bluuebunny/crossref_metadata_2025_split huggingface dataset:
Deconditioning after "Moving On" rehabilitation.
Authors: Fanning Suzanne R. 
Published: September 2018

291 Background: “Moving On” is a 12-week physical rehabilitation program that is offered to patients following cancer treatment. Autologous hematopoietic stem cell transplantation (HSCT) is considered a more aggressive cancer treatment due to myeloablative doses of chemotherapy. Our previous research has shown that deconditioning at the time of referral to Moving On is not significantly different in HSCT patients and non-HSCT cancer patients. Our objective here is to determine how deconditioning after Moving On completion compares in HSCT and non-HSCT groups, as well as by age. Methods: We retrospectively reviewed data from Moving On referrals made between March 2013 and March 2016 (N = 1,057) who completed the Moving On program (N = 322). This includes patients with solid or hematologic malignancies, some of whom received HSCT. Brief Fatigue Inventory scores and 6-minute timed walk (6-MTW) distances were recorded to assess deconditioning. Results: We found 296 of 615 (48%) non-HSCT patients evaluated for Moving On, completed the program; 26 of 43 (60%) HSCT patients evaluated for Moving On completed the program. For those completing Moving On, we found a mean fatigue score of 1.6 in non-HSCT patients (SD = 1.9) and 1.3 in HSCT patients (SD = 2.3) (p = 0.43). The mean distance walked in six minutes was 1543 feet (SD = 237) in non-HSCT patients and 1624 feet (SD = 247) in HSCT patients (p = 0.11). In patients < 70 years old, average fatigue scores were 1.6 for non-HSCT and 1.2 in HSCT (p = 0.29); average 6-MTW distances were 1564 ft. for non-HSCT and 1644 ft. in HSCT (p = 0.17). In patients ≥70 years old, average fatigue scores were 1.4 for non-HSCT and 1.6 in HSCT (p = 0.82); average 6-MTW distances were 1451 feet for non-HSCT and 1560 feet in HSCT (p = 0.20). Conclusions: We find that 25% more HSCT patients complete Moving On than non-HSCT patients. There is no significant difference in post-Moving On fatigue scores or 6-MTW distances between HSCT and non-HSCT groups. A significant difference in 6-MTW by age, is found in the non-HSCT group but not in HSCT patients. This may be due to selection bias in this group, as more fit patients ≥70 undergo HSCT. Our results show that deconditioning following rehabilitation in autologous HSCT is comparable to cancer patients not receiving HSCT, regardless of age.
Improved acute pain management in oncology patients using early scheduled contact with a pain coach.
Authors: LaSala Johanna M. , Chiang Anne C. , Severino Kimberly M 
Published: September 2018

293 Background: Pain control is a challenging balance in the ambulatory oncology practice. Standard methods of pain reassessment resulted in poor pain control in the majority of patients given prescriptions for narcotics. We developed a proactive reassessment of pain using patient reported outcomes and a coach to assist in medication usage. The aim was to decrease the time to reassessment of pain to fewer than 5 days and achieve acceptable pain control in greater than 50% of patients receiving new narcotic prescriptions in an ambulatory oncology setting. Methods: Patients receiving a new narcotic prescription or a new dose were provided with a pain diary and an appointment with their pain coach at 48 hours. Using a standard pain scale 1-10, patients’ pain scores were recorded by the patient in their pain diary and communicated via nurse/patient phone contact at 48 hour intervals. Dosing intervention by the patient’s oncologist was made for unacceptable pain and reassessed at 48 hours. Uncontrolled pain at 96 hours was followed by in person appointment with the oncologist. Pain scores and days to reassessment were recorded using an Excel data collection tool for patients receiving new or dose adjusted narcotic prescriptions between August and December31, 2017. Results: There were 17 patients encounters where the patient received a new prescription or a dose change from August 1- Dec 31, 2017. Reassessment of pain was achieved in 100% of patients in fewer than 5 days. The average time was 2.6 days (range 2-4). Acceptable pain control (pain scores 0-3) at the time of reassessment was achieved in 53% of patients. Conclusions: Cancer related pain is an ongoing challenge in oncology practices. Barriers include lack of planned follow-up and patient education. The institution of a pain coach, pain diary and scheduled contact decreased the time to reassessment of pain and decreased pain scores during short interval reassessment periods achieving better pain control in 50% of patients during the evaluated period. Quality interventions in ambulatory settings are achievable though multiple patient interactions and record keeping require additional staffing resources to sustain this change.
Implementing radiation oncology pathways at Dana-Farber Cancer Institute/Brigham and Women’s Hospital.
Authors: Hayne Victoria , Stein Leah A. , Tremonti Carole Kathleen , Baldini Elizabeth H. , Phillips John G. , Hilfer Susanna C. , Jackman David Michael , Hall Julia Cooper , Greenberg Teresa L. , Hamilton Joanna M. , Jacobson Joseph O. , Martin Neil E. 
Published: September 2018

301 Background: Modern cancer care faces increasing complexity and the challenge of delivering consistent, high-quality care across growing networks. Dana-Farber Pathways address these concerns by translating expert content into treatment algorithms delivered through a web-based platform and implemented across the network. We had previously built 31 Medical Oncology (MO) pathways. Our goal was to build and implement Radiation Oncology (RO) pathways for common cancer conditions in 18 months. Methods: Partnering with lead clinicians from each disease group, we chose the most appropriate framework for each pathway: expand previously established RO pathway; use corresponding MO pathway; or if no framework was available, develop RO pathway in its entirety. We worked with each disease group to gain consensus about the recommended on-pathway selections that reflect the latest research and institutional standard of care. Implementation consisted of pre- and post-launch department communications about metric goals and individual provider training on the system. Because the program was launched without provider incentivization, the usage rate goal was navigations for at least 25% of patients receiving radiation treatment. The on-pathway rate goal range was 70-80%. Results: We exceeded our goal: we built and implemented 25 pathways in 12 months and constructed all 27 pathways in 18 months. We have met both key rate goals across all disease pathways since time of launch: usage rate is 63%; on-pathway rate is 85% (39 providers across 3 sites). Conclusions: A preliminary analysis of RO Pathway data demonstrates collective adoption across all sites. Qualitative surveys show it to be a useful resource in radiation treatment decision-making and in palliative care service. We will continue to analyze the use of RO Pathways and develop strategies to collaborate with MO to further guide multi-disciplinary decision-making.[Table: see text]
Symptom management pathways to reduce ED visits and hospitalizations for patients with cancer.
Authors: Roy Mohana , Halbert Brian , Devlin Scott M , Zerillo Jessica A. 
Published: September 2018

302 Background: At our academic medical center, acute on chronic pain, gastrointestinal symptoms and fever led to most preventable ED visits and hospitalizations amongst cancer patients on chemotherapy. We developed management pathways to target these symptoms. Methods: Existing symptom management algorithms and internal expert consensus of multidisciplinary stakeholders, including palliative care and infectious disease, contributed to initial symptom management algorithms. After iterative revisions, the pathways were finalized by hematology/oncology physician and nursing leadership. We identified outpatient, non-oral, cancer directed treatment events using pharmacy billing data. These events included traditional chemotherapy, immunotherapy, and hormonal therapy. We then identified any ED visit or hospitalization at our medical center within 30 days of the event. We plan a pre-post analysis to determine change in 30-day ED visits and hospitalizations for any reason and for our target symptoms. Results: We developed pathways for acute on chronic pain, nausea/vomiting, diarrhea, constipation, and fever. Each pathway follows a standardized model including warning signs with guidance on direct referral to the ED or urgent clinic referral, the specific treatment algorithm, and helpful references. The pathways were implemented in May 2018. From January 2016 to February 2018, we identified 28,764 treatment events among 4,197 patients. Patient mean age was 63 years. The most commonly used treatments were fluorouracil, leuprolide, and paclitaxel. Within 30 days, 5.7% had an associated ED visit; 5.0% had any hospitalization. Conclusions: We developed management pathways for common symptoms among patients receiving cancer treatment. Generalizing care for such a heterogeneous population can be challenging and requires significant engagement from a multidisciplinary team. Post-intervention data is forthcoming to assess the impact of the pathways on reducing ED visits and hospitalizations.
Using a patient-reported outcomes tool as a gateway to identifying patients who would benefit from palliative care.
Authors: Dunn Kathleen , Hannaford Morgan , Hartman Scott , Denny, DBA Diane 
Published: September 2018

306 Background: Palliative care provides a wide range of supportive care services that aim to enhance the patient’s quality of life, reduce complications, address supportive care needs earlier, and avoid unnecessary resource consumption. A national network of five hospitals providing comprehensive cancer care noted barriers in identification of patients that may benefit from these services. Technology and objective criteria can circumvent human barriers such as, prognostic uncertainty and psychology of decision making. Referred to as the SIT (symptom inventory tool) process, an externally validated assessment tool that captures patients’ perceived symptom burden from baseline and every 21 days was used as means of identifying patients who might benefit from referral. Methods: A three-month pilot was initiated at two centers using a report run on a weekly basis, generated from the SIT process utilizing the following criteria: six or > symptoms from 27 increasing in severity by two points or > since their last assessment. This subset of patients identified by this filter was reviewed by the palliative care nurse to determine if they meet the following criteria: any stage with metastatic disease, stage 3 not in remission, and stage 4 not already enrolled in palliative care. Results: During the pilot timeframe, 1,127 SIT self-assessments were completed by patients at Site 1 with 168 patients flagged for review by the palliative care RN. Of these 168 patients 75 (or 44.6%) met the criteria for palliative care services. At Site 2, 802 self-assessments were completed, with 82 identified for review of which 46 (or 56.1%) met the criteria. Conclusions: Patients with overwhelming symptoms were identified for intervention that might otherwise have been missed by relying solely on referral. This patient population resulted in a request for practice integration across centers recognizing the clinical and financial benefits outlined below. [Table: see text]
Quality improvement using new technology to assess and reduce FDG PET/CT radiotracer infiltrations.
Authors: Kiser Jackson William 
Published: September 2018

313 Background: The reported aggregated PET/CT 18F-FDG radiotracer injection infiltration rate from 3 centers in 6 studies is 15.2% (425 infiltrations/2804 patients). Infiltrations can negatively affect cancer patient staging, therapy assessment, treatment planning, and can lead to unnecessary invasive procedures and patient radiation exposure. The radiotracer dose is essential to PET image quality and quantification. Efforts are made to ensure the exact dose administered is used to create the patient image; but, no measures ensure the administered dose completely enters the patient circulation. Our objective was to use new technology (Lara, Lucerno Dynamics) to assess our infiltration rate, determine potential causes, reduce our rate, and assess results sustainability. Methods: Our IRB determined the project did not meet the definition of research as defined by 45 CFR 46.102(d) and classified the initiative as “quality improvement”. In Phase 1, our PET/CT center monitored the injection process. Lara data were analyzed (SAS Enterprise Miner, v. 14.1 and v.9.4) and identified potential contributing factors. We then implemented a quality improvement plan to address these factors. In Phase 2 we remeasured our infiltration rate. After Phase 2, we assessed our rate over an extended period. Results: Lara added 30 seconds to patient imaging. In Phase 1, 263 injections were monitored, and 35 infiltrations were identified (13.3%). Five technologists’ rates ranged from 8%-19%. Patients less than 145lbs with non-antecubital fossa injection sites were highly associated with infiltrations. In Phase 2, 278 injections were monitored, and 8 infiltrations were identified (2.9%), a 78% decrease (p < 0.0001). The same technologists’ rates ranged from 0%-4%. Eight technologists performed the next 504 injections and six were infiltrated (1.2%). Conclusions: Our findings supported published PET/CT infiltration rates. Using new technology provided technologists with feedback on injections and lead to significant and sustainable improvements quickly, with minimal patient/procedure disruption. Infiltrations are a quality and safety issue. As a result, the injection process requires ongoing monitoring.
Cancer-related financial burden among patients with metastatic breast cancer.
Authors: Wheeler Stephanie B. , Spencer Jennifer , Manning Michelle L. , Samuel Cleo A. , Reeder-Hayes Katherine Elizabeth , Sellers Jean B. , Rosenstein Donald L. 
Published: September 2018

32 Background: Recent data suggest that the adverse financial impact of cancer is an underappreciated source of potential harm to patients, also known as “financial toxicity”. Little is known about the financial impact of cancer in patients with widespread, incurable disease, despite the relatively high cost of their care. We conducted a national survey of patients with metastatic breast cancer to address this gap. Methods: We partnered with the Metastatic Breast Cancer Network to field an online survey of metastatic breast cancer patients over a fourteen-day period using Qualtrics. The survey required approximately 20 minutes to complete, and participants were offered a $10 Amazon gift card. Survey items included sociodemographic information, health insurance status, cost-related communication with providers, post-treatment financial burden, financial coping strategies, and emotional well-being. We report financial outcomes stratified by health insurance status, as insurance is an important protective mechanism against health-related financial shocks. Results: 1,513 participants responded from 41 states. More than a third of these women (35%) were uninsured. Uninsured individuals more often reported refusing or delaying treatment due to cost (98% vs. 41% of insured, p < .001) and were also more likely to report skipping non-medical bills (40% vs. 16%, p < .001), stopping work after diagnosis (65% vs. 46%, p < .001), or being contacted by a collections agency (77% vs. 36%, p < .001). Despite this, insured participants reported higher cost-related emotional distress, including being “quite a bit” or “very” stressed about not knowing cancer costs (53% vs. 32%, p < .001) and about financial stress on their family due to their cancer (52% vs. 27%, p < .001). Conclusions: Metastatic breast cancer patients reported an unprecedented level of cancer-related financial harm and significant worry about the financial legacy left behind in the wake of their illness. Health insurance expansion is a necessary, but insufficient strategy to address this financial burden; additional interventions to prevent and mitigate cancer-related financial harm are urgently needed.
Effective interventions to improve cancer screening rates in adult Medicaid beneficiaries.
Authors: Spain Pamela Crenshaw , Clare Hannah Margaret , Fowler Christina 
Published: September 2018

322 Background: The Affordable Care Act (Section 1139B) requires the Secretary of HHS to identify and publish a core set of health care quality measures for adult Medicaid beneficiaries aimed at standardizing health care quality measurement across state Medicaid programs. On January 1, 2013, the Medicaid Quality Measurement Program was established to fund the development, testing, and validation of the adult health quality measures. The Medicaid Adult Core Set of Adult Health Care Quality includes two cancer screening measures (Exhibit 1). With grants from The Centers for Medicare & Medicaid Services (CMS), three state Medicaid agencies carried out quality improvement projects (QIPs) aimed at increasing breast and cervical cancer screening rates. This study describes a qualitative assessment of these states’ QIPs. Methods: Data included grantee applications, semi-annual, and annual progress reports to CMS, as well as in-depth interviews with grantees. Qualitative content analysis (using both structured abstraction and deductive and inductive coding) was conducted in NVivo 11. Results: Breast and cervical cancer screening rates for adult Medicaid beneficiaries improved in these states during the 3-year grant. The most effective interventions identified by the states included: System-level interventions such as the distribution of performance dashboards with peer comparison data; Provider-level interventions such as the distribution of unmet need or gap-in-care reports; and Beneficiary-level interventions such as direct nurse outreach to beneficiaries with a gap in care. Conclusions: QIPs can improve breast and cervical cancer screening rates in adult Medicare beneficiaries. The most effective interventions are multi-pronged and should target health care systems, providers, and beneficiaries.[Table: see text]
Utilizing a standardized order set to increase speech pathology referrals in head and neck cancer patients.
Authors: Gerretsen Carly , Jurgens Corrine 
Published: September 2018

324 Background: Treatment of head and neck cancers may include radiation, and side effects will result in short and long-term dysphagia. This can lead to feeding tube usage, malnutrition, loss of social interaction, and reduced quality of life. Rehabilitation therapies are available with speech pathologists to improve outcomes. Evidence supports initiating therapy prior to radiation. Computerized order entry systems (CPOE) support standardization of evidence- based order sets. The purpose of this study was to examine the effect of a standardized order set on referral rates to speech pathology in adult patients undergoing radiation treatment for head and neck cancer. Methods: A quality improvement project was implemented an outpatient oncology clinic within an academic hospital using the PDSA format. Approval was obtained through the hospitals quality assurance officer, and it was determined that IRB approval was not necessary. A chart review was completed to assess the rate of speech pathology consults. A brief education program targeting ordering providers was completed including demonstration of the order set. Post intervention chart review was performed to assess the change in referral rates. Results: A chi square analysis was used to compare the difference in referral rates and found to be statistically significant, x² (1, n = 56) = 17.147, p < 0.01. Demographic data was analyzed using descriptive statistics. The sample was mostly Caucasian (82%), male (84%) with an average age of 63. The most common cancer diagnosis was larynx (36%). The percentage of referrals post intervention (82%) was significantly higher than pre-intervention (18%) consistent with the hypothesis that a standardized order set would increase speech referral rates. Conclusions: Use of a CPOE system with standardized order sets increased the rate of speech pathology referrals. The success of this order set has led to an expansion of the project, and creation of additional order sets. Standardized computerized order sets should be considered to increase referrals to underutilized ancillary services. Providers should be encouraged to create relationships with these services to improve patient’s quality of life and long- term outcomes.
A data driven approach to immunotherapy toxicity management.
Authors: Mahmood Sadiqa , Schwamm Eli , Kehl Kenneth L. , Glotzbecker Brett , Andrews Robert , Singh Prabhsimranjot , Fraile Belen , Muthulingam Shobana , Wagner Andrew J. , Jacobson Joseph O. , LeBoeuf Nicole R. , Rahma Osama E. 
Published: September 2018

326 Background: The immune checkpoint inhibitors (ICIs) confer a risk of unique inflammatory immune-related adverse events (irAEs), which are highly distinct from the adverse events historically observed with cytotoxic therapy. To develop a strategy for easier identification and mitigation of irAEs, we sought to understand the frequency of ED visits and hospitalizations in 90 days following ICI start by implementing a rapid learning system (RLS). Methods: We convened an Immunotherapy Toxicities Management Committee with representatives from the Center for Immuno-Oncology, Quality and Patient Safety, and Informatics to draft a series of recommendations for the development of an irAE rapid learning system. The Committee requested an audit of all irAEs between June 2015 and April 2018 by drug, event type (clinical diagnosis), outcomes (including ED visits, hospitalization with length of stay, and death), and time-frame (days since beginning ICI course). An automated pipeline was created to merge structured data from the Electronic Health Record (Epic) and billing system (EPSi). This data was used to design a tool which consisted of an automated dashboard to monitor patient and enable interventions. Results: Over the course of 3 years, a total of 2,020 unique patients receiving ICIs were seen. 918 were treated with Pembrolizumab (45.4%), 768 with Nivolumab (38.0%), 234 with Atezolizumab (11.6%), 111 with Nivolumab & Ipilmumab (5.6%), 68 with Ipilimumab (3.4%), 9 with Durvalumab (0.4%), and 9 with Avelumab (0.4%). ED visits and hospitalization rates over 90 days were similar among the three most prescribed therapies, ranging from 332 unique patient events in the Pembrolizumab Cohort (36.1%) to 96 unique patient events in the Atezolizumab cohort (41.0%). Conclusions: The dashboard is effective tool to build a RLS for irAEs. The immediate output of this tool is using natural language processing (NLP) to distinguish between irAEs related ED visits and hospitalizations or regular disease progression, and measure the impact of interventions including (a) developing standardized algorithms for monitoring for irAEs, (b) designing an educational program for providers, and (c) developing an inpatient and outpatient immunotherapy toxicity management service.