bluuebunny/crossref_metadata_2025_split huggingface dataset:
Measuring palliative and end-of-life care for cancer patients who die in hospital in Canada.
Authors: Decaria Kristen , Dudgeon Deborah , Green Esther , Shaw Moxam Raquel , Rahal Rami , Niu Jin , Daly Corinne , Bryant Heather E. 
Published: April 2017

58 Background: High acute hospital utilization rates near end-of-life can signal that community-based palliative care may not be suiting patients’ needs. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce multiple admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improving the quality of life of advanced cancer patients. This analysis reports on indicators that describe the current landscape of acute-care hospital utilization at end-of-life and indirectly examines access to palliative care in patients who died of cancer in a hospital. Methods: Data were provided by the Canadian Institute for Health Information. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on ICU admissions include only facilities that report ICU data. Emergency department visit data were obtained from the National Ambulatory Care Reporting System. The analysis was restricted to adults aged 18+ who died in an acute-care hospital in fiscal years 2014/15 and 2015/16 for nine provinces and three territories. Results: A total of 48,987 (43%) cancer patient deaths occurred in an acute-care hospitals, with 70% admitted through the emergency department. Preliminary analysis revealed interprovincial variation in the cumulative length of stay in hospital 6 months prior to death from a median stay of 17 to 25 days. Some variation was also seen in the proportion of patients admitted to hospital two or more times in the last month of life (ranging from 18% to 33%), and the proportion of cancer patients admitted to ICU in the last 14 days of life (ranging from 15% to 6%). Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life. Conclusions: This study provides information on the current landscape of acute-care hospital utilization by cancer patients at end-of-life across Canada and identifies interprovincial variations in management of end-of-life care. An area of focus for the Palliative and End-of-Life National Network continue to be developing nationally agreed upon system-wide palliative care indicators.
Continuous quality management for complex blood cancers in Sarah Cannon Blood Cancer Network.
Authors: Kambhampati Suman , Dodd Therese , Sheridan Cheryl , LeMaistre Charles F. 
Published: April 2017

59 Background: Sarah Cannon Blood Cancer Network (SCBCN) is a network of seven markets dedicated to provide high quality and safe care to patients with complex blood cancers. Continuous quality management (QM) and improving patient safety are critical components to the mission of SCBCN. Methods: Four SCBCN disease-specific working groups have developed evidence-based pathways for complex blood cancers. However, there are currently no SCBCN clinical quality of care metrics to monitor value-based care. To address this unmet need, the SCBCN leadership endorsed a team-based approach to measure QM for complex blood cancers, using basic clinical performance metrics proposed by the American Society of Hematology, the American Medical Association-convened Physician Consortium for Performance Improvement, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality National Quality Measures Clearinghouse, and Centers for Medicare & Medicaid Services. Results: Between 2012 and September 2015, 1221 new adult cases of Acute Myeloid Leukemia (AML) and 253 new adult cases of Myelodysplastic Syndrome (MDS), respectively, were reported within the SCBCN. Based on the volume of cases and to measure QM in AML and MDS, quality indicators were selected based on meaningfulness to program goals and feasibility of data capture, leading to development of quality metrics dashboard for AML and MDS in SCBCN. Also, keeping in mind the changing paradigm of personalized care using new and emerging therapies in AML and MDS, exploratory quality metrics are also proposed to evaluate access to new trials as QM of AML and MDS in SCBCN. Conclusions: SCBCN is a wide network of community hospitals with expertise in managing complex blood cancers. As proof of concept study, the AML and MDS dashboard was developed and chosen as a model for continuous QM for complex blood cancers. This dashboard will initially be tested to evaluate QM at two SCBCN sites to facilitate the overarching programmatic goal of continuous QM for all AML/MDS and other blood cancers presenting within the SCBCN.
Increasing Epic staging module adherence in an academic cancer center.
Authors: Porter Julie , Segura Smith Andrea , Cook Marta , Boncato Kristine , Bruels Mary , Duda-Stavlund Erik , Blayney Douglas W. 
Published: April 2017

64 Background: Documenting tumor staging (TS) is an important quality measure from ASCO’s QOPI program as a useful Core component of care. Real-time, actionable TS documentation in structured fields is important to identify patient cohorts for value-based measurement and to trigger patient care interventions. TS at our institution was usually documented in plain text progress notes in our electronic health record (Epic, Verona WI), making it difficult to use for automating support services, clinical trial evaluation, pre-authorization, business operations, value-based initiatives, and clinical research. Methods: Entry of TS into structured fields in the Epic Staging Module was agreed upon as an internal cancer quality measure in Fiscal Year (FY) 16 (9/15 – 8/16). Patients with > 2 visits to an oncology outpatient department and who began surgical, radiation or chemotherapy treatment in the reporting month were included. The physician providing the first treatment was accountable. Monthly physician and patient-level reports were provided to physician leaders, in a phased roll-out. Targets were based off FY15 performance, which were doubled for a minimum of 40% and maximum of 70% adherence. Results: Nine cancer care programs (CCPs) participated. Average compliance increased from 24% in 9/15 to 79% in 8/16. 2089 of 2894 (72%) charts had clinical and/or pathologic TS entered in the Module. Adherence was driven by CCP leaders sharing data and allowing advanced practice providers staging privileges. We uncovered discordance among providers on what clinical information to input into the Module: original diagnosis or presenting diagnosis on which to base treatment. Conclusions: Our multidisciplinary care teams improved our ability to capture TS at first treatment. A rolled-out, rather than big-bang “hard stop,” approach was successful, as we uncovered unexpected flaws in the system including aligning clinical and staging privileges with Epic access privileges, inaccuracies in Module implementation, and unclear definition between stage and disease state. There are deficiencies in the current AJCC staging system, particularly in its use for relapsed or recurrent cancer, which make defining real-time actionable processes difficult.
Adoption of a regional physician peer review program for radiation oncology.
Authors: Harris Eleanor Elizabeth , Arastu Hyder Husain , Leinweber Clinton , Ju Andrew , McLaurin Robert , Blackburn Randall , Shelton Charles , Barnes Timothy , Holloman Michael 
Published: April 2017

67 Background: Physician peer review is an important component of patient quality and safety programs. In 2012, the American Society for Radiation Oncology (ASTRO) published a white paper on peer review standards with recommendations to evaluate quality standards and compliance. Methods: Per ASTRO guidelines, physician peer review policy was adopted in 2013 by the Radiation Oncologists at the medical school and health system regional network. Peer review was conducted via WebEx by 5 regional centers. Reviews were done prior to start of treatment for all but emergent cases. Data were collected prospectively on 25 quality metrics, and scored by pre-defined peer consensus as follows: no change, minor change, major change, refer to chair. A description of recommended change was notated. Major changes were required to be represented. Aggregate data for the group and per physician were analyzed quarterly and incorporated into annual performance evaluations. Results: Aggregate categorical scores were compared for time periods from June to December 2014 (N = 283 cases) and June to December 2015 (N = 352 cases), showing an overall improvement in average scores per physician from 1.150 to 1.001. There were 56 (19.7%) total variances in 2014 compared to 32 (9%) variances in 2015. Level 2 changes (“minor”) decreased from 15.5% in 2014 to 7.2% in 2015 (p = 0.001). Level 3 changes (“major”) decreased from 4.2% to 1.9%, respectively (NS). The most common minor and major changes recommended related to dose parameters and target volumes. Variance rates over 5% were addressed by the department chair with individual practitioners and improvement programs instituted as needed. Conclusions: Peer review among a geographically diffuse physician group including an academic group practice and solo community physicians was feasible using a telemedicine system. Acceptance by the peer group was high, and over time the conference was increasingly used by physicians to review cases prior to initiating treatment planning, resulting in overall improved quality of treatment plans presented. Improved quality of care for radiation patients’ was demonstrated by significant reductions in the number and severity level of changes to treatment plans recommended.
Palliative care pharmacists as advocates to conduct advance care planning.
Authors: Ma Joseph , Dullea Alexandra , Hagmann Chelsea , Russell Michelle , Cramer Arlene , Cohen-Arazi Yael , Roeland Eric 
Published: April 2017

73 Background: Advance care planning (ACP) is a process whereby individuals consider their end-of-life (EoL) treatment preferences and make them known to caregivers and clinicians in the event of decisional incapacity. We previously reported a focused ACP intervention led by a clinical social worker (J Palliat Med 2016). Based on this trial’s initial success, we aimed to evaluate this approach when led by a pharmacist. To date, no data exists regarding pharmacist-led ACP discussions. Methods: Advanced stage cancer patients were screened at a single, academic oncology palliative care clinic. Training of the pharmacist included observation of ACP interventions conducted by the clinical social worker, didactic lectures, and role playing. Subjects engaged in a 1-hour ACP intervention with a palliative care pharmacist within 4 weeks of consent. Details of the ACP intervention were documented in the electronic medical record and AD/POLST completion was encouraged but not required. The study outcome was the identification of an informed proxy. After the patient’s death, proxies were contacted to determine if EoL wishes were achieved. Descriptive analyzes were performed. Results: Patient demographics were 22 patients, who were mostly woman (n = 13), Caucasian (n = 17), married (n = 14), with a mean age ± SD of 60.3 ± 10.5 years and with gastrointestinal (n = 5) and genitourinary (n = 5) as the most common primary cancers. After the ACP intervention by the pharmacist, 21 of 22 patients identified an informed proxy. The most commonly identified proxy was a spouse (n = 13). Fourteen (64%) subjects completed an AD/POLST after the ACP intervention. As of October 2016, 27% (6/22) of patients have died. Four out of 6 patients died in a setting consistent with their EoL wishes. Mean time to death from ACP intervention was 133±132 days. Sixteen subjects remain in surveillance. Conclusions: Preliminary results suggest that a pharmacist can conduct ACP discussions to identify an informed HCP. To date, the majority of patients achieved a death concordant with their EoL wishes.
Improving immune-related adverse event management in a thoracic clinic.
Authors: Shea Meghan , Rangachari Deepa , Costa Daniel Botelho , Sato-DiLorenzo Aya , Zerillo Jessica A. 
Published: April 2017

74 Background: Widespread use of immunotherapeutic agents has transformed the profile of adverse events associated with systemic cancer therapy. Management of immune-related adverse events (IRAEs) is contingent upon grading severity using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE). Nivolumab and Pembrolizumab were recently approved for metastatic non-small cell lung cancer (NSCLC). United States Food and Drug Administration (US FDA)-approved package label inserts provide guidance on IRAE management and are predicated on CTCAE grade, including when to discontinue drug. Currently, clinicians in the thoracic oncology group are documenting CTCAE grade of IRAEs infrequently, and management is varied. Methods: A retrospective chart review of baseline data revealed 45 patients (8 on Pembrolizumab, 37 on Nivolumab) who initiated immunotherapy for metastatic NSCLC between March 2015 and August 2016. A team of clinicians developed a process map from diagnosis of IRAE to initiation of toxicity management. Physicians were surveyed. The team’s aim is by February 1, 2017, at least 50% of patients who develop an IRAE on immunotherapy for metastatic NSCLC have documentation of toxicity grade using the CTCAE criteria. Results: The physician survey response rate was 12 of 16 (75%). Physicians reported not using grade to guide management of IRAEs over two thirds (67%) of the time. Time to look up CTCAE criteria and knowing that grade is needed ranked as the top barriers. At baseline, 18 of 45 (40%) patients had 22 IRAEs, of which 6 IRAEs (27%) had grading documented; all graded IRAEs (100%) were managed according to guidelines in the drug-specific package insert. IRAEs included hypothyroidism, pneumonitis, hepatitis, dermatitis, adrenal insufficiency, colitis, and encephalitis. Conclusions: Education on toxicity grading and ease of accessibility to information regarding management of IRAEs are needed. Because clinicians were engaged, a survey to evaluate the current process succeeded with a high response rate. At baseline, there are significant gaps and variability in current practice. Interventions are underway to standardize documentation of grade and management of patients experiencing IRAEs.
Feasibility of capturing radiation oncology quality metrics in a large integrated oncology practice.
Authors: Dubey Ajay , Bernard Jeff , Limmer Jeffrey , Heintz Bret , Antes Kyle , Hartman Stacy , Taylor Bernard , Cheek Brennan Scott , Wilfong Lalan S. , Hoverman John Russell 
Published: April 2017

83 Background: Metrics to assess quality are important to improve processes of care. While such capture and reporting are common in medical oncology practices, it is less common with radiation oncology. As part of a large integrated oncology practice with more than 400 physicians and 57 radiation oncologists, we explored the feasibility of capturing and reporting a bundle of metrics at each of 52 radiation oncology practice sites. Methods: At the beginning of each quarter, the first 20 charts were sampled at each rad onc site of service to capture the following metrics: performance status at the start of radiation therapy, pain level at the start of XRT for patient with bone metastasis, cancer staging documented, dose limits to normal tissue tissues established and clearly documented for IMRT cases, and adherence to the 2015 US Oncology Breast Cancer XRT Pathways. Pathways adherence was captured via physician attestation. Beginning in the second quarter, Breast Cancer Pathways concordance with the final delivered plan was reported. Beginning in the 3rdquarter, additional pathways were captured (but not reported) for NSCLC, Prostate, Rectal Cancer, and Bone Metastasis sites. Results: See table. Conclusions: Availability of metrics data and compliance was greater than 80% in all 52 radiation oncology practice sites. Documentation of dose limits was seen as an opportunity for improvement via standardization of workflows, as there were multiple workflows within the record and verify system. Concordance rate between attestation of pathways compliance and the delivered plan was high. Breast cancer pathways compliance fell in the third quarter when additional pathways were added, suggesting that increasing complexity of metrics requirements may decrease performance. [Table: see text]
Stakeholder perspectives on the use of telehealth to improve ambulatory care for chemotherapy patients in a large urban cancer centre.
Authors: Doshi Samik , Chad Jeremy , Archer-Myles Karin , Krzyzanowska Monika K. 
Published: April 2017

86 Background: Chemotherapy outpatients are often left in vulnerable positions without direct access to their providers between appointments, which can lead to Emergency Department (ED) visits to address side effects. Improved use of telehealth has been postulated in the literature as a potential low-cost tool to manage this problem. Our objective was to explore, as a case study, how telehealth can be optimized to provide better care to ambulatory chemotherapy patients. Methods: This study was done at Princess Margaret Cancer Centre in Toronto. Semi-structured interviews (n = 21) were conducted to elicit a broad set of perspectives on the feasibility and constraints of implementing new telehealth measures in the breast cancer (BC) clinic. Interviewees included hospital administrators (n = 3), nurse managers (n = 4), BC nurses (n = 3), BC physicians (n = 2), one non-BC nurse, one pharmacist, BC patients (n = 4), and telehealth and technology experts (n = 3). Transcripts were reviewed separately by each author and themes were extracted using content analysis. Key learnings were established based on stakeholder agreement and theme novelty. Results: Provider-initiated proactive calling of chemotherapy patients was felt to bethe most valuable and feasible potential change according to all stakeholders. A number of key considerations emerged regarding the creation of a successful proactive calling system: 1) calls should address symptoms that are predictable, regimen-specific, and most likely to result in ED visits; 2) patients most likely to benefit are those beginning chemotherapy, starting new drugs, or fitting certain high-needs criteria; 3) structured call questionnaires can be valuable, but must be flexible to best meet patient needs; 4) the caller’s expertise is more important than his or her familiarity with the patient; and 5) basic IT support systems are necessary for operationalization. Conclusions: Simple telehealth initiatives such as proactive calls can improve outpatient care for chemotherapy patients, and may reduce ED burden. This study provides key principles that should guide development and implementation of proactive calling programs at cancer care institutions.
A multidisciplinary effort to decrease time from admission to chemotherapy on an inpatient oncology unit.
Authors: Man Louise Ming-Wai , Sen Jeremy , Cahan Jeanne , Degregory Kathlene , Thomas Tanya , Daniels Elizabeth , McLoughlin Erin , Huntsinger Lisa , Keng Michael Kenneth 
Published: April 2017

96 Background: Patients with established cancer diagnoses often experience delays in starting scheduled inpatient chemotherapy (CTX) after arrival on the University of Virginia (UVA) Medical Center oncology unit. These delays negatively impact hospital resource utilization. We formed a multidisciplinary team of physicians, nurses, and pharmacists to investigate these delays. We aim to decrease time-to-CTX (TTC) by 30% from baseline. Methods: From 340 planned inpatient CTX encounters in calendar year 2015, 100 were randomly reviewed to establish baseline retrospective data. The following were collected for each encounter: patient demographics; oncologic diagnosis; admitting team; CTX regimen and cycle; procedures and urinary parameters required prior to CTX start; times of lab orders and results, CTX signature and release, and start of intravenous fluid (IVF), premedications, and CTX; unit census data; available nursing staff; and length of stay. With guidance from ASCO’s Quality Training Program, we constructed a process map of the current state, an Ishikawa cause-and-effect diagram, a Pareto chart to assess causes of delays, and a priority matrix of potential interventions. XmR charts compared baseline and post-intervention data. Results: Baseline median TTC was 6.7 hours (range 1.5-105.3 h). Patients with pre-admission outpatient appointments started CTX 2.4 h earlier than those without appointments. Patients without urine parameters for treatment started CTX 3 h earlier than those with parameters. The Pareto chart indicated the longest delays occurred in pre-medicating patients, starting IVF, and signing CTX orders. In the first Plan-Do-Study-Act (PDSA) cycle, the CTX consent process was reformed. Post-intervention data showed no change in median TTC (7.2 h). Other PDSA cycles (setting patient arrival times and pre-admission pharmacy review of treatment plans) are ongoing; prospective data collection is pending. Conclusions: Retrospective data validate concerns that delays in starting inpatient CTX are longer than acceptable. They affect hospital length of stay, cost, and patient satisfaction. Our first PDSA cycle showed no change in TTC but additional interventions are ongoing.
Syncope
Authors: Cheshire William P. 
Published: April 2017

ABSTRACT

Purpose of Review: Syncope is a prevalent syndrome with diverse causes, which have in common a sudden transient failure of the autonomic nervous system to maintain blood pressure against the force of gravity at a level sufficient for cerebral perfusion. Neurally mediated syncope is an episodic phenomenon in which autonomic nervous system function is normal the rest of the time. Although relatively benign, syncope increases the risk for injury from falling and can substantially impair patients’ quality of life. Recognition of its various clinical presentations and knowledge of the underlying pathophysiology are essential for accurate diagnosis and successful management.

Recent Findings: The most effective forms of treatment remain education of patients, avoidance of triggers, physical counterpressure maneuvers, and hydration or intravascular volume expansion. Pharmacologic interventions may be appropriate for some patients but, in general, have limited evidence of efficacy in preventing syncope. Based on the findings of a recent study, the possibility of pulmonary embolism should be considered in patients hospitalized for syncope, whether or not an alternative etiology for syncope is identified.

Summary: This article focuses on the neurologic diagnosis, differential diagnosis, physiology, and management strategies for syncope, with an emphasis on neurally mediated syncope.