bluuebunny/crossref_metadata_2025_split huggingface dataset:
Addressing risk of financial toxicity in an ambulatory oncology practice: Our institutional experience with the ASCO Quality Training Program.
Authors: Hensing Thomas A. , Bauer Tyler , Palafox Anna , Whalen Margaret , Carro George W. 
Published: April 2017

114 Background: Due to escalating cost of cancer care, patients (PTs) with cancer are at increased risk for financial toxicity (FTOX) that can exacerbate disparities in care and lead to clinically relevant adverse PT outcomes; including quality of life; symptom burden; adherence; and survival. A review of our informed consent (IC) process demonstrated that PTs were not routinely informed of financial risks of high-cost (HC) cancer therapies at the time of IC. Methods: A multidisciplinary team was formed to conduct a rapid-cycle quality improvement project with the aim of reducing FTOX through improvement in patient education at the time of IC. Because of HC and increased utilization, the initial pilot focused on treatment with immune checkpoint inhibitors (ICI). A cause and effect diagram identified the potential causes that FTOX was not addressed during the IC process. Diagnostic data were obtained through staff surveys and querying our EMR from June to August, 2016. A Pareto chart identified lack of educational (ED) tools at the time of IC and a poorly understood prior authorization (PA) process as the most common causes for not addressing risk of FTOX during IC. Plan-do-study-act (PDSA) #1 began with development of a PT ED tool to be used during IC. The tool was approved by the Patient Advisory Board. Staff from clinical teams utilizing ICI for approved indication completed training on its use and a pilot study was initiated. PDSA#2 focused on optimizing the PA process and PDSA#3 focused on PT distress and FTOX monitoring through the NCCN distress and a validated patient-reported-outcome tools (COST), respectively. Results: The utilization of the PT ED tool reached the project aim (administer to > 65% of pts during IC) during initial phase of PDSA#1, although accrual is ongoing. A revised PA process (PDSA#2) was developed, staff were educated and the updated PA process was initiated. Work on PDSA#3 is ongoing. Conclusions: This QI project suggests that it is feasible to address FTOX through PT ED during IC for HC cancer therapies. However, the impact of this intervention on PT distress, overall FTOX and treatment disparities will need to be monitored closely.
Faster and better: Improving the diagnostic phase of lung cancer at a system level.
Authors: Kaan Melissa , Holloway Claire , Gilbert Julie , Simanovski Vicky , Matheson Garth 
Published: April 2017

115 Background: For many patients going through diagnostic testing for cancer, the time from suspicion to diagnosis or rule-out, can be a confusing and anxious time. In 2007, Cancer Care Ontario began investing in the implementation of diagnostic assessment programs (DAPs) across Ontario, Canada to improve the quality of care during the diagnostic phase of lung cancer. DAPs consist of multidisciplinary healthcare teams that manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis. The objectives of the DAPs are to: 1) decrease time from suspicion to diagnosis or resolution; 2) optimize the patient’s experience during the diagnostic process; 3) optimize satisfaction and experience among primary care providers and specialists; and 4) provide a sustainable solution by offering good value for money. Today over 35,000 patients have been diagnosed in one of the 18 lung DAPs that exist across the province. Methods: The implementation of DAPs featured the introduction of a patient navigator to act as the primary point of contact for patients, improve the patient experience and ensure their patients were progressing through any required diagnostic imaging and consultations in a timely manner. Cancer Care Ontario also engaged with primary care providers to refer patients with findings suspicious for lung cancer to DAPs as early as possible to ensure they benefited from organized assessment. Cancer Care Ontario has collected patient level data to measure wait times and implemented a patient survey to assess patient experience. Results: In the past five years, the median wait time from referral to a lung DAP to diagnosis or rule out has decreased by 19% to 24 days and the 90th %tile has decreased by 28% to 51 days. The large majority of patients have had a positive experience with their DAPs, with 95% of patients scoring their experience in the diagnostic process as “good” or “excellent”. Conclusions: The implementation of DAPs across the province is seen as a valuable component of quality of care by improving the diagnostic phase of cancer. The sustainability of the DAP model is demonstrated by the continued improvements in access and maintained patient experience in spite of growing volumes (91% increase in the past five years).
Trends in survival and costs among U.S. patients with multiple myeloma.
Authors: Maiese Eric , Evans Kristin , Chu Bong-Chul , Irwin Debra E. 
Published: April 2017

12 Background: Survival among patients with multiple myeloma (MM)has improved over time, but little is known about concurrent changes in health care costs. This study examined trends in both survival and health care costs over the same time periods in U.S. patients with MM. Methods: The MarketScan Commercial and Medicare claims dataset was used to identify 5199 adult patients diagnosed with MM from Jan. 2006 to Dec. 2014. Patients had no prior evidence of cancer, were continuously enrolled for ≥ 12 months prior to MM diagnosis, and were followed through the earliest event (death, end of enrollment, or end of the study period (9/30/2015)). Multivariate GLM and Cox proportional hazards models estimated health care costs and survival probabilities, respectively, for two time periods during which patients were diagnosed with MM (2006-2010 vs. 2011-2014) while controlling for demographic and clinical characteristics. The recycled prediction method was used to calculate the incremental cost estimates between the time periods. Results: Patients diagnosed in 2011-2014 had a 35% lower risk of death compared to those diagnosed in 2006-2010 (HR [95% CI] = 0.65 [0.57-0.74]). Patients diagnosed in 2011-2014 had 18% (95% CI: 6-31%) higher all cause and 26% (95% CI: 6-50%) higher MM-related per patient per month costs compared to those diagnosed in 2006-2010 (see table). Conclusions: Among patients with MM, survival has improved at a greater rate than the increase in health care costs. In addition to improvements in MM treatment, changes in overall disease management may have contributed to both the increased expenditures and survival improvements observed in this study.[Table: see text]
Right patient, right appointment, right provider at the right time.
Authors: Roy Megan , Fanslau Katie , Malloy Maria , Sweeney Suzanne , Miller Eleanor , Rummel Margaret 
Published: April 2017

125 Background: Patients with a suspicious scan or confirmed cancer diagnosis are anxious to be seen by an oncology provider. It’s important that patients are scheduled to see the most appropriate providers in the right order and timing for their clinical needs. At one large academic medical center, where patient volumes are high, the system is complex, and patients often travel. It was identified that patients were being scheduled out of order, had incomplete information, or could have been scheduled with improved timing and with additional support. This occurred in multiple disease sites. Methods: Based on this assessment, a process has been initiated to where the intake forms completed on each new patient scheduled are routed to the oncology nurse navigators via the electronic medical record. The nurse navigators then reach out to the patient prior to their appointment to further triage their needs, identify barriers and provide education and additional resources. Results: This intervention, while in early stages, has improved nurse navigator involvement with the new oncology patients to ensure they are set up appropriately, with accurate information, and has decreased providers scrambling to add patients on the same day. Outcomes from the navigator’s assessment can include any of the following: leave the appointment as is, reschedule it with the same or different provider, coordinate with another provider, or add additional information to the chart as the patient’s story evolves. Regardless, the patient receives an introduction to the nurse navigator, education, and support prior to being seen. Conclusions: By identifying an area where nurse navigators can improve patient care processes, patients are now able to get personalized assessment and appropriate appointments, no matter how they present to the cancer center. Not only are patients able to be seen by the most appropriate provider at correct timing, but the assessment for clinical needs and barriers to care can be addressed proactively. This wouldn’t be possible without the collaboration of staff and providers, willing and eager to improve the process for patient care.
ONCOPRE: A new chemotherapy benefit prediction model to assist treatment decision making.
Authors: Yusuf Dimas , Ho Maria Yi , Cheung Winson Y. 
Published: April 2017

126 Background: Clinical decision support tools (CDSTs) can help physicians make complex treatment decisions and inform care. For colon cancer, CDSTs such as Adjuvant! Online and Numeracy were widely used to estimate the effects of adjuvant treatment and guide conversations with patients. Existing CDSTs, however, do not consider more contemporary predictive and prognostic factors, such as microsatellite instability (MSI), BRAF mutational status, or the presence of additional high risk clinical or pathological features (HRFs), in their assessment of outcomes. Current CDSTs are also not optimized for handheld devices. Methods: We developed ONCOPRE, which is an adjuvant chemotherapy benefit calculator for colon cancer that addresses the limitations of current CDSTs. Based on a comprehensive review of epidemiological data and results of landmark trials, ONCOPRE was devised to predict 5 year colon cancer recurrence and death. To validate ONCOPRE, we compared its predictions with those generated by existing CDSTs as well as real-world data from 7 tertiary cancer centers across Canada. Results: ONCOPRE is able to predict 5-year DFS and OS of patients with colon cancer based on age, sex, TNM status, and contemporary risk factors such as MSI status, BRAF mutations, and other HRFs. ONCOPRE’s predictions compare favorably with real-world data and predictions from other CDSTs. ONCOPRE’s predictions are typically more optimistic than historical outcomes, and this likely reflects the fact that current day colon cancer patients experience better prognosis with the use of modern therapy and improved supportive care. These attributes make ONCOPRE a potentially new benchmark among CDSTs that can reliably predict colon cancer outcomes. Conclusions: ONCOPRE ( http://www.oncopre.com/ ) represents a new CDST that can assist in adjuvant treatment decision-making and patient counseling. We make the case that the next generation of CDSTs in oncology must take into account more contemporary clinical, biochemical, and genetic risk factors since these elements significantly affect outcomes. The ONCOPRE platform serves as a potential model on which to develop prediction tools for other forms of cancers.
Use of a comparative database to identify excessive hematology/medical oncology hospital days and readmissions.
Authors: Halbert Brian , Zerillo Jessica A. 
Published: April 2017

131 Background: Reducing length of stay and readmissions are important goals to improve healthcare quality and decrease costs. We identified diagnostic categories accounting for excessive hospital days and readmissions on our hematology/medical oncology (HO) service. Methods: We used a third-party comparative clinical database (Vizient Inc, Clinical Data Base/Resource Manager) to identify discharges from our HO service in 2015. Cases were categorized by All Patients Refined Diagnosis Related Groups (APR DRG), and we calculated excess hospital days attributed to each using the number of cases and their observed/expected length of stay. We also collected 30-day readmission rates for each APR DRG on our HO service and hospital wide. Readmission rates were compared using Fisher exact tests. Results: We identified 1,361 discharges from our HO service with 134 APR DRG codes and 880.5 excess hospital days. Fourteen APR DRGs accounted for over 80% of the excess hospital days. Readmission rates ranged from 0% to 66.7%, and were generally higher than rates hospital wide. Readmissions for septicemia and major operating room (OR) procedures for lymphatic neoplasms were significantly higher on the HO service. Conclusions: Relatively few APR DRGs accounted for the majority of our excess hospital days, and also had high readmission rates. We will conduct additional review of these APR DRGs to identify opportunities to improve quality and reduce cost. [Table: see text]
An EPIC electronic decision support tool to identify percentage of patients with stage IV thoracic or gastrointestinal malignancy who would benefit from concurrent palliative care but do not currently receive it.
Authors: Adelson Kerin B. , Trant Amelia Anne , Framski Kim , Swidler Mark , Kashyap Nitu 
Published: April 2017

133 Background: In 2016 ASCO updated its guideline for early integration of palliative care (PC) into standard oncologic care for all “inpatients and outpatients with advanced cancer.” PC has been shown to improve quality of life, align care at the end of life with patient preferences, and reduce health-care utilization. In preparation for the expansion of our palliative care service into ambulatory disease-based practices at Smilow Cancer Hospital at Yale-New Haven, we sought to create a decision support tool (DST) in the EPIC Electronic Health Record (EHR) that would identify patients for PC referral. Methods: This DST identifies patients with a GI or thoracic malignancy who have had an ICD-10 diagnosis of metastatic or stage IV disease, have not had a palliative care visit in the last 6 months, and are not enrolled in hospice. If the patient meets criteria, the DST will remind providers that “this patient meets ASCO and IOM criteria for concurrent palliative care with oncologic care ” and offers a one-click option to place the referral. To understand the volume of patients this DST would refer, we ran it silently in the EHR background from 7/15/16 through 9/1/16. We tracked how many patients were seen in the clinics, how many were eligible, and how many were referred to PC. Results: See table. Conclusions: Our silent BPA indicated that only 5% of patients eligible for a palliative care consult received it at baseline; this matches national data, which suggests that most patients who would benefit from PC do not receive it. This DST has the potential to dramatically improve PC referral rates and increase adherence with ASCO and IOM guidelines. We plan to move the DST into the live clinical EHR in 2017 after the integrated PC clinics are open. We anticipate that once our BPA is activated, we will see a dramatic increase in the number of eligible patients referred to palliative care. [Table: see text]
Quantifying the electronic medical record implementation to stabilization curve.
Authors: Kadish Sarah , Senderovich Arik , Leib Ryan , Mandelbaum Avishai , Momcilovic Petar Momcilovic , Trichakis Nikos , Bunnell Craig A. 
Published: April 2017

140 Background: The implementation of electronic medical records (EMR) has been noted to disrupt clinical workflows as providers acclimate to a new EMR. On May 30, 2015, Dana-Farber Cancer Institute (DFCI) implemented a new EMR. Using our Real Time Location System (RTLS), we sought to identify the time required to stabilize the experience for providers. We identified factors that may speed the stabilization rate to guide EMR implementations elsewhere. Methods: DFCI uses an RTLS to timestamp patient and provider locations throughout the day. To adjust for variation in appointment types, we measured the ratio of the actual exam duration (recorded by the RTLS) to the scheduled exam duration. We compared to a 3-month baseline average to quantify the immediate impact of implementation. We tracked the ratio over time to identify when stabilization occurred and compare to baseline performance. To infer influential factors, we performed a regression analysis based on RTLS data from the first 6 months post implementation. Results: The stabilization curve fits the “classical” power function model. Rapid improvement over the first ten days of clinical practice was followed by a gradual period of ongoing stabilization. The EMR impact on exam duration required approximately 30 clinical days for each provider to reach the baseline value with continued improvement over the next 30 clinical days. Factors with a potential to improve the rate of stabilization were provider type (MD, NP or PA), provider gender and provider age. Conclusions: The first ten clinical days experience a fast rate of improvement. Thus, while the initial impact is disruptive, operations improve rapidly. Initial improvement may be attributed to fixing “bugs” in the EMR and rapid learning by providers. Our presentation will explore factors that impact the rate of improvement. Understanding the stabilization rate and factors can aid organizations in training, implementation, and ongoing improvement to minimize the impact of EMR disruption. [Table: see text]
Leveraging a software application to prepare for regulatory inspection within a hematopoietic cellular therapy program.
Authors: Blunk Betsy , Jawanda Jesse , Drake Kevin , Billups Rocky Lee , Cox Tonya , Dodd Therese , LeMaistre Charles F. 
Published: April 2017

142 Background: The Sarah Cannon Blood Cancer Network (SCBCN) is comprised of seven Hematopoietic Cellular Therapy (HCT) programs. Regulations require that programs have a consistent and continuous process to identify and measure compliance to ensure standards are met. Every 3 years, programs undergo inspections by the Foundation for the Accreditation of Cellular Therapy (FACT). Historically, programs would prepare for inspections by utilizing paper documents that support and demonstrate compliance with standards. The goal of this project was to develop an electronic platform to manage the FACT inspection. COMAIBA (Compliance Management Actionable Intelligence Business Analytics) was selected as a development partner. Methods: Within our HCT programs, a thorough analysis was performed to determine the current processes by which inspections took place. The FACT assessment questionnaire was reviewed and each standard was evaluated. Quality coordinators within the programs highlighted the key documentation necessary to meet each standard. Results: In collaboration with COMAIBA, a regulatory compliance module was developed which allows the programs to electronically prepare for and manage FACT inspections. There are currently over 1600 questions within the application broken down into clinical, apheresis, marrow collection and processing facility subsections. Programs upload supporting documentation to demonstrate how they comply with each standard. From a programmatic level, administrators and key personnel can, at any time, view the preparation process via a dashboard and view the compliance measures electronically. Conclusions: This electronic solution allows quality teams to proactively prepare for inspections and keep information current and up to date on an ongoing basis. As standards evolve, the design of the COMAIBA application allows versatility in updating and maintaining compliance. COMAIBA is working to utilize this format for other regulatory and accrediting bodies i.e. CoC, UNOS. In addition, allowing the inspectors to view information electronically prior to coming onsite may enhance the inspection process and allow for a more comprehensive review.
Development of a patient question prompt list to improve communication and clinical trial enrollment in a diverse patient population.
Authors: Hamel Lauren M. , Penner Louis , Heath Elisabeth I. , Lansey Dina , Carducci Michael Anthony , Albrecht Terrance Lynn , Barton Ellen , Manning Mark A. , Wojda Mark , Eggly Susan 
Published: April 2017

143 Background: Few patients, especially racial/ethnic minorities, enroll in clinical trials (CT), in part due to patient-oncologist communication. Question prompt lists (QPLs) improve communication, but have not been tested in CT discussions in a diverse patient population. We describe the development and acceptability of a theory-based QPL to improve communication and enrollment of White and Black men in prostate cancer CTs. Methods: Two existing QPLs were adapted by a team of communication scientists, psychologists, clinicians and patients. Guiding theories were the common ingroup identity model, which suggests people from different social groups can better achieve goals when they are on the same team, and patient-centered communication, which suggests that patient active participation improves clinical communication. The revised QPL included text to encourage patients to see themselves and their oncologist as a team, and 33 questions about CTs to encourage patients to participate actively in clinical interactions that include a CT discussion. To test acceptability, we recruited 15 Black or White men currently enrolled in a prostate cancer CT at an urban comprehensive cancer center. We asked patients to provide feedback on the QPL, to endorse which questions were most important, and for suggested improvements. Results: Patients participated anonymously. All patients said the QPL would be useful. Four patients reported liking the graphics/layout. Six patients reported liking the team text, but one commented that it was unnecessary. Three patients liked that the QPL included many questions, several of which they had not thought to ask when they discussed a CT with their oncologist. Ten patients endorsed the questions they thought were important to ask (M = 24 questions, SD = 9). The most frequently endorsed questions were what is already known about this treatment and how serious are the side effects? Conclusions: Patients found the QPL to be acceptable and useful. The QPL was revised according to patient feedback. We are testing the revised QPL's influence on patient-oncologist communication about CTs, patient understanding of CTs offered, and patient decisions to enroll in a CT.