bluuebunny/crossref_metadata_2025_split huggingface dataset:
Statistical methods as a problem-solving strategy in health care.
Authors: Schaub Diane , Terrell James 
Published: February 2017

279 Background: Clinical personnel in healthcare are being challenged to improve quality and increase productivity in order to lower healthcare costs in the United States. With the effort to become more cost conscious, there is an ever increasing need to analyze processes and make them more efficient. The complexity of these processes and the data associated with them require more complex analysis and more sophisticated statistical tools. Unfortunately the statistical training of many health care employees is not adequate for the more complex tools and processes. Methods: At the University of Texas MD Anderson Cancer Center, we use Minitab software, widely used in the manufacturing sector, as our primary statistical analysis software. It is on this platform that the Office of Performance Improvement is creating training courses to assist in raising the statistical literacy level of clinical employees. This software is fairly easy to use, and contains tools for visualizing data such as control charts and box plots, as well as performing multivariable analysis such as regression or ANOVA (Analysis of Variance). Results: Early adopters of the methodology to utilize statistical tools in process improvement studies has been extremely positive. They enjoy being able to quantify their improvement results, document them, and share them with others. Conclusions: Process Improvement leaders need to improve their skills in several areas of statistical methodology. Specifically, they should be able to select the correct graphic to show the critical information in their data, they should be able to select the proper tools and perform analysis to interpret the data, and they should have a technical vocabulary to share and communicate their key learning with others. Minitab is a widely accepted software package for process improvement here at MD Anderson Cancer Center. There are many other very good software packages on the market but it is helpful for support, teaching, and consistency if an institution settles on a package as a basic standard.
Ongoing professional practice evaluation implementation within STATIT.
Authors: Shi Weiming 
Published: February 2017

283 Background: The OPPE allows the organization to identify professional practice trends that impact quality of care and patient safety. The intent of the standard is that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis, to allow them to take steps to improve performance on a more timely basis. Methods: Infrastructure development. We assigned people for data integration, technical support and metric development. The manager of Clinical Decision Support serve as the administrative coordinator to the program managed the progress of implementation. Leadership Support. To implement the STATIT for OPPE in any hospital, executive leadership support is required to secure funding and resources for the program as well as to support the quality improvement initiatives undertaken that will affect current policies and a wide range of personnel. The early support for the OPPE STATIT came from hospital’s administrative leadership and Performance Improvement leadership. Committed OPPE STATIT implementation team. The basic OPPE STATIT team, consisting of a Manager of Clinical Decision Support, two IT people, and ten Informatics Analysts, requires additional personnel such as departmental Quality Officer with differing expertise for indicator development. Results: All of medical knowledge, patient care activity, and system based indicators plus departmental specific cancer care indicators can be reviewed and any outliers can be drilled down for analysis by division head, department chair and quality officer and signed off on a six-month basis. All individual providers also are able to review his/her performance quality and peers’ comparison. Conclusions: The MIDAS + Statit Physican Profile & Review (PPR) solution is a Web-based system that allows medical providers easy access performance dashboards, which contain up-to-the-moment performance data, annual and interim reviews and drill down to patient level data. The information is necessary to align medical staff with key strategic objectives across the organization. It provides the statistical analysis of patient care quality and safety and opportunities of improvement.
The rapid quality reporting system: Assessing and improving the quality of cancer care with a prospective clinical performance tracking and reporting system.
Authors: McNamara Erica J. , Stewart Andrew , Gay E. Greer , Banasiak James , Palis Bryan E. , Edge Stephen B. 
Published: February 2017

286 Background: The Rapid Quality Reporting System (RQRS), developed by The Commission on Cancer of The American College of Surgeons, allows accredited cancer programs to prospectively monitor adherence to five National Quality Forum endorsed quality of care metrics for breast (BC) and colon (CC) cancer. This study assesses differences in performance rates by patient populations and demonstrates the impact a prospective clinical performance tracking system can have in impacting care. Methods: RQRS tracks and measures compliance with the following measures: Radiation therapy within one year of diagnosis (dx) for women <70 receiving breast conserving surgery for BC (BCS/RT); hormone therapy within one year of dx for AJCC T1c, N0M0, or stage II or II; hormone receptor positive BC (HT); multi-agent chemotherapy within four months of dx; age < 70; hormone receptor negative BC (MAC); adjuvant chemotherapy within four months of dx; age <80; AJCC stage III CC (ACT); pathologic examination of ≥12 regional lymph nodes for surgically resected CC (12RLN). 64,129 RQRS measure eligible cases diagnosed from 2006 to 2010 from 64 RQRS beta test centers were assessed. Performances rates, before and after implementing the RQRS beta test, were compared by patient demographics. Results: Between 2006 to 2010, compliance rates increased significantly for all five measures, ranging from a 16% increase for MAC to 36% for HT. Prior to RQRS participation, BCS/RT, HT and ACT compliance was significantly lower in patients of other races cf. to white and black; for MAC, other races were lower cf. to white. By 2010 a difference by race remained only in BCS/RT. Payer status and age also impact care. Private insurance cases were more likely to receive compliant care for BCS/RT, MAC and 12RLN; with Medicare for HT (p<.05). Age impacted HT (<40 less likely) and ACT (70-79 less likely cf. to 40-49) (p<.05). Conclusions: Increased performance rates show a system which promotes the ability to track patients in real clinical time can improve quality of care. By using RQRS to prospectively monitor expected adjuvant care, programs can proactively intervene and address potential issues that could impede delivery of timely standard of care.
The use of technology to improve the delivery process of ambulatory chemotherapy at the Odette Cancer Centre (OCC).
Authors: Trudeau Maureen E. , Sousa Philomena , Beattie Kathy , Fitzgerald Thane , Leung Michael Jung Chu , Cheung Matthew C. , Singh Simron , De Mendonca Ben 
Published: February 2017

290 Background: The OCC manages over 24,000 chemotherapy patient visits/year. Over time the number of patients, complexity of treatment and staffing requirements increase. Barriers to efficient delivery of chemotherapy include: same day (as clinic visit) treatment, missing MD orders, manual appointment scheduling and poor communication between chemo nurses and pharmacists during drug preparation. These issues were addressed by (1) non-same day chemotherapy, (2) MD orders expected day prior to treatment, (3) development of two web-based tools for chemotherapy scheduling and communication. Methods: Two independent process reviews were undertaken confirming system inefficiencies. The move to non-same day chemotherapy was implemented. An electronic Chemotherapy Appointment Reservation Manager (CHARM) was developed and linked to the computerized physician order entry (CPOE) system, and reminders were sent to MDs with outstanding orders 72, 48, and 24 hours pre-chemotherapy. The tool was developed to facilitate staff communication during chemotherapy preparation. Data relating to each process improvement was collected pre- and post-implementation. Results: Over 300 of the more than 400 chemotherapy regimens were reviewed for nurse assessment, medication preparation, and in-chair infusion times, with the results used to build the algorithms for CHARM. With the move to non-same day chemotherapy over 80% of patients are treated on a non-clinic day compared with 40% pre-implementation. With CHARM the average number of patients booked/day went from 68 to 100, a 47% increase. Currently, 90% of physician orders are entered by 2pm the day before treatment. Use of the communication tool resulted in an 89% reduction in phone calls between the nurses and pharmacy. 36% of patients started treatment +/- 30 min of scheduled time in both time peroids. Conclusions: OCC introduced several innovative approaches to improving the safe delivery of chemotherapy to cancer patients. Patient volumes have increased while communication around care delivery has improved. The approach allows ongoing research and development to improve workflow and communication.
Development of an electronic point-of-care quality monitoring system for palliative care.
Authors: Kamal Arif , Bull Janet , Abernethy Amy Pickar 
Published: February 2017

291 Background: Most current quality monitoring programs involve retrospective, manual data collection. These are inherently limited by accuracy issues and do not integrate well with national efforts to integrate electronic data documentation in all parts of medical practice. We aimed to build and test a prospective system for continuous quality monitoring in palliative care. Methods: Within a four-organization, academic/community quality consortium, we first conducted a focus group to inventory characteristics of an effective system. Then, with an interdisciplinary team of providers informatics, data security, and software programmers, we created an electronic solution for quality data collection and reporting. A usability study with think-aloud protocols followed using twenty providers and two mock cases across paper, laptop, and tablet computer platforms. Finally, a feasibility test assessing satisfaction, burden, and logistical issues was conducted. Results: Identified priorities for a proposed system were: 1. Use of information technology (IT); 2. Point-of-care use; and 3. Immediate, provider-level reporting on quality conformance. A previous systematic review of quality measures informed the development of a 92 item dataset comprised of variables drawn from validated clinical instruments and aligned with the National Consensus Project quality domains. To foster electronic, point-of-care data capture, the Quality Data Collection Tool (QDACT) user interface was then developed. Use at point-of-care in community-based palliative care settings can inform 82% (125) of identified relevant quality measures; a color-code reminder system provides immediate conformance feedback. The usability study demonstrated high satisfaction with electronic platforms, less than 15 minutes for completion, and a low error rate. Feasibility testing across 572 patient encounters demonstrated high acceptability and further improvements to the user interface. Feedback from an additional cycle of feasibility testing will inform further changes. Conclusions: Electronic systems that can integrate point-of-care quality monitoring and clinical assessments are buildable and usable in palliative care.
Clinical decision support tools to improve quality and practice efficiency across a large network of oncology practices.
Authors: Patt Debra A. , Nubie Madeline , Kazzaz Denise R. , Arlen Aimee , Sitarik Mark A. , Ahmad Asif , Busby Leslie T. , Beveridge Roy 
Published: February 2017

294 Background: Electronic health records (EHR) provide opportunities for quality enhancements at various points in care. It can support electronic orders, meaningful use, progress notes, medication and allergy data, electronic prescribing, and vital-signs tracking. Clinical decision support tools (CDST) can facilitate high-quality performance and practice efficiency. These enhancements reduce error, improve quality, and drive practice efficiency. The oncology specific EHR (IKnowMed) incorporates CDST including physician driven level 1 pathways prescribing, chemotherapy regimen order entry, dose calculation, supportive care drugs, and guidelines for safe prescribing. Methods: To understand scope and utilization of CDSTs within a large network of individual oncology practices we characterized (qualitatively and quantitatively) common modalities in our EHR (iKnowMed). Treatment regimens were populated by the network collaborative-care committee. Physicians selected regimens pre-populated w/doses and pre-medications. Antiemetic regimens were pre-populated for emetagenic potential of the chemotherapy regimen. Results: Across the US Oncology Network, 952 physicians used the EHR to deliver services over a 5-month period. During that time, 69,448 cancer treatment regimens were ordered, pre-populated by drug, dose and pre-medications; and 68,268 chemotherapy regimens were pre-populated with antiemetic therapy to mirror emetagenic potential. Conclusions: By enhancing the EHR to include CDSTs, treatment and appropriate antiemetic regimens can be pre-populated across a large network of individual oncology practices that have aligned together using common IT and CDST to drive quality care for their patients. The network is using technology to enhance quality and efficiency in practice.
An automated system for insuring monitoring of myelosuppression in patients receiving self-administered oral chemotherapy.
Authors: Morrell Robert , Tooze Janet , Harmon Michele , Carter Annette , Detroye Alisha , Lesser Glenn Jay 
Published: February 2017

296 Background: Protracted outpatient oral chemotherapy regimens have created new challenges for monitoring patients for toxicity. Unlike IV chemotherapy which guarantees clinician access to the patient before proceeding with therapy, oral agents can continue to be taken despite missed follow-up visits and lab draws. After observing patients return from unrecognized lapses in monitoring with severe myelosuppression, we sought to retrospectively measure risks and to prospectively test a software-based monitoring system designed to flag and notify team members of missed lab monitoring. Methods: We evaluated 117 patients who had received a standard 42-day continuous course of oral temozolomide as therapy for newly diagnosed primary malignant brain tumors to assess monitoring compliance, as well as adverse events. Standard practice is to obtain a weekly CBC with differential and platelets during the 6 weeks of concurrent chemoradiation. Grade 3 or higher hematologic events were observed in 9 (7.7%) patients. Gaps in monitoring were defined as no testing for 10 days or more, and were classified as minor (10-12 days) and major (13-27 days). Results: 34 (29.1%) patients had one or more gaps during treatment; 19 (16.2%) had majors and 18 (15.4%) had minors. 2 of the patients with gaps in coverage exhibited grade 3 or 4 myelosuppression upon their return to monitoring. We have currently monitored 36 patients prospectively with prototype software designed to email staff whenever a patient was not monitored for 7 days or had scheduled visits too far in the future. The software uses data downloaded from the electronic medical record (12,889 labs, [908 pertinent], 441 visits) and was effective in finding patients that missed labs or did not get properly scheduled visits. Five such mistakes were detected and 4 were corrected based on the system flag. Problems encountered were mainly false positives associated with entry of chemotherapy stop dates. Conclusions: Monitoring failures pose risks to patients receiving oral chemotherapy and traditional medical information systems make detection of missing data difficult. Systems such as ours are simple to build and could be integrated with most EMR systems.
The power of knowledge: Sharing patient test results electronically to improve quality of care.
Authors: Kaan Melissa , LeMar Jason , Gilbert Julie , Rae Erin , Sampson Anna , Meertens Elaine , Melamed Saul , Sarsfield Lisa , Kimball Jon , Hassam Shazmin , Matheson Garth 
Published: February 2017

305 Background: For many patients going through the cancer diagnosis journey, the time from suspicion to diagnosis or rule-out can be a confusing and anxious time. To better support patients during this time, Cancer Care Ontario (CCO) is supporting Diagnostic Assessment Programs (DAPs) and the web-based tool known as the Diagnostic Assessment Program–Electronic Pathway Solution (DAP-EPS). DAPs consist of multi-disciplinary healthcare teams who provide diagnostic and supportive care services in a patient-focused environment, improving access to care and the patient experience. DAPs help manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis and part of this support involves providing access to personal health information through the DAP-EPS. This work was undertaken to determine the best approach to sharing test results with patients, including the type of test results that should be released and the most effective method for sharing these results with patients, from both the patient and provider perspective. Methods: The exploratory project involved conducting key informant interviews with individuals who had been involved with implementing similar patient portals, a targeted literature review, and a series of engagement sessions with physicians to measure the clinical response to this new strategy. Results: Initial discussions with patients and nurses yielded a strong endorsement for releasing all results, with no time delay. Key Informant interviews yielded similar results from the majority of the hospital contacts consulted. The environmental scan did not suggest that releasing results was associated with any adverse patient or provider effects. The physician engagement sessions generated both positive and negative feedback but overall, doctors were comfortable releasing all results, provided there was a delay built into the system. Conclusions: The release of diagnostic test results is seen as a valuable component of quality of care from the perspective of informing and empowering the patient. As the DAP-EPS moves forward with this initiative, the DAP program will continue to monitor the impact that the release of results has on both patients and providers.
SAGE directory of cancer guidelines.
Authors: Brouwers Melissa C. , Rawski Ellen , Bahirathan Lavannya , Spithoff Karen , Zwaal Caroline 
Published: February 2017

306 Background: The Standards and Guidelines Evidence (SAGE) directory of cancer guidelines is a resource designed to facilitate evidence-based clinical practice, policy formation, and guideline adaptation, and reduce duplication in guideline development. Methods: Developed in 2008, SAGE is a publically available (www.cancerview.ca/sage), searchable database of English language cancer control guidelines and standards released since 2003. Qualifying guidelines in SAGE are rated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. These ratings can be used to measure trends in guideline quality. SAGE also documents guideline development status, including current guidelines, guidelines in progress, those in need of an update and guidelines undergoing updates. Results: SAGE contains over 1,900 indexed records from 271 developer organizations spanning 27 countries and international jurisdictions. There is considerable variability in guideline quality both within and across guideline developers, and AGREE II quality domains of applicability and editorial independence are the poorest performing. SAGE has the ability to provide information on guideline topic gaps and overlap, demonstrating that the majority of guidelines target breast, lung, colorectal and prostate cancers, and focus on the treatment stage of the cancer control continuum. This provides a channel of communication amongst organizational groups and facilitates guideline development partnerships. Conclusions: The value-add of SAGE to mitigate inconsistencies in guideline quality is the appraisal component of its records. It is the ultimate goal that SAGE will continue to assist efforts to leverage positive change in the field of practice guidelines, patient care and system performance in cancer control.
Building platforms for collaborative care and clinical research in testicular cancer (TC): New approaches for care delivery for a model neoplasm.
Authors: Nichols Craig R. , Kollmannsberger Christian K. , Demchak Victoria , Cigan Ellen 
Published: February 2017

308 Background: TC is a “model of a curable neoplasm.” In expert centers, more than 95% of patients are cured and enjoy long, high quality survivorship. Unfortunately, emerging data demonstrate variations in quality outcomes seen in high volume centers. Result are not fully replicated in U.S. community settings, low resources countries or in settings of uneven access. We hypothesize that real time, electronic information exchange in TC can influence favorably clinical decision making, patient-centered outcomes, value and quality of survivorship across business and geographic boundaries. Further, we speculate that aggregated, de-identified clinical/ biological information will serve as a template for a rapid learning system to refine clinical management and advance biological understanding. Methods: Our primary objectives were to (1) Build organizational/administrative capacity. (2) Engage patients/local providers. (3) Develop the information infrastructure to accomplish real time exchange of live patient-permitted clinical data (patient reported inputs, laboratory, imaging) and timely transmission of clinical decision support and ongoing oversight of care delivery in the community. (4) Establish a proof-of-principle demonstration in a community-based, electronically organized care delivery system. Results: Organizational: TC Commons, a nonprofit organization, was founded to house this effort. Leading academic institutions form the knowledge base, initial data sharing network and administrative structure for this electronic cooperative group. Early implementation has utilized cloud-based resources and telepresence. Community Engagement: We are utilizing organized social media efforts and partnering with patient advocacy groups. IT Infrastructure: We are creating public/private collaboratives to house the electronic capacity with appropriate privacy concerns. Proof of Principle: We are selecting community partner organizations and planning grant submissions. Conclusions: Expert platforms to enhance care delivery, patient value and experience, and clinical research can be built using a “bootstapping,” cost-sensitive approach.