bluuebunny/crossref_metadata_2025 huggingface dataset:
Persistence of quality improvement in a Veterans Affairs (VA) academic practice assessed by Quality Oncology Practice Initiative (QOPI).
Authors: Kiernan Kathleen L. , Williams Christina D. , Kamal Arif , Kelley Michael J.
Published: February 2017

209

Background: The success of quality improvement (QI) efforts is usually assessed initially within a year of implementation but performance may later decline. We sought to determine the longer-term effectiveness of practice improvement interventions and the characteristics of interventions associated with persistent improvement. Methods: The Durham VA Hem-Onc fellowship program affiliated with Duke University participated in QOPI twice yearly in 2007 to 2010 and Spring (Sp) 2012. Four interventions were implemented focused on treatment planning (TP; Sp07), treatment summary (TS; Fa07), consent (C; Sp07), and aprepitant use (A; Sp09). Effectiveness was determined by reassessment of 4, 3, 1, and 1 measures, respectively. The TP, TS, and C interventions were policy-dictated use of templated documentation or written consent, and, for TP and C, required conformance prior to chemotherapy administration; TS is not linked to a process. The A intervention modified order set templates to include A for highly emetogenic regimens. For each measure, we compared conformance pre-intervention with post-intervention conformance and, for quality indicators not targeted for improvement, the baseline with each subsequent assessment using chi-square. Results: Considering only measures in the core or symptom management modules with unchanged or similar definitions throughout the study period, 13 of 28 measures had conformance > 85% in the baseline 2007 data. TP conformance increased from 64% to 88, 94, 92, and 96% in subsequent years (p < 0.01). TS was 45% at baseline, 43% (p = NS) in the first post-intervention year, decreased to 24% for two years (p < 0.01) and then increased to 38% (p = NS). C increased from 64% to 97, 91, 94, and 100% (p < 0.01). Conformance with A increased from 9% to 78 and 86% (p < 0.01). Among measures not targeted by intervention, smoking assessment and counseling increased in later years. Conclusions: In this single practice experience, QI improvement interventions integrated into physician processes resulted in substantial and persistent improvement while no improvement was observed as a result of policy-required use of standard documentation alone.
Concordance and disease type variables between adjuvant chemotherapy (AC) recommended and received as assessed by the Quality Oncology Practice Initiative (QOPI).
Authors: Jacobson Joseph O. , Kadlubek Pamela , Malin Jennifer L. , Solem Caitlyn T. , Neuss Michael N.
Published: February 2017

214

Background: AC is indicated following curative-intent surgery for common solid tumors to reduce the chances of recurrence. Limited data are available to assess discrepancies between potential eligibility for chemotherapy, treatment recommendation and actual administration. For patients with completely resected early stage breast (BC), colorectal (CRC), and nonsmall lung cancer (NSCLC), QOPI assesses patient eligibility for AC, measures the rates of chemotherapy recommendation and administration. This analysis seeks to assess concordance between these measures and to explain differences. Methods: QOPI data are submitted by practices into a web-based system and stored as a relational database. For all categorical variables, frequency, and percent are presented. Concordance is shown as a rate—percent of charts eligible divided by those that met criteria. χ2tests were used to compare rates of recommended/received chemotherapy across cancer types. Results: Data were merged for 30,126 patients from the Fall 2011 and Spring 2012 QOPI collection periods. The analysis was limited to BC, CRC, and NSCLC patients for whom AC was clinically indicated by disease type and stage (eligible patients). Conclusions: Oncologists recommend AC with a high degree of predictability for eligible patients with BC and CRC, but at a lower rate for patients with NSCLC. Eligible NSCLC patients receive AC at a rate far lower than BC and CRC patients; these lower rates are due to patient refusal and medical contraindications. Patient factors such as consent and comorbidity must be considered in establishing quality measure benchmarks as they vary significantly among disease type. [Table: see text]
Quality of adjuvant chemotherapy in stage III colon cancer.
Authors: Krzyzanowska Monika Karolina , Gao Julia , He Helena , Hertz Sherrie , Kukreti Vishal , Kaizer Leonard
Published: February 2017

228

Background: The goal of the Systemic Treatment Program at Cancer Care Ontario is to ensure equitable access to high quality systemic therapy for all patients in Ontario. To provide information on performance and inform planning we evaluated the quality of care in stage III colon cancer pertaining to adjuvant chemotherapy using multiple indicators focusing on access, guideline concordance and toxicity. Methods: Patients with stage III colon cancer in 2010 were identified from the Ontario Cancer Registry then linked with several other health administrative databases to obtain information regarding wait times, consultation with medical oncology, receipt of guideline concordant adjuvant chemotherapy and treatment related toxicity. Results: In 2010, 1,133 patients were diagnosed with stage III colon cancer in Ontario of whom 49% were women and 60% were older than 65. 92% of patients were seen by a medical oncologist within four months of diagnosis. Among patients seen at one of the regional cancer centres, 56% consulted with an oncologist within the provincial target of 14 days from referral. Overall, 47% of patients received oxaliplatin-based adjuvant chemotherapy therapy; 70% of those younger than 65 versus 34% of those older than 65. Among patients older than 65 on whom information regarding oral chemotherapy use is available in Ontario, 58% received adjuvant chemotherapy (59% oxaliplatin-based, 41% capecitabine). With respect to timeliness of adjuvant chemotherapy, 85% of patients received chemotherapy within 120 days from diagnosis, 57% started treatment within 60 days of surgery and 61% started within 28 days of consultation with a medical oncologist. Among patients who received oxaliplatin based adjuvant chemotherapy, 42% had at least one ER visit and 18% at least one hospital admission during adjuvant treatment. There was evidence of geographic and age-based variation across multiple indicators. Conclusions: While good quality was observed for several of the indicators examined, opportunities for improvement were identified in access to treatment and toxicity management. Evaluating multiple indicators in the same population provides a broader perspective on quality facilitating a focused, efficient approach to improvement efforts.
Impact of race on early-stage lung cancer treatment and survival.
Authors: Williams Christina D. , Provenzale Dawn T. , Stechuchak Karen M. , Kelley Michael J.
Published: February 2017

232

Background: Studies have documented racial differences along the lung cancer continuum and equity in care is essential to quality improvement. The purpose of this study was to investigate the influence of race on lung cancer treatment and survival among early-stage non-small cell lung cancer patients in an equal access healthcare system. We hypothesize that patients receiving similar treatment will have similar survival. Methods: Data were from the External Peer Review Program (EPRP) Lung Cancer Special Study, which was a cross-sectional study conducted to assess the quality of care among patients diagnosed with lung cancer and receiving care at a VA facility. All patients were diagnosed between October 1, 2006 and December 31, 2007. Analyses were restricted to patients with Stage I/II NSCLC (n=1,426; 1,229 whites, 197 blacks). Multivariate logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95%CI). Results: The proportion of blacks who had surgery was significantly less than that among whites (OR: 0.56, 95% CI 0.39-0.79). There was no racial difference in receipt of adjuvant therapy (chemotherapy and/or radiation therapy) among patients who had surgery (p=0.08). Among patients who did not undergo surgery, blacks were more likely to refuse surgery (OR: 2.30, 95% CI 1.29-4.13); however, the proportion of patients with contraindications to surgery and those receiving palliative treatment were similar in both race groups. The 2-year survival rate was 69% and race was not a predictor of survival when controlling for receipt of surgery along with other covariates (p=0.76). The 2-year survival rate was 82% among patients who had surgery, and 48% among patients who did not have surgery. Specifically among patients who did not have surgery due to refusal, the survival rate was 55%. Conclusions: We observed a racial disparity in surgery, partially due to the greater rate of refusal among blacks, but not adjuvant or palliative treatment. Race did not have a major impact on 2-year survival for patients with early-stage lung cancer. These findings stress the need to better understand patient preferences regarding surgery and identify ways to reduce this variation in surgery to improve quality of lung cancer care.
Measuring patient satisfaction in oncology.
Authors: Steele Joseph Rodgers , Clarke Ryan Kristopher , Shoemaker Stowe
Published: February 2017

236

Background: Improving the patient experience has been an increasingly important quality improvement goal for most health care institutions; however, all patients are not equal. Within the oncology community exist a host of unique needs that must be identified, measured, and addressed. Commercially available questionnaires are too general and often non-diagnostic. The goal of our study was to develop a method to better identify, quantify, and address the needs of this population. Methods: Over 60 hours of in-depth qualitative interviews were conducted with a diverse population of patients (n=68), physicians (n=28), nurses. and technologists (n=33) at UT MD Anderson Cancer Center. A customized patient-experience questionnaire was created from the qualitative data obtained. A balanced incomplete block design was used so each patient answered only 60 questions, while the questionnaire contained over 85 questions. The questionnaire was administered via email to approximately 30,000 patients over one week time period. Results: A total of 4,179 patients completed the survey with average completion time of 24 minutes. A total of 6,909 opened the email invitation, 6,007 began the survey (a 69% completed/began response rate). Non-response bias was monitored via a short survey completed by 2,094 patients. Analysis revealed little difference between respondents and non-respondents. The survey results showed the following: (1) when relevant, a patient will complete a lengthy survey (2) a patient’s perception of their experience is directly related to how they perceive themselves (a number, customer, patient, or loved family member) (3) higher satisfaction is correlated with perception of a “unique” interaction or service (e.g. a visit with a sub-specialty oncologist versus one with a parking attendant). Conclusions: Proper survey techniques are necessary to identify, measure, and address the needs of oncology patients. Contrary to popular belief, patients are willing to complete lengthy questionnaires with little survey fatigue. Positive patient experiences correlate with patient perceptions of provider empathy, caring, and treatment similar to that of a “loved family member” as well as unique, health care services.
Quantification of physician workload for radiotherapy planning, and possible associations with performance.
Authors: Mazur Lukasz M. , Mosaly Prithima , Jones Ellen , Hoyle Lesley , Chera Bhishamjit S. , Zagar Timothy , Marks Lawrence B.
Published: February 2017

245

Background: Workload is a hypothetical construct representing the overall human cost incurred during a task. Across disciplines, the NASA Task Load Index (TLX) has been used as a subjective measure of workload. It quantifies six dimensions of work (mental, physical, and temporal demands, frustration, effort, and performance) on a scale of 1-100 scale, with scores >55 (i.e. overworked) associated with lesser performance. We herein quantify differences in physician workload for planning a relatively “simple” (palliative 2 field opposed lateral brain) versus relatively “complex” (curative 4 field pancreas) case. Further, we explore the association between workload and performance to define TLX levels where performance could be expected to decline. Methods: Nine physicians planned two cases, each case involving three tasks (i.e., task 1 - review written patient medical records; task 2 - review diagnostic images and design of treatment fields; and task 3 - review and approval of the treatment plan). After completing each case, TLX scores of each case/task was collected. Differences in workload between cases/tasks were assessed via ANOVA. The association between workload and performance (assessed using time-to-task completion and self-assessments) was assessed via Pearson’s correlation test. Results: 54 TLX workload and performance assessments were obtained. Workloads for the simple brain case/tasks averaged 41-48, versus 62-69 for the complex pancreas case/tasks (p<0.001 via ANOVA). There were no differences between tasks for the individual cases (p>0.1). There was a correlation between TLX scores and time-to-complete (r=0.54, p<0.001), and with physician self-assessments (r=-0.74, p<0.001). There was a trend towards reduced performance with TLX scores > 55. Conclusions: Physician workload levels are markedly lower for “simple” versus “complex” cases, indicating that TLX is a reliable tool to quantify workload. Performance appears to decline at TLX levels > 55, which is consistent with findings from other industries. Thus, we propose workload assessment (via TLX) to be considered as an independent quality measure to assess the quality assurance (QA) of processes used to deliver radiation therapy.
Thirty-day all-cause readmission rate at a cancer center as a quality of care measure.
Authors: Walters Ronald Stewart , Kidin Lisa M. , Roquemore Joyce , Jordan Victoria S. , Browning Douglas
Published: February 2017

247

Background: Recently, a 30-day all-cause readmission rate has been proposed as a measure of quality of care. Readmissions are assumed to reflect failure by the discharging physician, hospital, or post acute care. These rates are generally easily calculated from available administrative data, and classifiable as "related to the previous discharge diagnosis" or not. Present on admission modifiers may enhance classification and assignment to "preventable" or "non-preventable," "expected or non-expected." This methodology is not generally applicable to the oncology population. The experience with one major cancer center is presented as an example of the limitations of such an approach. Methods: We analyzed 52,097 oncology admissions in an all-payer population that occurred between January 2010 and January 2012. Results: A mean of 32.5% (n=16,918) were readmitted within 30 days, compared to a "peer" group in the database of the University Health Consortium, median of 15%. The attached graph demonstrates the stability of this proportion. Leukemia, lymphoma, stem cell patients (46%), all patients with intense medical needs and frequent readmissions, n=7,635, were the largest subgroup. 42% (n=7,099) were readmissions for chemotherapy or immunotherapy, both planned and expected, and 11% (n=1,803) due to neutropenic fever, pneumonia, or sepsis, all common in this population and neither unexpected nor usually preventable. The most preventable, unexpected, and unplanned readmissions were for postoperative infection, dehydration, and urinary tract infection, accounting for 3.6% (n=609). Thus, the majority of readmissions were planned, expected, or not preventable. Conclusions: In a cancer population at an academic cancer hospital, the majority of readmission are not only planned, but also expected for this population of patients and should not be construed as representative of a quality of care issue. Proper stratification and classification of readmissions is essential to the interpretation of such a measure.
The psychosocial matrix: A community-derived evaluative tool for designing quality psychosocial cancer care.
Authors: Forsythe Laura Pence , Rowland Julia Howe , Padgett Lynne , Blaseg Karyl , Siegel Scott , Dingman Chad M , Gillis Theresa A.
Published: February 2017

250

Background: Although the Institute of Medicine provided a vision for effective psychosocial care for cancer survivors, guidance regarding the essential components of comprehensive care or progressive steps for implementing each component is limited. This abstract presents a unique tool for self-assessing capacity to provide quality psychosocial care to cancer survivors and results of the first full-scale implementation of this tool. Methods: The psychosocial workgroup of the National Cancer Institute Community Cancer Centers Program (NCCCP) developed the Psychosocial Care Matrix Assessment Tool which covers 7 domains (e.g., distress screening, patient-provider communication, evaluation of psychosocial programs). All NCCCP sites (16 enrolled in 2007, 14 enrolled in 2010) completed the matrix in 2010 regarding their capacity for psychosocial care at entry into NCCCP (baseline), after two years of NCCCP participation (2007 sites only), and within the coming year (future aspirations). Results: At baseline, matrix responses reflected few or no systematic processes in place for most components of psychosocial care. However, reported capacity to deliver specific components improved at two years post-NCCCP entry for the 2007 sites and in all sites’ future aspirations. For example, about 80% of all sites reported no or inconsistent distress screening at baseline. After two years, 48% of the 2007 sites reported consistent screening with a standardized tool or consistent screening plus a comprehensive interview. Nearly all 2007 sites (89%) aspired to provide consistent screening plus comprehensive interview with 50% also hoping to add systematic follow-up screenings. The majority of 2010 sites (71%) aspired to provide consistent screening with a standardized tool. Conclusions: The psychosocial matrix tool was found to be useable and valuable. At the NCCCP sites, some aspects of psychosocial care (e.g., communicating the importance of psychosocial care) are more readily implemented than others (e.g., follow-up after a positive distress screen). With growing demand on cancer centers to meet new metrics of quality care, the psychosocial matrix can help identify and develop steps to address gap areas.
Development of quality indicators for women at high risk for breast cancer.
Authors: Shahrokni Armin , Chun Patrick Youngwhan , Naeim Arash , O’Leary Erin M. , Petruse Antonia , Keefer Lisa Jo , Wenger Neil
Published: February 2017

264

Background: Thousands of women are at higher risk for developing breast cancer because of personal (such as early menarche, nulliparity), familial (e.g. BRCAI and II gene mutations), or clinical risk factors (e.g. chest wall radiation). It is thought that many, if not most, of these high risk women are not currently recognized and therefore not offered approaches to risk mitigation and early diagnosis; however, there is currently no set of measures to evaluate the quality of care provided to these women. We aimed to develop valid and feasible process-of-care quality indicators (QIs) for care of women at high risk for breast cancer. Methods: 2,402 articles from 2002 to April of 2012 were found to be appropriate for our study by search on PubMed and Medline. Studies were included if they showed a relationship between care processes for the identification, detection and risk reduction of breast cancer in women at high risk of the disease. Two reviewers reviewed the abstracts and then full texts of articles, and reviewed guidelines from the American Cancer Society, US Preventive Services Task Force and the National Comprehensive Cancer Network guidelines in producing a monograph of evidence supporting proposed QIs. A multidisciplinary panel of clinicians reviewed the evidence and rated each proposed QI for validity and feasibility. They then convened for a face to face meeting to discuss disagreements and then re-rate the measures. Results: Of 36 proposed QIs, 18 QIs were judged as valid and feasible to measure quality of care provided to women at high risk of breast cancer. Four QIs focused on identification of high risk women and risk communication. Six QIs related to counseling and genetic testing. Four QIs aimed at early detection and four QIs related to risk reducing interventions. No physician intervention to change a woman’s life style was rated highly enough to be a quality of care measure. Conclusions: A set of 18 QIs for the care of women high risk for breast cancer was developed along with the supporting literature and these measures will be applied to identify whether there are areas of care in need of improvement.
Aligning cancer quality metrics across the continuum of community-based and academic medicine using a prioritization tool.
Authors: Kidin Lisa M. , Stary Susan , Schaub Diane , Walters Ronald Stewart , Jordan Victoria S. , Edwards David , Cianfrocca Mary E. , Simeone William , Browning Doug
Published: February 2017

270

Background: The Accountable Care Act (ACA) created a foundation for value based purchasing to increase quality of care. This resulted in a request for metrics from multiple organizations at both national and state levels interested in improving healthcare delivery through measurement. Competing with these are internal disease specific metrics requested by organizational leaders to judge the quality of services in their area. In 2009, Banner Health created a partnership with MD Anderson to form Banner MD Anderson Cancer Center. This partnership includes ensuring care provided across both organizations is comparable, and meets evidence based guidelines, including the challenges of developing and tracking clinical metrics that represented quality and value for both a community hospital and an academic medical center. Methods: Banner and MD Anderson compiled a list of all relevant external and internal metrics currently collected plus those in development to create a unified approach for collecting and comparison of cancer specific, hospital, physician, and department specific measures. However, both institutions faced the challenge of resource constraints, competing priorities and appropriate informatics infrastructure. To address this issue, an objective metrics prioritization tool was created based on Failure Mode and Effect Analysis and Quality Function Deployment methods used in quality improvement. The tool provides the flexibility of adjustable weights in the components of Quality, Data, and Organizational Utility for each organization. Results: Prior to the tool, both sites had no basis for comparison or strategic alignment as to which measures to report. The tool was independently scored by institution, resulting in 90% alignment. The remaining difference was attributed to variation in informatics systems and resource allocation. Conclusions: Data while limited, demonstrates that the tool provides an objective measure of comparison between two organizations. While it continues to evolve and require further testing, it does provide an opportunity to facilitate harmonization between measures and alignment of various stakeholders both internally and externally.
MD Anderson Cancer Center Ongoing Professional Practice Evaluation (OPPE): We can see clearly now.
Authors: Roquemore Joyce , Kian Leslie
Published: February 2017

277

Background: Reviewing clinical practice by provider has been an ongoing process for quite some time. The metrics reviewed and how the review was conducted were not clearly defined and, as a result, has varied widely between organizations. Recredentialing or some self-imposed process were the main drivers until The Joint Commission required a more regular review of the clinicians’ practice in a hospital and clinics setting. MD Anderson embraced the requirement as an opportunity to improve its clinical review process and create a more robust infrastructure. Methods: Organizational and technological support was critical for success. The OPPE effort is led by the V.P. for Medical Affairs. A new faculty role, Quality Officer (QO), was established in each clinical department. The Office of Performance Improvement (OPI) was enlisted for data support and provided educational resources to the QOs. The Information Services staff maintains the technology to support the project long term. The Medical Staff Office has administrative responsibility for the program. Results: Two bi-annual OPPE reviews for credentialed providers (physicians and mid-levels) have been completed under the new process. Electronic display and processing has eliminated volumes of paper needed to track OPPE for 1,000+ faculty. External audit requirements are easily supported. Early adopters of the new OPPE tools have been complimentary of the support provided by display of values in control chart versus table formats. The application of statistical process control rules help QOs understand variation in performance among faculty and aid in identifying statistically valid quality issues. Conclusions: MD Anderson leveraged the OPPE requirements to make organizational changes and create processes that enhance review of clinical practice with electronic tools that improve decision making and analytical capabilities. The implementation of clinical quality metrics has made it clearer to see how each practice is doing based on criteria they defined, as well as create a path towards developing oncology performance metrics that can be considered nationally.
Public reporting outcomes of multidisciplinary cancer care: Conceptual issues.
Authors: Talcott James Austin
Published: February 2017

280

Background: Patient outcomes are the most valid measures of quality of care. Public reporting makes them available to patients, referring physicians and payers. Our institution has committed to reporting all cancer patient outcomes. In carrying out that objective, we encountered novel analytical issues arising from differences between the usually reported treatments, surgical procedures, and multidisciplinary cancer care. We present important conceptual issues we identified. Methods: Analytic description of methodological issues encountered in publishing cancer patient outcomes. Results: Issues include: (1) Assigning responsibility. Patient outcomes of multidisciplinary cancer care can be influenced by multiple oncology specialties and institutions. While providers directly control only the treatment they provide, providers share collective responsibility for executing the treatment plan, coordinating care and vouching for the quality of collaborating providers. Therefore, reporting outcomes of one element of multidisciplinary care is incomplete and inadequate. (2) Claiming responsibility. Providers with institutional affiliations but no involvement in quality improvement or reporting processes should be excluded from public reporting. Minimum requirements to qualify for public institutional affiliation should be enforced and “free riders” identified. (3) Defining and presenting valid comparison populations. Treatment trials’ eligibility criteria and recruitment practices exclude poorer prognosis patients, producing biased comparisons to complete “registry” populations that distort patient expectations. Publishing outcomes of well-characterized subpopulations improves valid results and provides more individualized information. Conclusions: Reporting patient outcomes after multidisciplinary cancer care raises novel conceptual issues. We discuss our response to three important issues.
Single-institution evaluation of intrafraction motion during frameless stereotactic radiosurgery.
Authors: Kowalchik Kristin , Kim Siyong , Serago Christopher , Smith Ashley , Ko Stephen
Published: February 2017

284

Background: Frameless stereotactic radiosurgery (SRS) is single fraction radiation therapy delivered to an intracranial lesion. Rather than with a rigid head frame, frameless SRS uses a thermoplastic mask for immobilization. The benefit of this mask includes the ability to simulate and treat the patient at different times, ease of patient set-up and improved patient comfort. Clinically, frameless SRS is used for primary brain tumors and metastatic lesions. The length of the treatments may vary based on a number of factors, including total treatment dose, number of monitor units, number and arrangement of beams, and equipment manipulations. This is a single institution review of patients treated with SRS with positional checks made before, during and at the completion of treatment to evaluate intrafraction motion. Methods: Patients were treated with SRS at Mayo Clinic Florida between 2010 and 2011. All patients were immobilized with a thermoplastic mask and treated on a Varian IX Clinac. KV Cone beam CT was taken prior to the initiation of treatment to verify the treatment position. Cone beam CT’s were also performed at the midpoint and conclusion of treatment. The same physician analyzed all cone beam CT’s. Adjustments were recorded in each dimension and analyzed to determine intrafraction motion. Results: Intrafraction motion was evaluated during six separate SRS cases. The mean displacements at mid-treatment were 0.67±0.52 mm, 0.50±0.55 mm, 0.83±0.75 mm, and 1.35±0.78 mm in the medial/lateral, superior/inferior, anterior/posterior, and vectoral direction, respectively. The mean post-treatment displacements were 0.17±0.41 mm, 0.67±0.82 mm, 0.50±0.84 mm, and 1.11±0.96 mm in the medial/lateral, superior/inferior, anterior/posterior, and vectoral direction, respectively. Estimated overall margins to accommodate intrafraction motion in 90% of patients were 2.63 mm and 2.69 mm at mid-treatment and post-treatment, respectively. Conclusions: The majority of intrafraction motion occurred during the first portion of treatment. Intrafraction motion during the course of frameless SRS treatment is not negligible and approximately a 2.5 mm margin should be taken into account during the planning process.
Surgery and chemoradiotherapy in stage II and III esophageal cancer: A retrospective analysis of first-course treatment across different insurances using the NCDB.
Authors: Brin Lauren , Ganti Apar Kishor , Fang Xiang , Warlaumont Mary , Fuller Timothy , Whittaker Naomi , Silberstein Peter T.
Published: February 2017

29

Background: The current standard of care for stage II/III esophageal carcinoma for patients who can withstand aggressive therapy is chemotherapy, radiotherapy and surgery (tri-modality therapy). This is the largest study of its kind to date. Methods: Using the National Cancer Database (NCDB) 46,758 patients diagnosed with stage II/III esophageal carcinoma between 2000 and 2009 were identified. The NCDB database includes data from 70% of cancer patients in the US. Results: In stage II/III esophageal cancer private insurance holders received more tri-modality therapy (39%) than VA insurance (18%), Medicaid (22%), Medicare (18%), and the uninsured (19%) (p<0.0001). There was no statistically significant difference in the amount of tri-modality therapy received in patients with VA, Medicare, or no insurance. Medicaid patients received more tri-modality therapy than Medicare, uninsured, and VA patients (p<0.05). VA and uninsured patients received no treatment more frequently (13%) than those with private insurance (5%), Medicare (10%), and Medicaid (9%) (p<0.0003). Patients over 70 less frequently underwent tri-modality therapy (13%) as compared to those under 70 (34%, p<0.0001). Conclusions: Although VA, Medicare, and the uninsured patients received similar rates of tri-modality therapy (18-19%), it was much less than private insurance holders (39%). Medicaid patients received less tri-modality therapy than private insurance holders despite similar ages. Uninsured patients received a similar amount of tri-modality therapy as those with VA and Medicare. [Table: see text]
Automated telephone reminders: Potential to improve adherence to adjuvant hormonal therapy among patients with breast cancer.
Authors: Quinn Virginia P. , Schottinger Joanne E. , Green Kelley R. , Cheetham Craig T.
Published: February 2017

297

Background: As the U.S. population ages and life expectancy lengthens, the number of new estrogen receptor positive (ER+) breast cancer (bca) cases is expected to grow substantially from the current 150,000/year. Numerous studies show that adjuvant hormonal therapy (AHT) dramatically reduces bca recurrence (by 50%) and mortality (by 30%) among ER+ women. Daily treatment for 5 years is the recommended therapy. Yet, reports of under-utilization are alarming, ranging from 30% to more than 50%. Methods: We examined utilization of AHT among members of Kaiser Permanente Southern California, a nonprofit prepaid health care organization serving 3.6 million socio-economically diverse members. We identified 10,827 women diagnosed with bca between 2000 and 2007 from the plan’s SEER-affiliated cancer registry who were eligible for AHT. We used automated pharmacy records to assess uptake and utilization of AHT (primarily tamoxifen (TAM) and aromatase inhibitors (AIs)). Results: In this insured population, we found 14% of eligible bca survivors did not begin AHT. Among women who started AHT, over 30% had sub-optimal adherence defined as a medication possession ratio <80%. Discontinuation of AHT, defined as >90 days without medication, began in year 1 (7%) and reached 25% by year 5. To address this threat to quality bca care, the health plan recently initiated an innovative automated telephone reminder (ATR) system among women who filled at least 1 prescription for TAM. Each month, ATR calls are made to about 125 women >18 years, who are overdue between 2 and 6 weeks for a refill, and who have not developed intolerance to TAM or switched to an AI. To date, ATR calls have generated no or few complaints. Next steps include evaluation of the impact of the system on adherence to TAM and, subsequently, AIs, and incorporation of electronic prompts to clinical staff for follow-up with non-responders. Conclusions: Monitoring and intervention for improving adherence to AHT needs to begin at initiation and continue across the 5 years of recommended therapy. AVR can reach large numbers of bca survivors and may have the potential to ensure they receive optimal benefit from these life-saving treatments.
Information technology transforming quality of cancer care in developing nations.
Authors: Roy Rakesh , Dutta Shoumini
Published: February 2017

313

Background: Quality of cancer care is not uniform across developing nations because of poor economy, poor accessibility, illiteracy, lack of technology, etc. However Information technology (IT) has bridged the gap in recent times. Methods: Case files of patients of either sex suffering from non-small cell lung cancer of any stage. Age 35 years and above. Aim is to see impact of IT in quality of care. The following criteria were selected: Staging; Histological subtype categorization; Trucut biopsy; Search for EGFR mutations; Tailormade chemotherapy; Introduction of Palliative Care early in diagnosis. Contribution of IT for the medical team: Accessibility to standard guidelines online – NCCN, ASCO, ESMO, NICE. Using online AJCC guidelines for accurate staging. Accessing e-journals, mobile applications, online search engines. Email alerts from organisations. Systematic reviews from databases like COCHRANE. Web-based tutorials. Online mock examinations. Survival data from clinical trials. Contribution of IT for hospital administration: Computerized database of phase II and P– storing patient information. Results: Data collected in two different phases. (a) 1/1/2008– 31/12/2008. (b) 1/1/2011- 31/12/2011. Staging: complete correct staging 88% 1st phase compared to 95% in 2nd. 38% of the phase I patients could not be divided into adenocarcinoma or squamous variety whereas in 2nd group categorization could not be done in 13% of the cases. The proportion of trucut biopsy rose from 6% in phase I to 45% in phase II. Search for EGFR mutations was less than 2% in phase I vs 37% in 2nd phase. Tailormade chemotherapy – tyrosine kinase inhibitors were used as third line agents in almost all cases of phase I, but in the 2nd group 21% of patients received this agent earlier. Introduction of palliative care early in diagnosis was 3% in phase I compared to 12% in the 2nd group. Conclusions: IT support immensely changed the quality of cancer care in our institution and the standard was close to what is practiced in developed nations. Overall IT industry promoted evidence based cancer care in our institute.
Comprehensive and financially sustainable survivorship care.
Authors: Rosales Alicia R. , Clifford Kathleen , Brown Michele , Watts Lori , Burnham Christa , Thomas Nicole , Graves Julie , Thurston Nicole , Byrne Dia , Zuckerman Dan Sayam
Published: February 2017

32

Background: New 2015 Commission on Cancer (CoC) standards require that all patients who complete treatment receive an individualized survivorship care plan (SCP). To meet this new standard St. Luke’s Mountain States Institute (MSTI), with support from the NCCCP, implemented a process that is multidisciplinary, efficient and sustainable. Methods: At MSTI, the patient’s SCP is a modified ASCO template with a comprehensive care plan and is prepared in the EMR by a Registered Health Information Technician (RHIT). This document is reviewed during a one hour visit with a nurse practitioner and a social worker. The patient participates in the discussion and sets wellness goals for healthy survivorship. The provider’s dictation is mailed to the PCP with the SCP. From Aug. 2011 – June 2012, 53 breast cancer patients were seen in 1 hour joint nurse practitioner/social work survivorship visits. A chart audit was conducted for these patients and follow-up phone calls were done with 36 patients at one month post-visit to evaluate patient understanding and satisfaction. Financial analysis was also completed to determine return on investment (ROI). Results: From chart review, the most common patient concerns were nutrition and weight loss (36%), anxiety (23%), fatigue (21%), depression (17%), caregiver stress (19%) and sexuality (17%). Phone calls showed high patient satisfaction and understanding. Patients rated the following statements on a Likert scale from 5=strongly agree to 1= strongly disagree: I understand my treatment summary and care plan 92% strongly agree or agree, I feel the survivorship visit met my survivorship needs, 97% strongly agree or agree, and 76% of participants were still working on wellness goals at one month. Patient accounts were reviewed showing approximately 50% ROI. Conclusions: It is possible to implement sustainable and comprehensive survivorship care that meets the new CoC standards. The model at MSTI provides increased patient engagement, patient satisfaction, and improved patient provider communication in addition to ROI. Opportunities remain to measure long term health outcomes and downstream revenues associated with this survivorship model. Project funded with Federal funds from the NCI, Contract No HHSN261200800001E.
Implementation of electronic chemotherapy ordering: An opportunity to improve evidence-based oncology care.
Authors: Adelson Kerin , Holcombe Randall F. , Lutkowski Kristine , Peralta-Hernandez Damaris , McLean Michael , Evans-Smith Anika , Wynter Denise , Spencer-Cisek Patricia
Published: February 2017

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Background: On April 20, 2012, Mount Sinai Medical Center was the 63rd site to go-live with the Beacon chemotherapy module of the EPIC EMR. EPIC support reports that ours was one of the most successful launches to date. Previously, all our chemotherapy orders were handwritten with variable adherence to evidence-based chemotherapy and supportive care guidelines. Our goals were 1) reduce errors and improve patient safety, 2) increase use of evidence-based treatment, 3) optimize supportive care and 4) improve practice efficiency. Methods: Fourteen months prior to the go-live we formed a Chemotherapy Council, made up of Oncology physician, nursing and pharmacy leadership and a Beacon-trained Build Team, including an oncology nurse and two chemotherapy pharmacists. Individual disease groups submitted lists of their regimens with references, which were used to create paper orders. The council met weekly to review the orders, references, nursing communications, and NCCN treatment, antiemetic and supportive care guidelines. Once approved, these paper orders served as templates for more than 400 electronic protocols. Each protocol was validated by a utilizing physician. Results: 98% of patients had electronic orders entered prior to go-live (394 chemotherapy and 116 supportive). There were no patient safety issues during the go-live period. In a survey one-month post go-live, 72% of users felt that Beacon had improved their day-to-day efficiency and 72% of users felt that the quality of patient care had improved. Conclusions: The transition to electronic chemotherapy ordering offers an institution the chance to develop evidence-based oncology practice, standardize supportive care and enhance patient safety. It is essential to develop procedures to avoid electronically immortalizing unproven regimens or chemotherapy dosing errors. The key elements that made our Beacon transition so successful were: 1) extensive involvement of oncology leadership, 2) use of a chemotherapy council to enforce evidence-based practice, 3) clinician validation of every protocol and 4) ongoing collaboration between clinical operations and IT regarding the impact of electronic ordering on downstream operations.
Developing a cultural and socioecological patient-centered survivorship care plan template for African American survivors.
Authors: Ashing-Giwa Kimlin T. , Tapp Carlyn , Brown Shirley , Smith June , Mitchell Eudora , Santifer Rhonda , McDowell Kommah , Martin Virginia , Betts-Turner Betty , Carter DeBorrah , Adkins Jackson Paris , Rosales Monica , Fulcher Gingi
Published: February 2017

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Background: Cancer and its treatments bring added health and life challenges. Cancer survivors require ongoing surveillance and medical care. To facilitate best practice in follow-up care, the Institute of Medicine, the American Society of Clinical Oncology and advocacy organizations advise that cancer survivors be provided with treatment summaries and Survivorship Care Plan (SCP). African-American breast cancer survivors (AABCS) have poorer outcomes characterized by greater morbidity and mortality, hence warranting their careful surveillance and follow-up medical care. SCP investigations are urgently needed to improve follow-up care and cancer outcomes in AABCS. Methods: The study embraced a community-based participatory research framework, building upon a series of research projects conducted by the African American Cancer Coalition, a partnership of scientific researchers and community-based advocates. Three informative focus groups were conducted with AABCS (N=25) and advocates (N=3) to obtain input on cultural and socio-ecological SCP contents to increase patient responsiveness. Results: AABCS believed that increased mortality may be due to comorbidities and inadequate surveillance and follow-up care. Participants recommended that the SCP attend to and document all comorbidities and medications; allow for participation of primary care providers; referrals for providers especially surgeons who are familiar with treating AABCS to the reduce keloid, and health advisories on nutrition, exercise and stress management. Quality-of-life related components and community referrals should be included because they are important for overall health. AABCS noted the importance of spirituality in life, and the disproportionately high levels of socioecological stress in the community. Conclusions: Participants infused cultural and socioecologic relevance towards the development of a patient centered SCP template to increase acceptability and utilization among AABCS. Participants underscored that developing the SCP responsive to AABCS and facilitating adherence to SCP recommendations, are areas warranting increased intervention and research.
Standards for evaluating patient-reported outcome (PRO)-based performance measures.
Authors: Basch Ethan M. , Goertz Christine , Christenson Keri , Crawford Amaris , Dudley R. Adams , Spertus John
Published: February 2017

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Background: There is growing interest to use performance measures that integrate patient-reported outcomes (PROs), but there are no existing methodological standards for developing, implementing, or analyzing such measures in this context. Methods: To develop standards for evaluating PRO-based performance measures submitted to or developed by the American Medical Association-convened Physician Consortium for Performance Improvement, a multi-disciplinary expert technical panel was assembled. A systematic literature review and landscape overview were conducted to identify use cases and existing PRO standards in related contexts. Lessons learned from use cases and existing standards guided development of discrete methodological standards. Results: The systematic review identified only one use case, whereas the landscape overview identified eight. Five purposes were identified for which PROs might be measured to assess performance, including one categorized as process and four as outcome. Eight discrete methodological standards were developed which will be detailed at the meeting. Conclusions: The patient perspective is an essential but missing component of performance evaluation. When appropriately elicited, data from patients can be informative. Lack of adherence to good practices and inadequate patient input when developing measurement strategies are potential pitfalls to be avoided.