bluuebunny/crossref_metadata_2025 huggingface dataset:
Redesigning care to lower episode costs in bone marrow transplantation.
Authors: Johnston Laura J. , Patterson Diana , Tang Ning , McMurdo Christine , Adams Laura , Chang Susan
Published: April 2017

16

Background: Increased scrutiny over costs of cancer care has led to the introduction of episode-based payment by federal and commercial insurers. National average billed charges for autologous and allogeneic transplant episodes of care are approximately $375K and $925K, respectively. Through comprehensive analysis of claims data, we identified leading drivers of cost in BMT episodes (which span 30 days before transplant through 60-100 days post-transplant) and cost reduction opportunities. By redesigning care delivery, we can reduce post-transplant admissions and potentially improve the health and patient experience for this population. Methods: From September 1, 2013 – February 28, 2015, SHC performed 221 allogeneic and 241 autologous transplants. We analyzed internal claims data to map costs of BMT episodes, including pre-transplant, transplant (index), and post-transplant phases of care using standardized cost categories including room accommodations, medications, medical and surgical supplies, imaging, and labs. Results: 67% of episode cost was associated with pre-transplant and index phases. In both phases, patients’ treatment closely matched defined protocols. Imaging, medications, and blood utilization met clinical indications. The largest opportunity was seen in the post-transplant phase for patients with multiple myeloma who received autologous transplants. On average, episodes with post-transplant admissions were 35% more costly than episodes without post-transplant admissions. Many of these patients are admitted 5-9 days after transplant due to neutropenic fever, have short LOS, and receive empiric antibiotics. An estimated 37% of post-transplant admissions, totaling $790,000 in annualized cost, may be prevented with additional outpatient support. Conclusions: A multidisciplinary team proposed redesigning care to safely shift treatment from the inpatient to outpatient setting. Strategies include expanding Infusion Treatment Area and home pharmacy capacity and partnering with home health agencies.
Prediction of factors affecting clinical trial accrual at the Cancer Therapy and Research Center in San Antonio.
Authors: Iruku Praveena
Published: April 2017

168

Background: Oncology is a very rapidly emerging science with need for more investigational drugs. It is highly essential to accrue patients into clinical trials to develop new drugs. According to the available data, about 38 % of the CTEP/NCI supporting oncology trials close due to inadequate accrual. In this study, we propose to develop a model that will predict clinical trial accrual and retrospectively validate the effectiveness of this model. Methods: Eligible studies included treatment and supportive care intervention studies either open or closed to accrual between 09/1999 and 012/2015 at our center. Data abstracted includes coordinating group, sponsor type, presence of competing trials, trial phase, disease category, single institutional study, author, primary purpose of the study, interventional modality, targeted therapy, advanced disease, randomization, presence of placebo, rare cancer category and new investigational agents. Statistical analysis was performed in the statistic software R (R Foundation for Statistical Computing, Vienna, Austria). We used Chi-square test and Fisher’s exact test. The significance level was set to alpha = 0.05. Results: Retrospective univariate analysis at our institution showed that the variables significantly associated with clinical accrual are: the type of sponsor, author of the trial, and the type of interventional modality. Using these variables, that were statistically significant in accrual of clinical trials, we then determined the strength of our model in measuring the performance of the predictors. Our prediction model had an AUC of 64.1 %. Conclusions: Clinical trial accrual is a key factor in the development of new drugs in Oncology. Our intention was to predict factors that may affect clinical trial accrual and develop a predictive model based on it. In the future, we want to use our predictive model in a prospective validation setting in order to guide our clinical trials portfolio. Data from multiple institutions will improve the validity of this model.
The challenges of improving peripherally inserted central catheter (PICC) care instructions at hospital discharge.
Authors: Kilbridge Kerry L. , Glotzbecker Brett , Rosenbaum Cecilia H. , Morelli Erica , Hsieh Candace , Stuver Sherri Oliver , Yenulevich Eric , Jacobson Joseph O.
Published: April 2017

175

Background: Teaching patients and caregivers to manage a Peripherally Inserted Central Catheter (PICC) line placed during hospitalization is essential to successful outpatient transitions. The aim was to improve written care instructions at hospital discharge (CIHD) given to solid tumor oncology patients with new PICC lines by creating an electronic template in the electronic health record. Methods: Inpatients with newly placed PICC lines discharged from the physician assistants' (PA) oncology teams at Brigham and Women's Hospital were identified through PICC team consult lists. We identified 9 elements of complete line care, modeled on National Quality Forum discharge metrics, to include in a template for PICC line care instructions at discharge. PAs received instruction on template use at their weekly meeting. A retrospective chart review of CIHD (February 19, 2016 and October 13, 2016) was performed. Results: A total of 47 cases were reviewed, 19 cases Pre-introduction and 28 cases Post. Before introduction of the template, 74% of cases lacked PICC care instructions (including 13 cases with no mention of the PICC line), 26% had incomplete care instructions, and none had full instructions. Following the intervention, 64% still lacked care instructions (16 cases with no mention of the PICC line), 21% had incomplete care instructions, and 4 patients (14%) had full instructions. Only those CIHD that used the template had complete care instructions. A c-chart demonstrated special cause variation following the intervention but the process was chaotic. Conclusions: The introduction of a template for PICC care instructions led to modest improvement in the number of patients discharged with full instructions. This project highlights the limitations of solutions that incorporate technical solutions but only weak adaptive ones. The next phase of our work will introduce human factors interventions (e.g. automation and forcing functions) to improve the success rate of this critically important function. [Table: see text]
Feasibility of a clinic-based central line care teach-back program for pediatric oncology families.
Authors: Wong Quiles Chris Ivette , Desrochers Marie D , Mahan Riley M , Graham Kristen , Brill-Conway Margaret , Eng Kelly , Billett Amy
Published: April 2017

183

Background: Pediatric oncology (PO) patients with central lines (CLs) are at high risk for CL associated bloodstream infections (CLABSI), which increase morbidity, mortality, and costs. A large portion of ambulatory CL care in the home is provided by families who often have limited opportunities to develop the needed skills and adhere to best practice line care. Methods: A pilot quality improvement initiative was undertaken from 5/2015-6/2016 to develop a coaching program for families to demonstrate external CL care with a nurse during a routine clinic visit (teach-back), either on a simulation model or the patient. Tests of change were implemented to add teach-backs during routine clinic visits and ensure teach-back documentation in the medical record. Initial steps included assessing family interest in teach-backs by conducting surveys about CL care at home and unstructured incorporation into routine care by existing clinic nursing staff. After assessment of the pilot phase, targeted interventions started April 2016 including dedicated staff for scheduling, tracking, and performing teach-backs during routine clinic visits; culture change including an expectation that all families would participate and on-going staff education about the program; language change to increase participation by avoiding family perception of being tested; and incentives (gift-card raffle) for nurses to provide coaching. Results: Before April 2016, less than 25% of families participated due to a combination of family refusal; lack of nursing availability, space, or time; and inability to approach prior to line removal. In April 2016, 52% of families participated, reaching 90% by June 2016. Informal feedback from both staff and patient/family participants suggested increased job satisfaction by nurses and wide acceptance by all. In addition, many families participated in multiple teach-back sessions to improve line care skills. Conclusions: A CL teach-back program in a busy ambulatory PO clinic is feasible, but requires dedicated resources and culture change. Ongoing improvements are in place to ensure sustainability of the program and measure the impact on ambulatory CLABSI rate and family distress and line care skills.
Driving quality improvements of radiation treatment services through a centralized performance management approach.
Authors: Hagens Victoria Karuna , Gutierrez Eric , Xie Yidan , Ang Michelle , Simanovski Vicky , Warde Padraig Richard , Matheson Garth
Published: April 2017

188

Background: Radiation treatment services are delivered in 16 facilities spread across the province of Ontario, centralized through Cancer Care Ontario’s oversight of quality of care, equipment, hospital funding, clinical and technical guidelines. Methods: In order to ensure high quality care, Cancer Care Ontario employs a systematic approach performance management, whereby facilities are held accountable to achieving provincial quality targets. For radiation treatment, the quality improvement priorities that have leveraged this approach over the last 10 years have included: reduction of wait times to consultation; reduction of wait times to start of treatment; adoption of Intensity Modulated Radiation Therapy (IMRT) where appropriate; and implementation of peer review for treatment plans. In each case, key performance indicators were developed for use in provincial scorecards designed to focus the attention of local clinical and administrative leadership. Regular performance discussions with senior leaders took place throughout implementation, and targeted intervention occurred with facilities that were lagging behind their peers. Results: See table. Conclusions: The ability to centrally monitor the implementation of quality improvement initiatives across a large jurisdiction, and to hold the leadership of each facility accountable to provincial targets through regular feedback and escalation, has been a key component of highly successful change management initiatives in radiation treatment in Ontario. [Table: see text]
Utilizing patient reported outcomes for patients recieving oral chemotherapy.
Authors: Mackler Emily R. , Beekman Kathleen W. , Bushey Laura , Gentz Anne , Davis Kathleen , Yarrington Carol , Farris Karen B , Griggs Jennifer J.
Published: April 2017

190

Background: Management of oral chemotherapy presents many challenges to oncology practitioners. The purpose of this study is to describe how incorporation of patient reported outcomes (PRO) for patients receiving oral chemotherapy can identify those patients who are experiencing moderate to severe symptom burden and nonadherence. Methods: As part of a statewide quality collaborative, we wished to improve our monitoring of patients receiving oral chemotherapy. The quality collaborative created a PRO assessment that includes a revised Edmonton Symptom Assessment Scale (ESAS), a single-item adherence question, reasons for nonadherence, the patient’s most bothersome symptom and questions related to patient confidence. Our medical assistants provide the assessment to the patient before each appointment. Results: Patients completing the PRO during the first 3 months (7/7/16 – 9/27/16) were evaluated. We had 32 assessments completed by 23 patients. The oral chemotherapy prescribed were capecitabine (48%), erlotinib (13%), temozolomide (13%), and not recorded (26%). Of the 29 completed ESAS assessments, 72% included at least 1 moderate side effect, and 48% included at least 1 severe side effect. 29% of patients reported low-moderate confidence to self-manage their symptoms. Less than excellent adherence (<80% adherence) was reported in 30% of patients with the most commonly reported reason being related to side effects or concerns about side effects. Conclusions: Use of PROs in our oral chemotherapy population identified a large proportion of patients experiencing moderate to severe side effects. Further assessment of how this compares to what patients report to their oncologist during their visits will be reviewed. In addition, we found that approximately 30% of our patients are nonadherent to their oral chemotherapy. This is consistent with recent publications. We plan to continue assessing patient outcomes and utilizing the data we collect to improve patient self-management support.
Decreasing wait times for endobronchial ultrasound (EBUS).
Authors: Mackenney Karen L. , Faiz Saadia , Larson Andrew J , Eapen George A , Bashoura Lara
Published: April 2017

192

Background: The department of pulmonary medicine evaluates manifestations of cancer and complications of therapy that affect the lungs. It is a procedurally oriented specialty with many diagnostic and therapeutic interventions. Endobronchial ultrasound with transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive procedure that allows real time image guided sampling of tissue in the mediastinum. Current guidelines recommend use of EBUS for the initial test to diagnosis and stage lung cancer. It has a low complication rate, but needs specialized equipment as well as anesthesia support. Alternatives include CT-guided biopsy or surgery. The delay from time of referral to EBUS procedure has the potential to delay diagnosis and treatment, create patient anxiety, frustration and expense of travel for multiple appointments. The staff is under pressure to perform excessive cases on a daily basis resulting in overtime staffing costs. Our objectives were to reduce delays in diagnosis/treatment, improve patient satisfaction, improve referring services satisfaction and optimize the use of resources and improve staff working conditions. Methods: We used a Plan, Do, Study, Act process. Initially the process flow diagram was utilized along with a fishbone diagram to allow us to focus on the issues. The aim was to decrease EBUS wait time 20% by 7/2016. Our process flow sheet was arranged into swimlanes in order to identify focus areas. This allowed us to redesign the workflow to improve capacity and improve existing resources to be more efficient. Results: Working with anesthesia services and the cardiopulmonary center staff, we were able to open a second bronchoscopy suite 2 days a week for additional EBUS cases. We also had monthly meetings with issues and to monitor delays to other services. Conclusions: We were able to reduce our wait time from 7.5 days to 4.27 work days. The added capacity allows for surge in demand for EBUS. Our future studies will concentrate on patient and referring service satisfaction, cost savings with reduction in overtime, quantifying impact on decreasing delays in diagnosis and subsequent treatment.
Improving patient care through implementation of a QOPI-focused interactive patient note template.
Authors: Shaw Andrew , Ragon Brittany K. , Baez Vallecillo Luis , Rieber Alyssa G.
Published: April 2017

197

Background: Participation in the ASCO Quality Oncology Practice Initiative (QOPI) has been shown to improve the quality and value of care provided by oncology practices. Our fellows’ oncology practice participates in QOPI. We sought to utilize QOPI metrics in conjunction with the documentation capabilities of our electronic medical record (EMR) to create a quality-focused standardized new patient note template to be used by all practitioners in our oncology clinic, in an effort to improve patient care through improved communication and efficiency. Methods: We examined the results from our most recent QOPI assessment cycle in spring of 2016 and identified areas where our practice met the metric less than 50% of the time. Oral chemotherapy, tobacco cessation, and fertility preservation counseling were identified as target areas. We surveyed the practitioners in the group to establish baseline knowledge of QOPI metrics and desire for a standardized note template. We then developed and implemented a note template incorporating QOPI metrics, pulling data directly from other areas within the medical record, and excluding extraneous information. Results: Only 58% of the fellows in our fellowship program responded that they had a general idea of the QOPI metrics, and only 37% believed their notes were QOPI-compliant; 84% were interested in a standardized note template that incorporates QOPI metrics. Through the assistance of EMR specialists, we created a standardized note that auto-populates information recorded elsewhere in the patient’s chart and allows physicians to select appropriate options from pre-populated lists based on the patient’s treatment. The physician cannot close the encounter until these selections are made Conclusions: QOPI metrics provide guideposts for oncology practitioners to provide quality care and communicate effectively. We created a note that encourages practitioners to complete recommended QOPI tasks in an effort to improve communication and patient care. Data collection regarding practitioner use and satisfaction with the new template and compliance with QOPI metrics is ongoing.
Development and pilot of brief surveys to evaluate the quality of patient-centered cancer care.
Authors: Winget Marcy , Haji-Sheikhi Farnoosh , Asch Steve
Published: April 2017

202

Background: Oncology practices have increasingly engaged in patient-centered systematic quality improvement efforts. One test of their effectiveness is patient feedback, yet many existing instruments are unwieldy or insensitive to change. Here we describe the development and pilot testing of short patient surveys used to assess change in patient experience of the key domains of access, communication, and coordination. Methods: Domains and corresponding questions of patient-centered care were informed by existing literature and tools available online, with a focus on domains relevant to cancer patients. Questions were modified from validated or semi-validated instruments to have a consistent 4 or 5-category Likert response scale, put into four unique short instruments that included at most ten questions each and piloted in cancer clinic waiting rooms. Input from patients was sought to assess: 1) relevance and clarity of questions; 2) whether important concepts were missing; 3) acceptability to patients regarding place and timing of surveys and; 4) estimate top box scores. Internal consistency of the final question sets for each domain was examined using Cronbach’s alpha. Results: Patient feedback from the pilot was positive with respect to all above categories. The following modifications were made based on top box score analysis: 1) created a common 5-point Likert scale for all questions and 2) excluded questions with a top box score higher than 80%. An open comment field was also added to complement the quantitative responses. Cronbach’s alpha for all domains was ≥ 0.80 expect for the access domain which was 0.51. The final 4 complementary instruments have 7-8 questions each and take only a few minutes for patients to complete. Each return patient receives one of the instruments randomly at clinic visits so information on all domains is continuously collected and a given patient has the opportunity to provide feedback on all domains over time; response rates are approximately 60%. Conclusions: The short surveys are being used to assess the effectiveness of interventions. Other cancer centers and their patients may find similar short surveys an improvement over general patient satisfaction surveys e.g., Press-Ganey.
PROMs and PREMs in Dutch integrated head and neck cancer care: Measurements and evaluation.
Authors: van Overveld Lydia Francisca Jacoba , Takes Robert P. , Braspenning Jozé C.C. , Smeele Ludi E , Merkx Matthias A.W. , Hermens Rosella P.M.G.
Published: April 2017

209

Background: Providing patient-centred care is an essential component of high quality integrated care. Nowadays, patient reported outcomes and experiences are increasingly used to measure quality of care. As part of a quality registration, the Dutch Head and Neck Audit, patient reported outcomes (PROs) and experiences (PREs) of patients with head and neck cancer (HNC) are measured with questionnaires and evaluated to increase patient-centred care. Methods: Patientswere recruited from nine hospitals participating in the DHNA. Validated questionnaires were distributed at baseline, 3, 6 and 12 months follow-up. Included PROMs were EQ-5D-3L, EORTC QLQ-C30 and EORTC QLQ-H&N35. Included PREMs were Consumer Quality index for Oncologic care (CQO) and Radiotherapeutic care (CQR). CQO and CQR have similar domains with different questions. With descriptive analysis, ANOVA and mixed model analysis, differences over time and between treatment groups were analyzed. Results: Questionnaires were filled in by 238 patients. Pain decreased significantly at 6 and 12 months follow-up and dry mouth increased significantly at 3, 6 and 12 months follow-up compared to baseline. Sticky Salvia, problems with social eating and sense problems increased at 3 and 6 months follow-up, but were similar to the baseline score at 12 months follow-up. Pain and sticky saliva differed between radiotherapy and chemoradiotherapy or surgery and radiotherapy respectively (p ≤ 0.05). Regarding the CQO domain scores, all treatment groups differ significantly from each other (p ≤ 0.05). This was not regarding the CQR domain scores. Except for the domain Organisation, no differences between the CQO and CQR domain scores were found. Recognizing the emotional side of HNC (care) and intensifying guidance after the treatment period needs improvement. Conclusions: This study gives clues to improve healthcare according the experiences of the patient and we can predict more carefully the outcomes of the patients with different treatment types. PROMs according to the ICHOM criteria and PREMs are promising for measuring and improving quality and personalization of HNC care. However, the usage of two PREMs had no added value to evaluate and address points of improvement.
The Quality Oncology Practice Initiative program: Experience in Spain.
Authors: Camps Carlos , Diaz Rubio Eduardo , Lopez Rafael , Carrato Alfredo , Gascon Pedro , Margarita Feyjoo , Guillem Vicente
Published: April 2017

214

Background: Patient care quality is a discipline that is being considered highly important in today’s healthcare. Quality Oncology Practice Initiative (QOPI) is a referral worldwide in terms of quality for oncology practices. The ECO Foundation is a platform of experts representing the major Spanish hospitals involved in the treatment of cancer patients. ECO reached an agreement with QOPI in order to involve Spanish hospitals in the participation of the QOPI program. Methods: Two rounds of data collection were carried out (Fall 2015 and Spring 2016). Practices had to registered on-line and submit data into the platform provided by QOPI. ECO Foundation offers all centres the support of a CRO. 11 Spanish hospitals have participated in the first round and 6 in the second. 4 of them have participated in both rounds. Core and Lung Cancer modules were completed. Results: For the Fall 2015 round, 686 charts were included. In Spring 2016 334 charts were collected. For the first round, highest scores were: Pathology report confirming malignancy, Plan of care for pain, Effectiveness of narcotic, Patient consent, Tobacco cessation counselling, Patient emotional well-being assessed and in the 9 items of the lung cancer module. Lowest scores were: Pain addressed, Smoking status use, Smoking use cessation counselling, Smoking use cessation administered and Height, Weight, and BSA documented. For the Spring 2016 round, the results were similar, but for the items with the highest scores were now included: Chemotherapy intent discussion, Patient consents for chemotherapy, Smoking status documented, Height, Weight, and BSA documented. In Fall 2015, 7 out of 11 practices obtained a global score of over 70%, and in 2016, 3 out of 6. Regarding the 4 hospitals that repeated in both stages,3 reported an improvement of the global scoring in 2016. Conclusions: These preliminary results are a good starting point for the continued implementation of the QOPI program in Spain. Thus providing a well-structured approach to analyse cancer care in Spain, offering training programs for quality improvement in oncology practices. ECO Foundation will continue pursuing excellence and quality in Spain with future activities like the certification programs and training seminars.
Measurement of person-centered care delivery of adult oncology in Ontario, Canada.
Authors: Moody Lesley , Bridge Erica , Dhanju Suman , Nicholls Brett , Singh Simron
Published: April 2017

223

Background: In the Ontario, Canada, cancer system, the provincially endorsed Person Centred Care (PCC) Guideline provides recommendations for healthcare providers to implement PCC in the delivery of adult oncology services. However, it is unknown whether healthcare providers have incorporated these recommendations into their daily practice within the Regional Cancer Programs (RCPs). The purpose of this study was to develop an assessment tool to evaluate the implementation of the PCC Guideline in Ontario RCPs. Methods: Tool development consisted of a 3-step process: 1) literature review to identify relevant measures, 2) Modified Delphi with a panel of experts (n = 8), and 3) focus groups with patient/family advisors (n = 5) and RCP PCC leads (i.e., designated individual responsible for PCC deliverables) (n = 7). Results: Through the literature review, two relevant tools were identified ( i.e., Institute for Patient- and Family-Centered Care’s Hospital Assessment Tool and Accreditation Canada’s Cancer Care Standards), resulting in 187 measures deemed appropriate to include in the assessment tool. In round one of the Modified Delphi, each measure was evaluated independently by a panel of experts using a 5-point Likert Scale (1 = strongly disagree to 5 = strongly agree) to assess both the importance and feasibility of each measure. Sixty-seven measures were rated 4 or above by 70% of the experts. Consistent with Modified Delphi best practice, these measures were discussed during the second round with the panel of experts. An additional 33 measures were removed due to similarities/duplications. Nine measures were added. The 42 measures were presented to patient/family advisors and the RCP PCC Leads during focus groups and evaluated based on importance and feasibility of assessing PCC implementation in the RCPs. Wording recommendations were made and two additional measures were added. The final tool includes 44 measures to evaluate PCC implementation within the RCPs. The assessment tool was disseminated to the 14 RCPs in October 2016. Conclusions: The results of this assessment will provide an understanding of the current state of PCC Guideline implementation in Ontario, in order to identify facilitators and barriers to implementation.
Predictors of no-show among international patients with cancer: A 4-year analysis.
Authors: Bhulani Nizar , Xiao Lianchun , Hassan Manal , Lenzi Renato
Published: April 2017

23

Background: Patient no-show (NSh) for scheduled medical appointments negatively impacts quality of care, impedes optimal use of resources, has significant negative economic consequences secondary to missed appointments, and uncovered referral processing costs. International patients (IntlPts) present challenging financial/travel arrangements and cultural and linguistic needs. There are currently very limited data regarding numbers of IntlPts visiting the United States for medical care and no data regarding NSh rates. The purpose of this study was to quantify costs and identify IntlPts-related variables correlating with NSh to develop interventions aimed at minimizing the associated negative financial consequences. Methods: A retrospective study of IntlPts accepted and scheduled for an appointment at the International Assessment Center at MD Anderson in fiscal years 2010 – 2013 was conducted. Overall 52 variables were evaluated that included socio-demographic and clinical patient characteristics, financial responsibility, and appointment timeline. For univariate analysis, Chi-square test and Wilcoxon rank sum test were applied. For multivariate analysis, a multivariate logistic regression model was fit. The multivariate logistic model with independent covariates was used to construct a nomogram. The Time Driven Activity-Based Cost method was used to assess the cost of processing referral requests. Results: Of 1031 IntlPts scheduled, 311 (30%) were NSh. NSh was significantly associated (p <0.05) with country of origin, payer, diagnosis, referral source, disease stage, patient-delayed appointment date, number of symptoms, pain, bleeding, fatigue, dysphagia, jaundice, neurological symptoms, comorbidities, and appointment lag time. Direct operational costs were calculated using process maps and TDABC. Conclusions: These results provide the groundwork to understand operational costs and predictors of no-show of oncology IntlPts. Having knowledge of predictive factors for NSh in a new patient outpatient setting represents a necessary step towards decreasing its frequency, addressing associated costs, optimizing continuity of care, and ultimately improving outcomes and value of the provided care.
In hindsight if treatment had begun early: A study to determine the OS and PFS in patients with stage III lung carcinoma based on the time elapsed from the diagnosis to start of treatment.
Authors: Seepana Jyothirmai , Haddad Abdo S. , Mohapatra Suryanarayan , Khalid Sidra , Subramaniam Subanandhini , Jia Xuefei
Published: April 2017

230

Background: Stage III non-small cell lung cancer (NSCLC) is defined as loco-regionally advanced disease due to primary tumor extension into the extra-pulmonary structures (T3 or T4) or mediastinal lymph node involvement (N2 or N3) without evidence of distant metastasis. Patients are concerned about beginning treatment early after diagnosis. The role of the study is to determine the outcome if treatment is started within 8 weeks or after 8 weeks. In a retrospective study, the Cleveland Clinic’s database was used to identify patients treated through 2003 – 2014. Methods: Stage III NSCLC was ascertained as per the pathological or clinical stage. Kaplan-Meier estimate was used to determine the survival of patients. Results: Of the 561 patients patients with stage III NSCLC, 408 had treatment within 8 weeks and 153 after 8 weeks. See table. Treatment within 8 weeks of diagnosis: In total, 105 patients were recorded as having died, the median survival was 55.1 months (95% CI: 48.2, 62.5). The 2-year survival rate was 98% ± 0.9%, and the 5-year survival rate was 44.5% ± 4.7%. The median PFS was 15.3 months (95%Ci 12.0, 23.1). The 2-year PFS was 43% ± 0.28%, and the 5-year PFS was 14.5% ± 2.1%. Treatment after 8 weeks of diagnosis: In total, 34 patients were recorded as having died, the median survival was 60.6 months (95% CI: 50.3, 73.8). The 2-year survival rate was 97.5% ± 1.4%, and the 5-year survival rate was 53.2% ± 8.3%. The median PFS was 12.1 months (95%Ci 9.5, 15.3). The 2-year PFS was 32.8% ± 4.4%, and the 5-year PFS was 12.8% ± 3.2%. Among the following sub-groups: < 65 years, 65-75 years and > 75 years, there was no observable difference whether treatment was begun within eight weeks or after eight weeks. Conclusions: In the combined group and within subgroups, OS and PFS were not significantly different between patients who received treatment within 8 weeks and those who received treatment after 8 weeks. [Table: see text]
Chemotherapy for resected colorectal cancer pulmonary metastases: Utilization and outcomes in routine clinical practice.
Authors: Karim Safiya , Nanji Sulaiman , Brennan Kelly , Pramesh C S. , Booth Christopher M.
Published: April 2017

236

Background: The role of chemotherapy in the setting of resected colorectal cancer pulmonary metastases (CRCPM) is not well defined. Here we describe utilization of peri-operative chemotherapy and outcomes among patients with resected CRCPM in the general population. Methods: All cases of CRCPM who underwent resection from 2002-2009 were identified using the Ontario Cancer Registry (OCR). Electronic treatment records identified peri-operative chemotherapy delivered within 16 weeks before or after pulmonary metastectomy (PM). Modified Poisson regression was used to evaluate factors associated with chemotherapy delivery. Cox proportional models were used to explore the association between post-operative chemotherapy and cancer-specific (CSS) and overall survival (OS). Results: The study population included 420 patients. Thirty-six percent of patients (151/420) received peri-operative chemotherapy. Among these patients, 75% (113/151) received post-operative chemotherapy. Factors that were independently associated with use of post-operative chemotherapy included higher socioeconomic status (SES) and no prior adjuvant chemotherapy (p < 0.01). In adjusted analyses post-operative chemotherapy was not associated with improved CSS (HR 0.99, 95% CI 0.67-1.47) or OS (HR 0.93 95%CI 0.66-1.31). In exploratory analyses, among those patients who did not receive previous adjuvant therapy for the primary colorectal cancer, post-operative chemotherapy following lung metastatectomy was associated with HR 0.50 (95%CI 0.27-0.95) for OS and HR 0.59 (95%CI 0.27-1.27) for CSS. Conclusions: One third of patients with resected CRCPM in routine practice receive peri-operative chemotherapy. A randomized controlled trial is warranted to evaluate whether chemotherapy following resection of CRCPM is associated with improved survival.
Health utility scores (HUS) and health-related quality of life (HRQoL) in stage 4 lung cancer (S4LC) patients with brain metastases (BM).
Authors: Tam Vivian , Tse Brandon C , Tse Tiffany , Lu Lin , Tam Emily , Borean Michael , Labbé Catherine , Doherty Mark , Bradbury Penelope Ann , Leighl Natasha B. , Brown M Catherine , Xu Wei , Howell Doris , Liu Geoffrey , O'Kane Grainne
Published: April 2017

24

Background: Novel therapies have improved the survival of S4LC patients, particularly those with EGFR or ALK alterations. As BM are common among such patients, determining whether HUS appropriately capture BM-specific HRQoL is crucial in economic analyses. We evaluated the relationship between the FACT-Brain (Br) HRQoL, presence of BM, and HUS. Methods: This cross-sectional study of S4LC outpatients at a comprehensive cancer centre assessed FACT-Br and EQ-5D-3L-derived HUS. Correlational analyses, stratified by BM status, were performed between HUS and each of FACT-Br and its subscales: FACT-General (G), physical well-being (PWB), social well-being (SWB), emotional well-being (EWB), functional well-being (FWB), and brain cancer (BrC). Linear regression interaction models assessed whether BM modified the associations between FACT-Br or its subscales and HUS. Results: The 65 BM and 42 non-BM patients had similar demographics: median age (range) was 62 (30-83) years, 61% were female, 55% were Caucasian, and 54% were EGFR/ ALK+. Mean± standard error of the mean (SEM) values of HUS were similar between BM and non-BM groups (0.77±0.02 vs. 0.78±0.02; p=0.49). However, 40 BM patients with stable brain disease had higher HUS than the 14 with progressive disease (0.81 vs. 0.69; p=0.007). Mean±SEM values for FACT-Br, FACT-G, and BrC were 148±2.6, 79±1.5, and 69±1.3, respectively, with no differences between BM and non-BM groups. With the exception of SWB, FACT-Br and its subscales were each individually correlated with HUS (all p<0.001 unless specified), including between HUS and PWB (all patients: r=0.58; BM only: r=0.60; non-BM only: r=0.54), FACT-Br (all: r=0.55; BM: r=0.55; non-BM: r=0.54), FACT-G (all: r=0.51; BM: r=0.49; non-BM: r=0.55), and BrC (all: r=0.49; BM: r=0.51; non-BM: r=0.44, p=0.003). Having BM did not modify these relationships (each interaction, p>0.35). Conclusions: The FACT-Br HRQoL measures and the majority of its subcomponents moderately correlate with HUS but are not specific to patients with BM. Progression of CNS disease greatly alters HUS. EQ-5D-3L-derived HUS are a useful index of HRQoL in S4LC.
Health economic impact of breast cancer index (BCI) in patients with hormone responsive breast cancer (HRBC) considering extended adjuvant endocrine therapy (EET).
Authors: Sanft Tara Beth , Berkowitz Alyssa , Schroeder Brock , Hatzis Christos , Schnabel Catherine A. , Aktas Bilge , Brufsky Adam M. , Pusztai Lajos , Gustavsen Gary , Van Londen G J.
Published: April 2017

25

Background: Previous research has demonstrated the benefit of EET for HRBC, however, the absolute benefit is modest and commits women to an extra 5 yrs of treatment. The Breast Cancer Index (BCI) is a gene expression-based test that has been validated to quantify the risk of late recurrence (BCI subscore) and to predict likelihood of benefit from EET (H/I subscore). We have previously shown that the use of BCI increases patient and physician confidence in decision-making and leads to fewer recommendations for EET. The current analysis extends our results to a larger sample size and presents a health economic analysis to assess the cost effectiveness of the use of BCI for EET decision-making. Methods: We developed a fact-based economic model to project the cost effectiveness of BCI using a cohort of 140 patients with stage I-III HRBC from Yale Cancer Center and University of Pittsburgh Medical Center who had completed ≥3.5 yrs of endocrine therapy and had undergone BCI testing in the context of this study. Physicians completed questionnaires to indicate their recommendations for EET before and after BCI results. Costs associated with EET, toxicity, follow-up, and metastatic recurrence were modeled over 5 yrs of extended therapy. Model inputs were based on published literature. Sensitivity analyses were performed around key inputs to estimate effects on the model. Results: Changes in EET recommendations after BCI were observed in 29% of patients, with 21% changing from recommended to not recommended, and 8% from not recommended to recommended. The projected net cost savings of BCI testing in this population of patients who are disease free at 5 yrs post-diagnosis is $5,190 per patient tested. Gross cost savings were projected to be achieved through reduced recurrence in patients receiving EET based on BCI results and decreased adverse events and comorbidities for patients with low BCI scores who did not receive EET. Conclusions: Based on the decision impact of BCI in a real-world cohort, the test is projected to be cost saving for women with early stage hormone receptor positive breast cancer who are recurrence free at 5 yrs post-diagnosis on adjuvant endocrine therapy.
Influence of provider and health system factors on uptake and disparities in breast cancer gene expression profile testing.
Authors: Reeder-Hayes Katherine Elizabeth , Wheeler Stephanie B. , Roberts Megan , Meng Ke , Zhou Xi , Baggett Christopher , Meyer Anne-Marie
Published: April 2017

250

Background: Gene expression profiles (GEPs) have been rapidly and widely adopted to guide chemotherapy decisions in early hormone receptor-positive (HR+) breast cancer, but not all eligible patients receive testing. Patient-level predictors of testing have been reported. However, the role of provider and insurance factors in GEP use has not been well described. Racial disparities in access to testing are also under-studied. Methods: We used state cancer registry data linked to claims from multiple insurance payers to identify 11,958 patients eligible for GEP testing between 2005 and 2012. For each patient, we characterized specialty and breast cancer volume for the provider deemed most likely to make the testing decision. We identified claims for the most commonly used GEP (OncotypeDX) and used adjusted incidence rate models to examine predictors of testing, stratified by nodal status (N0 versus N1). Results: Overall, 26% of eligible patients were tested with rates increasing over time. In multivariable analyses among N0 patients, black women were 12% less likely than clinically similar whites to be tested. Patients treated by a general surgeon were less likely to be tested than those treated by oncologic specialists, while those seen by middle-volume providers were significantly more likely to be tested than patients of the highest-volume providers. Black women with N1 disease were 27% less likely to be tested. Among N1 patients, testing was most common among patients of highest-volume providers and declined consistently with provider volume. Private insurance increasing the likelihood of testing for N0, but not N1 disease. Conclusions: Insurance status and provider characteristics appear to influence the likelihood of GEP testing for early breast cancer, but do not fully explain racial disparities in access to testing. Black women are less likely than whites to receive testing in either the node-negative or node-positive setting after adjustment for clinical factors. These date suggest a need to develop quality programs that enable uptake of appropriate breast cancer genomic tests, with a focus on elimination of disparities.
Supportive oncology and survivorship care: Initial impact of the Coleman Supportive Oncology Collaborative.
Authors: Trosman Julia Rachel , Gerhart James , Garcia Sofia F. , Dale William , Patel Urjeet , Khosla Paramjeet , Lo Shelly S. , Macias Javier , Robinson Patricia A. , Knightly Eileen , Deamant Catherine , Scheu Amy , Boecher Stephanie , Diaz Aidnag , Newsom Carol , Berardi Rosa , Penedo Frank J. , Weldon Christine B.
Published: April 2017

27

Background: The Institute of Medicine (IOM) and Commission on Cancer (CoC) recommend supportive oncology and survivorship care. The Coleman Supportive Oncology Collaborative (CSOC) aims to improve quality of supportive care and survivorship in Chicago. Methods: CSOC includes 35 institutions (cancer centers, support and hospice), structured in two design teams (Distress & Survivorship and Palliative). Participants identified opportunities and gaps in supportive and survivorship care in an iterative development of: screening tools, follow-up processes, provider training, and quality metrics to assess CSOC impact. Six process improvement sites (2 safety-net, 3 academic, and 1 public) reviewed patient charts at baseline and Q1 2015, compared by Fisher’s exact test. Results: Eight metrics contained patient data at the 2 time points; improvements were seen in 6/8 metrics. Conclusions: CSOC successfully developed supportive oncology, survivorship screening, and care processes aligned with IOM and CoC standards. Significant improvements were shown after implementation in diverse settings. Ongoing work will continue to evaluate the impact of the CSOC on patient care.[Table: see text]
Implementing a patient-centered approach to immunotherapy treatment on an inpatient step-down unit.
Authors: Delacruz Buenagracia , Estrella Joylynn Mae , Reimschissel Elizabeth , Gonzalez Melissa , Buitrago Joaquin , Kuriakose Bindu , Partee Tara
Published: April 2017

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Background: Executing an innovative investigational therapy within a pre-existing infrastructure, while incorporating the organizational mission and vision is a complex process. Literature supports the use of patient-centered framework and integration of evidence in standardizing nursing practice to promote efficient workflow, accountability, and ultimately, optimal patient-care outcomes. The aim of this presentation is to describe the experience of a step-down unit at a comprehensive cancer center in developing and implementing processes to safely administer immunotherapy. Methods: A multidisciplinary workgroup reviewed the pre-existing infrastructure, determined the financial impact of new clinical trials and availability of resources, distinguished roles and stakeholder responsibilities, and developed staff education and technology utilization. A unit-prospective analysis, using the Strengths, Weaknesses, Opportunities, and Threats (SWOT) methodology was performed to assist in planning and reducing variations in processes during initial implementation. Results: This initiative resulted in the standardization of immunotherapy treatment workflow and development of patient care tools. The workflow consisted of patient education and treatment pathways, whereas the tools included the treatment calendar and nursing assessment forms comprised of daily handwriting sentence construction and CAR-T Toxicity (CARTOX) Grading Assessment. EHR collaboration resulted in the incorporation of CARTOX into nursing documentation in EMR. These workflow and tools are essential in ensuring timely assessment and management of treatment-related toxicities, escalation of care needs, and reduction of potential missed care and adverse events that impact staffing needs and health care costs. Conclusions: A patient-centered approach provides a framework in implementing innovative changes that promote patient safety. Engaging the frontline staff throughout the journey promoted empowerment and accountability. Multidisciplinary planning and nursing leadership transparency in orchestrating multi-level routines for actualization of competence proved immensely invaluable.
Post-antibiotic management of immunocompromised children with febrile neutropenia.
Authors: Russo Carolyn Lucille , Morgan Jennifer
Published: April 2017

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Background: Febrile neutropenia in immunocompromised children is a medical emergency and requires prompt administration of antibiotics and supportive care management to prevent death from sepsis. We have previously shown that improvement in time to antibiotic administration from a baseline of 108 minutes was decreased to 64 minutes in 67 children in six St. Jude affiliate clinics. The improvement was achieved by designing a unique order set and process for prompt dispensing of antibiotics at each affiliate site. However, the clinical assessment of patients after antibiotic administration to provide early intervention for treatment of septic shock did not improve. Management of fluid status, oxygen therapy, and blood pressure support are critical for optimal outcome. The time from antibiotic administration to clinical assessment remained above the expected time of 15 minutes at an average of 60 minutes. To improve the post-antibiotic management, additional guidelines were established and monitored for compliance. Methods: Clinical guidelines were written. The guidelines included: patient assessed by nurse and vital signs checked within 15 minutes of arrival, patient assessed by a clinician within 30 minutes of arrival, antibiotic administrated within 60 minutes of arrival, nurse completed post-antibiotic assessment and vital signs rechecked within 15 minutes of administration, and clinician completed post antibiotic assessment within 30 minutes of administration. Results: After establishing guidelines, each site developed a process for implementation using a similar approach of automated order sets, time reminders, and staff education of the initial management of septic shock. Chart reviews were done at one year after implementation and all were in compliance. Conclusions: Clinical guidelines, automated order sets, and continued awareness and education in the management of immunocompromised children with febrile neutropenia improved compliance with this quality project. Continued monitoring is needed to ensure the results are sustained.