanya , Franco Bryan B. , Stewart Janice , Sanders Gail , Boulianne Patrice , Laws Karen , Cheung Matthew C. , Singh Simron , Ismiil Nadia , Trudeau Maureen E.
Published: April 2017

179

Background: Biomarker testing is increasingly becoming an essential part of standard care. At Sunnybrook Health Sciences Centre (SHSC) in Toronto, Canada, our Department of Molecular Services handles some internal biomarker tests, while some tests are referred to citywide labs. The Odette Cancer Centre (OCC) of SHSC is one of the largest cancer centres in Canada, serving over 12,000 new patients per year, of whom many rely on biomarker tests for personalized treatment. We aimed to describe the work systems at the OCC for biomarker testing and reporting, and to initiate system improvements. Methods: This quality improvement initiative occurred in three phases: qualitative descriptive analysis of the current process of biomarker testing, exploration of future state process using LEAN, and implementation of a streamlined process. In phase one, ten medical oncologists, two administrative assistants, and one pathologist were interviewed. A multidisciplinary team was then assembled to investigate and initiate improvements. Results: Tracking results from external labs was managed by individual physicians and hard copy results were submitted to medical records for filing in patient paper charts, compared to internal tests which are posted on the electronic record, making outside tests harder to retrieve later. The current process involved more than 150 different tests with only 44% of results appearing in the hospital electronic record. In June 2016, a standardized process was implemented where a designated laboratory assistant managed requisition forms, sent corresponding specimens to qualified labs, ensured the receipt of results through various electronic tracking tools and validated the subsequent upload to the electronic medical system. Over a four-month implementation period, there were 364 cases/patients with 467 tests requested; 100% of these test results are stored in the electronic record. Conclusions: The lack of standardization of biomarker testing and reporting can have negative implications on quality of care and patient safety. Therefore, streamlining this process and incorporating electronic tracking tools can improve the accessibility of test results to improve the quality of oncology care.
Comparing patients with breast and prostate cancer in terms of their mental health comorbidities as predictors of cost and utilization.
Authors: Burke Harry , Russo C. Allison , Hopkins Laura , Jeffery Diana D
Published: April 2017

18

Background: We compared the role played by mental health comorbidities in the health care cost and utilization of non-elderly patients with breast and prostate cancer. Methods: The Military Health System affords its beneficiaries equal access to medical care. We performed a cross-sectional analysis using administrative data of all 9.5 million beneficiaries, ages 18-64, with direct care and a primary diagnosis of either invasive breast or prostate cancer during FY2007–FY2014. We used regression models to identify predictors of cost and utilization, including sociodemographic variables, system of care, treatment modalities, chronic disease comorbidities, and mental health comorbidities. Results: On average,annuallythere were 23,800 and 13,300 patients with breast or prostate cancer, respectively. More comorbid depression (16.8%) or anxiety (14.2%) occurred among breast cancer patients than prostate cancer patients (6.9%, 6.7%). Annual cost per patient (inc. pharmacy) was significantly higher for breast cancer ($16,287 vs. $11,069, p < 0.001). The strongest predictors of annual breast cancer costs were (in order from highest predictive value) chemotherapy, surgery, and mood or adjustment disorder (p < 0.0001); the strongest predictors for prostate costs were chemotherapy, radiation therapy, surgery, and mood or adjustment disorder (p < 0.0001). Mood and adjustment disorders were strong predictors of the annual number of ambulatory visits, hospital admissions, and bed days for both breast and prostate cancer (p < 0.0001). Conclusions: Mental health comorbidities play a significant role in health care costs and utilization of non-elderly adults who are breast and prostate cancer patients. An unexpected finding was that, although different in frequency, mental health comorbidities were important predictors of cost and utilization for both patients with breast and prostate cancer. For both breast and prostate cancer, routine screening and treatment for mental health disorders should be part of quality cancer care.
Cancer services phone triage center: Using live operators and state-of-the-art communication technology to improve the patient care experience.
Authors: Carpentier Michelle , Rose Candida , Begnoche Megan
Published: April 2017

185

Background: The term “telephone triage” best represents a large proportion of customer interactions carried out by telephone versus other contact channels. It’s often referred to as the “front door” to a business and is the place where the most crucial customer interactions take place. Therefore, the effective and efficient operation of managing these interactions is a key ingredient to the overall success of any organization. Over the last several years, customer feedback and monitoring of trends on the Press Ganey Patient Satisfaction surveys showed opportunity for improvement in the overall patient care experience at our centers. This led to the development of a strategic goal to create a decentralized phone triage center that would manage these interactions as a group across the service line. Methods: A subgroup of key stakeholders came together for a Failure Mode Effects Analysis of the current state. Results were used in the creation of standard work and process flow algorithms for training the new staff. Staff training included: customer service education; shadow experiences across sites; one to one mentoring on new software and technology Results: The Phone Triage room opened this fall and is staffed daily to manage roughly 400 calls. We track quality metrics that fall into three categories: service, quality and efficiency measures. Service measures include the total number of incoming call; number of abandoned calls; length of time the caller is on hold; and statistics on the telephone and answered service factor. Quality measures include: knowledge/competency of service agents; adherence to protocol; first call resolution rate and transfer rate. Lastly, efficiency measures include average handle time; on hold time; schedule efficiency; and agent availability. In October, the center managed 4657 calls over a 14-day period, 98% were answered in under 2.5 minutes with a 2% abandon call rate. Conclusions: Early data shows pooling of service line resources and utilization of technology has increased customer satisfaction. We plan to monitor trends on several key Press Ganey performance indicators with the next quarter results available in January 2017.
Quantifying episode-based costs of care under the oncology care model: Analysis of Medicare beneficiaries in the UAB cancer community network.
Authors: Williams Courtney , Azuero Andres , Pisu Maria , Halilova Karina I. , Huh Warner King , Partridge Edward E. , Rocque Gabrielle Betty
Published: April 2017

19

Background: The Oncology Care Model (OCM) is a specialty care model developed by the Centers for Medicare & Medicaid (CMS) Innovation Center aimed at providing higher quality, more highly coordinated cancer care and reducing costs for patients undergoing chemotherapy. The OCM calculates costs of care in a novel way by anchoring costs within episodes of care, defined as six-month intervals triggered by initial anti-cancer treatment, as opposed to diagnosis date. The purpose of this study is to assess costs within the OCM episodes of care. Methods: This was a secondary analysis of Medicare administrative claims data for beneficiaries 65 and older with cancer who received anti-cancer drug treatment (chemotherapy, hormone therapy) between 2012-2015 at an institution in the UAB Cancer Community Network (CCN). Total and service-specific costs (Medicare reimbursement to providers) per patient-episode were summed from inpatient, outpatient, chemotherapy, radiation therapy, testing/pathology, evaluation and management (E/M), home health, skilled nursing facility (SNF), and hospice claims. Prescription drug costs were not included. Mean costs for the first three OCM episodes were calculated and compared to (1) diagnosis-based costs (six-month intervals starting at cancer diagnosis) and (2) service type. Results: Average total cost in the first three OCM episodes of care was $24,922 (n=13,902), $18,534 (n=6,618), and $16,548 (n=4,672). Compared to episode-based cost, average total diagnosis-based cost was higher in the first episode of care ($33,244, n=9,615), and lower in the second and third episodes ($17,143, n=9,110; $12,897, n=8,002). Episode-based outpatient, inpatient, and chemotherapy costs were the highest service-specific costs in all three episodes of care (1st: $8,374, $5,493, $2,445; 2nd: $6,188, $3,913, $3,158; 3rd: $5,909, $3,251, $3,399). Conclusions: Costly chemotherapy and inpatient and outpatient visits indicate an opportunity for targeted improvement resulting in higher value care. Knowledge of current costs of care will aid oncology practices in transition to the OCM and in usage of value-based services for better quality cancer care.
Driving quality improvement with public reporting: Use of imaging tests outside guidelines for early-stage breast cancer in Ontario.
Authors: Bedford Colleen , Arnaout Angel , Anas Rebecca , Catley Christina , Clemons Mark , Earle Craig , Langer Deanna , Lee Vicki , Mittmann Nicole , Stiff Jennifer , Eisen Andrea
Published: April 2017

193

Background: Most patients diagnosed with breast cancer will have early stage (stage I or II) disease, with low chance of distant metastases. Thus most guidelines, including Choosing Wisely, recommend against imaging tests for distant metastases in asymptomatic early stage breast cancer. Despite this, most (86%) of these patients in Ontario received these tests from which they are not likely to benefit and may result in investigations that can be invasive and delay treatment. Publicly reported indicators, such as those in Ontario’s Cancer System Quality Index (CSQI), can bring research findings to action by identifying areas for improvement and facilitating ongoing assessment. In practice, this can be challenging due to limitations in administrative data. Moreover, relatively few quality improvement indicators focus on efficiency, the dimension of quality looking at best use of resources to achieve desired outcomes. We sought to examine trends in the use of imaging tests in early stage breast cancer and to drive quality improvement efforts via public reporting. Methods: Data from the Ontario Cancer Registry, the Discharge Abstract Database and the Ontario Health Insurance database was used to identify how many Ontario breast cancer patients diagnosed with early stage breast cancer received staging tests from 2012–2014. Imaging tests included were ultrasound, CT scan, MRI, x-ray and bone scan. The results were subsequently shared with the Regional Cancer Centres and publically released in the CSQI. Results: From 2012 to 2014, 75.1, 72.7 and 71.3% respectively of early stage breast cancer patients received at least one imaging test for staging. This is much higher than the 5-10% of patients expected to need tests due to symptoms or comorbidities. While the regional variation ranged from 47-80%, the rates were high across the province with no clear pattern. Conclusions: Public reporting may be having some effect on overtesting, but rates remain high. Following outreach by the Cancer Quality Council of Ontario and Cancer Care Ontario, targeted regional interventions are being developed and implemented, the impact of which will be assessed and reported in future releases of the CSQI.
Increase in the patient wait-time and delays in the clinic workflow post-implementation of the electronic health record.
Authors: Narayanan Meyyammai , Zhou Xiao , Janarthanan Shawn J , Daniel Mary , Olmedo Maria , Jernigan Colleen , Patel Shreyaskumar , Vadhan-Raj Saroj
Published: April 2017

194

Background: Growth in patient (pt) volume and limited clinic capacity can lead to long wait-times and pt/provider dissatisfaction. We have previously shown that the room pooling model, can reduce pt wait-time in the exam room, improve room utilization, and pt/providers satisfaction (ASCO 2016, Abstract 6595). One of the important goals of adopting electronic health records (EHR) is also to increase the clinical efficiencies, productivity and quality of care. The purpose of this study was to evaluate the impact of implementation of EHR on pt wait-time in the exam room and satisfaction in the Sarcoma Center. Methods: The time studies and pt and provider wait-time satisfaction surveys were carried out over 2 weeks prior to (baseline) and 6 months after the implementation of EHR. All times of when pts, mid-level providers, and doctors (MD) entered and exited the exam rooms were collected for a total sample size of 578 pts (300 before, 278 after) seen during the clinic hours and analyzed using JMP and SAS. Results: The proportion of pts seen within 30 minutes (Min) by MDs from the time pts roomed into exam room decreased by about 32% [from 53% (148/280) to 36% (94/259), p = 0.0001] post implementation of EHR. The median time for pts in the exam room waiting for MD increased (p = 0.0001) from 30 min (range: 0-126 min) to 40 min (range: 0-121 min). Although, the pt satisfaction did not significantly change [increase from 8% (23/278) to 12% (31/267) in the number of pts that were not satisfied to little-satisfied, and decrease from 92% (255/278) to 88% (236/267) in pts that were moderately to very-satisfied], the number of times MD had to wait for an open exam room increased from 8% (5/65) to 24% (14/59, p = 0.01). The delays to see MDs were associated with longer time spent with the nurse (from median 4 to 7 min), followed by delays in seeing Mid-level provider (from 11 to 18 min). Conclusions: These findings indicate that in the initial stages of implementation of EHR, the increase in pt wait-time and reduced clinical efficiencies can be related to the learning of and adapting to the new system. Attempts targeted to the areas of delays (such as training and redesigning workflow) may reduce the pt wait-time and improve the clinical efficiency.
Leveraging technology to facilitate distress screening.
Authors: Franco Susan , Jourdan Dawn
Published: April 2017

195

Background: Research has shown cancer patients are at increased risk for distress during their cancer treatment. Distress screening is required for cancer programs seeking accreditation from the American College of Surgeons, Commission on Cancer and certification from the American Society of Clinical Oncology Quality Oncology Practice Initiative. Developing a successful distress screening program is essential for cancer programs. Methods: The purpose of this project was to create a comprehensive distress screening program utilizing the electronic health record (EHR) to identify patients requiring screening and document interventions. A multidisciplinary team was established to develop a distress screening process for our cancer program. The team developed a screening tool based on the National Comprehensive Cancer Network Distress Thermometer. The distress screening tool was built into the EHR. An alert was created to notify staff at visit check-in to provide the distress screening tool. Once completed, the score and any areas of distress indicated by the patient are entered into the EHR by the medical assistant. When a score is documented, the nurse case manager (CM) receives a “Distress Score” alert when accessing the patient’s chart, indicating the need for nursing review. The CM reviews the score, assesses patient needs and documents any needed interventions or referrals. A specific score does not require a specific intervention, rather the CM is required to determine the needs of the individual patient and take appropriate action. Results: In 2015, 8069 patients were offered distress screening with 13,527 distress screenings completed. This resulted in 629 referrals to social work. 803 distress screens had a score of seven or greater (6%). Conclusions: The multidisciplinary team continues to evaluate the process and make changes. Auditing reveals compliance with documenting a distress score of 95% or greater across all oncology areas and review by the CM of at least 93% on a consistent basis. In many instances, the physician and/or the CM address distress related to the patient’s disease or symptom management. Use of the EHR has facilitated the workflow and allowed information to be visible to the care team.
Impact of universal screening of colorectal cancer (CRC) for detection of Lynch syndrome (LS) at a Hispanic-predominant county hospital.
Authors: Snedden Tyler William , McCracken Andrew , Vaidyanathan Anusha , McGruder Carla , Taranova Anna , Villarreal Roberto , Patel Sukeshi R.
Published: April 2017

199

Background: Historically, the Amsterdam and Bethesda criteria were used to select patients (pts) for LS screening. In 2014, universal screening (US) for LS was shown to be cost effective. Thus, to increase LS screening, we implemented an algorithm for pathologists to reflex immunohistochemistry (IHC) on newly diagnosed CRC. Here, we evaluate the effectiveness of US program with reflex testing for LS for all new CRC. Methods: Retrospective analysis of new diagnoses of CRC (01/2012 – 04/2016): a county hospital with follow-up at NCI-designated CTRC. 3 patient cohorts: 1) PRE-intervention (01/2012–09/2014): screening ordered per old guidelines; 2) PERI (10/2014–02/2015): clinician education on new guidelines; 3) POST (03/2015–04/2016): after implementation. Endpoints: proportion of pts screened and time to screening, quality of family history (FHX) by clinicians, FHX of LS-related cancer, genetic counseling. Results: 381 patients: mean age (57): 69 pts age < 50; 312 pts age ≥ 50. Female 151/male 230; 238 Hispanic/143 Non-Hispanic. % screened: PRE 31% (n = 83), PERI 64% (n = 16), and POST 58% (n = 49) (table for P values). Age < 50 vs. ≥ 50: PRE 56% vs. 25% (P 0.000013), PERI 80% vs. 60% (P 0.38), POST 81% vs. 53% (P 0.02); Loss of any IHC: PRE 12% (n = 10), PERI 19% (n = 3), POST 4% (n = 2); Pts with +screening who received genetic counseling: PRE 30% (n = 3), PERI 67% (n = 2), POST 100% (n = 2). Time from diagnosis to IHC result of < 8 days: PRE 28%, PERI 6%, POST 39%. Adequate FHX in PRE vs POST: 9% vs 20% (P = 0.016). No FHX in PRE vs POST: 47% vs 33% (P 0.019). Conclusions: Significant improvement in number of screens and more timely screening of newly diagnosed CRC pts screened for LS, especially over age 50, were observed after implementation of US. Providers took higher quality FHX after US implementation. Detection for FHX of LS-related cancers significantly improved with US for pts over age 50. Future prospective studies are warranted to evaluate referrals to genetic counselors and diagnoses of LS as well barriers to US. [Table: see text]
Improving patient wait time by implementing visual management tools in an outpatient oncology infusion unit.
Authors: Lu Kit Yu , Fuerst Candace , Veytsman Irina
Published: April 2017

200

Background: The number of cancer diagnosis and oncology visits have increased by 30% over the past decade nationwide. Similarly, our institution also experienced more than 30% growth this past year due to increased number of physicians and patients. However, the amount of resources including staffing, infusion chairs, and hour of operation remained the same. This has caused significant delays for patients and decreased patient/staff satisfaction. Methods: Visual Management tools can be used to communicate information by using visual diagrams instead of text. Various instruments were used to visually assess patient flow during their chemotherapy admission in the infusion unit. The workflow process was organized into a Value Stream Map. Root cause analysis was performed for high problematic areas. Results: Average patient wait time were as follows: patient registration to infusion chair (20min; range 5-45min), chair to nurse assessment (15min; range 0-30min), blood draw to “ok for treatment” (60min; range15-90min), “ok to treatment” to drug delivery (20min; range 15-30min). Through visual stream mapping, we identified the complexity of work flow and areas of highest impact for patient wait time (ex. blood draw/laboratory process, drug delivery). We used root-cause analysis to identify deficiencies and limitation in the process. Pick chart was created to assess and stratify useful ideas and current resources. We achieved several low effort/high impact interventions (i.e. designated parking space for drug delivery, supplying tools in nursing stations) and some high effort/high impact interventions (i.e. extending office hours and making changes to our computer order systems). These strategies has improved efficiency and decreased wait time by more than 50%, and also improved patient and staff satisfaction. Conclusions: Incorporation of Visualization Management tools helped engaged our high stake holders in the improvement processes. These tools helped facilitate a deeper understanding of department workflow, identify issues in the process, standardize the process and improve efficiency.