bluuebunny/crossref_metadata_2025_split huggingface dataset:
Safe and reliable inpatient chemotherapy administration: Impact of an ambulatory oncology pharmacist.
Authors: Yousef Mary , Li Melissa , Sengar Anjana , Lim Charles Henry 
Published: October 2023

389 Background: Given their extensive adverse effect profiles, any errors involving chemotherapy medications are at high risk for causing patient harm. Analysis of inpatient chemotherapy related incidents at Trillium Health Partners, a Canadian academically-affiliated health system, between May 2019 and April 2021 revealed a number of key drivers for incidents. These included gaps in coordination of care, provider ordering practices and communication between different clinical teams. Methods: A dedicated inpatient oncology pharmacist role, staffed by an ambulatory care oncology pharmacist, was implemented from August 2021 - July 2022. The primary goal was to achieve a 50% reduction in inpatient incidents per 100 doses of chemotherapy by July 2022. Secondary goals included improving interdisciplinary communication and coordination of care between providers especially at transitions in care. Three data elements were collected: number and severity of incidents, types of pharmacist interventions and provider satisfaction. The clinical and organizational impact of the pharmacists interventions were assessed by a multidisciplinary team including an oncologist, a nurse and a pharmacist using the validated CLEO tool. Results: Incidents per 100 doses of administered inpatient chemotherapy decreased by 80%, with a significant shift from actual incidents to reportable circumstances. Chemotherapy coordination, chemotherapy dose adjustments and adapting orders for inpatient use were the most common pharmacist interventions. The interventions had major and moderate clinical impact and a positive organizational impact as assessed by the CLEO tool. Feedback through provider satisfaction surveys showed a 52% increase in satisfaction with the inpatient chemotherapy process. Qualitative feedback indicated the specialized oncology pharmacist role facilitated collaboration and improved communication and coordination of care between inpatient and ambulatory settings. In addition, the implementation of this role facilitated safe provision of inpatient chemotherapy on non-oncology inpatient units. Conclusions: Implementing a dedicated ambulatory oncology pharmacist in an inpatient setting facilitated safe administration of inpatient chemotherapy and improved multidisciplinary coordination, allowing for a seamless patient experience. This demonstrates the value of utilizing the niche outpatient clinical knowledge of oncology pharmacists, applied to inpatient roles to coordinate care in corresponding specialized inpatient populations. This model can be extrapolated to other cancer centers to maximize the utilization of specialized skills and knowledge leading to system-wide impact.[Table: see text]
Community reporting on cost and quality in Washington state: Lessons learned.
Authors: Kreizenbeck Karma L. , Fedorenko Catherine R. , Kestner Shannon , Sun Qin , Li Li , Wright Winona E , Shankaran Veena , Ramsey Scott David 
Published: October 2023

39 Background: As part of an ongoing initiative to improve the quality and affordability of cancer care in WA state., the Hutchinson Institute for Cancer Outcomes Research (HICOR) releases open access reports showing cost and quality across several cancer care domains. Here, using the Agency for Healthcare Research and Quality’s (AHRQ) framework for quality reporting as a guide, we report processes, successes, challenges, and lessons learned. Methods: In 2014, HICOR began a transparent, inclusive, multi-stakeholder approach to identify priority metrics of oncology care quality and cost. Using a registry-claims database covering over 70% of cancer patients in WA state, HICOR constructed clinic-level adherence and episode costs for community-prioritized metrics. From 2018 to 2023, five reports were released. The 2018, 2019, and 2021 reports covered 4 domains (appropriate therapy, hospitalizations during chemotherapy, surveillance testing, and end-of-life care). The 2020 report compared quality measures between commercial and Medicaid-enrolled patients. The 2023 report expands the measure list to include biomarker and germline testing and timeliness of care. Between 2020 and 2022, HICOR reported on the impact of COVID-19 on cancer care in WA State. HICOR hosts an annual gathering of oncology practice leaders, payors, and patients to review findings, share best practices, and identify areas for regional research and quality improvement efforts. Results: HICOR’s processes relative to the AHRQ framework are summarized in the table. Conclusions: Community reporting of cancer cost and quality measure requires a flexible framework, balancing parsimony, relevance, and actionability of measures, transparency, and trust in methods, and providing multiple opportunities for feedback. Engaging the community in quality improvement research is critical but challenging due to unpredictability in funding. [Table: see text]
Utilizing a best practice advisory (BPA) to increase pneumocystis jirovecii pneumonia (PJP) prophylaxis prescribing for patients with cancer on high dose corticosteroids.
Authors: Spradlin Megan , Rhoads Sarah , Maloney James , Montague Brian , Wick Abraham , Ngov Li-Kheng , Norskog Sarah Samaya , Bowden Kasey , Graham Laura 
Published: October 2023

391 Background: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that can cause severe respiratory infection in immunocompromised patients. Corticosteroid use is a common risk factor for developing PJP in non-human immunodeficiency virus (HIV) patients. Corticosteroids are commonly prescribed medications for cancer patients to help with symptom control from cancer treatment (e.g. nausea, vomiting, and pain) as well as for immunotherapy related adverse events. The risk of developing PJP is significantly increased for patients on prednisone equal to or greater than 20 mg per day x 1 month or equivalent. Steroid related PJP (srPJP) is associated with a 30-50% mortality in non-HIV patients. Methods: We conducted an IRB-approved retrospective chart review of individuals diagnosed with PJP at an academic medical center and 6 partner hospitals between 2016-2022. Patients were excluded if they had a diagnosis of HIV or prior hematopoietic stem cell transplant (HSCT). We then created a best practice advisory (BPA) built into the electronic health record to notify clinicians if a patient is at risk of developing srPJP based on their outpatient corticosteroid prescription. The BPA is triggered system-wide if a clinician signs an outpatient prescription for a prednisone or equivalent steroid dose of 20 mg or more for a duration of at least 3 weeks. The BPA will suggest PJP prophylaxis and link to an order for the clinician to select. Results: There were 96 identified cases of srPJP in non HIV/HSCT patients. None of these patients received antibiotic prophylaxis. Among these cases, 32 patients died from ARDS due to PJP, a mortality of 33.3%. 45% of identified cases were related to steroids prescribed for cancer management, and 68% of these received dexamethasone as the primary steroid. The BPA launched in April 2023 system wide across UC Health. Since launching the BPA in April 2023, it has been triggered 911 times with action taken by selecting an order for PJP prophylaxis 24.5% of the time. Conclusions: Despite the efficacy of prophylaxis, many patients at risk of developing srPJP do not receive prophylaxis. Since launching the BPA, preliminary data shows that the BPA has increased the orders placed for concurrent PJP prophylaxis. Further work must be done to determine if these orders for concurrent PJP prophylaxis were signed and if the BPA can increase PJP prophylaxis prescribing for patients on high dose corticosteroids and ultimately decrease srPJP cases and deaths.
Stomatitis in patients receiving EGFR-targeted therapy for non-small cell lung cancer: A population-based cohort study across the United States.
Authors: Lu Chuan , Ma Kevin Sheng-Kai , Hsieh Tina Y.J. , Chen Sheng-Yin 
Published: October 2023

406 Background: As the standard therapy for non-small cell lung cancer (NSCLC) patients expressing epidermal growth factor receptor (EGFR) mutations, EGFR tyrosine kinase inhibitors (EGFR-TKIs) possess advanced potency and survival outcomes in clinical trials. However, little is known for stomatitis as a potential adverse event. This study aimed to assess the risk of stomatitis among patients initiating different EGFR-targeted therapy for NSCLC in a real-world study. Methods: Patients diagnosed with NSCLC and newly initiated EGFR-targeted therapy between 2008 and 2023 were included from 92 healthcare organizations across the U.S., then matched to non-users via propensity scores on age, comorbidities, metastatic status, and previous history of anticancer therapies. The primary outcome, stomatitis, was retrieved by ICD-9 or ICD-10 codes. The risk of stomatitis in association with EGFR-TKI was evaluated using regression models to obtain the odds ratio (OR) with 95% confidence intervals (CIs). Subgroup analyses were conducted to identify the EGFR-TKI agents that were associated with the risk of stomatitis. Results: A total of 22,225 EGFR-TKI initiators were included, including 719 on gefitinib, 16,404 on erlotinib, 1,864 on afatinib, and 5,300 on osimertinib. EGFR-TKIs initiators presented with a significantly increased risk of stomatitis compared to non-users (n= 445 vs 367; OR=1.22; 95% CI=1.058-1.399). Among all EGFR-TKIs, erlotinib (n=316; OR=1.56; 95% CI=1.394-1.739), afatinib (n=81; OR=3.49; 95% CI=2.794-4.365), and osimertinib (n=95; OR=1.40; 95% CI=1.139-1.711) were significantly associated with an increased risk of stomatitis before propensity score matching. The risk of EGFR-TKI-associated stomatitis in those treated with afatinib was validated after propensity score matching (OR=2.23; 95% CI=1.528-3.393). Conclusions: The present study demonstrated a significantly high risk of stomatitis in relation to EGFR-targeted therapy for NSCLC. Multidisciplinary care involving oral medicine specialists and dentists is needed for patients with lung cancer.
Optimizing discharge readiness to reduce health disparities for at-risk children with cancer in the Bronx.
Authors: Offenbacher Rachel , Parsons Susan K. , Weiser Daniel A. 
Published: October 2023

407 Background: Transitions in care between hospital and home are overwhelming for patients and families, and often result in medical errors. Children with cancer are at an increased risk of adverse outcomes due to their immunocompromised state. Despite a robust therapeutic armamentarium, unfavorable outcomes secondary to disease- and treatment-related complications remain a challenge, and children with cancer are particularly vulnerable to these outcomes during transitions of care. At our institution, the pediatric oncology team noted that caregivers of patients with new pediatric cancer diagnoses often admitted to confusion regarding infection precautions, central venous catheter care, and medications when returning for follow up appointments. This experience is supported by data showing that caregivers of patients with leukemia feel subjectively unprepared to take care of patients after hospital discharge. The increasing prioritization of outpatient management in healthcare has shifted responsibility for identifying and managing emergencies and complications to caregivers. Methods: We initiated a comprehensive cancer-specific program through the use of quality improvement measures and four plan-do-study-act (PDSA) cycles to ensure consistency of healthcare provider-delivered education and improve caregiver knowledge of homecare instructions in a high-risk patient population. Results: Based on our recent publication, overall retention of key discharge information was greater in the intervention cohort compared to the non-intervention cohort (median total scores: 89 and 63, respectively; p=0.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=0.059), from 0.71 to 0.78 for signs of sepsis (p=0.65), from 0.57 to 1.00 for accurate choice of on-call number (p=0.004), and from 0.71 to 0.94 for antiemetic management (p=0.14). Conclusions: Our study demonstrated that standardized processes with a multi-disciplinary team and task allocation significantly improves ability of caregivers to retain important information after a new cancer diagnosis, with specific improvement in retention of fever guidelines and on-call contact instructions. During our intervention, it became clear that as team members change (residents changing cycle, oncologist going off service, nurses switching), having one point person is absolutely critical in ensuring discharge education continues. We anticipate that a dedicated patient navigator focused on consistent psychosocial screening and health literacy comprehension of key discharge details would lead to a marked improvement in cancer care delivery for children with cancer in the Bronx; specifically, discharge readiness, medication adherence, family satisfaction, and patient safety for children with cancer in the Bronx.
Incidence and treatment of checkpoint inhibitor induced immune related adverse events in the emergency department.
Authors: Duell Colin Harrison , Doherty Patrick , Pamer Hannah , Blazawski Jon 
Published: October 2023

438 Background: Immune checkpoint inhibitors (ICPis) are currently indicated for the treatment of various types of cancers. Through inhibition of the cancer cell’s checkpoint mediated T-cell evasion, ICPis allow for sustained T-cell activation and proliferation, resulting in increased cancer cell death. However, due to increased activation and proliferation of cytotoxic T-cells, ICPis have been associated with a wide spectrum of adverse effects, known as immune related adverse effects (irAEs). Although recently updated, the 2018 NCCN and ASCO guidelines state that treatment is based on the location and severity of irAEs. In general, grade 3 toxicities warrant suspension of ICPis and initiation of high-dose corticosteroids. Corticosteroids should then be tapered over the course of at least 4-6 weeks. The diagnosis of an irAE is challenging, toxicities may be misdiagnosed as there is a diverse familiarity with ICPis and their associated irAEs. Subsequently, care may be delayed, and patients may not receive appropriate guideline directed care. Methods: This multi-center chart review included 7 hospitals within a large health system. Our electronic health record was utilized to compile a report of patients who had received ICPIs within 12 months of presentation to an ED within the health system between 9/1/2019 and 9/1/2022. Assessed outcomes included incidence and type of irAE, time between last ICPi dose and presentation to the ED, steroid used for treatment, time to steroid, treatment driver, and the action that deviated from the 2018 ASCO/NCCN guideline directed treatment if applicable. Results: Of the 241 patients receiving an ICPi, 26 (10.8%) experienced an irAE that prompted a visit to an ED within our health system. Guideline directed treatment of irAE(s) was followed 76.9% of the time, with the steroid dose being too low (15.4%) and the steroid taper occurring too quickly (7.7%) being the two reasons for discordant treatment. Treatment started a median of 1.1 after presentation to an ED, with colitis as the most prevalent irAE in 11 patients (42%) presenting. For all patients, there was an average of 20 days between the last ICPi dose and presentation to ED. The main steroid used was methylprednisolone (42%). Conclusions: The 10.8% of patients who experienced an irAE that prompted a visit to an ED within our health system is a lower rate than what has been described in the literature previously, where rates of presentation to an ED due to an irAE ranged from 25-37%. This could be due to previous data coming from before or shortly after the publication of ASCO and NCCN guidelines in 2018, or because our outpatient medical staff has become more aware of irAEs and their appropriate treatment. Limitations include this review was retrospective, no patients had an irAE that was refractory to steroids, and the study period being soon after national guidelines were published.
Intravenous hydration station in the chemotherapy infusion unit: A feasibility pilot study to improve efficiency, capacity, and wait times.
Authors: Feld Emily , Gabriel Danielle , Falbo Rosamaria , Wagner Keri , Kolb-Clark Sandra , Adams Lynn , Haughie Cheryl , OSullivan Maryellen , Reidy Diane , Zhi Iris 
Published: October 2023

44 Background: Intravenous hydration (IVH) is frequently administered to oncology patients in outpatient chemotherapy infusion units. High demand for IVH often leads to capacity restraints in the chemotherapy infusion unit, negatively impacting the availability of infusion chairs for cancer-directed therapy, causing long wait times and patient dissatisfaction. This feasibility study aimed to expand the capacity for IVH and chemotherapy at a regional site of an academic medical center, through a dedicated hydration station outside of the conventional infusion chairs. Methods: A mobile space adjacent to a nurses’ station, within the chemotherapy infusion unit, was designated and converted to accommodate two patients simultaneously for IVH. Privacy screens separated this area from the rest of the infusion unit. Patients were directly scheduled into hydration station chairs. One nurse provided patient monitoring within the hydration station. The hydration rate was standardized to 1 liter per hour, subject to change at the discretion of treating physicians. Outcomes collected included the number of patients treated, total hours of hydration, wait times, and patient satisfaction, which was ascertained by a survey administered during February 2023 of the pilot phase. Results: Over a six-month period from December 2022 through May 2023, a total of 784 patients received IVH in the hydration station. This equates to 11 hours of IVH per day, and a cumulative total of 1,590 hours over the course of six months. The average wait time from check-in to starting IVH was 7 minutes. During the same period, the average wait time for chemotherapy was halved to 16 minutes. Among 28 patients who completed the satisfaction survey and had previously received IVH in a conventional infusion chair, 24 (86%) reported that the hydration station was either better or equivalent to their prior hydration experience. 23 (82%) patients reported a shorter or similar wait time compared to the conventional process. Overall, 84% were satisfied with their experience. Importantly, no patient safety issues were reported during the six-month period. Conclusions: IVH can be safely and effectively administered outside the conventional infusion chair, resulting in decreased wait times and high patient satisfaction. This IVH model increased the capacity for cancer-directed therapy in the chemotherapy infusion unit, with no reported safety issues. It is being standardized and implemented across other infusion units across our institution.
Identification of best practices for training in remote symptom monitoring using electronic patient-reported outcomes.
Authors: Dent D'Ambra , Ingram Stacey A. , Patterson Megan Brooke , Hildreth Keyonsis , Young Pierce Jennifer , McGowen Chelsea , Huang Chao-Hui Sylvia , Odom James Nicholas , Basch Ethan , Stover Angela M. , Howell Doris , Smith J.D. , Weiner Bryan J. , Rocque Gabrielle Betty 
Published: October 2023

441 Background: As remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) is increasingly implemented as part of standard-of-care, practices must be prepared to train diverse clinical teams. Little is known about best practices for training multidisciplinary teams to engage effectively with ePROs. Methods: This quality improvement initiative evaluated a training approach for RSM using Plan Do Study Act (PDSA) cycles conducted in oncology practices at the University of Alabama at Birmingham (UAB). Multiple team members participated in training sessions over the duration of implementation scale-up. Training logs, field notes on barriers, and iterations to the training approach were updated using Excel spreadsheets. A recorded training session was utilized as an update to the training approach conducted via Zoom. Results: Overall, 145 providers (nurses, social workers, navigators, clinicians) were trained. Initial training (PDSA Cycle I) included a Zoom lecture for lay navigators, nurses, and physicians conducted by the physician lead, which included rationale for RSM, provider roles, and technical instruction. Barriers identified included limited knowledge retention and difficulty using ePRO technology in practice. In PDSA Cycle II, training included advanced practice providers. In addition, a nurse champion was added to the training team. Content was split into a lecture for rationale and roles (Zoom or in person, based on provider preference) and one on one hands on in-clinic training on technical aspects of ePRO delivery led by the training manager and nurse champion. While this approach increased engagement, provider turnover necessitating multiple trainings and low knowledge sustainment were barriers. In PDSA Cycle III, additional staff were trained including the intake team, nurse navigators, and social workers. The lecture was recorded for delivery by the training manager or independent viewing. In addition to the initial training, written standard operating procedures for providers, and check-ins or repeat sessions with participants were added for longitudinal engagement. Conclusions: Four key provider training elements were: (1) training more provider types to support the use of ePROs in clinical care delivery; (2) emphasizing in-person technical training by an individual with relevant experience; (3) using asynchronous materials to support both scalability and ongoing support; and (4) including additional sessions with longitudinal one-on-one provider training.