bluuebunny/crossref_metadata_2025 huggingface dataset:
Health information seeking preferences of Mexican cancer survivors: Creating an evidence base for the design of high-quality communication programs.
Authors: Soto Perez De Celis Enrique , Baltazar-Avalos Edgar , Rocha-Rojo Lorena Ali Guadalupe , Rojo-Castillo Patricia , Chavarri Guerra Yanin
Published: February 2017

190

Background: In order to improve the quality of the communication between the healthcare system and cancer survivors, it is fundamental to understand their preferred sources of health information. In low and middle-income countries (LMICs), little is known regarding which sources are used and trusted the most. This information is crucial to develop effective communication aimed at achieving high-quality equitable cancer care. Our objective was to explore the preferred sources of health information in Mexico, and to understand which factors influence these choices. Methods: We examined sources of health information among cancer survivors in Mexico City using questions from the Spanish Version of the Health Information National Trends Survey (HINTS). The characteristics of survivors who preferred the internet were compared with those who preferred other sources (doctors, printed materials, family members, organizations) using Fisher’s exact test. Logistic regression was used to assess the effects of patient characteristics on health information-seeking. Results: Of 148 participants, 82 (56%) had internet access. Of the 88 patients who had sought health information, 61 (69%) listed the internet as their preferred source. Those 65 and older were less likely to seek health information, regardless of the source (OR 0.17, p < 0.0001). Survivors who preferred the internet were more likely to be younger (p = 0.001), male (p = 0.003) and to have a higher educational level (p = 0.009). Comorbidities, stage, cancer type, and time from diagnosis had no effect on patient preferences. Doctors were the most trusted source of information (85%), followed by the internet (28%) and government agencies (23%). Conclusions: Mexican patients who seek health information online are more likely to be young educated males. Doctors represent the most trusted source of information, particularly for patients from vulnerable populations (such as older women with low educational levels). High-quality healthcare information programs in LMICs should be designed taking these behaviors into account, and patients should continue to receive health information via their most trusted sources.
Evaluating data-driven breast surgery treatment path visualizations from registry and administrative data.
Authors: Atreya Ravi V , Taylor Alexander S , Levy Mia Alyce
Published: February 2017

195

Background: Breast cancer patients face difficult decisions about their surgical care without a full understanding of their options. The learning health system goal is to use information from the care of prior patients to inform the care of future patients. We aim to apply this concept to generate data-driven surgical paths, develop interactive path visualizations to inform patients, and evaluate their impact. Methods: We used cancer registry and administrative CPT codes for women diagnosed with stage 0-III breast cancer between FY2010-14 at a comprehensive cancer center. We generated surgical event sequences and visualized them using interactive Sankey diagram path visualizations. We will run a prospective educational intervention this winter to evaluate their impact on the shared decision making process. A web-based application will be available to patients prior to, during, and after their surgical clinic visit; we will survey their reaction pre-visit, post-visit, and post-surgery. Results: 1556 patients had 1951 surgical events in the registry and 48% started their surgical care with a breast conserving surgery while 52% began with a mastectomy. Mastectomy paths are presented in Table 1. We have developed interactive visualizations for patients to view, will be conducting our prospective educational intervention this winter, and will be ready to present preliminary results in February. Conclusions: We have been able to develop interactive, data-driven surgical path visualizations for breast cancer patients from cancer registry and administrative data. We will be conducting a prospective educational intervention to evaluate our implementation of this learning health system concept. [Table: see text]
Using a web analytic tool to evaluate Pathways program engagement in 36 Michigan oncology practices.
Authors: Seung Amy Hatfield , Justus Rachel , Klamerus Justin Frank Antoni , Blayney Douglas W.
Published: February 2017

198

Background: Evidence-based, cancer treatment pathways reduce unnecessary variation in care, reduce waste, and improve value. Financial incentives and sharing adherence rates may motivate oncologists to change treatment patterns. The Michigan Pathways Program (Pathways) is a statewide quality improvement program sponsored by BlueCross BlueShield of Michigan and supported on the Caret web-based registry. Pathways measures and incentivizes adherence to local treatment pathways (JOP 8e32s, 2012; ASCO 2015 Ann Mtg, abst 6584). Caret reports allow participants to review adherence rates. Using Google Analytics (GA), we measured access by participants of adherence reports and attempted to correlate this measure of engagement with adherence. Methods: Caret provides decision support for regimen selection within the Pathways. BCBSM medical claims are uploaded to ensure completeness of data. Caret generates reports allowing participants to review site-specific adherence data and compare with de-identified aggregate data from all participants. GA gathers data about page tags being accessed at a location by users, which were assumed to correlate to Pathways practices. Unique page views for web-based adherence reports were assessed for each location and compared to adherence rates. Results: 36 practices were included from 34 unique locations. 34.4% of practices are accessing adherence reports. For users the mean treatment adherence was 82.7% compared to 79.3% for non-users. Conclusions: Web analytics offers a novel method for gauging practice engagement in our program. This initial assessment will help to target education sessions based on location in addition to identifying potential best practices. At this time conclusions cannot be made to correlate application engagement to adherence rates. We predict an increased need for web analytics to measure the use of resources utilized by practices. [Table: see text]
Building a new process: Nursing verification of pediatric oral chemotherapy.
Authors: Zerillo Jessica A. , Santacroce Erin , Zimmerman Mary Ann , Freeman Melissa , Lau Greenberg Teresa , Nguyen Phuong , Chi Susan N. , Bandopadhayay Pratiti , Lane Sharon , Szabatura Audrea , Houlahan Kathleen , Billett Amy
Published: February 2017

199

Background: While team-based safety checks ensure safe prescribing of parenteral chemotherapy, oral chemotherapy is usually prescribed by a single clinician. With the growing use of oral chemotherapy, processes are needed to protect these vulnerable patients from prescription errors. Methods: A team of nurses, clinicians, pharmacists and administrators developed a new process and checklist for nursing verification of oral chemotherapy prescriptions at Dana-Farber’s pediatric neuro-oncology program. Prescriptions are verified against the treatment plan by two pediatric oncology nurses. The verification checklist includes drug, dose with any modifications, height and weight, laboratory values and patient instructions. When available, the prescription bottle is also verified. Data was collected over a three-month pilot period. Results: From 6/18/15-9/16/15, 56 prescription verifications occurred. Verification rate of on-site retail pharmacy filled prescriptions was 47% (32/68 prescriptions). Median time for verification was 20 minutes (IQR 15, 40) per nurse. Nurses identified problems outside of prescription verification, including missing prior authorizations and unclear treatment plans. Medication bottles were not routinely available for verification. One identified near miss would have resulted in an 80% under-dose of everolimus. Conclusions: Prescription verification by nursing in a pediatric oncology clinic was feasible. While it was successful in identification of one medication error before it reached the patient, only 47% of prescriptions were verified. Since prescription bottles are usually obtained after a visit, verification of the actual bottles will require new workflows, such as additional clinic visits or uploading a picture via the patient portal. Involving the nurse in the review of oral chemotherapy not only identified a prescription error, but also highlighted issues within other aspects of patients’ care, including inconsistent documentation of the treatment plan. The inclusion of nursing in the review and management of oral chemotherapy has the potential to improve safety and outcomes for these patients.
Achieving excellence in colorectal cancer care through performance improvement: KP Georgia's implementation of the national vision.
Authors: Tomlin Juliane , Schottinger Joanne E. , Lagana Michele , Rabrenovich Violeta
Published: February 2017

207

Background: The Care Management Institute and The Permanente Federation have partnered over the past two years to develop an Improvement Portfolio for Colorectal Cancer, with the objective of accelerating improvement of Colorectal Cancer Care quality, timeliness, reliability, and the member care experience across the continuum, from prevention, reliable screening and diagnosis, through treatment and survivorship. The portfolio includes: 1) National clinical algorithms for diagnosis and treatment (colon), and for survivorship (colon and rectal); 2) Timeliness metrics for Time to Diagnosis, Time to Initial Treatment, and Time from Surgery to Adjuvant; 3) Patient Friendly Pathway. Methods: The National team has partnered with KP Georgia's clinical and operational leaders to successfully operationalize the Colon Cancer Diagnostic Clinical Algorithm using KP's Performance Improvement methodology. Results: KP Georgia improved time from diagnosis to treatment by 40.3% and reduced variation by 60.5%. Conclusions: Development of the National CRC Improvement Portfolio consisting of clinical algorithms, and timeliness metrics within the same scope of the colorectal cancer care journey, has provided KP regions with the basic tools and resources to significantly improve the quality, timeliness, reliability, and member care experience across the cancer continuum.
Economic burden of common adverse events (AEs) associated with metastatic colorectal cancer (mCRC) treatment in the United States (US).
Authors: Latremouille-Viau Dominick , Chang Jane , Guerin Annie , Shi Sherry , Wang Ed , Yu Justin , Ngai Christopher
Published: February 2017

21

Background: Treatments for mCRC have distinct safety and tolerability profiles. Common AEs associated with mCRC treatments may compromise the course of treatment, worsen quality of life, and increase healthcare resource utilization and costs. This study assessed the costs of common AEs in mCRC patients (pts) in the US. Methods: Adult mCRC pts treated with chemotherapy (chemo) or targeted therapies were identified from the Truven MarketScan databases (2009 - 2014). Up to the first 3 mCRC treatment episodes were considered. mCRC treatment episodes were categorized as with or without (w/o) AEs based on the occurrence of AEs, listed in product labels, during the episode. Total healthcare costs (medical and pharmacy; 2014 USD) were measured by mCRC treatment episode and reported per-patient-per-month (PPPM). mCRC treatment episodes with AEs were matched by type of treatment (monotherapy/combination, chemo, anti-VEGF, and anti-EGFR) and line of therapy to those w/o AEs. Adjusted total cost differences were estimated by comparing costs during mCRC treatment episodes with vs w/o AEs using multivariate two-part models, adjusting for potential confounding factors; 95% confidence intervals (CIs) and p-values were estimated with bootstrap. Results: A total of 4,158 mCRC pts with ≥ 1 mCRC treatment episode were included (mean age= 59 years; 58% male; 2261 [54%] with a 2nd and 1115 [27%] with a 3rdepisode). The most prevalent metastatic sites were liver (60%) and lung (14%). On average, 2 mCRC treatment episodes were observed per patient with an average length of 166 days per episode. Most mCRC treatments included chemo (96%) and were combination regimens (81%). Conclusions: The most costly AEs were hematologic, followed by respiratory, CNS, cardiovascular, and endocrine/metabolic AEs in mCRC pts. [Table: see text]
Evaluation of relative thrombocytopenia, identification of neuropathy, and bleeding risk secondary to utilization of neuromodulating agents in multiple myeloma patients receiving autologous stem cell transplant treated with melphalan, bortezomib, and lenalidomide.
Authors: Feinsilber Doron , Marcus Joel , Jackson Robyn , Ruiz Marco A. , Griffin Ryan Patrick , Khan Rubina Hafeez
Published: February 2017

212

Background: Chemotherapy–induced polyneuropathy (CIPN) is a crippling manifestation in multiple myeloma (MM) patients that requires attentiveness to safety and quality of life.2 Bortezomib, lenalidomide, and melphalan are commonly utilized chemotherapy agents that can cause both CIPN3,4 and significant myelosuppression. Within this subset of patients we wish to insure efficacy and minimization of neuropathic pain while being mindful of bleeding risks. Methods: IRB approval was obtained for a retrospective study of patients with MM who received a bone marrow transplant (BMT). Criteria included those who have undergone treatment with melphalan, bortezomib, and lenalidomide who experienced CIPN and placed on gabapentin, pregabalin, or duloxetine with thrombocytopenia defined by a platelet count less than 100,000 K/ul. We identified all patients seen on the BMT service at Ochsner Medical Center who received an autologous BMT for MM and treated with melphalan, bortezumib, and lenalidomide. Demographic data included age at diagnosis, gender, height, and weight. We examined characteristics including date of diagnosis and progression free survival. Endpoints included signs of peripheral neuropathy, onset of thrombocytopenia, initiation of therapy with gabapentin, pregabalin, or duloxetine. Results: 62 patients were selected with data capture. A preliminary chart review shows of patients meeting selection criteria, 53% of patients identified had shown undocumented or undertreated neuropathy, significant bleeding risk, or low platelet function assays. Complete breakdown of individual factors to be provided graphically. Conclusions: The standard treatment practices for MM patients with CIPN has placed patients at higher risk for development of thrombocytopenia and adverse bleeding risks, requiring more stringent institutional documentation practices.
Effect of better communication on patient care.
Authors: Khelfa Yousef , Mansour Munthir , Abdel-Aziz Yousef , Tirona Maria R. B. Tria , Lebowicz Yehuda Z.
Published: February 2017

216

Background: Considerable medical research done in the last decade, have brought new diagnostic and therapeutic options to the medical oncology field. This has, fortunately, greatly improved treatment options and outcomes of our cancer patients. Newer therapies such as immunotherapies have changed the toxicity profile of our interventions. In addition to “classic chemotherapy toxicity” these therapies can induce autoimmune phenomena including pneumonitis, colitis, etc. that may not initially be considered in patients’ differential diagnosis. We have noted that, we are frequently not being notified of our patients’ hospital admission. This creates an environment in which we can’t contribute to the patients care while they are in the hospital, and makes it difficult to gauge the degree of toxicity our therapies may be causing. Direct communication with the admitting services, asking them to consult us upon patients’ hospitalization would improve rate of consultation. This, we believe, will translate into better patient care. Methods: An official letter was sent to all admitting services’ head of department and program director in our hospital requesting them and their staff to notify/consult the oncology team regarding any cancer patient being admitted to the hospital. We reviewed 406 admissions prior to letter and 145 post. We compared consultation rates before and after the letter. Results: Consultation rate went up from 42 % before the letter to 59 % after, with an absolute increase of 17%. The odds ratio was 1.96 with 95% confidence interval [1.315-2.947], and statistically significant p value of 0.00066. Conclusions: Direct communication with admitting services showed an increase rate of consultation, which we believe improves inpatient care as well as outpatient follow up. This method is simple and we believe cost effective, taking in consideration that better patient care, likelihood of shorter hospital stay and proper outpatient follow up, outweigh the cost of consultation service. Also, we believe, that the presence of consulting service will provide fruitful educational environment for our residents.
HIV-testing in a cancer center emergency department.
Authors: Granwehr Bruno Palma , Merriman Kelly W. , Shelal Zeena , Bazerbashi Hadil , Brock Patricia A , Gonzalez Carmen E. , Torres Harrys A. , Rice Terry
Published: February 2017

225

Background: HIV is a cancer-associated virus classically associated with KS, NHL, and cervical cancer, but more recently with anal cancer, lung, and head and neck cancers. HIV testing and treatment are important for cancer patients for three reasons: 1) HIV treatment is associated with reduced transmission of a cancer-associated virus. 2) HIV treatment is associated with improved outcomes of cancer therapy in many cancers. 3) HIV testing optimizes quality of care, since testing is recommended by the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF)(A level recommendation) for patients between the ages of 15 and 65 years of age. Since emergency centers (EC’s) commonly provide immunizations and other preventive care, we implemented HIV testing at our cancer center EC. Methods: In our 44 bed cancer center EC with approximately 25,000 annual visits, routine implementation by physician order was implemented in July 2014. EC information technology (IT) assisted in modification of the order sets and facilitated documentation of specific consent for HIV. Educational materials were disseminated to patients and EC providers. A new consent form with integration of HIV consent, including a check box to refuse HIV testing, was implemented on June 19, 2015. Testing results are described through August 2015. Results: HIV testing increased significantly from July 2014 and August 2015. The impact on institutional testing was considerable, increasing from 1.2% of all HIV testing in 2013 to 15.1% to date in 2015. Between July 2014 and August 2015, 1.4% (0.4% incident) of 852 patients screened positive for HIV. Notably, 83% of patients agreed to HIV testing, but less than 20% of patients were actually tested. The highest refusal rate (18.8%) was in patients over age 70 and lowest (9.9%) in those 21-29 years of age. Conclusions: Routine HIV testing is feasible in a comprehensive cancer center ED, but increased awareness is necessary to optimize testing, given the high acceptance rate. Seroprevalence of HIV is comparable to non-cancer center EC’s (0.5-1.2%). These results demonstrate the acceptance by patients of testing for HIV, with implications in reduction of transmission of this cancer-associated virus.
Evaluating the cost-effectiveness of the hospital-based palliative care program at The Johns Hopkins Hospital.
Authors: Isenberg Sarina , Holtgrave David R , Lu Chunhua , McQuade John P , Weir Brian , Gill Natasha , Razzak A. Rab , Smith Thomas J.
Published: February 2017

23

Background: The objectives of the study were to determine whether a Palliative Care Unit (PCU) provides benefits not just from a cost perspective, but from a patient and caregiver quality of life (QOL) perspective. Methods: (1) Calculate the total costs of the PCU; (2) Leverage a threshold analysis to estimate the Quality-Adjusted Life Years (QALYs) required for the PCU to be cost effective; and (3) Determine whether it is feasible for the program to yield the required number of QALYs. Setting was the Johns Hopkins Health System Palliative Care Unit (PCU) in Baltimore, MD. Analysis was based on patient volume from March 2013-2014. Results: There were 209 palliative patients. The costs for the societal perspective was $2,044,364 and the required number of QALYs to deem it cost effective were 11.36. The net costs for the hospital perspective was $625,777 (gross cost was $993,528; however, the program generated $367,751 in savings for the hospital through treating patients in the PCU as opposed to other functional units), and the required number of QALYs to deem it cost effective were 3.48. To determine whether the program is able to achieve the number of QALYs required, the study team generated aggregated QALYs based on other studies’ evidence for palliative care’s improvement of quality of life for patients and their caregivers. Combining the QALYs generated from the aggregated calculations for patients (0.12) and caregivers (4.60), the program had the potential to yield a total of 4.73 QALYs. Conclusions: This analysis suggests that the PCU is cost effective from the hospital perspective in the sense that the benefits it provides to patients’ and caregivers’ quality of life outweighs the cost of care. Future studies should continue to evaluate palliative care from a cost effectiveness perspective that incorporates a consideration of the quality of life improvements, rather than just cost-reduction.
Reducing the percent of ICU deaths of patients with advanced cancer at Stanford.
Authors: Cinar Pelin , Bobokalonova Zarrina , Hadhazy Eric , Chan Sandy , Stallings Holley
Published: February 2017

234

Background: Intensive care at the end of life, for patients with advanced cancer can compromise quality of life and result in excessive costs for patients and their families. In 2014, 40% of patients with solid tumors admitted to the Stanford Health Care ICU died with advanced stage disease. Sixty-five percent of the patients with advanced stage saw palliative care (PC) < 7 days of life. The aim was to decrease the percent of advanced solid tumor ICU deaths by 25%, through early palliative care intervention. Methods: The current process was analyzed through mapping and a cause and effect diagram. The outcome measure was defined as percentage of patients with advanced solid tumors dying in ICU. A key intervention was the development of criteria designed to trigger an earlier PC referral for patients with stage III-IV lung/pancreatic cancer. PC referral triggers included: 2+ lines of prior chemotherapy with life expectancy < 6 months or refractory disease, hospitalization within prior 30 days, > 7days of hospitalization, uncontrolled symptoms. ICU trainees were to contact the primary oncologists and discuss the role of PC consultation for patients who met the criteria. A balance measure was developed to assess if primary oncologists were contacted. Charts of patients admitted to the ICU 2 weeks pre- and post-implementation were reviewed. Results: During the pre-PDSA cycle, 13 patients with cancer were admitted to the ICU while 10 were admitted post-PDSA cycle. Primary oncologists of the patients with advanced cancer who met our criteria were contacted in similar rate pre- and post-PDSA (39% vs 40%). PC consultation was also similar for pre- and post-PDSA cycles (31% vs 30%). The percent of ICU deaths of patients in the pre-PDSA was 22% and 22% in the post-PDSA cycles. Conclusions: The percentage of deaths in the ICU for patients with advanced cancer met our target goal of 25% reduction from the baseline. However, the improvement was independent of our intervention, given the timing and short interval. The percent of PC consults for patients meeting the criteria did not change. Data from subsequent PDSA cycles and a SPC chart will be reported in the conference.
New fields in the patient record: A tool or a nuisance?
Authors: Theodorakopoulou Ioanna , Stathaki Kalliope , Poufos Theodore , Vlachou Frosso , Spyri Olympia , Hatziyiasemi Lina , Rigakos Georgios , Labropoulos Stefanos V. , Prasini Ioanna , Razis Evangelia
Published: February 2017

235

Background: The Contemporary Oncology Team was the first practice in Greece to participate in the Quality in Oncology Practice Initiative (QOPI). As a result, several corrective measures were designed and implemented to improve the quality of the services provided to patients. Methods: The plan-do-check-act approach was used to implement changes, primarily in the follow up form, over a period of 18 months. Several improvement opportunities were identified. 1.) A numerical scale for pain intensity quantification became a required field. 2.) Emotional well-being fields were added so the patient’s state could be documented by providers. 3.) Fertility assessment and counseling was added as a required field in the patient record. For this report we evaluated retrospectively the effect of these changes on our QOPI scores. Results: Contemporary Oncology Team QOPI scores after the implementation of the new forms have shown increased compliance, compared to QOPI aggregate scores for all participating US practices, in the areas related to the changes made. Specifically, pain assessment documentation improved from -54.56% to +9.96%. The use of a numerical tool proved invaluable to comparing pain intensity between different visits. Emotional well-being documentation improved from -42.55% to +18.26%. Fertility assessment documentation has not improved but this finding could be due to a decrease in patient chart sample size. Providers seemed to adapt quickly and without difficulty. Conclusions: Developing new fields in the patient record is an evolving process because it requires provider education and acquaintance with the new method of documentation. However, in this retrospective analysis it proved to be an effective method to improve provider compliance with assessment of pain and emotional well-being, and it is likely to be useful in other areas in need of improved documentation.
“It looks good”: How a provincial radiation oncology program benefits from implementing peer review across cancer centers.
Authors: Brundage Michael Donald , Hart Margaret , O'Donnell Jennifer , Foxcroft Sophie , Gutierrez Eric , Reddeman Lindsay Elizabeth , Mitera Gunita , Warde Padraig Richard
Published: February 2017

238

Background: Peer review (PR) in radiation oncology (RO) has been endorsed as an indicator of treatment quality in North America and internationally. The direct benefits of PR include quality assurance (QA) on individual treatment plans. The indirect benefits for radiation oncology departments or programs (ROPs) have been postulated but not systematically evaluated. We used a rigorous and comprehensive qualitative approach to explore the indirect benefits of PR across a jurisdiction of cancer care, and to identify factors that facilitate PR, barriers to implementation, and strategies for expansion of PR across centers. Methods: Semi-structured qualitative interviews were held with all RO heads and Radiation therapy Managers (or delegate) in all 14 Radiation Oncology Programs (ROPs) in Ontario, Canada. The interview questions were developed using a Knowledge Translation Theoretical Domains Framework (TDF), guided by the results of a previous survey of Ontario cancer centers and by expert consensus. Interviews were audiotaped and abstracted for relevant themes by two independent analysts. Results: All interviewees endorsed numerous direct and indirect benefits of PR, and identified multiple facilitators and barriers to the implementation of PR. Thematic saturation was achieved. The structure-process-outcome model was used to categorize the results. Key findings included the identification of 34 independent benefits (structure n = 4, process n = 17, outcome n = 13), 40 key barriers (structure n = 9, process n = 26, outcome n = 5), and 22 facilitators (structure n = 4, process n = 15, outcome n = 3). Beyond QA, commonly endorsed benefits included enhanced knowledge sharing, efficiency, standardization, and education. Multiple potential strategies for the expansion of PR activities were revealed. Conclusions: The qualitative exploration of Ontario ROPs acknowledges that multiple barriers and facilitators to PR exist while clearly establishing the indirect benefit of PR on ROPs. Understanding reported barriers and facilitators and exploration of suggested strategies will inform continued implementation and expansion of PR activities, and seem generalizable to other jurisdictions.
Application of a standard practice-based system to measure and compare quality of cancer survivorship care.
Authors: Palos Guadalupe R. , Gilmore Katherine Ramsey , Chapman Patricia , Lewis-Patterson Paula A. , Rodriguez Maria Alma
Published: February 2017

239

Background: Despite the growing committment to improve survivorship care, measuring its quality remains difficult. In 2006, the American Society of Clinical Oncologists (ASCO) launched a practice-based system known as the Quality Oncology Practice Initiative (QOPI) to measure the quality of cancer care. Here, we demonstrate the use of QOPI procedures to compare compliance with survivorship care plans (SCPs) across different disease-specific clinics. Methods: Measures based on survivorship clinical practice guidelines were abstracted from SCPs issued to survivors scheduled for appointments in site-specific clinics. Following QOPI procedures, we identified the target condition as cancer, selected data collection methods, and determined core measures for abstraction. Procedures included; identifying the number of survivors arriving for appointments within the specified time period, standardizing denominators and numerators used per clinic, determining the number of full-time providers per clinic, and calculating the number of records to audit per clinic. All data were obtained from completed care plans, institutional electronic medical records, and scheduling systems. Descriptive statistics were used to conduct aggregate analyses of de-identified data. The same procedures were followed in each clinic. Results: From September 1, 2014, to August 31, 2015, we used a standard process to assess compliance for issuing survivorship care plans across 9 clinics. There were a total of 8864 arrived appointments; 46 providers completed a total of 7448 electronic survivorship care plans over the time period. Analysis of compliance rates indicated broad variation across clinics, including: breast (85.3%), gastrointestinal (80.2%), genitourinary (88.5%), gynecology (78.6%), head/neck (96.8%), lymphoma (99.3%), melanoma (62.2%), thyroid (75.4%) and thoracic (63.3%). Conclusions: Establishing uniform procedures, such as the QOPI process, to measure and compare compliance with SCPs will help achieve high quality standards of care for long-term cancer survivors. Further examination is warranted to determine longitudinal trends and factors contributing to variation in compliance rates.
Applying value stream mapping to improve patient flow and satisfaction.
Authors: Cummings Chad W , Kenney Rob , Glass Katherine , Monteleone Emily Elizabeth , Bolwell Brian James
Published: February 2017

244

Background: Value Stream Mapping (VSM) is a tool commonly used in manufacturing environments to analyze the current state process and to design an improved future state. VSM is a dynamic visual management tool that can be applied in the context of clinical activities to identify value-added (VA) and non-value added (NVA) activities along the spectrum of patient care. A VSM was created for the Breast Cancer Program to identify improvement opportunities in patient quality, flow, and communication across disciplines. Methods: A multidisciplinary team of physicians and clinical specialists were assembled to detail patient flows and coordination of care. Data for each process step was identified, and included, but not limited to: (1) lead times and (2) cycle times for each process. Clinical huddles were established to collect “real-time” patient information (n = 101 patients), and used to populate and validate the VSM. Additionally, retrospective analysis was performed using information from the tumor registry (n = 566 patients). Results: Visual representation of a patient’s journey revealed distinct opportunities to improve the coordination of care and communication. The Breast VSM identified 53 discrete steps, and illuminated 3 focus areas for action: (1) coordination and navigation of patients at multiple points of entry, (2) communication of diagnosis, and (3) reduction of time between major clinical activity (diagnosis to surgery or first treatment). NVA identified opportunities to reduce the number of steps (13) between diagnosis and first treatment, whereby up to 15% of these steps are financial clearance that can delay care. Process differences were discovered between external and internally referred patients, leading to delays in first consult, and a need for better patient navigation. Conclusions: VSM is an effective way to collaborate and drive improvements with multi-disciplinary teams. The non-value added activity highlighted on the maps provides an opportunity for improvements and reducing waste and delay in patient care. Providing timely communication and care will drive patient satisfaction around value-added steps.
Kaiser Permanente Georgia: Colon cancer care through the science of performance improvement.
Authors: Terrell Carlee
Published: February 2017

250

Background: While our patients reported high satisfaction with the care they received, Kaiser Permanente Georgia’s baseline assessment found variation in the way our colon cancer patients were diagnosed and received care. This variation also effects the cycle time from diagnosis to initiation of treatment (surgery or first infusion). Methods: Using Kaiser Permanente’s Performance Improvement methodology and interdisciplinary cooperation, this project launched in January of 2014. A multidisciplinary team representing the GI, Surgery, Oncology, Nursing, Radiology, Palliative Care and Patient Safety departments, was formed and facilitated by a PI specialist to examine the different workflows. The team performed an in-depth baseline analysis of the current state, including patient interviews and surveys. At the completion of the baseline analysis all clinical departments came to an agreement for future state process design. In addition to developing workflows, an order bundle was developed to bridge the gap between the baseline and future states. The improvements were tested and both qualitative and quantitative feedback was collected on effectiveness of the changes. Results: This project resulted in an agreed upon standardized nursing and provider workflow and identified a diagnostic bundle to be carried out on the day of colonoscopy for treating suspected CRC patients. These improvements resulted in a reduction to the average time from diagnosis to treatment for Colorectal Cancer patients by 40.3%. The variation in time from diagnosis to treatment was reduced by 60.5%. Conclusions: We are pleased these positive results improve on the cancer care we provide to our patients. Multidisciplinary communications and agreements were key to the success of this project. Our next steps involve migrating the CRC diagnostic bundle into KPs EMR, developing a reliable surveillance follow-up method, and further reducing the time to treatment by focusing on the surgical pathway.
Appropriateness of testing for heparin-induced thrombocytopenia in hospitalized patients.
Authors: Namakydoust Azadeh , Saha Debasmita , Ajeti Gresa , Bair Brandon , Hook Karen , Ballesteros Enrique , Holle Lisa
Published: February 2017

252

Background: Heparin induced thrombocytopenia (HIT) is a devastating thrombotic complication of heparin therapy and occurs in 0.2 to 5% of patients receiving heparin products and is a clinicopathologic diagnosis. The American Society of Hematology Guidelines, recommend the use of the “4Ts” scoring system to determine the pre-test probability of suspected cases. Also, a presumptive clinical diagnosis of HIT must be followed by immediate cessation of all forms of heparin and initiation of alternate anticoagulation. Proper diagnosis and treatment can be difficult for medical and surgical clinicians, with implications for morbidity, mortality, patient safety, and cost. The Objective of this study was to assess the incidence and appropriateness of HIT testing at our institution before and after an educational session for clinicians. We hypothesized that our intervention would provide better quality care of patients with suspected HIT. Methods: First, a retrospective chart review was conducted for a 3-month period, in which we collected baseline patient and HIT-testing data. Next, an “in-service” type lecture was delivered on seven occasions to various hospitalist groups. Follow-up data for an additional 3-month period was collected after these sessions. Results: See Table. Conclusions: In this single-center study, our educational interventions were successful in reducing inappropriate HIT testing, and encouraging consultation with hematology colleagues. Future studies are needed to evaluate the utility of online teaching modules, electronic order sets,and applicability to other medical centers. [Table: see text]
Preferred cost communicator and financial distress (FD) in patients with cancer.
Authors: Proussaloglou Ellie , Yap Bonnie J. , O'Connor Jeremy , Daugherty Christopher , De Souza Jonas A.
Published: February 2017

26

Background: Prior research has shown that cancer patients (pts) are willing to discuss the costs of their care. Professional societies have thus encouraged physicians to discuss these costs with their pts. We assessed the preferred communicator from the pts’ perspective and the predictors of this preference. Methods: Pts with advanced cancers who had completed at least 3 months of chemotherapy were asked for their preferred cost communicator. Pts were allowed to choose one or more cost communicators. Options included physician, financial counselor, social worker, nurse, and other. We collected demographics, therapy type, mood states, income, length of disease (LoD), clinical trial status, ECOG PS, and health-related quality of life (HRQoL). FD was assessed by the COmprehensive Score for financial Toxicity (COST – FACIT) instrument. Multivariable logistic regression was used to identify factors associated with the preferred cost communicator. Results: 233 patients were assessed. Most pts were female (58.4%), Caucasian (66.4%), and privately insured (67.4%). In total, 114 pts (48.9%) preferred speaking about costs to financial counselors, followed by physicians (n = 74, 31.8%), social workers (52, 22.3%), nurses (16, 6.9%), and others (7, 3.0%). In total, 91 patients (39.1%) had no FD, while 142 (60.9%) had some degree of FD. Restricting the analyses by the preferred cost communicator and controlling for sociodemographics, HRQoL, mood states, LoD, clinical trial status, and ECOG PS, the presence of any degree of FD was associated with willingness to discuss costs with financial counselors (OR = 1.94, p = 0.03). In contrast, the absence of FD (OR = 1.93, p = 0.03) was associated with willingness to discuss cancer costs with physicians. A trend was seen with pts on oral therapy willing to discuss costs with their physicians (OR = 1.78, p = 0.06). Lastly, non-Caucasians were more willing to discuss costs with a social worker (OR = 2.28, p=0.01). Conclusions: Physicians are not the preferred cost communicators for pts with FD. These pts are willing to discuss costs with financial counselors. Following an evidence-based approach that integrates patients’ preferences may facilitate the inclusion of cost discussions in clinical practice.
Development of an oncology quality metric evaluation and prioritization tool (QMEPT).
Authors: Holcombe Randall F. , Evangelista Michelle
Published: February 2017

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Background: For reporting purposes and to enable ongoing quality improvement, it is essential that metrics reflective of quality oncology care delivery are tracked and reviewed on an ongoing basis. Collection of performance data and incorporation into a usable dashboard can require significant IT resources, both in personnel time and direct costs. The Tisch Cancer Institute (TCI) identified a myriad of cancer quality metrics that required prioritization in order to best allocate limited IT resources and a standardized process to facilitate comparison across different disease groups. Methods: Quality metrics were identified from various sources: CMS, PQRS, Commission on Cancer, QOPI, AHRQ and others recommended by TCI disease management teams (DMTs). All measures were evaluated with QMEPT according to the following domains: 1) Regulatory (CMS or other certifications), 2) Cost & Feasibility (resource intensiveness of the collection process), 3) Patient Outcomes – (existence of standard benchmarks or known underperformance) and 4) Financial – (influence on payor contracting). All metrics were scored to generate a composite score for each metric and then weighted with 40% for Regulatory, 20% for Cost & Feasibility, 40% for Patient Outcomes. Financial was not weighted but given a yes/no designation. Results: Metrics across all disease sites were scored, weighted and compared. Composite scores ranged from 1.56 to 2.67 (range 1 - 3). Weighted scores ranged from 1.4 to 2.8. In general, metrics related to breast, prostate, colorectal and lung cancers scored higher because of the required reporting and existence of evidence-based standardized benchmarks. Metrics proposed by the DMTs were frequently found to have high resource requirements for data collection. Following the scoring process, information was disseminated to the DMTs, leading to alteration of many of the quality metric requests. Metrics with the highest priority scores were submitted to the IT group for incorporation into the quality dashboard. Conclusions: The QMEPT allowed comparison of quality metrics across disparate oncology disease groups, prioritization for incorporation into a quality dashboard and rational allocation of limited IT resources.
Establishing achievable benchmarks for quality improvement in systemic therapy for early-stage breast cancer.
Authors: Powis Melanie , Gonzalez Alejandro , Sutradhar Rinku , Enright Katherine , Taback Nathan , Booth Christopher M. , Trudeau Maureen E. , Krzyzanowska Monika K.
Published: February 2017

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Background: Setting realistic targets for performance on quality indicators (QI) is a consistent challenge in quality improvement. The purpose of this study was to utilize administrative data to define achievable targets for QI in the early stage breast cancer (EBC) population in relation to systemic therapy (ST) delivery based on best performers. Methods: Deterministically linked administrative healthcare databases were used to identify EBC cases diagnosed 2006 – 2010 in Ontario, Canada. Panel of previously established QIs for systemic therapy was applied to patients who met eligibility criteria for the individual indicators. Institutions with less than 10 eligible patients for a specific indicator were excluded. An empiric benchmark was defined as the proportion of patients meeting the indicator from institutions accounting for the top decile of eligible patients. Results: We identified 28,303 EBC patients who received surgery of which 12,252 received adjuvant chemotherapy. Benchmark results are summarized in Table. Conclusions: Many institutions fell considerably below the benchmark. Further analysis of institution-level drivers of high quality care is required to help characterize high performing institutions. [Table: see text]
Unwarranted variation in time to initiation of adjuvant chemotherapy in a statewide collaborative.
Authors: Griggs Jennifer J. , Braun Thomas , Dick Andrew W. , Gorski David H. , Bensenhaver Jessica Miley , Breslin Tara M. , Henry Norah Lynn
Published: February 2017

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Background: The purpose of this study was to investigate clinical and non-clinical factors associated with time to initiation of breast cancer adjuvant chemotherapy following the final definitive surgery in a state-wide collaborative. Methods: We collected prospective data from all patients who received adjuvant chemotherapy for Stages I - III breast cancer in 25 health systems in the Michigan Breast Oncology Quality Initiative (MiBOQI) between 2006 - 2014. MiBOQI is a Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored quality collaborative. The dependent variable was time to initiation of adjuvant chemotherapy. Time to chemotherapy was examined according to clinical and non-clinical patient and treatment factors and by health system, both with and without adjustment for patient and treatment variables. Results: Complete data were available for 7,513 of 8,236 eligible (91%) patients. The mean time to chemotherapy was 43 days (range 5-390). In multivariate analyses, clinical factors independently associated with longer time to chemotherapy included increasing age, greater comorbidity, and obesity (p value < 0.0001 for all). Higher stage disease was associated with shorter time to chemotherapy (p < 0.0001); there was no association with hormone receptor or HER2 status. Treatment factors associated with longer time to chemotherapy were breast reconstruction, receipt of genomic assays, and receipt of advanced imaging (p value < 0.0001 for all). Non-clinical factors—minority status, higher area-level poverty, and non-private insurance—were also independently associated with longer time to chemotherapy (p value < 0.0001 for all). In addition, time to chemotherapy varied significantly between health system (p < 0.0001); this difference persisted after adjustment for all patient and treatment factors. Conclusions: Clinical and non-clinical factors, including site of care, are associated with variation in time to initiation of chemotherapy. Identifying patient-level factors and processes of care that facilitate or impede timely initiation of chemotherapy may decrease unwarranted variation in care delivery across a collaborative network.