bluuebunny/crossref_metadata_2025 huggingface dataset:
Decreasing initiation of chemotherapy time in elective patients admitted to an inpatient hematology malignancy unit.
Authors: Galeas Jose Nahun , Packer Stuart H. , Sakalian Susan , Browne Royston , Binder Adam
Published: September 2018

120

Background: At our institution, we observed that 86% (n = 25) of patients admitted for elective chemotherapy experienced a delay (greater than 6 hours) in initiating their treatment. Methods: We measured time from admission to chemotherapy administration (Defined from time of vital signs taken at admission until time of chemotherapy administration) in patients admitted for elective chemotherapy. Key process measures were identified and monitored (i.e, time from admission to laboratory exam results, time from admission to chemotherapy signed, time from chemotherapy signed to chemotherapy released by nurse from the EMR). We collected data every two weeks. After collecting data and utilizing performance improvement tools such as a pareto chart and PICK chart, we developed multiple PDSA cycles as described in Table 1. Results: At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 25 hours to 8.85 hours. Median time to lab draws decreased from 2.33 hours to -0.63 hours. There was no change in time from signature to nurse releasing the chemotherapy. We noticed more providers were signing the chemotherapy prior to patient admission and more patients were receiving pre-admission alkalinization strategies. Conclusions: By implementing new admission workflows, optimizing our use of the EMR to communicate among providers, and improving pre-admission planning we were able to reduce our time to chemotherapy for elective admissions by 64.6%. Improvement still needed to meet our goals and fully standardize the processes as part of our daily workflow.[Table: see text]
Reducing infusion wait time: An initiative to increase early signing of medication orders by providers at a comprehensive cancer center.
Authors: Yakowec Jing Jing Wang , Rabin Michael S. , Matulonis Ursula A. , Shukla Shital , Kearney Michael D , Fine Barbara , Wolfberg Rachel A , Pettengill Mark , Hilton Nancy , Bartel Sylvia , Wagner Andrew J. , Lakhani Hakim
Published: September 2018

123

Background: Many factors contribute to long wait times for oncology patients on the day of their infusion appointment. At Dana-Farber Cancer Institute (DFCI), one of the main causes of delay to infusion start is providers not signing medication orders in advance of patients checking in for their infusion appointment. We conducted a project to improve provider order signing behavior on the gynecology cancer patient infusion floor at DFCI. Methods: A data working group was formed which consisted of the infusion floor medical leads, nurse lead, pharmacy lead, and analytics and process improvement leads. Starting in February 2018, the working group shared baseline order signing data from September 2017 through January 2018 with the Gynecology Cancer Group. Descriptive and timestamp data from Epic were extracted and cleaned via Tableau to analyze the percentage of non-investigational medication orders, including chemotherapy, that were signed after a patient checked into infusion and the distributions of late order signing times. Results: Gynecology cancer patient providers had higher late order signing percentages at baseline (September 2017 through January 2018) than after sharing those data, which occurred from February through May 2018. The table below provides medication order counts and late order signing percentages by month. Although late signing percentages decreased after sharing the baseline data, the distribution of how late the late orders were signed did not show improvement, staying at an average of 20 minutes late. Conclusions: Sharing late order signing data with providers on a routine basis reduced late signing percentages. Initiating this process with all disease groups is crucial so that downstream workflows can start sooner and patient wait times reduced.[Table: see text]
Responding to the opioid crisis in a manner that respects oncology patients: A single institution experience writing policy to promote safe opioid use.
Authors: Cellurale Cristina , Fenton Mary Anne , Cherenzia Katie , Begnoche Megan
Published: September 2018

132

Background: The current opioid crisis has had wide ranging implications across medicine and in particular oncology practice. Opioids have been used for centuries for their analgesic properties. As physicians and historians are aware, the abuse potential of opioids is significant. Despite this, a dramatic shift in medical education in the late 1990s and early 2000s and aggressive marketing and manufacture of opioids has led to widespread opioid misuse and abuse. Therefore, a slew of regulations has been put into effect within a brief period of time. Among practitioners, the oncologist holds a unique and arguably more challenging role, caring not only for those with acute cancer-related pain or those at the end of life, but also for cancer survivors or those who live with their cancer as a chronic condition. ASCO has put forth comprehensive guidelines for the safe use and monitoring of opioids. The ASCO policy statement also highlights the significant barriers that oncology patients face, thereby maintaining a focus on the unique needs of this patient population. Methods: The Lifespan Cancer Institute is an academic practice and writes approximately 880 opioid prescriptions each month with approximately 15% being new prescriptions. Our Multidisciplinary Quality Team implemented a safe opioid prescribing initiative including patient education sheets, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. Our palliative care team monitors pain scores. Results: During month one, 16% of patients newly prescribed an opioid had a completed patient-provider treatment agreement. For the second month, the number of completed agreements increased to 29%. Conclusions: Given the prevalence of opioid misuse, there is a growing overlap between oncology patients and those with opioid misuse disorder. Given high levels of psychological distress, the cancer patient is at risk for opioid misuse. Furthermore, oncology patients can be victims of diversion. Our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.
Examining the relative influence of multimorbidity on variations in older cancer patients’ experiences with care.
Authors: Kent Erin , Mollica Michelle , Klabunde Carrie N. , Arora Neeraj K. , Elliott Marc , McNeel Timothy S. , Wilder Smith Ashley
Published: September 2018

14

Background: Cancer patients often have multiple chronic conditions and require complex care coordination. We compared older (ages 66+) cancer patients’ reports of their healthcare experiences based on level of multimorbidity. Methods: Data from the SEER-CAHPS combines cancer registry (Surveillance, Epidemiology, and End Results; SEER), patient experiences (Consumer Assessment of Healthcare Providers and Systems; CAHPS) and Medicare claims data. Multimorbidity was captured as: (1) the National Cancer Institute-Combined Comorbidity Index (NCCI, 16 Charlson conditions diagnosed ≤12 months prior to cancer); and (2) a Multimorbidity Burden Index (MBI), which categorizes conditions based on the impact to cancer treatment (no comorbidity, low/medium, and high). Outcomes were CAHPS patient experience measures: Doctor Communication, Getting Care Quickly, Getting Needed Care, Obtaining Prescription Drugs, Customer Service, and ratings of Overall Care, Personal Doctor, and Specialist. Multivariable linear regression provided associations of each multimorbidity measure with CAHPS measures controlling for standard case mix adjustors, years from diagnosis to survey and diagnostic stage. Results: The study cohort included 9305 cancer patients (53% male, 84% Non-Hispanic White, average age 77, average time from diagnosis 29 months), with a distribution of NCCI conditions as: 0 (cancer only), 73%; 1, 17%; ≥2, 10%. Cancer patients with NCCI = 0 and those with MBI = no comorbidity rated their Personal Doctor more negatively than those with any comorbidities ( p < 0.02). Those with NCCI ≥ 2 or MBI = low/medium reported better Doctor Communication ( p < 0.04). Those with high MBI rated their specialist physician better than those with no multimorbidity ( p = 0.04), and those with low/medium MBI reported better experiences Getting Care Quickly ( p = 0.02). No other associations were significant. Conclusions: Cancer patients with multimorbidity report better communication with their doctor and care = by = personal doctors and specialists. Increased attention to the care experiences of cancer patients with multimorbidity may lead to insights and interventions that benefit all cancer patients.
Medically integrated pharmacy: A team-based approach to improve oral oncolytic therapy for cancer patients.
Authors: Doshi Gurjyot K. , Condon Kelani , Schwartz Jim R. , Dave Neal , Sellers Chris , Harville Margaret , Books Holly , Wilfong Lalan S.
Published: September 2018

140

Background: The use of oral oncolytic therapies in the treatment of cancer is rising dramatically.　Cost barriers to obtaining drugs and side effects of therapies lead 1 to poor adherence to oral regimens resulting in detrimental outcomes. External specialty pharmacies have attempted to assist patients but this often leads to further fragmentation of care. We report on the performance of a medically integrated pharmacy within a large community oncology practice to achieve better patient outcomes. Methods: The Texas Oncology medically integrated pharmacy (MIP)consists of oncologists, oncology nurses, advanced practice providers, and specially trained pharmacy staff utilizing real-time access to the patient’s electronic medical and pharmacy records when oral therapy is prescribed.　The team processes　prior authorizations and patient assistance requests,　ensures drug delivery, provides education, monitoring, and follow up of side effects for oral therapies. The care team is available to provide early intervention and side effect management. Treatment initiations, dose adjustments, and treatment discontinuations are communicated seamlessly in real time. Results: Texas Oncology MIPs process over 14,500 prescriptions annually with a 99% prior authorization approval rate. Service is timely with a representative sample of 4 practices showing 64% of prescriptions filled within 24 hours of prescribing and 72% filled within 72 hours. Prior authorization and patient assistance were the leading causes of delays. The patient assistance team processes over 3,200 requests annually with over $121 million copay assistance obtained. Adherence to therapy within Texas Oncology is over 92% for the 7 most commonly prescribed oral oncolytic drugs.　Patient satisfaction surveys reveal 96% satisfaction with the medically integrated pharmacy. Conclusions: The MIP is a fully aligned team based approach for the delivery of oral oncolytics. A medically integrated pharmacy provides timely access, copay assistance, monitoring and management of side effects resulting in increased adherence to therapy and an overall improvement in quality and satisfaction.
The Employers Centers of Excellence in Cancer Care: A collaboration of employers and providers to improve cancer care.
Authors: Patel Manali I. , Lee Rachel V , Smithline Neil , Ross Olivia
Published: September 2018

141

Background: Rising costs demand collaborations that lower expenditures and improve patients’ experiences and outcomes. We created a novel employer-provider collaboration to enhance value-based cancer care. Methods: We created an Employers Center of Excellence Network (ECEN) for the Pacific Business Group on Health (PBGH) employee groups. The ECEN provides competitive bundled rates that include travel for in-person patient consultation, advanced assessment and treatment by multidisciplinary case reviews, and ongoing specialized treatment care coordination and follow-up on a routine basis with the local care team.The ECEN development process included: focus groups, expert panel development, and a rigorous selection process. A Request for Proposal was publicized to all west coast NCI-designated comprehensive cancer centers. After interviews, selected sites were invited to submit a full proposal and a few were selected for a site visit.. In addition to overall cancer care excellence, a key criterion for acceptance was the demonstrated willingness and ability of the center to provide long-term support for the patient and home oncologist in the patient’s home market, so that the center’s expertise and support would be ongoing for the duration of the cancer treatment. Results: Of 8 sites that participated in team-assessment interviews, 4 were selected to submit a full proposal, 3 selected for in-person visits, and 1 selected to participate. In January 2019, we plan to implement a 6-month pilot with a PBGH employer group and the provider site to evaluate the ECEN's feasibility and effects on quality, patient-reported outcomes, and costs. Conclusions: Our novel employer-provider collaboration aims to improve cancer care delivery by providing planned and supported NCI-designated cancer care in close collaboration with the home oncologist. We plan to expand the ECEN development process across the US to develop a network of collaborating providers and employers to improve patient-centered, value-based cancer care.
Introducing enhanced navigation and supportive care into the curative treatment of cancer (SCOOP pathway).
Authors: Koprowski Christopher , Johnson Ej , Trzepkowski Kenneth , Sites Karen , Petrelli Nicholas J.
Published: September 2018

142

Background: We hypothesized that introducing supportive care management and enhanced electronic aids to nurse navigation in selective curative cases could result in cost savings and enhanced patient experience of the sort demonstrated in patients with advanced disease. Methods: To test this hypothesis, we introduced a clinical pathway in November 2016 called the Supportive Care of Oncology Patients (SCOOP) program. We limited the scope to patients receiving radiation and chemotherapy concurrently at the Helen F. Graham Cancer Center and diagnosed with potentially curable thoracic, colorectal or head and neck malignancies and seen in our mulitdisciplinary clinics (MDCs). 1. A nurse navigation check list was developed for nurse navigators in the Aerial information system to support standardization of care. The navigator has to opt out of ancillary service consults such as nutrition, behavioral health and social work. The check list includes other mandatory tasks that must be completed at various time points before, during and after the patient’s concurrent treatment. Examples include: Prescribed communication dates with the patient; capturing of scheduled consults; assessing additional/unmet needs before, during and after treatment phase. 2. A mandatory supportive and palliative care service screening during the MDC visit, and, if indicated, urgent or timely consultation. 3. Flags in the inpatient information system that alert in real time the supportive care service, the navigators and the oncologists whenever a patient is seen in the emergency room, admitted or discharged. Results: During the first year nurse navigation compliance increased from 94% to 99%.ED visits declined from 54% to 32% of SCOOP patients , admissions from 34% to 25% and readmissions from 32% to 20% . Opportunity cost savings were $1500.00 per patient. Conclusions: Much like the results observed in advanced disease, the early introduction of enhanced nurse navigation and palliative/supportive care in high acuity patients treated curatively improves the patient experience and reduces societal costs.
Addressing advance directive completion rates on an inpatient oncology unit.
Authors: McInnes Susan , Dhingra Navin
Published: September 2018

147

Background: Advanced directives (ADs), particularly heath care power of attorney (HC-POA), are not always obtained or documented for patients with cancer. Hospitalized cancer patients may become too ill to complete them, making treatment decisions difficult. Understanding patients’ end-of-life preferences and providing care congruent with their values is fundamental to quality care. Completing ADs is an important aspect of this process. However, AD rates for oncology patients are typically under 40%. Our team sought to measure and increase our oncology inpatient AD rates. Methods: An interdisciplinary group including oncology and palliative medicine physicians, nurses, social workers, care managers and quality leaders convened to address ADs on our inpatient oncology services as a quality improvement project. We completed a current state analysis, evaluated areas of wasted or redundant workflow and performed a root cause analysis, identifying 4 countermeasures: 1) educating patients and staff re the value of completing HC-POAs, 2) clarifying the role of each team member, 3) implementing a discussion script for HC-POA conversations and 4) tracking and reviewing HC-POA completion in daily multidisciplinary rounds. AD completion rate by discharge was collected weekly through the 12-week project (325 discharges) then monthly for 6 months (709 discharges.) Results: Our baseline HC-POA rate was 30% for hospitalized oncology patients. Completion increased to 39% with education, role clarification and use of a discussion script. When daily tracking was initiated with the entire care team, including medical oncology staff, fellow and residents, the AD rate increased as high as 65%. This model was implemented as a best practice and has been sustained with AD completion rates of 45-60% in the subsequent 6 months. Conclusions: Our interventions successfully and sustainably increased HC-POA completion rate by engaging the entire interdisciplinary oncology team around the need for HC-POA documentation. We standardized team communication about ADs into daily workflow in interdisciplinary rounds. This increased the comfort level of the entire team and normalized discussion of HC-POAs, contributing to increased AD completion.
Examining patient burden and drivers of delayed care in patients undergoing surgical treatment of primary lung cancer.
Authors: Barnhill Caleb , Hillenbrand Charles , Kaplan Stephen , Kuppusamy Madhan , Hubka Michal
Published: September 2018

153

Background: Patients’ geographic location can impact access to specialty care and affect the appropriateness and timeliness of evaluation leading to primary surgical treatment of lung cancer. Cancer care coordination has long been speculated to lead to greater efficiency in oncologic care, yet objective measures demonstrating the utility of such healthcare team members is lacking. We aimed to study the impact of patients’ residence on healthcare encounters, travel burden and the distribution of physiologic and oncologic workup leading to delays in care at a specialty cancer center. Methods: We conducted a single center retrospective cohort study of 103 patients undergoing workup of primary lung cancer between January 2015 and August 2017. The shortest route between patient residence and treating medical center was measured in miles and classified as: urban ( < 40 miles); rural (40.1 – 100 miles); and regional (100.1 – 1,000 miles). Average total miles traveled (i.e. travel burden), total number of healthcare encounters, and the distribution of physiologic and oncologic evaluations as drivers of delay in care were examined. Results: Patients were categorized as urban n = 80 (77.7%); rural n = 12 (11.7%); and regional n = 11 (10.7%). Median travel burden (urban = 100 miles [interquartile range, IQR 56-216.8]; rural = 385.7 [127.1 – 769]; regional = 780 [560 – 1936]; p < 0.001) and median total healthcare encounters (urban = 7 [6-9]; rural = 9 [7-9.5]; regional = 10 [7-12]; p = 0.3) increased with greater distance of patient residence from treating medical center. Additional necessary physiologic workup was associated with delayed care and greater burden in the rural and regional patients compared to those residing in urban locations (urban = 21% increase; rural = 152%; regional = 162%). Additional oncologic workup was associated with delayed care in the regional group only (49% increase). These trends remained even when controlling for clinical stage. Conclusions: These findings demonstrate the need for better cancer care coordination for rural and regional lung cancer patients to improve efficiency, appropriateness and timeliness of care while decreasing patient-related burdens.
Quality of care during active surveillance in low-risk prostate cancer patients: A population-based approach.
Authors: Timilshina Narhari , Finelli Antonio , Tomlinson George A. , Sander Beate , Alibhai Shabbir M.H.
Published: September 2018

16

Background: Active surveillance (AS) has become a widely accepted management strategy for low-risk (Gleason score ≤6) prostate cancer (PC). Given the large proportion of low-risk PC (60-90%) patients who currently receive AS, adherence to clinical guidelines on AS and variations in care at the population level remain surprisingly poorly understood. Further, it is presently unclear how often patients receive high quality AS care in community settings (almost all published data come from academic centers), yet the majority of AS occurs in community settings. Thus, there is significant interest in developing system-level quality indicators (QIs). We sought to develop structure-process-outcome-based QIs to enable benchmarking during AS follow-up using data available in Canadian administrative databases. Methods: We performed a detailed literature search on QIs in PC as well as broader theoretical concepts on QIs and consulted with clinical leaders from a major cancer centre. Current guidelines on AS and potential quality indicators were identified from a literature search. AS-specific QIs were tested among low-risk PC who were managed with AS between 2002-2011 using population-level cancer registry databases. We assessed adherence to clinical guidelines using QIs, and compared with health care system-related characteristics. Results: 25 indicators were proposed [structure of care (n = 5), process of care (n = 16) and health outcomes (n = 4)]. Overall 39% received AS, with 88% managed by a urologist. Only 43% of low volume (≤3 positive cores) patients underwent AS. Adherence of confirmatory biopsy with guidelines was performed on only 32% of patients, and adherence was better in higher volume institutions, among higher volume physicians, and in cancer centers. 5-and 10-year PC specific survival were significantly better among high volume physicians. Conclusions: We have proposed a set of QIs for measuring AS care. Initial data show that higher volume institution or higher volume physician and cancer center had better adherence to quality of AS care. Long term survival was better among patients treated by high volume physicians. Further validation of these QIs is ongoing.
Communication among oncology teams at an academic center.
Authors: Jensen Christopher Edward , Laughlin Amy Iarrobino , Landsburg Daniel Jeffrey
Published: September 2018

166

Background: Effective communication is essential to ensure optimal care for oncology patients admitted to the hospital and safe transitions between care settings. Methods: A questionnaire adapted from the Collaboration and Satisfaction about Care Decisions survey instrument addressing inpatient/outpatient communication was sent to nurses and physicians who cared for patients admitted to the housestaff oncology services at the University of Pennsylvania from 10/2016-2/2017. Questions addressed care plan formulation, communication, and satisfaction with medical decision making on a seven-point Likert scale. Contextual interviews with stakeholders were also conducted. Iterative adjusted rounding pilots were implemented in PDSA cycles including rounding checklist, multi-disciplinary rounds and a two-step paging process to inform nurses of teams’ rounding times. Results: For 66 respondents, the ranges of mean score for each question by provider type were: oncology nurses (4.07-4.29, n = 28), medicine interns (4.33-5.11, n = 9) and residents (4.00-4.83, n = 12), oncology fellows (5.00-7.00, n = 1), and oncology attendings inpatient (5.56-5.89, n = 9) and outpatient (4.71-5.57, n = 7). Given the lowest scores among nurses, rounding interventions targeting nursing attendance on rounds were trialed. Baseline data demonstrated nursing presence on rounds for 47.0% (95% CI: 37.2-56.8%) of patients. During a pilot of the two-step paging process, the rate increased to 63.1% (55.6-70.6%; p = 0.01 for two-sided Z test). A balancing metric of time per patient did not vary significantly before and during the pilot process. Contextual interviews surrounding interventions suggested several barriers to systematically restructuring provider rounds: time limitations for team rounds, frequent rotation of providers and variations in rounding styles as dictated by attending physicians. Conclusions: Satisfaction regarding the care of acutely ill oncology patients appears to negatively correlate with face-to-face time spent with patients in the inpatient setting. These findings provided the basis for a series of pilots of modified rounding models with a focus on integrating nursing staff into provider rounds, which have been difficult to sustain
Survivorship: The UHealth patient experience.
Authors: Vazquez Adrienne Marie , Trivedi Chinny , Amoros Annette
Published: September 2018

183

Background: The University of Miami has a formal Survivorship Program based on the Commission on Cancer (CoC) requirements. CoC requires accredited institutions to deliver survivorship care plans (SCP) to patients who fit analytic criteria. There is a lack of research on the patient experience as it pertains to survivorship care. Methods: Using a Likert-type scale, dual language survey (English and Spanish), patients were asked 6 questions about the Survivorship Clinic visit ranging from scheduling feasibility to information received during the visit and any opinions to improve the visit for future patients. Patients were given two weeks to complete the survey through a secure, HIPAA compliant online source (REDCap). Those who did not reply were called on the phone by a registered nurse to obtain a statistically significant sample size. Results: Of the 236 patients that were contacted, 45 responded (Breast 38.3%, Gastrointestinal 12.8%, Prostate 10.6%, Gynecologic 8.5%, Lymphoma 6.4%, Lung 6.4%, Sarcoma 4.3%, Other 12.8%). Our results found that 95.7% of patients would recommend this visit to anyone who has completed cancer treatment. Also, 59.6% of patients found the SCP to be most helpful, followed by Survivorship Provider input (38.3%) and then American Cancer Society Healthy living tips (36.2%). As a note, it was mentioned in free text that 11.1% would have preferred a similar visit at the beginning of treatment, at the completion of treatment and/or incremental follow up. Of those surveyed, 88.9% were referred to nutrition, 44.4% to exercise physiology and 27.8% to psychology/psychiatry. Conclusions: Of the patients surveyed 95.7% were satisfied with the survivorship visit. Our conclusion based on survey results shows that institutions should continue to provide formal survivorship care as per CoC requirements. Future directions should look at expanding services to patients at diagnosis and throughout the continuum of treatment and follow up. As survivorship programs grow, practices should consider increasing resources to accommodate the identified needs of patients at the beginning and end of cancer treatment.
Experience and outcomes of the Acute Leukemia Shared-Care Program.
Authors: Wong Amanda , Wong Audrey , McKay Cassandra , Maguire Bryan , Mozuraitis Mindaugas , Wang Jonathan , Maki Kim , Hertz Sherrie , Kouroukis C. Tom , Costello Judy
Published: September 2018

184

Background: Acute leukemia (AL) is a rapidly progressive disease requiring timely and intensive treatment. Historically, care for approximately 50% of AL patients in Ontario, Canada has been centralized resulting in significant resource pressures at the specialized center and travel pressures on patients and caregivers. The AL Shared-Care Program was launched in 2014 to enable delivery of appropriate portions of care at an AL Service Site and Partner Cancer Center closer to the patient’s home. Methods: The impact of the Program was evaluated through provider interviews (n = 22) and the Patient Experience Survey which included 20 non-shared-care (control) and 26 shared-care (intervention) patients. A retrospective analysis of 332 control and 70 intervention patients was used to evaluate the Program’s impact on travel, survival outcomes, and resource utilization. Results: Retrospective analysis revealed that an average intervention group patient saved a median round trip travel distance of 115 km [IQR: 88-179] and time of 91 min [IQR: 62-141]. 91% of health care providers reported that the Program provided person-centered care. Patients reported positive experiences with no statistically significant differences between the intervention and control groups in coordination of care (81% vs 90%, p = 0.39), overall care (88% vs 100%, p = 0.12), and experience (85% vs 90%, p = 0.60). There was no statistically significant correlation between patient satisfaction scores and patient-reported health status (r = 0.10, p = 0.51) and state of health (r = 0.03, p = 0.87). There was no significant difference in survival between groups (HR = 0.73, 95% CI [0.49, 1.13], p = 0.16). Finally, system cost estimated based on emergency department visits, admissions for febrile neutropenia, and follow-up clinic visits showed that there was no statistically significant difference in average monthly cost per patient between the intervention and control groups ($943 vs $1,197 respectively, p = 0.48). Conclusions: The AL Shared-Care Program reduced the travel burden for patients and caregivers without negatively impacting provider and patient experience, survival and system costs. Findings of this work will support the expansion of the Program to additional sites.
Integrating patient-reported outcomes data into the electronic health record.
Authors: Bosch Brandon , Hartman Scott , Caldarello Lauren , Denny, DBA Diane
Published: September 2018

186

Background: As a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer, the network was an early adopter of using patient reported outcome (PRO) data as part of its routine patient assessment and treatment. Since 2012 an externally validated tool has been used to capture patients’ perceived symptom burden for real-time clinical intervention, from the point of first visit throughout the course of treatment, at intervals of 21 days or greater. Research has demonstrated the use of PRO data as a valuable component of a patient’s treatment plan, promoting improved quality and length of life. Methods: The use of this data across the network was expanded such that results once only accessible on paper and via electronically stored images, has now been fully integrated into the electronic health record (EHR). A multidisciplinary project team formulated the specifications for a successful integration of PRO data into the EHR. Results: The project achieved its goal and went beyond data integration to include implementation of a solution to facilitate documentation of intervention against patients’ symptoms. Provider workflow efficiency is greatly enhanced via single system access and visual notification, with critical values flagged, to focus providers’ attention on severe symptoms. Incorporation of a unified EHR flowsheet provides a paperless, one-stop symptom assessment approach and streamlined mechanism for intervention documentation. The documentation module leverages structured data fields and linkage of PRO data with interventions, such as specialist referrals or medication orders, to support enhanced patient care and quality improvement. Conclusions: The ability to easily view an array of patient reported concerns and document interventions against severe or significantly worsening symptoms provides clinicians an enhanced ability to address quality of life related needs. PRO data is now stored electronically in the enterprise warehouse, thus enabling aggregation with data from which to perform population analysis and eventually, pursue opportunities for predictive modeling.
Impact of diabetes and hyperglycemia on health care utilization, infection risk, and survival in patients with cancer receiving glucocorticoids with chemotherapy.
Authors: Zylla Dylan M. , Gilmore Grace , Eklund Justin , Richter Sara , Carlson Anders
Published: September 2018

19

Background: Glucocorticoid (GC) use is commonly used in chemotherapy regimens and may lead to hyperglycemia and increased infection rates. We assessed the impact of diabetes (DM) and hyperglycemia on rates of health-care utilization, infections and survival among patients with cancer receiving chemotherapy. Methods: We performed a retrospective analysis on 1,781 patients who received intravenous chemotherapy with GC between 2010 and 2015. Demographic, clinical, and health-care utilization (HCU) data was obtained using electronic medical record, billing modules, and the tumor registry; HCU included tallies of emergency room, urgent care, and inpatient visits. Logistic regression models were used to compare survival and new infections between patients with and without DM, after adjusting for demographic and cancer-related variables. Results: In the first 12 months following chemotherapy, patients with DM (n = 330) had higher rates of hospital admissions (70.9% vs 57.4%, p< 0.001), more infection-related admissions (37.0% vs 29.2%, p = 0.007), and increased rates of new infections (61.2% vs 49.2%, p < 0.001) when compared to patients without DM (n = 1,451). One-year survival rate was worse among patients with DM (67.3% vs 78.3%, p < 0.001), as well as patients with at least one glucose reading above 300 mg/dL following chemotherapy (60.8% vs 78.5, p < 0.001). After adjusting for cancer stage, age, and gender, we found DM history increased the odds of dying within one year after diagnosis by 86% (OR 1.86, 95% CI (1.37  2.52), p < 0.001) and of new infections by 68% (OR 1.68, 95% CI (1.26  2.24), p < 0.001). Conclusions: Among patients with cancer receiving intravenous chemotherapy with GC we demonstrate patients with DM have more hospital admissions, increased rates of infections, and worse survival. Prospective studies are urgently needed to elucidate what level of glycemic control is needed to potentially improve outcomes for patients with DM receiving chemotherapy with GC.
Development of a PREM for acute leukemia and/or stem cell transplantation.
Authors: Bridge Erica , Dhanju Suman , Smith Andrea , Singh Simron , Moody Lesley
Published: September 2018

195

Background: People with complex hematologic malignancies (eg. acute leukemia) require highly specialized care from the time of initial diagnosis, throughout treatment and into survivorship. Often, stem cell transplantation is an essential component of treatment for some people with complex hematologic malignancies. A challenge with generic patient-reported experience measure (PREM) tools is that they do not capture areas of concern for a specific population, which was the case for people with complex hematologic malignancies. Therefore, a disease-specific PREM was developed to address relevant aspects of the patient experience. Methods: The development consisted of:1)literature review to identify relevant patient experience items;2)modified Delphi process where patient experience items were rated by experts (n = 10); 3)cognitive interviews (n = 8) to ensure that items were clear and understandable; and 4)pilot of survey. Results: Through the review of literature, two existing PREMs were identified as relevant for this patient population and potential items were extracted:1)the Ambulatory Oncology Patient Satisfaction Survey (n = 90); and2)the Canadian Patient Experience Survey – Inpatient Care (n = 44).The modified Delphi processes consisted of three rounds (an online survey and two in-person meetings to discuss results), which resulted in 73 items being eliminated and 29 items being added.A 90-item PREM was utilized for the cognitive interviews with patients and/or family members, where 14 items were removed and 6 items were added. Conclusions: The PREM was named Your Voice Matters-Acute Leukemia and Stem Cell Transplant, and includes 82 items for measuring the patient experience of complex hematologic malignancies.Surveys were distributed via mail to eligible patients from 10 Regional Cancer Centres in Ontario, Canada in May 2018.Results are anticipated for August 2018.
Does the risk of emergency department visits and hospitalizations during systemic therapy for cancer influence patient decisions regarding treatment?
Authors: Krzyzanowska Monika K. , Phillips Cameron , Deal Ken , Powis Melanie Lynn , Singh Simron , Dharmakulaseelan Laavanya , Naik Harsh , Dobriyal Aditi , Alavi Nasrin
Published: September 2018

213

Background: When different treatments (tx) produce similar prognostic outcomes, other tx attributes such as toxicity may impact tx preferences. We conducted a discrete choice experiment to evaluate how patients’ value the risk of an emergency department visit (ED) or hospitalization during treatment when deciding about chemotherapy. Methods: Patients with breast, head and neck or colorectal cancer who were contemplating, receiving or had previously received systemic treatment were recruited from 2 academic cancer centres in Toronto, Ontario. Each participant completed 10 choice tasks (5 each in the adjuvant and metastatic settings, respectively) from a possible 128 combinations. Each choice task prompted them to choose between two hypothetical systemic therapies, based on 3 attributes (likelihood of benefit, risk of requiring an ED visit and risk of hospitalization during treatment) that varied across 4 levels. Data was analyzed using a multinomial logit model and individual part-worth utility (PWU) values were estimated using hierarchal Bayes routines. Results: Between 06/2015 and 09/2017, 293 patients completed the survey. Most patients were female (76%), had a diagnosis of breast cancer (63%) and were currently receiving systemic therapy (72%). 59% of patients were receiving tx with curative intent. PWU values varied as expected with higher PWUs seen for higher treatment benefit, lower risk of ED visits and lower risk of hospitalization. Treatment benefit was the most important decision attribute in both the adjuvant (59%, 95%CI 57.8-60.1%) and metastatic (67.7%, 95%CI 66.8-68.7%) scenarios, followed by risk of hospitalization (18.8 vs 22.8%) then risk of ED visits (13.5 vs 18.3%). Results were the same when stratified by patient’s own treatment intent. Conclusions: While the risks of hospitalization and ED visits contribute to patient tx preferences, the extent of tx benefit was the most important attribute regardless of treatment intent.
Is there congruence between the types of triggers that cause delight or disgust in cancer care?
Authors: Holdsworth Laura M , Zionts Dani , Asch Steve , Winget Marcy
Published: September 2018

216

Background: Much of patient satisfaction theory relates to meeting expectations and resolving needs, especially around doctor-patient interactions and the care environment. While there is substantial literature on the correlates of patient satisfaction, few have compared how positive attributes that improve patient satisfaction might create dissatisfaction when negative. The aim of this paper is to explore the symmetry between the types of triggers that delight and disgust patients. Methods: Qualitative analysis of interviews and free-text handwritten survey comments collected in a medical center’s cancer clinics. We created a taxonomy for rating the intensity of attitudes expressed in handwritten comments and verbal data, with the extremes rated as delighters (positive) or disgusters (negative). Results: The main causes of delight for patients related to issues around the technical process of care, such as the technical skills of providers and nurses, and the interpersonal connection and communication with people involved in their care. Causes of disgust were broader, spanning all thematic categories, particularly: insensitive behavior, perceived poor quality technical care or communication, access problems (e.g. wait times, scheduling, and travel), and receiving test results. Handwritten comments related to patient disgust or negativity were frequently longer and included rich description, whereas delights were often brief and usually indicated people or attributes perceived as delightful, such as ‘caring, ‘friendly’, and ‘compassionate’. Conclusions: While issues of provider/staff skill and interpersonal relationships caused both delight and disgust, there was a lack of congruence between more systemic or mundane features of care which did not contribute to delight, but did feature in disgust. This suggests that there are normative expectations around systemic issues that appear invisible when they occur as expected, but are apparent only when negative. The implication for patient satisfaction models is that interpersonal and technical aspects of care might be weighted more heavily by patients, but that any aspect of the health care encounter may be important when it is negative.
The influence of patient engagement on the design and implementation of a clinical trial to improve cancer care delivery.
Authors: Barger Sarah , Sullivan Sean D , Lyman Gary H. , Hershman Dawn L. , Bell-Brown Ari , Watabayashi Kate , Egan Kathryn , Kreizenbeck Karma L. , Ciccarella Annemarie , Gorman Mark , Bott Brad , Walia Guneet , Johnson Judy , Seigel Carole , Railey Elda , Mason Ginny , Erwin Robert L. , Kurttila Florence , Segarra-Vazquez Barbara , Ramsey Scott David
Published: September 2018

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Background: We have engaged 10 patient partners in the development and implementation of S1415CD, a five-year pragmatic clinical trial currently in year 3 assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention (NCT02728596). Patient partners serve as part of a 21-person External Stakeholder Advisory Group (ESAG), which also includes providers, payers and guidelines experts. This abstract explores the influence of patient partners on the design, tools and implementation of S1415CD Methods: Patient partners advise the study team on protocol development, patient-facing materials and implementation challenges over four teleconferences each year, annual in-person meetings and targeted email communication. All patient partner input from 2014-2017 was tracked, collected and reviewed for impact on the trial. Results: Input from patient partners led to the refinement of the study’s patient-reported outcome (PRO) survey questions, the creation of a highly utilized patient brochure, and the formation of talking points for clinic staff to help explain the study. Patient partners in conjunction with high performing sites helped develop strategies for sites with lower patient accrual to optimize the approach and consent of study participants. Conclusions: The sustained engagement of patient partners in S1415CD ensured patient-centeredness in trial design and guided the development of PRO surveys and relevant, high quality patient-facing materials. Drawing on experiential knowledge and insights from their roles as caregivers and advocates, patient partners provided valuable feedback that influenced patient approach and engagement in the study. Embedding patient partners in the research continuum has catalyzed critical discussions and problem solving among the patient partners and study team, which has led to patient-centered solutions to study challenges. Clinical trial information: NCT02728596.
Improving informed breast cancer systemic treatment decision-making.
Authors: Hawley Sarah T. , An Larry , Li Yun , Jagsi Reshma , Katz Steven J.
Published: September 2018

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Background: Decision making for adjuvant chemotherapy is increasingly complicated for women with a new diagnosis of early stage breast cancer. Few decision tools are designed to help support informed systemic treatment decision-making, by improving knowledge and decision quality. Methods: We conducted a randomized controlled trial (RCT) of a tailored, comprehensive (locoregional and systemic treatment) and interactive decision tool (iCanDecide), compared with static online information. 537 newly diagnosed, early stage breast cancer patients were enrolled from 22 surgical practices. Participants were surveyed 5 weeks (N = 496; RR 92%) and those eligible for systemic treatment (N = 358) again at 9 months (N = 307; RR 88%). The main outcome for this analysis was knowledge about systemic treatment using 4 true/false items, categorized into high (3- 4 correct) vs. low (0-2 correct). We also assessed subjective decision quality (SDQ) for chemotherapy on a 5-point scale and dichotomized into high (4-5) vs. low (1-3) We evaluated the distribution of participants in each arm, and assessed the association between the study arm and the outcomes using bivariate and multivariable approaches. Results: Of the 358 respondents, 201 did not receive or intend to have chemotherapy. Significantly more intervention than control patients had high knowledge about systemic treatment (52.9% vs. 39.9%, p = 0.012). Overall SDQ for chemotherapy was slightly higher in intervention than control subjects (mean 4.8 vs. 4.6, p = 0.08). However, among women who did not receive chemotherapy, significantly more intervention subjects reported high SDQ than controls (87.1% vs. 75.2%, p = 0.06). Values significantly related to chemotherapy use included avoiding side effects, continuing to work, and being most extensive possible. Conclusions: We found that the interactive decision tool contributed significantly to higher knowledge about systemic treatment among eligible patients. We further found the tool shows promise for improving subjective decision quality, particularly in patients who choose not to have chemotherapy. Further work to integrate tools into the oncology clinical setting is needed. Clinical trial information: NCT01840163.