bluuebunny/crossref_metadata_2025_split huggingface dataset:
Introducing enhanced navigation and supportive care into the curative treatment of cancer (SCOOP pathway).
Authors: Koprowski Christopher , Johnson Ej , Trzepkowski Kenneth , Sites Karen , Petrelli Nicholas J. 
Published: September 2018

142 Background: We hypothesized that introducing supportive care management and enhanced electronic aids to nurse navigation in selective curative cases could result in cost savings and enhanced patient experience of the sort demonstrated in patients with advanced disease. Methods: To test this hypothesis, we introduced a clinical pathway in November 2016 called the Supportive Care of Oncology Patients (SCOOP) program. We limited the scope to patients receiving radiation and chemotherapy concurrently at the Helen F. Graham Cancer Center and diagnosed with potentially curable thoracic, colorectal or head and neck malignancies and seen in our mulitdisciplinary clinics (MDCs). 1. A nurse navigation check list was developed for nurse navigators in the Aerial information system to support standardization of care. The navigator has to opt out of ancillary service consults such as nutrition, behavioral health and social work. The check list includes other mandatory tasks that must be completed at various time points before, during and after the patient’s concurrent treatment. Examples include: Prescribed communication dates with the patient; capturing of scheduled consults; assessing additional/unmet needs before, during and after treatment phase. 2. A mandatory supportive and palliative care service screening during the MDC visit, and, if indicated, urgent or timely consultation. 3. Flags in the inpatient information system that alert in real time the supportive care service, the navigators and the oncologists whenever a patient is seen in the emergency room, admitted or discharged. Results: During the first year nurse navigation compliance increased from 94% to 99%.ED visits declined from 54% to 32% of SCOOP patients , admissions from 34% to 25% and readmissions from 32% to 20% . Opportunity cost savings were $1500.00 per patient. Conclusions: Much like the results observed in advanced disease, the early introduction of enhanced nurse navigation and palliative/supportive care in high acuity patients treated curatively improves the patient experience and reduces societal costs.
Addressing advance directive completion rates on an inpatient oncology unit.
Authors: McInnes Susan , Dhingra Navin 
Published: September 2018

147 Background: Advanced directives (ADs), particularly heath care power of attorney (HC-POA), are not always obtained or documented for patients with cancer. Hospitalized cancer patients may become too ill to complete them, making treatment decisions difficult. Understanding patients’ end-of-life preferences and providing care congruent with their values is fundamental to quality care. Completing ADs is an important aspect of this process. However, AD rates for oncology patients are typically under 40%. Our team sought to measure and increase our oncology inpatient AD rates. Methods: An interdisciplinary group including oncology and palliative medicine physicians, nurses, social workers, care managers and quality leaders convened to address ADs on our inpatient oncology services as a quality improvement project. We completed a current state analysis, evaluated areas of wasted or redundant workflow and performed a root cause analysis, identifying 4 countermeasures: 1) educating patients and staff re the value of completing HC-POAs, 2) clarifying the role of each team member, 3) implementing a discussion script for HC-POA conversations and 4) tracking and reviewing HC-POA completion in daily multidisciplinary rounds. AD completion rate by discharge was collected weekly through the 12-week project (325 discharges) then monthly for 6 months (709 discharges.) Results: Our baseline HC-POA rate was 30% for hospitalized oncology patients. Completion increased to 39% with education, role clarification and use of a discussion script. When daily tracking was initiated with the entire care team, including medical oncology staff, fellow and residents, the AD rate increased as high as 65%. This model was implemented as a best practice and has been sustained with AD completion rates of 45-60% in the subsequent 6 months. Conclusions: Our interventions successfully and sustainably increased HC-POA completion rate by engaging the entire interdisciplinary oncology team around the need for HC-POA documentation. We standardized team communication about ADs into daily workflow in interdisciplinary rounds. This increased the comfort level of the entire team and normalized discussion of HC-POAs, contributing to increased AD completion.
Examining patient burden and drivers of delayed care in patients undergoing surgical treatment of primary lung cancer.
Authors: Barnhill Caleb , Hillenbrand Charles , Kaplan Stephen , Kuppusamy Madhan , Hubka Michal 
Published: September 2018

153 Background: Patients’ geographic location can impact access to specialty care and affect the appropriateness and timeliness of evaluation leading to primary surgical treatment of lung cancer. Cancer care coordination has long been speculated to lead to greater efficiency in oncologic care, yet objective measures demonstrating the utility of such healthcare team members is lacking. We aimed to study the impact of patients’ residence on healthcare encounters, travel burden and the distribution of physiologic and oncologic workup leading to delays in care at a specialty cancer center. Methods: We conducted a single center retrospective cohort study of 103 patients undergoing workup of primary lung cancer between January 2015 and August 2017. The shortest route between patient residence and treating medical center was measured in miles and classified as: urban ( < 40 miles); rural (40.1 – 100 miles); and regional (100.1 – 1,000 miles). Average total miles traveled (i.e. travel burden), total number of healthcare encounters, and the distribution of physiologic and oncologic evaluations as drivers of delay in care were examined. Results: Patients were categorized as urban n = 80 (77.7%); rural n = 12 (11.7%); and regional n = 11 (10.7%). Median travel burden (urban = 100 miles [interquartile range, IQR 56-216.8]; rural = 385.7 [127.1 – 769]; regional = 780 [560 – 1936]; p < 0.001) and median total healthcare encounters (urban = 7 [6-9]; rural = 9 [7-9.5]; regional = 10 [7-12]; p = 0.3) increased with greater distance of patient residence from treating medical center. Additional necessary physiologic workup was associated with delayed care and greater burden in the rural and regional patients compared to those residing in urban locations (urban = 21% increase; rural = 152%; regional = 162%). Additional oncologic workup was associated with delayed care in the regional group only (49% increase). These trends remained even when controlling for clinical stage. Conclusions: These findings demonstrate the need for better cancer care coordination for rural and regional lung cancer patients to improve efficiency, appropriateness and timeliness of care while decreasing patient-related burdens.
Quality of care during active surveillance in low-risk prostate cancer patients: A population-based approach.
Authors: Timilshina Narhari , Finelli Antonio , Tomlinson George A. , Sander Beate , Alibhai Shabbir M.H. 
Published: September 2018

16 Background: Active surveillance (AS) has become a widely accepted management strategy for low-risk (Gleason score ≤6) prostate cancer (PC). Given the large proportion of low-risk PC (60-90%) patients who currently receive AS, adherence to clinical guidelines on AS and variations in care at the population level remain surprisingly poorly understood. Further, it is presently unclear how often patients receive high quality AS care in community settings (almost all published data come from academic centers), yet the majority of AS occurs in community settings. Thus, there is significant interest in developing system-level quality indicators (QIs). We sought to develop structure-process-outcome-based QIs to enable benchmarking during AS follow-up using data available in Canadian administrative databases. Methods: We performed a detailed literature search on QIs in PC as well as broader theoretical concepts on QIs and consulted with clinical leaders from a major cancer centre. Current guidelines on AS and potential quality indicators were identified from a literature search. AS-specific QIs were tested among low-risk PC who were managed with AS between 2002-2011 using population-level cancer registry databases. We assessed adherence to clinical guidelines using QIs, and compared with health care system-related characteristics. Results: 25 indicators were proposed [structure of care (n = 5), process of care (n = 16) and health outcomes (n = 4)]. Overall 39% received AS, with 88% managed by a urologist. Only 43% of low volume (≤3 positive cores) patients underwent AS. Adherence of confirmatory biopsy with guidelines was performed on only 32% of patients, and adherence was better in higher volume institutions, among higher volume physicians, and in cancer centers. 5-and 10-year PC specific survival were significantly better among high volume physicians. Conclusions: We have proposed a set of QIs for measuring AS care. Initial data show that higher volume institution or higher volume physician and cancer center had better adherence to quality of AS care. Long term survival was better among patients treated by high volume physicians. Further validation of these QIs is ongoing.
Communication among oncology teams at an academic center.
Authors: Jensen Christopher Edward , Laughlin Amy Iarrobino , Landsburg Daniel Jeffrey 
Published: September 2018

166 Background: Effective communication is essential to ensure optimal care for oncology patients admitted to the hospital and safe transitions between care settings. Methods: A questionnaire adapted from the Collaboration and Satisfaction about Care Decisions survey instrument addressing inpatient/outpatient communication was sent to nurses and physicians who cared for patients admitted to the housestaff oncology services at the University of Pennsylvania from 10/2016-2/2017. Questions addressed care plan formulation, communication, and satisfaction with medical decision making on a seven-point Likert scale. Contextual interviews with stakeholders were also conducted. Iterative adjusted rounding pilots were implemented in PDSA cycles including rounding checklist, multi-disciplinary rounds and a two-step paging process to inform nurses of teams’ rounding times. Results: For 66 respondents, the ranges of mean score for each question by provider type were: oncology nurses (4.07-4.29, n = 28), medicine interns (4.33-5.11, n = 9) and residents (4.00-4.83, n = 12), oncology fellows (5.00-7.00, n = 1), and oncology attendings inpatient (5.56-5.89, n = 9) and outpatient (4.71-5.57, n = 7). Given the lowest scores among nurses, rounding interventions targeting nursing attendance on rounds were trialed. Baseline data demonstrated nursing presence on rounds for 47.0% (95% CI: 37.2-56.8%) of patients. During a pilot of the two-step paging process, the rate increased to 63.1% (55.6-70.6%; p = 0.01 for two-sided Z test). A balancing metric of time per patient did not vary significantly before and during the pilot process. Contextual interviews surrounding interventions suggested several barriers to systematically restructuring provider rounds: time limitations for team rounds, frequent rotation of providers and variations in rounding styles as dictated by attending physicians. Conclusions: Satisfaction regarding the care of acutely ill oncology patients appears to negatively correlate with face-to-face time spent with patients in the inpatient setting. These findings provided the basis for a series of pilots of modified rounding models with a focus on integrating nursing staff into provider rounds, which have been difficult to sustain
Survivorship: The UHealth patient experience.
Authors: Vazquez Adrienne Marie , Trivedi Chinny , Amoros Annette 
Published: September 2018

183 Background: The University of Miami has a formal Survivorship Program based on the Commission on Cancer (CoC) requirements. CoC requires accredited institutions to deliver survivorship care plans (SCP) to patients who fit analytic criteria. There is a lack of research on the patient experience as it pertains to survivorship care. Methods: Using a Likert-type scale, dual language survey (English and Spanish), patients were asked 6 questions about the Survivorship Clinic visit ranging from scheduling feasibility to information received during the visit and any opinions to improve the visit for future patients. Patients were given two weeks to complete the survey through a secure, HIPAA compliant online source (REDCap). Those who did not reply were called on the phone by a registered nurse to obtain a statistically significant sample size. Results: Of the 236 patients that were contacted, 45 responded (Breast 38.3%, Gastrointestinal 12.8%, Prostate 10.6%, Gynecologic 8.5%, Lymphoma 6.4%, Lung 6.4%, Sarcoma 4.3%, Other 12.8%). Our results found that 95.7% of patients would recommend this visit to anyone who has completed cancer treatment. Also, 59.6% of patients found the SCP to be most helpful, followed by Survivorship Provider input (38.3%) and then American Cancer Society Healthy living tips (36.2%). As a note, it was mentioned in free text that 11.1% would have preferred a similar visit at the beginning of treatment, at the completion of treatment and/or incremental follow up. Of those surveyed, 88.9% were referred to nutrition, 44.4% to exercise physiology and 27.8% to psychology/psychiatry. Conclusions: Of the patients surveyed 95.7% were satisfied with the survivorship visit. Our conclusion based on survey results shows that institutions should continue to provide formal survivorship care as per CoC requirements. Future directions should look at expanding services to patients at diagnosis and throughout the continuum of treatment and follow up. As survivorship programs grow, practices should consider increasing resources to accommodate the identified needs of patients at the beginning and end of cancer treatment.
Experience and outcomes of the Acute Leukemia Shared-Care Program.
Authors: Wong Amanda , Wong Audrey , McKay Cassandra , Maguire Bryan , Mozuraitis Mindaugas , Wang Jonathan , Maki Kim , Hertz Sherrie , Kouroukis C. Tom , Costello Judy 
Published: September 2018

184 Background: Acute leukemia (AL) is a rapidly progressive disease requiring timely and intensive treatment. Historically, care for approximately 50% of AL patients in Ontario, Canada has been centralized resulting in significant resource pressures at the specialized center and travel pressures on patients and caregivers. The AL Shared-Care Program was launched in 2014 to enable delivery of appropriate portions of care at an AL Service Site and Partner Cancer Center closer to the patient’s home. Methods: The impact of the Program was evaluated through provider interviews (n = 22) and the Patient Experience Survey which included 20 non-shared-care (control) and 26 shared-care (intervention) patients. A retrospective analysis of 332 control and 70 intervention patients was used to evaluate the Program’s impact on travel, survival outcomes, and resource utilization. Results: Retrospective analysis revealed that an average intervention group patient saved a median round trip travel distance of 115 km [IQR: 88-179] and time of 91 min [IQR: 62-141]. 91% of health care providers reported that the Program provided person-centered care. Patients reported positive experiences with no statistically significant differences between the intervention and control groups in coordination of care (81% vs 90%, p = 0.39), overall care (88% vs 100%, p = 0.12), and experience (85% vs 90%, p = 0.60). There was no statistically significant correlation between patient satisfaction scores and patient-reported health status (r = 0.10, p = 0.51) and state of health (r = 0.03, p = 0.87). There was no significant difference in survival between groups (HR = 0.73, 95% CI [0.49, 1.13], p = 0.16). Finally, system cost estimated based on emergency department visits, admissions for febrile neutropenia, and follow-up clinic visits showed that there was no statistically significant difference in average monthly cost per patient between the intervention and control groups ($943 vs $1,197 respectively, p = 0.48). Conclusions: The AL Shared-Care Program reduced the travel burden for patients and caregivers without negatively impacting provider and patient experience, survival and system costs. Findings of this work will support the expansion of the Program to additional sites.
Integrating patient-reported outcomes data into the electronic health record.
Authors: Bosch Brandon , Hartman Scott , Caldarello Lauren , Denny, DBA Diane 
Published: September 2018

186 Background: As a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer, the network was an early adopter of using patient reported outcome (PRO) data as part of its routine patient assessment and treatment. Since 2012 an externally validated tool has been used to capture patients’ perceived symptom burden for real-time clinical intervention, from the point of first visit throughout the course of treatment, at intervals of 21 days or greater. Research has demonstrated the use of PRO data as a valuable component of a patient’s treatment plan, promoting improved quality and length of life. Methods: The use of this data across the network was expanded such that results once only accessible on paper and via electronically stored images, has now been fully integrated into the electronic health record (EHR). A multidisciplinary project team formulated the specifications for a successful integration of PRO data into the EHR. Results: The project achieved its goal and went beyond data integration to include implementation of a solution to facilitate documentation of intervention against patients’ symptoms. Provider workflow efficiency is greatly enhanced via single system access and visual notification, with critical values flagged, to focus providers’ attention on severe symptoms. Incorporation of a unified EHR flowsheet provides a paperless, one-stop symptom assessment approach and streamlined mechanism for intervention documentation. The documentation module leverages structured data fields and linkage of PRO data with interventions, such as specialist referrals or medication orders, to support enhanced patient care and quality improvement. Conclusions: The ability to easily view an array of patient reported concerns and document interventions against severe or significantly worsening symptoms provides clinicians an enhanced ability to address quality of life related needs. PRO data is now stored electronically in the enterprise warehouse, thus enabling aggregation with data from which to perform population analysis and eventually, pursue opportunities for predictive modeling.
Impact of diabetes and hyperglycemia on health care utilization, infection risk, and survival in patients with cancer receiving glucocorticoids with chemotherapy.
Authors: Zylla Dylan M. , Gilmore Grace , Eklund Justin , Richter Sara , Carlson Anders 
Published: September 2018

19 Background: Glucocorticoid (GC) use is commonly used in chemotherapy regimens and may lead to hyperglycemia and increased infection rates. We assessed the impact of diabetes (DM) and hyperglycemia on rates of health-care utilization, infections and survival among patients with cancer receiving chemotherapy. Methods: We performed a retrospective analysis on 1,781 patients who received intravenous chemotherapy with GC between 2010 and 2015. Demographic, clinical, and health-care utilization (HCU) data was obtained using electronic medical record, billing modules, and the tumor registry; HCU included tallies of emergency room, urgent care, and inpatient visits. Logistic regression models were used to compare survival and new infections between patients with and without DM, after adjusting for demographic and cancer-related variables. Results: In the first 12 months following chemotherapy, patients with DM (n = 330) had higher rates of hospital admissions (70.9% vs 57.4%, p< 0.001), more infection-related admissions (37.0% vs 29.2%, p = 0.007), and increased rates of new infections (61.2% vs 49.2%, p < 0.001) when compared to patients without DM (n = 1,451). One-year survival rate was worse among patients with DM (67.3% vs 78.3%, p < 0.001), as well as patients with at least one glucose reading above 300 mg/dL following chemotherapy (60.8% vs 78.5, p < 0.001). After adjusting for cancer stage, age, and gender, we found DM history increased the odds of dying within one year after diagnosis by 86% (OR 1.86, 95% CI (1.37  2.52), p < 0.001) and of new infections by 68% (OR 1.68, 95% CI (1.26  2.24), p < 0.001). Conclusions: Among patients with cancer receiving intravenous chemotherapy with GC we demonstrate patients with DM have more hospital admissions, increased rates of infections, and worse survival. Prospective studies are urgently needed to elucidate what level of glycemic control is needed to potentially improve outcomes for patients with DM receiving chemotherapy with GC.
Development of a PREM for acute leukemia and/or stem cell transplantation.
Authors: Bridge Erica , Dhanju Suman , Smith Andrea , Singh Simron , Moody Lesley 
Published: September 2018

195 Background: People with complex hematologic malignancies (eg. acute leukemia) require highly specialized care from the time of initial diagnosis, throughout treatment and into survivorship. Often, stem cell transplantation is an essential component of treatment for some people with complex hematologic malignancies. A challenge with generic patient-reported experience measure (PREM) tools is that they do not capture areas of concern for a specific population, which was the case for people with complex hematologic malignancies. Therefore, a disease-specific PREM was developed to address relevant aspects of the patient experience. Methods: The development consisted of:1)literature review to identify relevant patient experience items;2)modified Delphi process where patient experience items were rated by experts (n = 10); 3)cognitive interviews (n = 8) to ensure that items were clear and understandable; and 4)pilot of survey. Results: Through the review of literature, two existing PREMs were identified as relevant for this patient population and potential items were extracted:1)the Ambulatory Oncology Patient Satisfaction Survey (n = 90); and2)the Canadian Patient Experience Survey – Inpatient Care (n = 44).The modified Delphi processes consisted of three rounds (an online survey and two in-person meetings to discuss results), which resulted in 73 items being eliminated and 29 items being added.A 90-item PREM was utilized for the cognitive interviews with patients and/or family members, where 14 items were removed and 6 items were added. Conclusions: The PREM was named Your Voice Matters-Acute Leukemia and Stem Cell Transplant, and includes 82 items for measuring the patient experience of complex hematologic malignancies.Surveys were distributed via mail to eligible patients from 10 Regional Cancer Centres in Ontario, Canada in May 2018.Results are anticipated for August 2018.