bluuebunny/crossref_metadata_2025 huggingface dataset:
A new digital classification schema to detect treatment variances and enable value-based payment reforms.
Authors: Pecora Andrew , Schultz Eric V , Choi Kelly , Kea William , Smith Augie , Kim Cindy , Axelrod Matthew , Fletcher Teresa , Love Matthew , Pe Benito Ruth , Daswani Samira , Kaur Sukhi , Tanenbaum Kathyrn , Schaffer James , Hasan Ali , Raj Dilip , Prabhu Kumar Bharath , Suryadevara Kiran , Callahan Ryan , Goldberg Stuart L.
Published: February 2017

28

Background: Value based payment reforms which improve the outcome to cost ratio (paying for outcomes not for services) require detailed information on both elements. Although the digitalization of medicine via the EHR may facilitate data collection, the imprecise ICD9 and ICD10 schemas hinder analysis (eg: all breast cancers are ICD9 174.9). A more precise classification schema that accounts for biologic variances to allow analysis (and reduction) of treatment variances is needed. Methods: We have developed a digital classification (COTA Nodal Address) based on known clinically relevant prognostic variables. (eg: breast cancer variables include stage, tumor size, hormone status, her2 neu status, etc.). The digital classification also accounts for therapy status (neoadjuvant vs adjuvant, etc.) and line (1st or 2nd treatment, etc.). Results: Using breast cancer as an example, there are > 2975 unique CNA phenotypes that encompass prognostic and treatment status variables. However, in a series of 1204 patients in a community setting only 114 CNAs have been utilized, suggesting biologic disequilibrium. Two phenotypes accounted for the top 25% of cases, 6 for the top 50% and 16 for the top 75%. Early stage, small tumor, hormone receptor positive were most common. The CNA classification uncovered treatment variances among patients with similar phenotypes. In an ongoing episodes of care payment program, young breast cancer patients with early stage, good performance status, hormone positive, her2 neu negative, very small tumors (with similar extended attributes) received varying adjuvant treatment strategies (hormone alone 46% , non-anthracycline 35%, anthracycline chemotherapy 4%, observation 1%). Conclusions: Unlike ICD9/10 systems, a digital classification schema that precisely segregates cancers into unique cohorts based on complete biologic characteristics can rapidly identify behavioral variances at scale that drive differences in outcomes and costs. Using the breast cancer model, we have noted demographic disequilibrium in cancer presentations (potentially a factor of both biology and screening practices) and major variances in treatment strategies (with impact on outcomes/ costs).
Why do patients still go to low-volume hospitals for complex cancer surgery?
Authors: Liu Jason B , Bilimoria Karl Y. , Mallin Katherine , Ko Clifford Y. , Winchester David P
Published: February 2017

300

Background: While a strong volume-outcome relationship exists for many cancer operations, patients continue to undergo these operations at low-volume centers. Methods: Patients were identified from the National Cancer Data Base (NCDB) from 2010-2014 who underwent resection for bladder, breast, esophagus, stomach, pancreas, lung and rectal malignancies from 1,406 hospitals. Low-volume hospitals were defined as those in the bottom quartile by surgical volume for each operation separately. Regression models were developed to assess patient-level factors associated with undergoing surgery at a low-volume hospital for their malignancy. Results: Of 633,853 patients identified, 49,926 (7.9%) underwent cancer surgery at a low-volume hospital. The low-volume threshold was 1 case/year for bladder, 34 for breast, 1 for esophagus, 1 for stomach, 1 for pancreas, 5 for lung, and 2 for rectal cancers. For all the cancer surgeries examined, patients were more likely to undergo surgery at a low-volume hospital if they lived in a rural area or if they already had to drive a long distance just to reach the low-volume hospital. Patient demographics, socioeconomic factors, insurance type, comorbidities, and stage of disease were not consistently associated with undergoing surgery at a low-volume hospital across all malignancies. Although breast cancer is a common cancer with a less established volume-outcome relationship, the factors associated with undergoing surgery at a low-volume hospital were similar to those of the more complex cancer operations. Conclusions: Patients continue to undergo surgery at low-volume hospitals due to where they live and how far they have to travel. Regionalization policy initiatives will remain challenging in this population. Efforts should therefore continue to emphasize quality improvement locally at each facility caring for patients with cancer.
The influence of a composite hospital volume of upper gastrointestinal cancer resections on outcomes of gastric cancer surgery.
Authors: Busweiler Linde A.D. , Dikken Johan L. , van Berge Henegouwen Mark I. , Ho Vincent K.Y. , Henneman Daniel , Tollenaar Rob A.E.M. , Wouters Michel W.J.M. , van Sandick Johanna W.
Published: February 2017

305

Background: There is a known volume-outcome association for complex surgial procedures such as oncologic gastric resections. The aim of this study was to describe the process of centralization for gastric cancer surgery in the Netherlands in relation to other types of upper gastrointestinal (GI) cancer resections and to investigate whether the quality of gastric cancer surgery is affected by the overall experience with those related complex surgical procedures. Methods: Data on all patients (n = 4251) who underwent surgical treatment for non metastatic invasive gastric cancer between 2005-2013 were obtained from the Netherlands Cancer Registry. Annual hospital volume categories were based on the overall volume of gastrectomies, esophagectomies and pancreatectomies together (composite hospital volume). Volume-outcome analyses were performed for lymph node yield, 30-day mortality, and overall survival. Results: The percentage of gastric cancer patients who underwent a resection in a hospital with a volume of at least 20 gastrectomies per year increased. At the same time, the percentage of gastric cancer patients who underwent surgery in hospitals with an annual composite hospital volume of at least 20 upper GI cancer resections, such as esophageal and pancreatic cancer resections, increased. A higher composite hospital volume was associated with a higher lymph node yield, a lower 30-day mortality, and an increased overall survival. Conclusions: In the Netherlands, an increasing proportion of gastric cancer resections is performed in hospitals that are high volume centers for esophagectomies and pancreatectomies for cancer. Experience with these complex surgical procedures has a favorable effect on the outcomes of gastric cancer surgery.
Influencing antiemetic prescribing practices and funding changes through evidence-based guidelines.
Authors: Vu Kathy , Wan Michael , Pardhan Aliya , Redwood Erin , Crespo Andrea , Lakhani Nita , Kaizer Leonard
Published: February 2017

31

Background: In 2013 Cancer Care Ontario released updated antiemetic recommendations supporting the use of aprepitant-based combinations as 1st line therapy for highly emetogenic and 2nd line therapy for moderately emetogenic chemotherapy and discouraging the prolonged use of 5-HT3 antagonists. In 2014 changes were made in the Ontario drug formulary to align public funding to those recommendations. The impact of the changes in guidance and public funding on prescribing practices are now being analyzed. Methods: Using the Ontario Drug Benefit (ODB) database, data was extracted to analyze the prescribing practices of aprepitant, granisetron and ondansetron for chemotherapy-induced emesis between the pre-funding period (November 2013 to September 2014) and post-funding period (October 2014 to July 2015). Results: Prior to funding changes, an average of 197 prescriptions/month of aprepitant were billed to the ODB program totaling $22,422. After funding, an average of 1,165 prescriptions/month of aprepitant were billed totaling $132,145. This represented a 490% increase in utilization. The combined 5-HT3 receptor antagonists prescriptions/month billed during the respective time periods were 5,592 ($405,604) and 5,536 ($402,628). This represented a 1% decrease in utilization. Conclusions: There was a significant increase in aprepitant utilization and total expenditure to the ODB program indicating strong uptake of the triple-drug recommendation for highly emetogenic regimens. However, there was minimal change in prescribing practices related to the 5-HT3 receptor antagonists, indicating a reluctance to decrease utilization. Further work is necessary to discourage the prolonged use of 5-HT3 receptor antagonists.
Chemotherapy costs associated with receipt of the adoption of oncotype DX in early-stage breast cancer within the SEER-Medicare population.
Authors: Dinan Michaela Ann , Mi Xiaojuan , Reed Shelby D. , Lyman Gary H. , Curtis Lesley H
Published: February 2017

32

Background: The Oncotype DX (ODX) multigene assay has been previously suggested to result in an overall reduction in the use of adjuvant chemotherapy and associated costs for women with early stage, estrogen receptor (ER)-positive breast cancer. However, the association between adoption of ODX and chemotherapy costs has only previously been considered in theoretical models and has not been examined using actual patient outcomes in real world clinical practice. Methods: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER) -Medicare data of the association between overall and chemotherapy-specific costs associated with adoption of ODX testing in patients diagnosed with invasive, non-metastatic, ER-positive breast cancer between 2005 and 2009. We limited our primary analysis to women ages 66 to75 to include women in which adjuvant chemotherapy would be most likely to be considered. Total Medicare payments were used to calculate direct costs in the year following diagnosis. NCCN guidelines were used to stratify patients on the basis of clinical and pathologic features into low ( < 1.0 cm), intermediate, and high risk (node positive) disease. Results: A total of 21,272 women met study criteria. Average costs in the year following diagnosis were $31,532 in the overall cohort, and was highest for women with NCCN high risk ($45,192) vs. intermediate ($28,642) or low ($23,662) risk disease. Chemotherapy costs followed similar trends ($4,819, $1,157, and $226 respectively). In multivariable analyses, ODX was associated with a relative decrease in chemotherapy costs among high risk women (RR 0.54, 0.37-0.77), but increased costs among low and intermediate risk women (RR1.36, 1.13-1.26 and RR 3.73, 2.13-56.54). Women with high risk disease had significantly lower absolute chemotherapy costs associated with receipt of ODX (-$2,298, -$3,049 to -$1,547; All P < 0.001). Conclusions: Receipt of ODX testing was associated with relative and absolute decreases in chemotherapy costs, but only in women with high NCCN risk disease. Further research is needed to disentangle correlative vs. causative association of ODX testing with patient outcomes and costs.
Value in cancer care: Regional initiative to improve care through data reporting and interventions.
Authors: Kreizenbeck Karma L. , Hoopes Teah , Steuten Lotte , Shankaran Veena , Goulart Bernardo , Lyman Gary H. , Brown Thomas David , Chen Eric Y. , Conklin Ted , Corman John M. , Lonergan Matt , Lessler Daniel , Martins Renato , Mera Csaba , Rieke John Whitelaw , Saikaly Elie P. , Smith Julie C. , Stewart F. Marc , Whitten Richard , Ramsey Scott David
Published: February 2017

34

Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR), partnered with community members to launch a regional, stakeholder-driven initiative to define and report value metrics for cancer care for Washington State. Region-wide Summits were held in 2014 and 2015. Participants included local healthcare delivery organizations, patient advocacy groups, payers, and policymakers. The 2014 Summit identified priority metrics; these metrics were reported at the 2015 Summit. Methods: For the 2015 Summit, HICOR staff developed algorithms to measure adherence to the community-prioritized metrics using a claims-registry linked database. Metrics spanned diagnosis, treatment, continuing, and end-of-life (EOL) phases of care. After reviewing adherence at the clinic-level and for the region, attendees were invited to attend break-out sessions for metrics where there was the largest variation: hospital and ED use during treatment, hospital and ED use at EOL, and breast cancer surveillance. Within the breakout sessions, participants were asked to identify barriers to adherence and possible interventions to improve care. After discussion, participants individually ranked the top 3 interventions and estimated expected improvement to be gained by successful implementation of the intervention Results: Table. Working groups were formed to develop detailed protocols for implementable interventions. Conclusions: Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus to identify and prioritize value metrics in cancer care, and to develop consensus regarding approaches to improve adherence to those metrics. [Table: see text]
Characteristics associated with in-hospital death in commercially insured decedent.
Authors: Brooks Gabriel , Stuver Sherri Oliver , Zhang Yichen , Gottsch Stephanie , Fraile Belen , McNiff Kristen K. , Dodek Anton , Jacobson Joseph O.
Published: February 2017

35

Background: A majority of patients with poor-prognosis cancer express a preference for in-home death, however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death among commercially-insured decedents. Methods: Building on a data-sharing project between our institution and Blue Cross/Blue Shield of MA, we obtained health care claims records for a sample of commercially insured decedents who died between July 2010 and December 2013. All patients received cancer care at Dana-Farber. In-hospital vs. out-of-hospital death was ascertained from hospital claims. Odds ratios (OR) and 95% confidence intervals (CI) were used to evaluate the association of in-hospital death with patient characteristics and established retrospective measures of end-of-life (EOL) care quality. Results: 904 commercially insured decedents were included in our sample, and 537 decedents (59%) enrolled in hospice prior to death. There were 254 in-hospital deaths (28% of all deaths), and 79 in-hospital deaths (31%) occurred at unaffiliated hospitals. Three measures of EOL care quality were found to be associated with in-hospital death, including chemotherapy within 14 days (OR 4.0 [95% CI 2.6-6.2]) or 15-30 days (OR 2.1 [1.4-3.1]) of death, 2 or more ED visits within the last 30 days of life (OR 3.0 [2.1-4.3]), and non-enrollment in hospice (OR 28.8 [18.7-44.3]). Hematologic malignancy, but not other cancer types, was significantly associated with in-hospital death (OR 5.09 [3.1-8.5]). Age at death, sex, marital status, race/ethnicity, and distance of residence from the cancer center were not significantly associated with in-hospital death, though sample sizes for some comparison groups were small. Conclusions: In-hospital deaths are common among commercially insured cancer patients, and data sharing identified nearly 1/3 of in-hospital deaths that occurred at unaffiliated hospitals. Retrospective measures of intensive EOL care quality were significantly associated with in-hospital death, and patients enrolled in hospice were dramatically less likely to experience an in-hospital death.
Understanding total cost of cancer care to determine strategic interventions to improve value.
Authors: Adelson Kerin B. , Velji Salimah , Patel Kavita , Chaudhry Basit , Grizzle Sonia , Lyons Catherine A. , Lilenbaum Rogerio
Published: February 2017

3

Background: Cancer centers across the country are largely unprepared to move toward value-based payment. Total cost of care data is not readily available and centers do not know how much of their patients’ care is received at other hospitals, when in the trajectory of illness greatest cost is incurred, or the elements of care that present the greatest opportunity for savings. A previous examination of practice patterns Smilow Cancer Hospital (SCH) demonstrated that our patients had high rates of ED visits, hospital admissions and ICU use in their last month of life. While this data is consistent with other large academic cancer centers (AMCs), there is a clear opportunity to improve our end-of-life planning and reduce futile care. Cost data supplemented the overutilization analysis, informing the infrastructure investments to prepare us for value-based payment models. Methods: We accessed the 5% Medicare Limited Dataset (2012-2013) to map out cost of care in 6-month episodes for all Medicare patients receiving chemotherapy. Patients who had received chemotherapy at a SCH site were flagged and the analysis included all cost of care, regardless of the site of service or type of professional delivering the service. Results: On average, a first episode of care at SCH cost $26,500, a second episode $38,000 and a third $45,600. Our analysis demonstrated important associations between increases in spending and ED utilization. Patients who had 1 or fewer ED visits during an episode, averaged $21,000 vs. $49,000 for those with 2 or more. Patients who died during an episode cost $53,000 compared to $25,600 for patients who lived. SCH episodes were significantly more expensive than CT, and slightly more than a comparable east coast Academic Medical Center. Conclusions: The above demonstrates that aggressive treatments, ED visits and hospital admissions at the end-of-life are major cost drivers. We used the analysis to target infrastructure investments in Urgent Care to reduce ED utilization, Care Management to prevent hospital admissions/readmissions and early referral to Palliative Care for clarification of goals of care. We believe these investments will lead to significant cost reductions.
Cancer, depression, and health care coverage in the state of Nevada: A retrospective cross-sectional study.
Authors: Malalur Pannaga G. , Agastya Manas , Dawod Yaser , Phan Linha , Farooqui Mohammad talha , Yoo Ji won
Published: February 2017

42

Background: The prevalence of depressive disorders in patients with malignancies is estimated at 20-50%, significantly greater than the general population. Existing literature reports a negative impact of depression on both the patient and their families. There is limited information regarding the impact of healthcare coverage on the prevalence of depression in such patients both in the state of Nevada and nationwide. Methods: A retrospective cross-sectional study was performed using the Behavioral Risk Surveillance System (BRFSS) database from 2010 to 2014. All adult subjects with a history of malignancy were included. Demographic factors and health care coverage were reviewed. Individuals with skin cancer as well as those with missing data were excluded. Patients were assigned to two groups based on their insurance coverage status. Study population was further stratified into Nevada and non-Nevada residents and analyzed. Association between depression and health care coverage across the study groups were assessed using Pearson chi-square test and regression models. Results: 183,530 subjects nationwide met our inclusion criteria. The Nevada population represented 1% (1676) of the total study sample. In Nevada, the prevalence of cancer patients without healthcare coverage was 7.5% (N = 126) compared to individuals with coverage 92% (N = 1550). This is significantly higher when compared to the national average of 4.9 % without coverage (p = 0.001). Overall, the rate of depression in cancer patients with no healthcare coverage nationally was notably higher compared to those with coverage (37.5% vs 22.7%, p = 0.001). Similarly, statistically higher rates of depression were noted in non-insured Nevada patients compared to those insured [49 (38.8%) vs. 357 (23%), p 0.001)]. Conclusions: This study demonstrates significant association between depression and lack of insurance coverage; both nationwide as well as in the state of Nevada. The proportion of uninsured Nevada residents with malignancies were higher compared to the national average. Improved and early screening for depression is crucial in mitigating the potential complications and morbidity associated with depression in patients with cancer.
Trends in cancer care with the Affordable Care Act.
Authors: Kaleem Tasneem , Miller Robert Clell
Published: February 2017

46

Background: Accountable Care Organizations (ACO), as proposed by the Affordable Care Act, will change the delivery of health care in the United States. ACO serve as a network of providers with primary care providers (PCP) set up as gate-keepers for referrals to specialists. Within the next several years, many trends will emerge and drive progress of change, requiring oncologist to take a lead role to adapt to the evolving landscape of health care. Methods: Literature search of internet-based and academic sources for oncology and the Affordable Care, with a focus on ACO formation. Results: Four main expected trends and strategies to adapt to changes were formulated. Trend 1: Changes in referral patterns towards oncologists. Referral will be based on outcome data and ACO membership. Strategy: Increase communication and education to PCP and other providers. Endorse multidisciplinary clinics, which have shown to improve guideline compliance, coordination, and communication. Trend 2: Formation of large scale oncology provider groups collaborating with PCP/ACO. Physicians will be able to provide around the clock care to patients with the goal of reducing hospital visits. Strategy: Establish oncology homes with goal of reducing inpatient and ED visits by providing telephone symptom management, daily questionnaires and opportunities for end of life discussions. Trend 3: Reimbursement reform to oncologists based on quality measures. ACO can bill fee for service basis and eligibility for bonus payments based on outcomes. Strategy:Adherence to evidence based guidelines chosen by evaluating efficacy, toxicity and cost have been proven to increase quality of patient care. Trend 4: Development to pathway driven medicine.ACO structure lends to a centralized governance committee responsible in choosing guidelines for treatment within an ACO. Strategy: Oncologists should provide a voice for the field and patients when different guidelines are chosen. Conclusions: In the context of the Affordable Care Act, oncology specialists are encouraged to participate in the new organization model to ensure best outcomes for both physicians and patients. Awareness of future trends and ways to contribute will be the first step in adapting to implementation of the Affordable Care Act.
Connecting specialty practices with primary care.
Authors: Tirodkar Manasi , Morton Suzanne , Oberlander Tyler , Scholle Sarah Hudson , Barr Michael
Published: February 2017

47

Background: Public and private payers are beginning to adopt alternative payment structures that call for greater attention to patient-centered care and quality improvement activities (CMMI 2015; MACRA 2015). The National Committee for Quality Assurance (NCQA) developed standards for Patient-Centered Specialty Practice based on American College of Physicians principles. The report describes achievement on the standards among an initial cohort of recognized physicians. Methods: We analyzed practice characteristics and determined how practices performed on each of the 21 elements in the PCSP program by showing the percent of practices scoring less than 50% of points, or 100% of points (i.e. full credit) for each element. Results: One third of the 91 practices recognized in the first year of the program are Oncology/Hematology. Overall, about half of recognized practices have more than 5 clinicians and half are physician-owned (52%). Most specialty practices achieved full credit on having key clinical data in structured fields and using electronic prescribing. More than 75% of practices also achieved full credit for providing culturally and linguistically appropriate services, providing information about specialist visits back to primary care and providing patients/families information about the role of the specialist and coordination of care. Tracking of referrals to secondary specialists was most challenging, with only 6% of practices earning full credit. Only 34% of practices received full credit for coordinating care transitions from hospitals and other facilities; most practices did not even receive half credit. Measuring and improving performance was also challenging for all practices. Compared to other specialties, oncology/hematology practices were less likely to achieve full credit on the following elements: electronic access, measure patient/family experience, patient information, and care planning and support self-care. However, they performed better on documenting clinical data than other specialty practices. Conclusions: Specialty care practices have started to implement the patient-centered care model. Research to identify which components of the model have the greatest impact on outcomes is needed.
Prospectively measuring the acuity of outpatient chemotherapy treatment regimens for staffing allocation.
Authors: Weber Shani Michelle , Steele Cheryl A.
Published: February 2017

48

Background: UPMC CancerCenter is a large outpatient medical oncology network of 25 locations, located within a 200 mile radius of Pittsburgh, PA. Covering all of these centers with a limited pool of float nurses was a daily challenge. The literature describes many attempts to quantify nursing workload retrospectively based upon complexity, hours of nursing time, etc. The ability to schedule staff equitability in advance is critical to managing staff. New targeted therapies and complicated treatment regimens which impact patient acuity bring to light the need for accurate acuity measurement. Methods: The first step in designing an acuity model was to determine the level of complexity of each treatment regimen based on standardized criteria. The model is a five point system encompassing route, teaching, reaction potential, etc. designed by frontline nurses. A designated nurse at each site calculates the acuity and enters it into an online system prospectively. Nursing Administration can view the staffing and acuity rating across the entire network. This enables the assignment of float nurses to the location with the greatest need. Results: A stoplight report using the database was developed to highlight the sites that are outside of 0.5 standard deviation (SD) range for both the acuity and patient ratios. It was determined that the average nurse to acuity ratio was 11.92 (within SD range 10.69-13.16). The average nurse to patient ratio was 6.31 (within SD range 5.6-7.03). This enables Nursing Administration to identify sites that typically operate below or above the average range in order to better allocate nursing resources. This report is shared among all sites to provide transparency which has improved understanding by the staff of nursing resource allocation. Conclusions: The development of this prospective acuity system has helped to quantify treatment complexity to better allocate daily staffing resources. Further evaluation is necessary to determine the optimal ratios that are the most economical while still providing safe patient care. There are future plans to link the acuity levels to treatment regimens within the Electronic Medical Record to reduce the manual workload.
Lung cancer diagnosis transformation: Aligning the people, processes, and technology sides of the learning system.
Authors: Fung-Kee-Fung Michael , Maziak Donna E. , Pantarotto Jason R. , Smylie Jennifer , Taylor Leanne , Timlin Thomas , Cacciotti Tiziana , Villeneuve Patrick James , Dennie Carole , Bornais Chantal , Aquino Jose , Wheatley-Price Paul , Stewart David J.
Published: February 2017

50

Background: The Ottawa Hospital, serving a population of 1.2 million across a large geographic area, redesigned its regional lung cancer diagnosis and patient intake process using a systems approach. Although having a strong record of excellent coordinated care, recent challenges had created strains on delivery metrics. Prior to the implementation of the project (October 2014), it took patients a range of 15 – 225 days to get from a referral with a suspicion of lung cancer to initial treatment, with a 90th percentile of 117 days. Methods: An innovative care platform was developed to align the people, processes and technology sides of the regional lung cancer care. It formed a basis for a “learning” system mobilizing the wider community for transformational change. We redesigned 12 main business processes facilitating accurate and timely diagnoses using the Communities of Practice approach, the Lean and Constraints methodology and the IBM business process management technology tools. In a series of rapid learning cycles, 270 technology-enabled actions were logged and resolved to support 57 process changes in workflow. The main patient value outcome was defined as improvement in the monthly proportion of patients receiving initial treatment within provincial targets and a reduction of total wait time. Results: In 14 months, the TOH Lung Cancer Transformation program yielded substantial improvement across all levels of diagnostic process including a 48% reduction in the cumulative wait times from referral to initial treatment (surgical, systemic, radiation), increased patient satisfaction with care coordination, implementation of guideline standards, efficiency gains from more intensive use of hospital resources, and sustained engagement of over 100 regional lung cancer care providers in collaborative learning and knowledge sharing across disciplinary and organizational boundaries. Conclusions: A systems approach can improve the hospital capacity to facilitate and support inter-professional and intra-professional teamwork necessary for the diagnostic process transformation.
NCI Community Cancer Center Program (NCCCP): Understanding why hormonal therapy for breast cancer was considered but not administered.
Authors: Spain Pamela , Teixeira-Poit Stephanie , Halpern Michael T. , Castro Kathleen , Prabhu Das Irene , Adjei Brenda A. , Clauser Steven
Published: February 2017

74

Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve the quality of cancer care and reduce disparities at hospital-based community cancer centers. This study examined when guideline-concordant therapy was considered but not administered, who made the decision to not receive treatment. Methods: A retrospective analysis of patients diagnosed and receiving all or part of their initial cancer treatment at one of 12 NCCCP sites was conducted. We examined patients who were guideline-concordant with the hormonal therapy (HT) for breast cancer quality measure, but for whom treatment was considered but not administered. We compared patients diagnosed in the pre-NCCCP period (2006 – 2007) and during the NCCCP period (2008-2013). Results: Overall, a low proportion of cases had HT considered but not administered (4% in pre-NCCCP period; 5% in NCCCP period – difference not significant). In the pre-NCCCP period, white patients were twice as likely as Black patients to have HT considered but not administered, while there were no racial differences during the NCCCP period. In both time periods, older patients and Medicare patients were more likely to have HT considered but not administered. The most common reason for considering but not administering HT was refusal by the patient or patient’s family and this more likely for White patients, patients in the middle age groups (50-59 and 60 to 69), and Medicare patients. The second most common reason was that the physician determined it to be contraindicated due to patient risk factors. This was more likely to be a reason for Black and Medicaid patients. Conclusions: Results show that a large proportion of cases that had treatment considered but not administered did not receive treatment because of patient/family refusal or it was contraindicated due to other patient risk factors, both before and during the NCCCP period. Additional studies could inform the long-term outcomes of patients with comorbid conditions who were considered for guideline-concordant treatment but did not receive it (but the data were not available for this study).
Improving venous thromboembolism (VTE) prophylaxis for hospitalized malignant hematology/bone marrow transplant (heme/BMT) patients.
Authors: Wong Melisa L. , Dzundza John , Ajmera Archana , Gustafson Ashley , Lo Mimi , Fong Richard , Graff Larissa , Dao Bao , Young Rebecca , Damon Lloyd Earl , Martin Thomas G. , Olin Rebecca Leah
Published: February 2017

79

Background: Hospitalized patients on the heme/BMT service at our academic cancer center have historically not received pharmacologic VTE prophylaxis (VTEP) due to concerns regarding thrombocytopenia and bleeding risk. However, a retrospective review of heme/BMT admissions from 2009 to 2013 revealed that 59% of hospital-acquired VTE cases occurred at a platelet count > 50 x 10E9/L, suggesting missed opportunities for VTE prevention. Methods: To implement VTEP on the heme/BMT service, a multidisciplinary quality improvement team developed a pilot intervention with 5 strategies: 1) identification of heme/BMT-specific contraindications to VTEP, 2) standardized use of VTEP for all heme/BMT patients unless contraindications are present, 3) hold parameter for platelet count < 50 x 10E9/L within the VTEP order, 4) note template to document VTEP plan, and 5) provider, nurse, pharmacist, and patient education. We conducted audit and feedback every two weeks for two process measures: VTEP ordered for eligible patients (pre-pilot VTEP ordered for < 1%) and VTEP plan documented (pre-pilot documentation of 23%). Patients on therapeutic anticoagulation were excluded. We also tracked major bleeding events among patients receiving VTEP. Results: Since pilot implementation in July 2015, 105 patients admitted during audit periods met the inclusion criteria; 11 patients on therapeutic anticoagulation were excluded. Contraindications to VTEP were present for 56 patients, most commonly platelet count < 50 x 10E9/L (46%), central nervous system lymphoma (23%), and anticipated procedure (21%). Among the 49 eligible patients, VTEP was appropriately ordered for 42 (86%). VTEP plan was documented for 102 patients (97%). One VTEP-associated bleed occurred in a patient with recent polypectomy, prompting the addition of a new contraindication for recent procedures. Conclusions: Our multidisciplinary pilot successfully improved VTEP orders for eligible heme/BMT patients from < 1% to 86% and VTEP plan documentation from 23% to 97%. Rates of hospital-acquired VTE and major bleeding are being tracked prospectively to evaluate efficacy and safety.
Factors affecting receipt of invasive pain management among Medicaid beneficiaries with cancer.
Authors: Halpern Michael T. , Fiero Mallorie
Published: February 2017

7

Background: Previous studies have reported that a substantial proportion of cancer patients do not receive appropriate pain management. Inadequate pain management may be greater among Medicaid beneficiaries with cancer. However, it is unknown whether Medicaid policies or patient characteristics affect the likelihood of receiving pain management services. Methods: We used 2006-2008 Medicaid claims data for individuals diagnosed with breast or colon cancer to assess patient characteristics and state-level policy factors associated with receipt of invasive pain management (IPM). Generalized estimating equations (GEE) were used to examine factors influencing receipt of IPM, including patient age, race/ethnicity, comorbidities, Medicaid reimbursements, redetermination period for Medicaid eligibility, required patient co-payments. Separate analyses were performed for the breast and colon cancer study populations. Results: Overall, 3% of Medicaid beneficiaries in the study population with breast cancer and 6% with colon cancer received IPM. Among the breast cancer population, non-white patients were significantly less likely to receive IPM compared with white breast cancer patients (Odds Ratio (OR) = 0.88, p < 0.0001). Increased comorbidity score was associated with significantly increased likelihood of IPM (OR = 1.27, p < 0.0001). Among the colon cancer population, older age was associated with significantly increased likelihood of IPM (OR = 1.36 for 10 years of age, p = 0.02). Patients in states with a Medicaid eligibility re-determination period of 12 months were less likely to receive IPM compared to those in states with a period < 12 months (OR = 0.60, p = 0.046). Conclusions: Patient characteristics and (for colon cancer patients) state Medicaid policies predict receipt of IPM among Medicaid beneficiaries with cancer. As many of these factors are not associated with the need for pain management, quality improvements in supportive care are needed for this underserved population.
Preparedness for surgery as a quality indicator.
Authors: Kiely Deirdre , Pego Kristin D. , Schnabel Freya Ruth
Published: February 2017

80

Background: There has been growing attention to the informational priorities of patients in a shared decision making model of care. Patients report adequate information provision as an unmet need throughout their cancer experience. This is especially of concern when faced with complex decision making based on an understanding of medical information in an unfamiliar learning environment. This project is designed to identify informational priorities of patients related to diagnosis and treatment decisions. Methods: Patients’ perceived preparedness for surgery was measured to determine whether information needs were addressed and illustrate overall satisfaction with the surgical experience. A self-administered questionnaire was used to measure satisfaction with information related to diagnosis, treatment and recovery. Results: An active role in decision making that considers patients’ information needs increases satisfaction with treatment choices, preparedness for surgery and outcomes. Methods of providing information are often limited to written and verbal with written generally non-specific and not tailored to patients’ informational needs. Providers are also unable to control for access to other information sources such as the internet. Conclusions: A treatment plan developed through a shared decision making model should be evidence based including an assessment of the patient’s informational priorities. A combination of written and verbal information may be optimal with the written building on the verbal and not introducing new information. Encouraging recording of meetings may be helpful when stress becomes a barrier to comprehending and retaining the information. The patient should also be provided with reliable websites to supplement this information. This results in greater patient satisfaction with the interaction and overall surgical experience.
Patient support call center: Interaction with the oncology clinic.
Authors: Neubauer Marcus A. , Jameson Melissa , Eagye Kathryn , Abdullahpour Mitra , Kolodziej Michael A. , Sipala Maria , Supraner Amy , Hoverman J. Russell
Published: February 2017

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Background: Cancer patients receiving chemotherapy can become ill, often leading to hospitalization, adding huge costs to care. This is especially true with older cancer patients. Innovent Oncology (IO), an oncology disease management program, and Texas Oncology (TO) are conducting a novel program, funded by Aetna. Patients who begin IV chemotherapy are called by an IO nurse, working remotely, but with access to TO’s Electronic Medical Record. If the call center nurse detects a concern she notifies the practice. IO then tracks the action taken by the practice. We report on the incidence of practice notification, intervention that occurred, and incidence of hospitalization within 7 days of practice contact. Methods: This pilot program enrolls patients of Medicare age (Aetna Medicare Advantage members). Intervention calls (IC) to the practice are made at the discretion of the IO nurse. We identified all IC’s made from June 2013 to June 2015. We then categorized the actions taken by the practice and report on the four most common actions. IO receives a daily file from Aetna with hospital data. We looked at hospitalizations within 7 and 14 days from the IC. Results: 430 patients were enrolled over the above time period. 164 had at least one IC (215 total); 38% of patients had at least one IC. The four most common actions taken by the practice were: new medication prescription (N = 128); education over the phone (76); office visit within 24 hours (45); lab work ordered (22). 14 patients were admitted within 7 days of IC and 18 (inclusive of the 14) admitted within 14 days of IC. Conclusions: The IC’s are made when the IO nurse detects a problem during telephonic outreach. Therefore, this group of patients is at some risk for deterioration. Out of 215 IC’s made, 14 patients were admitted within 7 days of the call. We believe this number is low in this Medicare-age population and the results are promising. We believe the coordination between the patient support nurse and the clinic is partly responsible. This is a novel program so we can’t compare the IC/hospitalization rate to other data bases but, at the least, we can use this as a baseline going forward.
Reducing patient wait time on an inpatient hematology and transplant unit.
Authors: Mattison Ryan J. , Makielski Rory Joseph , Osterby Kurt , Fallon Mike , Domask Nicole , Hubbard Vicki , Allen Eva , Gage Blythe , Hettrick Gail , Fischer Jessica , Brown Andrew , Grahn Brianna , Welhouse Brett , Draayers Hannah , Juckett Mark , Ligocki Jean , O'Regan Ruth , Kaufman Laurie
Published: February 2017

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Background: The University of Wisconsin Hematology and Bone Marrow Transplant services admit 250 patients per year for scheduled treatment. Time from patient arrival to chemotherapy initiation averages 7 hours. This long time leads to patient dissatisfaction and prolonged length of stay. Chemotherapy often begins in the evening when physicians and pharmacists are not on site to clarify treatment questions. Methods: A multidisciplinary team was formed in April 2015 as part of the ASCO Quality Training Program. The team developed the aim to reduce time from 7 hours to 5 hours to allow for more daytime nursing shift chemotherapy starts. The group created a process map and an Ishikawa diagram to identify causes of treatment delays. The team observed that treatment orders were often written and signed after hospital admission, though the plan of care was available prior to admission. Using a prioritized list, the initial process change was to have physicians write and sign chemotherapy treatment plans prior to admission. The process measure was the percentage of orders signed before admission. The outcome measure was time from arrival to chemotherapy start. Balance measures included narrative comments from physician and nursing staff about the process change. Data were obtained from EHR time stamps. Physicians were asked to begin making signed treatment plans available after August 1, 2015. Results: Data from 55 patients prior to the change (May 1-July 31) and 52 patients post-change (August 1-October 16) were analyzed. The number of treatment plans signed prior to admission increased from 27% to 58% (p = 0.0018). Mean time from admission to treatment pre-process change was 404 minutes and 383 minutes post-change. When plotted on a control chart, a sustained shift in the process was not apparent. Feedback from physician and nursing staff did not identify efficiency or safety concerns with the new process. Conclusions: Though the percentage of orders signed prior to admission increased, there was no improvement in the time from patient admission to treatment initiation with this change. Future PDSA cycles will include increasing the percentage of orders signed prior to admission as well as address other sources of delay identified in the process map.
A multidisciplinary team approach to efficient breast cancer diagnosis.
Authors: Cianfrocca Mary E. , Shelby Melissa , Birdi Shefali , Byrum Stephanie Costa , Billar Julie Annie Yee , McCabe Kevin , Patel Jignesh , Loving Vilert A
Published: February 2017

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Background: System inefficiencies result in delayed breast cancer diagnoses. Inefficiencies include any non-value added steps between symptom onset/imaging abnormality to cancer diagnosis and treatment. Diagnostic delays can lead to more advanced disease and may negatively impact survival. Further, optimizing the efficiency of diagnostic evaluation models can reduce barriers to care and improve patient satisfaction. To achieve these efficiency goals, Banner MD Anderson Cancer Center (BMDACC) instituted the Undiagnosed Breast Clinic (UBC). The UBC expedites patient evaluation through a multidisciplinary diagnostic team of internists, surgeons, pathologists and radiologists. Patients with an abnormality on physical exam or imaging are promptly evaluated by the UBC team and any necessary diagnostic tests are performed. If malignancy is diagnosed, the BMDACC breast team swiftly institutes multidisciplinary care. Methods: We conducted a retrospective chart review of patients seen in the UBC from 12/2012 - 12/2013. We tallied patient demographics, diagnostic data, and treatment information. Results: 177 patients (174 females; 3 males) were identified. Mean age was 54 years (range: 16-91). Patient racial breakdown was 144 (81%) Caucasian; 8 (5%) Black, 6 (3%) Latina, 4 (2%) Asian, and 15 (8%) Other. Malignant diagnoses (invasive carcinoma or ductal carcinoma in situ) were found in 28 patients (16%), and high-risk lesions (atypia or lobular carcinoma in situ) were found in 8 patients (5%). Of the 46 patients who underwent needle biopsy as part of the UBC evaluation, 28 (61%) underwent biopsy the same day as the initial visit. An additional 5 patients (11%) underwent biopsy the next day.Genetics consults were obtained in 11 patients (6%). Of these 11 patients, one tested positive for BRCA 1 and one for BRCA2. Conclusions: A multidisciplinary team approach to breast cancer diagnosis is feasible. The resultant evaluation eliminates non-value added steps in the patients’ workup, thereby expediting time from presentation to diagnosis and, if needed, treatment.