bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving safety culture at a large AMC.
Authors: Lennes Inga Tolin , Bohlen Nie , Ryan David P. 
Published: February 2017

105 Background: Building a culture of safety in a large, growing academic oncology practice presents several challenges including: 1) lack of basic knowledge of QI and safety processes, 2) lack of systems thinking and 3) poor cross-disciplinary relationships. In 2011, the MGH Cancer Center piloted a program where groups of cancer center employees convened to address these issues. Safety reporting by physicians was tracked as a metric for improved safety culture. Methods: Quality Rounds are held bimonthly at the main campus of the MGH Cancer Center. A comprehensive group of all members of the Cancer Center including MDs, NPs, PAs, RNs, pharmacists, medical assistants, administrators, financial coordinators, students and members of our patient and family advisory committee are invited to attend. Groups are kept small to facilitate interaction and discussion. The program consists of a didactic section which includes: 1) definitions of quality and types of variation, 2) methods of performance improvement, and 3) safety reporting systems at MGH. Case studies developed for Quality Rounds are discussed. The MGH Cancer Center data regarding safety events on our campus was reviewed. Questions, discussion and personal reflection are encouraged. Results: 188 MGH employees have participated in the Quality Rounds program. Of the participants, 94/188 (50%) were physicians. During the course of the program, physicians have been allowed to repeat attendance once. Of the participating physicians 20/94 (21%) voluntarily repeated the program. Since the implementation of Quality Rounds, physician generated safety reporting has increased 42% over 3 years. Overall reporting by physicians has increased every year since 2011. Pre and post program surveys showed that Quality Rounds shifted the perception that errors are caused by only individuals to a more comprehensive appreciation of the multi-factorial nature of errors in healthcare. Conclusions: Implementing a program designed to teach the basic tenets of healthcare quality and safety to a wide variety of cancer center employees was feasible. Physicians were a majority of participants and their involvement in the quality and safety program at MGH has increased as evidenced by increased numbers of filed safety reports after participation.
Does three-dimensional intraoperative specimen imaging reduce the need for re-excision in breast cancer patients?
Authors: Chagpar Anees B. , Butler Meghan , Killelea Brigid K. , Horowitz Nina Ruth , Stavris Karen , Lannin Donald R. 
Published: February 2017

107 Background: Intraoperative specimen radiography is used by surgeons to evaluate partial mastectomy specimens to ensure that the lesion in question has been adequately removed. We sought to determine whether three-dimensional (3D) specimen imaging would better predict margin status and reduce the need for re-excision than conventional two-dimensional (2D) imaging. Methods: A prospective study using standard 2D as well as 3D specimen imaging was undertaken. Surgeons were asked whether the additional orthogonal view would change their management (i.e., result in further margins being taken intraoperatively), and the impact of this on final margin status. Results: Of the 100 women participating in the study, pathology results were available in 99. Of these, 10 had no residual tumor in the definitive specimen (either due to neoadjuvant chemotherapy, or due to the entire tumor being removed in the core biopsy). The remaining 89 patients formed the cohort of interest. 21 (23.6%) had DCIS, 18 (20.2%) had invasive cancer, and 50 (56.2%) had both. The median tumor size of the largest component was 1.7 cm (range; 0.2 – 8.1 cm). Based on the conventional two-dimensional imaging, surgeons stated they would take more tissue in 26 patients (29.2%). Of the 63 patients in whom no further excision would have been indicated on 2D imaging, the 3D imaging changed management in 4 patients (6.3%). Two of these patients would have had positive margins if the intraoperative resection done on the basis of the 3D imaging would have been omitted. Patients who surgeons felt, either by 2D or 3D intraoperative imaging, warranted intraoperative re-excision tended to have a closer initial margin than those in whom re-excision was thought not to be needed on the basis of intraoperative imaging (median 1.0 vs. 2.0 mm, p=0.038). Furthermore, patients in whom an immediate intraoperative margin was taken (either due to imaging or as a matter of routine) were less likely to require subsequent re-excision (13.4% vs. 40.9%, p=0.012). Conclusions: While 3D specimen imaging changes management in only 6.3% of cases, these data highlight the role of intraoperative immediate re-excision in potentially reducing re-excision rates.
The toxicity gap: Do real-life patients get hospitalized more during chemotherapy compared to trial patients?
Authors: Prince Rebecca Michelle , Krzyzanowska Monika K. , Atenafu Eshetu G. 
Published: February 2017

109 Background: Toxicity related hospitalizations during chemotherapy are poorly reported in the literature. We sought to compare “real world” versus clinical trial rates of hospitalizations among patients with metastatic non-small cell lung cancer (mNSCLC) receiving chemotherapy. We hypothesised that hospitalization rates in real life patients would be significantly higher. Methods: We conducted a systematic review of Medline and EMBASE (1946-June 2013) to identify articles reporting hospitalization rates during chemotherapy in patients with cancer. Both observational studies and clinical trials were eligible. This report focuses on patients with mNSCLC receiving palliative chemotherapy as data was available for this clinical scenario in both the observational and clinical trial setting, allowing comparison. Study results were abstracted using a standardised form. Summary statistics were used to describe results and the chi-square test used to compare hospitalization rates. Results: The search identified 61 articles (all published after 1987), of which 16 were clinical trials and 45 were observational (“real world”) studies. Nine studies examined chemotherapy in mNSCLC - four observational studies and five randomised trials. The four observational studies included 7,456 patients; three included patients on any chemotherapy while the other focused on doublet regimens. Of the five randomised trials which included 3,962 patients, three treated patients with platinum doublets and two used single-agent chemotherapy. The real life cohort was older (70 years vs. 62 years). The aggregate hospitalization rate among real life patients was significantly higher than among trial patients (49% vs. 16%, OR=7.7, 95% CI 7-8.5, p-value < 0.0001). Performance status and type of chemotherapy were associated with hospitalization during chemotherapy in clinical trials while type of chemotherapy was a risk factor in observational studies. Conclusions: Clinical trials in mNSCLC consistently report lower rates of hospitalization than real life cohorts of patients undergoing similar therapies but very few clinical trials report this information.
Standardizing coordination between surgical oncology and reconstructive surgery for breast cancer patients undergoing mastectomy with immediate reconstruction.
Authors: Golshan Mehra , Hergrueter Charles A. , Camuso Kristen , Lin Nancy U. , Cutone Linda , Hirshfield-Bartek Judith , Roberts Phil , Runkle William , Kadish Sarah , Losk Katya , Bunnell Craig A. 
Published: February 2017

110 Background: Timely diagnosis and treatment of breast cancer, endorsed by organizations such as ASCO and NCCN, are essential to ensure optimal clinical outcomes and patient satisfaction. Inefficient care coordination may adversely affect care quality. At our cancer center, 75% of patients who undergo mastectomy seek a reconstructive surgery consult and over 60% elect mastectomy with immediate reconstruction. We sought to evaluate and reduce the time to reconstructive surgery consult and first definitive surgery (FDS) by streamlining coordination between services. Methods: We studied 330 patients who underwent mastectomy with immediate reconstruction between January 2011 and April 2013. Time intervals between initial surgical consult, reconstruction consult, and FDS were calculated. After examining existing best practices in patient referral and scheduling, we established targets of 7 days from initial consult to reconstruction consult and 28 days from initial consult to FDS. To achieve these targets, facilitated sessions were held with administrative and clinical experts to create a standard referral and scheduling process, including a referral template and establishing surgical teams based on clinic and operating room alignment. The interventions were implemented over a 6-month period. Results: Mean days from initial consult to reconstructive surgery consult decreased, with significant improvement in reaching the 7 day target. No significant changes from time of initial consult to FDS were observed. Conclusions: Standardizing coordination has led to timelier reconstructive surgery consults for patients undergoing mastectomy with immediate reconstruction. Other factors, such as operating room availability, pre-operative testing and patient preference should be explored to reduce the time to FDS. [Table: see text]
Evaluation of a risk-adapted visit for post-treatment cancer survivors.
Authors: Rosenberg Carol A. , Flanagan Carol , Brockstein Bruce , Obel Jennifer Carrie , Wade Elaine Lee , Law Teresa Murray , Dragon Leon Harold , Merkel Douglas E. , Khandekar Janardan D. , Hensing Thomas A. 
Published: February 2017

113 Background: The Living in the Future (LIFE) Cancer Survivorship Program at NorthShore University HealthSystem provides a risk adapted visit (RAV) directed by a physician and facilitated by an oncology nurse during which an electronic medical record documented LIFE survivorship care plan (SCP) is provided and discussed. We evaluated the degree to which a RAV promotes individualized healthcare and self-management as survivors transition from active treatment to follow-up care. Methods: Patients anonymously complete a post-RAV evaluation on the day of their RAV and then another at least one year after their RAV. Results: 1,713 RAVS, the majority for breast cancer, occurred from 1/2007 to 3/2014.There are 1,615 complete “day of” post- RAV evaluative data with a median time from completion of last therapy of < 6 months. Respondents scaled statements as strongly agree/ agree/disagree/ strongly disagree. Combined strongly agree/agree ratings are: 94% felt more confident in their ability to communicate information about their cancer treatments to other members of their healthcare team; 90% felt more comfortable recognizing signs and symptoms to report to their healthcare provider; 98% had a better appreciation for potentially helpful community programs and services. Of the 488 respondents (RAV between 1/2007 and 12/2012 n=1,366) to a questionnaire at least one year after the RAV, nearly 100%/97%/93%/91%/85% found the SCP useful in at least 1/2/3/4/5 ways: to summarize medical information, to reinforce follow up care, to recognize symptoms to report, to identify lifestyle practices that promote health, and for assistance in identifying local resources for support. 72% discussed their SCP with their PCP or another healthcare provider, 97% stated they made at least one positive lifestyle change, 89% attended at least one LIFE health promotion seminar, and 80% continue to work on wellness goals. Conclusions: Participation in a LIFE RAV following oncology treatment helps survivors construct a useful understanding of their cancer experience to guide self-care behavior. Data demonstrate that benefits persist one year after the visit and support the feasibility of a nurse-led RAV to establish a SCP in post-treatment cancer survivors.
Implementation of clinical practice guidelines in a multicenter radiation oncology department.
Authors: Teckie Sewit , Lee Lucille , Chou Henry , Zuvic Petrina , Potters Louis 
Published: February 2017

117 Background: Recent reports suggest that less than 20% of cancer care is based upon level I evidence. As a result, the majority of cancer care tends to be ad-hoc. Furthermore, deviations from established standards-of-care are associated with worse clinical outcomes. Systematic and evidence-based approaches to cancer care are widely regarded as an effective way of improving quality and value in oncology, yet their implementation remains broadly circumspect. In our multicenter radiation medicine department, we developed clinical practice guidelines (CPGs) that encourage consistent care in order to minimize variations in patient treatment, outcome, and experience. We hypothesized that CPGs would also improve efficiency, performance, and cost. Methods: We developed a system for prioritizing value in radiation oncology (Smarter Radiation Oncology) comprising three pillars – quality, evidence-based care, and patient experience. We created 87 unique, evidence-based and consensus-driven electronic CPGs that apply to the majority of patients undergoing radiation therapy in our department. Each CPG delineates an evidence-based treatment approach for a specific cancer site and stage, as well as many technical components such as simulation, treatment planning, quality assurance, clinical care requirements and survivorship. Results: Overall compliance to CPGs was >88%. Six-sigma Z-scores indicated improvement in efficiency and compliance. Treatment delays decreased and patients reported more favorable ratings on a variety of measures, including likelihood to recommend, wait times, understanding of treatment, and physician sensitivity. For breast and prostate cancer, adherence to CPG treatment resulted in 20% and 15% average lower costs than standard, non-CPG treatment. Conclusions: We demonstrate that consensus- and evidence-based CPGs can be successfully implemented in a multicenter department, with high adherence rates. CPGs improve safety and reduce costs by minimizing variation and deviations from standards-of-care. In an era of rising cancer spending, CPGs can be expanded beyond radiation oncology to the entire oncologic care process, thereby improving value for all cancer patients.
Who dies in the ICU? A qualitative analysis of cancer deaths.
Authors: Donohue Caitlin C. , Fraile Belen , Zhang Yichen , Stuver Sherri Oliver , Dalby Carole Kathleen , Jacobson Joseph O. 
Published: February 2017

118 Background: Providing safe and nurturing end-of-life (EOL) care to cancer patients is a challenge in any setting, but particularly so in the intensive care unit (ICU). In a unique collaboration between a comprehensive cancer center and a payer, we sought to identify cancer patients who died in the ICU and conducted a chart review-based qualitative analysis to better understand their location of death. Methods: We completed an exploratory, qualitative analysis based on a cohort of 264 active Dana-Farber Cancer Institute (DFCI) patients who died during 2012 and had claims data from Blue Cross Blue Shield of Massachusetts. Of the 160 patients admitted to the hospital in the last 30 days of life, 28 (17.5%) expired in an ICU. For the 22 patients who died in the ICU of a DFCI-associated hospital, vignettes were created from a chart abstraction. Using an inductive qualitative analysis approach, we explored each vignette using rounds of open, axial, and selective coding and identified common themes that described the patients’ ICU death incidents. Results: For the 22 cases, the most salient themes are reflected in the Table below. Conclusions: Using a qualitative research approach, we identified relevant factors to help understand why cancer patients die in the ICU. Most families requested aggressive therapy and, even though goals of care may have been modified, patients remained in the ICU. In addition, a substantial proportion of patients were transferred from a community hospital to an academic, tertiary hospital presumably to receive more aggressive treatment. In the future, the relationships among the themes identified from this research should be tested by a quantitative approach. [Table: see text]
Cincinnati’s adoption of a web-based portal to promote reportable evidence-based care.
Authors: Loy Bryan A. , Gallagher Jude , Peterson Barry A. , Forston Stanley , Sturgill Michael 
Published: February 2017

121 Background: Health plans have limited ability to assess compendia and preferred pathways, as claims data lack tumor subtyping, staging, line of therapy, and performance status. Attempts by health plans to gain visibility into compendia compliance have resulted in pre-authorizations and medical record analysis, which incur administrative burdens for physicians and plans. Alternative, more efficient approaches for payers and oncologists to share clinical data on treatment decisions may promote evidence-based care. Methods: In 2011, Humana and New Century Health implemented a registry-like platform to improve administrative efficiencies and facilitate compendia and preferred pathways in participating oncology centers in the Cincinnati metropolitan area. This web-based platform replaced faxed pre-authorization forms and created the opportunity to obtain real-time authorization. In the 3 years after implementation of the platform, process metrics for breast, colon, lung cancers, and lymphoma were reported. Coverage determinations were grouped as 1) withdrawn or not approved, or 2) approved, defined as compendia-based, inclusive of pathways, off-compendia approvals, and clinical trial notifications. Results: Widespread physician adoption of the platform exceeded 99% in 2011 and remained above 95% in the following 2 years. The trends in non-approved and approved reviews remained stable. As a subset of approved-reviews, compendia-based care remained consistently above 95%, while off-compendia plus clinical trial notifications occurred at frequencies below 5%. Conclusions: Compendia compliance was high and remained stable over time. Widespread adoption of a web-based platform can ease the administrative burden and support timely enrollment of patients into clinical programs. Evolution of the platform intends to shift the information closer to the point of decision making by the treating oncologist. [Table: see text]
CANES family health team EMR optimization pilot.
Authors: Dhanji Zabin , Cunningham Nicki , Carr Dafna 
Published: February 2017

129 Background: While Electronic Medical Records (EMRs) have been widely adopted within primary care, practices are at various stages of maturity in their use. Cancer Care Ontario (CCO) has embarked on an EMR Optimization initiative, in collaboration with primary care providers (PCPs) and OntarioMD. The project is intended to support PCPs in leveraging the functionality in their EMR systems in order to support cancer screening through the development of training guides and tools. Working with the CANES Family Health Team (FHT), CCO is piloting the usefulness and effectiveness of these tools in meeting these objectives and using the results to inform how to support provincial pilots. Methods: The EMR Optimization guides and tools provide practices with training on five key areas: practice workflows, data discipline, searches, reminders and preventative care summary reports. Working with a multi-disciplinary team at the CANES FHT, CCO provided the team with the EMR Optimization tools and training on these five key areas. The training was supplemented with exercises on topics such as data discipline and practice workflow. The practice team then had opportunities to work with the guides and tools and integrate them into their daily workflow. Results: Preliminary results of an EMR maturity survey show that even after a short period of time, the team has developed an awareness of and a focus on improving data quality through standardization. In addition, they have learned how to leverage the functionality of their EMR system for preventative care purposes. Participant feedback indicates that they found the EMR guide and tip-sheets easy to understand and follow. Conclusions: The CANES pilot has resulted in practice staff moving up the EMR maturity curve and has taught the team how to leverage their EMR to support cancer screening. In addition, the pilot has helped inform CCO’s training strategy and refine the guides and tools. The next steps are to develop self-directed training tools and resources that will support a broader scale pilot to be implemented throughout 14 regions in Ontario.
Proteinuria monitoring in patients receiving bevacizumab at a community cancer center.
Authors: Benyounes Amin , Pomerantz Sherry , Christian Ann , King Gentry Teng , Leahy Nancy , Tester William J. , Leighton John Charles 
Published: February 2017

13 Background: The use of bevacizumab has been associated with the development of proteinuria. The manufacturer suggests monitoring for proteinuria with serial urine dipsticks. We set to evaluate the relevance and cost of this practice in a Community Cancer Center in Philadelphia. Methods: We performed a retrospective chart review at Albert Einstein Cancer Center. Consecutive patients treated with bevacizumab from January 2011 to March 2014 were included in the study. Primary endpoints were the incidence and grade of proteinuria under bevacizumab therapy and the implication of proteinuria in treatment (holding or cessation of bevacizumab). Secondary objectives included the association between the number of bevacizumab infusions or patient’s comorbidities (diabetes, hypertension, chronic kidney disease) and the development or worsening of proteinuria. We also calculated the cost of monitoring for proteinuria in our cohort. Results: 71 patients were screened. A total of 66 patients (corresponding to 738 infusions) were included in the analysis. Typical monitoring interval was every 2 cycles. None developed nephrotic range proteinuria. One patient (1.5%) developed grade 2 proteinuria. Bevaciuzumab was discontinued due to proteinuria in 2 patients (3%): neither of them developed permanent kidney damage or required an intervention as a consequence of the proteinuria. The most common reason of bevacizumab discontinuation was progression of disease (75%). Neither the number of infusions nor concomitant comorbidities were significantly associated with the development or worsening of proteinuria (p=0.8, p>0.05 respectively). The cost of monitoring for proteinuria in our cohort was estimated at $3980. Conclusions: These results show that the development of grade 2 proteinuria, let alone grade 3, with bevacizumab is uncommon and rarely affects treatment decisions in our Community Cancer Center. We therefore question the necessity of routine monitoring for proteinuria during bevacizumab treatment.