bluuebunny/crossref_metadata_2025 huggingface dataset:
Quantifying the electronic medical record implementation to stabilization curve.
Authors: Kadish Sarah , Senderovich Arik , Leib Ryan , Mandelbaum Avishai , Momcilovic Petar Momcilovic , Trichakis Nikos , Bunnell Craig A.
Published: April 2017

140

Background: The implementation of electronic medical records (EMR) has been noted to disrupt clinical workflows as providers acclimate to a new EMR. On May 30, 2015, Dana-Farber Cancer Institute (DFCI) implemented a new EMR. Using our Real Time Location System (RTLS), we sought to identify the time required to stabilize the experience for providers. We identified factors that may speed the stabilization rate to guide EMR implementations elsewhere. Methods: DFCI uses an RTLS to timestamp patient and provider locations throughout the day. To adjust for variation in appointment types, we measured the ratio of the actual exam duration (recorded by the RTLS) to the scheduled exam duration. We compared to a 3-month baseline average to quantify the immediate impact of implementation. We tracked the ratio over time to identify when stabilization occurred and compare to baseline performance. To infer influential factors, we performed a regression analysis based on RTLS data from the first 6 months post implementation. Results: The stabilization curve fits the “classical” power function model. Rapid improvement over the first ten days of clinical practice was followed by a gradual period of ongoing stabilization. The EMR impact on exam duration required approximately 30 clinical days for each provider to reach the baseline value with continued improvement over the next 30 clinical days. Factors with a potential to improve the rate of stabilization were provider type (MD, NP or PA), provider gender and provider age. Conclusions: The first ten clinical days experience a fast rate of improvement. Thus, while the initial impact is disruptive, operations improve rapidly. Initial improvement may be attributed to fixing “bugs” in the EMR and rapid learning by providers. Our presentation will explore factors that impact the rate of improvement. Understanding the stabilization rate and factors can aid organizations in training, implementation, and ongoing improvement to minimize the impact of EMR disruption. [Table: see text]
Leveraging a software application to prepare for regulatory inspection within a hematopoietic cellular therapy program.
Authors: Blunk Betsy , Jawanda Jesse , Drake Kevin , Billups Rocky Lee , Cox Tonya , Dodd Therese , LeMaistre Charles F.
Published: April 2017

142

Background: The Sarah Cannon Blood Cancer Network (SCBCN) is comprised of seven Hematopoietic Cellular Therapy (HCT) programs. Regulations require that programs have a consistent and continuous process to identify and measure compliance to ensure standards are met. Every 3 years, programs undergo inspections by the Foundation for the Accreditation of Cellular Therapy (FACT). Historically, programs would prepare for inspections by utilizing paper documents that support and demonstrate compliance with standards. The goal of this project was to develop an electronic platform to manage the FACT inspection. COMAIBA (Compliance Management Actionable Intelligence Business Analytics) was selected as a development partner. Methods: Within our HCT programs, a thorough analysis was performed to determine the current processes by which inspections took place. The FACT assessment questionnaire was reviewed and each standard was evaluated. Quality coordinators within the programs highlighted the key documentation necessary to meet each standard. Results: In collaboration with COMAIBA, a regulatory compliance module was developed which allows the programs to electronically prepare for and manage FACT inspections. There are currently over 1600 questions within the application broken down into clinical, apheresis, marrow collection and processing facility subsections. Programs upload supporting documentation to demonstrate how they comply with each standard. From a programmatic level, administrators and key personnel can, at any time, view the preparation process via a dashboard and view the compliance measures electronically. Conclusions: This electronic solution allows quality teams to proactively prepare for inspections and keep information current and up to date on an ongoing basis. As standards evolve, the design of the COMAIBA application allows versatility in updating and maintaining compliance. COMAIBA is working to utilize this format for other regulatory and accrediting bodies i.e. CoC, UNOS. In addition, allowing the inspectors to view information electronically prior to coming onsite may enhance the inspection process and allow for a more comprehensive review.
Development of a patient question prompt list to improve communication and clinical trial enrollment in a diverse patient population.
Authors: Hamel Lauren M. , Penner Louis , Heath Elisabeth I. , Lansey Dina , Carducci Michael Anthony , Albrecht Terrance Lynn , Barton Ellen , Manning Mark A. , Wojda Mark , Eggly Susan
Published: April 2017

143

Background: Few patients, especially racial/ethnic minorities, enroll in clinical trials (CT), in part due to patient-oncologist communication. Question prompt lists (QPLs) improve communication, but have not been tested in CT discussions in a diverse patient population. We describe the development and acceptability of a theory-based QPL to improve communication and enrollment of White and Black men in prostate cancer CTs. Methods: Two existing QPLs were adapted by a team of communication scientists, psychologists, clinicians and patients. Guiding theories were the common ingroup identity model, which suggests people from different social groups can better achieve goals when they are on the same team, and patient-centered communication, which suggests that patient active participation improves clinical communication. The revised QPL included text to encourage patients to see themselves and their oncologist as a team, and 33 questions about CTs to encourage patients to participate actively in clinical interactions that include a CT discussion. To test acceptability, we recruited 15 Black or White men currently enrolled in a prostate cancer CT at an urban comprehensive cancer center. We asked patients to provide feedback on the QPL, to endorse which questions were most important, and for suggested improvements. Results: Patients participated anonymously. All patients said the QPL would be useful. Four patients reported liking the graphics/layout. Six patients reported liking the team text, but one commented that it was unnecessary. Three patients liked that the QPL included many questions, several of which they had not thought to ask when they discussed a CT with their oncologist. Ten patients endorsed the questions they thought were important to ask (M = 24 questions, SD = 9). The most frequently endorsed questions were what is already known about this treatment and how serious are the side effects? Conclusions: Patients found the QPL to be acceptable and useful. The QPL was revised according to patient feedback. We are testing the revised QPL's influence on patient-oncologist communication about CTs, patient understanding of CTs offered, and patient decisions to enroll in a CT.
Does a treatment delay affect the survival of octogenarian patient population?
Authors: Raufi Ali Mehmood , Jafri Hassaan , Gress Todd W.
Published: April 2017

149

Background: The cancer management of the elderly patient is an increasingly important and challenging issue. The aim of this retrospective analysis is to evaluate the impact of treatment delay on survival outcome of cancer in octogenarian patients. Methods: From 2006 to 2015, established cancer patients age 80 and above who received treatment at our comprehensive cancer center were retrospectively reviewed. We evaluated the relationship between a delay in cancer treatment of more than 30 days in the octogenarian patient and survival using Kaplan-Meier survival and Cox proportional hazards models. Results: There were 235 octogenarian cancer patients available for evaluation and 115 of these had a delay in initiation of cancer treatment ( > 30 days). Mean age was 83.7 years the treatment delay (TD) group and 83.9 in the no treatment delay (NTD) group (p = 0.70) Eastern Cooperative Oncology Group (ECOG) score of 2 or more was present in 22.6% of the TD group and 18.3% of the NTD group (p = 0.42). Metastatic disease was higher in the NTD group (22.5% vs. 11.3% TD group; p = 0.051). There were more breast (36.5% TD vs. 12.5% NTD group) and lung cancer (26.9% TD vs. 18.3% NTD group) in the TD group, and more genitourinary (20.8% NTD vs. 9.6% TD group) and gynecological cancer (20.8% NTD vs. 15.6% TD group) in the NTD group (p < 0.001 for overall comparison). Median overall survival was higher in the TD group (50 vs. 24 months NTD group; p = 0.001). Treatment delay was still associated with improved survival even after adjusting for age, gender, ECOG, stage of disease, and type of tumor (HR 0.64, CI 0.44-0.92). Conclusions: We found that a delay in cancer treatment in the octogenarian patient was associated with better overall survivial. Bias in regards to the reasons for the treatment delay may exist and could have affected our results. We attempted to minimize this bias by adjusting for characteristics that influence treatment between our two study groups. Nevertheless, our findings suggest that a delay in cancer treatment at minimum did not adversely affect mortality in this older patient population.
Trends in the content and format of main and optional consent forms in oncology clinical trials.
Authors: Rummell Sonja , Chen Leo , Cheung Winson Y.
Published: April 2017

153

Background: Informed consent forms (ICFs) should provide prospective subjects with an opportunity to balance the risks and benefits of study participation. However, there are growing concerns about the quality of ICFs. Optional ICFs are also increasingly used as the number of companion studies and biomarker evaluations requiring additional tests become more frequent. We examined trends in the content and format of main and optional ICFs. Methods: ICFs from clinical trials at a tertiary cancer center in British Columbia from 2000 to 2015 were reviewed. We focused on breast or gastrointestinal (GI) cancer studies. Readability was evaluated with the Flesch Reading Ease Score (FRES) and Flesch Kincaid Grade Level (FKGL) where a higher FRES (maximum 100) and a lower FKGL (maximum 12) indicated easier readability. We applied t-tests and linear regressions to examine variations among clinical trials and changes over time. Results: We identified 133 main ICFs of which 70% had optional ICFs and where 57% and 43% were breast and GI cancer studies. Phase III trials (44%), industry funded investigations (70%), and studies involving palliative therapies (72%) were most common. Trials from recent years were more likely to have optional ICFs than those from earlier years (p < 0.001). The median length and median word count in main and optional ICFs were 16 and 6 pages and 6183 and 1862 words, respectively. These changed significantly over time whereby main ICFs increased approximately by 1 page and 364 words per year over the 15 year period (p < 0.001). Industry funded trials also had longer ICFs (p = 0.006). Study methods, risks, and confidentiality occupied 29%, 20%, and 11% of the content on ICFs, respectively. Sections pertaining to eligibility (p < 0.001) and screening procedures (p = 0.007) also increased with time, particularly for industry funded studies (p = 0.006). In terms of readability, optional ICFs were generally more difficult to read than main ICFs (FRES 48.3 vs 50.0, p = 0.024; FKGL 11.8 vs 11.1, p < 0.001), especially in recent years (p < 0.001). Conclusions: This is one of the first analyses to include optional ICFs. Length of ICFs is increasing and readability is discordant with the average reading level of potential trial participants.
A mixed-methods study of adolescent and young adult cancer patient’s preferences for patient navigation services by distance from cancer treatment centers.
Authors: Warner Echo L. , Fowler Brynn , Pannier Samantha , Fair Douglas Beaty , Perlman Holly , Yancey Jeffrey , Randall R Lor , Bott Brad , Reynolds Carolyn C , Kirchhoff Anne C.
Published: April 2017

155

Background: We describe patient navigator preferences for adolescent and young adult (AYA) cancer patients by geographical distance from cancer treatment centers. Methods: In this mixed methods study, N = 39 participants were recruited primarily from oncology clinics in Utah. Participants were diagnosed between ages 15-39 and had completed ≥ 1 month of treatment. Participants were interviewed and surveyed on preferences for patient navigation. Thematic content analysis revealed navigation preferences based on participants’ travel distance from their treatment center, classified as < 20 miles (local) and ≥ 20 miles (distance). Qualitative data was quantized and the proportion of codes in each theme was compared by travel distance using two-tailed z-scores. Results: Mean travel distance to cancer treatment center was 53.5 miles (SD = 77.4); 53.8% of participants were local ( < 20 miles) and 46.2% were distance ( ≥ 20 miles). There were no differences by age or ethnicity. Local patients were less likely to endorse that travel distance was a challenge for their oncology appointments than distance patients (25.0% vs. 75.0%, p = 0.01). Local patients reported a higher proportion of codes (62.5%) related to believing a patient navigator would be helpful to them compared to distance patients (37.5%, p = 0.01). Connecting with a patient navigator at the time of first diagnosis was endorsed by more local patients than distance (66.7% vs. 33.3%, p = 0.01). Local patients reported a greater need for navigation support regarding finances (local 69.6% vs. distance 30.4%, p = < 0.001) and social support (local 87.5% vs. distance 12.5%, p = 0.03). Most participants, regardless of travel distance, desired navigation primarily via telephone (audio and text messaging). Conclusions: While AYAs with cancer living further from their treatment location were more likely to report that travel was a barrier, local AYAs reported more needs related to patient navigation than remote patients. Patient navigators may need to consider different support services for distanced patients including strategies to address geographic barriers to care.
The relationships between patient volume per oncologist, social worker presence, and capacity to provide psychosocial care.
Authors: Bedard Louise , Steinl Gabrielle , Lindsay Jamie , Yanchula Jennifer , McLeod Chandler , Myers Stacie , Griggs Jennifer J.
Published: April 2017

156

Background: The purpose of this study was to investigate the relationships between new patient volume per oncologist, the availability of a social worker, and the capacity to provide psychosocial care. Methods: Community practices within Michigan Oncology Quality Consortium (MOQC), a statewide quality collaborative, completed NCI’s 10-item Cancer Psychosocial Care Matrix (CPCM). The CPCM speaks to communication, assessment, coordination, training, and outcomes and quality, each on a separate Likert scale. Analyses describe the ability to meet psychosocial care and the availability of a social worker, new patients/full time oncologist, payer mix, and percent minorities. Results: To date,15 of 47 practices (32%) completed the CPCM. We report on 4 measures with sizeable variation between practices. Scores were the highest on the ability to communicate the importance of psychosocial care and implementing a plan (scale of 1 – 3; mean of 2.36, standard deviation, SD 0.72; mean of 1.79, SD 0.89). The lowest scores were related to linking patients with services and offering provider education (scale of 1 – 5: mean of 2.18, SD 1.08; mean of 2.20, SD 0.94). Linear regression showed an association with number of patients/oncologist and the ability to provide staff training of effective patient/provider communication and monitoring this activity’s impact. For every 100-person increase in the number of patients/oncologist, there was a -0.16 (p = 0.046) rating difference in staff training and a -0.25 (p = 0.006) rating difference to monitor the communication’s effect. A dedicated social worker was present in 3 practices. Regression analysis showed a relationship between a social worker and recognizing (p=0.02) and addressing psychosocial care (p<0.001). There was wide variation in payer mix and percent minorities but no association between the dependent variables and these characteristics. Conclusions: Community practices with a larger volume of new patients/oncologist/year are less likely to provide staff training and monitoring on psychosocial communication. In this sample, payer mix and racial composition are not associated with a practice’s ability to deliver psychosocial care.
Gaps in integrating genetic testing into management of breast cancer.
Authors: Katz Steven J. , Hawley Sarah T. , Jagsi Reshma , Kurian Allison W.
Published: April 2017

160

Background: Genetic testing for breast cancer risk is evolving rapidly, with surging use of multiple-gene panels. However, little is known about the extent to which testing is effectively integrated into management after diagnosis of breast cancer. Methods: A population-based sample of 3930 patients diagnosed with breast cancer in 2014-15 and identified by two SEER registries (Georgia and Los Angeles) were sent surveys 2 months after surgery and responses merged to SEER data. A subgroup at higher pre-test risk of pathogenic mutation carriage (vs average risk) was defined according to testing guidelines. Results: Among 2502 eligible patients with unilateral breast cancer (response rate 70%), 666 (27%) reported genetic testing. The Table shows wide variability in patient report of which professional ordered the test and discussed the results. Few (18-21%) patients had testing ordered by a genetic counselor and approximately half (57% high-risk, 42% average-risk) discussed results with one. One third of patient received testing after they had surgery. In a multivariable model adjusted for age, race, education, pre-test risk of mutation carriage, stage, co-morbidities and study site, the only factor significantly associated with delayed testing was insurance status: Compared to private insurance, patients were more likely to be tested after surgery if they had Medicare (OR 2.1, 95% CI 1.1-4.2) or no insurance (OR 3.0, CI 1.6-5.3). Conclusions: There is wide variability in which professionals order genetic testing and discuss results. Many breast cancer patients who receive genetic testing never see a genetic counselor. Many patients do not get tested early enough to consider the results in surgery management. These findings suggest enormous challenges in personalizing communication about genetic testing after diagnosis of breast cancer. [Table: see text]
Development and implementation of clinical pathways across a network of blood cancer programs.
Authors: Brougher Laura Ione , Billups Rocky Lee , Cox Tonya , Dodd Therese , LeMaistre Charles F.
Published: April 2017

161

Background: The Sarah Cannon Blood Cancer Network (SCBCN) is comprised of 7 blood cancer and Hematopoietic Cell Therapy (HCT) programs providing care for complex blood cancer patients. Network commitment to achieving standardization of care for quality and clinical platforms led to process design for development of evidence-based pathways. Methods: Standard operating procedures and a document control process were developed by the network quality management (QM). With oversight by physician leaders, initial efforts focused on standardizing patient selection criteria for HCT followed by formation of disease-specific work groups (leukemia, lymphoma, multiple myeloma, HCT). Physician-led and composed of key network team members (PharmDs, QM professionals, SCBCN leaders, research staff), the groups are responsible for developing evidence-based diagnostic and treatment pathways/algorithms for hematologic malignancies. Members participate in monthly teleconferences to develop the pathways. Annual review and deviation tracking are conducted, providing a mechanism for subsequent pathway revisions reflecting changing treatment paradigms and updated clinical evidence. QM oversees implementation and tracking across the network. Deviation tracking is managed locally using pathway-associated algorithms, with attending physician attestation to either compliance or pathway deviation/reason (e.g. co-morbidity, age, disease status, enrolled on clinical trial, other). Results are reported quarterly with review by QM. Results: See table. To date, 13 HCT pathways (18 algorithms) have been developed and released to SCBCN programs. Final approval is pending for 5 disease-based pathways (19 algorithms). Conclusions: The first compliance report will be submitted to QM in December, 2016. While deviation tracking has been paper-based, work efforts are underway to implement an electronic solution, enabling automated real-time monitoring. Implementation is expected in early 2017. [Table: see text]
Quality of Dutch integrated head and neck cancer care: Measurement and evaluation.
Authors: van Overveld Lydia Francisca Jacoba , Takes Robert P. , Braspenning Jozé C.C. , Merkx Matthias A.W. , Smeele Ludi E , Hermens Rosella P.M.G.
Published: April 2017

173

Background: Oncologic care is very complex, and delivery of integrated care with optimal alignment and collaboration of several disciplines is crucial. To monitor and effectively improve high-quality integrated oncologic care, a dashboard of valid and reliable quality indicators (QIs) is indispensable. A set of QIs is developed specifically for head and neck cancer (HNC) patients from three perspectives: patients (development of indicators from patient perspective, including the first results, are described in the abstract "PROMs and PREMs in Dutch integrated head and neck cancer care: Measurements and evaluation"), medical specialist and allied health professionals. This presentation concerns the first results from medical and allied health professional perspective. Methods: QIs on process, structure and outcome of care, were developed using an evidence based method: the Rand modified Delphi method. Data was collected in nine Dutch hospitals nearly 1,500 patients (November 2014 - December 2016). Indicators were calculated on national and hospital level and corrected for case-mix using SPSS. Results: The final set contained 5 outcome indicators from both perspectives, 13 and 18 process indicators from the perspective of medical specialists and allied health professionals respectively, and three structure indicators from the perspective of allied health professionals. Besides, 10 case-mix factors were selected. Current practice assessment, in 1263 patients, produced high scores on integrated care indicators, e.g., the percentage of patients discussed in multidisciplinary team meeting before start of the treatment (93%) and availability of a treatment plan (99%). However, involvement of dental teams (range 57 – 100%) and malnutrition screening (range 8-35%) could be improved in most hospitals. In addition, most hospitals did not meet the standard of 80% on patients starting with treatment within 30 days. Conclusions: The quality of integrated multidisciplinary care for patients with head and neck cancer in the Netherlands is already high on some aspects, but varied between hospitals and shows room for improvement. This study can be an example for other oncologic diseases where integrated care is necessary.
A person-centered e-proms multi-faceted intervention to improve patient experience and health outcomes: A multi-site implementation study in diverse ambulatory oncology practices.
Authors: Howell Doris , Li Madeline , Rosberger Zeev , Montgomery Nicole , Mayer Carole , Snider Anne , Bryant-Lukosius Denise , Hamel Marc , Faria Rosanna , Martelli Lorraine , Macedo Alyssa
Published: April 2017

182

Background: The Improving Patient Experience and Health Outcomes Collaborative (iPEHOC) aims to improve health outcomes through uptake of electronic patient reported outcome measures (e-PROMs) in oncology practices in Ontario and Quebec. Building on screening with the Edmonton Symptom Assessment System (ESAS), e-PROMs were triggered based on cut scores to focus multidimensional assessment and management of pain (BPI), fatigue (CFS), anxiety (GAD-7) and depression (PHQ-9). Methods: Multifaceted implementation strategies and practice change coaching facilitated the use of e-PROMs to improve symptom outcomes. A mixed-method, pre-post quasi-experimental design assessed process and impact of the intervention on symptom screening rates, symptom burden, patient experience and activation, clinician satisfaction, team collaboration and health care use. Mann-Whitney U statistics examined significance of change from baseline to the 8-month post comparison. Qualitative data explored uptake of e-PROMs in practice. Results: Over the implementation period 10,248 ESAS screens were completed in iPEHOC clinics; 17.5% triggered an additional e-PROM. A slight improvement was noted in person-centeredness of communication (mean change of 1.43 to 1.37; four-point scale of 1 = very satisfied, 4 = very dissatisfied) and in team collaboration. A significant increase in patient activation levels (p = 0.045) was related to decreased emergency department visits (2% pre/post change, p = 0.81) and hospitalization within 30 days of an e-PROMs completion (2.2% change, p = 0.034) in Ontario. Patients and clinicians perceived e-PROMs as valuable to focus communication in the clinic visit and for shared treatment planning. Focus group data suggests that patients use e-PROMs as a ‘self-check-in’, to communicate their symptoms and normalize disclosure of depression in clinical care. Conclusions: Uptake of e-PROMs in diverse settings is complex and demanding. Improving symptom management quality requires PROM data to be fed-back for ‘real-time’ use in the clinical encounter and practice change facilitation for meaningful use in routine care.
Implementation of a systematic method for the identification, tracking, and treatment of malnutrition in pediatric patients with acute lymphoblastic leukemia.
Authors: Mangino Jennifer , Welin Elizabeth , Cole-Jenkins Cheri , Demmel Kathy , Weiss Brian D.
Published: April 2017

184

Background: It is estimated that the prevalence of malnutrition in children with cancer may be as high as 50%. Optimization of nutritional status is known to be associated with improved tolerance of cancer therapy, decreased infection risk, increased quality of life and increased survival. There are established methods for improving nutrition, but we have observed barriers to the identification of at risk patients, adherence to recommended interventions and continued surveillance. Methods: We identified patients in the intensive phases of therapy for acute lymphoblastic leukemia/lymphoblastic lymphoma. Using improvement science methods, we developed a standardized approach to the identification, treatment and tracking of patients at risk for malnutrition. We utilized quality improvement techniques to identify the problems with the current system and implement change. These changes included standardization of an algorithm for nutritional treatment and follow up, creation of a daily electronic report for identification of at risk patients, and improved communication with providers in regard to patient nutrition. Results: At baseline, nearly 10% of our target patients were impacted by significant weight loss. Utilizing quality improvement techniques, we were able to establish the most common causes of failure in our system (awareness of the problem, identification of at-risk patients, tracking and monitoring at-risk patients and provider/patient adherence to recommended nutritional interventions). Interventions were employed using plan-do-study-act quality improvement methods, including the development of an electronic identification and tracking system designed for these patients. We were able to significantly decrease the number of patients with weight loss using these methods. Conclusions: Malnutrition is associated with poor outcomes in patients with cancer. Use of quality improvement methods allowed us to identify key drivers and test/implement specific interventions to combat this problem. In this proof of principle cohort, this has resulted in a significant improvement in the nutritional status of our patients.
Risk factors for adverse outcomes in solid tumor interhospital transfer patients.
Authors: Wee Christopher , Varella Leticia , Rybicki Lisa A. , Stevenson James
Published: April 2017

191

Background: We previously reported that inter-hospital transfer patients to our institution’s oncology service experienced higher mortality and increased length of stay (LOS) compared to other origins of admission. We sought to identify risk factors for adverse outcomes in this hospital transfer population. Methods: We reviewed all inter-hospital transfers from Jan-June 2016 to the Cleveland Clinic’s solid tumor oncology service. Patient characteristics, including age, albumin, and case severity indices (mortality and severity risk scores and AP-DRG), as well as encounter characteristics, including admitting provider (house staff or hospitalist), admission time (8AM-5PM or evening), admission day (weekday or weekend), and time between transfer acceptance and admission were recorded. Adverse events examined included activation of adult medical emergency team (AMET), ICU transfer, LOS, in-hospital mortality, and 30-day readmission. Associations of patient and encounter characteristics with adverse events were assessed using Wilcoxon and Fisher’s exact tests. Results: Fifty-three transfer admissions were identified. Patients had a median age of 67 years and 58.5% were male. House staff admitted the majority of patients (81.1%) and most occurred after hours (62.3%). Age, admission time and day, and type of admitting physician were not associated with adverse events. There was a significant association between higher AP-DRG and mortality/severity risk scores with ICU transfers, AMET activations, and mortality. Patients who experienced any adverse events on average had a lower mean albumin than those who did not (2.3 vs 3.0 g/dL p=0.006). LOS and readmission were not significantly associated with any patient or encounter characteristics. Conclusions: Burden of disease as measured by mortality/severity risk and AP-DRG as well as lower albumin levels are associated with adverse events in solid tumor inter-hospital transfer patients, while encounter characteristics do not predict for poorer outcomes. This population should be targeted for improvements in communication and handoffs at the time of transfer, as well as early involvement of palliative care providers.
Educational program for medical residents in cancer pain management.
Authors: Ravisankar Shyam , Eris Ela , Cohen Alice Joy
Published: April 2017

198

Background: Studies have shown significant deficits in the knowledge of physicians in Cancer Pain Management (CPM). We implemented an educational program on CPM for medical residents with pre and post-testing to assess baseline knowledge and the improvement after education. Methods: The content of the lecture was derived from the Cancer Pain Education Resource (CAPER). It included assessment, non-pharmacological interventions, equi-analgesic conversions , titration, side effects, withdrawal, dependence and addiction. An online questionnaire was created to assess the baseline knowledge and the residents accessed it using their mobile phones. After the lecture the same was used to assess the improvement in knowledge. 22 residents from Newark Beth Israel Internal Medicine Residency Program participated in the lecture and the pre/post-tests. After the lecture, they were given a pocket card with opioid equi-analgesic dosing calculations.Two months later, the same questionnaire was used to assess the retained knowledge. Results: The pretest score was 71% and after the lecture it improved to 81%. After 2 months the score was 72%. Notably, the knowledge of equi-analgesic conversions had increased. 95 % of the residents were very satisfied with the lecture and wanted more education on CPM. Improvement in knowledge on specifics of CPM are shown in Table. Conclusions: One of the ways to improve CPM is to focus on education of residents. After a single lecture, there was improvement in all areas of deficiency.The use of simple tools like pocket cards can help to improve knowledge. Our plan is to expand this program to medical students and have additional lectures. We believe that these lectures will improve the quality of CPM in patients. [Table: see text]
Total healthcare, treatment, and supportive care costs among metastatic pancreatic cancer (MPC) patients (pts) treated with either nab-paclitaxel/gemcitabine (nab-P+G) or FOLFIRINOX (FFX) in the first-line (1L) setting.
Authors: Ung Brian , Patel Manish , Pelletier Corey , Ni Quanhong
Published: April 2017

20

Background: The economic burden of MPC is substantial while treatment options are limited. This study compared treatment, supportive care, and total health care costs in MPC pts who initiated nab-P+G or FFX in a large insured US population. Methods: A retrospective study was conducted using claims from the Clinformatics Data Mart Database. Adults who had ≥2 claims for PC, ≥1 claim with a secondary malignancy, completed >1 cycle of nab-P+G or FFX as 1L between 1/1/2013 and 12/31/2015, and had continuous enrollment in health plans for ≥6 months prior to and 3 months following the start of 1L, were selected. Total health care costs and MPC-related treatment costs were measured per patient per month (PPPM) during 1L. Results: 216 MPC pts met selection criteria ( nab-P+G, n=139; FFX, n=77). Pts on nab-P+G were significantly older (mean age: 67.6 vs. 61.4 years; p<0.001) vs. FFX. nab-P+G pts incurred similar total health care costs but less supportive care and treatment administration costs vs. FFX (table). The nab-P+G group had a significantly lower proportion of pts who received peg-filgrastim (13.7% vs. 50.6%; p<0.001); with lower PPPM number of fills (0.11 vs. 0.71; p<0.001), anti-emetics (92.8% vs. 100%; p=0.0154), and hydration procedures (63.3% vs. 98.7%; p=0.0001), but a higher proportion received oral opioids (66.2% vs. 54.5%, p=0.0066) during 1L. Conclusions: Total health care costs were similar. nab-P+G pts had higher chemotherapy drug costs while FFX pts had higher treatment administration and supportive care costs. [Table: see text]
Timely antibiotic administration in febrile neutropenia.
Authors: Nyatsanza Ignatius , Khan Irum , Windhorst Jennifer , Gerardo Nicole , Cadman Kasandra , Valero LeeAnn , Knightly Eileen , Feldman Lawrence Eric , Galanter William , Venepalli Neeta K.
Published: April 2017

204

Background: The University of Illinois currently lacks a standard process to ensure timely antibiotic administration for patients with febrile neutropenia. The Infectious disease society of America (IDSA) guidelines recommend administration of antibiotics within two hours. Given the variability in patient encounters, we sought to implement an early identification and interventional strategy in the ambulatory setting for febrile neutropenic patients. A retrospective chart review over 10 weeks demonstrated that of 40 patients diagnosed with neutropenia 15 % (N = 6) had febrile neutropenia. Of these 6 patients, 50% (N = 3) received antibiotics within the IDSA time frame. We aimed to increase the percentage of febrile neutropenic patients receiving antibiotics within 2 hours from 50% to 100% in 8 weeks. Methods: A focus group at our quarterly morbidity mortality and improvement conference brainstormed a list of causes of delay in antibiotic initiation based on an index case discussion. A task force generated a pareto chart after affinity sorting the prior list, and created actual and ideal process maps, from identification of neutropenic patients to patient disposition. A standard operative protocol (SOP) was developed involving the creation and implementation of an electronic provider generated neutropenia check list triggering specific actions per IDSA recommendations, and a standardized order set including STAT cultures, and STAT antibiotics. Results: The febrile neutropenia SOP will be piloted over an 8 week period starting in early November in four ambulatory settings. The primary outcome data is the time from event to antibiotic administration. Process data will include time from event to antibiotic order, time from antibiotic order to administration and compliance with high risk neutropenic check list. We plan to assess our interventions every 3-4 weeks, and pilot at least 2 PDSA cycles within the next 8 weeks. Conclusions: Although febrile neutropenia is a recognized medical emergency with clear guidelines on treatment, not all patients may receive antibiotics within the appropriate time frame. It is therefore imperative for institutions to be aware of their level of IDSA compliance and implement appropriate quality improvements as required.
Funding model for stem cell transplant.
Authors: Monakova Julia , Tariq Huma , Hertz Sherrie , Kouroukis Tom , Blais Irene
Published: April 2017

22

Background: A call for development of a new model for funding Stem Cell Transplant (SCT) services in Ontario led to a costing initiative described below. The new model needed to be in alignment with current costs and clinical practices, and to avoid over or under-funding the required components of care for all types of transplant (autologous, allogeneic-related, allogeneic un-related). Methods: The patient care path was broken down by transplant type into the following phases: Pre-Transplant, Graft Harvesting or Procurement, Transplant, and Follow-Up. The following Canadian and Ontario data sources were used for fiscal year 2013/14 and 2014/15 to identify costs of care: -Case Costing data submitted by the six hospitals providing SCT services, -Discharge Abstract Database (DAD), -National Ambulatory Care Reporting System (NACRS), -Other data sources, as needed (e.g. Specialized Services Oversight Information System, Health Indicator Tool). Additionally, the costs for high cost drugs, infrastructure, psychosocial support, and pathology services components were specifically identified. Broad consultation with clinical, administrative, and costing experts ensured the data was complete and appropriate to patient care needs. Once the costs for each component and phase were estimated, the funding model was developed using the bundling approach where the costs of specific activities and/or phases were bundled together for the purposes of funding. Results: The SCT Funding Model developed based on this costing initiative consists of the following four bundles covering the continuum of a patient’s care from pre-transplant to post-transplant care follow-up: 1.) Pre-Transplant, 2.)Graft Acquisition, 3.)Transplant (includes transplant and follow-up), and 4.) High Cost Drugs. Conclusions: The new SCT Funding Model reflects up-to-date costs and addresses the gaps of the previous approach. It has been implemented and is widely supported due to the extensive stakeholder engagement throughout the process. It is an important component of provincial-level planning for SCT service delivery.
Are we choosing wisely? Operationalizing Choosing Wisely in the Ontario cancer system.
Authors: Singh Simron , Earle Craig , Mittmann Nicole , Coburn Natalie G. , Rahman Farah , Liu Ning , Cheung Matthew C.
Published: April 2017

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Background: The Choosing Wisely (CW) campaign aims to initiate conversations about unnecessary treatments contributing to the rising cost of cancer care. We aim to develop a data linkage research platform to operationalize CW recommendations within administrative health care databases and the population-based performance of these recommendations. We initiated testing with the CW recommendiation against routine surveillance imaging in patients with aggressive histology lymphoma and pancreatic/gastric (P/G) cancer treated with curative intent. Methods: We used population-based administrative databases from Ontario, Canada to examine a cohort of adult patients with diffuse large B-cell lymphoma (DLBCL) (2004-2011) and P/G cancer post-surgical resection (2003-2013). For the DLBCL cohort, we defined an index date of 2-years after the last dose of R-CHOP as the time-frame beyond which surveillance CT imaging would be inappropriate. For the P/G cohort, the index date was 6 months post-resection. The primary outcome was cumulative incidence of CT scans within 3 years of the index date. To ensure that only surveillance scans were captured, we censored 6 months prior to development of recurrent disease, a new cancer diagnosis, or death. Results: The cohort consisted of 2,838 DLBCL and 2,930 P/G patients. The cumulative incidence of receiving CT imaging in the three years post index date was 55.6% (95% CI 53.7%-57.5%) among DLBCL and 82.8% (95% CI 81.3%-84.3%) among P/G patients. DLBCL patients ≥65 were more likely to receive imaging (p<0.01) as were those with more comorbidities (p<0.01). Younger patients with P/G were more likely to receive imaging (p<0.01) as were men (p<0.01). Income and rurality did not predict for increased imaging in either cohort. Surveillance CT imaging decreased over time among DLBCL patients (p<0.01), but increased among P/G cancer patients (p<0.001). Conclusions: During a time-frame in which surveillance imaging is deemed unnecessary by the CW campaign, the practice in Ontario remains excessive. This study represents a real-world demonstration that CW statements can be operationalized within population-based administrative databases and used as quality indicators in cancer care.
Clinic level variation in emergency department and inpatient utilization in a community setting.
Authors: Panattoni Laura , Fedorenko Catherine R. , Kreizenbeck Karma L. , Greenlee Stuart , Walker Julia Rose , Greenwood-Hickman Mikael Anne , Barger Sarah , Rieke John Whitelaw , Conklin Ted , Chance Sharon , Eaton Keith D. , Guerrero Rose , Gunkel Mary , Martins Renato G. , Moorhouse Marilyn , Smith Bruce , Lyman Gary H. , Ramsey Scott David
Published: April 2017

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Background: Early studies of the oncology medical home suggest that intensive outpatient care (e.g. 24-hour phone triage, same-day infusion) reduces emergency department (ED) and inpatient (IP) use during cancer treatment. Little is known about which services are most cost-effective. One strategy is to measure observed variation in ED and IP rates to pinpoint care features associated with low-use clinics. This study examined clinic-level variation in ED and IP use in a community setting. Methods: Cancer registry records for Western Washington from 2011 to 2015 were linked with claims from two regional commercial insurers. Included patients were diagnosed with breast, lung, colorectal, or prostate cancer and treated with chemotherapy or radiation. All ED and IP use was tracked 1 year after treatment start using claims data. Observed clinic rates were measured as the percentage of patients with 1 or more visits. Expected clinic rates were determined from regional average rates weighted by clinic’s cancer-specific stage mix. Observed-to-expected clinic ratios were calculated and the Wilson Score test (95% CI) was used to determine statistically different rates. Results: The 18 clinics included 4,558 eligible patients (median 196 pts/clinic; range: 35-859). Unstaged lung patients had the highest ED rates (38.5%); unstaged breast had the lowest (13.3%). The highest IP rate was among unstaged colorectal (66.7%); the lowest in local breast (11.1%). One clinic had an observed rate that was significantly above its expected rate in both ED only and ED to IP. One clinic was significantly below its expected rate in both ED to IP and IP only. Conclusions: Even after adjusting for cancer-specific stage, there was sizable clinic-level variation in the percentage of patients visiting the ED or IP. Investigation into care delivery features and practice characteristics, along with further risk adjustment, may yield insights into best practices and identify clinics for intervention. [Table: see text]
CAHPS Cancer Care Survey: Development, testing, and final content of a survey of patient experience with cancer care.
Authors: Evensen Christian , Yost Kathleen J. , Keller San , Cowans Tamika , Frentzel Elizabeth , Jenkins Sarah , Egginton Jason , Arora Neeraj K. , Garfinkel Steven
Published: April 2017

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Background: The objective of this work was to develop a reliable and valid survey measuring aspects of cancer care important to patients to be used in both inpatient and outpatient settings, and that allows comparisons of patient experiences across treatment centers and treatment modalities (medical oncology, radiation, surgery). Other objectives included testing various modes of data collection and developing a standardized sampling methodology based on ICD diagnosis and procedure codes. Methods: We conducted focus groups with patients who had received cancer treatment and with family members of cancer patients. We convened a panel of experts representing quality improvement, oncology, shared decision-making, patient safety, and patient advocacy to obtain feedback on the development of the survey. We interviewed stakeholder groups representing oncology associations to obtain feedback on focal provider, attribution and sampling. We then conducted a field test of the survey among six cancer centers around the country, conducted psychometric analyses, revised the survey, conducted a second field test among four community oncology practices in CA, re-analyzed the data, and finalized the survey. Results: Final survey content was determined using results of the formative research, psychometric analyses, and input from the CAHPS Consortium. The core survey includes 56 questions, 23 of which map to eight composites: Provider Communication, Enabling Patient Self-management, Team Available to Provide Information, Access to Care, Care Coordination, and Office Staff. Supplemental item sets include seven items assessing Shared Decision Making, four items measuring Keeping Patients Informed, and two additional Access to Care items. Mail-only, mail-telephone mixed-mode, and web-mail mixed-mode are recommended methods of data collection. The survey and all recruiting materials are available in English and Spanish. Conclusions: The CAHPS Cancer Care Survey is a rigorously developed, well-tested, reliable and valid survey of patient experiences with their cancer care. The survey and supporting materials are available free of charge on the CAHPS website (www.ahrq.gov/cahps).