bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving interdisciplinary communication in MDT-meetings: Identification of barriers and facilitators in nationwide implementation of standardized structured reporting.
Authors: Swillens Julie Elisa Maria , Voorham Rinus , Nagtegaal Iris D. , Hermens Rosella 
Published: October 2019

321 Background: Standardized structured reporting (SSR) improves quality of diagnostic reporting for cancer patients, resulting in improved interdisciplinary communication in multidisciplinary-team meetings (MTMs) and subsequently better health outcomes and patient safety. In addition, SSR is important to secondary users including (tumor) registry organizations. Nevertheless, SSR-template usage, for example in pathology, varies widely among oncology related medical disciplines. Because of the advantages during MTMs, multidisciplinary-team (MDT) members could play an important role in encouraging and supporting pathologists to use SSR-templates. Therefore, the objective is to identify both barriers and facilitators for SSR-implementation from a MDT-member perspective. Methods: We used a mixed method design. Four focus group interviews with MDT-members, operating in the field of urological, gynecological or gastrointestinal oncology were performed, to identify barriers and facilitators in SSR in relation to the MTMs. Findings were classified into the domains of Flottorp et al. (2013). We used a web-based survey among Dutch MDT-members to quantify the findings. Results: Twenty-three MDT-members of nine medical disciplines participated in the focus group interviews. The survey yielded 211 responses. Main barriers of SSR among MDT-members were lack of information in the standardized structured report, particularly lack of information to retrieve doubts of the pathologist (56%, n = 211); lack of nuances (39%, n = 184); and lack of transparency on development of SSR-templates (50%, n = 211). Pathologists (59%, n = 54) also mentioned the numerous clicking when using SSR-templates as a barrier. Main facilitator was to expand the recommendation of SSR-usage in national guidelines (81%, n = 174). Conclusions: Although the use of SSR by multiple disciplines has benefits, as diagnostic reports are more complete, this study shows important barriers that have to be dealt with in the implementation process of SSR. The next step is to use the barriers for developing and testing implementation tools to encourage SSR-implementation.
From guidelines to practice: Patient-focused and evidence-informed update of antiemetic recommendations in Ontario.
Authors: Vu Kathy , Warr David , Forbes Leta Marie , Gallo-Hershberg Daniela , DeAngelis Carlo , Brule Stephanie Yasmin , Comfort Dayna , Randall Lisa , Williams Julie , Salama Sarah 
Published: October 2019

39 Background: Cancer Care Ontario (CCO) last updated their guidance for the management of chemotherapy-induced nausea and vomiting (CINV) in 2013. Since then, new evidence emerged which changed antiemetic recommendations internationally. The CCO Antiemetic Working Group reviewed the current literature and updated existing recommendations for the prevention and management of CINV in adult patients. Methods: Ontario subject matter experts consisting of oncologists, pharmacists and nurses formed the Group. Relevant guidelines published from prominent jurisdictions were assessed. A literature search was done to incorporate the latest evidence. All chemotherapy regimens in the CCO Drug Formulary were reviewed. Ontario Cancer Leads for each disease site were consulted to ensure emetic classifications for all regimens and antiemetic recommendations reflected both the evidence (including gaps in the literature) and clinical practice (including gaps between evidence and practice). Results: Recommendations for antiemetic agents for highly, moderately, low and minimal emetic risk intravenous and oral chemotherapy are outlined. Chemotherapy regimens in the CCO Drug Formulary were reviewed and emetic risks updated. Recommendations differed from those of major international guidelines (including ASCO) around olanzapine dosing, cannabinoids and emetic risk classification. Conclusions: A systematic approach to updating antiemetic recommendations resulted in evidence-informed recommendations that are patient-focused and clinically feasible.
Impact of timing of palliative care consults on disposition to type of hospice care.
Authors: Baratam Praneeth , Bemis Thomas Stiles , Seiders Dawn , Ward Kristine Marie , Styler Michael 
Published: October 2019

50 Background: The 2018 ASCO palliative care guidelines recommend palliative care team (PCT) involvement within 8 weeks for patients with an advanced cancer diagnosis. However, the optimal timing and impact of PCT consults on patient disposition in the inpatient setting has not been established. We investigated whether the timing of PCT involvement for in-patients with an advanced cancer diagnosis affected disposition to a home or inpatient hospice setting. Methods: We queried Hahnemann University Hospital’s Palliative Care In-patient database from 2016-2018 for patients with advanced cancer diagnosis, estimated life expectancy of < 6 months, and recommendation for hospice. Dates of admission, initial PCT consult, discharge to an outpatient vs an inpatient hospice setting/in hospital death were examined. We then examined differences in hospice disposition and timing of PCT consults to determine the ideal consult time. Chi square analysis was used to determine differences in hospice disposition setting and timing of PCT consult. Results: We observed that 75% of PCT consults in our hospital are placed <10 days of admission. We also found that a statistically significant higher percentage of patients were discharged to a home hospice setting (35.1%) when using a PCT consult time of <10 days (p<0.01). Only 17.5% were discharged home when PCT was consulted >10 days after admission. We examined other cut-off times for consultation, but the difference in outcome was not statistically significant. Conclusions: Our findings show that a statistically significant higher percentage of patients went to a home hospice setting if PCT was consulted <10 days of admission. This suggests that early PCT involvement can result in more patients being discharged to a home hospice setting and by extension improve the quality of end of life care for patients. We aim to implement criteria for appropriate timing of PCT consults at our institution and measure post implementation data with the goal of increasing the number of patients discharged to a home hospice setting. [Table: see text]
Improving physical performance through independent, home-based exercise program prior to cancer-related surgery.
Authors: Fontillas Rhodora C. , Ngo-Huang An , Ng Amy , Asumbrado Roan , Holder Betty , Williams Janet L. , Bianty Josephine , Braveman Brent , Shin Ki , Bruera Eduardo 
Published: October 2019

54 Background: Surgery in older adults is a physiologically stressful event associated with reduced functional capacity and decreased quality of life. Poor preoperative performance is linked to risk of postoperative complications and prolonged functional recovery. The goal of this study is to determine the efficacy of an independent, home-based exercise program in improving physical performance prior to cancer-related surgery. Methods: Retrospective study of 217 consecutive patients referred for comprehensive prehabilitation including physical medicine and rehabilitation physician and physical therapy visits prior to intended oncologic surgery. Physical performance was assessed at consultation (baseline) and at the preoperative follow up visit in physical therapy. Physical performance measures included Six-Minute Walk test (6MWT), Five Times Sit to Stand (5xSTS), hand grip strength (HGS), gait speed (GS), and Timed Up and Go (TUG). Results: Median (IQR) age was 71 (64,77). The most common primary cancer diagnoses were gastrointestinal (43%), genitourinary (15%), breast (9%), and sarcoma (7%). 144 of the 217 (66%) underwent surgery and of these, 75 (52%) completed preoperative functional measures during their physical therapy follow-up. For the entire cohort of 217 patients, baseline median (IQR) measures included: 6MWT distance was 357 (193.3, 420) meters, 5xSTS was 12 (9.1, 16.3) seconds, right HGS was 43.3 (30.0, 58.3) pounds, GS was 1.4 (1, 1.7) meters per second, and TUG was 8.6 (7.3, 12.2) seconds. There were similar baseline physical function results in the cohort who completed preoperative measures. During the preoperative period (from baseline to pre-surgery visit), there was significant improvement in the 6MWT ( P=0.003), 5xSTS ( P=0.000), and TUG ( P=0.027). There was no significant change in HGS or GS. Conclusions: At baseline, most patients had major functional impairment, especially decreased submaximal exercise capacity. With the independent, home-based exercise prehabilitation program, patients had significant improvement in physical performance. Prehabilitation should be further investigated in these patients.
A systematic approach for high-quality care in complex malignant hematology.
Authors: Kouroukis C. Tom , Bredeson Christopher , Pollett Aaron , Meertens Elaine , Monakova Julia , Wang Jonathan , Hart Jennifer , Beglaryan Hasmik , Moody Lesley , Hertz Sherrie 
Published: October 2019

57 Background: Capacity limits in Ontario, Canada, resulted in long waits and out-of-country care for hematopoietic cell therapy (HCT) and inconsistent access for acute leukemia (AL) patients. A multi-pronged system improvement approach was implemented to ensure high quality care as close to home as possible. Methods: Robust forecasting models and physician workload benchmarks were developed to quantify needs and drive health human resource and capital planning. Clinical and organizational guidelines were developed for new models of care, pathology and laboratory medicine services, and networks of care. Funding models were introduced to support care needs and service models. A comprehensive measurement strategy, including patient reported experience measures, was developed. Results: Six services sites providing HCT and AL care are networked with four AL sites and three supporting sites. Capital expansion projects have been completed and others continue. Two biomarker reference centers were established to serve as quality leads and ensure timely testing. Average turnaround time is 12 days for cytogenetic testing. 19 additional physician specialists and 5 additional fellowships were approved for allocation across Ontario. Three nurse practitioners participated in mentorship programs. Access has improved and wait times are monitored. In 2018 there were 736 autologous and 357 allogeneic transplants done vs 396 and 159 respectively in 2014. 43 patients were referred out of country in 2016 compared with two in 2018, with a median wait of 70 days from AL remission to transplant in 2018. Nine (of 14) regional cancer centers offer outpatient AL consolidation. Patient experience was highest in treatment planning, physical comfort and patient preferences. Conclusions: A multi-pronged approach to planning, funding and quality assurance resulted in measureable increased capacity and high quality care closer to home.
A quality improvement approach to optimizing infusion wait times.
Authors: Plourde Collin , Gleaton Barbara , O'Hara Aliceson , Varnado William , Das Devika Govind 
Published: October 2019

61 Background: Long wait times are a common and occasionally unavoidable experience for patients receiving chemotherapy infusions. It unfavorably impacts patient satisfaction and clinic efficiency. Our primary objective was to evaluate the impact of infusion clinic process changes on patient wait times within a Plan, Do, Study, Act (PSDA) framework. Methods: A multi-disciplinary team, consisting of oncology, nursing, pharmacy, quality improvement, and support staff, met to have brainstorming sessions, make surveys, and conduct time studies to analyze our current process (Plan). A Pareto chart created using survey results showed communication issues were likely causing the largest modifiable impact on our wait times. A common source of miscommunication was whether patients are waiting on labs results for treatment. Beginning March 2019, patients not requiring labs on the day of treatment were assigned to a separate scheduling title to designate them as priority for vital signs and review by pharmacy (Do). Upon clinic check-in, these patients now have vitals signs collected immediately and pharmacy is notified of their arrival to begin chemotherapy preparation. Results: Baseline as well as prospective wait time data was collected from 30 clinic days (360 patient wait times) from chart reviews and timestamp data available in the electronic medical record (EMR). Results were analyzed (Study) using Statistical Process Control (SPC) charts to allow for early detection of improvement. Pre-implementation wait times averaged 1 hour and 37 minutes. Post implementation wait times average 1 hour and 16 minutes (Act). This change was significant based on a shift visible on the SPC chart. Our balancing measure of wait times for all patients did not increase compared to baseline (2 hours and 15 minutes). No significant correlation was observed between average daily wait times and the day of the week or the number of patients treated that day at baseline. Conclusions: Implementation of a new clinic scheduling title and workflow reduced wait times for patients not requiring labs on the day of treatment without increasing wait times for patients requiring labs. Additional PDSA cycles will be conducted for further reductions in wait times for all patients at our site.
Improving time to start bone modifying agents in newly diagnosed multiple myeloma patients.
Authors: Lee Sarah , Rosko Nathaniel , Reed Janice , Karam Mary Ann , Faiman Beth , Mathur Saveta , Hamilton Kimberly , Mejia Alex V. , Anwer Faiz , Samaras Christy Joy , Valent Jason Neil 
Published: October 2019

65 Background: Current ASCO and IMWG guidelines recommend all patients (pts) on active myeloma therapy receive concurrent supportive care with a bone modifying agent (BMA) to decrease the risk of skeletal related events (SRE). Unfortunately, recent data shows only 51% of Medicare pts with myeloma received a BMA within 90 days of first chemotherapy. We implemented a quality improvement project to identify the average time to BMA initiation at all Cleveland Clinic affiliated sites, with the primary goal to improve time to start BMA in newly diagnosed multiple myeloma (NDMM) pts by 4 weeks at Cleveland Clinic Main Campus (MC). Methods: Barriers to start BMA were identified using quality improvement tools developed at ASCO Quality Training Program. The first PDSA cycle ran from Sept 2018–Jan 2019 with an emphasis on education. This included review of updated guidelines, literature review of risks and toxicities associated with BMAs, and strategies for choosing BMA based on pt factors. Baseline data on time to start BMA and data to evaluate impact of PDSA intervention was done by chart review. Results: 161 NDMM pts were evaluated from 2015–2018 at all sites. The average time difference between the start of myeloma therapy and the start date of BMA in NDMM pts was 10.5 weeks. Subset analysis based on whether pts were treated at MC vs affiliate site was 10.6 weeks vs 9.1 weeks, respectively. During the first PDSA cycle, 14 NDMM pts were treated at MC. 86% (12/14) pts were treated with BMA. The average time between cycle 1 day 1 of first line treatment and first dose BMA was 4.3 weeks (range 4-12 weeks). Conclusions: With increased physician education and awareness of internal baseline data, we achieved our initial goal and observed a significant improvement in time to start BMA from 10.5 weeks to 4.3 weeks. Obstacles regarding effective communication with patients on the benefit of BMAs as well as need for dental clearance were barriers identified early on. We plan to incorporate BMA guidelines in our institutional care path with the goal to decrease time to initiation at all affiliated practices. Further mechanisms to ensure reinforcement of BMA initiation in NDMM patients is warranted to maintain therapeutic benefit.
Use of nonclinical staff to coordinate oral anticancer drug prescriptions.
Authors: O'Neil Daniel , Accordino Melissa Kate , Wright Jason Dennis , Law Cynthia , Nitta Suzuka , Buono Donna , Abbott Maura , Ustoyev Yelena , Hu Jianhua , Neugut Alfred I. , Hur Chin , Patel Khilna , Hershman Dawn L. 
Published: October 2019

72 Background: In September 2018, Herbert Irving Comprehensive Cancer Center (HICCC) began using non-clinical pharmacy liaisons to oversee coordination of oral anticancer drug (OACD) prescriptions (RXs), a task previously performed by clinical staff. Liaisons interact with payers, specialty pharmacies and financial assistance (FA) groups. We assessed the impact of this strategy on time to receipt of OACDs. Methods: We collected prospective data on all new OACD RXs from HICCC’s medical oncology practice from 1/1/2018 to 9/17/2018 (pre-liaisons) and 9/17/2018 to 5/1/2019 (post-liaisons). We collected patient demographic and insurance data; date of prescription; date of drug delivery; and interactions with payers and FA groups. Federal Drug Association labels were reviewed for drug approval dates and indications. Daily drug cost was defined according to average wholesale price. We define time to receipt (TTR) as days from RX to OACD delivery and used multivariable linear regression to determine factors associated with TTR (log transformed). Results: Over the study period, we evaluated 707 RXs; 93 (13%) were never filled. Of 614 filled RXs, 350 (57%) were placed in the pre-liaison period and 264 (43%) in the post-liaison period. After introduction of liaisons, FA was pursued for more RXs (17% vs 25%, p = 0.007); there was no difference pre- and post-liaisons in patient demographics, distribution of payers, RXs needing prior authorization (PA) (76% vs 77%), off-label RXs (14% vs 16%), RXs for drugs approved < 2 years earlier (5% vs 3%) or mean daily cost ($471 vs $470). Mean TTR before and after liaisons were 11.9 and 11.6 days, respectively. Linear regression showed longer TTR was associated with commercial payers (p = 0.02), need for PA (p = 0.03), FA pursuit (p ≤ 0.0001) and daily OACD cost (p = 0.03); no association was seen with use of liaisons, patient age, off-label use or OACDs approved < 2 years earlier. Conclusions: Implementation of pharmacy liaisons to coordinate OACD prescriptions did not impact the time to OACD receipt, though liaisons were able to pursue financial assistance for more patients. Insurance and cost factors had the greatest impact on time to drug receipt. Task shifting may reduce the clerical workload for providers.
A staff leadership model in an NCI-designated comprehensive cancer center: Quality begins with the team.
Authors: Kotwal Juee , Loscalzo Matthew J. , Clark Karen L. , Dale William , Schnaitmann Natalie 
Published: October 2019

73 Background: Patients with cancer face a range of complex biopsychosocial needs and challenges. To manage the complex needs of such “high-risk, high-cost” patients, an integrated interdisciplinary team approach is crucial. Although team members are highly skilled, cancer settings are emotionally charged environments which may create high levels of distress in providers. In 2007, the Department of Supportive Care Medicine (DSCM) at City of Hope (COH) developed the nation’s first Staff Leadership Model (SLM) to enhance relationships among team members which has been demonstrated to improve both the quality of patient care and safety. Within this model, the focus was on creating a high-performance team where team members are as valued as patients and families. Methods: DSCM implemented methods centered on maximizing team engagement by creating trusting relationships, detoxifying conflicts, depersonalizing feedback, and taking personal accountability. Cultural change was achieved by implementing the following interventions: communication skills to manage conflict, frequent team check-ins to identify areas of growth, non-management staff assuming responsibility for meetings and annual retreats and a “buddy” system to orient new team members. Results: Gallup scores increased from 4.46 in 2015 to 4.62 in 2017 (much higher than COH overall). Transition to Press Ganey in 2018 resulted in 2nd highest engagement score across COH departments (4.42 compared to COH overall 4.16). Conclusions: Results suggest support for the relationship between the SLM and the high quality of team relationships as reflected by the consistent increase in engagement scores. The department philosophy focuses on consciously, systematically and strategically activating the best of each team member in an environment of courageous, compassionate and relentless honesty.
Navigating oncology inpatient care from admission to discharge: A quality improvement study.
Authors: Lightheart Erin , Kucharczuk Colleen 
Published: October 2019

76 Background: Ensuring successful transitions between inpatient and outpatient settings is key in providing quality oncology care. To this aim, our team of inpatient Advanced Practice Providers (APP) recognized that critical components of discharge planning were often left to the provider’s memory, leading to errors, omissions, and inefficiencies. After brainstorming a number of possible quality improvement interventions, the clear choice for a high-impact, low-effort solution was the development of a comprehensive discharge checklist, a tool which has been shown in the literature to be effective in similar settings. Methods: Based on best practice recommendations by the Society of Hospital Medicine regarding key considerations for planning safe discharges, a multidisciplinary group developed a comprehensive discharge document housed within the electronic record, to be initiated at the point of admission and updated continually by both providers and discharge coordinators. The document is not simply a list of tasks, but rather, a comprehensive navigator which guides care throughout the entire inpatient stay. Providers are prompted to consider individualized care critical to timely discharge, such as early administration of blood or electrolytes. We have maintained 100% compliance with utilizing the navigator since its inception. Results: Results are summarized in the table below. Conclusions: What started as a discharge checklist grew into a comprehensive navigator, guiding inpatient oncology care from admission through discharge, and into the outpatient setting. Ultimately, it has improved communication and collaboration among providers, CRCs, nursing, physical therapy, social work, and inpatient and outpatient pharmacy. We believe this systematic approach to the discharge process is applicable in any inpatient setting with any patient population. [Table: see text]