bluuebunny/crossref_metadata_2025 huggingface dataset:
Linking commercial claims and state registry data to assess cancer care quality at the medical group level: Early lessons from California.
Authors: Woo Ann , Foley Kathleen A.
Published: February 2017

269

Background: The Integrated Healthcare Association (IHA) is a non-profit organization which runs the largest Pay for Performance program in California. We describe a feasibility study to apply NQF cancer quality measures to linked commercial claims and state registry data and calculate results at the physician organization level. We describe phase I of the study: identifying appropriate measures and securing access to the data. Methods: We requested technical specifications for 9 NQF breast and colon cancer quality measures from the measure stewards and 2009 –2012 claims data from 7 California health plans. Results: Two barriers were identified in phase I: First, California Cancer Registry (CCR) data policies, designed for public health surveillance and not quality measurement, caused delays and present hurdles to public reporting. CCR data is not available until it is at least 95% complete, so 2011 data was not available until October 2013. Moreover, CCR requires that they conduct the data linkage, which required new data use agreements between the data aggregator and each participating insurer – costly in both time and legal fees. Finally, obstacles to public reporting any of the CCR data at the provider level still exist. Barrier 2: NQF measure specifications for linked claims-registry data sets do not currently exist, so the project team developed them, adding to the problem of proliferating non-harmonized quality measures. Conclusions: While the application of NQF measures to claims-registry linkage appears feasible for measurement of cancer care quality at the medical group level, registry policies and the lack of standard technical specifications for linked claims-registry data sets adversely impact the timeliness, usability, and comparability of results using two widely available data sources. More flexible policies on the part of data registries and attention to measure harmonization could improve data quality and usability for cancer care quality assessment and public reporting, and should be considered. In phase 2, we will apply the measures at the physician group level, and assess the feasibility of public reporting at the physician group level.
Overall survival and complications of cancer therapy in HIV-positive cancer patients on HAART compared to HIV-negative cancer patients.
Authors: Fritz Kelly Ann , Stenehjem David D. , Sanders Stephanie A. , Cohen Adam Louis
Published: February 2017

276

Background: HIV-positive patients are living longer and are at higher risk for any type of cancer, not only traditional AIDS-defining cancers (ADC). This study aims to assess our overall survival rate in HIV-positive cancer patients compared to HIV-negative patients, and identify differences in complications of cancer therapy in order to ensure quality of care and outcomes in this patient population. Methods: HIV-positive patients ≥ 18 years of age with a diagnosis of cancer in the Huntsman Cancer Institute Tumor Registry from 2008-2013 were matched to HIV-negative cancer patients by cancer type, stage, age, and sex. Overall survival (OS), admission for febrile neutropenia (FN), total hospital length (LOS) of stay for any reason, and the total number of blood transfusions were assessed. Kaplan-Meier methodology was used to assess differences in cancer survival. Results: A total of 55 HIV-positive patients and 40 HIV-negative patients were included. HIV-positive patients were younger at cancer diagnosis than HIV-negative patients, 50 vs. 56 years old (p = 0.0017). A trend for reduced median OS in HIV-positive patients was observed compared to HIV-negative patients (HR 1.81; 95% CI 0.77-4.71; p = 0.1835). One-year OS was 78% for HIV-positive vs 88% for HIV-negative patients (p = 0.2673). Numerically an increased mean number of hospital admissions for FN (0.7 ± 2.0 vs. 0.4 ± 1.3; p = 0.2663), transfusions (2.5 ± 12.7 vs. 0.9 ± 2.5; p = 0.4907), and inpatient LOS (12.7 ± 23.6 vs. 7.0 ± 13.0; p = 0.2381) were observed in the HIV-positive group compared to the HIV-negative group, however this did not meet statistical significance. Conclusions: This retrospective study highlights a trend for a reduction in survival and increased FN admissions, LOS and transfusion requirements in HIV-positive patients with cancer. We have identified a need for improvement in supportive care treatments such as primary febrile neutropenia prophylaxis, opportunistic infection prophylaxis, and anemia management to improve the quality of cancer treatment in this patient population.
Proof-of-concept: A working demonstration of real-time patient tracking using time-driven activity-based costing.
Authors: Jones Tiffany M. , Huang Yu-Ting , Guzman Alexis B. , DelValle-Garza Monica , Kolom Christian C. , Incalcaterra James , Feeley Thomas W.
Published: February 2017

28

Background: Historically, hospital costs are based on a cost-to-charge ratio. The current cost system determines when a charge is filed and a bill is created, which can be days following the patient visit. This time lag between the patient visit and the billed charges can be problematic. In preparation for episode-based payments, it is essential to know the true cost of care at the time of delivery. To accomplish this goal, the University of Texas MD Anderson Cancer Center (MDACC) leveraged existing time-driven activity-based costing (TDABC) process maps to track the true costs of the patient care cycle. Methods: The first steps were to understand the patient care cycle through process mapping. Next, data sources were identified to capture patient volumes. Process maps were adjusted to capture the data sources and provide a more accurate cost. Trigger logic models were created to link data sources and the TDABC process maps to the true cost for each patient appointment. Lastly, we developed a SAS software program to compute the real-time TDABC costs for 50 patients in the Head & Neck Center. Results: Our existing data sources capture information relevant to TDABC on a regular basis. Patient appointment data provided the patient visit, and billing and time data provided approximations of the amount of time spent in the encounter and the number of resources involved in the patient visit. Out of 219 process maps, 148 (70%) were matched to existing patient appointment and charge data using the trigger logic. This allowed us to track 4,980 patient appointments for 50 patients in fifteen minutes. Conclusions: As data are collected throughout the institution, it is realized that multiple data sources are needed to reconcile the patient’s experience and to match the TDABC process maps to existing data sources. Since our data sources are updated daily and are based on a patient’s date of service, we can capture our costs of delivering care close to real-time. This process is continually refined as additional data sources are made available and as process maps are developed in other parts of MDACC.
Establishing a system to monitor and evaluate the quality of cancer care in Japan.
Authors: Iwamoto Momoko , Nakamura Fumiaki , Higashi Takahiro
Published: February 2017

287

Background: To ensure equitable access to high-quality cancer care, efforts to routinely measure key performance indicators of cancer policy began in Japan in 2014. Although assessing the quality of cancer care is a vital component of this initiative, a system for evaluating process of care across a large number of hospitals has not yet been established. We aimed to establish this system by creating a database of health claims data linked to hospital-based cancer registry (HBCR) and measuring quality indicators (QIs) for cancer care. Methods: We created a database of 28 months (Sept10-Dec12) of health claims data linked to HBCR for 100,825 breast, prostate, colorectal, stomach, lung, liver, and cervical cancer patients who were newly diagnosed in 2011 from 178 designated cancer care hospitals in Japan. Among 206 QIs that were previously developed by a panel of experts, we measured 13 that were measureable from claims data: 1) seven QIs on adherence to guidelines on adjuvant therapy, 2) four QIs on lab tests, procedures, and medication, and 3) two QIs on supportive care. Results: QIs investigating adherence to clinical guidelines on adjuvant therapy tended to be lower compared to QIs for supportive care. For example, 48.0% [46.4, 49.6] of stage III colorectal cancer patients (n=3,638) received adjuvant chemotherapy (5FU+LV, UFT+LV, Cape, FOLFOX, or CapeOX) within 8 postoperative weeks, whereas 68.1% [67.2, 69.0] of patients (n=10,104) received three-drug combination (5HT3-r antagonist, dexamethasone, and aprepitant) before receiving highly emetogenic chemotherapy. QIs on appropriate testing and procedures were higher overall, such that 83.3% [82.6, 84.0] of invasive breast cancer patients (n=12,447) received HER2 testing. In all QIs, there was large variability in performance across hospitals. Feedback was given to hospitals through interactive webpages. Conclusions: This is the first attempt at measuring the quality of cancer care across such a large number of hospitals in Japan. Our research showed that in all QIs, there was ample room for improvement. Continuous monitoring, improving feedback methods, expansion of QIs, and application of electronic health records, will be our next challenge as we move forward in this initiative.
A decision-analytic model of idelalisib in relapsed or refractory patients with follicular lymphoma in the United States.
Authors: Smith Nathaniel , Xenakis Alexander , Beckerman Rachel , Chhatwal Jagpreet , Gregory Stephanie A. , Briggs Andrew
Published: February 2017

30

Background: There are currently few treatment options for relapsed/refractory (RR) indolent non-Hodgkin’s lymphoma (iNHL) patients. Idelalisib (IDELA) is a first-in class PI3Kδ inhibitor with substantial clinical efficacy in iNHL patients refractory to rituximab and an alkylating agent. A single-arm clinical trial (Study 101-09) showed RR iNHL patients treated with IDELA have a median of 11 and 20.3 months of progression-free and overall survival (PFS and OS), respectively. Efficacy was also demonstrated in patients with iNHL subtypes such as follicular lymphoma (FL). The objective of this study was to project the health outcomes of IDELA versus the current standard of care for US FL patients. Methods: A partitioned survival model simulated a cohort of RR FL patients over 10 year time horizon. Patients first received IDELA or an aggregate comparator of current RR iNHL chemotherapy regimens in a progression-free state before transitioning to a progressive-disease state where they received palliative care until death. Survival data was fit and extrapolated from Study 101-09 (IDELA) for FL patients. A real-world database claims analysis provided survival, disease- and treatment-related adverse event (AEs) profiles, and medical resource utilization data for RR iNHL patients for the comparator. All outcomes were discounted at 3%. Results: Claims data predicted a median of 6.16 and 13.04 months of PFS and OS, respectively, for the comparator. Our model suggests that IDELA treatment improved health outcomes over 10 years versus the comparator, increasing life-months (LMs) and progression-free life-months (PFLMs) by 9.94 and 4.63 mos, respectively. Over 1 year, IDELA reduced both AEs and hospitalisations in FL patients by 40.3% and 49.8%, respectively. Deterministic and probabilistic sensitivity analyses demonstrated the model results are robust across different methods of survival extrapolation. Conclusions: IDELA was projected to improve health outcomes in RR FL patients compared to current treatments, largely driven by improved PFS and OS; short-term reductions in AEs and hospitalisation were specifically related to a delayed disease progression.
Personal history of atypical ductal hyperplasia and risk of multifocal breast cancer among newly diagnosed women: Implications for workup and management.
Authors: Petersen Curtis Lee , Onega Tracy
Published: February 2017

300

Background: Multifocal breast cancer (MFBC) is associated with a higher risk of mortality than unifocal and often changes evaluation and management compared to unifocal breast cancer. Although there are known risk factors for invasive breast cancer, including atypical ductal hyperplasia (ADH), none have been explicitly associated with risk of MFBC. Our objective was to determine if there is an association between ADH and MFBC to help guide clinical decisions in workup and management in women with newly-diagnosed breast cancer. Methods: Using data (1999-2008) from the New Hampshire Mammography Network (NHMN) – a longitudinal breast imaging registry, including pathology data – we identified a cohort of 3,039 women (median age: 59) with a diagnosis of invasive or in situ breast cancer, and ascertained all prior biopsy results if applicable. We performed multivariable logistic regression to test the association of ADH with MFBC v. unifocal, adjusting for other benign breast disease, family history, breast density, age, race, and DCIS/invasive. Results: Of the 3,039 women with breast cancer during the study period, 498 had a diagnosis of ADH (16.4%) and 277 had MFBC (9.1%). Women with a history of ADH had over a two-fold greater likelihood of having MFBC compared to women without an ADH diagnosis (OR: 2.20, 95% CI: 1.61-2.99). No notable difference in this association was noted for DCIS v. invasive, and no other risk factors were found to have a significant difference, except for number of biopsies. Conclusions: We found that ADH diagnosis is positively associated with MFBC among women with a diagnosed invasive or in situ breast cancer. Our results suggest that among women with a newly diagnosed breast cancer, history of an ADH diagnosis increases the pre-test probability of MFBC, which may influence evaluation of extent of disease, such as adding breast MRI, and ultimately in treatment and management.
Evaluation of health care resource utilization (HRU) in real-world patients treated for chronic lymphocytic leukemia (CLL).
Authors: Feinberg Bruce A. , Schenkel Brad , McBride Ali , Ellis Lorie , Radtchenko Janna
Published: February 2017

302

Background: Elucidating healthcare resource utilization (HRU) in real-world clinical practice is essential in understanding the economic burden of a disease. The objective of this study was to evaluate HRU in treated CLL patients. Methods: Using proprietary MORE Registry Research Edition claims, patients treated with antineoplastics for CLL identified by ICD-9 codes during a 48-month period (August 2009-2013) were selected. Patients who were pregnant or <18 years of age, or were treated for secondary malignancies were excluded. Descriptive statistics were used to analyze HRU primarily focused on hospitalizations, office visits, and emergency room (ER) visits. Chi-square tests were used to compare HRU rates by age group (<65 and ≥65); t-tests were used to compare means. Results: Of 2,013 CLL patients, median age was 72 years, 78% were ≥65 years of age, 61% were male, 67% Medicare, and 34% were treated in the relapsed setting. The mean comorbidity index was significantly higher in the ≥65 age group compared to the <65 age group (2.2 vs. 1.3, p<0.001). Overall, 97% of patients had an office visit, 31% had a hospitalization, and 34% had an ER visit. There were no statistically significant differences in HRU between age groups, although rates trended higher in the older group: office visits 97% vs. 96%, hospitalizations 32% vs. 29%, and ER visits 34% vs. 32%. Mean hospital length of stay (LOS) was 5.7 days and trended higher in the ≥65 age group (5.8 vs. 5.4 days), but the difference was not statistically significant. Conclusions: Healthcare resource utilization was considerable among patients treated for chronic lymphocytic leukemia. Approximately one-third of patients were hospitalized, and one-third experienced an emergency room visit. Despite a higher mean comorbidity index in the ≥65 age group, HRU was not significantly higher in the older group. Further evaluation of HRU among CLL patients by line of therapy, age, comorbidity index, and payer type is warranted.
Smarter radiation oncology.
Authors: Potters Louis , Kapur Ajay
Published: February 2017

32

Background: The evolution of radiation oncology (RO) has established granular and detailed CPT codes that define the process of care for patients receiving radiation services. And while each of these codes are legitimately and carefully crafted within the relative value system, they nonetheless serve as surrogates for treatment. As health care moves into a value based future, RO is uniquely situated to offer high-value and affordable cancer care. In addition, ASTRO’s ‘safety is no accident’ and other authoritative articles show a high emphasis of structure, a ‘learning curve’ in process but a dearth of direction on outcomes. A truly integrated practice standard for RO has therefore not yet been realized. Methods: Over the last 5-yrs, based on learning from incidents reported in our department and a risk mitigation study, we have reshaped our practice to be based on three measurable aspects – evidence based and consensus driven care pathways, patient experience and quality. By assimilating the cost perspective into this three-tiered matrix, we believe we have created a model for RO that is predictive of value. We summarize facets of this model that embrace structure, process and outcomes aspects of quality that we believe add most value to the care we provide. Results: The elements of Smarter Radiation Oncology (SRO) were determined to be process mapping, standardization of treatment pathways and toxicity grading, incident reporting, pre-treatment peer review planning contour rounds, our no-fly policy, the Kaizen approach to overhead mitigation, an electronic whiteboard for process co-ordination, survivorship, patient perception of care and the Z-score for measuring operational efficiencies. Conclusions: SRO has shown a sustained and substantial level of improvement in many aspects of the care we provide. And while it is designed to allow for the unencumbered freedom to practice RO, we are often times limited by payers who refuse care based on the artificial and differential aspects of complex therapy. We plan to present how SRO improves value by offering less expensive care that can be used as a foundation for a new episodic payment system based on cost. If adopted, the decision process of therapy becomes agnostic of technology and patient focused.
Cost, value, and policy in quality: Evolving relationship of payers and providers.
Authors: Denny Diane , Keenan Caitlin
Published: February 2017

44

Background: Cancer Treatment Centers of America (CTCA), a network of five hospitals, has multiple pay for performance contracts. Some apply to all hospitals, while others are unique to individual facilities. While many metrics are managed by site, some metrics are collected and measured centrally by corporate. Varying levels of oversight were required from site quality teams, executive teams and externally-facing corporate departments. In order to coordinate these efforts, CTCA implemented a real-time tracking system for monitoring pay for performance metrics. Methods: CTCA’s corporate Quality department designed a central repository for monitoring metrics that is populated monthly using customized workbooks submitted from each site. The central repository compiles monthly data and displays it in several formats broken down by timeframe, site and contract. The repository incorporates features allowing easy sharing and data accuracy. An accompanying process for collecting data was created to ensure timely, efficient updates to the repository. Results: The monthly monitoring process was implemented in January 2014 and continues to operate successfully. For one enterprise-wide contract cycle closing on April 31, CTCA met requirements and outperformed the contract-specified goal for each by an average of 19.8%. Pre-implementation, metrics were monitored quarterly. Although two metrics showed a small (<2.5%) decrease in average performance, given the intensified focus, the remaining metrics showed an average 7.95% improvement in performance during the second six months with monthly monitoring. Metrics associated with the remaining contracts are on track to meet or exceed specified performance standards. Conclusions: The new tool and monthly reporting process successfully monitored pay for performance metrics at CTCA. Most importantly, the system allowed for close to real-time assessment and therefore promoted ongoing intervention if warranted. The repository created a single source of data sharing and visibility for these important elements of performance. As CTCA continues to participate in pay for performance activities, this method will be adapted to accommodate more contracts and metrics.
Improving radiotherapy utilization rates in Ontario.
Authors: Ang Michelle , Gutierrez Eric , Foster Nicoda , Favell Lisa , Warde Padraig Richard
Published: February 2017

48

Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontario’s utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. Methods: CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. Results: Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. Conclusions: The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.
Evaluating the implementation of computerized prescriber order entry (CPOE) for systemic treatment (ST) in Ontario.
Authors: Gradin Sharon , Wolf Nancy , Yurcan Marta , Yardley Tim , Kaizer Leonard , Kukreti Vishal
Published: February 2017

54

Background: A successful effort was led in Ontario to increase ST CPOE adoption from 73% to 92% to support safety of patients receiving complex systemic treatment. This work included implementation at 19 hospitals from 2011-2013. The implementation process included identification of multidisciplinary team champions, baseline workflow analysis and development of a future desired state. Findings from this project’s benefits evaluation are presented. Methods: Each hospital was required to collect pre and post implementation measurements for medication errors, transcription errors and order clarity/completeness. Six months post implementation, a semi-structured telephone interview was conducted with representative hospitals (9/19) to obtain qualitative feedback on how implementation impacted workflow, inter-professional practice and workload. Results: Hospitals that implemented showed: 1) decrease in overall medication error rates. 2) decrease in transcription error rates and 3) decrease in number of unclear or incomplete orders. Qualitative feedback from hospital leads indicated that the “future desired” workflow was achieved by all. Most hospital respondents indicated that clarity of inter-professional communication regarding orders improved and in most cases overall workload did not increase. Conclusions: The findings reinforce the benefit associated with implementation of ST CPOE in outpatient settings. Lessons learned in Ontario can be leveraged to support successful implementation of ST CPOE in other jurisdictions. Critical implementation success factors included: 1) leadership and multi-disciplinary involvement; 2) provision of funding and cost sharing; 3) facilitation of process improvement through established methodologies, 4) knowledge transfer and peer group led education and training sessions. [Table: see text]
Does hospital academic status impact colon cancer care value?
Authors: Veenstra Christine Marie , Epstein Andrew J , Pollack Craig Evan , Armstrong Katrina
Published: February 2017

6

Background: Given the high cost of cancer care, delivery of high-value care is crucial. The effect of hospital academic status on value of care for patients with stage II and III colon cancer is unknown. Methods: SEER-Medicare cohort study of 20,118 patients age 66+ with stage II or III colon cancer diagnosed 2000-2005 and followed through December 31, 2007. Patients were assigned to a treating hospital based on hospital affiliation of the primary oncologist. We constructed Kaplan-Meier curves to assess unadjusted overall survival. We estimated a Cox proportional hazards model to assess adjusted overall survival. To examine associations between hospital academic status and mean cost of care we estimated a generalized linear model (GLM) with log link and gamma family. We estimated quantile regression models to examine associations between hospital teaching status and cost at various quantiles (25th, 50th, 75th, 90th, 95th, 99th, 99.5th, 99.9th). Standard errors were adjusted to account for clustering of patients within hospitals. Results: 4449/20,118 (22%) patients received care from providers affiliated with academic hospitals. There was no significant difference in unadjusted median survival based on hospital academic status for patients with stage II (academic 6.4 yrs vs. non-academic 6.3 yrs, p=0.711) or stage III disease (academic 4.2 yrs vs. non-academic 4.2 yrs, p=0.81). After adjustment, treatment at academic hospitals was not associated with significantly reduced risk of death from colon cancer (stage II HR 1.05, 95% CI: 0.97 - 1.13; p=0.23; stage III HR 0.99, 95% CI: 0.94-1.07; p=0.98). Excepting stage III patients at the 99.9th percentile of costs, there were no significant differences in adjusted costs between academic and non-academic hospitals. Conclusions: We find no difference in overall survival for patients with stage II or stage III colon cancer based on academic status of the treating hospital. Furthermore, costs of care are similar between academic and non-academic hospitals across virtually the full range of the cost distribution. Most colon cancer patients do not receive cancer care at academic hospitals. Our findings indicate that for patients with stage II or III disease, this inequity does not impact the value of care.
Reducing colorectal cancer mortality: The e-Autopsy tool.
Authors: Schottinger Joanne E. , Brasfield Farah , DiFronzo Andrew , Lau Helen , Litman Kerry C. , Schwartz Gary Edward , Kanter Michael H.
Published: February 2017

60

Background: Colorectal cancer (CRC) remains the second leading cause of cancer death in the US, despite the availability of highly effective screening and treatment modalities. Kaiser Permanente Southern California is a non profit integrated health care organization that serves 3.7 million socio-economically diverse members. Our region has developed a goal to reduce colorectal cancer mortality by 50% in the next decade, from our baseline measurement of 13.8 deaths/100,00 members to 6.9 deaths/100,000 members. Methods: A literature search was conducted by the evidence based services unit to identify interventions demonstrated in published literature to reduce CRC mortality. These interventions were used to develop a spread sheet to guide the e-Autopsy, an electronic medical records review of 50 cases of recent death with CRC that was conducted by a multi-specialty group of reviewers: physicians in primary care, medical and surgical oncology, and pathology. Records of patients who died were compared to the best practices identified in the literature review to measure how often care was not matching the best practices. Review and comments were tallied by a quality nurse and reviewed by a multi-disciplinary steering group. Results: Electronic record review revealed multiple areas of opportunity for focus: Improve screening rates; Reduce diagnostic errors in evaluation of anemia/abdominal complaints; Improve care co-ordination to reduce time to surgery and chemotherapy administration; Evaluate metastatic disease for resection; Improve rates of delivery of adjuvant chemotherapy; Engage patients in lifestyle modifications. Ongoing system wide metrics and a dashboard have been developed to monitor progress in each of these areas. The relevant chiefs of service groups have developed goals and work plans to improve these metrics, which are also monitored by a central quality steering committee. Conclusions: Electronic medical record "autopsy" review of deaths in the system can be used to find and demonstrate multiple areas of focus for quality improvement projects that will help support the ultimate big region wide goal of halving the deaths from colorectal cancer.
Feasibility testing of ecomapping in neuro-oncology caregivers to identify social support networks.
Authors: Warner Echo L. , Parnell Kathrine , Cohen Adam Louis , Colman Howard , Reblin Maija
Published: February 2017

66

Background: The role of family caregivers (FCGs) is expanding in the U.S. health care system, but caregiver burden may adversely affect health. A functional social network of friends, family, and other acquaintances may alleviate FCG burden and improve FCG health by providing support resources. Ecomaps are visualizations that are created to organize and depict information on the size, quality and function of a person’s social network; and, thus, may be a useful tool for highlighting existing support and identifying where additional support is needed. Our objective was to test the feasibility of ecomapping to identify support networks within a sample of neuro-oncology caregivers. Methods: Participants included 4 spouse caregivers of neuro-oncology patients undergoing treatment at a national cancer hospital. Semi-structured interviews were conducted in person (n=3) and by phone (n=1). Participants either completed or were sent example ecomaps and, using the “think-aloud” approach, were asked to describe their social network. Participants were also asked about the process and usefulness of the ecomap. Interviews were recorded and transcribed and then content analyzed by two members of the research team. Results: All participants were female, mean age 35.5 (SD=5.5) years, caring for husbands whose mean age was 38.2 (SD=7.4) years. The mean length of relationship was 13 years (SD=2.2). All participants found ecomapping to be feasible, acceptable, and useful for identifying sources and types of social support. Network structure and sources of support varied by participant but consistently included religious networks and family. Quality and types of support also varied; each participant identified strengths and weaknesses within their networks. Participants were in favor of using ecomaps to explore their support networks with providers in a clinical setting and desired clinical guidance on developing and interpreting their ecomap. Conclusions: Despite a small sample, this pilot shows evidence for the feasibility and utility of ecomapping. This cost-effective tool could be more widely implemented to identify and harness existing social support and improve neuro-oncology caregiver quality of life.
Using the experience-based design (EBD) approach to strengthen patients’ impact.
Authors: Moody Lesley , Bak Kate , Singh Simron , Macdougall Laura , Green Esther
Published: February 2017

69

Background: The Experience Based Design (EBD) approach uses patient and clinician experiences to identify opportunities for improvement in the healthcare system. The EBD approach elicits subjective and personal patient, carer, and staff experiences at crucial points in the care pathway by encouraging them to share their stories. Methods: Cancer Care Ontario (CCO), an agency that oversees cancer services in Ontario, held an EBD workshop with the objectives of capacity building and facilitating healthcare improvements throughout the province. 110 participants (27 teams) from across Ontario attended the workshop to engage participants to take an active role in developing actionable plans to address patient experience issues. An evaluation following two years of EBD was necessary to: (a) determine EBD progress and effectiveness; (b) identify successes/challenges for getting projects off the ground; and (c) identify additional resources required to spread EBD across Ontario. The evaluation consisted of: 1) two province-wide electronic surveys (long survey for those directly involved in EBD projects; short survey for frontline staff) and 2) semi-structured phone interviews with patients/caregivers. Results: Some EBD projects have completed multiple initiatives; others are just beginning. Projects address process improvement (e.g., streamlining patient bookings), resource/tool development (e.g., symptom screening tools) and establishing patient advisory boards and committees. Five (28%) survey respondents said that EBD projects elicited implementation of 6 to 10 changes and 6 (38%) respondents indicated that: (1) respect for patient preferences and (2) communication, information and education were two principles of Person-Centred Care (PCC) that improved the most. Conclusions: Future steps include development of a collaborative website, a symposium to showcase projects, an evaluation of the EBD initiative and peer-reviewed publication.
Canadian cancer site-specific health utility values: Creating the basis for measuring value and costs of therapy.
Authors: Naik Hiten , Howell Doris , Qiu Xin , Brown Catherine , Vennettilli Ashlee , Irwin Margaret , Pat Vivien , Solomon Hannah , Wang Tian , Hon Henrique , Eng Lawson , Mahler Mary , Tiessen Kyoko , Thai Henry , Ho Valerie , Pringle Dan , Xu Wei , Seung Soo Jin , Mittmann Nicole , Liu Geoffrey
Published: February 2017

7

Background: Health utility values (HUVs) play an integral role when conducting health economic analyses, but a paucity of reference HUVs exists for cancer patients. Using EQ-5D, we generated reference HUVs for multiple malignancies. We further assessed patient willingness to compete the instrument on a regular basis by adding the EQ-5D to an Ontario-wide patient-reported symptom tool mandated by Cancer Care Ontario, the provincial cancer government agency. Methods: 1,831 cancer patients across all non-CNS solid and hematologic cancer sites at the Princess Margaret Cancer Centre completed the EQ-5D instrument; a subset (n=618) were asked about the acceptability of regularly completing the EQ-5D. HUVs were calculated using Canadian valuations. Results: The mean±SD HUV for all patients was 0.81±0.15, but were significantly different across different disease sites (p<0.0001): Testicular cancer, 0.87±0.13; prostate, 0.87±0.15; colorectal, 0.83±0.12; head/neck, 0.82±0.15; lymphoma, 0.82±0.15; breast, 0.81±0.17; esophageal, 0.81±0.16; ovarian, 0.79±0.15; leukemia, 0.78±0.15; lung, 0.78±0.13 and myeloma, 0.77±0.14. Confirming the validity of these HUVs, patients with PRO-ECOG scores of 0, 1, 2 and 3 had HUVs of 0.90±0.14, 0.77±0.11, 0.65±0.14 and 0.59±0.19, respectively (p<0.0001). In patients with solid tumors, those with local disease had HUVs of 0.82±0.15; metastatic disease, 0.80±0.15; p=0.015. 88% of patients reported that the EQ-5D was easy to complete, 92% took less than 5 minutes, 89% were satisfied with its length and 86% were satisfied with the types of questions asked. Importantly, 92% reported that they would complete the EQ-5D, even if it was used solely for research purposes and 73% agreed with the notion of completing it regularly at their clinic visits. Conclusions: We present the first Canadian reference dataset of HUVs for common cancers; stage-and site-specific reference values will be presented at the meeting. Mean HUVs varied by disease site, performance status, and disease severity. Furthermore, a majority of patients surveyed were willing to complete the EQ-5D on a regular basis, suggesting that routine administration is feasible across Ontario.
Understanding the interaction between physicians and pharmacists as a method of quality improvement.
Authors: Fontaine Calder Jessica Lynn , Choy Vivian , Kwan Denise , Li Sophia , Lo Melissa , Kukreti Vishal
Published: February 2017

90

Background: Pharmacists and pharmacy technicians are essential to safe medication delivery. Filling prescriptions can be time consuming when the prescription is not complete or clear and requires inter-professional communication. To improve the quality and efficiency of dispensing medication we performed an audit of callbacks to physicians in the outpatient pharmacy associated with our cancer center with a focus on oral chemotherapy. Methods: The Princess Margaret is one of the largest cancer centers in the world, with an outpatient pharmacy on the premises that fills over 70,000 prescriptions a year. The pharmacists have access to the hospital’s Health Information System and chemotherapy prescribing system. A Prescription Audit Form was developed to track the mode of oral chemotherapy prescription (handwritten, preprinted, computerized physician order entry (CPOE), verbal) and reason for callback. The form was implemented from February 10th until March 7th, 2014 with coded data collection. The form was incorporated into the normal workflow of the outpatient pharmacy and concurrently used to document pharmacy interactions for billing purposes. Results: A total of 5,546 prescriptions were filled with 1,166 prescriptions for oral chemotherapy. Nine percent of prescriptions for oral chemotherapy required a callback to a physician and accounted for 32% of the total callbacks made to physicians. Of the 1,166 oral chemotherapy prescriptions; 39% were refills, 34% were handwritten, 22% were CPOE, 4% were verbal, 1% were preprinted, and 1% were not documented. The top two reasons for callbacks were; drug interaction (32%) and incorrect dose (24%). In the 9% of cases where the physician was contacted to clarify a prescription, the prescription was changed 43% of the time. Conclusions: Understanding the reasons for callbacks can be used to determine optimal data fields required in oral chemotherapy prescribing. Ensuring that prescriptions are appropriately completed will reduce the number of callbacks to physicians - significantly impacting the workflow and efficiency of the pharmacy. Reducing unnecessary callbacks will allow the pharmacy team to deliver timely, safe and effective patient centered care.
Determinants for the decision of chemotherapy in advanced cancer patients.
Authors: Velter Charles , de-La-Menardiere Helene , Goldwasser Francois
Published: February 2017

110

Background: Chemotherapy is often prescribed in order not to despair a patient in an advanced stage of cancer, while the physician identifies an unfavorable benefit/risk ratio. The use of chemotherapy in terminally ill cancer patients in the last months of life is associated with an increased risk of aggressive care (Wright A et al. BMJ; 348:g1219 doi: 10, 2014). We previously showed that multidisciplinary meetings with palliative specialists reduce futility (Colombet I et al. BMJ Support Palliat Care; 2(3):239-47, 2012). We studied the parameters leading to inappropriate palliative chemotherapy in France: How oncologists face to unrealistic expectations and what is the process for the decision-making leading to chemotherapy beyond evidence-based medicine? Methods: The study was conducted in April 2014 in Paris, France. We designed a Multiple Choice Questionnaire. The first part described a clinical situation of a patient with advanced pancreatic cancer with evidence-based factors for not doing chemotherapy. The second part included questions regarding the behavior of the oncologist. Results: We included 62 oncologists. While 58 oncologists (94%) considered beneficial to include palliative medicine specialists, 44 (71%) chose to prescribe cytotoxic chemotherapy. In the decision-making process, 49 oncologists (79%) gave more weight to the demand of the patients than to the benefit/risk ratio. The validated scores for the evaluation of life-expectancy in this setting were not known in 19 cases (31%). In advanced disease, 42 oncologists (68%) acknowledged to decide without multidisciplinary staff meeting. Conclusions: The decision-making in advanced disease tended to be solitary. Cytotoxic chemotherapy appears as a common answer to unrealistic expectations. Multidisciplinary meetings with palliative medicine specialists are recommended to improve end-of-life decisions.
Pilot study to evaluate a novel advance-care planning tool to identify informed health care proxies in an oncology palliative care clinic.
Authors: Roeland Eric , Benn Melanie , Heavey Sean , Campillo Ashleigh , Revta Carolyn , Atayee Rabia S. , Ma Joseph D.
Published: February 2017

136

Background: To increase the probability that cancer patients receive care consistent with their wishes, medical providers require simple, practical, and effective communication tools to initiate and complete meaningful advance care planning (ACP) discussions. Ideally, ACP discussions occur in the non-emergent setting with a selected health care proxy and trusted medical provider and may lead to completion of an advance directive (AD). The primary aim of this study is to determine the proportion of advanced cancer patients who identify an informed health care proxy implementing a novel ACP tool. Methods: In an American Cancer Society funded pilot study, advanced cancer patients were evaluated in an academic oncology palliative care clinic (n=35). Subjects engaged in a 1-hour ACP intervention completed by a licensed clinical social worker utilizing a novel ACP tool developed by the investigators. The ACP tool identifies a health care proxy and defines three key elements an informed health care proxy must know. Details of this ACP conversation were documented in the electronic medical record with the goal of completing an AD. After subject’s death, health care proxies were contacted to determine if end-of-life wishes were honored. Results: 35 subjects (51% woman, 71% Caucasian, 54% married) were enrolled with a mean age ± SD of 57.4 ± 14.1 years with gastrointestinal as the most common primary cancer (13/35). The ACP intervention was completed in 80% in 1-2 clinic visits. After the ACP intervention, 94% of subjects (33/35) identified an informed health care proxy. The most common identified health care proxies were either a spouse (17/35) or child (11/35). 43% of subjects (15/35) completed an AD after the ACP intervention. As of July 2014, 69% (24/35) of subjects had died and 71% of these (17/24) died in a setting consistent with their end-of-life wishes. Mean time to death from ACP intervention was 4.5 ± 3.2 months. 11 subjects remain in surveillance. Conclusions: Results suggest that this novel ACP tool facilitates successful identification of an informed health care proxy. Despite low AD completion, death consistent with end-of-life wishes was achieved in the majority of patients.
Structured advanced care planning facilitated by case managers.
Authors: Rackow Eric , Rodkey Wendy , Morrison Jackie
Published: February 2017

142

Background: Although advanced care planning facilitates end-of-life decisions, less than half of severely or terminally ill patients have completed an advanced care plan. Accordingly, Humana launched a pilot of care manager-facilitated structured advanced care planning discussions among individuals with complex chronic conditions, including cancer. Process metrics were reviewed to determine whether the pilot would be scalable to a larger population. Methods: The pilot included two groups, 1) high-severity patients who had been receiving long term in-home care management for ≥30 days with a high comorbidity burden, and 2) functionally-challenged patients who had been receiving telephonic care management for ≥30 days and had a moderate comorbidity burden. Twenty care managers participated in 2 live and 9 virtual training sessions on the structured discussion approach. Care managers documented the following process metrics: number and length of structured advanced care planning discussions, number of advanced directives completed or updated, and number of times hospice services were reviewed. Results: Among the 169 high-severity patients in home settings, structured discussions occurred with 54.4% of the population, and 20.1% either updated or completed an advanced directive. Among the 106 functionally challenged patients receiving telephonic care management, 37.7% had structured discussions, and 13.2% either updated or completed an advanced directive. Hospice services were reviewed with 23.6% of the high-severity patients, and 3.7% of the functionally-challenged patients. The amount of time spent by the care managers was longer for the home consultations (average=15.1 minutes) compared to the telephonic consultations (average=10.24 minutes). Conclusions: In this pilot, a higher percentage of advanced care discussions were completed with high-severity patients receiving home care management than functionally-challenged patients receiving telephonic care management. The differences could be attributed many variables, including the health state or setting. This pilot was determined not to be scalable to a broader population, and alternative approaches for advanced care planning currently being evaluated.