bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reducing the percent of ICU deaths of patients with advanced cancer at Stanford.
Authors: Cinar Pelin , Bobokalonova Zarrina , Hadhazy Eric , Chan Sandy , Stallings Holley 
Published: February 2017

234 Background: Intensive care at the end of life, for patients with advanced cancer can compromise quality of life and result in excessive costs for patients and their families. In 2014, 40% of patients with solid tumors admitted to the Stanford Health Care ICU died with advanced stage disease. Sixty-five percent of the patients with advanced stage saw palliative care (PC) < 7 days of life. The aim was to decrease the percent of advanced solid tumor ICU deaths by 25%, through early palliative care intervention. Methods: The current process was analyzed through mapping and a cause and effect diagram. The outcome measure was defined as percentage of patients with advanced solid tumors dying in ICU. A key intervention was the development of criteria designed to trigger an earlier PC referral for patients with stage III-IV lung/pancreatic cancer. PC referral triggers included: 2+ lines of prior chemotherapy with life expectancy < 6 months or refractory disease, hospitalization within prior 30 days, > 7days of hospitalization, uncontrolled symptoms. ICU trainees were to contact the primary oncologists and discuss the role of PC consultation for patients who met the criteria. A balance measure was developed to assess if primary oncologists were contacted. Charts of patients admitted to the ICU 2 weeks pre- and post-implementation were reviewed. Results: During the pre-PDSA cycle, 13 patients with cancer were admitted to the ICU while 10 were admitted post-PDSA cycle. Primary oncologists of the patients with advanced cancer who met our criteria were contacted in similar rate pre- and post-PDSA (39% vs 40%). PC consultation was also similar for pre- and post-PDSA cycles (31% vs 30%). The percent of ICU deaths of patients in the pre-PDSA was 22% and 22% in the post-PDSA cycles. Conclusions: The percentage of deaths in the ICU for patients with advanced cancer met our target goal of 25% reduction from the baseline. However, the improvement was independent of our intervention, given the timing and short interval. The percent of PC consults for patients meeting the criteria did not change. Data from subsequent PDSA cycles and a SPC chart will be reported in the conference.
New fields in the patient record: A tool or a nuisance?
Authors: Theodorakopoulou Ioanna , Stathaki Kalliope , Poufos Theodore , Vlachou Frosso , Spyri Olympia , Hatziyiasemi Lina , Rigakos Georgios , Labropoulos Stefanos V. , Prasini Ioanna , Razis Evangelia 
Published: February 2017

235 Background: The Contemporary Oncology Team was the first practice in Greece to participate in the Quality in Oncology Practice Initiative (QOPI). As a result, several corrective measures were designed and implemented to improve the quality of the services provided to patients. Methods: The plan-do-check-act approach was used to implement changes, primarily in the follow up form, over a period of 18 months. Several improvement opportunities were identified. 1.) A numerical scale for pain intensity quantification became a required field. 2.) Emotional well-being fields were added so the patient’s state could be documented by providers. 3.) Fertility assessment and counseling was added as a required field in the patient record. For this report we evaluated retrospectively the effect of these changes on our QOPI scores. Results: Contemporary Oncology Team QOPI scores after the implementation of the new forms have shown increased compliance, compared to QOPI aggregate scores for all participating US practices, in the areas related to the changes made. Specifically, pain assessment documentation improved from -54.56% to +9.96%. The use of a numerical tool proved invaluable to comparing pain intensity between different visits. Emotional well-being documentation improved from -42.55% to +18.26%. Fertility assessment documentation has not improved but this finding could be due to a decrease in patient chart sample size. Providers seemed to adapt quickly and without difficulty. Conclusions: Developing new fields in the patient record is an evolving process because it requires provider education and acquaintance with the new method of documentation. However, in this retrospective analysis it proved to be an effective method to improve provider compliance with assessment of pain and emotional well-being, and it is likely to be useful in other areas in need of improved documentation.
“It looks good”: How a provincial radiation oncology program benefits from implementing peer review across cancer centers.
Authors: Brundage Michael Donald , Hart Margaret , O'Donnell Jennifer , Foxcroft Sophie , Gutierrez Eric , Reddeman Lindsay Elizabeth , Mitera Gunita , Warde Padraig Richard 
Published: February 2017

238 Background: Peer review (PR) in radiation oncology (RO) has been endorsed as an indicator of treatment quality in North America and internationally. The direct benefits of PR include quality assurance (QA) on individual treatment plans. The indirect benefits for radiation oncology departments or programs (ROPs) have been postulated but not systematically evaluated. We used a rigorous and comprehensive qualitative approach to explore the indirect benefits of PR across a jurisdiction of cancer care, and to identify factors that facilitate PR, barriers to implementation, and strategies for expansion of PR across centers. Methods: Semi-structured qualitative interviews were held with all RO heads and Radiation therapy Managers (or delegate) in all 14 Radiation Oncology Programs (ROPs) in Ontario, Canada. The interview questions were developed using a Knowledge Translation Theoretical Domains Framework (TDF), guided by the results of a previous survey of Ontario cancer centers and by expert consensus. Interviews were audiotaped and abstracted for relevant themes by two independent analysts. Results: All interviewees endorsed numerous direct and indirect benefits of PR, and identified multiple facilitators and barriers to the implementation of PR. Thematic saturation was achieved. The structure-process-outcome model was used to categorize the results. Key findings included the identification of 34 independent benefits (structure n = 4, process n = 17, outcome n = 13), 40 key barriers (structure n = 9, process n = 26, outcome n = 5), and 22 facilitators (structure n = 4, process n = 15, outcome n = 3). Beyond QA, commonly endorsed benefits included enhanced knowledge sharing, efficiency, standardization, and education. Multiple potential strategies for the expansion of PR activities were revealed. Conclusions: The qualitative exploration of Ontario ROPs acknowledges that multiple barriers and facilitators to PR exist while clearly establishing the indirect benefit of PR on ROPs. Understanding reported barriers and facilitators and exploration of suggested strategies will inform continued implementation and expansion of PR activities, and seem generalizable to other jurisdictions.
Application of a standard practice-based system to measure and compare quality of cancer survivorship care.
Authors: Palos Guadalupe R. , Gilmore Katherine Ramsey , Chapman Patricia , Lewis-Patterson Paula A. , Rodriguez Maria Alma 
Published: February 2017

239 Background: Despite the growing committment to improve survivorship care, measuring its quality remains difficult. In 2006, the American Society of Clinical Oncologists (ASCO) launched a practice-based system known as the Quality Oncology Practice Initiative (QOPI) to measure the quality of cancer care. Here, we demonstrate the use of QOPI procedures to compare compliance with survivorship care plans (SCPs) across different disease-specific clinics. Methods: Measures based on survivorship clinical practice guidelines were abstracted from SCPs issued to survivors scheduled for appointments in site-specific clinics. Following QOPI procedures, we identified the target condition as cancer, selected data collection methods, and determined core measures for abstraction. Procedures included; identifying the number of survivors arriving for appointments within the specified time period, standardizing denominators and numerators used per clinic, determining the number of full-time providers per clinic, and calculating the number of records to audit per clinic. All data were obtained from completed care plans, institutional electronic medical records, and scheduling systems. Descriptive statistics were used to conduct aggregate analyses of de-identified data. The same procedures were followed in each clinic. Results: From September 1, 2014, to August 31, 2015, we used a standard process to assess compliance for issuing survivorship care plans across 9 clinics. There were a total of 8864 arrived appointments; 46 providers completed a total of 7448 electronic survivorship care plans over the time period. Analysis of compliance rates indicated broad variation across clinics, including: breast (85.3%), gastrointestinal (80.2%), genitourinary (88.5%), gynecology (78.6%), head/neck (96.8%), lymphoma (99.3%), melanoma (62.2%), thyroid (75.4%) and thoracic (63.3%). Conclusions: Establishing uniform procedures, such as the QOPI process, to measure and compare compliance with SCPs will help achieve high quality standards of care for long-term cancer survivors. Further examination is warranted to determine longitudinal trends and factors contributing to variation in compliance rates.
Applying value stream mapping to improve patient flow and satisfaction.
Authors: Cummings Chad W , Kenney Rob , Glass Katherine , Monteleone Emily Elizabeth , Bolwell Brian James 
Published: February 2017

244 Background: Value Stream Mapping (VSM) is a tool commonly used in manufacturing environments to analyze the current state process and to design an improved future state. VSM is a dynamic visual management tool that can be applied in the context of clinical activities to identify value-added (VA) and non-value added (NVA) activities along the spectrum of patient care. A VSM was created for the Breast Cancer Program to identify improvement opportunities in patient quality, flow, and communication across disciplines. Methods: A multidisciplinary team of physicians and clinical specialists were assembled to detail patient flows and coordination of care. Data for each process step was identified, and included, but not limited to: (1) lead times and (2) cycle times for each process. Clinical huddles were established to collect “real-time” patient information (n = 101 patients), and used to populate and validate the VSM. Additionally, retrospective analysis was performed using information from the tumor registry (n = 566 patients). Results: Visual representation of a patient’s journey revealed distinct opportunities to improve the coordination of care and communication. The Breast VSM identified 53 discrete steps, and illuminated 3 focus areas for action: (1) coordination and navigation of patients at multiple points of entry, (2) communication of diagnosis, and (3) reduction of time between major clinical activity (diagnosis to surgery or first treatment). NVA identified opportunities to reduce the number of steps (13) between diagnosis and first treatment, whereby up to 15% of these steps are financial clearance that can delay care. Process differences were discovered between external and internally referred patients, leading to delays in first consult, and a need for better patient navigation. Conclusions: VSM is an effective way to collaborate and drive improvements with multi-disciplinary teams. The non-value added activity highlighted on the maps provides an opportunity for improvements and reducing waste and delay in patient care. Providing timely communication and care will drive patient satisfaction around value-added steps.
Kaiser Permanente Georgia: Colon cancer care through the science of performance improvement.
Authors: Terrell Carlee 
Published: February 2017

250 Background: While our patients reported high satisfaction with the care they received, Kaiser Permanente Georgia’s baseline assessment found variation in the way our colon cancer patients were diagnosed and received care. This variation also effects the cycle time from diagnosis to initiation of treatment (surgery or first infusion). Methods: Using Kaiser Permanente’s Performance Improvement methodology and interdisciplinary cooperation, this project launched in January of 2014. A multidisciplinary team representing the GI, Surgery, Oncology, Nursing, Radiology, Palliative Care and Patient Safety departments, was formed and facilitated by a PI specialist to examine the different workflows. The team performed an in-depth baseline analysis of the current state, including patient interviews and surveys. At the completion of the baseline analysis all clinical departments came to an agreement for future state process design. In addition to developing workflows, an order bundle was developed to bridge the gap between the baseline and future states. The improvements were tested and both qualitative and quantitative feedback was collected on effectiveness of the changes. Results: This project resulted in an agreed upon standardized nursing and provider workflow and identified a diagnostic bundle to be carried out on the day of colonoscopy for treating suspected CRC patients. These improvements resulted in a reduction to the average time from diagnosis to treatment for Colorectal Cancer patients by 40.3%. The variation in time from diagnosis to treatment was reduced by 60.5%. Conclusions: We are pleased these positive results improve on the cancer care we provide to our patients. Multidisciplinary communications and agreements were key to the success of this project. Our next steps involve migrating the CRC diagnostic bundle into KPs EMR, developing a reliable surveillance follow-up method, and further reducing the time to treatment by focusing on the surgical pathway.
Appropriateness of testing for heparin-induced thrombocytopenia in hospitalized patients.
Authors: Namakydoust Azadeh , Saha Debasmita , Ajeti Gresa , Bair Brandon , Hook Karen , Ballesteros Enrique , Holle Lisa 
Published: February 2017

252 Background: Heparin induced thrombocytopenia (HIT) is a devastating thrombotic complication of heparin therapy and occurs in 0.2 to 5% of patients receiving heparin products and is a clinicopathologic diagnosis. The American Society of Hematology Guidelines, recommend the use of the “4Ts” scoring system to determine the pre-test probability of suspected cases. Also, a presumptive clinical diagnosis of HIT must be followed by immediate cessation of all forms of heparin and initiation of alternate anticoagulation. Proper diagnosis and treatment can be difficult for medical and surgical clinicians, with implications for morbidity, mortality, patient safety, and cost. The Objective of this study was to assess the incidence and appropriateness of HIT testing at our institution before and after an educational session for clinicians. We hypothesized that our intervention would provide better quality care of patients with suspected HIT. Methods: First, a retrospective chart review was conducted for a 3-month period, in which we collected baseline patient and HIT-testing data. Next, an “in-service” type lecture was delivered on seven occasions to various hospitalist groups. Follow-up data for an additional 3-month period was collected after these sessions. Results: See Table. Conclusions: In this single-center study, our educational interventions were successful in reducing inappropriate HIT testing, and encouraging consultation with hematology colleagues. Future studies are needed to evaluate the utility of online teaching modules, electronic order sets,and applicability to other medical centers. [Table: see text]
Preferred cost communicator and financial distress (FD) in patients with cancer.
Authors: Proussaloglou Ellie , Yap Bonnie J. , O'Connor Jeremy , Daugherty Christopher , De Souza Jonas A. 
Published: February 2017

26 Background: Prior research has shown that cancer patients (pts) are willing to discuss the costs of their care. Professional societies have thus encouraged physicians to discuss these costs with their pts. We assessed the preferred communicator from the pts’ perspective and the predictors of this preference. Methods: Pts with advanced cancers who had completed at least 3 months of chemotherapy were asked for their preferred cost communicator. Pts were allowed to choose one or more cost communicators. Options included physician, financial counselor, social worker, nurse, and other. We collected demographics, therapy type, mood states, income, length of disease (LoD), clinical trial status, ECOG PS, and health-related quality of life (HRQoL). FD was assessed by the COmprehensive Score for financial Toxicity (COST – FACIT) instrument. Multivariable logistic regression was used to identify factors associated with the preferred cost communicator. Results: 233 patients were assessed. Most pts were female (58.4%), Caucasian (66.4%), and privately insured (67.4%). In total, 114 pts (48.9%) preferred speaking about costs to financial counselors, followed by physicians (n = 74, 31.8%), social workers (52, 22.3%), nurses (16, 6.9%), and others (7, 3.0%). In total, 91 patients (39.1%) had no FD, while 142 (60.9%) had some degree of FD. Restricting the analyses by the preferred cost communicator and controlling for sociodemographics, HRQoL, mood states, LoD, clinical trial status, and ECOG PS, the presence of any degree of FD was associated with willingness to discuss costs with financial counselors (OR = 1.94, p = 0.03). In contrast, the absence of FD (OR = 1.93, p = 0.03) was associated with willingness to discuss cancer costs with physicians. A trend was seen with pts on oral therapy willing to discuss costs with their physicians (OR = 1.78, p = 0.06). Lastly, non-Caucasians were more willing to discuss costs with a social worker (OR = 2.28, p=0.01). Conclusions: Physicians are not the preferred cost communicators for pts with FD. These pts are willing to discuss costs with financial counselors. Following an evidence-based approach that integrates patients’ preferences may facilitate the inclusion of cost discussions in clinical practice.
Development of an oncology quality metric evaluation and prioritization tool (QMEPT).
Authors: Holcombe Randall F. , Evangelista Michelle 
Published: February 2017

260 Background: For reporting purposes and to enable ongoing quality improvement, it is essential that metrics reflective of quality oncology care delivery are tracked and reviewed on an ongoing basis. Collection of performance data and incorporation into a usable dashboard can require significant IT resources, both in personnel time and direct costs. The Tisch Cancer Institute (TCI) identified a myriad of cancer quality metrics that required prioritization in order to best allocate limited IT resources and a standardized process to facilitate comparison across different disease groups. Methods: Quality metrics were identified from various sources: CMS, PQRS, Commission on Cancer, QOPI, AHRQ and others recommended by TCI disease management teams (DMTs). All measures were evaluated with QMEPT according to the following domains: 1) Regulatory (CMS or other certifications), 2) Cost & Feasibility (resource intensiveness of the collection process), 3) Patient Outcomes – (existence of standard benchmarks or known underperformance) and 4) Financial – (influence on payor contracting). All metrics were scored to generate a composite score for each metric and then weighted with 40% for Regulatory, 20% for Cost & Feasibility, 40% for Patient Outcomes. Financial was not weighted but given a yes/no designation. Results: Metrics across all disease sites were scored, weighted and compared. Composite scores ranged from 1.56 to 2.67 (range 1 - 3). Weighted scores ranged from 1.4 to 2.8. In general, metrics related to breast, prostate, colorectal and lung cancers scored higher because of the required reporting and existence of evidence-based standardized benchmarks. Metrics proposed by the DMTs were frequently found to have high resource requirements for data collection. Following the scoring process, information was disseminated to the DMTs, leading to alteration of many of the quality metric requests. Metrics with the highest priority scores were submitted to the IT group for incorporation into the quality dashboard. Conclusions: The QMEPT allowed comparison of quality metrics across disparate oncology disease groups, prioritization for incorporation into a quality dashboard and rational allocation of limited IT resources.
Establishing achievable benchmarks for quality improvement in systemic therapy for early-stage breast cancer.
Authors: Powis Melanie , Gonzalez Alejandro , Sutradhar Rinku , Enright Katherine , Taback Nathan , Booth Christopher M. , Trudeau Maureen E. , Krzyzanowska Monika K. 
Published: February 2017

263 Background: Setting realistic targets for performance on quality indicators (QI) is a consistent challenge in quality improvement. The purpose of this study was to utilize administrative data to define achievable targets for QI in the early stage breast cancer (EBC) population in relation to systemic therapy (ST) delivery based on best performers. Methods: Deterministically linked administrative healthcare databases were used to identify EBC cases diagnosed 2006 – 2010 in Ontario, Canada. Panel of previously established QIs for systemic therapy was applied to patients who met eligibility criteria for the individual indicators. Institutions with less than 10 eligible patients for a specific indicator were excluded. An empiric benchmark was defined as the proportion of patients meeting the indicator from institutions accounting for the top decile of eligible patients. Results: We identified 28,303 EBC patients who received surgery of which 12,252 received adjuvant chemotherapy. Benchmark results are summarized in Table. Conclusions: Many institutions fell considerably below the benchmark. Further analysis of institution-level drivers of high quality care is required to help characterize high performing institutions. [Table: see text]