bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Ontario oncology electronic medical record (EMR): The integration of end user and provincial needs.
Authors: Kukreti Vishal , Lankshear Sara , Manzon Arthur G. , Wolf Nancy , Habib Shafiq , Hertz Sherrie , Melamed Saul , Yardley Tim , Sarsfield Lisa 
Published: February 2017

248 Background: The use of ambulatory electronic medical record (EMR) systems within oncology provides an opportunity for aligning provincial, local and end-user patient-centred quality indicators in the design, delivery and evaluation of clinical care and resource utilization. The aim of this provincial initiative is to define the “meaningful use” for the Oncology EMR by identifying the essential data elements and functional requirements required to facilitate integrated care, information standards (both local and provincial), and system integration needs. This paper presents the results of a provincial field study designed to determine end-user needs for information and quality metrics. Methods: Data collection included two separate onsite focus groups at each of the 13 regional cancer programs, with a focus on Clinical and Operational requirements. A total of 141 participants, representing physicians, interprofessional clinical team members, administrators and health information specialists were involved. An additional online survey was used for optimal engagement, with a total of 194 respondents, primarily nurses and physicians. Inclusion and exclusion criteria were developed to assist in coding and distillation of concepts generated. Results: A total of 1,598 ideas were generated (Clinical = 997, Operational = 601). Multiple rounds of content analysis were used to eliminate duplicates, identify common themes and distill the wealth of information down to the “vital few” discrete information requirements that should be included in the oncology EMR. At this time, 63 clinical and 55 operational concepts have been identified to support clinical care as well as operational planning and system evaluation. The online survey has helped define the data required for a Provincial Oncology Patient Profile within the EMR. Conclusions: The study employed significant consultation to merge end user and existing provincial quality measurement needs in order to define the Ontario Oncology EMR. A full spectrum of quality indicators identified through these processes will inform the future provincial priorities for information standards and quality monitoring that will be facilitated by a standardized EMR.
Implementation of EMR and effects on health care delivery.
Authors: Viana Nicacio Leonardo , Turner Nat , Weinberg Zach , Dulko Dorothy , Calkins Geoffrey , Shklarski Gil 
Published: February 2017

250 Background: Electronic health records have potential to enhance health care safety and quality by enabling effective communication, Clinical Decision Support technology, and generation of structured data for analysis. Despite the fact that EHRs have been shown to improve health care processes, the rapid growth of technology used to support medical care has resulted in the creation of enormous volumes of data used to assess and manage healthcare delivery. Valuable data is often siloed in multiple IT systems or captured in free-text clinical notes and non-searchable documents (unstructured data) making it impossible to quickly develop and act on real-time longitudinal data. Methods: Flatiron (FI) operates a "big data" software platform that aggregates, cleans and structures deep clinical oncology data thus facilitating understanding of operational, clinical and financial analytics related to cancer care. The platform proposes to solve these fundamental data challenges, enabling a range of real-time quality measures. It is best understood as three related components: the first is the technical integration between FI and providers' IT and data systems. That integration serves as the plumbing through which data flows securely from the provider to FI. The second is FI’s structured database, which transforms raw clinical, operational, and billing data into clean, structured, longitudinal, real-time patient data. The third is the FI user interface portal, which is a web-based analytics tool that facilitates access to the continually updated structured database. Results: Over 10 institutions have partnered with FI to deploy the platform. The full integration of an institution can be achieved in 12 to 16 weeks with daily updates to the analytics after the initial phase. Over 15,000 patients are expected to be fully integrated in the next 3-6 months. Initial QOPI and other quality measures have been included and customizable dashboards linking charge databases with clinical outcomes have been created. Dashboards with quality metrics will be presented in the conference. Conclusions: Implementation of EMRs alone does not improve healthcare delivery. Data on colorectal cancer patients will be presented at the meeting.
How effective is telephonic case management of patients with cancer?
Authors: Wu Charlotte , Bannister Wade M. , Rosen Michael W. , Schumacker Pam , Rossof Arthur H. 
Published: February 2017

254 Background: Case management offers the opportunity to improve quality of cancer care but the financial impact is largely unknown. Optum’s Cancer Support Program (CSP) provides patients and their caregivers with telephonic case management services which are focused on reducing emergency department visits and hospitalizations, and helping patients comply with treatments and more effectively manage symptoms related to their disease or to its treatment. This study evaluates the effectiveness of CSP primarily from financial perspectives. Methods: The study used a case control approach to compare participants and non-participants of the Optum CSP program. The propensity score method was applied to adjust for baseline differences between the two groups. The study population consisted of cancer patients (N=8,833) enrolled in commercial health plans through self-insured employers. The patients were referred to CSP between July 2009 and June 2011. Analyses were conducted for survivors and decedents separately to account for mortality bias. Outcomes of cost and hospice days were estimated with generalized linear models. Results: For program participants who were under active treatment and survived at least 6 months after referral, cancer-related medical cost per patient per month during the six months of follow up was reduced by 9.8% (95% confidence interval [3.7%, 15.6%], p-value 0.002), and almost 60% of the cost savings were from inpatient admissions. The decedent’s cost during the last 3 months of the life was reduced by 19.9% (95% confidence interval [2.8%, 34.1%], p-value 0.025), and more than 80% of the cost savings were from inpatient admissions. The average hospice days of all deceased CSP participants increased by 42.3%, (95% confidence interval [13.9%, 77.8%], p-value 0.002). Conclusions: We conclude the Optum CSP program is effective in reducing medical cost among both cancer survivors under active treatment and those who did not survive, while promoting hospice utilization during end-of-life.
A rapid method to estimate the value of genetic analysis of excised cancers: A comparison in the phase I setting.
Authors: Conter Henry Jacob , Kurzrock Razelle , Gopalakrishnan Vancheswaran , Zwelling Leonard A. 
Published: February 2017

264 Background: There is great interest in delivering personalized phase I clinical trials for patients. The value of this strategy will be determined by the increased benefit of the testing against the testing’s associated increased costs. We developed and employed a rapid method for determining this value in a cohort of metastatic melanoma patients who participated in phase I clinical trials at M.D. Anderson Cancer Center. Methods: The clinical parameter of benefit used was time to treatment failure (TTF) and the charges were those accrued by patients during their participation on the trial. Charge data were extracted from the MD Anderson business database. Clinical and charge data were employed in a simulation to compare two strategies: testing all patients' tumor for genetic aberrations or not. Results: In the subcohort of patients (N = 103) that were reviewed for this analysis, patients who underwent molecular testing experienced an increase in TTF of 2 months (4.2 versus 2, p=0.1) compared to those not tested, but this was not the primary concern of this study. Rather, the charges and clinical data allowed for a calculation of the value of the testing. The incremental cost-effectiveness ratio (ICER) of genetic sequencing was $49,103 per failure-free month. Ninety-four percent of the this incremental cost was due to the cost of staying on the phase I trial, with only 6% due to the cost of the genetic testing. If the cost of the genetic test was zero, the incremental ICER would still over $46,000 per failure-free month. Probabilistic sensitivity analysis demonstrated that the untested strategy was predicted to be the most cost-effective strategy with a willingness-to-pay (WTP) under $52,000 per failure-free month. The sequencing of tumors becomes 85% likely to be the most acceptable strategy by a WTP threshold of $360,000 per failure free month. Conclusions: These data suggest that making molecular testing cost effective requires reducing the costs of clinical research. This methodology is a way to make a determination of value, as well as attributable costs, which we believe will have to be made for each individual clinical setting.
Readmissions following allogeneic hematopoietic stem cell transplantation.
Authors: Spring Laura , Li Shuli , Soiffer Robert , Alyea Edwin , Glotzbecker Brett 
Published: February 2017

265 Background: Recent initiatives to improve patient safety and reduce healthcare costs have focused on preventing hospital readmissions. Historically, patients treated with allogeneic hematopoietic stem cell transplantation (HSCT) have high rates of hospital readmission. The purpose of this study was to identify the incidence and reasons for readmissions in allogeneic HSCT patients as well as associated risk factors for readmission. Methods: A retrospective review of patients receiving a myeloablative or reduced intensity conditioning (RIC) HSCT at Dana Farber/Brigham and Women’s Hospital between January 1, 2005 and December 31, 2010 was performed. Reasons for readmission, along with sociodemographic, disease, and transplant related variables were evaluated. Potential risk factors for readmission were determined by multivariate regression analysis. Results: A total of 1,097 HSCT patients were reviewed. In the myeloablative group, 130 of 495 (26.3%) patients were readmitted within 30 days of discharge, among whom the majority of patients (71.5%) had one readmission. For RICs, 105 of 602 (17.4%) patients were readmitted within 30 days, among whom 62.9% of patients had one readmission. In the myeloablative group, the most frequent reasons for readmission were infection or fever without identified source (40.7%) and graft versus host disease (GVHD) (23.7%). Similarly, the most common diagnoses at readmission in the RICs were infection or fever without source (54.9%) and GVHD (11.0%). In the RICs, a logistic regression model of the probability of being readmitted suggested active disease (OR 2.0, p=0.005), a mismatched donor (OR 2.4, p=0.029), infection during the index admission (OR 5.8, p<0.0001) and non-private insurance (OR 1.8, p=0.025) are significant factors for readmission within 30 days. Conclusions: Infection and fever without a source were the most common causes of readmission after HSCT. In the RIC group, multiple disease, transplant, and sociodemographic factors were associated with readmission. Better defining the risk factors for readmission in this population will allow for more transitional care resources to be focused on high risk patients.
Making the (business) case for outpatient and home-based palliative care for cancer patients.
Authors: Cassel Brian , Kerr Kathleen , Del Fabbro Egidio 
Published: February 2017

266 Background: Randomized controlled trials by Temel (2010) and Brumley (2003, 2007) have demonstrated the positive clinical, psycho-social, and utilization impact of providing early clinic or home-based palliative care (PC) concurrently with standard disease-focused treatment. Despite clear benefits, the growth of outpatient PC has been constrained by lack of clarity about the “business case” for hospitals or health systems to develop and fund PC services outside the inpatient setting. Methods: We will present findings from Virginia Commonwealth University (VCU) that provide a compelling quantification of the risks for hospitals to continue “business as usual” in this changing environment. Our approach measures quality, quantity, and costs of care for patients with cancer over a period of 6-12 months prior to death. Performance on some of these measures impact revenues in the prevailing fee-for-service reimbursement model; others are utilized in national, public ratings of quality; and still others influence organizational ability to compete in the population health management model that rewards quality and efficiency over time. Results: We used these data to highlight VCU Health System’s exposure to financial risks to create a strong business case for outpatient palliative care in which patient-centered and hospital-centered outcomes are aligned. This approach elevated our proposal to be included in a broader strategic initiative by our health system to manage complex care more efficiently, and to manage population health more proactively. Our analytic approach was then replicated by a diverse group of California provider groups who adopted or adapted the VCU model to advance their community-based palliative care programs as part of the California Health Care Foundation’s “Palliative Care Action Community” initiative. Conclusions: Our analytic model and articulation of the business case for community-based palliative care can help others to create and sustain quality-driven, patient-centered, cost-effective PC programs in their own institutions.
Use of radiation pathways to drive standardization of evidence-based care across a large network.
Authors: Lokay Kathleen 
Published: February 2017

27 Background: UPMC CancerCenter includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology, now marketed as Via Pathways. The program has served UPMC well for over eight years and is now a key foundation for UPMC’s overall healthcare reform strategy for accountable care. Methods: Radiation treatment algorithms for 90% of cancers were developed by committees of academic and community radiation, surgical, and medical oncologists, with current representation from multiple cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for contouring, planning and delivery are provided along with applicable citations. Clinical trials open at UPMC sites are also imbedded into the algorithms. Converting these algorithms into measureable decision support is accomplished with a web portal that presents the individual pathways status through the physician’s daily schedule. Results: Thirty-one (31) radiation oncologists at UPMC use Via Pathways in their daily practice. For the 12 months ended May 31, 2013, UPMC physicians confirmed a pathways status for 98% of their patient visits (n=9,400) and achieved an On Pathway rate of 95% for their 5,575 treatment decisions. All off pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC. Reasons for going off pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care. We continue to expand the scope of Via Pathways to include additional cancer types, surveillance protocols, and end of life prompts as well as surgical oncology pathways.
Application of a novel method weighing drug costs against survival in castrate-resistant prostate cancer cancer.
Authors: Guirgis Helmy M. 
Published: February 2017

271 Background: In the last few years, 5 new anticancer drugs have been introduced for the treatment of castration-resistant prostate cancer (CRPC). The objective was to apply a simplified methodology of weighing drug costs against overall survival (OS) in CRPC. Methods: Estimated cost in United Sates (US) dollars of an entire treatment course of an evaluated drug was divided by previously reported median OS gain over control. An initial survey of 45 drugs demonstrated that the maximal cost/OS/day gain was $757. Accordingly, a scale of crude scores was constructed with a 0% assigned to a cost/OS gain greater than $1,000 and 100% to a cost/OS gain of $1. Value scores were calculated after adjusting for quality of life (QoL), adverse events (AEs), and specialized administration and preparation (AP). Results: The lowest cost/OS gain and highest value score were demonstrated by generic docetaxel. Enzalutamide in previously-treated and abiraterone in chemo-naïve and treated patients x 6 months showed cost/OS gain lower than that of docetaxel but significantly higher than cabazitaxel. Pricing of sipuleucel-T based on cost of the entire course partly accounted for its highest cost/OS and lowest scores. Extending abiraterone and enzalutamide treatment to 12 months increased cost/OS gain and decreased scores. Conclusions: Methodology was proposed to weigh drug cost against OS/day gain with and without adjustment for QoL, AEs, and AP. Results in CRPC tend to support use of docetaxel, abiraterone, and enzalutamide rather than cabazitaxel and sipuleucel-T. Varying drug indications and different populations within the CRPC spectrum preclude direct drug comparison.
Finding the value point in oncology care: Optimizing clinical quality.
Authors: McCrone Daniel , Tran Cecilia , Flocco Jessica , Gill Dudley 
Published: February 2017

272 Background: New Century Health is an Oncology Care Management company. Evidence-based medicine is not a new trend, however, we believe that New Century Health has developed a way to quantify quality and cost outcomes based on our innovative approach to utilizing Clinical Pathways and Compendia. Methods: A retrospective clinical review was performed on 1,938 chemotherapy treatment requests (CTRs) withdrawn or recommended adverse determination (RAD), in calendar year 2012, for two national health insurance carriers. Financial impact associated with the clinical intervention was calculated at ASP +6%, net of confirmed resubmissions. Resubmissions are defined as those approved treatment requests received within one month of the original withdrawal/RAD for an alternative treatment resulting from the original withdrawal/RAD. Financial impact of gross administrative errors was mitigated through manual adjustments to the projected costs. Results: The average combined membership was 795,679; 5,731 unique patients had requests for chemotherapy treatment during 2012, generating 15,446 CTRs. Twelve point five (12.5) percent (1,938) of those were withdrawn/RAD resulting in a net impact of $15.1 million. Of the 1,938 withdrawn/RAD, 12.4% (241) resulted in increased quality with an associated increase in cost ($1.8M). Conclusions: New Century Health believes that cost effective treatment is a function of quality and not the ultimate goal at the expense of patient outcomes. Detailed retrospective case studies were performed on all of the requests that resulted in additional costs. New Century Health believes that in each case the quality of care or patient safety was significantly improved by our peer-to-peer clinical interventions. This is a patient-centric innovative approach to evidence-based medicine that embraces necessary cost increases in favor of clinical quality and patient safety.
How payment reform drives innovation in interventional oncology.
Authors: Steele Joseph Rodgers , Clarke Ryan Kristopher , Ninan Elizabeth Priya , Mahvash Armeen 
Published: February 2017

276 Background: Innovation has transformed healthcare; however, our current fee-for-service payment system can actually stifle creativity. When procedures are streamlined, fewer CPT codes may be charged, resulting in lower total reimbursement. Payment reform is necessary not only to control costs, but also to support constructive innovation. We describe how an innovative, lower reimbursed, technique of catheter-directed cancer therapy failed widespread acceptance in spite of being faster, safer and cheaper than the standard of care. Methods: Retrospective patient review was performed using the radiology information system and electronic health record. Medicare Part A and Part B payments were obtained from the Hospital Outpatient Prospective Payment System (HOPPS) for Harris County, Texas, and disposable supply costs were obtained from Premier Group Purchasing Organization. Results: From May 2008 to May 2013, 292 Yttrium-90 hepatic radioembolization procedures were performed for primary and metastatic disease. Eighty patients received the innovated balloon occlusion technique. This technique resulted in less fluoroscopy dose to the patient, faster procedure times, similar clinical outcome and a disposable cost savings of $1,138.72. However, because numerous procedure steps were avoided, the total average per-patient reimbursement was decreased by $8,044.05. Conclusions: Innovation that simplifies a procedure frequently obviates process steps that correspond to specific CPT codes. Hence, in a fee-for-service payment system, a faster, safer and cheaper option may result in fewer CPT codes and lower reimbursement, a disincentive that slows adoption. Our experience resulted in lost profit of over $8,000 per case for a total exceeding $640,000. Not surprisingly, this technique has not been widely embraced since we described it nearly two years ago. Conversely, a bundled payment model would have resulted in better aligned incentives, increased profit, and cost savings shared by patients, providers, and payers.