bluuebunny/crossref_metadata_2025_split huggingface dataset:
The implementation of a streamlined process for biomarker testing in medical oncology.
Authors: Dharmakulaseelan Laavanya , Jorden Tanya , Franco Bryan B. , Stewart Janice , Sanders Gail , Boulianne Patrice , Laws Karen , Cheung Matthew C. , Singh Simron , Ismiil Nadia , Trudeau Maureen E. 
Published: April 2017

179 Background: Biomarker testing is increasingly becoming an essential part of standard care. At Sunnybrook Health Sciences Centre (SHSC) in Toronto, Canada, our Department of Molecular Services handles some internal biomarker tests, while some tests are referred to citywide labs. The Odette Cancer Centre (OCC) of SHSC is one of the largest cancer centres in Canada, serving over 12,000 new patients per year, of whom many rely on biomarker tests for personalized treatment. We aimed to describe the work systems at the OCC for biomarker testing and reporting, and to initiate system improvements. Methods: This quality improvement initiative occurred in three phases: qualitative descriptive analysis of the current process of biomarker testing, exploration of future state process using LEAN, and implementation of a streamlined process. In phase one, ten medical oncologists, two administrative assistants, and one pathologist were interviewed. A multidisciplinary team was then assembled to investigate and initiate improvements. Results: Tracking results from external labs was managed by individual physicians and hard copy results were submitted to medical records for filing in patient paper charts, compared to internal tests which are posted on the electronic record, making outside tests harder to retrieve later. The current process involved more than 150 different tests with only 44% of results appearing in the hospital electronic record. In June 2016, a standardized process was implemented where a designated laboratory assistant managed requisition forms, sent corresponding specimens to qualified labs, ensured the receipt of results through various electronic tracking tools and validated the subsequent upload to the electronic medical system. Over a four-month implementation period, there were 364 cases/patients with 467 tests requested; 100% of these test results are stored in the electronic record. Conclusions: The lack of standardization of biomarker testing and reporting can have negative implications on quality of care and patient safety. Therefore, streamlining this process and incorporating electronic tracking tools can improve the accessibility of test results to improve the quality of oncology care.
Comparing patients with breast and prostate cancer in terms of their mental health comorbidities as predictors of cost and utilization.
Authors: Burke Harry , Russo C. Allison , Hopkins Laura , Jeffery Diana D 
Published: April 2017

18 Background: We compared the role played by mental health comorbidities in the health care cost and utilization of non-elderly patients with breast and prostate cancer. Methods: The Military Health System affords its beneficiaries equal access to medical care. We performed a cross-sectional analysis using administrative data of all 9.5 million beneficiaries, ages 18-64, with direct care and a primary diagnosis of either invasive breast or prostate cancer during FY2007–FY2014. We used regression models to identify predictors of cost and utilization, including sociodemographic variables, system of care, treatment modalities, chronic disease comorbidities, and mental health comorbidities. Results: On average,annuallythere were 23,800 and 13,300 patients with breast or prostate cancer, respectively. More comorbid depression (16.8%) or anxiety (14.2%) occurred among breast cancer patients than prostate cancer patients (6.9%, 6.7%). Annual cost per patient (inc. pharmacy) was significantly higher for breast cancer ($16,287 vs. $11,069, p < 0.001). The strongest predictors of annual breast cancer costs were (in order from highest predictive value) chemotherapy, surgery, and mood or adjustment disorder (p < 0.0001); the strongest predictors for prostate costs were chemotherapy, radiation therapy, surgery, and mood or adjustment disorder (p < 0.0001). Mood and adjustment disorders were strong predictors of the annual number of ambulatory visits, hospital admissions, and bed days for both breast and prostate cancer (p < 0.0001). Conclusions: Mental health comorbidities play a significant role in health care costs and utilization of non-elderly adults who are breast and prostate cancer patients. An unexpected finding was that, although different in frequency, mental health comorbidities were important predictors of cost and utilization for both patients with breast and prostate cancer. For both breast and prostate cancer, routine screening and treatment for mental health disorders should be part of quality cancer care.
Cancer services phone triage center: Using live operators and state-of-the-art communication technology to improve the patient care experience.
Authors: Carpentier Michelle , Rose Candida , Begnoche Megan 
Published: April 2017

185 Background: The term “telephone triage” best represents a large proportion of customer interactions carried out by telephone versus other contact channels. It’s often referred to as the “front door” to a business and is the place where the most crucial customer interactions take place. Therefore, the effective and efficient operation of managing these interactions is a key ingredient to the overall success of any organization. Over the last several years, customer feedback and monitoring of trends on the Press Ganey Patient Satisfaction surveys showed opportunity for improvement in the overall patient care experience at our centers. This led to the development of a strategic goal to create a decentralized phone triage center that would manage these interactions as a group across the service line. Methods: A subgroup of key stakeholders came together for a Failure Mode Effects Analysis of the current state. Results were used in the creation of standard work and process flow algorithms for training the new staff. Staff training included: customer service education; shadow experiences across sites; one to one mentoring on new software and technology Results: The Phone Triage room opened this fall and is staffed daily to manage roughly 400 calls. We track quality metrics that fall into three categories: service, quality and efficiency measures. Service measures include the total number of incoming call; number of abandoned calls; length of time the caller is on hold; and statistics on the telephone and answered service factor. Quality measures include: knowledge/competency of service agents; adherence to protocol; first call resolution rate and transfer rate. Lastly, efficiency measures include average handle time; on hold time; schedule efficiency; and agent availability. In October, the center managed 4657 calls over a 14-day period, 98% were answered in under 2.5 minutes with a 2% abandon call rate. Conclusions: Early data shows pooling of service line resources and utilization of technology has increased customer satisfaction. We plan to monitor trends on several key Press Ganey performance indicators with the next quarter results available in January 2017.
Quantifying episode-based costs of care under the oncology care model: Analysis of Medicare beneficiaries in the UAB cancer community network.
Authors: Williams Courtney , Azuero Andres , Pisu Maria , Halilova Karina I. , Huh Warner King , Partridge Edward E. , Rocque Gabrielle Betty 
Published: April 2017

19 Background: The Oncology Care Model (OCM) is a specialty care model developed by the Centers for Medicare & Medicaid (CMS) Innovation Center aimed at providing higher quality, more highly coordinated cancer care and reducing costs for patients undergoing chemotherapy. The OCM calculates costs of care in a novel way by anchoring costs within episodes of care, defined as six-month intervals triggered by initial anti-cancer treatment, as opposed to diagnosis date. The purpose of this study is to assess costs within the OCM episodes of care. Methods: This was a secondary analysis of Medicare administrative claims data for beneficiaries 65 and older with cancer who received anti-cancer drug treatment (chemotherapy, hormone therapy) between 2012-2015 at an institution in the UAB Cancer Community Network (CCN). Total and service-specific costs (Medicare reimbursement to providers) per patient-episode were summed from inpatient, outpatient, chemotherapy, radiation therapy, testing/pathology, evaluation and management (E/M), home health, skilled nursing facility (SNF), and hospice claims. Prescription drug costs were not included. Mean costs for the first three OCM episodes were calculated and compared to (1) diagnosis-based costs (six-month intervals starting at cancer diagnosis) and (2) service type. Results: Average total cost in the first three OCM episodes of care was $24,922 (n=13,902), $18,534 (n=6,618), and $16,548 (n=4,672). Compared to episode-based cost, average total diagnosis-based cost was higher in the first episode of care ($33,244, n=9,615), and lower in the second and third episodes ($17,143, n=9,110; $12,897, n=8,002). Episode-based outpatient, inpatient, and chemotherapy costs were the highest service-specific costs in all three episodes of care (1st: $8,374, $5,493, $2,445; 2nd: $6,188, $3,913, $3,158; 3rd: $5,909, $3,251, $3,399). Conclusions: Costly chemotherapy and inpatient and outpatient visits indicate an opportunity for targeted improvement resulting in higher value care. Knowledge of current costs of care will aid oncology practices in transition to the OCM and in usage of value-based services for better quality cancer care.
Driving quality improvement with public reporting: Use of imaging tests outside guidelines for early-stage breast cancer in Ontario.
Authors: Bedford Colleen , Arnaout Angel , Anas Rebecca , Catley Christina , Clemons Mark , Earle Craig , Langer Deanna , Lee Vicki , Mittmann Nicole , Stiff Jennifer , Eisen Andrea 
Published: April 2017

193 Background: Most patients diagnosed with breast cancer will have early stage (stage I or II) disease, with low chance of distant metastases. Thus most guidelines, including Choosing Wisely, recommend against imaging tests for distant metastases in asymptomatic early stage breast cancer. Despite this, most (86%) of these patients in Ontario received these tests from which they are not likely to benefit and may result in investigations that can be invasive and delay treatment. Publicly reported indicators, such as those in Ontario’s Cancer System Quality Index (CSQI), can bring research findings to action by identifying areas for improvement and facilitating ongoing assessment. In practice, this can be challenging due to limitations in administrative data. Moreover, relatively few quality improvement indicators focus on efficiency, the dimension of quality looking at best use of resources to achieve desired outcomes. We sought to examine trends in the use of imaging tests in early stage breast cancer and to drive quality improvement efforts via public reporting. Methods: Data from the Ontario Cancer Registry, the Discharge Abstract Database and the Ontario Health Insurance database was used to identify how many Ontario breast cancer patients diagnosed with early stage breast cancer received staging tests from 2012–2014. Imaging tests included were ultrasound, CT scan, MRI, x-ray and bone scan. The results were subsequently shared with the Regional Cancer Centres and publically released in the CSQI. Results: From 2012 to 2014, 75.1, 72.7 and 71.3% respectively of early stage breast cancer patients received at least one imaging test for staging. This is much higher than the 5-10% of patients expected to need tests due to symptoms or comorbidities. While the regional variation ranged from 47-80%, the rates were high across the province with no clear pattern. Conclusions: Public reporting may be having some effect on overtesting, but rates remain high. Following outreach by the Cancer Quality Council of Ontario and Cancer Care Ontario, targeted regional interventions are being developed and implemented, the impact of which will be assessed and reported in future releases of the CSQI.
Increase in the patient wait-time and delays in the clinic workflow post-implementation of the electronic health record.
Authors: Narayanan Meyyammai , Zhou Xiao , Janarthanan Shawn J , Daniel Mary , Olmedo Maria , Jernigan Colleen , Patel Shreyaskumar , Vadhan-Raj Saroj 
Published: April 2017

194 Background: Growth in patient (pt) volume and limited clinic capacity can lead to long wait-times and pt/provider dissatisfaction. We have previously shown that the room pooling model, can reduce pt wait-time in the exam room, improve room utilization, and pt/providers satisfaction (ASCO 2016, Abstract 6595). One of the important goals of adopting electronic health records (EHR) is also to increase the clinical efficiencies, productivity and quality of care. The purpose of this study was to evaluate the impact of implementation of EHR on pt wait-time in the exam room and satisfaction in the Sarcoma Center. Methods: The time studies and pt and provider wait-time satisfaction surveys were carried out over 2 weeks prior to (baseline) and 6 months after the implementation of EHR. All times of when pts, mid-level providers, and doctors (MD) entered and exited the exam rooms were collected for a total sample size of 578 pts (300 before, 278 after) seen during the clinic hours and analyzed using JMP and SAS. Results: The proportion of pts seen within 30 minutes (Min) by MDs from the time pts roomed into exam room decreased by about 32% [from 53% (148/280) to 36% (94/259), p = 0.0001] post implementation of EHR. The median time for pts in the exam room waiting for MD increased (p = 0.0001) from 30 min (range: 0-126 min) to 40 min (range: 0-121 min). Although, the pt satisfaction did not significantly change [increase from 8% (23/278) to 12% (31/267) in the number of pts that were not satisfied to little-satisfied, and decrease from 92% (255/278) to 88% (236/267) in pts that were moderately to very-satisfied], the number of times MD had to wait for an open exam room increased from 8% (5/65) to 24% (14/59, p = 0.01). The delays to see MDs were associated with longer time spent with the nurse (from median 4 to 7 min), followed by delays in seeing Mid-level provider (from 11 to 18 min). Conclusions: These findings indicate that in the initial stages of implementation of EHR, the increase in pt wait-time and reduced clinical efficiencies can be related to the learning of and adapting to the new system. Attempts targeted to the areas of delays (such as training and redesigning workflow) may reduce the pt wait-time and improve the clinical efficiency.
Leveraging technology to facilitate distress screening.
Authors: Franco Susan , Jourdan Dawn 
Published: April 2017

195 Background: Research has shown cancer patients are at increased risk for distress during their cancer treatment. Distress screening is required for cancer programs seeking accreditation from the American College of Surgeons, Commission on Cancer and certification from the American Society of Clinical Oncology Quality Oncology Practice Initiative. Developing a successful distress screening program is essential for cancer programs. Methods: The purpose of this project was to create a comprehensive distress screening program utilizing the electronic health record (EHR) to identify patients requiring screening and document interventions. A multidisciplinary team was established to develop a distress screening process for our cancer program. The team developed a screening tool based on the National Comprehensive Cancer Network Distress Thermometer. The distress screening tool was built into the EHR. An alert was created to notify staff at visit check-in to provide the distress screening tool. Once completed, the score and any areas of distress indicated by the patient are entered into the EHR by the medical assistant. When a score is documented, the nurse case manager (CM) receives a “Distress Score” alert when accessing the patient’s chart, indicating the need for nursing review. The CM reviews the score, assesses patient needs and documents any needed interventions or referrals. A specific score does not require a specific intervention, rather the CM is required to determine the needs of the individual patient and take appropriate action. Results: In 2015, 8069 patients were offered distress screening with 13,527 distress screenings completed. This resulted in 629 referrals to social work. 803 distress screens had a score of seven or greater (6%). Conclusions: The multidisciplinary team continues to evaluate the process and make changes. Auditing reveals compliance with documenting a distress score of 95% or greater across all oncology areas and review by the CM of at least 93% on a consistent basis. In many instances, the physician and/or the CM address distress related to the patient’s disease or symptom management. Use of the EHR has facilitated the workflow and allowed information to be visible to the care team.
Impact of universal screening of colorectal cancer (CRC) for detection of Lynch syndrome (LS) at a Hispanic-predominant county hospital.
Authors: Snedden Tyler William , McCracken Andrew , Vaidyanathan Anusha , McGruder Carla , Taranova Anna , Villarreal Roberto , Patel Sukeshi R. 
Published: April 2017

199 Background: Historically, the Amsterdam and Bethesda criteria were used to select patients (pts) for LS screening. In 2014, universal screening (US) for LS was shown to be cost effective. Thus, to increase LS screening, we implemented an algorithm for pathologists to reflex immunohistochemistry (IHC) on newly diagnosed CRC. Here, we evaluate the effectiveness of US program with reflex testing for LS for all new CRC. Methods: Retrospective analysis of new diagnoses of CRC (01/2012 – 04/2016): a county hospital with follow-up at NCI-designated CTRC. 3 patient cohorts: 1) PRE-intervention (01/2012–09/2014): screening ordered per old guidelines; 2) PERI (10/2014–02/2015): clinician education on new guidelines; 3) POST (03/2015–04/2016): after implementation. Endpoints: proportion of pts screened and time to screening, quality of family history (FHX) by clinicians, FHX of LS-related cancer, genetic counseling. Results: 381 patients: mean age (57): 69 pts age < 50; 312 pts age ≥ 50. Female 151/male 230; 238 Hispanic/143 Non-Hispanic. % screened: PRE 31% (n = 83), PERI 64% (n = 16), and POST 58% (n = 49) (table for P values). Age < 50 vs. ≥ 50: PRE 56% vs. 25% (P 0.000013), PERI 80% vs. 60% (P 0.38), POST 81% vs. 53% (P 0.02); Loss of any IHC: PRE 12% (n = 10), PERI 19% (n = 3), POST 4% (n = 2); Pts with +screening who received genetic counseling: PRE 30% (n = 3), PERI 67% (n = 2), POST 100% (n = 2). Time from diagnosis to IHC result of < 8 days: PRE 28%, PERI 6%, POST 39%. Adequate FHX in PRE vs POST: 9% vs 20% (P = 0.016). No FHX in PRE vs POST: 47% vs 33% (P 0.019). Conclusions: Significant improvement in number of screens and more timely screening of newly diagnosed CRC pts screened for LS, especially over age 50, were observed after implementation of US. Providers took higher quality FHX after US implementation. Detection for FHX of LS-related cancers significantly improved with US for pts over age 50. Future prospective studies are warranted to evaluate referrals to genetic counselors and diagnoses of LS as well barriers to US. [Table: see text]
Improving patient wait time by implementing visual management tools in an outpatient oncology infusion unit.
Authors: Lu Kit Yu , Fuerst Candace , Veytsman Irina 
Published: April 2017

200 Background: The number of cancer diagnosis and oncology visits have increased by 30% over the past decade nationwide. Similarly, our institution also experienced more than 30% growth this past year due to increased number of physicians and patients. However, the amount of resources including staffing, infusion chairs, and hour of operation remained the same. This has caused significant delays for patients and decreased patient/staff satisfaction. Methods: Visual Management tools can be used to communicate information by using visual diagrams instead of text. Various instruments were used to visually assess patient flow during their chemotherapy admission in the infusion unit. The workflow process was organized into a Value Stream Map. Root cause analysis was performed for high problematic areas. Results: Average patient wait time were as follows: patient registration to infusion chair (20min; range 5-45min), chair to nurse assessment (15min; range 0-30min), blood draw to “ok for treatment” (60min; range15-90min), “ok to treatment” to drug delivery (20min; range 15-30min). Through visual stream mapping, we identified the complexity of work flow and areas of highest impact for patient wait time (ex. blood draw/laboratory process, drug delivery). We used root-cause analysis to identify deficiencies and limitation in the process. Pick chart was created to assess and stratify useful ideas and current resources. We achieved several low effort/high impact interventions (i.e. designated parking space for drug delivery, supplying tools in nursing stations) and some high effort/high impact interventions (i.e. extending office hours and making changes to our computer order systems). These strategies has improved efficiency and decreased wait time by more than 50%, and also improved patient and staff satisfaction. Conclusions: Incorporation of Visualization Management tools helped engaged our high stake holders in the improvement processes. These tools helped facilitate a deeper understanding of department workflow, identify issues in the process, standardize the process and improve efficiency.
Hepatitis B virus screening in patients receiving intravenous chemotherapy.
Authors: Remo Mylene Hernandez , Chacra Wadih , Cuellar Sandra , Golick Janet , Nguyen Phuc , Armgardt Emily , Venepalli Neeta K. 
Published: April 2017

205 Background: Patients with chronic hepatitis B (HBV) who undergo chemotherapy without antiviral prophylaxis may develop HBV reactivation, hepatitis, liver injury, and even death. The University of Illinois Cancer Center (UICC) lacks a standardized guideline for screening patients for HBV prior to chemotherapy initiation. A retrospective chart review was conducted on chemotherapy orders submitted to UICC pharmacy over 4 weeks for both hematological and solid tumor malignancies. Of 63 new orders for intravenous chemotherapy, only 14 patients (22%) underwent HBV screening prior to chemotherapy initiation. We aimed to increase HBV screening from 22% to 50% over 2 months. Methods: A multidisciplinary taskforce comprised of hematology/oncology and hepatology physicians, clinical pharmacy, and nursing was created. An ideal process map was created identifying a clear management schema for HBV screening including differences in screening tests for various populations and management recommendations for positive test results. Two Plan-Do-Study-Act (PDSA) cycles were tested with post intervention data collected over eight weeks. Results: Of 192 chemotherapy orders submitted to outpatient pharmacy over 8 weeks, 62 patients (32%) were determined to be appropriate for HBV screening prior to initiation of chemotherapy. Of these, 36 patients (58%) were screened appropriately for HBV. Additionally, a subset analysis revealed 100% of patients successfully screened for HBV prior to initiation of anti-CD20 therapies. Conclusions: At UICC, a multidisciplinary team created and successfully piloted the implementation of a HBV screening policy in both hematological and solid tumor malignancies. Our initial aim was reached after 8 weeks of implementation, and ongoing efforts are being conducted to further improve HBV screening rates to 90%.