bluuebunny/crossref_metadata_2025_split huggingface dataset:
Quality of care for cancer survivors: Does a model of shared care affect experience of care?
Authors: Halpern Michael T. , Cohen Julia , Lines Lisa M , Mollica Michelle , Kent Erin E 
Published: October 2019

213 Background: Cancer survivors may have unique medical care needs due to chronic/late-occurring effects of cancer or cancer treatment. “Shared care,” survivorship care delivered by both oncologists and primary care providers (PCPs), may better address these needs. Little is known about outcomes for survivors receiving shared care vs. oncologist-led or PCP-led patterns of care. We compared patient reported experiences of care for survivors receiving oncologist-led, PCP-led, shared care, or other patterns of care. Methods: Analyses of SEER-CAHPS, a data resource linking NCI's Surveillance, Epidemiology, and End Results (SEER) registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. Individuals age ≥ 65 in SEER-CAHPS diagnosed 2000-2011 with breast, cervical, colorectal, lung, renal, or prostate cancer or hematologic malignancies who completed a Medicare CAHPS survey ≥ 18 months after diagnosis and were continuously enrolled in Medicare A & B ≥ 6 months before and 6 months after survey completion were included. CAHPS included ratings of Overall Care, Personal Doctor, Specialist Physician, Health Plan, and composite scores for Doctor Communication, Care Coordination, Getting Needed Care, Getting Care Quickly, and Getting Needed Drugs. Survivorship care patterns were identified using proportions of oncologist, PCP, and other physician encounters. Multivariable regressions examined associations between survivorship care patterns and CAHPS outcomes. Results: Among 10,132 survivors, 15% received Shared Care; 10% Oncologist-led; 33% PCP-led; and 42% Other. Compared with Shared Care, we found no significant differences in survivors' experience of care except for Getting Needed Drugs (lower for PCP-led and Other). Sensitivity analyses using different pattern of care definitions showed no associations between survivorship model and experience of care. Conclusions: Survivors’ experiences of care were similar for those in Shared Care vs. Oncologist-led, PCP-led, and Other patterns of care. Within the study’s limitations, these results do not indicate enhanced patient reported medical care experiences for survivors receiving shared care.
Meeting lung cancer value based care requirements with documentation of patient goals and preferences.
Authors: Bhatia Avnish K , Das Devika Govind , Wujcik Debra , Owenby Susie , Hall Wanda D. , Smith Tasha , Zinner Ralph 
Published: October 2019

222 Background: Non-small cell lung cancer (NSCLC) accounts for 25% of all cancer deaths with 5-year survival of 6%. Recent scientific advances in molecular based treatments and immunotherapy and insurers’ emphasis on patient-centered care is changing patient care. This study sought to incorporate patients’ perceptions, goals, and preferences into treatment planning. Methods: After provider education and using electronic care planning software (CPS), a pilot of 50 patients with advanced NSCLC from two academic centers completed tablet-based surveys addressing treatment goals, decision-making preferences, and interest in clinical trials. Results were shared with the provider during the visit. Once treatment was selected, the CPS generated a personalized care management plan. Results: Participants were mean age 65 (range 41-86), 52% female, and 78% white. 60% (12/20) Stage IV patients believed that their cancer was curable. 62% (31/50) were not interested in clinical trial participation. 48% (24/50) wanted to share treatment decision making; 34% (12/50) wanted to make the final decision after seriously considering the doctor’s opinion; 6% (3/ 50) wanted the provider to make the final decision but consider their opinion, and 10% (5/50) wanted to leave all decisions to the provider. Conclusions: Patient perception of curability and decision-making preferences were important domains identified by personalized-care management planning in this Lung Cancer pilot study. Pre-visit CPS use provided the opportunity for the provider to address treatment intent and decision-making at the point-of-care. Academic centers generally expect their patients to have strong interest in clinical trials; Investigation for the reasons for disinterest warrants further exploration.
Women at risk for hip fracture following decline in bisphosphonate use.
Authors: Perraillon Marcelo Coca , Bradley Cathy J 
Published: October 2019

239 Background: Hip fractures in older adults are associated with increases in morbidity, mortality, and costs of care. Breast cancer treatment, including chemotherapy and endocrine treatment, interfere with bone health, increasing the risk of hip fracture for breast cancer survivors. Multiple studies report large and steady declines in hip fracture incidence coinciding with the availability of bisphosphonates to prevent osteoporosis, although black label warnings about side effects in 2011 steered physicians away from their widespread use. This study estimates trends in hip fracture incidence in a cohort of women with breast cancer before and after 2011. Methods: Retrospective observational study using 2007-2015 SEER-Medicare data for women aged 66 years or older continuously enrolled in fee-for-service Medicare with a first primary diagnosis of breast cancer. Primary outcome was an inpatient admission for a hip fracture within two years of cancer diagnosis. Monthly discrete time survival models were used to estimate the probability of hip fracture after diagnosis conditional on observable factors including demographic characteristics, comorbidities, and the concurrent use of bisphosphonates and cancer treatment. Results: A total of 67,577 patients met the inclusion criteria. The age adjusted incidence of hip fracture declined by 25.1% from 2007 to 2011; from 1093.662 (95% CI, 1027.9-1159.4) to 819.224 (95% CI, 762.1-876.4) per 100,000. However, the incidence of hip fractures stabilized after 2011, with a decline of only 4% from 2011 to 2014, when the incidence was 785.4 (95% CI, 728.6-842.1). The risk of hip fracture increases with age and the number of comorbid conditions. Although more women are prescribed bisphosphonates after a cancer diagnosis, prescription rates declined after 2011. Conclusions: The incidence of hip fractures in breast cancer survivors stabilized after years of steady declines. This significant change in incidence coincided with a large reduction in the use of bisphosphonates after warnings of rare but serious side effects were issued. More research is needed to prevent hip fracture in women with breast cancer and further consideration of available treatments is required for women at high risk for hip fracture.
Implementation of a pregnancy screening protocol prior to chemotherapy for women of childbearing potential.
Authors: Eastlake Christian , Jeffers Kate 
Published: October 2019

246 Background: Many cancer therapies currently available are teratogenic in nature. Several patients cared for within our community ambulatory oncology infusion center are women of childbearing potential (WOCP). Pregnancy testing of these women within our oncology infusion center was sporadic at best. There currently are no standardized guidelines related to pregnancy testing of these women. Methods: A retrospective chart analysis of WOCP receiving chemotherapy was done to determine baseline pregnancy screening rates. Subsequently a protocol was developed in which WOCP was defined as women under 50 years of age, without a history of hysterectomy or tubal ligation. The nurse-driven protocol allowed the infusion nursing staff to order a pregnancy screen to be done within the infusion center if testing had not already taken place within 48 hours of initiation of treatment. Following protocol implementation a retrospective chart analysis was performed to re-examine screening rates. Results: Utilizing patients with an active treatment plan within a one month time period, retrospective analysis of pregnancy screening prior to initiation of chemotherapy was performed. Baseline pregnancy screening rate was 21%. Point of care pregnancy equipment was obtained and nursing staff was educated on the protocol to include a medical delegation. Post-implementation chart analysis of WOCP initiating chemotherapy within a six-week timeframe resulted in improved pregnancy screening to 57% compliance. Continued education and clarification of the protocol was provided to the nurses in an effort to further improve compliance. Conclusions: Lack of standard guidelines regarding pregnancy screening of WOCP led to the development and implementation of a protocol for pregnancy screening for this at-risk population. Medical delegation allowed nursing to initiate the screening for these patients allowing for improvements in the safety and quality of patient care provided.
Using deep learning with registry linked claims data to predict hospitalization during chemotherapy: Feasibility study.
Authors: Panattoni Laura Elizabeth , Li Li , Fedorenko Catherine R. , Silgard Emily , White Scott , Rhine Adam , Kreizenbeck Karma L. , Egan Kathryn , Ittes Annika , Ramsey Scott David 
Published: October 2019

270 Background: Approximately half of cancer patients undergoing outpatient chemotherapy experience unplanned Emergency Department (ED) visits and Inpatient (IP) stays. Current machine learning algorithms that identify high-risk patients are based on pre-treatment variables which can not detect changes in risk over time. Deep learning recurrent neural networks can model complex longitudinal patient histories. This study tests the feasibility of using an interpretable recurrent neural network to predict a patient’s daily likelihood of ED and unplanned IP stays in the six months following chemotherapy initiation. Methods: Medicare and commercial claims data were linked with cancer registry records for patients in Washington State from 2011 to 2017. The study included patients diagnosed with any primary tumor site, excluding leukemia, and treated with chemotherapy. We used the Reverse Time Attention model (RETAIN) with a 1:10 case-control match and included registry elements; diagnoses, procedures, medication, and utilization pre-and post-chemotherapy initiation. Patients were randomly divided into internal training, validation, and test sets (75%, 10%, 15%). Model accuracy was measured by the areas under the receiver operating curve (ROC) and precision-recall curve (PRC), and the Youden sensitivity and specificity. Results: Of the 15,400 eligible patients; 4,037 (26.2%) visited the ED a median of 1 time (6,080 total visits); 5,116 (33.2%) had a median of 1 IP stay (7,839 total stays). Both models had good predictive accuracy: The top 20 predictors for ED visits included 5 chemotherapy regimes, 12 procedures, and 2 tumor characteristics; IP stays included all chemotherapy regimes. Conclusions: The promising performance of RETAIN supports the possibility of building a tool capable of estimating daily hospitalization risk. However, future research, particularly with alternative data sources, may be required to predict hospitalization in a real time clinical setting. [Table: see text]
Concurrent opioid and benzodiazepine use after breast cancer diagnosis.
Authors: Check Devon , Winn Aaron N. , Fergestrom Nicole , Neuner Joan Marie , Roberts Andrew 
Published: October 2019

28 Background: Benzodiazepines contribute to one-third of opioid overdose deaths in the U.S. Guidelines caution against co-prescribing these two drug classes. Although patients with cancer commonly experience pain and anxiety, no studies have assessed trends in concurrent opioid/benzodiazepine use after cancer diagnosis. Our study examined trends in, and predictors of concurrent opioid/benzodiazepine use in older women diagnosed with breast cancer. Methods: We conducted a retrospective cohort analysis using 2012-2016 SEER-Medicare data for women diagnosed with stage 0-III breast cancer who had no concurrent opioid/benzodiazepine use in the 3 months prior to diagnosis. Using modified Poisson regression, we estimated the adjusted probability of concurrent use (≥1 day of overlapping opioid/benzodiazepine supply) in the 12 months post-diagnosis for patients diagnosed in each calendar quarter from Q2:2013 to Q4:2015. We also estimated the overall relative risk (RR) of concurrent use associated with patient demographic and clinical characteristics. Results: Among the 19, 267 women in our cohort, the quarterly adjusted probabilities of concurrent use were stable over time, ranging from 12% to 15%. Risk of concurrent use decreased with age but increased with cancer stage. Prior opioid use and prior benzodiazepine use increased the risk of concurrent use in the 12 months post-diagnosis (RR prior vs. no prior opioids = 2.57, 95% CI = 2.27-2.92; RR prior vs. no prior benzodiazepines = 15.05, 95% CI = 13.19-17.19). Women who underwent mastectomy (vs. no or minimal surgery) were 71% more likely to have concurrent use (RR = 1.71, 95% CI = 1.40-2.10). Similarly, women who received chemotherapy (vs. no chemotherapy) were 28% more likely to have concurrent use (RR = 1.28, 95% CI = 1.07-1.54). Finally, Black women (vs. White women) were 38% less likely to have concurrent use (RR = 0.62, 95% CI = 0.50-0.76). Conclusions: Up to 1 in 8 older women diagnosed with breast cancer exhibited concurrent opioid/benzodiazepine use in the 12 months after diagnosis. Clinicians must be mindful of exposing patients to this high-risk combination during cancer and survivorship care, particularly among patients with more intensive cancer treatment or prior use of either drug.
Effect of high patient out-of-pocket (OOP) cost for oral tyrosine kinase inhibitors (TKIs) on survival in EGFR and ALK positive stage IV non-small cell lung cancer (NSCLC).
Authors: Goulart Bernardo H. L. , Unger Joseph M. , Chennupati Shasank , Egan Kathryn , Fedorenko Catherine R. , Ramsey Scott David 
Published: October 2019

3 Background: Patients with EGFR+ or ALK+ NSCLC benefit from oral TKIs, but high patient OOP TKI costs could negatively impact survival by reducing likelihood of continuing TKI therapy. We assessed the association of high OOP TKI costs with overall survival (OS), medication possession ratio (MPR) and duration of TKI therapy (DOT) in patients with metastatic EGFR+ and ALK+ NSCLC. Methods: We identified patients with EGFR+ and ALK+ NSCLC diagnosed between 01/01/2010 and 12/31/2016 in the Washington State SEER registry using natural language processing, followed by manual confirmation of molecular tests. We linked registry records to commercial and Medicare (including part D) claims. Eligible patients had stage IV NSCLC, sensitizing EGFR mutations or ALK+ by FISH, ≥1 pharmacy claims for EGFR or ALK TKIs, ≥3 months survival from TKI start, and ≥12 months of insurance enrollment post diagnosis. We estimated OOP TKI costs by subtracting the amount paid from the amount allowed in pharmacy claims. We categorized patients by quartiles of monthly OOP costs calculated for the first 3 months of TKI therapy (Q1 < Q2 < Q3 < Q4). We used landmark survival analysis with multivariate Cox regression to test the association of monthly OOP costs in the first 3 months of TKIs and OS starting at 3 months of TKI therapy between Q1-Q3 vs Q4. We used t-tests to compare MPR and DOT for the 1st TKI between Q1-3 and Q4. Results: For 106 eligible patients (median age 69; 67% female; 73% White; 35% Medicare, 85% EGFR+), the median monthly OOP TKI costs at 3 months were $0 (Q1); $1,432 (Q2); $1,798 (Q3); $2,888 (Q4). Mean MPR was 1.20 vs. 1.06 (P = 0.02), and median DOT was 8 vs. 4 months (P < 0.01) for Q1-3 vs. Q4. Median OS was 22 vs. 9 months for Q1-3 vs 4. Compared with Q1-3, Q4 patients had a hazard ratio for death of 1.76 (95% CI = 1.05; 2.94; P = 0.03), adjusted for age, sex, insurance, mutation, income, chemotherapy use, and time to TKI start. There were no statistically significant associations comparing Q1 to Q2-4, or Q1-2 to Q3-4. Conclusions: Higher patient OOP TKI costs are associated with lower number of TKI prescriptions, shorter duration of TKI therapy and inferior survival in advanced EGFR+ and ALK+ NSCLC.
Development of a time to treatment metric across an NCI designated academic health system.
Authors: Najarian Maya L , Shaw Pooja , Severino Kimberly M , Hamrick James , Adelson Kerin B. 
Published: October 2019

307 Background: Time to treatment (TTT) is an important quality metric as shorter times improve patient satisfaction and retention, overall survival, as well as reduce distress. Multiple factors can lengthen TTT including provider availability, biopsy, pathology review, assembly of medical records, multidisciplinary care coordination, staging studies, and patient preference. No national benchmarks exist for TTT, however one large health system noted baseline TTT (indexed on diagnosis date) of 29d for internally diagnosed and 41d for externally diagnosed patients ( Khorana & Bolwell, NEJM Catalyst, 2019 ). Limited guidance exists on how best to measure TTT for cancer patients across an institution. Methods: We developed a consistent TTT metric across Yale’s Smilow Cancer Hospital, comprised of an academic hub and community practices, using data obtained from Flatiron Health’s EHR-derived de-identified database, with disease team assigned for each provider. Qualifying patients had a new patient visit between Jan - Dec 2018, and scheduled treatments from Jan 2018 - Mar 2019. We defined TTT as calendar days from the first qualifying visit to the sooner of either an IV antineoplastic administration or interventional surgery. Results: The population sample included 1,090 patients seen by five disease teams. 558 (51%) patients had a qualifying intervention. The overall median TTT was 26d (IQR14 - 44). The median TTT for IV antineoplastic administration was 24d (IQR 14 - 43). The median TTT for interventional surgery was 27d (IQR 15 - 45). The median TTT by disease team: Breast 24d (IQR 14 - 38), GI 24d (IQR13 - 36), Head & Neck 27d (IQR 15 - 40), Hematology 35d (IQR 11 - 76), and Thoracic 28d (IQR 16 - 51). Conclusions: Evaluating TTT across an institution can help identify opportunities for practice improvements. We hypothesize that recurring delivery of this metric will enable assessment and benchmarking of quality improvement interventions. Future work will focus on improving this measure by incorporating additional cancer treatments (e.g. radiation therapy), and development of interventions to shorten TTT at our center.
Artificial Intelligence (AI) and machine learning (ML) in risk prediction of hospital acquired pressure injuries (HAPIs) among oncology inpatients.
Authors: Ravi Vinod , Zheng Jing , Subramaniam Aparna , Thomas Lavonia G , Showalter John , Frownfelter John , Miller Kelly 
Published: October 2019

309 Background: Utilizing AI and ML is an emerging method to improve risk identification, characterization and stratification for clinical outcomes such as HAPIs. The Jvion Cognitive Clinical Success Machine (CCSM) utilizes the Eigen Sphere technique to factor in clinical, socioeconomic, and behavioral covariates at the individual patient level to maximize accuracy of risk prediction and provide insights on prevention of HAPIs. Methods: A retrospective analysis was performed utilizing claims and EHR data on 63,476 inpatient admissions between June 2016 and June 2018 at M D Anderson Cancer Center, a 660-bed oncology facility (Table 1) . All risk assessment indicators in the data were removed prior to analysis by the CCSM to compute unbiased risk probabilities for HAPIs. The performance of the CCSM risk prediction for all new stage 2 and above HAPIs (>=Stage 2 HAPIs) was compared with the Braden scale using AUC. Results: The Jvion CCSM had an AUC of 0.84 compared to the AUC of 0.72 for the Braden scale in the prediction of >=Stage 2 HAPIs. Conclusions: The AUC indicates that the Jvion CCSM has better predictive accuracy than the Braden scale. It also has better discrimination in risk identification. Thus, Jvion CCSM can be a valuable tool in risk screening for HAPIs which can lead to early preventative interventions. Characteristics of admission records used to compare accuracy of Jvion CCSM and Braden scale in predicting new >=Stage 2 HAPIs (N=58,228). [Table: see text]
Methods of implementation for an electronic ongoing professional practice evaluation system.
Authors: Park Woo Yeon , Patel Dhruvkumar , Samedy Patrick , Li Alicia 
Published: October 2019

313 Background: Hospitals accredited by the Joint Commission are required to provide Ongoing Professional Practice Evaluation (OPPE) for all privileged providers. Historically, OPPE reports had been created and completed by a peer review process on a paper-based system, where the data was managed in spreadsheets. The Division of Quality and Safety (DQS) developed an electronic system of collecting clinical and administrative data, with the goal of assessing quality of care in an impartial, modernized, and efficient process. Methods: Electronic implementation of the OPPE process can be divided into three main parts: metric development using electronic medical records (EMR), report automation, and application development for review. We designed queries to extract EMR data to validate the quality measures developed in collaboration with clinical leadership. Data pulls are then automated to populate outcomes to a table, from which the OPPE reports are populated according to selected parameters such as provider’s unique ID and OPPE period. Reports are then accessed by supervisors and providers directly through a web application developed by DQS. After verifying the data, clinicians can sign off in the application to complete the OPPE review process. Results: We have distributed 8,630 electronic OPPE report since 2012, and 1,486 distinct physicians had received reports. We evaluated engagement of the process by looking at engagement rate (number of OPPE signed reports divided by the total number of OPPE reports). The engagement rate varies by department, but the median of engagement rates of the OPPE process is 100%. Conclusions: Moving from paper chart reviews to an electronic process enables the institution to scale, lower the burden on employees, and improve the convenience of OPPE for busy providers. It also provides opportunities to evaluate quality of care on the provider level by analyzing outliers using the OPPE measure outcomes and finding the correlation of engagement rate and the quality outcomes.