bluuebunny/crossref_metadata_2025_split huggingface dataset:
Near miss or safety incident in patients treated with radiotherapy: What are the contributing factors?
Authors: Judy Greg D. , Mosaly Prithima , Mazur Lukasz M. , Tracton Gregg , Chera Bhishamjit S. 
Published: April 2017

36 Background: To identify 1) factors that are associated with a near miss or safety incident (NMSI) in patients undergoing radiation therapy; 2) the most common root causes of NMSIs and their relationship with incident severity. Methods: We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with a NMSI (n=200; incident group) and a similar group of control patients (n=200) matched in time, without a NMSI. A root cause was determined for each incident. A univariate analysis was performed to determine which patient-, disease-, and treatment-specific factors were different between the incident and control groups. Next, multivariate logistic regression was used to determine the significant factors contributing to NMSIs. Multivariate logistic regression was used to determine the most common root causes of NMSIs and their relationship with incident severity. A p value of 0.05 was used to test the statistical significance. Results: NMSIs were associated with the following factors: i) head and neck treated sites versus other disease sites (OR 5.2, p=0.01), ii) image-guided intensity modulated radiotherapy (IGIMRT) versus other treatment modalities (OR 3, p=0.009); tumors staged as T2 more frequently had incidents versus other T stages (OR 3.3, p=0.004), and iv) daily imaging versus no imaging or weekly imaging (OR 7, p<0.001). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients (p<0.0001) and technical treatment delivery errors were most associated with a higher severity score (p=0.005). Conclusions: Several treatment- and disease-specific factors were found to be associated with a NMSI. These factors are similar to what has been previously reported by others. Overall, our results suggest that complexity (e.g., head and neck, IGIMRT, T2, and daily imaging) might be a contributing factor for a NMSI. This promotes an idea of developing a more dedicated and robust QA system for complex cases. Our study highlights the importance of a strong reporting system to support a safety culture and promote continuous learning and improvement efforts.
Significant and sustained reduction in chemotherapy errors though improvement science.
Authors: Weiss Brian D. , Scott Melissa , Demmel Kathleen , Perentesis John Peter , Kotagal Uma R , Walsh Kathleen 
Published: April 2017

37 Background: The majority of children with cancer are now cured with highly complex chemotherapy regimens incorporating multiple drugs and demanding monitoring schedules. The risk for error is high and can occur at any stage in the process, from order generation through pharmacy formulation to bedside drug administration. Our objective is to describe a program to eliminate errors in chemotherapy use among children. Methods: To increase reporting of chemotherapy errors, we supplemented the hospital-reporting system with a new chemotherapy near-miss reporting system. Following the model for improvement, we then implemented several interventions, including a daily chemotherapy huddle, improvements to the preparation and delivery of intravenous therapy, headphones for clinicians ordering chemotherapy, and standards for chemotherapy administration throughout the hospital. Results: Twenty-two months into the project, we saw a centerline shift in our U Chart of chemotherapy errors that reached the patient from a baseline rate of 3.82/1,000 doses to 1.9/1,000 doses. This shift has been sustained for over 4 years. In Poisson regression analyses, we found an initial increase in error rates, followed by a significant decline in errors after 16 months of improvement work (p < 0.001). Conclusions: Following the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors which reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimized interruptions during ordering.
Readmission among patients with cancer who were discharged with hospice care.
Authors: Manzano Joanna-Grace Mayo , Barbo Andrea G. , Lin Heather Y. , Zhao Hui , Halm Josiah , Suarez-Almazor Maria E. 
Published: April 2017

46 Background: Palliative and hospice care are appropriate recommendations for patients with high symptom burden and who are at end of life. Patients with cancer who are discharged to hospice care are less likely to be readmitted and this is expected. There remains a proportion of patients however, who rescind hospice after enrolling. We sought to describe this subgroup of patients and determine their readmission rate. Methods: This is a retrospective cohort study using administrative data of adult patients discharged from a non-surgical solid tumor service at The MD Anderson Cancer Center who were discharged to hospice care. Readmission was defined as any rehospitalization after discharge regardless of timing. Descriptive statistics are presented. Results: There were 1,452 discharge encounters with a disposition of hospice in our cohort with 50 resulting in readmission (readmission rate=3.4%). The mean age of patients who were readmitted was 59 years. Majority of the readmitted patients were female (60%), had a religious affiliation (83%), were English-speaking (85%), and were from Texas (94%). 54% of the patients who were readmitted were married versus 42% who were either single, divorced, widowed or separated. 42% had Medicare insurance, 44% had private insurance, 4% were indigent, and 10% were self-pay. 75% of the patients had metastatic disease at time of first presentation at MD Anderson. Conclusions: Transitioning to hospice care is a difficult decision for most patients and caregivers. Rescinding hospice after discharge to seek acute care in the hospital potentially reflects the difficult and daunting nature of this transition. Our study provides an insight into the characteristics of patients who are readmitted after hospice care has been initiated. More analysis is needed to determine if the characteristics described are associated with readmission in this population. Other factors such as those that are related to the caregiver, the patient’s symptom burden, or the care setting, may need to be investigated as well to have a better understanding of why patients decide to rescind hospice.
Evaluating the patient-centered quality of cancer survivorship care models.
Authors: Mead Holly , Pratt-Chapman Mandi , Cleary Sean , Raskin Sarah 
Published: April 2017

48 Background: With 15.5 million cancer survivors in the U.S., cancer is increasingly viewed as a chronic illness that requires systematic, coordinated care. Yet research has not determined what models of survivorship are most effective in providing high quality, patient-centered care. This study evaluates the quality of three models of cancer survivorship care using a newly developed patient-centered measure. Methods: We conducted a comparative effectiveness study with 32 cancer programs distributed across 3 distinct models of survivorship care: 1) Consultative Specialized Survivorship Clinic; 2) Longitudinal Specialized Survivorship Clinic; and 3) Oncology-Embedded Survivorship Clinic with Referrals. We developed the Patient-Prioritized Measure of High Quality Survivorship Care (PPM), a scale comprising 9 patient-prioritized components of survivorship care. We enrolled 991 survivors of breast, colorectal and prostate cancer across these programs and followed them over 6 months collecting self-reported data on quality of survivorship services. Results: Preliminary results suggest statistically significant differences across models of care for six PPM components. Model 1 is more likely than the other two models to provide a full spectrum of services (p=0.0001), mental health and social support (p<0.0001), and information and resources for patients in survivorship (p=0.0002). Model 2 is better than model 3 at providing a medical home (0.04), and outperforms both other models at coordinating care and transitions (p=0.0059). Both Models 1 and 2 are better than model 3 in ensuring productive patient-provider interactions (p=0.006). Conclusions: It appears that certain models of survivorship care are better at specific domains of patient-centered quality, suggesting cancer centers should consider their organizational context and their patients’ needs before committing to a particular model of care.
Improving care with portfolio of physician-led cancer quality measures at an academic center.
Authors: Porter Julie , Segura Smith Andrea , Winget Marcy , Rosenthal Eben Lloyd , Seshadri Sridhar Belavadi , Vetteth Yohan , Kiamanesh Eileen F , Badwe Amogh , Advani Ranjana H. , Buyyounouski Mark K. , Coutre Steven , Dorigo Oliver , Ganjoo Kristen N. , Johnston Laura J. , Recht Lawrence David , Shrager Joseph B , Skinner Eila C. , Swetter Susan M. , Visser Brendan C. , Blayney Douglas W. 
Published: April 2017

49 Background: Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the required manual data collection is slow and resource-intensive. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCP). Methods: CCP physician leaders (MD) identified two measures that were meaningful to their team and patients. The quality team worked with hospital and university analytics teams to develop metrics and reports. Hospital leadership provided financial incentives (FI) for each CCP if jointly set targets were met. Results: 16 metrics were identified and measured for 13 CCPs (Table). Measures spanned from new diagnosis (ND) through end of life or survivorship care, and were a mix of process and outcome measures. To build and manage metrics required 2 full-time equivalent data analysts and quality specialists over 12 months. CCP MDs received monthly reports for dissemination to their team. Almost all measures improved or maintained initial high levels (*). FI awards will be used for quality improvement, education, and team-building, as determined by CCP MDs. Conclusions: A successful quality reporting system with measured improvements takes considerable engagement and resources, including FI, data systems, and staff to build, manage, and improve measures. This may not be feasible or sustainable for centers in the current fiscal environment. [Table: see text]
Developing and evaluating new models of care in hematology.
Authors: Kouroukis Tom , Ratcliffe Jenna , Running Karen , Sussman Jonathan 
Published: April 2017

53 Background: The duration of care for patients with hematological malignancies (HM) from diagnosis to discharge can often be five years or longer, during which patients frequently visit their hematologist but may not maintain contact with their primary care physician (PCP). This can result in gaps in the care of non cancer health problems. A number of studies in solid tumors have highlighted the benefits of maintaining contact with the PCP however there has been little published on survivorship care in HM. Objective. Develop and evaluate models of care in hematology that facilitate transition to the PCP where appropriate. Methods: This study used a stepwise approach to inform the development and evaluation of care models. Models were developed using: a literature review; expert opinion; input from patient and PCP focus groups. The survivorship model (SM) was evaluated in a longitudinal, cohort of patients using validated patient surveys: Coordination of Cancer Care Questionnaire; Edmonton Symptom Assessment Scale; EQ5D-QoL. Results: Focus groups were conducted with 26 participants. Patients indicated they would be willing to engage with their PCP if primary care were more confident in their cancer care abilities, and if communication improved between specialty and PCP. PCPs felt care plans should be clear, concise and within their scope. Three new models of care were developed based on level of care need (survivorship, shared, engagement). The SM has been tested with 50 patients who have completed treatment and follow up. Survey results indicated the majority of SM patients: continued to feel well; reported high functioning; had seen their PCP since discharge; were satisfied with the coordination of their care. Fifteen PCPs responded to a follow up survey. PCPs were: satisfied with the SM care plan and aware of the repatriation process to specialty care, if needed. Conclusions: Patient involvement in model design was instrumental in the success of the project. PCPs reported that the tools developed in this pilot enhanced the care experience and provider collaboration. These findings warrant further testing of care models in a comparative study with this complex cancer population.
Quality of life after morphine treatment in patients with advanced and terminal cancer.
Authors: Alonso Tammy 
Published: April 2017

54 Background: Life quality evaluation is the main indicator of the impact of palliative care, which has the objective of diminished suffering. It includes symptoms control and the satisfactions of patients and relatives. Opioids constitute a milestone in pain treatment. Present work is aimed to evaluate the secondary effects in oncological patients with bad prognosis treated with morphine at the Palliative Care Unit (PCU) of the National institute of Oncology and Radiobiology. Methods: The sample includes 72 cancer patients that arrive to the Palliative Care Unit of the National Institute of Oncology and Radiobiology of Cuba, from May 2015 to May 2016. It was characterized in terms of the demographic and clinical parameters. Severity of symptoms was evaluated using the Visual Analogue Scale (VAS). Pain was evaluated using Analogue Visual Scale. Morphine was administered subcutaneously. Incidence of adverse effects related to morphine administration and accuracy of moderate to severe pain was measured. Results: The age range was from 41 to 50 and females predominate. Gynecological cancers were the most frequent pathology. Most frequent adverse effects related to morphine administration were: constipation (35%), nauseas and vomiting (25%) and somnolence (22%). Despite of morphine myths that terrify many physicians and make them use this drug at the end of analgesic scale, in the present work was used in patients in clinical stage III (58.6 % of the 63.8 % survivors) with an effective pain control. Life quality, that includes mood, functional capacity, social interaction and recurrent symptoms, was improved. Conclusions: The use of morphine for pain relief in stage III oncological patients increases the quality of life of patients and relatives for a longer period of time.
Bringing the patient voice into quality assessment: National stakeholder perceptions of facilitators and barriers for the use of PROs as performance measures.
Authors: Stover Angela M. , Chung Arlene , Jansen Jennifer , Basch Ethan M. 
Published: April 2017

61 Background: An emerging trend in quality improvement is to incorporate the patient voice into performance metrics for routine care delivery using patient-reported outcomes (PRO). For instance, patients may complete a questionnaire about how well their symptoms are controlled (e.g., nausea). High-quality care is then determined by adjusting scores and comparing similar practices on symptom control. However, stakeholder (clinicians, administrators, and researchers) perspectives of facilitators and barriers are not well characterized because PRO performance measures are an emerging concept. Methods: Key informant interviews were conducted with 35 stakeholders (9 medical oncology clinicians, 13 administrators, and 13 health services researchers) from 5 healthcare systems across the U.S. Interview guides were used to elicit perceptions of barriers, facilitators, and acceptability for using PROs as performance measures. Transcripts were content analyzed by stakeholder group using standard methodology. Results: Clinicians reported barriers that were structural (e.g., complexity of programming electronic health record [EHR] changes) and process-oriented (e.g., changing clinic workflow to accommodate PRO review and alerts). Clinicians noted concerns about appropriate adjustments to ensure fair quality comparisons across practices. Clinicians and administrators reported structural barriers such as reimbursement and staff training, and outcome barriers such as choosing symptoms that have clear treatment guidelines. Facilitators included dashboards to visually display results that are intuitive and easily accessible in the EHR. Researchers focused on standardization and selecting thresholds for symptom alerts. Conclusions: Clinicians, administrators, and researchers reported barriers to the integration of PROs as quality measures. These barriers are mainly structural- and process-oriented but generally did not focus on acceptability. Facilitators focused on presenting PRO scores in an easily interpretable and accessible way within the EHR. Results will inform multi-site feasibility testing of PROs as quality metrics.
Improving end-of-life care: Palliative care embedded in an outpatient oncology clinic.
Authors: Einstein David Johnson , DeSanto-Madeya Susan , Gregas Matt , Lynch Jessica A. , McDermott David F. , Buss Mary K. 
Published: April 2017

77 Background: Patients with advanced cancer benefit from early involvement of palliative care. Nonetheless, the ideal method of palliative care integration remains to be determined. Prior studies proposed automatic referral criteria and embedding palliative care teams within specialty clinics. Methods: We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic based on automatic referral criteria. Patients seen in this clinic on a specific day had access to the “embedded” model, whereas patients seen on two other days could access a separate palliative care clinic upon oncologist referral (usual care). We abstracted data from the medical records of 118 patients who were cared for in this oncology clinic and died during the 3 years following implementation of the embedded model. Results: Compared with those with access to usual care (n = 88), patients with access to the embedded model (n = 30) encountered palliative care as outpatients more often (p < 0.001) and twice as long before death (mean 223 versus 106 days, p = 0.001). Hospice enrollment rates were similar (p = 0.717) but duration was twice as long (mean 53.5 versus 25.3 days, p = 0.03), and enrollment greater than 7 days before death—a core Quality Oncology Practice Initiative metric—was significantly higher in the embedded model (OR 5.60, p = 0.034). Place of death (p = 0.505) and end-of-life chemotherapy (OR 0.361, p = 0.204) did not differ significantly. Conclusions: A model of embedded palliative care with automatic referral criteria, compared with usual practice, was associated with significant improvements in utilization and timing of palliative care and hospice.
Challenges, barriers, and keys to success for sustainable quality improvement in oncology: A focus group of oncology quality leaders.
Authors: Chiang Anne C. , Reeder-Hayes Katherine Elizabeth , McNiff Kristen K. , Evans Tracey L. , Lennes Inga Tolin , Eaton Erica , Kamal Arif 
Published: April 2017

78 Background: A sustainable, standardized approach for quality assessment and improvement is increasingly expected in oncology. This requires oncology leaders to identify processes and infrastructure to facilitate sustainable initiatives for practice refinement. To date, few summative reports of lessons learned, key success factors, and barriers to regular quality improvement have been reported. Methods: After IRB protocol approval, a focus group of 11 diverse physician oncology leaders was conducted, using a guide developed through multiple discussions by investigators. The physicians represented diverse organizations with community-based, private practice and academic settings. Data analysis of interview transcripts was performed iteratively, with a grounded theory approach with a method called “constant comparisons”, with related open and axial coding techniques. Transcripts were coded independently by two or three coders, and the resulting code lists integrated prior to final analysis. Differences in coding were resolved by consensus. Results: Overall, physician quality leaders discussed needs and barriers in 5 major domains: coordination of care, communication, finances, value, and quality improvement. Two major themes emerged: rapid change cycles in a dynamic landscape of practice--changing business models and care delivery, new expensive drugs, oral chemotherapy--and their respective unintended consequences on quality of care, e.g. financial toxicity for patients, misalignment of financial incentives and a quality agenda. Participants discussed responding to these changes and key factors in harnessing the practice model to deliver quality care. Conclusions: Cancer care delivery is rapidly evolving and undergoing intrinsic cycles of quality improvement. This project helps to inform systemic quality improvement efforts targeted towards oncology practices by identifying areas of concern and highlighting key factors to be addressed to achieve value, alignment and quality of care. Institutional culture and infrastructure including resources and incentives for quality improvement/measurement were identified as critical success factors.
Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.
Authors: Atiq Mohammad Omar , Ravilla Rahul , Kumar Ajay , Haider Sajjad , Tang Ji-Ling , Arnaoutakis Konstantinos , Motwani Pooja , Siegel Eric R , Sasapu Appalanaidu , Mahmoud Fade A. , Harrington Sarah Elizabeth 
Published: April 2017

80 Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]