bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of Sarah Cannon national and international multidisciplinary cancer tumor boards: Initial results.
Authors: Geer Richard J. , Kennedy Andrew S. , Burris Howard A. , Dugger Crystal , Lemaistre Charles Fred
Published: February 2017

138

Background: Optimal cancer care is achievable when input is available from specialists in all related disciplines. To exploit the breadth and depth of clinical expertise within a large healthcare network, regularly scheduled web-based multidisciplinary tumor boards related to complex GI and breast cancers have been established. Methods: Monthly national and quarterly international multispecialty tumor boards were held in 2014. Each center presented a case for discussion and suggested management on a predetermined solid tumor subtype or clinical scenario. A web-based interface was used to show key information to the group in real time, including imaging, pathology, and laboratory results. Subspecialty participation included well known centers of excellence in radiation oncology, medical oncology, clinical research, surgical oncology and interventional oncology. A process to assure HIPPA compliance was implemented, and CME awarded. Results: Sarah Cannon centers in Nashville, Kansas City, Denver, San Antonio, Austin and London participated. An average attendance of ten physicians per center (range 4-18) was seen. Survey results demonstrated significant value as reported by participants in improving patient care leading to the development of a prospective clinical trial in one instance. Therapeutic options not available in the US but offered in the London center were discussed and a mechanism for direct referral to the London facility was developed. Improved rates of breast conservation (18% increase), breast reconstruction (31% increase) and use of AJCC staging (24% increase) were the product of breast conferences in each market. Conclusions: Physicians overwhelmingly supported and valued multidisciplinary tumor boards for GI and breast cancers. Consensus development, sharing of best practices, and promotion of the latest evidence based management led to changes in patient care. Additional centers will be invited to join meetings this year, with planned expansion to initiate similar meetings in blood and thoracic malignancies.
Costs and outcomes in stage IV non-small cell lung cancer at an urban safety net hospital.
Authors: Lel Julian , Folefac Edmund , Zaner Ken Scott , Hartshorn Kevan L.
Published: February 2017

14

Background: Stage IV NSCLC is an incurable illness with significant morbidity. Chemotherapy prolongs average survival from 6 to 10 months and targeted therapies further reduce morbidity and prolong survival. These advances pose financial challenges for safety net hospitals, which may also disproportionately feel the impact of racial disparity. Outcomes in advanced lung cancer may thus differ in the underserved population and resources may not be allocated optimally. Methods: A retrospective review was conducted on all patients diagnosed with Stage IV NSCLC between 2005 and 2011 at Boston Medical Center, an urban safety net hospital. Data were collected on survival from time of diagnosis, type and duration of treatment, utilization of healthcare resources, as well as detailed personal characteristics. We calculated costs of treatment for all patients. We assessed the effect of treatment and patient characteristics on survival. Results: Of 198 patients analyzed, 57% were white, 32% were black, 6% were Hispanic. 11% were homeless. 57% did not receive antineoplastic therapy, 24% received cytotoxic chemotherapy, 18% received combined cytotoxic and targeted therapy. Median survival was 5.0 months without therapy, 7.0 months with cytotoxic chemotherapy and 9.2 months with combined therapy. Any therapy was associated with 56% longer survival. Hazard of death in white patients was 0.68 relative to non-white patients. Median total and monthly costs for patients on no therapy were $70,000 and $14,000, on cytotoxic chemotherapy were $112,000 and $19,000 and on combined therapy were $247,000 and $26,000. Cost per month of survival was $12,000 less for white patients and $15,000 more for homeless patients. Conclusions: The majority of patients did not receive antineoplastic therapy, despite robust survival gains associated with its use. Untreated patients nevertheless incurred a high cost of care. White patients showed better survival at a lower cost. Further topics for study and intervention in this population include barriers to therapy, early involvement of palliative and home-based care in patients not suitable for treatment, strategies for cancer care in the homeless, as well as closer inquiry into drivers of racial disparity.
Designing a multidisciplinary oral chemotherapy education and monitoring program.
Authors: Lane Sharon , Ng Kimmie , Sommers Robin , Dalby Carole Kathleen , Conley Susanne , Rizzo Patricia , Bagley Janet , Harris Christy , Fuller Frances , Nguyen Phuong , Szabatura Audrea
Published: February 2017

146

Background: In 2013 ASCO and ONS published guidelines to promote safe practices for oral chemotherapy use. These agents can have significant toxicities and pose safety risks without proper adherence. Guided by the ASCO/ONS recommendations, Dana-Farber Cancer Institute (DFCI) designed a program to provide comprehensive patient education and adherence monitoring. Methods: To address patient safety risks associated with oral chemotherapy use, a multidisciplinary team assembled to design a process for timely and appropriate patient education and adherence monitoring. Physicians, Nurse Practitioners or Physician Assistants initiate education by reviewing the dosing schedule, side effects and providing a standard education sheet. Within 24 hours, a pharmacist contacts the patient and completes a teaching session utilizing a template based upon the MOATT Tool, a teaching tool developed by the Multinational Association of Supportive Care in Cancer. The MOATT Tool includes a review of the dosing schedule, side effects and management, drug handling, drug/food interactions and practice contact information for questions. Lastly, within five days of therapy initiation, a nurse calls the patient to reinforce education and to assess toxicity and adherence. To evaluate the effectiveness of the program, chart audits and patient satisfaction surveys were conducted. Results: To date 78% of patients started on oral chemotherapy have received a teaching session and 73% have received a follow up adherence call. Patient satisfaction surveys conducted demonstrate that 100% (N=12) of patients strongly agreed with the following statement; “following my counseling session with the Dana-Farber pharmacist, I understood how and when to take my oral chemotherapy medication(s)” and 94% agreed with the statement; “overall I feel that the oncology nurse phone session provided me with useful information.” Conclusions: Implementing a standard patient education and adherence monitoring program for patients initiating oral chemotherapy is essential to guarantee safe patient care. Compliance monitoring at the disease and provider level is necessary to ensure continual quality improvement.
A national strategy for quality and safety in radiotherapy: A comprehensive quality improvement approach.
Authors: Mitera Gunita , Kumar Eshwar , Parliament Matthew , Angers Crystal , Brundage Michael Donald , Drodge Suzanne , Gillan Caitlin , French John , Bird Louise , Bissonnette Jean-Pierre , Wilson Lianne , Brown Erika , Milosevic Michael
Published: February 2017

148

Background: Canada utilizes a public payer, private health care delivery model, delegated sub-nationally. Effective coordination of uniform access to safe, high quality care can be challenging in this and similar international models. Quality improvement in radiotherapy (RT) involves approximately 50% of all cancer patients who will require RT during their illness. The Canadian Partnership for Quality Radiotherapy (CPQR) is a national quality improvement approach employing pan-Canadian engagement of a multi-disciplinary group of physicians, allied health professionals, administrators and patients. The objectives are to create a national culture of safe, high quality RT delivery for all patients; develop and implement a comprehensive sustainable national program for safe, high quality RT. Methods: All CPQR QA products/programs are processed using standard methodology of review and validation through community consultation, and endorsed by national stakeholders. QA products are incorporated into national QA guidelines and indicators for RT programs, technical equipment and patient experiences; integrating these into a national accreditation program; developing a national RT incident reporting and learning system. Active dissemination strategies use bottom-up and top-down approaches. Results: The national RT programmatic QA guidelines and key quality indicators were released in 2011 and 2013, with 3849 downloads. Approximately 50% of Canadian RT centres indicated implementing CPQR guidelines and changing local QA practices. 9 equipment QA guidelines were developed and validated, 6 are in development. National monitoring and learning structures are being developed through an accreditation program and incident reporting repository to be operated by national organizations for sustainability. Knowledge exchange activities included 26 presentations and 10 national/international invited discussions. A national systematic evaluation process will be executed shortly. Conclusions: CPQR’s national RT QA development and implementation approach is a successful model that can be adopted in other areas of healthcare considering system improvement.
Practice of venous thromboembolism (VTE) prophylaxis in hospitalized cancer patients at a comprehensive cancer center.
Authors: Rodriguez M.Alma , DeJesus Alma Yvette , Cheng Lee , Kroll Michael
Published: February 2017

149

Background: VTE prophylaxis measures are endorsed by the National Quality Forum in alignment with quality indicators from the Centers for Medicare & Medicaid Services. Accordingly, documentation of VTE risk, prophylaxis measures, and contraindications are recommended for hospitalized patients. To standardize practice we embedded a VTE risk assessment and prophylaxis module into admission and post-surgical order sets (OS), starting August 15, 2011. Methods: A retrospective study of 9,065 cancer patients (≥18 years) admitted to The University of Texas MD Anderson Cancer Center between June 01, 2013 through September 30, 2013. Pharmacological prophylaxis was executed with low-molecular-weight heparin or unfractionated heparin. Mechanical prophylaxis was executed with graduated compression stockings and/or sequential compression devices. Chi-square testing was used to determine the association between categorical variables. All statistically significant levels were determined with P values < 0.05. Results: 7,366 (81%) of all hospital admissions had documented VTE risk assessment and prophylaxis through the standardized VTE module. Before implementation of the new OS, only 40% of eligible patients received an order for VTE prophylaxis. The majority of patients were designated high or moderate risk (91.1%). Patients with high risk were more likely to receive pharmacological prophylaxis than those with moderate risk (74.1% vs. 38.2%, P<0.01). The most frequent contraindications to pharmacological prophylaxis were major surgery with risk of bleeding and thrombocytopenia (Table). Conclusions: Most patients received VTE prophylaxis based on VTE risk levels presented in a standardized OS. There is is limited information in the clinical literature about the impact of VTE prophylaxis on outcomes among cancer patients, we plan to assess anticoagulation-related outcomes in this cohort of patients. [Table: see text]
Development of a medical record-based trigger tool for identifying adverse events during cancer care.
Authors: Lipitz Snyderman Allison Nicole , Pfister David G. , Anderson Christopher , Epstein Andrew S. , Killen Aileen , Sima Camelia S. , Atoria Coral L. , Fortier Elizabeth , Classen David , Weingart Saul
Published: February 2017

152

Background: Adverse events for patients with cancer can be harmful and costly. Our understanding of these events and their associated harm for this patient population is limited. The objective of this study was to develop a medical record based trigger tool that can be used to help detect adverse events during cancer care. Methods: The trigger tool was developed using input from a multidisciplinary group of clinicians and researchers. First, clinicians from the study team, with input from specialists, compiled lists of adverse events that may occur during the receipt of cancer-directed treatment. Then, they created symptom-based or treatment-based ‘triggers’ that might indicate that the adverse event had occurred. From this list, the study team narrowed the triggers based on feasibility, frequency, severity of the associated adverse events, and overall expected usefulness. Additional feedback was obtained from an expert panel of nine clinicians outside the study team using a modified Delphi approach. The expert panel included representatives from medical oncology, radiation oncology, surgery, nursing, anesthesiology, general medicine, and emergency medicine. Feedback was summarized and the study team narrowed the list of triggers to create the final tool. Results: The final trigger tool for use in detecting adverse events during cancer care consisted of 76 triggers representing adverse events across organ systems. For ease of use, the tool was organized by general care, vital signs, medication related, labs, orders, and consults. Conclusions: From this study, we created a trigger tool to be used to detect key adverse events in cancer care, with an emphasis on those that may be preventable or for which the harm may be able to be mitigated. This information can be used to prioritize quality improvement activities, help to develop quality measures, and set relevant benchmarks for these events for cancer patients in order to improve the safety of cancer care.
Measuring chemotherapy appointment duration and variation utilizing real-time location systems (RTLS).
Authors: Barysauskas Constance , Hudgins Gina , Kupferberg Gill Katie , Camuso Kristen , Bagley Janet , Rozanski Sheila , Kadish Sarah
Published: February 2017

154

Background: Clinical schedules drive resource utilization, cost, and patient wait time. Accurate appointment durations ensure appropriate staffing ratios to the daily caseload and maximizes scarce resources. Dana-Farber Cancer Institute (DFCI) adjusts infusion appointment durations for each chemotherapy regimen using a consensus method of experts including pharmacists, nurses, and administrators. Utilizing RTLS, we examined the accuracy of appointment duration compared to suggested duration. Methods: Appointment duration was calculated using RTLS in three disease centers at DFCI between August 1st and September 30th, 2013. Duration was defined as the amount of time a patient occupied an infusion chair. The top 10 administered infusion regimens were statistically investigated (n=805). Results: All median observed appointment durations were statistically different than the suggested durations. Appointment duration was shorter than scheduled 98% [C], 95% [I], and 75% [F] of the time and longer than scheduled 77% [A] and 76% [G] of the time. Almost all C and I appointments were more than 30 minutes shorter than scheduled. Among A appointments longer than scheduled, 56% were more than 30 minutes longer than scheduled. Conclusions: RTLS provides reliable and unbiased data to improve schedule accuracy. Replacing consensus with system-based data may improve clinic flow, relieve staff stress, and increase patient satisfaction. Further investigations should elucidate factors that cause variation in appointment duration. [Table: see text]
Using real time locating systems (RTLS) to redesign room allocation in an ambulatory cancer care setting.
Authors: Overmoyer Beth , Kadish Sarah , Haskett Courtney , Sanderson Kendall , Benneyan Jim , Reilly Christine , Pedulla Lillian Vitale , Brown Linda , Camuso Kristen , Bunnell Craig A.
Published: February 2017

157

Background: Growing clinics need innovative ways to maximize capacity to ensure efficiency, a core element of quality care. Providers at the Dana-Farber Cancer Institute (DFCI) are assigned specific exam rooms for each clinic day. Despite room utilization below 50%, providers reported feeling constrained, and patients waited an average of 15 minutes to room. Furthermore, in February 2014, DFCI consolidated two facilities requiring that clinics absorb an immediate 10% increase in patient volume using available capacity. We sought to redesign the exam room allocation process by leveraging RTLS. Methods: Using computer simulation, we compared three options for allocating exam rooms. The simulation indicated a “pooled” room approach that did not designate rooms to individual providers would minimize patient wait time. A team was assembled to pilot the intervention in one clinic. An algorithm was developed to prioritize patients based on appointment time, arrival time, and provider availability. We utilized RTLS to automate the algorithm and indicate available exam rooms to coordinate transport of patients from the waiting area to exam rooms. Patient wait time was extracted from RTLS and compared between the baseline (provider-designated rooms) period and the post-intervention (pooled, undesignated rooms) period. Providers were asked post-intervention to provide feedback using a survey. Results: There was a significant decrease in the average wait to exam room despite a simultaneous increase in average appointment volume during the post-intervention period. Cumulative wait time gains averaged 3.3 hours daily. In addition, providers preferred the pooled rooming method over the designated rooming method. Conclusions: Allowing providers to utilize any available room has allowed this clinic to efficiently accommodate a larger number of appointments per day with an overall decrease in patient wait time. RTLS provided the real-time information necessary to succeed and drive improvement initiatives. [Table: see text]
Population-based economic impact of nab-paclitaxel plus gemcitabine in metastatic pancreatic cancer.
Authors: Milentijevic Dejan , Binder Gary , Whiting Scott , Penenberg Darryl Neil , Wei Xinyu , Kayitalire Louis , Renschler Markus Frederic
Published: February 2017

16

Background: Increasingly, assessing the quality of cancer treatment involves scrutiny of both outcomes and economics, particularly for advances in areas where generic agents have been standards of care. With nab-paclitaxel plus gemcitabine (nab-P/G) demonstrating a significantly improved updated median overall survival in first-line metastatic pancreatic cancer (1mPanc) patients (pts) vs gemcitabine (G) monotherapy (8.7 vs 6.6 months), this analysis aims to estimate the economic impact for a US health plan population, from adding nab-P/G as a treatment option for this condition. Methods: A three-year budget impact model was constructed to estimate 1mPanc costs for nab-P/G, G, gemcitabine + erlotinib (EG), other G combinations (OG), and FOLFIRINOX (F), from a US health plan perspective in 2013 US dollars. Inputs for prevalence, drug, administration, G-CSF, and adverse events were derived from SEER, prescribing information, publications, 3Q2014 Medicare reimbursement rates, and other public sources. The model used 2013 patient treatment mix rates as reported by Cartwright et al (ASCO 2013) with nab-P/G growing to 25% by 2015. Results: A population mirroring the US age mix would have 7 pts with 1mPanc annually per 100,000 lives. Treatment mix for 2013 was 27% F, 8% nab-P/G, 51% G, 8% EG, and 6% OG. Total costs per course of therapy per patient (pt) are shown in table. Baseline (before nab-P/G) population costs per 100,000 lives were $111,400 ($15,914 per average pt). Adding nab-P/G to the treatment mix for 1mPanc added $6,083 to population costs ($869 per average pt) for 2013, rising to $20,117 ($2,874 per average pt) for 2015 vs the baseline. Conclusions: Adding nab-paclitaxel plus gemcitabine as a treatment option for first-line metastatic pancreatic cancer pts was estimated to increase costs by 12% (about $2000 per average pt per year) over a three year period. The principal cost drivers were replacement of generic gemcitabine monotherapy, partially offset by savings from replacing FOLFIRINOX. [Table: see text]
Root-cause and failure-mode analyses with an in-house incident reporting system: Comparison of its structure with ASTRO RO-ILS.
Authors: Chou Henry , Kapur Ajay , Goode Gina M. , Riehl Catherine , Meier Jason , Bloom Beatrice , Potters Louis
Published: February 2017

163

Background: In industries with well-established processes for failure analyses, incident reporting systems facilitate analyzing root causes of adverse or near-miss events, and the dissemination of lessons learned. Such a system is now being promoted in radiation medicine as patient safety and care quality come into focus in clinical practice. Methods: An incident reporting system has been in place in our department since 2010 for staff to report actual or near-miss events. A quality management committee was concurrently established to review reported incidents on a weekly basis. A taxonomy of root causes was set up to analyze and categorize root causes of incidents. This taxonomy is compared to that of the 2012 consensus recommendations for incident learning database (Ford et al.) which was the basis of ASTRO RO-ILS currently in prototype phase. Results: To date, over 2,000 incidents have been analyzed in our in-house system. The majority of the reported incidents pertain to procedural mis-steps or miss-cues in the process leading up to patient treatment, resulting in delays. Identifying the root causes has helped re-engineer or fine-tune department processes and has resulted in smoother clinical operations (e.g., obtaining third-party imaging prior to making treatment appointments) as well as more safety checks (e.g., pace-maker alerts.) Our taxonomy of root causes is multi-dimensional and quite specific to clinical radiation oncology, e.g., drilling down to specific morbidities. In comparison, the taxonomy of causes in the RO-ILS is more generic and at a higher level (e.g., procedural or technical issues). The RO-ILS has at most second-degree branches compared with our taxonomy of 6-8 degrees in depth. Conclusions: Incident reporting is vital in analyzing and learning from reported events. Process changes in our clinic has been aided by the incident database and a hierarchical taxonomy between 6 to 8 degrees in root causes. The RO-ILS system in prototype is only 2 degrees deep. While the RO-ILS system appears capable of cataloging data from multiple centers, it is not clear that it will be able to understand or affect meaningful process changes given its lack of depth.
Management of basal cell carcinoma in the United States: Can we simplify care and reduce cost?
Authors: Wu Xinyuan , Elkin Elena B. , Chen Jason Chih-Shan , Marghoob Ashfaq A.
Published: February 2017

17

Background: Basal cell carcinoma (BCC) is the most common cancer in the US, affecting more than 3 million people every year, and the incidence of BCC is increasing. Traditional management of BCC involves multiple physician visits and a pre-treatment biopsy which may be unnecessary. We assessed the costs of treating BCC, comparing traditional management with a simplified scheme. Methods: We developed a decision analytic model to compare the costs of traditional BCC management with a simplified Detect and Treat (DAT) scheme that eliminates pre-treatment biopsy. We assumed that all patients had an unequivocal BCC diagnosis based on clinical and dermoscopic findings. In the traditional approach, all patients had a biopsy prior to treatment. In the DAT scheme, well delineated lesions ≤1cm in diameter on the trunk and extremities were treated with shave removal and Mohs indicated lesions were referred to Mohs for on-site histologic check, both eliminating pre-treatment biopsy. Distributions of lesion location, size and treatment modality, and estimates of clinical diagnostic accuracy and success of shave removal were from the literature and from an analysis of 240 consecutive BCC cases seen over 5 years at our institution. Costs were based on assumptions about the number of dermatologist visits, tests and procedures required for each strategy, and unit prices from the 2014 Medicare physician fee schedule. Results: The average cost per case in the DAT scheme was $449 for non-Mohs-indicated lesions and $819 for Mohs-indicated lesions, compared with $566 and $864, respectively, with traditional management. DAT was associated with a savings of $117 (21% of total average cost) per non-Mohs-indicated case and $45 (5% of total average cost) per Mohs-indicated case. The combined weighted average savings per case was $95 (15% of total average cost). The magnitude of savings varied with changes in model parameters, but conclusions were similar under a wide range of plausible scenarios. Conclusions: A simplified management strategy that avoids routine pre-treatment biopsy can reduce the cost of treating BCC without compromising quality of care.
Reducing unwarranted variability in care in radiation oncology through clinical pathways.
Authors: Lokay Kathleen , Heron Dwight Earl
Published: February 2017

171

Background: UPMC CancerCenter (UPMC) includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology (Via Pathways). The program has served UPMC well for almost ten years and is now a key foundation for UPMC’s overall strategy to move from volume to value. Methods: Radiation treatment pathways for over 90% of cancers were developed by committees of academic and community radiation oncologists from UPMC as well as other cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly-specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for simulation contouring, planning and treatment delivery are provided along with applicable citations. A web-based portal presents the pathways on a patient specific basis using the physician’s daily clinic schedule (through an interface with the EMR). The UPMC radiation oncologists also utilize a feature of the pathways that allows for peer review of Off Pathway decisions by disease experts within the UPMC Radiation Oncology department. Results: Thirty-one (31) radiation oncologists at UPMC use pathways in their daily practice. For the 12 months ended May 31, 2014, UPMC physicians confirmed a pathways status for 98% of their patient consults (n=10,178) and achieved an On-Pathway rate of 95% for their 6,239 treatment decisions. All Off-Pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC, typically within 24 hours of request. Reasons for going Off-Pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care.
Meaningful reporting in primary care: An evaluation of the screening activity report.
Authors: Cunningham Nicki , Stogios Christine , Umar Shama , Carr Dafna , Garay Jason , Hader Joanne , Lee Alex
Published: February 2017

173

Background: Cancer Care Ontario (CCO) developed the ColonCancerCheck Screening Activity Report (CCC SAR) as a supplementary tool for primary care physicians (PCPs) who are part of a patient enrolment model in Ontario, Canada to support them in increasing their colorectal cancer screening rates and appropriate follow-ups. The report provides PCPs with a summary of their eligible patients’ colorectal cancer screening-related history and was designed with the intent of supporting both population health management and opportunistic screening. Delivered through an online platform, the SAR offers PCPs access to data to facilitate quality cancer screening practices aligned with CCO’s evidence-based clinical guidelines. Methods: The report leverages provincial datasets to summarize screening activities on a per-patient level and actionable follow-up recommendations based on CCO’s clinical guidelines. To evaluate the impact of the reports on colorectal screening participation rates, a Generalized Estimating Equation model was used. Results: Results on the report’s impact on colorectal cancer screening participation rates from the first release (February 2013) are promising. By identifying for PCPs which patients are overdue for screening, the SAR demonstrated a modest and statistically significant 6% increased likelihood of patients being screened using a Fecal Occult Blood Test (FOBT) if their PCP was registered to access the online report, compared to patients of unregistered PCPs. The impact to screening increased to 25% when comparing registered PCPs who logged in and viewed their SAR to registered PCPs who did not login; however, this analysis is at a greater risk of a volunteer bias. Such PCPs may be more likely to screen their patients independent of viewing their SAR. Conclusions: By equipping PCPs with patient-level data grounded in CCO’s evidence-based clinical guidelines, the SAR is innovative in its potential to increase screening rates and the appropriate follow-up of abnormal results. The successful launch of two online CCC SARs, sharing meaningful colorectal cancer screening data to frontline providers, has driven the report’s expansion to include breast and cervical cancer screening data in spring of 2014.
Driving action through data: Delivering online cancer screening reports to primary care providers.
Authors: Cunningham Nicki , Umar Shama , Carr Dafna , Smith Richard , Flynn Patrick
Published: February 2017

174

Background: The Screening Activity Report (SAR), a supplementary tool for primary care providers (PCPs), was released in April, 2014. Providers are able to access this comprehensive report securely via an online solution and view the screening activity of their patients across Cancer Care Ontario (CCO)’s three organized cancer screening programs; breast, cervical and colorectal. The objectives of the SAR are to improve the quality of cancer screening by increasing provincial screening rates, improving the rate of appropriate follow-up of abnormal results and promote the alignment of cancer screening practices with CCO’s evidence-based clinical guidelines. Methods: CCO partnered with eHealth Ontario in 2012 to leverage their identity and access management system to provide safe and secure online access to the report. Since this time, CCO has implemented a multi-faceted campaign to support registrations to the system, encourage report access, and gather feedback on how to improve the report for future iterations. Using a detailed methodology developed by a wide range of subject matter experts at CCO, the SAR employs numerous provincial data sources to provide an overview of the patient rosters. Actionable categories are assigned at the patient level using a unique algorithm based on the latest clinical guidelines. Results: Previous to April 2014, the SAR was referred to as the ColonCancerCheck SAR (CCC SAR) as it included colorectal cancer screening data only. The last release of the CCC SAR was in October, 2013. At this time 4,824 providers were registered to the identity and access management system and adoption of this report had reached 31% after being available for five months to providers. To date, 4,992 providers are now registered and adoption of the April SAR has already reached 27% after being available for almost two months. Conclusions: The SAR is the first tool of its kind to make widespread use of eHealth’s identity and access management system service and target a broad user base of PCPs. The successful launch of the SAR has provided key insights into how technology can be leveraged to share provincial data in a meaningful way with providers and support them in improving the quality of cancer screening.
Developing symptom management quality improvement reports with data from a registry-based patient reported outcomes (PRO) collection method.
Authors: Smith Tenbroeck , Castro Kathleen , Troeschel Alyssa , Arora Neeraj K. , Stein Kevin , Clauser Steven , Portier Kenneth M. , Ward Elizabeth M. , McCabe Ryan M
Published: February 2017

180

Background: Symptom management is critical to quality cancer care, affecting treatment completion, functioning and quality of life. We describe the use of the Commission on Cancer’s Rapid Quality Reporting System (RQRS) to ascertain cases for PRO collection, identify key PRO quality indicators, and provide actionable symptom management quality improvement (QI) reports to community cancer centers (CCC). Methods: The Patient Reported Outcomes Symptoms & Side Effects Study used RQRS to sample patients (pt) 4-12 months from diagnosis with locoregional breast/colon from 17 National Cancer Institute Community Cancer Centers Program centers. Surveys were mailed with web option. Pts were asked if they talked to a health professional about pain (Talk about) and, separately, if the health professional gave advice about what to do if pain started, got worse, or came back (Advice). Similar questions were asked about fatigue and emotional distress (ED). QI reports were designed with CCC staff feedback and produced for each CCC providing crude and case-mix adjusted CCC-specific rates, and study-wide rates. Direct standardization methods were used to adjust CCC-specific rates for cancer type and education. Results: 2,487 eligible participants responded (RR=61%). This table shows overall study-wide estimates and the range of adjusted CCC-specific estimates for six key indicators. (See Table.) Conclusions: This pilot study shows the registry-based method for PRO collection was successful and has potential for wider dissemination. Study-wide, 20-45% of pts did not report discussing or getting advice about three common symptoms from their healthcare team. CCCs varied significantly on these indicators, suggesting room for improvement. Quality reports were well received by hospital staff, who report sharing them with clinicians, navigators and cancer committees. CCC-specific reports may promote efforts to improve care through professional/patient education and applying standards of care. [Table: see text]
Understanding disparities and organisational variation in cancer patient experience: Lessons from the English National Cancer Patient Experience survey.
Authors: Lyratzopoulos Georgios , Saunders Catherine L , Mendonca Silvia , Abel Gary
Published: February 2017

181

Background: Surveys of the experience of cancer patients are currently being introduced in several countries, including the U.S. and Canada. Insights to inform the development and use of such surveys can be acquired from the English Cancer Patient Experience Survey programme. Methods: Each of the three national surveys (2010, 2011/12 and 2012/13) had a responder sample of ~70,000 patients (response rate 64-67%) and included about 60 evaluative questions on all domains of experience, from cancer diagnosis to care after hospital treatment. Anonymous data were analysed, using appropriate logistic regression models for positive/negative experience outcomes, based on public reporting conventions. We illustrate a research programme using the survey data focusing on two questions. 1. Who are the patients at greater risk of a negative experience? 2. Does case-mix explain apparent variation between hospitals? Results: There was evidence of socio-demographic variation in cancer patient experience, consistently across questions: younger and very old patients, ethnic minorities, and women reported poorer experience. Regarding variation between patients with 36 common and rarer tumours, those with hepato-biliary and thyroid cancers were most likely to be less satisfied with their overall experience, whereas patients with breast cancer were least likely (top-to-bottom odds ratio 3.7, p<0.0001). There were disparities in experience between patients treated by the same specialty for 5/9 services (p<0.0001). For example, patients with ovarian, multiple myeloma, anal and renal cancer reported worse experiences than patients with other gynaecological, haematological and urological malignancies, respectively. There was high concordance between crude and adjusted ranks of hospital scores (median Kendall's τ=0.84; interquartile range: 0.82-0.88). Conclusions: Initiatives to improve cancer patient experience may be suitably targeted on patients at higher risk of poorer experience. Evidence about disparities in experience and the effect of case-mix provide useful priors to motivate similar inquiries in other healthcare settings.
Patient expectations of palliative cancer treatment for noncurable malignancies: A pilot study.
Authors: Faricy-Anderson Katherine E. , Allen Susan M. , Freeman Nancy J. , Mor Vincent
Published: February 2017

194

Background: Many people with advanced non-curable malignancies have unrealistic expectations of palliative cancer treatment including a belief that treatment may cure their cancer. However, qualitative data describing how patients define “cure” or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anti-cancer treatment. Methods: Patients with advanced non-curable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, co-morbidities, and palliative care involvement. Results: We enrolled 30 patients initiating non-curative anti-cancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancer. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of “cure” ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.” Conclusions: Patient-reported definitions of “cure” and other treatment goals vary widely and a substantial number of patients report unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments. “The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.”
Quality of end-of-life care: Are blood cancers different?
Authors: Odejide Oreofe Olukemi , Salas Coronado Diana , Watts Corey D. , Wright Alexi A. , Abel Gregory Alan
Published: February 2017

195

Background: Hematologic cancers have been associated with aggressive cancer-directed care near death and underutilization of hospice and palliative care services. We sought to explore hematologic oncologists’ perspectives and decision-making processes regarding end-of-life (EOL) care. Methods: Between September 2013 and January 2014, 20 hematologic oncologists from the Dana-Farber/Harvard Cancer Center participated in four focus groups regarding EOL care for leukemia, lymphoma, multiple myeloma and hematopoietic stem-cell transplantation. Focus groups employed a semi-structured format with open-ended questions, and were followed by thematic analysis. Results: Many participants felt that identifying the EOL phase for patients with hematologic cancers was challenging due to the continuing potential for cure despite advanced disease and the often rapid pace of decline near death. This difficulty was reported to result in later initiation of EOL care. Barriers to high-quality EOL care were multi-factorial, including unrealistic expectations from patients and physicians, long-term patient-physician relationships resulting in difficulty conducting EOL discussions, and inadequacy of existing home-based EOL services. Participants also expressed concern that some EOL quality measures developed for solid tumors may be unacceptable for patients with blood cancers given their unique needs at the EOL (see Table). Conclusions: Our analysis suggests that hematologic oncologists need better clinical markers of when to initiate EOL care.In addition, current quality measures may be inappropriate for identifying overly-aggressive care for patients with blood cancers. Further research is needed to develop effective interventions to improve EOL care for this patient population. [Table: see text]
ICU deaths in advanced cancer patients: Reasonableness of ICU admissions.
Authors: Weir Alva B , Ryder Katheryn M , Niell Harvey B. , Muthia Muthia , Clark Karen
Published: February 2017

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Background: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Methods: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Results: In our patients the mean duration of cancer awareness was 7.3 months. The majority (38) had expected duration of life prior to ICU of 6 months or less. Only 16 patients had documented discussions regarding treatment preferences or advanced directives prior to hospital admission. In establishing reasonableness of admission: 8 were post procedure complications; 21 had an ECOG performance status of 0-1 prior to admission; 14 had been notified of their incurable cancer for one month or less; an additional 3 patients had a life expectancy > 6 months. Of the 52 ICU deaths of patients with advanced cancers, 31 (60%) met our criteria for reasonableness of admission in spite of advanced cancer. Of the remaining 21 patients, 9 had advanced directives in place prior to hospitalization, but without specific decisions regarding ICU care. Only 23% of futile ICU admissions in advanced cancer patients lacked both advanced directives prior to hospital admission and reasonableness of ICU admission by the above criteria. Conclusions: The majority of patients with advanced cancer who die in the ICU in our medical center are reasonable admissions, as defined by recent diagnoses, good performance status, > 6 month life expectancy and admission for post procedure complications.
A radiation oncology peer review program for community hospitals.
Authors: Sturdevant Laurie , Martinez Wendi , Thaker Nikhil , Jhingran Anuja , Kuban Deborah A.
Published: February 2017

200

Background: Certified Members within the MD Anderson Cancer Network must perform prospective internal review of radiation oncology cases treated at their institution. Since 2009, several Network sites have been systematically added to a quality oversight program. As part of this process, a sample of the internally peer reviewed cases are assessed by radiation oncology Faculty from MD Anderson Cancer Center (MDACC) who are considered disease site experts. Methods: An electronic tool was used by Network sites to enter clinical treatment information on patients undergoing peer review. This case log was used to select a sample size of not less than 10% of each physician’s case load for an in-depth quarterly evaluation by our Faculty. Quality and appropriateness metrics included review of the technical components of the radiation treatment (RT) plan and multidisciplinary management.. RT was scored as being concordant/non-concordant with MDACC or national guidelines. Non-concordant cases were further reviewed for appropriateness given the individualized case. Feedback was then provided by Faculty to the treating radiation oncologists quarterly, to discuss recommendations and practice pattern modifications. Results: To date, 6 of our 13 Network sites are participating in this peer review process with others being phased in. In 2013, we selected 104 of 719 cases entered into our database by the first four sites. 78% (81) of cases were concordant with guidelines, while 22% (23) were non-concordant. Of the non-concordant cases, 23% were deemed individually appropriate but the remainders (17 of 104) were not appropriate. Concordance in the most frequent disease sites ranged from 80 to 89%. In the less frequent disease sites concordance was lower, ranging from 50 to 73%. Conclusions: The highly technical aspects of radiation treatment, the frequent need to integrate a multidisciplinary approach, and the reality that low volume disease sites will need to be increasingly treated in the community accentuate the need for enhanced oversight and more effective consultation with high volume, expert providers. Our study suggests that an integrated approach to peer review can improve the quality and value of cancer therapy in the community setting.
Increasing clinical trial enrollment with the use of incentives in a community oncology practice.
Authors: Blanchard Elizabeth M , Soucy Ann-Marie , Mulvey Therese M.
Published: February 2017

205

Background: Clinical trials represent a critical component of progress in cancer care, however, enrollment of patients onto adult cancer clinical trials remains disturbingly low at 3-5 percent of patients. In an effort to increase enrollment onto open trials at our center as well as to meet our ACOS requirements, our community cancer center instituted an incentive program to compensate the time medical oncology providers spend enrolling patients onto trials. Methods: In October of 2013 (the beginning of fiscal year 2014), an incentive was given to medical oncologists in our practice if they met an enrollment target of 1% of patients onto trials open at our center. Comparison of enrollment was performed between fiscal year 2014, when the incentive existed, and corresponding months of fiscal year 2013. Results: Enrollment at our center from October 2012-May 2013 was 9 patients with an average of 1.125 per month. For the corresponding period of October 2013-May 2014, when the incentive existed, enrollment was 48 patients, with an average of 6 patients per month. This far exceeded the 1% threshold required to achieve the incentive and has not abated despite the completion of the metric. In addition, enrollment has been similar to unfunded investigator initiated trials and pharmaceutical trials. Cooperative group trials remain limited by lack of funding. All physicians in the group have qualified for the incentive. Conclusions: Incentive programs designed to compensate the time involved with enrolling patients onto clinical trials was very effective in this busy community oncology practice.