bluuebunny/crossref_metadata_2025_split huggingface dataset:
HBV screening before adjuvant chemotherapy in patients with early breast cancer: A cost-effectiveness analysis.
Authors: Wong William W. L. , Hicks Lisa K. , Tu Hong-Anh , Krahn Murray , Pritchard Kathleen I. , Feld Jordan J. , Chan Kelvin K. 
Published: February 2017

11 Background: The seroprevalence of hepatitis B virus (HBV) infection among Canadian was 0.4%, and 1.6% among immigrants. Most infected individuals have clinically silent disease. Cytotoxic chemotherapy causes reactivation in 30% of the HBV infected patients. This can be severe and fatal, may also lead to interruption of chemotherapy. HBV screening before adjuvant chemotherapy (ADJ) for breast cancer (BC) seems to be a plausible strategy. Our objective is to estimate the health and economic effects of HBV screening strategies. Methods: We developed a state transition microsimulation model to examine the cost effectiveness of 3 strategies for 55 year old BC patients undergoing ADJ: (1) No screen; (2) Screen Imm: Screen immigrant only and treat; (3) Screen all: Screen all and treat; with antiviral therapies. In the model, health states were constructed to reflect the natural history of BC and HBV. Model data were obtained from published literature. We used a payer perspective, a lifetime time horizon, and used a 5% discount rate. Results: Screen all would prevent 43 severe reactivations (SR), 9 deaths from reactivation (DR), 22 chemotherapy interruptions (CI), 36 decompensated cirrhosis (DC), 48 HCCs, and 67 HBV deaths per 100,000 persons screened over the lifetime of the cohort. Screen Imm would prevent 34 SR, 4 DR, 20 CI, 30 DC, 41 HCCs, and 52 HBV deaths. Screen all was associated with an increase of at least 0.00368 quality adjusted life years (QALY) and cost C$116 more per person, translating to an incremental cost effectiveness ratio (ICER) of C$31,518-51,276/QALY gained compared with No screen, depends on different antiviral therapies. Screen all was the most cost effective, while Screen Imm was ruled out due to extended dominance (ED) by No Screen and Screen all. Conclusions: HBV screening before ADJ for BC patients would prevent a significant number of reactivations, and is likely be cost effective. [Table: see text]
Impact of advance directive (AD) completion among patients with metastatic cancer treated at an academic medical center.
Authors: Kapadia Nirav S. , Snide Jennifer , Gelb Daniel J , Schlosser Evelyn 
Published: February 2017

114 Background: Between February and September 2013, AD documentation for oncology patients across Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) increased from 36% to 48%. However, it remains unclear whether AD completion itself is associated with other indicators of quality care. Methods: Using the tumor registry and National Death Index patient data, we examined a cohort of deceased NCCC patients diagnosed with metastatic disease between April 1, 2011 and October 31, 2013. To account for unmeasured care provided outside of NCCC, only patients with at least two NCCC visits, one of which occurred within the last six months of life, were included. Individual patient electronic medical record data were then linked to the registry data and multivariable regression was performed to determine the effect of AD completion on end-of-life quality metrics. Results: The cohort consisted of 225 patients, 182 (81%) of whom had an advance directive on file and 43 (19%) who did not. There were no significant differences in the age, gender or cancer diagnosis between the two groups. Patients with an AD had shorter commutes to the medical center (mean 42 vs 58 minutes, p<0.01) and more visits with cancer center providers (median 11.5 vs. 4.0, p=0.03). Palliative Care consulted with 73% of patients with an AD, versus 28% of patients without an AD (p<0.01). Completion of an AD did not decrease the likelihood of hospital death (OR 0.90, 95% CI 0.33-2.49), intensive care unit (ICU) death (OR 0.83, 0.19-3.66), hospital admission in the last 30 days of life (OR 0.94, 0.40-2.21), or ICU admission in the last 30 days of life (OR 1.30, 0.37-4.55). Patients with an AD were twice as likely to receive hospice referrals (OR 2.04, 0.73-5.68) and 70% less likely to visit the emergency department in the last 30 days of life compared with patients without an AD on file (OR 0.28, 0.06-1.40), although these trends were not statistically significant. Conclusions: For patients with metastatic cancer, an advance directive was associated with increased use of palliative care, though not with other measures of quality care. In an attempt to improve the cancer care provided at the end of life, we must expand our strategies beyond the use of an AD.
Can protocol development improve breast cancer and breast surgery quality measures?
Authors: Samiian Laila , Rivera-Fernandez Ricardo , Puckett Katherine , Patrick Jilma , Chesire David 
Published: February 2017

119 Background: Since 2009, UF Health Jacksonville has made significant changes in the Breast Cancer Program. These changes spanned across multiple specialties and have focused on creating protocols, guidelines, checklists, and policies for the management of breast cancer. This study evaluated the effect of standardized institutional protocols on breast cancer quality measures. Methods: Tumor registry was used to identify 350 patients who were diagnosed and treated at UF Health Jacksonville for breast cancer from 2006-2012 (Stage 0-III excluding LCIS). A retrospective review of electronic health records was performed to compare the achievement of quality measures 2 years before program development (6/2006 – 6/2008) to that of 2 years after program development (6/2010 -6/2012). Results: There were significant improvements in breast cancer diagnosis and surgical treatment quality measures after establishment of standardized protocols. Performance of pre-surgical needle biopsies regardless of diagnostic outcome (90% vs. 96%, p=0.02), and diagnosis of carcinoma via needle biopsy (50% vs. 87%, p=0.04) both showed significant improvement. More patients underwent sentinel lymph node biopsy post-protocol (43% vs. 68%, p<0.001). There was improvement in surgical specimen orientation (58% vs. 88%, p<0.001), and image confirmation of the specimen post-protocol (86% vs. 97%, p=0.01). There was a reduction of second or additional operations (44% vs. 26%, p=0.004), which included a significant reduction in lumpectomy re-excisions for margins (30% vs. 14%, p=0.003). There was a non-significant improvement in attempted (64% vs. 71%, p=0.17), and successful breast conservation surgery (57% vs. 65%, p=0.10). There were no significant changes in the rates of recommendation for adjuvant radiation, endocrine, or chemotherapy. There was no improvement in patient adherence to the recommended adjuvant therapy based on protocol implementation. Conclusions: Implementation of standardized institutional protocols can significantly increase achievement of quality measures in breast cancer diagnosis and surgery. However, these protocols did not have a significant effect on systemic therapy or radiation therapy quality measures.
Clinical documentation improvement as a quality metric in oncology.
Authors: Farber Jeffrey Ian , Holcombe Randall F. 
Published: February 2017

123 Background: With the rapid pace of healthcare reimbursement transformation from a fee-for-service to a fee-for-value system, clinical documentation is increasingly recognized as a critical area of focus for quality improvement. Engaging busy physicians to improve their clinical documentation is a challenging endeavor. Many hospitals utilize clinical documentation improvement specialists to query physicians for more specific and comprehensive clinical documentation. In this paper, we will report on a novel, complementary, and replicable approach we utilized to improve clinical documentation in the medical oncology clinical service line at the Mount Sinai Hospital in New York City. Methods: We organized a team of stakeholder physicians, clinical documentation specialists, clinical informaticists, and data analysts in July 2013 to address a perceived gap in publicly-reported severity-adjusted quality metrics in medical oncology. We used University Health System Consortium data to conduct a detailed comparative analysis of the rates of coding for common and important secondary ICD-9 diagnoses on inpatient claims by base Diagnosis Related Group (DRG). A list of 34 diagnoses was targeted for improvement in the accuracy and specificity of clinical documentation. We then developed an electronic medical record tool to assist clinicians in real-time clinical documentation. We rolled out a new quality metric with monthly reporting on CC/MCC (complication or comorbidity and major complication or comorbidity) capture rates to departmental leadership, provided educational outreach to front-line providers and developed additional non-electronic reminder tools for provider use. Results: We increased the overall CC/MCC capture rate from 88% to 94% and the case mix index (CMI) for the chemotherapy base MS-DRG from 1.11 to 1.28 from March 2013 to March 2014. The capture rate remained the same (6) or increased (18) in 82% of the targeted diagnoses. Conclusions: Adding clinical documentation metrics to the existing quality infrastructure, supported with comparative analytical data and EMR tools, can drive sustainable improvements in clinical documentation which supports publicly-reported severity-adjusted quality measures.
Reduction of emergency department utilization via access to outpatient cancer care.
Authors: Bishop Kenneth D. , Fenton Mary Anne , Szymanski Tara , Begnoche Megan 
Published: February 2017

128 Background: Emergency department (ED) utilization for non-emergent medical problems is an inefficient use of medical resources. During calendar year 2013, 224 RIH adult cancer patients presented to the RIH ED. Retrospective review indicated up to 50% of these ED visits were avoidable. Methods: This project was developed for the ASCO Quality Training Program. A multidisciplinary team was assembled to address ED utilization. Retrospective chart review of ED visits included time and reason for visit and primary tumor site. The team selected the Lung Cancer as the target group, developed a cause-and-effect analysis for ED visits, administered a patient survey, and implemented a series of Plan-Do-Study-Act (PDSA) cycles. The team implemented a patient education process of nurse sick-line symptom management and same-day sick visits at RIH CCC as well as developing a single-page patient “sick-line tool” with oncology nurse sick-line contact telephone numbers. A patient navigator introduced the sick-line tool at the first visit and its usage was reinforced at subsequent visits. Results: For RIH CCC lung cancer patients, a standardized symptom-control education process correlated with 30% decrease in ED visits for any presenting complaint (42 visits vs. 60 visits) and 32% decrease in ED visits with presenting complaint of pain (13 visits vs. 19 visits) during January/February 2014 compared to January/February 2013. We did not find significant differences between the proportion of ED visits during Cancer Center business hours, evenings, or weekends. Sick-line calls were found to increase by 53% during January 2014 compared to December 2013 with an additional 35% increase in February 2014. Conclusions: A standardized patient education process resulted in a significant decrease in ED visits, concurrent with an increase in outpatient sick-line utilization. This may reflect an improvement in efficiency of outpatient cancer patient care in a single-institution setting. Given other reports of increased ED utilization by lung cancer patients for similar presenting reasons, these improvements may be generalizable to other institutions.
Improving telephone management of patient clinical concerns.
Authors: Sudheendra Preeti , Gilbert Beth , Gillespie Dawna , Coniglio Mary , Evans Tracey L. 
Published: February 2017

137 Background: As the majority of oncology care is delivered in the ambulatory setting, patients and families require reliable and efficient ways to contact the care team with clinical concerns. The Abramson Cancer Center is comprised of 40 medical oncologists seeing over 100,000 annual outpatient visits. Press Ganey phone access satisfaction scores in the 12th percentile reflect patient dissatisfaction with phone communication. We initiated a pilot project to improve phone access. Methods: Baseline data was collected from 3 main sources of patient calls: intake office, administrative assistants, and triage RN’s. Over 2,000 patient calls were tallied during a one week period documenting: time of call; live answer vs voice mail; reason for call; whether and to whom the call was transferred. A subset analysis of calls related to symptom/medication management (SM) was performed via EMR audit to determine: time to call resolution (TTR), % resolved within 2 hours, % documented in the EMR, and % answered live. The TTR of patient SM calls and % resolved in < 2hrs were calculated by comparing the time of call receipt per log to the time of closed phone encounter in the EMR. The percent of calls documented was determined by comparing the call log to corresponding EMR encounters. The percent answered live was determined by review of the call log. As a pilot test of change, all calls in one of the practices were forwarded to a single source (intake office) to ensure live answer. The staff was educated to create an EMR encounter for each SM call and then route the encounter to a clinical pool (RN, APP and MD). An automated report enabled monitoring of key metrics. Results: The goals set for the pilot project were exceeded for 2 of the 3 performance metrics (Table). Conclusions: Within a complicated academic health system, we utilized our EMR and modified our phone triage system to streamline and reduce variation for management of SM calls. 62% of these calls were resolved within 2 hours, and the mean time to resolution of SM calls was reduced from 127 to 87 minutes. [Table: see text]
An assessment of neoadjuvant therapy for breast cancer and treatment wait times at the BC Cancer Agency Vancouver.
Authors: Adilman Rachel , Leonard Robyn , Poonja Zia , Simmons Christine E. 
Published: February 2017

140 Background: Neoadjuvant therapy (NAT) is widely considered to be the standard of care for patients diagnosed with locally advanced breast cancer (LABC) or inflammatory breast cancer (IBC). NAT is also considered in patients with more aggressive subtypes (Her2+ or triple negative cancers). However, it remains unclear which patients are being considered for NAT, which patients are indeed receiving NAT, and how long the current wait times for chemotherapy and hormone therapy are in this patient population. This study was designed to characterize the breast cancer patients being referred to the BC Cancer Agency (BCCA) Vancouver’s NAT clinic, and to determine the average wait times for chemotherapy and hormone therapy in these patients. Methods: Between May 13th, 2013 and June 3rd, 2014, a total of 160 potential NAT candidates were seen at the BCCA Vancouver NAT clinic. Breast cancer characteristics and wait times for these patients were assessed prospectively using a secure database. Results: Of these 160 patients, 119 (74%) actually received NAT; 76.7% of these were deemed LABC patients (clinical stage IIB or III), and 6% were “window of opportunity” (WOP) patients (those considered for NAT due to long surgical wait times). NAT patient receptor status differed significantly from the receptor statuses of patients who did not receive NAT (p=0.006), with Her2+ and triple negative breast cancer patients being most likely to receive NAT. Seventy-eight percent of ER+Her2+, 86% of ER-Her2+, 67% of ER+Her2-, and 80% of triple negative patients received NAT. A total of 4 patients (2.5%) presented in clinic with metastatic disease and thus were not considered for NAT. The average wait time between when a patient was referred to the BCCA and when they commenced chemotherapy was 18.1 days (median: 16), while the average wait time to receive hormone therapy alone was 12.3 days (median: 10). Conclusions: These findings suggest a need to expedite screening and care for these high-risk breast cancer patients in order to characterize and treat the disease neoadjuvantly before it has metastasized. Strategies to reduce wait times in this breast cancer population are being further assessed.
Mobile solution for clinical research documentation.
Authors: Philip Lindsay , Grant Jasmine , Eggert Calven , Di Nardo Aaron , Sellmann Susanna , Cole Heather , Flynn-Post Marcia , Williams-Brennan Leslie , Degendorfer Pamela 
Published: February 2017

153 Background: As trial complexity increases, there is a growing need to facilitate rapid communication of trial data among members of the research and clinical care teams. Timeliness of investigator review and high quality data are critical to clinical trial documentation. Princess Margaret developed an electronic application that meets these needs, is integrated into a patient’s medical chart, and is accessible at the point of care on a mobile device. Methods: Focus groups were held with research staff to evaluate application and device needs. Device needs were usability, compatibility with the electronic patient record (EPR), and encryption ability, which were considered and a device was selected. Standard templates were developed for the informed consent process, clinical notes, vital signs, baseline symptoms, adverse events, and concomitant medications. Electronic source (eSource) was linked to an existing CTMS, the Clinical Research Record. eSource is accessible via the EPR, allows for electronic review and sign off by investigators, and allows data capture directly into the EPR from a mobile device. Results: A 4 month pilot was completed in December 2013 with 10 clinical research nurse coordinators (CRNCs) from 3 different treatment areas, enrolling 40 patients. The project continues to roll out and will be completely integrated by July 2014. CRNCs enter information at the point of care that is easily shared amongst research and clinical care teams; important safety information is available to all staff; investigators can sign off electronically; and data has an audit trail. Metrics collected over a two-month span demonstrate average investigator sign off is completed within 7 days, well under our established timelines of within a cycle of treatment. Conclusions: Enhancements were made within the system during the pilot to facilitate workflow as issues were identified. The system provides solutions for delayed documentation, the transfer of paper charts between team members, and investigator sign-off. This has allowed for tracking of metrics including the timeliness of documentation, review, and sign off; and quality improvements to documentation will be measured through internal quality assurance reviews.
Using tablet technology in routine patient-reported outcome measure surveys to improve cancer quality care: A patient acceptability assessment.
Authors: Pat Vivien , Brown Catherine , Vennettilli Ashlee , Zarrin Aein , Dobriyal Aditi , Chen Linda , Mirshams Maryam , Patel Deval , Hon Henrique , Irwin Margaret , Ho Anthea , Solomon Hannah , Tiessen Kyoko , Mahler Mary , Ho Valerie , Thai Henry , Eng Lawson , Xu Wei , Howell Doris , Liu Geoffrey 
Published: February 2017

155 Background: Patient-reported outcome measure (PROM) surveys are a tool used to collect information about clinically-relevant symptoms in patients. Touch-screen technology has been previously identified as a feasible and effective method of routinely capturing PROMs.Our aim was to evaluate cancer patients’ acceptance and perception of usefulness of tablet technology as a means of communicating PROMs to healthcare providers during delivery of quality care. Methods: 337 adult cancer patients across all outpatient clinics and disease sites at Toronto’s Princess Margaret Cancer Centre (PMCC) completed PROMs surveys using touch-screen technology. Acceptance and feasibility of completing the tablet-based PROMs data on a routine basis were also assessed. Results: The study population consisted of 45% males; median age 59 (19-91) years; 75% Caucasian, and 48% had a post-secondary degree.20% had lung cancer, 20% genitourinary, 16% breast, 16% lymphoma, 11% gastrointestinal, 7% gynecologic, and 7% head/neck. 88% were happy to complete the survey on a touch-screen tablet and 65% of these were willing to complete such surveys routinely. 86% did not find it time-consuming. Only 2% found that the completion of surveys made their clinic visit more difficult. Of the 72% that thought the survey was a useful means to inform the clinician of how they felt physically and emotionally, only 81% were willing to complete the survey at every visit. Conclusions: Tablet-technology was found to be an acceptable tool for survey administration, however, not on a routine basis. While the majority of patients found PROMs to be clinically important, almost 20% did not want to fill it in regularly at every visit. Current mixed-methods analysis is being utilized to help discern whether this discrepancy is related to the tablet technology or survey burden.
A strategic roadmap for oncology electronic medical records (EMRs) in Ontario’s complex multiregional health care system.
Authors: Kukreti Vishal , Yardley Tim , Derman Yaron , Kennedy Margaret , Dhoot Rummy , Melamed Saul , Gilks John 
Published: February 2017

159 Background: Ontario’s cancer system comprises 14 regions; from large and sparsely populated to dense urban areas. Each region, and the hospitals within it, is responsible for its own IT solutions to support oncology. In 2011 Oncology EMRs in 4 regions were funded as there are no oncology specific Health Information Systems (HIS). Cancer Care Ontario (CCO) also obtained funding to develop standards, and a roadmap for their use, from eHealth Ontario. Methods: Early work focused on establishing standards based on the integrated patient cancer journey. Work-streams included functional standards, an interoperability framework for CCO tools and provincial assets and information standards to be supported through EMRs. These were evaluated through internal and external review and validation processes. The strategic IT roadmap was developed via interviews with leaders in the clinical, management and IT domains to obtain input on how the standards might be used and what role CCO should play. Results of the consultations were consolidated into key themes and validated through a facilitated workshop with an expert panel. Results: Standards can be incorporated into EMRs in a consistent way by basing the design around the patient journey and by working with the point of care tools that clinicians need to support accurate, timely and relevant data at each stage of the patient journey. This approach is location and vendor neutral. Focusing on the data needed at point of care provides insight into reporting needs and how data can be exchanged between systems; directly, via a provincial repository or via CCO provided tools. CCO’s role should be to provide support to the regions through standards and advocacy with stakeholders rather than development of tools. Conclusions: Oncology has unique IT needs that may not be fully incorporated in hospital wide IT strategic plans or decisions. The standards and roadmap provide a basis for oncology programs to ensure that IT decisions meet their needs. The role of CCO should evolve toward strategic counsel and advocacy rather than provision of IT tools.