bluuebunny/crossref_metadata_2025_split huggingface dataset:
Oral oncolytics: Patient-monitoring improvements in private practice.
Authors: Mahmood Tallat , Redouty Lindsey , McNamera Elaine 
Published: February 2017

215 Background: The use of oral oncolytics is becoming more common. These drugs have their own unique challenges in managing patient initiation, monitoring side effects and adherence. Methods: We conducted a baseline chart audit of patients prescribed oral oncolytics in our private oncology practice followed by a quality improvement program and subsequent reassessment. Information obtained included: prescription date, actual start date and any documented problems with the oral therapy. The baseline audit included patients from may of 2011 to July 2013. Subsequently we joined the Michigan oncology quality consortium’s oral chemotherapy collaborative and initiated the following: office procedures for identification of all patients on oral therapy, use of the Edmonton Symptoms assessment system (ESAS), and a self-care management education program including patient self-monitoring of symptoms with recommended initial treatments. A postintervention audit was conducted from August 2013 to March 2014. Results: We identified 25 patients in the first time period and 13 in the second. In the first time period we found only 13 of the 25 patients had an actual start date documented, and of these 13, 10 had a >/=4 week delay prior to starting therapy, with 3/13 having a 2-4 week delay prior to start of therapy. 12 of the 25 patients discontinued their drug within the first month due to side effects without consulting their physician. After participating in the quality initiative, we identified only one patient without a documented start date, only 1/13 that had a > 4 week delay from prescription date to starting the drug, with 12/13 having a less than 2 week lapse. We also found that there were no patients who discontinued the drug and only one dose reduction as directed by the physician. Conclusions: The introduction of new office procedures to easily identify all patients on oral therapy and improved patient management of symptoms at home with the use of self-care guidelines, and in the office with use of ESAS contributed to greater adherence to oral chemotherapy regimens.
Communicating comfort: How do cancer outpatients and health care providers talk about pain?
Authors: LeBaron Virginia Townsend , Blonquist Traci M. , Beecy Autumn , Berry Donna Lynn 
Published: February 2017

229 Background: Pain remains a significant problem for many cancer patients. Poor communication between healthcare providers and patients can contribute to this problem. This secondary analysis explored patient-provider discussions of current pain in the ambulatory oncology setting. Methods: Audio recordings from 66 adult oncology clinic visits in Boston and Seattle were selected from a pre-existing data set of a larger trial. To ensure a diverse sample, all minority recordings (n=33) were selected with a random sample of non-minority recordings (n = 33) matched on patient characteristics. Recordings were reviewed by two independent investigators and each pain discussion was quantitatively coded using 12 variables based on a review of the literature. A pain discussion was defined as any reference to pain or discomfort initiated by either patient or provider. Results: Preliminary analysis of 33 cases revealed 57 separate discussions of pain (6 involved patients denying any pain). Patients and providers were equally likely to initiate discussions about pain (patient initiated total: 27/57; 47%; provider initiated total: 30/57, 53%). Pain discussions overlapped with general symptom assessment, and pain was commonly attributed to effects of oncologic therapy and discussed as stiffness, soreness, or aching, not necessarily as ‘pain.’ Discussions of pain were typically brief and providers asked more close-ended and leading questions (n= 87) versus open-ended questions (n=18) when assessing pain. Providers rarely (n=3) used a validated pain intensity scale (e.g., 0-10) and explored reports of pain slightly more often than acknowledging only (n=27/51; 53%; n=24/51; 47%, respectively). Conclusions: Discussions of cancer related pain in the ambulatory setting are complex, often with multiple reports of pain of varying etiologies discussed throughout the clinic visit. Providers may limit communication by asking mainly close-ended questions and only exploring patient's pain reports about half the time. This analysis offers insights into areas for improvement in communication patterns related to cancer pain.
Psycho-oncology via telemedicine: A model to provide services to a rural population.
Authors: Krigel Susan , Nelson Eve-Lynn , Spaulding Ashley , Krebill Hope , Leepers Melanie , Doolittle Gary C. 
Published: February 2017

236 Background: The Midwest Cancer Alliance (MCA), the outreach arm of the University of Kansas Cancer Center, developed psycho-oncology services over videoconferencing in partnership with its rural members. The collaborative goal is to address patient-identified psychosocial needs that are not currently being met in the communities. Methods: Following telemental health best practices, MCA personnel, rural site leaders, local oncology and behavioral health teams, and telemedicine staff collaborated closely to establish the service. They developed detailed protocols related to: referral and scheduling; technical training and support; paperwork; videoconferencing sessions; post-visit follow-up/documentation; and emergency management procedures. Attention was given to: confidential space; equipment to meet therapy needs; the telemedicine coordinator’s role; and completion of professional requirements (e.g., licensing, credentialing, malpractice coverage). Results: Credentialing, site implementation, and patient recruitment took longer than anticipated. To date, 15 patient visits have occurred through the psycho-oncology service across two rural sites. Worsening illness has impacted referrals as well as retention in therapy. Videoconferencing services have approximated onsite psycho-oncology strategies, with focus on evidence-based care. In general, patients have had advanced medical illness as well as significant premorbid psychosocial difficulties, such as mood disorders, substance abuse history, and relationship problems. Basic challenges to care have remained, including lack of consistent transportation. The telepsychologist’s role in relation to the rural medical team expectations is still evolving. Conclusions: The early lessons learned will continue to strengthen the psycho-oncology service as videoconferencing services expand in order to increase access. Ongoing, site-specific needs assessment remains essential, as “one size does not fit all.” Future plans include improving recruitment by coordinating referrals with distress screening. In order to provide sites with maximum flexibility, new methods of communication will be offered as they become available.
Change in symptom burden within one day of palliative care consultation in a cohort of gynecologic oncology inpatients.
Authors: Lefkowits Carolyn , Teuteberg Winifred , Courtney-Brooks Madeleine , Sukumvanich Paniti , Kelley Joseph L. 
Published: February 2017

28 Background: Change in symptom burden after inpatient palliative care consultation for symptom management in gynecologic oncology patients has not been described. Our objective was to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. Methods: Women with a gynecologic malignancy and a PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographics and disease characteristics. PC provider reports of patient symptom intensity on a modified Edmonton Symptom Assessment System were retrospectively reviewed. Data was analyzed with descriptive statistics and two sample test of proportions to compare prevalence of moderate to severe symptom intensity on the day of consultation to the day after consultation. Results: Over 12 months, there were 172 PC consultations for symptom management involving 123 unique patients. The median age was 58 and most common cancer was ovarian (44%), followed by cervical (26%) and uterine (24%). Prevalence of moderate to severe symptoms on the day of consultation is outlined below. There were statistically significant decreases in prevalence of moderate to severe symptom intensity within one day of PC consultation for pain, anorexia, fatigue and shortness of breath (SOB) (see table). Conclusions: PC consultation is associated with significant improvements in symptoms within one day of consultation. Palliative care consultation may be an effective tool for symptom management during even very short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief. [Table: see text]
Parent distress related to child health outcomes during hematopoietic stem cell transplant (HSCT).
Authors: Ullrich Christina Kathleen , Rodday Angie Mae , Parsons Susan Kenyon 
Published: February 2017

31 Background: HSCT offers possible cure yet remains intensive and high risk. Parent distress related to potential child outcomes during HSCT is unexplored. Methods: Parents of children undergoing HSCT (n=363) at 8 US transplant centers completed the Child Health Ratings Inventories (CHRIs) measuring parent and child general health and QOL at baseline (BL) through 12 mos post HSCT. Main outcomes: responses to 2 CHRIs items regarding parent worry about child "health worse" and "might die," rated on a 5-point Likert scale ranging from none to all of the time, and transformed to 1-100 (higher, more worry). Analyses focus on BL to D45 when parent worry decrease was pronounced. Clinical data were abstracted from charts. BL personal, clinical and HSCT course characteristics with p<0.2 on univariate analysis were entered into multivariable models adjusting for transplant center, then eliminated by backward selection (p<0.1). Results: Parents were 83% female, 77% White, median age 38.7 yr (IQR 33-44). Child median age was 9.6 yr (IQR 6-14). Most (72%) had cancer; 78% underwent allogeneic HSCT. By D45, 33% had systemic infection, 33% acute graft versus host disease (aGVHD) and 20% intermediate/poor Bearman toxicity score. Mean parent "might die" worry decreased from BL (41.9, SD 8.3) to D45 (26.6, SD 24.6) (p<0.001). "Health worse" worry similarly decreased. Despite this, ongoing worry risk factors exist including younger child age, solid tumor and hematologic malignancy but not HSCT course characteristics (Table). Conclusions: Some parents remain at risk for unmitigated distress about child health, largely irrespective of the HSCT course. Enhanced supports such as palliative care consultation may be of benefit. [Table: see text]
Return-to-work issues in outpatient palliative care.
Authors: Glare Paul A. , Nikolova Tanya , Alickaj Alberta , Blinder Victoria Susana , Patil Sujata 
Published: February 2017

35 Background: Early integration of palliative care (PC) with oncologic care means return to work (RTW) issues will apply to some patients. There is an extensive literature on RTW after completing definitive treatment but much less is known about RTW in patients with active disease and on treatment. Methods: Cross-sectional survey of patients in two Pain & Palliative Care (PC) clinics at a comprehensive cancer center. Respondents were aged 25-65 and had been in paid employment prior to or during their treatment. The survey consisted of 37 items covering three domains: clinical details and demographics; work status, occupation, and work ability; importance of work and factors interfering with work. Results: 105 surveys were completed. 54% respondents were females, median age 53. 79% had been working at the time diagnosis. The commonest primaries were breast, colorectal, lung, GYN, and melanoma/sarcoma. 80% reported having active disease, median 2 years since diagnosis, and 73% were currently on treatment. In patients with active disease (n=86), 47% were currently working, 63% of them full time, typically RTW after taking < 6 months off. Work was important to 80% them, making 83% "feel normal", and 58% feel like they are “beating the cancer”. 35% would have liked to work more hours. Fatigue interfered with work in 49%, pain in 38%, and side effects of pain medicines in 31%. Almost ¼ were anxious or depressed about their work situation. More than 20% experienced discrimination in the work place, although usually minor. Conclusions: It is not uncommon for patients with advanced cancer to RTW even when they are on treatment and are sick enough to need to be followed in a PC clinic. Work is important to them and many would like to work more. Symptoms and side effects may interfere with their work ability. Some may be experiencing discrimination in the work place. Interventions to overcome these problems should be part of comprehensive, interdisciplinary PC.
Randomized trial of high- versus low-intensity breathing training for dyspnea due to intrathoracic cancer: Cost-effectiveness.
Authors: Johnson Miriam , Kanaan Mona , Richardson Gerry , Nabb Sam , Barton Rachael , Torgerson David , Booth Sara 
Published: February 2017

54 Background: About 90% of patients with lung cancer experience dyspnea. Breathing training is helpful, but multiple sessions may be onerous. Methods: UK multisite phase 3 RCT, comparing three weekly sessions of breathing training to a single session for refractory dyspnea due to intrathoracic cancer. Primary outcome: self-report “worst” dyspnea/24 hours, (0–10 numerical rating scale [NRS], 0=none; 10=worst imaginable). Secondary outcomes: “average”, distress due to dyspnea (NRS); quality of life (QoL) (CRQ-SAS; EQ-5D); health service utilisation. Primary analysis point: 4 weeks for dyspnea/QoL. An economic analysis addressed cost-effectiveness from the perspective of UK National Health Service (NHS) and personal social services in a budget constrained system; costs at NHS 2012/13 prices. Primary outcome: Quality Adjusted Life Year (QALY) over 8 weeks. Results: 156 were randomized: age 69 (SD 9.4); 40% women; Karnofsky performance status 71% (SD 9.5); 133 primary lung. “Worst” score improved, 6.8 (SD1.9) at baseline to 5.8 (SD 2.4) at week 4. There was no detected difference in area under curve (AUC): three 22.9(SD 7.1) versus single 22.7(SD 7.1); P = 0.83; 95% difference CI (-2.3, 2.9), or for AUC “average”, or CRQ-SAS. AUC “distress” was less in the single group (16.2 versus 12.3; P = 0.01). Using complete cases, three sessions were associated with a QALY reduction of 0.006 (95% CI -0.18 to +0.006) over 8 weeks and 0.008 (95% CI -0.022 to 0.006) with multiple imputation, and showed increase in costs when adjusted for baseline health related QoL (Mean increased cost £37; 95% CI -506 to +581). Conclusions: Three sessions conferred no benefits over one and had a worse QALY profile. Though statistically insignificant, a single session seems to be a cost-effective way to provide breathing training, minimising the burden of healthcare visits. Clinical trial information: ISRCTN49387307.
Challenging conversations in oncology: A workshop for fellows.
Authors: Ramchandran Kavitha , Schapira Lidia , Spiegel David , Harman Stephanie , Fronk Joshua , Kogon Manuela , Kostopoulos Kay , Tribett Erika L , Berek Jonathan S. 
Published: February 2017

60 Background: Compassionate communication is critical to patient-centered cancer care. Conversations about sensitive topics are necessary to help patients make well-informed decisions. Still, many oncologists feel ill-equipped during these conversations and thus avoid them or approach them with a purely clinical perspective. Fortunately, empathic communication skills can be learned. This project, Challenging Conversations in Oncology (CCO), involves the development of an experiential workshop to help build skill and confidence communicating with cancer patients. The workshop is part of a movement to reimagine cancer care at Stanford. Methods: The first iteration of CCO was multi-day event with didactic lectures, self-awareness exercises and small group role-play. The faculty was multi-disciplinary, including clinicians in various subspecialties, communications experts and patients themselves. Activities were designed to build skills in interviewing, cultural humility, adapting communications, and dealing with patient and provider emotions. A post-workshop evaluation survey assessed overall effectiveness as well as self-reported learning and perceived enhancement of patient care as a result of participation. Results: The CCO workshop was implemented in Fall 2013. Participants included 17 physicians from various oncology subspecialties. Participants reported that the workshop was very valuable (rating at least 4 on a 5-point scale of overall effectiveness). Common themes included learning to “slow down” and do “less talking, more listening,” taking time to “let patients express themselves…cry, be silent.” Faculty reported enthusiasm watching trainee communication skills “evolve along with…the patient’s story.” Conclusions: This workshop was a significant educational opportunity for junior faculty at Stanford. Feedback suggests the experience was rewarding and influential. It encouraged cultivation of communication skills that will likely benefit doctors and their patients. This fall (Year 2), we will extend this workshop to senior faculty, staff, and administration. The course will continue to evolve to meet the needs of providers and align with comprehensive institutional enhancements in cancer care.
Advance-care planning quality improvement plan: A Cancer Care Ontario toolkit to support primary care teams to implement advance care plans in practice.
Authors: Myers Jeff , Strasberg Suzanne , Carroll Kathi , Dhanji Zabin , Harle Ingrid , Urowitz Sara , Walton Tara , Zwicker Victoria 
Published: February 2017

76 Background: In Ontario, the Ministry of Health and Long Term Care’s (MOHLTC) uses Quality Improvement Plans (QIPs) to drive system improvement aimed at providing high value, high quality care for all. To support the introduction of QIPs into the primary care sector, Cancer Care Ontario has developed an Advance Care Planning (ACP) toolkit for practices that include ACP as part of their annual QIP. ACP is an ongoing and dynamic process that involves a capable individual reflecting on their current values and beliefs for their health care, communicating their personal wishes for future health care and identifying an individual who will make decisions on their behalf in the event that they are unable to provide informed consent. The process is iterative and wishes may change over time with changes in health status. Methods: The ACP QIP was developed based on the Plan, Do, Study, Act cycle of continuous quality improvement. The ACP QIP provides primary care practices with detailed instructions on how to implement, monitor and report on an ACP Quality Improvement initiative. Importantly, the ACP QIP provides guidance and practical tools for developing objectives, establishing targets, and identifying measures and baselines for performance. CCO is actively promoting the ACP QIP in an effort to encourage uptake and broad adoption across Ontario. Results: There is now evidence that with ACP there is a greater likelihood EOL wishes will be both known and followed resulting in improved EOL care. ACP is also associated with decreased distress among the family members. Conclusions: Creating an ACP QIP supports primary care’s focus on advancing quality patient care. Importantly, implementing the ACP QIP into primary care practices has the potential to improve EOL care and secondarily reduce health care costs ultimately working towards achieving the triple aim of “better care, better health, and lower costs”.
Care, quality, and cost implications of the timing of palliative care consultation among patients with advanced cancer.
Authors: Scibetta Colin , Rabow Michael W. , Kerr Kathleen 
Published: February 2017

8 Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (>90 days prior to death) versus late PC (<90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service <3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.
Physicians' perceptions of palliative care.
Authors: Gidwani Risha , Meier Diane E. , Asch Steven M , Kirch Rebecca A 
Published: February 2017

80 Background: Physicians are often gatekeepers to palliative care for their patients. Physicians’ attitudes and beliefs regarding palliative care will therefore influence patient receipt of these services. Here, we explored physicians’ perceptions of palliative care. Methods: We conducted a focus group with 2 hospitalists and 3 medical oncologists. We asked physicians to define palliative care and elicited their suggestions regarding best way to communicate the role of palliative care to patients as well as to other physicians. Results: Physicians generally defined palliative care as comfort care, with two physicians denoting palliative care as occurring during the end of life. Focus group participants felt the best way to communicate the role of palliative care to other physicians was to denote its ability to support physicians in their work by helping coordinate patient care, managing complex physical and emotional symptoms, devoting time to intensive family meetings, and resolving conflicts between patients/families and physicians concerning goals of care, do-not-resuscitate orders, and treatment requests. They disagreed that palliative care should be integrated at all points in a patient’s disease trajectory. Conclusions: Physicians had generally positive reactions to palliative care. Palliative care is often associated with end-of-life care. Further research and exchange about the appropriate timing of palliative care is needed.