bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cost, value, and policy in quality: Evolving relationship of payers and providers.
Authors: Denny Diane , Keenan Caitlin 
Published: February 2017

44 Background: Cancer Treatment Centers of America (CTCA), a network of five hospitals, has multiple pay for performance contracts. Some apply to all hospitals, while others are unique to individual facilities. While many metrics are managed by site, some metrics are collected and measured centrally by corporate. Varying levels of oversight were required from site quality teams, executive teams and externally-facing corporate departments. In order to coordinate these efforts, CTCA implemented a real-time tracking system for monitoring pay for performance metrics. Methods: CTCA’s corporate Quality department designed a central repository for monitoring metrics that is populated monthly using customized workbooks submitted from each site. The central repository compiles monthly data and displays it in several formats broken down by timeframe, site and contract. The repository incorporates features allowing easy sharing and data accuracy. An accompanying process for collecting data was created to ensure timely, efficient updates to the repository. Results: The monthly monitoring process was implemented in January 2014 and continues to operate successfully. For one enterprise-wide contract cycle closing on April 31, CTCA met requirements and outperformed the contract-specified goal for each by an average of 19.8%. Pre-implementation, metrics were monitored quarterly. Although two metrics showed a small (<2.5%) decrease in average performance, given the intensified focus, the remaining metrics showed an average 7.95% improvement in performance during the second six months with monthly monitoring. Metrics associated with the remaining contracts are on track to meet or exceed specified performance standards. Conclusions: The new tool and monthly reporting process successfully monitored pay for performance metrics at CTCA. Most importantly, the system allowed for close to real-time assessment and therefore promoted ongoing intervention if warranted. The repository created a single source of data sharing and visibility for these important elements of performance. As CTCA continues to participate in pay for performance activities, this method will be adapted to accommodate more contracts and metrics.
Improving radiotherapy utilization rates in Ontario.
Authors: Ang Michelle , Gutierrez Eric , Foster Nicoda , Favell Lisa , Warde Padraig Richard 
Published: February 2017

48 Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontario’s utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. Methods: CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. Results: Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. Conclusions: The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.
Evaluating the implementation of computerized prescriber order entry (CPOE) for systemic treatment (ST) in Ontario.
Authors: Gradin Sharon , Wolf Nancy , Yurcan Marta , Yardley Tim , Kaizer Leonard , Kukreti Vishal 
Published: February 2017

54 Background: A successful effort was led in Ontario to increase ST CPOE adoption from 73% to 92% to support safety of patients receiving complex systemic treatment. This work included implementation at 19 hospitals from 2011-2013. The implementation process included identification of multidisciplinary team champions, baseline workflow analysis and development of a future desired state. Findings from this project’s benefits evaluation are presented. Methods: Each hospital was required to collect pre and post implementation measurements for medication errors, transcription errors and order clarity/completeness. Six months post implementation, a semi-structured telephone interview was conducted with representative hospitals (9/19) to obtain qualitative feedback on how implementation impacted workflow, inter-professional practice and workload. Results: Hospitals that implemented showed: 1) decrease in overall medication error rates. 2) decrease in transcription error rates and 3) decrease in number of unclear or incomplete orders. Qualitative feedback from hospital leads indicated that the “future desired” workflow was achieved by all. Most hospital respondents indicated that clarity of inter-professional communication regarding orders improved and in most cases overall workload did not increase. Conclusions: The findings reinforce the benefit associated with implementation of ST CPOE in outpatient settings. Lessons learned in Ontario can be leveraged to support successful implementation of ST CPOE in other jurisdictions. Critical implementation success factors included: 1) leadership and multi-disciplinary involvement; 2) provision of funding and cost sharing; 3) facilitation of process improvement through established methodologies, 4) knowledge transfer and peer group led education and training sessions. [Table: see text]
Does hospital academic status impact colon cancer care value?
Authors: Veenstra Christine Marie , Epstein Andrew J , Pollack Craig Evan , Armstrong Katrina 
Published: February 2017

6 Background: Given the high cost of cancer care, delivery of high-value care is crucial. The effect of hospital academic status on value of care for patients with stage II and III colon cancer is unknown. Methods: SEER-Medicare cohort study of 20,118 patients age 66+ with stage II or III colon cancer diagnosed 2000-2005 and followed through December 31, 2007. Patients were assigned to a treating hospital based on hospital affiliation of the primary oncologist. We constructed Kaplan-Meier curves to assess unadjusted overall survival. We estimated a Cox proportional hazards model to assess adjusted overall survival. To examine associations between hospital academic status and mean cost of care we estimated a generalized linear model (GLM) with log link and gamma family. We estimated quantile regression models to examine associations between hospital teaching status and cost at various quantiles (25th, 50th, 75th, 90th, 95th, 99th, 99.5th, 99.9th). Standard errors were adjusted to account for clustering of patients within hospitals. Results: 4449/20,118 (22%) patients received care from providers affiliated with academic hospitals. There was no significant difference in unadjusted median survival based on hospital academic status for patients with stage II (academic 6.4 yrs vs. non-academic 6.3 yrs, p=0.711) or stage III disease (academic 4.2 yrs vs. non-academic 4.2 yrs, p=0.81). After adjustment, treatment at academic hospitals was not associated with significantly reduced risk of death from colon cancer (stage II HR 1.05, 95% CI: 0.97 - 1.13; p=0.23; stage III HR 0.99, 95% CI: 0.94-1.07; p=0.98). Excepting stage III patients at the 99.9th percentile of costs, there were no significant differences in adjusted costs between academic and non-academic hospitals. Conclusions: We find no difference in overall survival for patients with stage II or stage III colon cancer based on academic status of the treating hospital. Furthermore, costs of care are similar between academic and non-academic hospitals across virtually the full range of the cost distribution. Most colon cancer patients do not receive cancer care at academic hospitals. Our findings indicate that for patients with stage II or III disease, this inequity does not impact the value of care.
Reducing colorectal cancer mortality: The e-Autopsy tool.
Authors: Schottinger Joanne E. , Brasfield Farah , DiFronzo Andrew , Lau Helen , Litman Kerry C. , Schwartz Gary Edward , Kanter Michael H. 
Published: February 2017

60 Background: Colorectal cancer (CRC) remains the second leading cause of cancer death in the US, despite the availability of highly effective screening and treatment modalities. Kaiser Permanente Southern California is a non profit integrated health care organization that serves 3.7 million socio-economically diverse members. Our region has developed a goal to reduce colorectal cancer mortality by 50% in the next decade, from our baseline measurement of 13.8 deaths/100,00 members to 6.9 deaths/100,000 members. Methods: A literature search was conducted by the evidence based services unit to identify interventions demonstrated in published literature to reduce CRC mortality. These interventions were used to develop a spread sheet to guide the e-Autopsy, an electronic medical records review of 50 cases of recent death with CRC that was conducted by a multi-specialty group of reviewers: physicians in primary care, medical and surgical oncology, and pathology. Records of patients who died were compared to the best practices identified in the literature review to measure how often care was not matching the best practices. Review and comments were tallied by a quality nurse and reviewed by a multi-disciplinary steering group. Results: Electronic record review revealed multiple areas of opportunity for focus: Improve screening rates; Reduce diagnostic errors in evaluation of anemia/abdominal complaints; Improve care co-ordination to reduce time to surgery and chemotherapy administration; Evaluate metastatic disease for resection; Improve rates of delivery of adjuvant chemotherapy; Engage patients in lifestyle modifications. Ongoing system wide metrics and a dashboard have been developed to monitor progress in each of these areas. The relevant chiefs of service groups have developed goals and work plans to improve these metrics, which are also monitored by a central quality steering committee. Conclusions: Electronic medical record "autopsy" review of deaths in the system can be used to find and demonstrate multiple areas of focus for quality improvement projects that will help support the ultimate big region wide goal of halving the deaths from colorectal cancer.
Feasibility testing of ecomapping in neuro-oncology caregivers to identify social support networks.
Authors: Warner Echo L. , Parnell Kathrine , Cohen Adam Louis , Colman Howard , Reblin Maija 
Published: February 2017

66 Background: The role of family caregivers (FCGs) is expanding in the U.S. health care system, but caregiver burden may adversely affect health. A functional social network of friends, family, and other acquaintances may alleviate FCG burden and improve FCG health by providing support resources. Ecomaps are visualizations that are created to organize and depict information on the size, quality and function of a person’s social network; and, thus, may be a useful tool for highlighting existing support and identifying where additional support is needed. Our objective was to test the feasibility of ecomapping to identify support networks within a sample of neuro-oncology caregivers. Methods: Participants included 4 spouse caregivers of neuro-oncology patients undergoing treatment at a national cancer hospital. Semi-structured interviews were conducted in person (n=3) and by phone (n=1). Participants either completed or were sent example ecomaps and, using the “think-aloud” approach, were asked to describe their social network. Participants were also asked about the process and usefulness of the ecomap. Interviews were recorded and transcribed and then content analyzed by two members of the research team. Results: All participants were female, mean age 35.5 (SD=5.5) years, caring for husbands whose mean age was 38.2 (SD=7.4) years. The mean length of relationship was 13 years (SD=2.2). All participants found ecomapping to be feasible, acceptable, and useful for identifying sources and types of social support. Network structure and sources of support varied by participant but consistently included religious networks and family. Quality and types of support also varied; each participant identified strengths and weaknesses within their networks. Participants were in favor of using ecomaps to explore their support networks with providers in a clinical setting and desired clinical guidance on developing and interpreting their ecomap. Conclusions: Despite a small sample, this pilot shows evidence for the feasibility and utility of ecomapping. This cost-effective tool could be more widely implemented to identify and harness existing social support and improve neuro-oncology caregiver quality of life.
Using the experience-based design (EBD) approach to strengthen patients’ impact.
Authors: Moody Lesley , Bak Kate , Singh Simron , Macdougall Laura , Green Esther 
Published: February 2017

69 Background: The Experience Based Design (EBD) approach uses patient and clinician experiences to identify opportunities for improvement in the healthcare system. The EBD approach elicits subjective and personal patient, carer, and staff experiences at crucial points in the care pathway by encouraging them to share their stories. Methods: Cancer Care Ontario (CCO), an agency that oversees cancer services in Ontario, held an EBD workshop with the objectives of capacity building and facilitating healthcare improvements throughout the province. 110 participants (27 teams) from across Ontario attended the workshop to engage participants to take an active role in developing actionable plans to address patient experience issues. An evaluation following two years of EBD was necessary to: (a) determine EBD progress and effectiveness; (b) identify successes/challenges for getting projects off the ground; and (c) identify additional resources required to spread EBD across Ontario. The evaluation consisted of: 1) two province-wide electronic surveys (long survey for those directly involved in EBD projects; short survey for frontline staff) and 2) semi-structured phone interviews with patients/caregivers. Results: Some EBD projects have completed multiple initiatives; others are just beginning. Projects address process improvement (e.g., streamlining patient bookings), resource/tool development (e.g., symptom screening tools) and establishing patient advisory boards and committees. Five (28%) survey respondents said that EBD projects elicited implementation of 6 to 10 changes and 6 (38%) respondents indicated that: (1) respect for patient preferences and (2) communication, information and education were two principles of Person-Centred Care (PCC) that improved the most. Conclusions: Future steps include development of a collaborative website, a symposium to showcase projects, an evaluation of the EBD initiative and peer-reviewed publication.
Canadian cancer site-specific health utility values: Creating the basis for measuring value and costs of therapy.
Authors: Naik Hiten , Howell Doris , Qiu Xin , Brown Catherine , Vennettilli Ashlee , Irwin Margaret , Pat Vivien , Solomon Hannah , Wang Tian , Hon Henrique , Eng Lawson , Mahler Mary , Tiessen Kyoko , Thai Henry , Ho Valerie , Pringle Dan , Xu Wei , Seung Soo Jin , Mittmann Nicole , Liu Geoffrey 
Published: February 2017

7 Background: Health utility values (HUVs) play an integral role when conducting health economic analyses, but a paucity of reference HUVs exists for cancer patients. Using EQ-5D, we generated reference HUVs for multiple malignancies. We further assessed patient willingness to compete the instrument on a regular basis by adding the EQ-5D to an Ontario-wide patient-reported symptom tool mandated by Cancer Care Ontario, the provincial cancer government agency. Methods: 1,831 cancer patients across all non-CNS solid and hematologic cancer sites at the Princess Margaret Cancer Centre completed the EQ-5D instrument; a subset (n=618) were asked about the acceptability of regularly completing the EQ-5D. HUVs were calculated using Canadian valuations. Results: The mean±SD HUV for all patients was 0.81±0.15, but were significantly different across different disease sites (p<0.0001): Testicular cancer, 0.87±0.13; prostate, 0.87±0.15; colorectal, 0.83±0.12; head/neck, 0.82±0.15; lymphoma, 0.82±0.15; breast, 0.81±0.17; esophageal, 0.81±0.16; ovarian, 0.79±0.15; leukemia, 0.78±0.15; lung, 0.78±0.13 and myeloma, 0.77±0.14. Confirming the validity of these HUVs, patients with PRO-ECOG scores of 0, 1, 2 and 3 had HUVs of 0.90±0.14, 0.77±0.11, 0.65±0.14 and 0.59±0.19, respectively (p<0.0001). In patients with solid tumors, those with local disease had HUVs of 0.82±0.15; metastatic disease, 0.80±0.15; p=0.015. 88% of patients reported that the EQ-5D was easy to complete, 92% took less than 5 minutes, 89% were satisfied with its length and 86% were satisfied with the types of questions asked. Importantly, 92% reported that they would complete the EQ-5D, even if it was used solely for research purposes and 73% agreed with the notion of completing it regularly at their clinic visits. Conclusions: We present the first Canadian reference dataset of HUVs for common cancers; stage-and site-specific reference values will be presented at the meeting. Mean HUVs varied by disease site, performance status, and disease severity. Furthermore, a majority of patients surveyed were willing to complete the EQ-5D on a regular basis, suggesting that routine administration is feasible across Ontario.
Understanding the interaction between physicians and pharmacists as a method of quality improvement.
Authors: Fontaine Calder Jessica Lynn , Choy Vivian , Kwan Denise , Li Sophia , Lo Melissa , Kukreti Vishal 
Published: February 2017

90 Background: Pharmacists and pharmacy technicians are essential to safe medication delivery. Filling prescriptions can be time consuming when the prescription is not complete or clear and requires inter-professional communication. To improve the quality and efficiency of dispensing medication we performed an audit of callbacks to physicians in the outpatient pharmacy associated with our cancer center with a focus on oral chemotherapy. Methods: The Princess Margaret is one of the largest cancer centers in the world, with an outpatient pharmacy on the premises that fills over 70,000 prescriptions a year. The pharmacists have access to the hospital’s Health Information System and chemotherapy prescribing system. A Prescription Audit Form was developed to track the mode of oral chemotherapy prescription (handwritten, preprinted, computerized physician order entry (CPOE), verbal) and reason for callback. The form was implemented from February 10th until March 7th, 2014 with coded data collection. The form was incorporated into the normal workflow of the outpatient pharmacy and concurrently used to document pharmacy interactions for billing purposes. Results: A total of 5,546 prescriptions were filled with 1,166 prescriptions for oral chemotherapy. Nine percent of prescriptions for oral chemotherapy required a callback to a physician and accounted for 32% of the total callbacks made to physicians. Of the 1,166 oral chemotherapy prescriptions; 39% were refills, 34% were handwritten, 22% were CPOE, 4% were verbal, 1% were preprinted, and 1% were not documented. The top two reasons for callbacks were; drug interaction (32%) and incorrect dose (24%). In the 9% of cases where the physician was contacted to clarify a prescription, the prescription was changed 43% of the time. Conclusions: Understanding the reasons for callbacks can be used to determine optimal data fields required in oral chemotherapy prescribing. Ensuring that prescriptions are appropriately completed will reduce the number of callbacks to physicians - significantly impacting the workflow and efficiency of the pharmacy. Reducing unnecessary callbacks will allow the pharmacy team to deliver timely, safe and effective patient centered care.
Determinants for the decision of chemotherapy in advanced cancer patients.
Authors: Velter Charles , de-La-Menardiere Helene , Goldwasser Francois 
Published: February 2017

110 Background: Chemotherapy is often prescribed in order not to despair a patient in an advanced stage of cancer, while the physician identifies an unfavorable benefit/risk ratio. The use of chemotherapy in terminally ill cancer patients in the last months of life is associated with an increased risk of aggressive care (Wright A et al. BMJ; 348:g1219 doi: 10, 2014). We previously showed that multidisciplinary meetings with palliative specialists reduce futility (Colombet I et al. BMJ Support Palliat Care; 2(3):239-47, 2012). We studied the parameters leading to inappropriate palliative chemotherapy in France: How oncologists face to unrealistic expectations and what is the process for the decision-making leading to chemotherapy beyond evidence-based medicine? Methods: The study was conducted in April 2014 in Paris, France. We designed a Multiple Choice Questionnaire. The first part described a clinical situation of a patient with advanced pancreatic cancer with evidence-based factors for not doing chemotherapy. The second part included questions regarding the behavior of the oncologist. Results: We included 62 oncologists. While 58 oncologists (94%) considered beneficial to include palliative medicine specialists, 44 (71%) chose to prescribe cytotoxic chemotherapy. In the decision-making process, 49 oncologists (79%) gave more weight to the demand of the patients than to the benefit/risk ratio. The validated scores for the evaluation of life-expectancy in this setting were not known in 19 cases (31%). In advanced disease, 42 oncologists (68%) acknowledged to decide without multidisciplinary staff meeting. Conclusions: The decision-making in advanced disease tended to be solitary. Cytotoxic chemotherapy appears as a common answer to unrealistic expectations. Multidisciplinary meetings with palliative medicine specialists are recommended to improve end-of-life decisions.