bluuebunny/crossref_metadata_2025 huggingface dataset:
Objective measures of performance status in cancer: A pilot Alliance study.
Authors: Wood William Allen , Tan Xianming , Grover Natalie Sophia , Stover Angela M. , Kannappan Arun , Carr Philip M , Burkes Robert , Shea Thomas C. , Artz Andrew S. , Devine Steven Michael , Ligibel Jennifer A. , Bennett Antonia Vickery , Basch Ethan M.
Published: September 2018

284

Background: Clinician-assessed performance status (cPS) is prognostic in oncology. However, cPS may be limited by subconscious bias, and is confined to clinic visits. A more objective PS measure derived from cardiorespiratory fitness (VO2peak) and/or sensor-derived biometrics (activity (A), heart rate (HR), and activity/HR combinations (A/HR)) could better inform treatment selection, trial design, safety monitoring, and outcomes assessment. A multi-site study was conducted to examine the feasibility and utility of VO2peak and sensor-derived biometrics as complements to cPS and patient-reported PS (pPS). Methods: We enrolled 45 patients receiving chemotherapy at 4 institutions in 3 cohorts (solid tumor, hematologic malignancy, bone marrow transplant) to assess the feasibility and usefulness of VO2peak and sensor-derived biometrics. Patients underwent VO2peak prior to a cycle of treatment, wore a sensor for 4 weeks, and self-reported PS, physical function (PF), mental health (MH), and instrumental activities of daily living (IADLs). Sensor-derived variables included A, HR, and A/HR. Spearman’s rank correlations described bivariate relationships. Results: 70% of participants underwent VO2peak testing. 81% provided ≥ 2 weeks of sensor data. At baseline, VO2peak was moderately to strongly correlated with pPS and A/HR (r = 0.44-0.66, p < 0.05). pPS, but not cPS, was correlated with MH, PF, and IADLs (r = 0.58-0.69, p < 0.05). During treatment, pPS, PF, and IADLs were moderately to strongly correlated with A/HR (r > 0.4, p < 0.05). Conclusions: VO2peak testing and biometric sensor deployment were feasible within a multi-institutional setting of cancer patients receiving chemotherapy. Sensor-derived A/HR variables were correlated with underlying fitness, as well as patient-reported functioning throughout treatment. A/HR variables are candidates for further development and validation as digital biomarkers of performance status in cancer patients. Support: UG1CA189823; Clinicaltrials.gov Id: NCT02786628
Characterization of sick visits at an enhanced oncology urgent care center.
Authors: Parikh Anish , Berizzi Donna , Tsao Che-Kai , Smith Cardinale B.
Published: September 2018

285

Background: The Oncology Care Unit (OCU) is an urgent care center open during after-hours and weekends for patients with cancer and blood disorders at the Mount Sinai Hospital. This 6-bed, nurse practitioner-run unit aims to decrease the need for emergency room (ER) visits and hospitalization in this high risk patient population. Herein we characterize utilization of this unit for urgent clinical management (“sick visits”). Methods: We identified all patients treated in the OCU between 5/12/17 and 4/8/18, and collected information on diagnosis, treatment, and utilization of the ER or hospitalization. We used descriptive statistics to identify characteristics of those patients treated in the OCU. Results: Of the 1,934 visits to the OCU, 100 (5%) were coded as “sick visits”. Of this cohort, 39% had solid tumors, 44% liquid tumors, and 17% benign hematologic conditions. Among the oncology patients, the average number of prior treatment lines was 4.6 and average time since diagnosis was 51.3 months. Of all cancers, 84% were classified as advanced stage or high-risk. Treatments for the entire group included: transfusion (T, 20%), hydration (H, 20%), and infusion (I, 13%). Similarly, 39% of visits were for H+I, 3% for T+H, 4% for T+I, and 1% for T+H+I. 5% of patients had a repeat, unplanned OCU sick visit in the next 7 days. Among the sick visits, 28% resulted in hospitalization, with a 14-day average length of stay. Further results are shown in Table 1. Conclusions: The OCU provides enhanced diagnostic and therapeutic services for high-risk hematology/oncology patients. These services often exceed the capabilities of a busy practice and would otherwise prompt an ER visit and/or hospitalization. We now aim to study the effect of the OCU on ER utilization and admission rates as well as to analyze its cost effectiveness. [Table: see text]
Implementation of a hepatitis B screening process prior to CD20 therapy treatment in an oncology practice.
Authors: McBride Ali , Elquza Emad , Kumar Abhijeet , Persky Daniel Oscar , Cho Cindy , Ng Yvonne , Rim Koanhee
Published: September 2018

287

Background: Reactivation of hepatitis B virus (HBV) during or after chemotherapy is a serious complication of cancer treatment. Guidelines suggest hepatitis B testing prior to the initiation of CD20 based therapies. Black box warnings mandate clinicians screen patients for HBV before starting immunosuppressive therapy due to the risk of hepatitis B reactivation. We conducted a workflow implementation change at our infusion center sites to improve hepatitis B serological testing in patients receiving CD20 agents at our cancer center. Methods: For baseline evaluation, patients at The University of Arizona Cancer Center who were treated with CD20 agents between the years 2013 to April 2014 were retrospectively evaluated for HBV serology results prior to the initiation of first treatment. We implemented a pharmacy and nursing workflow process regarding chemotherapy orders and lab testing through the integrated EMR technology. Presence of Hepatitis B Surface Antigen (HBsAg) and Hepatitis B Core Antibody (HBcAb) were considered complete; absence of all 2 was ‘not done’ with remaining being incomplete. We focused on improving our screening process during our analysis post-intervention from April 2014 to November 2017. Results: In our baseline study, 35% (n = 17) out of 48 patients had been tested for hepatitis B for hematologic malignancies. Post-implementation yielded 89 patients with 63 lymphoma patients, and 11 leukemia and 15 other hematological-associated diagnosis. Ninety one percent (n = 81) had been tested post-implementation for Hepatitis B labs prior to starting CD20 treatment. No Hepatitis B reactivation was identified in either study arms. Conclusions: Prior to implementation less than 35% of our patients were tested and our implementation process more than doubled our testing percentages to 91%. This process allows for an integrated workflow between pharmacy and nursing to mitigate required lab testing for CD20 agents in hematologic malignancies. The utilization of this workflow process is now being implemented with other CD20 agents for non-oncologic diagnosis.
Reducing inappropriate empiric vancomycin use in neutropenic fever.
Authors: Kim Nina , Caro Jessica , Jacobs Samantha , Rana Meenakshi , Smith Cardinale B.
Published: September 2018

290

Background: Neutropenic fever is an oncologic emergency associated with high morbidity and mortality, requiring prompt antibiotic initiation. National infectious disease and oncology guidelines do not recommend vancomycin for standard empiric therapy, unless used for certain evidence-based indications. At our institution, we observed inappropriate use of vancomycin for neutropenic fever and implemented an intervention to educate providers regarding appropriate indications. Methods: We conducted a series of educational sessions focused on the evidence-based indications for vancomycin use in neutropenic fever with residents, nurse practitioners, fellows, and attending physicians. We also displayed educational posters in work rooms and patient units. We conducted a retrospective chart review to assess the impact on vancomycin prescribing practices and patient outcomes pre-intervention (9/1/17 - 2/28/18) and post-intervention (3/1/18 - 5/24/18). We used descriptive statistics and chi-square tests to assess differences. Results: Vancomycin was frequently prescribed without an appropriate indication in the pre-intervention period. Both the overall use and the inappropriate use of vancomycin decreased significantly in the post-intervention period (Table 1). There was no significant difference in mean duration of fever (2.7 vs 2.1 days, p = 0.06) or length of stay (30 vs 34 days, p = 0.58) between the pre- and post-intervention groups, respectively, despite the reduction in vancomycin use. Conclusions: Multidisciplinary educational sessions reduced unnecessary vancomycin use as empiric treatment for neutropenic fever without adverse patient outcomes. This is a low resource intervention that can be applied to other healthcare settings. Future work will evaluate the effect on cost.[Table: see text]
Deconditioning after "Moving On" rehabilitation.
Authors: Fanning Suzanne R.
Published: September 2018

291

Background: “Moving On” is a 12-week physical rehabilitation program that is offered to patients following cancer treatment. Autologous hematopoietic stem cell transplantation (HSCT) is considered a more aggressive cancer treatment due to myeloablative doses of chemotherapy. Our previous research has shown that deconditioning at the time of referral to Moving On is not significantly different in HSCT patients and non-HSCT cancer patients. Our objective here is to determine how deconditioning after Moving On completion compares in HSCT and non-HSCT groups, as well as by age. Methods: We retrospectively reviewed data from Moving On referrals made between March 2013 and March 2016 (N = 1,057) who completed the Moving On program (N = 322). This includes patients with solid or hematologic malignancies, some of whom received HSCT. Brief Fatigue Inventory scores and 6-minute timed walk (6-MTW) distances were recorded to assess deconditioning. Results: We found 296 of 615 (48%) non-HSCT patients evaluated for Moving On, completed the program; 26 of 43 (60%) HSCT patients evaluated for Moving On completed the program. For those completing Moving On, we found a mean fatigue score of 1.6 in non-HSCT patients (SD = 1.9) and 1.3 in HSCT patients (SD = 2.3) (p = 0.43). The mean distance walked in six minutes was 1543 feet (SD = 237) in non-HSCT patients and 1624 feet (SD = 247) in HSCT patients (p = 0.11). In patients < 70 years old, average fatigue scores were 1.6 for non-HSCT and 1.2 in HSCT (p = 0.29); average 6-MTW distances were 1564 ft. for non-HSCT and 1644 ft. in HSCT (p = 0.17). In patients ≥70 years old, average fatigue scores were 1.4 for non-HSCT and 1.6 in HSCT (p = 0.82); average 6-MTW distances were 1451 feet for non-HSCT and 1560 feet in HSCT (p = 0.20). Conclusions: We find that 25% more HSCT patients complete Moving On than non-HSCT patients. There is no significant difference in post-Moving On fatigue scores or 6-MTW distances between HSCT and non-HSCT groups. A significant difference in 6-MTW by age, is found in the non-HSCT group but not in HSCT patients. This may be due to selection bias in this group, as more fit patients ≥70 undergo HSCT. Our results show that deconditioning following rehabilitation in autologous HSCT is comparable to cancer patients not receiving HSCT, regardless of age.
Improved acute pain management in oncology patients using early scheduled contact with a pain coach.
Authors: LaSala Johanna M. , Chiang Anne C. , Severino Kimberly M
Published: September 2018

293

Background: Pain control is a challenging balance in the ambulatory oncology practice. Standard methods of pain reassessment resulted in poor pain control in the majority of patients given prescriptions for narcotics. We developed a proactive reassessment of pain using patient reported outcomes and a coach to assist in medication usage. The aim was to decrease the time to reassessment of pain to fewer than 5 days and achieve acceptable pain control in greater than 50% of patients receiving new narcotic prescriptions in an ambulatory oncology setting. Methods: Patients receiving a new narcotic prescription or a new dose were provided with a pain diary and an appointment with their pain coach at 48 hours. Using a standard pain scale 1-10, patients’ pain scores were recorded by the patient in their pain diary and communicated via nurse/patient phone contact at 48 hour intervals. Dosing intervention by the patient’s oncologist was made for unacceptable pain and reassessed at 48 hours. Uncontrolled pain at 96 hours was followed by in person appointment with the oncologist. Pain scores and days to reassessment were recorded using an Excel data collection tool for patients receiving new or dose adjusted narcotic prescriptions between August and December31, 2017. Results: There were 17 patients encounters where the patient received a new prescription or a dose change from August 1- Dec 31, 2017. Reassessment of pain was achieved in 100% of patients in fewer than 5 days. The average time was 2.6 days (range 2-4). Acceptable pain control (pain scores 0-3) at the time of reassessment was achieved in 53% of patients. Conclusions: Cancer related pain is an ongoing challenge in oncology practices. Barriers include lack of planned follow-up and patient education. The institution of a pain coach, pain diary and scheduled contact decreased the time to reassessment of pain and decreased pain scores during short interval reassessment periods achieving better pain control in 50% of patients during the evaluated period. Quality interventions in ambulatory settings are achievable though multiple patient interactions and record keeping require additional staffing resources to sustain this change.
Implementing radiation oncology pathways at Dana-Farber Cancer Institute/Brigham and Women’s Hospital.
Authors: Hayne Victoria , Stein Leah A. , Tremonti Carole Kathleen , Baldini Elizabeth H. , Phillips John G. , Hilfer Susanna C. , Jackman David Michael , Hall Julia Cooper , Greenberg Teresa L. , Hamilton Joanna M. , Jacobson Joseph O. , Martin Neil E.
Published: September 2018

301

Background: Modern cancer care faces increasing complexity and the challenge of delivering consistent, high-quality care across growing networks. Dana-Farber Pathways address these concerns by translating expert content into treatment algorithms delivered through a web-based platform and implemented across the network. We had previously built 31 Medical Oncology (MO) pathways. Our goal was to build and implement Radiation Oncology (RO) pathways for common cancer conditions in 18 months. Methods: Partnering with lead clinicians from each disease group, we chose the most appropriate framework for each pathway: expand previously established RO pathway; use corresponding MO pathway; or if no framework was available, develop RO pathway in its entirety. We worked with each disease group to gain consensus about the recommended on-pathway selections that reflect the latest research and institutional standard of care. Implementation consisted of pre- and post-launch department communications about metric goals and individual provider training on the system. Because the program was launched without provider incentivization, the usage rate goal was navigations for at least 25% of patients receiving radiation treatment. The on-pathway rate goal range was 70-80%. Results: We exceeded our goal: we built and implemented 25 pathways in 12 months and constructed all 27 pathways in 18 months. We have met both key rate goals across all disease pathways since time of launch: usage rate is 63%; on-pathway rate is 85% (39 providers across 3 sites). Conclusions: A preliminary analysis of RO Pathway data demonstrates collective adoption across all sites. Qualitative surveys show it to be a useful resource in radiation treatment decision-making and in palliative care service. We will continue to analyze the use of RO Pathways and develop strategies to collaborate with MO to further guide multi-disciplinary decision-making.[Table: see text]
Symptom management pathways to reduce ED visits and hospitalizations for patients with cancer.
Authors: Roy Mohana , Halbert Brian , Devlin Scott M , Zerillo Jessica A.
Published: September 2018

302

Background: At our academic medical center, acute on chronic pain, gastrointestinal symptoms and fever led to most preventable ED visits and hospitalizations amongst cancer patients on chemotherapy. We developed management pathways to target these symptoms. Methods: Existing symptom management algorithms and internal expert consensus of multidisciplinary stakeholders, including palliative care and infectious disease, contributed to initial symptom management algorithms. After iterative revisions, the pathways were finalized by hematology/oncology physician and nursing leadership. We identified outpatient, non-oral, cancer directed treatment events using pharmacy billing data. These events included traditional chemotherapy, immunotherapy, and hormonal therapy. We then identified any ED visit or hospitalization at our medical center within 30 days of the event. We plan a pre-post analysis to determine change in 30-day ED visits and hospitalizations for any reason and for our target symptoms. Results: We developed pathways for acute on chronic pain, nausea/vomiting, diarrhea, constipation, and fever. Each pathway follows a standardized model including warning signs with guidance on direct referral to the ED or urgent clinic referral, the specific treatment algorithm, and helpful references. The pathways were implemented in May 2018. From January 2016 to February 2018, we identified 28,764 treatment events among 4,197 patients. Patient mean age was 63 years. The most commonly used treatments were fluorouracil, leuprolide, and paclitaxel. Within 30 days, 5.7% had an associated ED visit; 5.0% had any hospitalization. Conclusions: We developed management pathways for common symptoms among patients receiving cancer treatment. Generalizing care for such a heterogeneous population can be challenging and requires significant engagement from a multidisciplinary team. Post-intervention data is forthcoming to assess the impact of the pathways on reducing ED visits and hospitalizations.
Using a patient-reported outcomes tool as a gateway to identifying patients who would benefit from palliative care.
Authors: Dunn Kathleen , Hannaford Morgan , Hartman Scott , Denny, DBA Diane
Published: September 2018

306

Background: Palliative care provides a wide range of supportive care services that aim to enhance the patient’s quality of life, reduce complications, address supportive care needs earlier, and avoid unnecessary resource consumption. A national network of five hospitals providing comprehensive cancer care noted barriers in identification of patients that may benefit from these services. Technology and objective criteria can circumvent human barriers such as, prognostic uncertainty and psychology of decision making. Referred to as the SIT (symptom inventory tool) process, an externally validated assessment tool that captures patients’ perceived symptom burden from baseline and every 21 days was used as means of identifying patients who might benefit from referral. Methods: A three-month pilot was initiated at two centers using a report run on a weekly basis, generated from the SIT process utilizing the following criteria: six or > symptoms from 27 increasing in severity by two points or > since their last assessment. This subset of patients identified by this filter was reviewed by the palliative care nurse to determine if they meet the following criteria: any stage with metastatic disease, stage 3 not in remission, and stage 4 not already enrolled in palliative care. Results: During the pilot timeframe, 1,127 SIT self-assessments were completed by patients at Site 1 with 168 patients flagged for review by the palliative care RN. Of these 168 patients 75 (or 44.6%) met the criteria for palliative care services. At Site 2, 802 self-assessments were completed, with 82 identified for review of which 46 (or 56.1%) met the criteria. Conclusions: Patients with overwhelming symptoms were identified for intervention that might otherwise have been missed by relying solely on referral. This patient population resulted in a request for practice integration across centers recognizing the clinical and financial benefits outlined below. [Table: see text]
Quality improvement using new technology to assess and reduce FDG PET/CT radiotracer infiltrations.
Authors: Kiser Jackson William
Published: September 2018

313

Background: The reported aggregated PET/CT 18F-FDG radiotracer injection infiltration rate from 3 centers in 6 studies is 15.2% (425 infiltrations/2804 patients). Infiltrations can negatively affect cancer patient staging, therapy assessment, treatment planning, and can lead to unnecessary invasive procedures and patient radiation exposure. The radiotracer dose is essential to PET image quality and quantification. Efforts are made to ensure the exact dose administered is used to create the patient image; but, no measures ensure the administered dose completely enters the patient circulation. Our objective was to use new technology (Lara, Lucerno Dynamics) to assess our infiltration rate, determine potential causes, reduce our rate, and assess results sustainability. Methods: Our IRB determined the project did not meet the definition of research as defined by 45 CFR 46.102(d) and classified the initiative as “quality improvement”. In Phase 1, our PET/CT center monitored the injection process. Lara data were analyzed (SAS Enterprise Miner, v. 14.1 and v.9.4) and identified potential contributing factors. We then implemented a quality improvement plan to address these factors. In Phase 2 we remeasured our infiltration rate. After Phase 2, we assessed our rate over an extended period. Results: Lara added 30 seconds to patient imaging. In Phase 1, 263 injections were monitored, and 35 infiltrations were identified (13.3%). Five technologists’ rates ranged from 8%-19%. Patients less than 145lbs with non-antecubital fossa injection sites were highly associated with infiltrations. In Phase 2, 278 injections were monitored, and 8 infiltrations were identified (2.9%), a 78% decrease (p < 0.0001). The same technologists’ rates ranged from 0%-4%. Eight technologists performed the next 504 injections and six were infiltrated (1.2%). Conclusions: Our findings supported published PET/CT infiltration rates. Using new technology provided technologists with feedback on injections and lead to significant and sustainable improvements quickly, with minimal patient/procedure disruption. Infiltrations are a quality and safety issue. As a result, the injection process requires ongoing monitoring.
Cancer-related financial burden among patients with metastatic breast cancer.
Authors: Wheeler Stephanie B. , Spencer Jennifer , Manning Michelle L. , Samuel Cleo A. , Reeder-Hayes Katherine Elizabeth , Sellers Jean B. , Rosenstein Donald L.
Published: September 2018

32

Background: Recent data suggest that the adverse financial impact of cancer is an underappreciated source of potential harm to patients, also known as “financial toxicity”. Little is known about the financial impact of cancer in patients with widespread, incurable disease, despite the relatively high cost of their care. We conducted a national survey of patients with metastatic breast cancer to address this gap. Methods: We partnered with the Metastatic Breast Cancer Network to field an online survey of metastatic breast cancer patients over a fourteen-day period using Qualtrics. The survey required approximately 20 minutes to complete, and participants were offered a $10 Amazon gift card. Survey items included sociodemographic information, health insurance status, cost-related communication with providers, post-treatment financial burden, financial coping strategies, and emotional well-being. We report financial outcomes stratified by health insurance status, as insurance is an important protective mechanism against health-related financial shocks. Results: 1,513 participants responded from 41 states. More than a third of these women (35%) were uninsured. Uninsured individuals more often reported refusing or delaying treatment due to cost (98% vs. 41% of insured, p < .001) and were also more likely to report skipping non-medical bills (40% vs. 16%, p < .001), stopping work after diagnosis (65% vs. 46%, p < .001), or being contacted by a collections agency (77% vs. 36%, p < .001). Despite this, insured participants reported higher cost-related emotional distress, including being “quite a bit” or “very” stressed about not knowing cancer costs (53% vs. 32%, p < .001) and about financial stress on their family due to their cancer (52% vs. 27%, p < .001). Conclusions: Metastatic breast cancer patients reported an unprecedented level of cancer-related financial harm and significant worry about the financial legacy left behind in the wake of their illness. Health insurance expansion is a necessary, but insufficient strategy to address this financial burden; additional interventions to prevent and mitigate cancer-related financial harm are urgently needed.
Effective interventions to improve cancer screening rates in adult Medicaid beneficiaries.
Authors: Spain Pamela Crenshaw , Clare Hannah Margaret , Fowler Christina
Published: September 2018

322

Background: The Affordable Care Act (Section 1139B) requires the Secretary of HHS to identify and publish a core set of health care quality measures for adult Medicaid beneficiaries aimed at standardizing health care quality measurement across state Medicaid programs. On January 1, 2013, the Medicaid Quality Measurement Program was established to fund the development, testing, and validation of the adult health quality measures. The Medicaid Adult Core Set of Adult Health Care Quality includes two cancer screening measures (Exhibit 1). With grants from The Centers for Medicare & Medicaid Services (CMS), three state Medicaid agencies carried out quality improvement projects (QIPs) aimed at increasing breast and cervical cancer screening rates. This study describes a qualitative assessment of these states’ QIPs. Methods: Data included grantee applications, semi-annual, and annual progress reports to CMS, as well as in-depth interviews with grantees. Qualitative content analysis (using both structured abstraction and deductive and inductive coding) was conducted in NVivo 11. Results: Breast and cervical cancer screening rates for adult Medicaid beneficiaries improved in these states during the 3-year grant. The most effective interventions identified by the states included: System-level interventions such as the distribution of performance dashboards with peer comparison data; Provider-level interventions such as the distribution of unmet need or gap-in-care reports; and Beneficiary-level interventions such as direct nurse outreach to beneficiaries with a gap in care. Conclusions: QIPs can improve breast and cervical cancer screening rates in adult Medicare beneficiaries. The most effective interventions are multi-pronged and should target health care systems, providers, and beneficiaries.[Table: see text]
Utilizing a standardized order set to increase speech pathology referrals in head and neck cancer patients.
Authors: Gerretsen Carly , Jurgens Corrine
Published: September 2018

324

Background: Treatment of head and neck cancers may include radiation, and side effects will result in short and long-term dysphagia. This can lead to feeding tube usage, malnutrition, loss of social interaction, and reduced quality of life. Rehabilitation therapies are available with speech pathologists to improve outcomes. Evidence supports initiating therapy prior to radiation. Computerized order entry systems (CPOE) support standardization of evidence- based order sets. The purpose of this study was to examine the effect of a standardized order set on referral rates to speech pathology in adult patients undergoing radiation treatment for head and neck cancer. Methods: A quality improvement project was implemented an outpatient oncology clinic within an academic hospital using the PDSA format. Approval was obtained through the hospitals quality assurance officer, and it was determined that IRB approval was not necessary. A chart review was completed to assess the rate of speech pathology consults. A brief education program targeting ordering providers was completed including demonstration of the order set. Post intervention chart review was performed to assess the change in referral rates. Results: A chi square analysis was used to compare the difference in referral rates and found to be statistically significant, x² (1, n = 56) = 17.147, p < 0.01. Demographic data was analyzed using descriptive statistics. The sample was mostly Caucasian (82%), male (84%) with an average age of 63. The most common cancer diagnosis was larynx (36%). The percentage of referrals post intervention (82%) was significantly higher than pre-intervention (18%) consistent with the hypothesis that a standardized order set would increase speech referral rates. Conclusions: Use of a CPOE system with standardized order sets increased the rate of speech pathology referrals. The success of this order set has led to an expansion of the project, and creation of additional order sets. Standardized computerized order sets should be considered to increase referrals to underutilized ancillary services. Providers should be encouraged to create relationships with these services to improve patient’s quality of life and long- term outcomes.
A data driven approach to immunotherapy toxicity management.
Authors: Mahmood Sadiqa , Schwamm Eli , Kehl Kenneth L. , Glotzbecker Brett , Andrews Robert , Singh Prabhsimranjot , Fraile Belen , Muthulingam Shobana , Wagner Andrew J. , Jacobson Joseph O. , LeBoeuf Nicole R. , Rahma Osama E.
Published: September 2018

326

Background: The immune checkpoint inhibitors (ICIs) confer a risk of unique inflammatory immune-related adverse events (irAEs), which are highly distinct from the adverse events historically observed with cytotoxic therapy. To develop a strategy for easier identification and mitigation of irAEs, we sought to understand the frequency of ED visits and hospitalizations in 90 days following ICI start by implementing a rapid learning system (RLS). Methods: We convened an Immunotherapy Toxicities Management Committee with representatives from the Center for Immuno-Oncology, Quality and Patient Safety, and Informatics to draft a series of recommendations for the development of an irAE rapid learning system. The Committee requested an audit of all irAEs between June 2015 and April 2018 by drug, event type (clinical diagnosis), outcomes (including ED visits, hospitalization with length of stay, and death), and time-frame (days since beginning ICI course). An automated pipeline was created to merge structured data from the Electronic Health Record (Epic) and billing system (EPSi). This data was used to design a tool which consisted of an automated dashboard to monitor patient and enable interventions. Results: Over the course of 3 years, a total of 2,020 unique patients receiving ICIs were seen. 918 were treated with Pembrolizumab (45.4%), 768 with Nivolumab (38.0%), 234 with Atezolizumab (11.6%), 111 with Nivolumab & Ipilmumab (5.6%), 68 with Ipilimumab (3.4%), 9 with Durvalumab (0.4%), and 9 with Avelumab (0.4%). ED visits and hospitalization rates over 90 days were similar among the three most prescribed therapies, ranging from 332 unique patient events in the Pembrolizumab Cohort (36.1%) to 96 unique patient events in the Atezolizumab cohort (41.0%). Conclusions: The dashboard is effective tool to build a RLS for irAEs. The immediate output of this tool is using natural language processing (NLP) to distinguish between irAEs related ED visits and hospitalizations or regular disease progression, and measure the impact of interventions including (a) developing standardized algorithms for monitoring for irAEs, (b) designing an educational program for providers, and (c) developing an inpatient and outpatient immunotherapy toxicity management service.
Building a novel near real-time multisource database to assess and improve infusion wait time at a comprehensive cancer center.
Authors: Yakowec Jing Jing Wang , Pettengill Mark , Mahmood Sadiqa , Fraile Belen , Lakhani Hakim
Published: September 2018

4

Background: Evidence has shown that long infusion wait time is one of the main contributors to oncology patient dissatisfaction. To identify bottlenecks and inefficient processing, a comprehensive understanding of the infusion workflow at Dana-Farber Cancer Institute was explored. The goal of the project is to leverage existing data sources to quantify time to process completion and to serve as the database for multiple wait time improvement projects. Methods: Infusion workflow from patient check-in or appointment time to first infusion medication administration (wait time) was mapped. Data from Epic and Real-Time Locating System (RTLS) were pulled into a single integrated source in Tableau and SAS for analysis. Using a custom SQL query, the following tables including crucial timestamps were pulled and pooled: encounters, pharmacy processing and dispense, treatment plan and protocol, RTLS events related to infusion chair occupancy, and medication administration records. Further programming was written to flag categories such as investigational versus non-investigational drugs, linked versus un-linked to exam appointments, and inclusion and exclusion criteria regarding date range, infusion floor, and encounter type. Results: The final clean infusion database includes data from September 1, 2017 through the day before current day via automatic data pull. Processing and wait times were analyzed at multiple levels by drug, encounter, department, staff, and protocol. To date, four known wait time improvement projects that aim to shorten processing time, such as early signing of orders by providers, have leveraged this near real-time dataset to monitor and evaluate the impact of the projects. The automation of data to pre-built visualizations in Tableau comparing baseline processing time to post-pilot impact and overall wait time trends has been extremely well received by all improvement stakeholders at the institute. Conclusions: A novel database merging Epic and RTLS data was successfully built to explore and improve infusion patient wait time. This technique can be applied at other institutions interested in reducing wait times and improving patient satisfaction.
Tiers of service: Outpatient medical oncology services for British Columbia, Canada.
Authors: Letwin Shallen , Pereira Astra , Currie Tammy , Pansegrau Gary K. , Hawkins Marie
Published: September 2018

40

Background: The vision is for cancer care in British Columbia to be delivered in a coordinated, efficient manner, governed through effective partnerships between the Regional Health Authorities and BC Cancer. Systemic Therapy is delivered throughout BC by several providers, however service provision standards do not exist. BC Cancer and Fraser Health embarked on a process to develop a provincial Tiers of Service that outlines the responsibilities and requirements for the delivery of systemic therapy. Methods: From October 2017-April 2018, a working group drafted a Tiers of Service framework to be further approved by a Provincial Working Group. A scan of the literature and review of other jurisdiction's frameworks were evaluated. BC Cancer in partnership with the Regional Health Authorities have identified that the increased need for outpatient medical oncology services, combined with human resource and healthcare facility constraints requires a framework for organizing and delivering cancer care services in British Columbia. Therefore, a need to update the framework and shift nomenclature from the current “Levels of Service” to “Tiers of Service” was identified. Results: A survey of the working group was utilized to understand their level of confidence with regards to the development and utilization of the framework. Overall the working group increased their level of confidence from 33% to 100%. Conclusions: Tiers of Service: Outpatient Medical Oncology Services provides a practical framework which will be used to define and plan medical oncology services in British Columbia utilizing a common language and methodology. It describes the minimum responsibilities and requirements of each tier in providing a safe, sustainable and appropriate level of service. Tiers of Service will set standards and provide clarity for service provision, help build a capacity plan, plan where resources should be located, measure and monitor performance and improve the quality of the patient experience.
Pan-Canadian Oncology Drug Review (pCODR): A unique model to support harmonization of cancer drug funding decisions in Canada.
Authors: Trudeau Maureen E. , Chambers Alexandra , Christiansen Kendra , Mai Helen
Published: September 2018

41

Background: Unlike most other countries, Canada has a dedicated HTA process to review cancer drugs. pCODR, a program of CADTH, conducts thorough and objective evaluations of clinical and economic evidence; as well as considering clinician and patient perspectives, and using this information to make recommendations to the participating jurisdictions to guide their drug funding decisions. Previously, Canadian provinces had separate regional drug review processes to inform their local funding decisions. The pCODR process reduces duplication of effort by individual funders and ensures that reviews are done in a timely and consistent manner. Methods: In a retrospective review, we identified all anticancer drugs reviewed by pCODR from July 2011 to March 2018. Results: As of March 31, 2018, pCODR has issued 103 notifications to implement a final recommendation. Of note, 96% of the submissions include patient group input and 88% of the submissions include clinician input. The median time to complete a review is 146 business days. The pCODR Expert Review Committee has issued 21 negative recommendations, while the remainder were either positive recommendations (n = 10), or conditional recommendations (n = 72). The “condition” that must be addressed most frequently in the conditional recommendations is the cost-effectiveness of the drug. Over 75% of the 82 positive and conditional recommendations have received uptake from one or more participating jurisdictions. The concordance rates are as follows: Conclusions: With the implementation of the pCODR process, there is greater harmonization in cancer drug funding decisions and supports equitable access across Canada.[Table: see text]
Impact of nontreatment oncology research trials on physician engagement in clinical research in an oncology community practice setting.
Authors: Night Susan S. , Roemisch Juston S. , Smith David A.
Published: September 2018

44

Background: The rapid development of new oncology drugs has created a significant increase in the number of clinical research studies. This underscores the need for greater participation in research by physicians as well as patients. Many physicians hesitate to participate in oncology clinical trials that provide treatment options for their patients given the complexity of the protocols. Non-treatment clinical trials may serve as a bridge for engaging physicians in clinical research and enhance the culture of research in community oncology practices. Methods: A large non-treatment oncology clinical trial was opened in a network of community oncology practices with approximately 1,000 physicians. We evaluated the number of physicians who did not enroll a patient onto a clinical trial in Year 1 but did enroll patients onto the non-treatment study. We further examined the number of physicians who enrolled a patient onto the non-treatment study that also enrolled patients onto a treatment clinical trial. Overall physician engagement in clinical research was measured by comparing practices where non-treatment study was offered to locations that did not participate in the non-treatment study. Negative impact on treatment accruals was also evaluated. Results: There were 105 physicians that practice at a site with the non-treatment study who had 0 accruals in Year 1 but enrolled a patient to any clinical trial in Year 2. Ninety-two of those physicians were responsible for enrolling over 900 patients to the non-treatment study in Year 2. Additionally, 46 of the 0 accruing physicians in Year 1, enrolled a patient to the non-treatment study also enrolled a patient to a treatment clinical trial. We also found that 24 physicians who did not did not enroll a patient in Year 1 and did not enroll a patient to the non-treatment study did enroll patients to a treatment clinical trial in Year 2. Conclusions: Participation in oncology treatment clinical trials can be difficult in the community oncology setting. Participation in a non-treatment study may serve as a bridge to engage more physicians in clinical research and enhance the culture of research within a community oncology practice.
A nonrandomized study on compliance with IDSA guidelines on the choice and dosing of empiric antibiotics for patients with febrile neutropenia after implementation of a new Computerized Physician Order Entry (CPOE).
Authors: Meleveedu Kapil , Kaza Sai , Phuong Lisa , Perry Edward Belk , Tannenbaum Susan
Published: September 2018

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Background: More than 80% of patients with hematologic malignancies and 10-50% of patients with solid tumors are expected to experience fever after one cycle of chemotherapy. Studies have shown all-cause mortality to be 15% higher in cancer patients with febrile neutropenia than comparably matched patients without febrile neutropenia and compliance for choice of empiric antibiotics in febrile neutropenia to be as low as 56%. Methods: We conducted a retrospective chart review of patients who presented with febrile neutropenia to our institution for one year prior to and after implementation of a CPOE set. Data was collected on basic demographics, oncological diagnosis, labs, choice of antibiotics and dosing frequency. Awareness sessions were conducted among admitting staff following the initial retrospective analysis followed by implementation of a CPOE set in order to improve guideline concordant management of febrile neutropenia patients. The IDSA risk was assessed based on the above data and the pre and post order set compliance with IDSA guidelines were compared. Fisher’s exact test was applied to assess the percentage of compliance before and after implementation of the order set, with significance set at two-sided p value < 0.05. Results: Among the patients managed before order set, 15 of the total 26 (58%) were found to be non compliant with IDSA guidelines in terms of either antibiotic choice or dosing frequency. A post order set analysis showed that only 7/27 (26%) were non compliant with IDSA guidelines. The Fisher exact test showed a statistically significant value of 0.0267 (p < 0.05). Conclusions: Education and implementation of a CPOE order set showed significant improvement in compliance with IDSA guidelines for management of febrile neutropenia. Based on the data from our study an IDSA concurrent institutional guideline for management of febrile neutropenia was formulated and further efforts are under way to incorporate results in our new EMR order set entries.[Table: see text]
Implementation of a multifaceted program to improve uptake of guideline recommendations for adolescent and young adults (AYAs) with acute lymphoblastic leukemia (ALL).
Authors: Hahn Erin Elizabeth , Ghai Nirupa R. , Cooper Robert Michael
Published: September 2018

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Background: ALL is one of the most common malignancies in the AYA population (age 15-39) and is associated with poor survival in AYAs when compared with children. There is compelling evidence demonstrating a survival benefit for AYAs treated with pediatric regimens vs adult regimens, and guidelines from the National Comprehensive Cancer Network now recommend consideration of pediatric inspired treatment. However, uptake has been suboptimal, with only 25%-35% of AYAs with ALL receiving a pediatric regimen in the U.S. There are several potential barriers to uptake, including lack of knowledge and guidance about the recommendations. For this study, we implemented and evaluated a multi-faceted program to improve uptake in a large health care system, Kaiser Permanente Southern California (KPSC), with 14 medical centers across the region. Methods: The program was initiated regionally in 2013 across all 14 medical centers. Content included education of clinical leaders, rapid identification of newly diagnosed AYA ALL patients by the hematopathology team, and guidance and support from a pediatric oncologist for adult oncology teams treating AYA ALL patients emphasizing a pediatric regimen when appropriate. We subsequently identified AYA ALL patients diagnosed and treated between 2012-2016. A detailed chart review was conducted to determine treatment regimens prior to implementation of the program and post-implementation. Results: We identified 58 patients, 11 in the period prior to implementation and 47 post-implementation. Overall, 18% of patients in the pre-intervention period were treated on a pediatric regimen vs. 77% post-implementation. We found an increasing trend over time in the post-intervention period, with 46% receiving a pediatric protocol in 2013, 64% in 2014, 92% in 2015, and 100% in 2016. Conclusions: We were successful at increasing the proportion of eligible patients who received pediatric protocols for treatment of AYA ALL. Implementing a multi-faceted approach to improve care for this rare condition was feasible and acceptable to oncology clinicians across the region, with potential for large-scale scale-up and spread.
Patterns in breast cancer staging imaging: Are we choosing wisely?
Authors: Barlow Brett , Williams Courtney , Gilbert Aidan , Watkins Stacey M , Rocque Gabrielle Betty
Published: September 2018

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Background: The American Society of Clinical Oncology’s Choosing Wisely guidelines recommend no staging imaging in early stage breast cancer (ESBC) patients with low risk of metastasis, as it is potentially harmful and provides no survival benefit. This study evaluates local adherence to this recommendation and identifies factors contributing to unnecessary staging imaging. Methods: This retrospective cohort study included patients with AJCC stage 0-II BC diagnosed from 2013-2015 at a single-site, academic medical center. Data was abstracted from chart review. Imaging included computed tomography, positron emission tomography, or bone scans. Imaging for documented symptoms was considered appropriate. Abstracted patient data included demographics, medical oncologist, and clinical characteristics. To evaluate factors influencing inappropriate screening imaging, risk ratios (RR) and corresponding 95% confidence intervals (CI) were estimated using generalized linear models with a log link and Poisson distribution with robust variance estimates. Results: Of the 872 ESBC patients, 262 (30%) underwent staging imaging. Median diagnosis age of patients receiving imaging was 55 (IQR 48-63) compared to 60 (IQR 52-68) for patients with no or appropriate imaging. Risk of inappropriate screening imaging was increased for patients who were younger (RR 0.98, 95% CI 0.97-0.98), had triple negative disease vs any hormone receptor positive (RR 2.98, 95% CI 2.25-3.95), had higher stage BC (I vs. 0, RR 3.58, 95% CI 2.05-6.25; II vs. 0, RR 10.86, 95% CI 6.43-18.33), and did not have Medicare insurance (RR 1.52, 95% CI 1.22-1.89). Rates of imaging did not vary by race (non-white vs. white: RR 0.98, 95% CI 0.78-1.23). For medical oncologists with at least 15 patients, prevalence of inappropriate imaging varied from 26-68%. Conclusions: A substantial proportion of ESBC patients received unnecessary and potentially harmful staging imaging inconsistent with guidelines. Staging imaging was associated with patient demographic and clinical characteristics related to increased recurrence risk, suggesting a need for further physician education about the low-risk nature of this ESBC population to ensure high value oncologic care.