bluuebunny/crossref_metadata_2025_split huggingface dataset:
Design and implementation of a predictive risk model to improve oncology patient management.
Authors: Young Garrett , Church Whitney , Roper Ashley , Hoy Tiffany 
Published: September 2018

154 Background: Methods to identify cancer patients that are likely to seek inpatient care for conditions that can be treated in the outpatient setting are not well defined. In light of the rise in value-based care programs, there is increased pressure on oncology providers to decrease costs of care while continuing to achieve high-quality outcomes. One way this can be achieved is by decreasing avoidable, high-cost utilization through population management. We sought to investigate the feasibility of creating a model to predict which patients were more likely to utilize emergency department (ED) and inpatient hospital (IP) services as well as the impact such a model may have on patient management. Methods: For a sample of 1093 patients, historical information was gathered across four domains: Cancer-specific Attributes, Comorbidity Burden, Social Factors, and Utilization History. This data set was then used to design a predictive model which assigned a numerical “acuity” score to each patient. Patients were ranked by numerical score, and their subsequent ED and IP utilization was measured. The developed model was then tested on an independent set of 591 patients to assess broader validity. After development, the predictive model was built into a tool for use in patient management by a team of nurse care managers. Results: Of the 100 highest-ranking patients in the training sample, 29% had at least one future hospitalization and 33% had at least one future ED visit, compared to 13% and 19% in the entire sample, respectively. In the validation sample, 11% of the 100 highest-ranking patients had at least one future hospitalization and 20% had at least one future ED visit, compared to 5% and 13% in the entire sample, respectively. Before model deployment, an average of 39 follow-up touchpoints were completed for high-risk patients per month. In the 6 months after deployment, the average rose to 171 touchpoints per month, an increase of 335%. Conclusions: Models can be developed to proactively identify cancer patients at higher risk of utilizing ED and inpatient hospital services. Implementation of such a model can also increase targeted outreach and communication with patients at greater risk of utilizing high-cost services.
Standardizing and optimizing institutional-level documentation in the electronic medical record era.
Authors: Moreno Amy Catherine , Choi Seungtaek , Colbert Lauren Elizabeth , Farooqi Ahsan , Umberson Katie , Korah Bobby , Herman Joseph M. 
Published: September 2018

155 Background: Although electronic medical records (EMR) offer numerous potential benefits, there are significant challenges to balance high quality patient care and clinical efficiency with the rising demands of required documentation. Our objective was to propose and implement a strategy to standardize and optimize EMR documentation. Methods: An EMR taskforce was created within our institution’s radiation oncology (RO) department consisting of representatives of the clinical staff and EMR coders. To optimize clinical documentation, disease-site specific consult templates were created using EMR standard data elements and personalized drop down menus (Smartlists). Meetings were held with the billing department for template review and with the analytics team to begin automated data extraction into research databases. Quality metrics such as the average number of clinic visits billed at levels 4 or 5 (B45) and the average number of hours per visit (AHV) were compared in different clinics within a 6-month pre- and post- template implementation time period. Results: Within 3 months of establishing the taskforce, 32 RO disease-specific templates were created and distributed for usage in clinic. Optimized template features include consistent cancer staging, standardized oncologic history entry, usage of macros for patients’ symptoms for multiple provider verification, imbedded disease-specific protocol list to improve patient screening and enrollment, and multiple Smartlists for common treatment recommendations. In the GI Clinic, B45 increased from 49.3 to 61.4 per month and similar trends were seen in the Thoracic Clinic (B45, 51.4 to 85.2 per month). The AHV decreased in both the GI (21 to 10 hours) and Thoracic (22 to 13 hours) clinics, showing a significant added value to use of standard documentation. Conclusions: EMR systems can be challenging to navigate; however, they also present a unique opportunity to optimize clinical and research efficiency if used properly. The implementation of standard documentation in our department led to significant improvement in clinical efficiency. Further efforts are being made to adopt these changes on an institutional-wide level.
Role of effective care plans in reducing admissions for sickle cell patients.
Authors: Ahmed Bilawal , Day Tami , Hirner Cara , Trendle Michael , Heidt Jonathan , Singh Sindhu 
Published: September 2018

156 Background: Adults with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED) which often results in hospital admissions. The Hematology-Oncology at Ellis Fischel Cancer Center collaborated with organization’s ED to develop and implement individualized care plans for adults with SCD presenting to the ED with the goal of adequate outpatient management and a reduction in hospital admissions. Methods: Baseline data collected from November 2014 through December 2016 indicated that 108 SCD patients accounted for 195 inpatient hospital admissions, and 40% of all 30-day readmissions for the Hematology-Oncology service line. Further, the average length of stay for patients admitted for SCD crisis was 6.8 days per stay. Medical Director, Oncology Unit Manager, and Performance Improvement Professional collaborated with the ED Medical Director and representatives to develop a disease-specific acute care plan for our adult SCD patient population. The care plan include pathways for lab collection, pain medication regimens, prescription opioid refill policies, a timeline for outpatient follow-up, and criteria for hospital admission. These care pathways were then transitioned to order sets in within the organization’s electronic medical record. Results: Implementation of the SCD care plans resulted in significant improvement in the 30-day readmission rate among the SCD patient population, from 40% to 3%. Further, use the SCD care plans helped reduce the average length of stay for patients admitted with SCD crisis from 6.8 days to 3 days. More importantly, we have been able to sustain this improvement over time. Conclusions: This study clearly demonstrates that collaboration with the ED and development of care plans are key to reducing ED and hospital utilization among patients with SCD, and reducing the average length of stay for SCD patients who require hospitalization for disease management.
Methods for alerting clinicians to concerning symptom questionnaire responses during cancer care: Approaches from two randomized trials (STAR, AFT-39 PRO-TECT).
Authors: Stover Angela M. , Henson Sydney , Deal Allison Mary , Stricker Carrie Tompkins , Hammelef Karen Joan , Bennett Antonia Vickery , Carr Philip M , Jansen Jennifer , Kottschade Lisa A. , Dueck Amylou C. , Basch Ethan M. 
Published: September 2018

158 Background: There is limited research on methods for alerting clinicians to concerning patient-reported outcome (PRO) responses and how often PROs trigger alerts to nurses during cancer care. Methods: In two randomized trials, adults with advanced cancer receiving chemotherapy were enrolled. Participants were randomized to usual care vs. weekly PROs completed between visits (with automated feedback to nurses). PRO responses in the intervention arm triggered automated email alerts to nurses for frequent, severe, or worsening symptoms in the last 7 days. Alert thresholds for PROs were chosen a priori but were unique to each study. The “Symptom Tracking and Reporting” (STAR) trial was conducted at one academic medical center. The “PROs to Enhance Cancer Treatment” (PRO-TECT [AFT-39]) cluster-randomized trial is being conducted in > 30 community practices. Results: In STAR, 766 patients participated (58% female, 38% ages ≥65, 17% minority, 28% ≤high school). 441 participants were randomized to the intervention arm, where 1,431/84,212 items (2%) triggered a concerning symptom alert, during 1,070/8,498 weeks (13%). Frequent alerts were for fatigue (62%), pain (32%), and appetite (16%). In PRO-TECT (AFT-39), 300 patients have been enrolled (58% female, 49% ages ≥65, 8% minority, 47% ≤high school) out of 1,000. 146 participants have been randomized to the intervention arm, where 1,422/24,739 items (6%) triggered an alert, during 824/2249 weeks (37%). Common alerts were for pain (48%), physical function (35%), and diarrhea (15%). PRO-TECT provided clinical decision support with alerts. Conclusions: In two randomized trials in advanced cancer, PROs collected during care delivery enabled tailored treatment based on issues identified on PROs. Pain, physical function, appetite, and diarrhea commonly triggered alerts for concerning symptoms. Early PRO-TECT results are showing a trend for higher weekly alert rates for concerning symptoms (37% vs. 13% in STAR), which may indicate that the PRO intervention will be even more effective in community practices. Results assist in addressing logistical considerations for implementing PROs into routine care. Clinical trial information: NCT03249090.
Choice of radioactive iodine treatment for thyroid cancer: Results from a population-based survey.
Authors: Wallner Lauren P. , Reyes-Gastelum David , Hamilton Ann S , Ward Kevin C. , Hawley Sarah T. , Haymart Megan Rist 
Published: September 2018

159 Background: For many patients with differentiated thyroid cancer, use of radioactive iodine (RAI) does not improve survival or reduce recurrence risks. Yet, most patients continue to receive RAI suggesting the need for a better understanding of patient perspectives regarding RAI decision making. Methods: All eligible sequentially diagnosed patients with thyroid cancer in 2014-15 from the Georgia and Los Angeles SEER registries were surveyed (N = 2097, current response rate: 63%). Patients with intermediate risk thyroid cancer where selective RAI use is recommended were included in this analysis (N = 1357). Patients were asked whether or not they felt they had a choice to receive RAI (yes/no), how strongly their physician recommended initial RAI treatment (5 point Likert responses: Strongly against RAI--Strongly recommended RAI), whether they received RAI (yes/no), how satisfied they were with their RAI decision (5-pt Likert-type scale), categorized as more (score ≥4) vs. less satisfied. Multivariable logistic regression was used to assess 1) association between patient characteristics and perception of no RAI choice, 2) perception of no RAI choice with receipt of RAI and 3) perception of no RAI choice with decision satisfaction. Results: In this sample,over half (57%) of the respondents perceived they did not have a RAI choice, and the majority of them (76%) received RAI. The odds of perceiving no RAI choice was greater among Hispanic and Asian patients (Hispanic OR: 1.4, 95%CI: 1.0, 1.9, Asian OR: 1.9, 95%CI: 1.2, 2.9), and those whose physician strongly recommended RAI (OR: 1.9, 95%CI: 1.4, 2.6). Patients who perceived they did not have a RAI choice were more likely to receive RAI (Adjusted OR: 3.2, 95%CI: 2.1, 4.9) and report lower decision satisfaction (Adjusted OR: 2.7, 95%CI: 1.9, 3.7). Conclusions: Many patients in whom selective RAI use is recommended, particularly those of more vulnerable groups, did not feel they had a choice about whether or not to receive RAI. Patients who perceived they did not have a RAI choice were more likely to receive RAI and report lower decision satisfaction, suggesting a need for more shared treatment decision making to reduce overtreatment.
Essential elements of caregiver support in gynecologic oncology.
Authors: Hand Lauren , Campbell Grace , Hagan Teresa , Lee Young Ji , Belcher Sarah M. , Roberge Mary , Donovan Heidi AS 
Published: September 2018

160 Background: Caregivers are instrumental to the health and well-being of gynecologic cancer patients and can be deeply affected by the demands of caregiving. Our aims were to increase awareness of the unmet needs of family caregivers of women with gynecologic cancers and provide recommendations for essential elements of support needed by caregivers to ensure that family caregivers are recognized and supported as key members of the patients’ care teams. Methods: Over the course of a year, a 16-person steering committee and 40 stakeholders, including caregivers, patients, and clinicians, participated in a modified Delphi approach to assemble, review and prioritize a set of essential elements for caregiver support. The process culminated in a multi-disciplinary research roundtable. Stakeholders prioritized caregiver needs and discussed, brainstormed and prioritized essential support services necessary to meet those needs, using three rounds of consensus-building activities. Basic descriptive statistics were performed to feed means and rankings back to stakeholders prior to each round. Results: Stakeholders prioritized the top three needs of caregivers as: 1) to obtain information about their loved one’s cancer (M = 4.18, SD = 4.33), 2) how to provide support and comfort to their loved one (M = 3.18, SD = 3.92) and 3) how to maintain their own emotional health and well-being (M = 2.94, SD = 3.90). Fifteen Essential Elements of Support to address the needs of caregivers of women with gynecologic cancers were identified. These ranged from supports that are immediately actionable (e.g., information for the caregiver on managing the patient’s symptoms, skilled-care training, a point-person to help navigate the system) to more aspirational supports (e.g., integrative services focused on the health and well-being of the caregiver). Conclusions: Caregivers are an integral part of cancer care, though their needs are inconsistently addressed by the care team. In order to provide comprehensive quality care, clinicians and healthcare systems should strive to provide caregivers with the Essential Elements of Support identified in this study and continue to build a healthcare system incorporating caregivers’ needs.
Care coordination and emergency department (ED) use at the end of life for patients with cancer: Findings from structured interviews with primary caregivers.
Authors: McDermott Cara L. , Ramsey Scott David , Engelberg Ruth , Woo Cossette , Curtis J. Randall , Starks Helene 
Published: September 2018

161 Background: For cancer patients who want to die at home, care coordination helps ensure that patients’ symptoms are managed at home, avoiding an ED visit and subsequent hospitalization. We conducted a qualitative study with patients’ primary caregivers, assessing the relationship between care coordination and ED visits in the last month of life. Methods: From October-December 2017, we audio-recorded semi-structured phone interviews with 35 adults who were primary caregivers for a patient who died with cancer between July-December 2016. Two analysts independently coded transcripts using qualitative content analysis and summarized results as major themes. Results: Most respondents were white (91%), female (63%) and spouses (89%). Twenty-four patients (69%) enrolled in hospice; of those, 15 (63%) received services for < 14 days, often enrolling after an unanticipated hospitalization or developing higher symptom burden. We identified three major themes related to care coordination and unanticipated ED visits/hospitalizations. First, caregivers reported insufficient at-home medical support especially following changes in patient status due to falls, pain, infection, or diarrhea/dehydration: “We have to go back to the hospital. You are getting worse and you are getting so weak, you are going to fall. And he said: ‘Okay, let's go.’ And he never came back home.” Second, lack of knowledge regarding whom to contact with needs: “We could eventually get people, but…there tended to be some significant delay… there weren’t facilities open... the emergency room…always seemed like a questionable best choice… the time and stress involved to the patient seemed like a big negative.” Third, caregiver burden: “We have got to go back to the hospital. I can't do this. I can't do this.” Conclusions: Caregivers reported significant gaps in care coordination and caregiving burdens that prompted ED visits and subsequent hospitalization. Active facilitation of hospice enrollment by oncologists and improved access to hospice resources are key targets to help patients avoid adverse events such as ED visits/hospitalizations while providing adequate support to caregivers.
Clinical workflows to support cost-of-care conversations: Multisite design study.
Authors: Henrikson Nora B. , Banegas Matthew P. , Tuzzio Leah , Lim Catherine , Schneider Jennifer L , Walsh-Bailey Callie , Scrol Aaron , Hodge Stephanie M 
Published: September 2018

168 Background: Patients prefer to discuss costs in the clinical setting, but current workflows are not designed to support cost-of-care conversations. Methods: We conducted a human centered design study to identify clinical workflows that optimize cost of care conversations. We conducted ethnographic observations at primary care departments or oncology clinics at two integrated health systems, assessing barriers and facilitators to discussing costs with patients. We then designed three unique patient experiences of having financial concerns addressed in the clinic setting. We refined these experiences following in-person patient interviews (n = 20). All data was synthesized into (1) a set of clinical workflow requirements and (2) journey maps describing sample workflows for the three patient experiences. Results: Most patient cost concerns take one of three unique pathways, each with workflow implications: (1) informing clinical decision-making, such as alternative treatment selection, mode of administration, or therapy sequence; (2) planning and budgeting concerns for therapy; and (3) addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost of care conversations; access to cost and benefits data to support each conversation pathway; clear team member roles and responsibilities for addressing cost of care concerns, including the role of the physician; pursuit of a patient experience that includes a clinical culture where cost questions are normal and each patient's values, preferences, and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected OOP costs before treatment begins. Conclusions: Clinic-based workflows for cost-of-care conversations that optimize patients’ care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach.
A collaborative program for educating urban youth about HPV risk and cancer prevention.
Authors: Jarvey Balistreri Jennifer , Schulz Cathy , Barry-Weers Anne Marie , Weese James L. 
Published: September 2018

169 Background: HPV infection is the most common sexually transmitted disease. Exposure to this infection is associated with cancer later in life. Public data regarding HPV vaccination rates and health disparity (as evidenced by low-income, high teen birth and STI rates) were identified. Methods: Based on the supposition that health disparity is associated with low socioeconomic status, a Wisconsin state map provided by the Center for Urban Population Health identified 29 zip codes in the City of Milwaukee, and are broken by low, medium, and high income brackets. An HPV education program, in partnership with Milwaukee Public Schools (MPS), was developed with a focus on the low income bracket to emphasize infection exposure and the safety and efficacy of the HPV vaccine in cancer prevention. This included education on safe relationships and emphasis on personal health advocacy. Program development was aimed at the health literacy of youth. Collaboration occurred with MPS leadership and their established health curriculum to ensure the HPV program accommodated the academic level of the freshman health classroom. Results: The data is reflective of HPV vaccine series completion rates within the zip codes where the HPV program was presented. Logistic regression was used and a significant rise for HPV completion rates by year (p = 0.0003) and by zip code (p < 0.0001) were observed. Conclusions: As the program evolves, program evaluations and public data continue to be reviewed along with feedback from various stakeholders to maintain the quality and integrity of the program. Additionally, Aurora Health Care has received requests to share this HPV program best practice with other institutions to expand it throughout urban areas of Wisconsin and Illinois.[Table: see text]
Improving end-of-life care in GI oncology patients.
Authors: Hathaway Lindsey Jackson , Rose Tim , Sekunda Michelle , Qin Yi , Silvestre Julio , Keng Michael Kenneth 
Published: September 2018

172 Background: In FY17, there were 108 patients with cancer who died on an inpatient unit at UVA, and of these, 17 patients (16%) died with incurable advanced stage GI cancer. In addition, 54% of these GI cancer patients did not have an outpatient palliative care consult prior to their time of death. Lack of early palliative care consultation leads to poor end of life care, compromises quality of life for patients and their families, and promotes the overutilization of healthcare. Methods: We participated in the ASCO Quality Training Program for this project. Our first aim (AIM#1) was to increase inpatient palliative care consults by 25% in patients with advanced stage GI cancers who were considered unscheduled admissions by hospital day 2. Our second aim (AIM#2) was to increase outpatient palliative care referrals by 25% in patients with pancreatic and hepatobiliary cancers by the second visit. We conducted these aims at UVA from August 2017 to February 2018. The intervention was to remind the GI oncologists and the house staff to place the palliative care consult. Results: From our pre-intervention data for AIM#1, 33 patients with advanced GI cancer (34%) had a palliative care consult in the inpatient setting from July 2017 to July 2018. Post intervention data showed that 14 patients (73%) had a palliative care consult, 10 patients (71%) with palliative care consult went to hospice, 11 patients (59%) have died since our intervention with only 1 death occuring in the inpatient setting and 1 patient with an readmission. From our pre-intervention data for AIM#2, 24 advanced GI cancer patients (5.5%) had a palliative care referral, and post-intervention 11 patients (21%) had a palliative care referral. Of the 11 patients with palliative care referrals, 6 patients (55%) went to hospice. Conclusions: We met both of our primary inpatient and outpatient aims to increase palliative care consults for advanced stage GI oncology patients. Our data clearly shows a benefit of early palliative care referral in GI oncology patients both in the outpatient and inpatient setting. We plan to continue to collect data on long-term outcomes for our patients, and investigate future directions to improve sustainability and to expand to other cancer service line populations.