bluuebunny/crossref_metadata_2025_split huggingface dataset:
Avoiding late-stage colorectal cancer: The outpatient safety net.
Authors: Schottinger Joanne E. , Kanter Michael H. , Smith Andrea 
Published: February 2017

177 Background: The Institute of Medicine report "To Err is Human" highlighted two vulnerabilities that introduce possible diagnostic errors — information overload and failure to follow up abnormal cases. The Southern California Permanente Regional Safety Net program was instituted to identify, using electonic medical records, instances where these inadvertent outpatient safety lapses may have occurred and intervene before patient harm develops. A centralized regional team catches the omission and intervenes to ensure necessary follow up care, early diagnosis, treatment monitoring, or preventing harmful interactions from medications. Methods: For colorectal cancer detection and prevention, a safety net system was already in place to ensure the prompt evaluation of a positive fecal occult blood screening test with colonoscopy. However, evaluation of late stages of colorectal cancer at presentation revealed that failure to diagnose/follow up signs of iron deficiency anemia or rectal bleeding (often attributed to hemorrhoids) were opportunities to intervene. The electronic medical record is mined for evidence of iron deficiency anemia in laboratory results or a diagnosis of rectal bleeding that was not followed by a colonoscopy in patients aged 50-75. A list of these patients is reviewed quarterly by a gastroenterologist, who contacts the primary care physician to arrange colonoscopy. Results: During the first six months of the program, 42 patients, aged 52-75, underwent colonoscopy for evaluation of either evidence of iron deficiency anemia or rectal bleeding. Polypectomies were performed in 17 patients (40%) with pathology revealing adenomas in 13 patients and one patient with a bleeding carcinoid tumor. Other findings included hyperplastic polyps, hemorrhoids, diverticular disease, colitis, ulcer, and angiodysplastic lesions. Conclusions: Using an electronic medical record system, an outpatient safety net function allows proactive identification of possible safety issues in the population, helping to avoid late stage diagnoses and adverse outcomes. This system currently encompasses other cancer screening tests, medication monitoring, avoiding harmful medication interactions, and immunizations.
Driving improvement in oncofertility.
Authors: Darland Shelby , Eichmeyer Jennifer N. , Christiaens Kelli , Penchansky Kallie , Betts Michele , Zuckerman Dan Sayam , Beck Thomas M. 
Published: February 2017

183 Background: In 2006 the American Society of Clinical Oncology (ASCO) recommended that oncologists discuss infertility as a result of cancer treatment with patients of reproductive age and provide referrals to specialists as needed. Despite these guidelines the majority of cancer centers are not in compliance. Mountain States Tumor Institute (MSTI) piloted a process to improve quality of oncofertility preservation (OP) through identification, documentation, and referral to reproductive specialists. Methods: A physician survey in 2010 indicated that perceived barriers to OP discussion were a lack of accessible materials as well as oversight on the part of the provider. Random chart audits of the Quality Oncology Practice Initiative (QOPI) measures (infertility risks discussed prior to treatment and fertility preservation options discussed/referral to a specialist) occurred biannually at that time. To increase awareness of the data chart audits and reporting shifted to quarterly and included all patients that met OP criteria. Additionally, a committee was formed in 2011 to develop patient/provider packets, collaborate with the local reproductive specialists, and create an OP process. The committee established an OP algorithm involving support staff to flag patients of reproductive age at initial medical oncology consultation and utilizing genetic counselors (GC) and social workers (SW) to expedite and facilitate referrals to reproductive specialists. GC/SW were chosen due to sensitivity with psychosocial issues and to share the additional workload. The OP program was launched in October of 2012. Results: Baseline assessment in 2009 revealed MSTI was compliant 6% and 6%. Six months after program initiation the OP measures improved to 47% and 45% respectively. Notably March and April 2013 showed dramatic improvements with 100% and 75% compliance for both OP measures. Conclusions: It is well known that OP has been a challenge for many cancer centers. This multipronged approach is an example of a novel process implementation that demonstrated significant improvement with the QOPI oncofertility measures. Continued work is needed on improving physician documentation and consistency of OP patient identification.
Managing chemotherapy drug shortages in Ontario.
Authors: Kaizer Leonard , Hertz Sherrie , Yeung Lyndee , Milgram Lisa , Gavura Scott , Iyer Ram , Krzyzanowska Monika K. 
Published: February 2017

192 Background: Chemotherapy drug shortages are common and unpredictable. The causes are multifactorial and the negative effects on patients and practitioners have been well described. In an effort to mitigate the impact of this problem, Cancer Care Ontario (CCO) has developed a coordinated approach to the management of chemotherapy drug shortages. Tactics have included a system level strategy to promote communication through a virtual collaborative workspace for providers to network and share management strategies and inventory, where feasible. Disease site experts have also developed clinical guidance for the management of specific drug shortages which have then supported public funding decisions that enabled the use of substitute chemotherapy agents in a number of instances. Methods: The impact and management of a recent shortage of liposomal doxorubicin (LD), a publically funded drug for patients with platinum refractory ovarian cancer is described for both new chemotherapy starts and for prevalent LD treated cases. Expert clinical guidance supported a funding policy amendment so patients already on treatment could switch to a recognized substitute drug, topotecan (TT). This also became the preferred funded option for new platinum refractory patients. Results: LD was in short supply between August 2011 and December 2012. In the quarter prior to shortage, 83 new platinum refractory patients started on LD and 1 on TT. During that time, the average number of monthly prevalent LD and TT treated cases was 80 and 4 respectively. For the first quarter post shortage, 20 new patients started on LD and 34 patients started on TT. The average monthly prevalent treated cases were 49 and 21 respectively. Funding for the switch from LD to TT was requested in only 7 cases. Therefore, the total number of new and prevalent treated cases on either preferred therapy dropped post LD shortage. This decline worsened with each subsequent quarter and immediately returned to baseline when the shortage resolved. Drug procurement costs were lower during the period of shortage. Conclusions: Drug shortages have a significant impact on patients and providers. Even when appropriate substitutes are available, quality of care may be affected.
Pap Hub: A system to improve compliance with pap smear screening guidelines in a large health care system.
Authors: Teoh Deanna Gek Koon , Fall Lisa A. , Beitelspacher Erin A. , Lais Charles W. 
Published: February 2017

193 Background: Cervical cancer is the most prevalent gynecologic cancer worldwide, but is third in the U.S. due to pap smear screening. However, American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines are complex and frequently changed, resulting in guideline adherence as low as 33-44%. We describe a centralized pap smear tracking system (“pap hub”) and report preliminary results. Methods: On 1/1/13 we implemented the pap hub, routing all screening pap smear results to a dedicated OB/Gyn nursing staff with a new Epic workbench. Epic Health Maintenance Modifier updated to recommend pap smears for women age 21-65 years (not younger or older per guidelines). Screening Pap/HPV results auto routed to Pap Pool Epic inbasket (not to individual providers). Centralized nurse reviews results alongside past pap results on Pathology flowsheet in Epic If normal Normal history -> appropriate follow-up interval per screening guidelines If abnormal history -> repeat pap as determined by previous history and treatment If abnormal -> manage per ASCCP guidelines Document plan in Epic Result Note Update Epic problems list If Normal: document “Pap Hub Normal History” If Abnormal: document “Pap Hub Abnormal History” with specifics in Overview History Communicate results/plan to the patient. Update Health Maintenance Modifier with next step. Review abnormal results to ensure proper follow-up, with reminders as indicated. Results: Guideline recommendations against pap smears for patients <21 years and >65 years have not changed since 2009. Comparison of first-quarter data for 2010 (pre-Pap Hub) to 2013 (post-Pap Hub) have shown a 63.86% reduction in pap smears in women <21 years. Pap smears in women >65 years has always been low, but has decreased slightly from 2.4% of all pap smears in 2010 to 1.5% of all pap smears in 2013. The 2012 ASCCP guidelines have changed recommended pap smear frequency and abnormal pap smear follow-up, and compliance with these new recommendations is being collected. Conclusions: Pap smear screening has decreased the incidence of invasive cervical cancer in the United States. The Pap Hub, a centralized pap smear tracking system, improves compliance with pap smear screening guidelines.
New tools for enhancing the quality of phase I clinical trials: The Armada and Labtracker computer systems.
Authors: Karp Daniel D. , Falchook Gerald Steven , Subramanian Harihara , Lockett Passion , Harleaux Dina , Fullmer Cheryl , El Osta Badi Edmond 
Published: February 2017

235 Background: The MD Anderson Clinical and Translational Research Center (CTRC) focuses on Phase I and early Phase II clinical trials and is managing approximately 156 studies annually. This 18-room combined treatment and laboratory unit manages an average of 12,500 research pharmacologic time points and over 3,000 individual shipments yearly. In FY12, 74% of shipments were done on the day of collection (DOC), whereas 26% of the shipments were shipped periodically as required by the corresponding protocol. All studies are monitored at each step for errors - minor (simple DOC label corrections) or major (improper or missed specimen). Activity is analyzed and reported monthly. Methods: In 2010, to ensure accuracy of timing, collection method, proper storage, specimen condition, and destination accuracy, we developed a robust proprietary Oracle-based laboratory tracking system (LabTracker). In addition, we designed an Advanced Research Management and Data Analysis interface (ARMADA) which provides daily step by step protocol guidance using an innovative color-icon touch-screen display of all required protocol activities for patients in the CTRC. LabTracker contains all auditable items required in the clinical trial and markedly reduces work duplication and handwritten data transcription. We hypothesized that this input system would help decrease errors and improve research quality. Results: In FY10 there were 2,506 DOC shipments with an overall error rate of 3.07%. In FY12 errors decreased to 1.31% out of 3,128 DOC shipments. In FY10, there were 14,507 timepoints with 28 major errors (0.19%). In 2012, with 13,490 timepoints, major errors decreased to 19 (0.076%). LabTracker database also supports billing and has catalogued over 275,000 samples. This system provides real-time accounting and has revolutionized the quality control system of the CTRC as well as the research finance component with 98% charge capture efficiency within 30 days. Conclusions: The LabTracker/ARMADA systems are high volume phase I protocol management tools which have improved quality, decreased redundant work, and support a real time financial management system for complex phase I clinical trials.
SupportScreen: A prospective automated approach to real-time symptom and problem identification, triage, and tailored education.
Authors: Kassab Tricia , Loscalzo Matthew , Clark Karen L. , Alvarnas Joseph C. , Avanessian Priscilla , Levine Alexandra M. 
Published: February 2017

240 Background: The links among supportive care services quality of life, patient satisfaction, cost, quality and safety are well established. The Institute of Medicine 2008 report recommended that distress screening be instituted as the standard of cancer care. More recently, ASCO and ACOS created new standards for the universal distress screening. Parallel to this process have been advances in automated technologies that are efficient and easily tailored to the patient population. Methods: SupportScreen is a patient-friendly automated process that identifies, triages and provides educational information all in real time. SupportScreen also facilitates patient, physician and multi-specialist communication and is used to maximize the effectiveness of clinical encounters and overall cancer care. Results: Based on over 15 years of biopsychosocial screening experience, SupportScreen was implemented at the City of Hope as a standard of care in medical oncology, HEM/HCT and surgery outpatient clinics. SupportScreen is also being administered to caregivers and to collect patient satisfaction and research data. In a sample of 4,819 outpatients the top problems rated as high distress are: problems with finances (40%), sleep (38.3%), worry about the future (37.1%), fatigue (36.7%) and side effects of treatments (34.5%). In addition, patients requested assistance (meet with a member of team or educational materials) in many areas related to their quality and coordination of medical care: finances (33.6%), health insurance (27.5%), finding community resources (26.6%), talking with the health care team (26.3%), needing help coordinating my medical care (24%) and transportation (20.7%). Conclusions: Patients and their caregivers have a significant number of unmet needs that may directly impact the quality, safety, and cost of their care. Prospectively managing these barriers may enhance the quality and efficiency of care, especially in those patients who manifest high risk, cost and suffering characteristics.
Building a specialty accountable care organization (ACO) for cancer: Using cost groupers in breast cancer (BC) and malignant hematology (MH).
Authors: Culumber Janene , Kiss Brian , Fernandez Hugo Francisco , Wartenberg Karen , DeMaria Lisa , Shimkhada Riti , Peabody John W. 
Published: February 2017

253 Background: New payment models, such as accountable care organizations (ACOs), bundled payments and global budgets will shift some financial risk from payers to providers. The first step in creating a cancer ACO will be to partner with payers to understand aggregate costs over time. Methods: Moffitt Cancer Center (MCC) is partnering with Florida Blue in (BCBS of FL) in developing a specialty ACO strategy for cancer. As an initial step, we created an analytical framework to group and estimate the total costs of cancer care for newly diagnosed breast cancer (BC) and malignant hematology (MH) patients. We used HIPPA-compliant Florida Blue claims billings from 2010-2012 to capture all episodes of care within each calendar year. BC and MH patients were attributed to MCC if they had at least 3 annual visits. Claims from attributed patients were grouped into 7 categories. We calculated the annual costs and the costs by category to generate a Per Member Per Year (PMPY) cost and determine the stability and/or trends in these costs. Results: The PMPY data for the three years (2010, 2011, 2012) were stable over time. Important trends, however, were noted: outpatient (OP) costs, which include infusion chemotherapy, rose similarly (16 and 13%, respectively), inpatient (IP) costs for BC increased 10%, compared to an 8% decrease in IP cost for MH over the 3 years. Physician costs remained stable, consistent with other reports. Conclusions: Moving away from volume-based reimbursement requires building partnerships between payers and providers. We created disease-based cost groupers for two cancer conditions as a first step. Cost trends were stable over time. These findings will give payers and partners confidence to explore ways to improve quality and reducing cost as they consider new arrangements such as a specialty ACO. [Table: see text]
A provider-payor approach for determining value in the health reform era: Early reports on the mQure initiative.
Authors: Letson Douglas D. , Fields Karen K. , Hammon Diane K. , Lee Rachel V. , Peabody John W. , List Alan F. 
Published: February 2017

255 Background: Determining value requires detailed measurement of clinical services and associated costs. In the health reform era value demonstration presents a challenge for both providers and payors: providers, unable to demonstrate value, will be unable to attract payors or patients and expand market share; payors, unable to choose the right providers, will lose opportunities to lower costs and raise quality. Methods: In July 2012, the Moffitt Cancer Center (MCC) launched the mQure (MCC – Quality Understanding Research and Evidence) Initiative to (1) measure and improve clinical performance, (2) increase compliance to evidence-based/cost conscious cancer-care pathways, and (3) demonstrate value. We introduced Clinical Performance and Value (CPV) vignettes, a value measurement tool, to measure pathway adherence, determine diagnostic accuracy and appropriate use of diagnostic tools starting with breast and lung cancer. For selected performance items identified by the CPVs, we audited medical records directly. Results: Measurement revealed high value practices, for example, diagnostic accuracy, appropriate rates of biopsy and more accurate staging compared to other groups. Value determination led to one signed plus two pending payor partnerships to implement a shared savings contract, find ways to reduce utilization and explore creating payor-led networks. The focus on individual responsibility for adherence to evidence-based practices has had an unanticipated and seemingly paradoxical benefit of shifting the group to narrow practice variation thereby shifting providers to a more self-aware culture. An external benefit is that the value signal has led to discussions to form accountable care organization (ACO) networks for cancer care. Since mQure’s inception, MCC has created partnerships with 3 hospitals. Based on the breast cancer initiative alone, financial models indicate an estimated savings of up to $2 million annually that arise from higher quality, fewer unnecessary tests and improved pathway compliance. Conclusions: In just one year, the large scale mQure project has led to expanded provider partnerships, new quality-based arrangements with payors and the formation a specialty-ACO.
Impact of Medicare Part D on out-of-pocket drug costs and utilization for patients with cancer.
Authors: Kircher Sheetal Mehta , Johansen Michael , Davis Matthew M. 
Published: February 2017

275 Background: Medicare Part D was designed to reduce out of pocket (OOP) costs for Medicare beneficiaries, but the extent to which this occurred for patients with cancer has not been measured. The aim of this study is to quantify the impact of Part D eligibility on OOP cost for prescription drugs and utilization for cancer patients. Methods: Differences-in-differences analyses were used to estimate the effects of Medicare Part D eligibility on OOP drug costs, by comparing 4 year periods before and after Part D implementation. Analyses were based on data from the publicly available Medical Expenditure Panel Survey, a nationally representative, all-payer sample of the United States non-institutionalized civilian population. Our analysis compared per-capita OOP burden between Medicare beneficiaries (age 65+) with cancer to near-elderly individuals age 55-64 years old with cancer. Results: 2,077 near-elderly individuals with cancer and 4,723 individuals with Medicare and cancer were included (total n=6,800), representing over 85 million people. Prescription drug coverage increased among individuals with Medicare from before Part D (39%) to after (65%); in contrast, prescription drug coverage among the near-elderly remained stable before vs. after Part D (82.4% vs. 81.4%). The mean per-capita OOP cost for Medicare beneficiaries with cancer before Part D was $1,111 (SE ±45) and decreased to $694 (±35) after implementation of Medicare Part D—a decline of 37%. Compared with changes in OOP drug costs for non-elderly patients with cancer over the same period, implementation of Medicare Part D was associated with a further reduction of $286 per person. OOP costs for cancer-associated drugs (i.e., antineoplastic, pain medications, anti-emetics) accounted for 6.5-11.1% of the total OOP cost with no significant trends between 2002-2010. Conclusions: The implementation of Medicare D has significantly reduced OOP prescription drug costs for seniors with cancer, beyond trends observed for younger patients. Considering prescription drugs for all medical conditions, cancer associated drugs compose a minority of the cost, highlighting that cancer patients have many comorbid conditions contributing to overall costs.
Development of a capital investment strategy for radiation (RT) equipment in Ontario.
Authors: Gutierrez Eric , Warde Padraig Richard , Belfour-Barnett Dianne , Matheson Garth , Meertens Elaine , Favell Lisa 
Published: February 2017

279 Background: To ensure appropriate access to radiation treatment (RT) for Ontario cancer patients for the next decade and that future capital investments in radiation equipment are appropriately timed and strategically placed, Cancer Care Ontario (CCO) has updated its RT Capital Investment Strategy. The strategy was designed around 4 core principles: i) recognizing treatment machine capacity should match the demand resulting from increasing cancer incidence rates and increasing utilization rates as per CCO goals; ii) keeping pace with advancing technology; iii) ensuring value for money by maximising the use of current infrastructure; and iv) minimizing costs through centralized planning and procurement processes. Methods: A multidisciplinary provincial expert panel reviewed and revised the planning parameters used to project treatment demand and required capacity (including fractions of RT per treated case, number of cases treated per hour, uptime of treatment units). The panel reviewed current practice, impact of new and emerging treatment technologies and benchmarks from other jurisdictions. To project the future demand for radiation therapy, growth in cancer incidence (by county) as well as modest improvement in RT utilization rates were assumed. Results: Recommendations included: i) moving to 12-hour treatment days in all large centres and on 50% of equipment in centres operating fewer than 6 treatment units; ii) ensuring appropriate funding for the replacement of existing RT equipment; iii) equipping constructed rooms in 4 regional cancer centers – thereby adding 6 linacs; iv) equipping swing bunkers across the province – thereby adding 10 linacs; and v) planning for the construction of new facilities to add RT capacity in 3 regions of the province. Conclusions: Funding to implement recommendations from previous capital investment strategies has resulted in an equitable distribution of RT resources across the province. We believe the planning strategies and recommendations outlined in the strategy will improve access to quality RT care as close to home as feasible for Ontario patients.