bluuebunny/crossref_metadata_2025_split huggingface dataset:
Value in cancer care: Regional initiative to improve care through data reporting and interventions.
Authors: Kreizenbeck Karma L. , Hoopes Teah , Steuten Lotte , Shankaran Veena , Goulart Bernardo , Lyman Gary H. , Brown Thomas David , Chen Eric Y. , Conklin Ted , Corman John M. , Lonergan Matt , Lessler Daniel , Martins Renato , Mera Csaba , Rieke John Whitelaw , Saikaly Elie P. , Smith Julie C. , Stewart F. Marc , Whitten Richard , Ramsey Scott David 
Published: February 2017

34 Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR), partnered with community members to launch a regional, stakeholder-driven initiative to define and report value metrics for cancer care for Washington State. Region-wide Summits were held in 2014 and 2015. Participants included local healthcare delivery organizations, patient advocacy groups, payers, and policymakers. The 2014 Summit identified priority metrics; these metrics were reported at the 2015 Summit. Methods: For the 2015 Summit, HICOR staff developed algorithms to measure adherence to the community-prioritized metrics using a claims-registry linked database. Metrics spanned diagnosis, treatment, continuing, and end-of-life (EOL) phases of care. After reviewing adherence at the clinic-level and for the region, attendees were invited to attend break-out sessions for metrics where there was the largest variation: hospital and ED use during treatment, hospital and ED use at EOL, and breast cancer surveillance. Within the breakout sessions, participants were asked to identify barriers to adherence and possible interventions to improve care. After discussion, participants individually ranked the top 3 interventions and estimated expected improvement to be gained by successful implementation of the intervention Results: Table. Working groups were formed to develop detailed protocols for implementable interventions. Conclusions: Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus to identify and prioritize value metrics in cancer care, and to develop consensus regarding approaches to improve adherence to those metrics. [Table: see text]
Characteristics associated with in-hospital death in commercially insured decedent.
Authors: Brooks Gabriel , Stuver Sherri Oliver , Zhang Yichen , Gottsch Stephanie , Fraile Belen , McNiff Kristen K. , Dodek Anton , Jacobson Joseph O. 
Published: February 2017

35 Background: A majority of patients with poor-prognosis cancer express a preference for in-home death, however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death among commercially-insured decedents. Methods: Building on a data-sharing project between our institution and Blue Cross/Blue Shield of MA, we obtained health care claims records for a sample of commercially insured decedents who died between July 2010 and December 2013. All patients received cancer care at Dana-Farber. In-hospital vs. out-of-hospital death was ascertained from hospital claims. Odds ratios (OR) and 95% confidence intervals (CI) were used to evaluate the association of in-hospital death with patient characteristics and established retrospective measures of end-of-life (EOL) care quality. Results: 904 commercially insured decedents were included in our sample, and 537 decedents (59%) enrolled in hospice prior to death. There were 254 in-hospital deaths (28% of all deaths), and 79 in-hospital deaths (31%) occurred at unaffiliated hospitals. Three measures of EOL care quality were found to be associated with in-hospital death, including chemotherapy within 14 days (OR 4.0 [95% CI 2.6-6.2]) or 15-30 days (OR 2.1 [1.4-3.1]) of death, 2 or more ED visits within the last 30 days of life (OR 3.0 [2.1-4.3]), and non-enrollment in hospice (OR 28.8 [18.7-44.3]). Hematologic malignancy, but not other cancer types, was significantly associated with in-hospital death (OR 5.09 [3.1-8.5]). Age at death, sex, marital status, race/ethnicity, and distance of residence from the cancer center were not significantly associated with in-hospital death, though sample sizes for some comparison groups were small. Conclusions: In-hospital deaths are common among commercially insured cancer patients, and data sharing identified nearly 1/3 of in-hospital deaths that occurred at unaffiliated hospitals. Retrospective measures of intensive EOL care quality were significantly associated with in-hospital death, and patients enrolled in hospice were dramatically less likely to experience an in-hospital death.
Understanding total cost of cancer care to determine strategic interventions to improve value.
Authors: Adelson Kerin B. , Velji Salimah , Patel Kavita , Chaudhry Basit , Grizzle Sonia , Lyons Catherine A. , Lilenbaum Rogerio 
Published: February 2017

3 Background: Cancer centers across the country are largely unprepared to move toward value-based payment. Total cost of care data is not readily available and centers do not know how much of their patients’ care is received at other hospitals, when in the trajectory of illness greatest cost is incurred, or the elements of care that present the greatest opportunity for savings. A previous examination of practice patterns Smilow Cancer Hospital (SCH) demonstrated that our patients had high rates of ED visits, hospital admissions and ICU use in their last month of life. While this data is consistent with other large academic cancer centers (AMCs), there is a clear opportunity to improve our end-of-life planning and reduce futile care. Cost data supplemented the overutilization analysis, informing the infrastructure investments to prepare us for value-based payment models. Methods: We accessed the 5% Medicare Limited Dataset (2012-2013) to map out cost of care in 6-month episodes for all Medicare patients receiving chemotherapy. Patients who had received chemotherapy at a SCH site were flagged and the analysis included all cost of care, regardless of the site of service or type of professional delivering the service. Results: On average, a first episode of care at SCH cost $26,500, a second episode $38,000 and a third $45,600. Our analysis demonstrated important associations between increases in spending and ED utilization. Patients who had 1 or fewer ED visits during an episode, averaged $21,000 vs. $49,000 for those with 2 or more. Patients who died during an episode cost $53,000 compared to $25,600 for patients who lived. SCH episodes were significantly more expensive than CT, and slightly more than a comparable east coast Academic Medical Center. Conclusions: The above demonstrates that aggressive treatments, ED visits and hospital admissions at the end-of-life are major cost drivers. We used the analysis to target infrastructure investments in Urgent Care to reduce ED utilization, Care Management to prevent hospital admissions/readmissions and early referral to Palliative Care for clarification of goals of care. We believe these investments will lead to significant cost reductions.
Cancer, depression, and health care coverage in the state of Nevada: A retrospective cross-sectional study.
Authors: Malalur Pannaga G. , Agastya Manas , Dawod Yaser , Phan Linha , Farooqui Mohammad talha , Yoo Ji won 
Published: February 2017

42 Background: The prevalence of depressive disorders in patients with malignancies is estimated at 20-50%, significantly greater than the general population. Existing literature reports a negative impact of depression on both the patient and their families. There is limited information regarding the impact of healthcare coverage on the prevalence of depression in such patients both in the state of Nevada and nationwide. Methods: A retrospective cross-sectional study was performed using the Behavioral Risk Surveillance System (BRFSS) database from 2010 to 2014. All adult subjects with a history of malignancy were included. Demographic factors and health care coverage were reviewed. Individuals with skin cancer as well as those with missing data were excluded. Patients were assigned to two groups based on their insurance coverage status. Study population was further stratified into Nevada and non-Nevada residents and analyzed. Association between depression and health care coverage across the study groups were assessed using Pearson chi-square test and regression models. Results: 183,530 subjects nationwide met our inclusion criteria. The Nevada population represented 1% (1676) of the total study sample. In Nevada, the prevalence of cancer patients without healthcare coverage was 7.5% (N = 126) compared to individuals with coverage 92% (N = 1550). This is significantly higher when compared to the national average of 4.9 % without coverage (p = 0.001). Overall, the rate of depression in cancer patients with no healthcare coverage nationally was notably higher compared to those with coverage (37.5% vs 22.7%, p = 0.001). Similarly, statistically higher rates of depression were noted in non-insured Nevada patients compared to those insured [49 (38.8%) vs. 357 (23%), p 0.001)]. Conclusions: This study demonstrates significant association between depression and lack of insurance coverage; both nationwide as well as in the state of Nevada. The proportion of uninsured Nevada residents with malignancies were higher compared to the national average. Improved and early screening for depression is crucial in mitigating the potential complications and morbidity associated with depression in patients with cancer.
Trends in cancer care with the Affordable Care Act.
Authors: Kaleem Tasneem , Miller Robert Clell 
Published: February 2017

46 Background: Accountable Care Organizations (ACO), as proposed by the Affordable Care Act, will change the delivery of health care in the United States. ACO serve as a network of providers with primary care providers (PCP) set up as gate-keepers for referrals to specialists. Within the next several years, many trends will emerge and drive progress of change, requiring oncologist to take a lead role to adapt to the evolving landscape of health care. Methods: Literature search of internet-based and academic sources for oncology and the Affordable Care, with a focus on ACO formation. Results: Four main expected trends and strategies to adapt to changes were formulated. Trend 1: Changes in referral patterns towards oncologists. Referral will be based on outcome data and ACO membership. Strategy: Increase communication and education to PCP and other providers. Endorse multidisciplinary clinics, which have shown to improve guideline compliance, coordination, and communication. Trend 2: Formation of large scale oncology provider groups collaborating with PCP/ACO. Physicians will be able to provide around the clock care to patients with the goal of reducing hospital visits. Strategy: Establish oncology homes with goal of reducing inpatient and ED visits by providing telephone symptom management, daily questionnaires and opportunities for end of life discussions. Trend 3: Reimbursement reform to oncologists based on quality measures. ACO can bill fee for service basis and eligibility for bonus payments based on outcomes. Strategy:Adherence to evidence based guidelines chosen by evaluating efficacy, toxicity and cost have been proven to increase quality of patient care. Trend 4: Development to pathway driven medicine.ACO structure lends to a centralized governance committee responsible in choosing guidelines for treatment within an ACO. Strategy: Oncologists should provide a voice for the field and patients when different guidelines are chosen. Conclusions: In the context of the Affordable Care Act, oncology specialists are encouraged to participate in the new organization model to ensure best outcomes for both physicians and patients. Awareness of future trends and ways to contribute will be the first step in adapting to implementation of the Affordable Care Act.
Connecting specialty practices with primary care.
Authors: Tirodkar Manasi , Morton Suzanne , Oberlander Tyler , Scholle Sarah Hudson , Barr Michael 
Published: February 2017

47 Background: Public and private payers are beginning to adopt alternative payment structures that call for greater attention to patient-centered care and quality improvement activities (CMMI 2015; MACRA 2015). The National Committee for Quality Assurance (NCQA) developed standards for Patient-Centered Specialty Practice based on American College of Physicians principles. The report describes achievement on the standards among an initial cohort of recognized physicians. Methods: We analyzed practice characteristics and determined how practices performed on each of the 21 elements in the PCSP program by showing the percent of practices scoring less than 50% of points, or 100% of points (i.e. full credit) for each element. Results: One third of the 91 practices recognized in the first year of the program are Oncology/Hematology. Overall, about half of recognized practices have more than 5 clinicians and half are physician-owned (52%). Most specialty practices achieved full credit on having key clinical data in structured fields and using electronic prescribing. More than 75% of practices also achieved full credit for providing culturally and linguistically appropriate services, providing information about specialist visits back to primary care and providing patients/families information about the role of the specialist and coordination of care. Tracking of referrals to secondary specialists was most challenging, with only 6% of practices earning full credit. Only 34% of practices received full credit for coordinating care transitions from hospitals and other facilities; most practices did not even receive half credit. Measuring and improving performance was also challenging for all practices. Compared to other specialties, oncology/hematology practices were less likely to achieve full credit on the following elements: electronic access, measure patient/family experience, patient information, and care planning and support self-care. However, they performed better on documenting clinical data than other specialty practices. Conclusions: Specialty care practices have started to implement the patient-centered care model. Research to identify which components of the model have the greatest impact on outcomes is needed.
Prospectively measuring the acuity of outpatient chemotherapy treatment regimens for staffing allocation.
Authors: Weber Shani Michelle , Steele Cheryl A. 
Published: February 2017

48 Background: UPMC CancerCenter is a large outpatient medical oncology network of 25 locations, located within a 200 mile radius of Pittsburgh, PA. Covering all of these centers with a limited pool of float nurses was a daily challenge. The literature describes many attempts to quantify nursing workload retrospectively based upon complexity, hours of nursing time, etc. The ability to schedule staff equitability in advance is critical to managing staff. New targeted therapies and complicated treatment regimens which impact patient acuity bring to light the need for accurate acuity measurement. Methods: The first step in designing an acuity model was to determine the level of complexity of each treatment regimen based on standardized criteria. The model is a five point system encompassing route, teaching, reaction potential, etc. designed by frontline nurses. A designated nurse at each site calculates the acuity and enters it into an online system prospectively. Nursing Administration can view the staffing and acuity rating across the entire network. This enables the assignment of float nurses to the location with the greatest need. Results: A stoplight report using the database was developed to highlight the sites that are outside of 0.5 standard deviation (SD) range for both the acuity and patient ratios. It was determined that the average nurse to acuity ratio was 11.92 (within SD range 10.69-13.16). The average nurse to patient ratio was 6.31 (within SD range 5.6-7.03). This enables Nursing Administration to identify sites that typically operate below or above the average range in order to better allocate nursing resources. This report is shared among all sites to provide transparency which has improved understanding by the staff of nursing resource allocation. Conclusions: The development of this prospective acuity system has helped to quantify treatment complexity to better allocate daily staffing resources. Further evaluation is necessary to determine the optimal ratios that are the most economical while still providing safe patient care. There are future plans to link the acuity levels to treatment regimens within the Electronic Medical Record to reduce the manual workload.
Lung cancer diagnosis transformation: Aligning the people, processes, and technology sides of the learning system.
Authors: Fung-Kee-Fung Michael , Maziak Donna E. , Pantarotto Jason R. , Smylie Jennifer , Taylor Leanne , Timlin Thomas , Cacciotti Tiziana , Villeneuve Patrick James , Dennie Carole , Bornais Chantal , Aquino Jose , Wheatley-Price Paul , Stewart David J. 
Published: February 2017

50 Background: The Ottawa Hospital, serving a population of 1.2 million across a large geographic area, redesigned its regional lung cancer diagnosis and patient intake process using a systems approach. Although having a strong record of excellent coordinated care, recent challenges had created strains on delivery metrics. Prior to the implementation of the project (October 2014), it took patients a range of 15 – 225 days to get from a referral with a suspicion of lung cancer to initial treatment, with a 90th percentile of 117 days. Methods: An innovative care platform was developed to align the people, processes and technology sides of the regional lung cancer care. It formed a basis for a “learning” system mobilizing the wider community for transformational change. We redesigned 12 main business processes facilitating accurate and timely diagnoses using the Communities of Practice approach, the Lean and Constraints methodology and the IBM business process management technology tools. In a series of rapid learning cycles, 270 technology-enabled actions were logged and resolved to support 57 process changes in workflow. The main patient value outcome was defined as improvement in the monthly proportion of patients receiving initial treatment within provincial targets and a reduction of total wait time. Results: In 14 months, the TOH Lung Cancer Transformation program yielded substantial improvement across all levels of diagnostic process including a 48% reduction in the cumulative wait times from referral to initial treatment (surgical, systemic, radiation), increased patient satisfaction with care coordination, implementation of guideline standards, efficiency gains from more intensive use of hospital resources, and sustained engagement of over 100 regional lung cancer care providers in collaborative learning and knowledge sharing across disciplinary and organizational boundaries. Conclusions: A systems approach can improve the hospital capacity to facilitate and support inter-professional and intra-professional teamwork necessary for the diagnostic process transformation.
NCI Community Cancer Center Program (NCCCP): Understanding why hormonal therapy for breast cancer was considered but not administered.
Authors: Spain Pamela , Teixeira-Poit Stephanie , Halpern Michael T. , Castro Kathleen , Prabhu Das Irene , Adjei Brenda A. , Clauser Steven 
Published: February 2017

74 Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) was designed to improve the quality of cancer care and reduce disparities at hospital-based community cancer centers. This study examined when guideline-concordant therapy was considered but not administered, who made the decision to not receive treatment. Methods: A retrospective analysis of patients diagnosed and receiving all or part of their initial cancer treatment at one of 12 NCCCP sites was conducted. We examined patients who were guideline-concordant with the hormonal therapy (HT) for breast cancer quality measure, but for whom treatment was considered but not administered. We compared patients diagnosed in the pre-NCCCP period (2006 – 2007) and during the NCCCP period (2008-2013). Results: Overall, a low proportion of cases had HT considered but not administered (4% in pre-NCCCP period; 5% in NCCCP period – difference not significant). In the pre-NCCCP period, white patients were twice as likely as Black patients to have HT considered but not administered, while there were no racial differences during the NCCCP period. In both time periods, older patients and Medicare patients were more likely to have HT considered but not administered. The most common reason for considering but not administering HT was refusal by the patient or patient’s family and this more likely for White patients, patients in the middle age groups (50-59 and 60 to 69), and Medicare patients. The second most common reason was that the physician determined it to be contraindicated due to patient risk factors. This was more likely to be a reason for Black and Medicaid patients. Conclusions: Results show that a large proportion of cases that had treatment considered but not administered did not receive treatment because of patient/family refusal or it was contraindicated due to other patient risk factors, both before and during the NCCCP period. Additional studies could inform the long-term outcomes of patients with comorbid conditions who were considered for guideline-concordant treatment but did not receive it (but the data were not available for this study).
Improving venous thromboembolism (VTE) prophylaxis for hospitalized malignant hematology/bone marrow transplant (heme/BMT) patients.
Authors: Wong Melisa L. , Dzundza John , Ajmera Archana , Gustafson Ashley , Lo Mimi , Fong Richard , Graff Larissa , Dao Bao , Young Rebecca , Damon Lloyd Earl , Martin Thomas G. , Olin Rebecca Leah 
Published: February 2017

79 Background: Hospitalized patients on the heme/BMT service at our academic cancer center have historically not received pharmacologic VTE prophylaxis (VTEP) due to concerns regarding thrombocytopenia and bleeding risk. However, a retrospective review of heme/BMT admissions from 2009 to 2013 revealed that 59% of hospital-acquired VTE cases occurred at a platelet count > 50 x 10E9/L, suggesting missed opportunities for VTE prevention. Methods: To implement VTEP on the heme/BMT service, a multidisciplinary quality improvement team developed a pilot intervention with 5 strategies: 1) identification of heme/BMT-specific contraindications to VTEP, 2) standardized use of VTEP for all heme/BMT patients unless contraindications are present, 3) hold parameter for platelet count < 50 x 10E9/L within the VTEP order, 4) note template to document VTEP plan, and 5) provider, nurse, pharmacist, and patient education. We conducted audit and feedback every two weeks for two process measures: VTEP ordered for eligible patients (pre-pilot VTEP ordered for < 1%) and VTEP plan documented (pre-pilot documentation of 23%). Patients on therapeutic anticoagulation were excluded. We also tracked major bleeding events among patients receiving VTEP. Results: Since pilot implementation in July 2015, 105 patients admitted during audit periods met the inclusion criteria; 11 patients on therapeutic anticoagulation were excluded. Contraindications to VTEP were present for 56 patients, most commonly platelet count < 50 x 10E9/L (46%), central nervous system lymphoma (23%), and anticipated procedure (21%). Among the 49 eligible patients, VTEP was appropriately ordered for 42 (86%). VTEP plan was documented for 102 patients (97%). One VTEP-associated bleed occurred in a patient with recent polypectomy, prompting the addition of a new contraindication for recent procedures. Conclusions: Our multidisciplinary pilot successfully improved VTEP orders for eligible heme/BMT patients from < 1% to 86% and VTEP plan documentation from 23% to 97%. Rates of hospital-acquired VTE and major bleeding are being tracked prospectively to evaluate efficacy and safety.