bluuebunny/crossref_metadata_2025_split huggingface dataset:
A quality outcomes analysis following treatment with personalized genomic cancer medicine.
Authors: Nadauld Lincoln , Perkins Bryce , Stone Gary , Gilbert Heather , Tudor Brian P. , Lin Karen Yin , Ford James M. , Haslem Derrick S. 
Published: February 2017

12 Background: Personalized genomic cancer medicine is an approach that has long shown efficacy in molecularly-defined subsets of breast and lung cancers, amongst others, but has not been employed more broadly, in part, due to limitations in testing technologies. Recent advances in genomic technologies have increasingly alleviated these constraints, thereby enabling precision cancer medicine. Data regarding the quality outcomes of patients treated with precision cancer medicine is an important next step along the path to widespread employment of this approach. Methods: We performed an IRB-approved retrospective analysis evaluating the use of targeted therapies matched to patients’ molecular aberrations as determined by genomic testing and recommended by a Molecular Tumor Board (MTB). This study assessed whether a detailed molecular profile of advanced solid malignancies including, but not limited to, the lung, gastrointestinal tract, bladder, prostate, ovary, uterus and skin, that were subsequently treated with matched targeted therapies resulted in improvements in three quality outcome measures: 1) Progression Free Survival (PFS), 2) treatment related morbidity, and 3) cost of treatment. Results: Preliminary results of the cohort analysis suggest that the costs associated with genomic targeted therapy are comparable to standard therapies; however, the costs of treatment related morbidities is significantly lower for patients receiving genomic cancer medicine compared to standard chemotherapy approaches. In line with these findings, overall treatment related morbidities are significantly reduced in the genomic cancer medicine cohort compared to a control cohort. Data regarding the Progression Free Survival are pending at the time of this report. Conclusions: These retrospective data suggest that personalized genomic cancer medicine approaches result in decreased morbidities and cost savings compared to standard chemotherapeutic approaches. In patients with advanced cancer, genomic-based treatments appear to be cost-effective, safe and viable option for treating advanced cancer patients. Additional data regarding survival outcomes are required to determine efficacy of treatment.
Developing a standardized protocol for the prescription of oral chemotherapy.
Authors: Shah Nirav Niranjan , Capozzi Donna L. , Casella Erica , McGettigan Suzanne , Gangadhar Tara C. , Schuchter Lynn Mara , Myers Jennifer 
Published: February 2017

120 Background: Over the last 10 years there has been a dramatic increase in the use of oral chemotherapy in the treatment of cancer. However, despite the route of administration, oral chemotherapies carry many of the same risks as intravenous agents and may have greater risks of drug-drug interactions due to variability in absorption and metabolism. Due to these risks, ASCO included oral chemotherapy as part of their updated chemotherapy safety standards in 2013. With this in mind, we sought to examine and improve the reliability and safety of the oral chemotherapy prescription process at the Abramson Cancer Center (ACC) of the University of Pennsylvania. Methods: A multi-disciplinary quality improvement team consisting of oncologists, nurse practitioners, and pharmacists was formed to analyze the current state of our oral chemotherapy practice. We identified an absence of signed informed consent and lack of pharmacist prescription review as areas for improvement. To address these deficiencies, we electronically routed our oral chemotherapy orders to an oncology specific pharmacist for review and implemented a policy change requiring that oral chemotherapy have signed informed consent. These changes were applied to the melanoma group of the ACC. Results: Over a 3 month time period, 33 orders for oral chemotherapy were placed for 18 individual patients. Signed informed consent was obtained in 9 of 18 patients (50%). Of the 33 orders, all were reviewed by ACC pharmacists, and as a result, 11 interventions were made by these providers (33%). Types of interventions included dose adjustment (9%), modification of an interacting drug (27%), and additional monitoring specific to the oral agent (64%). Conclusions: Despite its route of administration, oral chemotherapy should be prescribed and reviewed with the same oversight as intravenous chemotherapy. At our institution, involvement of an oncology specific pharmacist in the review of oral chemotherapy led to meaningful interventions in about 1/3 of orders, and with a policy change, signed informed consent was performed in 1/2 of patients. Given these findings, and the clinical implications of this pilot, we plan to continue to study and disseminate this intervention throughout our cancer center.
Quantifying physician performance using peer review during prospective contouring rounds.
Authors: Cox Brett Wayne , Chou Henry , Kapur Ajay , Goode Gina M. , Antone Jeffrey , Sharma Anurag , Potters Louis 
Published: February 2017

125 Background: This study presents the results of a physician evaluation system (PES) associated with a novel prospective contouring rounds (CR). Traditional chart rounds in radiation therapy (RT) occur after treatment planning and initiation of therapy. In CR, peer review occurs at a more logical process-point, once the contours and written directive (WD) are completed, but before initiation of treatment planning. We previously reported that CR improved quality of care, with the percentage of timely, errorless cases increasing over time. Methods: Starting 9/12, all patients undergoing RT at a high-volume academic center were reviewed in a daily prospective CR attended by physicians, medical physicists, and therapists. The clinical suitability for RT, contours, prescription, and remainder of the WD were prospectively peer reviewed. PES was implemented in 9/13, with each case receiving a grade (A = no deficiencies, B = minor modifications of PTV,OARs, WD, or a prescription/WD mismatch, and C = incomplete contours, significant contour modifications, prescription changes, or laterality modifications). A's were cleared for planning. B's were cleared for planning once remediated. C's were re-presented at CR upon remediation. Information was pooled to determine physician performance by assigning a grade point average. Results: 1,260 cases from 10 physicians have been reviewed using the PES. 25% of cases (318 patients) required modifications before treatment planning commenced. The breakdown of grades was 70% A’s, 18% B’s and 12% C’s. The average number of cases reviewed per day was 7. The median number of weekdays between contour completion and CR review was 0.8 days. The median contour grade point average was 3.6 (3.3 – 3.9). Conclusions: Peer review during a prospective CR can be used to develop physician performance metrics. 25% of all cases required modifications before starting treatment planning, and 12% of cases required significant remediation. Using the PES, several metrics can be combined to transparently quantify general physician performance. We intend to develop this PES to improve physician performance, optimize continuing medical education efforts, and integrate its use in PQIs for MOC.
Using an online portal and nurse navigators to improve access to cancer care between network hospitals.
Authors: Miller Eleanor , Rummel Margaret 
Published: February 2017

126 Background: Nurse navigation-facilitated access to cancer care is an emerging trend in healthcare. One way to improve access to specialized cancer care is through nurse navigators in collaboration with affiliated network hospitals. The Abramson Cancer Center (ACC) has a network of 15 community hospitals in the tri-state area that provides patients access to an academic medical center for subspecialty care that is not always available the community cancer center. Methods: In 2010, a navigation referral process was developed using nurse navigators from the ACC and the network hospitals. Then in 2012, an online portal was developed to further streamline physician referrals to and from the ACC. Updates were made to the online portal in 2013 and 2014 for continued improvement. Results: Prior to the online portal, no central repository for network referrals existed to ensure that patients were scheduled with the correct provider(s). Now with the portal patients are referred, assessed, and scheduled with appropriate providers by the nurse navigator. This has increased accountability and streamlined the scheduling process. Now, patients can be seen by multiple providers during one visit to the ACC. It has also provided a network for the ACC nurse navigators to connect patients back to the community setting for ongoing care once consults or treatments at the ACC are completed. Since the navigation process was implemented, over 1200 patients have been referred (over 500 in the past year alone) for second opinions, clinical trials, proton radiation, bone marrow transplants, surgical options, and cutting- edge technology that may not have otherwise been available. Conclusions: Using nurse navigators at the core of the process ensures that patients are triaged and scheduled in a timely and medically-appropriate manner, thus enhancing their access to specialized cancer care.
Development of an evidence-based clinical pathway for patients undergoing pancreaticoduodenectomy.
Authors: Wei Alice Chia-chi , Devitt Katharine Sarah , Ahmed Mahrosh , Barretto Beverly , Kacikanis Anna , Gallinger Steven 
Published: February 2017

130 Background: Pancreas cancer is the 4th cause of cancer death. Surgical resection is the optimal treatment. But pancreaticoduodenectomy (PD) is complex with high perioperative morbidity. Complications following PD have a negative effect on quality of life and survival. Clinical pathways (CPW) are quality improvement (QI) tools that standardize the processes of care. Our aim was to develop and implement an evidence-based CPW for PD in the province of Ontario, Canada. Methods: A CPW following PD was developed using the Knowledge-to-Action framework. All 9 high volume Hepato-Pancreato-Biliary (HPB) centers in Ontario were invited to participate in a needs assessments workshop to promote awareness and early agreement for a CPW. Enthusiasm for a CPW was confirmed. End user input was incorporated into a multidisciplinary CPW. Barriers and enablers to implementation were assessed. Evidentiary support for CPW elements was integrated into the final product. An active implementation strategy that addressed key barriers was developed to promote CPW adoption and adherence. Pilot testing was undertaken. CPW uptake, compliance, and impact on clinical outcomes were evaluated. Pilot results were used to design the final CPW product and implementation strategy. Results: The needs assessment confirmed variability of perioperative processes at all sites. Participants expressed interest for a CPW and consensus was obtained on essential CPW components. During a 15 month pilot phase, 83/122 (68%) of eligible patients were initiated on CPW. Subjects able to achieve the goals of the CPW had a shorter length of stay (7 vs 11 days), lower in-hospital complications (9, 22% vs 19, 45%) and readmission (6, 15% vs 11, 26%) compared to those who were unable to achieve CPW targets. The majority of CPW users reported that the CPW was easy to use (26, 93%) and did not adversely affect workload (20, 71%). Pilot data were used to finalize the strategy used to implement the CPW at all Ontario HPB centers. Conclusions: We report that introduction of a standardized CPW for complex cancer surgery is possible with early engagement of stakeholders. Initial results suggest that this standardized approach is safe and positively impact quality of surgical care.
A new model of care: An advanced practice radiation therapy role.
Authors: Lockhart Elizabeth , Gutierrez Eric , Warde Padraig Richard , Bak Kate , Zychla Laura , Bolderston Amanda , Lewis Donna , Smoke Marcia , Wenz Julie , Nagata Lynne , Ang Michelle , Harnett Nicole 
Published: February 2017

131 Background: Due to the rising incidence of cancer, increasing complexity of cancer treatment and growing resource constraints, there is demand for innovative interprofessional models of care. Cancer Care Ontario (CCO), in collaboration with Ontario’s Ministry of Health and Long-Term Care, launched the Clinical Specialist Radiation Therapist (CSRT) project to investigate a new advanced practice (AP) radiation therapy (RT) role. Methods: A series of pilot phases commenced in 2004. A system wide implementation phase began in 2010. The overall goal of the project was to enable CSRTs to assume responsibility for certain key radiation medicine activities, optimize RT team functioning, and improve quality of care. This was to be achieved by applying advanced clinical, technical and professional RT competencies. A project team coordinated assessment of new position proposals, implementation activities, and data collection. Work towards formalizing the role is being conducted through partnerships with cancer centre administrations and the national professional association for RTs. Results: Currently there are 17 CSRTs in 6 of 14 Ontario cancer centres, practicing in palliative and disease-site specific positions. The provincial total will be 24 CSRTs in 10 centres by Fall 2014. Data show a major impact on patient throughput and wait times, with significant increased capacity in some clinics. CSRTs’ impact within their departments is being evaluated with regards to: 1) capacity building, 2) quality of care, and 3) knowledge translation (KT). In terms of role formalization, 6 positions are now considered permanent within their centres and the first iteration of a national certification process is anticipated for fall 2014. Conclusions: The CSRT project is aligned with CCO's priorities of improving Ontario’s cancer system performance by implementing innovative models of care and providing high quality care. This jurisdictional implementation project has demonstrated that an AP RT role can be successful in addressing system pressures and improving quality of care and innovation in Radiation Medicine. Further work is necessary to develop and formalize this AP role and leverage learnings for national implementation and future models of care work.
Incorporation of externally generated next-generation tumor genotyping into clinical and research workflows: Successes and lessons learned.
Authors: Rioth Matthew J. , Staggs David , Warner Jeremy 
Published: February 2017

156 Background: The future of oncology will increasingly utilize information about tumor genomics. A growing number of tumor subtypes require genomic information as standard of care to inform treatment decisions. Clinical decision support (CDS) systems are able to improve healthcare and ensure best practices, but rely on machine-readable data. Typically, 3rd party genotyping results are returned in PDF reports that are not computable for standard presentation, CDS, or research purposes. Proposed oncology CDS platforms (such as CancerLinQ) will require computable tumor genomic information. Methods: A 3rd party CLIA-certified laboratory performed targeted exome tumor sequencing for a subset of cancer patients seen at Vanderbilt University (VUMC). The variants considered “actionable” were packaged into a standardized extensible markup language (XML) message and transmitted securely to a clinical server on a daily basis; the full PDF report was also transferred electronically. These messages were automatically received and parsed to match patients and display mutation data in their electronic medical record (EMR) for clinicians. This information was also placed into the VUMC Research Derivative (see Danciu et al. J Biomed Inform 2014 for more details). Results: The XML message, including specimen metadata, was successfully created by the 3rd party lab and received by VUMC after an iterative testing process was conducted. Clinicians were notified automatically when results were ready, within their EMR workflow. Because the primary purpose of the test is clinical, variants of unknown significance were not included in the XML transfer (these were however available in the PDF report). Conclusions: To our knowledge, this is the first demonstration of the automated incorporation of tumor genotype information from a 3rd party lab into a clinical EMR. Electronic transfer of genotype data enables rapid consumption of results by clinicians within their standard workflow, passive CDS (e.g. pointers to external knowledge bases), active CDS (e.g. standard and clinical trial treatment recommendations), and secondary use: all activities that improve the quality of cancer care.
Improving the efficiency of a block schedule for treatment planning simulation in a radiation oncology department.
Authors: Martin Neil E. , Potiris Spyros , Mersereau Robert , Mackin Mark J. , Jaehn Barbara A. , Nissen Kristopher , Nguyen Paul Linh 
Published: February 2017

158 Background: The use of a weekly assigned block time schedule to allocate appointment slots to providers for treatment planning simulations caused appointment delays, provider frustration, and a perceived lack of capacity at the Dana-Farber/Brigham and Women's Cancer Center Department of Radiation Oncology. While providing predictability for physician schedules, the slots assigned to individual providers often could not accommodate their patient volume or patient availability. Consequently, providers in need of additional slots had to ‘borrow’ them from other providers. To increase schedule flexibility and reduce the need to ‘borrow’ slots, we proposed opening part of the weekly appointment slots for use by any provider. Methods: Historical data from the scheduling system were obtained to identify the weekly volume of appointment slots used by each provider within and outside their assigned time. Using these data we developed a mathematical model that allowed clinicians to convert a desired number of weekly assigned slots to slots open for use by any provider and examine the resulting effect on the number of ‘borrowed’ slots. The model illustrated the availability and usage of weekly assigned and open slots, as well as the number of ‘borrowed’ slots. Results: In the original schedule, 40% of the weekly appointment slots are ‘borrowed’. The mathematical model revealed that converting 38% of the weekly assigned slots to open slots would completely eliminate the need to ‘borrow’ slots. Conclusions: Data-driven, simple models can address complex problems in clinic operations. A mathematical model that illustrates the effect of opening slots in a block time schedule can help end-users increase efficiency in clinic, as well as eliminate provider and staff frustration, patient dissatisfaction, and delays. [Table: see text]
Moving to secondary use of IT solutions: A provincial “near miss indicator” for chemotherapy.
Authors: Kukreti Vishal , Teimoortagh Megan , Cheung Annie , Gradin Sharon , Gilks John , Rae Erin , Kaizer Leonard 
Published: February 2017

161 Background: In Ontario, 93% of outpatient IV chemotherapy is prescribed through Systemic Treatment Computerized Order Entry Systems (ST CPOE). To support this, Cancer Care Ontario (CCO) has developed guidelines, evaluation tools, a Community of Practice (COP) and quality indicators. Using data collected in ST CPOE systems a “Near Miss Indicator” is being developed. Methods: Clinical consensus indicated that intercepted order rate, a proxy for a near miss indicator, would further the provincial safety agenda. This is defined as the percent of course 1, day 1 intravenous (IV) chemotherapy drug orders that were changed post-first time prescribing a new regimen (excludes clinical trials). An extraction standard for dose adjustments was developed encompassing clinical and laboratory values and body surface area (BSA). Three months of data was collected from 3 centres using the same ST CPOE system. Results: A total of 6822 orders were reviewed for possible near misses; 1,446 (21.2%) were course 1 orders. For course 1, day 1 IV chemotherapy drug orders, 209 (3.2%) were changed. Most orders were changed several hours to days post prescribing and hence were not felt to represent normal clinical workflows. Physicians modified 65 and pharmacy modified 169 orders. “Other” was chosen as the reason for change in 95 (45.5%) of orders and despite multidisciplinary team review, these records were not interpretable. A near miss rate of 2.2% resulted (32/1,446). Clinical and laboratory values and BSA were equally responsible. A fourth category of “dose rounding for ease” by pharmacy was identified and felt to possibly represent poor regimen builds and pharmacy workload. Conclusions: A near miss indicator is under development via a process of identifying a need, exploration of data and socialization of the results through a COP. Initial results show a low near miss indicator rate of 2.2% which is felt to be clinically actionable. Future system modifications may facilitate capture of this indicator. The feasibility of extending the indicator to multiple vendor ST CPOEs is under study.
Use of self-reporting outcomes to inform patient care.
Authors: Bosch Brandon , Denny Diane , Markman Maurie 
Published: February 2017

176 Background: Cancer Treatment Centers of America, Inc (CTCA) is a national network of hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients’ perceived symptom burden for real-time clinical intervention, from the point of no intervention (baseline) and every 21 days or greater. The SIT is comprised of 27 questions utilizing the MD Anderson Symptom Inventory tool, a validated assessment instrument with eight questions added and a free text box by CTCA. The SIT became an integral part of patient care at CTCA beginning in 2012. Methods: Non-clinical stakeholders administer the SIT via an electronic tablet. Upon completion of the assessment, a trending graph known as Symptoms-at-a-Glance (SAG) report is auto populated and available to clinicians in the EHR or may be printed at the point of care. The SAG provides run graphs for each symptom including arrows identifying clinically relevant changes in score. An accompanying e-mail notification system was created for physicians to review specific symptoms of interest at a threshold of their choosing, and refer patients to other specialties deemed integral for the patient’s treatment plan. Results: The SIT assessment is utilized by the nurse as a starting point from which they can initiate a more pointed conversation with the patient including the need for appropriate intervention including follow-up with the oncologist and/or referral to a member of the extended integrative care team. The percentage of new and returning patients completing an assessment is at 94.94% and 84.81%, respectively, for patients (1/1/14-6/9/14) across CTCA suggesting this process is useful for both patient and clinicians. Patients comment that the time for self-reflection is a healthy exercise enabled by the user-friendly tablet. Clinicians value both the ease of administration/use as well as the ability to create a large data set for quality improvement. Conclusions: With a majority of new and returning patients participating in the SIT, the SAG report fully implemented into the EHR along with the use of an e-mail functionality, clinicians and physicians can now better manage symptom burden real time