bluuebunny/crossref_metadata_2025_split huggingface dataset:
Utilization of care at the end of life in Medicare decedents with advanced cancer.
Authors: Wallace Audrey S. , Williams Courtney , Pisu Maria , Oliver Debra Parker , Rocque Gabrielle Betty 
Published: September 2018

22 Background: Despite increasing evidence supporting minimization of aggressive care at the end of life, little literature exists reporting timing of chemotherapy and radiation in relation to hospice referral. Methods: Deceased Medicare beneficiaries age ≥65 years with stage IV cancer at 12 sites in 5 southeast US states were identified from 2012-2015. All utilization of radiation, chemotherapy, hospice, hospitalizations, and emergency department [ED] visits were abstracted and tabulated from Medicare claims during the last 6 months of life. Results: Among 3516 deceased patients, median age at time of metastatic disease was 73 years (IQR 68-79). Most patients were white (81%), male (55%), with two or more comorbidities (54%). The most common primary cancer sites were lung (38%), gastrointestinal (27%), and genitourinary (10%). In the last 6 months of life, 65% and 66% of patients visited the ED or were hospitalized; 11% received radiation and 28% received chemotherapy. Median days from last course of treatment to death for patients with chemotherapy (n = 978) was 45 days (IQR 23-83) and with radiation (n = 380) was 52 days (IQR 19-100). After completion of radiation, 54% of patients continued to receive systemic therapy. In subset analysis of patients with a hospice referral after final delivery of radiation and/or chemotherapy (n = 768), there was persistent late referral to hospice. Patients referred to hospice within 0-7 days of completing radiation or chemotherapy had similar median length of time on hospice when compared to those referred to hospice between 91-180 days after treatment (median 14 [IQR 4-35] vs. median 18 [IQR 8-43] days). Conclusions: In decedents with poor performing cancer histologies, low utilization of hospice and high rates of ED visits and hospitalization remain. Late referral to hospice persisted irrespective of last course of radiation or chemotherapy timing. High utilization of hospitalization and emergency visits at EOL may be ameliorated by earlier hospice referral.
Evolving best practice for take-home cancer drugs in Ontario.
Authors: Pardhan Aliya , Vu Kathy , Gallo-Hershberg Daniela , Forbes Leta Marie , Gavura Scott , Kukreti Vishal 
Published: September 2018

246 Background: Take-home cancer drugs (THCD) have become a standard treatment for many cancers and present opportunities and challenges for patients, providers and administrators. Ontario’s system has been described as two-tiered, with intravenous cancer drugs (IVCD) viewed as more comprehensive, organized, safer, and more patient-centred. Cancer Care Ontario (CCO) is the Ontario government’s principal cancer advisor. In April 2017, CCO established an Oncology Pharmacy Task Force to develop consensus-based recommendations on best practices for THCD to ensure that all patients are receiving consistent high-quality care regardless of the method of delivery of treatment. Methods: The Task Force included 34 members with representation from patient advocacy groups, pharmacy and pharmacist associations, regulatory and standard setting organizations, and subject matter experts. Standards, guidelines and recommendations from leading authorities were extracted by CCO’s Evidence Search and Review Service and synthesized by a core working group to develop 29 statements. The consensus process included a three-step modified Delphi method with two electronic surveys and a face-to-face meeting. Seventy percent agreement was required to include a recommendation. Thereafter, an extensive review process was conducted with relevant CCO programs and committees as well as subject matter experts, stakeholders and standard setting bodies at the local-regional and national levels. Results: Sixteen consensus-based recommendations were developed: training and education for providers (2); drug access (1); prescribing (4); patient, family/caregiver education (3); communication (1); dispensing (3); monitoring for adherence, identification and management of symptoms/adverse effect (1); and incident reporting (1) . This guidance will have most relevance for patients receiving THCD that require routine monitoring and for clinicians involved in delivering systemic treatment, and associated medications. Conclusions: Through the rigorous use of the Delphi technique, the Task Force developed a robust set of recommendations for THCD delivery in Ontario. Further work will be required to understand implementation enablers and barriers
Developing a standard approach to immune checkpoint inhibitor toxicity management in Ontario.
Authors: Crespo Andrea , Abella Lourdes , Baetz Tara D. , Gallo-Hershberg Daniela , Lakhani Nita , Leighl Natasha B. , Pasetka Mark , Seymour Lesley , Vu Kathy , Forbes Leta Marie 
Published: September 2018

255 Background: The use of immune checkpoint inhibitor medications (ICIs) in the province of Ontario, Canada has increased in volume by almost 4 fold between 2015/16 to 2017/18 and has expanded from use primarily in melanoma to lung, genitourinary, and other cancers. Lack of widespread clinical experience with ICIs and provincial variation in the management of the potentially life-threatening immune-related adverse effects (irAEs) was identified as a safety and quality gap. Cancer Care Ontario (CCO) set out to develop user-friendly health care provider and patient resources to facilitate a standard approach to ICI toxicity management in Ontario. Methods: A multidisciplinary working group of oncology clinicians with ICI experience reviewed available literature and current approaches to ICI toxicity management. An iterative consensus-building process was used to develop a practical guideline. This was circulated to an external expert review panel for content validity. Complementary patient/caregiver information was created based on best practices in health literacy and input from patient and family advisors. All resources were made publicly available via the CCO website and disseminated broadly to relevant stakeholders. Results: A user-friendly clinical practice guideline was created. It contains a description of irAEs associated with ICIs, guidance on the general management of irAEs, detailed algorithms describing the assessment and management of ten specific irAEs, and general considerations for patients on ICIs. A toolkit was developed with direct links to the algorithms, a customizable wallet card, a “Dear Healthcare Professional” letter template, and a patient information sheet. The guideline and toolkit webpages were accessed over 1500 times in the first month, suggesting that broad dissemination has been successful. Informal reports of guideline implementation were received from several Ontario hospitals. Conclusions: Careful analysis of the available literature and application of oncology professionals’ expertise resulted in evidence-informed, consensus-based practical resources to help facilitate safe, standardized ICI toxicity management across the Ontario health care system.
Safety and clinical efficacy of programmed cell death 1 antibodies (PD-1 Ab) in patients with advanced non-small cell lung cancer (NSCLC).
Authors: Ksienski Doran , Wai Elaine , Croteau Nicole , Lesperance Mary 
Published: September 2018

260 Background: In advanced NSCLC, clinical trials have shown significant benefits to pembrolizumab (P) and nivolumab (N). At BC Cancer, clinicians utilize protocol based algorithms to manage immune related adverse events (irAE). The incidence of irAE and efficacy of PD-1 Ab in everyday practice might differ from clinical trials. Methods: Advanced NSCLC patients (pts) treated with N or P between 11/2015 to 10/2017 at BC Cancer were identified. Demographic, tumor, treatment details, and frequency and grade (Gr, CTCAE v4.0) of irAE, were abstracted. Kaplan-Meier curves of median overall survival (OS) from initiation of PD-1 Ab were generated. Multivariable analysis (MVA) with 6-week landmark analysis was performed with Cox proportional hazard regression models. Results: Characteristics of cohort (230 N- and 41 P- treated): median age 64y (range 39-82), non-squamous histology 75%, ECOG PS > 1 at start of PD-1 Ab 31%, brain metastases (mets) 13%, liver mets 12%, and median Charlson Comorbidity Index (CCI) score 6. One hundred sixteen pts experienced 169 separate irAE: Gr1(74), Gr2 (68), Gr3(13), Gr4(10), Gr 5(4). Pneumonitis (14.6% vs. 4.8%, p = 0.041) and arthralgias (12.2% vs. 3.5%, p = 0.044) were more common in P than N. Steroids were administered to 25.2% of N pts and 19.5% of P pts (p = 0.557). Median follow-up from initiation of PD-1 Ab was 8.1months (range 0.1-33.9); median OS (95% CI) for N was 9.2 months (7.75-12.4) and for P was 13.5 months (10.6-not reached). 6-week landmark MVA for whole cohort revealed that male sex (p = 0.051), CCI≥3 (p < 0.001), ECOG PS > 1 (p < 0.001), liver mets (p = 0.017) and development of irAE > Gr2 versus no irAE (p = 0.036) were associated with decreased OS. Age, smoking status, histology, brain mets, EGFR status, irAE Gr 1/2 versus no irAE, and type of PD-1 Ab were not significant. Conclusions: Severe irAE were rare; pneumonitis and arthralgias were more common in P- than N- treated patients. The association with CCI, ECOG PS, and liver mets with decreased OS are consistent with literature. Association of severe irAE with shorter OS might reflect the need for improved physician education in irAE treatment algorithms.
Optimization of immune-related adverse event management in a thoracic oncology clinic.
Authors: Berwick Lexie , Rangachari Deepa , Costa Daniel Botelho , Sehgal Kartik , Shea Meghan 
Published: September 2018

261 Background: Improved awareness and management of immune checkpoint inhibitor (ICI) related adverse events (IRAEs) is a mandate for best practice given widespread use of ICIs in clinic. IRAE grading is standardized by the Common Terminology Criteria for Adverse Events (CTCAE); management has been standardized in recently published consensus guidelines. In the thoracic oncology clinic at the Beth Israel Deaconess Medical Center grading and management of IRAEs has been inconsistent. Methods: A retrospective review of 98 patients receiving ICIs in the thoracic oncology clinic from March 2015-April 2018 was conducted with a focus on IRAE grading and management. Oncologists were surveyed regarding barriers to grading, management, and subspecialty referral for IRAEs. We aimed to improve documentation of IRAE grading to 75% as well as the rate of specialist referral for grade 3-4 IRAEs. As an intervention we implemented a macro to document IRAE CTCAE grade and management. Additionally, our team created a pathway for specialist referral for patients with grade 3-4 IRAEs. Results: Upon review of 98 patient charts, 38 patients developed 58 IRAEs of which 36% were grade 1-2, 17% were grade 3, 0% were grade 4 and 47% were ungraded. The most commonly affected organs were skin (25%), thyroid (25%) and lung (11%). 53% of active IRAEs were formally graded in the oncologist’s assessment, only 6% of resolved IRAEs were documented in the subsequent oncologic history. A total of 11 patients were hospitalized for IRAEs, 7 of which had undocumented severity; 40% of grade 3 IRAEs were hospitalized. 14 specialist referrals were made, most with undocumented severity; 30% of patients with grade 3 IRAEs were referred. Overall, 18 patients required steroids, of these 40% were ungraded, and 19 had immunotherapy stopped or held, of these 45% were ungraded. Conclusions: While the presence of IRAEs is consistently documented, documentation of severity and subsequent management are inconsistent- including amongst those patients requiring hospitalization, specialty referral and/or treatment modification. Further data will be reported regarding utilization of the macro, documentation of IRAE grading and management as well as specialist referral rate.
Improving the assessment and documentation of constipation at UF Health Cancer Center through mandatory prompts.
Authors: Ramnaraign Brian Hemendra , Farooqi Bilal , Gopalan Priya Kadambi , Markham Merry Jennifer 
Published: September 2018

263 Background: Opioids are commonly prescribed to patients for management of pain and the most common and persistent side effect from opioid use is constipation. Opioid-induced constipation (OIC) affects 52% of patients with advanced cancer and 87% of terminally ill patients. In the Spring 2017 Quality Oncology Practice Initiative (QOPI) chart abstraction round, UF Health Cancer Center’s Medical Oncology clinic notes documented the assessment of constipation in only 45.45% of charts. This is below the academic hospital aggregate documentation rate of 55.61%. Methods: Our objective was to improve the rate of documentation of assessment of constipation in the Thoracic Oncology Clinic at UF Health Cancer Center by 33% to a goal rate of at least 60% by 3 months. We used a Plan-Do-Study-Act model in order to design our project. We worked with the EPIC developers to include a mandatory prompt at the end of the assessment/plan section of the clinic template notes for the Thoracic Oncology practice. Our prompt was “Constipation was addressed and @HE@ {DOES/DOES NOT} have symptoms” where the author chooses from a drop down list to select whether the patient “does” or "does not” have symptoms. We planned to assess a total of 60 random charts in the 3 month post intervention period. Results: At the end of our study, a total of 48 out of 60 charts (80%) documented constipation thus surpassing our goal of 60%. Of the 12 charts assessed that did not address constipation, 11 did not use our revised templates and were notes that were “copied forwarded” from previous encounters. Conclusions: Given that our intervention was a success, we plan to expand these revised templates to the other medical oncology subspecialties in order to better document assessment of constipation for all cancer patients. While our mandatory prompt was shown to lead to increased documentation of constipation, further studies to show whether or not this leads to decreased complaints of abdominal pain, decreased incidences of bowel obstructions, and/or decreased hospital admissions, would be interesting to pursue.
Central venous access in oncology patients: A pragmatic approach to minimizing complications following port insertion.
Authors: Skelton William Paul , Franke Aaron J , Woody Lindsey , Welniak Samantha , Bosse Raphael , Murphy Martina Cathryn , Starr Jason Scott 
Published: September 2018

267 Background: Subcutaneous venous access devices, specifically implantable ports, are vital in the care of oncology patients. Despite routine use, complications remain prevalent. This retrospective single-institutional review was performed to identify rates of complications following port placement and target areas to improve patient outcomes. Methods: Retrospective analysis of 539 cancer patients who underwent port insertion in a one-year span at University of Florida was conducted. Data examining 18 potentially predictive factors was collected, and multivariate analysis was conducted using logistic regression and odds ratios with standard errors to determine predictive factors. Results: Of 539 patients, 100 (19%) experienced a complication, and 12 (2%) experienced 2 or more complications. An overall lower rate of complications was seen in patients on therapeutic anticoagulation (OR 0.17, p < 0.001) or on antiplatelet agents (OR 0.47, p = 0.02). No patients on therapeutic anticoagulation developed VTE (0%). Right-sided port insertion was associated with decreased rates of infection (OR 0.44, p = 0.04). Insertion as inpatient was associated with increased risk for mechanical failure (OR 4.60, p < 0.01) and catheter migration (OR 4.33, p < 0.01). Conclusions: This analysis identified multiple predictive factors that can potentially put patients at higher risk of complication following port insertion. A thorough risk assessment for VTE should be done prior to port insertion, and high-risk patients (i.e. prior VTE, Khorana score > 3) should be considered for prophylactic anticoagulation. Further analysis on optimal port insertion site (right/left) and location (inpatient/outpatient) are also targets that can potentially decrease complication rates. As ports inserted while inpatient had increased risk of both mechanical failure and catheter migration, and as ports inserted on the left side had increased risk of infectious complications, a prospective quality improvement initiative coordinated between Oncology and Interventional Radiology departments as to whether insertion of right-sided ports on an outpatient basis may improve outcomes is the next step in our investigation.
Tele-oncology at MSK: Delivering innovative, patient-centered care.
Authors: Otto Christian , Wang Jennifer , Walters Chasity , Robson Mark E. , Breitbart William , Cotter Kylie , Harris Jashonna , Harlan Fleischut Megan , Kim Youngho Paul , Saldivar Reggie , Nelson Judith Eve , Sidlow Robert 
Published: September 2018

272 Background: MSK is deploying teleoncology solutions that improve the patient experience, quality of care, and enhance patient access. MSK’s teleoncology mission is to utilize digital technology as a mainstream channel for connected care across the cancer continuum. Methods: Teleoncology programs were established between Manhattan and four regional sites in support of Psychiatry, Genetic Counseling, and Supportive Care. MSK’s “Virtual Programs” delivered tele-education and tele-support to patients and caregivers in their home or place of work to prepare them for each stage of their care. Patient acceptability ratings were evaluated for quality of care, ease of use, interaction quality, and satisfaction and future use. Results: The four programs generated 7563 teleoncology visits. Virtual Programs served 3865 patients over 766 sessions. Fifty-eight percent (N = 2269) of patients participated in group education sessions (8.3±1.2 patients per session), while 41.3% (N = 1596) participated in support groups (3.2±0.3 patients per session). Overall, 60% of Virtual Program sessions were delivered to patients at home, and 20% to patients at work. Tele-genetics counseling was provided to 3516 patients. The majority of tele-genetics sessions occurred at regional sites (61.4%). Thirty-eight patients completed 159 telepsychiatry visits (4.2±5.8 visits/patient). In Supportive Care, 23 patients completed 38 visits (1.6±1.4 visits/patient). Patients saved 95 minutes of travel time per teleoncology visit. Acceptability ratings for teleoncology were collected from 1185 patients (15.7%). Ninety-one percent of patients were satisfied or extremely satisfied with their teleoncology experience, 95.6% with the information they received, 94.4% with the skill of the provider, and 86.3% with the ease of use of the teleoncology platform. Conclusions: Teleoncology offers an innovative means of providing cancer care to patients by decreasing the stress of travel, missed work, and caregiver requirements. Patients reported that teleoncology made care more accessible and allowed them to remain in their community with family support. For clinicians, teleoncology expanded patient outreach, and improved patient adherence.
Assessing the impact of a digital coaching program for patients with cancer.
Authors: Srivastava Uma , Burton Stephen , Lewis M'Kayl , Patel Dhiren , Rasulnia Mazi 
Published: September 2018

274 Background: Cancer pain is found in 64% of patients with metastatic disease which can lead to negative effect on patient’s functional status which can then lead to psychological distress.Cancer pain can significantly affects an individual’s quality of life extending into mood or mental health and physical health.3 Various studies have shown that coaching is a useful strategy to address cancer pain and pain management. The hypothesis was by providing patients with cancer the Pack Health digital coaching solution, would lead to a reduction of cancer pain and increase in mental health over a 12 week intervention. Methods: This was a prospective study conducted between January 1, 2017 and December 31, 2017. 78 patients with cancer opted into the study, giving consent, and received intervention over 12 weeks. Patients were given standard print information and tools for self-care management in addition to a personal health advisor, who was in weekly communication with the participant to provide support, motivation, additional education, and accountability. Patient reported outcomes were collected using validated instruments, and patient satisfaction was measured using the Net Promoter Score (NPS). Results: The group was 86% female, and the average age was 55 years. Though not statistically significant, patients with a cancer diagnosis saw marginal improvements across some domains after 12 weeks. These results included a 15% decrease in perceived pain, 10% fewer prescreen for depression, and 11% more getting the recommended 7-9 hours of sleep each night. The slight decrease seen on average in both the mental health (-0.19%) or physical health (-0.30%) from the PROMIS Global-10 scores did not rise to the level of statistical significance. An NPS score of 69 for the program indicated strong patient satisfaction. Conclusions: Preliminary results illustrate that intensive behavioral counseling intervention help patients achieve their goals related to their chronic condition. The program showed adherence to health is linked to an increase in healthy habits leading eventually to an increase in patient’s overall health.
Malnutrition screening: A screening tool for outpatient oncology patients, leveraging EMR data.
Authors: Mills Jeannine B. , Shapiro Alice C. , Spees Colleen , Trujillo Elaine , Cushman Elise , Stephens Natalie , Johnson Sarah , Wood Alexandra , Duffy Kimberly 
Published: September 2018

275 Background: The provision of adequate nutritional care in outpatient cancer centers was the focus of a 2016 NAS Workshop, “Assessing Nutrition Care in Outpatient Oncology.” Here we report our internal project evaluating ongoing documentation of a malnutrition screening tool (MST) at 3 national cancer centers (CC). Methods: Screening scores from a validated 2 question MST scale were entered into the EMR. Questions probe for: 1) unintentional weight loss; and 2) eating poorly because of a decreased appetite. A score of ≥ 2 indicated nutrition risk. De-identified oncology clinic visit data were examined monthly to assess MST utilization and scores for radiation and medical oncology patients across the CC’s. Results: Approximately two-thirds (67%) of unique medical oncology patients that visited the CC’s had documented MST data with 9% (n = 144,129) scoring at nutritional risk. MST completion rates were higher in radiation oncology clinics secondary to staff education. Of those that had a valid MST score in radiation clinics, 13% (n = 23,202) of MST scores indicated nutritional risk. Conclusions: The MST is a valid malnutrition screening tool for outpatient oncology patients, yet this tool is not uniformly being utilized nationally. Consistent use of the MST in the electronic medical record and leveraging data on utilization are needed to inform staff compliance, consistency in care, future dietitian staffing patterns, cost/benefit analysis, and health outcomes for oncology patients. [Table: see text][Table: see text]