bluuebunny/crossref_metadata_2025_split huggingface dataset:
Closure of Medicare Part D coverage gap by the Affordable Care Act (ACA) and use of oral anti-myeloma agents.
Authors: Olszewski Adam J. , Dusetzina Stacie , Davidoff Amy J. , Trivedi Amal N 
Published: September 2018

6522 Background: Medicare Part D pays for oral anti-myeloma immunomodulatory drugs (IMiDs, lenalidomide and thalidomide), but has a coverage gap resulting in an out-of-pocket (OOP) expense of > $ 3000 for the 1st prescription (Rx). Patients (pts) eligible for Low Income Subsidies (LIS) are exempt from cost sharing, and LIS is associated with IMiD receipt ( Olszewski, ASH 2016). In 2011, the ACA partly closed the coverage gap with a 50% manufacturer discount on the price of brand-name drugs within the gap. We examined effects of this policy on IMiD use. Methods: From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we selected Part D enrollees who started anti-myeloma chemotherapy in 2008-2012. We identified IMiD use in periods pre-ACA (2008-10) and post-ACA (2011-12), among pts with or without LIS. After confirming parallel trends in IMiD use before the ACA, we examined the effect of ACA discount on IMiD use in a difference-in-differences (DiD) model, using LIS recipients as controls whose OOP costs were not influenced by the ACA. Results: Among 3,313 Part D enrollees (of whom 31% received LIS), 41% received IMiDs as part of their anti-myeloma regimen. Compared with the pre-ACA period, in the post-ACA period the median gross IMiD cost of the 1st Rx increased for all pts (Table). OOP costs for the 1st Rx, and for the 1st year of IMiD therapy, decreased for LIS non-recipients. Proportion of pts entering catastrophic coverage with their 1st IMiD Rx decreased from 71% to 49%. However, there was no statistically significant effect of the ACA discount on the proportion of pts treated with IMiDs (DiD estimator, 3% [95%CI, -4 to 10]; P=.40), or on the time from diagnosis to 1st Rx (median 1.5 mo. in all groups). Conclusions: The ACA-mandated partial closure of coverage gap lowered the OOP costs for Part D enrollees treated with IMiDs. As the median OOP cost remains > $2400 for the 1st Rx, and > $4900 for the 1st year of therapy, the policy may be insufficient to overcome the financial barrier for beneficiaries who do not receive the LIS. [Table: see text]
Disrupting end-of-life cancer care delivery: Results from the engagment of patients with advanced cancer trial.
Authors: Patel Manali I. , Sundaram Vandana , Desai Manisha , Periyakoil VJ , Kahn James , Asch Steven M , Milstein Arnold , Bundorf Kate 
Published: September 2018

6525 Background: Sustainable approaches to improve quality and safety of care of patients with advanced cancer while concurrently reducing costs is a growing national need. As part of the Veterans Administration Engagement of Patients with Advanced Cancer (EPAC) trial, we trained a lay health worker (LHW) to engage patients with stage 3 and 4 cancer in early advance care planning (ACP). The goal of this follow-up study was to examine the effect of the LHW intervention on patient-reported care experiences, healthcare utilization, and costs in the last 30 days of life for patients who died within 15 months of enrollment. Methods: We evaluated patient-reported experiences with decision-making, healthcare utilization, and total healthcare costs 30 days prior to death. A T-test was used to compare patient experiences with decision-making. To compare ED use and hospitalizations, we utilized an exact Poisson regression. A generalized linear model with gamma link-log function was used to compare total costs. The latter methods adjusted for length of follow-up. Results: In the 30 days prior to death, 60 patients died in each arm within 15 months of enrollment (difference not statistically significant). Patients in the intervention had significantly improved rates of ACP documentation (98% versus 18% p < 0.001), improved experiences with decision-making as measured by an index ranging from 0-5 with higher values representing more favorable experience (4.73 (SD 0.61) vs 4.15 (SD 1.02)) p < 0.001), higher utilization of hospice (77% vs 52%, p < 0.005), lower rates of any emergency department use (5% versus 45% p < 0.001) and any hospitalization (5% versus 43% p < 0.001), and significantly lower total costs of care ($1,048 versus $23,482 p < 0.001) compared to the patients randomized to the usual care arm. Conclusions: Integrating a LHW into oncology care to engage patients in early advance care planning resulted in significantly improved patient experience, decreased utilization and decreased total costs in the last month of life. LHWs may represent a sustainable resource to facilitate optimal patient-centered cancer care at the end-of-life. Clinical trial information: NCT02966509.
Telehospice: Implementation lessons from rural hospice care with mobile tablets.
Authors: Doolittle Gary C. , Nelson Eve-Lynn , Spaulding Ashley , Kuhlman Sandy 
Published: September 2018

6546 Background: In underserved rural communities, hospice personnel often travel great distances to reach patients, resulting in challenges to maintain access, quality, cost-effectiveness and safety. To address these disparities, the University of Kansas Medical Center piloted the country’s first TeleHospice (TH) service in 1998. Barriers such as technology limitations, costs and attitudes towards technology limited adoption (Cook et al., 2001). An updated academic-community project utilizes secure mobile videoconferencing to support TH services in Kansas’ frontier communities. Methods: Leveraging lessons learned from the early work, a secure cloud-based videoconferencing solution was chosen for ease of use. To maximize limited resources, the selection of hospice partners was guided by Gustafson et al.’s (2003) Organizational Change Manager, which also informed implementation gaps. The academic team partnered with Hospice Services, Inc., a leader in rural hospice care, providing services to 16 Kansas counties. Results: From February 2016 through January 2017, 116 TH encounters occurred, encompassing 707 attendees over 7,462 minutes. The most common TH uses to date have been: administrative (e.g., connecting hospice staff across 16 counties); professional-to-professional (e.g., connecting hospice nurses at homes to additional TH professionals); and family support (e.g., connecting adult children with loved ones). Initial use of videoconferencing for administrative purposes developed a comfort level in using it for clinical and family support purposes. For staff meetings alone, the hospice has saved approximately $2,500/month in travel, with TH staff noting increased morale driven by increased team communication. Conclusions: Compared with early work, technology advances and a community-centered approach have increased TH adoption. With decreasing budgets as well as rural hospice closures, innovative, cost-effective and community-driven approaches such as TH are needed to decrease disparities. As dissemination occurs in national hospice organizations, continued research is needed to understand best fit within frontier hospices, to inform future urban applications and to address reimbursement.
Themes and costs underlying avoidable terminal oncology ICU hospitalizations.
Authors: Daly Robert Michael , Hantel Andrew , Polite Blase N. , Prigerson Holly Gwen 
Published: September 2018

6548 Background: ICU admissions in the last 30 days of life are an indicator of poor care. Our prior research found nearly half of terminal oncology ICU hospitalizations are potentially avoidable. Methods: Data were derived from 72 patients consecutively cared for in an academic medical center’s oncology practice who died in an ICU between July 1, 2012 and June 30, 2013. Oncologists, intensivists, and hospitalists used a standardized assessment tool to review each patient’s electronic health record from 3 months prior to hospitalization until death; they made a clinical determination of avoidability. Two investigators, blinded to the specialty, used a grounded theory approach to extract clinical themes associated with the reviewer’s determination of avoidability. Total, direct, and indirect costs were abstracted for each avoidable hospitalization. Results: Thirty-four (47%) of the examined hospitalizations were deemed avoidable. The primary themes associated with avoidability, and the percentage by specialty, were as follows: 1) failure to initiate appropriate advance care planning in the outpatient setting (68% oncologists, 55% intensivists, 65% hospitalists), 2) failure to integrate understanding of limited prognosis (23% oncologists, 24% intensivists, 26% hospitalists), and 3) failure of clinical management (6% oncologists, 21% intensivists, 6% hospitalists). A failure to educate and integrate surrogates into timely medical decision-making was a prominent secondary theme for oncologists (22%), intensivists (18%), and hospitalists (29%). The total cost per patient averaged $44,532 with direct and indirect costs averaging $25,215 and $19,317, respectively. High cost areas were ICU level care (35%) and pharmaceuticals (16%). Conclusions: The themes identified suggest potential preventative interventions, including higher rates of outpatient advance care planning, oncology inpatient communication to promote patient’s prognostic understanding, prevention of failures in clinical management, and better education and integration of surrogates. Given 8% of oncology patients expire in the ICU and 47% were identified as avoidable, the potential national annual cost of these avoidable hospitalizations is $997MM.
Are physicians social networks linked to breast cancer screening recommendations for older adults?
Authors: Pollack Craig Evan , Radhakrishnan Archana , Parker Andrew M , Visvanathan Kala , Nowak Sarah A 
Published: September 2018

6550 Background: Physicians’ prior experiences caring for patients with breast cancer along with experiences in their social networks including family members and friends may be a key and understudied driver of recommendations for cancer screening. Methods: The Breast Cancer Social Networks study (CanSNET) is a national, mailed survey of 2,000 primary care providers (PCPs) randomly selected from the American Medical Association Masterfile. PCPs were asked to provide detailed characteristics on up to 2 women they know who have been diagnosed with breast cancer and “whose cancer, broadly speaking, had the greatest impact” on them, including friends, family members and patients. Each woman was categorized as being diagnosed (a) through screening with a good prognosis, (b) not through screening with a good prognosis, (c) through screening with a poor prognosis or (d) not through screening with a poor prognosis. We used a logistic regression model to assess the association between the network member and recommendations for routine screening mammograms to average-risk women ages 75+, adjusting for provider and practice characteristics. Results: Overall 871 physicians responded to the survey yielding an adjusted response rate of 52.3% (out of 1665 eligible). We found that 67% of physicians recommended screening for women 75+. The sample reported on 762 patients, 378 family members and 476 other network members who had been diagnosed with breast cancer. Ten percent of patients and 25.1% of family members reported on died of their disease. In adjusted models, we found that physicians who reported on family members who did not receive a mammogram and had a poor prognosis were significantly more likely to recommend screening compared to those who did not (Odds Ratio 1.22, 95% Confidence Interval 1.03, 1.43). Conclusions: Physicians’ experiences with their social networks was linked to their breast cancer screening recommendations, underscoring the potential for information that is learned from social networks to differ from clinical guidelines and highlighting the need to address a broad array of influences in trying to reduce potential over-screening in cancer.
The association between employment changes and healthcare use in the year after cancer diagnosis.
Authors: Dickerson John F. , Chubak Jessica , Rabin Borsika , Nekhlyudov Larissa , Varga Alexandra M , Fujii Monica , Ziebell Rebecca , Banegas Matthew P. 
Published: September 2018

6551 Background: Employed adults diagnosed with cancer face difficult decisions about continuing/returning to work and intensity of work following diagnosis. We examined the association between employment changes and healthcare use among cancer survivors. Methods: Data on adults enrolled at two health plans (Kaiser Permanente (KP) Colorado and KP Washington), diagnosed with breast, colorectal, lung, melanoma, and prostate cancers between 2003-2008, who responded to a 2013 survey with items on employment patterns following diagnosis were used. Survey data were linked to electronic health record (EHR) data on healthcare use, demographics, and cancer characteristics. Employment status and changes following diagnosis were measured. Multivariable logistic and negative binomial regression models were used to assess associations between employment changes and healthcare use in the year after diagnosis, adjusting for demographic and cancer characteristics. Results: Among 465 cancer survivors with complete survey and EHR data, 225 (48.4%) reported being employed since diagnosis. Among employed survivors, 126 (56.0%) reported making an employment change. Those who made a change were more likely to be female, diagnosed with AJCC stage 3 or 4 cancer, have received chemotherapy or hormone therapy, and had a caregiver (all p < 0.01). The most common employment changes were taking extended paid time off (53.2%), unpaid time off (39.7%), and switching to a flexible schedule (29.4%). Employment changes were made at initial diagnosis (18.3%), during treatment (70.6%), and ≤12 months post-treatment (26.2%); 28.6% made more than one change. Survivors who made an employment change had significantly more oncology visits (IRR = 1.85 [95% CI: 1.14-3.00]) and higher odds of hospitalization (OR = 5.18 [95% CI: 2.50-10.8]), but not primary care visits (IRR = 1.19 [95% CI: 0.94-1.50]) in the year after diagnosis, compared to those who did not make a change. Conclusions: Employment changes among cancer survivors are common and may be associated with treatment intensity and other healthcare use in the year after diagnosis. Prospective studies are needed to assess the impact of employment and healthcare use patterns on health outcomes.
Self-reported financial stress among patients evaluated at a community cancer program.
Authors: Lathan Christopher S. , Akindele Ruth N. , Svoboda Ludmila , Gundersen Daniel A. 
Published: September 2018

6553 Background: Cancer related financial stress has been linked to a multitude of factors including socio-economic status, but its impact on the quality of life (QOL) for underserved populations is less well characterized. We evaluated patient reported financial stress, QOL, and quality of health (QOH) at an outreach cancer program located in a federally qualified health center. Methods: Study participants were interviewed at initial clinic visit for financial stress, QOH and QOL between January 2012 and December 2016. Demographic information, insurance coverage, clinical parameters, and comorbidities were abstracted from participants’ medical records. Responses to the financial stress index question “how difficult is it for you or your family to meet monthly payment of your/your family bills?” and overall QOL and QOH of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 were analyzed. Proportional odds logistic regression models were constructed for 5-point quality of life measures and three levels of financial toxicity. Results: Of the 288 participants analyzed, 52% and 12% reported somewhat and extreme financial stress. In an adjusted analysis, patients who reported financial stress were more likely to be younger in age (OR = 4.03, p < 0.001) unemployed (OR = 3.24, p = 0.002), have less than bachelor’s degree (OR = 0.035, p = 0.018), insured by Medicaid (OR = 3.22, p < 0.011), and were more likely to rate their QOL (OR = 3.76, p = 0.031) as poor, compared to those without financial stress. Race, gender, presence of cancer diagnosis and comorbidities were not associated with financial distress. Independent predictors of poor QOL were disability (OR = 3.12, p = 0.005), depression (OR = 2.12, p = 0.007) and extreme financial difficulty (OR = 2.57, p = 0.011). There was a nearly perfect positive correlation between overall QOL and QOH (r = 0.984, p < 0.001). Conclusions: There is a high prevalence of financial burden among underserved minority patients seeking cancer related care, and this is closely associated with poor quality of life. Interventions targeting cancer disparities need to assess financial stress in order to address this issue.
Inpatient hematology and oncology rehabilitation.
Authors: Blankenship Leann , Foluso Ogunleye , Lanni Thomas B. , Hakmeh Basil , Akhtar Adil Jamal , Riutta Justin , Gaikazian Susanna S. , Anderson Joseph M , Stender Michael J. , Jaiyesimi Ishmael A. 
Published: September 2018

6580 Background: Functional decline in cancer patients impacts quality of life and overall survival. Increasing attention has been focused on cancer rehabilitation in survivors, largely in the outpatient setting. Beaumont Health System has shifted its focus to include the acute setting by developing an inpatient cancer rehabilitation unit (IPCR) to improve the comprehensive care of patients. Methods: We retrospectively reviewed the patients admitted to IPCR from January 1 - December 31, 2016 for the following: demographics, length of stay (LOS), function independence measure (FIM) gain and efficiency, discharge location, and primary tumor type. Results: IPCR had 117 inpatient admissions; 98 (83.7%) were solid malignancies while 19 (16.3%) were benign hematological disorders and hematological malignancies. Of the 98 patients with solid malignancies, 22 (22.4%) patients had breast cancer, 22 (22.4%) had gastrointestinal cancers, 5 (5.1%) had gynecological cancers, 23 (23.5%) had lung cancer, 8 (8.2%) had CNS malignancies, 11 (11.2%) had other cancers, and 7 (7.2%) had prostate cancer with 81.6% of patients having metastatic disease. Among the hematological malignancies, lymphoma was diagnosed in 11 (57.9%) patients while 3 (15.9%) each had multiple myeloma and leukemia. The mean age of the patients was 68 years and 59% were female. The average LOS was 8.6 days. The mean admission total FIM was 66.7 ±12.8 and discharge total FIM was 87.3 ±16.1. The total improvement in FIM was 20.6 ±13.8 with FIM efficiency of 2.9. There were 21 (18%) patients transferred back to acute care units for decompensation, 7 (6%) went to subacute rehabilitation, 1 (0.85%) went to hospice while 87 (74.3%) were discharge to their homes upon completion of IPCR. Conclusions: Our focused rehabilitation was able to decrease the LOS, well above the 90th percentile Center for Medicare and Medicaid Services (CMS) benchmark and other prior studies, as well as enable patients to safely return home with improved FIM. Creating an IPCR unit proved to be beneficial, allowing for more comprehensive and individualized care, even in the setting of advanced malignancies.
Value frameworks for cancer care: Do they account for potential durable survival with immunotherapies?
Authors: Goldstein Daniel A. , Magnezi Racheli , Leshno Moshe , Ben-Aharon Omer 
Published: September 2018

6601 Background: Modern immuno-oncologic agents may have the potential to provide durable survival for some patients. Simultaneously, there is growing concern regarding the cost of cancer care, and multiple frameworks have been developed to assess value. The points based framework created by the American Society of Clinical Oncology (ASCO) has a specific threshold, and more points are awarded if substantial durable survival is demonstrated. The objective of this study was to assess if modern immuno-oncologic agents reach defined efficacy thresholds in this framework. Methods: We reviewedall FDA approvals for immuno-oncologic agents since the first approval in 2011. We collected data regarding study endpoints, specifically the parameters defined in the updated ASCO value framework: improvement in proportion of patients alive with the test regimen, and survival rate with standard. We assessed whether bonus points would be rewarded as per the updated ASCO value framework for durable responses demonstrated on the tails of the Kaplan-Meier curves. These parameters were used as an input to check whether each drug reaches the required achievement defined in the framework. Results: 17 indications for four immunotherapy active ingredients were approved by FDA between 2011-2016: ipilimumab, pembrolizumab, nivolumab and atezolizumab. 59% of the approvals rely on survival endpoints such as overall, progression-free, or relapse-free survival. 41% are based on objective response rates. Only one drug (nivolumab indicated for melanoma first-line treatment) was found to fulfill the threshold defined for the survival rate of standard care (above 20%). Six drugs achieved the required level of improvement in proportion of patients alive in the test regimen compared to the standard (above 50%). As there was no overlap between these two groups of drugs, no drug was found to gain the durable survival bonus points defined by the ASCO framework. Conclusions: Durable survival and responses of modern immuno-oncology agents are currently not recognized to be significant by the ASCO value framework. This may be due to insufficient demonstration of efficacy of such agents, or may be due to an inappropriately calibrated value framework.
Challenges of diagnostic concordance of lung cancer cases in Qualified Clinical Data Registry (QCDR) measure collection by CMS in calculating MACRA's rewards and penalties.
Authors: Glisson Shawn Dana , Goede Patricia Anne , Allen Timothy Craig 
Published: September 2018

6604 Background: QCDR was introduced for the Physician Quality Reporting System (PQRS) beginning in 2014. A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. Those who satisfactorily participate in PQRS through a QCDR may avoid the 2018 negative payment adjustment -2.0% of total Medicare payments. PQRS #396 is an example of a measurement by which oncologists may be evaluated. A physician’s QCDR score is determined by his/her numerator and denominator per patient based on total data submitted by various healthcare providers. Methods: IRB approval was obtained for a retrospective review of 60 randomly selected NSCLC pathology reports that were diagnosed at UTMB. The Denominator was determined by CMS to be: The patients were between the ages of 18-75; the diagnosis of NSCLC was coded by the appropriate ICD and CPT codes. The Numerator was determined by CMS to be: Pathology reports with a diagnosis that included pT pN for NSCLC with histologic type vs those not documented for medical reasons vs those specimens that were not of lung origin, or were classified as NSCLC-NOS. Results: The study consisted of 60 NSCLC pathology reports of which 2 were determined in retrospect not to have been lung cancer cases. Another 10 were considered to be incomplete. A final 2 were diagnosed as a different histological lung cancer type. As [60 - (2+10+2)]/60 = 76.67%, adherence to the quality standard was less than perfect even though excellent medical care was delivered. This score puts the institution at risk of a 2% Medicare Payment Reduction in 2018 if a majority of other institutions score even slightly higher. Conclusions: Physician remuneration will be reduced by current information submitted to CMS. As the quality scores will be made public, reputations may be negatively impacted. Coding and billing operations may be hindered in their attempt to accurately submit data to CMS. Healthcare Systems may be less inclined to request outside consults (including NGS) that may provide a different diagnosis that could confuse the QCDR.