bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of telemedicine on colonoscopy education among veterans.
Authors: Khuc Thi , Jackson Christian , Chao Daniel
Published: October 2019

276

Background: The VA Loma Linda Healthcare System (LLVA) offers an in-person colonoscopy education class (IPCC) and a telehealth based education class to patients living closer to outlying VA designated Community Based Outpatient Clinics (CBOCs). We noticed a significant number of cancellations and no-shows for colonoscopy from patients who sought care from CBOCS. We developed a telehealth based colonoscopy class (TBCC) to be given at CBOCs. The primary aim of the study was to determine effectiveness of TBCC compared to IPCC on class attendance rates, colonoscopy attendance and quality measures of colonoscopy. Methods: We reviewed records of 1429 LLVA and CBOC patients referred for colonoscopy class from April 2014 to April 2015. Primary end points were polyp detection rate (PDR), adenomas detection rate (ADR) and adenocarcinoma detection rate (ACDR). Secondary endpoints were attendance to TBCC and IPCC and attendance to colonoscopy. Attendance was defined as compliance with the first scheduled appointment. We examined age, BMI, sex, race, and indication for colonoscopy in the IPCC and TBCC populations. Results: TBCC attendance rate was higher than IPCC (p = 0.001). There was no difference in attendance to colonoscopy (p = 0.50). Patients receiving primary care at CBOCs more likely chose TBCC; patients receiving primary care at LLVA more likely chose IPCC (92.53% vs 24.77%, p < 0.0001). African Americans and Hispanics more likely chose IPCC; Whites more likely chose TBCC (p = .01). Patients with family history of colorectal cancer or bright red blood per rectum more likely chose IPCC (p = 0.004, p = 0.008). Sixty eight percent of colonoscopy preparations were noted to be good. There was no difference in the number of good preparations between TBCC and IPCC groups (94.3% and 96%, p = 0.025). ADR was higher in patients who received IPCC (44.55% and 52.17%, p = 0.02). There was no significant difference in PDR and ACDR between TBCC and IPCC groups. Conclusions: A TBCC program can increase patient attendance to colonoscopy preparation training without negatively affecting quality of colonoscopy preparation. Prospective, randomized studies on differences in adenoma detection and distance from home residence on class and colonoscopy attendance rates is needed.
A novel tool to monitor adherence to oral oncolytics: A pilot study.
Authors: Sun Wendy , Reeve Rebecca , Ouellette Timothy , Stutsky Martha , De Jesus Rachel , Huffer Michael J , Mougalian Sarah Schellhorn
Published: October 2019

286

Background: Non-adherence is an important issue in cancer care as more oral cytotoxic and targeted agents become available. Although oral therapies may be more convenient for patients, measuring and optimizing adherence is challenging. The Nomi system records real-time medication taking behavior from a "smart" prescription bottle and displays the data on a web-based interface. Nomi can also communicate with patients via text message to intervene in cases of non-adherence. We report the results of a 28-patient pilot study aiming to assess Nomi’s ability to assist patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. Methods: Eligible patients were prescribed capecitabine for breast, colorectal, pancreatic, or biliary cancer. The study had a pre-intervention stage, during which patients were monitored, and an intervention stage, in which the text messaging feature was enabled. Adherence was defined as the number of correct doses (both timing and quantity) over the total number of prescribed doses. Conversions were events in which patients took a dose after receiving a text intervention (from Nomi). We defined three categories of patients by percent change in adherence: category 1 ( > 8%), category 2 (-8% to 8%), and category 3 ( < -8%). Results: We collected data from 28 patients (24 pre/post and 4 pre-only). On average, patients were 84% adherent (N = 28; SD = 11%). During pre-intervention, patients had a self-adherence of 89% (SD = 12%), and afterwards, they had an average adherence of 90% (SD = 6%). Most of the patients in category 1 demonstrated a substantial conversion rate ( > 35%). Patients in category 1 tended to live in regions with lower average household income (Mean = $58,937) than those in category 2 (Mean = $77,482) and category 3 (Mean = $90,972). Of survey respondents, 56% indicated that they would want to continue using Nomi, while 67% indicated that they would recommend it to others. Conclusions: This innovative technology is able to monitor, measure and intervene for patients taking capecitabine in real-time. Adherence overall was high, and some patients appeared to benefit more from text message interventions. Future work should focus on patients deemed high risk for non-adherence.
A nutrition-focused quality improvement program to improve rate of documented nutrition plan at a safety-net hospital gastrointestinal (GI) oncology clinic.
Authors: Levonyak Nicholas , Hodges Mary P , Broome Nicole , Beg Muhammad Shaalan , Kainthla Radhika , Sanjeevaiah Aravind , Sadeghi Navid , Pandey Neha , Mhoon Verca , Cox John Vernon , Kazmi Syed Mohammad Ali
Published: October 2019

289

Background: Patients with GI cancer have amongst the highest rates of malnutrition, which contributes to decreased quality of life, increased morbidity and mortality, as well as higher healthcare costs. In the GI Oncology clinic at Parkland Health and Hospital System (PHHS), the number of patients with a documented nutritional plan by a registered dietitian was 7%, and there was no standardized screening method for malnutrition in place. Methods: The aim was to increase the rate of documented nutritional assessment by a registered dietitian to 25%. Multidisciplinary sessions involving physicians, registered dietitians, registered nurses, and hospital administration were arranged to identify barriers to nutritional interventions for GI Oncology clinic patients. Results: Prior to QI interventions, between October-December 2018, the total number of GI cancer patients referred to registered dietitian clinic was 11- 30 referrals, which accounted for 7-10.1% of GI cancer patient in the respective month. As part of first PDSA cycle, a registered-dietitian was assigned to GI oncology clinic. The total number of documented nutrition plan after first intervention was 22 GI cancer patient (15% of GI cancer patients). We then developed an adapted-version of the Malnutrition Screening Tool (MST) and implemented it through the institute electronic medical record. The nursing staff and physicians were educated about administering the screening tool and the referral process to a registered-dietitian after a positive MST screen. After the first month during which MST was implemented, the rate of nutritional assessment increased to total of 20.5% of GI cancer patients (total 37 referrals). Twenty out of the 37 referrals (54%) were due to the positive MST screening tool. Conclusions: Through a nutrition focused QI program, we doubled the rate of a documented nutritional plan for PHHS GI cancer patients in a month of starting the 2nd PDSA cycle intervention. Through future PDSA cycles, we plan to further increase patient access to nutritional assessments and then broaden our efforts to the entire PHHS oncology clinic.
Quality improvement and implementation science in cancer care: Identifying areas of synergy and opportunities for further integration.
Authors: Check Devon , Zullig Leah L. , Davis Melinda , Stover Angela M. , Davies Louise , Schroeck Florian Rudolf , Fleisher Linda , Chambers David , Proctor Enola , Koczwara Bogda
Published: October 2019

29

Background: Efforts to improve cancer care delivery have been driven by two approaches: quality improvement (QI) and implementation science (IS). QI and IS have developed independently but have potential for synergy. To inform efforts to better align these fields, we examined 20 cancer-related QI and IS articles to identify differences and areas of commonality. Methods: We searched PubMed for cancer care studies that used IS or QI methods and were published in the past 5 years in one of 17 leading journals. Through consensus-based discussions, we categorized studies as QI if they evaluated efforts to improve the quality, value, or safety of care, or IS if they evaluated efforts to promote the adoption of evidence-based interventions into practice. We identified the 10 most frequently cited studies from each category (20 total studies), characterizing and comparing their objectives, methods – including use of theoretical frameworks involvement of stakeholders – and terminology. Results: All IS studies (10/10) and half (5/10) of QI studies addressed barriers to uptake of evidence-based practices. The remaining five QI studies sought to improve clinical outcomes, reduce costs, and/or address logistical issues. QI and IS studies employed common approaches to change provider and/or organizational practice (e.g., training, performance monitoring/feedback, decision support). However, the terminology used to describe these approaches was inconsistent within and between IS and QI studies. Fewer than half (8/20) of studies (4 from each category) used a theoretical or conceptual framework and only 4/20 (2 from each category) consulted key stakeholders in developing their approach. Most studies (10/10 IS and 6/10 QI) were multi-site, and most were observational, with only 4/20 studies (2 from each category) using a randomized design to evaluate their approach. Conclusions: Cancer-related QI and IS studies had overlapping objectives and used similar approaches but used inconsistent terminology. The impact of IS and QI on cancer care delivery could be enhanced by greater harmonization of language and by promoting rigor through the use of conceptual frameworks and stakeholder input.
Improving the chemotherapy consent: From paper to tablet.
Authors: Bhardwaj Aarti Sonia , Parra Jessica , Rampertaap Kavita , FitzPatrick Katherine , Caridi Raina , Liu Mark , Casani Victoria , Berizzi Donna , Isola Luis M. , Smith Cardinale B.
Published: October 2019

298

Background: A comprehensive chemotherapy informed consent process improves shared decision-making. Additionally, the Oncology Care Model (OCM) emphasizes providing patients with a documented care plan that contains the 13 components in the Institute of Medicine Care Management Plan. Within our health system, we incorporated the care plan into our existing chemotherapy consent process and utilized technology to increase compliance and reduce administrative burden. Methods: Our 2 phase PDSA included: 1) updating our existing paper chemotherapy form with the 13 components of the IOM care plan and then 2) piloting an electronic version of the chemotherapy consent form. We updated our new chemotherapy consent with the addition of Prognosis, Expected Response to Treatment, Potential Effect on Quality of Life, Potential Benefits/Goals of Treatment, and added more options for potential side effects/harm. Given the increased administrative burden, we created and piloted the use of an electronic version of the consent form in our breast oncology program. Results: Baseline, monthly random chart audit of 20-40 patients revealed compliance with completing every question of the paper chemotherapy consent at 30% of all patients receiving IV chemotherapy at our cancer center that month- 7/2018. When the new chemotherapy consent incorporating the IOM elements was rolled out, compliance initially rose to 50% (8/2018), however the following months dropped to 10-20% (9-11/2018) and then back up to 41% briefly (12/2018). The results were low and inconsistent. A pareto chart confirmed that redundancy and too many questions were the reasons for under-completion. By auto-populating fields for certain questions on the paper consent, compliance increased to 75% (2/2019). Finally within our breast cancer pilot group our compliance rose to 100% (3-4/2019), by converting to an electronic form with the maximum options for auto-population and drop-down selections for certain fields. Conclusions: Incorporating regulatory requirements into an existing workflow can reduce administrative burden. The use of innovative technology can further increase clinician and OCM compliance while delivering value to patients.
Using Lean methodology to improve the time to antibiotics in oncology patients on chemotherapy who present to the ED with neutropenic fever.
Authors: Byrne Brian J. , Bailey Frederick , Montanaro Pat , DeFusco Patricia Anne
Published: October 2019

31

Background: Neutropenic fever is a medical emergency. Delays in treatment can lead to increase in morbidity, mortality, and increase length of stay. The American Society of Clinical Oncology currently recommends that antibiotics be prescribed within 60 minutes of triage. Literature review shows through a multidisciplinary effort involving the ED, lab, oncology, and pharmacy significant improvement in time to antibiotics can be achieved. Since many patients with neutropenic fever present with sepsis, these guidelines also will need to be followed. Methods: Three PDSA cycles were conducted. The first involved education of the ED staff on the importance of treating neutropenic fever and using the correct antibiotic. The second PDSA cycle involved the laboratory and the calling of critical white counts and low neutrophil counts. The third PDSA involves patient education on the importance of temperature monitoring and reporting they are on chemotherapy to ED staff. Results: Baseline data show only 33% of patients receive the correct antibiotic and the average time to administration is 3 hours and 41 minutes. Results of the quality improvement project show a substantial improvement in time to antibiotic administration to 1 hour 58 minutes and an increase in the percentage of patients who receive the correct antibiotic. The time from the specimen received in the lab until critical called also improved from 1 hour 14 minutes to 18.5 minutes. Conclusions: This quality improvement led to a significant improvement in time to correct antibiotics, but several additional steps need to be taken to meet ASCO guidelines.

[Table: see text]
Got stage fright? A fellow-led initiative to improve cancer staging documentation.
Authors: Velazquez Manana Ana I. , Banerjee Rahul , Kambhampati Swetha , Parks Anna , Brondfield Sam , Mulvey Claire , Cinar Pelin
Published: October 2019

310

Background: Accurate cancer staging is essential for estimating prognosis, guiding treatment, populating cancer registries, and assessing clinical trial eligibility. Hence, timely staging of new solid oncology patients (NSOP) is an ASCO QOPI priority. At our institution, baseline review of staging documentation revealed fellows staged only 47% of NSOP, generally as unstructured free text. During the 2017-18 academic year, our structured electronic medical record (EMR) staging tool (ST) was used in only 11% of NSOP. We used Quality Improvement (QI) methods to improve structured EMR staging documentation rates of NSOP seen by fellows during the 2018-19 academic year. Methods: A fellow focus group identified poor integration of the EMR ST as root cause of our low staging rates. We set a cumulative goal of 70% structured EMR staging of NSOP within 1 month of initial visit as our target (50% increase from baseline). We incorporated the EMR ST into our visit workflow and used promotional flyers and fellow orientation to introduce our QI initiative. Staging rates were tracked by EMR-generated reports. We used periodic emails and QI-specific boards to disseminate progress among our oncology practices. Fellows were anonymously surveyed for feedback. Results: Over an 8-month period, the cumulative rate of NSOP staging by fellows increased from 47% to 70% (Table). Statistical process control analysis showed special-cause variation in July 2018 (low performance) and December 2018 (high performance). Fellow feedback highlighted the educational value of this QI intervention and identified incomplete workup as a barrier to staging. Conclusions: Our fellow-led QI intervention achieved our goal of leveraging an existing EMR tool to increase staging documentation. In addition, this QI intervention facilitated fellow education and use of data for clinical and research purposes. Future steps include ensuring sustainability and expansion into our hematology clinics.

[Table: see text]
Prevalence of anemia and compliance to the National Comprehensive Cancer Network guidelines for workup and treatment of anemia among patients with gynecologic malignancies.
Authors: Hufnagel Demetra , Mehta Sumit , Ezekwe Chinyere , Brown Alaina J. , Prescott Lauren S.
Published: October 2019

32

Background: The National Comprehensive Cancer Network (NCCN) recommends prompt evaluation of anemic patients with hemoglobin (Hb) ≤ 11g/dL. There are a paucity of studies evaluating compliance with the NCCN guidelines. Our objective was to investigate the prevalence of anemia among patients diagnosed with gynecologic cancers and assess compliance with NCCN guidelines. Methods: We performed a retrospective cohort study of patients diagnosed and treated with gynecologic cancer at our institution from 2008-2018. Tumor-registry-confirmed cancer cases were identified using ICD codes from the Synthetic Derivative (SD) database which is a de-identified copy of our institution’s electronic medical record. Patients were included if they were between the ages of 18 and 89, had their initial care at our institution, and had a Hb within the first 6 months of diagnosis. Dual primaries were excluded. Anemia was defined as Hb ≤ 11g/dL. Anemia was graded using the CTCAE v.4.0. Absolute and possible iron deficiency were defined by NCCN Guidelines. Results: We identified 1031 patients who met our inclusion criteria. The median age was 61 years (range 20 - 86). The most common malignancy was uterine cancer 509 (49%) followed by ovarian 262 (25%), cervical 133 (13%), vulvar 107 (10%) and vaginal 20 (2%). Of the 1031 patients in our study, 662 (64%) were noted to be anemic within six months of diagnosis. Of these patients 128 (19%) were noted to have grade 1, 309 (47%) grade 2, and 225 (34%) grade 3 anemia. Of those who were anemic, 90 (14%) underwent any workup for anemia, of which 63 (10%) had iron studies performed. Of those with iron studies performed, 7 (1%) patients had absolute iron deficiency and 24 (4%) had possible iron deficiency. Despite the small percentage of individuals with anemia evaluation, 266 (34%) patients received treatment of anemia. Treatments included: oral iron 47 (7%), IV iron 6 (1%), and blood transfusion 213 (32%). Conclusions: Anemia is pervasive among gynecologic cancer patients, but compliance with NCCN guidelines is low. Our data suggest there are opportunities for improvement in evaluation and management of anemia among gynecologic cancers.
Improving interdisciplinary communication in MDT-meetings: Identification of barriers and facilitators in nationwide implementation of standardized structured reporting.
Authors: Swillens Julie Elisa Maria , Voorham Rinus , Nagtegaal Iris D. , Hermens Rosella
Published: October 2019

321

Background: Standardized structured reporting (SSR) improves quality of diagnostic reporting for cancer patients, resulting in improved interdisciplinary communication in multidisciplinary-team meetings (MTMs) and subsequently better health outcomes and patient safety. In addition, SSR is important to secondary users including (tumor) registry organizations. Nevertheless, SSR-template usage, for example in pathology, varies widely among oncology related medical disciplines. Because of the advantages during MTMs, multidisciplinary-team (MDT) members could play an important role in encouraging and supporting pathologists to use SSR-templates. Therefore, the objective is to identify both barriers and facilitators for SSR-implementation from a MDT-member perspective. Methods: We used a mixed method design. Four focus group interviews with MDT-members, operating in the field of urological, gynecological or gastrointestinal oncology were performed, to identify barriers and facilitators in SSR in relation to the MTMs. Findings were classified into the domains of Flottorp et al. (2013). We used a web-based survey among Dutch MDT-members to quantify the findings. Results: Twenty-three MDT-members of nine medical disciplines participated in the focus group interviews. The survey yielded 211 responses. Main barriers of SSR among MDT-members were lack of information in the standardized structured report, particularly lack of information to retrieve doubts of the pathologist (56%, n = 211); lack of nuances (39%, n = 184); and lack of transparency on development of SSR-templates (50%, n = 211). Pathologists (59%, n = 54) also mentioned the numerous clicking when using SSR-templates as a barrier. Main facilitator was to expand the recommendation of SSR-usage in national guidelines (81%, n = 174). Conclusions: Although the use of SSR by multiple disciplines has benefits, as diagnostic reports are more complete, this study shows important barriers that have to be dealt with in the implementation process of SSR. The next step is to use the barriers for developing and testing implementation tools to encourage SSR-implementation.
From guidelines to practice: Patient-focused and evidence-informed update of antiemetic recommendations in Ontario.
Authors: Vu Kathy , Warr David , Forbes Leta Marie , Gallo-Hershberg Daniela , DeAngelis Carlo , Brule Stephanie Yasmin , Comfort Dayna , Randall Lisa , Williams Julie , Salama Sarah
Published: October 2019

39

Background: Cancer Care Ontario (CCO) last updated their guidance for the management of chemotherapy-induced nausea and vomiting (CINV) in 2013. Since then, new evidence emerged which changed antiemetic recommendations internationally. The CCO Antiemetic Working Group reviewed the current literature and updated existing recommendations for the prevention and management of CINV in adult patients. Methods: Ontario subject matter experts consisting of oncologists, pharmacists and nurses formed the Group. Relevant guidelines published from prominent jurisdictions were assessed. A literature search was done to incorporate the latest evidence. All chemotherapy regimens in the CCO Drug Formulary were reviewed. Ontario Cancer Leads for each disease site were consulted to ensure emetic classifications for all regimens and antiemetic recommendations reflected both the evidence (including gaps in the literature) and clinical practice (including gaps between evidence and practice). Results: Recommendations for antiemetic agents for highly, moderately, low and minimal emetic risk intravenous and oral chemotherapy are outlined. Chemotherapy regimens in the CCO Drug Formulary were reviewed and emetic risks updated. Recommendations differed from those of major international guidelines (including ASCO) around olanzapine dosing, cannabinoids and emetic risk classification. Conclusions: A systematic approach to updating antiemetic recommendations resulted in evidence-informed recommendations that are patient-focused and clinically feasible.
Impact of timing of palliative care consults on disposition to type of hospice care.
Authors: Baratam Praneeth , Bemis Thomas Stiles , Seiders Dawn , Ward Kristine Marie , Styler Michael
Published: October 2019

50

Background: The 2018 ASCO palliative care guidelines recommend palliative care team (PCT) involvement within 8 weeks for patients with an advanced cancer diagnosis. However, the optimal timing and impact of PCT consults on patient disposition in the inpatient setting has not been established. We investigated whether the timing of PCT involvement for in-patients with an advanced cancer diagnosis affected disposition to a home or inpatient hospice setting. Methods: We queried Hahnemann University Hospital’s Palliative Care In-patient database from 2016-2018 for patients with advanced cancer diagnosis, estimated life expectancy of < 6 months, and recommendation for hospice. Dates of admission, initial PCT consult, discharge to an outpatient vs an inpatient hospice setting/in hospital death were examined. We then examined differences in hospice disposition and timing of PCT consults to determine the ideal consult time. Chi square analysis was used to determine differences in hospice disposition setting and timing of PCT consult. Results: We observed that 75% of PCT consults in our hospital are placed <10 days of admission. We also found that a statistically significant higher percentage of patients were discharged to a home hospice setting (35.1%) when using a PCT consult time of <10 days (p<0.01). Only 17.5% were discharged home when PCT was consulted >10 days after admission. We examined other cut-off times for consultation, but the difference in outcome was not statistically significant. Conclusions: Our findings show that a statistically significant higher percentage of patients went to a home hospice setting if PCT was consulted <10 days of admission. This suggests that early PCT involvement can result in more patients being discharged to a home hospice setting and by extension improve the quality of end of life care for patients. We aim to implement criteria for appropriate timing of PCT consults at our institution and measure post implementation data with the goal of increasing the number of patients discharged to a home hospice setting.

[Table: see text]
Improving physical performance through independent, home-based exercise program prior to cancer-related surgery.
Authors: Fontillas Rhodora C. , Ngo-Huang An , Ng Amy , Asumbrado Roan , Holder Betty , Williams Janet L. , Bianty Josephine , Braveman Brent , Shin Ki , Bruera Eduardo
Published: October 2019

54

Background: Surgery in older adults is a physiologically stressful event associated with reduced functional capacity and decreased quality of life. Poor preoperative performance is linked to risk of postoperative complications and prolonged functional recovery. The goal of this study is to determine the efficacy of an independent, home-based exercise program in improving physical performance prior to cancer-related surgery. Methods: Retrospective study of 217 consecutive patients referred for comprehensive prehabilitation including physical medicine and rehabilitation physician and physical therapy visits prior to intended oncologic surgery. Physical performance was assessed at consultation (baseline) and at the preoperative follow up visit in physical therapy. Physical performance measures included Six-Minute Walk test (6MWT), Five Times Sit to Stand (5xSTS), hand grip strength (HGS), gait speed (GS), and Timed Up and Go (TUG). Results: Median (IQR) age was 71 (64,77). The most common primary cancer diagnoses were gastrointestinal (43%), genitourinary (15%), breast (9%), and sarcoma (7%). 144 of the 217 (66%) underwent surgery and of these, 75 (52%) completed preoperative functional measures during their physical therapy follow-up. For the entire cohort of 217 patients, baseline median (IQR) measures included: 6MWT distance was 357 (193.3, 420) meters, 5xSTS was 12 (9.1, 16.3) seconds, right HGS was 43.3 (30.0, 58.3) pounds, GS was 1.4 (1, 1.7) meters per second, and TUG was 8.6 (7.3, 12.2) seconds. There were similar baseline physical function results in the cohort who completed preoperative measures. During the preoperative period (from baseline to pre-surgery visit), there was significant improvement in the 6MWT ( P=0.003), 5xSTS ( P=0.000), and TUG ( P=0.027). There was no significant change in HGS or GS. Conclusions: At baseline, most patients had major functional impairment, especially decreased submaximal exercise capacity. With the independent, home-based exercise prehabilitation program, patients had significant improvement in physical performance. Prehabilitation should be further investigated in these patients.
A systematic approach for high-quality care in complex malignant hematology.
Authors: Kouroukis C. Tom , Bredeson Christopher , Pollett Aaron , Meertens Elaine , Monakova Julia , Wang Jonathan , Hart Jennifer , Beglaryan Hasmik , Moody Lesley , Hertz Sherrie
Published: October 2019

57

Background: Capacity limits in Ontario, Canada, resulted in long waits and out-of-country care for hematopoietic cell therapy (HCT) and inconsistent access for acute leukemia (AL) patients. A multi-pronged system improvement approach was implemented to ensure high quality care as close to home as possible. Methods: Robust forecasting models and physician workload benchmarks were developed to quantify needs and drive health human resource and capital planning. Clinical and organizational guidelines were developed for new models of care, pathology and laboratory medicine services, and networks of care. Funding models were introduced to support care needs and service models. A comprehensive measurement strategy, including patient reported experience measures, was developed. Results: Six services sites providing HCT and AL care are networked with four AL sites and three supporting sites. Capital expansion projects have been completed and others continue. Two biomarker reference centers were established to serve as quality leads and ensure timely testing. Average turnaround time is 12 days for cytogenetic testing. 19 additional physician specialists and 5 additional fellowships were approved for allocation across Ontario. Three nurse practitioners participated in mentorship programs. Access has improved and wait times are monitored. In 2018 there were 736 autologous and 357 allogeneic transplants done vs 396 and 159 respectively in 2014. 43 patients were referred out of country in 2016 compared with two in 2018, with a median wait of 70 days from AL remission to transplant in 2018. Nine (of 14) regional cancer centers offer outpatient AL consolidation. Patient experience was highest in treatment planning, physical comfort and patient preferences. Conclusions: A multi-pronged approach to planning, funding and quality assurance resulted in measureable increased capacity and high quality care closer to home.
A quality improvement approach to optimizing infusion wait times.
Authors: Plourde Collin , Gleaton Barbara , O'Hara Aliceson , Varnado William , Das Devika Govind
Published: October 2019

61

Background: Long wait times are a common and occasionally unavoidable experience for patients receiving chemotherapy infusions. It unfavorably impacts patient satisfaction and clinic efficiency. Our primary objective was to evaluate the impact of infusion clinic process changes on patient wait times within a Plan, Do, Study, Act (PSDA) framework. Methods: A multi-disciplinary team, consisting of oncology, nursing, pharmacy, quality improvement, and support staff, met to have brainstorming sessions, make surveys, and conduct time studies to analyze our current process (Plan). A Pareto chart created using survey results showed communication issues were likely causing the largest modifiable impact on our wait times. A common source of miscommunication was whether patients are waiting on labs results for treatment. Beginning March 2019, patients not requiring labs on the day of treatment were assigned to a separate scheduling title to designate them as priority for vital signs and review by pharmacy (Do). Upon clinic check-in, these patients now have vitals signs collected immediately and pharmacy is notified of their arrival to begin chemotherapy preparation. Results: Baseline as well as prospective wait time data was collected from 30 clinic days (360 patient wait times) from chart reviews and timestamp data available in the electronic medical record (EMR). Results were analyzed (Study) using Statistical Process Control (SPC) charts to allow for early detection of improvement. Pre-implementation wait times averaged 1 hour and 37 minutes. Post implementation wait times average 1 hour and 16 minutes (Act). This change was significant based on a shift visible on the SPC chart. Our balancing measure of wait times for all patients did not increase compared to baseline (2 hours and 15 minutes). No significant correlation was observed between average daily wait times and the day of the week or the number of patients treated that day at baseline. Conclusions: Implementation of a new clinic scheduling title and workflow reduced wait times for patients not requiring labs on the day of treatment without increasing wait times for patients requiring labs. Additional PDSA cycles will be conducted for further reductions in wait times for all patients at our site.
Improving time to start bone modifying agents in newly diagnosed multiple myeloma patients.
Authors: Lee Sarah , Rosko Nathaniel , Reed Janice , Karam Mary Ann , Faiman Beth , Mathur Saveta , Hamilton Kimberly , Mejia Alex V. , Anwer Faiz , Samaras Christy Joy , Valent Jason Neil
Published: October 2019

65

Background: Current ASCO and IMWG guidelines recommend all patients (pts) on active myeloma therapy receive concurrent supportive care with a bone modifying agent (BMA) to decrease the risk of skeletal related events (SRE). Unfortunately, recent data shows only 51% of Medicare pts with myeloma received a BMA within 90 days of first chemotherapy. We implemented a quality improvement project to identify the average time to BMA initiation at all Cleveland Clinic affiliated sites, with the primary goal to improve time to start BMA in newly diagnosed multiple myeloma (NDMM) pts by 4 weeks at Cleveland Clinic Main Campus (MC). Methods: Barriers to start BMA were identified using quality improvement tools developed at ASCO Quality Training Program. The first PDSA cycle ran from Sept 2018–Jan 2019 with an emphasis on education. This included review of updated guidelines, literature review of risks and toxicities associated with BMAs, and strategies for choosing BMA based on pt factors. Baseline data on time to start BMA and data to evaluate impact of PDSA intervention was done by chart review. Results: 161 NDMM pts were evaluated from 2015–2018 at all sites. The average time difference between the start of myeloma therapy and the start date of BMA in NDMM pts was 10.5 weeks. Subset analysis based on whether pts were treated at MC vs affiliate site was 10.6 weeks vs 9.1 weeks, respectively. During the first PDSA cycle, 14 NDMM pts were treated at MC. 86% (12/14) pts were treated with BMA. The average time between cycle 1 day 1 of first line treatment and first dose BMA was 4.3 weeks (range 4-12 weeks). Conclusions: With increased physician education and awareness of internal baseline data, we achieved our initial goal and observed a significant improvement in time to start BMA from 10.5 weeks to 4.3 weeks. Obstacles regarding effective communication with patients on the benefit of BMAs as well as need for dental clearance were barriers identified early on. We plan to incorporate BMA guidelines in our institutional care path with the goal to decrease time to initiation at all affiliated practices. Further mechanisms to ensure reinforcement of BMA initiation in NDMM patients is warranted to maintain therapeutic benefit.
Use of nonclinical staff to coordinate oral anticancer drug prescriptions.
Authors: O'Neil Daniel , Accordino Melissa Kate , Wright Jason Dennis , Law Cynthia , Nitta Suzuka , Buono Donna , Abbott Maura , Ustoyev Yelena , Hu Jianhua , Neugut Alfred I. , Hur Chin , Patel Khilna , Hershman Dawn L.
Published: October 2019

72

Background: In September 2018, Herbert Irving Comprehensive Cancer Center (HICCC) began using non-clinical pharmacy liaisons to oversee coordination of oral anticancer drug (OACD) prescriptions (RXs), a task previously performed by clinical staff. Liaisons interact with payers, specialty pharmacies and financial assistance (FA) groups. We assessed the impact of this strategy on time to receipt of OACDs. Methods: We collected prospective data on all new OACD RXs from HICCC’s medical oncology practice from 1/1/2018 to 9/17/2018 (pre-liaisons) and 9/17/2018 to 5/1/2019 (post-liaisons). We collected patient demographic and insurance data; date of prescription; date of drug delivery; and interactions with payers and FA groups. Federal Drug Association labels were reviewed for drug approval dates and indications. Daily drug cost was defined according to average wholesale price. We define time to receipt (TTR) as days from RX to OACD delivery and used multivariable linear regression to determine factors associated with TTR (log transformed). Results: Over the study period, we evaluated 707 RXs; 93 (13%) were never filled. Of 614 filled RXs, 350 (57%) were placed in the pre-liaison period and 264 (43%) in the post-liaison period. After introduction of liaisons, FA was pursued for more RXs (17% vs 25%, p = 0.007); there was no difference pre- and post-liaisons in patient demographics, distribution of payers, RXs needing prior authorization (PA) (76% vs 77%), off-label RXs (14% vs 16%), RXs for drugs approved < 2 years earlier (5% vs 3%) or mean daily cost ($471 vs $470). Mean TTR before and after liaisons were 11.9 and 11.6 days, respectively. Linear regression showed longer TTR was associated with commercial payers (p = 0.02), need for PA (p = 0.03), FA pursuit (p ≤ 0.0001) and daily OACD cost (p = 0.03); no association was seen with use of liaisons, patient age, off-label use or OACDs approved < 2 years earlier. Conclusions: Implementation of pharmacy liaisons to coordinate OACD prescriptions did not impact the time to OACD receipt, though liaisons were able to pursue financial assistance for more patients. Insurance and cost factors had the greatest impact on time to drug receipt. Task shifting may reduce the clerical workload for providers.
A staff leadership model in an NCI-designated comprehensive cancer center: Quality begins with the team.
Authors: Kotwal Juee , Loscalzo Matthew J. , Clark Karen L. , Dale William , Schnaitmann Natalie
Published: October 2019

73

Background: Patients with cancer face a range of complex biopsychosocial needs and challenges. To manage the complex needs of such “high-risk, high-cost” patients, an integrated interdisciplinary team approach is crucial. Although team members are highly skilled, cancer settings are emotionally charged environments which may create high levels of distress in providers. In 2007, the Department of Supportive Care Medicine (DSCM) at City of Hope (COH) developed the nation’s first Staff Leadership Model (SLM) to enhance relationships among team members which has been demonstrated to improve both the quality of patient care and safety. Within this model, the focus was on creating a high-performance team where team members are as valued as patients and families. Methods: DSCM implemented methods centered on maximizing team engagement by creating trusting relationships, detoxifying conflicts, depersonalizing feedback, and taking personal accountability. Cultural change was achieved by implementing the following interventions: communication skills to manage conflict, frequent team check-ins to identify areas of growth, non-management staff assuming responsibility for meetings and annual retreats and a “buddy” system to orient new team members. Results: Gallup scores increased from 4.46 in 2015 to 4.62 in 2017 (much higher than COH overall). Transition to Press Ganey in 2018 resulted in 2nd highest engagement score across COH departments (4.42 compared to COH overall 4.16). Conclusions: Results suggest support for the relationship between the SLM and the high quality of team relationships as reflected by the consistent increase in engagement scores. The department philosophy focuses on consciously, systematically and strategically activating the best of each team member in an environment of courageous, compassionate and relentless honesty.
Navigating oncology inpatient care from admission to discharge: A quality improvement study.
Authors: Lightheart Erin , Kucharczuk Colleen
Published: October 2019

76

Background: Ensuring successful transitions between inpatient and outpatient settings is key in providing quality oncology care. To this aim, our team of inpatient Advanced Practice Providers (APP) recognized that critical components of discharge planning were often left to the provider’s memory, leading to errors, omissions, and inefficiencies. After brainstorming a number of possible quality improvement interventions, the clear choice for a high-impact, low-effort solution was the development of a comprehensive discharge checklist, a tool which has been shown in the literature to be effective in similar settings. Methods: Based on best practice recommendations by the Society of Hospital Medicine regarding key considerations for planning safe discharges, a multidisciplinary group developed a comprehensive discharge document housed within the electronic record, to be initiated at the point of admission and updated continually by both providers and discharge coordinators. The document is not simply a list of tasks, but rather, a comprehensive navigator which guides care throughout the entire inpatient stay. Providers are prompted to consider individualized care critical to timely discharge, such as early administration of blood or electrolytes. We have maintained 100% compliance with utilizing the navigator since its inception. Results: Results are summarized in the table below. Conclusions: What started as a discharge checklist grew into a comprehensive navigator, guiding inpatient oncology care from admission through discharge, and into the outpatient setting. Ultimately, it has improved communication and collaboration among providers, CRCs, nursing, physical therapy, social work, and inpatient and outpatient pharmacy. We believe this systematic approach to the discharge process is applicable in any inpatient setting with any patient population.

[Table: see text]
Reducing radiation oncology time to treatment for definitive cancers.
Authors: Young Ronald , Yu Naichang , Patt Molly
Published: October 2019

84

Background: Time to first treatment intervention has been associated with improved patient outcomes. Although, radiation therapy is not always the first treatment intervention, a reduced time to treatment for radiation therapy patients reduces the anxiety and worry of the patient and their family. At the Cleveland Clinic, TTT is considered an important metric that is reviewed by our Cancer Committee and is considered within our tumor boards as well as our multi-disciplinary clinics. Methods: A value stream mapping exercise starting at the time of diagnosis and ending at the first scheduled treatment date allowed us to understand where our opportunities were to improve our TTT. Analytics and reporting was developed to track and report objective data that was incorporated into our operational huddles. Process improvements were implemented to improve clinical template access for our physicians, we eliminated the sequential nature of insurance authorization after consult and created reporting tools that our teams could monitor our success. Results: We improved our median time of consult to first treatment by 29% . Driving our consults to treatment times down a full 4 days on average. We have sustained this improvement with team based visual management boards, team huddles and incorporating TTT into our culture. Conclusions: Radiation therapy time to treat was reduced with the use of continuous improvement tools, analytics, and team based huddles.
Implementation of a geriatric oncology screening tool (G8) in an academic oncology practice serving a Hispanic-rich population.
Authors: Salazar Mary , James Deborah , Welch Carolyn , Viles Jeremy , Karnad Anand B. , Arora Sukeshi Patel
Published: October 2019

87

Background: ASCO recommends utilization of the G8 screening tool to assist in predicting mortality, but there are limited data in Hispanic patients. Our practice utilizes the G8 to identify patients who may need additional support and/or treatment modifications to decrease risk of mortality. Therefore, we built the G8 in our Electronic Medical Record (EMR) with reflex to geriatric consultation in our Hispanic-rich patient population. Methods: This is an implementation study with a team-based approach to improve the utilization and increase geriatric oncology assessments in our practice. The G8 is a geriatric screening tool of eight questions (completion time: 3 to 5 minutes). If the score is </=14, a reflexive geriatric consultation box appears on the screen to recommend a referral to Geriatrics for a Comprehensive Geriatric Assessment (CGA). Nurses were empowered to complete the G8 on all new cancer patients 65+ years. Results: 215 patients had a G8 recorded in the EMR between August 2018 - March 2019. Providers completing: 10 (5%) MD/APP, 205 (95%) RNs. 119 patients were non-Hispanic, 96 were Hispanic. Of Hispanic patients, 74 (77%) spoke English, 5 (5%) spoke English and Spanish, 16 (17%) spoke Spanish, 1 (1%) spoke other. 205 patients (95.3%) were 65+ years. Average G8 score for all patients 65+ was 11.1. Of patients 65+, 169 patients (82%), scored </=14, indicating higher mortality risk. Conclusions: Integration of the G8 into our practice has been slow and steady. We believe this is partly due to lack of awareness of the benefit of the G8. Empowering nurses to complete the G8 has improved screening at our cancer center. To further improve awareness and utilization, we have initiated an interprofessional education lecture series regarding care of geriatric oncology patients, which provides nurses CNE. As we gather data on the reflex referrals to geriatricians for CGA, we will work on goals to increase MD/APP engagement.

[Table: see text]
Collaboration with commercial payor to eliminate prior authorization.
Authors: Sharma Mallika , Gustafson Annika , Jagels Barbara , Wong Tracy
Published: October 2019

9

Background: For commercial insurance plans, there is often a requirement to obtain prior-authorization for specific services. Prior-authorization though intended to ensure medical necessity, can cause significant delays in patient care and create an unnecessary administrative burden. It often leads to undue anxiety in patients, dissatisfaction among providers and substantial waste in the system. To increase our efficiency and improve patient and provider experience, we partnered with one of our region’s largest commercial payors to eliminate prior-authorization. Methods: A Lean Six-sigma DMAIC approach was adopted: Define- created a process map. Measure- calculated baseline for prior-authorization denials. Analyze- conducted retrospective analysis to identify areas to improve. Improve- conducted provider training for appropriate imaging guidelines. Control- established internal auditing to check provider compliance. Results: At SCCA, we found that 94.8% of prior-authorizations were approved instantly or after providing more documentation, thus prior-authorization did not add value. Moreover, 2.15% were approved after peer-to-peer review that involves significant administrative burden and delay in care. Only 3% prior-authorizations did not meet medical necessity criteria, major reasons being- PET/CT and CT CAP ordered in combination, or PET/CT ordered without clear justification. 2.46% prior-authorizations led to a patient receiving a letter of denial. SCCA and the payor agreed to eliminate prior-authorizations for all imaging (except PET and PET/CT). This required all ordering providers to attest to completion of training on the NCCN Imaging Appropriate Use Criteria. In addition, a quarterly internal audit was put in place to check provider compliance to NCCN guidelines for ordering Imaging tests. SCCA achieved a 100% provider training completion rate and 100% provider compliance to NCCN guidelines in the first two internal audits. Conclusions: A strong partnership and shared vision with a payor enabled us to eliminate wasteful prior-authorizations. Our high training completion rate and compliance rate implies strong support from our providers and leadership to provide value-based care to our patients.