bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reducing inappropriate PSA-based prostate cancer screening in men age 75 or older with a highly specific computerized clinical decision support tool.
Authors: Shelton Jeremy B. , Ochotorena Lee , Bennett Carol J. , Shekelle Paul , Goldzweig Caroline 
Published: February 2017

233 Background: The value of PSA-based screening for prostate cancer is a topic of intense debate, however the Veterans Health Administration's (VHA) national clinical policy is to use age as a proxy for life expectancy and avoid screening in men ≥ age 75. To facilitate this we developed and implemented a highly specific computerized clinical decision support (CCDS) reminder to remind providers of current guidelines, at the moment of entering an inappropriate PSA order. Methods: We defined screening PSA as: any PSA ordered on men excluding those a) with a diagnosis of existing malignant prostate disease or “elevated prostate specific antigen”, b) who are using either enhancers or suppressors of testosterone, or d) who had a PSA of 2.5ng/ml or greater on either of the two most recent PSA tests. We measured PSA-based prostate cancer screening rates using this definition and on a monthly basis from 07/2011 to 07/2013. Using an interrupted time-series design, we turned the reminder on from 6/2012-8/2012 and then again from 1/2013-4/2013. Results: There were a total of 24,705 men eligible for screening during the two year period of analysis and 1,524 men who were screened. The mean screening rate during the 12 months prior to the study period was 7.8% among men, and during the 12 months of the intervention period it was 4.3%. During the 12 month baseline period the screening rate declined by 29.3%. During the two periods when the CCDS tool was turned on the screening rate feel by 59.7% and 29.8%, whereas during the two periods when it was off, it rose by 84.3% and 18.4%. Conclusions: The overall reduction in screening rate before and after the intervention period is likely substantially confounded by the secular event of the May, 2012 release of the USPSTF grade D recommendation against all PSA-based screening and its substantial media coverage. Despite this, the striking correlation between rate of change in screening rate and the turning on and off of the CCDS tool, suggests that this highly specific CCDS tool was able to reduce inappropriate PSA-based screening, even in an era of significant public discussion of the merits of PSA-based prostate cancer screening.
Use of electronic medical record queries to support clinical decision quality assurance.
Authors: Nielsen Michelle , Senthelal Senti , Lian Jidong , MacPherson Miller , Medlam Gaylene , Larsen Tessa , Tsao Jonathan , Radwan John , Finlay Marisa , Yuen Jasper , Wang Yongjin , Rauth Sarah , Wan Jonathan Fung , McGowan Thomas 
Published: February 2017

239 Background: Clinical Treatment Decisions in radiation oncology direct the patient’s treatment plans. There is a need for Clinical Decisions to be peer reviewed preferably in real time before the patient plan is completed. Traditional peer review of clinical decisions which ensure high quality patient treatments can be challenging in a busy radiation oncology clinic. Leveraging Electronic Medical Records (EMR) to query standard patient staging and demographics data per disease type allows for efficient peer review of the clinical decision. Methods: Through the use of EMR system (Aria, Varian Medical Systems, Palo Alto CA), data is entered into the radiation oncology chart by the primary radiation oncologist during a patient’s work up. Tools within the EMR have been configured to automatically query patient charts and summarize the data. A second Oncologist runs the query, reviews the data and peer reviews clinical decision for radiotherapy including treatment intent, dose and target contours. The radiation oncologist can then discuss modifications with the original oncologist, or indicate to the dosimetrist to continue planning. Those clinical decisions that are uncertain are escalated to review in a traditional peer review setting. Results: The EMR queries have allowed a shift to real time peer review of clinical decisions. The summary of disease specific staging and demographics data has added to efficiency in clinic in both the oncologists’ ability to complete a timely peer review and the lowering the amount of planning rework. Traditional peer review setting is then used to discuss the controversial and complex cases that would receive the most benefit. Conclusions: The ability to leverage electronic medical record data has made the peer review of clinical decisions in our institution more efficient and therefore the majority can be completed in real time.
Usability evaluation of HemOnc.org, a collaborative online hematology/oncology reference.
Authors: Yang Peter C. , Cowan Andrew , Warner Jeremy 
Published: February 2017

244 Background: With an ever-growing body of medical knowledge, open access to accurate information is critical to quality care. HemOnc.org is a free online collaborative wiki created by health care professionals to record, access, and share information about chemotherapy treatment regimens and drugs. As of June 2013, the site contains referenced information for 931 regimens and 316 drugs. The site receives >7,000 visits/mo and has had >425,000 total page views from around the world (29% from outside the United States). We conducted a survey to evaluate the usability of the site. Methods: The survey was open May 1 to May 31, 2013. Participants were invited by site announcements, social media, and emails to hematology/oncology fellowship programs. Usability was assessed by 100-point scales (higher = better). Other data were collected via multiple choice questions with optional free text entry. Results: There were 139 respondents; demographics are shown in the Table. They felt that the site was useful (median 90, interquartile range (IQR) 76-99.5), usable (median 85, IQR 69-98), and recommendable to colleagues (median 87, IQR 72-99). Although 100% of users reported using other references (e.g. textbooks), 70.5% reported accuracy issues with these references (Table). Conclusions: HemOnc.org provides a new way to access and share curated knowledge. No resource is 100% accurate, but the open and transparent nature of the site allows users to actively correct errors and inconsistencies. Feedback has been positive, suggesting that an unmet need for information is being satisfied. Our goal is to improve collaboration, foster greater knowledge sharing among the oncology community, and improve quality of care through open dissemination of accurate information to a widespread audience. [Table: see text]
Concordance with best-practice guidelines for systemic treatment computerized prescriber order entry systems.
Authors: Hertz Sherrie , Gilks John , Kaizer Leonard , Yurcan Marta , Kukreti Vishal 
Published: February 2017

245 Background: In 2012, Cancer Care Ontario, released evidence-based guidance for the key features, functionalities, and components of a Systemic Treatment Computerized Prescriber Order Entry (ST CPOE) system to ensure safe, high-quality care. Concordance measurement indicators were developed alongside the guidelines and a survey was then conducted to understand the current state in a meaningful and practical manner in the province of Ontario. Methods: A self-assessment survey was distributed to 22 hospital groups, including cancer centres and both academic and community hospitals, using four different ST CPOE systems in Ontario. 52 items were assessed on a four-point Likert scale, and descriptive hospital data was collected. Composite scores were calculated by category (regimen and protocols, functionality, useful alerts, audit logs, system integration, usability) and overall. Local and provincial results were analyzed. Results: Twenty-one (21) responses were received, with the majority (17) of surveys being completed by pharmacists. 48% had been using a ST CPOE system for more than 5 years and 38% for less than one year. 81% responded that they did not, or did not know if, they had local/institutional indicators for monitoring their systems. The mean total concordance score overall was 79% (range 65% to 92%) of a potential 208 total points. The highest mean score was in the category of audit logs (92%) and the lowest in system integration (69%). Approximately half (48%) had a multidisciplinary ST CPOE advisory group. While 16 hospitals were using the same ST CPOE system, there was distinct variability in responses from these sites, indicating the effects of tailored implementations and/or discrepancy in level of knowledge of system functionalities. Conclusions: Current concordance with best practice guidelines for ST CPOE systems in Ontario is incomplete and variable. While ST CPOE systems have potential to improve safety in the chemotherapy delivery, differences in system functionalities and their implementation have been identified. This study will be used to inform specific areas of strength, set benchmarks and potential areas for improvement.
Customization of electronic health record (EHR) to implement meaningful use for quality improvement (QI).
Authors: Miller Laura M. , Heard Bridgette , Howard Kendall , Kumar Pankaj 
Published: February 2017

246 Background: Meaningful Use is a government program that encourages providers to use an electronic health record (EHR) for QI. The goals of MU are to have complete and accurate information in the patient’s electronic record and share that information with other care providers to improve the quality of patient care and avoid duplication of services. The MU program is divided into 3 stages. Providers can earn incentive bonuses for successfully reporting on MU criteria set forth by CMS. There are incentive bonuses for each year until 2015 when penalties for non-reporting are assessed. Stage I has 20 criteria to report on with thresholds for 11 of the criteria. In stage II and III those thresholds will increase. When using an EHR, user efficiency is particularly important. Our goal was to collect MU data by facilitating efficient workflow and taking the documentation burden off the providers. Methods: We identified the MU criteria that required data collection. Some criteria required one time patient data; others involved collecting data at each patient visit. Committees were formed. Processes and responsible staff were identified. We customized features in our EHR to maximize efficiency for the staff collecting the data. We used reports to audit compliance with data collection. Results: We successfully met and reported all 20 Meaningful Use criteria for 16 providers in 2012 and are on track to meet all criteria again in 2013. 11 criteria had measureable thresholds. The average threshold for the 11 measures is 54.5%; our average for the 16 providers for those 11 measures is 86.8%. We collected $288,000 in incentive money for 2013. Since most of the data collection is done by staff, physician documentation is minimal. Conclusions: Customization of EHR allowed us to collect MU data efficiently, obtain the financial incentive in 2012 and helped us get ready for stage II of data collection.
Utilizing a “navigation app” to ensure quality and consistency of oncology patient navigation.
Authors: Sheaffer Heather 
Published: February 2017

251 Background: Measuring the impact of the patient navigator has presented an on-going challenge since the inception of patient navigation in 1990. The Oncology Navigation team initially relied upon a spreadsheet to record data later utilized to evaluate the quality of the program however the spreadsheet did not meet the needs of the navigators nor of those who attempted to make sense of the voluminous data collected. This abstract offers an overview of the creation and implementation of a Navigation App to record the navigation workflow-ensuring quality and consistency in practice. Methods: The Navigation App is a web-based platform serving as the framework into which navigation data is entered. The customized version allows the collection of data specific to the metrics of interest to navigation including: care coordination, triage, reinforcement of the care plan and appointment scheduling. The App was designed as a means of evaluating the quality of the navigation process but also serves as a useful tool in organizing the navigators’ daily workflow. Results: The creation and implementation of a Navigation App has illuminated the complexity of the role of the navigator by recording both quantitative and qualitative data. The App allows the navigators to collect “real-time” data detailing their daily workflow with patients, families and providers. The navigators were quickly able master the App and significantly reduce the time needed to record data from hours to minutes each month. Entering data into the App concurrently also allows for instantaneous evaluation of productivity and quality. Finally, the App has proved to be a valuable tool for navigators in organizing their daily workflow and in prioritizing patient and provider needs. Conclusions: A web-based Navigation App can serve as an invaluable tool in driving quality patient navigation. The App not only serves as a means of recording data but also as an organizational tool to maximize productivity, quality and consistency of navigation. Utilizing a web-based application as opposed to a spreadsheet allows both navigators and administrators to track workflows in “real time” to ensure the highest quality of service to cancer patients, families and providers.
Developing a virtual collaborative to facilitate palliative care and quality improvement learning in oncology.
Authors: Kamal Arif , McNiff Kristen , Prestrud Ann A. , Lupu Dale , Gavigan Molly , Zafar Yousuf , Schilsky Richard L. , Abernethy Amy Pickar 
Published: February 2017

252 Background: Despite a strong evidence base and increasing calls for integration, oncologists find it difficult to deliver primary palliative care concurrent with standard oncology care. Solutions that promote practical integration of palliative care in oncology are needed. In an AHRQ-funded pilot, ASCO and the American Academy of Hospice and Palliative Medicine are developing the Virtual Learning Collaborative (VLC) to develop and test a scalable model for quality improvement and dissemination of best practices in palliative care within the oncology setting. Methods: The VLC will be a web-based learning and collaboration system built upon existing ASCO technology resources. We will select at least 25 oncology practices to participate in regular, facilitated learning sessions, collaborative discussions, and sharing of best practices. The VLC will equip each practice with the knowledge, tools, and coaching to select, test, and adopt a quality improvement intervention relevant to their own palliative care needs. Development of the VLC is ongoing; oncology practices begin participation in Spring 2014. Results: We will assess the VLC using protocol-driven evaluation methods common to technology development, quality improvement, implementation science, and educational initiatives. VLC usability, feasibility, and acceptability will be assessed through surveys of participating practices and focus groups. Longitudinal changes in conformance to palliative care metrics will be assessed using ASCO’s Quality Oncology Practice Initiative (QOPI) system. We will use mixed qualitative and quantitative evaluation methods to assess ongoing changes in clinician knowledge and self-efficacy in applying palliative care principles. Conclusions: We aim to develop and test a novel method for facilitating quality improvement and palliative care learning in oncology. Through this pilot, we will refine the VLC for implementation in the greater oncology community. Ultimately, this effort supports other ASCO and AAHPM quality improvement initiatives focused on clinician education and dissemination of best practices.
Creation and implementation of a corporate compliance program (CCP): The Illinois CancerCare (ILCC) experience.
Authors: Heard Bridgette , Howard Kendall , Miller Laura M. , Kumar Pankaj 
Published: February 2017

256 Background: In 2000, Office of Inspector General (OIG) provided guidance for physician practices in the adoption of corporate compliance program (CCP). The notice provided a basic outline that would allow organizations to detect, prevent and possibly report potential fraud and abuse as it relates to federal health care payers. Insurance payers, e.g., United, Healthcare, and Humana, are also requiring organizations to institute CCP for reimbursement. As health care reform evolves there is will be a greater need for an alliance between providers and payers as each are increasingly held accountable for their actions related to ethical behavior in documentation, billing and coding, HIPAA, improper inducements, kickbacks, financial conflicts of interest, in addition to other areas. Methods: The Illinois CancerCare (ILCC) is one of the largest private oncology practice in Midwest. We implemented the components outlined by OIG by completing the following tasks: identifying and empowering a compliance officer; identifying high-risk areas; developing policies and standards for major processes that might lead to fraud, waste, or abuse; developing a training program for all physicians, NPs, and employees; creating and implementing an auditing and monitoring program; developing investigation and remediation standards; and establishing committees for oversight. Results: The entire process took 18 months to be fully functional. We have developed a plan that is completely complaint and meets all the criteria as required and our personnel have been trained. Conclusions: In future most large practices in the United States will likely be required to have a CCP. It is complicated and includes multistep processes. In the end, implementing a CCP allows organizations to show their desire to be a quality organization with internal monitors to ensure they are participating in federal health care programs using ethical standards.
Cost-minimization analysis of pemetrexed/carboplatin with maintenance pemetrexed (PemC) versus paclitaxel/carboplatin/bevacizumab with maintenance bevacizumab (PCB) in nonsquamous non-small cell lung cancer (NS-NSCLC).
Authors: Graham Christopher N. , Knox Hediyyih N. , Winfree Katherine B. , Hess Lisa M. , Liu Jingyi , Ortuzar Waldo Feliu , Zinner Ralph 
Published: February 2017

263 Background: The PRONOUNCE trial was a phase III, randomized, open-label U.S. study comparing pemetrexed (PemC) with bevacizumab (PCB) in the treatment of advanced chemo-naive nonsquamous non-small cell lung cancer (NS-NSCLC). The primary endpoint of improved PFS without grade 4 toxicity for PemC over PCB was not met. There were no differences in PFS or OS. This analysis was conducted to estimate differences in costs of treatment and related patient care between the groups to inform evidence-based treatment decision making. Methods: A cost-minimization analysis was performed using data from the PRONOUNCE trial and publically available U.S. unit costs. Drug costs modeled included induction, maintenance, and subsequent therapies. Other estimated medical costs were drug administration, concomitant medications, and treatment of grade 3/4 toxicities. A probabilistic sensitivity analysis (PSA) was conducted to model joint uncertainty associated with model parameters. Results: The average cost of treatment with PemC was $4,689 less than PCB ($30,334 vs $35,024). Drug acquisition and administration costs were less in all modeled settings (induction, maintenance, and subsequent lines) for PemC. Costs associated with concomitant medications and grade 3/4 toxicities were similar ($13,286 vs $13,738). PemC was cost saving in 99% of 10,000 PSA iterations. Conclusions: Based on the PRONOUNCE trial and model results, PemC may present a similarly effective but less costly treatment option for patients in the United States compared with PCB. While treatment decision making should consider the overall safety profile and patient preferences, this study provides estimates of the costs of treatment of these two therapeutic options. The analysis was based on clinical trial data; therefore, the results may not be generalizable to all patients. [Table: see text]
The financial burden of unexpected hospitalizations for childhood cancer patients and their families.
Authors: Kirchhoff Anne C. , Warner Echo L. , Fluchel Mark 
Published: February 2017

267 Background: Complications of therapy, such as infection, pain, or dehydration, may cause financial stress for childhood cancer patients due to unexpected hospitalizations. Treatment for childhood cancer is typically provided at tertiary health care centers, requiring rural patients to travel long distances for care. We evaluated the perceived financial burden of unanticipated hospitalizations, insurance, and rurality on childhood cancer patients and their families. Methods: A single-site, cross-sectional survey of primary caretakers of childhood cancer patients was performed from July 2010-July 2012. Eligible patients were treated at a pediatric cancer hospital, diagnosed age ≤21 years and were ≤5 years from diagnosis (N=310). Financial burden was rated on a visual analog scale of 0-100. Multivariable linear regression models were used to calculate coefficients and 95% Confidence Intervals (CI) of financial burden by number of unexpected hospitalizations (0, 1-4, ≥5) and time since diagnosis. Results: The average age at diagnosis was 7.0 (SD 5.6) years. The most common diagnosis was leukemia (47.4%). The mean number of unexpected hospitalizations was 4.2 (SD 7.3). Patients did not differ on number of unexpected hospitalizations by current age, gender, race/ethnicity, or household income. In multivariable analyses, patients 1-5 years past diagnosis with ≥5 unexpected hospitalizations reported financial burden was 22.6 (95% CI 6.2-39.1, p=0.007) points higher than those with no hospitalization and 13.7 (95% CI 2.8-23.6 p=0.007) points higher than those with 1-4 hospitalizations. Patients <1 year from diagnosis did not differ. While type of insurance (public vs. private) did not impact burden, rural patients reported 15.0 (95% CI 6.8-23.2, p<0.001) points higher financial burden than urban patients. Conclusions: A high number of unexpected hospitalizations and rural residence were associated with greater financial burden for families of childhood cancer patients. Efforts to reduce unexpected admissions by managing side effects in outpatient visits, utilizing home health nurses and collaborating with local primary care physicians for remote patients could help ease the financial burden.