bluuebunny/crossref_metadata_2025_split huggingface dataset:
Novel clinical definitions for immune-related adverse events (irAEs): A QI intervention to improve accuracy in irAE diagnosis.
Authors: Brito Amanda , Grover Shilpa , Abdulnour Raja-Elie E , SINGH PRABHSIMRANJOT , Yenulevich Eric , Kehl Kenneth L. , Ni Jian , LeBoeuf Nicole R. , Jacobson Joseph O. , Rahma Osama E. 
Published: October 2019

290 Background: Use of immunotherapy has increased exponentially with survival benefit in many malignancies. As a result, suspected irAEs are commonly encountered, but lack of a gold standard for diagnosis puts patients at risk. We describe preliminary results of a QI project to improve accuracy of irAE diagnosis. Methods: Specialists at our institution created algorithms to define the likelihood of immune-related hepatitis, colitis, and pneumonitis based on clinical data, diagnostic results, and treatment response. Records of patients admitted from June-November 2018 with possible irAE were retrospectively reviewed by an oncology provider and an immunotoxicity specialist. A web-based tool automated irAE likelihood from clinical data based on the aglorithms. Reviewers could agree or disagree with the result and share their clinical impression. We evaluated concordance between providers and between provider and algorithm. Results: Of 65 patients, most had non-small-cell lung cancer (29%), melanoma (15%), or breast cancer (9%) and were treated with pembrolizumab (48%), nivolumab (23%), or ipilimumab/nivolumab (22%). There were 4 irAE-related deaths and 40 patients (71%) discontinued therapy for presumed toxicity. After 14 cases were excluded due to incomplete information, algorithms were applied to the remaining 51 cases (19 colitis, 8 hepatitis, 24 pneumonitis). The algorithm generated the likelihood of an irAE in 63% of reviews. Overall agreement with the algorithm was 86% (84-100% for individual algorithms), Kappa 0.8 (0.7-1.0). Overall concordance between reviewers was 76% (75-88%), Kappa of 0.7 (0.6- 0.8). Conclusions: While algorithm definitions and provider impressions were fairly consistent, cases lacking a generated likelihood suggest that some clinical scenarios are not addressed. Different interpretation of clinical information or varying experience with irAEs may explain inter-reviewer discordance, which underscores the importance of applying a standardized approach to irAE diagnosis across settings and experience levels. In the next improvement cycle, the algorithm will be refined to broaden algorithm scope, clarify criteria, and improve accuracy.
Real world implementation of patient report outcomes: Sustainability constraints and impact on patients health outcomes.
Authors: Faria Rosana , Langleben Adrian , Kushneryk Ashley , Wilson Jennifer 
Published: October 2019

291 Background: St Mary’s Hospital, an affiliated McGill Teaching University Hospital, receives ~700 new cancer patients yearly. In 2014-17, electronic PROs were implemented through the Improving Patient Experience and Health in Outcomes Collaborative in partnership with Cancer Care Ontario, granted by Canadian Partnership against Cancer and Rossy Cancer Network, as part of a PRO Canadian Initiative to improve the Patient Experience across Canada through standardized measurement of health-related outcomes for patients. Methods: The PROs measures included the Edmonton Symptom Assessment Scale (ESAS), additional measures for Fatigue, Anxiety, Depression, and Pain, the Social Difficulties Inventory-21 and Quality of Life. PRO-data was scored in real-time; nurses and patients received a printed summary report. Nurses were provided with an algorithm and instructions. Monthly Distress Screening Dashboard were generated with key indicators. In 2016, all patients receiving chemotherapy were assessed at each cycle of treatment. After project completion, due to nursing staff shortage, the frequency of screenings was reduced. Yearly Dashboard results were used to promote discussion with clinicians and address sustainability constraints of PROs in real-word oncology practice. Results: In 2016 1366 total screens completed ( 376 patients) and in 2018, 753 total screens (325 patients). This comparison indicates that a decrease in frequency of screenings resulted in an increase in symptom severity in all health-related outcomes. Physicians’ participation was proposed as mitigation plan to increase screening frequency. We propose to present a three year retrospectively cross analyzed patient data to examine symptom change over time, frequencies of screening, impact on patients’ health outcomes, overlapping sustainability constraints encountered and mitigation plans. Conclusions: Embedding the use of PRO into existing hospital structures requires constant review involving administrative, clinician and patient engagement.
Can we keep patients home? Decreasing hospitalizations in the oral chemotherapy patient.
Authors: Karlin Michelle Rene , Mikan Sabrina Q. , Wilfong Lalan S. , Books Holly 
Published: October 2019

294 Background: The Oncology Care Model (OCM) pilot includes all types of cancer with an aim to test whether additional funding for enhanced services and financial incentives to improve quality and efficiency, could reduce Medicare spending while maintaining or improving quality for a broad array of cancer types. Patients taking oral chemotherapy are included in the OCM. Often these patients require hospitalization due to side effects,decreased access and ability to communicate with providers. Limited documented strategies exist showing how to decrease hospitalizations in patients with cancer. The aim of this study was to decrease the hospitalization rate of oral chemotherapy patients at five sites by improving access to care and communication via establishment of phone triage nursing management. Methods: The aim of this project was to reduce hospitalizations for oral chemotherapy patients being treated at home over an eight month period. The Model for Improvement served as the research framework and design for this improvement project. The model includes identifying, defining and diagnosing a problem, before developing solutions and implementing interventions that are anticipated to solve the identified issues. Plan, Do, Study, Act (PDSA) cycles were utilized to develop and test changes in support of the oral chemotherapy patients. Five clinical sites affiliated with a community oncology practice in Texas collaborated with a Patient Support Service (PSS) nursing call center. Results: Implementing the PSS center resulted in a lowered number of monthly hospitalizations over eight months in patients receiving outpatient oral chemotherapy as compared to monthly volume of hospitalizations over eight months before implementation while demonstrating positive patient satisfaction with the oral regimen. Conclusions: This quality initiative found that OCM patients receiving oral chemotherapy can be supported to remain in their homes while decreasing unnecessary hospitalizations through the establishment of a PSS center. Through support systems for out-patient oncology patients, outcomes can be improved, unnecessary hospitalizations decreased, patient satisfaction sustained, and overall cost of care reduced.
Applying quality improvement methodologies to decrease the time-to-activation of new clinical trials at an NCI-designated comprehensive cancer center.
Authors: Brown Timothy J , Williams Erin Fenske , Griffith Patrice , Rahimi Asal Shoushtari , Oilepo Rhonda , Hammers Hans J. , Laetsch Theodore Willis , Kurian Pamela , Currykosky Penny , Partridge Susan , Beg Muhammad Shaalan 
Published: October 2019

296 Background: Initiating a new clinical trial is burdensome and complex. The time to activate a clinical trial can directly affect the ability to provide innovative, state-of-the-art care to patients. We sought to understand the process of activating an oncology clinical trial at a matrix National Cancer Institute-designated, comprehensive cancer center. Methods: A multidisciplinary team of stakeholders within the cancer center, university, and affiliate hospitals held a retreat to map out the process of activating a clinical trial from packet receipt to enrollment of the first patient. We applied classical QI and Six Sigma methodology to determine bottlenecks and redundancies in activating a clinical trial. During this process, particular attention was paid to time to pass through each step and perceived barriers and bottlenecks were identified through group discussions. The time to activation was measured from the day the trial packet was received until the time when the trial was open for enrollment. Results: The process map identified 66 steps with 12 decision points to activate a new clinical trial. The following two steps were instituted first: 1) allow parallel scientific committee and institutional review board (IRB) review and 2) allow the clinical research coordination committee to review protocols for feasibility and university interest separate from the IRB approval process. These changes resulted in a mean time-to-activation change from 194 days at baseline to 135 days after these changes were implemented. The committee continues to track the activation time and this frame work is used to identify additional improvement steps. Conclusions: By applying quality improvement methodologies and Six Sigma principles, we were able to redesign redundant aspects of the process of activating a clinical trial at a matrix comprehensive cancer center. This was associated with a reduction of time to activation of trials. More importantly, the process map provides a framework to maintain these gains and implement further changes.
Tumor board automation.
Authors: Zechmann Stephanie , Schreiner Susan 
Published: October 2019

297 Background: Coordinating tumor boards is a complex resource intensive process. Nebraska Medicine has 16 oncology-based Tumor Boards weekly. Preparation included multiple emails between disciplines for each conference regarding case request, case reminders, agenda modification, final agendas and printing. Other tasks include recording of attendance, completion of staging sheets, tracking tumor board summaries, totaling cases presented, and completion of CoC summaries. A full time employee completed these tasks. Developing an efficient streamlined approach to managing tumor boards became critical. Methods: Standardized agenda templates and tumor board communication processes were created. Multiple email groups were developed per tumor board to allow for specificity and clarity for individuals within a targeted tumor group to reduce email traffic. Leveraged available technology within Microsoft Office 365 Suite at our organization. Microsoft Flow and SharePoint applications were selected to manage data information sharing and ease communication flow as well as provide immediate notification of agenda changes. SharePoint subsites were set up for each tumor board including: current agenda Excel file, archive agendas and summaries. Microsoft Flow turns repetitive tasks into multistep workflows. It makes decisions in workflow, running specific actions when certain conditions are met. Flow is used for automated emails for case requests, submission reminders, and final agendas to selected group of individuals including Imaging, Pathology, Physicians, Researchers and nurse. A condition was built in Flow for agenda modification. This auto-checks the agenda for updates and auto email notifies targeted individuals of updates. Results: Oncology Tumor Boards/Multi-Disciplinary Conference processes are automated with streamlined flow of communication, reduction in emails, better accommodation of late additions and greater number of patient presentations. This has improved patient care and reduction in employee time. Conclusions: Through exploration, collaboration and innovation, it is possible to automate tumor boards/MDC to create a seamless process, expand number of conferences and patient presentation while reducing resource utilization and staffing expense.
ASCO Research Community Forum: Impact on clinical research.
Authors: Waterhouse David Michael , Robert Nicholas J. , Kim Edward S. , Kurbegov Dax , Burris III Howard A. , Thompson Michael A. , Nowakowski Grzegorz S. , Hurley Patricia A. , Davis Courtney , Lilenbaum Rogerio 
Published: October 2019

299 Background: In 2011, ASCO launched a forum for the oncology research community to facilitate and promote the implementation of quality clinical research. The ASCO Research Community Forum (RCF) was created to provide a solution-oriented venue for research sites to address common challenges with conducting clinical trials. It offers in-person and virtual forums and resources to learn and share best practices with peers on a variety of topics, including site quality assessment and improvement, research site operations, and clinical trial access and accrual. Methods: An assessment was performed to measure the ASCO RCF output and to gather information on its potential impact on the cancer community. Results: The ASCO RCF has provided an in-person venue for physicians and research administrators with a steady increase in attendance, from 52 attendees in 2012 to 159 in 2018. Multi-stakeholder meetings and manuscripts have promoted best practices and solutions to address challenges with implementing quality clinical trials. Tools and resources to facilitate best practices and quality improvement at trial sites have been accessed by a range of types of research sites from across the U.S. and internationally. Its web-based library of resources was accessed over 27,000 times in 2018, alone. An online forum was launched in 2019 to provide a new opportunity to connect and impact the research community. Conclusions: The ASCO RCF is a productive and esteemed resource for the cancer research community. In-person and virtual forums, along with practical tools, promote access and accrual to clinical trials by facilitating networking, developing solutions, and providing education and resources. The ASCO RCF impact has extended from community-based oncology practices to larger research networks and academic centers across the U.S. and internationally. Its efforts to promote and facilitate access to quality clinical trials align with the vision and mission of ASCO to conquer cancer through research, education, and promotion of the highest quality patient care.
Reducing administrative burden through the use of IT tools.
Authors: Rothacker Andrew , Glass Katherine 
Published: October 2019

300 Background: With the increasing cost of healthcare, providers have been tasked with increasing efficiencies. While the Electronic Medical Record (EMR) is a great tool for managing the patient at the time of their appointment, it can be difficult to utilize that information outside of and prior to the appointment. We recognized the need for better reporting to enable the end users to spend less time in front of a screen and more time with their patients. The need for better, more efficient data was evident. Simple data extracts from the EMR were not working. Methods: The operations analysts attended weekly huddles, shadowed clinicians, and immersed themselves in the data to better understand what is required from the reports. Multiple patient databases were created, along with dashboards, using a visual software package to display patient information. Information is then filtered into the dashboard for reporting, examples include: the patient’s appointments, treatment length, treatment location, and any other pertinent information that is needed. The reports are then automated to provide users a report with a specific snapshot of the patients coming to the clinic the following day/week. End users are then able to take the reports provided to them automatically and plan their time accordingly. Results: The reports are used daily/weekly (depending on the need of the report) by clinical and non-clinical teams. By leveraging appointment data from the back end of the EMR and the visual software package, end users no longer need to spend time combing through the EMR to identify future appointments. Information is tailored to their specific needs, which may be different from a clinical team to a non-clinical team. While it is difficult to quantify the exact value each report provides, one specific example for the Art & Music Therapy team is saving end users an estimated 4 hours per day, extrapolating out to 1,040 hours per year and freeing them up to provide better service to their patients. Conclusions: Combining appointment data and data visualization and automation tools allows teams to review the necessary information more efficiently. By reducing the manual burden of searching through the EMR, end users are able to free up their time and spend more time with the patient.
Evaluation of an NCCN guideline-based weight management pathway on weight loss in female breast cancer patients.
Authors: Hansra Damien Mikael , Ahn Eugene R , Schoeber Nathan , Cargile Jennifer , Johnson Anita , Alvarez Ricardo H. 
Published: October 2019

301 Background: Obesity is a risk factor for many breast cancer (BC) subtypes & is associated w/ inferior BC outcomes. Here, we investigate the effect of a NCCN based intervention on weight loss (WL) in BC pts. Methods: Prospective study using WL guidelines adapted from NCCN Survivorship (V. 2.2017). Data collected: demographics, clinical, cardiovascular risk factors (CVD), weight, height, body fat%. Stats: 1 sample T-Test w/ 2 tail p-value & 95% CI used to calculate change in weight from baseline to 3 & 6 months (mo) using hypothetical mean of 0. Inclusions: Female BC pts, stage 0-III, OW (BMI > 25mg/m2) or OB (BMI > 30kg/m2). Exclusions: No BC, stage IV, not OW/OB, lost to follow up (f/u), non-compliance, death, or recurrent disease. Intervention: BMI assessed at baseline at initial visit where pt received 20 minute OB counseling by oncologist (ONC). Pts include NEW pts (treatment & surgery naïve) & F/U pts (pts finished definitive treatment in survivorship). ONC counseling included pt education on OB & cancer outcomes & CVD risk. Initially, pts referred to physical therapy (PT) for exercise program & dietician (DT) for nutrition counseling. Pts visit PT & DT q 3 mo. ONC counseling provided periodically during scheduled visits. Results: 70 pts enrolled 10/26/2017 – 10/8/2018. Median pt age = 56 yrs (37-87). Menopausal status: 25/70 (36%) pre menopause vs. 45/70 (64%) post menopause. Race: 29/70 Caucasian (41%), 41/70 (59%) African American, 0/70 (0%) other. Ethnicity: 2/70 (3%) Latin vs. 68/70 (97%) non-Latin. Avg. BMI = 34 kg/m2 (26-54). Avg. weight = 90 kg (61-143). Stage: 0 = 7/70 (10%) , I = 26/70 (37%), II = 21/70 (30%), III = 16/70 (23%). Receptors: 12/70 (17%) triple negative, 13/70 (19%) Her-2+, 49/70 (70%) ER/PR+. CVD risk factors & body fat% shown separately. Mean WL for the 70 pts (NEW + F/U, N = 70) = -0.7 kg @ 3 mo. (p = 0.08), 95%CI (-1.510- +0.101); mean WL = -0.7 kg @ 6 mo. (p = 0.16), 95%CI (-1.703-+0.295). Mean WL for NEW pts, (N = 52) lost -0.9 kg @ 3 mo. (p = 0.0467), 95%CI (-1.809- -0.014). New pts lost -0.7 kg @ 6 mo. (p = 0.21), 95% CI (-1.868 - +0.440). Conclusions: Implementation of the NCCN guidelines + ONC counseling as part of a WL program mitigates weight gain @ 3 & 6 mo in all OW & OB BC pts & induced significant weight loss in NEW pts @ 3 mo.
Maintaining clinical pathways: What does it really take?
Authors: McNeil Debra , Hamilton Joanna M. , Meserve Emily , Hayne Victoria , Holtz Laura , Wolfson Matthew , Milne Dana , Jackman David Michael , Leblebjian Houry , Jacobson Joseph O. , Tremonti Carole Kathleen 
Published: October 2019

305 Background: Building pathways to support clinical decision making is one step, maintaining them is a mountain. Dana-Farber Cancer Institute has built 34 medical oncology (MO) pathways (PWs) and 27 radiation oncology (RO) PWs. These PWs are managed by 28 lead MDs, 8 pharmacists, 6 project managers (PMs), 1 data analyst and 1 coordinator. Once PWs are built, attention shifts to platform and content maintenance. Methods: Maintaining PW clinical and informatics content is complicated and laborious. It requires collaboration amongst clinical and non-clinical experts; these resources form the PW team. PW content is updated quarterly or semi-annually, based on the pace of scientific change in a disease. These review meetings serve as a forum for physicians to review, discuss and revise content. Infrastructure support is provided by the PW team. Supporting the meeting requires a pre-meeting, the formal review meeting, a post meeting, and extensive revisions and content validation along the way. To prepare, PW performance data and emerging relevant evidence is reviewed with the lead MD to establish the meeting agenda. In both MO and RO the PW team is responsible for all content management. Results: We reviewed 6 months of data (2/18-7/18) and analyzed the hours and cost to maintain the pathway portfolio. Conclusions: PW maintenance is costly therefore labor efficiency is critical to overall success. There are 4 strategies for success: building trust; MD engagement; data; and program coordination. The MD/PM relationship is the foundation and consistency is key. MD engagement is crucial; having an influential lead MD sets the tone for the disease center overall. Establishing clear expectations and frequent check-ins keeps the lead MD engaged. Actionable, frequent, and transparent data reports give MDs feedback on their practice patterns. The coordinator is a central point of contact and ensures programmatic execution and success. Though PW maintenance is resource intensive, it facilitates standardized decision-making for the dissemination of cutting-edge cancer care. [Table: see text]
Quality improvements in palliative radiotherapy at end of life: The FutRE Study.
Authors: Goutam Siddhartha , Stosky Jordan Mark , Wu Jackson S.Y. , Fairchild Alysa M. , Kerba Marc 
Published: October 2019

306 Background: Palliative radiation therapy (RT) is offered to patients with cancer for symptom management. RT planning and delivery is resource intensive. Benefits may take weeks to develop. Palliative RT at the end of life may not be completed due to patient and disease factors. RT courses that are not completed may indicate a need for improved patient selection for RT and choice of RT prescription, minimizing the likelihood of delivering futile treatment. Methods: The FUTile Radiotherapy at End of life survey was implemented in the electronic RT workspace across Alberta in 2018. Radiation oncologists (ROs) were tasked with survey completion, at the time of palliative RT prescription approval, as part of their workflow on domains pertaining to patient and treatment decision-making. This survey data was linked to the cancer registry and date of death. Data association were examined among patients completing RT within 90 days of death for the accuracy of oncologist’s provided survival prognostication estimates, number of RT fractions prescribed, number of RT fractions completed, prescribing physician, including disease factors and treatment intent. Results were explored using descriptive statistics and tests of associations (STATA 11.1) Results: 1963 RT surveys were included in our analysis. Prescribing ROs overestimated patient survival 67% of the time, by a mean of 145 days, and underestimated survival 12% of the time by a mean of 109 days. Multi-fraction RT (1403 courses) was more frequently prescribed over single fraction (SF) RT (560 courses)(one-sample t-test, p≤0.001). SF treatments were more likely to be completed than MF treatments (RR = 10.3, 95% CI = [4.85, 21.7], p < 0.0001). Treatments were less likely to be completed when survival was overestimated by 6 or more months and were over twice as likely to be completed than when patient survival was underestimated (RR = 2.6, 95% CI = [1.04, 6.50], p = 0.04). Conclusions: Survival among end of life patients is overestimated by ROs prescribing palliative MF RT treatments.