bluuebunny/crossref_metadata_2025_split huggingface dataset:
Quantifying the psychosocial needs of cancer patients and associated provider workload to build PSO services into the funding model for systemic treatment in Ontario.
Authors: Zwicker Victoria , Andrien Tory , Blais Irene , Green Esther , Ismail Zahra , Kaizer Leonard , Lalonde Carlin , Simanovski Vicky , Tabing Reena 
Published: February 2017

18 Background: As part of a broader set of provincial health funding reforms, Cancer Care Ontario (CCO) developed a new funding model for systemic treatment. A decision was made to build dedicated funding for psychosocial oncology (PSO) services into the model. The objective of this work was to estimate the psychosocial needs of cancer patients and the associated PSO provider workload to inform the incorporation of these services into the model. Methods: PSO clinicians formed advisory groups for six disciplines: social work, psychology, nutrition, physiotherapy, occupational therapy, and speech language pathology. For each cancer type, treatment intent, and phase of the cancer journey, advisors were asked to estimate: 1) proportion of patients who need services, 2) length of an average visit, and 3) average number of visits needed to address patient needs. Groups utilized online surveys to generate estimates to serve as a starting point for discussion. Evidence was used to inform the advisory groups’ consensus when available. Results: Each group produced recommendations based on estimated patient needs and associated workload. For example, the dietitian group recommended that prior to beginning systemic treatment, 50% of lung cancer patients receive a first consult visit (~75 minutes), followed by 1-2 follow up visits (~30 minutes each). Direct activities for these visits included nutrition assessment, weight loss management, and managing symptoms such as dysphagia. Indirect activities included documentation, chart review, and making referrals. Conclusions: This was an initial attempt to measure PSO workload based on patient needs, and the consensus process used could be leveraged by other jurisdictions. This work allowed the identification of specific funding for PSO services for patients who undergo systemic treatment in Ontario. Limitations included a lack of rigorous evidence and the complex nature of the funding model. Further efforts are underway to refine the recommendations and to leverage this work for quality improvement purposes.
Assessing the true nature of unplanned cancer care.
Authors: Tamang Suzanne , Patel Manali I. , Finlayson Sam , Chen Xuemei , Kuznetsov Julie Lawrence , Blayney Douglas W. , Shah Nigam 
Published: February 2017

183 Background: Unplanned care can result in poor outcomes that are potentially preventable. The design of effective interventions to improve outcomes for cancer patients requires a better understanding of the true nature of unplanned care. Although cancer care teams document each patient’s care trajectory in detailed free-text notes, care outcomes are typically measured from structured patient record data and do not contain key information necessary for quality improvement efforts, such as the etiology of emergent events, or events that occur at outside facilities. To inform clinical effectiveness work at Stanford’s Cancer Institute, we describe our application of text-mining to improve the assessment of post-diagnosis morbidity outcomes. Methods: We conducted a retrospective study of unplanned care among 3,318 patients with a new diagnosis of breast, gastrointestinal, or thoracic cancer during 2010-13. Using a validated framework for clinical text-mining, we analyzed 308,000 notes for two tasks. First, we extract information on external unplanned events that are documented by providers. Second, we profile symptom mentions in Emergency Department (ED) notes. Results: For all cancer patients, text-mining detected over 400 unplanned events (93% PPV) at outside facilities, resulting in patient rates of 5% in the first 30 days, and 11% up to one year post-diagnosis. Among breast cancer patients, the top three symptoms reported in ED notes are pain (89%), nausea (37%) and fever (18%). Pain is consistently the most prevalent symptom up to one year after diagnosis, other symptoms exhibit more dynamic trends; wound related disorders and nausea are more prevalent among ED admissions in the first three months, whereas fever, cognitive impairment and mental health issues become more prevalent among admissions after the first three months of cancer care. Conclusions: The application of text-mining methods can improve the quantification of morbidity outcomes by improving the estimation of unplanned care rates and by providing continued learning for symptom-driven interventions to mitigate preventable emergent care. Although additional information gaps in care trajectories may continue to exist, text-mining can aid in assessing the true nature of unplanned care.
Developing and evaluating composite measures of cancer care quality.
Authors: Samuel Cleo A , Landrum Mary Beth , Zaslavsky Alan M , Lorenz Karl A. , Keating Nancy Lynn 
Published: February 2017

187 Background: Composite measures are useful for distilling quality data into summary scores; yet, there has been limited use of composite measures for cancer care quality measurement. We compared multiple approaches for generating composite measures of cancer care quality and evaluated how well composite measures summarize dimensions of cancer care and predict survival. Methods: We computed hospital-level rates for 13 colorectal, lung, and prostate cancer process measures for care delivered in 59 Veterans Affairs (VA) hospitals between 2001-2004. We generated 3 sets of composite measures: 3 cancer-specific composites (colorectal, lung, prostate), 3 care-modality-specific composites (diagnosis, surgery, non-surgical treatment), and 4 empirical-factor domain composites based on an exploratory factor analysis. We assessed correlations among all composite measures and estimated separate Cox proportional hazards models predicting all-cause survival for colon, rectal, non-small cell lung, and small cell lung cancers as a function of composite scores, controlling for patient clinical and demographic characteristics. Results: Four factors emerged from the factor analysis and accounted for 68.7% of the total variation in the cancer care measures. The factor domains included a combination of cancer-specific factors for "colorectal early diagnosis" and "prostate treatment" and care-modality-specific factors for "surgical treatment" and "non-surgical treatment.” We observed strong correlations (r) among composite measures comprised of similar process measures (r=.58 to 1.00, p<.0001), but not among composite measures reflecting different care dimensions. Across the different approaches, few composite measures were associated with survival. Conclusions: Each of the composite measure approaches examined reflected different aspects of cancer care quality, with the empirical-factor domains reflecting a combination of cancer-specific and modality-specific care domains. However, there was little evidence pointing to a single best approach for cancer care composite measurement. Weak associations across different care domains suggest that low- and high-quality cancer care delivery may coexist within VA hospitals.
Evaluation of radiation oncology workflows to optimize efficiency and ensure sufficient time for quality assurance testing.
Authors: Weintraub Sheri , Schofield Deborah , Scott Amanda , Carnes Samuel , Vinson Desiree , Kumar Tushar , Gagnon Patrick James , Herrick Beth , Ventura Deborah , Astle Lindsay , Mulvey Therese M. , Andrade Urszula 
Published: February 2017

193 Background: Radiation treatment plan development involves many people throughout the various stages of the planning process. Delays at any point can result in compressed timeframes for final checks which can thereby threaten the quality and safety of the plan. We have used six sigma tools to establish goals, monitor delays, and to provide a framework for efficiency improvement. Methods: A team of physicians, physicists, dosimetrists, and therapists established time goals and broke the planning workflow into critical to quality elements. It was determined that contouring tasks shall be completed within 2 days of simulation and treatment plans shall be ready for final checks a minimum of 4 or 8 business hours prior to treatment (for 2-5 days or > 5 days from simulation to treatment respectively). Emergent patients were excluded. Time measurements were calculated based on plan upload time and the patient’s scheduled start time. Delayed starts were accounted for to ensure that improved compliance was not at the expense of such delays. Six sigma methodology was used to perform a failure modes and effects analysis and to identify the most significant workflow challenges. Results: Baseline data involving 34 patients was collected. Only 73.5% of these patients complied with the established time goals. From the six sigma process, it was determined that physicians’ schedules were a major contributor to compliance failures. Enhancements were made in physician scheduling and communication with staff. Over the following 6 months, 129 additional patients were evaluated and 89.1% were in compliance with the set time goals. This was a statistically significant improvement (P-test, p=.052). Delayed patient starts made up 5.9% of the baseline data and 6.2% of the 129 additional patients. There was no significant change in these delays (Fisher’s exact test, p=1.000). Conclusions: Our findings validate the employment of six sigma practice in improving workflow. Continued efforts will be employed to ensure consistent quality improvement.
Getting quality data back to frontline providers.
Authors: Barry-Weers Anne , Huibregtse Carol , Ihde Sue , Bjegovich-Weidman Marija , Weese James L. 
Published: February 2017

196 Background: Oncology quality performance metrics may be improved by establishing a coordinated process for getting data back to providers. However, establishing ownership of quality metric data can be a challenge, especially in a large, integrated health system. Methods: Aurora Cancer Care’s team developed quality charters and a coordinated process for its 15-hospital, integrated health system that outlines a course of action for metric selection, data distribution, peer review and development of process improvement plans. A weighted tool was developed and implemented to prioritize measure selection. The weighted tool described and scored each quality measure against its performance improvement opportunity, ease in data collection, national benchmarks, regulatory and reimbursement impact, value to the patient and consideration of the resources required to implement change. The final score was used to prioritize and select measures. The System Multidisciplinary Disease-Specific Quality Subcommittees established quality measures. Abstraction began, outliers were reviewed and results were disseminated to the System Cancer Leadership Council as well as the 15 hospitals via the Regional Cancer Quality Subcommittees (RCQS). The RCQS chairs and quality directors meet quarterly with the system quality liaison to ensure the communication of data back to the front-line providers. Results: We found a rise in the percentages of invasive rectal cancers diagnosed with endorectal ultrasound or magnetic resonance imaging (no stage IV) (2012: 76%, 2013: 84%) and treated with total mesorectal excision (no stage IV) (2012: 72%, 2013: 87%). In addition, increases in the examination of at least 12 regional lymph nodes for invasive colorectal cancer (2012: 93%, 2013: 98%; p<0.05) and partial, rather than total, nephrectomy for renal cancer patients with T1a tumors (2012: 71%, 2013: 95%; p<0.05) were statistically significant. Conclusions: Though our coordinated process to get quality data back to providers continues to evolve, our front-line providers have shown greater enthusiasm for the data, engaged in behavior modification and become more accountable with process improvement plans that are integral to establishing the best patient outcomes.
Effect of physical activity (PA) perceptions in cancer survivors on PA behaviors: Helping health care providers improve patient communication.
Authors: Naik Hiten , Liu Geoffrey , Qiu Xin , Pringle Dan , Brown Catherine , Eng Lawson , Mahler Mary , Hon Henrique , Tiessen Kyoko , Thai Henry , Ho Valerie , Gonos Christina , Charow Rebecca , Pat Vivien , Irwin Margaret , Herzog Lindsay , Ho Anthea , Jones Jennifer M. , Xu Wei , Howell Doris 
Published: February 2017

201 Background: While engagement in PA can lessen fatigue, improve quality of life (QOL) and/or improve survival in cancer survivors, to what extent patients are aware of this and how it affects their behavior is unclear. Methods: 1,244 adult cancer survivors across disease sites and stages (mostly curative) at the Princess Margaret Cancer Centre (PMCC) were surveyed about their perceptions of PA, the barriers that prevent them from being physically active, and their level of PA currently. Multivariable logistic regression evaluated the associations between clinical and socio-demographic factors on these perceptions and current activity levels. Analyses were adjusted for performance status and important covariates. Results: Cancer survivors were surveyed at a median of 26 months after diagnosis. 16% had breast, 12% GI, 26% gyne/GU, 14% head and neck, 6% lung and 19% hematologic cancers. 55% of survivors reported being physically active. Overall, 76% believed PA could lessen their fatigue, 91% reported PA could improve their QOL, and 89% felt PA could improve their 5-year survival. Common barriers to PA were: being too ill (41%), too tired (33%), too busy (29%) and having too many home responsibilities (28%). Older patients were more likely to believe that PA would not improve their fatigue (p=0.005) and not improve their 5-year survival (p=0.001). Lower household income was associated with belief in lack of benefit of PA on fatigue (p=0.0001) or QOL (p=0.02). Not perceiving benefit of PA on fatigue, QOL, or survival was associated with substantially lower levels of PA (p<0.01; each comparison), as was being older and having a lower income (p=<0.01, each comparison). Conclusions: Older patients (even those with good performance status) and those coming from a lower socioeconomic status were more likely to have negative perceptions of the effect of PA on major cancer outcomes, resulting in lower PA levels. At PMCC, we are using this information to shape how we communicate with our patients in our survivorship program to help them with their decision-making on PA.
Determining optimal first-line chemotherapy for good and intermediate prognosis testicular germ cell tumors using decision analysis.
Authors: Vanderburg Sky Breeden , Frazier A. Lindsay , Kim Jane 
Published: February 2017

209 Background: Since 80-90% of testicular germ cell tumors (GCTs) are cured after first line therapy alone, minimizing toxicity should be an important consideration in the initial treatment decision between cisplatin and carboplatin. Cisplatin has been shown to be superior in 5-year disease-free survival, but cisplatin use confers a higher risk of key long-term toxicities. This study aims to quantify this trade-off between disease-free survival and toxicities using decision analysis. Methods: We developed a mathematical decision-analytic model that simulates competing strategies of initial treatment with cisplatin or carboplatin in terms of treatment response, long-term toxicity, and mortality associated with first, second, and third line therapies for patients with good and intermediate prognosis testicular GCTs and a median age of 20 years at diagnosis. Treatment toxicities included ototoxicity, neurotoxicity, and nephrotoxicity. Monthly probabilities were weighted means derived from a systematic review of total follow-up data reported in seminal clinical trials. The model projected life expectancies for each strategy. Sensitivity analysis was conducted to examine the impact of uncertain inputs and assumptions. Results: The life expectancies at diagnosis for cisplatin and carboplatin strategies were 436.1 months (36.3 years) and 663.2 months (55.3 years) respectively. Sensitivity analyses revealed life expectancy figures largely dependent on the risk of nephrotoxicity occurrence from first line therapy and death from nephrotoxicity. Unless these base monthly probabilities were reduced by 87% and 99% respectively, carboplatin consistently yielded higher life expectancy than cisplatin. Conclusions: Under the current model, first line carboplatin therapy yields longer life expectancy than cisplatin, but this difference is highly sensitive to variables concerning nephrotoxicity. These preliminary results suggest that first line carboplatin therapy could yield higher life expectancy, though this result may be mediated by inclusion of other factors in future analyses, including updated estimates of mortality from nephrotoxicity or other toxicities.
Refining the clinical trials assessment of infrastructure matrix tool.
Authors: Weiner Bryan , Teal Randall , Dimond Eileen P. , Good Marjorie J. , Carrigan Angela , St. Germain Diane C. , Denicoff Andrea , McCaskill-Stevens Worta J. , Dempsey Kandie , Zon Robin , Grubbs Stephen S. 
Published: February 2017

230 Background: Many community cancer research programs aim to exceed Good Clinical Practices. To support such efforts, the National Cancer Institute and collaborators began developing the Clinical Trials Assessment of Infrastructure Matrix (CT AIM) Tool in 2008. CT AIM’s 3 levels of exemplary performance span 11 infrastructure attributes. 2013’s revisions focused on interpretability, usability, and measurability. Methods: Tool input was obtained at national research meetings. Also, 4 Principal Investigator-Program Administrator (PI/PA) pairs from NCI-funded community cancer programs with varied demographics (eg, size, population) underwent cognitive interviews. Aggregated responses and a major-themes summary led to tool revisions. Next a web-based version was piloted with 4 more PI/PA pairs. The frequency/distribution of responses within pairs was assessed. The revised tool was then field-tested with 9 more PIs and scoring method feedback was collected; the tool was further revised. Results: Per community input and cognitive interviews: (1) “best practice” designation was replaced with “assessment of infrastructure”, (2) attributes were reordered based on perceived importance, (3) terms and cumulativeness of levels were clarified. Receiving 0 “don’t understand”s indicated improvement in clarity. 64% of “don’t know” responses were from respondents at the same program and 5 were from the biospecimen research attribute, indicating the information is difficult for programs to obtain. PI/PA responses varied 36% of the time, of which 70% involved a 1-level difference in response, indicating variation in responses by program role. 2 questions generated inconsistent responses from all 4 pairs, indicating possible further revisions. Average scoring was more accurate and sensitive to incremental program improvements. Conclusions: Broad community input, cognitive interviews, and piloting improved the tool’s clarity. Program leaders are encouraged to use CT AIM with research team members to enhance site infrastructure. CT AIM is useful for quality improvement, benchmarking research performance, progress reporting, and communicating program needs with institutional leaders. NCI Contract No. HHSN261200800001E
Using algorithms to standardize peripheral stem cell mobilization and collection.
Authors: Jourdan Dawn , Schmit Pokorny Kim 
Published: February 2017

233 Background: Review of peripheral stem cell (PSC) collection data showed a significant practice variation in the number of collections, minimum and target dose of PSC collected, and the use of plerixafor for mobilization of PSC. In addition, the peripheral blood CD34 test was not used to determine the start of collections. At this institution, approximately 100 adult patients collect PSC per year with a mean of 3 (range 1-10) collections per patient. Cost per patient varied from $9,800 to $74,600. Methods: Patients planned to undergo an autologous PSC transplant, 18 years and older, were included. Three years of historical data was analyzed and pilot algorithms developed. Algorithms identified when to start and stop collecting, if and when to start plerixafor, and when to re-evaluate the mobilization method. The use of the peripheral blood CD34 test was implemented. The minimum CD34 cell dose was standardized and the target dose was lowered. The entire collection process was reviewed and additional efficiencies were identified. Results: Analysis of 42 patients’ collections January 2013 through July 2013 revealed that the majority of patients (86%, n=36) were able to achieve the target CD34 dose in 3 or fewer collections (mean = 1.5, range = 1-4). The algorithms were followed in 41/42 patients. The patients’ engraftment and length of stay were similar to historical data suggesting that the minimum and target CD34 dose is acceptable. Work flow changes associated with the use of the peripheral CD34 test didn’t produce any negative impact on the departments involved. The initial collection cost decreased by approximately $2,000 and each additional collection decreased by approximately $800. The average cost savings per patient was $9,500. The actual total cost savings over a six month period was $303,204. The mean total number of collections per patient decreased from 3 to 1.5. Conclusions: Standardization of practice can result in significant cost savings. Using an expensive drug (plerixafor) in well-defined situations makes good clinical and economic sense. Reviewing processes also identifies additional opportunities in which to make positive changes.