bluuebunny/crossref_metadata_2025 huggingface dataset:
A multidisciplinary quality improvement project to improve the safety of oral chemotherapy in hospitalized patients.
Authors: Sica R. Alejandro , Sidani Amer , Domingo Gelenis Calzadilla , Sullivan Diana , Sencion Katherine , Ho Dominic , Haaf Christina , Bursua Adam , Venepalli Neeta K.
Published: February 2017

110

Background: At the University of Illinois Hospital and Health Sciences System (UIC), inpatient IV chemotherapy administration occurs in the setting of specific protocols and multidisciplinary safety assessments while oral chemotherapy agent (OCA) inpatient administration occurs less formally. Baseline 8 week review of 174 admissions to the oncology service revealed that of 16 patients (9.2%) on outpatient OCA, 50% received OCAs while inpatient, with 12. 55% having a formal chemotherapy note in place. We aimed to increase the percentage of administered OCAs with associated provider generated chemotherapy notes from 12.5% to 75% over 16 weeks. Methods: A multidisciplinary task force comprised of oncology providers, clinical pharmacy, nursing leadership, and information technology was assembled. An actual and ideal process map was created, and using tools such as affinity sorting and root cause analysis, interventions were implemented focusing on residents (knowledge of OCA), nurses (documentation and policy adherence), pharmacists (education, policy adherence) and IT team (order modification). A standardized multidisciplinary hospital wide process was implemented for OCA ordering, administration, documentation, and patient education. A novel REDCap (research electronic data capture) auditing procedure was designed by which a weekly pharmacy report of every oral chemotherapy order at UI Health is automatically generated. Results: Between June and September 2015, a total of 67 OCA administration reports were audited. OCA notes were associated with OCA administration in 58% of cases in June, 100% in July, 78% in August and 93% in September. Furthermore, OCA notes were entered within 4 hours of OCA ordering in 58% of cases in June, 54% in July and 78% of the cases in August and September. No adverse events were reported. Conclusions: At the University of Illinois Hospital and Health Sciences System, a multidisciplinary team designed and implemented a standardized OCA administration, ordering, and documentation process focused on safe, appropriate and timely inpatient OCA administration. A novel REDCap auditing process assisted the team to identify the areas in need of optimization.
Clinical trial enrollment expansion to the community.
Authors: Kostka Judith , Zerillo Jessica A. , Kruse Andrea , Sinclair Natalie Faye , Patrick Maureen , McGovern Lauren , Fuller Frances , O'Neil Kelly , Hixon Nicole , Weeks Kristie , Johnson Bruce E. , Krop Ian E. , Savoie Jen , Daftary Farah , Constantine Michael , Kaddis Mona S. , Rossi Humberto A. , Tahir Naeem , Norden Andrew David
Published: February 2017

112

Background: Oncology patients at community cancer practices generally do not access clinical trials to the same degree as patients at academic medical centers. Collaborations between research and clinical teams across academic hospitals and their affiliated community sites may help to improve this disparity. Methods: To improve clinical trial enrollment, a multidisciplinary team of research and clinical staff from the Dana-Farber Cancer Institute main campus and a community-based satellite site implemented a program to enhance identification of breast cancer patients eligible for clinical trials. The team constructed a process map, cause and effect diagram and collected diagnostic data, which was displayed with a Pareto chart. Process control charts were used to track data over time. Interventions included: (1) a web-based tool to pre-screen patients for community and main campus trials, (2) a training session for clinicians on trial communication skills, (3) designated clinician visits for follow-up trial discussions, and (4) research nurse telephone calls after the initial consultation. Results: Before the program (7/14-10/14), research staff screened 83% of new breast cancer patients for clinical trials, which increased to 97% after the program (11/14-9/15) (p < 0.001). There was not a significant change in trials presented to eligible patients or enrollment in trials. Conclusions: The proportion of patients identified for clinical trials increased and there was numeric improvement in the proportion of eligible patients presented trials. There was an increase in clinical trial enrollment that did not reach statistical significance, possibly due to the low sample size. These results suggest that the interventions would benefit from further modification and use. The project demonstrates the challenges and opportunities inherent in growing successful clinical trial programs in community-based satellite sites. [Table: see text]
Developing a one-team approach to meet three infusion centers’ staffing needs.
Authors: Winkelbauer Laurie , Stull Ellie , Yager Ann
Published: February 2017

116

Background: Our cancer service line provides infusion services for oncology patients at three locations. The numbers of chairs vary by location from 10 to 30. Each location has a nurse manager. Staff are hired for specific locations. Hours of operation differ at each location, depending on patient needs. With increasing pressure to streamline operations and maintain productivity, along with challenges of RN vacancies and growing volumes, efforts were needed to coordinate staffing between locations to ensure best utilization of resources. Methods: The leadership team met to identify opportunities for improvement and develop an action plan. Issues identified included: Locations worked in silos to manage staffing issues and patient volumes. Decisions were made without consideration of the other locations; Staff were reluctant to float; Lack of consistent communication and comradery among managers/leads; Critical decisions were made inconsistently by staff; Lack of communication to senior management and physician leadership when capacity and staffing situations were occurring. Strategies were proposed to address the issues. Phone huddles with leadership from all locations are held daily to discuss staffing, patient scheduling and concerns. A tool was developed to assist with decision making related to staffing and patient scheduling. A “One Team” approach was implemented for staffing with the expectation that staff would float to cover staffing needs at the other locations. Processes were standardized across all units to ensure staff feel competent when floating. Results: Several positive outcomes have been noted since changes were implemented 10 months ago. Staff are more willing to float and have bought into the “One Team” concept. Cross coverage of staffing vacancies occurs daily, allowing for better and more cost effective utilization of staff across locations. Decisions to block schedules are made by managers using the developed tool. There is improved awareness of critical staffing and capacity issues by senior leadership and physician leaders. Conclusions: Implementing a One Team staffing approach to cover three infusion center locations increases staff productivity and allows for fluctuations in patient volumes.
Long-term employment outcomes among partners of patients with early-stage breast cancer.
Authors: Veenstra Christine Marie , Wallner Lauren P. , Bradley Cathy , Hawley Sarah T.
Published: February 2017

12

Background: Undesired work loss comprises one of the many personal costs faced by cancer patients and their families. Multiple studies have described the long-term employment outcomes among patients with early-stage breast cancer, and show that a significant proportion of women face long-term job loss as a result of their cancer diagnosis and treatment. However, little is known about the employment outcomes of partners of breast cancer patients. Methods: Women with non-metastatic breast cancer identified by the Detroit and Los Angeles SEER registries between 6/05-2/07 were surveyed at 9 months (Time 1) and 4 years (Time 2) after diagnosis. Latina and black women were oversampled. Partners were surveyed at Time 2. We performed descriptive analyses of those partners who were not retired at the time they completed the survey. As part of a larger survey assessing the experiences of partners of breast cancer patients, partners were queried regarding the impact of the patient’s breast cancer diagnosis and treatment on their own employment and finances. Results: Of 774 eligible partners, 517 (67%) completed the survey. We included 280 non-retired partners in our analyses. 54% were white, 31% were Latino, and 10% were black. The majority of partners (86%) worked during the year following the patient’s diagnosis and 219 (90%) were working at the time of survey 4 years post-diagnosis. 50% of partners reported that work was a welcome source of support; 32% decreased their work hours as a result of the patient’s breast cancer. In order to maintain health insurance, 64% reported it was very/extremely important to keep their jobs and 51% reported it was very/extremely important to avoid changing jobs. 32% of partners reported their financial status was worse off because of the patient’s breast cancer; 20% were worse off regarding health insurance, and 19% were worse off regarding employment status. Conclusions: In contrast to breast cancer patients, most partners reported long-term job retention. Many partners kept working or avoided changing jobs in order to maintain health insurance. Nearly one-third of partners reported that their financial status was worse off because of the patient’s breast cancer diagnosis and treatment.
Communities of practice: A jurisdictional approach to improving the quality of care in radiation medicine in Ontario.
Authors: Lockhart Elizabeth , Ang Michelle , Reddeman Lindsay Elizabeth , Sharpe Michael , Hart Margaret , Simniceanu Carina , Breen Stephen , Kim Joon-Hyung J. , Scott Dani , Zaza Khaled , D'Souza David , Milosevic Michael F. , Gaede Stewart , Marshall Andrea , Yaremko Brian P , Sixel Katharina , Harnett Nicole , Gutierrez Eric , Warde Padraig Richard
Published: February 2017

122

Background: The Radiation Treatment Program (RTP) at Cancer Care Ontario (CCO) established several Communities of Practice (CoPs), with the goal of improving radiation treatment (RT) quality and safety. The RTP identifies variation in practice and quality improvement (QI) opportunities in the 14 Regional Cancer Centres (RCCs) and facilitates the development of CoPs to share best practices and standardize care. Methods: Since 2010, the RTP has formed 7 CoPs ( > 185 members in total): 4 intra-disciplinary (Radiation Therapy, Medical Physics, Advanced Practice Radiation Therapy, Radiation Safety) and 3 inter-disciplinary (Head and Neck (HN), Gynecological (GYNE) and Lung Cancer). Members are recruited with the aim of securing engagement from all RCCs to ensure representation of regional diversity and to facilitate adoption of best practices. CoPs are supported with nominal funding and resources provided by CCO, but are led and driven by members, who identify and prioritize key quality issues and select corresponding QI projects to pursue. The RTP performs regular evaluation activities to assess initiative engagement and impact. Results: RTP CoPs have enhanced the quality and safety of RT delivery in Ontario through QI initiatives, advice documents and tools that have enabled: Improved RT safety (use of safety straps in RT delivery); Adoption of best practices (RT plan evaluation guidance); Education and knowledge transfer – (stereotactic body RT implementation and training framework); and Support for infrastructure improvements (recommendation for additional Magnetic Resonance-guided brachytherapy units) ( https://www.cancercare.on.ca/ocs/clinicalprogs/radiationtreatment/ ). Advice documents have improved alignment with recommended practice (40% and 50% absolute increases in two HN initiatives). Evaluation surveys indicate that members believe the CoPs have enhanced inter-regional communication and collaboration (89%), knowledge transfer/exchange (91%), and professional networking between RCCs (92%). Conclusions: CoPs can be a highly effective model for improving quality of care. The establishment of CoPs should be considered for QI in other areas of the healthcare system.
A single institution’s experience with the value of FDG-PET-CT imaging in patients with newly diagnosed stage IIB-IIIB breast cancer.
Authors: Schnur Gary , Glass Katherine , Cummings Chad W , Montero Alberto J. , Abraham Jame , Moore Halle C. F. , Budd G. Thomas
Published: February 2017

123

Background: The Cleveland Clinic is utilizing disease specific teams to craft care paths for value based disease management. The report by Groheux (JNCI 2012; 104:1879-1887), reported 18 FDG-PET-CT detected distant metastasis in 10.7, 17.5 and 36.5% of stage IIB- IIIB breast cancer patients. Based on this report, the breast team incorporated 18 FDG-PET- CT imaging for initial staging of IIB-IIIB patients. Methods: Treatment algorithms were developed by a multi-disciplinary breast cancer team. The content was reviewed by stakeholders throughout the health system, and feedback was incorporated into the care paths as appropriate. Content was communicated using physician meetings, electronic communication, tumor boards, and operational pilots. The treatment algorithm, along with the supporting narrative, was placed on the cancer center intranet, accessible to all practicing physicians. Additional intranet analysis was performed using Google Analytics, which identifies the site location and frequency of document downloads. We retrospectively examined the impact of this posting after one year (7/2014-7/2015). Manual chart review identified new patient consults for Stage IIB-IIIB breast cancer at our main campus and highest volume regional sites. Results: PET scans were ordered in 36 stage IIB, 19 stage IIIA, and 3 stage IIIB patients. Of the 36 IIB patients scanned, occult metastatic disease was noted in 1, and 2 patients migrated to IIIA without a change in treatment. 19 IIIA patients had no change in stage, although an asymptomatic second primary lung cancer was discovered in 1 .Three stage IIIB patients were without staging change. Conclusions: PET/CT imaging did not contribute to patient management for stage IIB-IIIB breast cancer patients at our institution, unlike the results reported elsewhere. Analysis of care path metrics allows us to expediently review and adjust recommendations to affiliated physicians.
Cancer care decision support for WBC growth-factors (GF): Geographic differences in utilization and provider malleability.
Authors: Bennett Charles L. , Wurtz Kenneth Sherman , DiMarco Anna , Feliciano Lourdes , Huff Dinah Faith Q. , Knopf Kevin B. , Hrushesky William J. , Baum Michael
Published: February 2017

128

Background: Growth factor use is the largest single category of drug expenditure for US cancer patients. Oncology Analytics is a decision support company that assists physicians in determining the appropriate use of GF based on the NCCN, ASCO, and ASH guidelines and the level one data that underlies these guidelines. We hypothesized that there would be geographic variation among GF preference and in the malleability of those practice patterns after OA entered a market. We determined the proportion of initial pegfilgrastim requests for preauthorization over other types of GF as well as the review outcomes and final drug of choice after OA intervention of inappropriate GF requests across three specific jurisdictions: Florida, Puerto Rico, Georgia and Texas. Methods: We analyzed data from drug preauthorization requests for febrile neutropenia prophylaxis submitted by providers in these four states from 10/01/2013 through 09/30/2015. We tested geographic differences in the preference for pegfilgrastim over other GFs; and in review outcomes and final GF of choice after OA intervention for inappropriate pegfilgrastim requests. Chi-square test and linear regression was employed at 95% CL. Results: Oncologists in PR are among the most evidence-based of all GF users, preferring to order the more cost-effective filgrastim. Our research indicates that, on average, 2-3 doses of filgrastim are given at a total cost of $600 to $900 per cycle, compared to pegfilgrastim at $3,800 per cycle. GA and TX oncologists, on the other hand, chose pegfilgrastim over other GFs more than their colleagues (70% GA vs. 72% TX vs 60% FL vs 33% PR) but reduced their pegfilgrastim preference substantially in the last two years by 11% and 36% respectively (linear trend, p < 0.05). Filgrastim was the most common replacement of pegfilgrastim across all states. Conclusions: There are significant geographic variations in the management of febrile neutropenia. These variations contribute to differences in financial toxicity without clinical benefit. Optimizing growth factor utilization management needs to be focused upon certain locales to be most effective. The impact of GF biosimilars has not yet been evaluated.
Integration of a clinical pathways software into an EHR in a large, multisite, hospital-affiliated community oncology setting.
Authors: Shamah Corey J. , Saphner Thomas James , Frick Jacob C. , Huibregtse Carol , Stiemke Gail S.
Published: February 2017

129

Background: Via Oncology (Via) is a decision support tool that integrates patient information, their disease, and goals of care to develop a treatment algorithm. Via prioritizes treatments by efficacy first, toxicity second, and cost third. The recommended regimen is offered to the doctor and patient who may accept it or choose an off pathway treatment. The pathways are updated quarterly and are expected to speed the integration of new treatments into practice, standardize therapy, improve quality, and decrease cost. Physicians are often unaware that a trial is available for a patient and EHR’s are not commonly used to facilitate accrual to clinical trials. A pathway system could also alert doctors to the availability of a clinical trial and is designed to increase accrual to clinical trials. Methods: The integration of Via into the Epic EHR was facilitated by 3 major interfaces: patient information sent from the EHR to Via, the providers’ schedules sent from the EHR to Via, and the protocol selected in Via sent back to the EHR. Within the decision algorithm, clinical trials were recommended as the first option in all lines of therapy when available. Results: After 11 months and 103,515 visits, the visit capture rate was 82.7%%. With 3,844 decisions made, 83.9% of all treatment decisions were on pathway. Clinical trial enrollment was 122 patients in the 459 days prior to Via implementation, and 102 patients in the 271 days afterwards. This increase in accrual rate was significant (p = 0.00174.) Conclusions: The pathway program was rapidly accepted by physicians and the recommendations were commonly accepted. The subsequent increase in clinical accrual, while not definitive of causation, is promising. An upgrade of the Epic EHR is planned in the near future. A single log in to open Via and the EHR concomitantly is planned. An additional interface to bring staging information from the EHR to Via is being planned.
The impact of a "just culture" environment on the reporting of medication errors/near misses.
Authors: Steele Cheryl A. , Weber Shani Michelle
Published: February 2017

131

Background: UPMC CancerCenter is a large outpatient medical oncology network of 25 locations, located within a 200 mile radius of Pittsburgh, PA. The Cancer Center administers approximately 118,000 treatments and 38,000 injections per year by 200 oncology nurses. Staff members have been strongly encouraged for years to report not only medication errors but also near misses. Despite the continual encouragement it was suspected that the actual number of reported medication errors and near misses was frequently underreported. Methods: In 2012 a Safety Culture Survey comprised of 43 questions was administered to all clinical staff in order to evaluate the comfort level of the staff in speaking up about medication safety issues. Cancer Center leadership wanted to convert from a ‘no blame’ response to errors to a ‘Just Culture’ environment that includes not only a robust accountability model but a model for addressing system and behavioral risks both before and after events occur. This survey was again repeated in 2014. At the conclusion of each survey period nursing leaders conducted on site in-services at every Cancer Center location. Individual site results along with Cancer Center aggregate results were reviewed with all participants. Participants were challenged to identify action items that could contribute to improving patient safety. Results: The results indicated a decrease in the number of respondents who reported feeling fearful of reporting in in 2012 (33%) compared to 2014 (28%). The number of reported near misses increased by 181% while actual error reported increased by 45% from 2012 to 2014. Conclusions: Staff quickly realized that should an error occur they would be treated fairly when they report medication errors. The staff also realized the positive impact that reporting has on patient safety. The conversion to a “Just Culture’ environment significantly increased the number of medication errors reported as a result of open communication and the implementation of a well-established system of accountability.
Banning the use of intracorporeal morcellation.
Authors: Schink Julian C. , Rechner Stephen F. , VanDrie Douglas M , Rogers Ralph N
Published: February 2017

132

Background: In response to the FDA safety communication we banned the use of intracorporeal morcellation effective April 22nd 2014. Clinicians expressed frustration and a concern that an increase in the abdominal hysterectomy rate or percentage, wound complications, and length of stay would occur. Our PDCA (plan, do, check, and act) safety process reviewed these quality and safety metrics one year later. Methods: This is a retrospective evaluation of a prospective institutional decision. Data evaluated in a patient anonymous fashion using Crimson and Optum quality reporting software. Results: In 2013 the power morcellator was used in 157 cases. In the twelve months following the ban, the wound complication rate, SSI's, and LOS all decreased, and vaginal hysterectomy rate increased. Conclusions: An institutional ban of intracorporeal and power morcellation resulted in a decrease in the overall number of hysterectomies, including abdominal hysterectomy. Laparoscopic supracervical hysterectomy was replaced by vaginal hysterectomy and an associated decrease in complications and length of stay. [Table: see text]
Hepatitis B reactivation in patients with solid tumors: A systematic review and meta-analysis.
Authors: Hicks Lisa K. , Feld Jordan J. , Saluja Ronak , Truong Judy , Haynes Adam E. , Chan Kelvin K.
Published: February 2017

138

Background: Hepatitis B virus (HBV) affects over 250 million people worldwide. Most people with chronic HBV (HBsAg positive) have no signs or symptoms of infection. However, when exposed to immunosuppression they are at risk of HBV reactivation which can cause hepatitis, liver failure and death. The risk of HBV reactivation in patients receiving chemotherapy for solid tumors, the efficacy of antiviral prophylaxis, and the clinical impact of HBV reactivation in this setting are uncertain. Primary Aim: To estimate the risk of clinical HBV reactivation (increased HBV DNA + transaminitis) among HBsAg-positive patients administered chemotherapy for a solid tumor. Secondary Aims: To estimate the efficacy of anti-viral prophylaxis and the risk of death from HBV reactivation in patients receiving chemotherapy for solid tumors. Methods: A systematic review and meta-analysis of the English language literature on HBV reactivation was completed (OVID Medline, 1946 to Aug 2013). All citations were reviewed by two or more authors. Data from patients with hematologic malignancies were excluded. Pooled probabilities of HBV reactivation risk, death from HBV reactivation, and odds ratio for the impact of anti-viral prophylaxis were estimated with a random effects model. Results: 2,667 citations were identified; 19 were eligible for inclusion. The pooled estimate for clinical HBV reactivation in HBsAg-positive patients receiving chemotherapy for a solid tumor was 21.9% (95% CI; 16.5% to 27.3%) in those not receiving anti-viral prophylaxis, and 2.4% (95% CI 0.7% to 4.2%) in those receiving anti-viral prophylaxis. The odds ratio for clinical HBV reactivation with antiviral prophylaxis compared to no prophylaxis was 0.12 (95% CI 0.06 to 0.25). In the absence of viral prophylaxis, the risk of dying from HBV reactivation in HBsAg-positive solid tumor patients was estimated at 1.3% with a 95% CI of 0.3% to 2.3%. Conclusions: Patients with chronic HBV who are administered chemotherapy for a solid tumor appear to be at substantial risk of clinical HBV reactivation; this risk may be mitigated by anti-viral prophylaxis. In the absence of anti-viral therapy, patients may experience a small but important risk of dying from HBV reactivation.
Engaging managing physicians in clinical staging prior to the initiation of cancer treatment.
Authors: Barry-Weers Anne , Huibregtse Carol , Bjegovich-Weidman Marija , Weese James L.
Published: February 2017

143

Background: Managing physicians (medical oncologist, radiation oncologist, surgeons) have a responsibility to clinically stage patients prior to the initiation of cancer treatment. Clinical staging not only directs the treatment plan, but identifies appropriate clinical trials and estimates prognosis. We sought to determine whether engagement of managing physicians would result in increased clinical staging for various types of cancer. Methods: Baseline data on clinical staging for breast, colorectal (colon, rectal, anal, rectosigmoid junction)*, thoracic (lung esophageal)†, genitourinary (prostate, penis, testes)‡, and pancreatic primary cancers were obtained. The data were grouped by disease type and sub-specialty of the managing physicians. Based on that data, several performance improvement initiatives were implemented to provide managing physicians the opportunity to clinically stage the cancer patient prior to the initiation of treatment. The initiatives for completing and documenting staging were: a tutorial on use of Problem List in the electronic medical record (EMR); modification of history & physical and consult notes to include a field for staging; sharing among sub-specialties the smart lists within the template to allow for customization of existing templates; and 1:1 review with physicians who had outliers without clinical staging. Results: Clinical staging documented prior to the initiation of cancer treatment significantly increased in all five types of cancers studied (p < .01; Table). Conclusions: Though collaborative efforts by managing physicians continues to evolve, in many cases, use of the electronic medical record through a variety of performance improvement initiatives has facilitated documentation of clinical staging of cancer patients prior to the initiation of treatment. This engagement changed practice patterns, aligned our institution with best practice guidelines and aided in treatment selection for the best possible patient outcomes. [Table: see text]
Refining the use of an electronic medical record (EMR) to define and implement psychosocial distress screening and treatment.
Authors: Marcus Joel
Published: February 2017

144

Background: All cancer patients experience some level of distress associated with cancer and its treatment at all stages of the disease. Psychological and social problems created or exacerbated by cancer cause additional suffering, weaken adherence to prescribed treatments and threaten patients' return to health." Health care providers often tend to under estimate psychological distress. Screening and early identification of distress promote improved management of symptoms, which facilitates medical care. Psychosocial care must be integrated into the routine treatment of cancer patients, per the Institute of Medicine's 2008 report "Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs." Methods: Developing operational standards for Distress Screening our cancer center both NCCN guideline, Commission on Cancer Standards. These operational standards integrated our Electronic Medical Record to create "best practice advisories" to alert the physician to the possible need for further evaluation of distress and the possible need for referral to Social Work staff or the on-site Psychologist. Results: Referrals to our on-site staff Psychologist at our main campus were monitored. 306 unique patients were referred to our staff psychologist for evaluation and treatment during the 2014 calendar year. In the first three quarters of the 2015 a total of 445 were made. Surgical oncology clinics (Head & Neck, Breast & Upper Gastro-Intestinal) made the majority of referrals. Conclusions: In accordance with published guidelines and accrediting standards our cancer center utilized our electronic medical record to increase our ability to identify psychosocial distress in our population.
Utilizing information and telehealth technology to enhance clinical ethics education outreach.
Authors: Gallagher Colleen M. , Moore Jessica Anne , Campbell Brittany C
Published: February 2017

149

Background: Integrated Ethics provides continuing education monthly for physicians, nurses, social workers, and others to enhance knowledge and understanding of ethical challenges associated with patient care and research. These are offered live at the main campus. There are four regional centers within a thirty-five mile radius of the main campus. Participants from those locations used to have to come to the main campus to participate. This project was initiated to help alleviate rising financial costs associated with the online recording/redistributing of continuing education credit presentations, travel expenses for regional center employees, removal of employees for 4+ hours from the regional centers daily clinical operations to attend presentations, and payment to outside institutions to obtain required ethics CME and CEU credits. Methods: Steps included internal and external discussions, establishing the need, tracking current process, determining which resources were needed, and then updating the process and evaluating it. Among the primary elements was the inclusion of nursing leaders, physicians and social workers from the centers. Ethics staff went to each center for discussions which had the added value of building relationships. Telehealth and information technology representatives assisted in developing the possible methods for delivery of the education and provided information about the process and costs of each for evaluation. Of note was the fact that the profession of the attendees was different among the main campus and regional centers. At main campus 58% of the attendees are physicians, at the regional center 66% are nurses. Varying requirements for continuing education in the professions had to be accounted for in the selection of method delivery and accreditation processes. Results: This project saves a minimum of $22,634 annually and participation at the Regional Care Centers increased by 20%. An average of 309 productivity hours are no longer lost at the centers. Conclusions: Understanding and utilizing new technology and consistent personalized communication efforts realized both cost savings and increased participation.
Real-world treatment patterns and health care resource utilization (HRU) among patients with chronic lymphocytic leukemia (CLL) by regimen.
Authors: Schenkel Brad , Ellis Lorie , Korrer Stephanie , Byfield Stacey DaCosta
Published: February 2017

15

Background: Few studies examine HRU of CLL, the most common hematologic malignancy in adults. This study describes HRU by the most common regimens among CLL patients (pts). Methods: A retrospective study using a large, national U.S. claims database from 1/2007-10/2013 was conducted. Adult CLL pts (≥2 claims for CLL) with ≥1 claim for systemic anticancer therapy (SACT) were identified; first SACT claim date was the index date. Pts had to have a CLL diagnosis ≤3 months (m) prior to the index date and be continuously enrolled (CE) in the health plan for 24m pre- and ≥6m post-index date. Pregnant pts and those with SACT in the pre-index period were excluded. A line of therapy (LOT) started with the first SACT; regimens included all agents received in the first 60 days. LOTs ended at the earliest of, start of a new drug, ≥60-day gap in receipt of initial regimen drugs, death or CE end. All-cause HRU was examined by regimen. Results: There were 946 CLL pts identified. Mean age was 68 years, 63% were male, and by insurance type, 41% were Medicare Advantage vs. 59% commercially insured. During the first LOT, 96% and 78% of pts had ≥1 office or hospital outpatient visit with mean per patient per month (PPPM) visits of 4.3 (standard deviation, SD = 2.8) and 2.2 (SD = 2.8), respectively. 31% and 25% had ≥1 ER visit or inpatient stay with mean PPPM visits of 0.2 (SD = 0.4) and 0.1 (SD = 0.3), respectively. Mean PPPM count of inpatient stay days was 1.4 (SD = 8.0). In first LOT, the top 3 regimens accounted for 56% of pts: FCR: fludarabine, cyclophosphamide, rituximab (19%); R: rituximab (19%); BR: bendamustine, rituximab (18%). During the study period, 318 pts (34%) started a second LOT. The top 3 LOT2 regimens accounted for 52% of pts: R (30%); BR (14%); chlorambucil (8%). Conclusions: HRU of CLL pts varied by initial regimen received. Future studies should examine influences of regimen choice and whether regimen choice is associated with differences in outcomes. [Table: see text]
An electronic intervention to improve structured cancer stage data capture.
Authors: Adelson Kerin B. , Framski Kim , Lazette Patricia , Vega Teresita , Lilenbaum Rogerio
Published: February 2017

151

Background: Cancer Staging is critical for prognosticating, treatment planning, outcomes analysis, registry reporting and clinical trial eligibility determination. Oncology EHRs have structured staging modules but use by physicians is inconsistent. Typically, stage is entered as unstructured free text in clinical notes and cannot be used for reporting. Instead, institutions depend the tumor registry (TR) which typically lag 6 months behind. Our Cancer Committee determined that real-time capture of structured cancer staging was an imperative. Methods: We created an EPIC best practice advisory (BPA) decision support tool that requires physicians to enter cancer stage if the following criteria are met: 1)unstaged cancer on the problem list 2)EPIC staging module exists for that cancer 3)physician is from a specialty with staging expertise. This BPA was implemented 12/18/14. If physicians chose not to stage they had to enter a reason why. Choices were: 1) cancer diagnosed before 2014, at which the BPA was permanently removed 2) staging studies not yet completed, at which the BPA fired at a future encounter 3) Not a staging provider, at which the BPA no longer fires for that individual provider 4) Cannot stage: document reason, at which the BPA was permanently removed. Results: We used TR data to determine the number of patients who were eligible for staging. In 12 months prior to the intervention, 1480/5222, or 28% of patients who were eligible for staging were staged in the structured staging module. After we launched the intervention, between 12/18/14 and 4/30/15, 1654/1831 or 90% of eligible patients were staged electronically. This is an absolute improvement of > 200% Conclusions: Electronic decision support can dramatically improve rates of structured staging. Such data allows automated reports for clinical trial screening, outcomes analysis, quality comparisons, and reporting. We are now building automated reports for: clinical trial eligibility, Commission on Cancer/ QOPI breast, colon and lung measures, rates of palliative care consultation for advanced disease and outcome measures like disease free interval by stage and overall survival.
Actionable biomarkers in a non-small cell lung cancer (NSCLC) clinical pathway (CP).
Authors: Ellis Peter G. ,   Aurora Health Care, Baystate Regional Cancer Program, Broward Health Medical Center, Kahlert Regional Cancer Center, Indiana University Health, Tennessee Oncology, The Center for Cancer & Blood Disorders, UPMC CancerCenter
Published: February 2017

155

Background: Oncologists use Via Pathways (VP) to drive standardization to best evidence-based cancer care. VP include guidance for biomarker testing and associated treatments. Practices collaborated to analyze the first line non squamous carcinoma NSCLC VP. An unexpectedly large percentage of treatment decisions captured by oncologists in the VP portal had unknown ALK translocation or EGFR mutation test results. The VP was modified to require input of whether or not the test was ordered. This analysis examines the impact of this change. Methods: ALK and EGFR testing responses from the VP database were analyzed pre and post implementation of the change. Treatment decisions were reviewed to analyze prescribing patterns. Results: From 1/1/2014 to 1/29/2015, ~40% of EGFR or ALK testing responses were unknown. Post-implementation (1/30/2015 to 5/31/2015), 29.8% were charted as awaiting ALK results and 9.4% did not order the test; 29.5% were charted as awaiting EGFR results and 7.6% did not order the test. For the combined period, appropriate targeted agents were selected for 91.9% (n = 37) and 86.5% (n = 133) of patients who were ALK translocation positive and EGFR sensitizing mutation positive, respectively. Conclusions: Results demonstrate the ability of CP to promote testing of key biomarkers and use of appropriate targeted agents. Frequent evaluation and modification of pathway content is needed to ensure practice patterns are accurately captured. [Table: see text]
Using information technology (IT) to improve communication between the emergency room and cancer clinic.
Authors: Balchin Katelyn Sarah , Falkson Conrad B , Baetz Tara D.
Published: February 2017

158

Background: A communication gap was identified at the Cancer Centre of Southeastern Ontario which resulted in oncologists at the cancer centre (CC) not consistently being informed when oncology patients (pt) were seen in the emergency room (ER). An automated IT notification system was developed to inform oncologists when their pt were seen in the ER. Methods: Pt who had been seen within 60 days in the CC were considered active. An IT notification system linked active CC visits and ER visits. A list was generated daily of pt that were both CC and in the ER and this was emailed through a secure system to treating oncologists. Following six months of usage an evaluation was performed which identified which pt were being seen in ER (by disease site, treatment regimen and other factors). A survey evaluated oncologist feedback regarding usefulness of this system. Results: From December 2014 to May 2015 notifications were analyzed. A total of 773 pt (12% of total active cancer patients) had an ER visit resulting in 1267 visits; 56% of pt had more than one visit. Thirty-three percent of visits result in admission to the hospital. The highest usage of the ER was palliative care (26% of pt) and hematology (29% of visits). The risk of dying in the three months following an ER visit was 20% as compared to < 2% for all pt seen in the ER during that time period. Sixty-three percent of the 41 oncologists responded to a survey. The majority used this notification system (85%) and found that the report improved patient care (87%). Oncologists typically used this information to check up on pt information on the electronic medical record and if appropriate visited pt that had been admitted to hospital. Conclusions: Cancer pt who have an ER visit are now automatically being reported to the treating oncologists. This process has been able to identify at risk pt for ER visits and this information will be used to develop targeted measures for these high risk populations. The report is very popular with oncologists and is now considered standard practice at our CC.
A novel auditing procedure for an oral chemotherapy process improvement project.
Authors: Bursua Adam , Sica R. Alejandro , Sencion Katherine , Sidani Amer , Haaf Christina , Sullivan Diana , Venepalli Neeta K.
Published: February 2017

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Background: A process to standardize ordering, documentation, and administration of inpatient oral chemotherapy was implemented at the University of Illinois Hospital and Health Sciences System. The process requires oncology clinician review and endorsement of inpatient oral chemotherapy drug orders via an oral chemotherapy note within the electronic health record. Pharmacists are instructed to reject oral chemotherapy drug orders that lack this required documentation. A novel auditing procedure was established in order to track adherence to these new requirements and provide real time and adaptable feedback to front-line staff critical to the project’s success. Methods: To support continuous quality improvement (QI) with this project, an auditing tool was developed in REDCap, a secure, web-based data management application. The auditing tool was originally developed as a traditional web-based data collection instrument with the primary purpose of tracking performance. By utilizing more advanced features offered by the REDCap platform, the auditing tool generated automated follow-up surveys to pharmacists involved in non-adherent outlier cases. The survey solicited information on the root cause of non-adherence, and based on the end-user response, provided adaptable continuing education tailored to this root cause. Results: Between June and September 2015, a total of 67 orders for oral chemotherapy were audited. Compliance with process improvement requirements was noted in 58%, 100%, 78%, and 93% of cases in June, July, August, and September, respectively. Outlier surveys were sent to 12 pharmacists in the non-adherent cases; of 11 responses, the most common response reflected an unfamiliarity with the process. Following targeted education, through September 2015, no single pharmacist has been involved in more than one non-adherent case. Conclusions: The novel auditing tool supported the continuous quality improvement process by engaging front-line staff, generating automated and real time surveys for outlier responses, and providing targeted and personalized education aimed at resolving the root cause in non-adherent cases. As such, it can be applied towards any REDCap QI projects.
Creating an online resource providing hospital cancer surgery volumes in California.
Authors: Clarke Christina A , Baker Laurence C , Malin Jennifer , Parker Joseph , Holliday-Hanson Merry , Fong Niya , Teleki Stephanie , Lang Lance , O'Sullivan Maryann
Published: February 2017

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Background: Little evidence is available to help patients and providers, payers and policymakers find the highest-quality hospitals for cancer surgery. We initiated a groundbreaking effort in California ( www.calqualitycare.org ) to publicly report hospital cancer surgery volume data online. Methods: With financial support from the nonprofit California HealthCare Foundation, we assembled a multidisciplinary team to oversee the project and ensure sound methodology. We obtained existing hospital discharge summary data from the California Office of Statewide Health Planning and Development (OSHPD). We selected cancer surgeries eligible for display through comprehensive review of the literature addressing the association of hospital volume and mortality. We found eleven cancer sites with sufficient evidence of association including bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach. Experts advised volume calculation and display of results. Leaders of low volume hospitals were interviewed to understand the reasons for low volume. Results: In 2014, about 60% of cancer surgeries in California were performed at hospitals in the top 20% of volume, but many hospitals performed low numbers of complex procedures, with the per hospital median number of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries at 4 or less. Low-volume hospitals included rural and urban hospitals, with small and large bed sizes, and teaching and non-teaching status. At least 670 Californians received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer site; 72% of those patients lived within 50 miles of a top-20% volume hospital. Conclusions: This project demonstrates the potential for public information about hospital volumes to point patients towards high-volume and away from low-volume hospitals. Data regarding 2014 volumes are now available online.
Validation of a real-time patient-reported experience measurement tool for cancer patients in Ontario.
Authors: Moody Lesley , Benn Sarah , Ieraci Luciano , Ingale Saurabh , Singh Simron
Published: February 2017

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Background: Cancer Care Ontario (CCO) organizes and ensures quality cancer care for 16 million residents in Ontario. CCO's goal is to create a tool to enable reporting of the patient experience in real time. The study objective was to develop a validated real-time (close to or at point of care) patient reported experience measurement (PREM) tool to drive quality improvement, advance system planning and ensure cost effective resource allocation based on patients’ needs, wants and preferences in ambulatory oncology treatment phase. Methods: Consisting of 28 questions – 18 core questions; 2 open-ended responses; and 8 demographic questions the tool underwent cognitive testing with patient family advisors and was validated using a pilot at 6 cancer centres from April to August, 2015. It was administered using several delivery modes: tablets, patient portals, post cards and paper. The patient journey in visiting centres was conceptualized as containing the steps or domains of interest: arrival, appointment/consultation and overall experience. To validate the patient experience conceptual model, an exploratory factor analysis was performed and compared to CCO’s 8 domain patient experience model. Reliability and validity of the tool was tested using Cronbach’s alpha and multiple variable regression analysis in partnership with Ipsos Reid. Results: 557 responses (496 electronic and 61 paper) formed the basis of the analysis. The tool was shown to be both valid and reliable - an overall adjusted R2 value of 64% from multiple variable regression on overall patient experience; and an overall Cronbach alpha value of 0.83, respectively. Individual Cronbach alpha values ranged from: 0.69 for “appointment/consultation”, 0.55 for “overall experience” and 0.24 for patient “arrival.” Conclusions: Statistical analysis results were used to produce a final validated tool for deployment to systematically capture PREMs through an electronic system in Ontario, Canada in 2016.To our knowledge this is the first of its kind. Collection of real time PREMS will ensure local and system level planning and quality improvement in the cancer system are rooted in what matters most to patients and their families.