bluuebunny/crossref_metadata_2025_split huggingface dataset:
Optimizing the precision oncology workflow at the Bellevue Cancer Center.
Authors: Diasti Kevin , Yu Peter , Varma Gaurav , Bhatt Ahan , Wu Jennifer J. 
Published: October 2023

416 Background: Comprehensive tumor molecular profiling using next-generation sequencing (NGS) enables personalized cancer treatment and is standard of care in the management of patients with advanced solid tumors. Efficient implementation of NGS testing into health care systems can be challenging, particularly in safety-net health systems with a high proportion of underserved populations. Here we evaluated the workflow for tissue NGS testing at Bellevue Cancer Center, the tertiary referral center of the NYC Health and Hospitals System. We also investigated the impact of a specimen courier service intervention. Methods: We constructed a process map of the NGS tissue testing workflow to identify key stakeholders and potential sources of delays. Surveys were administered to all NGS ordering clinicians (n=26). Survey questions included time spent ordering NGS testing, how often providers referenced an ordering process guide, and how consistently key steps in the ordering process were completed. Utilization and process data from 2019-2022 was provided by our NGS vendor. The primary measure of process quality was Turn Around Time (TAT) defined as the time from order placement to result report. Secondary measures of process quality included Order to Specimen (OTS) and Specimen to Report (STR), defined as the time from order placement to specimen receipt by the NGS vendor and the time from specimen receipt to result report, respectively. Data were divided into 3-month intervals and median and interquartile range were calculated. We compared TAT, OTS, and STR six months before and after courier service introduction. Data normality was tested using Kolmogorov-Smirnov test and distributions were compared using Mann-Whitney test (Graphpad Prism). A Root Cause Analysis was conducted to identify the causes of delays and opportunities for further workflow optimization. Results: Our findings revealed median TAT from 2019-2022 was 22 days. However, there was a trend towards decreased median TAT in that time period with median TAT of 19 days in 2022. Our analysis demonstrated a decrease in median OTS following courier service introduction (median 8 vs 7 days, p<0.05), but not with overall TAT. STR remained relatively stable throughout the periods of interest. Survey results indicated that only 76.2% of clinicians placed test orders correctly, and 61.9% of clinicians properly notified pathology, both possibly contributing to delays in OTS and TAT. Conclusions: We assessed the complex effort of optimizing the NGS testing workflow at the largest municipal safety net health system in the United States. Courier service implementation improved the OTS but not the overall TAT, suggesting that further interventions will be necessary for improvement in TAT. Survey results identified key inefficiencies in the provider side of the ordering process. Additional interventions such as NGS test integration with electronic health record system may be warranted.
The big bang vs. phased approach: ASCO standard implementation within a large academic medical center.
Authors: Kelvey-Albert Michele , Taiwo Victoria 
Published: October 2023

419 Background: The implementation of quality improvement initiatives within a large academic medical center can present as challenging and complex. Research findings indicate that the most successful of the large service corporations maintain a strong focus on the small, functional units who carry out the core activities that involve interaction with customers. (Quinn J, Baruch J, Zien K. Innovative Explosion: Using Intellect and Software to Revolutionize Growth Strategies. New York: Free Press; 1997.) This phased approach allows a larger medical center the opportunity to target implementation around one or two sites at a time with a focus on the staff education, workflow processes, and technology integration. Our institution found that the big bang approach can pose as a threat to the success of implementation at a large academic medical center. Methods: The initial approach taken by our large academic medical center was the roll out of all required ASCO PC4 standards throughout the entire enterprise: the big bang approach. This approach would entail the implementation of 7 standards, 17 sub-standards within 15 sites and over 84 departments within the span of one year. Instead, we took the phased approach: a less burdensome, more efficient, and cost-effective strategy. Between 11/2023 1/2023, we implemented a total of 6 standards within two sites and 3 departments. In the span of three month, a multidisciplinary approach was applied, engaging all levels of employees at each site, including MDs, NPs, MAs and Front Desk Staff. The two sites identified were strategically selected based on current resources and initiative alignment with those of ASCO requirements. On 1/30/23 the two sites went live with 6 ASCO standards. Results: Some challenges in implementation included training of staff in a timely manner, influencing the change of behavior, and education retention of staff. Despite the challenges faced, between 2/6/23 and 3/24/23 data showed adequate engagement and compliance. 567 patients were identified by for patient tracking through developed reporting, 328 patients had a chart review or a follow-up from the oncology care coordinator. Between 1/30/23 and 3/24/23, 61% of patients were screened for SDOH needs with 32 referrals to a community health worker, 8 referrals to social service and 12 interventions with patients indicating self-harm. 100% of patients received education around OMH, with a total of 1,923 MyChart messages sent to patients regarding support with ACP. 68.8% of clinician completed adequate goals of care documentation to meet standard requirements and new workflow. Conclusions: A phased approach of first piloting ASCO's PC4 quality program at 2 sites within our large cancer center was successful. The experiential knowledge gained will allow more efficient role out of necessary staff education, workflow processes, and technology integration to support wider adoption across our center.
Virtual inpatient continuity visit to reduce readmissions, establish goals of care and engage palliative care: A feasibility pilot.
Authors: Mulvey Therese Marie , Seigal Botti Eirian , Jenkins Courtney , Hathaway Nora , McGuire Jessica , Meller Benjamin , Reynolds Kerry Lynn , Kamdar Mihir , Soumerai Tara , Rowland Michaela , Ryan David P. , Thompson Ryan W 
Published: October 2023

421 Background: Patients with solid tumors readmitted within 30 days (d) have a median overall survival of less than 90d. Decisions regarding goals of care (GOC), engagement with Palliative Care (PC) and further therapy are often deferred to the outpatient team leading to future readmissions. Methods: A pilot virtual continuity visit (VCV) program was developed using a video platform to arrange meetings with outpatient oncologists, inpatient teams, patients, families and PC providers during a hospital readmission within 30d. The intervention occurred on a single solid tumor oncology service at an academic medical center. Patients were included if discharged from the same hospital within 30d and not readmitted from hospice or SNF. Exclusion criteria included admission for scheduled therapy, curative-intent treatment, or acute side effects of new therapy. Orders were placed at the discretion of the inpatient team. Visits were scheduled only on weekdays. A structured discussion tool was used for prognostic awareness, GOC and availability of PC services. Results: From April 1, 2022 through March 31, 2023, 96 unique patients were eligible for VCVs. This represented 6% admissions to this floor. 15 VCV were completed, 23 were scheduled but not completed, 58 were not scheduled. Reason scheduled visits not completed included: in-person family meeting (7 ), physician unavailable (9), transfer off floor (1), conversation deferred to outpatient visit (4), not clinically necessary (2). Reason visits not scheduled: unable to schedule prior to D/C (37), deferred to outpatient (2) hospice D/C (3), not appropriate (5), in person visit (1). Of the 15 patients who completed VCV, 0% were readmitted within 30d, 100% had documented GOC discussion and 100% had PC engaged in the VCV. Of the 7 patients who had in person visits, 3 of 7 were readmitted, 1 of 7 in person visits had a documented GOC discussion. No PC engagement was present for the in-person meetings. 51/58 patients without scheduled VCV were readmitted, 22 within 30d. Conclusions: VCV are feasible via a video platform with the patient, primary oncologist, inpatient team and PC. The structured discussion provided clear documentation of prognostic awareness, GOC and engagement with PC. No patient who completed a VCV was readmitted.
Association of early antibiotic de-escalation with length of stay in patients with myeloid neoplasms and neutropenic fever.
Authors: Wang Xiao , Arya Swarn V , Decena Mary Angela , Powers Julia , Landsburg Daniel J , Hirsh Rebecca , Ziegler Matthew J 
Published: October 2023

425 Background: Neutropenic fever is a common complication in patients with myeloid neoplasms. While patients typically receive intravenous (IV) antibiotics until neutrophil recovery, a growing body of literature shows the safety of de-escalation prior to this endpoint. The impact of this early de-escalation on health care utilization remains unclear. Methods: We conducted a retrospective analysis of hospitalized myeloid neoplasm patients at our institution with neutropenic fever, assessing the impact of IV antibiotic de-escalation prior to neutrophil recovery on length of stay (LOS). Manual chart review was performed on this cohort to assess clinical outcomes. Multivariable linear regression was performed, adjusting for age, diagnosis, Charlson Comorbidity Index, intensity of chemotherapy received, positive bacterial culture result, last hospital day with fever, and last hospital day with neutropenia. Results: Patient characteristics are shown in Table 1. Most de-escalation patients (67.7%) were discharged within 72 hours of stopping IV antibiotics. After adjusting for the above variables, early antibiotic de-escalation was associated with lower LOS of 2.7 days (95% confidence interval [CI] 2.0–3.3 days, p < 0.001), an effect that appeared most pronounced in the high very risk chemotherapy group (3.6 day reduction, 95% CI 2.5–4.6 days, p = 0.007). Review of clinical outcomes of de-escalation patients showed 5 potentially preventable recurrent or worsening fever or infectious incidents. Conclusions: Early de-escalation of IV antibiotics was associated with a statistically and clinically significant reduction in LOS, with very few clinical complications. To our knowledge, our study is the first to demonstrate a significant reduction in length of stay, an important hospital quality metric. Further prospective data is needed to confirm this relationship.[Table: see text]
Feasibility of implementing an intervention to reduce burden of adjuvant therapy for older women with low-risk breast cancer.
Authors: Wright Jean L. , Rocque Gabrielle Betty , Carlos Ruth C. , Throckmorton Alyssa 
Published: October 2023

445 Background: In patients ≥70 with early stage (pT1, c/p N0), hormone-receptor positive/ HER2 negative breast cancer, there is an opportunity to reduce adjuvant treatment burden through short-course radiotherapy (RT) approaches and/or endocrine therapy (ET) monotherapy. However, practices may vary in approach to treatment, necessitating differences in approach to interventions designed to tailor decision-making. Methods: Site needs assessment and semi-structured stakeholder interviews at 6 Minority Underserved NCORP sites was conducted, including 3 radiation oncologists (RO), 2 medical oncologists (MO), 1 research coordinator, and 2 breast surgeons (BS). Participant responses were manually recorded and used to construct structural and workflow maps for the possible patient care pathways across the 6 sites. Baseline information on ET and RT use was collected. A planned multi-level intervention that includes patient questionnaires (including a mortality risk calculator) to inform tailored decision-making, and education on guideline-concordant, lower burden options was introduced and dominant themes for barriers and facilitators of the intervention were abstracted. Results: Patients followed multiple pathways and received care at more than one site. The 6 sites span urban, suburban, and rural areas with variable presence of provider types (RO, MO, BS), research support, and RT technology. At baseline, patient reported data, geriatric assessments, mortality risk calculators, and decision aid tools were not routinely used. About 85% of eligible patients receive both ET and moderately hypofractionated whole breast RT; the only commonly used form of partial breast RT is intra-operative. Themes were physician acceptability of the intervention, multidisciplinary care, and physician willingness to offer lower burden treatment options. Physician acceptability subthemes included high baseline guideline knowledge, interest in mortality risk calculator use, need for support to interpret and incorporate patient questionnaire data, and variable physician research engagement. Multidisciplinary care facilitators were multi-campus tumor boards and strong research support staff; barriers were variable insurance across providers and surgeon-driven care plan expectations. Lower burden care subthemes included support for ET for almost all patients; barriers to RT omission were concern about ET non-adherence and to short-course RT were lack of data and toxicity concerns in patients with larger body habitus/resultant RT dose inhomogeneity. Conclusions: Results demonstrated multiple barriers and facilitators of interventions targeting lower burden treatment options for low-risk early-stage breast cancer and identified physician education about interpretation/use of patient-reported data and mortality risk assessments as key to successful study design.
The Johns Hopkins Hope at Hopkins Clinic: Supporting the comprehensive needs of individuals with metastatic breast cancer.
Authors: Stearns Vered , Chen Ruizhe , Blackford Amanda L. , Saylor Elizabeth , Folmer Ann , Jelinek Jessica , Hodgdon Christine , Bacon Jacqueline , Engle Jessica , Shah Mirat , Sheinberg Rosanne , Pedraza-Cardozo Sandra , Wilkinson Mary , Alvendia Melissa , Snyder Claire , Smith Karen L. 
Published: October 2023

452 Background: Individuals with metastatic breast cancer (MBC) may live with their disease for many years. We initiated the Johns Hopkins Hope at Hopkins Clinic, a multi-pronged quality improvement initiative that aims to optimize care for individuals with MBC. Methods: Individuals with MBC were offered participation in the Clinic, in addition to their usual care. Participants completed baseline patient reported outcome (PRO) surveys through REDCap. They were offered a menu of services, including cancer rehabilitation, supportive oncology, social work, nutrition, navigation, and access to optional services based on baseline PRO data and preferences. A medical oncologist assembled and delivered a comprehensive Care Plan synthesizing recommendations from all consultants with a focus on optimizing treatment, managing symptoms, and promoting wellness. Patients were asked to complete an evaluation survey 3 days after the clinic session, and follow-up PRO surveys at 3 and 6 months after the Care Plan was delivered. We report summary statistics of baseline demographics, tumor characteristics, and PRO scores at the pre-clinic visit. Results: From 11/2020 to 6/2022, 53 patients were referred, and 44 (83%) completed baseline surveys and participated in the Hope at Hopkins Clinic. Median age (N=44) was 58 (32-86); 32 (73%) were white, and 6 (14%) were Black; 24 (55%) had BMI>25. Tumors were mostly estrogen receptor-positive (85%) and HER2-negative (68%). Physical and mental health was not good for ≥14 days for 9/44 (20%) and 4/44 (9%), respectively. PROMIS measure scores were >1 standard deviation below average for 14/44 (32%) for Physical Health, 7/44 (16%) for Mental Health, and 10/44 (23%) for Physical Function. PHQ8 scores indicated depression for 10/44 (23%); GAD7 scores indicated anxiety for 3/44 (7%). 37 (84%) participants received an individualized Care Plan and educational materials based on identified symptoms, concerns, and interests. We will report the number and types recommendations by domain. Follow-up PRO data are available for 10 and 4 patients at 3- and 6-months, respectively. Conclusions: We have provided individualized assessment, education, and recommendations and created a comprehensive Care Plan to guide patients living with MBC. We have used the experience to implement a new multidisciplinary model, and to extend support services to patients living with MBC and their care teams.
Quality control patterns in comprehensive genomic testing of malignancies.
Authors: Carabaño Miguel , Claus Jessica , Uzun Ece , Cheng Liang 
Published: October 2023

456 Background: Molecular genetic testing is a crucial tool to detect genetic alterations in tumor samples and can aid in identifying targeted therapies for patients. Next generation sequencing (NGS) testing is a comprehensive technology to detect a broad spectrum of targetable biomarkers with a high sensitivity, while providing a cost- and time-effective strategy compared to other molecular genetic tests such as Sanger sequencing. NGS requires a minimum sufficient genetic material to detect a true mutation and report a significant result. Methods: In our study, we have analyzed NGS results from clinical samples from different organs or malignancies, obtained from 278 patients (median age 55, average age of 64, range 20-89) were analyzed. The specimens were collected between September 2005 and December 2022 from adenocarcinomas, not otherwise specified (NOS, 34.95%), metastatic adenocarcinomas, NOS (13.42%); metastatic carcinomas, NOS (4.49%), and others (47.14%). A total of 5127 individual results were reported. NGS testing (DNA-seq and RNA-seq) was performed and reported by Caris Life Sciences. Results: From our molecular genetic results analysis, 28 specimens (n= 12 female, 16 male) were reported to be ‘Quantity Not Sufficient’ (QNS), representing 9.45% of all specimens tested. To further understand the patterns of reported QNS, we identified the prevalence of QNS results in various tumor types. The majority of QNS results occurred in adenocarcinomas (NOS) representing 45.16%; followed by metastatic adenocarcinoma (NOS), 16.33%; and glioblastoma, 6.45%. The majority of specimen sites with QNS reported were the liver 15.12%, lung (NOS) 13.71%, and the prostate (NOS) 12.10%. Conclusions: Understanding patterns of QNS can be helpful to optimize testing and sampling strategies specifically for tissues with a high prevalence of insufficient quantity of genetic material. Additionally, analyzing and comparing biomarkers and their QNS pattern can be supportive to identify testing errors and improve testing methodologies.
Assessing capacity for culture change in serious illness communication across McGill University cancer centers.
Authors: Skamene Sonia , Fiorentino Laura , Gingras Stefanie , Basile Charles-Olivier , Chang Harvey , Korsos Victoria , Sanders Justin J 
Published: October 2023

457 Background: Patients with advanced malignancy at McGill University’s Rossy Cancer Network (RCN) frequently die in the emergency room or hospital in the context of cancer directed therapy. Internal data indicate delayed referral to palliative care for high-risk patient groups and lack of training and physician discomfort with serious illness communication (SIC). To plan for a system-wide quality improvement (QI) initiative, we aimed to assess capacity for culture change around SIC across three university-affiliated cancer centers. Methods: Interdisciplinary oncology and palliative care leaders from the three RCN sites completed an institutional readiness survey to assess local data and QI infrastructure and potential strengths and challenges related to SIC. We conducted a retrospective chart review of patients who received care at RCN sites for advanced malignancy and who died over a 24-month period. We organized pilot three-hour multi-disciplinary training sessions in use of a Serious Illness Conversation Guide and targeted physicians, nurses, and social workers from each RCN site. Participants completed a survey upon training completion. We developed a quality improvement plan. Results: Institutional readiness surveys highlighted challenges in identifying patients who could benefit from serious illness conversations and lack of consistency and localization of electronic health record documentation of SIC. Preliminary analysis from a retrospective chart review (n=370) demonstrated that 98% of patients had documentation of some aspect of SIC. Only 38% of SIC documentation described patient goals and values, and only 23% referred to patient preferences or wishes. Most instances of SIC documentation (74%) focused on code status and orientation of treatment toward either comfort or cure. 28% of patients had first documentation of SIC within 30 days of death. Fifteen healthcare providers took part in the multidisciplinary training sessions. Training evaluation data suggest that trainees found the training acceptable and feasible, and appreciated the interprofessional nature of the sessions. Results include presentation of an implementation plan. Conclusions: Culture change initiatives related to SIC benefit from a robust assessment of existing resources and challenges. We used a multi-modal approach to assess and build capacity for a cross-institution QI initiative. This process and the resulting network and hospital-level QI plans can assist other academic institutions in leveraging SIC to transform and improve cancer care.