bluuebunny/crossref_metadata_2025_split huggingface dataset:
Creating value: Institution of outpatient infusional EPOCH-based chemotherapy at a safety-net hospital.
Authors: Gupta Arjun , Hon Mary C. , Keshvani Neil , Marley Eileen M. , Johnson David H. , Sadeghi Navid , Li Hsiao Ching 
Published: September 2018

128 Background: EPOCH-based chemotherapy regimens are traditionally administered inpatient because they include a continuous 96-hour infusion. These admissions are costly, and disruptive to patients’ lives. We transitioned EPOCH-based chemotherapy regimens to an ambulatory infusion model at our safety-net hospital (Parkland Health and Hospital System, Dallas, TX), where patients visit the infusion center daily for 5 days. Methods: Guidelines for chemotherapy administration and educational materials were developed through a multidisciplinary collaboration with physicians, nursing, and pharmacy. Data were collected through chart review and the finance department. Project costs included purchase of portable infusion pumps and increasing outpatient infusion clinic capacity. Patient satisfaction with home infusions compared to hospitalization was measured on a Likert-type scale via direct-to-patient survey. Results: From 1/30/2017 through 1/30/2018, a total of 87 cycles of EPOCH-based chemotherapy were administered to 23 unique patients. 61 (70%) of these cycles were administered in the outpatient setting to 18 unique patients. There was a 58% reduction in drug costs in the outpatient setting due to lower drug acquisition cost. An estimated 336 days of hospital stay were avoided. There were no inappropriate prophylactic antimicrobial prescriptions and daily blood draws in the outpatient setting. 88% of survey responders reported > 3 (scale, 1 to 5) on a Likert-type scale for both overall experience with home infusions, and likelihood they would use home infusions again. No chemotherapy spills or extravasation occurred; 1 cycle was complicated by pump failure where chemotherapy was given at a slower rate than intended. Conclusions: Multiday EPOCH-based regimens were successfully and safely administered in an ambulatory setting at our safety net urban hospital. Patients reported satisfaction with the experience, and received less unnecessary interventions in the outpatient setting. Significant cost savings from avoided hospitalization and decreased drug acquisition cost were demonstrated.
Navigation models in diverse outpatient settings: Shared themes, challenges, and opportunities.
Authors: Greenwood Narcessa Gail-Rosales , Taniguchi Cynthia B. , Sheldrick Amy , Hurley Leslie 
Published: September 2018

134 Background: Navigation has been recognized by the Centers for Medicare and Medicaid Services (CMS) as a component of quality oncology care. This discussion highlights progress of Nurse Navigation implementation within 3 US Oncology Network practices. A team-based approach optimizing patient care coordination and providing enhanced services has been identified. Study practices demonstrate common navigation goals and desired outcomes, despite variations in practice size, dissimilar workflows, and unclear best-practice guidelines for navigation in the outpatient setting. Methods: The US Oncology Network formed a committee to study and develop evidence-based nurse navigation processes for recommendation to the greater Network. The committee includes 6 members, each a lead Oncology Nurse Navigator, practicing in different US geographical regions. Preliminary steps were to seek evidence-based support through: Existing models for Oncology Nurse Navigation that are adaptable for the community setting Best-practice in navigation recommendations from esteemed professional organizations Challenges and solutions identified and implemented Scope of practice for the Nurse Navigator in a community setting Performance metrics targeting effective, value-driven navigation Results: Focusing on scientific Nursing Process, study practices provided navigation services to 3762 patients. Gaps in navigation processes were identified, as well as barriers throughout the continuum of care. Scope of Practice for the community-based Nurse Navigator was defined. Navigation framework was established to include patient/family education, psychosocial interventions, referral outsourcing, and patient advocacy. A formal job description was created for the role of the Oncology Nurse Navigator. The Interdisciplinary Care Team Conference Standard was finalized to support coordination of care. Conclusions: Work remains to define, implement, and test effective navigational models to support challenges of patients receiving care in the outpatient setting. Benefits resulting from Nurse Navigation processes are emerging as healthcare trends advance quality of care while decreasing total cost of care.
A physical assessment tool to evaluate functional status compared to ECOG scores in cancer outpatients.
Authors: Crandell Catherine Elizabeth , Quinn Sarah Elizabeth , Wingard Christopher Jon , Imel Reid , Penney Jarek , Swartz Kevin , Weiss Jessica , Wilson Joshua , Flynn Joseph M. , Hamm John Turner 
Published: September 2018

135 Background: Individuals with cancer may experience loss of function, disability and fatigue. There is interest in team-based functional and physical assessment as part of a comprehensive oncology care plan. The Bellarmine Norton Assessment Tool (BNAT) was developed to provide an objective physical assessment tool for interprofessional use. The purpose of this study was to evaluate the BNAT and correlate its outcomes with ECOG scores across groups diagnosed with pancreatic (P), breast (B) and lung (L) cancers. Methods: The BNAT was developed by the Bellarmine University Physical Therapy Program utilizing validated physical assessment tests. It consists of 1 subjective question about physical activity frequency followed by 4 objective tests: 2-Minute Step Test (2MST), 30 Sec Sit-to-Stand, Timed Arm Curl (TAC) and Timed Up and Go. The ECOG was administered by attending oncologists during the same visit as BNAT testing. 18 participants were identified 6 in each of the diagnosis groups from a recruitment cohort of 57. The avg. age for P was 68.8±9 yrs 4♀,2♂; B 71.5±15.8 yrs 6♀; L 65.0±12.4 yrs 3♀,3♂. Results: The combined mean ± SD ECOG score was 1.2±1.0 (range 0-3) while the combined BNAT score was 15.4±6.5 (range 7-29). Mean BNAT score by diagnosis: P 16.6±7.4; B 13.0±5.5; & L 18.3±5.7. Spearman correlation analysis of BNAT and ECOG scores revealed a significant (p = 0.0001) negative correlation of agreement (r = -0.79). Both B and L cancers had significant (p < 0.05) correlation of agreement (B r = -0.71 & L r = -0.88). TAC correlation to ECOG was strongest in L group (r = -0.86), but 2MST was strongest for P group (r = -0.62). There was a reciprocal relationship of slopes between TAC and 2MST based on diagnosis. L steepest slope in TAC (-6.2 with deviation from 0, p = 0.014) while P had steepest slope with 2MST (-13.1). Slope for B group consistently fell between the 2 other diagnoses. Conclusions: There was a strong linear relationship of BNAT, TAC & 2MST to ECOG scores across the 3 cohorts of diagnoses. The BNAT subcomponents have varying degrees of contribution to the total that can be attributed to diagnosis-related functional deficits, thus giving providers information to determine appropriate care.
Identifying delays in care for patients with NSCLC using value-stream mapping.
Authors: Cummings Chad W. , Habecker Becky , Tullio Katherine , Rothacker Andrew , Pennell Nathan A. , Videtic Gregory M.M. , Raymond Daniel , Mazzone Peter J. , Ibsen Alison 
Published: September 2018

136 Background: Value-Stream Mapping (VSM) was employed to evaluate non-value added activities focused on minimizing time between pathological diagnosis and first treatment (Time-To-Treat or TTT). Objective is to identify unnecessary delays in care for NSLC patients treated at a large academic medical center. Methods: A total of 253 patient records were examined between 1/15/2015 and 7/19/2016 and divided into stages: Stage I (Non-Surgical), Stage I-II (Surgical), Stage III, and Stage IV. Selection criteria required a min. of 50 patients/stage, including internally and externally diagnosed patients. A VSM was developed for each stage. Spreadsheets were used to detail dates and sequences of events, including consults, E&M visits, imaging, procedures, and testing. Results: Overall TTT results by stage (median days) are as follows: Stage I (Non-Surgical) = 46 days (n = 55), Stage I-II (Surgical) = 35 days, n = 50), Stage III = 34 days (n = 71), Stage IV = 19 days (n = 77). Consults were reviewed among 4 specialties (Med/Onc, Rad/Onc, Surgical, Pulmonary), revealing Pulmonary Consults most common regardless of stage, 38%, 40%, 49%, 29%, respectively. It was found consults among specialties were rarely coordinated (stage III: 11/70 patients had consults same day between 2 specialties). Bronchoscopy procedures were most common method of Dx; sampling (n = 60, all stages) revealed MD orders are placed within 1 median day for each stage (15% ≥ 5days), but lead time to procedure ranged 7-12 median days depending on stage. Comorbidities for surgical patients (n = 46) were reviewed and found TTT delays correlates with number of comorbidities and FEV1 test results. Interventions included weekly, multi-disciplinary identification and review of patients across the 4 specialties, development of a TTT visual dashboard, and creation of communication standards across specialties. Conclusions: A VSM will identify areas where excessive delays occur. Opportunities exist to combine activities (same-day appointments/consults), reduce delays between activities, and/or improve communication. Decision-making can be accelerated when time between events (consults, staging, procedures, and tests) is minimized, regardless of diagnosis origin.
Optimizing the use of trimethoprim-sulfamethoxazole for prevention of PCP and opportunistic infections in allogeneic hematopoietic cell transplant recipients.
Authors: Baneman Emily , Kim Nina , Rana Meenakshi , Renteria Anne Sigrid , Steinberg Amir S. , Jakubowski Rita M. , Yum Kendra , Saunders Patricia , Jacobs Samantha 
Published: September 2018

138 Background: Trimethoprim-sulfamethoxazole (TMP-SMX) is preferred for prevention of Pneumocystis pneumonia (PCP), toxoplasmosis and other opportunistic infections after allogeneic hematopoietic cell transplantation (HCT), but it is often withheld due to potential adverse events (AE). From July 2016-June 2017 we observed that 31% of allogeneic HCT recipients at our hospital were prescribed TMP-SMX throughout the high risk period (day +30-180). Therefore, we developed an intervention to explore reasons for such a low prescription rate and to optimize TMP-SMX use. Methods: Our institution’s HCT practice guidelines were revised to include indications for TMP-SMX and alternative agents for PCP and Toxoplasma prophylaxis and specific clinical and laboratory criteria for withholding TMP-SMX. Education on the guidelines was provided to transplant clinicians. Outpatient encounters were prospectively audited from January to April 2018. Providers received real-time feedback with recommendations in accordance with our guidelines prior to patients’ visits. Results: We reviewed 321 outpatient encounters among 112 patients. Seventy-six (68%) patients were on TMP-SMX prophylaxis at the first reviewed encounter. Cytopenias were the most common reason for withholding TMP-SMX, occurring in 50 (57%) encounters, followed by elevated liver function tests (LFTs) (13.6%), hyperkalemia (3.4%), elevated creatinine (3.4%), rash or hypersensitivity (3.4%), and unknown/other (22%) . In 73 encounters in which patients received alternative or no PCP prophylaxis, we recommended changing to TMP-SMX. This intervention was accepted in 15 patients, 11(73%) of whom tolerated TMP-SMX well. In the remaining four patients, TMP-SMX was subsequently discontinued due to unrelated AE (N = 3) and possible TMP-SMX-associated elevated LFTs (N = 1). Conclusions: Provider education and real-time feedback led to increased utilization of TMP-SMX for prevention of PCP and other opportunistic infections in HCT recipients without an increase in TMP-SMX-related adverse effects. Further study is needed to understand the low clinician acceptance rate of the intervention.
Strategies supporting reduced hospitalization rates in a successful OCM practice.
Authors: Mendenhall Molly , Sheldrick Amy , Dyehouse Karyn M. , Guinigundo Andrew S , Waterhouse David Michael 
Published: September 2018

139 Background: Team-based implementation of care is a foundational tenant to reducing avoidable ER visits and hospitalizations. This care strategy supports the OCM mission of improving quality and reducing cost through practice transformation. Methods: Comprehensive care team: Physician, Advanced Practice Provider, Nurse Navigator, Financial Navigator, Phone Triage Nurse; Consistent Message: “Call Us Early – Call Us First” campaign. Verbal and written instructions at all staff member touch points, emphasizing patient responsibility to call before going to the hospital; Supporting infrastructure: 2-hour teaching visit with the entire care team prior to all new treatments; Triage Phone Unit, COME HOME (Barbara McAneny, M.D.) triage pathways – 38 symptom and 27 symptom f/u pathways modified; Blocked time-slots at all offices for same-day APP triage appts; Proactive ER and hosp f/u calls. Results: 2017 phone triage data: 9,841 total symptoms calls. 2,476 same day visits. 338 ER saves. 67 ER f/u calls (Nov/Dec 17’ only). OCM pt survey scores improved and internal Netpromoter scores remained stable. Conclusions: A comprehensive team-based patient navigation strategy, supported by consistent “Call Us First” messaging, symptom pathways and same-day patient access, resulted in decreased hospitalization without commensurate increases in ER visits or 24hr observation stays. Pt satisfaction was not impacted negatively. [Table: see text]
Assessing the appropriate utilization of the palliative care service by the Carol and Ray Neag Comprehensive Cancer Center at UConn Health.
Authors: Stoute Trena , Loschiavo Sarah , Hook Karen 
Published: September 2018

144 Background: The American Society of Clinical Oncology recommends initiation of palliative care concurrently with active treatment within 8 weeks of advanced cancer diagnoses. We studied the referral practice in our institution. Methods: We reviewed charts of all outpatients seen between June and November 2017 with a diagnosis of leukemia or breast, thoracic, head and neck, pancreas, and prostate malignancies. Data collection included: diagnosis, stage, age, race, gender, deceased/alive, lines of therapy, referral to palliative care, time to referral, reason for referral, time from referral to death, referring provider, inpatient/outpatient, follow up visits, hospitalizations, time from chemotherapy to death, referral for services, social worker referral, and insurance type. Patients with incomplete records were excluded. Fisher’s exact test and Wilcoxon rank-sum test were used to compare groups. Results: Of the 174 eligible patients, 49 (28%) were referred to Palliative Care. Only 22% of patients were referred within 8 weeks of diagnosis. The most common reason for referral was pain management; with the least common being goals of care. Women were more likely to be referred than men, 38% vs 22% (p = 0.035). The mean [SD] age was 63.9[14.7] years. By stage, 96% of patients had stage IV disease and the only stage III patients were those with lung cancer. Amongst stage IV cancers, breast and lung cancer had the highest referral rate, each 50%, with prostate cancer having the lowest at 5% (p < 0.001); despite prostate cancer being the most common diagnosis. There were more referrals to hospice (24% vs 6%; p = 0.002) and home palliative care (16% vs 1%; p < 0.001) in the group referred. The mean [SD] time (weeks) from last chemotherapy to death was shorter in the group referred 6.51[4.19] vs. 16.3 [11.29] (p = 0.037). There was no difference in referral rates to home care (p = 0.192), based on insurance type (p = 0.683) or race (p = 0.647). Conclusions: Referral rates in this analysis did not achieve the recommended guideline standards. Additional educational interventions are planned to identify and overcome barriers to referral.
Cancer survivorship care plans time and effort.
Authors: Begnoche Megan , Higel-Mcgovern Camille , Szymanski Tara , Korber Susan F. , Fenton Mary Anne 
Published: September 2018

146 Background: The Lifespan Cancer Institute (LCI) is one program based at three hospitals in the Lifespan healthcare system, a main teaching affiliate of Brown Medical School. All sites are ASCO QOPI certified. In 2017, 1,742 patients from radiation, surgical, and medical oncology were diagnosed and/or treated for cancer. The Commission on Cancer guidelines specify patients with a new diagnosis of cancer treated with curative intent receive a survivorship care plan (SCP) within one year of diagnosis extended to 18 months for those receiving hormone therapy. Methods: The LCI Quality team is a multidisciplinary group comprised of nursing, leadership, physicians, midlevel providers, administrative assistants, and tumor registry staff. Our Quality Improvement Project for 2017 was generation and distribution of survivorship care plans to 50% of eligible patients. Our project underwent 5 plan/do/study/act cycles (PDSA). Prior to the intervention only 271 care plans were prepared and delivered for 2016 diagnoses. Results: For the total 2017 diagnoses, 843 eligible patients were treated within the LCI (medical and radiation oncology). Survivorship Care plans completed by midlevel providers were generated and distributed to 100% of LCI patients during January -April 2018 (244 in total), a 37% increase compared to the same timeframe, one year previous. The electronic medical record provides tools for SCP preparation including auto population of demographics and chemotherapy plan. Staging, radiation, and surgery are manually entered. On average, each SCP required 1 hour to complete for approximately 244 hours of midlevel provider time for January -April 2018. This abstract’s time and effort does not include the time for patient calls, survivorship visits or administrative monitoring. Conclusions: Survivorship care plans provide patients and primary care providers a summary of the treatment plan and recommendations for follow up/survivorship goals in transitions of care. Significant time and effort is required to generate an individual SCP therefore the goal should be to increase electronic efficiencies within the medical record, and focus on the clinically relevant patient population who are most likely to survive 5 years and be impacted by diagnosis and treatment.
Implementation of a regional structure across an oncology collaborative quality initiative and the impact on physician engagement.
Authors: Beusterien Samkeliso , Bedard Louise , Griggs Jennifer J. 
Published: September 2018

149 Background: The Michigan Oncology Quality Consortium (MOQC) is a statewide collaborative quality initiative (CQI) sponsored by Blue Cross/Blue Shield of Michigan. The consortium uses Quality Oncology Practice Initiative (QOPI) measures to identify gaps in care and opportunities to improve quality. Data are collected on patients regardless of payer. MOQC includes nearly 90% of eligible medical oncologists (n = 364) in Michigan. We describe physician engagement within MOQC and quality improvement efforts after implementation of a regional structure in the CQI. Methods: The MOQC regional structure was introduced in Spring 2017. Forty-eight practices self-selected into 6 regions roughly by geographic location. Beginning in Spring 2017, a physician from each practice was required to attend both the Spring and Fall Regional Meetings and encouraged to bring an additional representative (e.g. administrative leader) from their practice. Regional meetings were facilitated by the MOQC Coordinating Center. Within each region, practices selected to work on one measure from a finite set of QOPI measures. and shared best practices gleaned from their quality improvement work, according to the Plan-Do-Study-Act cycle of quality improvement. We report on our primary outcome, the change in physician engagement, defined as attendance at biannual MOQC meetings (distinct from the Regional Meetings), before and after the introduction of the regional structure. Results: Provider engagement, measured by attendance at the biannual meetings increased from an average of 17.3 physicians in the 3 years before the introduction of the regional structure, to 33 physicians in the first meeting, and 22 physicians in the second meeting after the introduction of the regional structure. Conclusions: Implementation of a regional structure increased provider engagement, and provided a systematic approach to the launching of quality improvement efforts in an oncology CQI. Engaging providers at the regional level, which incorporates cultural aspects of geographically similar practices, may provide opportunities not otherwise recognized in larger consortia.
Pharmacy contributions to improving care and sustaining change in a comprehensive cancer center.
Authors: Brown Megan , Crosby David L. , Howe Megan H. , Dragnev Konstantin H. 
Published: September 2018

150 Background: Delivery of care in an outpatient hematology/oncology clinic is complex and requires the coordination of numerous services for timely and efficient treatment of patients. The Norris Cotton Cancer Center in Lebanon, NH, began a comprehensive assessment of clinic and infusion operations in 2012 and developed a system-wide initiative to address inconsistent performance in infusion, clinic and pharmacy services. Methods: Cancer center staff and leadership were trained on lean six-sigma methodology to initiate system-wide improvements through targeted project work. We collaborated with quality improvement experts and our analytics team to obtain and analyze data from our EMR. Then we established process measures for all operational areas and a key performance indicator (KPI) for hem/onc infusion: “on time performance.” The pharmacy contributed to on-time performance by focusing improvement initiatives on turn-around time (TAT) for clinical reviews and order verification, TAT for drug preparation, and initiating a process for pre-making chemotherapy. Results: "On-time performance” was initially defined as the percentage of patients whose first medication began within 45 minutes of their scheduled infusion start time. The baseline of 63% in 2012 was improved to 86% in 2018. Through sustained process improvement work and concerted efforts to further improve the patient experience and utilization of resources, an interdisciplinary team targeted a 15 minute on-time performance measurement; this baseline of 28% was improved to 47% in less than a year. In 2012 the pharmacy set a goal of reviewing and verifying orders within 30 minutes, and completing drug preparation within 45 minutes of order verification. The baseline percentage of orders reviewed within 30 minutes was 47% and this increased to 93% in 2018. Our baseline percentage of doses prepared within 45 minutes was 37% and the current median time for drug preparation across all orders is 45 minutes. The pharmacy currently pre-makes approximately 11% of doses. Conclusions: The cancer center pharmacy increased efficiency and improved on-time performance in delivery of care by using data-driven continuous improvement methods.