bluuebunny/crossref_metadata_2025_split huggingface dataset:
Creative strategies to address challenges in access.
Authors: Ruiz Carlos , Franco Susan 
Published: September 2018

215 Background: The Cancer Center is structured across multiple campuses with clinics at three different locations. Patients, providers and referring offices encountered difficulty accessing services and encountered a fragmented structure and a non-standardized process. Patient and provider calls often resulted in multiple transfers. Referring providers and patients frequently left a voicemail for new patient appointments. There was no standardized process for addressing urgent clinical calls from patients. This led to delays in access for new patient appointments, delays in patient care and poor patient experience scores. Overall telephone statistics went untracked. Methods: A multidisciplinary team was organized and tasked with the creation of a centralized Cancer Contact Center (CCC). In August 2015 the CCC became a reality with the vision of “One Call Resolution” for anybody needing access to the services of the Cancer Center. Single telephone and fax numbers were created and all staff were placed together in one location. Three distinct job roles made up the CCC: Telephone Operators, as the main point of initial contact; New Patient Coordinators, to facilitate new patient referrals, record collection and scheduling; and Lead Nurses to provide clinical oversight and guidance. Processes were put in place to ensure standardization and consistent outcomes. Operator guidelines were conceived and an articulated approach to managing patient clinical concerns was planned. Clinical triage of these concerns initially involved the Telephone Operators, RN Case Managers and Lead Nurses. Later, clinical triage evolved into the creation of a specific triage line and Triage Nurses for clinical questions and to further ensure patient safety. Results: Patient experience scores relating to telephone accessibility for patients have increased from a 56.9 Top Box score to a 67.5 score. Telephone answer rates have been sustained above 95%. Conclusions: The creation of a centralized Cancer Contact Center has enabled all calls, referrals and clinical triage to be initially managed in one location under a standardized process with sustainable results.
Results from a pilot of an innovative 4R Cancer Care Delivery Model: Impact on patient self-management.
Authors: Trosman Julia Rachel , Weldon Christine B. , Perez Claudia B. , Kulkarni Swati , Khan Seema Ahsan , Hansen Nora M. , Nelson Valerie , Stein Jennifer , Simon Melissa A. , Spagnoli Cathy , Tepper Jennifer , Pearson Kay , Gradishar William John 
Published: September 2018

224 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R is Right Info / Care / Patient / Time. It enables patient (pt) and care team to manage interdependent care along the care continuum with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed its impact on pSM. Methods: 4R Plans were administered to breast cancer pts stage 0-III Sep ’16 – Aug ’17 (4R cohort). We surveyed the 4R cohort and a comparable historical cohort of pts who received care pre-4R, Jun ’15 – May ’16 (control). We used simple frequencies and Fisher’s exact test in analyses. Results: Survey response rates: 68%, 185/271 (4R cohort); 47%, 241/410 (control). 75% of 4R respondents reported 4R Plans very useful / useful in overall understanding and organizing their care; 68% found 4R’s novel “project” component, very useful / useful in managing timing & sequencing of interdependent care. Care complexity impacted 4R usefulness: 67% of pts who received > 6 care services found 4R very useful / useful vs. 47% of pts who received < = 6 services, p = .01. Pts with lower care complexity suggested how to make 4R more useful to them, eg focus on endocrine therapy. Table compares pSM metrics in the 4R and control cohort. Care complexity was a significant factor of feeling overwhelmed for pts in the control cohort (51% of pts receiving > 6 care services felt overwhelmed vs. 31% of pts receiving < = 6 services, p = .02), but not a significant factor for pts in the 4R cohort (30% vs. 28%, p = .9). Conclusions: The 4R model significantly improved pt self-management in early breast cancer and reduced the impact of care complexity on pts, but provider factors of pSM need improvement. A 4R pilot at additional 12 cancer centers across the U.S. is in progress.[Table: see text]
Nationwide utilization and costs of targeted anti-cancer drugs for elderly patients with solid tumors in the United States, 2004-2015.
Authors: Wilson Lauren E , Greiner Melissa , Altomare Ivy , Rotter Jason , Dinan Michaela Ann 
Published: September 2018

23 Background: Studies of patients age < 65 suggest large increases in utilization and costs of targeted anti-cancer drugs (TADs). However, use and costs of TADs in patients age 65+ have not been examined in a national sample. Methods: We conducted a retrospective analysis of patients ≥ 65 years with invasive lung (LC), breast (BC), or colorectal (CC) cancer using Medicare 5% claims from 2004-2015. We identified the yearly proportion of cancer patients receiving an intravenous TAD and the proportion of Part D enrolled Medicare patients receiving an oral TAD. We examined yearly costs of TADs as a proportion of total Medicare cancer and all-cause spending. Using generalized linear models, we estimated yearly trends in mean cost per beneficiary for TADs, all cancer spending, and total Medicare cost with adjustment for age, sex, region and comorbidities. Costs were adjusted to 2015 dollars using the CPI medical cost index. Results: We observed higher uptake of IV TADs in the 65+ patient population for each of the three cancers compared to oral TADs. IV TAD utilization reached 9.8% in CC patients, 5.0% in lung cancer patients, and 3.7% of BC patients. Use of oral TADs remained lower than use of IV TADs (≤ 1% of patients across all three cancers). From 2005-2015, total and cancer-specific Medicare spending per beneficiary decreased slightly for CC and LC patients and remained stable for BC patients. However, adjusted mean IV TAD spending per beneficiary increased from $139 in 2005 to $897 in 2015 for LC, from $96 to $550 for BC, and from $384 to $455 for CC. For Part D patients, the combined contribution of IV and oral TADs to total yearly cancer spending increased significantly from 2006 to 2015 for LC (2 to 5%), BC (4 to 18%), and CC (6 to 12%) cancers. Conclusions: Use of IV TADs in the US elderly lung, breast, and colorectal cancer populations grew rapidly in the years following FDA approval and stabilized. Use of oral TADs remained low compared to IV agents. Against the backdrop of largely stable Medicare spending, TADs are increasingly responsible for a growing proportion of that spending, particularly in breast cancer patients where TADs accounted for nearly a fifth of all 2015 cancer spending for Part D patients.
Mitigating risk of preventable medical errors across a network through event sharing.
Authors: Denny, DBA Diane , Shinners Caitlyn 
Published: September 2018

234 Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to preventable medical errors occurring in the treatment of their patients. As a national network of five hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer, clinicians and quality professionals recognized an opportunity to encourage and formalize the process of sharing safety events, lessons learned, and action plans to mitigate the risk of repeat occurrence. Methods: An Alert Notification process was established consisting of an algorithm depicting two avenues for action when an event occurs. If the event is considered urgent, characterized by immediate high-risk of repeat occurrence or high-risk of severe harm, an alert is called. The hospital nursing officers and quality directors along with the corporate director of pharmacy and vice president of quality/safety convene within 24 hours of the event to: 1) resolve or “halt” the process; 2) escalate if needed; and 3) formulate a communication plan regarding any change in process. If the event does not meet urgent criteria, the hospital conducts a root cause analysis (RCA) or common cause analysis, depending upon the algorithm. A summary of RCAs conducted for events resulting in temporary or permanent severe harm or worse are presented at the network’s monthly safety meeting, with action plans implemented across sites. Results: The notification algorithm was implemented in September 2017. Since its inception, three events have been communicated using the Urgent Alert Notification, including a syringe recall that halted use at all sites until all lot numbers could be checked, and affected syringes pulled. Several events and near misses have been communicated using the non-urgent process, including for example, discussion of a retained foreign object which resulted in review of processes for orienting staff to new products. Conclusions: The process has promoted communication across the five centers as an error prevention strategy. The sharing allows all sites to cross-fertilize resolutions to minimize rework, reduce the risk of repeat events, and build collective knowledge ensuring patient safety is our first commitment.
Ongoing professional practice evaluation: An infrastructure for accountability.
Authors: Denny, DBA Diane , Gross Danielle , Bernstein Gary 
Published: September 2018

239 Background: As a national network of five hospitals treating patients fighting complex cancers, continuous monitoring of clinical staff competence is a priority. Recognizing an opportunity for an enhanced structure for ongoing professional practice evaluation (OPPE), a process mandated by The Joint Commission, the network set out to create heightened accountability, reliability and understanding of the review of performance data. Methods: Two work groups were established. The first was charged with the selection of meaningful specialty specific measures applicable to the oncology patient population. The second tasked to leverage resources expended using existing software and limiting the need for manual intervention. This group was responsible for creation and implementation of a consistent workflow with defined roles for physicians, medical staff operations and quality reviewers. Results: Over 50 subspecialties were mapped to over 250 selected metrics, with overlap when applicable to more than one specialty. A standard network-wide policy was approved by each center’s medical executive team. A workflow was clearly defined to include responsibilities associated with (pre-review) analyst role, service chief and credential committee. The use of the network’s reporting tool was standardized for OPPE as well as additional sources of quality data identified outside of the tool as needed, specifically for low volume and non-patient facing providers. A review calendar was created to guide the process on a rolling basis. Lastly, an OPPE Toolkit was created to govern and educate on the process that includes a pocket guide, Q&A, and on-boarding materials for physicians to understand their data relevant to metrics for which they are accountable. Conclusions: This systemic and timely evaluation of practitioner specific data supports improvement of practitioner performance and provides objective information for credentialing and privileging decisions across the network. Physicians’ visibility into their own data has increased. Automating the majority of efforts associated with OPPE has reduced the time associated with fulfilling this external requirement and resulted in full compliance.
Developing and testing a novel hospital readmission score for patients with cancer.
Authors: Power Steve , Kamal Arif 
Published: September 2018

244 Background: Up to 50% of cancer patients experience an unplanned hospitalization. This represents opportunities for both improvements in quality of care and utilization of low value resources. Hospital readmission scores, to best target post-discharge navigation and follow-up, are needed yet not widely available. Methods: We conducted a retrospective cohort study among oncology patients admitted to Duke University Hospitals in 2015. The readmissions risk test model was built using multivariate analysis to identify and ‘weight’ four key readmission predictors. The model was subsequently analyzed in a validation data set using 2016 & 2017 admission data. Results: Of the 4987 admissions in 2015, 55% were male, 73% were Caucasian, and mean age was 61 (SD 14.1 years). Common cancers were GI (31%), Thoracic (27%) and GU (24%). Factors used to build the readmission predictor model based on the relative Odds Ratios were race (1), length of stay (1), discharge disposition (2), and previous admission with < 90 days (2) or 91-180 days (1). The patient cohort used to test the model had 1926 admissions and each were assigned a point value according to the model specifications, see Figure 1. We found significant differences in risk for readmission among differences in scores (p < 0.05). We have subsequently launched a post-discharge navigation program, with frequency of contacts dictated by readmission risk from the model. Conclusions: Predictor models in the oncology setting can identify combinations of factors that are associated with readmission. Programs that integrate such models may identify cancer patients at high risk of readmission and thus tailor a personalized approach to preventing a subsequent admission.[Table: see text]
Standardization of inpatient CPR status discussions and documentation within the division of hematology-oncology at UPMC Shadyside: Results from PDSA cycle 1 and 2.
Authors: Garcia Christine Ann , Bhatnagar Mamta , Rodenbach Rachel , Chu Edward , Marks Stanley M. , Graham-Pardus Abigail , Kriner Jamie , Winfield Melissa , Minnier Christopher , Leahy Janet , Hanchett Sharon , Baird Emily , Levenson Joshua 
Published: September 2018

257 Background: In December 2016, 49% of patients admitted to inpatient oncology services at UPMC Shadyside had CPR status discussion documentation prior to discharge. This project aims to improve quality and rates of CPR status conversations. Methods: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses and advance practice providers (APPs), medicine house staff, and palliative care faculty. All oncology clinicians were reminded weekly to discuss and document CPR status preferences. APPs received communication training with palliative care specialists. Oncology leadership received a monthly update of CPR status documentation rates, and endorsed CPR status best practice guidelines developed by the workgroup. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed. Results: PDSA cycle 1 resulted in CPR status assessment rates increasing from 49% to > 80%. 1400+ more CPR status discussions were documented in 2017 than 2016. The percentage of patients discharged “Comfort Measures Only” or “Do Not Resuscitate” increased from 14.2 (S.D. 2.4) to 20.0 (S.D. 2.1). For PDSA cycle 2, 60 patients without CPR assessment were reviewed. Fifty-two percent were admitted overnight by nocturnists, 48% by daytime APPs, and none by housestaff. 55% (33/60) had metastatic disease. Fifty-three percent (31/60) of patients had prior CPR status documentation in the past 12 months. Fifteen percent (11/60) of patients were admitted for scheduled inpatient chemotherapy. Conclusions: PDSA 1 showed that standardization of CPR status assessment with formal training increased CPR status assessments. More patients wanted CMO or DNR when asked, which may indicate the need for earlier goals of care discussions. PDSA 2 indicated that focusing efforts on completing CPR assessment as part of the admission process, especially for scheduled inpatient chemotherapy admissions, is critical in further improving our rates.
Electronic monitoring of patient-reported adherence and symptoms on oral chemotherapy at an academic and a community site.
Authors: Doolin Jim , Roberts Daniel Aaron , Cibotti Christina , Devlin Scott M , Dowling Holly , Seery Virginia , Tocci Noah Xavier , Trillo Kelsey , Wright Danielle , Yenulevich Mary , Zerillo Jessica A. , Shea Meghan 
Published: September 2018

283 Background: Monitoring of toxicity and adherence is often lacking for patients recently started on oral chemotherapy. National guidelines recommend active outreach to patients within a week after treatment start. We developed an online tool to actively reach out to patients newly started on oral chemotherapy at one academic medical center and community practice. Methods: A multi-disciplinary team, including patients, developed an online oral chemotherapy adherence, symptom, and financial toxicity assessment tool within REDCap. We implemented this tool for new oral chemotherapy prescriptions in May 2018 in the gastrointestinal oncology group of an academic medical center and a general community practice. To quantify the impact of this tool on symptom management, we completed a retrospective analysis of patients receiving new oral chemotherapy prescriptions at these same sites, in the 13 months immediately preceding clinical implementation of the online tool, May 2017 to May 2018. Results: In the pre-intervention historical cohort (n = 58) the median time to first symptom assessment by a clinician was 7 days (range 1 – 41 days, SD 7 days), median time to identifying a new or worsening symptom was 10 days (range 1-55 days, SD 10 days), and median time to clinical action regarding a new or worsening symptom was 10 days (range 1-104, SD 20 days). Our first intervention patient used the online tool in May 2018 to report symptoms of “nausea and fatigue,” 4 days after starting oral chemotherapy. This resulted in an oncology clinical nurse calling the patient to review symptom management by phone. Conclusions: The median time to first symptom assessment in our historical control cohort is 7 days, with standard deviation of 7 days, suggesting potential room for improvement. Thus far, the online tool has been completed by one patient. Further data will be reported regarding the uptake of this tool, the tool’s impact on quality measures, and patient reported symptoms, adherence, and financial toxicity.
Incidence of diabetes and hyperglycemia among patients receiving glucocorticoids with chemotherapy.
Authors: Zylla Dylan M. , Steele Grant , Gilmore Grace , Davidson Janet , Carlson Anders 
Published: September 2018

286 Background: Over 30 million adults in the U.S. have diabetes (DM), 7 million of which are undiagnosed. Patients with DM undergoing cancer treatment have been shown to have increased rates of complications and shorter survival. Patients commonly receive glucocorticoids (GC) with chemotherapy (CT), which may lead to hyperglycemia. Data regarding the optimal approach to screening and outpatient management of patients receiving CT with GC is lacking. We sought to describe the incidence of diabetes, hyperglycemia, and implemented a quality improvement project to refer eligible patients for DM education and management. Methods: We identified 100 patients with cancer starting a new CT regimen including GC. We obtained screening labs, baseline random glucose, HbA1c, and body-mass index (BMI) for each patient prior to starting CT. Follow-up glucose values were obtained with each cycle; patients were followed for a maximum of 3 cycles of CT. Patients with a baseline HbA1c ≥6.5%, a baseline random glucose ≥200mg/dL, follow up glucose ≥200mg/dL, and/or a prior DM diagnosis were referred to the Park Nicollet International Diabetes Center (IDC) to receive DM education and management. Results: 23% of patients had known DM and 17% had known prediabetes prior to their first CT cycle. Baseline HbA1c values were ≥6.5% in 18% of patients, 5.7-6.4% in 39% of patients, and ≤5.6% in 43% of patients. Among the 18 patients with baseline HbA1c ≥6.5%, 13 had known DM, 1 had known prediabetes, and 4 were undiagnosed. 67% of our study population had a baseline BMI ≥25. 12 patients had at least one follow up glucose ≥200mg/dL. Of those 12, 92% had known DM, 67% had a baseline HbA1c ≥6.5%, and 75% had a baseline BMI ≥25. 29 patients met IDC referral criteria, however, only 14 were ultimately seen in consultation. Conclusions: Adding HbA1c to baseline laboratory evaluations identified individuals with undiagnosed DM. DM history, baseline HbA1c, and BMI were associated with hyperglycemic events among patients receiving CT with GC. Future studies are needed to evaluate the impact of DM education and management on both glycemic control and clinical outcomes.
The impact of C1/D1 treatment follow-up calls on emergency room visits for chemotherapy patients.
Authors: Davidson Kimberly 
Published: September 2018

289 Background: One of the more challenging aspects of managing patients receiving chemotherapy is to reduce Emergency Room (ER) visits and ultimately hospital readmissions. Patients may not understand who or when to call with issues and may be concerned about reaching their physician or receiving a call back in a reasonable amount of time. Methods: C1/D1 calls were initiated with the Medical Oncology Care Coordinator (CC) staff in August 2017. All patients receiving a C1/D1 dose of a new treatment and change in regimen were called by the CC. During this call, the patient is asked several questions including how they are currently feeling, if they are having any issues as well as reviewing contact information and direction regarding if they have a fever. Re-education was provided to the staff in January 2018 regarding the importance of the calls. Also at this time, the CC were asked to do Nadir calls (repeat call 7-10 days after D1) for those patients who were determined to be high risk (percentage calculated using a toxicity formula). Results: Initially the % of ER visits were reduced after the C1/D1 calls were initiated but then began trending upward again. After re-education and the initiation of the Nadir calls, ER visits again trended down. Conclusions: Increased touch points with patients, including C1/D1 follow up calls, Nadir calls and toxicity checks for high risk patients contributed to a downward trend of treatment patients visiting the ER.[Table: see text]