bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impact of radiotherapy practice structure on prostate cancer treatment and outcomes.
Authors: Hoffman Karen Elizabeth , Huo Jinhai , Giordano Sharon Hermes , Smith Benjamin D. 
Published: February 2017

47 Background: Traditionally men with prostate cancer were treated in clinics created, managed and overseen by radiation oncologists. Urology-owned “integrated” practices emerged in the 2000s. Proponents of integrated (INT) practices argue they improve quality-of-care by fostering multidisciplinary care while detractors argue they decrease quality-of care because they employ only one or two radiation oncologists which limits quality-assurance peer review. We compared radiation techniques and treatment toxicity for men who received radiation therapy (RT) in INT and non-INT practices. Methods: Men 66 years and older diagnosed with prostate cancer from 2006 to 2009 were obtained from the Texas Cancer Registry. Cancer-directed therapy, comorbid medical conditions and late treatment toxicity (diagnosis or procedure codes for toxicity 12 or more months after diagnosis) were determined from linked Medicare claims. Practice type was classified based on practice location of the treating radiation oncologist. Chi-square statistics compared categorical variables. Cox proportional hazards models evaluated predictors of toxicity. Results: External beam RT (> 20 fractions) was administered to 781 men in INT and 3,257 men in non-INT practices. Median follow up was 44 months. Men treated in INT practices lived in counties with higher income (p<0.001). There was no difference in patient age (p=0.55) or comorbidity (p=0.88) between practice types. Men treated in INT practices were more likely to receive intensity-modulated RT (98% vs. 82%, p<0.001) and image-guided RT (73% vs. 23%, p<0.001). Androgen deprivation therapy use was similar between practice types (p=0.36). Adjusting for patient and tumor characteristics, there was no difference in risk of late gastrointestinal (p=0.52), urinary (incontinence, p=0.10; other p=0.28), or erectile (p=0.28) toxicity between practice types. Conclusions: Men treated in INT practices were more likely to receive intensity-modulated RT and image-guided RT for their prostate cancer. Risk of late gastrointestinal, urinary and sexual side effects for men who received radiotherapy in INT practices was similar to risk of late side effects for men who received radiotherapy in non-INT practices.
Baseline evaluation of the patient-centered oncology care model.
Authors: Tirodkar Manasi A. , Scholle Sarah Hudson 
Published: February 2017

50 Background: The patient-centered medical home (PCMH) model of care is being widely adopted as a way to provide accessible, proactive, coordinated care and self-care through primary care practices. During active treatment for cancer, the oncology practice is often the primary setting supporting the patient and coordinating cancer treatment. For this project, we are implementing a Patient-centered Oncology Care model in five oncology practices and evaluating the impact on cost, quality, and patient experiences. Methods: To determine the structures and processes present in the practices at baseline, we conducted a self-assessment on the standards, followed with an on-site “audit” for compliance with the standards. To get a sense for organizational culture and motivation to change, we conducted site visits which included interviews with providers, staff and patients and observation of clinical encounters and workflow. Results: Among the highest priority structures and processes, the most common were telephone triage, symptom management, advance care planning, and the use of evidence-based guidelines. The least common were patient/family orientation, availability of same day appointments, discussion and documentation of goals of therapy, symptom assessment, and tracking of appointments. All of the practices had made patient-centered care a priority and staff were motivated to change. There was variation in the way providers and the care team used health information technology during clinical workflow. There was also variation in which staff coordinated care for patients and whether or not financial counseling was offered. All of the practices stated that they needed to work on implementing survivorship care planning, shared decision-making, and patient engagement in quality improvement and practice transformation Conclusions: The pilot oncology practices have many structures and processes in common. However, there is little standardization within practices in the way these processes are established and documented. Practices vary in how they are implementing patient-centered care processes. However, with motivation to change, staff and providers are actively engaged in the transformation process.
Do case rates affect physicians' clinical practice in radiation oncology?
Authors: Loy Bryan A. , Shkedy Clive , Tankersley Mark A. , Altonen Brian , Royalty Julie 
Published: February 2017

59 Background: Radiation oncology practices and health plans typically engage in fee for service (FFS) contractual relationships, which employ utilization management techniques to manage treatment accordance with recognized guidelines. FFS contracts often result in unpredictable revenue streams for practices and burdensome administrative processes for both practices and payers. Moreover, there are limited mechanisms in FFS arrangements for practices and payers to systematically measure quality. Radiation oncologists and health plans share the common goal of systematically improving quality of patient care while reducing administrative burden. Methods: In 2012, Humana collaborated with a large national radiation therapy provider to implement ‘bundled’ case rate reimbursement instead of FFS. The case rate model was developed with HealthHelp, a radiation oncology quality vendor, and the payments were developed in the context of the appropriate modality for each cancer type. Changes in practice patterns were measured in the Medicare population by average fraction ratios across breast cancer, bone metastases, and prostate cancer. Fraction ratios compare delivered fractions to standards established by the National Comprehensive Cancer Care Network guidelines. A ratio of 1.0 means that the delivered amount met the recommended guideline. Ratios nearer to one (over or under) demonstrate appropriate therapy. Ratios were compared for 2011 vs. 2013 using T-tests. Results: Conversion from a FFS to case rate reimbursement did not coincide with a change in fraction ratios for breast cancer treatment. Fraction ratios for both bone metastases and prostate cancer moved towards the target ratio of 1.0 after the move to case rate reimbursement. Conclusions: After the implementation of case rate reimbursement, fraction ratios improved for bone metastases and prostate cancer, while breast cancer fraction ratios did not change. Future work will evaluate additional markers of quality and practice efficiency measurements. [Table: see text]
Process outcome measures of patients with head/neck, thoracic, and gynecologic malignancies in the MDC clinic.
Authors: Ogata AnnaLyn S. , Conde Francisco A. , Morris Paul , Halford Peter , Chadwick Darlena , Tsuruoka Perry 
Published: February 2017

61 Background: Queen’s Medical Center (QMC) was selected as one of 14 sites nationwide to participate in the expansion of the National Cancer Institute’s Community Cancer Centers program in 2010. In 2011, QMC implemented Multidisciplinary Clinics (MDC) to make the treatment of patients with head and neck (H&N), thyroid, thoracic, and GYN malignancies more efficient and seamless. The purpose of this study was to examine the following process outcomes: timeliness of care, adherence to MDC treatment plans and national guidelines, and utilization of ancillary services in H&N, thyroid, thoracic, and GYN MDC. Methods: Retrospective, chart review of patients with H&N, thyroid, thoracic, and GYN malignancies who were seen at the MDC from Jan 2012 to Dec 2012 was conducted. Variables collected were patient demographics, initial date of referral to the MDC, date of first cancer treatment, clinical variables (e.g. cancer diagnosis, co-morbidities, social habits [smoking, drinking, drug use]), and hospital process variables (e.g. reasons for delay in treatment, adherence to national guidelines, and use of ancillary services [e.g. navigation, dietary, survivorship, social work, chaplain, genetic counseling]). Results: 222 charts were reviewed (H&N = 69, Thyroid = 54, Thoracic = 48, Gyn = 51). Ethnic minorities represented over 50% of the sample. For all cancers combined, average time to referral to first treatment was 32 days. Post-hoc analysis showed that patients seen in GYN MDC (mean = 17.5 + 12.3 days) had significantly fewer days from referral to first cancer treatment compared to patients seen in the H&N MDC (mean = 41.3 + 25.6 days), F = 4.3, p = 0.003. For all sites combined, there was 99.5% adherence to the MDC recommended treatment plans, and 100% adherence to NCCN guidelines in the treatment received. Most patients with GYN malignancy (96.1%) were referred to one or more ancillary services followed by H&N (88.4%), thoracic (85.4%), and thyroid (46.3%). Conclusions: Study provided baseline process outcomes for MDC of disease sites which are often less studied in literature. MDC nurse coordinator played a critical role in ensuring efficient and quality patient care. Results can serve as basis for further quality improvement.
Understanding oral chemotherapy use at the end of life: Analysis of a Massachusetts claims database.
Authors: Zerillo Jessica A. , Stuver Sherri Oliver , Fraile Belen , Dodek Anton , Jacobson Joseph O. 
Published: February 2017

8 Background: Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. But the appropriateness of oral chemotherapy specifically is not yet described, and there are little available data on utilization of oral chemotherapy at the end of life. Methods: We analyzed results from 200 patients of Dana-Farber Cancer Institute, covered by the Blue Cross/Blue Shield of Massachusetts (BCBSMA) pharmacy benefit, and who died in 2012. We collected data on chemotherapy use in the last 6 months of life. We analyzed oral chemotherapy use in the categories of any oral prescription and timing of first oral prescription. We compared results to intravenous (IV) and any other administration route. Results: Most of our target population had gastrointestinal, thoracic, or breast malignancies. In the last 6 months of life, 75% received some form of chemotherapy, including 23.5% who were prescribed an oral agent. 11 patients were prescribed oral chemotherapy in the last 30 days of life. For 45% (n=5) this was the first oral prescription. In the last 14 days of life, only 5.5% of patients received any chemotherapy, including one patient prescribed an oral agent. Conclusions: The collection of oral chemotherapy utilization data through insurance claims was feasible. Use of any chemotherapy, including oral, sharply declined during the last 30 and 14 days of life, consistent with a shift to palliative end-of-life management. This analysis highlights the need for a more comprehensive understanding of oral chemotherapy use at the end of life. Furthermore, with the growing use of oral chemotherapy, the development of measures to define quality of end-of-life care with these agents is warranted. [Table: see text]
Health risk assessment of head/neck cancer patients.
Authors: Salner Andrew , Dornelas Ellen A 
Published: February 2017

81 Background: Effective methods of screening head and neck cancer patients for health risk behaviors are needed. Methods: The present study assessed 452 cancer patients with an assessment that covered the following domains: psychological distress, smoking status, nutritional intake, functional activity level and need for support services. Thirty six out of the 452 patients recruitedfrom radiation oncology carried a diagnosis of head/neck cancer. Results: Patients with head/neck cancer had higher levels of depressive symptoms measured by the Patient Health Questionnaire (PHQ9) with mean scores of 6.3 (SD=4.8) compared to the scores of patients with other cancer diagnoses (mean PHQ9 score= 4.3, SD=5.4) p=.04. Twenty percent of head/neck patients had PHQ9 scores greater than 12 and 52% had a distress thermometer score of >4. Head/neck patients were more likely to be current smokers or have quit since diagnosis (31%) compared to patients with other diagnoses (16%) p=.02. Head/neck patients were more likely to be male 68% (p<.001). When asked if they would like services from any of the following practitioners, 29% requested a nutritionist, 14% requested a social worker and 25% requested integrative medicine services. None of the smokers with head/neck cancer requested services from the smoking cessation counselors compared to 25% of smokers with other cancer diagnoses. In the sample of head/neck patients, 73% of smokers were likely to endorse feeling “worry, fear or nervousness” compared to 33% of non-smokers (p=.04). Referrals were facilitated with an automated email to the clinician within 2 days of the assessment. Conclusions: Head/neck patients in this sample are more likely to have depressive symptoms and to have health risks such as smoking. Smokers are less likely to be receptive to smoking cessation counseling. Cumulatively, these data suggest that the needs of head/neck cancer patients are distinct and this diagnostic group may benefit from enhanced survivorship services both during treatment and to follow.
Mismatch of available cancer therapeutic trials to patient populations in community practices.
Authors: Lai Lily L. , Woo Doni , Chapman Yvonne , Sudan Nimit , Yeon Christina Haeyoung , Trisal Vijay , Waisman James Ross 
Published: February 2017

84 Background: Clinical cancer research has consistently been associated with improvements in the quality of cancer care in community practices. We initiated a project to better identify the barriers to enrollment into adult oncology therapeutic trials in a community setting. Methods: Over a 12-month period from June 2013 – May 2014, all consecutive new patients presenting to medical oncologists at two community practices (CP1 and CP2) affiliated with an NCI-designated Comprehensive Cancer Center (NCI CCC) were screened by trained clinical research nurses. Data captured included demographics, diagnoses, stage of disease, previous treatments. Therapeutic trials available through the NCI CCC were matched to the patients. Actual enrollments rates into the trials were calculated. Results: A total of 1,430 new patients was seen in the time period studied (CP1, n=1,088; CP2, n=342). Of these, 912 (CP1, n = 667; CP2, n = 245) patients had a cancer diagnosis. At CP1, 63 therapeutic trials were available through the NCI CCC. 64 (8.3%) patients matched the criteria for any of the available trials, 33 enrolled, 18 declined, 13 failed screening. The accrual rate was 51.5% (33/64) of the patients who matched available trials and 4.9% (33/667) of all new cancer patients. At CP2, 32 (13%) patients matched available trials. The factors associated with the inability to match therapeutic trials with the new patients included: adjuvant treatment status, disease sites, prior treatment requirements, protocol specific tests, protocol specific requirements for correlative studies. Conclusions: Of the 912 new cancer patients treated at 2 community sites affiliated with an NCI CCC, only 10.5% matched available therapeutic trials. Although the enrollment rate into therapeutic trials is high in patients who matched available trials (51.5%), the overall accrual rate of all new cancer patients is 4.9% and consistent with previous studies. Our study highlights the significant mismatch between available trials and clinical populations treated at community sites. We suggest that an improved process to better match patient populations and available trials will improve on clinical trial accruals and efficiencies.
Optimizing smoking cessation resource awareness among patients and providers.
Authors: Ma Laura , Donohue Caitlin C. , Denofrio Tina , Pedulla Lillian Vitale , Haddad Robert I. , Jacobson Joseph O. , Rabinowits Guilherme 
Published: February 2017

85 Background: Despite receiving a cancer diagnosis, many patients continue to smoke during treatment, negatively affecting their outcomes and putting them at risk for secondary cancers. We witnessed that limited smoking cessation (SC) discussions were occurring among patients and providers (MDs/NPs) and hypothesized that this was partially due to the providers' lack of awareness of the current SC resources available. Methods: We surveyed the head and neck oncology (HNO) providers at Dana-Farber Cancer Institute to evaluate their awareness about existing SC resources within the community. We performed a 6-month chart review of active smokers to evaluate frequency of documented SC discussions in clinic, and developed several targeted interventions: we educated the HNO providers on available SC resources within the community; developed a SC resource teaching sheet for smoking patients; placed a provider alert page in exam rooms to remind the providers to discuss the SC teaching sheet with the patient; and built a SC discussion template in the electronic medical record to ease documentation. Four weeks post intervention we resurveyed providers and performed chart reviews of active smokers to reevaluate the frequency of SC discussion documentations. Results: Pre-intervention, only 13% of HNO providers were aware of SC resources available within the community and the mean SC discussion documentation was 33%. Post-intervention, 100% of HNO providers became aware of the SC resources available, and the mean SC discussion documentation increased to 76% at 7 weeks. Identification of active smokers in clinic increased from 2-5 smokers per week pre-intervention to 4-13 smokers per week post intervention. Eighty-eight percent of HNO providers felt the intervention prompted them to discuss SC with their patients. Conclusions: The limited number of SC discussions among patients and providers is at least partially due to unawareness of SC resources available within the community. Educating providers, and alerting them to their active smoking patients at the time of their clinic visits, successfully prompted providers to discuss the importance of SC, and empower patients with resources to help them quit.
Utilizing TQM and CQI prinicples in establishing a Type 1 observation unit in a comprehensive cancer center.
Authors: Halm Josiah 
Published: February 2017

96 Background: CMS defines Observation Services as outpatient care ordered by a physician and provided in a hospital bed to determine the need for inpatient admission or discharge. Recent CMS rules on Observation stay and 2-midnight rule has created confusion amongst Medicare beneficiaries, providers and hospitals. Two-thirds of US hospitals deliver observation care without using an observation unit. Review of our hospital observation care and a survey of Cancer Centers within the Alliance of Dedicated Cancer Centers revealed that observation care was provided in a bed anywhere in the hospital with unstructured care provided at the discretion of the treating physician. This leads to less favorable outcomes compared to protocol driven and closed observation units (Type 1). Methods: Plan- Institutional stakeholders consisting of administrators, hospitalists, ED physicians, case managers and nurse managers developed an observation services guideline policy and project team. Do- pilot initiated with ED admitting Observation patients to dedicated hospitalist providers and unit. Order sets were developed, education and staff training was provided and target start date set. Baseline and performance measures were developed. Study- impact on ED flow, admissions, ED length of stay, provider satisfaction, diagnoses, patient case-mix, and financial costs. Act– Implemented changes and lessons learned from pilot Results: Before implementation of pilot less than 10 patient per month were placed in observation status (Sept 2011- Aug 2012). After pilot average of 30 patient per month were initially placed in Observation (Sept 2012-April 2014). Approximately 73% of patients placed on observation are discharged and not admitted. Observation counts for approximately 25,000 dollars in professional charges per month. ED LOS decreased to less than 6-hours. Patient satisfaction and ED provider satisfaction scores have improved. Conclusions: Majority of Observation patients are not admitted thus avoiding the higher cost associated with inpatient stays with resulting cost saving. ED wait times have improved leading to less over-crowding with ED physicians having time to see more patients.
Development and implementation of clinical pathways in lung cancer at an academic comprehensive cancer center.
Authors: Tan Sally , Porter Julie M. , Barysauskas Constance , Mach Stacy L. , Rodgers Ed , Elfiky Aymen , Jacobson Joseph O. , Jackman David Michael 
Published: February 2017

98 Background: Clinical pathways (CP) is an emerging tool aiming to reduce unwarranted variation and maximize value in cancer care. We describe the preliminary experiences and challenges of developing, implementing and testing pathways at a comprehensive cancer center. Methods: Dana-Farber Cancer Institute (DFCI) partnered with Via Oncology to develop and pilot institution-derived CP in lung cancer. The Via platform tracks usage rate, adherence to the DFCI-designed CP (on-pathway rate), and reasons why off-pathway treatments were chosen. An online satisfaction survey was conducted among providers participating in the pilot. Results: Between 1/27/14 and 5/30/14, 277 chemotherapy treatments were initiated, with 124 new patients. CP was used to generate 98% of new chemotherapy orders; 63% were on-pathway. The most common off-pathway reasons were 1) poor patient performance status and 2) treatment beyond 3rd line. 22 of 41 specialists who participated in the CP pilot at DFCI’s main campus responded to the survey (54% response rate). Respondents ranked the Institute as the stakeholder who most benefits from CP, followed by payers, DFCI network community physicians, DFCI main campus physicians, and patients. Respondents recognized CP reflects appropriate care but are concerned about workflow (Table). Conclusions: Implementation of an institution-derived CP is feasible at a comprehensive cancer center. Physician input into pathway design is essential to build buy-in. Academic specialists perceived more benefit of CP for their community peers and raised concerns about workflow. On-pathway rates were lower than those reported in community settings, due to many potential factors (to be explored with updated data for final presentation). [Table: see text]