bluuebunny/crossref_metadata_2025_split huggingface dataset:
Physician referral patterns and use of adjuvant therapy among patients with stage IB-IIIA non–small cell lung cancer (NSCLC) (2010-2017).
Authors: Kale Hrishikesh , Wang Wei-Jhih , Chirikov Viktor , Shah Anne , Apple Jon 
Published: September 2022

114 Background: As the treatment landscape for early-stage NSCLC continues to evolve with the recent approvals of targeted and immunotherapy agents in the adjuvant setting, it is important to understand physician referral patterns and predictors of adjuvant therapy (AT). This study examined physician referral patterns at key treatment phases and assessed predictors of receiving AT in stages IB-IIIA NSCLC patients. Methods: A retrospective study using the linked SEER-Medicare database (01/01/2010-12/31/2017) included patients newly diagnosed with stages IB-IIIA NSCLC who received surgical resection. Specialties were identified by linking NSCLC claims to AMA Physician Masterfile. AT was defined as the use of systemic chemotherapy or radiation therapy within 4 months of surgery. Multivariable logistic regression was conducted to assess predictors of receiving AT. Results: A total of 7,108 patients met study criteria (53% IB; 9% IIA; 19% IIB; 20% IIIA). Primary care physician (PCP) (71%), surgical oncologist (29%), medical oncologist (36%) were the most frequently visited first specialist during pre-diagnosis, diagnosis to surgery, and post-surgery phases, respectively. The median time from diagnosis to surgery was 44 days. After surgery, 74% patients visited medical oncologist (62% IB; 87% IIA; 83% IIB; 88% IIIA). About 41% received AT (21% IB; 64% IIA; 56% IIB; 69% IIIA). Of those, the median time from surgery to adjuvant therapy was 46 days. Later stage at diagnosis and shorter referral time to medical oncologist significantly increased the odds of receiving AT (Table). Conclusions: The strongest predictors of receiving adjuvant therapy were time to medical oncologist post-surgery and stage at diagnosis. Future studies in the era of targeted therapies can use our results as a benchmark to optimize management and outcomes as well as assess changes in referral patterns in IB-IIIA NSCLC patients.[Table: see text]
Transitions in care for ER patients with a suspected cancer diagnosis.
Authors: Roy Megan , Rummel Margaret , Miller Eleanor , Fanslau Katie L. , Gambino Patricia , Hemmert Keith 
Published: September 2022

117 Background: The oncology nurse navigators (ONNs) at Penn Medicine’s Abramson Cancer Center (ACC) observed that patients seen in the Emergency Room (ER) and found to have a suspicion of cancer were being told to call a medical oncologist. The oncologist in the ACC are highly specialized and since the patient has not had a confirmed cancer diagnosis, they were being told they couldn’t schedule an appointment. Some patients waited for the ACC to call them to schedule. When this didn’t happen they would call the ACC a week later. These barriers led to delays in care, poor patient experience, and a financial loss for the health system. The ONNs identified this as an opportunity to change the process to improve patient care. Methods: The initiative formally began in June 2021 when the ONNs reached out to the ER leadership to collaborate on a quality improvement project to streamline the process from ER visit to oncology work up and diagnosis. Direct referral to oncology nurse navigation from the ER facilitates timely navigation assessment and coordination of care. The Plan Do Study Act (PDSA) methodology was utilized. A “Consult to Nurse Navigation” order was built into the electronic medical record (EMR) for ER providers to directly refer patients to the navigation team. The ONNs contacted the patient within one business day to assess next steps. The ONNs scheduled the patient with the appropriate oncology specialist. The ONNs follows the patient through the diagnostic phase of care and assists with decreasing barriers to care. Data collection is ongoing to assess the impact of the interventions. Results: The EMR consult to ONNs went live April 2022. It includes 3 hospital ERs in the health system with diverse populations that often have limited access to health care. To date, 90% were appropriate referrals and triaged to cancer specialists for diagnostic workup and treatment. 90% had insurance accepted by the health system. Patients with unacceptable insurance plans were referred to ER social work and financial advocates. 70% were diagnosed with cancer and began treatment. Conclusions: ONNs are vital in identifying and removing barriers to care. The ONN team’s clinical knowledge, assessment skills, and expertise of the Penn health system have closed a gap in care while increasing patient satisfaction, patient retention, and downstream revenue. The ONNs leadership has directly enhanced the diagnostic process and timeliness to care for patients newly effected by cancer.
Lessons learned from a lung cancer screening patient navigation program at a safety-net hospital system.
Authors: Semlow Andrea R , Natchimuthu Vijaya Subbu , Lee Simon Craddock , Gerber David E , Zhu Hong , Hamann Heidi A. , Browning Travis , Santini Noel O. , Lee Jessica L. 
Published: September 2022

121 Background: As part of a CPRIT prevention services grant led by UTSW, Parkland Health adapted a patient navigation model previously piloted in 2017 to optimize low-dose computed tomography (LDCT) imaging for lung cancer screening and evidence-based tobacco cessation services. Methods: Non-clinical patient navigators (PN) contacted patients with a LDCT order to discuss their lung scan and smoking cessation options via telephone encounters. The PN has three planned touchpoints to assess patient knowledge, identify barriers, and refer to appropriate resources. Program evaluation data has been collected monthly for enrolled patients (n = 460) from August 2021-June 2022 via REDCap and EPIC. Navigation excluded patients who were incarcerated, had no phone number listed in medical record, or patients opted out of the program on intake. Results: Of the LDCT-eligible patients, PNs were able to complete two or more navigation calls with 55.62% of patients assigned. 77% of patients completed their first LDCT, compared to 80% in the initial trial. The most common barriers to screening completion included transportation (n = 38), insurance coverage (n = 22), and cost (n = 9). Of the navigated patients who were active smokers (75%), 33% scheduled at least one smoking cessation-related visit. Some patients unresponsive to conversations about quitting, were responsive to language around “reducing” tobacco use. Conclusions: Disproportionately under- and uninsured, Parkland Health patients face a variety of barriers to screening. As a result, PN staff must balance reaching all patients with a LDCT order and spending additional time navigating patients with complex barriers. To address these barriers, the PN program facilitates coordination of patients between primary care providers, radiology operations, smoking cessation clinics, patient financial services, lung diagnostic clinic, and social work. For example, patients can schedule a smoking cessation visit directly with our PN instead of being referred. As Parkland has a decentralized LCS program model, having embedded non-clinical PNs within existing roles in the cancer center, like medical practice assistants, increases continuity of care. These individuals have the benefit from day-to-day knowledge of downstream services that bolster their ability to connect patients to external services to address barriers.
COVID-19 impact on multiple myeloma prescribing patterns.
Authors: Shah Dipti , McAuliff Kelly , Pittos Elias , McCarthy Amanda , Cavers William , Grover Rashmi , Feczko Lucia , Avalos-Reyes Elisea , Johnson Kjel Andrew 
Published: September 2022

123 Background: COVID-19 has impacted several areas of oncology patient care, most notably the reduction of patient visits for treatments. Standard treatment of multiple myeloma (MM) involves a combination of intravenous (IV) and oral therapies. The purpose of this study is to assess the impact COVID-19 had on IV and oral medication prescribing patterns pre and during the COVID-19 pandemic among MM patients. Methods: This is a retrospective review of adult MM patients insured by a large commercial and Medicare health plan in the United States who started a new IV or oral MM agent during the study period. To assess the impact of COVID-19 on IV and oral medication prescribing patterns, we compareda pre-COVID period (March 1-August 31, 2019) to a COVID period (March 1-August 31, 2020). We utilized medical and pharmacy claims to identify patients and calculated new therapy starts per newly diagnosed patient (defined as the number of patients starting a new IV or oral medication for MM divided by the total number of patients with a first indication date of MM within the study timeframe). We compared rates using a Chi-square test; p-values ≤ 0.05 were considered statistically significant. Results: 1,754 patients were enrolled in the study; there were no significant differences in demographic characteristics pre and during COVID-19 between the two groups with respect to age (67.05 vs. 66.64; p = 0.45), gender (p = 0.80), insurance plan type (p = 0.17), geographical region (p = 0.26) and medication (p = 0.59). During COVID-19, the number of newly diagnosed MM patients decreased by 22% (9,657 to 7,560) and the total number of new therapy starts decreased by 11% (930 to 824). When looking at rates of new therapy starts per newly diagnosed patient, both IV (11%; p = 0.03) and oral (51%; p = 0.03) medication rates significantly increased. Additionally, there were significant increases in new therapy start rates by region in the Northeast for oral (157%; p < 0.01) and West for IV (32%; p = 0.02) medications. There were no significant differences in new start rates by insurance plan type (all p > 0.08). Conclusions: While the total count of new therapy starts, a proxy for new diagnoses, decreased during COVID-19, the rate of new starts for both IV and oral therapies for patients diagnosed with MM significantly increased. These increased start rates may be explained by a remarkable 22% drop in the total number of newly diagnosed MM patients during COVID-19. As the pandemic continues, further study is warranted to understand how COVID-19 may impact IV vs. oral usage in MM.[Table: see text]
Real-world racial disparities in EGFR testing and third-generation EGFR TKI use among U.S. patients with stage IV NSCLC.
Authors: Sacchi Elizabeth , Li You , Miller Vincent A. , Curtis Melissa D. , Ali Siraj Mahamed 
Published: September 2022

124 Background: Biomarker testing for EGFR mutations (EGFRm) is recommended for all newly diagnosed patients with metastatic NSCLC. Third-generation EGFR TKIs are the recommended standard-of-care therapy for patients with EGFRm+ NSCLC regardless of race, although EGFRm occur more frequently in Asian patients (Table). We investigated the association between race, EGFR testing and receipt of subsequent first-line (1L) treatment with the third-generation EGFR TKI, osimertinib. Methods: This retrospective, observational study used the nationwide Flatiron Health EHR-derived de-identified database. Adults with an initial diagnosis of stage IV NSCLC who initiated systemic 1L therapy between Apr 2018 (osimertinib approval) and Feb 2022 (data cutoff date) were eligible. Two cohorts were defined: those eligible for EGFR testing, and those EGFRm+ patients eligible for 1L osimertinib. Multivariable logistic regression was used to investigate odds of 1) EGFR testing, and 2) 1L osimertinib use, by race. Random-effects logistic regression was used as a sensitivity analysis to evaluate the impact of inter-practice variation on each outcome. Confidence intervals (CI) were calculated at 95%. Results: 9,505 patients were eligible for EGFR testing. After adjustment, Asian patients were nearly twice as likely to be tested (adjusted odds ratio [aOR]: 1.93, CI: 1.33 – 2.89, p = 0.0001), while Black patients were 25% less likely to receive testing (aOR: 0.75, CI: 0.62 – 0.90, p = 0.002), both relative to White patients. Including a random factor of practice attenuated the effect of race for Asian patients (aOR: 1.74, CI: 1.15 – 2.64, p = 0.0009) as well as Black patients (aOR: 0.8, CI: 0.65-0.97, p = 0.021). Of these patients, 1,247 were confirmed EGFRm+ and were thus eligible for 1L osimertinib. Asian patients were marginally more likely to receive 1L osimertinib, even after adjustment ( aOR: 1.51, CI: 0.958 – 2.43, p =.082). The inclusion of a random factor of practice diminished the marginal effect of race ( aOR: 1.46, CI: 0.90 – 2.36, p = 0.1). Conclusions: Retrospective analyses using real-world data revealed differences across races in EGFR testing among patients with stage IV NSCLC, suggesting disparities in quality of care. Racial disparities were also observed in 1L osimertinib use among patients with EGFRm+. Sensitivity analyses suggest that these disparities may partially be attributed to differences in care between practices. Future studies are warranted to further characterize this unexpected race-based difference in biomarker testing and treatment initiation. This work highlights the need for investigations of racial disparities in access to both biomarker testing and effective treatment options across precision oncology.[Table: see text]
Creating a single point of referral and standardized care pathway for patients with melanoma to improve access to care.
Authors: Rubin Fitzgerald Sydney , Hanson Bailey , Loehrer Andrew Phillip 
Published: September 2022

127 Background: Access to care is often a challenge for healthcare organizations  especially as pressures on time increase and workforce availability decreases  and is often complex to solve. In this quality improvement (QI) initiative, a team from a rural academic medical center deployed the Lean Six Sigma approach to develop a two-pronged method that reduced the median time to first visit for new melanoma patients. Methods: The project team deployed the Define, Measure, Analyze, Improve, and Control (DMAIC) processes to address access for melanoma patients after the healthcare organization set a goal that 55% of new specialty care patients be seen within 10 days. Define: Concern was raised by the melanoma clinical care team that the lack of a well-defined and standardized referral workflow for melanoma patients could delay patient care. Measure: Data from the electronic medical record (EMR) indicated that only 31% of incoming referrals were seen within 10 days, and the median number of days to first visit was 15, or 50% over the organizational standard. Analyze: Analysis found considerable waste in the existing referral system. First, untrained staff made referral and routing decisions, meaning patients could potentially be seen by inappropriate departments based on the assessment of those not specialized in melanoma care and treatment. This led to the second area of waste: rework. Every referral had to be reviewed by multiple staff in several departments to ensure the referral made was appropriate based on the characteristics of disease. This was a very labor-intensive processes that allowed too many patients to slip through the cracks of the system. Improve: Two interventions were deployed to address the identified waste. First, a centralized referral point for all melanomas monitored by the Program Coordinator. Second, a referral questionnaire developed by an interdisciplinary team to guide where routine cases should be referred. Early results show that the interventions had marked impact on the time to first appointment for all referrals, whether originating inside of the organization or out. After the intervention 54% of newly referred patients were seen within 10 days. Results: Control: A standard report was built to support the project team in monthly monitoring of the KPI, days from referral to patient seen. The report is monitored by a dedicated Program Coordinator who can escalate any issues during regular interdisciplinary care team meetings. Conclusions: Improvements in access can be achieved by adopting standard work that is targeted to reduce waste in the referral workflow. The model developed by this QI initiative is easily replicable and may be especially useful for interdisciplinary teams who provide care to complex diseases.[Table: see text]
Prevalence of social risks among oncology patients in an integrated health care delivery system.
Authors: Kumar Deepika , Zamani Constanza , Martin Ernesto , Kolevska Tatjana , Payne Jessica , Sheehan Tammy Rene , Gordon Nancy P. , Egorova Olga , Kroenke Candyce , Neeman Elad , Liu Raymond 
Published: September 2022

128 Background: Social risks and needs can affect oncology treatment and outcomes, and some may be amenable to intervention before or during treatment. We surveyed Kaiser Permanente Northern California (KPNC) oncology patients to estimate prevalence of social risks among cancer patients. Methods: Adults undergoing treatment at KPNC infusion centers between 11/2021 – 05/2022 completed a print questionnaire that included questions about recent (past 3 month) financial strains, living, relationship, and transportation situation, and different aspects of social support. Results: A total of 767 patients completed surveys in English. Respondents were 63% female, median age 63y, and majority White (61% White, 19% Asian, 11% Latino, 7% Black) and college-educated (28% some college, 45% ≥ bachelor’s degree). About 20% lived alone, 35% were not in a committed relationship, 13% reported they did not usually get the social or emotional support they needed, and 3% often felt lonely or socially isolated. Approximately 24% said they had no one to help them with daily activities (shopping, cooking, transportation, etc.), 8% reported need for more help with daily activities, and 8% indicated that lack of transportation made it hard to get to medical appointments. Patients with no one to help them were more likely to indicate needing more help (14% vs. 6%). Additionally, while undergoing treatment, 6% were also acting as a primary caregiver to someone who was frail, chronically ill, or had a disability. Approximately 18% had experienced at last one recent financial strain, including trouble paying for medical/dental needs (9%), debts (8%), utilities (6%), food (5%), housing (3%), phone/internet (3%), or transportation (2%). Conclusions: Many patients lack adequate emotional and instrumental social support and may also be experiencing difficulties paying for recommended or essential medical and dental needs while undergoing cancer treatment. These findings highlight the importance of incorporating social risk screening into the oncology intake process so that this information is available to the oncology team for care planning and referral to institutional and community resources. In this way, the oncology care team may be able to improve social support and reduce financial and other barriers that may impact patient participation in treatment and treatment outcomes.
Real-world variability in use of bone-modifying drugs for multiple myeloma by payer type.
Authors: Soni SOPHIA Monica Monica , Hertler Andrew Allan 
Published: September 2022

129 Background: The use of bone-modifying agents (BMAs) in multiple myeloma is gold standard. Benefits include prevention of skeletal-related events, reduction in bone pain, and improved progression-free survival. Guidelines recommend that patients with active multiple myeloma receive a BMA for up to two years. Unfortunately, real-world data has shown undertreatment with delays in initiation, interruptions in dosing, and premature discontinuation. These gaps are more pronounced for Black patients. The objective of this study was to describe real-world BMA treatment patterns across different payer types: Medicaid, Medicare, and Commercial/Exchange. Methods: This was a retrospective observational study using oncology prior authorization data from multiple payers in the New Century Health (NCH) database. NCH is specialty risk management company who supported over 107,000 oncology patients in 2021. All patients with a diagnosis of multiple myeloma, as indicated by the treating provider’s office, were included who had a prior authorization request for anti-cancer therapy between January 1, 2021, and December 31, 2021. Use of BMA was defined as having ≥1 authorization request for zoledronic acid or denosumab any time in the prior 24 months. BMA use was also evaluated by payer: Medicaid, Medicare, or Commercial/Exchange. Results: A total of 4774 patients were identified as having active multiple myeloma from January 1, 2021, to December 31, 2021. Fifty-nine percent (59.6%) of patients had at least one authorization request for a BMA submitted by their treating provider any time in the preceding 24 months. While most of the identified patients had Medicare, when request for BMA was disaggregated by payer, meaningful differences were found. For patients with commercial or exchange coverage, 64.6% (281/435) had a BMA requested; for patients with Medicare coverage, 60.1% (2339/3890) had a BMA requested. However, for patients with Medicaid, only 51% (229/449) had a BMA requested. Conclusions: Like other studies, our findings highlight underuse of BMAs in multiple myeloma. Differences in request for BMA across payer types suggests variability in adherence to guidelines may be based on patient insurance. To achieve equitable outcomes, including for patients of lower socioeconomic status, targeted efforts must be put in place to ensure receipt of guideline-directed therapy. A strength of this study is the large population and diversity of patients from practices in 41 states with multiple payer types. However, our analysis is limited by several unknown factors such as patient contraindication to or declination of BMA in past that are not captured in the NCH database. This retrospective study, using a large real-world oncology database, highlights that many patients with multiple myeloma may not be receiving guideline-based BMA therapy and that there are meaningful differences depending on patient insurance type.