bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patient-centered cancer care (PCCC) as a roadmap to success in Alternate Payment Model (APM): A case study-based learning.
Authors: Patel Kashyap B. , Clinton Natasha 
Published: September 2018

318 Background: Cancer care is among the fastest-growing segments of the US healthcare system. In the US, total spending on cancer care has increased to $124 billion in 2010. Total costs of cancer care for the US population are predicted to increase across all phases of care. One possible way to reduce overall cost, improve patient experience, and improve outcomes is to shift care away from volume and towards value. Patient-centered cancer care (PCCC) holds the promise of addressing these issues. The Oncology Care Model (OCM), developed by CMS’s Center for Medicare & Medicaid Innovation (CMMI), is a pilot designed to assess the efficacy of PCCC for Medicare beneficiaries over the next 5 years. Our practice participates in the OCM model. We share our practice transformation into PCCC reducing cost, reduce ER visit and improve patient experience. Methods: At CBCCA, we transitioned to PCCC center for accreditation as a Patient Centered Specialty Practice (PCSP) through the National Center for Quality Assurance (NCQA). Our path for PCSP primed us for the OCM with expanded access (including same-day appointments and weekend access), reduced ER visits and hospitalizations. We predicted that transition to PCCC would lower expenses, improve the patient experience, and likely improve outcomes. Based on our projected savings with the delivery of PCCC, we expected CMMI to save about a million dollars. Upon receiving reconciliation reports from CMMI, we were pleased to see that our projections were well within the actual outcomes of savings. Results: Pursuant to our transition to PCCC we were able to reduce ED visits by 40%, hospital stay by 20%, Observation unit stay by 45%, stay in long term care unit by 40% and home health visits by 24%, resulting in overall savings to over $500,000 savings to CMS. Our patient satisfaction survey was in 75% across major parameters. Conclusions: PCCC transition is a viable option for physicians to reduce overall cost, maintain or improve outcomes and patient experience. OCM is the first major initiative that will likely validate journey towards value-based care. Close to 25% of all practices have achieved target savings.
Using Best Practice Advisory alert to increase early advanced care planning discussion and palliative care referral in advanced cancer patients.
Authors: Pandya Chintan , An Amy , Duberstein Paul , Dougherty David W. , Noel Marcus Smith 
Published: September 2018

320 Background: Patients with advanced cancer can benefit from early initiation of palliative care (PC) and advanced care planning (ACP). In theory, the Medical Order for Life-Sustaining Treatments (MOLST), which provides a vehicle for end-of-life discussion, could lead to improved uptake of ACP and PC. In order for MOLST forms to influence these care process outcomes, methods are needed to help clinicians introduce the forms to patients in a compassionate manner. The objective of this study is to develop a best practice advisory (BPA) alert in the electronic medical record (EMR) to help oncologists identify appropriate patients for ACP and PC referral and evaluate its impact on improving MOLST form and palliative referral order documentation in EMR for these patients. Methods: BPA alert criteria included Lung and GI cancer patients with stage IV disease or undergoing treatment with palliative intent. The oncologists could act on the alert by either acknowledging it with action statement (I have already discussed ACP, I intend to discuss ACP in this or next visit, Patient unlikely to die in next 12 months, other) or dismiss it. We examined the rates of MOLST form and PC referral orders in the EMR 12-months before and after the BPA was implemented in 03/2018. Results: The BPA fired in 424 patients who met the criteria over a period of 9 weeks. It was acknowledged in 409 and cancelled in 15 patients. Following the alert, 40 (9%) patients had a MOLST form added to the chart compared to only 9 (2%) patients before the alert and 17 (4%) patients had palliative care referral order placed vs. 10 (2%) patients before the alert. Physicians acknowledged discussing ACP in 145 patients, most of whom (25/30) initiated these conversations after the BPA was implemented. Data collection is ongoing to capture BPA effect for longer follow-up. Conclusions: The BPA alert intervention resulted in significant increase in documentation of ACP and palliative referral order suggesting the potential of this tool in improving adherence to national guidelines calling for early initiation of palliative care and advance care planning in patients with advanced cancers.
Best practice alert and cost transparency information for high cost oncology medications.
Authors: Cinar Pelin , Lin Tracy , Rodondi Kevin 
Published: September 2018

323 Background: Oncology medication cost is often absent from therapy decision process until issues arise with payer denial resulting in potential patient financial toxicity. To incorporate cost, Best Practice Alert (BPA) and Cost Transparency Information (CTI) for high cost oncology medication (HCOM) were implemented into prescribing platform as care coordination tools. Methods: Ten HCOM were identified in gastrointestinal (GI) and breast oncology groups for which BPA and CTI were developed. Over a 6 month period, HCOM prescriptions triggered BPAs to alert providers and to place automated referrals to social work (SW). CTI – with drug costs and comparable treatment plan(s) – were posted in prescribing platform. Descriptive analyses examined differences in total payment to hospital and patients out-of-pocket payments (OPP) between treatment plans. Pre- and post-intervention surveys evaluated oncologists’ perception and behavior toward treatment cost. Results: The analysis included 162 patients and 1406 medication claims. In the GI group, BPAs effectively identified treatments incurring higher mean total payment (diff = 46733, p < 0.001) and higher mean OPP (diff = 115, p < 0.001). For the breast group, the impact was mixed. BPAs identified treatments with higher total payment at the 90% quantile (p < 0.001) and higher mean total payment (diff = 72612, p < 0.001), but there was no statistically significant difference in OPP between treatments. Pre-intervention survey (n = 26, 50% response rate) indicated 46% of oncologists rarely discuss medication cost with patients and 35% rarely refer patients to SW. Only 4% of oncologists strongly agreed that they could easily acquire cost information. Post-intervention survey highlighted that CTI improved oncologists’ awareness of medication costs, but BPA exerted no substantial influence on provider behaviors. Conclusions: BPA intervention effectively highlighted treatment cost and accurately identified patients at risk for financial toxicity. The lack of statistically significant difference in oncologists’ behavior and perception may be due to a small sample size. Comments from providers suggest that BPA combined with OPP would be more useful in reducing financial toxicity.
Impact of travel time on hospitalizations and patient cost responsibility by phase of care for older patients with cancer.
Authors: Williams Courtney , Kenzik Kelly , Pisu Maria , Ingram Stacey A. , Gilbert Aidan , Rocconi Rodney Paul , Rocque Gabrielle Betty 
Published: September 2018

37 Background: Healthcare reimbursement changes are contributing to increased closures of community hospitals and oncology practices, which may lead cancer patients to travel greater distances for care. Limited data exists on the impact of travel time on hospitalization rates and patient cost responsibility by phase of care for older cancer patients. Methods: This was a secondary analysis of Medicare claims from 2012-2015 for cancer patients age ≥65 receiving care in the University of Alabama at Birmingham Cancer Community Network. Patient addresses were obtained from network data, hospitalizations from inpatient claims, and patient cost responsibility from inpatient, outpatient, skilled nursing facility, carrier, and durable medical equipment claims. Drive time was calculated from patient home to cancer care site (CCS). Phase of care-specific (initial, survivorship, end-of-life [EOL]) rates of hospitalizations overall and by CCS vs. other care site (OCS) were calculated per 100 person-years. Hierarchical linear models compared average monthly phase-specific costs by drive time to CCS. Results: Of 23,605 older cancer patients, median drive time to CCS was 32 minutes (IQR 18-59), with 24% driving ≥1 hour to CCS. Rates of hospitalizations by initial (n = 14,225), survivorship (n = 18,805), and EOL (n = 8,211) phases of care were 54, 26, and 301 per 100 person-years, respectively. Higher rates of hospitalizations at OCS vs. CCS were shown for patients traveling ≥1 hour to CCS (initial, survivorship, and EOL rate of 41 vs. 20, 21 vs. 6, and 220 vs. 95 per 100 person-years, respectively). Median monthly costs by phase were $401 (IQR $182-$814) for initial, $369 (IQR $123-$1046) for survivorship, and $2075 (IQR $1123-$3723) for EOL. Patients traveling ≥1 hour to their CCS had higher cost responsibility, with patients in initial, survivorship, and EOL phases having $303 (95% CI $130-$476), $75 (95% CI $46-$105), and $736 (95% CI $308-$1164) higher average costs per month than those traveling < 1 hour, respectively. Conclusions: Cancer patients traveling further to receive care are potentially vulnerable to higher cost responsibility and limited access to care if community hospitals close, especially at EOL.
Using standardized electronic pathology data to identify practice variation, potential impact to patient outcomes, and quality improvement initiatives.
Authors: Kitchen Jessica , Sone Shaalee , Mukhi Shaheena , Argent-Katwala Mary , Srigley John 
Published: September 2018

45 Background: Practice variation in diagnosis and treatment exists between clinicians and regions across Canada. This variation can impact the quality of care that patients receive and affect patient outcomes. We aimed to gain a better understanding of the scale and type of variation between clinicians and provinces within the cancer system. Methods: Fifty pathologists, surgeons, and medical oncologists from 10 regions were convened to leverage literature and the College of American Pathologists data standards to create 48 indicators related to five cancers: breast, lung, colorectal, endometrial and prostate. Six months of synoptic pathology data were used to generate the indicators, which were reviewed by 65 clinicians to identify practice variation and potential quality improvement areas. Results: Five provinces generated 48 indicator data analyses. Practice and performance variation across five cancer sites and jurisdictions was found. For example, guidelines recommend examining at least 12 lymph nodes in colorectal cancer resections as this directly impacts staging, treatment and patient prognosis. Only one province met this guideline in 90% of cases. Another example is Lynch syndrome testing, a hereditary condition that increases the risk of developing multiple primary cancers – particularly colorectal and endometrial. The data showed unequitable access to screening with 0-70% of colorectal cancer patients aged ≤70 years and only 10-40% of endometrial cancer cases being screened for Lynch syndrome. The value of these indicators is enormous to inform potential training opportunities and set standards of care at the local or broader clinical governance level so that consistent, high-quality care is delivered in accordance with evidence-based guidelines. Conclusions: Practice variation exists between clinicians and jurisdictions. In two jurisdictions (200 pathologists), comparative pathology indicator data are being used to self-reflect and converse with peers with the goal of reducing practice variation and improving patient care.
Institutional adherence to National Comprehensive Cancer Network (NCCN) guidelines in neoadjuvant treatment of breast cancer and its correlation to outcomes.
Authors: Vaddepally Raju Kumar , Hejab Amal , Ali Haythem Y. 
Published: September 2018

47 Background: The aim of the study is to assess the adherence to National Comprehensive Cancer Network (NCCN) guidelines in the neoadjuvant treatment of breast cancer and evaluate its correlation to outcomes. Higher adherence rates correlate with improved survival and are a potential measure of the quality of care. Methods: We screened patients who were treated with neoadjuvant chemotherapy at our institution for the years 2015 & 2016, a total 46 patients met the criteria. To evaluate adherence we tabulated 8 adherence categories per NCCN. We then screened patients who were only eligible to receive the treatment specific to a certain adherence category. A total adherence rate was calculated by dividing the number of categories for which they underwent intervention by the total number of eligible adherence categories. Rates of pathologic complete response (PCR) and Breast Conservation surgery (BCS) were calculated to measure the outcomes. Results: We had 9 triple negative breast cancer (TNBC), 28 Her2 overexpression (Her2+) and 17 triple positive patients. We had 100% adherence in categories such as, appropriate pre-chemotherapy evaluation {total eligible patients, n = 46}, completeness of histopathology report (n = 46), use of anti-Her2 antibody drug in patients with Her2 overexpression positive by IHC or FISH (n = 28) and adjuvant radiation therapy (n = 39). In the following categories, adherence rates were as follows, 70% (n = 33) genetic consult, 69% (n = 32) reconstructive surgery, 65% (n = 46) cancer distress screen performed. We could not assess the adherence to reproductive gynecology consult. Our median total adherence rates were 85% for all of the adherence categories in eligible patients. We had PCR and BCS rates of 39% & 41% respectively. Further analysis showed PCR & BCS rates of 46% & 39% in Her2+ patients, 33% & 44% in TNBC patients, 35% & 38% in Doxorubicin treatment and 46% & 39% in anti-Her2 antibody treatment group respectively. Conclusions: Our study shows adherence to NCCN guidelines leads to improved outcomes. To improve quality of care, institutions should closely monitor the adherence to NCCN or other alternative national guidelines.
Pathology quality improvement in British Columbia using performance measurement and knowledge mobilization.
Authors: van der Westhuizen Nick , Lee Cheng-Han , Rabel Brigette , Young Katherine , Mukhi Shaheena 
Published: September 2018

54 Background: Pathology reporting content and formatting varies considerably in British Columbia (BC). The impact of this variability on the quality of care is unknown but it hinders effective data collection and measurement to guide quality improvement. A knowledge mobilization project that digitalized standardized reporting would ensure report completeness and generation of comparative performance data could be used within communities of practice to facilitate peer-to-peer conversations and create action plans to improve patient care. Methods: In 2014 BC adopted the College of American Pathologists cancer checklists as the standard for synoptic reporting using a single standalone electronic synoptic reporting program which interfaced with all five provincial laboratory information systems. Using the tool ensures all mandatory clinical prognostic indicators are reported. Discrete data elements were transmitted to a central data repository (CDR) which was mined to compile key performance indices reports for individual pathologists and generate comparative data reports at the institutional, regional and provincial level. Results: In the first six months of its implementation there was variation from 11-94% across different laboratories in their adoption of the reporting tool. The goal is to increase the average adoption rate from 76% to 90%. Analysis of data showed a highly comparable pattern of pathology practice across the major cancer sites/types and comparable to other Canadian provinces and the literature. Advisory committee reviews with interdisciplinary discussion of comparative data reports revealed potential areas for clinical improvement. For example, significant variation in the number of lymph nodes in colorectal resections was identified with some sites falling short of published recommendations. Conclusions: Population-based standardized digitalized pathology data reporting with centralized data collection can be achieved. Analysis of this data enables monitoring of performance metrics and meaningful discussions via communities of practice identify areas for quality improvement and create action plans.
Evaluation of the impact of a multidisciplinary intervention to increase pneumococcal vaccination rates in patients with advanced lung cancer.
Authors: Rostamnjad Leila , Goodwin Kelly , Temel Jennifer , Connolly Pamela , Zydel Julie , Blouin Gayle C. 
Published: September 2018

61 Background: National Comprehensive Cancer Network recommends pneumococcal vaccination for adults 19 years and older with cancer. Currently at Massachusetts General Hospital (MGH) pneumococcal vaccination is not part of routine cancer care. A vaccination quality improvement project was developed to increase pneumococcal vaccination in lung cancer patients. The primary objective of this evaluation is to assess the impact of a multidisciplinary intervention to increase pneumococcal vaccination in patients with advanced lung cancer receiving intravenous anticancer therapy. Methods: Thoracic oncology clinic schedule and patient electronic medical records were reviewed prospectively from 01/01/2018 to 05/31/2018 by the clinical pharmacist to identify patients with advanced lung cancer eligible for vaccination. Patients list along with recommended vaccine type and schedule was emailed by the clinical pharmacist to clinical team (oncologist, nurse practitioner and practice nurses). Practice nurses obtained immunization records for patients with non-MGH primary care providers. A designated thoracic oncology nurse practitioner ordered appropriate vaccines. Vaccinations were administered by infusion nurse. Results: 50 patients were identified as eligible for vaccination: 7 patients had history of receiving prevnar 13, and 9 patients had history of pnemovax 23. 34 patients had no prior vaccination history. Through this intervention, 10 patients completed vaccination with both prevnar 13 and pnemovax 23. 15 patients received one of the two recommended vaccines. 22 patients refused vaccination, and 3 patients died before their next scheduled infusion visit. Conclusions: Pneumococcal vaccination is recommended for patients with cancer prior to initiation or three months after completion of immunosuppressive therapies. However, it is not always feasible to vaccinate patients prior to start of therapy as delays in cancer care can lead to disease related complications. Incorporating multidisciplinary intervention to identify patients with advanced lung cancer who are candidate for pneumococcal vaccination can improve the adherence to the guidelines.
Timing of adjuvant chemotherapy administration for early breast cancer.
Authors: Salner Andrew L. , Smith Shelby , Yu Peter Paul 
Published: September 2018

62 Background: Adjuvant chemotherapy treatment has contributed to the reduction in cause-specific mortality from early stage breast cancer by reducing the risk of recurrence and metastasis. The initiation of adjuvant chemotherapy is typically started within 4-8 weeks following surgery. Although earlier treatment does not necessarily render a better prognosis, treatment delayed beyond 12 weeks may result in an unfavorable decrease in disease-free survival. In order to explore quality data for each of our 5 cancer centers and their breast surgeons, we conducted a quality outcomes project to examine our data and factors which could result in delay. Methods: We conducted a retrospective review evaluating all cases of patients diagnosed with stage 1 and 2 breast cancer at all of our cancer centers during the 2015 and 2016 calendar years, utilizing patient lists obtained from our cancer registries. Patients who received neoadjuvant chemotherapy or who had inadequate data were excluded. Variables included stage at diagnosis, percent of nodal positivity, age at diagnosis, race and ethnicity, attending surgeon, type of surgery (breast conservation vs. mastectomy +/- reconstruction), and number of days from final breast surgery to initiation of adjuvant chemotherapy treatment. Results: 757 and 319 patients with Stage I and II breast cancer respectively were identified in our 5 cancer centers. 16% had nodal positivity, and 25.6% received adjuvant chemotherapy. Average age at diagnosis was 62.5, and average age for node positive and adjuvant chemotherapy were 58.5 and 56.8. Days to chemotherapy ranged from 3-208, with 94% of patients treated in less than 12 weeks and ranges of mean days to begin chemotherapy 35.6 to 55.4 in our cancer centers. No significant differences were noted by age, race, ethnicity, stage, surgery type, surgeon, or hospital. Conclusions: This study reveals outcomes suggesting that our breast cancer teams at our cancer centers are meeting the current standard of care for initiation of adjuvant chemotherapy, and points to the value of quality studies in assuring standards of care.
Treatment patterns, toxicity, and outcomes of elderly patients with advanced pancreatic cancer receiving first-line chemotherapy.
Authors: Kudlovich Robert , Zhang Hanbo , Kim Christina , Dawe David 
Published: September 2018

71 Background: Advanced pancreatic cancer (APC) has a poor prognosis despite treatment with palliative chemotherapy. Randomized trials have demonstrated improved overall survival (OS) with combination chemotherapy including 5-fluorouracil, irinotecan, leucovorin, and oxaliplatin (FOLFIRINOX) or nab-plaxictaxel and Gemcitabine (NG) compared to Gemcitabine (GEM) alone, however, combination therapy is associated with higher rates of toxicity. There is limited data regarding the efficacy and toxicity of FOLFIRINOX, NG, and GEM in elderly patients with APC. Objective: Describe the treatment patterns, toxicity, and outcomes of patients ≥ 65 years of age treated with first-line palliative FOLFIRINOX, NG, or GEM. Methods: Patients ≥ 65 diagnosed with APC from 2012-2016 and treated with palliative chemotherapy in Manitoba were identified from the Manitoba Cancer Registry. Retrospective review identified patients who received first line FOLFIRINOX, NG, or GEM. Patient and treatment characteristics including hematologic and non-hematologic toxicities, dose reductions or delays, tumour response and survival were recorded. Results: 87 patients aged ≥ 65 received palliative chemotherapy: 52 (60%) FOLFIRINOX, 21 (24%) NG, and 14 (16%) GEM, with median ages of 69 (65-84), 75 (65-88), and 73 (67-82), respectively. More patients treated with FOLFIRINOX had an ECOG 0-1 compared to other treatments (p = < 0.001). There was no difference in hematologic toxicity according to treatment group (p = 0.807). There was more non-hematologic toxicity with FOLFIRINOX (p = < 0.001), particularly neuropathy (p = 0.008), fatigue (p = < 0.001), and nausea/vomiting (p = 0.008). Tumour response was highest with FOLFIRINOX (p = 0.005), with a trend towards improved survival compared to NG and GEM (median OS 267 vs 232 and 126 days, respectively, p = 0.057). Conclusions: Many older patients with APC received FOLFIRINOX, with more toxicity, but also greater tumour response and a trend toward improved survival. This suggests that selected elderly patients can tolerate first-line FOLFIRINOX. This may be also due to effective patient evaluation and appropriate assignment to different treatments.