bluuebunny/crossref_metadata_2025 huggingface dataset:
Contralateral prophylactic mastectomy decision-making in the population-based iCanCare study of early-stage breast cancer patients.
Authors: Jagsi Reshma , Hawley Sarah T. , Griffith Kent A. , Janz Nancy K. , Kurian Allison W. , Ward Kevin C. , Hamilton Ann S. , Katz Steven J. , Morrow Monica
Published: February 2017

177

Background: Contralateral prophylactic mastectomy (CPM) use is increasing in women who are not at increased risk of contralateral cancer development and will experience no survival benefit from the more morbid procedure. Little is known about treatment decision-making or provider interactions. Methods: We surveyed a weighted random sample of newly diagnosed patients with early-stage breast cancer who were treated in 2013-14, identified through the population-based SEER registries of Los Angeles and Georgia about 3 months after surgical treatment, and merged with SEER data (N=2632, RR=70%), to determine receipt of diagnostic tests and factors related to the decision about surgery (including knowledge and perceived physician recommendation). Results: Nearly half of 2,436 respondents with unilateral non-metastatic cancer considered CPM (25% strongly). Only 37% of those who considered CPM knew that it does not improve survival for all women with breast cancer (24% believed it does, 39% didn’t know). Among women receiving CPM, 37% believed it generally improves survival. Ultimately, 1,464 (60%) received BCS and 972 (40%) mastectomy (of whom 438, or 18% overall, received CPM). On multivariable analysis, pts who received CPM were younger, more likely to be white, and more likely to have a family history, private rather than Medicaid insurance, and received MRI. Even among pts without a deleterious genetic mutation or family history in multiple relatives (2,303), 400 (17%) received CPM. CPM was uncommon among pts who reported that their surgeons recommended against it (2.0% [17/832]) but much higher among those who reported no surgeon recommendation regarding CPM (21.3% [229/1,077]), and among those who perceived their surgeons to have recommended it (55.4% [147/265]). Conclusions: Many patients consider CPM, but knowledge is low. Use of CPM is substantial among patients without clinical indications but is low when patients report their surgeon recommended against it. In the context of shared decision-making, surgeon recommendations against CPM might help reduce potential overtreatment.
Patient and oncologist discussions of treatment costs.
Authors: Hamel Lauren M. , Eggly Susan , Penner Louis , Chapman Robert , Klamerus Justin Frank Antoni , Albrecht Terrance Lynn
Published: February 2017

178

Background: Financial toxicity–the burden of treatment costs and its impact on well-being, treatment decisions, and outcomes—affects many cancer patients, especially racial minorities. Discussing cost during clinic visits may ease financial toxicity, but oncologists are often hesitant to discuss cost. A better understanding of cost discussions is needed to improve care and inform oncologist training interventions. We conducted an observational study of patient-oncologist treatment cost discussions during clinic visits. Methods: Data were video-recorded clinic visits of African American patients (114) and their medical oncologists (19) meeting for the first time to discuss treatment. Cost discussions were any verbal expression of a direct (paying for scans) or indirect (time off work) expense to the patient for treatment. Trained coders observed the videos and coded for presence, duration, initiation, topic, oncologist response, and patient reaction of cost discussions. Results: Cost discussions occurred in 44% (n = 50) of the visits with a range of 1-6 per visit for a total of 93 discussions (M = 35 seconds; SD = 28). Patients initiated (61%) more than oncologists (38%), and patients were more likely to initiate multiple times. Time off work was discussed most (48%), followed by insurance (26%), transportation (12%), paying for treatment (8%), and job loss (4%). Time off work was the most commonly patient initiated topic and insurance was the most commonly oncologist initiated topic. Oncologists typically addressed the issue (72%), and patients often reacted positively (81%) but passively. A few times (9%) the oncologist acknowledged the patient’s initiation but did not address it. Negative patient reactions were rare and only occurred when the oncologist responded to a patient initiation (5%). Younger patients were more likely discuss cost than older patients (p = .02) and retired patients were less likely to discuss cost (p = .05). Conclusions: Findings suggest discussing indirect cost is important to patients, but oncologists infrequently initiate and do not always respond adequately when patients initiate. Further research and interventions are needed to address patient-oncologist cost discussions and the economic impact of cancer treatment.
A schematic case episode format to aid in “Choosing Wisely."
Authors: Hoverman J. Russell , Mann B. Brooke , Hayes Jad , Wilfong Lalan S. , Neubauer Marcus A.
Published: February 2017

181

Background: The recommendations of the Choosing Wisely campaign are evidence –based strategies to reduce cost without sacrificing outcomes. Yet tying the recommendations to indicators of use at the physician and case level has been challenging. As practices become responsible for total cost of care, an easy to use analytic method to determine appropriate use will be critical. We here describe a tool for rapid assessment of individual cases to achieve that objective. Methods: The population was a payer defined cohort of lung cancer patients treated at Texas Oncology (TxO). TxO maintains a payer patient list, updated daily with demographics and diagnosis details for all enrolled patients. The list of lung cancer patients was cross-referenced against billing data from TxO's financial data warehouse (FDW). The FDW data is generated monthly, based on billing details from TxO's practice management system, and includes procedure codes and dates of service. Radiation therapy, chemotherapy, and GCSF administrations for each enrolled lung cancer patient were identified in the FDW data based on CPT codes. SAS software (version 9.4 for Windows) was used to generate a time series plot for each patient, based on date of service for each procedure. The time series plots were inserted into an Excel report template, along with general patient information, using a Visual Basic script, for review by TxO's medical director and quality committees. Results: Each patient-specific time series schematic displays elapsed weeks on the x-axis, beginning with week 1 to end of treatment. Three variables are displayed on the y-axis, using distinct colors and symbols: dates of radiation therapy (orange #), dates of GCSF administration (red x), and dates of chemotherapy administration (green ^). Each of the three y-axis variables is assigned a constant value that is plotted along a straight line. A graphic representation for a patient with stage III lung cancer could look as shown in the Table. Conclusions: Treatment episodes can be distilled into a meaningful format that allows rapid case review and the opportunity for continuous learning. Additional diseases and graphics will be available for presentation. [Table: see text]
An interactive video-based approach to diet education for patients posthematopoietic stem cell transplantation.
Authors: Close Sara , Emmert Amy , Soiffer Robert , Alyea Edwin , Antin Joseph Harry , Glotzbecker Brett
Published: February 2017

183

Background: Hematopoietic stem cell transplantation (HCT) is a complex process in which patient education is increasingly recognized as a critical element to enhance patient preparedness and survivorship. Diet-related education to prevent infectious complications is an essential part of HCT care. Current teaching methods include one-on-one clinician/patient discussion supported with printed materials. Video based teaching may strengthen the learning process of patients and their caregivers. The audio and interactive components may be particularly useful in older patients as sensory ability declines with age. Methods: Focus group methodology was utilized. Four groups of patients, nurses, physicians, pharmacists and dietitians were asked semi-structured questions to allow for collection of systematic data. Multiple rounds of content analysis were used to eliminate duplicates and identify common themes. An interactive video based on items identified and institutional protocols was developed. After refinement of both content and usability, the video was presented to 10 patients and their caregivers admitted to the hospital for HCT. They were instructed on its use and given unlimited time to view it. A survey was conducted by a member of the HCT team to collect feedback regarding length and content of the program. Results: All patients felt the program was a helpful supplement to the written materials. They also felt that the content was consistent and the program was easy to use. Two patients said the video was long, though commented positively on how comprehensive it was. One patient preferred printed materials to have during food preparation. All patients requested that the video be available to view after discharge. Conclusions: Feedback from a multidisciplinary team was instrumental in the development of an interactive tool reviewing post-HCT nutrition guidelines. Feedback from an initial cohort of patients has been positive in regards to usability and knowledge gained. This video will enhance patient and caregiver education and allow them the ability to take an active role in their HCT care. Next steps include a more formal evaluation of clinical outcomes related to this method of learning.
Changing physician compensation and implementing new technology to enhance pathways compliance.
Authors: Wilfong Lalan S. , Hoverman John Russell , Gosse Nate , Neubauer Marcus A. , Torres Vanessa
Published: February 2017

187

Background: Pathways have shown to decrease cost of care while maintaining efficacy of treatment. In 2005, The US Oncology Network, which includes Texas Oncology, P.A. (TOPA) developed physician-led clinical pathways based on national guidelines, cost and efficacy. This abstract reviews the impact of changes TOPA initiated to improve pathway compliance Methods: Since 2011, TOPA has assessed pathways compliance using the iKnowMed (iKM) electronic medical record. Individual compliance was reported to each physician, but no incentives were tied to this. In 2015, the TOPA annual productivity bonus structure (2% of compensation) was changed to introduce pathways compliance and exception documentation thresholds, with penalties for sub-threshold performance. Additionally, TOPA sought to improve on iKM-based data collection and assessment. Previously, there were data challenges with pathways assessed retrospectively, offering limited visibility at the time of decision-making. In September 2015, new technology (Clear Value Plus – CVP) was embedded within iKM, which allowed prospective pathways assessment and provided real-time compliance reporting. Results: Introduction of individual incentives and improved decision support increased pathways compliance. For the initial yearly bonus measurement period, TOPA pathways compliance was 78%. After implementation of the new bonus structure, compliance increased significantly to 83% (p<0.0001). Implementation of CVP further improved pathway compliance for comparable reporting periods from 78% in September 2014 to 90% in September of 2015 (p<0.0001) Conclusions: We have shown that even a small change in compensation significantly influences physician pathways compliance. Additionally, technology to assist physicians with documentation and real-time assessment also significantly improves pathway compliance. [Table: see text] [Table: see text]
Cancer communication in the social media age: Could Twitter help clinical trial accrual?
Authors: Sedrak Mina Samir , Cohen Roger B. , Merchant Raina M. , Schapira Marilyn M.
Published: February 2017

194

Background: Twitter, a social networking site, is transforming communication. Effective use of Twitter might be one way to communicate with the public about cancer clinical trials and increase awareness and perhaps enrollment. We conducted a content analysis of tweets about lung cancer, describing dialogues specific to lung cancer clinical trials and seeing where embedded-links in tweets about therapeutic trials are leading the public. Methods: We used the Twitter search engine to identify a cohort of 26,059 tweets with the keyword “lung cancer” from January 5 - 21, 2015. Tweets were captured and prepared using Nvivo qualitative data analysis software. Duplicate and non-English tweets were excluded. Of the remaining 15,346 unique tweets, 1,516 (10%) were randomly selected for detailed content analysis (kappa = 0.71). Tweets related to clinical trials underwent further analysis to categorize the trial type and embedded-links. University of Pennsylvania IRB exempted this study from review. Results: Most, 83% (1,260/1,516) of tweets in our sample contained lung cancer-specific content and 17% (256/1,516) were categorized as miscellaneous (e.g., extraneous content, non-sequiturs). Table 1 shows the distribution of content categories of lung cancer related tweets by frequency. Most of the tweets focused on support or prevention. Among the lung cancer related tweets, 18% (221/1,260) related to clinical trials. Of clinical trial tweets, 83% (183/221) concerned therapeutic trials, 13% (28/221) non-therapeutic, and 4% (10/221) basic research. Among the therapeutic clinical trial tweets, 79% (144/183) concerned immunotherapy and 86% (158/183) had embedded-links directing users to news articles. Only 1 tweet linked to a patient recruitment website. Conclusions: A significant proportion of lung cancer tweets are about clinical trials, but virtually none direct patients to enrollment sites. Twitter is a new communication medium for the cancer community, and further research is needed to test its potential to promote clinical trial accrual. [Table: see text]
Assessing the quality of chemotherapy in an episode-based funding model in Ontario.
Authors: Kaizer Leonard , Simanovski Vicky , Tariq Huma , Lalonde Carlin , Blais Irene , Evans William K.
Published: February 2017

1

Background: On April 1, 2014, the delivery of systemic treatment in Ontario transitioned to an episode-based funding model, which provides bundled payments for a full course of therapy delivered with adjuvant/curative intent and a monthly bundled payment for palliative intent. Disease Site Teams have defined treatment options and “best practice” for each funded adjuvant/curative regimen. Methods: The utilization of treatment according to disease and intent was analyzed for 35 systemic treatment facilities in Ontario, comparing actual practice (AP) with “best practice” (BP) (dose/schedule/cycle number), for common adjuvant/curative regimens. Variation in the choice of chemotherapy regimen was also reviewed. Results: Cases were included if they started a new course of adjuvant/curative therapy after January 1, 2014, and completed their treatment before July 31, 2015 (17,341 cases). For all disease sites and facilities, AP was equal to BP in 34.6% of cases, AP < BP in 57.5%, and AP > BP in 7.8% (Table). There was significant variation by disease site and facility. As a specific example, 1,368 courses of adjuvant mFOLFOX were completed for colorectal cancer: AP = BP (12 cycles) in 34% (range 7-70%), AP < BP in 66% (range 30-93%), and AP > BP in 1% (range 0-4%). Variation in choice of adjuvant regimen for breast cancer was also observed. Provincially, 21.5% of patients received non-anthracycline containing therapy, but the range in the 20 largest volume centers was 0% to 39.8%. Conclusions: With the administration of potentially curative therapy, it might be assumed that BP would be administered in the majority of cases. However, initial results demonstrate significant variation in practice in an episode based funding model. There is a need to understand the reasons for this variation and to identify potential opportunities to drive efficiency and to increase standardization by engaging clinical experts and practitioners. [Table: see text]
Patient activation measures, distress levels, and causes of distress in chronic lymphocytic leukemia.
Authors: Halilova Karina I. , Van Laar Emily , Borate Uma , Jackson Bradford E. , Pisu Maria , Peters Pamela M. , Butler Thomas Wayne , Davis Randall S. , Mehta Amitkumar , Acemgil Aras , Knight Sara J. , Safford Monika M. , Rocque Gabrielle Betty
Published: February 2017

201

Background: Patients with chronic lymphocytic leukemia (CLL) reporting high levels of distress due to knowledge gaps and emotional concerns can have negative outcomes and suffer from lower quality of life. Understanding patients’ activation levels, causes of distress, knowledge gaps, and psychosocial needs are crucial in high quality care. Optimally activated, educated and empowered patients are better positioned to communicate effectively with providers regarding selection of, and adherence to, CLL treatment protocols and long-term care plans, and potentially improving quality of life. Methods: We recruited 44 adults with CLL from the University of Alabama at Birmingham Health System Cancer Community Network from April to July of 2015 as part of an educational and quality improvement initiative. Patient-reported distress assessments were collected to evaluate distress levels and causes of distress. The Patient Activation Measure (PAM 13) was used to evaluate patient activation (1-4 scale with 4 maximally activated). Results: The median participant age was 69 years old (range 50-89 years). Thirty percent had completed ≤ 12 years of education, 20% had some college education. Thirty-nine percent were on active treatment, 59% were in observation; 2% were uncertain of treatment. Fifty seven percent of participants were maximally activated (level 4); 11% had an activation level of 3; 20% had a level of 2; and 11% had the lowest level of activation (level 1). Twenty-five percent reported moderate distress (≥ 4) and 5% reported severe distress (≥ 8); 34% reported distress due to psychosocial concerns and 25% due to knowledge gaps. Conclusions: This project demonstrates a need to improve patient activation levels and minimize patient distress related to knowledge gaps and psychosocial concerns related to CLL. Well-designed, easily accessible educational interventions and multi-level quality improvement programs may be helpful in improving patient engagement by providing necessary knowledge to improve patient-provider communication and optimize patient outcomes.
End-of-life care for glioblastoma multiforme patients at an academic institution.
Authors: Kuchinad Kamini , Strowd Roy E , Evans Anne , Knight Louise , Riley W. Anthony , Smith Thomas J.
Published: February 2017

202

Background: End of life care for glioblastoma patients has not been studied in the United States. We studied 100 patients with GBM to examine use of advance directives (AD), symptom assessments, hospitalizations, chemotherapy use, and hospice use. Methods: A single center retrospective cohort study of adult patients actively treated for GBM at Johns Hopkins Hospital from 2009-2014. 100 patients were randomly chosen from the group of 317 GBM patients. Information included documentation of AD, code status, hospitalizations, chemotherapy use, code status and symptom assessments. A secondary analysis of all JHH GBM patients who received hospice care at Gilchrist Hospice during this time period was analyzed using the electronic medical record and hospice records to evaluate date of referral to hospice, length of stay in hospice and location of death. Results: Of 100 patients, 76 were referred to hospice. Only 40% of individuals had documentation of code status and only 17% had any documentation of ADs in the outpatient chart. Formal symptom, spiritual, or psychosocial assessments were seldom documented in the outpatient record. Only 17% used chemotherapy in their last month of life. 37% were hospitalized in the last month of life for an average of 9 days. Of the Gilchrist Hospice patients, the median length of stay in hospice was 21 days and 64% of these patients died in their residence with hospice services. Conclusions: More formalized palliative care utilization and structure could improve end of life care for GBM patients, especially in the use of ADs; formal symptom, spiritual, and psychosocial assessments; and earlier use of hospice to prevent end of life hospitalizations.
Preoperative triage and multidisciplinary consultation for patients with breast cancer: A pilot study between surgery and medical oncology.
Authors: Adilman Rachel , Simmons Christine E. , Eslami Maryam , Illmann Caroline , Warburton Rebecca , McKevitt Elaine
Published: February 2017

208

Background: Breast cancer management has become exceedingly collaborative across specialties. Preoperative multidisciplinary input in particular is increasingly needed as indications for neoadjuvant therapy (NAT) continue to expand. In British Columbia, as in many other regions, breast cancer surgery is typically performed by community surgeons working in settings away from medical and radiation oncologists, making preoperative multidisciplinary input challenging. Methods: This prospective pilot study was designed to enhance and streamline preoperative breast cancer care at the BC Cancer Agency Vancouver Centre (BCCA) and Mount Saint Joseph’s Hospital (MSJ). Patients with a new diagnosis of breast cancer at the MSJ Breast Clinic are included in this pilot triage project if tumors meet one or more of the following criteria: triple negative, HER2+, clinically palpable ≥ 2cm, or present with positive/palpable nodes. Before the patient has consulted with a surgeon, the pathology, imaging, and GP’s assessment is faxed by a MSJ nurse navigator to BCCA for preoperative triage by a medical oncologist. A BCCA navigator facilitates this confidential electronic triage process, and communicates the medical oncologist’s recommendation [a) urgent referral for NAT, or b) upfront surgery] back to MSJ for appropriate booking and management. Results: Since inception in November 2014, 42 patients have undergone electronic preoperative triage through this pilot project. Of those, 47.6% were recommended to have, and did have, a preoperative medical oncology consult to discuss NAT. 90% of patients who had a NAT consult ultimately received NAT compared to a 66% uptake of NAT through the traditional referral process (P = 0.029). Median wait time from ‘biopsy result’ to ‘start of chemotherapy’ was significantly reduced by 9 days through this novel triage process (P = 0.047). Conclusions: This preoperative multidisciplinary triage project has significantly reduced treatment wait times and improved patient selection for and uptake of NAT for breast cancer. Breast cancer care benefits from increased preoperative navigation to help streamline and expedite care for high-risk patients.
Prophylactic use of Granulocyte-colony stimulating factors (G-CSF) in cancer patients: Adherence to NCCN guidelines.
Authors: Khanna Rashi , Alva Venur Vyshak , Narechania Shraddha , Elson Paul , Daw Hamed , Spiro Timothy Peter , Haddad Abdo
Published: February 2017

209

Background: G-CSF are used for prophylactic and therapeutic treatment of febrile neutropenia (FN). NCCN guidelines (version 1.2015) recommend prophylactic use of G-CSF based on the chemotherapy regimen and patient related risk factors, especially for the high (> 20%) and intermediate (10-20%) risk groups for developing FN. This study investigates the practice patterns and adherence to NCCN guidelines for use of G-CSF at a community based academic outpatient facility. Methods: Cleveland Clinic IRB was obtained. Charts of all patients with underlying non-small cell lung cancer, small cell lung cancer, and breast cancer, treated in the year 2013, were reviewed for G-CSF use on their initial chemotherapy encounter. Risk assessment for developing FN was assessed based on individual risk factors and chemotherapy regimen. Analysis was obtained for appropriate guideline based use of G-CSF. Results: A total of 172 (n = 172) patients were included in the study. Overall, 63% (108/172) of patients had breast cancer; 81% (140/172) were female, most patients (64%, 108/170) were aged < 65 years; 29% (49/172) had metastatic disease; and almost all patients (91%, 106/117) had good ECOG performance status (0 or 1). The overall risk of FN was estimated to be low (< 10%) for 9% (16/172) of patients, intermediate (10-20%) for 45% (77/172) of patients, and high (> 20%) for 45%. Overall, 5% (8/172) of patients did not follow the NCCN guidelines. Only 86% of the patients in metastatic group were adherent to NCCN guidelines compared to 99% of patients in non-metastatic group (p< .01). Among patients with metastatic disease, 14% (7/49) did not follow NCCN guidelines; in a univariable analysis, among patients with metastatic disease - risk of neutropenia (p < .0001), age (p < .01), and prior chemotherapy and or radiation (p = .04), were associated with whether or not the NCCN guidelines were followed. Conclusions: In our limited study population, more use of G-CSF was seen among patients with metastatic cancer with a higher number of metastatic patients being non-adherent to NCCN guidelines. Further research is required to elucidate the potential benefit and cost-effectiveness of G-CSF use in the palliative setting.
Understanding the comorbidome and its effect on survival in colorectal cancer.
Authors: Hahn Erin Elizabeth , Shen Ernest , Lee Janet S. , Munoz-Plaza Corrine E. , Parry Carly , Gould Michael K
Published: February 2017

210

Background: Effectively managing comorbidities is an essential component of high-quality cancer care. Evidence suggests colorectal cancer (CRC) patients with multiple comorbid conditions are less likely to complete standard treatments and can have lower rates of survival. In order to provide personalized care, it is critical to understand how comorbid conditions cluster within CRC patients. Methods: We identified Kaiser Permanente Southern California CRC patients diagnosed with first malignancy between 01/01/2008 - 12/31/2013. We used latent class analysis to identify clinically useful phenotypes defined by combinations of comorbidities at diagnosis, and compared survival using the Kaplan-Meier method. Results: The cohort included 7803 patients: 52% male; average age at diagnosis 66 years (SD: 13); 22% Hispanic, 15% Black, 9% Asian, 52% White; 42% Stage I, 22% Stage II, 22% Stage III, and 14% Stage IV. One-fifth of patients had a Charlson comorbidity index score of ≥ 4. We found 4 distinct classes (Lo-Mendell-Rubin p<0.001). Class 1 was relatively healthy with few comorbidities (Table). Class 2 included individuals with cardiovascular diseases; those in Class 3 had complicated diabetes. Class 4 members had multiple chronic conditions, including diabetes with micro- and macrovascular complications. Kaplan-Meier estimates revealed a statistically significant difference in overall survival by class (log rank p<0.001). Conclusions: We identified 4 clinically distinct classes of comorbid conditions in CRC patients. These data can be used to inform personalized care for CRC patients throughout the cancer care continuum. [Table: see text]
Patients as partners in managing cancer treatment-related toxicity.
Authors: Redwood Erin , Vu Kathy , Wright Meaghan , Fox Colleen , Ahmad Noor , Simanovski Vicky , Kaizer Leonard , Krzyzanowska Monika K.
Published: February 2017

215

Background: Cancer Care Ontario is the government agency responsible for improving cancer services across Ontario’s 14 regions. To promote advances in best practices related to systemic treatment, Cancer Care Ontario hosts annual Systemic Treatment Safety Symposia, which serve as a platform to discuss quality and safety issues and results of quality improvement (QI) initiatives in alignment with the Systemic Treatment Provincial Plan. For the first time, the 2015 Symposium brought together patients and providers to discuss gaps and opportunities for improvement in relation to toxicity management (TM) during chemotherapy. The main goal of the event was to define improvement priorities. Methods: The Symposium presents a valuable engagement opportunity with regional stakeholders including medical oncologists, nurses, pharmacists, administrators and patient and family advisors. An interactive agenda was designed to elicit direction from these stakeholders. At the event attendees identified and prioritized improvement opportunities using a simulated investment scenario, where marked bills were given to participants to finance the solutions they felt would best address the challenges posed by current TM. The mock money was counted and analyzed based on the role of the ‘investors’ and the prioritized theme. Results: The Symposium had 92 attendees including 17 patients and caregivers. Themes that emerged are presented in the Table below. Endorsement varied depending on stakeholder group. For example, Access was the top improvement priority for patients, whereas Communication was highest for providers. Conclusions: A one day engagement event that brings together patients and providers can be successful in identifying priority areas for quality improvement. Based on the outcomes of the prioritization exercise, improving access to oncology providers for TM 24/7 was identified as a focus area for provincial and regional QI initiatives. [Table: see text]
Clinical pathways: An emerging tool for quality improvement.
Authors: Kleiner Hillary , Pirog Francesca
Published: February 2017

222

Background: Clinical pathways have emerged as a tool for payers to encourage provider adherence to evidence-based care. Avalere sought to understand how oncology pathways are incorporated into broader organizational quality improvement initiatives and what impact they have on care quality. Methods: Avalere conducted white and grey literature searches to assess pathways used in quality improvement initiatives. The research was augmented by interviews with leading pathways organizations. Results: Research suggests that pathways can play the following roles in quality improvement: Ensure Adherence to Guidelines. Pathways are typically built on guidelines. Guideline adherence thresholds improve care quality by incentivizing appropriate care. While pathway adherence thresholds are typically set at 80%, little research has been conducted on whether adherence thresholds have improved guideline adherence. Ensure Adherence to Quality Measures. Quality metrics can be tied to pathway adherence, which in turn can also incentivize appropriate care. Quality measures tied to pathways can be used as a risk-mitigation and management tool for providers that assume more risk. Improve Patient Outcomes by Reducing Treatment Variability. Some clinical pathways programs have been shown to improve outcomes. Between 2010-2012, after implementing breast, colon and lung cancer pathways, US Oncology and Aetna experienced 1.2 inpatient days for patients vs. 2.1 prior to launch, as well as a 10% ER visits in the pathways group vs. 14% in the control group. Enable Comparative Outcomes Assessment. CPs could allow for benchmarking of outcomes over time. Treatment choices could be tracked through pathways and the outcomes could potentially be matched to those choices. Conclusions: While pathways have been shown to play a role in quality improvement, initial results have been short-term and isolated. To ensure that pathways can be a viable part of organizational quality improvement, additional research must be conducted on the impact of pathways on outcomes. Additionally, given the lack of pathway transparency and consistency there is a need for increased oversight to ensure that pathways are appropriately incentivizing adherence to guidelines and quality measures.
MD and RN ECOG-PS assessments prior to chemotherapy and concordance rates: A quality initiative at a comprehensive cancer center.
Authors: Shinde Arvind Manohar , Dashti Azadeh , Makoff Eve , Ovasapians Navasard , Hendifar Andrew Eugene , Tuli Richard , Figlin Robert A.
Published: February 2017

228

Background: ECOG-PS is a widely implemented scale in oncology to assess performance status (PS). Higher scores are associated with poorer tolerance to higher-intensity chemotherapy (Ct). While professional societies recommend limiting Ct in patients with solid tumors and poor PS, the practice remains pervasive. To reduce this practice, in 2014 the Cedars-Sinai (CS) cancer quality committee developed a quality initiative (QI) requiring oncologists to indicate ECOG-PS on IV chemotherapy orders, with a structured hard-stop to evaluate patients with ECOG-PS≥3. Previously ECOG-PS was not required. Ct nurses also scored ECOG-PS, though their evaluation was not reported back to oncologists, and did not affect Ct decisions. Earlier studies have suggested a bias for oncologists to rate the ECOG-PS more positively than nurses when evaluating the same patient. Methods: 1084 of the total 12,259 Ct orders activated from 3/1/14-2/28/15 in a CS infusion center were randomly audited for ECOG-PS scoring by MD and RN for quality assurance. Completion and concordance rates for ECOG-PS were determined. Results: 93% and 83% of charts documented MD and RN ECOG-PS, respectively. 827 charts had both MD and RN ECOG-PS scores. Concordance rates, and discordance directionality are described in the Table. Conclusions: This QI achieved high rates of ECOG-PS documentation by oncologists, and low rates of Ct administration to patients with ECOG-PS≥3. MD/RN concordance rates were similar to those described in the literature. Interestingly, and in stark contrast to previous studies, MDs were more likely to score ECOG-PS as poorer compared to RNs in solid tumor discordant cases. [Table: see text]
Documentation of pharmacist-provided patient education for oral chemotherapy.
Authors: Jennifer Anderson , Venepalli Neeta K. , Fleming Patrick Joseph , Haaf Christina , Bursua Adam , Park Little Irene , Cuellar Sandra
Published: February 2017

237

Background: Pharmacist-provided patient education for oral chemotherapy is poorly documented in patient electronic medical records (EMR) at UIC Oncology Pharmacy. At baseline, 41% of patients who started new therapy with selected oral chemotherapies had a patient education note documented by a pharmacist in their EMR. Our aim is to provide and document patient education for at least 90% of patients who start new oral chemotherapy and fill their prescriptions at UIC Oncology Pharmacy over three months. The importance of patient counseling and documentation is recognized by the Quality Oncology Practice Initiative (QOPI) group. Approximately 25% of patients undergoing chemotherapy are on oral chemotherapy. (Deutsch S, Koerner P, Miller RT, Craft Z, Fancher K. Utilization patterns for oral oncology medications in a specialty pharmacy cycle management program. J Oncol Pharm Pract. 2014;0:1-8.) Methods: A multi-disciplinary team performed an affinity sort and created a process map to identify areas of intervention. The first intervention was labelling prescription bags to identify them as oral chemotherapy prescriptions that require counseling by a pharmacist. Data was collected after two weeks. Results: At the completion of the first PDSA cycle, 40% of patients who started new oral chemotherapy had a documented patient education note written by a pharmacist in their EMR. Documentation of education was performed on the day of pick-up in 89% of cases. Table 1 shows the percentage of notes that included the elements recognized by QOPI standards: documentation of start date, adherence, and adverse effects. Conclusions: Documentation of patient education for oral chemotherapy should be a well-integrated component of ambulatory pharmacy practice. A second PDSA cycle is planned to increase rates of documentation by utilizing the pharmacy resident to perform patient counseling and documentation. Future interventions will be aimed at improving the quality of the data included in the documented notes. [Table: see text]
National Comprehensive Cancer Network petitions: Submissions and outcomes.
Authors: Bobolts Laura , Huff Dinah Faith , Hrushesky William J. , Bennett Charles Lee , Knopf Kevin , Baum Michael
Published: February 2017

248

Background: The National Comprehensive Cancer Network (NCCN) invites petitions to its scientific panels. Most ( > 95%) are from the pharmaceutical industry lobbying to include their products in the NCCN Guidelines. Rarely, physicians request scientific scrutiny of the guidelines. We report the experience of Oncology Analytics (OA) with petition submissions and the possible impact on guidelines. Methods: From 2011-2015, OA made 7 petitions to NCCN. The content of each was tracked into subsequent NCCN Guidelines to ascertain whether any changes resulted. Results: 1) The Survivorship Panel was petitioned to add liposomal doxorubicin to the list of cardiotoxic anthracyclines: No changes were made. 2-3) The NSCLC Panel was asked in 2014 to remove the category 2A listing for trastuzumab and afatinib as HER-2 targeted drugs, and cabozantinib as a RET rearrangement target based on absence of phase I-III full text scientific literature. This was done, however, cabozantinib was reverted to 2A status late 2015 based on abstract-only data. 4) Per FDA approval, the NSCLC Panel was asked to recommend bevacizumab only in combination with carboplatin/paclitaxel for 1st line non-squamous NSCLC based on a survival advantage in ECOG 4599: No changes were made. 5) Given the FDA-approval, the Ovarian Cancer Panel was requested to add doxorubicin: This was done. 6) A 2012 Supportive Care Panel petition pointed out the absence of data supporting palonosetron as the preferred 5-HT3 antagonist with aprepitant for moderate or high emetic risk chemotherapy: No change was made upon request; however, preferred status was removed in 2015 from high emetic risk. 7) Based on a preponderance of evidence, a Supportive Care Panel petition requested re-categorization of the febrile neutropenia risk for carboplatin/paclitaxel from intermediate to low except in patients of Japanese ancestry and/or carboplatin AUC > 6: This was done. Conclusions: Majority of NCCN physician petitions came from OA, yet constituted less than 5% of all petitions submitted. NCCN does not provide direct petitioner feedback, so we cannot say for certain that our petitions led to changes in subsequent guidelines. Not all requests resulted in NCCN changes, despite level one supportive data or accentuating an absence of data.
A patient-centered, symptom-focused qualified clinical data registry (QCDR) as a framework to guide quality improvement.
Authors: Struth Deborah L. , Mallory Gail , Galioto Michele
Published: February 2017

253

Background: Clinically meaningful quality measures have been identified as a catalyst for healthcare improvement and better patient outcomes. Amidst rapidly changing quality reporting and re-imbursement schema, eligible providers struggle to choose a portfolio of measures across multiple registries that will demonstrate the value of their practice to consumers and payers. It is critical that a roadmap to quality improvement be evident to registry users. Utilizing the Model for Improvement developed by the Associates in Process Improvement and adapted to health care by the Institute for Healthcare Improvement, a framework to guide performance improvement was developed and incorporated into an oncology specific QCDR for PQRS reporting. Methods: Fourteen patient-centered quality measures with a focus on cancer related symptom assessment and intervention were piloted and tested in 40 practices and incorporated into the Oncology Nursing Society (ONS)/CE City QCDR. Six measures focus on the active treatment phase of cancer care and eight on breast cancer survivorship. The registry platform was designed with capabilities for tracking of data over time, goal setting, benchmarking, and providing suggested performance improvement (PI) activities. A technical expert panel (TEP) was convened to develop a model to guide PI activities to address QCDR identified practice gaps. Results: A quality improvement framework was developed to help QCDR subscribers answer the question “How Do I Improve” and was incorporated into the ONS/CE City QCDR platform. This framework provides the subscriber with the education and training necessary to improve care through use of quality improvement tools and implementation strategies aimed at practice change. Conclusions: It is essential that measures be incorporated into an infrastructure that provides opportunities for the assessment and improvement of care quality provided by practices. The QCDR can act as a means to drive performance improvement along with supporting quality measurement for PQRS and Meaningful Use reporting. The “How Do I Improve” Framework developed as part of the ONS/CE City QCDR platform provides a model to accomplish this goal.
Patient perception of nighttime noise in the hospital setting.
Authors: Alessandroni Stephanie , Peterson Lynette
Published: February 2017

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Background: The national standard survey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), measures the patient’s perspective on hospital care. One area that continually evokes sub-optimal results is the ‘quiet at night’ measurement. Our investigation explored the patient’s perception of nighttime “noise” in the hospital setting. Methods: Patients in our medical surgical/telemetry floors subjectively evaluated the noise level at night. An ethnographic interview method was utilized that was approved and standardized to prevent bias. Results were stratified and coded. Results: A total of 224 patients completed the process prior to any intervention to provide our hospital with a baseline understanding of the current state. We then utilized two evidenced-based approaches which have been shown to decrease a patient’s perception of noise: a sleep pack consisting of ear plugs, headphones, and a sleep mask, and one-on-one education on how to use the relaxation channel. Of the additional 101 patients who received this education, twenty-seven of these participants completed a second interview the following day, which allowed for comparison data to be compiled. By speaking with the patients, our investigation not only yielded information regarding the perception of noise level in their room, but additionally identified factors that were the cause of the noise. Although, our two interventions did not produce a positive change in noise level, it did provide valuable feedback and insight for quality initiatives. Conclusions: Noise level is a quality issue which needs to be continually addressed. Our interdisciplinary team, along with nursing leadership, intends to move forward with developing a plan to promote an optimal healing environment.
Current landscape of acute myeloid leukemia quality measures in the United States.
Authors: Flanders Scott C , Bui Cat N. , Song Kyung Min , Fitall Eleanor , Mitchell Kristi , Braun Stephanie Greenstein , Bahceci Erkut , Pandya Bhavik , Jagun Dayo
Published: February 2017

261

Background: Acute myeloid leukemia (AML) is a rare, but deadly hematological, disease with 20,830 new cases estimated in 2015 in the United States (US). As new treatments emerge, quality measures (QMs) will become important to assess the value of care. Our aim was to evaluate the current US AML QM landscape. Methods: We reviewed literature and online resources (eg, National Quality Measures Clearinghouse, Centers for Medicare & Medicaid Services, etc.) published within the last 5 years to identify AML-specific and AML-related QMs. All QMs were categorized using a “continuum of care” framework according to the 5 stages of AML: 1) symptom assessment, 2) diagnosis/risk stratification, 3) initial treatment, 4) monitoring/additional treatment, and 5) advanced/late stage care. Quality measures were categorized by the measure type (eg, process or outcome measure) and use by the Centers for Medicare & Medicaid Services (CMS). Results: In total, 30 QMs were identified: 1 leukemia-specific QM and 29 general oncology QMs. The leukemia-specific QM is a clinician-level process measure that evaluates the percentage of patients aged ≥ 18 years with a diagnosis of myelodysplastic syndrome or acute leukemia who had baseline bone marrow cytogenetic testing performed. Among the 29 general QMs: 8 are specific to stem cell transplantation, 13 are specific to chemotherapy, and 8 are general to oncology. Across the AML continuum of care: 2 QMs focus on symptom assessment, 1 supports diagnosis/risk stratification, 11 are for initial treatment, 9 for monitoring/additional treatment, and 7 for late-stage care. Twenty-seven QMs are based on process of care: 1 addresses resource utilization and 2 are outcomes based. The single leukemia-specific QM is used in CMS quality improvement programs, along with 3 other oncology-related QMs. Conclusions: While only one identified QM was specific to leukemia, other general oncology QMs may also apply. Unfortunately, QMs addressing AML-related morbidity and mortality are still lacking. Research into patient-centered communication, shared decision-making, patient-reported outcomes and resource use by AML patients may inform development of new QMs. Sponsorship: This research was funded by Astellas Pharma, Inc.
Validation and quality assessment of the Kilimanjaro Cancer Registry.
Authors: Zullig Leah L. , Muiruri Charles , Nyindo Pili , Namwai Theresia , Karia Francis , Oresto Michael , Silayo Elvis , Msomba Angelah , Bartlett John , Zafar Yousuf
Published: February 2017

266

Background: The global cancer burden has increasingly shifted to low and middle-income countries and is particularly pronounced in Africa. However, there remains a lack of comprehensive information about cancer incidence due to limited development of cancer registries. In Moshi, Tanzania, a regional cancer registry exists at Kilimanjaro Christian Medical Center (KCR). The quality of the registry data is unknown. Our objective was to evaluate the completeness and quality of the KCR. Methods: In October 2015 we conducted a retrospective review, validating internal consistency of registry records compared with paper-based medical and pathology records. We randomly sampled approximately 3% of over 3000 registry cases (n = 100), focused on cases abstracted from 2014-15. Four independent reviewers not associated with the KCR manually collected and compared key data elements (e.g., cancer site, morphology, diagnosis date). Data were collected using Microsoft Excel. Data management and analysis were conducted in Stata. Results: The KCR contains information on over 3000 patients from 32 tribal groups and 8 geographic areas in the Kilimanjaro region. All of the 100 reviewed cases had complete cancer site and morphology in the registry. Six had a recorded stage. For the majority of cases (n = 92) the basis of diagnosis was pathology. Pathology records were found in the medical record for 41% of cases; for the remainder, pathology records were stored separately in the pathology department. Of sampled cases, the KCR and medical records were 98% and 94% concordant for primary cancer site and morphology, respectively. For 28% of cases, recorded diagnosis dates were within 14 days of what was found in the medical record, and for 32% of cases they were within 30 days. Conclusions: Although training is needed to standardize diagnosis date definitions, this study suggests that KCR data is high quality. Research is needed to determine effectiveness at ascertaining all patients in its catchment area. The registry may have utility for resource planning and research purposes.