bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Choosing Wisely Canada cancer initiative.
Authors: Mitera Gunita , Bezjak Andrea , Booth Christopher M. , Delouya Guila , Desbiens Christine , Earle Craig , Laing Kara E. , Latosinsky Steven , Camuso Natasha , Agent-Katwala Mary , Porter Geoff 
Published: February 2017

5 Background: Choosing Wisely Canada is a campaign modelled after Choosing Wisely in the USA and aims, through a pan-Canadian cancer physician-based consensus process, to identify a list of low value or harmful cancer services/practices frequently used in Canada. The following describes the approach taken for this work related to cancer in Canada. Methods: A Task Force approach was used, facilitated by the Canadian Partnership Against Cancer (CPAC), and included representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: (1) identify potentially relevant items and a framework for their subsequent selection; (2) develop a long list; (3) refine and reduce the long list to a short list; and (4) select and endorse a final list of low value or harmful cancer practices. Phases 2–4 followed a framework-driven consensus process and used a series of electronic surveys and voting processes. Results: For Phase 1, 66 cancer relevant practices were initially identified. The framework for subsequent selection included: (1) the size of population to which the practice is relevant; (2) frequency of use in Canada; (3) cost; (4) evidence of low value/harm; and (5) potential for change in use of the practice. The long list (41 practices) was refined and reduced to a short list of 19 practices and a final list including 10 practices. Of these, 5 are completely new, and 3 are revisions/adaptations practices from USA Choosing Wisely. Of the 10 practices, 6 are involve multiple disease sites, while 4 practices are disease-site specific. One practice relates to diagnosis, 6 are treatment- focussed, 2 target surveillance/survivorship, while one practice spans the cancer continuum from diagnosis through survivorship. Conclusions: Through CPAC facilitation, the collective input and work of three professional oncology societies informed this initiative. The content of the final list will be officially released through Choosing Wisely Canada in October 2014, and will be fully revealed at the ASCO Quality Care Symposium.
A "continuously connected team support" model to facilitate high-quality gynecologic cancer care in rural and remote regions.
Authors: Silver David F. , Aukers Steven M. , Simon Melissa A. 
Published: February 2017

51 Background: Quality gynecologic cancer care (GCC) in rural and remote regions (RRR) of the U.S. is limited by poor access to gynecologic oncology expertise (GOE). While a variety of telehealth programs in other specialties have enhanced healthcare in RRR, none have resulted in provision of the comprehensive medical and surgical services required to treat gynecologic cancer patients. We propose a model to improve access and quality for comprehensive GCC in RRR. Methods: PubMed, Medline, and Google searches identified and characterized: 1) core quality components of GCC models; 2) RRR lacking GOE; and 3) current models for delivering healthcare services in remote regions. A new model was developed addressing needs of RRR. Results: Characteristics observed in high-performing GCC models include: 1) gynecologic oncologists (GO) guide all aspects of GCC, 2) care is performed by high-volume providers (HVP), and 3) multidisciplinary provider teams (MDT) address all patient needs. Without equal access to GO, HVP, or MDT, patients in RRR do not share benefits of high-quality outcomes. Integrating components of successful telementoring models with identified high-quality characteristics of traditional GCC, our model is developed to address the comprehensive and ongoing unique GCC needs of RRR. This Continuously Connected Team Support (CCTS) model utilizes a semi-remote GO to facilitate quality GCC through mentorship and education of a local MDT, transforming it into a transdisciplinary team (TDT). Off-site activities include 24/7 availability via phone or HIPAA-compliant videoconferencing. The GO’s on-site activities include proctoring the TDT in surgeries, mentoring and educating in clinical conferences, and continuous quality improvement activities. Long-term, regular on-site and remote interactions with the local TDT makes CCTS unique in its commitment and service beyond that of itinerant surgeons, locum tenens, international surgical charity efforts or established telehealth programs. Conclusions: Deployment of CCTS in RRR offers an innovative solution for the facilitation of high-quality comprehensive GCC in RRR lacking GOE. Further outcomes research is warranted.
Population-based standardized symptom screening: Cancer Care Ontario’s Edmonton Symptom Assessment System and performance status initiatives.
Authors: Molloy Sean , Pereira Jose , Green Esther , Dudgeon Deborah Jane , Howell Doris , Krzyzanowska Monika K. , Mahase Wenonah , Tabing Reena , Urowitz Sara , Macdougall Laura 
Published: February 2017

56 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are: (a) promote the adoption of electronic symptom assessment using a standardized tool and (b) increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are to manage cancer symptoms through a patient reported measurement tool; improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and drive improvement through the adoption of an electronic symptom assessment platform The following aims were established for this work: (1) Aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month) (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores) (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan) and (4) aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success. (a.) Leadership at all levels of the system; (b.) clinical tools at the point of care; (c) engagement of patients in the design of care; (d) communications support to spread information to all stakeholders; and (e) using to data to drive performance improvement and accountability.
Transition of breast cancer (BC) survivors to primary care: Results of a Cancer Care Ontario (CCO) pilot project.
Authors: Sussman Jonathan , Grant Maria 
Published: February 2017

58 Background: Emerging evidence indicates that the transition of well breast cancer survivors to primary care is safe and effective. Methods: Prospective longitudinal cohort study across 14 health regions in Ontario, Canada. Each region received $100 000 (CAN) to develop and implement a sustainable new model of survivorship care for BC survivors that involved transition from medical oncology-led practice. Each region had a designated lead, and support from primary care. Funding could be used to develop any aspect of the model including personnel support, development of communication materials and outcome measurement. A minimal dataset reporting requirement included a description of the program, documentation of transitioned BC survivors as well as standardized patient and provider experience feedback once transition completed. Results: All 14 health regions in Ontario participated and all developed a survivorship care plan and patient educational materials. The models developed included direct transition to primary care in 6 regions, a nurse-led transition clinic in 4 and a GP-led transition clinic in 4. To date, 3,418 BC survivors have transitioned. Of 676 BC respondents to date, 83% felt there was a clear plan for follow up and 87% felt adequately prepared for transition. Feedback from primary care providers demonstrated that many feel informed about intent of transition and understand their role in on-going follow-up care. Process outcomes such as re-referral back to cancer center and adherence to follow-up guidelines are currently underway. Conclusions: The wide scale transition of appropriate BC survivors to a primary setting appears feasible with high acceptability by patients and providers.
Treatment of stage IV NSCLC with chemotherapy in a community setting based on ECOG PS.
Authors: Singh Rahul , Saucier Jillian , Schreiber Andrew Michael 
Published: February 2017

62 Background: ECOG Performance Status (PS) plays a pivotal role in the decision to treat patients with NSCLC Stage IV. The current ASCO guidelines for offering cytotoxic chemotherapy in stage IV NSCLC state that a PS of ≤2 can be considered for intravenous treatment. The goal of our retrospective evaluation was to evaluate treatment patterns based on ECOG PS in a community setting. Methods: An IRB-retrospective chart review of all stage IV NSCLC patients at our institution between 1/1/2008 and 1/1/2013 was conducted. A total of 150 patients with NSCLC and an ECOG of ≤2 were randomly selected and reviewed from the cancer registry (12 were excluded for undocumented ECOG PS status). 138 patients were included. The data was analyzed using X2 test of independence, Fisher’s exact, and students T-Test all run by SAS 9.1. Results: Of the 138 patients observed, 92 (66.7%) had an ECOG PS of 0, 16 (11.6%) were PS 1 and 30 (21.7%) were PS 2. There were no significant differences in ECOG PS based on race, gender or payer status. Patients with a PS of 2 received chemotherapy (N=1/30, p <0.0001) significantly less than those with PS 0-1 (N=54/108, p <0.0001). Those with PS 2 were more likely to have additional comorbidities as well (N=23/30, p<0.0001) versus patients with a PS 0 or 1. Chemotherapy was not offered to 76.7% of patients with a PS of 2 (N= 23/30, p <0.0001). Conclusions: In our community setting cytotoxic chemotherapy was offered significantly less in patients with ECOG PS of 2 compared to those with 0 and 1. While it is more likely that patients with better PS will be offered treatment, this significant difference reflects practice that differs from ASCO’s guidelines. It is suspected the disparity in offering treatment depending on the PS of 2 vs 0-1 likely was due to many cofounding variables as well as provider and patient preference. Another disparity noted was that of undocumented ECOG PS. As the system of healthcare is switching to an electronic based system one proposed theory would be to add the quality measure ECOG PS as an additional vital sign in an oncologist progress note, with a prompt to consider chemotherapy in patients with PS ≤2 and not to consider in PS 3 or 4. This could greatly benefit the medical oncologist in considering possible treatment.
Improving prophylactic growth factor (pGCSF) use in non-small cell lung cancer (NSCLC) patients (pts) receiving chemotherapy (CT) at the Cleveland Clinic Taussig Cancer Institute (TCI).
Authors: Goodman Lindsey Martin , Moeller Machelle , Dalby Carole Kathleen , Guthrie Amy E. , Earl Marc A. , Pennell Nathan A. , Shapiro Marc A. , Velcheti Vamsidhar , Ma Patrick C. , Stevenson James 
Published: February 2017

83 Background: Per guidelines (ASCO, NCCN, EORTC), pGCSF is not recommended for pts receiving CT regimens with low risk (< 10%) for febrile neutropenia (FN). Inappropriate use of pGCSF increases pt morbidity and healthcare costs. In the current healthcare environment, it is critical to maximize value via alignment with accepted care standards and elimination of unnecessary costs. Methods: A multidisciplinary team was created to perform a quality improvement (QI) project under ASCO’s Quality Training Program. We reviewed all NSCLC pts at TCI who initiated a new CT regimen from April to November 2013. First-cycle pGCSF use was identified and deemed appropriate if prescribed for CT associated with high risk of FN (>20%) or intermediate risk (10-20%) if other risk factors for FN were present (age, gender, performance status, renal/hepatic function, prior treatment with radiation or CT, and pre-existing neutropenia, wounds, or infection). Use with low-risk CT was recorded as inappropriate. Results: 179 NSCLC pts received a new CT regimen during the specified time period. 22/90 pts (24%) treated with low-risk CT received pGCSF. Each pt received an average of 3 doses with 69 total doses administered. In all other instances pGCSF was prescribed in accordance with guidelines. Using QI strategies, we identified and implemented three PDSA cycles: education of NSCLC providers, development of TCI Consensus Guidelines for the use of pGCSF in NSCLC, and removal of standing pGCSF orders from low-risk CT regimens in the EMR. Cost analysis shows the potential to save 1.6 million dollars in charges over 1 year when pGCSF is not administered to NSCLC pts receiving low risk CT. Conclusions: pGCSF was excessively prescribed for NSCLC pts at a tertiary care academic medical center. Factors contributing to inappropriate pGCSF use included providers’ lack of familiarity with guidelines and the risk of FN for CT regimens as well as EMR CT templates with standing pGCSF. Appropriate pGCSF administration leads to significant cost savings without adverse impact on pt outcomes. Re-measurement is in progress and will be presented at the time of the meeting.
Implementation of code status discussion early in the course of treatment for oncology patients.
Authors: Faggen Meredith , Gilchrist Heather , Donohue Caitlin C. , Burke Reanne 
Published: February 2017

88 Background: Having a code status discussion early in the treatment course of patients with advanced stage cancer is important to ensure that patients make decisions about life sustaining treatment in a non-urgent setting. There was not a standardized approach to addressing the code status of patients with stage IV cancer enrolled on the Supportive Oncology (SO) Pathway at Dana Farber Cancer Institute/South Shore. We addressed this problem by implementing a standardized method of documenting code status at or before the 3rd visit in patients with stage IV disease participating in our SO pathway. Methods: A process map highlighted that most patients with advanced cancer discussed their code status the day of hospice enrollment. A fishbone chart detailed the barriers to obtaining code status, and a priority pay-off matrix identified opportunities for improvement, including standardizing the process of the code status discussion and emphasizing the importance of the discussion early in the course of treatment. Physicians were educated on the importance of code status discussions and agreed that documentation should occur by the 3rd visit. Patients enrolled on the SO Pathway were tracked for the first three visits after initial referral to the pathway. We developed a script to assist physicians with code status discussions, which was placed on the encounter form at these visits. To measure the number of discussions, patient charts were reviewed on a weekly basis for documentation of code status. Results: Pre-intervention, during a 1 year period, only 14% (n=42) of patients enrolled on the SO pathway had a code status documented by the 3rd visit. After a 6 week implementation period, 70% (n=10) of patients enrolled on the SO Pathway had a code status documented in the chart by the 3rd visit. Conclusions: Substantial improvement in code status documentation was seen post-implementation of our intervention. We conclude that a script/reminder is a useful tool to prompt physicians to have a meaningful code status discussion in a non-urgent setting. This project has made the often difficult process of obtaining code status a more standardized process, and a more integral part of the culture at the Cancer Center.
Interventions to optimize the use of colony-stimulating factors.
Authors: Rathod Heena , Yoder Sol 
Published: February 2017

92 Background: The Food and Drug Administration approved granulocyte colony-stimulating factors filgrastim (fil) and pegfilgrastim (peg) for use in the prevention of chemotherapy-induced neutropenia. The objective of this study was to characterize and optimize the current utilization of these costly colony-stimulating factors within a tertiary care health system. Methods: Data parameters and improvement measures were defined based on the current literature, national guidelines and institutional standards. Data was collected retrospectively by chart review and analyzed to develop interventions that would optimize fil/peg utilization. Existing policies and procedures were updated, and feedback and approval was obtained through collaborative groups. Improvement measurements will be reassessed post implementation of the proposed interventions. Results: Chart review yielded 156 fil/peg orders. The following observations and interventions were applied. All indications were determined appropriate per established oncology guidelines; however, 3 patients received an unwarranted fil/peg dose within a week of peg administration. An electronic alert was created to prevent administration of an additional fil dose if a recent peg dose had been administered. Of inpatient fil orders (n=38), 24% of weight-based dose rounding and 32% of predetermined discontinuation parameters were not compliant with the institutional standards. Fill electronic order entries were modified to automatically round doses based on patient weight. If an additional one-time absolute neutrophil count (ANC) discontinuation parameter was applied, it is anticipated that fil treatment duration could decrease in 30% of patients. The one-time ANC discontinuation parameter for fil was added. Conclusions: Although our system’s utilization of colony-stimulating factors was in compliance with national guidelines and institutional standards, opportunities for optimization were identified and targeted for improvement.
Effects of variation of sentinel lymph nodes submitted during breast cancer sugery: Analysis of practice variation and costs.
Authors: Barr Louis H. , Wu Meiling , Shao Yai-Ping Mimi , Zhu Xiang 
Published: February 2017

94 Background: Routine node evaluation involves simple bivalving the node with slides made from the resultant surfaces. SLNs are more thoroughly evaluated with 2-3 mm slices and histologic evaluation of each slice, resulting in many more slides to review. These slides would often have immunohistochemical analysis adding to the time and cost. In early studies of SLN efficacy and accuracy, the mean number of nodes was between 2 and 3 per patient though with some variation. As the number of submitted SLNs increases, the concern of benefit of the procedure comes into question. This is a retrospective examination of all SLN procedures for the year 2012 to examine the variation in the number of SLNs submitted for focused pathologic evaluation. Variation in the number of nodes submitted by surgeon is determined along with the associated costs of the pathologic evaluation. In addition, intraoperative evaluation of lymph node status may be useful to allow for immediate axillary node dissection during the initial operation. Utilization of this procedure was also examined to determine ultimate correlation with permanent pathologic evaluation. Methods: Retrospective examination of all breast cancer patients >=18 yrs who underwent SLN procedures during 2012. Introperative evaluation of lymph node for metastatic disease was also examined for correlation with permanent pathologic result. Results: 259 cases among 21 surgeons had touch prep performed. True positive number: 29. True negative number: 224. False negative number: 6. Fasle negative rate (FNR): 17.14%. Cost Effectiveness Evaluation: CPT 88307 - surg path gross and micro level V. CPT 88342 - Immunohistochemistry. CPT 88333 - Touch Prep. Pathologist time: 30 minutes per case. Conclusions: There is significant variation among surgeons as to number of cases and number of nodes submitted. There is a significantly greater number of sentinel lymph nodes examined by the pathologist as compared to the number of nodes submitted by the surgeon. The frequency of outliers is infrequent, but when it occurs there is significant cost in terms of time and dollars. The false negative rate from pathological evaluation is under study for isolated tumor cells.
Process of standardizing time to follow-up when initiating oral chemotherapy.
Authors: Shea Meghan , Giampietro Donna , Lennes Inga Tolin , McDonnell Theresa Margaret , Bohlen Nie 
Published: February 2017

95 Background: With the explosion of oral chemotherapy agents, cancer care is shifting from the hospital to the home. The many safeguards developed for parenteral chemotherapy have not translated to oral chemotherapy. Patients are responsible for adherence to complex medication regimens while managing the side effects of chemotherapy at home. Many clinicians at Massachusetts General Hospital (MGH) improvise systems to monitor patients on oral agents, and practices remain varied. The 2013 American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS) addressed standards for safe administration and management of oral chemotherapy, which served as the framework for improving follow up care at MGH. Methods: Theclinicians in the thoracic and gastroenterology disease centers were surveyed and selected standardization for the first follow up appointment after initiation of oral chemotherapy as a safety initiative. The team, which consisted of the thoracic clinicians, delineated a process map from writing the prescription for erlotinib or crizotinib to the follow up appointment, as well as identified barriers to ensuring a standardized time for follow up. A second survey established a consensus of a 28 day ceiling for time to first follow up for both oral agents. The aim was for 95% of patients to be seen within 28 days of initiating oral chemotherapy. An education campaign for providers regarding the standardized algorithm for time to follow up and a text template to incorporate in the clinic note was instituted. Results: Prior toan intervention, patients initiated on erlotinib or crizotinib were seen in follow up within 19 days (on average), and 82% reached the aim of within 28 days. A time frame for return to follow up was established as well as required documentation for initiation of each drug. Conclusions: The process of implementing standardized drug specific time to follow up highlighted a number of key lessons. It is crucial to evaluate and measure the current process prior to developing interventions. Support of local leadership and “buy in” from all clinicians and staff is essential to the success of the intervention. Additionally, a regular setting to discuss and present updates on the process improvement is vital.