bluuebunny/crossref_metadata_2025_split huggingface dataset:
Standardization of inpatient CPR status discussions and documentation within the Division of Hematology and Oncology at UPMC Shadyside Hospital.
Authors: Garcia Christine Ann , Bhatnagar Mamta , Rodenbach Rachel , Winfield Melissa , Graham-Pardus Abigail , Minnier Christopher , Hanchett Sharon , Kriner Jamie , Baird Emily , Leahy Janet , Chu Edward , Marks Stanley M. , Levenson Josh 
Published: November 2017

147 Background: Medical professionals are trained to provide life-sustaining and cardiac resuscitation measures for admitted hospital patients. However, not all patients desire such aggressive measures. Lack of discussion and/or documentation about resuscitation preferences has led to care incongruous with patient’s wishes as previously documented or reported to providers or family members. In December 2016, 49% of adult patients admitted to the inpatient oncology service at UPMC Shadyside had a code status discussion documented prior to discharge. The aim of this project is to improve the quality and rates of CPR status conversations. Methods: A workgroup was formed in January 2017 among key stakeholders representing oncology physicians and fellows, palliative care faculty, oncology nursing, advance practice providers (APPs), and internal medicine house staff. A quality improvement (QI) proposal was developed and approved by the UPMC Quality Improvement Committee in February 2017. All oncology faculty, fellows, housestaff, and APPs were reminded weekly to complete CPR status conversations and documentation. APPs were formally trained by palliative care specialists to discuss and document CPR/code status with all admitted patients. Hospital leadership received a monthly update of CPR status documentation rates. Results: Since project implementation, CPR status assessment rates have improved from 49% to 80% as of June 2017, and an additional 714 patients had a CPR status discussed and documented compared to June 2016. Formal system-wide expectations are being developed by the CPR assessment workgroup that all admitted patients should have CPR/Code status discussions and documentation upon admission. Conclusions: Standardization of CPR status assessment with formal training of clinicians and APPs has resulted in a significant increase in the number of CPR status assessments on the inpatient setting. A formal CPR status assessment expectations document is in the process of being developed among the workgroup. Formal trainings by palliative care specialists for APPs are ongoing. Future trainings are planned for physicians, housestaff and fellows.
Raising all boats in supportive oncology: Initial impact of the Coleman Supportive Oncology Collaborative (CSOC).
Authors: Gerhart James , Weldon Christine B. , Dale William , Patel Urjeet , Khosla Paramjeet , Lo Shelly S. , Newsom Carol , Robinson Patricia A. , Martin Joanna , Azizoddin Desiree , Knightly Eileen , Berardi Rosa , Diaz Aidnag , Lillis Teresa , Trosman Julia Rachel , Penedo Frank J. 
Published: November 2017

150 Background: The Institute of Medicine (IOM) and Commission on Cancer (CoC) recommend systematic delivery of supportive oncology and survivorship care to all cancer patients. CSOC aims to improve the quality of supportive care across Chicago-area providers. Methods: 35 CSOC participating institutions (cancer centers, support centers, hospice) formed care delivery design teams - Distress, Survivorship and Palliative. Teams collaboratively developed solutions to supportive oncology gaps: patient screening tools, care delivery processes, provider training, and quality metrics to assess supportive oncology quality and the CSOC impact. Six implementation centers (2 safety-net, 3 academic & 1 public) reviewed charts at baseline (2014 diagnoses) and after the initial implementation period (2015 diagnoses), compared by frequencies and Fisher’s exact test. Results: Eight metrics contained patient data at 2 time points; improvements were seen in 7/8 metrics. (See Table). Conclusions: CSOC developed supportive oncology screening, and care processes aligned with IOM and CoC standards. Significant improvements were shown after implementation across diverse settings. Ongoing work will further evaluate the impact of CSOC efforts on patient care. [Table: see text]
Integration of supportive care in immuno-oncology trials: Investigating the incidence and severity of immune-related toxicities among older adults versus mid-age patients on immunotherapy-based phase I clinical trials.
Authors: Subbiah Ishwaria Mohan , Hess Kenneth R. , Fujii Takeo , Lui Anna , Subbiah Vivek , Naing Aung , Hong David S. 
Published: November 2017

152 Background: Older adults (65y+) with cancer are underrepresented in trials of novel drugs notably in phase I clinical trials with immunotherapies. The trepidation over immune-related toxicities in the context of older age and associated comorbidities may function as a barrier to participation. To that end, we investigated the enrollment and incidence of immune related adverse events of older adults enrolled in phase 1 immunotherapy trials. Methods: We identified 422 consecutive pts w advanced cancer treated on immunotherapy-based phase I trials bw 04/2009-09/2015, and collected pt/disease characteristics and immune-related adverse events (irAE) such as endocrinopathies, diarrhea/colitis, pneumonitis, constitutional (fatigue, fever, anorexia), myalgia, and dermatitis. Results: Older adults comprised 27% of trial participants (116 of 422 pts, median age 70y) while 256 pts were mid age (61%, median 56y). Most common cancers were GI (n = 108, 26%), thoracic/head/neck (n = 84, 20%), GU (n = 54, 13%), and GYN (n = 47, 11%). Median PFS was comparable among older pts (2.4m) and mid age (2.1m). Older adults had a higher incidence of irAE than mid age (low grade [G1/2] 49% vs 34%, p 0.02; high grade [G3/4] 19% vs 11%. p 0.14). The odds ratio of high grade events among older adults vs mid age pts was 1.81 (95% CI 1.01, 3.24; p 0.05) and low grade events was 1.85 (95% CI 1.20, 2.85; p 0.0055). Most common G1/2 irAE among all patients was fatigue (n = 76, 18%), dermatitis (n = 59, 14%), fever (n = 29, 7%) and anorexia (n = 28, 7%) with older adults having a greater incidence of low grade fatigue (25% vs 15%, OR 1.84, 95% CI 1.09, 3.10, p 0.025). Conclusions: Older adult participation remained under 30% for immunotherapy-based phase I trials. This early analysis suggests a higher incidence of toxicities among older adults, which calls for the urgent integration of comprehensive supportive care strategy to guide seniors through therapy. This work lays the foundation for future studies investigating the early involvement of supportive care through treatment on early phase clinical trials with immunotherapeutic agents.
Defining the elements of early palliative care (PC) that are associated with patient-reported outcomes (PROs) and the delivery of end-of-life (EOL) care.
Authors: Hoerger Michael , Temel Jennifer S. , Jackson Vicki , Park Elyse , Pirl William F. , El-Jawahri Areej , Gallagher Emily R. , Hagan Teresa , Jacobsen Juliet , Perry Laura , Greer Joseph 
Published: November 2017

154 Background: Early PC integrated with oncology care improves quality of life, mood and the delivery of EOL care among patients with advanced cancer, but little is known about which elements of PC practice are associated with such outcomes. The goals of this study were to describe the key elements of early PC across the illness trajectory and examine whether variation in visit content was associated with changes in PROs and the delivery of EOL care. Methods: The study cohort included patients with incurable lung or non-colorectal gastrointestinal cancer who were randomized to early PC integrated with oncology care (n = 171). Patients completed measures of quality of life (Functional Assessment of Cancer Therapy-General, FACT-G) and mood (Hospital Anxiety and Depression Scale, HADS; Patient Health Questionnaire–9, PHQ-9) at baseline and 24 weeks. PC clinicians completed electronic post-visit surveys documenting PC visit content. Data on EOL care were abstracted from electronic health records. We examined variation in visit content over time and used linear and logistic regression to identify whether the percentage of visits emphasizing a given content area was associated with PROs and EOL care. Results: We analyzed 2,921 PC visits, most of which focused on coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher percentage of visits focused on coping experienced improved quality of life (p = .02) and depression (HADS: p = .002; PHQ-9: p = .005). Having a higher percentage of visits focused on treatment decisions was associated with a reduced odds of new chemotherapy (p = .02), hospitalization (p = .001), and ED admission (p = .04) in the 60 days prior to death. Focusing on advance care planning was associated with an increased odds of receiving hospice care (p = .01) and dying at home (p = .03). Conclusions: PC clinicians’ attention to coping is associated with improvements in PROs, and the focus on treatment decisions and advanced care planning is associated with higher quality EOL care. This study defines the key elements of early PC for patients with advanced cancer and furthers the development and dissemination of this integrated model of care. Clinical trial information: NCT01401907.
Evaluation of family perceptions of palliative medicine department family meetings: Before, during, and after.
Authors: Cartin Andrea , Ocampo Sonia , Méndez Adriana , Murillo Yandali , Zeledón Daniela , Campos Rodbin , Rebolledo María Luisa , Hincapie Tatiana , Houed Julia , Vasquéz Alberth , Williams Marco Vinicio ,   Administración del Hospital México
Published: November 2017

156 Background: A Palliative Medicine Department (PMD) began in March of 2011 at a national hospital in Costa Rica. Treatment has focused on patient care, and attending the needs of the patients’ family; therefore, an integral approach to the family unit has been performed by a program of Family Meetings(FM). The program has allowed the families of Hematooncological disease patients to be involved in advanced care planning, and defining primary goals of treatment, while receiving information and psychological support. This study reports the families´ perception of the PMD FM before and after the meeting; and the evaluation of the family by the Palliative Care team, during the meeting. Methods: Information was gathered between of April and July of 2015 using a set of three questionnaires - one before, one during and one after - the meetings in the PMD. The information included population characteristics, the family’s feelings and concerns, and their level of satisfaction of their doubts being addressed and answered. Also, information was obtained concerning the agreed upon care plan and the diagnosis of the family established by the team. Results: A total of 47 family members ware included the study. Before, the interviewees most commonly referred feeling anxious (67.4%), sad (19%) and powerless (14%); the information they wanted to obtain was associated with the evolution and prognosis of the disease, and the best moment to initiate hospice care. Afterwards, families referred feeling anxious (35%), sad (34%) and powerless (31%). The most common family diagnosis was anticipatory grief (59%), and an adequate support network was identified in 38.5% of families. The agreed upon care plan mainly included education of coping and communication methods with the patient, patient homecare education, and immediate referral to hospice care. Conclusions: This study concluded that despite an increase in feelings of sadness and powerlessness, families reported a decrease in anxiousness; this was associated with families’ reporting that their doubts were addressed and answered in 97.9% of cases. Also, the set of questionnaires used during the Family meetings are a useful tool for patients’ family evaluation and diagnosis.
Propensity score matched analysis of a palliative radiation oncology consult service’s impact on length of stay and total costs during hospitalization.
Authors: Chang Sanders , May Peter , Goldstein Nathan , Ricks Doran , Rosenzweig Kenneth , Dharmarajan Kavita Vyas 
Published: November 2017

162 Background: The Palliative Radiation Oncology Consult Service (PROC) was a clinical service model developed in 2013 at Mount Sinai Hospital to provide individualized, goal-directed treatment to advanced cancer patients requiring palliative radiation therapy (PRT). We assessed its impact on length of stay (LOS) and total costs incurred during a hospitalization among patients who underwent PRT for symptomatic bone metastases while in the hospital. Methods: In our observational cohort study, we identified patients who underwent their first PRT course for bone metastases during a hospitalization between 2/2010 and 12/2016. Total costs (direct and indirect costs) during the hospitalization were extracted from the institution’s cost accounting system. Propensity score matching (PSM) was performed against age, Charlson comorbidity index (CCI), gender, race, primary cancer, and health insurance status. Balance across groups was verified by standardized differences before and after PSM. Average treatment effects (ATE) of hospital costs and LOS were calculated from generalized linear models with a γ distribution and log link adjusted by propensity score weights. PRT patients treated before 2013 (before PROC was established) were compared to those treated after 2013 (after PROC was established). Results: In total, 181 patients were included, with 76 treated before and 105 treated after PROC. Before propensity score matching, patients treated prior to PROC’s establishment had a median total hospital cost of $72,787 (range, $5,981-$324,652) and a median LOS of 28 days (range, 2-105); whereas patients treated after PROC had a median total hospital cost of $49,950 ($7,585-$620,943) and a median LOS of 19 days (2-139). After matching, patients had an ATE of -$16,877 total hospital cost (95% CI [-33,250,-504], p = 0.043) and -8.5 days in LOS (95% CI [-13.9,-3.2], p = 0.002). Conclusions: PROC, a clinical service model that integrated principles of palliative care practice within radiation delivery, led to substantial cost-savings and shorter lengths of stay for advanced cancer patients requiring PRT for bone metastases during a hospitalization.
Treatment, logistical, and cost burden of prior authorization in community practice.
Authors: Bulbul Ajaz , Huber Matney , Rashad Sadaf , Mino Emilio Araujo , Bautista Adrianna , Salcido Paula , Marquez Jowana , Khorsand-Sahbaie Masoud 
Published: November 2017

164 Background: Prior authorization (PA) process is complicated and labor intensive and with limited resources available to community practices, significant opportunity to reduce the costs of therapy exists by transforming this decision support process while being compliant with guidelines Methods: We retrospectively evaluated 123 patients between November 2016 and June 2016 across our three rural oncology practices with no dedicated in-house pharmacy. An established PA workflow involved two physicians, 1 nursing staff and 2 clerical staff involved in the process to manage PA for high cost imaging (PET/CT/MRI) or after a high-risk/cost prescription was initiated by a medical provider to a local pharmacy, specialty or mail-order pharmacy. Two Physicians determined strength of concordance with National Comprehensive Cancer Network (NCCN) guidelines. We examined approval rates, method of communications, time to approval and whether these variables were associated treatment delay and insurance provider Results: Eight decision steps were necessary to obtain a PA. Forty-nine Medicare (39%), 21 managed Medicaid (17%), 29 commercial insurance (23.5%) and 14 commercial insurances (11%) required PA mostly for targeted therapy (29%), oral chemotherapy (28%), PET/CT (24%). Approval rate was 94.3% on first attempt with only 1.6% being denied after an appeal process. 89% concordance with NCCN guidelines was seen. Median time to start treatment was 4 working days (Mean 4.7; Range 0-18 days). PA requests were associated with greatest delay in approval time with managed Medicaid (7 v 1.51 days; p < 0.0001) compared to Medicare, when specialty pharmacy was used (5.2 v 2.3 days p < 0.03) and when fax was used versus online (4.1 v 2.3 days p < 0.02). Conclusions: The impact of the PA process on care delivery and cost reduction are not clear. Current process is particularly burdensome on small practices especially given the high approval rates. Significant opportunity exists to reduce the inefficiency of this system using a computer algorithm-based PA using real-time online decision support system using NCCN guideline concordance
Could payer mix affect length of stay or readmissions among an outpatient palliative care cohort?
Authors: Zarrabi Ali John , Armstrong Karen , Curseen Kimberly A. , Quest Tammie E. 
Published: November 2017

165 Background: Outpatient palliative care clinics (PCC) are a developing frontier of palliative medicine. Characterizing and promoting financially viable models for payment of services are imperative to the sustainability of PCC. There is a paucity of research addressing payer mix – meaning the breakdown of individuals and organizations that pay for a provider's services – in PCC or its impact on metrics important to quality in PC such as hospital length of stay (LOS) and hospital readmissions. We seek to describe the payer mix for our academic outpatient PC practice. Furthermore, we sought to identify if payer mix (commercial, government—Medicare, Medicaid – or self-pay) influenced hospital LOS, discharge to hospice, or readmissions. Methods: After obtaining IRB approval, we conducted a retrospective chart review of supportive oncology patients from 2014-2017 (n = 3137) using data restricted to ICD10 codes for solid tumors. We performed bivariate tests and multivariable logistic regressions to examine the main effects of length of stay (LOS), readmissions, insurance status, and discharge disposition using SAS version 9.4 (Cary, NC). Results: Payer mix included 711 (24%) commercial insurance enrollees, 2357 (75%) Medicare or Medicaid recipients, and 38 (1%) self-pay. Mean LOS was 12.7 days (SD 16.38). The majority (94%) of patients had more than 5 readmissions. Commercial insurance was associated with prolonged LOS ( > = 30 days), discharge disposition to hospice, and hospital readmissions ( > 5) compared to government insurance (p < 0.05). Of the 3137 patients, 325 (10%) expired, 1328 (42%) were discharged to hospice, while 1463 (47%) were discharged to rehab, skilled nursing facilities or home care. Conclusions: The majority of patients in our academic PCC had governmental insurance and were less likely than those with commercial insurance to have prolonged LOS, discharge to hospice, or hospital readmission. These findings provide evidence that further investigation is needed to examine the effect of payer mix on PCC and patient outcomes.
Implementation of an interdisciplinary care team to create individualized care plans for high risk oncology patients: A model to decrease aggressiveness of care at the end of life and improve cost effectiveness of care.
Authors: Kunapareddy Girish Chandra , Hooley Joseph , Varella Leticia , Poole Christa , Tackitt Helen , Booker Stacey , Best Carolyn , Fetto Julie , Lagman Ruth , Montero Alberto J. , Parala Armida 
Published: November 2017

171 Background: Due to complexity of disease and treatments, oncology patients have among the highest hospitalization rate, especially towards End of Life (EOL). In our cancer institute, just 6% of all discharged patients accounted for >40% of unplanned readmissions, and continue to be highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and under use of hospice care. We hypothesized that developing individualized care plans (ICP) for this high-utilization group will provide guidance in the complex care they require to reduce unnecessary and aggressive medical services. Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, and nurses. On a bimonthly basis, patients with at least two unplanned hospital readmissions over the last 60 days were identified. ICPs were created using a team-based approach with parallel input from patient’s primary outpatient providers. Results: A total of 36 patients, 226 hospitalizations, and 163 ED visits were evaluated over a 6-month period, with an average number of hospitalizations of 1.08 per patient month (ppm). After implementation of ICP, hospitalizations decreased to 0.23 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days. Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay. A dedicated focus from a team of experts, beyond disease biology, on a unique patient situation may result in improved patient experience with decreased aggressiveness of care at EOL and overall resource utilization.
Early specialist palliative care for all hospitalized advanced cancer patients (ACP)? Effect of “up-front” versus “on demand” palliative care on outcomes.
Authors: Malec Monica , Hlubocky Fay J. , Levine Stacie K. , Wroblewski Kristen , Thomas Ashley , Lane Bradford , Dale William , Daugherty Christopher 
Published: November 2017

172 Background: Palliative care improves outcomes for cancer patients, especially those with advanced disease. Optimal timing for initiation of specialist palliative care remains undetermined. We created a Supportive Oncology inpatient service that integrates immediate “up-front” palliative care (IPC) consultation for selected ACP to supplement our usual oncologic care (UOC) service, which continued to utilize “on-demand” palliative care consultation. Here, we compare ACP populations and selected outcomes between these two versions of in-patient cancer care. Methods: A retrospective cohort analysis of ACP receiving either IPC or UOC between Jan 2015-Dec 2015 (N=809). ACP were compared for age, gender, race, and ethnicity. Disease severity was determined by APR DRG weight, Risk of Mortality (ROM), and Severity score. Outcomes included examining differences between groups for: Length of stay (LOS), Cost, and 30 day readmission rate. Univariate and multivariate analysis were employed. Results: 468 ACP were admitted to IPC and 341 to UOC. Compared with UOC, ACP assigned to IPC were significantly younger (61.1±13.2 vs 63.3±13.0, p=0.02); more likely female (50% vs 40%, P=0.005); and more likely to be AA (47% vs 35%, P=0.005). After adjusting for gender, age, race, and encounter type, ACP receiving IPC had higher ROM (52% v 47%, p=0.03). There were no differences in APR DRG weight (p=0.30) or Severity scores (p=0.34). IPC had significantly lower costs ($12,050 vs $15,990, p=0.003), less 30-day readmissions (16% vs 23%, p=0.03), and a trend toward shorter LOS (5.6 ± 4.9 vs 6.2 ± 6.5, p=0.10). Hospice referral and survival data will be presented. Conclusions: Our data provides additional evidence for the benefits of earlier specialist palliative care consultation services, including patients traditionally identified as underserved.