bluuebunny/crossref_metadata_2025_split huggingface dataset:
Process mapping and time study to improve efficiency of HDR prostate brachytherapy.
Authors: Doyle Laura A. , Lockamy Virginia L. , Peng Cheng , Dicker Adam , Yu Yan , Den Robert Benjamin , Harrison Amy S. 
Published: February 2017

103 Background: New technologies and procedures have the potential to improve outcomes; however, initial implementation is often associated with a steep learning curve, decreased efficiency, and patient safety implications. Since process mapping, checklists and external benchmarks have been proven to be useful quality improvement (QI) tools in health care, we sought to use these QI tools in a novel setting to decrease new procedure times without sacrificing the quality of care. Methods: Implementation of a real-time, ultrasound based prostate high-dose-rate brachytherapy procedure involved a multidisciplinary team composed of approximately 6-8 team members and numerous complex tasks. To characterize time spent on various aspects of the procedure and improve efficiency, our team developed a detailed process map including checklists and team debriefings. A benchmark was created based on an experienced institution which has performed >100 procedures annually. Times for key events, such as induction of general anesthesia, acquisition of first image, catheter insertion and completion of planning were recorded during each case. The process map was analyzed based on clinical tasks and treatment planning tasks. Results: The expert institution completed a procedure in 65 minutes. Over the course of ten cases at our institution, total procedure time ranged from 222-107 minutes. Implementation of the process map resulted in a reduction of total time by 52% (51% for clinical tasks and 65% for planning). Process improvements included changes to room layout, availability of supplies and identification of parallel processes. Improvement in efficiency was done without compromising quality as defined by dosimetric parameters. Conclusions: The implementation of a new procedure benefits from the integration and utilization of a process map. We were able to reduce procedure time significantly, which resulted in decreased time under general anesthesia, reduced risk of deep vein thrombosis and improved overall patient safety.
Quantitating the impact of satisfaction drivers on the chemotherapy patient experience: Employing MaxDiff survey analytics to identify key organizational strengths and potential enhancement opportunities.
Authors: Waterhouse David Michael , Ward Patrick J. , Dyehouse Karyn M. , Miller Robert , Schiano Richard 
Published: February 2017

108 Background: Patient satisfaction surveys using Likert-style rating scales are subject to response, level, and dispersion bias. "MaxDiff" or "worst-best" scaling allows opportunity to determine and quantify the relative importance of satisfaction drivers. The focus of this conjoint survey was to assess satisfaction with factors related to the chemotherapy experience, while simultaneously defining the relative importance of these satisfaction drivers. Methods: Sequential chemotherapy pts at four independent office sites were offered an "in chair" electronic tablet survey. The 38 question survey instrument was adapted from the Community Oncology Alliance Oncology Medical Home (COA OMH) patient satisfaction survey. Sample size was calculated to allow maximum sensitivity for analysis of questions/attributes at a 90% confidence level. MaxDiff scaling (Sawtooth Software) was analyzed using hierarchal Bayes estimation. Comparisons were made between male/female pts, age, length of time as OHC pt, and office site; statistical significance was determined by the Mann-Whiney test. Results: In total, 297 pts of 320 pts (92.8%) responded; mean patient age was 61.7 yrs, 197 female/100male. MD and staff wait times, professional skills, concern and communication abilities weighed heavily in driving high satisfaction; whereas scheduling, availability of clinical trials, facilities, account, and pharmacy services had low influence. Wait times (higher importance/lower satisfaction) offered the highest enhancement opportunity for process improvement. Both genders had similar priorities for factors driving chemotherapy satisfaction. Wait time, staff and facility satisfaction differed slightly by office. No significant age or time differences were identified. Conclusions: The addition of MaxDiff scaling to conventional patient satisfaction surveys is novel, feasible and acceptable in the community oncology office setting, and can yield relevant, interpretable data. Results of this survey are currently being used to inform ongoing OHC process and quality improvement initiatives.
Enabling quality data reporting: National implementation of standardization pathology reporting.
Authors: Kwiatkowski Avril 
Published: February 2017

122 Background: The Canadian Partnership Against Cancer (the Partnership) launched its Electronic Synoptic Pathology Reporting Initiative (ESPRI) to advance the implementation and promote the wide adoption of standardized synoptic pathology reporting tools in Canada. This presentation will highlight strategies to ensure successful implementation of this program across the Canadian health system as well as lessons learned. Methods: Upon consultation with clinical and system leaders, clear and measureable program targets (such as 90% completeness rates against mandatory elements of the College of American Pathology cancer protocols and disease-specific clinical indicators) were agreed upon. Thorough provincial planning to understand the variances across provincial current states, establish strategies and solidify plans was supported by the Partnership; followed by implementation of those plans. Key approaches to enable adoption and implementation include coordination of Pathologist and Vendor-led education sessions, establishment of clinical expert panels and assignment of Canadian representatives to the College of American Pathologists’ (CAP) Cancer Protocol Review Panels. The Partnership continues to collaborate with national/international standards organizations such as NAACCR, CAP, and Canada Health Infoway to support standards maintenance. Results: As a result of ESPRI, approximately 80% of Canadian pathologists will be reporting synoptically by 2017, across 7 of 10 provinces. It is expected that this will reflect approximately 25,000 reports per year for the five cancer types of focus (breast, colorectal, lung, prostate and endometrial) from about 950 pathologists. The Partnership, with CAP-ACP, has partnered with pathology communities from the US, UK, and Australasia to form the International Collaboration on Cancer Reporting (ICCR) to collaborate on internationally-harmonized core datasets for cancer pathology. Conclusions: Adoption of structured pathology reporting in Canada will enable better patient care, improve data quality, create efficiencies and enable interoperability. Through adoption and implementation efforts, this will impact patient care.
Avoidance of fulminant liver failure from hepatitis B reactivation with chemotherapy and immunotherapy: A value-based approach.
Authors: Knopf Kevin B. , Siegel Samantha , Bennett Charles L. 
Published: February 2017

134 Background: Fulminant liver failure (FLF) is a potentially fatal complication of hepatitis B reactivation in patients who receive rituximab and cytotoxic chemotherapy. Often patients receiving these regimens are treated with curative intent (e.g. diffuse large cell Non Hodgkin’s lymphoma, adjuvant chemotherapy for breast cancer) and thus avoidance of this complication is desirable. The only known treatment for fulminant liver failure is orthotropic liver transplant. We have developed a cost-effective approach to avoiding FLF. Methods: NCCN recommends screening for hepatitis B serologies in any patient who is to receive Rituximab therapy. Review of the literature regarding fulminant liver failure and cytotoxic chemotherapy revealed that the regimens most strongly associated with reactivation of HepB and fulminant liver failure included doxorubicin and high dose of cyclophosphamide—we have targeted Hepatitis B screening to patients receiving these two chemotherapy drugs. We target patients either felt to have a high probability of occult hepatitis B are screened—these include patients who have had a blood transfusion in a foreign country, those with a transfusion more than 20 years ago, and those patients where Hepatitis B can be passed vertically—including first and second generation Asian American immigrants. Patients deemed at high risk are checked for Hepatitis B surface Antigen and Hepatitis B Core antibodies. No routine imaging is performed. Patients who are HepBSag or HepBCoreAb positive who are to receive high risk chemo/immunotherapy are then started on entecavir 0.5 mg/d two weeks before starting therapy and this is continued for 6 months after completion of therapy. Patients who are HepBAg- and HepBCab+ are monitored with HBV DNA levels monthly during therapy with initiation of entecavir if HBV DNA becomes detectable. Results: Patients receiving chemo/immunotherapy associated with Hep B reactivation can be safely identified and given prophylactgic entecavir treatment. Conclusions: We have created a value-driven cost effective approach to minimizing FLF in patients receiving chemo/immunotherapy. Cost estimates based on US pricing will be presented.
Improving the quality of care for patients receiving radiation therapy: Increasing the proportion of radiation treatment plans undergoing peer review in Ontario.
Authors: Reddeman Lindsay Elizabeth , Brundage Michael Donald , Foxcroft Sophie , Hart Margaret , Gutierrez Eric , Mendelsohn Marissa , Warde Padraig Richard 
Published: February 2017

136 Background: Peer review of radiation treatment (RT) plans is recognized as an essential component of quality assurance programs in radiation medicine (Marks et al., 2013). The benefits of peer review include: (1) identifying errors that may compromise treatment outcomes, (2) enhancing safety by promoting standardization, and (3) promoting greater attention to detail in RT staff. Current state analysis conducted in 2011 identified considerable variation in the proportion of cases undergoing peer review across Ontario’s 14 cancer centres (Brundage et al., 2013). In 2012, Cancer Care Ontario launched an initiative to ensure all patients receiving radical/adjuvant radiotherapy have the benefit of peer review of their RT plans. Methods: A multi-professional project team was established to conduct site visits to promote peer review at the cancer centres. They also provided guidance on the organization of peer review rounds so that the activity could be incorporated into local workflows. The education, training, methods, and a centralized reporting infrastructure were developed in collaboration with centres over a one year ramp-up phase and patient-level data was available to the centres for audit purposes. The reporting infrastructure enabled reporting of (1) the proportion of cases peer reviewed and (2) the timing of peer review – prior to treatment, <25% dose delivered, >25% dose delivered. Results: Data for each centre is now a key quality metric and is publicly reported (see Cancer System Quality Index at http://www.csqi.on.ca/). The target for year-one of the project (2013-14) – the proportion of cases to be peer reviewed – was set at 50% with the intent that 100% of cases will be peer reviewed within the next two years. In the ramp-up year, the proportion of cases peer reviewed increased across all centres, though high variation still exists between centres. Conclusions: This initiative demonstrates that it is possible to substantially increase peer review activities on a jurisdictional basis. Key success factors include: a dedicated project team, buy-in and confidence in data quality from centres, investment in education and training, and commitment to public reporting.
Reducing the time from diagnosis to treatment of patients with stage II/III rectal cancer at a large county hospital.
Authors: Jacobs Ryan , Hoffmann Marc Steven , Leslie Lori Ann , Jackson Lymesia W. , Rieber Alyssa G. , Bhadkamkar Nishin Anil 
Published: February 2017

141 Background: The treatment of stage II/III rectal cancer is complex and requires multidisciplinary collaboration. Delays in definitive treatment may increase morbidity and compromise outcomes. The goal was to reduce the time from pathologic diagnosis to initiation of treatment by 30% for patients with stage II/III rectal cancer at Lyndon B. Johnson General Hospital (LBJGH), which provides care to uninsured and underinsured patients in Harris County, TX. Methods: The charts of 32 patients with rectal cancer diagnosed between July 2012 and December 2013 were reviewed. Baseline data regarding diagnostic and treatment time points were collected. Potential areas for improvement were identified through analysis of the baseline data, affinity sorting, and fishbone diagrams. A multidisciplinary rectal cancer working group with all relevant administrative and subspecialty stakeholders was created to discuss potential interventions and implementation strategies. The project was approved by the MD Anderson Quality Improvement Assessment Board. Results: Twenty-four of the thirty-two patients reviewed had stage II/III rectal cancer and were eligible for multimodality therapy with curative intent. The median time from pathologic diagnosis to treatment initiation was 62 days. The referral process was identified as the greatest source of delays. The median times from diagnosis to medical oncology and radiation oncology referral were 15 and 32 days, respectively. The median time for eligibility verification and clinical review by Case Management was 13 days. Conclusions: Based on these findings, two primary interventions have been instituted: (1) A synchronized referral process that will result in simultaneous consultation of all involved subspecialty services (surgery, medical oncology, and radiation oncology) was created for patients with rectal cancer; (2) Redundancy in the clinical review process was eliminated by coordination between Case Management and the Medical Oncology Chief Fellow. In tandem, these interventions are projected to reduce the time from diagnosis to treatment by approximately 50% (from 62 to 29 days).
Predictors of positive test results in patients with cancer undergoing hepatitis B screening before chemotherapy.
Authors: Hwang Jessica , Lok Anna S.F. , Cantor Scott B. , Fisch Michael , Barbo Andrea G. , Lin Heather Y. , Suarez-Almazor Maria E. 
Published: February 2017

143 Background: Optimal hepatitis B virus (HBV) screening strategies for patients with cancer awaiting chemotherapy are unknown. We aimed to identify predictors of HBV infection in a large cohort of patients with cancer who were systematically screened for HBV before chemotherapy. Methods: In this prospective observational study, patients with cancer at MD Anderson Cancer Center awaiting first administration of chemotherapy in an outpatient chemotherapy unit were identified and approached for HBV screening. Enrolled patients completed a CDC risk survey and had blood tests to screen for HBV (HBsAg, anti-HBc) and hepatitis C virus (anti-HCV) infection. We developed a logistic regression model to identify clinical predictors of either chronic (HBsAg+/anti-HBc+) or past (HBsAg-/anti-HBc+) HBV infection. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test. We present results from year 1 of our ongoing 2-year study. Results: From July 2013 to June 2014, 1176 patients (mean [SD] age, 58 [13] years) have completed the risk survey and HBV screening. Of these, 54% were women, 84% white, 9% black, 4% Asian, and nearly 11% Hispanic. Over 20% had a hematologic malignancy, 1% liver cancer, and 77% a solid tumor other than liver cancer. Almost 12% of patients were born outside the US. Three patients (0.26%) had chronic and 84 (7%) had past HBV infection. Among the latter, 9 patients were also anti-HCV+. Predictors (odds ratio [OR]; 95% CI) of having either HBsAg+ or anti-HBc+ result included black race (4; 2-7), Asian race (4; 2-9), birthplace outside the US (5; 3-10), and having lived with someone with HBV (3; 2-7). Patients who reported ever injecting drugs (OR 7; 2-24) or being a man currently having sex with another man (OR 42; 6-277), or who were anti-HCV+ (OR 5; 1-16) had high risk of HBsAg+ or anti-HBc+ result. Conclusions: Known HBV risk factors are predictive of chronic or past HBV infection in patients with cancer. These results can assist in the development and testing of risk-based screening strategies to enhance accurate and cost-effective identification of patients with HBV infection.
Implementation of pharmacy services in 22 oncology clinics.
Authors: Feldt Ashley , Godden Jennifer 
Published: February 2017

145 Background: Our integrated health care system consisted of 15 hospitals and 159 clinics. Since 2011, 22 private practice oncology clinics transitioned to hospital-based clinics. This presented an opportunity to standardize safe and effective pharmacy services at these locations. Methods: Using patient volumes, system leaders determined six pharmacists would serve the 22 new clinics via telepharmacy. Baseline pharmacy services to be offered were prospective order verification, product checking and drug information dissemination. To prepare for the transition, over 25 physicians agreed to standardize electronic order sets and develop one formulary. Vial sizes were consolidated and a uniform way to prepare each chemotherapy agent was designated. Over 75 policies were reviewed and updated. Education was provided to all caregivers prior to the transition. Once baseline services were integrated, additional patient-focused services such as supportive care counseling, follow-up phone calls, medication reconciliation and chemotherapy education were offered. Results: Pharmacists verified over 66,000 physician-ordered chemotherapy prescriptions in 2013, intervening on about 6% by suggesting adjustments for potential organ dysfunction or toxicity. For the past year pharmacists counseled nearly 90 patients a month regarding their supportive care medications. Survey results revealed a consistent increase in overall understanding, although the sample size did not allow for statistical significance. In addition, pharmacists made about 25 follow-up phone calls to patients to assess control of nausea and vomiting, completed medication histories for about 10 patients new to chemotherapy and were consulted for about 5 chemotherapy teachings per month. Conclusions: Integration of pharmacy services in our oncology clinics has allowed for development of a streamlined and safe process for ordering and preparing chemotherapy. It also has increased patient access to pharmacists and education related to supportive care medications.
Improving quality of prostate cancer care in an integrated care delivery system.
Authors: Rabrenovich Violeta , Loo Ronald , Tamaddon Kirk 
Published: February 2017

147 Background: Kaiser Permanente (KP) is an integrated care delivery system that provides clinical services to over 9 million members in nine states and the District of Columbia with the goal of providing high-quality and affordable health care to our patients. Over the last decade, the rapid adoption of prostate cancer (Pca) screening practice and technology have resulted in increased detection of Pca and helped identify opportunities for care improvement. KP initiated improvements of continuum of services provided to Pca patients. Methods: Transforming the care provided to Pca patients evolved into the first population-based cancer program that manages the entire continuum of care by taking advantage of our integrated health delivery system. Major accomplishments include appropriate Pca screening to prevent over-diagnosis (Prostate Cancer Screening), improved patient safety and claims reduction to prevent missed abnormal cancer screening (PSA Safety Net), comparative effectiveness of cancer treatment choices to improve quality, and benchmark outcomes in efficiency and clinical quality utilizing a new technology (Robotic Surgery). In addition, the program has achieved superior outcomes and value through innovative chemotherapy management for advanced disease (Lupron Management). Evidence-based medicine, research, analytics and continuous quality improvementare cornerstones of the program, while the pinnacle is our patients, who receive informed, shared decision making and equitable unbiased care. Results: We strongly believe that measures of how well our patients are living with Pca are as important as the cancer-specific survival measures; because of this, we established a prospective registry to measure quality of life for every newly diagnosed patient and stratified by all treatment types. This practice is being disseminated across the Program. Conclusions: By systematically stratifying this diverse population, we have been able to achieve efficient reliable care, and spread each successful process to other regions through collaboration with KP’s Interregional Chiefs of Urology.
Measuring alignment with evidence-informed practice in Ontario’s systemic treatment funding model.
Authors: Kaizer Leonard , Simanovski Vicky , Blais Irene , Lalonde Carlin , Tariq Huma , Lam Jennifer , Evans William K. 
Published: February 2017

15 Background: A new systemic treatment funding model (STFM) was implemented in Ontario on April 1, 2014, transitioning from life-time per case funding to reimbursement based on evidence-informed episodes of care. The effectiveness of the model will be evaluated against key indicators including the percent of patients on evidence-informed regimens (PPEIR). Methods: Provincial Disease Site Group (DSG) experts reviewed all chemotherapy regimens administered in Ontario over the two years prior to implementation. Each DSG identified the treatment regimens to be STFM reimbursed, based on evidence of clinical benefit according to treatment intent (curative/adjuvant vs. palliative or both). A year of pre-implementation data will serve as a baseline to assess the impact of transition to the new funding model. Clinical and administrative stakeholders have received their baseline facility-level data and will receive monthly reports, including the PPEIR, to aid in identifying and resolving clinical practice and/or data quality issues post-implementation. Results: Of approximately 1,000 regimens reviewed by the DSGs, ~100 were deemed to be evidence informed for adjuvant/curative intent, ~325 for palliative intent, and ~90 for both intents. Overall, the 2013/14 baseline provincial PPEIR was 91.6% for 16,200 treatment courses given with adjuvant/curative intent while 93.2% of 56,800 patient-months of treatment with palliative intent were aligned with the proposed evidence informed definition. Significant variation in baseline PPEIR was seen for the 29 level 1-3 provincial treatment facilities (range = 71-99%) and for the 10 different disease sites. Conclusions: Knowledge of the PPEIR utilized increases understanding of practice at the system (provincial), regional, facility and disease site level and will provide opportunities for benchmarking and ongoing improvement in quality of care.