bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bridging efforts to longitudinally improve and evaluate venous thromboembolism prophylaxis uptake in hospitalized cancer patients through interprofessional teamwork (BELIEVE IT): A study by Princess Margaret Cancer Centre.
Authors: Seki Jack Toshimine , Vather Triyu , Kukreti Vishal , Krzyzanowska Monika Karolina 
Published: February 2017

170 Background: Thromboprophylaxis continues to be underutilized in hospitalized cancer patients despite the demonstrable risk of venous thromboembolism (VTE). Our study evaluated institutional VTE prophylaxis rates after devising a series of strategic interventions to longitudinally improve adherence rates over a period of eight years. Methods: Solid tumour patients admitted between 2004 and 2012 were selected as the primary study population for analysis. The bleeding risk associated with thromboprophylaxis was discernibly minimal. Guidelines were developed and formalized into an institutional thromboprophylaxis policy. Educational in-services were provided to physicians, nurses and pharmacists to review the most updated guidelines and tools added to encourage compliance to VTE prophylaxis. Support also arose from clinical members of the Cancer Quality Committee. An amalgamation of manual and electronic audit formats were undertaken to asses VTE prophylaxis rates prior to, and following strategy implementation. These audit formats either comprised of visiting inpatient units and examining anticoagulant orders on a per-patient basis, or viewing patient consensus reports and active anticoagulant orders electronically. Results: At the 2004 outset, 11 (19.3%) patients received appropriate pharmacological prophylaxis, and thus formed the baseline of our analysis. Post-2009 policy implementation and educational sessions, 46.5% of an eligible 185 inpatients were administered thromboprophylaxis. Following a two-year grace period to allow for policy acceptance, a series of three audits were conducted in 2011 for which an average prophylaxis rate of 62.3% resulted. In 2012, following awareness by clinicians of previous rates and rigorous strategy execution, a 96.7% rate was achieved and maintained five weeks thereafter. Conclusions: A reproducible 96.7% prophylaxis rate was the result of our cumulative eight-year efforts. A multidisciplinary approach is critical to improving thromboprophylaxis uptake rates and ensuring long-term sustainability of this outcome.
Safe chemotherapy: Clinicians driving technology and not the other way around.
Authors: Kukreti Vishal , Cosby Roxanne , Cheung Annie , Hamasoor Marie , Hertz Sherrie , Kaiser Leonard , Lankshear Sara 
Published: February 2017

183 Background: Although information technology (IT) has the potential to improve the quality and safety of patient care, introduction into the clinical work flow may create unanticipated consequences. IT solutions such as computerized physician order entry (CPOE) are often designed and executed without end-user involvement. An evidence based guideline for systemic treatment (ST) CPOE was developed. The guideline looks at the features, functionalities and components of a ST CPOE system required to ensure safe and high-quality care. Methods: The guideline was developed by an interdisciplinary panel of physicians, nurses, pharmacists, methodologists, IT specialists, and human factors experts. A systematic review was conducted of the available clinical and technology literature and key informant interviews were conducted. Role-specific CPOE functionalities were process mapped for physicians, nurses and pharmacists. Two expert panels (i.e., clinical and supporting tools) were convened to review the information and provide feedback on guideline content. The guideline was also reviewed externally by content experts from provincial, national and international organizations. Results: The resulting evidence-based guideline focused on two distinct yet interconnected parts: clinical practice (e.g., error prevention, unanticipated consequences, impact on practice, clinical decision support), and technology requirements (e.g., usability features, system integration, effective alerts, audit logs, regimen building). The recommendations also highlight the importance of change management strategies and clinician engagement. Conclusions: This innovative guideline provides an approach to technology evaluation focusing on clinical practice needs driving IT solutions. Future research to help standardize design and usability of such systems is necessary. The non-vendor specific recommendations can be used as the foundation for evaluation of ST CPOE systems to reduce errors, improve safety, and support clinical practice. The application of the recommendations as an assessment of ST CPOE system guideline concordance will also be valuable.
The future delivery of oncology care: Thoughts on the impact of quality improvement, personalized medicine, and integrating interprofessional collaboration.
Authors: Robinson Caroline Osborne , Abdolrasulnia Maziar , Nevins Holder , Ruggiero John E. 
Published: February 2017

19 Background: A significant thrust within recent innovation has been focused on improving the quality of diagnostics and system adherence to guidelines; equally important are attempts to improve patient-specific therapy plans, or personalized medicine. These two approaches—quality improvement and personalized medicine—have equally laudable goals toward improving cancer care and outcomes, yet have not been fully examined for their concomitant impacts, particularly among and within interprofessional teams, in which a mix of health care providers present varied foci within the oncology care delivery process. Methods: Twenty phone-based qualitative interviews were facilitated with community-based medical oncologists in active practice in July 2012. Transcripts of the interview sessions were examined through grounded qualitative analysis, and overall findings are presented. Results: Oncologists hold varied definitions of personalized medicine, yet share understanding of the central nature of the patient within personalized medicine care delivery. More varied are oncologists’ perceptions of the goals and value of implementation of quality improvement initiatives, which range from those focused on pragmatic concerns of the oncology clinic, such as patient flow, to the quality of clinical decision-making and outcomes. Oncologists value well-functioning and clearly defined roles within interprofessional teams within oncology practices, both among other clinicians and allied team members. However, functional and perceptional gaps remain in the practical application of quality improvement objectives within interprofessional teams and within the implementation of personalized oncology care delivery. Conclusions: This exploratory qualitative analysis approach provides grounded identification of practicing oncologists’ definitions of quality improvement, personalized medicine, interprofessional care delivery, and the practical interrelationships between these domains, enabling a framework for future research and quality initiatives.
De-adoption of epidermal growth factor receptor (EGFR) inhibitors following recommendations for KRAS testing to guide treatment of metastatic colorectal cancer (mCRC).
Authors: Dotan Efrat , Li Tianyu , Hall Michael J. , Meropol Neal J. , Beck Robert J. , Wong Yu-Ning 
Published: February 2017

191 Background: KRAS mutation status is a predictive biomarker for resistance to EGFR antibodies among mCRC pts, and is recommended for use by ASCO and the FDA. Little is known about the uptake of clinical recommendations in oncology practice. We sought to study the effect of ASCO and FDA guidelines on the use of EGFR antibodies among a commercially insured population. Methods: The LifeLink Health Plan Claims Database (formerly the PharMetrics Patient-Centric Database) was used to create a cohort of >18 yo mCRC pts treated between 2004-2010. We identified treatment and diagnosis using ICD-9 or HCPCS (J) codes. We defined 1st-line therapy as any chemotherapy +/- bevacizumab given after the pt had a claim for mCRC, excluding pts treated with EGFR antibodies in the 1st line. 2nd-line therapy was defined as the initiation of a new chemotherapy agent (irinotecan/oxaliplatin) +/- EGFR antibody. We examined pts in two-month time intervals and calculated the fraction of pts in each interval who received EGFR antibody at any point beyond their 1st-line treatment. Chi 2 tests were used to compare treatment rates at the time points shown in the Table. Results: 5,099 pts received 2nd-line therapy of which 2,603 pts received an EGFR antibody. Median age was 61 years, with 57% males. 59% received an EGFR antibody as a single agent. The remainder received this in combination with one or more of the following agents: fluorouracil 13.5%, irinotecan 36.7%, oxaliplatin 3.9%, and bevacizumab 6.1%. Rates of EGFR antibody use are outlined in the Table. Conclusions: The utilization of EGFR antibodies for mCRC treatment decreased following the presentation of clinical trial data, publication of ASCO guidelines and FDA label change. These data suggest that oncologists respond rapidly to new evidence and professional guidelines, and readily accept the use of predictive biomarkers in clinical practice. [Table: see text]
Adherence to head and neck cancer guidelines: Setting the stage for continual quality improvement.
Authors: Nurgalieva Zhannat , Weber Randal S. , Lai Stephen Yenzen , Sturgis Erich M. , Beadle Beth Michelle , William William , Lewis Carol M. 
Published: February 2017

193 Background: Adherence to clinical guidelines, such as those developed by the National Comprehensive Cancer Network (NCCN), can serve as a quality measure for delivered care. We aimed to assess multidisciplinary conference (MC) treatment recommendations’ adherence to NCCN head and neck cancer guidelines, while identifying potential areas for quality improvement. Methods: Patients presented with previously un-treated head and neck cancers are being prospectively accrued as they are presented at weekly MC. The charts of patients presented between 10/20/2011 and 6/31/2012 were retrospectively reviewed for clinical data leading up to MC to allow us to assess whether, based on the available information, the recommendations of conference are compliant with NCCN treatment guidelines. Results: We identified 231 eligible patients. TNM staging was documented in 90.9% of MC notes and treatment recommendations were documented for 93.5% of patients; the remainder of presented patients required further evaluation before a treatment plan could be determined. Of 196 enrolled patients, 53% had oropharyngeal cancer, 25% had oral cavity cancer, 18.4% had laryngeal cancer, and 3.6% had nasopharyngeal cancer. For the entire cohort, the mean age at presentation was 59.5 years. One hundred fifty nine patients (81.1%) were men. The recommendations of conference were compliant with NCCN treatment guidelines for 92.3% patients. The main reasons for non-compliance in 15 patients were treatment of T1/2N2 oropharyngeal cancer with definitive radiation alone (6 patients), incomplete documentation (4 patients), and recommended over-use of adjuvant therapy (3 patients) and induction chemotherapy (2 patients). Conclusions: NCCN guideline compliance can be used to evaluate the quality of head and neck cancer care. Although most cases involving deviation resulted from incomplete MC documentation, areas for improvement were identified. Further study is needed to evaluate how care that deviates from NCCN guidelines affects patient outcomes.
The impact of “significant others” on breast cancer patients’ treatment decision making.
Authors: May Suepattra G. , Rendle Katharine , Halley Meghan , Ventre Nicole , Kurian Allison W. , Yu Peter Paul 
Published: February 2017

20 Background: Shared medical decision making (SDM) has been lauded by advocates for its potential to democratize the patient-physician relationship. However, the practice of SDM is still conceived of as largely a dyadic moment that exists between the patient and the physician. Few studies have looked at the role of significant others (spouses, partners, family members and friends) in decision making or considered how discussions and actions outside the consultation room affect a patient’s medical decisions. This prospective study investigated the impact of significant others on the decision making deliberations of newly diagnosed breast cancer patients. Methods: Forty-one newly diagnosed breast cancer patients were interviewed at four critical time points throughout treatment to explore how they deliberated decisions with both care providers and significant others. Surveys assessing HRQOL, role preferences and treatment satisfaction along with EHR abstraction augmented interview data. Grounded theory analysis was used to identify recurrent themes in the qualitative data, and survey data were analyzed using IBM SPSS Statistics 20. Results: Emergent themes from our analysis identified several factors that patients consider when faced with cancer treatment decisions, including 1) presentation of treatment options 2) patient or significant other conflict/concordance with care team recommendations 3) perceived risk of recurrence and 4) short and long term impact of treatment on daily life. Participants stressed the need for clinicians to view patients beyond diagnosis and recognize their larger care network as influential factors in their decision making. Conclusions: Our interviews highlight how the current healthcare delivery structure rarely acknowledges the circles of care that can exert influence on decision making. Lack of attention to non-clinical others can lead to sub-optimal medical decision making because these influences are not adequately understood by clinicians. Findings from this study suggest the need to enhance clinicians’ and researchers’ understanding of the influence of others in patients’ treatment decision making, enabling them to intervene in these practices.
Quantification of the impact of multifaceted improvements in patient safety culture: A case study from academic medical center radiation oncology department.
Authors: Chera Bhishamjit S. , Maszur Lukasz , Mosaly Prithima , Jackson Marianne , Taylor Kinely , Burkhardt Katharin , Chang Sha , LaChapelle Dana , Rockwell John , Miller Seth , Zagar Timothy , Jones Ellen , Church Jessica A. , Adams Robert D. , Marks Lawrence Bruce 
Published: February 2017

205 Background: We have systematically been incorporating several safety initiatives (based on process-engineering and Lean methodologies) into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful metrics. Methods: The data from five quality improvement initiatives are presented. For each, data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using descriptive statistics and unpaired student t-test. Each initiative focused on a specific safety/process concern in our clinic. Results: 1) Workload levels for nurses assisting with brachytherapy were too high (NASA task load index scores >55-60, suggesting, “overwork”). Changes in work flow and procedure room layout reduced workload scores to more acceptable limits (<55). 2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range 1-11) times per patient treatment to a mean < 1 (range 0-3, p<0.001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (e.g., delayed, on time). 3) The rates of replans by dosimetrists was reduced from 11% in 2010 to 6% in 2011 though a more systematic pre-treatment peer review process. 4) Standardizing nursing/resident functions reduced patient wait times by ≈ 45% (14 min). 5) Standardizing pre-simulation instructions from the physician within the EMR reduced the number of patients experiencing delays on the simulator (from approximatley >50% to <10%). Conclusions: Process engineering and Lean methodologies can be successfully applied in an academic radiation oncology department to yield measurable improvements in operations likely improving quality/safety.
Persistence of quality improvement in a Veterans Affairs (VA) academic practice assessed by Quality Oncology Practice Initiative (QOPI).
Authors: Kiernan Kathleen L. , Williams Christina D. , Kamal Arif , Kelley Michael J. 
Published: February 2017

209 Background: The success of quality improvement (QI) efforts is usually assessed initially within a year of implementation but performance may later decline. We sought to determine the longer-term effectiveness of practice improvement interventions and the characteristics of interventions associated with persistent improvement. Methods: The Durham VA Hem-Onc fellowship program affiliated with Duke University participated in QOPI twice yearly in 2007 to 2010 and Spring (Sp) 2012. Four interventions were implemented focused on treatment planning (TP; Sp07), treatment summary (TS; Fa07), consent (C; Sp07), and aprepitant use (A; Sp09). Effectiveness was determined by reassessment of 4, 3, 1, and 1 measures, respectively. The TP, TS, and C interventions were policy-dictated use of templated documentation or written consent, and, for TP and C, required conformance prior to chemotherapy administration; TS is not linked to a process. The A intervention modified order set templates to include A for highly emetogenic regimens. For each measure, we compared conformance pre-intervention with post-intervention conformance and, for quality indicators not targeted for improvement, the baseline with each subsequent assessment using chi-square. Results: Considering only measures in the core or symptom management modules with unchanged or similar definitions throughout the study period, 13 of 28 measures had conformance > 85% in the baseline 2007 data. TP conformance increased from 64% to 88, 94, 92, and 96% in subsequent years (p < 0.01). TS was 45% at baseline, 43% (p = NS) in the first post-intervention year, decreased to 24% for two years (p < 0.01) and then increased to 38% (p = NS). C increased from 64% to 97, 91, 94, and 100% (p < 0.01). Conformance with A increased from 9% to 78 and 86% (p < 0.01). Among measures not targeted by intervention, smoking assessment and counseling increased in later years. Conclusions: In this single practice experience, QI improvement interventions integrated into physician processes resulted in substantial and persistent improvement while no improvement was observed as a result of policy-required use of standard documentation alone.
Concordance and disease type variables between adjuvant chemotherapy (AC) recommended and received as assessed by the Quality Oncology Practice Initiative (QOPI).
Authors: Jacobson Joseph O. , Kadlubek Pamela , Malin Jennifer L. , Solem Caitlyn T. , Neuss Michael N. 
Published: February 2017

214 Background: AC is indicated following curative-intent surgery for common solid tumors to reduce the chances of recurrence. Limited data are available to assess discrepancies between potential eligibility for chemotherapy, treatment recommendation and actual administration. For patients with completely resected early stage breast (BC), colorectal (CRC), and nonsmall lung cancer (NSCLC), QOPI assesses patient eligibility for AC, measures the rates of chemotherapy recommendation and administration. This analysis seeks to assess concordance between these measures and to explain differences. Methods: QOPI data are submitted by practices into a web-based system and stored as a relational database. For all categorical variables, frequency, and percent are presented. Concordance is shown as a rate—percent of charts eligible divided by those that met criteria. χ2tests were used to compare rates of recommended/received chemotherapy across cancer types. Results: Data were merged for 30,126 patients from the Fall 2011 and Spring 2012 QOPI collection periods. The analysis was limited to BC, CRC, and NSCLC patients for whom AC was clinically indicated by disease type and stage (eligible patients). Conclusions: Oncologists recommend AC with a high degree of predictability for eligible patients with BC and CRC, but at a lower rate for patients with NSCLC. Eligible NSCLC patients receive AC at a rate far lower than BC and CRC patients; these lower rates are due to patient refusal and medical contraindications. Patient factors such as consent and comorbidity must be considered in establishing quality measure benchmarks as they vary significantly among disease type. [Table: see text]
Quality of adjuvant chemotherapy in stage III colon cancer.
Authors: Krzyzanowska Monika Karolina , Gao Julia , He Helena , Hertz Sherrie , Kukreti Vishal , Kaizer Leonard 
Published: February 2017

228 Background: The goal of the Systemic Treatment Program at Cancer Care Ontario is to ensure equitable access to high quality systemic therapy for all patients in Ontario. To provide information on performance and inform planning we evaluated the quality of care in stage III colon cancer pertaining to adjuvant chemotherapy using multiple indicators focusing on access, guideline concordance and toxicity. Methods: Patients with stage III colon cancer in 2010 were identified from the Ontario Cancer Registry then linked with several other health administrative databases to obtain information regarding wait times, consultation with medical oncology, receipt of guideline concordant adjuvant chemotherapy and treatment related toxicity. Results: In 2010, 1,133 patients were diagnosed with stage III colon cancer in Ontario of whom 49% were women and 60% were older than 65. 92% of patients were seen by a medical oncologist within four months of diagnosis. Among patients seen at one of the regional cancer centres, 56% consulted with an oncologist within the provincial target of 14 days from referral. Overall, 47% of patients received oxaliplatin-based adjuvant chemotherapy therapy; 70% of those younger than 65 versus 34% of those older than 65. Among patients older than 65 on whom information regarding oral chemotherapy use is available in Ontario, 58% received adjuvant chemotherapy (59% oxaliplatin-based, 41% capecitabine). With respect to timeliness of adjuvant chemotherapy, 85% of patients received chemotherapy within 120 days from diagnosis, 57% started treatment within 60 days of surgery and 61% started within 28 days of consultation with a medical oncologist. Among patients who received oxaliplatin based adjuvant chemotherapy, 42% had at least one ER visit and 18% at least one hospital admission during adjuvant treatment. There was evidence of geographic and age-based variation across multiple indicators. Conclusions: While good quality was observed for several of the indicators examined, opportunities for improvement were identified in access to treatment and toxicity management. Evaluating multiple indicators in the same population provides a broader perspective on quality facilitating a focused, efficient approach to improvement efforts.