bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prediction of acute care service utilization for patients with hematologic malignancies.
Authors: Zu Kai , Greenwood Kristina , Lamori Joyce , Smith Besa , Smith Tyler C , Lee Alaina 
Published: October 2019

312 Background: Improving the ability to predict which patients are at increased risk for acute care services subsequent to hospitalization can lead to more effective interventions and quality care. This study evaluated the performance of risk models to predict 30-day acute service utilization among adult inpatients with newly diagnosed hematologic malignancies. The study explored the impact of medical complications on potentially preventable service utilization, aligned with specifications for proposed measure OP-35 from the CMS Hospital Outpatient Quality Reporting Program. Methods: The study included 933 unique adult patients admitted to four acute care inpatient facilities within a non-profit community based healthcare system during calendar years 2012 to 2017. Risk models integrated a comprehensive set of data elements using clinical information from electronic medical records and facility oncology registries. Predictive models were constructed using a multivariable logistic regression, with calculation of standardized coefficients to rank order variables with the greatest impact on unplanned readmissions. Exploratory data mining techniques were conducted to augment classification of at-risk patients. Results: The mean age of study participants was 65 years and 55.1% were male. In order of prevalence, the types of hematologic malignancy were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days after the index hospitalization (lymphoma = 23.1%, myeloma = 22.1%, leukemia = 18.6%). Among the risk models, the most influential predictors included initial length of stay, severity of illness, and consult for social work. Overall, 56.6% of patients who were readmitted within 30 days of hospitalization presented with one or more symptoms associated with the CMS medical complication measure, including cytopenia, infection, negative hydration, and/or pain. Conclusions: Optimizing quality care in a value-based health care environment requires proactive approaches such as risk prediction models for identifying patients who can benefit most from care transition interventions.
Five-year longitudinal mammographic follow-up after breast cancer.
Authors: Bruce Laura , Kerns Jessica , Carter W. Bradford , Frazier Thomas G. 
Published: October 2019

37 Background: Breast Cancer recurrences following radiation are seen in the first three to five years after treatment. As part of our Survivorship Program, annual screening mammography is a guideline following treatment with the exception of those patients who undergo bilateral mastectomy. To evaluate compliance with this guideline, we followed patients treated in 2012 for breast cancer at our institution, over the five-year period through 2017. Methods: A retrospective chart review of patients diagnosed with breast cancer in 2012 was conducted and annual mammography was assessed for compliance for a period of five-years. Compliance was defined as having annual mammography screening for five years, until recurrence or until death. Results: 252 patients were treated for Breast Cancer in 2012. Of these, 15 patients had follow-up elsewhere. 4 patients had metastatic disease at the time of diagnosis and were not included. 3 patients with male breast cancer had no mammographic follow-up. 5 patients had bilateral mastectomies and were excluded leaving 225 patients followed for compliance. Of the 225 evaluable patients, 134 (59.5%) were compliant with mammography. 126 (56.0%) had a full five years of follow-up and had no recurrent breast cancer. 158 (70.2%) had four years of follow-up. 168 patients (74.7%) had three years of follow-up. 178 (79.1%) had two years of follow-up. 190 (84.4%) had at least one year of follow-up. 14 (6.2%) died before the five year follow-up of causes not related to breast cancer. 7 (3.1%) developed metastatic disease during follow-up and no additional mammography was carried out. 7 had ipsilateral recurrence, 3 had contralateral recurrence (4.4%). Conclusions: In an upper-middle class population that is well insured and should be compliant, only 59.5% of eligible patients were compliant with mammography for five-years, until recurrence or death. Since almost 5% of patients in this cohort recurred in the breast, follow-up with annual mammography is critical. The Survivorship Care Plan (SCP) discussion with the patient is a strategy to address compliance with annual follow-up. Future studies are planned to re-evaluate compliance with annual mammography.
Integration of palliative care into the inpatient oncology service.
Authors: Waldstein Sasha , Smith Benjamin , Nunnink J. Chris 
Published: October 2019

46 Background: Research has demonstrated that early palliative care involvement for patients with advanced cancer has multiple benefits, including improved symptom control/quality of life and reduced readmission rates. Based on this data, the American Society of Clinical Oncology (ASCO) has developed guidelines for early palliative care consultation. At the University of Vermont Medical Center, historically 40% of such patients were evaluated by palliative care during hospital admission. The purpose of this study was to better integrate palliative care into the oncology inpatient setting through the use of a standardized admission template. Methods: A specific oncology H&P template, with inclusion of a drop down menu of ASCO based criteria for palliative care consultation, was created. Providers were educated on template use, and data then were collected for oncology admissions from 2/1-8/31/2018 regarding template usage, if criteria was met for palliative care consultation, and whether consultation occurred. Additionally, 30 day post discharge ED visits and readmissions were recorded, extending data collection for this purpose to 9/30/2018. Results: There were 372 medical oncology admissions during the studied time period, with 284 individual patients. The template was used for 95 (26%) admissions. 267 of those patients admitted qualified for palliative care consultation and, of those in which the template was used, 72% had palliative care consulted versus 50% without the template (p= 0.0013). There was no statistically significant difference in readmission rates between those with palliative care consultation and without. Conclusions: Early palliative care consultation for patients with advanced malignancy has been shown to have multiple benefits on an individual and system-wide basis. It was shown in this study that, though the created template was used for a minority of admissions, with template use a significantly greater proportion of appropriate patients had palliative care consulted. This suggests that, with more widespread practice, this strategy could further promote inpatient palliative care involvement for appropriate oncology patients.
Pragmatic randomized trial of a distress screening program using an effectiveness-implementation hybrid design.
Authors: Hahn Erin Elizabeth , Munoz-Plaza Corrine E. , Pounds Dana , Lyons Lindsay Joe , Lee Janet S. , Shen Ernest , La Cava Shannon , Brasfield Farah , Durna Lara N. , Kwan Karen W. , Beard David B. , Ferreira Alexander , Schottinger Joanne E. , Mittman Brian S. , Gould Michael K. 
Published: October 2019

5 Background: Implementation of guideline-recommended distress screening in oncology remains challenging. Evidence suggests that multicomponent care pathways to identify distress severity with algorithm-based referral and management are effective, yet testing of pragmatic implementation in community settings remains limited. We conducted a pragmatic randomized trial of a distress screening program in a large healthcare system to evaluate effectiveness and simultaneously examined implementation outcomes. Methods: We designed a highly pragmatic study per the Pragmatic-Explanatory Continuum Indicator Summary-2 with adaptive workflow design. Randomization was at the medical center level (N=6); eligible patients had a new diagnosis of breast cancer (no exclusions). Eligible patients were offered the distress screening program as part of usual care: PHQ-9 screening, algorithm-based scoring and referral, referral tracking, and audit and feedback of performance data. Control sites had access to the PHQ-9 and scoring algorithm. We compared number screened, distress severity, and referral. We conducted qualitative interviews with stakeholders on implementation barriers and facilitators. Results: We enrolled 1,436 eligible patients; 692 control, 744 intervention. Groups were similar in demographic and tumor characteristics (Table); 80% of patients completed screening at intervention sites vs <1% at control sites. Of those screened at intervention sites, 10% scored in the medium/high range indicating need for referral; 94% received an appropriate referral. We conducted 20 interviews; the program was found to be highly feasible and acceptable. Conclusions: Our pragmatic, adaptive approach resulted in the large majority of patients screened and appropriately referred with a high degree of acceptability and feasibility. Our results can promote more widespread, sustained adoption of effective distress screening programs. Clinical trial information: NCT02941614. [Table: see text]
A trainee-led quality improvement project to improve rates of palliative care utilization in patients with advanced cancer.
Authors: Sedhom Ramy , Gupta Arjun , Shah Mirat , Marrone Kristen , Browner Ilene S. , Smith Thomas J. 
Published: October 2019

51 Background: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. 1st year oncology fellows at our institution identified low rates of palliative care in their longitudinal clinic as an avenue for improvement. Methods: A Fellow-led multidisciplinary team aimed to increase palliative care utilization for patients with advanced cancer followed in first-year fellows’ clinic from baseline 11.5% (5/43 patients, Jul-Dec, '18) to 30% over a 4-mo period. Utilization was defined as evaluation in the outpatient palliative care clinic hosted in the cancer center. The team identified several barriers to referral: orders difficult to find in EMR, multiple consulting mechanisms (EMR, by phone, in person), EMR request not activating formal consult, no centralized scheduler to contact/confirm appointment, and poor awareness of team structure. PDSA cycles were implemented based on identified opportunities. Data were obtained from the EMR. Results: The PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and dissemination of process changes. The PDSA was implemented Jan-Apr '19. Rates of palliative care use increased from 11.5% pre-intervention to 43% (27/62 patients) post-intervention. In addition, median time to evaluation in palliative care clinic after placing a consult improved from 23 days (range, 10-60 days) to 12 days (range, 6-19 days). Conclusions: A multidisciplinary approach and classic QI methodology improved palliative care use for patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional support of efforts. Straightforward EMR interventions and ancillary staff use are effective in addressing under referrals.
Exploratory analysis of the cost of episodes of care in metastatic renal cell carcinoma in the United States.
Authors: Kangethe Anne , Polson Michael , Speicher Lindsay C. , Zheng Ying , Bhanegaonkar Abhijeet , Krulewicz Stan , Kim Ruth 
Published: October 2019

55 Background: Treatment decisions in oncology care have financial implications. A shift in reimbursement from traditional fee-for-service models toward episode-based care sets the framework for assessing the value of therapies. The objective of this study was to determine episode-based total cost (medical and pharmacy) and resource utilization by therapy for patients with metastatic renal cell carcinoma (mRCC) using the Oncology Care Model methodology. Methods: Retrospective analysis of commercial claims data incurred between Jan 1, 2013 and Jun 30, 2018. Patients included had ≥1 claim with a diagnosis code of renal cell carcinoma (RCC), ≥2 claims for metastasis on or after initial RCC diagnosis date, evidence of any mRCC systemic therapy on or after initial mRCC diagnosis date, and continuous enrollment from ≥6 months before until ≥6 months after the index date and were ≥18 years old on the index date. Patients were classified by 1 of 6 therapy classes: tyrosine kinase inhibitors (TKIs) monotherapy, mechanistic target of rapamycin (mTOR) monotherapy, immuno-oncology (IO) monotherapy, other (e.g., interferon) monotherapy, changed therapy class (e.g., from TKI to mTOR), or traditional chemotherapy. Results: 606 commercially insured patients with mRCC met the inclusion criteria. Most received monotherapy, and 53% had ≥2 episodes. Specifically, 59% of TKI, 17% of mTOR, 28% of IO, 59% of other, 85% of changed therapy class, and 38% of chemotherapy patients had ≥2 episodes. IO patients had the longest average inpatient length of stay per episode (7 days; p = 0.0002). There were differences in total episode costs among each selected therapeutic class: TKI (n = 161; $61,417), mTOR (n = 30; $67,637), IO (n = 75; $92,082), other (n = 34; $98,877), changed therapy (n = 130; $84,480), and chemotherapy (n = 34; $55,743) (p < 0.0001). Conclusions: Differences in total episode costs exist in each monotherapy class used to treat mRCC, even in an episode-based structure. As healthcare financing shifts to alternative payment models, it is important to investigate overall episode cost of care for various therapies, as the cost for the individual drug may not accurately reflect the total episode value.
Why do payers refuse to fund "effective" therapies?
Authors: Conter Henry Jacob , Cheema Parneet Kaur 
Published: October 2019

6 Background: The pan-Canadian Oncology Drug Review (pCODR) provides funding recommendations to the provinces of Canada on Health Canada approved systemic therapies. Why would they recommend against funding drugs that meet regulatory standards? Methods: 136 reviews for 70 compounds were completed by pCODR from inception to January 1, 2019 were collected and data abstracted using a standardized form. For all submissions that received a negative recommendation, the Clinical Guidance Panel (CGP), Economic Guidance Panel (EGP), and Expert Review Committee (pERC) reports were examined to determine the underlying cause for rejection. Results: 32 (24%) of submissions received a negative recommendation. In all cases, this was due to concerns regarding the clinical effectiveness of the compound. Economic considerations were never cited as rational for rejection. 10 (32%) were submitted with supporting evidence from non-comparative phase 2 clinical data, and this level of evidence was cited as the basis for the recommendation. 4 (12%) supported by randomized phase 2 evidence were rejected in support of awaiting phase 3 trials in progress. 6 phase 2-based recommendations have since been overturned on re-submission with phase 3 data. Of the 18 (56%) rejected with phase 3 data, 4 had demonstrated an overall survival advantage over standard of care (range 1.5-3.8 months) that was deemed not clinically significant. 12 were rejected due to lack of confidence in surrogate end-points employed in the trial. 1 was rejected due to diminishing clinical benefit observed over time, and 1 was rejected due to data quality. The EGP calculated the median cost-effectiveness of the proposed indications to be $188,537/QALY (range 22,326-2,120,433), with a median cost increase of $47,529 (2,536-226,752) and life-years gained of 3.8 months (0.8-11). Conclusions: Regulatory approval does not translate to clinically meaningful effectiveness. Bodies that consider opportunity cost may have a higher threshold for minimum benefit than regulators.
Establishing a prostate cancer referral pathway between urology and medical oncology at Lyndon B. Johnson Hospital.
Authors: Wiele Andrew , Ajufo Helen , Gulvin Joshua Michael , Laccetti Andrew L. , Brown Sarah , Stapleton Leslie , Rizvi Sarah , Park Anne , Ma Hilary Y. , Rieber Alyssa G. 
Published: October 2019

60 Background: Treatment for biochemically recurrent (bcr) and metastatic prostate cancer (pc) is evolving, making multidisciplinary evaluation a critical need. Our center, a community public hospital, lacked clear referral criteria between the Urology (Uro) and Medical Oncology (Onc) clinics, resulting in inconsistent care. We aimed to improve multidisciplinary communication and the rate of patient (pt) referrals by establishing standardized referral criteria for pc pts between Uro and Onc. Methods: Referral criteria were based on the presence or concern for primary refractory, bcr, castrate resistant (cr), or metastatic pc, as established by the PCWG3 and RTOG-ASTRO Phoenix consensuses. Primary refractory pc was defined as a failure of the PSA to fall to undetectable levels after radical prostatectomy (rp). Bcr pc was defined as two consecutive PSA values ≥ 0.2ng/mL after rp, or a rise in PSA 2ng/mL above post-treatment nadir after radiation therapy. Cr pc was defined as radiographic (progressive measurable disease) or chemical (two rising PSA levels 6-12 weeks apart) progression despite castrate levels of testosterone (T), defined as a serum T < 50ng/dL. Metastatic pc was defined as the development of bone lesion(s), organ involvement, or lymphadenopathy above the bifurcation of common iliac vessels. The referral criteria were organized into a chart and visibly displayed, discussed during multidisciplinary meetings, and distributed during educational sessions with Uro Residents and Onc Fellows in January 2019. Referral rate was collected from July 2018 through December 2018, and collection of post-intervention referral rate is planned from January 2019 through June 2019. Results: Pre-intervention, 39% (23/59 pts) of the pts that met referral criteria were referred to Onc. Preliminary data from January through April 2019 demonstrated a referral rate of 60% (9/15 pts). Conclusions: In 4 months, our intervention improved the referral rate by 21%. These criteria continue to be reinforced during multidisciplinary meetings and more educational sessions are planned as new personnel establish in the clinics. Ultimately, more time and pts are required to determine the full impact of this project.
Medical record documentation of cancer patients after an integrated engagement plan.
Authors: Bariani Giovanni M. , Macedo Caroline , Da Silva Mariana , Yamashita Karine , Ruiz Amanda , Pedroso Aline , Ledo Carla Bernardes , Oliveira Fabrícia de Santi Silva de , Vieira Silvia de Lima , Luciani Camila , Katz Artur 
Published: October 2019

68 Background: Complete and accurate medical record (MR) documentation is essential to quality of cancer patient care, whose complex health and social needs should be addressed during medical consultation. We aimed to evaluate the MR compliance before and after an engagement plan (EP) and an education meeting (EM) for oncologists. Methods: An integrated EP was designed to improve medical notes in a Brazilian cancer center. Firstly, a pool of 160 selected MR of patients with prevalent neoplasms was reviewed to identify frequently missed components. Based on this result, a set of MR documentation standards was developed and presented in an EM for oncologists. To verify its effect, a cross-sectional analysis was performed using 25 standard elements collected from randomized MR before and after the EM such as pathology report, cancer stage, medical history, treatment plan, patient comprehension, and initial psychological assessment. It was given particular emphasis to psychological assessment during the EM as a low documentation of it was identified after the first MR review. The variation of the proportions pre- and post-EM was assessed using the chi-square test. Results: A total of 850 elements were collected from 34 patients’ MR two months pre-EM and 950 elements of 38 patients’ MR two weeks after. Of these patients, pre-EM 18 were under intravenous (IV) therapy and 16 under oral antineoplastic therapy and, post-EM, 14 and 24 patients were under IV and oral therapy, respectively. Pre-EM, MR compliance of patients under oral therapy was 68% and for patients under IV therapy 78% (P = 0.0013). Post-EM, the difference between MR compliance of patients under oral and IV therapy was 6% (82% vs. 88%, P = 0.0167). Overall MR compliance pre-EM was 73% and post-EM 84% (P < 0.0001). Psychological assessment pre- and post-EM were 9% and 50% (P = 0.0002), respectively. Conclusions: Patients under IV therapy have a more accurate MR documentation than patients under oral therapy. Overall compliance of MR documentation was significantly improved after an EM, a part of an integrated EP. Psychological assessment documentation has not only improved, but it is expected that more attention has been given to this valuation by oncologists.
Reducing emergency department utilization by improving patient access to their oncology care team.
Authors: Philip Tony , Gleason Karen , Nekola Claire , Tucker Todd , Paul Valadez Jenny , Prasad-Goyal Shreya , Meisels Samantha , Bowman Ronda Marie , Kaufman Laura 
Published: October 2019

77 Background: At Monter Cancer Center, we observed that when patients on active intravenous chemotherapy presented to our local ED about 70% arrived during the hours of 8am and 6pm. ED utilization by active chemotherapy patients results in cancer care by providers not familiar with their disease or treatment, increased costs, poor patient experience and potential treatment delays. Our goal was to create 20% reduction in daytime ED utilization, compared to Q4 2018, by patients that received intravenous chemotherapy within 30 days of their ED visit. Methods: Through the ASCO Quality Training program, a multidisciplinary team of frontline staff was formed to create a Process map, Cause and effect diagram and Priority Matrix to develop solutions. Our first PDSA created a simplified criteria to help office secretaries triage urgent and non-urgent calls to providers. This allowed patients with urgent issues to speak to their care team on first call rather than await a callback. In our second PDSA, our treatment room nurses emphasized to patients on their treatment discharge to contact their care team first for symptom management rather than going to the ED. Results: Compared to our baseline, we have seen a 33% decrease in ED utilization by re-educating patients to call us first for symptoms and providing a clear tool to help secretaries triage calls to the care team. Conclusions: Our study shows improving patient access to their oncology care teams can decrease ED utilization, increase cancer center utilization while improving patient safety across multiple disease types.