bluuebunny/crossref_metadata_2025_split huggingface dataset:
A cost-utility analysis of sentinel lymph node mapping, selective lymphadenectomy, and routing lymphadenectomy in the management of low-risk endometrial cancer.
Authors: Suidan Rudy Sam , Sun Charlotte C. , Cantor Scott B. , Mariani Andrea , Soliman Pamela T. , Westin Shannon Neville , Lu Karen H. , Giordano Sharon Hermes , Meyer Larissa 
Published: April 2017

10 Background: Our objective was to evaluate the cost-utility of 3 lymphadenectomy (LND) strategies in the treatment of low-risk endometrial cancer (EC). Methods: A decision analysis model compared 3 LND strategies in women undergoing minimally invasive surgery (MIS) for EC: 1) routine LND in all pts; 2) selective LND based on intraoperative frozen section, in which 60% of pts undergo LND; and 3) sentinel lymph node mapping (SLN) based on a published algorithm, in which 15% of pts map unilaterally (requiring a contralateral LND) and 5% don’t map (requiring bilateral LND). Costs and outcomes were obtained from published literature and Medicare reimbursement rates. Costs categories consisted of hospital, physician, operating room, pathology, and lymphedema treatment. Effectiveness was defined as 3-year disease-specific survival adjusted for the impact of lymphedema (utility = 0.8) on quality of life. Incremental cost-effectiveness ratios (ICERs) per quality-adjusted life years (QALYs) gained were calculated. QALYs and costs were discounted at an annual 3% rate. Results: For the estimated 40,000 women undergoing surgery for low-risk EC each year in the US, the annual cost of routine LND, selective LND, and SLN is $722 million, $681 million, and $656 million respectively. In the base case scenario, routine LND had a cost of $18,041 and an effectiveness of 2.79 QALYs. Selective LND had a cost of $17,036 and an effectiveness of 2.81 QALYs, while SLN had a cost of $16,401 and an effectiveness of 2.87 QALYs. With a difference of $1,005 and 0.02 QALYs, selective LND was both less costly and more effective than routine LND, dominating it. However, with the lowest cost and highest effectiveness, SLN dominated the other modalities and was the most cost-effective strategy. No ICER could be determined. These findings were robust to multiple one- and two-way sensitivity analyses varying the rates of lymphedema and LND, surgical approach (open or MIS), lymphedema utility, and costs. Conclusions: Compared to routine and selective LND, SLN had the lowest cost and highest quality-adjusted survival, making it the most cost-effective strategy in the management of low-risk EC.
A quality verification tool to assure complete pre-treatment electronic medical records (EMR) for patients undergoing radiation therapy.
Authors: Barnes Timothy , Harris Eleanor Elizabeth , Holloman Michael , Arastu Hyder Husain , Leinweber Clinton , Ju Andrew Wenhua , Naves James 
Published: April 2017

103 Background: Complete medical records are critical for correct implementation of the intended care plan. Sentinel items include pathological reports, tumor staging, complete history and physical, pre-treatment performance and pain assessment, documented informed consent, and written directive/plan of care. The advent of electronic medical records and expanded use of technology have necessitated methodology to assure medical record completeness and quality. The technical portions of radiation oncology practice require unique EMR systems that are often used in addition to other institutional systems. The complete patient record is the aggregate of all systems. Methods: We developed a list of sentinel items that compose a complete pre-treatment radiation oncology medical record. This list was developed into an electronic spreadsheet and is recorded for each patient and his/her attending radiation oncologist. This tool is completed at the pre-treatment peer-review presentation and recorded for completeness and deficiencies. Any deficiencies were noted for resolution and tracked as a continuous quality improvement (CQI) activity to identify deficit root cause, interventions, and effectiveness of action(s). Results: Accumulative data showed the number and percentage of variances from standard practice as recorded at the time of initial peer review case presentation. Generally, the data showed improvement in completeness of the pre-treatment EMR by physician for the period February, 2015- November 2015. An initial 16% variance rate was recorded upon observation only in February of 2015. Variances over 5% were addressed and improvement programs instituted as needed. A final variance rate of 2.3% recorded in November 2015. Conclusions: Ongoing monitoring is an important strategy to assure complete pre-treatment medical records. The reasons for deficits are multi-factorial. Physician compliance and data availability, particularly for patients referred from outside facilities, were especially notable but resolution strategies have improved the system’s performance. These lessons will be part of the implementation plan for new EMRs over the upcoming months.
Survey of community pharmacists regarding their role and desire for managing chemotherapy related toxicities in cancer patients.
Authors: Vu Kathy , Santaera Daniella , Redwood Erin , Krzyzanowska Monika K. 
Published: April 2017

104 Background: There is little published about the readiness and needs of community pharmacists to manage chemotherapy related toxicities in cancer patients. A survey was conducted to understand community pharmacists’ current toxicity management practices and their education and communication needs in this area. Methods: A 21 question electronic survey was sent to community pharmacists in Ontario, Canada from April 1 – June 30, 2016. The survey asked about demographics, toxicity management behaviours/preferences, communication and training needs/preferences. Results: Out of 559 responses received, 167 were excluded due to ineligibility giving a final response of 392 surveys. The majority of respondents were full time pharmacists practicing for more than 10 years in community pharmacy. While many pharmacists reported providing assessment (80%), advice (92%) and/or monitoring (70%) at least sometimes, few reported providing assessment (10%), monitoring (10%) or advice (18%) routinely. Types of toxicities encountered and their frequency are summarized in Table 1. There was a high level of interest (96%) among the respondents in being involved in assessing and managing chemotherapy toxicity, however, only 13% reported that they felt sufficiently trained to do so. Conclusions: Community pharmacists encounter chemotherapy-related toxicities in their daily work. While there is a strong interest in managing toxicity symptoms, many community pharmacists feel that they are not adequately trained to do so. Continuing education programs for this provider group may improve toxicity management in community pharmacy settings. [Table: see text]
Performing complex cancer surgery in the ambulatory setting.
Authors: Laudone Vincent Paul , Durany Robert , Ehdaie Behfar , Leitao Mario M. , Levine Marcia , Mehrara Babak , Patel Snehal G. , Scardino Peter T. , Sclafani Lisa M. , Sivaraman Arjun , Stein Daniel , Tseng Beverly , Twersky Rebecca , Simon Brett A 
Published: April 2017

106 Background: The drive to move complex surgeries into the ambulatory setting will impact the cancer population. In anticipation, we developed an “ambulatory extended recovery” (AXR) program for pathway-based management of patients undergoing procedures with traditional 1-4 day hospital stays. Then in 2016 we opened the Josie Robertson Surgery Center (JR), a freestanding ambulatory surgical facility designed for complex cancer surgeries with one overnight stay. Methods: Using hospital databases we identified AXR cases eligible to be performed at JR and examined pathway completion (discharge home on POD 1), and 30-day institutional urgent care center (UCC) visits and readmissions. We compared AXR program results before and after opening JR in January 2016. Results: The most frequent AXR procedures were mastectomy ± immediate reconstruction, thyroidectomy, and minimally invasive prostatectomy, nephrectomy, and hysterectomy. 3307 and 2359 AXR procedures were done in 2015 and Jan-Sep 2016. In 2016 74% of AXR cases were performed at JR with the remainder at Memorial Hospital (MH), primarily for scheduling considerations or patient or surgical complexity. Pathway completion was 92% in 2015 and 95% in 2016 (p < 0.001). 30-day UCC visits/readmission rates were 8.8%/3.7% in 2015 and 8.6%/3.1% in 2016 (ns). Comparing cases at JR vs MH in 2016, pathway completion rates were 98.3% at JR vs 86.4% at MH (p < 0.001). Patient satisfaction was high for care provided at both facilities. Conclusions: Many complex cancer surgeries may be safely completed with a single overnight stay at a freestanding ambulatory facility. UCC visits and readmissions were not different between years, suggesting that quality of care was maintained in the ambulatory setting. The difference in pathway completion in 2016 at JR compared to MH may reflect successful triage of more medically complex patients and/or surgically complex procedures to MH.
Improving care coordination for brain tumor patients through value-based care redesign of a virtual integrated practice unit.
Authors: Nghiemphu Phioanh Leia , Dezelan Darlene , Tran Jackie H , Cloughesy Timothy Francis , Liau Linda M. , Ahn Christine , White Preston 
Published: April 2017

110 Background: Brain tumor care at our institution involves providers from multiple departments in separate clinics and can cause patient frustration and poor patient experience. We previously reported on engaging care teams from Neurosurgery, Neuro-Oncology, Radiation Oncology, Neuroradiology and Neuropathology using lean methodology to re-design the care pathway for patients with brain tumors. A Patient Navigator Program was also established to help with patient’s care coordination. For this study, we evaluate whether this value-based care redesign has improved patient coordination and satisfaction. Methods: The care pathway and navigator process were implemented at the end of Dec 2015. We identified 202 patients who had brain tumor resections and were followed by our Navigator Program from July 2015 – Sept 2016. We evaluated the time from surgery to appointments and whether these appointments were all made within 1 week. We also reviewed our patient satisfaction scores using Press Ganey percentile ranks and HCAHPS metrics in the areas of patient education and coordination. We compared these data from July-Dec 2015 (pre-redesign) to data from Jan-Sep 2016 (post-redesign). Results: Of the patients followed by the Navigator Program, 137 patients required follow-up with providers from at least 2 different departments for treatment planning. Pre-redesign, the program followed 49 patients and made their appointments 14 median days from surgery (range 3-37), with 59% within 1 week. The 88 patients followed after-redesign had appointments in 16 median days (range 1-33) with 70% scheduled within 1 week. Pre-redesign, our Press Ganey Percentile rank ranged from 1st-32nd. After-redesign, the ranks increased to 16th-99th percentile, with most domains over the 80th percentile. Patients also reported higher satisfaction on HCAHPS post-redesign compared to pre-redesign. Conclusions: Development of a clear process for care coordination within the patient navigator program helped improve our patient satisfaction and streamline timely follow-up care. For our future coordination, we will implement a centralized access to care for our patients with brain tumors.
Incorporating medical marijuana in clinical practice.
Authors: Daleo Stephen James , Davis Matthew , Pham Trinh , Abdelghany Osama , Putnam Andrew , Lilenbaum Rogerio 
Published: April 2017

117 Background: Medical marijuana (MM) is legal in the state of Connecticut. Regulatory issues, appropriate patient selection, and outcomes assessment have made it difficult for oncology centers to incorporate MM into clinical practice. At Smilow Cancer Hospital at Yale New Haven, a tertiary academic comprehensive cancer hospital, a multidisciplinary team was convened to propose guidelines. Based on the recommendations, the Smilow Cancer Hospital implemented a policy that outlines the use of MM in selected patients with nausea, anorexia and refractory pain. Here we describe the Smilow Experience with MM in clinical practice. Methods: Using health system-wide electronic medical record, a review of patients initiated on MM from 9/2015 to 10/2016 was conducted. Demographics, malignancy type/stage, MM indication, and preliminary data on formulation used and treatment outcomes were collected. Results: 108 cancer patients, majority evaluated by a Palliative Care physician, were initiated on MM (55.6% males/44.4% females). MM was prescribed more to patients with solid tumors compared to hematologic malignancies (91% versus 9%). The most common malignancy was gastrointestinal (34.3%), followed by lung (26.9%). Among patients with available definitive tumor staging, more had stage III or IV tumors (73.4%) compared to stage I or II tumors (26.6%). The most common indications are pain (81.8%) followed by cachexia (49.4%), and 40% of patients had more than one documented indication. Inhalation was the most common route of administration. Outcome data is limited at this juncture, though documentation indicates that more patients have reported “positive effects” from MM than “negative effects”. Conclusions: Despite legalization, the prescription of MM in cancer patients has been limited to individual practices, often outside of the context of a comprehensive cancer program. In these cases, follow up and outcomes assessment is minimal. Our review reveals that a health system-wide protocol allows patients to gain access to MM without having to leave the system. Our findings demonstrate interest among providers and patients in the potential therapeutic benefits of marijuana. Detailed data on efficacy and outcomes will be available at the time of the meeting.
The implementation of a lay care navigation service at the Stanford Cancer Institute.
Authors: Brown-Johnson Cati , Holdsworth Laura J , Rosenthal Eben , Asch Steve , Winget Marcy 
Published: April 2017

119 Background: Lay care navigators address barriers to care, provide a single point of contact in complex health systems, and help efficiently resolve non-clinical patient issues. Despite navigation program proliferation, each is crafted to fit local institutional and patient needs. In Summer 2016, Stanford Cancer Institute (SCI) launched a care navigation pilot to improve patient engagement, facilitate better access to services, and improve coordination. The Stanford Care Navigator (SCN) program was based on a framework for lay navigation from the University of Alabama at Birmingham (UAB) who consulted on this project. This study describes the evolution of the SCN model and drivers of changes as SCN was iteratively designed and implemented. Methods: Qualitative study including document review of training materials, observation of cross-functional design meetings, stakeholder interviews, and a focus group with Care Navigators. Results: In spite of common goals of reducing patient distress and improving care coordination, the resulting SCN service is quite distinct from the consulting organization. Primary factors driving design changes were differences in: clinic access, patient populations and needs (e.g., SCN language translation needs vs. UAB poverty-related barriers), and a suite of pre-existing services at SCI (e.g. referral triage). Navigators call all new patients to address common barriers (traffic, parking vs. lack of transportation in Alabama). SCN refers some service items (e.g., financial support) to existing service groups, including Social Work. Conclusions: While Stanford navigation retains elements of the UAB-originating lay navigator program, in this radically different setting, service parameters differ substantially. The model was, therefore, substantially adapted rather than simply adopted. Ongoing evaluation explores navigators’ impact on patients and staff/providers.
Quality of care improvements resulting from a model of care that incorporates the primary clerk into the care team.
Authors: Cox Jennifer Anne , Hamm Caroline 
Published: April 2017

122 Background: One common model of care within the oncology outpatient clinic setting is composed of the physician and primary nurse. We propose that the quality of care provided to oncology patients can be improved in this setting by incorporating the primary clerk into the care team, working in the same office space with the physician and nurse. Methods: Three care teams operating under the new model of care were observed during oncology outpatient clinics periodically from February 2016 to May 2016. The primary clerk’s interactions with the other team members were recorded, along with other tasks completed by the clerk that did not require team interactions but impacted quality of care. Data was later complied and organized into four domains that impacted the quality of care provided to patients. Results: The contributions to the care team by the primary clerk include improved clinic flow (e.g., ensuring treatment orders are inputted by the physician), patient convenience (e.g., identifying regularly scheduled blood work that is no longer necessary), patient safety (e.g., identifying patients scheduled for treatment with rituximab that have not had the required Hepatitis B & HIV screening), and hospital flow (e.g., preventing additional workload in the hospital laboratory by identifying when lab work can be combined in already scheduled appointments, and rescheduling clinic visits when results are not yet ready, which translates into time and cost savings to the hospital). Conclusions: As a result of the enhanced quality of care delivered, it is recommended that this model of care be adopted in the place of the traditional model, which lacks the essential element of interaction between the primary clerk and the rest of the care team.
Improving the quality of oncology fellows' clinical documentation.
Authors: Saha Debasmita , Tannenbaum Susan 
Published: April 2017

124 Background: Proper documentation in oncology is a vital skill for fellows to learn. It not only allows for delivery of safe patient care by providing a mean for communication within providers, but it is also essential for coding and reimbursements, audits, research, quality/healthgrade scores and provides the the main body of medico-legal defense. From an educational perspective, it takes into account all 6 competences of medical education and hence is an integral part of fellowship training. The objective of this quality improvement project is to improve our fellows' documentation by ensuring they communicate timely and effectively a comprehensive care plan. Methods: We identified 10 random charts of patients who are actively being treated with systemic therapy by 4 of our senior fellows. The initial and a random follow up notes were reviewed and 34 areas thought to be of importance, specifically in oncology, were identified and logged. Verbal and written feedbacks were provided regarding their performances and areas of improvement, after which charts were re-evaluated in 6 months. Results: See table below. Conclusions: We successfully improved the fellows' documentation skills through this project, creating a better practice module. [Table: see text]
Using cancer registry data to improve adherence with breast cancer pathways.
Authors: Fields Karen K. , Watson Alicia , Durand Ashley , Simpson Tracy , Stewart Sandra , Shi JuQing , Liu Jack , Rollison Dana Elise 
Published: April 2017

127 Background: Evidence-based clinical pathways have been shown to improve quality and cost effectiveness. Moffitt Cancer Center (MCC) has developed clinical pathways for more than 50 cancer sites. Using data derived from multiple sources, we performed a series of measurements of adherence to breast cancer (ca) pathways, provided clinician feedback and evaluated changes over time. Methods: We developed an automated method to evaluate pathway adherence for 1st line systemic treatment (tx) recommendations using data from Stages I-IV analytic breast ca cases presenting to MCC for tx during calendar years (CY) 2013-2015. As a baseline, cases were manually audited for adherence in CY 2012. Data sources included Cancer Registry and electronic health record (EHR). A patient (pt) was considered “On” pathway if the correct tx, including relevant clinical trials, was administered based on various prognostic and clinical factors. Only pts who received all 1st line systemic tx at MCC were included. Pts who refused txor had contraindications, non-applicable histologies or multiple primary cancers were excluded. The EHR was reviewed to assure the accuracy of “Off” pathway determinations. Results: A total of 3727 analytic breast ca cases were seen at MCC between CY 2012-2015; 873 met all criteria and were eligible for analysis. 80% was set as an institutional target for adherence. The following table displays yearly trends for pts “On Pathway” for all applicable chemotherapy, immunotherapy and hormonal tx. Conclusions: Cancer Registry and EHR data can be used to automate surveillance of pathway adherence creating a feedback loop to clinicians who can, in turn, improve adherence over time. [Table: see text]
Use of a secure mobile application to inform clinicians on adverse event management and drug-drug interactions for ribociclib: Experiences with CT scholar in ribociclib clinical trials.
Authors: Small Tania , Bugazia Najla , Nezami Brigette , Vinegra Michael , Fernandez Alberto , Dhuria Shyeilla V. , Feeley Jaclyn , Burroughs Lance 
Published: April 2017

134 Background: Understanding and gaining familiarity with the adverse event (AE) and drug-drug interaction (DDI) potential of novel agents can be challenging, cumbersome, and time consuming for clinicians. A comprehensive and secure AE management/DDI mobile application (CT Scholar [Novartis Pharmaceuticals Corp]) was developed to ease the management of clinical trial participants with hormone receptor–positive, human epidermal growth factor receptor 2–negative advanced breast cancer receiving ribociclib. Methods: CT Scholar was designed specifically for the ribociclib clinical program to provide easy access to information on AE and DDI management. The AE management module characterizes and quickly informs drug-specific AE management based on protocol guidelines and supportive care guidance. The DDI module includes a database of > 100 drugs searchable by both trade and generic name. Number of application visits, unique users, and screen views were monitored from Jan to Sept 2016. Results: There were 1055 visits to CT Scholar (117/month) by 145 unique users (28/month), with 5764 screen views (640/month) and 5.5 screens viewed/visit. Among the most-viewed modules were hematologic AE management (1132 views), gastrointestinal AE management (771), and DDI (734). Diarrhea, neutropenia, and nausea were the most viewed submodules (308, 230, and 205 views, respectively). The information on CT Scholar was consistently shown to be accessed more quickly than information obtained from printed clinical protocols. No patients discontinued from the ribociclib studies due to AEs following the introduction of CT Scholar. Conclusions: CT Scholar was widely used by clinicians, and it responded to their needs by providing essential information, especially on prevalent AEs, which could be easily updated and rapidly accessed. Additionally, CT Scholar provides a platform showing how technology can assist clinicians and patients in managing care during a trial, which can inform the development of future supportive materials.