bluuebunny/crossref_metadata_2025_split huggingface dataset:
Understanding what drives patients with cancer to visit the emergency department: A qualitative study.
Authors: Longmore Avery , Veloce Nicole , Mercado Marck , Dainty Katie , Hicks Lisa K. 
Published: September 2018

173 Background: Visits to the emergency department (ED) are common among patients with cancer (PWCs). Previous research suggests that few ED visits are precipitated by true oncologic emergencies (Diaz-Couselo 2004). Designing initiatives to reduce ED visits requires a rich understanding of factors that drive PWCs to visit the ED. Methods: Standardized interviews were conducted with 12 oncology clinicians at an academic oncology clinic in Toronto, Canada. Interviews were also conducted with 10 PWCs. Interviews explored factors that may drive ED visits, and interviewees’ insights into interventions to prevent ED visits. Interviews were audio recorded and transcribed. Transcriptions were qualitatively analyzed by two independent reviewers using the constant comparison method (Strauss and Corbin 1998). Results: Ten themes were identified as factors that may drive ED visits, with little overlap between themes identified by clinicians versus those identified by PWCs. Clinicians identified low socioeconomic status, lack of social support, advanced age, comorbidities, anxiety and non-adherence as important factors. In contrast, PWCs focused on the severity and expectedness of symptoms, lack of access to afterhours oncology advice and care, and adherence with medical and non-medical advice as drivers of ED visits. Regarding potential interventions, there was broad agreement between clinicians and PWCs regarding what might be helpful. Both groups identified improved access to expert cancer advice/care, improved coordination of care between clinics and ancillary health services, and patient education as important interventions. Clinicians also believed increasing community supports would help prevent ED visits. PWCs emphasized that some ED visits are not preventable. Conclusions: Clinicians and PWCs have different views on what drives ED visits. Despite identifying different drivers, clinicians and PWCs identified common solutions for reducing ED visits.
End of life: A focus upon making doing the right thing easier in challenging conversations.
Authors: Dunn Kathleen , Hepler Marjorie , Shariff Imran , Denny, DBA Diane , Crilley Pamela A. 
Published: September 2018

174 Background: Communication surrounding end of life decisions is difficult for patients and their loved ones as well as the clinicians involved in their care. An audit of end of life measures brought to light an area of opportunity across a national network of five geographically dispersed medical centers that resulted in a quality improvement project which sought to enhance communication processes among clinicians and patients. Methods: Utilizing principals of complexity theory, a multidisciplinary task force developed a communication tool to guide clinicians in discussions with patients and improved upon the electronic health record (EHR) to make documentation clearer, easier and more meaningful. “Words that Matter” with scenarios and suggestions for clinicians to introduce palliative care or hospice to patients were established. EHR enhancements included structured fields for hospice discussion and referral based upon network defined objective clinical criteria. A hospice referral field was also created to allow physicians to place an order along with discontinuing chemotherapy without leaving the note. Education was provided to clinicians in various formats. Implementation occurred early fall 2017. Results: Structured fields allow for easier electronic data pulls for reports to measure process improvement and communication. Outcome measures of interest include: chemotherapy administered in the last 14 days of life and timeliness of referral to hospice. Additional process metrics are in place to measure utilization of supporting resources. Conclusions: Effective communication of end of life issues and timely hospice referral is an integral part of care. Communication tools and criteria prompt our physicians to engage in discussions and refer patients earlier in their journey, when appropriate. Providing structured fields in the EHR has made documentation more complete.[Table: see text]
Mobile device access to electronic patient portals in oncology: Potential implications for patient and practice experiences.
Authors: Pho Kelvin Ky-Minh , Lu Rong , Gates Samantha , Cai Jennifer , Xie Donglu , Xie Yang , Lee Simon Craddock , Gerber David E. 
Published: September 2018

179 Background: Mobile devices provide individuals with rapid and frequent access to electronic patient portals. How patients use this growing and widespread technology to review test results and communicate with providers is not known. Methods: Retrospective study of patients enrolled in the MyChart electronic health portal associated with the EPIC electronic medical record in the Harold C. Simmons Comprehensive Cancer Center. We recorded type of portal access according to year and patient characteristics. Associations between patient characteristics and type of portal access were tested using Mann-Whitney test, Chi-square test, and linear Gaussian regression models. Results: Since the availability of mobile access in 2012, 2,524 patients accessed MyChart from a mobile device at least once, accounting for 291,526 mobile logins. The proportion of patients with mobile MyChart logins increased from 4% in 2012 to 13% in 2017 ( P= 0.004). Among these patients, the proportion of logins from mobile devices increased from 22% to 72% ( P< 0.001). Mobile access occurred more frequently among younger ( P< 0.001), black ( P= 0.002), and Hispanic ( P= 0.004) patients. In 2017, among patients who accessed MyChart from mobile devices at least once, those under age 40 years used the mobile application for over 90% of logins; those over age 60 years used the mobile application for 65% of logins. Black and Hispanic patients who used mobile MyChart access did so for approximately 80% of logins, compared to 70% of logins for non-Hispanic white patients. Before 2012, patients who went on to use mobile access averaged about five more logins per year than did mobile application never-users. While login frequency increased for both groups, the change was far greater for mobile application users. After 2012, total portal login frequency increased approximately 110% among patients who used mobile access, compared to 25% among non-users ( P< 0.001). Conclusions: Mobile access to electronic health portals has increased patient portal use, particularly among traditionally underserved populations. How this widely and immediately available technology impacts patient and practice experiences warrants further study.
Impact of radiotherapy facility volume on the management and survival of patients with muscle-invasive bladder cancer receiving bladder-preserving therapy.
Authors: D'Rummo Kevin , TenNapel Mindi , Shen Xinglei 
Published: September 2018

18 Background: Higher facility surgical volume predicts for improved survival in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. Here, we investigated the association between facility radiotherapy (RT) case volume and compliance with National Comprehensive Cancer Network (NCCN) guidelines as well as overall survival (OS) for patients with MIBC receiving radiation-based bladder preservation. Methods: The National Cancer Database (NCDB) was used to identify patients who were diagnosed with non-metastatic MIBC from 2004 to 2015 and received RT at the reporting institution. Patient, tumor, and treatment characteristics were recorded. Facility RT case volume was defined as the summed MIBC cases treated with RT during the study period. Facilities were divided into high or low volume groups at the 80th percentile of RT case volume. We compared compliance with NCCN guidelines regarding total RT dose of at least 55 Gy, use of TURBT prior to RT, and planned use of concurrent chemotherapy using the χ2 test. OS was assessed using Kaplan-Meier method. A Cox proportional hazard model was used to evaluate predictors of survival. Results: There were 7,562 included patients, and 3,816 (50.5%) were treated at a high-volume center. Median RT case volume was 21 for high-volume centers versus 8 cases for low-volume centers. Higher rates of compliance with all three NCCN recommendations were observed at high-volume centers (48% vs 41%, P< .0001). Age, sex, tumor stage, nodal status, Charlson Comorbidity Index, insurance status, and use of a TURBT prior to RT were predictive of survival. Volume as a continuous variable was an independent predictor of OS ( P= .002). Treatment at a high-volume facility was associated with significantly greater OS for all patients (log-rank P= .001), including patients with a Charlson Comorbidity Index of 0 ( P= .012). Further division of facilities into quartiles revealed incremental improvement in OS with higher facility volume ( P= .001). Conclusions: Bladder preservation treatment at a high-volume facility is associated with greater guideline-concordant management and improved OS among patients with MIBC.
The impact of routine ESAS use on receiving palliative care services: Results of a population-based retrospective matched cohort analysis.
Authors: Barbera Lisa Catherine , Sutradhar Rinku , Earle Craig , Mittmann Nicole , Seow Hsien , Howell Doris , Li Qing , Deva Thiruchelvam 
Published: September 2018

191 Background: In 2007 Cancer Care Ontario began standardized symptom assessment as part of routine clinical care using the Edmonton Symptom Assessment System (ESAS). The purpose of this project was to evaluate the impact of this program on referrals to palliative care. We hypothesized that patients exposed to ESAS would be more likely to be referred. Methods: A retrospective matched cohort study was conducted to examine the impact of ESAS screening on the initiation of palliative care services provided by physician or homecare nurse among newly diagnosed cancer patients in Ontario, Canada. The study included all adult patients who were diagnosed with cancer between 2007 and 2015. Exposure was defined as completing ≥1 ESAS during the study period. Using four hard matched variables and propensity-score matching with 14 variables, cancer patients exposed to ESAS were matched 1:1 to those who were not. Matched patients were followed from first ESAS until initiation of palliative care, death or the end of study at Mar 31, 2017. Results: The final cohort consisted of 204,688 matched patients with no prior palliative care consult. The pairs were well matched. The probability of receiving palliative care within the first 5 years was higher among those exposed to ESAS compared to those who were not (20.6% vs. 15.2%, p < .0001). The risk of death without receipt of palliative care within the same period was low in both groups. In the adjusted cause-specific Cox proportional hazards model, ESAS assessment was associated with a 6% increase in palliative care services (HR: 1.06, 95% CI: 1.04-1.08). Conclusions: Cancer patients who completed ESAS were more likely to initiate palliative care services than those who didn’t. ESAS screening may help identify patients who would benefit from a palliative approach to care earlier in their clinical course.
Financial toxicity among patients with lung cancer in a publicly funded health care system.
Authors: Ezeife Doreen Anuli , Morganstein Joshua , Lau Sally C , Le Lisa , Cella David , Bradbury Penelope Ann , Liu Geoffrey , Sacher Adrian G. , Shepherd Frances A. , Leighl Natasha B. 
Published: September 2018

192 Background: Financial distress has been established as a clinically relevant patient-reported outcome (PRO) associated with worse mortality and quality of life, but remains under-recognized by health care providers. Our goal was to define factors associated with financial toxicity (FT) in a public healthcare system. Methods: Patients with advanced lung cancer were recruited from outpatient clinics at the Princess Margaret Cancer Centre (Toronto, Canada). FT was measured with the validated Comprehensive Score for Financial Toxicity (COST) instrument, a 12-item survey scored from 0-44 with lower scores reflecting worse financial well-being. Data on patient and treatment characteristics, total out-of-pocket costs (OOP) and extended insurance coverage (EIC) were collected. Multivariable logistic regression models were fit for COST score and each variable, to determine factors associated with greater FT (COST < 21). Results: Of 251 patients approached, 200 (80%) participated. Median age of the cohort was 65 years; 56% were female, 64% immigrants and 77% employed or on pension. Median total OOP while on treatment ranged between $1000-5000 CAD. Median COST score was 21 (range 0-44). FT was associated with age, with patients < 65 years reporting greater FT than older patients (COST 18.0 vs. 24.0, p < 0.0001). In multivariable logistic regression analysis, younger age was associated with greater FT, when adjusting for income, employment status, OOP and EIC (OR 3.6, [95% CI, 1.5-9.1]; p < 0.0001). Total OOP > $1000 and EIC also were associated with greater FT (adjusted OR 5.0 [95% CI, 2.0-12.1] and 3.7 [95% CI, 1.5-9.1], respectively). Conclusions: Age is significantly associated with FT in the Canadian (Ontario) public healthcare system, with younger lung cancer patients reporting greater financial distress. This study highlights priority patient populations where FT should be routinely assessed and appropriate resources for support offered.
Decisional preferences and satisfaction with short-course radiation for breast cancer.
Authors: Culbert Matthew , Bidermann Gregory , Wallace Audrey S. 
Published: September 2018

193 Background: Limited literature exists regarding preferences and decisional satisfaction for women who choose accelerated partial breast irradiation (APBI) in lieu of 6-7 weeks of radiation. This analysis provides long-term patient reported outcomes in women treated with APBI at one institution. Methods: Records of women treated primarily with balloon-based APBI (2005-2013) were reviewed after IRB approval. Women with recurrent disease or poor prognosis second primary cancer were excluded. Assessment of decisional factors important to the patient, as well as satisfaction and regret with treatment choices (Decisional Regret and Satisfaction Scales) were captured via mail or telephone. Results: In 141 women who met inclusion criteria, 83 participated. Median age at diagnosis was 62 years (SD = 9), and median time from RT to survey completion was 102 months (SD = 8). Histology was pre-invasive, (25%), invasive (52%), and combined invasive/pre-invasive (23%). The majority had estrogen/progesterone receptor positive disease. Factors that were important in decision making included convenience, physician recommendation, financial considerations, novelty of treatment, desire to avoid mastectomy, and recovery time. The majority (48%) reported convenience to be the single most important factor. Provider recommendation was the primary factor in decision making for 20% of women. Most women agreed that their choice was the right decision (96%) and most felt adequately informed (90%). The majority (92% and 90% respectively) of women agreed that their decision was consistent with their personal values and was the best decision for them personally. Decisional satisfaction was high (95%). Overall satisfaction with treatment choices was high: 84% and 10% reported being totally and somewhat satisfied respectively. The majority (90%) of women stated they would make the same treatment choice again. Conclusions: Decisional satisfaction remains high almost a decade after completion of short course radiation. Practitioners should consider patient values and preferences as part of shared decision making when determining type and duration of radiation as part of breast conservation therapy.
Real-world economic outcomes of early progression in newly diagnosed multiple myeloma (NDMM) patients (Pts).
Authors: Clancy Zoe , Pandya Shivani , Shrestha Sulena , Wang Li , Baser Onur , Ni Quanhong 
Published: September 2018

194 Background: Despite improved survival with advanced multiple myeloma (MM) treatments (Tx), 15–20% of pts experience early relapse. We assessed the economic impact of early progression among non-stem-cell transplant NDMM pts. Methods: NDMM pts with ≥ 1 Tx (1st claim date: index date) from 01Jan2011–31Dec2015 were identified from the 100% Medicare database. Eligible pts had ≥ 1 full cycle of therapy and continuous health plan enrollment from 6 months pre-index or first MM diagnosis date until ≥ 12 month post-index date unless pts died < 12 months post-index date. First line of therapy (LOT1) included all Txs prescribed ≤ 60 days post-index date. Among pts who progressed to LOT2, median time to next Tx (TTNT) was estimated from a Kaplan–Meier curve as duration from LOT1 start until the earliest of an addition/switch/restart of non-maintenance MM Tx, or dose increase from maintenance to relapse therapy. Pts who progressed to LOT2 prior to and after median TTNT were included in the early and delayed progression cohorts, respectively. Annual all-cause and MM-related healthcare costs estimated from a generalized linear model were compared between doublet therapy pts in LOT1 in the early and delayed progression cohorts. Results: Of 3,768 MM pts with LOT1, 36.1% progressed to LOT2 with median TTNT of 302 days; 81.3% pts initiated doublet therapy in LOT1, of which 19.2% (n = 589) and 17.3% (n = 533) were included in the early and delayed progression cohorts, respectively. Pts in the early progression cohort were younger and incurred higher all-cause inpatient ($17,332 vs $10,455), outpatient hospital ($18,183 vs $15,097), emergency department ($462 vs $395), office ($37,728 vs $29,174), and total costs ($130,948 vs $108,003) compared with the delayed progression cohort. Similarly, the early progression cohort had higher MM-related total costs ($87,284 vs $72,150) including inpatient and outpatient costs (all P< 0.001). All-cause and MM-related pharmacy costs were similar between cohorts. Conclusions: Early progression after LOT1 is associated with substantially higher economic burden indicating the need for future studies of therapies that delay progression and potentially result in cost savings.
Can administrative data improve the performance of clinical trial economic analyses?
Authors: Hanna Timothy , Nguyen Paul , Pater Joe , O'Callaghan Christopher J. , Mittmann Nicole , Earle Craig , Tu Dongsheng , Jonker Derek J. , Hay Annette E. 
Published: September 2018

2 Background: Economic analyses of trials often rely on trial-collected health resource utilization data, which is expensive and may be incompletely recorded. We investigated whether routinely collected health administrative data (RCD) can be utilized to improve trial economic analysis performance. Methods: Health administrative data was probabilistically linked to Ontario patient data from the Canadian Cancer Trials Group CO.17 trial (n = 572), evaluating cetuximab plus best supportive care (n = 75 linked Ontario patients) versus best supportive care alone (n = 73). Completeness of trial data was compared to RCD. Cost-effectiveness in 2007 Canadian dollars was determined using RCD up to trial date of last contact (DOLC), and up to RCD DOLC. Incremental cost effectiveness ratio (ICER) confidence intervals (CI) were determined using bootstrapping with 5000 iterations. Cost-effectiveness acceptability curves were determined. Sensitivity analyses were performed. Results: Among 148 Ontario patients, up to trial DOLC, RCD vital status was concordant in > 96%. 29 deaths occurred after trial DOLC. Up to trial DOLC there were 34 net additional hospitalizations in RCD, and 28 net additional emergency room visits. Using RCD, total cetuximab group costs were $3,023,034, and $1,191,118 for best supportive care alone up to trial DOLC. Cost difference was driven by cetuximab drug costs ($1,531,370). Using RCD, the ICER was $211,128 per life-year gained (90% CI: $101,396, $694,950) when data was limited to trial DOLC, and $164,378 (90% CI: -$138,260, $644,555) using routinely collected data DOLC. ICER estimates were similar to the original economic analysis using trial-collected data ($199,742 (95% CI $125,973, $652,492)). Estimates were robust in sensitivity analysis. Conclusions: Administrative data were more complete than trial-collected utilization data, even under optimal conditions. There was also longer follow-up. We found that cost differences were robust to varying costing assumptions. Our findings demonstrate the potential of administrative data sources to relieve institutions, sponsors and patients from the burden of collecting key utilization information which requires considerable effort and cost.
PROeverywhere: Bridging the implementation gap of patient-reported outcomes with a mobile app.
Authors: Hung Kin Wai (Tony) , Banerjee Natasha , Miller Jeffrey M. 
Published: September 2018

203 Background: Patient reported outcome (PRO) data are critical for informing patient-centered care and have been shown to enhance our ability to communicate with patients, to control their symptoms, and to impact their survival. However, PRO data are not commonly collected in routine cancer care due to implementation challenges such as cost, technological rigidity of existing electronic health records, and misalignment of stakeholders’ incentives. Methods: In an effort to bridge the unmet needs of PRO collection and integration into routine cancer care, we aim to develop an effective, scalable, and sustainable symptom monitoring and management system that can be accessible worldwide. The system was developed using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On Nov 28th, 2017, we launched a free, mobile PRO application on the Apple App Store – PROeverywhere. PROeverywhere is designed for reporting twelve common symptoms from the National Cancer Institute’s Common Terminology Criteria for Adverse Events. These symptoms include pain, fatigue, nausea/vomiting, appetite loss, diarrhea, constipation, shortness of breath, depression, anxiety, insomnia, memory problems, and neuropathy. Symptoms are reported in a 5-point scale – no symptom, mild, moderate, severe, and disabling. PROeverywhere has the functions to record symptoms, summarize the reporting in printout, and automatically store and analyze the input into graphical interpretations. Updates to PROeverywhere will be released in July 2018, with additional features that include longitudinal tracking dashboard, emoji scale, Spanish questionnaire, and “social networking” capability to connect users with potential to allow remote, real-time, reporting and monitoring. PROeverywhere is downloadable worldwide and securely powered by Google Firebase. Conclusions: PROeverywhere is developed to enable PRO data to be shared more easily and regularly in routine cancer care. Implementation of this free mobile application would allow for consistency in collection of PRO data with the potential to impact patient outcomes globally.