bluuebunny/crossref_metadata_2025_split huggingface dataset:
Norris Cotton Cancer Center (NCCC) neuro-oncology glioma tumor quality improvement project.
Authors: Schlosser Evelyn , Fadul Camilo E. , Snide Jennifer , Homa Karen 
Published: February 2017

137 Background: Glioma patients represent 30% of the primary brain tumor population at NCCC, and often require surgical intervention prior to medical management. In order to ensure coordinated, comprehensive and timely care, reliable referral to the neuro-oncology program is needed. Earlier quality improvement efforts identified 10 best practices designed to facilitate referral into the neuro-oncology program, though over the years these practices lapsed. A manual record review of 2010 cases revealed 43 glioma patients, of which compliance with best practices ranged from 29% to 93%, and none of the patients had all best practices when indicated. Additionally, the percentage of 9 out of the 10 best practices (excluding post-operative order sets) completed for all consecutive patients from January 2010 to May 2011 was 63%. Methods: A project was chartered by leadership and a multidisciplinary team was convened twice a month from May to October 2011. The team was organized into three groups (entry into the system, surgical, and post-op care, and continuing care) and assigned a coach with instructions to flowchart the current processes and identify factors that contributed to poor performance. The three process maps were then combined to create one system map by which the team brainstormed improvement ideas to pilot. Results: Concurrent review of the individual case-level data during the project team meetings was helpful in identifying process weaknesses as changes were being piloted. Performance of best practices improved significantly when measured several months following completion of the project; furthermore, best practices completed for consecutive patients from June 2011-May 2012 was 87%. Conclusions: The team was challenged to identify changes in process that were not dependent upon individual providers/staff members and that took advantage of a newly implemented electronic medical record. Manual chart abstraction was replaced by electronic data abstraction. Sustained measurement and reporting of performance is essential and has been incorporated into the Neuro-Oncology Tumor Board meetings on a quarterly basis.
Emerging development and use of clinical pathways to improve quality and standardize care in oncology.
Authors: Nash Colin , Williams Ken , Pirog Francesca , Mitchell Kristi 
Published: February 2017

139 Background: Clinical pathways have emerged as a tool for payers to encourage provider adherence to evidence-based care. Avalere sought to understand how oncology pathway developers consider different types of evidence and physician input in designing pathways, and how the experiences of early programs may serve as an indicator for future implementation. Methods: Avalere conducted targeted white and grey literature searches to identify and analyze pathways used by oncology practice groups, provider networks, and major commercial payers. The research was augmented by informant interviews with representatives from leading organizations that have developed or implemented pathways. Results: Current pathways programs differ in their origins and objectives. Across these programs, Avalere identified findings in three key areas: Development: Developers consider efficacy of treatments first, followed by toxicity, and then cost. Many developers conduct an independent evidence review, while others leverage clinical practice guidelines. All developers solicit physician input on pathway design and updates; Use: Independent pathway developers partner with commercial insurers and large provider networks to design pathways with cost-saving components. Physicians are evaluated based on their adherence to the pathways, but are not held accountable for reporting or performance on NQF-endorsed quality measures; Impact: Cost savings in early programs are largely due to reduced toxicity-related medical costs, use of less expensive drugs, and lower total drug use. However, there is limited evidence on the impact of pathways on patient outcomes. Conclusions: There is variability across oncology pathway developers regarding their scope, granularity, and processes related to evaluating and incorporating evidence. If clinical programs demonstrate early cost reductions while improving patient outcomes, payers will likely attempt to expand pathways programs to new geographies and therapeutic areas. Existing practice patterns and previously implemented pathways programs will likely play heavily in determining which pathways are adopted in a given region, but national standardization is highly unlikely.
Natural language processing (NLP) of Internet conversations to evaluate prostate cancer (PC) patients’ perceptions of active surveillance (AS).
Authors: Mishra Mark Vikas , Bennett Michele , Vincent Armon , Lee Olivia T. , Lallas Costas D. , Trabulsi Edouard John , Gomella Leonard G. , Dicker Adam , Showalter Timothy Norman 
Published: February 2017

14 Background: Less than 10% of qualifying PC patients receive primary management with AS. Qualitative research aimed at identifying patient acceptance of AS has been identified as a national health research priority. The primary objective of this study was to determine if NLP of anonymous internet conversations (ICs) could be utilized to identify unmet public needs regarding AS. Methods: After obtaining IRB approval, English-language ICs regarding PC treatment with AS from 2002-2012 were identified using a novel internet search methodology. Web spiders were developed to identify, mine, and gather content from the internet for ICs centered on AS. All ICs identified were screened programmatically to remove any not-on-topic ICs. Collection of ICs was not restricted to any specific geographic region of origin. NLP was used to evaluate content and perform a sentiment analysis. Conversations were scored as positive, negative, or neutral. A sentiment index (SI) was subsequently calculated according to the following formula to compare temporal trends in public sentiment towards AS: [(#Positive IC/#Total IC) – (#Negative IC/#Total IC) x 100]. Results: A total of 464 ICs were identified. Sentiment increased from -13 to +2 over the study period. The increase sentiment has been driven by increased patient emphasis on quality-of-life factors and endorsement of AS by national medical organizations. Unmet needs identified in these ICs include: a gap between quantitative data regarding long-term outcomes with AS versus conventional treatments, desire for treatment information from an unbiased specialist, and absence of public role models managed with AS. Conclusions: This study demonstrates the potential utility of NLP to analyze ICs in order to provide insight into patient preferences and decision-making. Based on our findings, we recommend that multidisciplinary clinics consider including an unbiased specialist to present treatment options and that future decision tools for AS include quantitative data regarding outcomes after AS, so that patients can make decisions with an amount of information that is more similar to the resources available regarding radiation or surgery.
Systems engineering in health care: Overview and examples from The University of Texas MD Anderson Cancer Center.
Authors: Jordan Victoria S. 
Published: February 2017

140 Background: The University of Texas has six health institutions and Industrial and Systems Engineering faculty throughout university locations across the state. These academic medical centers, including MD Anderson Cancer Center, and schools of engineering, business, and medicine are partnering to implement Systems Engineering in healthcare throughout the UT system. The “systems approach to implementing Systems Engineering” is an opportunity to serve as a world-class model for collaboration across academic institutions for engineering, business, medicine, and healthcare organizations to implement Systems Engineering and systems thinking in healthcare. The objective of the collaboration is not just to produce successful projects, but to achieve transformational change. Methods: This presentation will provide an overview of Systems Engineering and provide examples of the different tools and strategies from the discipline including lean, six sigma, mathematical simulation, optimization and operations research, human factors, facility design layout, statistical process control, design of experiments, scheduling, supply chain and inventory management, staffing models, etc. Funding, leadership, training, and communication efforts associated with the effort will be reviewed including the grant application process for transformational efforts. (The implementation follows the PDSA process.) Results: Currently nine grants have been awarded in the UT system for implementing Systems Engineering. Results will be shared (in terms of cost savings and/or avoidance and patient satisfaction) from specific projects such as a lean effort in the Diagnostic Center and simulation models to schedule nurses in the OR and to determine resource requirements in the ICU. Conclusions: Systems Engineering is a valuable discipline that is relatively new to healthcare. Practicing clinical oncologists can increase efficiency, patient flow, and patient and physician satisfaction by applying Systems Engineering tools and strategies.
Quality improvement using lean methods to increase access and utilization of support services in younger breast cancer survivors.
Authors: Mayer Deborah , Gerstel Adrian , Taylor Kinley , Jackson Marianne , Shea Thomas C. , Rosenstein Donald , Marks Lawrence Bruce 
Published: February 2017

143 Background: A variety of ‘structured support services’ (SS) are available to patients (e.g., genetics, fertility, counseling, physical functioning, nutrition). Many of these SS have value for breast cancer survivors (BCS) as they are often likely to face issues regarding genetic factors, fertility, parenting, relationships, work, and financial hard-ships. As part of an ongoing CDC-funded initiative, we report our preliminary findings regarding perceived needs and actual rates of use of these SS, and identified barriers to their use for BCS. Methods: We assessed the needs for and utilization of SS by 1) conducting a survey of younger breast cancer survivors; and 2) performed chart reviews for documentation of assessment and referral for each SS. To identify barriers to the receipt of SS we 1) conducted key informant interviews, and 2) performed extensive observations in the clinic to value-stream map the flow of the patient throughout the care process. Results: Survey results: Women (n= 59/283) responded with a mean age of 39 (range 19-46) at the time of diagnosis. The most common limitations to using SS included lack of information about SS (60%), distance from services (54%), and inconvenient times (51%). Chart results: We reviewed 57 charts from 2011 for assessment and referral for any SS. The lack of consistent documentation made it challenging to extract meaningful data. Observation and interview results: Common barriers to the receipt of SS include lack of patient and staff education about available services, lack of consistent referral mechanisms, heavy burden on the provider to make referral, and poor feedback loop between SS and provider. Conclusions: Patients and providers both perceive many challenges to the delivery of support services. We are applying lean processes to improve the delivery of consistent information about SS to patients and providers, to standardize methods to refer patients for them, and to provide feedback to providers, in order to improve the delivery of SS to BCS, therefore improving their quality of care.
Off-shift Administration operations improvement collaborative.
Authors: Hayes-Rodgers Angela , Revis Altrivice D. 
Published: February 2017

144 Background: Off-Shift Administration (OSA) supports the senior leadership by overseeing clinical operations for both inpatient and outpatient areas at MD Anderson. Our team is responsible for resolving and/or managing issues that could impede patient care, particularly when unsuccessful at the departmental level. This project focuses on streamlining inpatient discharge activities. Data reports from December 2010 to February 2011 revealed that OSA received 1,923 assistance requests institution-wide of which 13% were case management related. A taskforce familiar with patient care and case management processes ultimately resolved to decrease the number of calls made to Off-Shift Administration requesting case management services by 50% by June 2011. Methods: The pilot period began March 1, 2011 and ended May 31, 2011. The earliest intervention was to re-route after hours case management requests directly to the case manager on-call. In the new process, the RN paged the case manager on-call directly who would then escalate calls to OSA as deemed necessary for internal support. A staff education plan complemented the intervention. The education plan entailed in-services with nursing staff, discharge planning teams and nurse leaders for each unit. Education by way of posters was delivered on select units. Piloted areas were also surveyed to assess their knowledge of case management processes and wait time experiences. Results: Outcomes were favorable. OSA experienced an 80% reduction in call volume from the piloted areas. Survey results showed educational efforts yielded a positive practice change and increased awareness of case management protocol. Survey results also revealed a 20-minute reduction in wait time for case management assistance. Certainly, of greatest benefit were the reduced wait times and more expedient patient care and customer service for staff. Conclusions: The project was successful and knowledge gained was be used to implement permanently and within all patient care settings. This project also serves as a useful paradigm of Clinical Operations’ improved ability to distinguish operational trends requiring attention, thereby increasing operational efficiency and customer satisfaction.
Caring for our deceased.
Authors: Tripp Kimberly , Hayes-Rodgers Angela , Revis Altrivice D. 
Published: February 2017

145 Background: In spring 2010, Off-Shift Administration (OSA) at MD Anderson Cancer Center received a spike in inquiries from staff concerned about the lack of uniformity in processing patient deaths occurring on campus. Procedures were known within administration, but no formal policy existed to substantiate requirements. A core team from Medical Affairs, Nursing, and OSA joined forces to address deficiencies and enhance the quality of end-of-life care across the organization. The core team then assembled two multidisciplinary groups to contribute to outcomes. Specific project aims were to increase physician completion of a death note within one hour of death from 83% to 95% compliance by April 2011. Monitoring of the death note was selected because it is often the first action barrier that further hinders processing a patient death. Methods: Key activity was carried out from July 2010 to July 2011. The first working group met to consider all processes relevant to expirations and write a policy. A second convened to address needed updates to clinical documentation. CLN1084 Caring for the Deceased Policy was implemented in January 2011. Education to physicians occurred in March 2011 and to ancillary staff in July 2011. In-services were given and announcements were made in various institutional communiqué. Results: Results were tabulated following a randomized monthly audit of deceased inpatient medical records. Audit specifications included a) determining presence of a death note and b) verifying that the note was completed within one hour of pronouncement. A March 2011 audit revealed 100% compliance of death note completion within one hour of the death. After the target end date, the team continued to see a superior 96.6% compliance rate. Clinical and support staff alike have also expressed great appreciation for reference tools now available to guide activity following a death on campus. Conclusions: Monitoring for compliance will continue as deemed necessary. The policy will also be reviewed regularly to assure accuracy and ongoing compliance with state law and hospital requirements. Finally, the core group continues to consult with departments who express interest in outlining specific departmental procedures (Rotary House, Regional Care Centers, etc.) that align with policy.
The role of ACOs in accelerating high-quality care: Implications for prostate cancer.
Authors: Picarillo Grant , Jivani Natasha , Nash Colin , Mitchell Kristi 
Published: February 2017

151 Background: Accountable Care Organizations (ACOs) seek to promote high quality, coordinated care by eliminating unnecessary procedures, sharing clinical information, and meeting quality targets. Of the 65 proposed quality measures outlined in the Medicare Shared Savings Program (MSSP), only two relate specifically to cancer care, calling into question how such models will accelerate high quality care in oncology. Prostate cancer offers an insightful case study as it is characterized by a lack of consensus around diagnosis and treatment and the involvement of several providers throughout the care continuum. Methods: As part of a multi-layered analysis to evaluate the impact of the ACO model on quality improvement and the management and treatment of prostate cancer, Avalere examined recent legislation (e.g., the Affordable Care Act, MSSP) to identify key characteristics of the model. Avalere then reviewed the potential impact of these characteristics in oncology by examining clinical guidelines and reviewing public statements by key opinion leaders. After identifying gaps specifically related to prostate cancer, Avalere categorized the characteristics into three groups based on their potential impact on prostate cancer care: high, moderate, and low. Results: Our analysis yielded the following categorization of the ACO characteristics: High Impact: Streamlined coordination of care between facilities and providers Focus on high-risk, high-cost populations Moderate Impact: Emphasis on preventative health Standardized use of outcomes-based quality measures Low Impact: Improved medication continuity Chronic disease management Shared savings incentives Conclusions: As providers involved in prostate cancer care explore the ACO concept, it will be critical to identify the characteristics with the greatest potential to improve the quality and coordination of care, and to incorporate these characteristics into the guideline recommendations influencing the standard of care. Our research indicates that prostate cancer guidelines should emphasize the low quality and high cost of fragmented care in this patient population and develop recommendations on proven methods of care coordination and quality improvement.
Transitioning chemotherapy administration from the inpatient setting: Creating bed capacity and improving the patient experience.
Authors: Cunningham Regina , Vozniak Michael , Wiley Kathleen , Kucharczuk Colleen , Swisher Brandi , Land Danielle , Tobin Robert , Holmes Marianna , Sullivan Mauri , Bell Tonita 
Published: February 2017

152 Background: Administration of selected multiday chemotherapy regimens typically requires an inpatient stay at an academic quaternary care facility. A growing oncology population exceeding the capacity of oncology allocated beds led to occasional cancellation of patients scheduled for curative-intent treatment, necessitating a reevaluation of our processes. A multidisciplinary group formed to pilot a process by which certain regimens would be transitioned to the outpatient arena and others would be split, requiring only a portion of the regimen to be given inpatient. Methods: The utilization of a variety of quality improvement tools and processes determined the feasibility and safety of transitioning previously inpatient-based regimens to the outpatient setting and identified those regimens that were most appropriate to pilot. An evaluative ranking process identified high-dose cytarabine for treatment of acute myeloid leukemia and infusional cyclophosphamide for multiple myeloma as most appropriate to be home-based regimens. Phase II of the pilot involved developing a process for the administration of select rituximab-based regimens between the inpatient and outpatient setting, with tightly fitted communication to ensure seamless transitions in care. Patients receive rituximab in the ambulatory clinic and are then admitted to a reserved hospital bed for the remainder of the regimen. Results: Since pilot inception and abstract submission, 20 patients have either received their entire regimen as an outpatient or by using our split location process. Preliminary analyses reveal an increased bed capacity for acute patients and outside hospital referrals by preventing scheduled admissions and reducing overall length of stay for rituximab-based regimens. Survey responses from patients and families are overwhelmingly positive. Conclusions: Care delivery models must be continually evaluated to adapt to change in this dynamic health care era. Our pilot suggests beneficial outcomes for patients and health care systems alike. As an institution, we have seen the effects that integrated team communication and tighter care coordination have on patient care and outcomes.
Efficacy of oral ketamine against opioid-refractory cancer pain due to bone metastases: Four case reports.
Authors: Hagihara Takeshi 
Published: February 2017

161 Background: The use of oral ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is reported to be effective against opioid-refractory cancer pain. Only a few studies have been performed worldwide so far, and in Japan we have more difficulty evaluating it, as the insurance doesn’t cover the application of ketamine to the tumor pain unlike in some other countries. Here we present the successful treatment of four patients with severe cancer-related pain due to bone metastases, by oral administration of ketamine. Methods: Inclusion criteria were cancer pain refractory to standard opiates. After institutional approval and informed patient consent were obtained, the treatment started with 40mg/day of oral ketamine. The ketamine regimen was adjusted individually based on analgesia and any adverse effects. Results: Self-reported pain significantly improved. In addition, serious adverse effects such as nightmares were not observed. In one case, epidural anesthesia became unnecessary. In another case, base and rescue opiates regimen can decreased. Conclusions: Ketamine is considered one of the World Health Organization essential drugs for the management of refractory pain. By oral administration of ketamine the quality of life can be improved, so we consider that further studies should be performed.