bluuebunny/crossref_metadata_2025_split huggingface dataset:
Building a population management informatics infrastructure for oncology care.
Authors: Lafata Jennifer Elston , Harris Stephen , Fasold Megan , Holdren Audrey , Sanoff Hanna Kelly 
Published: October 2019

315 Background: While most primary care practices have informatics infrastructures to support population management, such infrastructures are not commonplace in oncology. Yet, value-based care requires that oncology practices be able to identify patients in real time, use risk stratification to target care efficiently, and monitor care quality to identify improvement opportunities. We describe an oncology informatics infrastructure development initiative in a large academic medical center. Methods: We convened a quality improvement team of administrators, analysts, clinicians, health services researchers and performance improvement staff. The team was sponsored by a senior leadership committee convened for a strategic planning initiative. We used PDSA cycles to develop and test ways to leverage data from an electronic health record (EHR) and billing system for oncology patient identification, risk stratification, and routine quality monitoring. We used clinician engagement, medical record review, and tumor registry comparisons to validate query strategies. Results: After considering different query strategies, we opted to identify patients via a new cancer treatment episode (as defined by a cancer diagnosis combined with evidence of pharmaceutical, radiation, and/or surgical treatment for cancer with no evidence of such treatment in the prior six months). This was done using diagnostic and procedural codes for chemo/immunotherapy and radiation treatment, and pathology reports and procedural codes for surgery. Using this approach, we identified over 7800 cancer treatment episodes within the health system in 2018. These episodes corresponded to 4178 chemo/immunotherapy, 1437 radiation, and 3440 surgical treatments. Quality monitoring has identified opportunities to enhance data capture, harmonize documentation processes across practitioners and practices, and initiate quality improvement efforts. Conclusions: Using data from the EHR and billing systems we are able to identify oncology patients as they initiate a cancer treatment episode. In so doing, we are able to track the quality of care delivered to oncology patients as they move across the care continuum from treatment to survivorship.
The impact of an electronic medical record alert on code status documentation for hospitalized patients with advanced cancer.
Authors: Switzer Benjamin , Jazieh Khalid , Bernstein Eden , Khan Mohammad , Harris David 
Published: October 2019

319 Background: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Advanced care planning (ACP) in this population has exhibited improvements in quality, patient satisfaction, hospice utilization, rates of harm, and healthcare costs. We have sought to observe the changes in ACP documentation by Internal Medicine residents within a tertiary hospital’s inpatient oncology service following a mandatory caregiver training module and enterprise-wide modification in Epic, as well as identify self-reported barriers in code status documentation. Methods: Patients admitted to the Cleveland Clinic’s oncology service were retrospectively reviewed for 8 weeks before and after the implementation of an ACP caregiver training module and code-status best-practice-alert (BPA) into Epic. ACP documentation was assessed in admission notes and direct orders into Epic. In addition, Internal Medicine residents were surveyed on behaviors and perceived barriers contributing to code status documentation. Results: A total of 551 patients (181 pre and 370 post-BPA) were reviewed, exhibiting a 17.2% (44.2 to 61.4) increase of code status documentation in resident admission notes and a 17.6% (10.5 to 28.1) increase in code status orders by residents into patient Epic charts by the time of discharge. Observed 30, 60, and 90-day mortality rates from the day of admission were 18.2, 24.9, and 32%, respectively. The most common self-reported barrier to resident ACP documentation was “forgetting to discuss during the admission process”, and 58% of first-year residents admitted to feeling “uncomfortable” in orchestrating goals-of-care conversations. Conclusions: Resident ACP documentation continues to be suboptimal in the high-risk cohort of hospitalized advanced cancer patients. However, documentation rates appear to be positively influenced by large-scale and multimodal approaches. Further efforts to improve the current practice and culture of advanced directives and code status for the inpatient oncology patient population remains a crucial aspect in the quality and safety of our approach to patient care.
Enhancing the electronic health record to promote and measure adherence to breast cancer clinical pathways.
Authors: Geisel Lauren E. , Johnson Helen M. , Weil Andrew , Muzaffar Mahvish , Vohra Nasreen A. , DeAntonio Phyllis , Mulligan Katherine H. , Morey Chantel L. , Wong Jan H. 
Published: October 2019

322 Background: Clinical pathways are widely accepted tools for improving the quality of cancer care. We developed and implemented, within the electronic health record (EHR), a standardized multidisciplinary breast cancer conference template comprised of NCCN clinical pathway elements, with triggers to promote adherence and measure compliance. Methods: The records of breast cancer patients diagnosed from January 2016 to December 2017 were reviewed. Baseline data on (1) the documentation of clinical stage prior to prospective presentation at multidisciplinary conference, (2) documentation of family history, and (3) functional breast imaging utilization were recorded. EHR enhancements developed throughout 2018 were implemented in January 2019. Post-implementation data were obtained via an EHR query of records from January 2019 to the present. Results: At baseline, 56.5% of new patients (n = 435) had a clinical stage documented appropriately (goal 100%). After the EHR enhancements went live, this rate increased to 76.9% (n = 78 new diagnoses), ranging from 40% for patients with metastatic disease to 85.7% for non-metastatic. Compared with baseline data, EHR-derived data from 149 multidisciplinary conference notes demonstrated relatively stable rates of compliance with the family history and imaging metrics: 94.3% to 93.9% (goal 100%), and 12.8% to 13.4% (goal ≤20%), respectively. In 2019, there were 128 instances of an EHR trigger prompting physicians to review the multidisciplinary conference recommendations. While 89.1% of users responded that they reviewed the note, only 42.1% of these clicked on the link to view it. Conclusions: The EHR is a powerful tool for incorporating clinical pathways into oncology providers’ daily workflow. Quality improvement data can be extracted rapidly and efficiently, which facilitates continuous QI. We observed a notable improvement in documentation of clinical staging prior to multidisciplinary conference after the implementation of the clinical pathways in the EHR. Our first report identified several areas for improvement, which will be the focus of subsequent PDSA cycles.
Multi-institution quality improvement in supportive oncology: Results of the Coleman Supportive Oncology Collaborative (CSOC).
Authors: Trosman Julia Rachel , Roggenkamp Betty , Khosla Paramjeet , Lillis Teresa , Martin Joanna , Pasquinelli Mary , Knightly Eileen , Lo Shelly S. , Bowman Anne , Chow Selina Lai-ming , Patel Urjeet , Berardi Rosa , Diaz Aidnag , Kircher Sheetal Mehta , Weldon Christine B. 
Published: October 2019

33 Background: The Institute of Medicine and Commission on Cancer recommend systematic delivery of supportive oncology care for cancer patients. The CSOC is focused on quality improvement (QI) of supportive care across Chicago cancer centers (Weldon ASCO ’17). Supportive oncology includes distress, practical, family, physical, nutrition, pain, fatigue and care concerns. To support QI, cross-institution teams developed unique, relevant tools, methods, care delivery processes, patient handouts and online training. Methods: Ten centers (5 academic, 1 VA, 1 public, 2 safety net, 1 community) implemented supportive oncology screening and care delivery quality improvements. Centers collected data for relevant Quality Oncology Practice Initiative (QOPI) metrics. Analyses used simple frequencies and Fishers exact test. Results: Five of six QOPI measures were improved at statistically significant levels from 2014 to 2017, p < .00001. Improvements are more modest in 2016 & 2017 as 4 of the centers started this QI in 2017. Conclusions: The CSOC achieved significant improvements in supportive oncology screening and identifying and addressing patients’ needs and concerns. Additional work is needed to improve these measures to achieve the best quality of cancer care possible for every patient based on their needs and concerns. [Table: see text]
Contemporary analysis of bone mineral density in men initiating androgen deprivation therapy for prostate cancer.
Authors: Hu Jason , Aprikian Armen G. , Vanhuyse Marie , Dragomir Alice 
Published: October 2019

38 Background: Androgen deprivation therapy (ADT) is a cornerstone of advanced prostate cancer (PCa) treatment, however several side-effects are associated with its long-term use. Notably, loss of bone mineral density (BMD) is accelerated which increases fracture risk. Guidelines recommend BMD testing when initiating ADT to properly assess baseline fracture risk. The objective was to examine the proportion of BMD testing in men initiating long-term ADT in Quebec. Methods: The cohort consists of men extracted from Quebec public healthcare insurance administrative databases who were diagnosed with PCa from 2001-2012 and treated by ADT for at least one continuous year. The primary study outcome was the receipt of baseline BMD testing (defined as a BMD test identified in the period from 6 months prior to and up to 12 months after ADT initiation). Multivariable generalized linear mixed with a logit link was performed to identify variables associated with baseline BMD testing accounting for physician clustering. Results: We identified 7,069 patients, of which 887 (12.6%) underwent baseline BMD testing. Baseline BMD testing varied by year of ADT initiation, from 7.7% in 2001-2003 to 12.3% in 2013-2012. Following multivariable analyses, later years of ADT initiation (2004-2006, 2007-2009, 2010-2012, 2013-2015) remained associated with higher odds of baseline BMD testing compared to the earlier years (2001-2003) (ORs ranging from 1.43-1.88; p < 0.001). Conversely, age > 80 (OR 0.73; 95% CI 0.57-0.94; p = 0.001), greater Charlson comorbidity score (OR 0.51; 95%CI 0.34-0.75; p = 0.001), and rural residence (OR 0.60; 95%CI 0.48-0.75; p < 0.001) were associated with lower odds of baseline BMD testing. Conclusions: In our study population, rates of baseline BMD testing in men initiating ADT are low, although the rates increased over the course of the study period. Potential gaps identified in baseline BMD testing include older, more comorbid patients, and rural residence. Additional efforts emphasizing the importance of BMD testing in PCa guidelines may be needed.
Timely administration of antibiotics in febrile neutropenia per updated ASCO/IDSA guidelines.
Authors: Ghimire Krishna Bilas , Lin Po-Hung , Khan Irum , Cadman Kasandra , Valero LeeAnn , Golick Janet , Walker Maria , Knightly Eileen , Windhorst Jennifer , Owens Jovonne , Fleming Patrick Joseph , Cuellar Sandra , Crawford John , Feldman Lawrence Eric , Venepalli Neeta K. 
Published: October 2019

41 Background: Current ASCO guidelines for management of febrile neutropenia (FN) recommend initial antibiotic administration within one hour of triage, and initial assessment within 15 minutes of triage for patients presenting with FN within 6 weeks of chemotherapy. The University of Illinois Cancer Center (UICC) implemented an early identification and management strategy in the ambulatory setting for FN in 2017, with success in increasing the percentage of FN patients receiving antibiotics within 2 hours from 50% to 92% over a 6 months (05/2017-11/2017) period. Given updated joint ASCO/IDSA guidelines, we aimed to increase percentage of FN patients receiving antibiotics within 1 hour from 56% to more than 90% over 16 months. Methods: A multidisciplinary team involving oncology, hematology (attendings and fellows), pharmacy, and nursing met quarterly to review FN cases including time to antibiotic administration and documentation of prompt assessment. Two Plan-Do-Study-Act (PDSA) cycles were completed, including development and deployment of an electronic medical record automated order set and targeted education for fellows and nurses. Results: Between 12/17 and 04/19, of 7 patients with FN, 100% (N = 7) received antibiotics in clinic. The percentage of FN patients receiving antibiotics within 1 hour of triage post first and second interventions was as follows: 25% (N = 1), 100% (N = 4). 100% (N = 7) of FN patients had documentation of prompt assessment, but time from triage was not specified. Conclusions: We were successful in improving the percentage of FN patients receiving antibiotics from 56% to more than 90% over 16 months. We are targeting our next PDSA cycle to increase assessments within 15 minutes of triage. Additional future interventions include tailoring antibiotics based on FN with low or high risk of complication via focus group and root case analyses discussion with our attendings, fellows, and nurses, and collaborating with ED on a standard care pathway for FN management.
Co-management of elevated glucose in chemotherapy patients in the community: Working with primary care physicians.
Authors: Shander Ellen , Ronnen Ellen A. , Peng Eileen Ruey-Fun , Cruz Melissa Isabel , Balinski Beth , Ryan Sharon 
Published: October 2019

53 Background: Approximately 8-18% of oncology patients also have diabetes. A diabetes diagnosis increases the risk of recurrence by 21% and decreases both overall and cancer-related 5-year survival. Chemotherapy has also been associated with hyperglycemia in non-diabetic patients. At one office in a multi-site outpatient oncology practice in central New Jersey, 13% of 904 chemotherapy patients treated between August 1, 2018 and October 31, 2018 had blood glucose greater than 200 mg/dL. Community practice models post a challenge to coordinated multidisciplinary care. Methods: Between 12/1/18 and 4/1/19, weekly lab reports were run revealing all active chemotherapy patients with glucose levels greater than 200. The initial run in period was 12/1/18-1/31/19, and follow up for the group (while on chemotherapy) was from 2/1/19-4/1/19. Patients and their primary medical doctors (PMDs) were contacted within 2 weeks of lab draw, labs and recent chemotherapy history shared and all communication was documented. Patients with > one blood glucose above 200 were contacted monthly. Concurrent steroid use with chemotherapy and addition/adjustment of antihyperglycemics was also studied. Results: Of 324 patients who entered into the study between 12/1/18 and 1/3/19, 42 had baseline elevated glucose levels. 36 (85%) of the 42 were on concomitant corticosteroids. During the follow up period, 10 (23%) had elevated glucose levels over 200, 32 (76%) patients had levels under 200 consistently. 12 of the 32 (30%) of those patients had documented diabetic medication adjustments. Oncology/PCP communication was documented in 35 (83%) charts compared with 0% prior to the intervention, amongst our office and PMDs. Percentage of patients who saw their PCP during the intervention time will also be presented. Conclusions: Working more closely with PCPs and better electronic data sharing is needed in the community setting. Accurate medication lists and history sharing are critical to optimal multidisciplinary community care. Management of elevated glucose in oncology patients is challenging and multi factorial.
Successful implementation of a quality improvement intervention towards a QOPI-compliant breast cancer center in Mexico.
Authors: Peña-Curiel Omar , Villarreal-Garza Cynthia , Canavati-Marcos Mauricio , Velazquez-Ayala Karen M. , Castro-Carrasco Janeth , Garza-Ledezma María Alejandra , Zarzar-Handal Katia , Díaz-Pérez Héctor , Rodriguez David Omar , Guerrier Vedner 
Published: October 2019

59 Background: Ensuring quality of care in our breast cancer center (BCC) at Hospital Zambrano Hellion in Monterrey, Mexico has been one of the main objectives since its commencement in 2016. To achieve this goal, we evaluated our compliance to ASCO’s Quality Oncology Practice Initiative (QOPI) 84 breast cancer related metrics as a part of a quality improvement (QI) project undertaken during the 2018 Quality Training Program (QTP) in Alexandria, VA. Methods: We established a multidisciplinary QI team engaged in data acquisition, process improvement and implementation in our BCC. We developed a Microsoft Word medical record template and established a new “first time visit” model to achieve our objective of 80% documentation rate of 13 identified reasonably achievable QOPI metrics. Monthly Plan-Do-Study-Act cycles were conducted for 6 months from August through December 2018. Results: After a sample data abstraction of 20 patients’ medical records, our baseline QOPI-compliance resulted in 40/84 QOPI metrics being met by our BCC program. The remaining 44/84 were distributed in two categories, the first 13/44 were labeled as “done/not documented” metrics, and the second set of 31/44 metrics were labeled as “not done/not documented” metrics given they were not performed at all. We approached the 13/44 “done/not documented” metrics for this project based on our priority matrix. After our QI intervention, we surpassed our objective by the third PDSA cycle. Furthermore, by March 2019 we reached 95% cumulative compliance of those metrics. Conclusions: The development of a systematic QI approach enhanced our BCC QOPI-compliance in 13 reasonably achievable metrics to 95% over a 6-month period. Currently, we are targeting the remaining 40/84 metrics to ultimately adhere to all breast cancer QOPI standards. To our knowledge, we are the first Mexican BCC pursuing a QOPI-compliant practice through ASCO’s QTP initiative.
Oncology multidisciplinary clinic development.
Authors: Jacobs Sheila , Mashanic Kathy 
Published: October 2019

62 Background: In 2014 it was decided that a multidisciplinary approach would be beneficial for our breast cancer patients. A pre-conference for a multidisciplinary discussion on the treatment plan for the patients and their ability to see medical oncology, surgical oncology, and radiation oncology in one visit was the goal. Methods: A multidisciplinary planning committee was established to discuss operational issues. Location of the pre-conference and exam rooms were assigned along with the development of the MDC schedule templates for the physicians. The staffing resources were identified along with any additional equipment or supplies. Key staff were engaged to determine a new scheduling workflow including how patient referrals would be handled between departments, phone numbers the patient/family or physician would call for an appointment, and scripted messages to educate all on this model of care. Physicians developed triage questions to direct the caller to appropriate clinic and schedule an MDC appointment. A single phone number was created to ensure adequate access. Physician leadership and the managers of the affected areas worked with marketing on developing a variety of communication strategies to introduce the multidisciplinary initiative to providers, staff, referral networks, and patients. Results: Since the pilot in 2014, additional breast, thyroid/endocrine, thoracic, genitourinary, and gastrointestinal/colorectal MDC clinics have been launched as the outcomes have been very positive. Total MDC’s visits have increased by 200% from 132 in 2017 to 399 projected in 2019. Market share in the MDC programs has increased an average of 3.6 points. There has been a 44% increase in diagnosis at an earlier stage and both patient and provider satisfaction have trended upwards. Conclusions: The MDC’s have been a positive addition to our cancer program. The comprehensive approach to care has resulted in quality experience for all touched by cancer.
Efficacy of systemic treatment for metastatic renal cell carcinoma (mRCC) guided by comprehensive genomic profiling (CGP).
Authors: Bergerot Paulo Gustavo , Bergerot Cristiane Decat , Dizman Nazli , Salgia Nicholas , Hsu Joann , Pal Sumanta K. 
Published: October 2019

63 Background: Comprehensive genomic profiling (CGP) has been used to guide treatment selection in metastatic renal cell carcinoma (mRCC). This study sought to determine if genomic alterations guided treatment and contributed to improved outcomes. Methods: From a single institution, patients (pts) diagnosed with mRCC who had CGP in the course of clinical care were identified. Pts were tested on a CLIAA-certified platform (FoundationOne; Cambridge, MA). Pts who died/initiated hospice within the 30 days after the test was performed or who were lost to follow-up were excluded. Duration of therapy (DOT) was measured as months between first and last day of therapy following CGP test. The Kaplan-Meier method was undertaken to estimate the association of CGP-directed therapy with overall survival (OS). Cox regression was also performed and adjusted for histologic subgroup. Results: A total of 64 patients underwent CGP between February 2014 and August 2018. From this group, 15 patients were excluded due to death/hospice within 30 d (n = 10) and lack of follow-up (n = 5). Median age at diagnosis was 60 years (range, 24-84), and 79% were male. Most patients (69%) were diagnosed with clear cell RCC. The median identified genomic alterations (GAs) was 3 (range, 0-7). The most common GAs were VHL (54%), PBRM1 (28%), TERT (21%), TP53 (15%), BAP1 (13%), and SETD2 (13%). Of the 49 patients included in this analysis, 47% had actionable mutations based on their CGP results. Of those, 13 patients received directed-therapy of whom 57% had stable disease, 28% had partial response, and 14% had progressive disease. The median time from CGP test to treatment was 1 month (range, 0-17). The median duration of directed-therapy was 12 months (range, 1-28) and of non-directed therapy was 4 months (range, 1-40) (P = 0.04). Directed-therapy was significantly associated with better OS (adjusted HR, 0.32 [95% CI, 0.13 to 0.82]; P = 0.018) compared to non-directed therapy. Conclusions: This study provides preliminary evidence to justify CGP-guided therapy in mRCC. Forthcoming studies should prospectively explore the use of CGP in treatment allocation for mRCC to validate these findings.