bluuebunny/crossref_metadata_2025_split huggingface dataset:
Electronic medical records: Assessment of recorded cancer stage in support of quality of care.
Authors: Hess Gregory P. 
Published: February 2017

129 Background: Electronic medical records (EMRs) are being increasingly adopted in part driven by reports of their positive impact on patient’s quality of care. An underlying assumption is that data recorded will be relatively complete. As a field of primary importance, this study assessed the frequency with which cancer stage was recorded within an EMR data field during a historical and recent 12-month period. A random sample of records with missing stage was assessed to identify at a qualitative level reasons that stage may be omitted. Methods: Two datasets were constructed. The first comprised of oncology EMRs from 77 practices covering 476 sites of care across 34 states from 1/1/2000-12/31/2010. The second dataset from 58 practices covering 391 sites of care across 37 states. Inclusion criteria required patients to have a valid visit (i.e., not simply ‘scheduled’) and ≥ 1 diagnosis of a primary, malignant, neoplasm (except brain or spine). All data fields utilized to record stage (stage I, II, etc.) or from which stage could be reliably derived (T, M, N fields) were defined as "recorded." Practices were not required to exist in each dataset. Recorded stage by age, gender, state, and payer type was also assessed. Results: Reasons reported for absent stage within the data field included: consult visit only, written in the progress notes, text present in a scanned report, stage X (insufficient information), continuing treatment initiated elsewhere, and missing entry error. Conclusions: A significant proportion of cancer patients may not have stage recorded in the designated, searchable, data field within an EMR. The frequency of recorded stage is increasing over time. Reasons for unpopulated stage field(s) include use of nonsearchable text entries, scanned reports, and short episodes of care. Further research is needed to validate the observations in this study, determine root causes, and employ appropriate solutions. [Table: see text]
Improving chemotherapy consent compliance.
Authors: Hegedus Patricia D. , Bearden James D. , Grant Bruce 
Published: February 2017

130 Background: Palmetto Hematology Oncology (PHO) is the medical oncology practice of Spartanburg Regional Healthcare System (SRHS) and has participated in QOPI since 2009 and earned QOPI certification in September 2011. Our Fall 2010 QOPI Patient Consent for Chemotherapy score was 70.73%, lower than the QOPI aggregate score of 86.46%. Methods: A workgroup was convened to address chemotherapy consent documentation compliance. QOPI data revealed the need for a uniform, system-wide chemotherapy consent process. A chemotherapy consent form specifically for our cancer center was created following an extensive literature review and benchmarking with American Society of Clinical Oncology guidelines, NCI Designated Cancer Centers, NCI Community Cancer Centers Program (NCCCP funded with federal funds from the NCI, Contract # HHSN261200800001E) resources, and other healthcare institutions. Our chemotherapy administration policy was revised to include a “hard stop” if a signed chemotherapy consent was not available prior to administration of chemotherapy in all areas of our institution. Results: Patient Consent for Chemotherapy QOPI scores revealed an increase from Fall 2010 to Spring 2012 of 70.73% to 100%. As a result of the workgroup’s efforts, it was approved by our Cancer Care Committee to develop a Chemotherapy Safety Committee (CSC) to standardize chemotherapy practices throughout our system. The CSC integrated key staff responsible for chemotherapy administration. The CSC was instrumental in reviewing and updating policies and procedures during our QOPI certification efforts. Conclusions: Our participation in QOPI provided data to support efforts for a system-wide chemotherapy consent revision and process implementation. The availability of ASCO, Oncology Nursing Society, and other key resources provided turn key processes for this performance improvement project. Practice scores for the Patient Consent for Chemotherapy have reached 100% compliance signifying our performance at a “best practice” level. References: QOPI The Quality Oncology Practice Initiative, available at: http://qopi.asco.org/program .
Quality improvement for symptom control in underserved Chinese cancer patients.
Authors: Dhingra Lara , Lam Kin Y. , Cheung William , Shao Theresa , Chang Victor Tsu-Shih , Chen Jack , Cheng Sabrina , Li Vanessa , Lam Wan , Chan Selina , Bookbinder Marilyn , Lo Graciete , Portenoy Russell 
Published: February 2017

132 Background: Chinese Americans, the largest Asian subgroup, have high cancer rates. Many are recent immigrants who are economically disadvantaged. Patients often present with advanced illness and poorly controlled pain. Although quality improvement (QI) methodologies, such as rapid-cycle QI, may improve clinical practice and patient outcomes, few QI programs for pain management exist for this population. We aim to 1) test the effectiveness of a rapid-cycle QI intervention to enhance the processes and outcomes of pain management for poor and underserved ethnic Chinese patients; 2) determine whether a rapid-cycle QI intervention for pain can be generalized to other symptoms (fatigue and dyspnea), and 3) identify demographic, cultural, and other barriers and facilitators that are related to intervention uptake. Methods: In this ongoing community study, we are developing and testing a rapid-cycle QI model to improve pain among underserved Chinese American cancer patients, and evaluating factors that influence its uptake and sustainability. Ethnic Chinese patients and clinicians from four oncology practices are the intervention targets. The systems-based intervention incorporates repeated “plan-do-study-assess” QI cycles, including: pain screening, follow-up and early treatment for pain, referral, and provider education. Results: Initial data demonstrates that documentation of pain scores improved from 24-71% of patients overall. In one practice, 37% of 89 patients screened over 45 days had moderate or severe pain; 90% with moderate pain had follow-up appointments within 1 week; 92% with severe pain had immediate clinician attention. Intervention effectiveness will be determined by 2-week longitudinal surveys. The primary outcome is the change in the proportion of patients who achieve adequate and timely pain control after initial presentation. Conclusions: Multiple cultural, system-related, and provider challenges to QI implementation are being addressed. Findings will show the importance of QI interventions to reduce pain disparities, the importance of programs that address underserved Chinese Americans, and the relevance of community-based QI programs for long-term changes in clinical pain management.
Can we improve community adjuvant treatment reporting to a hospital tumor registry?
Authors: Bickell Nina , Wellner Jill , Franco Rebeca , McAlearney Ann 
Published: February 2017

136 Background: Accurate cancer treatment reporting to a hospital tumor registry (TR) is critical as data measurement is the foundation for improvement. Yet as adjuvant treatment moves to outpatient settings, reporting is problematic. We undertook a solutions-focused exercise to identify reporting barriers and facilitators and devise a pilot intervention to improve reporting. Methods: We convened a multidisciplinary group of community-based surgical and medical oncologists, TR staff, and hospital leadership. The group identified 3 key barriers: 1) inability to identify correct managing MD, 2) poor communication, and 3) manual reporting burden. The intervention focused on the 1st 2 barriers—those with easy fixes and great potential impact: TR obtained correct information, changed contact forms, worked with pathology to ascertain cases in real-time, tracked and reported practice responses weekly; MDs primed office staff to respond to TR requests. Results: Pre-intervention, the TR identified none of 20 pilot patients’ managing medical oncologist or adjuvant treatment. During the April to May 2012 intervention, 22 breast cancer patients listed our volunteer surgeon as managing MD. The TR sent 22 treatment letters to the surgeon’s office, received 20 (91%) responses with managing MD data provided for all. Patients were referred to full-time (26%) and community (74%) medical oncologists; 64% of required adjuvant treatment was reported. 47% of cases were closed; 53% remain open. Closed cases required 5.9 contacts (38.9 mins; sd=8.99), open cases had 8.2 contacts (48.4 mins; sd=2.85). Surgical staff spent ~1/2 hour per case to identify the oncologist prescribing adjuvant treatment. Conclusions: The solutions-focused exercise successfully improved identification of managing oncologists from 0% to 86% for patients treated by community oncologists. Treatment reporting increased from 2.6% to 64%. The pilot did not address the burden of reporting which remains great for both TR and community oncologists. While electronic access can reduce this burden through direct interface between an EMR and TR software, this approach is not currently feasible for community-based oncologists.
Implementing independent double checks for patient-controlled analgesia (PCA) pump programming.
Authors: Bohlen Nie , Lyons Hannah Felton , Cashavelly Barbara J. , Lennes Inga Tolin 
Published: February 2017

153 Background: Pain is the most common symptom experienced by oncology patients. Up to 90% of all patients with advanced cancer experience pain and 50% of those describe their pain as moderate to severe. The patient controlled analgesia (PCA) is commonly used to treat pain on the acute care oncology unit at The Massachusetts General Hospital (MGH). The PCA pump can be programmed incorrectly, resulting in over or under dosing of patients with opiates. Both the Federal Drug Administration (FDA) and the Institute for Safe Medication Practice (ISMP) recommend an independent double check (IDC) be done on error prone processes like the use of high alert medications. An IDC involves two clinicians separately checking (alone and apart from each other, then comparing results) the infusion settings in accordance with the physician’s order. Methods: The nurses on the acute care oncology unit at MGH were surveyed to determine their baseline understanding of an IDC. Training was conducted and a process for documentation implemented. A second intervention included further education initiatives such as posters of key points and a web-based knowledge survey of the IDC definition, process, and documentation. Results: Prior to the initial implementation 80% (32/40) of the nurses provided a partially correct definition of an IDC, 17.5% (7/40) an incorrect definition of an IDC and only 2.5% (1/40) provided a correct definition of an IDC. After the initial educational activities, a second knowledge survey was administered. Performance improved with only 13.4% (7/52) of the nurses missing one or more of the three questions on survey. After the initial education, of the 126 opportunities to document an IDC 21.4% (27/126) were done correctly. Performance improved to 80.7% (67/83) after the second intervention. Conclusions: Prior to implementing this IDC education, nurses at MGH did not have a clear understanding of what is required for an IDC of a PCA. This pilot education module was effective in decreasing the knowledge gaps and improving performance. Education must be concise and repetitive to change practice. Successful implementation of an IDC process improves the safety of a high-alert medication for the patient.
Redesigning the transfer center process to adapt to increasing demands for services.
Authors: Douglas-Ntagha Pamela Bernice 
Published: February 2017

156 Background: Hospitals are faced with limited resources and a need to provide care to patients with the greatest needs. Methods: Develop a systematic approach for accepting external transfers to the appropriate setting of care based on clinical criteria Initiate communication between external physicians and accepting MDA (MD Anderson) physicians and ICU physicians as appropriate Identify a process for documenting clinical information to ensure appropriate and timely transfers to MDA Ensure policies and procedures align with EMTALA regulation. Results: MDA ICU physicians involved in the initial decision, as appropriate External transfer acceptance based on bed availability MDA physician must be physically present to manage transfer, conduct evaluation and develop treatment plan Incorporate into procedure telephone communication with external physician, TC Medical Director, MDA accepting physician (ICU and Pedi physician as appropriate) Operational definitions for routine and urgent have been established Non-emergent transfers occur weekdays between the hours of 8AM and 5PM Transfer Acceptance Form to capture clinical information was developed. Conclusions: Problem 1: Suboptimal Communication Developed a TC form. During first eight months of operation we achieved 85% compliance with regards to documentation of transfer. Compliance continues to trend upward. Problem 2: Placement of Patients in Appropriate Care Settings Decreased utilization of MDA Emergency Center beds noted as external transfer to inpatient beds increased. Problem 3: Sporadic Arrival of Non-emergent Transfers The majority of after-hours (between 5PM and 8AM) transfers were routine and urgent prior to project. After the intervention, the number of routine and urgent after-hours transfer trended downwards. After-hour emergent transfers increased indicating appropriate utilization of beds for patients with the greatest needs. Problem 4: Lack of Systematic Screening and Documentation Retrospective medical record audits of 100% of emergent transfers were conducted by the TCMedical Directors in collaboration with the Director of Patient Resources. 97% of emergent transfers were confirmed as emergent on retrospective review.
Clinical process analysis.
Authors: Barnes Courtney , Hayes Beverly , Aranzamendez Gina , Kaufman Laurie 
Published: February 2017

157 Background: MD Anderson has been working with Harvard on a pilot project for Time Driven Activity Based Costing: a component is Clinical Process Analysis, which brings value on its own. It provides a visualization that “speaks” to those delivering the service. This brings great awareness of frontline reality for staff and leaders alike and the many “ah-ha” moments creates a urgency for improvement. As Berwick shared in his keynote speech at IHI 2011, "the quality movement will rise or fall on its success in reducing the cost of health care.” In order to make the right changes, who best to reduce the cost, than those delivering the service? According to Don Berwick and Dr. Brent James, the burden of changing the face of healthcare lies with us. Methods: When frequencies, probabilities and salaries are incorporated into processes of patient care, the cost of direct labor can be determined and opportunities for improvement visualized. Based on lessons learned, tools (data driven road maps, blueprints) and successful strategies (standardized process flow maps templates) have been developed to efficiently and effectively disseminate Clinical Process Analysis throughout clinical areas. Results: Data analysis and front-line reality are synchronized. Allows a “broader” view of the patient’s journey outside of one’s own discipline. Builds bridge between financial and clinical worlds by engaging clinicians through a patient-centered care perspective rather than a perspective of budget, variance and financial cost reduction. Identifies opportunities for improvement. Provides opportunities to build “psychological safety” in order for frontline staff to share with clinical area leadership the process realities of patient care. Based on feedback from physicians, managers, staff and financial experts, the process flow charts are useful to track patient flow, resource utilization, customer satisfaction, patient education, and on-boarding of new staff. Conclusions: Clinical Process Analysis provides an engaging first step to drive improvement in clinical quality and financial performance.
Avenues to integrate and improve care: Surgeon attitudes toward end-of-life care.
Authors: Bergman Jonathan , Lorenz Karl A. , Scales Charles D. , Ryan Gery , Saigal Christopher , Bennett Carol J. , Litwin Mark S. 
Published: February 2017

16 Background: To examine urology trainees’ views about the quality and current practices of end-of-life care, and to explore strategies for improving integration and quality of care. Methods: We conducted semi-structured interviews with 20 urology trainees from four institutions in different regions of the United States. Stage of training ranged from intern to senior urologic oncology fellow; all were clinically active at busy academic institutions caring for many patients with advanced malignancies. Open-ended questions allowed participants to express themselves independently, and follow-up discussions explored their perception of current end-of-life practices, as well as avenues for future integration and improvement. We analyzed transcripts using a multi-stage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Results: Clinicians unanimously agreed that their patients do not currently receive ideal care and were unanimously interested in joining a team geared towards improving care at the end-of-life. They expressed a preference for a multidisciplinary team, although the precise role each wanted to play within the team varied. Better identification of depression, pain, and patient-centered goals to allow value-congruent care were high in priorities for improvement. Trainees sited the lack of an educational curriculum on end-of-life care as a barrier to improving care, and expressed a desire for formal education on this topic. Conclusions: Urology trainees do not think that current care at the end-of-life is ideal for patients, and are interested in participating as part of a multidisciplinary team to better care for these individuals. There was a unanimous consensus that end-of-life care should be formally taught to all intern and resident physicians, and care at the end-of-life must be integrated to pursue value-congruent care for each patient. In response to the information gathered, we built a web-based, interactive, self-directed learning module emphasizing high-quality end-of-life care, issues to address with patients during clinic visits, and integration of end-of-life care. We have also integrated palliative care into the team caring for our patients with advanced disease.
Standardizing quality breast cancer care throughout all New York university facilities.
Authors: Pavlick Anna C. , Schnabel Freya Ruth , Tiersten Amy , Volm Matthew , Wu Jennifer J. , Boester Cindy , Carroll William L. 
Published: February 2017

160 Background: NYU physicians provide breast cancer care (BCC) at several locations throughout New York. The NYU Clinical Cancer Center (NYUCCC) is a private, university-based facility while Bellevue and Woodhull Hospitals are city hospitals. The diversity of BCC provided to patients (pts) in city hospitals can vary greatly from that of private centers and intra-center physician variability also diversifies care. This variability can impact on pt satisfaction and outcomes. Breast cancer (Br Ca) pts make up the greatest number of pts seen and treated at all NYU affiliated sites, therefore, a "Br Ca Quality of Care Program" will be incorporated into the electronic medical record (EMR) at all facilities. A treatment algorithm based on the pt’s stage and a simple "drop-down menus" will simplify use. It will encompass diagnostic imaging, pathology, biopsy procedures, surgery, radiation, chemo, and hormonal therapy as well as survivorship guidelines for maintaining wellness. Methods: Leaders of each Br Ca program have identified potential barriers to care and rectifiable issues. Algorithms and “drop down menus” in the EMR will be presented to the NYUCCC Br Ca physicians for feedback. This tool will then be refined and launched at NYUCCC. After evaluating this program at NYUCCC, the data will be presented to the all NYUCCC faculty. Achieving the city hospitals to adopt this EMR program will be the ultimate success and standardized quality care will be the result. Results: An assessment of the endpoints of physician adherence to guidelines, cost effectiveness and pt/provider satisfaction will be conducted 6 months later. Random audits of breast cancer pt charts will evaluate provider compliance. A cost analysis of this care will be done and compared to a random sampling of previously treated pt charts. Review and analysis of this data would be presented to the NYUCCC faculty, then programs launched at both city-hospitals. Conclusions: If the endpoints of quality standardized care, cost effectiveness and pt/provider satisfaction are met, incorporation of similar programs into other high volume oncologic disease entities seen at all NYU facilities would be developed.
Central reporting of human epidermal growth factor receptor-2 (HER2) status and adherence to testing and adjuvant trastuzumab treatment guidelines in Ontario.
Authors: Earle Craig , Ferrusi Ilia L. , Trudeau Maureen E. , Leighl Natasha B. , Pullenayegum Eleanor , Khong Hoa , Hoch Jeffrey , Marshall Deborah 
Published: February 2017

166 Background: Quality monitoring pertaining to trastuzumab treatment requires knowledge of 1) HER2 status, 2) testing methods and sequence, and 3) treatment received. We examined the patterns of HER2 test documentation for early-stage breast cancer (ESBC) patients in Ontario and the adherence of practice patterns to Canadian HER2 testing consensus guidelines and adjuvant trastuzumab treatment guidelines from Cancer Care Ontario (CCO). Methods: Using tumor pathology reported centrally to the Ontario Cancer Registry (OCR) a population-based retrospective cohort of ESBC patients diagnosed in 2006 or 2007 was identified. We evaluated the use of subsequent HER2 fluorescence in situ hybridisation (FISH) after initial immunohistochemical testing, and predictors of trastuzumab use. HER2 test type, sequence, result(s) and status, tumour grade, and hormone receptor status were determined. Trastuzumab treatment was determined from linked drug funding records. Sociodemographic characteristics, prior surgical, radiation and anthracycline treatment, and comorbidity were also determined from administrative data sources. Logistic models estimated adjusted odds ratios for factors associated with guideline (non-)adherence. Results: A HER2 test was documented for 66% of the 13,396 patient cohort. HER2 equivocal tumors were more likely to be retested vs. positive: OR 116 (95% confidence interval [CI] 79, 169). Patients diagnosed with stage III disease had higher odds of having a FISH test vs. stage I (OR 1.5 [CI 1.1, 2.1]). HER2 status was the largest predictor of trastuzumab use, with HER2 equivocal, negative or unknown patients less likely to receive treatment than positive. Patients with advanced age (≥70y) had lower odds of trastuzumab treatment compared to younger patients (OR 0.48 [0.32, 0.73]). Higher tumor grade was associated with higher odds of treatment. Reporting, testing, and treatment all varied significantly by region. Conclusions: Despite limitations in centrally-reported tumour pathology at the time, the use of FISH testing and trastuzumab treatment in Ontario was largely consistent with guidelines, though practices vary across regions.