bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving patient retention by optimizing appointment scheduling in an underserved oncology population within a public safety-net health system.
Authors: Meshman Jessica , Patel Nirav , Asher David , Muniz Erudye , Hidalgo Mario , Abad Maria-Ana , Rodriguez Marla , Alayon Kevin , Truglio Isabel , Samuels Stuart , Yechieli Raphael
Published: October 2020

193

Background: Cancer patients in underserved populations are at high risk for patient attrition and treatment delay. We theorized that decreased appointment scheduling was contributing to a high no-show rate within an urban safety-net hospital. Clinic appointments were being scheduled in the department-specific record and verify system rather than the hospital-wide electronic health record (EHR). We sought to adopt EHR scheduling with the long-term goal of decreasing the no-show rate. Our aim was to utilize the Lean Six Sigma (LSS) methodologies to increase EHR scheduling of follow-up and rescheduling of no-show appointments to 50%. Methods: While involving the entire clinic staff, we utilized the Lean Six Sigma DMAIC model: define, measure, analyze, improve and control, to improve EHR appointment scheduling. Appointment data was collected for the 3 months prior to and during the intervention time period. We determined the root causes for delinquent scheduling, including lack of staff availability to schedule patients into two electronic systems and to call no-show patients. Interventions included implementation of an electronic order for follow-up scheduling and blocked time for personnel to contact no-show patients and verify scheduling. After the formation of a novel process map, control plan, and Failure Modes Effects Analysis (FMEA), the pilot study ran for 2 months. Results: Follow-up appointment scheduling into the EHR improved from 2% to 98% (p < 0.01). After the first intervention month, the no-show rescheduling rate improved from 0% to 43% (p < 0.01): below goal. The team revised the process map by substituting a no-show EHR order in place of the calendar intervention. This constituted the beginning of month 2 and no-show appointment rescheduling subsequently improved from 43% to 87% (p < 0.01). The patient no-show rate was 19% during the pre-intervention period, 17% for the first intervention cycle and 15% for the second intervention cycle (p = 0.3). Conclusions: Utilization of LSS allowed for successful adoption of EHR appointment scheduling within our department. While not yet significant, the no-show rate appears to be trending downward as a result of improved scheduling, and we expect the no-show rate to continue to decline as the study matures. These findings suggest that optimized appointment scheduling may decrease patient retention in an at-risk population. Future directions include evaluating cancer outcomes and decreased healthcare costs as a result of higher patient retention.
Current state assessment of the organization and delivery of systemic treatment in Ontario.
Authors: Vu Kathy , Gallo-Hershberg Daniela , Pardhan Aliya , Ku Rosemary , Paras Sivanuja , Kukreti Vishal , Forbes Leta Marie
Published: October 2020

20

Background: In 2019, Ontario Health (Cancer Care Ontario) published 54 standards to ensure high quality and safe delivery of systemic treatment (ST) in Ontario, along with 16 recommendations for take-home cancer drugs (THCD). The standards/recommendations focused on 7 domains for the delivery of ST delivery and 8 domains for THCD. These domains varied between the two documents but also overlapped on issues including prescribing, patient care, patient education and training and education for providers. The standards for ST delivery were also prioritized according to Very High, High or Medium priority with regards to implementation expectations. The objective of this project was to obtain a baseline assessment of alignment with the standards/recommendations for all ST sites within Ontario. Methods: A validated electronic survey that linked to all standards/recommendations was distributed to 75 ST sites in August 2019. Sites had 8 weeks to complete the survey with their multi-disciplinary teams. Data was analyzed centrally using quantitative analysis methods by region as well as by site level. Results: The response rate was 100%. Overall, alignment in all domains was higher for intravenous cancer drug (IVCD) delivery as compared to THCD delivery. Important areas of gaps include CPOE/PPO use (75% for both IVCD and THCD); appropriate drug labels (90% for IVCD versus 52% for THCD); prescribing/dispensing independent double checks (IDC) (95% for IVCD versus 38% for THCD); pump independent double check (83% of sites); continuous ST with central line (86% of sites); standardized tool for THCD education (40%); and oncology training/education (96% of RNs versus 20% of pharmacists). Conclusions: The main gaps that were identified through the current state assessment were related to THCD, as opposed to IVCD. To ensure alignment with the standards/recommendations, these gaps should continue to be an area of focus for quality improvement. The survey was instrumental in informing provincial, regional, and local strategies to address these gaps and to ensure high quality, safe practices are embedded in ST delivery as outlined in the published best practice documents.
Comparing characteristics and outcomes of cancer to non-cancer patients admitted to general internal medicine (GIM).
Authors: Eng Lawson , Verma Amol A , Shin Saeha , Raissi Afsaneh , Berlin Alejandro , Brezden Christine , Chan Kelvin K. , Enright Katherine , Bouchard-Fortier Genevieve , Linett Lauren , Powis Melanie Lynn , Samawi Haider , Liu Geoffrey , Krzyzanowska Monika K. , Razak Fahad
Published: October 2020

21

Background: Cancer prevalence is rising and there is a corresponding increase in hospitalizations across the cancer continuum. However, little is known about the patterns of care and outcomes of cancer inpatients as administrative data may not capture in-hospital details including investigations and medications required for characterization. Understanding how cancer inpatients are managed and their outcomes can help to optimize care delivery. Methods: We conducted a multicenter study of all patients admitted to GIM at seven hospitals (Toronto, Canada) from 2010 to 2017 where we deterministically linked administrative data with each hospital’s electronic information (pharmacy, orders, notes, laboratory/imaging and results) at the patient level. Multivariable regression models compared characteristics and outcomes between cancer and non-cancer patients for the top 5 non-cancer patient discharge diagnoses. Results: Among 230,040 hospitalizations, 15% had cancer listed as an ICD-10 comorbidity. The most common cancer disease sites were gastrointestinal (20%), lung (13%) and leukemia (11%). The most common discharge diagnoses for cancer patients were disease progression (9%), palliative care (6%), pneumonia (4%), leukemia (4%) and lung cancer (4%), while for non-cancer patients were: heart failure (5%), pneumonia (5%), stroke (5%), COPD (5%) and urinary tract infections (5%). In general, compared to non-cancer patients, cancer patients were younger (70 vs 72), had greater length of stay (LOS; 6.4 vs 4.6 days), in-hospital mortality (16% vs 5%), ICU use (12% vs 11%), 30 day re-admission rate (17% vs 10%) and were more likely to receive CTs (64% vs 52%), MRIs (14% vs 12%) and interventional procedures (22% vs 8%) (p < 0.001, all comparisons). When evaluating the top 5 non-cancer patient discharge diagnoses, results (adjusted for age, gender, Charlson comorbidity score and hospital) were similar wherein cancer patients had a higher in-hospital mortality (aOR = 2.02 p < 0.001), 30 day re-admission rate (aOR = 1.09 p = 0.08) and were more likely to receive CTs (aOR = 1.88 p < 0.001), MRIs (aOR = 1.66 p < 0.001) or interventional procedures (aOR = 1.78 p < 0.001), despite similar mean LOS (5.7 vs 5.1 days p = 0.35). Results were similar across discharge diagnoses. Conclusions: Cancer patients represent a unique population on GIM and have higher resource use, mortality and LOS compared to non-cancer patients, with similar trends even for the same non-cancer diagnoses. Specialized models of care for hospitalized cancer patients may be warranted.
Real-world patterns of chemotherapy and immunotherapy utilization at end of life in a large community oncology network.
Authors: Schleicher Stephen Matthew , Young Garrett , Arrowsmith Edward , Prince Cheryl A. , Winters Lynn Kay , Lyss Aaron J. , Waynick Christopher A. , Mudumbi Sandhya , Allen Duncan , Dickson Natalie R. , Schwartzberg Lee S.
Published: October 2020

22

Background: End-of-life anti-neoplastic treatment does not improve quality of life nor prolong survival of advanced cancer patients. It is also not cost-effective. To-date, there has been little data examining real-world patterns of chemotherapy and immunotherapy treatment at end of life. We investigated use of chemotherapy and/or immunotherapy in the last 14 days of life across a community oncology network of 5 practices, 100 sites of care, and 160 oncology providers. Methods: Using a real-time, network-wide database, we identified patients with solid tumor malignancies who died during an episode of active treatment, defined as having received intravenous (IV) chemotherapy and/or immunotherapy within 90 days of death. We then identified patients in this cohort who received IV chemotherapy and/or IV immunotherapy within 14 days of death (TxEoL). We studied TxEoL patterns by cancer type, treatment type, line of therapy, patient age, patient race, and oncology provider years in practice. Statistical significance was assessed using Pearson’s Chi-squared test. Results: 2,858 qualifying solid tumor cancer patients with dates of death between 1/1/2019 and 5/31/2020 were identified. Observed rates of TxEoL were 16.7% for immunotherapy alone vs. 19.6% for chemotherapy +/- immunotherapy (p = 0.09). We found high variation in TxEoL across 132 oncologists that had 5 or more deceased patients (range: 0% to 50%, mean: 19.2%, median: 19.6%). We found no association of TxEOL with physician years in practice, patient age or race. Rates of TxEoL in the first-line setting were significantly higher than in second-line setting or later (23.3% versus 16.4%, p < 0.01). Patients with head and neck, pancreatic, and hepatobiliary malignancies were the most likely to receive TxEoL, while patients with prostate, brain, and ovarian malignancies were the least likely to receive TxEoL. Conclusions: Our data and method identified wide variation in TxEoL patterns across a large community oncology network, suggesting room for provider-level interventions to improve treatment decisions in patients at high risk of death. Studies within our group, such as examining the impact of palliative care referrals on IV anti-cancer treatment in patients potentially facing end of life, are ongoing.
ECO Experts’ consensus on establishing renal cancer healthcare quality measures in Spain.
Authors: Guillem Vicente , Puente Javier , Camps Carlos , Climent Durán Miguel Ángel , Gallardo Diaz Enrique , González del Alba Aránzazu , Lázaro Quintela Martín Emilio , Méndez Vidal María José , Antón Cristina , Caballero Fernando , Campos Francisco J. , Lugo Ilse , Monge Diana , Rogado Álvaro , Santamaría Rodríguez Irene , Pinto Alvaro , Duran Ignacio
Published: October 2020

220

Background: The ECO Foundation (Excellence and Quality in Oncology) proposes to establish a set of healthcare quality measures (including indicators and standards) for the diagnosis, treatment and follow-up of renal cancer in Spain which all healthcare professionals involved can assume, being suitable for implementation in the continuous improvement process of our healthcare system. Methods: a) International literature review on the quality of healthcare in renal cancer; b) multidisciplinary driving group (9 oncologists with expertise in renal cancer plus 2 methodologists) to identify and choose possible quality measures to be applied in Spain; c) global evaluation of the relevance of these measures through experts’ consensus (Delphi modified by a stratified state panel, n = 55 oncologists specialized in renal cancer); d) selection of definitive measures, according to their feasibility and efficiency (information provided/effort in obtaining it) using a quantitative online priority grid; e) standard wording of the chosen measures: definition, indicator, sources of information, exclusions, clarifications, categorization and acceptable standard. Results: The nominal group proposed 43 quality measures for the Delphi panel. Consensus agreement rate = 84.5% (47/55). The professional consensus was reached on 40 measures (4 structural, 33 in healthcare procedures and 3 in clinical results). Therefore, there is a high level of consensus (93%) among Spanish oncologists who specialize in renal cancer on the content of the healthcare quality measures in the management of renal cancer. The final measures were chosen using a high confidence level (95%) in the unanimity of the experts (oncologists in the driving group) for prioritization depending on the feasibility and efficiency in the healthcare system. Finally, 25 measures were chosen (2 structural, 20 in procedures and 3 in results). Conclusions: The level of consensus and prioritization of measures achieved, will most likely translate in a widespread acceptance and viability for implementation in the National Health System. This could provide a valuable tool for quality assessment and equality in the care of renal cancer patients in Spain.
Defining high-quality NSCLC care at U.S. cancer centers.
Authors: Socinski Mark A. , Boehmer Leigh
Published: October 2020

229

Background: While clinical guidelines for non-small cell lung cancer (NSCLC) provide recommendations on individual components of care and advocate multidisciplinary collaboration, guidance spanning the complete patient journey is lacking. We aimed to compile quality-focused recommendations for the multidisciplinary team and selected clinical criteria for ideal NSCLC care, and propose a new set of metrics encompassing the entire care continuum. These metrics would be used as a new benchmark for ideal NSCLC care via the Association of Community Cancer Centers’ (ACCC) national quality care initiative for patients with advanced (stage III/IV) NSCLC. Methods: The ACCC convened an expert steering committee of multidisciplinary specialists and representation from patient advocacy to compile evidence-based recommendations via a systematic search of clinical and quality care guidelines and peer-reviewed journals. Quality recommendations were organized within key care areas of the patient journey: care coordination and patient education, diagnosis and biomarker testing, staging and treatment planning, and survivorship. Results: A total of 32 recommendations were included across the 4 key NSCLC care areas. Key quality recommendations are listed (Table). Conclusions: The full set of recommendations define ideal NSCLC care and serve as a valuable guide for multidisciplinary practice and quality improvement initiatives. [Table: see text]
EHR innovations to optimize cancer care delivery in New York City during the COVID-19 pandemic.
Authors: Bhardwaj Aarti Sonia , Gu Edward , Pratko Joseph , McLean Michael , Hernandez Damaris Peralta , Smith Cardinale B.
Published: October 2020

249

Background: The Mount Sinai Health System was in the epicenter of the COVID-19 pandemic in NYC. We implemented dynamic testing, isolation and treatment policies in order to continue delivering necessary cancer treatments and ensure the safety of our patients and our staff. Here, we describe the rapid rollout of IT optimizations to enhance the delivery of quality cancer care during the COVID-19 pandemic. Methods: We developed a cancer center incident command structure that involved integration of a health informaticist, IT analyst, and data analyst along with cancer center leadership to help create and optimize electronic health record (EHR)-based tools to support the clinical mission. Results: We developed and implemented EHR-based COVID-19 screening protocols, clinical decision support, reporting and analytics tools, and telehealth technology related to COVID-19 (Table). Conclusions: Dynamic EHR optimizations were essential to continue our cancer care delivery services during the pandemic. [Table: see text]
Understanding the supportive care needs of early-phase cancer clinical trial (CT) participants.
Authors: Lundquist Debra , Juric Dejan , Jimenez Rachel , Capasso Virginia , McIntyre Casandra , Cashavelly Barbara J. , Johnson Andrew , Healy Megan , Nipp Ryan David
Published: October 2020

26

Background: Early phase CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the use of supportive care services among participants in early phase CTs. Methods: We conducted a retrospective chart review of consecutive patients enrolled in Phase 1 CTs from 2017-2019, capturing sociodemographics, clinical data, and use of supportive care services from the electronic health record. We calculated the Royal Marsden Hospital (RMH) prognostic score using data at the time of CT trial enrollment based on patients’ lactate dehydrogenase, albumin, and number of sites of metastasis. The RMH score ranges from 0-3, with scores of 2+ indicating a poor prognosis. We explored differences in patient characteristics, supportive care use, and clinical outcomes based on the RMH prognosis score. Results: Among 426 patients treated on Phase 1 CTs during the study period, the median age was 63.0 years (range 20.5-85.2 years), and most were female (56.1%), white race (85.1%), and had metastatic cancer (97.7%). The most common cancer types were gastrointestinal (22.1%), lung (20.0%), and breast (10.6%) cancer. Under half (31.6%) had an RMH score indicating a poor prognosis. Patients with a poor prognosis score had a worse performance status (ECOG ≥1: 80.2% v 58.3%, p < .001) and more prior treatment (3+ prior lines: 49.5% v 35.0%, p = .001) compared to those without a poor prognosis score. Those with a poor prognosis score were more likely to receive palliative care before or during CT participation (40.5% v 27.1%, p = .011). We observed no significant differences in the rates of nutrition (69.1% v 64.0%), social work (62.2% v 63.8%), or physical therapy (64.5% v 61.7%) consults between those with and without a poor prognosis score. We found that those with an RMH score indicating a poor prognosis had a shorter time on trial (median: 49 vs 87 days, p < .001) and worse survival (median: 139 v 379 days, p < .001). Conclusions: Early phase CT participants represent an advanced cancer population with unique supportive care needs, and we identified a group with a particularly poor prognosis for whom earlier intervention with supportive care services may be needed. Our findings highlight the need to prospectively examine these characteristics along with patient-reported outcomes to better understand the distinct supportive care needs of this population and guide the development of targeted interventions.
Telehealth to expand access of oncology care in Utah during COVID-19 pandemic.
Authors: Gill David Michael , Rhodes Terence Duane , Brant Jamie , Yeatman Timothy Joseph , Haslem Derrick S.
Published: October 2020

267

Background: Intermountain Healthcare has used telehealth since 2015 to expand oncology care for patients living in rural Utah communities. Telehealth services have historically not been widely available to patients living in non-rural locations due to restrictions in reimbursement policies. Changes during the COVID-19 pandemic, including the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act, allows for reimbursement of provider professional fees for electronic visits occurring at any location including a patient’s home. This has allowed greater access to telehealth care for patients with cancer, many of whom are at increased risk of contracting SARS-CoV-2. Methods: Patient visits from Intermountain Healthcare’s two largest oncology sites, Intermountain Medical Center and Dixie Regional Medical Center, were evaluated from the electronic health record (iCentra). Four types of encounters were considered “televisits”: scheduled video visits (SVVs), alternative video visits (AVVs), telehealth visits, and phone visits. All visits were synchronous. Patients were seen from home except for telehealth visits where patients were seen remotely from a rural Intermountain site. SVVs occurred over Intermountain’s Connect Care software platform. AVVs utilized a non-Intermountain software such as FaceTime, Google Duo, Skype, or Webex. Visits were analyzed from December 1, 2019 to June 1, 2020. Results: From December 2019 to May 2020, there were 1,798 televisits performed. Three-month televisit totals increased from 175 from December-February to 1,623 from March-May (Table). Intermountain Medical Center increased televisits from 8 to 514 over these same time periods. Conclusions: Televisits have been utilized to maintain continuity of oncology care while minimizing patients’ exposure to healthcare facilities. On May 15, 2020, Governor Gary Herbert issued an executive order de-escalating Utah COVID-19 risk phase from moderate to low-risk. This may be associated with the decrease in televisits from April to May. [Table: see text]
Readiness of health care systems to generate RWE: Frequency of radiographic imaging of metastatic disease during first-line systemic therapy.
Authors: Chan Brandon , Cameron David , Shokoohi Aria , Regier Dean , Lim Howard John , Ho Cheryl
Published: October 2020

268

Background: Regulatory and Health Technology Assessment (HTA) agencies are increasingly using real world data (RWD) to support real world evidence (RWE), but the readiness of healthcare systems to reliably generate RWE is unknown. As a quality assurance measure we examined the preparedness of a single payer system to provide RWE by evaluating the frequency of CT imaging during standard first line metastatic systemic treatment of breast, colorectal (CRC) and lung cancer. Methods: A 1-year cohort of de novo metastatic breast, CRC, lung cancer patients treated with first line systemic therapy (excluding hormone therapy) referred to BC Cancer in 2016 was retrospectively reviewed. Duration of first line treatment was calculated from first to last dose of therapy. Baseline CT included imaging within 8 weeks prior to and 3 weeks after treatment initiation (first cycle). Last CT included imaging up to 8 weeks after the last dose of therapy. Results: A cohort of 675 patients was identified from the BC Cancer Registry. The distribution of de novo metastatic disease at diagnosis was lung (n = 379), CRC (n = 214) followed by breast cancer (n = 82). Conclusions: In our publicly funded health care system, baseline CT scans within 4 weeks prior to treatment ranged from 57-72%. The median CT imaging interval during first line metastatic treatment was ranged from 7.9-11.3 weeks. RWD from routine clinical practice differs significantly from clinical trials, the gold standard for regulatory and HTA assessments. Population-based data may contribute to RWE with caution due to limitations imposed by clinical practice. [Table: see text]
Patient-reported outcomes (PRO) in patients (pts) with advanced or recurrent dMMR/MSI-H endometrial cancer (EC) treated with dostarlimab in the GARNET trial.
Authors: Kristeleit Rebecca Sophie , Mathews Cara Amanda , Redondo Andrés , Huang Joice , Eliason Laurie , Im Ellie , Brown Jubilee
Published: October 2020

275

Background: PRO enable direct measurement of the experiences of patients with cancer. Anti-programmed death 1 (PD-1) therapies have shown favorable PRO in lung cancer but a data gap remains in EC. Dostarlimab is an investigational anti-PD-1 monoclonal antibody which has shown promising activity in GARNET in advanced mismatch repair deficient (dMMR) EC pts and a low incidence of symptomatic grade ≥3 treatment-related adverse events. Here, we report on PRO measures collected from pts with dMMR/microsatellite instability high (MSI-H) EC in the single-arm GARNET trial. Methods: Pts with dMMR/MSI-H EC confirmed by local tests, with recurrent or advanced disease that progressed on a platinum regimen were enrolled. Pts received 500 mg Q3W of dostarlimab for 4 cycles, then 1000 mg Q6W until disease progression or discontinuation. PRO assessment was an exploratory endpoint and was measured by the EORTC Quality of Life Questionnaire (QLQ-C30), a validated instrument used evaluate quality of life (QOL), functioning, disease symptoms, and treatment-related side effects. PRO were collected at each dose administration, end of treatment, and follow-up. A mixed-model for repeated measures was used to assess change from baseline, accounting for time and baseline ECOG scores. The threshold to determine clinically meaningful group-level change was ±10 points. Results: PRO data were available for 43 pts. Compliance rates were 98%. Relative to baseline, pts reported meaningful improvements in pain, insomnia, and social and emotional functioning over the trial duration. Appetite, nausea, vomiting, constipation, diarrhea, and physical and role functioning were stable over the trial duration. QOL and global health status were also maintained. Conclusions: PRO from 43 pts enrolled in the GARNET trial show that disease- and treatment-related symptoms and QOL are improved or maintained while receiving treatment. These data, along with the efficacy and safety profile of dostarlimab, strongly support the use of dostarlimab in dMMR/MSI-H advanced EC. Funding: GlaxoSmithKline, Waltham, MA, USA. Clinical trial information: NCT02715284 .
Evaluation of outpatient cancer rehabilitation for upper extremity functioning for individuals with breast cancer.
Authors: Pergolotti Mackenzi , Covington Kelley Renee , Stubblefield Michael Dean , Kendig Tiffany
Published: October 2020

287

Background: Specialized cancer rehabilitation is recommended for individuals with breast cancer from diagnosis throughout survivorship to mitigate the negative acute, late and lasting effects of cancer and cancer treatment on upper extremity functioning. However, evidence supporting the impact of community-based outpatient rehabilitation services is lacking, especially for older adults. Methods: Individuals with breast cancer attended cancer-specialized outpatient physical or occupational therapy provided by a single institution with multiple locations across the US in 2019, and completed the Quick DASH (Disabilities of the Arm, Shoulder and Hand). From de-identified rehabilitation records, we abstracted patient and therapy characteristics, Quick DASH scores and therapy satisfaction scores (0-10 point scale) for individuals with a history of breast cancer (identified by ICD code). We used descriptive statistics to summarize characteristics, paired samples t-tests to evaluate Quick DASH scores from initial evaluation (pre) and discharge (post) therapy, and independent samples t-test to compare mean pre-post difference for individuals younger than 65 ( < 65) versus 65 and older (≥ 65). Results: Patients ( N= 556) were 60.56 ± 12.24 (range = 31.52-89.95) years old and predominantly female ( n= 551, 99.1%). They attended cancer rehabilitation (Physical: n= 477, 85.8%, Occupational: n = 79 (14.2%)) for a median of 8 ( IQR= 5.0 – 13.0) sessions over 8.97 ± 7.57 (range = 0.71-47.7) weeks. Average pre-post change in Quick DASH score (-13.51) was significant (p < .01) and exceeded the validated minimal clinically important difference (-11.20). There was no significant difference between average pre-post change for Quick Dash scores between < 65 (n = 334, 60.1%) and ≥ 65 (n = 222, 39.9%) groups (-15.84 vs. -10.01, p = .07). Therapy satisfaction was rated high (median = 10.0, IQR = 10.0-10.0). Conclusions: Specialized rehabilitation for individuals with breast cancer was associated with statistically and clinically significant improvement in upper extremity function and high rates of satisfaction. Older adults demonstrated benefits similar to younger adults. These findings add to the growing evidence for specialized outpatient cancer rehabilitation.
Initial implementation of an electronic oncology trigger tool for adverse event detection.
Authors: Lyons William
Published: October 2020

298

Background: In 2009, the Institute for Healthcare Improvement (IHI) conceived the Global Trigger Tool (GTT), a method for identifying adverse events that relies on correlated clinical documentation, “triggers”, in the medical record. This method is intended to augment traditional quality of care, data collection initiatives that primarily depend on voluntary reporting or error tracking. However, the original trigger tool called for a manual identification of trigger events and is too broad to be useful in an oncology setting. We propose a method for the development, selection, electronic extraction and management of triggers relevant to an oncology setting, with the primary aim of improving our understanding of the prevalence of adverse events occurring during an inpatient stay. Methods: Our implementation of an Electronic Trigger Tool includes three parts: trigger selection, review system development, and the chart review process. Through literature review, we developed a library of 40 oncology-relevant trigger tools. We then selected two pilot triggers based on expert opinion and a trigger analysis on length of stay, cost, and patient satisfaction. Next, we developed a web-app that allows reviewers to automatically receive trigger events. Finally, two clinical professionals reviewed five trigger events from each trigger for five subsequent weeks. Results: We selected Narcan administration (M9) and unexpected/unplanned ICU admission after non-emergent surgical procedure (S3) as pilot triggers. Our reviewers each performed a chart review on 25 for each trigger, resulting in 100 independent reviews. We found that M9 had a positive predictive value (PPV) of .52 (26 AEs / 50 reviews) and S3 had a positive predictive value of .88 (44 AEs / 50 reviews). We also found that most of these adverse events were not found by other quality systems. Conclusions: Our pilot of two triggers demonstrated we can capture adverse events that exist outside known quality and safety resources on a small scale and with high PPV. We anticipate using novel trigger information to inform process improvement and quality of care for patients with cancer at our hospital.
Relationship between clinical work intensity, hopefulness and well-being among medical oncologists.
Authors: Hudson Matthew F. , O'Rourke Mark Allen , Blackhurst Dawn W. , Caldwell Jennifer D. , Feldman David B. , Corn Benjamin W. , Horner Ronnie D.
Published: October 2020

46

Background: Oncology providers’ well-being particularly concerns administrators, as projections suggest a shortfall in number of providers available to care for an increasing cancer survivor population. This pilot study solicited medical oncologists’ ratings on Clinical Work Intensity (CWI), well-being, and hope constructs: agency (goal-directed determination) and pathways (planning ways to meet goals), to understand relationships between clinical work intensity, hopefulness and well-being. Methods: Eleven providers (8 = MD and 3 = NP) practicing in three distinct community-based oncology sites completed the CWI measure, NASA-TLX, immediately following an office visit, for 20 separate visits. Each provider also completed one well-being index and one Adult Hope Scale that included agency and pathways subscales after the 20 visits. Lower well-being scores indicated higher well-being; higher hope scores indicated greater hopefulness. Results: Clinical work intensity positively correlates with well-being (Spearman rho = 0.16; p = 0.02). Clinical work intensity was inversely related to the total hopefulness score (Spearman rho = -0.25; p < 0.001) and Hope construct subcomponents of perceived pathway to goal achievement (Spearman rho = -0.24; p < 0.001), and determination to meet goals (agency) (Spearman rho = -0.15; p < 0.001). Favorable provider well-being was also related to agency (Spearman rho = -0.71; p < 0.0001). Conclusions: Higher provider-rated work intensity in sampled clinical encounters correlates, albeit weakly, with less favorable well-being scores. Higher CWI also correlates with lower hope scale scores. Thus, providers’ perceptions of their mental workload in clinical care are potentially related to their sense of well-being and hopefulness. Results also suggest provider determination to meet goals (agency) is also reflected in sense of well-being. These findings support further investigation using larger, more diverse samples to affirm observed relationships. Future research may also elucidate intervention targets through which to abate provider distress portending burnout. Insights gleaned from future work may inform improvements to the work life of oncology care providers.
Medical cost of care by line of treatment (LoT) in Medicare Fee-for-Service (FFS) beneficiaries with KRAS-mutated metastatic non-small cell lung cancer (mNSCLC).
Authors: Matsuda Tara , Jamotte Aurelien , Xi Ann , Jones Barton , Petrilla Allison , Markward Nathan , Murunga Anne , Stevinson Kendall Lee
Published: October 2020

63

Background: While no targeted therapy is currently approved for patients with KRAS-mutated mNSCLC, new therapies are being developed for patients with KRAS p.G12C-mutated NSCLC. However, real-world evidence on cost of care in managing this population is currently lacking. This study addresses this gap by describing costs of mNSCLC patients with KRAS mutations, stratified by LoT and relative to exposure to a PD(L)1 inhibitor [PD(L)1i]. Methods: Medicare FFS claims (100% sample, Parts A/B) and the PROGNOS NSCLC Explorer dataset were linked to identify patients with mNSCLC, a positive KRAS biomarker test result, and anti-cancer treatment from July 2014 - June 2018. Patients were followed from date of metastasis and stratified by LoT and prior and current exposure to PD(L)1i. Mean total medical costs included all Medicare-covered Parts A/B costs. On treatment medical costs during each LoT were reported per patient per month (PPPM) and were categorized as anti-cancer drug costs or medical management costs (excluding anti-cancer drugs). Results: 438 beneficiaries met inclusion criteria: median age 75 years, 54% female, 91% white, 116 with G12C mutations. 1L patients receiving PD(L)1i had higher total medical costs ($14,331) than those not receiving PD(L)1i ($10,055). Total medical cost of care was similar between patients on 1L ($12,178) and 2L/3L ($12,042). Although total cost of care was similar among 2L/3L patients, irrespective of PD(L)1i exposure status, the medical management costs in patients who progressed after a PD(L)1i or had never received a PD(L)1i were almost twice the medical management costs of the PD(L)1i treated patients. Conclusions: This study demonstrates a high economic burden exists among Medicare patients with KRAS-mutated mNSCLC who have progressed after 1L therapy and for whom there are no targeted treatment options available. [Table: see text]
Applying the ASCO and ESMO Value Frameworks to nasopharyngeal cancer treatments: Is adding induction chemotherapy or adjuvant chemotherapy to concurrent chemoradiotherapy worthwhile?
Authors: Tan Teng Hwee , Soon Yu Yang , Cheo Timothy , Wong Lea Choung , Leong Yiat Horng , Tey Jeremy Chee Seong , Ho Francis
Published: October 2020

67

Background: To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) added to RT and CC + adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC). Methods: We searched phase III randomized controlled trials (RCTs) which reported overall survival (OS) benefit with the use of IC, CC and CC+AC in LA-NPC. We quantified the ICB using the ASCO and ESMO value framework. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database. Results: We identified three RCTs on IC, three RCTs on CC and four RCTs on CC + AC. The ICB was judged to be Grade A based on the ESMO framework. The ASCO Net Health Benefit Score (NHBS) ranged from 17.43 to 57.39. The incremental drug costs ranged from 133.46 to 626.14. There were no statistically significant differences in the means of NHBS [39.37 (IC) vs 37.61 (CC) vs 33.98 (CC+AC), P = 0.89] and costs [383 (IC) vs 253 (CC) vs 460 (CC+AC), P = 0.27] between these three approaches. There was no statistically significant correlation between ICB and costs. Conclusions: The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT and CC + AC to RT for LA NPC are not significantly different.
Disproportionate impact of COVID-19 disease among racial and ethnic minorities in the U.S. cancer population as seen in CancerLinQ Discovery data.
Authors: Potter Danielle , Riffon Mark , Kakamada Sirisha , Miller Robert S. , Komatsoulis George Anthony
Published: October 2020

84

Background: Patients with cancer may face difficult care decisions during the COVID-19 outbreak in the US. Understanding COVID-19 risk factors may help patients and oncologists identify high-risk patients and plan for the best cancer treatment in a timely fashion. This analysis provides an assessment of racial and ethnic risk factors for COVID-19 disease within the CancerLinQ (CLQ) Discovery database. Methods: CLQ is a health technology platform developed by ASCO, which collects and aggregates longitudinal electronic health record (EHR) data from oncology practices throughout the United States. Patients with a diagnosis of a malignant neoplasm and at least two encounters in the past year at a reporting CLQ practice were defined as the underlying cancer patient population at risk for SARS-CoV-2 infection. COVID-19 cases were identified via a positive RT-PCR test for SARS-CoV-2 RNA and/or an ICD-10 code for coronavirus (e.g., B97.29, U07.1, or U07.2). Relative risks and 95% CI were calculated using SAS. Results: We identified 232,428 patients with cancer. From 1/1/2020-4/30/2020, we identified 223 COVID-19 cases in patients with cancer. Of these, 203 had a positive RT-PCR, 26 had an ICD-10 diagnosis code for SARS-CoV-2, and 6 had both. SARS-CoV-2 cases were identified from 19 of the 35 CLQ practices (52.8%) reporting data during the study period. Compared to white patients, African Americans were approximately 2 times more likely to have COVID-19 disease (RR = 1.95; 95% CI = 1.40-2.71), and Hispanics were more than 4 times more likely (RR = 4.65; 95% CI = 3.36-6.43). Patients with hematologic cancers were 1.5 times as likely to be diagnosed with COVID-19 (RR = 1.53; 95% CI = 1.09-2.16) compared to patients with solid tumors. At the time of this abstract, 10 patients (4.5%) died. Conclusions: These results are based on data from a sample of CLQ practices and represent an initial analysis of COVID-19 in the CLQ population. The elevated risk for COVID-19 among African Americans and Hispanics with cancer is noteworthy, particularly since these patients often suffer poorer cancer outcomes. The elevated risk among patients with hematologic cancers is also worth noting because these patients often have compromised immune systems and are already susceptible to many other types of infection. Because the US is in the midst of an active outbreak, we are continuing to analyze new cases and additional risk factors, such as geographical location, anti-cancer treatments, and other cancer variables (e.g. stage).
Racial disparities in adolescent and young adult cancer clinical trial enrollment.
Authors: Siembida Elizabeth , Loomans-Kropp Holli Ann , Trivedi Neha , Bleyer Archie , Roth Michael
Published: October 2020

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Background: African American/Black (Black) patients have historically been underrepresented in cancer clinical trials (CCTs); additionally, adolescents and young adults (AYAs; diagnosis between 15-39 years) enroll on CCTs at alarmingly low rates. However, few studies have explored the participation of Black AYAs in CCTs. Therefore, we aimed to assess Black AYA CCT enrollment onto National Cancer Institute (NCI)-sponsored CCTs and compare enrollment of Black AYAs to enrollment of Black children (< 15 years) and adults (40+ years). Methods: Utilizing data from the Cancer Therapy Evaluation Program, we examined Black AYA enrollment onto CCTs from 2000-2016. We described the total Black AYA enrollments and the proportion of Black AYA enrollments by age (15-19, 20-29, 30-39 years) and sex. We also compared the proportion of Black AYA enrollments to the proportion of Black children and adult enrollments. Enrollment proportion was defined as Black enrollments over total age group enrollment. The χ² test was used to assess differences in proportional enrollment between groups. P values < 0.05 were considered statistically significant. Results: From 2000-2016, 3,893 Black AYAs enrolled onto NCI-sponsored CCTs. Black AYA enrollment was lowest among 20-29 year-old AYAs (N=719) compared to 15-19 year-old (N=1,074) and 30-39 year-old AYAs (N=1,408). The proportion of enrollments of Black AYA patients age 15-19 was significantly higher than enrollments for AYAs age 20-29 and 30-39 (12.6% vs. 10.9% vs 10.9%, respectively, both p's <0.003). The proportion of male Black AYA enrollments decreased by age, with 61.8%, 40.9%, and 22.6% male enrollment for patients age 15-19, 20-29, 30-39, respectively. Despite a significantly higher incidence of cancer in AYAs compared with children, 20.5% more Black children enrolled on trials compared with Black AYAs. The proportion of Black AYA enrollment was marginally higher than Black children (11.3% vs. 10.6%, p = .04), and significantly higher than Black adults (11.3% vs. 8.0%, p < .001). The proportion of Black AYA enrollments did not significantly change between 2000-2007 and 2008-2015 (10.9% vs 11.8%, p=0.33). Conclusions: Racial disparities exist within AYA enrollment on CCTs, with Black AYAs age 20-29 and Black male AYAs least likely to enroll. Despite an increasing focus on improving CCT enrollment of underrepresented groups, enrollment of Black AYAs has not increased. Future studies are needed to elucidate barriers and facilitators to CCT enrollment and guide future intervention development.
Role of oncology-advanced practitioners to enhance clinical research.
Authors: Braun-Inglis Christa Marie , Boehmer Leigh , Zitella Laura J , Hoffner Brianna , Rhee Jessica , Shvetsov Yurii B , Oyer Randall A. , Benson Al Bowen
Published: October 2020

95

Background: Oncology Advanced Practitioners (APs), including Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, and Pharmacists are highly trained health care providers that contribute significantly to quality cancer care. Given low clinical trial enrollment among adult oncology patients, understanding current research responsibilities of APs could lead to identification of opportunities to leverage this workforce to enhance accrual and conduct of clinical trials. Methods: A 65-item validated survey addressing attitudes, beliefs and responsibilities of oncology APs participating in clinical research was distributed from January 22 through March 6, 2020. Outreach via the Association of Community Cancer Centers (ACCC) and Harborside was utilized to reach a sample set of 14,601 oncology APs’ emails. The survey was administered and data were analyzed using Survey Monkey. Results: 408 U.S. oncology APs completed the survey. Respondents were primarily white (83%), female (92%) and nurse practitioners (71%). Thirty-five percent practiced in an academic setting and 62% practiced in a community setting. Nearly all respondents believed that clinical trials are important to improve oncology care standards and more than 90% reported that clinical trials were available at their practice. Nearly 80% reported that they are comfortable discussing treatment options with patients, discussing clinical trials in general, and know where to find clinical trials. Furthermore, 80% participate in the care of patients enrolled on clinical trials. Only 60%, however, are comfortable discussing trials available at their practice and only 38% routinely explore whether a clinical trial is available for their patients. While 70% of APs approach eligible patients about clinical trials at their practice, only 20% reported doing so “a great deal” or “a lot”. Ninety percent of APs reported that they should play a role in clinical research and 75% would like to be more involved in the clinical trial process. Barriers to greater involvement in clinical trials include lack of time, inadequate awareness of clinical trial specifics, and under-representation on research committees. Conclusions: The majority of oncology APs are engaged and interested in clinical trials and believe that research is important to improve cancer care. However, they are not being utilized to their full scope. Multidisciplinary team integration, trials-related education, and policy change is needed to allow this group of skilled professionals to realize their full potential within cancer clinical trials.
How Does Critique Become Effective?
Authors: Montag Warren
Published: October 2020

Critique has been the site of a conflict from the time of its origins: the conflict over the proper relation between theory and practice. Must critique protect its fundamental separation from practice, in order to guard against the intrusion of particular interests into what ought to be a realm of rational deliberation? In this case, critique would precede and direct practice. Or, in contrast, does practice precede and make possible the endeavor of critique, by providing, through the struggles it wages, understood as so many experiments and tests, the information without which critique becomes an empty or, worse, an apologetic exercise?
Climate change is a major stressor causing poor pregnancy outcomes and child development
Authors: Olson David M. , Metz Gerlinde A.S.
Published: October 2020

The climate crisis is the existential threat of our times and for generations to come. This is no longer a threat but a reality affecting us, our children, and the generations that follow. Pregnant mothers, their fetuses, and their children are among those at greatest risk in every population and every jurisdiction. A timely consideration is the health of racialized groups who are particularly vulnerable owing to the confluence of several risk factors that are compounded by climate change. Included among these are Indigenous communities that are the most directly threatened by climate change. This review discusses the main health challenges faced by mothers, fathers, and their children during the climate crisis, focusing on mental health as a causal factor. Exploration of this topic includes the role of prenatal maternal and paternal stresses, allostatic load, and the effect of degradation of the environment and ecosystems on individuals. These will be examined in relation to adverse pregnancy outcomes and altered developmental trajectories of children. The climate crisis is a health threat multiplier that amplifies the health inequities of the most at-risk populations and individuals. It accelerates the increase in allostatic load of those at risk. The path of tragedy begins with an accumulating allostatic load that overwhelms both individual and socio-ecological resilience. This can lead to worse mental health including depression and anxiety and, in the case of pregnant women and their children, more adverse pregnancy outcomes and impaired developmental trajectories for their newborn children. We argue that there is an urgent need to develop new (or re-discover or re-purpose existing) tools that will predict communities and individuals who are experiencing the highest levels of climate-related hazards and intervene to reduce stress and increase resilience in pre-conceptual women and men, pregnant and post-partum women, and their young children.