bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment trends for stage III non-small cell lung cancer for noninsured patients compared with other types of insurances: A National Cancer Database analysis.
Authors: Abou El Ezz Khaled , Olson David Charles , Silberstein Peter T.
Published: February 2017

262

Background: This study investigated trends in management of stage III NSCLC in patients with no insurance versus other insurance types using the National Cancer Database (NCDB). Methods: 281,277 patients with Stage III NSCLC were identified from 2000 to 2009 using the NCDB. Reported use of surgery, radiation, chemotherapy, or no treatment were analyzed by insurance status. Results: Radiation/chemotherapy was most often used to treat stage III NSCLC among non-insured (41.7%), Medicare (31.3%), Medicaid (42.3%), and private insured patients (43.9%). Non-insured were just as likely to receive radiation/chemotherapy as Medicaid (41.7% vs. 42.3%, p=0.36) but less likely than privately insured (41.7% vs. 43.9%, p<0.001). Non-insured were more likely to receive no treatment than privately insured (20.8% vs. 11.7%, p<0.001) and Medicaid (20.8% vs. 16.8%, p <0.001) but less likely than Medicare (20. 8% vs. 24.6%, p<0.001). Tri-modality treatment was given less often to non-insured patients than privately insured (4.6% vs. 10.2%, p<0.001) and Medicaid (4.6% vs. 6.2%, p<0.001) but more often than Medicare patients (4.6% vs. 3.7%, p<0.001). Conclusions: Stage III NSCLC was most often given chemotherapy/radiation regardless of insurance status. Non-insured patients received this treatment as often as Medicaid but less often than privately insured. Non-insured patients also received no treatment more often than Medicaid and privately insured and less often than Medicare. Future studies could examine if average age among the populations impacted these findings. [Table: see text]
National Radiation Oncology Registry: The pilot prostate cancer registry.
Authors: Efstathiou Jason Alexander , Nassif Deborah , Chen Ronald C. , Hoffman Karen Elizabeth , Kuban Deborah A. , Lawton Colleen Anne , Michalski Jeff M. , Potters Louis , Rose Christopher M. , Sandler Howard Mark , Suh Warren , Wall Terry , Zietman Anthony L. , Bekelman Justin E.
Published: February 2017

267

Background: The National Radiation Oncology Registry (NROR), sponsored by the Radiation Oncology Institute and the American Society for Radiation Oncology, is building a nationwide electronic infrastructure to collect standardized information on cancer care delivery among patients treated with radiotherapy in the United States. The NROR pilot registry will focus on patients with prostate cancer (PCa). Methods: Since October 2010 the NROR has undertaken four main efforts (1) stakeholder engagement, including hosting a forum with ongoing opportunities for feedback from patients, clinicians, payers, vendors, and federal agencies; (2) electronic infrastructure development to facilitate transfer of information from disparate clinical systems to a database model designed for efficient aggregate analysis; (3) data dictionary development with guidance from PCa and technical experts, and health services researchers; and (4) pilot site engagement, in which over 80 clinical centers indicated willingness to participate in the pilot registry by filling out an online survey. Results: The stakeholder forum revealed enthusiasm for the NROR and emphasized the need for patient-centered outcomes, minimal data burden, and maximal connectivity to existing registries and databases. In partnership with Healthcare IT, Inc, the NROR is building an electronic infrastructure to provide connectivity across radiation oncology and hospital information systems. The data dictionary provides standardized data elements in seven domains: facility characteristics, physician demographics, patient demographics and comorbidity status, radiotherapy technical data for external beam and brachytherapy, hormone therapy details, clinician- and patient-reported outcomes. Up to 30 clinical centers will be selected to serve as pilot sites through an objective, blinded, and transparent process. Pilot registry endpoints include percentage of eligible patients enrolled, percentage of data elements captured for each participant, determination of barriers to participation, and patterns of care delivery. Conclusions: The NROR pilot study will provide the framework for expansion to a nationwide electronic registry for radiation oncology.
Matching physician resources with demand in a cancer hospital emergency center.
Authors: Terrell John Allen , Todd Knox H. , Burke Laura
Published: February 2017

276

Background: In early 2010 the Emergency Center (EC) at MD Anderson Cancer Center identified a need to adjust the physician staffing to better meet the demand of increasing patient work-load and improve physician satisfaction. There was also a strong interest in learning more about variations in work methods and how physician time was spent in the EC. Methods: The EC partnered with the Office of Performance Improvement (OPI) to perform a work sampling study and analyze how physicians’ time is spent by physician, time of day, and day of week. Also needed to properly match resources to demand was how the patient demand varied with time of day and day of week. Before the study was performed the tasks and categories of interest were established and training as well as a measurement study to ensure consistency from one data collector to another. A sampling plan and method were then developed to identify and record the frequency of tasks performed to be studied by shift, day, and physician. Patient data was collected through the internal computerized whiteboard to identify patient arrivals and occupancy. Results: The results showed the variation in tasks performed was most highly attributable to the individual physician rather than time of day and day of week. Percentages of the shifts were calculated, summarized, and presented to the EC leadership. This data was then combined with the patient volumes data in an interactive spreadsheet to simulate different scheduling patterns and provide recommendations to best match resources with workload. Conclusions: The project provided a valuable resource to contribute to identifying the best scheduling pattern for the EC including start times and shift length. The results have been further used to strive towards inter-physician consistency over the past two years and have led to additional studies and opportunities for improvement. By using a data based methods, even for qualitative studies, important process understanding and opportunities are available which can help break through barriers and improve data based decision making in health care.
Use of palliative care measures to support improved patient outcomes and quality of life.
Authors: Williams Ken , McBride Tilithia
Published: February 2017

281

Background: Key public-private quality improvement entities, such as the National Quality Forum (NQF) and the National Priorities Partnership, have identified palliative care measures as being critical for the care of cancer patients. In this study, Avalere sought to understand whether current palliative care measures are adequate to support desired patient outcomes, including quality of life. Methods: Avalere conducted searches of large, national quality measure databases—including the Agency for Healthcare Research and Quality’s National Quality Measure Clearinghouse and NQF—as well as public quality measurement programs to better understand the range of existing palliative care measures and the use thereof. In addition, Avalere augmented this research through a review of the white and grey literature to determine how such measures may be better used to support desired outcomes. Results: Several organizations—most notably the American Society of Clinical Oncology (ASCO); the American Medical Association–convened Physician Consortium for Performance Improvement, with the National Comprehensive Cancer Network and ASCO; and the RAND Corporation—have developed measures addressing palliative care for cancer patients. Several of these measures have been subsequently endorsed by NQF. Despite this, few palliative care measures have been incorporated into national quality measurement programs, outside of ASCO’s proprietary Quality Oncology Practice Initiative (QOPI). Conclusions: While it is widely acknowledged that palliative care measures are critical for the care of cancer patients, particularly as it relates to supporting quality of life, little has been done to ensure such measures are incorporated into national public quality improvement initiatives, such as the Centers for Medicare & Medicaid Services’ Physician Quality Reporting System. As calls for increased use of patient-reported outcomes and other palliative care measures continue to rise, policymakers may need to consider incorporating existing, NQF–endorsed measures, such as those used in QOPI, into public programs.
Data-driven transformation to an oncology patient-centered medical home.
Authors: Sprandio John David , Flounders Brian , Lowry Maureen R. , Tofani Susan Higman
Published: February 2017

285

Background: Consultants in Medical Oncology and Hematology (CMOH) implemented an EMR in 2003. It fell short in the compilation and presentation of meaningful data upon which to base clinical decisions. CMOH created a new workflow and effectively integrated the EMR with a practice-developed clinical decision support software (CDSS) called Iris. Methods: A project team outlined the data sources required in making a clinical decision and reviewed staff workflow. Within six months, they developed a system for displaying data from internal and external sources into a single scrollable screen for use by the physician at the point of care. Results: Iris promotes a rapid-learning cycle that results in 1) improved adherence to NCCN guidelines; 2) enhanced access and continuity of symptom management; 3) enhanced communication, tracking, and coordination of care; 4) reduction in ER utilization/hospital admissions; 5) a performance status driven approach to end of life care; 6) a systematic measurement of physician performance. This approach enabled CMOH to meet the NCQA’s criteria for level III Patient-Centered Medical Home in 2010. Conclusions: Implementation of EMRs alone does not improve health care delivery. Rather, it is the merger of clinical operations workflow and technology infrastructure delivering consumable data to providers that drives quality improvements and enhancements to the value of cancer care. [Table: see text]
Telehealth for oncology genetic counseling: An Idaho experience.
Authors: Eichmeyer Jennifer N. , Zuckerman Dan Sayam , Beck Thomas M. , Camilo Nicolas , Mark Kevin , Barbera James , Bradshaw Nicole , Greenburg Brett , Johnson Devan
Published: February 2017

288

Background: Access to qualified genetics specialists continues to be a barrier for patients in rural settings. Our institution aimed to develop a proof-of-concept telehealth program that supports the vision of transforming the way healthcare is delivered specific to Idaho. Methods: Based on a needs assessment with 40 direct caregivers the program was designed to eliminate inconsistency and variation through the system and expand the specialty care footprint from the tertiary care hospital. To gain traction, specific areas (genetic counseling and nutritional counseling) were identified that could move forward with telehealth. This small-scale implementation could be rapidly executed using few system resources while providing feedback for future refinement and expansion. Technology needs included, Microsoft Lync, a HD web camera, USB speaker/microphone, dual monitors, and a document camera to be added to workstations for the provider. A transportable cart with computer and dual monitor workstation was assembled for the outreach site with the same technology components. The metrics chosen to track the benefits of this service included: provider travel time and costs, elapsed time from referral to first scheduled appointment, comparison of patient volumes, and patient satisfaction. Satisfaction measures were collected by written questionnaires and interviews with the patient. Results: During a 3-month period 23 genetic counseling appointments were conducted by telehealth. This resulted in a savings of $1050.63 in mileage and travel wages and 13.5 travel hours. Wait times for appointments dropped from 23 days to 16 days, and appointment volumes increased from 6/month to 8/month. Access to services increased from 8 hours per month to 16 variable hours per month with the availability of immediate needs appointments. Patient scores (N=12) demonstrated “Excellent” ratings (5/5) in the following: 83% satisfaction using the telehealth cart, 83% likelihood to use telehealth again, and 92% recommend telehealth to a friend. Conclusions: Improved convenience, access, and cost savings while providing high quality care were maintained using telehealth. Expansion of the program to another outreach site has already been approved by leadership.
Short-term outcomes of implementation of a computer-based breast cancer risk assessment program during screening mammography.
Authors: Ray Debra , Grumet Sherry , Lagmay-Fuentes Portia , Jacob Lolita , Terzo Annette , Puma Alex , Hwang Shirley
Published: February 2017

298

Background: Major barriers to high risk breast cancer risk assessment include inadequate documentation of family history, complexity of risk calculation and model selection, and lack of awareness. We have established a high risk breast cancer assessment program using a computer-based real time risk calculation at time of screening mammography. Objectives were to facilitate identification of high risk patients needing genetic counseling/testing and MRI breast screening. Methods: Beginning 11/23/2010, prior to screening mammogram all patients completed a self reported risk assessment using a wireless tablet. With real time risk calculation for risk of genetic mutation (Myriad and BRCAPRO models) as well as life time risk of breast cancer (Gail, Claus, Tyrer-Cuzick, and BRCAPRO models) using HughesRiskApps patients were categorized into high risk ( ≥ 10% gene mutation risk or ≥ 20% life time breast cancer risk) or average risk groups and received a risk assessment letter. The risk data was integrated into mammography information system (Penrad) simultaneously. High risk patients were contacted by a coordinator to facilitate high risk clinic evaluation. Results: As of June 30, 2012, 24,213 patients without a cancer history completed HRA; 2,196 patients (9.1%) have been identified as high risk- for genetic mutation 1,051 pts, (4.3%), life time risk 1,570 pts, (6.5%), and both risks 425 pt, (1.8%). 416 patients (18.9%) of those high risk patients have been evaluated in the high risk clinic. 231 patients have been evaluated by genetic counselor and 97 have had genetic testing and 9 with positive results (9.3%). Yearly screening breast MRI has been recommended to 254 patients. Conclusions: We have successfully implemented breast cancer risk assessment through screening mammography service. Results suggest that 9.1% of our patients can benefit from high risk clinic assessment and 4.3% should have consideration for gene mutation testing. 6.5% of our patients may benefit from screening breast MRI. We strive to improve the number of patients who proceed with high risk clinic assessment by education of our patients regarding benefits of screening and risk reducing strategies.
Using computerized chemotherapy ordering to improve performance and documentation of informed consent.
Authors: Brandman James F. , Knop Carol , Giammicchio Karen
Published: February 2017

299

Background: Informed consent is the foundation of patient-centered care. In the context of clinical trials involving chemotherapy, rigorous adherence to this principle is required. However, for the large majority of patients treated with chemotherapy outside of clinical trials, adherence to obtaining consent is suboptimal. In the past five Quality Oncology Practice Initiative (QOPI) audits, Northwestern University Hematology/Oncology performed worse than other academic cancer centers and the aggregated QOPI cohort. Methods: Informatics devised three steps to transform the process from memory dependent to electronically driven: 1. Insertion of “InformedConsentChemotherapy” generates text documentation of the required elements of informed consent: Cancer/Stage, Goals, Dose/Schedule, Side effects, Alternatives. 2. Required completion of the following pop-up attestation before electronic orders can be signed: “Informed consent (including the required elements) has been discussed and documented.” 3. Display of the completed attestation statement when the patient’s chemotherapy module is accessed. Results: One month after implementation an audit showed 100% display of the attestation statement and 98% concordance with actual informed consent documentation. Conclusions: This innovative informatics process change yielded major improvement in adherence to the fundamental patient-centered standard that chemotherapy informed consent be discussed and documented. Potential weaknesses in this informatics solution include completion of the attestation without documentation of informed consent and completion of the attestation without an actual consent discussion. The audit demonstrated that the first occurs rarely while the second is impossible to measure without continuous direct observation. Minimizing dependence on memory, the advantages of electronic chemotherapy ordering provide the capacity to make doing the right thing—documenting informed consent—the easy thing. [Table: see text]
Developing and implementing a balanced scorecard to improve efficiency, cost-effectiveness, and patient experience.
Authors: Colman Gerard , Moorad Julianna Grisham
Published: February 2017

3

Background: MD Anderson Cancer Center’s Balanced Scorecard initially created in 2005 by the Office of the SVP and Chief of Operations reports key monthly financial, productivity, process and satisfaction metrics for 29 outpatient care centers on the main campus. It was developed as a management tool of standardized metrics to help align the centers’ annual operational goals with the institution’s overall strategy, goals, and processes, to improve operational efficiency, drive down costs and improve access and patient experience. Methods: The first step to develop the scorecard was to identify metrics that could be measured across all centers under each key strategic goal: financial, productivity, process, and satisfaction. The next step was to set target goals with a standard improvement percentage based on previous year’s performance. The result is a monthly overall trend score for each center. Lastly, a two-way communication process for reporting and recording the metrics was established. Results: The ultimate benefit of the scorecard is to positively impact patients and oncology care by not only delivering quality patient care, but doing it efficiently and cost effectively. The tool is transparent to all center directors and promotes accountability and sharing of best practices. Centers are actively engaged in the achievement of metrics by continuous monitoring and improving processes. The impact of improvement initiatives is easily identified via trends on the scorecard. Specific results include increased billed activity per FTE, reduced access time for new patients, increased exam room utilization and increased patient satisfaction. Within the past year, one center reduced access time for new patients by 50% from 15.59 days to 7.75 days, another center increased room turns by 5.7% from 4.01/hour to 4.25/hour. Conclusions: The value of the balanced scorecard comes from the transparent reporting and continuous owner pursuit of improvement within each of the four strategic areas. It aids in the challenge of balancing clinical care measured outcomes, patient access and throughput, and satisfaction with the business processes so that MD Anderson can continue to provide quality patient care.
Implementation of a visual appointment system to enhance oncology infusion suite efficiency at Norris Cotton Cancer Center (NCCC).
Authors: Schlosser Evelyn , Gladstone David , Scribner Deborah , Snide Jennifer
Published: February 2017

301

Background: Infusion suite patients were experiencing excessive delays for administration of chemotherapy, blood products, and hydration. Manually collected data revealed that 80% of patients did not start their infusion appointments on time, though there was limited additional data available for further analyses. The scheduling system allowed for booking a "start time" for infusion therapy, but there was no connection between the appointment slots and the actual number of infusion stations, length of the infusions, and available nursing staff. There was an identified need for 1) a “visual” scheduling system that would aid in better matching available resources with patient demand and 2) real time collection of electronic timestamps to better understand patient flow and improve efficiency. Methods: An already existing and supported visual scheduling system was introduced to the infusion schedulers. This system works by assigning patients to available resources (chairs and nurses) and timeslots. The system was piloted for four months before fully implemented. An electronic interface was created between the existing scheduling system and the visual system, eliminating the need for dual entry. Nursing began using the system to record the actual arrival and discharge times for patients. Scheduling guidelines were updated and additional functionality within the system was employed. Results: Adherence to the arrival and discharge processes are tracked on a monthly basis and shared with the infusion suite leadership and nursing staff. As compliance with check-in/out processes increase, actual utilization of the infusion suite by oncology service and treatment regimen is being evaluated. These data are useful in the identifying opportunities to reduce treatment delays and improve efficiency. Conclusions: Maximizing efficiency and utilization of infusion suite services is a goal of NCCC. Access to detailed electronic data that facilitates understanding of the demand for services and capacity of the system is critical to achieving this goal. It is our belief that a more efficient infusion suite will result in less treatment delays for patients.
Documentation of code status at an outpatient academic cancer center: A marker of discussing end-of-life preferences.
Authors: Ranganathan Anjana , Reardon Deborah , Evans Tracey L.
Published: February 2017

307

Background: Documentation of a patient’s code status preference is becoming an increasingly emphasized part of medical care. Hospitals are adopting protocols that encourage code status documentation at the time of admission; however, this requires patients to consider end of life care at a time of acute illness with a practitioner with whom they have little familiarity. We sought to assess the proportion of patients with a documented code status preference in the electronic medical records (EMR) of our outpatient oncology clinics. Methods: The EMR for all patients seen at the Abramson Cancer Center in the months of March, April, and May 2012 were reviewed for the presence of a documented code status and the specific code status designation. The query was limited to patients seen by a medical oncologist and to patients with at least five outpatient visits occurring during or prior to the month being studied. Demographic information regarding patient age, race, religion, medical comorbidities, and oncologic diagnosis including stage were also recorded. Results: A median of 2,071 patients who have had at least five prior visits were seen per month by staff medical oncologists. Of these patients, a median of 49 patients (2%) had a documented code status recorded in the EMR. Patients seen by the thoracic medical oncology group were more likely to have a documented code status (17% vs. <1%); however, these results were not statistically significant (p=0.3173), likely due to extremely small numbers of documentation. Given the low numbers of code status documentation, we were unable to detect an association with any other demographic factor. Conclusions: At our institution, only a small minority of patients with an oncologic diagnosis has documentation of code status in the readily available EMR. This initial analysis emphasizes the need for a larger effort targeted at increasing documentation of code status in the outpatient setting where patients have a longitudinal relationship with their care provider.
Combining web-based educational tools and mobile apps.
Authors: Kukreti Vishal , Sutcliffe Ken , Dosis Angela , Hertz Sherrie
Published: February 2017

315

Background: Mobile apps (MA) can be useful resources to provide point of care information. Over 50% of patients use a smartphone (SP), 75% of North American physicians own a SP, and 58% of SP users have downloaded mobile MA. MA are more readily accessible than web-based tools and usable without network connectivity. Methods: Cancer Care Ontario (CCO) has developed MA for patients and providers using the principles of end user satisfaction, simplicity and intuitiveness. These MA are taken from established web based, validated educational modules. Designed to ensure a rich native experience for each platform (WP7 and iOS), CCO’s process includes proof of concept, information design, and user interface design supported by user acceptance testing. Results: Two MA have been created: “CCO Drug Formulary” and “CCO Symptom Management Guidelines Application”. The first MA provides information on both drugs and regimens used in cancer treatment for patients and providers through alternate navigation in the same MA. From launch in October 2011 until June 2012, the Drug Formulary app had 4,280 downloads, including 39% from Asia and 14% from Europe, suggesting a global market. The second app provides symptom management guidelines for providers, hence supporting clinical decision making at point of care. From January 2011 to June 2012, the Symptom Management Guidelines MA had 4,050 downloads, in a mainly North American market. Both patient and provider feedback on preliminary evaluation has been positive. Conclusions: Patients and providers are receptive to MA as a tool to deliver real-time information at point of care. MA are another interface to existing technology solutions and other rich data sources. Further research into patient outcomes from adoption of such technology is needed.
30-day mortality of surgeries in disseminated cancer patients: An analysis using NSQIP, dividing surgeries into low, medium, and high risk.
Authors: John Pesavento Anton , Silberstein Peter T.
Published: February 2017

38

Background: This study is the first comprehensive analysis of surgical outcomes in disseminated cancer patients. Methods: ACS NSQIP has 30-day mortality data on 3,250 disseminated cancer patients and 144,199 patients who did not have disseminated cancer who underwent major surgery. Results: The most common procedures disseminated cancer patients had performed can be divided based on 30-day mortality into low risk (<3%), moderate risk (3-15%), and high risk (19-44%). Low risk surgeries include mastectomy, partial removal of the liver, and repair of the bowel opening (none of which were an emergency). Moderate risk includes non-emergent small intestine removal, bowel-to-bowel fusion, colon removal, and partial removal of the colon. High risk includes a non-emergent exploration of the abdomen, and the following surgeries if performed as an emergency: bowel-to-bowel fusion, colon removal, small intestine removal, cholecystectomy, or partial removal of the colon. Conclusions: The 30-day operative risk for disseminated cancer can be divided into low, medium, and high risk surgeries. All procedures performed under emergency circumstances have a 30-day mortality greater than 18%. Mastectomies, partial removals of the liver, and bowel opening repairs have a 30-day mortality of less than 3%. [Table: see text]
Patient (Pt) and caregiver (Cg) perspectives in non-small cell lung cancer (NSCLC).
Authors: Langer Corey J. , Evans Tracey L. , Belani Chandra Prakash , Middleton Gary William , Chouaid Christos , Pearson Kathleen , Ball Daniel E. , Bush Elizabeth N. , Guba Susan C. , Vansteenkiste Johan F.
Published: February 2017

4

Background: Research investigating Pts’ preferences in treatment (tx) decisions for advanced (NSCLC) has generally been limited to smaller, single-country studies or anecdotal reports, and has rarely included Cgs’ perspectives. Methods: A 30 minute online or phone survey was conducted 28 June to 9 August, 2011. Survey participants (SP) included NSCLC Pts (n=245) or Cgs of NSCLC Pts (n=251) treated in the prior 12 months. A 1:1 non-paired sample of Pts and Cgs was sought in the US (n=295), France (FR; n= 100) and Germany (DE; n=101). FR and DE data were weighted to better reflect the age distribution of NSCLC in those countries, then combined. Results: For NSCLC SP, 64% were ≤65 years; 52% were male; 13% current smokers; 64% former smokers. Disease was localized in 21%, advanced in 73% and unknown in 6%. Tx was ongoing in 54%, and in 15% and 31% respectively tx was completed < 3 or 3-12 months previously. SPs elected tx to maintain independence (90%) and to control the cancer (89%); 81% were willing to continue tx indefinitely to maintain disease control. Although 69% of SP were greatly concerned about chemotherapy side effects, 60% were willing to endure significant side effects to live longer. SPs were comfortable asking their doctor questions (84%), and 68% were comfortable asking questions if they disagreed with recommended tx; 58% of SPs usually deferred tx decisions to the doctor. Comprehension of the tx plan was higher upon tx initiation (71%) than at diagnosis (46%) or at time of initial explanation by the doctor (62%). Many SPs (77%) relied on the nurses to help them understand their condition/tx. Among SPs in whom tx was discontinued (n=230), the most common reported reasons for stopping were that the cancer decreased in size (41%) or had stopped growing (28%). Only 14% believed tx was stopped because the cancer was not responsive, while 13% believed the cancer was gone. Conclusions: This large 3-country survey characterized factors important to the NSCLC SP in determining motivations for tx including a desire to control the disease and willingness to continue treatment for disease control if there was an acceptable risk/benefit balance. The survey also indicated a possible misapprehension on the reason(s) tx was halted.
Patient-reported oncology readmission factors.
Authors: Kangovi Shreya , Evans Tracey L. , Mitra Nandita
Published: February 2017

48

Background: Reducing the risk of readmissions is an important quality goal for hospitals. Little is known of the perspectives of patients on underlying challenges that may lead to readmission. The objective of this study was to elicit perspectives of readmitted oncology patients on barriers to a successful transition from hospital to home. Methods: As part of a larger survey of readmitted inpatients, a 36-item survey was administered to 197 oncology patients readmitted to the hospital within 30 days of discharge to home. Surveys were administered at The Hospital of the University of Pennsylvania (an urban tertiary care academic medical center) and Penn Presbyterian Medical Center (an affiliated urban community hospital), both located in Philadelphia. Responses were entered in real-time into the electronic medical record (EMR) and used by the care team to address patient concerns and improve quality. Results: 45.2% of readmitted oncology patients reported challenges during the transition from hospital to home which they perceived as contributing to readmission. The most commonly reported transition challenges within the oncology population included difficulty with activities of daily living (ADLs) (17.8%), feeling unprepared for discharge (14.2%) and difficulty adhering to medications (7.1%). 15.2% of patients could not identify any modifiable factor contributing to readmission and reported returning simply because of symptoms from progressive illness. After adjusting for potential confounders (age, gender and severity of illness) using multivariable logistic regression models, uninsured and Medicaid patients were more likely than other patients to attribute readmission to difficulty accessing medications (OR 4.5, 95%CI 1.0, 19.9) and performing ADLs (OR 2.7, 95%CI 1.18, 6.1). Conclusions: Understanding challenges reported by readmitted oncology patients may enable inpatient oncologists to tailor transitions interventions to patient needs. Specifically, ensuring patients are able to perform necessary ADLs, are prepared for discharge and have assistance with medication adherence may help prevent unplanned readmissions. Uninsured and Medicaid patients may require additional assistance with accessing medications and ADLs.
Copayment assistance and adherence to prescription medication among patients with cancer.
Authors: Zullig Leah L. , Peppercorn Jeffrey M. , Schrag Deborah , Taylor Donald H. , Zhong Xiaoyin , Samsa Gregory , Abernethy Amy Pickar , Zafar Yousuf
Published: February 2017

57

Background: The relationship between prescription medication adherence and copay assistance is understudied and directly impacts quality of care. Methods: We conducted a cross-sectional survey study assessing patient-reported failure to take medication as prescribed (nonadherence) and application for copay assistance. Participants were enrolled between 6/2010-5/2011 from the HealthWell Foundation (a copay assistance program) and Duke Cancer Center. Eligible patients were adults receiving treatment for a solid malignancy. Nonadherence was defined as taking a less than prescribed amount of medication, not filling or partially filling a prescription, or taking medications prescribed for someone else. Adherence and receipt of copay assistance were not linked to a specific drug. Logistic regression assessed the association between medication nonadherence, copay assistance application, and financial burden. Results: Among 258 participants, 75% applied for copay assistance. 38% (n=99) reported nonadherence with medications due to cost. Compared to adherent participants, nonadherent participants were more likely to: ask their doctor for a less expensive medication than prescribed (p<0.001); reduce spending on basics like food or clothing to pay for medication (p<0.001); purchase an over-the-counter drug to replace a more costly prescription (p<0.001); borrow/use credit to pay for medications (p<0.001); and talk with doctors about treatment-related costs (p=0.014). In adjusted analyses applying for copay assistance did not change odds of nonadherence. Having a prescription drug plan (OR 6.56, 95% CI 1.69-25.53) and utilizing coping strategies (OR 2.72, 95% CI 2.03-3.65) increased odds of nonadherence; older age (OR 0.93, 95% 0.88-0.98) decreased odds of nonadherence. Conclusions: Medication nonadherence due to cost was prevalent among cancer patients whether or not they applied for copay assistance. To afford medications cancer patients adapted their lifestyles and altered their care. Future research should investigate whether underinsured patients have timely access to copay assistance programs and whether copay assistance impacts the quality of care.
My choices, my wishes: Advance care planning advocacy in the adult oncology population.
Authors: Mikan Sabrina Q. , Hoverman J. Russell , Patt Debra A. , Turnwald Brian
Published: February 2017

6

Background: Working through end-of-life care (EOL) issues with our patients is one of the most challenging aspects of cancer care. Although studies of EOL care interventions that are patient-focused and result in high-quality EOL experiences are increasing, most still do not achieve an EOL experience consistent with preferences. We aimed to provide an intervention for standardized advanced care planning (ACP) documentation and education to improve quality of life (QOL) for patients (pts) with terminal cancer (TC). Methods: Pts with TC (for this study defined as stage IV cancer or metastatic disease) were evaluated retrospectively through our EHR IKnowMed (IKM) before and after an ACP documentation and an education intervention. Descriptive statistics were used to identify and measure utilization of ACP introduction and charting as well as completion of advance directive documentation. Within IKM there are discrete fields for EOL data including ACP discussion, ACP facilitation, documentation of ADs. Education on tool documentation occurred in early 2012. Our ACP program was launched in March 2012. This included an ACP office visit conducted by a practitioner with ACP training, standardized education literature on EOL and ACP, launch of a website with EOL and ACP educational material, recording of ACP documents and documentation of hospice utilization and ACP preferences within our EHR. Results: Baseline characteristics and improvements in ACP introduction, charting, and AD documentation that occurred during our documentation and intervention process can be seen in the Table. Conclusions: Implementation of a standardized ACP program improves utilization and documentation of ACP planning, and documentation of ADs. These interventions improve QOL and health literacy for patients with TC. By incorporating these strategies with definable metrics, strategic intervention can be measured and reported. Further study of the relationships between ACP documentation and patient outcomes is necessary for comprehensive oncology care. [Table: see text]
Expanding patient-reported outcomes to oral health complications from systemic cancer therapy.
Authors: Miksad Rebecca A. , Goyal Rohit , Gazelle G. Scott , Swan J. Shannon
Published: February 2017

60

Background: Cross-disciplinary patient reported outcomes (PROs) assess the full range of side effects from systemic cancer therapy. For oral health complications, however, the validity of oral-health specific and generic health-related quality-of-life (QoL) instruments is unknown for cancer patients. This study evaluates the performance, measurement, and prediction characteristics of the Oral Health Impact Profile (OHIP–14) and EQ–5D in cancer patients with bisphosphonate-associated Osteonecrosis of the Jaw (ONJ). Methods: 34 cancer patients assessed the QoL of their own ONJ with the OHIP–14 and evaluated the QoL of 4 standardized ONJ Health States with the EQ–5D, as previously published. For each instrument, the standard response mean (SRM), effect size (ES), and ability to distinguish minimally important differences (MID) were evaluated for ONJ compared to baseline (longitudinal responsiveness). Instrument MIDs (cross-sectional responsiveness) were also calculated. Performance of a published general dentistry algorithm to predict EQ–5D values from OHIP–14 results was tested. Results: The OHIP–14 and EQ-5D instruments demonstrated moderate to large longitudinal and cross-sectional responsiveness. Pain was one of the most responsive domains for both instruments. Ceiling/floor effects were most prominent for OHIP–14. A general dentistry algorithm did not adequately predict EQ–5D values for cancer patients. Conclusions: This study provides the first empirical evidence for the performance, measurement, and prediction characteristics of oral-health specific and generic QoL instruments for the oral health side effects of systemic cancer treatment. Instrument validity is supported for oral health complications in cancer patients. These results provide benchmarks for PROs at the intersection of oral medicine and surgery, dentistry, and oncology. [Table: see text]
Key concerns and symptoms of patients undergoing second- and third-line treatment for non-small cell lung cancer: Findings from a patient interview study.
Authors: Magasi Susan , Kaiser Karen , Mallick Rajiv , Cella David
Published: February 2017

63

Background: Understanding key concerns and symptoms of patients undergoing cancer treatment is important for characterizing drug treatment benefit as well as developing appropriate psychosocial support interventions. The purpose of this interview study of patients undergoing second and third line therapy for non-small cell lung cancer (NSCLC) was to characterize their physiological, especially pulmonary, symptoms, functional impacts, emotional distress, health-related quality of life (HRQOL), and coping strategies. Methods: Semi-structured thematic interviews with 20 patients in second and third line treatment for advanced NSCLC. Interviews included open elicitation of NSCLC symptoms, their functional impact, and coping strategies. Results: Mean age was 62 years (range 30-79); 80% of patients had non-squamous histology, and 25% had co-morbid COPD. Patients described a range of core symptom experiences, severity, functional impacts, and coping strategies. Shortness of breath (reported by 16/20, 13/20 rated as very important), cough (reported by 14/20, 10/20 rated as very important), and chest tightness (reported by 15/20, 9/20 rated as very important) emerged as key pulmonary symptoms. Ninety percent (18/20) of patients reported tiredness or fatigue, mostly as “very important.” A quarter (5/20) of the patients reported having no pulmonary symptoms. The symptom importance ratings were influenced by the symptom’s impact on valued roles and responsibilities. Patients reported diverse coping strategies including breaking down activities into manageable tasks, priority setting, using physical assistance, emotional support, and adoption of diet/exercise changes. Conclusions: Findings from this interview study of patients receiving second and third line treatment for advanced NSCLC reveal the importance and relevance of core physiological, especially pulmonary, symptoms in characterizing the benefits of drug therapies. These findings offer insights to the patient education and psychosocial interventions that are likely to enhance patients’ HRQOL.
Development of a quality infrastructure for a 135-site statewide network of community oncologists.
Authors: Lindsey Gay , Hoverman J. Russell
Published: February 2017

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Background: The delivery of patient centered, high-value care requires a formal system of continuous quality improvement. In order to bring metrics to the site and physician level the need to revamp our program for 364 physicians was apparent The starting point was 4 physician-led network wide quality committees. Methods: In 2010, the position of Director of Quality Programs was created to assist in the development of a quality infrastructure for a statewide network of community oncologists. Beginning in January 2011 meetings were held with the management team of each site for education on national quality initiatives and the IOM 6 aims for improvement in healthcare. The discussion also included review of quality metrics set forth by ASCO’s QOPI, evidence-based pathway reporting, variance reporting on patient safety and employee safety, and processes to improve patient satisfaction. Each site then identified their team members, physician champion, and frequency of committee meetings. An action plan format was provided with discussion on components of the plan and the reporting structure to the physician-lead quality oversight committees. Results: The network currently has 38 quality committees serving 84 sites of service. Within a year’s time pathways assessable data improved from 84% to 90%, pathways adherence improved from 60% to 68%, and exception documentation rose from 14% to 25%. Variance reporting increased 35% and a network Patient Satisfaction Survey was created and administered with 10 surveys per physician collected and tabulated for baseline data. The survey process was reviewed and refined and will now be administered twice yearly at each site. Documentation of hospice referrals and follow-up processes on deceased patient information are key initiatives at each site. Conclusions: Development of a robust quality infrastructure at the site level can increase adherence to quality measures by identifying common barriers to improvement, sharing of best practices, and supporting the delivery of patient-centered, value-based care.
Securing discharge follow-up appointments in a women’s cancer program.
Authors: Dalby Carole , Campos Susana M. , Doverspike Lisa , Spinks Melissa , Jacobson Joseph O.
Published: February 2017

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Background: Ensuring patients have a follow-up appointment scheduled prior to discharge is one of several key interventions shown to reduce hospital readmission rates (Hansen L.O., Young R.S., Hinami K., et al. [2011, October]. Interventions to reduce 30-day rehospitalization: a systematic review. Annals of Internal Medicine, 155[8], 520-528). Lack of follow-up diminishes continuity between the inpatient and outpatient setting, can lead to patient dissatisfaction, as well as delays in proposed therapy. Methods: A three-month review of discharge data highlighted 49% of Women’s Cancer Gynecologic patients at an academic medical center were discharged from the hospital without securing a follow-up appointment. A multidisciplinary team involved in the scheduling process was assembled and determined failure to schedule appointments was attributed to a lack of communication between the inpatient and outpatient services, a complicated scheduling process, as well as ambiguity regarding when patient’s should return. Several rapid PDSA cycles were implemented over a three month period of time. The intervention created a standardized electronic template, including the establishment of standard time frames for follow-up appointments post discharge (7 to 10 days). The template details all required scheduling elements such as services requested, required laboratory studies, and patient preferences. Within the electronic template is the ability to directly email essential staff through a centralized email address embedded within the form. Staff engaged through reviewing of data, identification of the importance of securing a follow-up appointment, and weekly huddles. Results: Post intervention, the rate of compliance of scheduled discharge follow-up appointments rose from 49% to 87%. Staff reported high satisfaction with the new process, highlighting its simplicity and efficiency. Conclusions: Securing a follow-up appointment prior to discharge is feasible as evidence by increased compliance from baseline 49% to 87%. Future endeavors will implement this process across other disease programs in hopes of obtaining similar results.