bluuebunny/crossref_metadata_2025_split huggingface dataset:
Examining the role of treatment complexity in survivorship care planning.
Authors: Mahr Nicole Marie , de Sola-Smith Karen Marie , Bell Janice 
Published: April 2017

242 Background: The cancer survivor population will reach 19M by 2025, increasing demand on primary care providers to manage late and long-term effects of treatment. To improve care quality, the IOM recommends survivorship care plans (SCPs) that include two components: a treatment summary (TS) detailing disease and treatment characteristics; and evidence based follow up care instructions (FCI). SCPs remain underutilized despite evidence they enhance physician communication, increase self-efficacy and improve health outcomes of cancer survivors. Little is known about treatment related and socio-demographic factors associated with receipt of SCPs and their components. The purpose of this study was to examine the relationship between care complexity, operationalized as multiple cancers or treatments, and survivor reported SCP receipt. Methods: This was a secondary analysis of data collected in the 2012 LIVESTRONG Survey for People Affected by Cancer, an online self-selection survey. Descriptive statistics and multivariate regression were used to examine relationships between survivor characteristics and SCP receipt among 3,599 respondents. Results: Half (52%) of survivors received a complete SCP. Care complexity was significantly associated with lower odds of SCP receipt. Each additional treatment modality lowered odds of receipt by 8% (95% CI 0.86-0.99). Survivors with multiple diagnoses had 19% lower odds of receipt than those with single diagnoses (CI 0.68-0.95). Other predictors of SCP receipt were being female (OR 0.56; 95% CI 0.48-0.65), having at least a bachelor’s degree (OR 0.77; CI 0.60-0.99), age over 66 years (OR 1.38; CI 1.01-1.89), and race of “other” (OR 1.56; CI 1.14-2.13). Similar results were found for receipt of TS alone. Conclusions: Only 52% of survivors received SCPs as recommended by the IOM. Increased case complexity was associated with lower odds of SCP receipt, suggesting patients at highest risk are least likely to receive coordination. Results indicate the need to identify and eliminate barriers to SCP implementation, with special focus on high risk patients. Future research should investigate these findings in diverse populations and identify specific characteristics associated with SCP receipt.
Comparison of initial and recertification QOPI scores: Maintaining compliance through direct surveyor and practice interaction.
Authors: Chiang Anne C. , Barysauskas Constance , Conti-Kalchik Tara , Gilmore Terry , Hendricks Carolyn Bennett , Neuss Michael N. , Jacobson Joseph O. 
Published: April 2017

246 Background: Since 2006, the ASCO QOPI certification program has certified 322 practices, of which 197 practices have recertified. This retrospective study compares the number and type of standards passed at the time of initial and subsequent re-certification, and examines if on-site audits at the original certification influenced re-certification scores. Methods: 87 unique US practices that obtained QOPI certification with on-site audits at the original and re-certification between 2006 and 2014 were included. 17 QOPI certification standards were included in the analysis. Standards are metric based, except 3 standards that are observable. We defined total score per certification round as the total number of standards passed and used a Wilcoxon Rank Sum Test to test the concordance of standards passed between rounds. Linear regression models were used to identify factors related to higher recertification scores. A two-sided p<0.05 defined statistical significance. Results: 31 practices (36%) showed concordance of the 3 observable standards in the initial and re-certification rounds. For standards that assess policies, procedure and credentials of the practice, and do not require direct observation, 52 practices demonstrated improvement whereas 14 did not (p<0.0001). In contrast, for the standards that require direct observation, only 22 practices showed improvement versus 34 that did not (p=0.07). Three standards were most commonly missed in both rounds: initial chart documentation and at each clinical visit, and double verification of chemotherapy administration. There were no significant predictors of higher recertification scores. Conclusions: Many diverse oncology practices are voluntarily achieving and maintaining QOPI certification. Sustainable improvement is easier to identify in policy-based measures compared to directly observed ones. Three standards not usually passed at recertification highlight the need for assessment of psychosocial and performance status, comprehension of treatment goals, and chemotherapy double-verification. On-site evaluation of practices is key for targeting and sustaining quality efforts.
Treatment patterns among patients with higher-risk myelodysplastic syndromes in a real-world setting: Electronic medical record (EMR)-based data.
Authors: Dezube Bruce Jeffrey , Bell Jill , Galaznik Aaron , Farrelly Eileen , Blazer Marlo , Seal Brian S. , Shih Huai-Che , Eaddy Michael 
Published: April 2017

247 Background: Treatment decisions in MDS are based on a prognostic scoring system that divides pts into five distinct risk categories (NCCN 2016). Treatment guidelines for HR MDS pts include hypomethylating agents (HMAs) alone (azacitidine & decitabine), high-intensity induction chemotherapy (IC), & stem cell transplant (SCT) alone or after HMAs. Limited information is available on how these recommendations are applied in practice. This study evaluated the real-world treatment of HR MDS pts. Methods: Newly diagnosed HR MDS pts who were ≥18 years old & initiated first-line therapy (1LT) were retrospectively identified from a large United States EMR database between 1/1/2008 & 7/31/2015. As complete cytogenetics were not available in the database, HR was based on: ICD coding: ≥1 inpatient claim with an HR MDS ICD-9/10 code (ICD-9 code: 238.73; ICD-10 codes: D46.20, D46.21, D46.22), or ≥2 outpatient claims with an MDS ICD-9/10 code, or an adapted HR MDS algorithm (NCCN Guidelines in Oncology for MDS v.1.2016; Greenberg, et al. Blood. 2012;120:2454-65; Schanz et al. J Clin Oncol. 2012;30:820-9). The first MDS claim served as the index date. 1LT was defined as an MDS-specific treatment initiated on or after the index date. Pts were followed until death, progression to acute myeloid leukemia (AML), loss to follow-up, or end of study (9/30/2015). Results: 720 newly diagnosed HR MDS pts were identified; of these, 229 (32%) pts received MDS-specific treatment. Median time to treatment was 22 days (interquartile range [IQR]: 10, 74). HMAs were the most common agents in the 1LT with 60% (n= 138) & 24% (n=54) receiving azacitidine & decitabine, respectively. Lenalidomide was used in 7.4% of pts (n=17), 4.8% received SCT alone (n=11), & 3.9% (n=9) received IC. At median follow-up of 9.4 months (IQR: 4.3, 18.4), 38% (n=86) died & 28% (n=63) progressed to AML. Conclusions: Despite guidelines, most HR MDS pts in a real-world setting were not treated with MDS-specific treatment. Among treated pts, 1LT with HMAs & azacitidine predominated. Subsequent research is needed to understand reasons for lack of treatment.
A method to integrate an institutional database with multiple practice EHRs.
Authors: Barr Louis H. , Wu Meiling , Burner Heather 
Published: April 2017

248 Background: Survivorship care plans (SCP) are endorsed or required for accreditation by many organizations including ASCO, NCCN and ACoS. SCP elements include a treatment summary and follow up plan. Information for these elements is usually found in a practice’s electronic health record (EHR), but is not always readily identifiable. Practitioners get information from multiple EHRs across practices and hospitals. Barriers include EHRs not readily accessible to all staff or don’t communicate with each other. No simple means exists for the required data points to auto-populate from practice-based databases. Methods: We approached this by combining Cancer Registry data with an online template to populate a SCP, utilizing the Electronic Registry System, Inc. (ERS), a Cancer Registry software company, and a survivorship template provided by a free online open source company Journey Forward (JF). The Registry is told when a patient is scheduled for a survivorship appointment. A file is created of the patient’s demographics, specific cancer characteristics, and treatment summary. This is sent to the practitioner through a shared drive or secure email. The tumor site-specific JF template is then selected by practice staff who import the Registry file created from ERS. Information required for the SCP is auto-populated in the template during this process. Results: The remainder of the template contains recommendations for follow up and is completed by a physician or designated practitioner working with their EHR. Supplemental tumor site-specific education materials are available in the JF Library. Patient-specific concerns such as cancer recurrence or treatment side-effects can be addressed as well. Any of these prepared documents may be incorporated into the SCP follow up recommendation section with a mouse-click. The printed SCP is given to the patient and forwarded to care providers. A notice of SCP given to the patient is then sent to the Registry which closes the loop. Conclusions: This process utilizes the Cancer Registry, allows specific input from patient care providers, and eliminates the necessity to access multiple EHRs to complete SCPs.
Clinical and nonclinical factors associated with confirmatory biopsy in metastatic breast cancer.
Authors: Griggs Jennifer J. , Braun Thomas , Severson Dawn Marie , Layhe Elizabeth Marie , Gorski David H. , Breslin Tara M. , Henry Norah Lynn 
Published: April 2017

249 Background: In patients with metastatic breast cancer, clinical practice guidelines include obtaining histologic confirmation of metastases when possible. The purpose of this study was to investigate patterns and correlates of receipt of a confirmatory biopsy. Methods: Data were abstracted from the records of patients diagnosed with metastatic breast cancer in the Michigan Breast Oncology Quality Initiative (MiBOQI), a statewide registry of 25 health systems. Patients with Stage IV disease at diagnosis were excluded. Analyses investigated associations between receipt of a confirmatory biopsy and disease, clinical and non-clinical factors, and treating health system. Results: Data were available for 1,231 (96%) of eligible patients between 2006 and 2015. Of these, 66% had a confirmatory biopsy; the proportion of patients having a biopsy varied between the 25 sites from 41% to 100% (p = 0.03). In bivariate analyses, younger age (p = 0.02), lower comorbidity (p = 0.007), longer time between the primary and recurrence (p < 0.001), more recent year of recurrence (p = 0.01), having liver, skin, soft tissue, or multiple metastases (p < 0.001), and private or government insurance (p = 0.002) were associated with biopsy. In multivariate analyses, longer time since the primary diagnosis (p < 0.001), more recent year of recurrence (p = 0.03), initial site(s) of recurrence (p < 0.001), and private or government insurance (p = 0.004) remained significant predictors of biopsy. Treatment site was no longer significant (p = 0.14). Minority status, obesity status, and disease characteristics (stage, estrogen receptor, progesterone receptor, HER2, grade) of the primary were not significant in either bivariate or multivariate analyses. Analyses were repeated without insurance with no change in the other findings. Conclusions: In a statewide collaborative, the proportion of patients having a confirmatory biopsy increased over the study period and was associated with several clinical factors. Insurance was an independent and significant predictor of receipt of what is considered standard care.
Pancreatic cancer cost-of-care in inpatient setting.
Authors: Bansal Dhruv , Bansal Pranshu , Kapoor Vidit 
Published: April 2017

28 Background: Pancreatic cancer continues to carry bad prognosis with modest improvement in survival in the last decade. SEER analysis from 2006-2012 shows a 5-year survival of 7.7% for pancreatic cancer and number of new diagnoses were 11.3 per 100,000 U.S. population in 2003 and 12.7 in 2013. The mortality rate was 10.5 and 10.8 per 100,000 during the same time period. In spite of modest improvement in survival, the cancer care costs including pancreatic cancer continue to rise and inpatient costs contribute a major chunk to cancer care which is often ignored. Methods: We used National Inpatient Sample (NIS) to extract data for patients hospitalized with primary diagnosis of pancreatic cancer using clinical classification software code 17, and corresponding ICD9 codes for the years 2004-2013. NIS is a nationally representative survey of hospitalizations conducted by the Healthcare Cost and Utilization Project. It represents 20% of all hospital data in the US. Trend of rate of hospitalization, mean length of stay (LOS), and mean cost of hospitalization were analyzed. Results: The rate of hospitalization for pancreatic cancer were 11.0 +/-0.5 in 2004 and 11.0 +/-0.3 per 100,00 hospitalizations in 2013. Mean LOS declined from 8.978 +/-0.141 to 7.616 +/-0.105 days between 2004-2013. In the same time period the mean cost of hospital stay increased from $39,533 +/-1,514 to $74,216 +/- 2,408. Conclusions: In the years 2004-2013 the rate of hospitalization for pancreatic cancer remained stable (z test p = 1.0), LOS decreased significantly by approximately 15% (z test p < 0.001), but the mean cost of hospitalization showed the most significant increase throughout the decade with a mean increase of approximately 47% (p < 0.001) in hospital costs. National inflation rate was 23.3% during this time. The gains made in decreasing the LOS has not lead to a decrease in inpatient cost of care. Pancreatic cancer treatment lags behind other cancers with dismal survival rates, and combination chemotherapies are increasingly being used which may add to inpatient cost in future as well although results at this time remain modest. Further research efforts to better identify the factors contributing to inpatient cost should be undertaken.
Cost and survival analysis before and after implementation of Dana-Farber Clinical Pathways for Patients with Stage IV Non-Small Cell Lung Cancer.
Authors: Zhang Yichen , Fraile Belen , Dalby Carole Kathleen , Nguyen Tom , Nagle Julia , Lydon Christine A. , Rabin Michael S. , McNiff Kristen K. , Jacobson Joseph O. , Jackman David Michael 
Published: April 2017

3 Background: Oncologists face challenges associated with increasing cost and medical complexity. The Dana-Farber Cancer Institute (DFCI) has created a customized clinical pathways program that seeks to prospectively support and guide medical decision-making across our network. It also allows the Institute to track and learn from the medical decisions made. We have analyzed cost and outcomes data from before and after the implementation of Dana-Farber Pathways in our thoracic oncology program. Methods: Our lung cancer group created a customized clinical pathway for the treatment of non-small cell lung cancer (NSCLC). We partnered with Via Oncology to provide a web-based platform for real-time pathway navigation and post-treatment data aggregation. DFCI Pathways for NSCLC went live in January 2014. We identified all patients who were diagnosed with and treated for stage IV NSCLC in 2012 (pre-pathways) and 2014 (post-pathways). Demographics, clinical characteristics, treatments, and clinical outcomes were captured. Costs of care for each patient were determined for one year from the time of diagnosis. Results: We identified a total of 160 Stage IV NSCLC patients diagnosed in 2012, and 210 patients diagnosed in 2014. The pretreatment group had more women (61% vs. 50%) but was otherwise similarly matched in terms of smoking status and presence of targetable changes in EGFR and ALK. The total 12-month cost of care (adjusted for age, sex, race, distance to DFCI, clinical trial enrollment, and EGFR and ALK status) demonstrated a $15,013 savings after the implementation of pathways ($67,050 pre, $52,037 post). Clinical outcomes were not compromised, with no significant difference in median overall survival (10.7 months pre, 11.2 months post; p = 0.08). Conclusions: In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of a clinical pathways program can provide a means to harness and deploy institutional expertise and track and learn from care decisions. Patients treated after the implementation of a clinical pathways program in lung cancer saw preserved clinical outcomes and a significant decrease in cost of care.
Development of a complex patient identification process for the CMS’ Oncology Care Model.
Authors: Sinanis Naralys , Abdelghany Osama , Strait Michael , Lyons Catherine A. , Adelson Kerin B. 
Published: April 2017

32 Background: The CMS’ Oncology Care Model (OCM) provides practices with enhanced monthly payments for beneficiaries with cancer receiving chemotherapy. While the program will distribute a retrospective beneficiary list, practices need to track and identify eligible patients upfront to initiate care management and financial counseling processes and to bill for the enhanced payment. The eligibility criteria require information that many practices do not have. We describe a stepwise approach to patient identification that can be used by other OCM practices. Methods: We ran a report that identified patients with Medicare who received an OCM-eligible drug. We classified drugs into four categories: IV chemo confirmed by our own billing, oral specialty tracked and/or filled by our specialty pharmacy, general prescriptions filled at offsite pharmacies, and oral drugs billed under Medicare Part B. Because patients on general oral drugs receive 11 refills when first prescribed, we could not rely on a new prescription to trigger enrollment; we created a candidate list of patients who received oral prescriptions in the last year. Our pharmacists manually checked QS1, to verify Medicare Part D status and Surescripts to confirm that patients filled their prescription. Results: The build took time to validate due to disparate data and incomplete insurance information. 1039 IV chemo, 249 oral chemo, 196 oral Medicare Part B, were definitively eligible. 2991 with general prescriptions made the oral candidate list, which required additional verification of last visit date, Medicare Part D status, and prescription fill date. Approximately 70% of our patients have Medicare Part D and over 90% filled their prescription. We billed IV for July and August and are awaiting final confirmation of drug fill before billing the patients from the oral categories. Conclusions: The patient identification process was more complex than expected. Implementation required a multi-disciplinary effort with extensive collaboration across several departments as well as a time-intensive manual insurance and drug fill-verification process. Opportunities exist to automate Medicare Part D verification using our real-time eligibility software.
Access to care in cancer: Barriers and challenges.
Authors: Gonzalo Maria Belen , House Linda , Santiago Kristen , Buzaglo Joanne S , Zaleta Alexandra K , Gupta Niraj K. 
Published: April 2017

33 Background: In the current climate of health care reimbursement, coverage reform, and escalating health care costs, navigating cancer care becomes increasingly complex for patients and caregivers. Given the truly fluid marketplace and many payment and care models being established sans engagement with or even information from the patient, it is imperative to assess the ongoing reality of patient access to comprehensive, quality cancer care: care that includes biomedical as well as psychosocial care. Methods: We launched an online research survey project to further explore the cancer patient experience as it relates to accessing health care and living within a new and evolving system of health care. The analysis is based upon a cross-sectional survey of adults (18 years old and older) affected by cancer. The survey was conducted online between June and August of 2016. 1,218 cancer survivors completed survey questions regarding access to insurance, services, and providers as well as direct and indirect costs of care. Results: 78% of patients with cancer either have not or do not recall discussing costs with their health care team prior to treatment. 53.5% of survey respondents reported not knowing the meaning of the term “Clinical Practice Guidelines,” and 73% of participants had never heard the term “Clinical Pathway.” 25% of patients experienced delays in accessing cancer care, 18% of patients reported that costs inhibited them from filling prescription drugs to treat their cancer, 22% of patients chose not to get some of the healthcare services they needed due to high out-of-pocket costs, and 53% reported not receiving social or emotional support. Conclusions: These findings demonstrate that despite progress being made in expanding access to health care, many patients still experience significant barriers and challenges to accessing care. We also find there is a gap in patient knowledge about practice guidelines and payment policies. To create a system where all patients have access to high-quality and comprehensive cancer care, educational efforts are needed to enhance patient understanding of information about practice guidelines and payment policies, including information regarding health risk and benefits, costs, patient health, and quality-of-life outcomes.
Early national dissemination of abiraterone and enzalutamide for advanced prostate cancer in Medicare Part D.
Authors: Caram Megan Veresh , Borza Tudor , Min Hye-Sung , Griggs Jennifer J. , Miller David Christopher , Hollenbeck Brent K. , Mukherjee Bhramar , Skolarus Ted A. 
Published: April 2017

35 Background: Abiraterone and enzalutamide are oral medications approved by the Food & Drug Administration in 2011 and 2012 to treat men with advanced castration-resistant prostate cancer. Most men with advanced prostate cancer are over age 65 and thus eligible for Medicare Part D. We conducted a study to better understand the early dissemination of these drugs across the United States using national Medicare Part D data. Methods: We evaluated the number of prescriptions for abiraterone and enzalutamide by provider specialty and hospital referral region (HRR) using Medicare Part D and Dartmouth Atlas data. We categorized HRRs by abiraterone and enzalutamide prescriptions, adjusted for prostate cancer incidence, and examined factors associated with regional variation using multilevel regression models. Results: Among all providers who wrote prescriptions for abiraterone or enzalutamide in 2013 (n=2121), 87.5% were medical oncologists, 3.3% urologists, and 9.2% were listed as other provider specialties. Among those who prescribed either drug, 5% of providers were responsible for 75% of the claims for abiraterone, and 7% were responsible for 75% of the claims for enzalutamide. Some HRRs demonstrated low-prescribing rates despite average medical oncology and urology physician workforce density. Conclusions: The majority of prescriptions written for abiraterone and enzalutamide through Medicare Part D in 2013 were written by a minority of providers with marked regional variation across the United States. Better understanding the early national dissemination of these effective but expensive drugs can help inform strategies to optimize introduction of new, evidence-based advanced prostate cancer treatments.