bluuebunny/crossref_metadata_2025_split huggingface dataset:
Root-cause and failure-mode analyses with an in-house incident reporting system: Comparison of its structure with ASTRO RO-ILS.
Authors: Chou Henry , Kapur Ajay , Goode Gina M. , Riehl Catherine , Meier Jason , Bloom Beatrice , Potters Louis 
Published: February 2017

163 Background: In industries with well-established processes for failure analyses, incident reporting systems facilitate analyzing root causes of adverse or near-miss events, and the dissemination of lessons learned. Such a system is now being promoted in radiation medicine as patient safety and care quality come into focus in clinical practice. Methods: An incident reporting system has been in place in our department since 2010 for staff to report actual or near-miss events. A quality management committee was concurrently established to review reported incidents on a weekly basis. A taxonomy of root causes was set up to analyze and categorize root causes of incidents. This taxonomy is compared to that of the 2012 consensus recommendations for incident learning database (Ford et al.) which was the basis of ASTRO RO-ILS currently in prototype phase. Results: To date, over 2,000 incidents have been analyzed in our in-house system. The majority of the reported incidents pertain to procedural mis-steps or miss-cues in the process leading up to patient treatment, resulting in delays. Identifying the root causes has helped re-engineer or fine-tune department processes and has resulted in smoother clinical operations (e.g., obtaining third-party imaging prior to making treatment appointments) as well as more safety checks (e.g., pace-maker alerts.) Our taxonomy of root causes is multi-dimensional and quite specific to clinical radiation oncology, e.g., drilling down to specific morbidities. In comparison, the taxonomy of causes in the RO-ILS is more generic and at a higher level (e.g., procedural or technical issues). The RO-ILS has at most second-degree branches compared with our taxonomy of 6-8 degrees in depth. Conclusions: Incident reporting is vital in analyzing and learning from reported events. Process changes in our clinic has been aided by the incident database and a hierarchical taxonomy between 6 to 8 degrees in root causes. The RO-ILS system in prototype is only 2 degrees deep. While the RO-ILS system appears capable of cataloging data from multiple centers, it is not clear that it will be able to understand or affect meaningful process changes given its lack of depth.
Management of basal cell carcinoma in the United States: Can we simplify care and reduce cost?
Authors: Wu Xinyuan , Elkin Elena B. , Chen Jason Chih-Shan , Marghoob Ashfaq A. 
Published: February 2017

17 Background: Basal cell carcinoma (BCC) is the most common cancer in the US, affecting more than 3 million people every year, and the incidence of BCC is increasing. Traditional management of BCC involves multiple physician visits and a pre-treatment biopsy which may be unnecessary. We assessed the costs of treating BCC, comparing traditional management with a simplified scheme. Methods: We developed a decision analytic model to compare the costs of traditional BCC management with a simplified Detect and Treat (DAT) scheme that eliminates pre-treatment biopsy. We assumed that all patients had an unequivocal BCC diagnosis based on clinical and dermoscopic findings. In the traditional approach, all patients had a biopsy prior to treatment. In the DAT scheme, well delineated lesions ≤1cm in diameter on the trunk and extremities were treated with shave removal and Mohs indicated lesions were referred to Mohs for on-site histologic check, both eliminating pre-treatment biopsy. Distributions of lesion location, size and treatment modality, and estimates of clinical diagnostic accuracy and success of shave removal were from the literature and from an analysis of 240 consecutive BCC cases seen over 5 years at our institution. Costs were based on assumptions about the number of dermatologist visits, tests and procedures required for each strategy, and unit prices from the 2014 Medicare physician fee schedule. Results: The average cost per case in the DAT scheme was $449 for non-Mohs-indicated lesions and $819 for Mohs-indicated lesions, compared with $566 and $864, respectively, with traditional management. DAT was associated with a savings of $117 (21% of total average cost) per non-Mohs-indicated case and $45 (5% of total average cost) per Mohs-indicated case. The combined weighted average savings per case was $95 (15% of total average cost). The magnitude of savings varied with changes in model parameters, but conclusions were similar under a wide range of plausible scenarios. Conclusions: A simplified management strategy that avoids routine pre-treatment biopsy can reduce the cost of treating BCC without compromising quality of care.
Reducing unwarranted variability in care in radiation oncology through clinical pathways.
Authors: Lokay Kathleen , Heron Dwight Earl 
Published: February 2017

171 Background: UPMC CancerCenter (UPMC) includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology (Via Pathways). The program has served UPMC well for almost ten years and is now a key foundation for UPMC’s overall strategy to move from volume to value. Methods: Radiation treatment pathways for over 90% of cancers were developed by committees of academic and community radiation oncologists from UPMC as well as other cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly-specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for simulation contouring, planning and treatment delivery are provided along with applicable citations. A web-based portal presents the pathways on a patient specific basis using the physician’s daily clinic schedule (through an interface with the EMR). The UPMC radiation oncologists also utilize a feature of the pathways that allows for peer review of Off Pathway decisions by disease experts within the UPMC Radiation Oncology department. Results: Thirty-one (31) radiation oncologists at UPMC use pathways in their daily practice. For the 12 months ended May 31, 2014, UPMC physicians confirmed a pathways status for 98% of their patient consults (n=10,178) and achieved an On-Pathway rate of 95% for their 6,239 treatment decisions. All Off-Pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC, typically within 24 hours of request. Reasons for going Off-Pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care.
Meaningful reporting in primary care: An evaluation of the screening activity report.
Authors: Cunningham Nicki , Stogios Christine , Umar Shama , Carr Dafna , Garay Jason , Hader Joanne , Lee Alex 
Published: February 2017

173 Background: Cancer Care Ontario (CCO) developed the ColonCancerCheck Screening Activity Report (CCC SAR) as a supplementary tool for primary care physicians (PCPs) who are part of a patient enrolment model in Ontario, Canada to support them in increasing their colorectal cancer screening rates and appropriate follow-ups. The report provides PCPs with a summary of their eligible patients’ colorectal cancer screening-related history and was designed with the intent of supporting both population health management and opportunistic screening. Delivered through an online platform, the SAR offers PCPs access to data to facilitate quality cancer screening practices aligned with CCO’s evidence-based clinical guidelines. Methods: The report leverages provincial datasets to summarize screening activities on a per-patient level and actionable follow-up recommendations based on CCO’s clinical guidelines. To evaluate the impact of the reports on colorectal screening participation rates, a Generalized Estimating Equation model was used. Results: Results on the report’s impact on colorectal cancer screening participation rates from the first release (February 2013) are promising. By identifying for PCPs which patients are overdue for screening, the SAR demonstrated a modest and statistically significant 6% increased likelihood of patients being screened using a Fecal Occult Blood Test (FOBT) if their PCP was registered to access the online report, compared to patients of unregistered PCPs. The impact to screening increased to 25% when comparing registered PCPs who logged in and viewed their SAR to registered PCPs who did not login; however, this analysis is at a greater risk of a volunteer bias. Such PCPs may be more likely to screen their patients independent of viewing their SAR. Conclusions: By equipping PCPs with patient-level data grounded in CCO’s evidence-based clinical guidelines, the SAR is innovative in its potential to increase screening rates and the appropriate follow-up of abnormal results. The successful launch of two online CCC SARs, sharing meaningful colorectal cancer screening data to frontline providers, has driven the report’s expansion to include breast and cervical cancer screening data in spring of 2014.
Driving action through data: Delivering online cancer screening reports to primary care providers.
Authors: Cunningham Nicki , Umar Shama , Carr Dafna , Smith Richard , Flynn Patrick 
Published: February 2017

174 Background: The Screening Activity Report (SAR), a supplementary tool for primary care providers (PCPs), was released in April, 2014. Providers are able to access this comprehensive report securely via an online solution and view the screening activity of their patients across Cancer Care Ontario (CCO)’s three organized cancer screening programs; breast, cervical and colorectal. The objectives of the SAR are to improve the quality of cancer screening by increasing provincial screening rates, improving the rate of appropriate follow-up of abnormal results and promote the alignment of cancer screening practices with CCO’s evidence-based clinical guidelines. Methods: CCO partnered with eHealth Ontario in 2012 to leverage their identity and access management system to provide safe and secure online access to the report. Since this time, CCO has implemented a multi-faceted campaign to support registrations to the system, encourage report access, and gather feedback on how to improve the report for future iterations. Using a detailed methodology developed by a wide range of subject matter experts at CCO, the SAR employs numerous provincial data sources to provide an overview of the patient rosters. Actionable categories are assigned at the patient level using a unique algorithm based on the latest clinical guidelines. Results: Previous to April 2014, the SAR was referred to as the ColonCancerCheck SAR (CCC SAR) as it included colorectal cancer screening data only. The last release of the CCC SAR was in October, 2013. At this time 4,824 providers were registered to the identity and access management system and adoption of this report had reached 31% after being available for five months to providers. To date, 4,992 providers are now registered and adoption of the April SAR has already reached 27% after being available for almost two months. Conclusions: The SAR is the first tool of its kind to make widespread use of eHealth’s identity and access management system service and target a broad user base of PCPs. The successful launch of the SAR has provided key insights into how technology can be leveraged to share provincial data in a meaningful way with providers and support them in improving the quality of cancer screening.
Developing symptom management quality improvement reports with data from a registry-based patient reported outcomes (PRO) collection method.
Authors: Smith Tenbroeck , Castro Kathleen , Troeschel Alyssa , Arora Neeraj K. , Stein Kevin , Clauser Steven , Portier Kenneth M. , Ward Elizabeth M. , McCabe Ryan M 
Published: February 2017

180 Background: Symptom management is critical to quality cancer care, affecting treatment completion, functioning and quality of life. We describe the use of the Commission on Cancer’s Rapid Quality Reporting System (RQRS) to ascertain cases for PRO collection, identify key PRO quality indicators, and provide actionable symptom management quality improvement (QI) reports to community cancer centers (CCC). Methods: The Patient Reported Outcomes Symptoms & Side Effects Study used RQRS to sample patients (pt) 4-12 months from diagnosis with locoregional breast/colon from 17 National Cancer Institute Community Cancer Centers Program centers. Surveys were mailed with web option. Pts were asked if they talked to a health professional about pain (Talk about) and, separately, if the health professional gave advice about what to do if pain started, got worse, or came back (Advice). Similar questions were asked about fatigue and emotional distress (ED). QI reports were designed with CCC staff feedback and produced for each CCC providing crude and case-mix adjusted CCC-specific rates, and study-wide rates. Direct standardization methods were used to adjust CCC-specific rates for cancer type and education. Results: 2,487 eligible participants responded (RR=61%). This table shows overall study-wide estimates and the range of adjusted CCC-specific estimates for six key indicators. (See Table.) Conclusions: This pilot study shows the registry-based method for PRO collection was successful and has potential for wider dissemination. Study-wide, 20-45% of pts did not report discussing or getting advice about three common symptoms from their healthcare team. CCCs varied significantly on these indicators, suggesting room for improvement. Quality reports were well received by hospital staff, who report sharing them with clinicians, navigators and cancer committees. CCC-specific reports may promote efforts to improve care through professional/patient education and applying standards of care. [Table: see text]
Understanding disparities and organisational variation in cancer patient experience: Lessons from the English National Cancer Patient Experience survey.
Authors: Lyratzopoulos Georgios , Saunders Catherine L , Mendonca Silvia , Abel Gary 
Published: February 2017

181 Background: Surveys of the experience of cancer patients are currently being introduced in several countries, including the U.S. and Canada. Insights to inform the development and use of such surveys can be acquired from the English Cancer Patient Experience Survey programme. Methods: Each of the three national surveys (2010, 2011/12 and 2012/13) had a responder sample of ~70,000 patients (response rate 64-67%) and included about 60 evaluative questions on all domains of experience, from cancer diagnosis to care after hospital treatment. Anonymous data were analysed, using appropriate logistic regression models for positive/negative experience outcomes, based on public reporting conventions. We illustrate a research programme using the survey data focusing on two questions. 1. Who are the patients at greater risk of a negative experience? 2. Does case-mix explain apparent variation between hospitals? Results: There was evidence of socio-demographic variation in cancer patient experience, consistently across questions: younger and very old patients, ethnic minorities, and women reported poorer experience. Regarding variation between patients with 36 common and rarer tumours, those with hepato-biliary and thyroid cancers were most likely to be less satisfied with their overall experience, whereas patients with breast cancer were least likely (top-to-bottom odds ratio 3.7, p<0.0001). There were disparities in experience between patients treated by the same specialty for 5/9 services (p<0.0001). For example, patients with ovarian, multiple myeloma, anal and renal cancer reported worse experiences than patients with other gynaecological, haematological and urological malignancies, respectively. There was high concordance between crude and adjusted ranks of hospital scores (median Kendall's τ=0.84; interquartile range: 0.82-0.88). Conclusions: Initiatives to improve cancer patient experience may be suitably targeted on patients at higher risk of poorer experience. Evidence about disparities in experience and the effect of case-mix provide useful priors to motivate similar inquiries in other healthcare settings.
Patient expectations of palliative cancer treatment for noncurable malignancies: A pilot study.
Authors: Faricy-Anderson Katherine E. , Allen Susan M. , Freeman Nancy J. , Mor Vincent 
Published: February 2017

194 Background: Many people with advanced non-curable malignancies have unrealistic expectations of palliative cancer treatment including a belief that treatment may cure their cancer. However, qualitative data describing how patients define “cure” or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anti-cancer treatment. Methods: Patients with advanced non-curable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, co-morbidities, and palliative care involvement. Results: We enrolled 30 patients initiating non-curative anti-cancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancer. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of “cure” ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.” Conclusions: Patient-reported definitions of “cure” and other treatment goals vary widely and a substantial number of patients report unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments. “The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.”
Quality of end-of-life care: Are blood cancers different?
Authors: Odejide Oreofe Olukemi , Salas Coronado Diana , Watts Corey D. , Wright Alexi A. , Abel Gregory Alan 
Published: February 2017

195 Background: Hematologic cancers have been associated with aggressive cancer-directed care near death and underutilization of hospice and palliative care services. We sought to explore hematologic oncologists’ perspectives and decision-making processes regarding end-of-life (EOL) care. Methods: Between September 2013 and January 2014, 20 hematologic oncologists from the Dana-Farber/Harvard Cancer Center participated in four focus groups regarding EOL care for leukemia, lymphoma, multiple myeloma and hematopoietic stem-cell transplantation. Focus groups employed a semi-structured format with open-ended questions, and were followed by thematic analysis. Results: Many participants felt that identifying the EOL phase for patients with hematologic cancers was challenging due to the continuing potential for cure despite advanced disease and the often rapid pace of decline near death. This difficulty was reported to result in later initiation of EOL care. Barriers to high-quality EOL care were multi-factorial, including unrealistic expectations from patients and physicians, long-term patient-physician relationships resulting in difficulty conducting EOL discussions, and inadequacy of existing home-based EOL services. Participants also expressed concern that some EOL quality measures developed for solid tumors may be unacceptable for patients with blood cancers given their unique needs at the EOL (see Table). Conclusions: Our analysis suggests that hematologic oncologists need better clinical markers of when to initiate EOL care.In addition, current quality measures may be inappropriate for identifying overly-aggressive care for patients with blood cancers. Further research is needed to develop effective interventions to improve EOL care for this patient population. [Table: see text]
ICU deaths in advanced cancer patients: Reasonableness of ICU admissions.
Authors: Weir Alva B , Ryder Katheryn M , Niell Harvey B. , Muthia Muthia , Clark Karen 
Published: February 2017

199 Background: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Methods: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Results: In our patients the mean duration of cancer awareness was 7.3 months. The majority (38) had expected duration of life prior to ICU of 6 months or less. Only 16 patients had documented discussions regarding treatment preferences or advanced directives prior to hospital admission. In establishing reasonableness of admission: 8 were post procedure complications; 21 had an ECOG performance status of 0-1 prior to admission; 14 had been notified of their incurable cancer for one month or less; an additional 3 patients had a life expectancy > 6 months. Of the 52 ICU deaths of patients with advanced cancers, 31 (60%) met our criteria for reasonableness of admission in spite of advanced cancer. Of the remaining 21 patients, 9 had advanced directives in place prior to hospitalization, but without specific decisions regarding ICU care. Only 23% of futile ICU admissions in advanced cancer patients lacked both advanced directives prior to hospital admission and reasonableness of ICU admission by the above criteria. Conclusions: The majority of patients with advanced cancer who die in the ICU in our medical center are reasonable admissions, as defined by recent diagnoses, good performance status, > 6 month life expectancy and admission for post procedure complications.