bluuebunny/crossref_metadata_2025_split huggingface dataset:
Successes with and barriers to patient-reported outcome deployment at a comprehensive cancer center.
Authors: McCleary Nadine Jackson , Schrag Deborah , Martin Neil E. , Mahmood Sadiqa , Beyer Elizabeth , Joyce Linda , Martin Shawn , Tulsky James A. , Wolpin Brian M. , Jacobson Joseph O. , Johnson Jason , Hassett Michael J. 
Published: September 2018

292 Background: Routine collection of patient reported outcomes (PROs) reduces hospitalizations and improves quality of life. In the absence of clear implementation guidelines and research guiding deployment, PROs may not have the desired impact on outcomes in routine oncology practice. We share lessons learned from PRO deployment at Dana-Farber Cancer Institute. Methods: We developed a symptom/toxicity assessment tool based on the PRO-CTCAE to capture 15 symptomatic adverse events with a 1-week recall: fatigue/ decreased appetite/insomnia/ shortness of breath/numbness and tingling/concentration, general pain/anxiety/sadness, rash, nausea/vomiting/fever, constipation, and diarrhea. Responses from eligible English-literate patients scheduled for a gastrointestinal cancer center or adult palliative care visit between January 18 to March 22, 2018 were transmitted directly from clinic tablet to the EMR. To evaluate the deployment, we sought qualitative feedback from clinic staff and three multidisciplinary working groups comprised of patients, nurses, pharmacists, operations leaders, quality/safety experts, and health services researchers to identify technical and workflow gaps in PRO Content, Implementation, and Analytics. Results: We noted a 38% response rate of the N = 4440 PROs assigned to N = 4440 scheduled visits for N = 2055 unique patients (36% were completed, 2% started but not completed); 62% were not started. Workflow enhancement requests include an updated summary view, a clinical documentation tool, a scoring algorithm to highlight severe responses, and a quality metric dashboard to evaluate the deployment. Ongoing analyses are studying the proportion of moderate-severe symptomatic adverse events reported and their association with provider action (i.e., supportive care referral, chemotherapy treatment plan modification, or unplanned ED/hospitalization in the subsequent 30 days). Conclusions: Refinement of the PRO deployment strategy is needed to guide implementation efforts and demonstrate meaningful impact in routine oncology practice.
Improving the Medical Orders for Life-Sustaining Treatment (MOLST) form documentation process in an outpatient oncology clinic.
Authors: Faig Jennifer , Zerillo Jessica A. , Wright Danielle , Sato-DiLorenzo Aya , Mahony Michelle , Mantia Charlene , Salazar Rolando , O'Leary Carol , Nguyen Mayca , Buss Mary K. 
Published: September 2018

299 Background: Advance care planning is an important aspect of providing high quality care to oncology patients. ASCO Quality Oncology Practice Initiative (QOPI) recognizes the importance of advance directive documentation as a quality measure. MOLST forms are often completed to document a patient’s preferences for medical care at the end of life. The primary objective of this study was to improve the MOLST form documentation process in an outpatient solid tumor oncology clinic. Methods: We conducted a survey to identify areas for improvement and created a process map illustrating the complexities of the current MOLST form documentation process. A multidisciplinary team comprised of physicians, nurses, administrative staff, a quality improvement leader and a palliative care expert was created to focus on this initiative. We developed a new process whereby completed MOLST forms were uploaded into the electronic medical record (EMR) system. We implemented the following interventions: 1) made MOLST forms accessible to clinicians; 2) created a centralized location to place MOLST forms; 3) educated oncology staff about the new process; and 4) streamlined the MOLST form scanning process into the EMR. This process was studied during a pilot between January 22, 2018-February 2, 2018. A pre-pilot convenience sample was compared to pilot data. Results: Oncologists identified the need to improve the MOLST form documentation process on the pre-pilot survey. The percentage of completed MOLST forms scanned into the EMR increased from 44.4% (4 out of 9 forms) pre-pilot to 87.5% (7 out of 8 forms) during the pilot (p = 0.06). All of the MOLST forms completed using the new process were scanned into the EMR. Physician satisfaction with the MOLST process increased from 7.1% (2 out of 28 survey respondents) pre-pilot to 87.5% (14 out of 16 survey respondents) post-pilot (p < 0.01). Conclusions: A targeted process to enhance the documentation of completed MOLST forms succeeded and increased physician satisfaction. Further work will need to be performed to better identify oncology patients appropriate for MOLST form discussions.
Advance electronic screening of patients with cancer leveraging a new EHR to increase efficiency of care delivery, driving clinical care pathways in a perioperative anesthesia assessment center (PAAC), at a comprehensive cancer center.
Authors: French Katy E. , Popovich Shannon , Speer B. Bryce , Recinos Iris , Andrabi Tayab 
Published: September 2018

308 Background: Most cancer institutions are using electronic health records (EHRs). With MACRA and MIPS, this number will continue to grow. EHR’s can be frustrating as some are seen as more cumbersome than useful to patient care delivery. In 2017, the MD Anderson cancer center (MDACC) PAAC assessed over 20,000 patients. We wanted to demonstrate positive utility of our EHR. We hypothesized that advanced electronic screening of our cancer patients, leveraging a questionnaire embedded in the EHR, could increase efficiency by driving patient specific perioperative care pathways leading to positive patient experience while not negatively affecting our low same day surgery cancellation rate of 2.07%. Methods: In March of 2016, MDACC launched a new EHR and the PAAC commenced an online medical and anesthesia screening questionnaire to be completed via a secure online portal by our cancer patients in advance of the surgery date. The questionnaire was developed and vetted by specialists from many areas including anesthesia, cardiology, internal medicine, and surgery. The answers to these questions were validated by a healthcare provider, and the patient was directed to one of two care pathways. Complex patients were scheduled for an in person clinic assessment prior to surgery and all other patients were scheduled for a phone call assessment. We used reports created within our EHR to track baseline and 2017 data for numbers of patients directed to the 2 different pathways and same day surgery cancellation data throughout this time frame. Results: Using the online patient entered questionnaire, we were able to improve clinic efficiency by implementing two patient care delivery pathways. Using our new EHR we saw an increase of 18.4% in our phone assessment pathway for patients. Patient experience improved as we were able to offer patients more options in the delivery of care saving them time. Conclusions: Use of our new EHR and IT analytics helped drive patient-specific care pathways, improve efficiency and the patient experience. MDACC same day surgery cancellation rate remained 2.07%.
Content evaluation of Watson for Oncology: A feasibility study.
Authors: Keikes Lotte , Medlock Stephanie , van de Berg Daniel , Zhang Shuxin X. , Guicherit Onno Robert , Punt Cornelis J. A. , van Oijen Martijn G.H. 
Published: September 2018

325 Background: Digital decision support tools such as Watson offer a promising opportunity to recommend the best cancer treatment to doctors around the globe. Although concordance studies between Watson's recommendations and routine daily practice or expert opinion were reported; scientific papers demonstrating how Watson affects medical decision-making are scarce. The first step of external validation and localization is content evaluation against national guidelines. Therefore, we present a feasibility study of the content evaluation of Watson for Oncology. Methods: We developed synthetic patient cases exhaustively testing the adjuvant treatment of stage I to stage III colon cancer based on relevant patient, clinical and tumor characteristics, and entered these in Watson. We used cross tabulations and a novel scoring system to compare Dutch and NCCN guideline recommendations with Watson’s treatment advice. Our scoring system allows a range from +12 to -12, reflecting the difference between minor disagreement (possible treatment not mentioned) versus serious error (contraindicated treatment was recommended). Treatment options that were contraindicated according to the national guidelines were labeled with a "red flag" if Watson recommended it, and an "orange flag" if Watson considered it. Results: In total, we developed 190 synthetic patient cases (stage I: n = 8; stage II: n = 110; and stage III: n = 72). Overall concordance scores per case for Watson versus Dutch guidelines ranged from a minimum score of -4 (n = 6) to a maximum score of +12 (n = 17) and from -4 (n = 9) to +12 (n = 24) for Watson versus the NCCN guidelines. In total, 69 cases (36%) were labeled with red flags, 96 cases (51%) with orange flags and 25 cases (13%) without flags. For the comparison of Watson with the NCCN guidelines, no red or orange flags were identified. Conclusions: Evaluation of the content of Watson for Oncology against national guidelines is feasible. Overall concordance scores varied considerably between synthetic patient cases. Non-concordance is partially attributable to guideline differences between the United States and The Netherlands. This implies that further adjustments and localization are required before implementation of Watson outside the United States.
The institution of a white cell growth factor appropriate non-use policy for incurable metastatic solid tumors within a community oncology practice.
Authors: Hoverman J. Russell , Turnwald Brian , Garey Jody S. , Hayes Jad , Mann B. Brooke , He Bo , Wilfong Lalan S. 
Published: September 2018

33 Background: Texas Oncology (TO) is a community-based practice. with over 250 physicians (MD) who order chemotherapy. In 2015, pegfilgrastim (pgcsf) was the highest individual drug in billed claims. Concurrently, TO was participating in the United Healthcare (UHC) Episode of Care (EOC) program and anticipating the Oncology Care Model. Patient and program expense dictated understanding pgcsf utilization. Methods: Data were obtained in 9/2015 from EOC claims to identify overall and individual pgcsf use in solid tumor metastatic disease (MDx). Chart review was done for the top prescribers. In 3/16, ASCO pgcsf guidelines and TO education materials were emailed to all physicians. In 3/17 appropriate non-use recommendations were communicated and a real-time internal approval process begun. On 10/1/2017, UHC instituted a pgcsf prior authorization (PA) program. Retrospective data from the iKnowMed EHR system was collected in 3-month intervals from April 2016 through March 2018 and evaluated for number of pgcsf administrations at TO for MDx, as well as, administrations/provider/quarter for TO and The US Oncology Network. MDx was defined by any of the following criteria: stage IV at diagnosis (with certain disease exceptions); TNM M value of “1” or “+”; a metastatic line of therapy; evidence of metastatic disease documented within the EHR. Results: Initial survey of EOC claims indicated 16% of patients received pgcsf for MDx. Rates per MD ranged from 0 to 57%. Review of the top users indicated 90% of uses could have been addressed with dose reduction. In the first measured quarter of April to June 2016 to the last, October to December 2017, pgcsf use dropped by 50%. Changes for some diseases were dramatic: Use in colon cancer fell from 132 uses/quarter to a low of 46, and for non-small lung cancer – 80 to 23 respectively. Conclusions: The deadopting of low value care can be challenging. In the case of pgcsf substantial reductions in use were achieved using data and guidelines for education in the setting of value based contracts. Ultimately, the most change was achieved by an internal real time approval process. This was reinforced by a payer PA requirement.
External validation of a screening instrument to identify cardiometabolic predictors of mortality in individuals with cancer.
Authors: Koczwara Bogda , Kaambwa Billingsley , Miller Michelle 
Published: September 2018

5 Background: Cancer survivors are at risk of higher mortality from other causes, in particular, cardiovascular and metabolic. We have previously reported on a development of a brief screening instrument to identify cardiometabolic predictors of mortality in older individuals using the Australian Longitudinal Study of Ageing, which showed that age, sex, history of cerebrovascular disease, non-adherence to exercise guidelines, and smoking predicted for mortality(Lim et al. 2017). The objective of this study was to validate our findings using an external database. Methods: Two external validation cohorts of cancer survivors recruited to the Australian Longitudinal Study on Women’s Health study were used: an older group aged between 70 and 75 at time of recruitment (cohort 1) and a younger group aged between 45 and 50 at time of recruitment (cohort 2). These were compared to the original development cohort who were aged 70 years and over at time of recruitment. The Cox proportional hazards model previously estimated in the development cohort was used to predict mortality at 10 years in the validation cohorts. Measures of discrimination and calibration were calculated. Results: There were 1764 and 1833 women in the two validation cohorts and 294 men and women in the original development cohort. Validation cohorts had lower mortality rates (31% and 4% in validation cohorts 1 and 2, respectively, versus 61% in the development cohort) and validation cohort 2 had a higher proportion of individuals reported to have met exercise guidelines (59%) compared to the development cohort (24%) and validation cohort 1 (0.11%). All measures of discrimination for the validation cohorts were within the range of acceptable published estimates. Calibration showed that, overall, the tool had acceptable predictive accuracy but performed best in the good prognostic groups. Conclusions: We have demonstrated that the screening tool developed in older cancer survivors, performs adequately in cohort of younger women cancer survivors although further calibration is needed to improve performance. Further validation in mixed gender cohorts and usability testing are planned.
Utility and factors associated with imaging early-stage breast cancer: Are we choosing wisely?
Authors: Velazquez Manana Ana I. , Nguyen Nina , Rodriguez Bonilla Carlos , Shao Theresa 
Published: September 2018

52 Background: Breast cancer (BC) is the most common malignancy in women with estimated care costs of $20.50 billion/year by 2020. In 2012, ASCO released the Choosing Wisely Initiative which recommended against the use of routine imaging in patients with newly diagnosed early stage BC. We examined the adherence rate and factors associated with non-adherence in patients with early stage BC treated within a large health care system. Methods: We identified all women with stage I-II BC diagnosed between January 1, 2014 and December 31, 2015 from the Cancer Registry of Mount Sinai Health System. Demographic, clinical and treatment related factors were collected. Medical records were reviewed to identify patients who had routine staging scan. Data of initial and follow-up imaging over 1-year period were collected. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from logistic regression models. Results: Among 733 BC patients, the median age at diagnosis was 58 (range 26-98). One hundred thirty nine patients (19%) had routine imaging with a mean number of initial scans of 1.53 and 59 (42%) patients had at least 1 subsequent scan in the 1-year follow up (range 1-4 scans/year). PET/CT was the most frequent modality, followed by CT. Medical oncologist was the ordering provider in 52% of the cases and surgical oncologist in 44.6%. Routine scan identified no cases of metastatic disease. False-positive findings were identified in 43% and incidental findings in 8% of cases. Total cost of imaging in this group was $4480/patient. Young age ( < 50), TN disease, tumor size > 2cm and positive lymph node were associated with increased staging scan on univariate and multivariate analysis. Conclusions: Our study highlights the prevalence of unnecessary scan in up to 19% of patients with stage I-II BC. Routine imaging resulted in increased radiation exposure and additional cost of $4480/patient. The presence of T2 tumor, positive lymph node, TN disease and young age were associated with increased staging scan. Further educational efforts are needed to avoid unnecessary scans in patients with early stage BC. [Table: see text]
From A to Xeloda: Practical considerations for implementing a chemotherapy regimen ordering system intervention.
Authors: Egan Kathryn , Bell-Brown Ari , Kreizenbeck Karma L. , Watabayashi Kate , Lyman Gary H. , Hershman Dawn L. , Bansal Aasthaa , Barlow William E. , Sullivan Sean D , Ramsey Scott David 
Published: September 2018

57 Background: SWOG S1415CD (NCT02728596) is a pragmatic trial comparing outcomes of colony stimulating factor (CSF) use in usual care with care that uses guideline-informed standing CSF orders for protocol chemotherapy regimens. To develop the regimen list, we reviewed, reconciled, and compiled a comprehensive list of 77 NCCN-recognized core regimens and 40 biologic variants for breast, non-small cell, and colorectal cancer, meant to capture a broad population and variety of practices and settings. The 24 intervention sites chose regimens representative of the 3 febrile neutropenia (FN) risk categories (high, intermediate, low) from the list to reconfigure in prescription ordering systems. The current analysis seeks to determine whether providing a comprehensive list of regimens resulted in increased enrollment of patients. Methods: For each site, we compared how many core regimens the site reconfigured to their average weekly rate of enrollment from date of first patient enrolled to 4/1/2018, controlled for cooperative group type and site-reported volume of breast, non-small cell lung, and colorectal cancer patients. For each regimen, we determined its relative popularity by tallying how many sites chose to reconfigure it for the trial. Results: Sites reconfigured an average of 56% (range: 19%-100%) of core regimens on our list. The 18 most popular core regimens chosen by 83-96% of sites provided enrollment coverage across all FN risk categories for all intervention sites and accounted for 91% of enrollment, although enrollment among those regimens varied widely (0-18% of all patients enrolled). Reconfiguring more regimens did not correlate with higher average weekly enrollment (r < 0.1). Conclusions: Studies that wish to limit the number of regimens may want to focus on the most popular regimens as identified by committee or preliminary polling. Starting from a comprehensive set of regimens for a pragmatic trial focusing on chemotherapy ordering systems takes more time to compile and vet, is more difficult to implement in databases, is a burden to sites to review and reconfigure in ordering systems, and does not necessarily translate to increased enrollment rates. Clinical trial information: NCT02728596.
Impact of clinic characteristics on the adoption of a guideline-based standing order algorithm and patient accrual in the pragmatic cluster-randomized trial SWOG S1415CD (NCT02728596).
Authors: Watabayashi Kate , Bell-Brown Ari , Egan Kathryn , Kreizenbeck Karma L. , Lyman Gary H. , Hershman Dawn L. , Bansal Aasthaa , Barlow William E. , Sullivan Sean D , Ramsey Scott David 
Published: September 2018

60 Background: The S1415CD intervention requires the integration of guideline-based prescribing recommendations and standing orders for primary prophylactic colony stimulating factors into existing chemotherapy order systems at community practices within the National Cancer Institute’s Community Oncology Research Program. We looked at the impact of clinic level characteristics on the length of time needed to successfully adopt the intervention and subsequent patient accrual. Methods: We calculated the length of time between randomization and intervention completion for each intervention arm clinic and classified them as short onset (2-5 months, N = 5), medium onset (6-8 months, N = 12) or long onset (10-12 months, N = 7). We compared baseline survey responses about clinic characteristics to onset times. Results: Type of EMR software and the number of chemotherapy regimens reconfigured for the trial had no effect on onset time. All short and medium onset clinics placed orders through an EMR, while 5 of 7 long onset clinics used paper orders. Long onset clinics had less reported nurse involvement in the reconfiguration workflow (change initiation, approval, fulfillment and dissemination) at 14% of clinics vs. 25% of medium onset and 75% of short onset clinics. The average weekly patient accrual rates observed after intervention completion were 1.0 in the short onset (range 0.6-1.5), 0.8 in the medium onset (0.2-1.3) and 0.6 in the long onset (0.1-2.0). Conclusions: When recruiting clinics for trials that require health record system changes, it may be helpful to consider aspects of the system modification workflow such as type of hospital departments involved, as clinics with less nursing involvement may take longer to complete the changes. The inclusion of clinics using different EMR software did not impede onset, but clinics using paper may require more time. Length of onset had no meaningful impact on weekly accrual rates; however, it did determine when clinics could start recruitment, affecting the total number of months clinics could recruit during the study accrual period. Clinical trial information: NCT02728596.