bluuebunny/crossref_metadata_2025_split huggingface dataset:
Real-world antiemetic utilization in patients undergoing carboplatin chemotherapy.
Authors: Polson Michael , Harrow Brooke 
Published: September 2018

10 Background: More than 70% of patients receiving chemotherapy will experience chemotherapy-induced nausea and vomiting (CINV). Chemotherapeutic regimens (regimens) are classified as highly emetogenic, moderately emetogenic, low potential, or minimal risk for emesis. The NCCN has recently reclassified carboplatin emetogenicity according to the AUC (target area under the concentration versus time curve) with a carboplatin AUC ≥4 classified as highly emetogenic and carboplatin AUC < 4 as moderately emetogenic - but highly emetogenic in certain patients. This study assessed use of anti-emetic agents in carboplatin based regimens. Methods: This study consisted of a retrospective analysis of administrative claims data from multiple commercial health plans. Claims from 1/1/2010-10/31/2017 were analyzed. Index date for each patient was the first medical claim of the regimen of interest. Included patients had ≥1 medical claim for the selected regimen and were eligible for both medical and pharmacy benefits for ≥6 months prior to, and 12 months post index date. CINV-related hospitalizations and ER cost and utilization were assessed for patients treated with carboplatin based regimens. Results: In total, 4,430 mostly female (74%) patients met criteria for treatment with a carboplatin-based index regimen. Between 2010 and 2017, the following trends were noted in the study population: Adherence to NCCN recommended 3 drug CINV prophylaxis (triplet therapy) ranged from about 23% to 35%. The rate of CINV related emergency department (ED) visits was 5.3% and the overall rate of CINV related inpatient visits was 0.11%. The average cost for CINV related hospitalization for a carboplatin patient was $8,562 (SD 6,207) with an average LOS of 3.1 days. ED visits that were CINV related cost $2,463 on average (SD 3,054). Conclusions: Guidelines recommend use of up to three agents in the prevention of chemotherapy induced nausea and vomiting. Use of a triplet therapy for CINV prophylaxis in carboplatin based highly emetogenic regimens has increased over time in the plans analyzed and may offer an opportunity to reduce rate of CINV related hospitalizations and ED visits, as well as associated costs.
Lessons from Reporting National Performance Measures in a Regional Setting: Washington State Community Cancer Care Report.
Authors: Panattoni Laura Elizabeth , Fedorenko Catherine R. , Kreizenbeck Karma L. , Sun Qin , Li Li , Lyman Gary H. , Ramsey Scott David 
Published: September 2018

105 Background: While many quality metrics are generated and reported at a national level, regionally reported metrics may be more meaningful to stakeholders and more amenable to locally-generated interventions aimed at improving quality. We present the lessons learned from adapting national performance reporting standards to our regional setting. Methods: We linked 2014-2016 Washington State cancer registry records with Medicare and commercial insurance claims, capturing about 70% of the state’s cancer patients. A consortium of payers, oncology providers, and patients selected metrics from national initiatives (QOPI, MACRA, OCM, and the Choosing Wisely Campaign). We then searched the National Quality Forum and the National Quality Measures Clearinghouse for published specifications on those metrics. If none were available or there was a lack of consensus, we constructed algorithms with clinical and technical expert review. We calculated clinic-level risk standardized rates (RSRs) using hierarchical regression modeling to adjust for variation in clinic size and constructed quality composites. Results: We generated 13 quality metrics for 36,900 cancer patients cared for at 27 clinics. Our adaptation of national performance measures and implications include: 1) Many treatment process measures had too few numbers to individually report annually requiring us to group quality metrics and cancer types, and report over a three year period. 2) Although we were able to include tumor characteristics (e.g. AJCC stage) from registry records, risk adjustment was challenged by limitations in the number of risk adjustors due to the smaller number of patients. 3) After applying the hierarchical models, risk adjustment had minimal effect on clinic rankings. 4) The small number of clinics and limited range of clinic RSRs were more accurately captured by a quality composite that reflected clinic level differences to the regional average rather than national quintile groupings. Conclusions: Refinement of national metrics is necessary for public reporting in a regional setting. Further methodological development is critical for robust reporting and applications to value based purchasing.
An evaluation of shifting administration of high-cost chemotherapy from the inpatient to an outpatient setting.
Authors: Crosby David L. , Karkowski Katie , Rodriguez Catherine , Lansigan Frederick 
Published: September 2018

107 Background: Patients often require critical management during chemotherapy and may need constant monitoring during and post-treatment in an inpatient (IP) unit. However, many patients can receive safe and effective administration of chemotherapy in an outpatient (OP) infusion setting, which respects patient’s wishes to shorten hospitalization stays. Optimizing OP treatment can also result in better utilization of resources that require critical monitoring. Since IP chemotherapy is not reimbursed separately, it is often considered a financial loss. This study evaluated the opportunity to decrease length of stay (LOS), reduce costs for our hematology/oncology inpatient practice, and increase utilization of a new infusion suite adjacent to IP unit. Methods: Work followed a Lean Six Sigma methodology – Define, Measure, Analyze, Improve, and Control. Multi-disciplinary clinical teams worked with quality improvement subject matter experts to explore regimens associated with inpatient administration of high-cost medications. Rituximab-based regimens were identified as the greatest opportunity to optimize cost reduction in the IP unit. The team set a goal to deliver rituximab as an OP in the infusion suite following hospital discharge. Baseline utilization of rituximab in the IP unit, revenue of the new infusion suite, and mean LOS for patients receiving R-EPOCH, a rituximab based regimen, were determined. Results: Percentage of IP rituximab administration was reduced by 56% resulting in $355,506 of cost avoidance in the IP unit. Mean quarterly revenue in the OP infusion suite increased from $104,363 at baseline to $293,607 through the first nine months by shifting rituximab to the OP setting, which projects to an annualized improvement of $756,976. Median LOS for patients receiving R-EPOCH was reduced by 12 hours (p < 0.001). Conclusions: Our intervention has resulted in decreased administration of high-cost chemotherapy in the IP unit, reduced LOS, and increased patient convenience. In addition, the significant revenue generated in the OP infusion suite will support improving patient services at our not-for-profit medical center.
Real-world adherence in patients with metastatic colorectal cancer (mCRC) treated with trifluridine/tipiracil (FTD/TPI) or regorafenib (REG).
Authors: Patel Anuj K. , Barghout Victoria , Yenikomshian Mihran Ara , Germain Guillaume , Jacques Philippe , Laliberté François , Duh Mei Sheng 
Published: September 2018

11 Background: Adherence to oral chemotherapies is a critical but difficult to measure factor in the care of patients with advanced cancer. FTD/TPI and REG have both demonstrated prolonged survival in patients with refractory mCRC, but with notably different side effect profiles. This study utilizes real-world data to assess adherence and discontinuation of patients treated with FTD/TPI or REG and explore the effect of sequencing on adherence. Methods: Adults diagnosed with mCRC were identified using the nationally representative IQVIA Real-World Data Adjudicated Claims – US database (10/2014–07/2017). The first dispensing date of FTD/TPI or REG (if after FTD/TPI approval [10/2015]) was defined as the index date and the 3 months before as the baseline period. The observation period spanned from the index to the earliest date of a switch to another mCRC agent, end of continuous enrollment, or end of data availability. Medication possession ratio (MPR), proportion of days covered (PDC) at 3 months, and discontinuation (i.e., allowable gap≥45 days) were compared. Logistic (odds ratio [OR]) and Cox proportional hazards (hazard ratio [HR]) regressions, adjusting for baseline characteristics, were used to compare adherence and discontinuation, respectively. A subgroup analysis was conducted among switchers (FTD/TPI to REG vs REG to FTD/TPI). Results: A total of 469 FTD/TPI and 311 REG users were identified. FTD/TPI users had higher compliance with an MPR ≥ 80% (OR = 2.47; p < 0.001) and PDC ≥ 80% (OR = 2.77; p < 0.001). FTD/TPI users had lower risk of discontinuation (HR = 0.76; p = 0.006). Among switchers (96 FTD/TPI to REG; 83 REG to FTD/TPI), those switching from FTD/TPI to REG were more likely to have an MPR ≥ 80% (OR = 2.91; p < 0.001) and PDC ≥ 80% (OR = 4.60; p < 0.001) compared to REG to FTD/TPI switchers. Additionally, FTD/TPI to REG switchers had a lower risk of first treatment discontinuation (HR = 0.66; p = 0.009). Conclusions: In this study, FTD/TPI users had significantly higher compliance, lower discontinuation rate, and switchers treated first with FTD/TPI had better compliance, demonstrating that claims data can provide insight into oral chemotherapy adherence patterns in mCRC.
Decreasing initiation of chemotherapy time in elective patients admitted to an inpatient hematology malignancy unit.
Authors: Galeas Jose Nahun , Packer Stuart H. , Sakalian Susan , Browne Royston , Binder Adam 
Published: September 2018

120 Background: At our institution, we observed that 86% (n = 25) of patients admitted for elective chemotherapy experienced a delay (greater than 6 hours) in initiating their treatment. Methods: We measured time from admission to chemotherapy administration (Defined from time of vital signs taken at admission until time of chemotherapy administration) in patients admitted for elective chemotherapy. Key process measures were identified and monitored (i.e, time from admission to laboratory exam results, time from admission to chemotherapy signed, time from chemotherapy signed to chemotherapy released by nurse from the EMR). We collected data every two weeks. After collecting data and utilizing performance improvement tools such as a pareto chart and PICK chart, we developed multiple PDSA cycles as described in Table 1. Results: At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 25 hours to 8.85 hours. Median time to lab draws decreased from 2.33 hours to -0.63 hours. There was no change in time from signature to nurse releasing the chemotherapy. We noticed more providers were signing the chemotherapy prior to patient admission and more patients were receiving pre-admission alkalinization strategies. Conclusions: By implementing new admission workflows, optimizing our use of the EMR to communicate among providers, and improving pre-admission planning we were able to reduce our time to chemotherapy for elective admissions by 64.6%. Improvement still needed to meet our goals and fully standardize the processes as part of our daily workflow.[Table: see text]
Reducing infusion wait time: An initiative to increase early signing of medication orders by providers at a comprehensive cancer center.
Authors: Yakowec Jing Jing Wang , Rabin Michael S. , Matulonis Ursula A. , Shukla Shital , Kearney Michael D , Fine Barbara , Wolfberg Rachel A , Pettengill Mark , Hilton Nancy , Bartel Sylvia , Wagner Andrew J. , Lakhani Hakim 
Published: September 2018

123 Background: Many factors contribute to long wait times for oncology patients on the day of their infusion appointment. At Dana-Farber Cancer Institute (DFCI), one of the main causes of delay to infusion start is providers not signing medication orders in advance of patients checking in for their infusion appointment. We conducted a project to improve provider order signing behavior on the gynecology cancer patient infusion floor at DFCI. Methods: A data working group was formed which consisted of the infusion floor medical leads, nurse lead, pharmacy lead, and analytics and process improvement leads. Starting in February 2018, the working group shared baseline order signing data from September 2017 through January 2018 with the Gynecology Cancer Group. Descriptive and timestamp data from Epic were extracted and cleaned via Tableau to analyze the percentage of non-investigational medication orders, including chemotherapy, that were signed after a patient checked into infusion and the distributions of late order signing times. Results: Gynecology cancer patient providers had higher late order signing percentages at baseline (September 2017 through January 2018) than after sharing those data, which occurred from February through May 2018. The table below provides medication order counts and late order signing percentages by month. Although late signing percentages decreased after sharing the baseline data, the distribution of how late the late orders were signed did not show improvement, staying at an average of 20 minutes late. Conclusions: Sharing late order signing data with providers on a routine basis reduced late signing percentages. Initiating this process with all disease groups is crucial so that downstream workflows can start sooner and patient wait times reduced.[Table: see text]
Responding to the opioid crisis in a manner that respects oncology patients: A single institution experience writing policy to promote safe opioid use.
Authors: Cellurale Cristina , Fenton Mary Anne , Cherenzia Katie , Begnoche Megan 
Published: September 2018

132 Background: The current opioid crisis has had wide ranging implications across medicine and in particular oncology practice. Opioids have been used for centuries for their analgesic properties. As physicians and historians are aware, the abuse potential of opioids is significant. Despite this, a dramatic shift in medical education in the late 1990s and early 2000s and aggressive marketing and manufacture of opioids has led to widespread opioid misuse and abuse. Therefore, a slew of regulations has been put into effect within a brief period of time. Among practitioners, the oncologist holds a unique and arguably more challenging role, caring not only for those with acute cancer-related pain or those at the end of life, but also for cancer survivors or those who live with their cancer as a chronic condition. ASCO has put forth comprehensive guidelines for the safe use and monitoring of opioids. The ASCO policy statement also highlights the significant barriers that oncology patients face, thereby maintaining a focus on the unique needs of this patient population. Methods: The Lifespan Cancer Institute is an academic practice and writes approximately 880 opioid prescriptions each month with approximately 15% being new prescriptions. Our Multidisciplinary Quality Team implemented a safe opioid prescribing initiative including patient education sheets, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. Our palliative care team monitors pain scores. Results: During month one, 16% of patients newly prescribed an opioid had a completed patient-provider treatment agreement. For the second month, the number of completed agreements increased to 29%. Conclusions: Given the prevalence of opioid misuse, there is a growing overlap between oncology patients and those with opioid misuse disorder. Given high levels of psychological distress, the cancer patient is at risk for opioid misuse. Furthermore, oncology patients can be victims of diversion. Our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.
Examining the relative influence of multimorbidity on variations in older cancer patients’ experiences with care.
Authors: Kent Erin , Mollica Michelle , Klabunde Carrie N. , Arora Neeraj K. , Elliott Marc , McNeel Timothy S. , Wilder Smith Ashley 
Published: September 2018

14 Background: Cancer patients often have multiple chronic conditions and require complex care coordination. We compared older (ages 66+) cancer patients’ reports of their healthcare experiences based on level of multimorbidity. Methods: Data from the SEER-CAHPS combines cancer registry (Surveillance, Epidemiology, and End Results; SEER), patient experiences (Consumer Assessment of Healthcare Providers and Systems; CAHPS) and Medicare claims data. Multimorbidity was captured as: (1) the National Cancer Institute-Combined Comorbidity Index (NCCI, 16 Charlson conditions diagnosed ≤12 months prior to cancer); and (2) a Multimorbidity Burden Index (MBI), which categorizes conditions based on the impact to cancer treatment (no comorbidity, low/medium, and high). Outcomes were CAHPS patient experience measures: Doctor Communication, Getting Care Quickly, Getting Needed Care, Obtaining Prescription Drugs, Customer Service, and ratings of Overall Care, Personal Doctor, and Specialist. Multivariable linear regression provided associations of each multimorbidity measure with CAHPS measures controlling for standard case mix adjustors, years from diagnosis to survey and diagnostic stage. Results: The study cohort included 9305 cancer patients (53% male, 84% Non-Hispanic White, average age 77, average time from diagnosis 29 months), with a distribution of NCCI conditions as: 0 (cancer only), 73%; 1, 17%; ≥2, 10%. Cancer patients with NCCI = 0 and those with MBI = no comorbidity rated their Personal Doctor more negatively than those with any comorbidities ( p < 0.02). Those with NCCI ≥ 2 or MBI = low/medium reported better Doctor Communication ( p < 0.04). Those with high MBI rated their specialist physician better than those with no multimorbidity ( p = 0.04), and those with low/medium MBI reported better experiences Getting Care Quickly ( p = 0.02). No other associations were significant. Conclusions: Cancer patients with multimorbidity report better communication with their doctor and care = by = personal doctors and specialists. Increased attention to the care experiences of cancer patients with multimorbidity may lead to insights and interventions that benefit all cancer patients.
Medically integrated pharmacy: A team-based approach to improve oral oncolytic therapy for cancer patients.
Authors: Doshi Gurjyot K. , Condon Kelani , Schwartz Jim R. , Dave Neal , Sellers Chris , Harville Margaret , Books Holly , Wilfong Lalan S. 
Published: September 2018

140 Background: The use of oral oncolytic therapies in the treatment of cancer is rising dramatically.　Cost barriers to obtaining drugs and side effects of therapies lead 1 to poor adherence to oral regimens resulting in detrimental outcomes. External specialty pharmacies have attempted to assist patients but this often leads to further fragmentation of care. We report on the performance of a medically integrated pharmacy within a large community oncology practice to achieve better patient outcomes. Methods: The Texas Oncology medically integrated pharmacy (MIP)consists of oncologists, oncology nurses, advanced practice providers, and specially trained pharmacy staff utilizing real-time access to the patient’s electronic medical and pharmacy records when oral therapy is prescribed.　The team processes　prior authorizations and patient assistance requests,　ensures drug delivery, provides education, monitoring, and follow up of side effects for oral therapies. The care team is available to provide early intervention and side effect management. Treatment initiations, dose adjustments, and treatment discontinuations are communicated seamlessly in real time. Results: Texas Oncology MIPs process over 14,500 prescriptions annually with a 99% prior authorization approval rate. Service is timely with a representative sample of 4 practices showing 64% of prescriptions filled within 24 hours of prescribing and 72% filled within 72 hours. Prior authorization and patient assistance were the leading causes of delays. The patient assistance team processes over 3,200 requests annually with over $121 million copay assistance obtained. Adherence to therapy within Texas Oncology is over 92% for the 7 most commonly prescribed oral oncolytic drugs.　Patient satisfaction surveys reveal 96% satisfaction with the medically integrated pharmacy. Conclusions: The MIP is a fully aligned team based approach for the delivery of oral oncolytics. A medically integrated pharmacy provides timely access, copay assistance, monitoring and management of side effects resulting in increased adherence to therapy and an overall improvement in quality and satisfaction.
The Employers Centers of Excellence in Cancer Care: A collaboration of employers and providers to improve cancer care.
Authors: Patel Manali I. , Lee Rachel V , Smithline Neil , Ross Olivia 
Published: September 2018

141 Background: Rising costs demand collaborations that lower expenditures and improve patients’ experiences and outcomes. We created a novel employer-provider collaboration to enhance value-based cancer care. Methods: We created an Employers Center of Excellence Network (ECEN) for the Pacific Business Group on Health (PBGH) employee groups. The ECEN provides competitive bundled rates that include travel for in-person patient consultation, advanced assessment and treatment by multidisciplinary case reviews, and ongoing specialized treatment care coordination and follow-up on a routine basis with the local care team.The ECEN development process included: focus groups, expert panel development, and a rigorous selection process. A Request for Proposal was publicized to all west coast NCI-designated comprehensive cancer centers. After interviews, selected sites were invited to submit a full proposal and a few were selected for a site visit.. In addition to overall cancer care excellence, a key criterion for acceptance was the demonstrated willingness and ability of the center to provide long-term support for the patient and home oncologist in the patient’s home market, so that the center’s expertise and support would be ongoing for the duration of the cancer treatment. Results: Of 8 sites that participated in team-assessment interviews, 4 were selected to submit a full proposal, 3 selected for in-person visits, and 1 selected to participate. In January 2019, we plan to implement a 6-month pilot with a PBGH employer group and the provider site to evaluate the ECEN's feasibility and effects on quality, patient-reported outcomes, and costs. Conclusions: Our novel employer-provider collaboration aims to improve cancer care delivery by providing planned and supported NCI-designated cancer care in close collaboration with the home oncologist. We plan to expand the ECEN development process across the US to develop a network of collaborating providers and employers to improve patient-centered, value-based cancer care.