bluuebunny/crossref_metadata_2025_split huggingface dataset:
Creating a multi-payer provider database for cancer outcomes research.
Authors: Meyer Anne-Marie , Barkhurst David , Meyer Adrian , Shai Saray , Trogdon Justin G , Mucha Peter 
Published: April 2017

138 Background: Cancer care is multi-disciplinary in nature and relationships between healthcare providers may potentially influence outcomes. Yet understanding how patient care or outcomes are affected by these relationships has been hindered by the paucity of temporal and multi-relational data on physicians. We demonstrate a method for uniquely identifying and linking providers across multiple databases longitudinally. Methods: We identified unique, individual healthcare providers in Medicare, Medicaid, and private payer data in North Carolina (NC) from 2003-2014. In order to link the providers between the different identifiers (e.g., NPI, UPIN, etc.), five provider data sets were obtained. These databases included the National Plan and Provider Enumeration System (NPPES), the Medicare Physician Identification and Eligibility Records (MPIER), the NC State Medicaid provider file, private payer provider files and the NC medical license file. Identification and linking was performed using a novel approach leveraging relational database tools in Oracle and then verified via a second approach applying network analysis in Python. Sub-set validation was performed using claims from cancer cohorts in NC with continuous enrollment in multiple payers. Results: There was significant variation in data quality as well as temporal and geographic overlap between datasets. Linking across all data resulted in a Cartesian product of over 50 billion combinations. This was overcome by aligning provider identifiers under unique combinations of matching variables (given name, last name, zip code and specialty). From all five datasets, approximately 158,000 unique physicians were identified. In subset validation, the NPI and UPIN matches agreed 99-100% with the 2008 Medicare professional claims in a cohort of NC cancer patients. The NPI and private provider ID matches agreed between 73-79% of the time for those cancer patients with claims aligned in both payers. However, only about 30% of the Medicaid provider IDs were individually attributable and matched. Conclusions: Providers can be uniquely identified and matched across disparate databases enabling us to measure and contrast provider networks and their variation across payers and systems.
Development of an oncology-specific instrument to measure care coordination.
Authors: Holcombe Randall F. , Cortese Marisa , Zinghini Isabelle , Mahida Rupali , Draluk Dinah , Ru Meng , Winkel Gary 
Published: April 2017

148 Background: Care coordination (CC) has been identified by the IOM as critically important for the delivery of quality medical care. Coordination of care is especially important in oncology due to multiple encounters, many physicians, significant toxicities and several care transition points. Standard patient satisfaction surveys do not accurately measure CC and there are few instruments to measure a patient’s perspective of CC directly. In this project, multiple PDSA cycles were utilized with oncology patients to develop a Care Coordination Instrument (CCI) that was then used to compare the level of CC in two distinct practices. Methods: Survey questions were initially prepared by the research team after review of existing literature, submitted to oncology RNs, NPs and MDs and then modified based on their feedback. A new survey was then administered to 30 patients. This was again modified to eliminate or improve questions that were confusing to patients. A third survey instrument was developed and administered to an additional 30 patients. Statistical analysis identified that several questions were too structured leading to many “not applicable” responses. These were changed to a more conceptual framework. The survey was then administered to 30 patients in the myeloma practice and 30 in the GI oncology practice. Results: The CCI included questions from 4 areas of coordination (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care) and 3 domains (Communication, Operational, Navigation). The GI oncology practice scored significantly better than the myeloma practice on the communication and navigation domains (p < 0.01). There was no significant difference in the operational domain. Conclusions: Testing to date suggests that the CCI is a useful instrument in measuring an oncology patient’s perception of CC. For two distinct practices, significant differences in the delivery of CC were identified. Further refinement is necessary to modify or eliminate questions with high levels of missing data due to non-responsiveness. Separate sub-scores across domains help identify specific targets for quality improvement interventions.
What are the health care costs for chronic lymphocytic leukemia?
Authors: Matasar Matthew J. , DaCosta Byfield Stacey , Blauer-Peterson Cori , Montez Melissa , Reyes Carolina , Masaquel Anthony 
Published: April 2017

15 Background: New drugs for chronic lymphocytic leukemia (CLL) have recently been approved, including oral therapies. We examined total health care costs, including drug and patient out-of-pocket (OOP) costs, in patients (pts) initiating CLL treatment. Methods: This retrospective studyused a U.S. health insurance claims database. Adult commercially insured and Medicare Advantage pts from 5/2013 - 6/2015, with ≥2 medical claims for CLL were included. Pts required ≥1 claim for NCCN-recommended systemic cancer therapy. Pts were categorized based on first-line of therapy. Aggregate costs during a fixed 9-month follow-up period (treatment switch or discontinuation were possible) were investigated. Mean and standard deviation (SD) of total healthcare costs, regimen costs, and pt OOP regimen costs are presented. Results: A total of 707 CLL pts met all study criteria during the study period; 40% were commercially insured and 60% had Medicare Advantage. Mean age was 70 years (SD 11). Some of the most common regimens received included Bendamustine+Rituximab (BR) (N=186), Ibrutinib (Ibr) (N=101), Fludarabine, Cyclophosphamide, and Rituximab (FCR) (N=62), and Obinutuzumab +/- Chlorambucil (Ob+/-Chl) (N=51). Mean length of therapy varied by regimen; BR 4.2 months (m) (SD 2.7), Ibr 6.7m (SD 4.8), FCR 4.7m (SD 2.1), and Ob±Chl 4.0m (SD 2.1). The table shows aggregate costs among pts with ≥ 9 months follow-up. Ob±Chl had lower costs compared to other cohorts. Ibr had the highest drug costs. Conclusions: While the study has limited follow-up, Ob+/-Cl had the lowest drug and total costs. Oral therapy with Ibr had the highest drug and OOP costs compared to those associated with a prescribed fixed number of cycles. The magnitude of the difference between orals and infusions is expected to be greater with a longer follow-up and is a consideration in patient treatment decision-making in CLL.[Table: see text]
Identifying latent factors in the Living With Cancer (LWC) patient-reported outcomes (PRO) tool for patients with advanced malignancies.
Authors: Paramanathan Dhakshila , Khoury Raya , Bunce Mikele , Patel Sharmi Narendra , Arunajadai Srikesh , DeVincenzo Victoria , Kaur Sukhi , Pe Benito Ruth , Goldberg Stuart L. , Choi Kelly 
Published: April 2017

150 Background: End-of-Life Care (EOLC) discussions are frequently delayed past the time of usefulness, resulting in cancer patients (pts) receiving aggressive, expensive, non-desired care. The “Living with Cancer” project has developed a 7-item, 5-level Likert scale PRO tool that evaluates, from the pt perspective, their concerns regarding performance status, pain, family/financial burden, and depression during their cancer journey. The instrument was shown to correlate well with the oncologist’s opinion of appropriateness to continue treatment and might be useful as a quality metric in guiding timing of EOLC discussions (J Palliative Med 2016). Methods: The LWC PRO was administered to 1302 pts with advanced malignancies receiving care by Regional Cancer Care Associates (NJ) between Sept 2015 and Aug 2016, with confirmation of life status in Sept 2016. Exploratory factor analysis was conducted on the LWC instrument to identify latent constructs (factors) contributing to the item scores. The data set was deemed suitable for factor analysis based on standard statistical tests, including Bartlett’s test (p < 0.001). Results: A 3-factor model comprised of factors (1) Global functioning (using 5/7 items), (2) Financial toxicity (1/7 items), and (3) Depression (1/7 items) was fitted to the data using maximum likelihood and promax rotation (p = 0.043). Factor scores were compared between the cohort of 133 pts who expired within 3 months of completing their final survey and the 1124 who remained alive after 3 months. The mean global functioning score was significantly greater (worse) in the expired cohort (p < 0.001), suggesting the PRO description of distress correlated with survival. Financial toxicity and depression factor scores did not correlate with survival. Conclusions: The 7-item LWC PRO instrument contains 5 items defined by a global functioning factor that discriminates based on 3-month overall survival. This finding adds further evidence that the 7-item PRO tool can be used to time EOLC discussions with the aim to ensure better correlation between pts’ treatment desires and delivered care. LWC may also serve as a quality metric evaluating timing of EOLC discussions.
Redesigning care to lower episode costs in bone marrow transplantation.
Authors: Johnston Laura J. , Patterson Diana , Tang Ning , McMurdo Christine , Adams Laura , Chang Susan 
Published: April 2017

16 Background: Increased scrutiny over costs of cancer care has led to the introduction of episode-based payment by federal and commercial insurers. National average billed charges for autologous and allogeneic transplant episodes of care are approximately $375K and $925K, respectively. Through comprehensive analysis of claims data, we identified leading drivers of cost in BMT episodes (which span 30 days before transplant through 60-100 days post-transplant) and cost reduction opportunities. By redesigning care delivery, we can reduce post-transplant admissions and potentially improve the health and patient experience for this population. Methods: From September 1, 2013 – February 28, 2015, SHC performed 221 allogeneic and 241 autologous transplants. We analyzed internal claims data to map costs of BMT episodes, including pre-transplant, transplant (index), and post-transplant phases of care using standardized cost categories including room accommodations, medications, medical and surgical supplies, imaging, and labs. Results: 67% of episode cost was associated with pre-transplant and index phases. In both phases, patients’ treatment closely matched defined protocols. Imaging, medications, and blood utilization met clinical indications. The largest opportunity was seen in the post-transplant phase for patients with multiple myeloma who received autologous transplants. On average, episodes with post-transplant admissions were 35% more costly than episodes without post-transplant admissions. Many of these patients are admitted 5-9 days after transplant due to neutropenic fever, have short LOS, and receive empiric antibiotics. An estimated 37% of post-transplant admissions, totaling $790,000 in annualized cost, may be prevented with additional outpatient support. Conclusions: A multidisciplinary team proposed redesigning care to safely shift treatment from the inpatient to outpatient setting. Strategies include expanding Infusion Treatment Area and home pharmacy capacity and partnering with home health agencies.
Prediction of factors affecting clinical trial accrual at the Cancer Therapy and Research Center in San Antonio.
Authors: Iruku Praveena 
Published: April 2017

168 Background: Oncology is a very rapidly emerging science with need for more investigational drugs. It is highly essential to accrue patients into clinical trials to develop new drugs. According to the available data, about 38 % of the CTEP/NCI supporting oncology trials close due to inadequate accrual. In this study, we propose to develop a model that will predict clinical trial accrual and retrospectively validate the effectiveness of this model. Methods: Eligible studies included treatment and supportive care intervention studies either open or closed to accrual between 09/1999 and 012/2015 at our center. Data abstracted includes coordinating group, sponsor type, presence of competing trials, trial phase, disease category, single institutional study, author, primary purpose of the study, interventional modality, targeted therapy, advanced disease, randomization, presence of placebo, rare cancer category and new investigational agents. Statistical analysis was performed in the statistic software R (R Foundation for Statistical Computing, Vienna, Austria). We used Chi-square test and Fisher’s exact test. The significance level was set to alpha = 0.05. Results: Retrospective univariate analysis at our institution showed that the variables significantly associated with clinical accrual are: the type of sponsor, author of the trial, and the type of interventional modality. Using these variables, that were statistically significant in accrual of clinical trials, we then determined the strength of our model in measuring the performance of the predictors. Our prediction model had an AUC of 64.1 %. Conclusions: Clinical trial accrual is a key factor in the development of new drugs in Oncology. Our intention was to predict factors that may affect clinical trial accrual and develop a predictive model based on it. In the future, we want to use our predictive model in a prospective validation setting in order to guide our clinical trials portfolio. Data from multiple institutions will improve the validity of this model.
The challenges of improving peripherally inserted central catheter (PICC) care instructions at hospital discharge.
Authors: Kilbridge Kerry L. , Glotzbecker Brett , Rosenbaum Cecilia H. , Morelli Erica , Hsieh Candace , Stuver Sherri Oliver , Yenulevich Eric , Jacobson Joseph O. 
Published: April 2017

175 Background: Teaching patients and caregivers to manage a Peripherally Inserted Central Catheter (PICC) line placed during hospitalization is essential to successful outpatient transitions. The aim was to improve written care instructions at hospital discharge (CIHD) given to solid tumor oncology patients with new PICC lines by creating an electronic template in the electronic health record. Methods: Inpatients with newly placed PICC lines discharged from the physician assistants' (PA) oncology teams at Brigham and Women's Hospital were identified through PICC team consult lists. We identified 9 elements of complete line care, modeled on National Quality Forum discharge metrics, to include in a template for PICC line care instructions at discharge. PAs received instruction on template use at their weekly meeting. A retrospective chart review of CIHD (February 19, 2016 and October 13, 2016) was performed. Results: A total of 47 cases were reviewed, 19 cases Pre-introduction and 28 cases Post. Before introduction of the template, 74% of cases lacked PICC care instructions (including 13 cases with no mention of the PICC line), 26% had incomplete care instructions, and none had full instructions. Following the intervention, 64% still lacked care instructions (16 cases with no mention of the PICC line), 21% had incomplete care instructions, and 4 patients (14%) had full instructions. Only those CIHD that used the template had complete care instructions. A c-chart demonstrated special cause variation following the intervention but the process was chaotic. Conclusions: The introduction of a template for PICC care instructions led to modest improvement in the number of patients discharged with full instructions. This project highlights the limitations of solutions that incorporate technical solutions but only weak adaptive ones. The next phase of our work will introduce human factors interventions (e.g. automation and forcing functions) to improve the success rate of this critically important function. [Table: see text]
Feasibility of a clinic-based central line care teach-back program for pediatric oncology families.
Authors: Wong Quiles Chris Ivette , Desrochers Marie D , Mahan Riley M , Graham Kristen , Brill-Conway Margaret , Eng Kelly , Billett Amy 
Published: April 2017

183 Background: Pediatric oncology (PO) patients with central lines (CLs) are at high risk for CL associated bloodstream infections (CLABSI), which increase morbidity, mortality, and costs. A large portion of ambulatory CL care in the home is provided by families who often have limited opportunities to develop the needed skills and adhere to best practice line care. Methods: A pilot quality improvement initiative was undertaken from 5/2015-6/2016 to develop a coaching program for families to demonstrate external CL care with a nurse during a routine clinic visit (teach-back), either on a simulation model or the patient. Tests of change were implemented to add teach-backs during routine clinic visits and ensure teach-back documentation in the medical record. Initial steps included assessing family interest in teach-backs by conducting surveys about CL care at home and unstructured incorporation into routine care by existing clinic nursing staff. After assessment of the pilot phase, targeted interventions started April 2016 including dedicated staff for scheduling, tracking, and performing teach-backs during routine clinic visits; culture change including an expectation that all families would participate and on-going staff education about the program; language change to increase participation by avoiding family perception of being tested; and incentives (gift-card raffle) for nurses to provide coaching. Results: Before April 2016, less than 25% of families participated due to a combination of family refusal; lack of nursing availability, space, or time; and inability to approach prior to line removal. In April 2016, 52% of families participated, reaching 90% by June 2016. Informal feedback from both staff and patient/family participants suggested increased job satisfaction by nurses and wide acceptance by all. In addition, many families participated in multiple teach-back sessions to improve line care skills. Conclusions: A CL teach-back program in a busy ambulatory PO clinic is feasible, but requires dedicated resources and culture change. Ongoing improvements are in place to ensure sustainability of the program and measure the impact on ambulatory CLABSI rate and family distress and line care skills.
Driving quality improvements of radiation treatment services through a centralized performance management approach.
Authors: Hagens Victoria Karuna , Gutierrez Eric , Xie Yidan , Ang Michelle , Simanovski Vicky , Warde Padraig Richard , Matheson Garth 
Published: April 2017

188 Background: Radiation treatment services are delivered in 16 facilities spread across the province of Ontario, centralized through Cancer Care Ontario’s oversight of quality of care, equipment, hospital funding, clinical and technical guidelines. Methods: In order to ensure high quality care, Cancer Care Ontario employs a systematic approach performance management, whereby facilities are held accountable to achieving provincial quality targets. For radiation treatment, the quality improvement priorities that have leveraged this approach over the last 10 years have included: reduction of wait times to consultation; reduction of wait times to start of treatment; adoption of Intensity Modulated Radiation Therapy (IMRT) where appropriate; and implementation of peer review for treatment plans. In each case, key performance indicators were developed for use in provincial scorecards designed to focus the attention of local clinical and administrative leadership. Regular performance discussions with senior leaders took place throughout implementation, and targeted intervention occurred with facilities that were lagging behind their peers. Results: See table. Conclusions: The ability to centrally monitor the implementation of quality improvement initiatives across a large jurisdiction, and to hold the leadership of each facility accountable to provincial targets through regular feedback and escalation, has been a key component of highly successful change management initiatives in radiation treatment in Ontario. [Table: see text]
Utilizing patient reported outcomes for patients recieving oral chemotherapy.
Authors: Mackler Emily R. , Beekman Kathleen W. , Bushey Laura , Gentz Anne , Davis Kathleen , Yarrington Carol , Farris Karen B , Griggs Jennifer J. 
Published: April 2017

190 Background: Management of oral chemotherapy presents many challenges to oncology practitioners. The purpose of this study is to describe how incorporation of patient reported outcomes (PRO) for patients receiving oral chemotherapy can identify those patients who are experiencing moderate to severe symptom burden and nonadherence. Methods: As part of a statewide quality collaborative, we wished to improve our monitoring of patients receiving oral chemotherapy. The quality collaborative created a PRO assessment that includes a revised Edmonton Symptom Assessment Scale (ESAS), a single-item adherence question, reasons for nonadherence, the patient’s most bothersome symptom and questions related to patient confidence. Our medical assistants provide the assessment to the patient before each appointment. Results: Patients completing the PRO during the first 3 months (7/7/16 – 9/27/16) were evaluated. We had 32 assessments completed by 23 patients. The oral chemotherapy prescribed were capecitabine (48%), erlotinib (13%), temozolomide (13%), and not recorded (26%). Of the 29 completed ESAS assessments, 72% included at least 1 moderate side effect, and 48% included at least 1 severe side effect. 29% of patients reported low-moderate confidence to self-manage their symptoms. Less than excellent adherence (<80% adherence) was reported in 30% of patients with the most commonly reported reason being related to side effects or concerns about side effects. Conclusions: Use of PROs in our oral chemotherapy population identified a large proportion of patients experiencing moderate to severe side effects. Further assessment of how this compares to what patients report to their oncologist during their visits will be reviewed. In addition, we found that approximately 30% of our patients are nonadherent to their oral chemotherapy. This is consistent with recent publications. We plan to continue assessing patient outcomes and utilizing the data we collect to improve patient self-management support.