bluuebunny/crossref_metadata_2025_split huggingface dataset:
Concurrent hospice healthcare utilization in the hematology/oncology patient population at veterans affairs.
Authors: Hemrajani Anshu , Lo Shelly S. , Vahlkamp Alexi , Silva Abigail , Limaye Seema 
Published: June 2023

12125 Background: The benefits of early hospice enrollment include improved quality of life and overall survival (Kumar, 2017). Yet, most oncology patients continue to receive aggressive treatments including chemotherapy, radiation therapy, and hospitalizations until close to death (Ersek, 2017). Veterans have the unique opportunity to receive concurrent hospice which allows patients enrolled in hospice to receive disease modifying treatments and other interventions not typically provided under the traditional Medicare hospice benefit. Methods: A single institution retrospective review of 72 hematology and oncology patients who enrolled in the concurrent care program at the Hines VA between 12/28/2018-4/3/2021 was conducted. Patients were eligible for the concurrent care program if they (1) had a life-limiting illness with a prognosis of less than six months (2) were willing to enroll in hospice (3) had an oncologist willing to administer cancer-directed therapy. Data were summarized with descriptive statistics including medians and percentages. Results: Patients in the concurrent care hospice program were predominantly White (69.4%) and older than 70 years of age (63.9%). Most patients were diagnosed with primary gastrointestinal (29.2%), thoracic (22.2%), or genitourinary (19.4%) malignancies. While enrolled in concurrent care hospice, 15.3% of patients visited the emergency department and 45.8% had at least one hospitalization. Few patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.8%), or pain procedures (4.2%) while enrolled in concurrent care hospice. Of the 19 patients who received chemotherapy, only one patient received treatment within 7 days prior to death. The minority of patients (11.1%) received a blood product and of those patients that did, 8.3% required one to three transfusions and 2.8% required three or more transfusions. Most (91.7%) patients died while in concurrent care hospice; 21.2% died within 30 days of enrollment and 56.1% died within 31 to 180 days of enrollment. Patients were more likely to die at home (63.6%) or in inpatient hospice (13.6%) as opposed to the hospital (3%). Conclusions: Enrollment in concurrent hospice care prevents patients from having to choose between comfort care and cancer-directed treatments, which is often a barrier to early hospice enrollment (Salz, 2009). At Hines VA, most patients receiving concurrent hospice care rarely or never utilized cancer directed treatments, pain procedures, blood products, or emergency room visits/hospitalizations despite having access to these resources. Furthermore, the majority of patients died with hospice-style care at home or in inpatient hospice rather than in the hospital. This observational study demonstrates that when offered the choice to pursue cancer-directed treatments, most patients opt instead to focus on comfort care at end of life.
Utilization of early integrated palliative medicine among patients with metastatic solid tumor cancers: Findings from a safety net medical center treating a majority African American population.
Authors: Ananthula Aneesha , Sweeney Patrick L , Mishra Pallavi , Gupta Kanika , Worley Jason , Carroll Brandon , Manogna Dharmini , Hoerger Michael , Chowdry Rajasree Pia , Malhotra Sonia 
Published: June 2023

12128 Background: Early interdisciplinary Palliative Medicine (PM) involvement is known to provide significant benefits when added to usual oncology care, however a study by Ferrari et al looking at oncologic patients between 2001 to 2016 found that only 36% of patients with cancers with a very poor prognosis received Palliative Medicine services. In 2016 ASCO provided a practice guideline recommending specialty PM services to begin within 8 weeks of diagnosis. Our study aimed to assess the integration of the above recommendation in a newly built academic, safety net hospital serving as a regional tertiary healthcare facility with a newly built PM service that included a free-standing outpatient clinic. Methods: This is a retrospective cohort study of all patients on the tumor registry with de novo stage IV cancer diagnosed in a four-year period from 2018 to 2021. Patient data was collected from the electronic medical record (EMR) and included demographics, health history, PM utilization, and advance care planning documentation. Logistic regression was used to analyze key predictors of PM utilization and advance care planning. Results: The majority of patients (N = 510) were African American (race: Black [56.5%], White [35.7%], all other racial groups [7.8%]; mean age = 59.8 [range from 18 or over 90]; sex: 60.6% male). Diagnoses included gastrointestinal (38.2%), thoracic (27.8%), genitourinary (26.3%), and other (7.7%) cancers. Out of the group, 60.5% of the patients received PM services and 55% of those had a visit within the ASCO recommendations of 8 weeks. A surprising 32.7% of those referred to PM had a first visit within the first 2 weeks via an urgent referral system, most often for symptom management. About 40.0% of initial visits were outpatient rather than inpatient and there were no racial or other demographic differences in the setting of the first visit. Patients receiving cancer care in more recent years (P < .001), who were younger (P = .025), and with non-genitourinary cancers (P = .005) were more likely to receive PM services. Also, patients who received PM were more likely to have a medical power of attorney (P < .001) and living will (P < .001) documented in the EMR. Conclusions: This study demonstrates that in centers with a robust PM team including an outpatient clinic, patients with advanced cancer are receiving early Palliative Medicine evaluation in accordance with the 2016 ASCO guidelines. In contrast to a previous study by Johnson et al our study shows that African-Americans were also equally referred and established with PM services. Our study is limited by the presence of a free-standing PM clinic rather than embedding into a cancer center which may assist with even earlier integration.
Key components of goals of care conversations on determining end-of-life care for advanced cancer patients.
Authors: An Amy , Alio Amina P , Epstein Ronald M. , Seplaki Christopher 
Published: June 2023

12130 Background: Early goals of care (GOC) conversations appear to improve end of life (EOL) care in patients with advanced cancer. However, interventions to facilitate GOC conversations may be unsuccessful in changing EOL outcomes due to incomplete understanding of the components of such conversations essential to impacting EOL care. This study seeks to identify the specific components of GOC conversations between patients and oncologists that are associated with less aggressive EOL care. Methods: This was a secondary, sequential mixed-methods analysis of data collected as part of the Values and Options in Cancer Care (VOICE) study, an RCT to improve communication between patients and oncologists. We used qualitative methods to describe and quantify components of GOC conversations occurring in recorded oncology office visits. We then conducted logistic regression analyses to examine the associations between key components identified with less aggressive EOL care. Results: 107 patients who died within 1 year of the recorded visit were included for analysis. Content related to GOC conversations could be found in 80.4% of visits. Most commonly discussed content was related to treatment (72.9%), followed by prognosis (43.9%), EOL care (17.8%), and patient values and preferences (16.8%). In adjusted analyses, discussion of treatment expectation, offer of an alternative to cancer-directed treatment, and mention of hospice were significantly associated with less aggressive EOL care, OR 4.66 (p = 0.047), OR 6.09 (p = 0.008), and OR 7.60 (p = 0.046) respectively. We did not find significant association between discussion of life expectancy and EOL care. Conclusions: GOC conversations may be more effective at impacting EOL care when it includes discussion regarding treatment expectations and offer of an alternative option to cancer-directed therapy, such as hospice.
Comparing the time toxicity of cancer treatments in the CCTG LY.12 trial.
Authors: Gupta Arjun , Hay Annette E. , Crump Michael , Djurfeldt Marina , Zhu Liting , Cheung Matthew , Shepherd Lois E. , Chen Bingshu E. , Booth Christopher M. 
Published: June 2023

12135 Background: When different cancer treatments have similar oncologic outcomes, their respective time-related burdens can aid patient-oncologist decision-making regarding which treatment approach to pursue. We have previously developed a pragmatic and patient-centered metric of these time burdens-- which we term ‘’time toxicity’’-- as any day with physical healthcare system contact. This includes outpatient (e.g., bloodwork, scans, clinician, etc.) and emergency room visits, and overnight stays in a healthcare facility. Herein we sought to assess time toxicity in a completed RCT. Methods: We conducted a secondary analysis of the Canadian Cancer Trials Group LY.12 RCT that evaluated 2-3 outpatient cycles of gemcitabine, dexamethasone, and cisplatin (GDP) vs. dexamethasone, cytarabine, and cisplatin (DHAP) in 619 patients with relapsed/refractory lymphoma prior to stem cell transplant. Primary analyses reported similar response rates, transplantation rates, event-free-survival, and overall survival across arms. We calculated patient-level time toxicity by analyzing RCT forms. The study period was the date of assignment to the date of progression or the day before stem cell transplant. We considered days without healthcare contact as ‘’home days’’. We compared time measures across arms. Results: The median study duration was longer in the GDP arm (50, vs. 47 days in the DHAP arms, p=0.007). Median time toxic days were comparable in both arms (18 vs 19 days, p=0.79), but median home days were higher in the GDP arm (33 vs 28 days, p<0.001). The proportion of time toxic days (time toxic days divided by study duration) was lower in the GDP arm (34%, vs. 38%, p=0.009). The GDP arm experienced more time toxicity related to planned outpatient chemotherapy (median, 10 vs. 8 days), but the DHAP arm experienced many more hospitalization days (median, 11 vs. 0 days) (Table). Conclusions: This study demonstrates that measures of time toxicity can be extracted from RCTs. These measures can add clinical insight into patient burdens. In LY.12, despite broadly comparable short- and long-term oncologic outcomes, the GDP arm experienced less time toxicity. Such information can guide decision-making for patients with aggressive hematological cancers, who already spend a significant portion of time with healthcare contact. Clinical trial information: NCT00078949 . [Table: see text]
Prior authorizations for oral anticancer drugs and delayed prescription fills.
Authors: Kyle Michael Anne , Keating Nancy Lynn 
Published: June 2023

1504 Background: Oral anticancer drugs have proliferated in recent decades. These drugs are increasingly approved based on provisional data via the FDA’s accelerated approval pathway and have high prices, motivating payers to closely monitor how they are used. We assessed use of prior authorization (PA) of oral cancer drugs for Medicare Part D beneficiaries and assessed the impact of PA on delays in prescription fills. Methods: Using Medicare Part D formulary and claims data from 2010-2019, we described trends in Part D plans’ use of PA for oral oncology drugs, identified using the Oncology Care Model drug list (excluding hormonal therapies). We then examined changes in access to imatinib after the introduction of a new PA. We focused on imatinib because it is a highly effective first-in-class drug with a generic entrant in 2016. We compared Part D beneficiaries continuously enrolled in a plan with a policy change (new PA introduced) or a control plan (no change) in the 120 days before and after the policy change or equivalent date (control) and had at least three 30-day imatinib fills in the pre period. This restriction aimed to identify individuals filling regularly and plausibly expected to continue the drug. For each index fill in the post period, we calculated predicted fill (date of previous fill + days supply received). Our outcome variable was the difference (in days) between predicted and observed index fill date, censored at 120 days for post-period observations without an observed fill. We used an event study to model predicted vs. actual time to first fill following a policy change (new PA) relative to the controls (no change), adjusting for patient age, sex, low-income subsidy, average number of days between pre-period fills, year of fill, and plan type (standalone or Medicare Advantage). Results: The proportion of oral anticancer drugs requiring a PA increased from 52.8 to 96.3% from 2010 to 2019. For imatinib, PA increased from 65% to 89% from 2010-16, the year generic imatinib entered. PA for generic imatinib was 95% on market entry. In the imatinib event study sample, there were 1,354 index fills for patients. Unadjusted mean delay in index fill was 40 days for new PA and 15 days for controls; median difference was 4 and 3 days, respectively. Discontinuation was comparable: 9.3% (new PA) vs. 9.5% (control). The adjusted difference between predicted and actual fills for new PA was 20.3 days (95% CI 6.5-34.2, p<0.004). Conclusions: Use of PA for oral oncology drugs has increased substantially over 10 years. In the setting of high prices and provisional outcomes data, PA may be appropriate. However, PA may delay fills, even for high-value drugs like imatinib. Oral anticancer drug adherence is an NCI priority; further study is warranted to identify opportunities to reduce administrative burden of PA and lessen barriers in access to effective medications.
State mandatory paid medical leave policies and survival among adults with cancer in the US.
Authors: Barnes Justin Michael , Chino Fumiko , Johnson Kimberly J. , Zheng Zhiyuan , Han Xuesong , Yabroff Robin , Johnston Kenton J 
Published: June 2023

1511 Background: Cancer treatment is often costly and time intensive. Paid medical leave can help employed patients with cancer more effectively manage side effects and complete recommended cancer treatments without loss of income. Since 2012, several states have introduced mandatory paid medical leave policies. We examined whether mandatory paid medical leave policies were associated with better survival among working age adults with cancer. Methods: Adults ages 18 to 64 years diagnosed with cancer 2007- 2019 were identified from the Surveillance, Epidemiology, and End Results registry program covering 12 states. The primary outcome was overall survival (OS). The exposure of interest was the presence of state mandatory paid medical leave policies. Difference-in-differences (DID) analyses with additive hazards regression models compared changes in OS from pre- to post- mandatory paid sick leave policy implementation in states with vs. without paid sick leave policies. Models adjusted for year-quarter fixed effects, state fixed effects, state Medicaid expansion status, age, race, sex, marital status, metropolitan residence status, county-level income, cancer site, cancer stage, and insurance status. Clustered standard errors by state were achieved via the cluster bootstrap. The plausibility of the common trends assumption was tested using event study analyses and was satisfied for all analyses. Primary analyses focused on data from 2007-2016, where information on month of diagnosis, county, and insurance coverage status were available (note these variables are not available for 2017-2019), though sensitivity analyses with data through 2019 without these additional variables were conducted. Results: A total of 1,491,208 adults with cancer were identified. In adjusted DID analyses, after policy implementation, 1-year OS improved from 85.0% to 86.4% in states with mandatory medical leave policies compared to 85.1% to 85.6% in states without such policies. This translates to a 0.85% improvement in 1-year OS (hazard DID: -0.0007, 95% CI = -0.0016 to -0.0001, P = .027). The largest improvement was found among the uninsured population (hazard DID: -0.0038, 95% CI = -0.0076 to -0.0011, P = .013). In sensitivity analyses with abbreviated data through 2019, results were similar (DID for 1-year OS: 1.3%; hazard DID: -0.0010, 95% CI = -0.0025, 0.0001, P = .070). Conclusions: State mandatory paid medical leave was associated with improved survival for working-age adults with newly diagnosed cancer, particularly for those who are uninsured. Policy changes that better support patients through cancer treatment may pay off with improved cancer outcomes.
English- and Spanish-preferring patient perspectives on managing acute care needs at two disparate health systems.
Authors: Kyalwazi Beverly , Halm Ethan A , Courtney D. Mark , Sweetenham John W. , Sadeghi Navid , Cox John V. , Lee Simon Craddock , Hong Arthur 
Published: June 2023

1524 Background: Although nearly every participating provider group in Medicare’s Oncology Care Model sought to reduce emergency department (ED) use by their patients with cancer, few achieved this. Despite growing spread of specialized oncology urgent care clinics (OUCC) as an ED-alternative to treat commonly anticipated treatment-related symptoms, these clinics are underused. The University of Texas Southwestern (UTSW) and Dallas County Safety-net (Parkland Health) have run OUCCs since 2015. Parkland patients use the ED twice as often as UTSW patients in the first 6 months after cancer diagnosis. Utilizing semi-structured interviews, we investigated oncology patient perspectives on acute care needs and ED decision-making in both systems among English and Spanish-preferring patients. Methods: We interviewed 24 UTSW and 16 Parkland oncology patients (5 English-preferring, 11 Spanish-preferring). UTSW is an urban regional academic referral center serving nearly 8 million people with a cancer patient population that is 35% nonwhite and 7% Medicaid or uninsured. Parkland serves patients in Dallas County including a cancer patient population that is 77% nonwhite and 80% with Medicaid or county charity care (uninsured). Translated transcripts were analyzed using iterative thematic analysis and the constant comparative method. We evaluated decision-making, attitudes, beliefs, and barriers to access that influenced decisions to present to the ED across a diverse patient population. Results: Patients in both health systems endorsed that they did not receive adequate information about expected side effects from cancer treatment. UTSW patients described direct access (e.g., personal cell phone numbers) to their oncologist, whereas Parkland patients commonly relied on non-clinician family to triage symptoms. Parkland patients reported experiencing barriers to outpatient care (lack of insurance, language barriers, and limited access to outpatient care), and described an acculturation to visiting the ED for acute care needs. When patients called a clinician for triage advice, they were often referred to the ED. Overall, patients were largely unaware of OUCCs and a 24/7 telephone triage line, but were very interested in accessing the OUCC to avoid prolonged wait times and exposure to infectious pathogens in the ED. Conclusions: Among ED-visiting patients with cancer, we found notable disparities in rapid informal access to clinicians between oncology patients receiving care through UTSW compared to Parkland. Highlighting the available 24/7 phone line as part of patient counseling on treatment side-effects might mitigate this disparity in access, increase utilization of the OUCCs, and reduce low-acuity ED visits in both health systems. Patient perspectives provide valuable insights on how to better integrate care delivery innovations for this high-risk population.
Implementation of a multi-cancer early detection (MCED) test using a centralized model within (w/i) a multi-state health system.
Authors: Agarwal Gautum , Carlson Jay W. , Broyles Damon R. 
Published: June 2023

1526 Background: Cancer is the second leading cause of death globally. Currently, USPSTF recommends screening for only 5 (breast, cervical, colorectal, lung [high-risk], prostate [individualized basis]) cancers, but ~70% of cancer-related deaths are from cancers without recommended screening. Galleri (GRAIL, LLC, Menlo Park, CA), an MCED test, that uses a cell-free DNA-based targeted methylation assay and machine learning classifiers to detect a shared cancer signal and predict the cancer signal origin is available for use as a complement to existing screening tests. We present a model of centralized MCED test implementation w/i a multi-state health system. Methods: From 11/2021-7/2022, clinical and operational leadership w/i the Mercy Health System (headquartered in St. Louis, MO), including 44 acute and specialty hospitals with over 4000 integrated providers and 44000 coworkers in 5 states (MO, KS, AR, OK, IL), created an MCED test implementation plan for their health system. Results: A model with centralized navigation was developed such that patients (pts) and providers contacted a singular team (MCED team) w/i the Mercy Precision Medicine Division using telemedicine to order an MCED test and navigate processes. In the 2 months prior to and after launch (7/12/2022), 12 medical education sessions were held for various groups w/i the health system, including the centralized MCED team, leaders of subspeciality departments, and all primary care providers, to inform on the MCED test implementation plan. In this model, access to MCED testing commences in 2 ways: (1) pts register through an online form or (2) providers w/i the health system submit a referral to the MCED team through the electronic medical record system. Pts are then contacted by a nurse practitioner on the MCED team for pretest counseling w/i 2 business days. If the pt is still interested after counseling, an MCED test is ordered. Pts go to 1 of 11 Mercy labs to have their blood drawn for MCED testing. “Cancer signal detected (CSD)” test results are given to a specialized navigator who helps schedule diagnostic testing and initial appointments with specialists and coordinates follow-up care and treatment (tx) w/i the health system. Early analytics show that from launch to 1/31/2023, there were 3777 total referrals (2931 pt, 846 provider) that led to 925 MCED test orders, of which 6 had a CSD result. Median time from a CSD test result to pt notification was 22.8 hours, to initial diagnostic evaluation was 3.1 days, and to a cancer diagnosis was 8.7 days. Median time from cancer diagnosis to initiation of tx or first postdiagnosis specialist visit was 33 days. Conclusions: This model allowed for efficient time to diagnosis and tx or triage of eligible-risk pts using an MCED test and is an example of how a healthcare system can incorporate and scale the implementation of the MCED test into clinical practice.