A 54-year-old white woman presented to the emergency department with inability to smile, difficulty in closing her right eye and drooling when attempting to drink liquids for two days prior to presentation. Neurological examination revealed classic signs of right peripheral seventh cranial nerve paresis. The patient also complained of fatigue, general malaise and weight loss of 20 pounds during the past few weeks.
e21000 Background: VIA Oncology evidence-based pathways have been integrated into our medical oncology workflows since November 2014. Within 3 months, compliance was high for our 42 medical oncologists at 19 sites working with a common EHR with over 85% of pts treated on pathway. The aim of this study was to determine if there was a significant difference in the overall cost of treatment between pts treated on pathway versus off pathway, and whether on pathway pts had a lower rate of ED use and unplanned admissions within 30 days of chemotherapy as required in the new CMS directives. Methods: Newly diagnosed NSCLC pts diagnosed between January 1, 2017 to December 31, 2018 were identified from the tumor registry for the system. The VIA database was queried to separate these pts into two groups – those pts who were treated on pathway, and those who were off pathway. In addition, we divided pts into early diagnosis, advanced/curative, and advanced/non-curative. The data warehouse was utilized to determine the total charges of adjuvant medical oncology treatment for these pts. In addition, data was extracted for the same groups to determine those pts who sought ED evaluation and or hospital admission within 30 days of chemotherapy treatment (CMS-35). Statistical analysis was performed using Chi-square/Fisher’s exact test to compare proportions and t-test for independent samples to compare treatment costs and ED/hospitalizations between the on and off pathway groups. Results: During the 2 years, 407 (81.4%) NSCLC pts were treated on pathway (including clinical trials); 93 (18.6%) were off pathway. All patients undergoing treatment were ECOG 0-2 Performance Status. Mean cost for treating the on-pathway group was $104,436 compared to $183,717 for the off-pathway pts (p = 0.01). Since implementing pathways, clinical trial entry rose from 27 to 66/yr. 25.8% of on pathway compared to 29% of off pathway fell into the CMS 35 group. Conclusions: Standardized usage of evidence-based pathways can be used successfully across a large number of providers over wide geography. Adherence to pathways results in significant cost savings for each patient and significant rise in clinical trial entry.
e17555 Background: Via Oncology (Via) is a decision support tool that integrates patient information with a treatment algorithm. Via prioritizes treatments by efficacy first, toxicity second, and cost third. The recommended regimen is offered to the doctor and patient who may accept it or choose an off pathway treatment. The pathways are updated quarterly and are expected to speed the integration of new treatments into practice, standardize therapy, improve quality, and decrease cost. Physicians are often unaware that a trial is available for a patient and EHR’s (Electronic Health Record) are not commonly used to facilitate accrual to clinical trials. A pathway system could also alert doctors to the availability of a clinical trial and potentially increase accrual to clinical trials. Methods: The integration of Via into the Epic EHR was facilitated by 3 major interfaces: patient information sent from the EHR to Via, the providers’ schedules sent from the EHR to Via, and the protocol selected in Via sent back to the EHR. Within the decision algorithm, clinical trials were recommended as the first option in all lines of therapy when available. Results: After 3 months and 18,198 visits, the visit capture rate was 76.1%. With 1,590 decisions made, 91.6% of decisions were on pathway. Information about the number of trials recommended by the pathway and the number of times the recommendation was accepted is not available at this time. Information from our research department documented that 22 patients were accrued to clinical trials in the 79 days after Via implementation. Conclusions: The pathway program was rapidly accepted by physicians and the recommendations were commonly accepted. Information about trial accrual is not available is promising. An upgrade of the Epic EHR is planned in the near future. A single log in to open Via and the EHR concomitantly is planned. An additional interface to bring staging information from the EHR to Via is being planned. Quantification of the number of times a trial is offered and accepted is being captured.
159 Background: Our CCC serving a mixed rural/urban population is part of a large integrated healthcare system in Eastern WI. The closest PC specialist/team is 45 miles away at one of the tertiary care facilities. To fill this service gap we implemented a primary PC model. An initial outpatient palliative care family conference (OFC) and use of cancer nurse navigators (CNN)are hallmarks of this program. Methods: The VLCC, housed in a standalone facility is staffed by two medical oncologists and one radiation oncologist and has an infusion center and a full-fledged radiation oncology unit with support staff, including cancer nurse navigators, research nurses, social workers, a clinical psychologist, a pharmacist, a nutritionist, a therapy dog and a chaplain. Specialized pain management teams and services like acupuncture and hypnotherapy are readily available in the community. The patients have had access to multiple clinical trials since 2004. A team of a physician champion, a CNN and a social worker prioritized the needs and designed a program with support from system leadership. A CNN took additional training in PC. Funding from a research grant provided support for an occupational therapist (OT). Difficulties in communication was identified early as a barrier to integration of PC. OFCs were designed and conducted to discuss multiple domains of palliative care and referrals were made to different services. Pre and post enrollment surveys were administered. The following flow diagram was used (see Table). Results: In 2015, of 334 new patient visits for all stages of cancer, 32 were managed through the new PC model. Patient satisfaction scores were near 100%. Detailed methodology and data analyses will be presented. Conclusions: A successful new model of early integration of PC that is easily replicable in communities without access to specialist PC services is presented. [Table: see text]
69 Background: Aurora Health Care is comprised of 15 hospitals and 22 oncology clinics. Aurora Cancer Care (ACC), a Commission on Cancer (CoC) accredited program, diagnoses and treats 7,000 adult cancer patients annually, more than any other healthcare system in Wisconsin. The CoC’s Survivorship Standard 3.3 requires accredited cancer programs to provide cancer patients with survivorship counseling and a written care plan. ACC was challenged to develop a consistent model of survivorship care that can work at multiple sites across the system. Methods: Workflow planning and education began at all oncology clinics in fourth quarter of 2014. Thirteen disease specific survivorship care plan templates were built into the EMR with some-auto population functionality. A system wide delivery plan was launched in first quarter of 2015 with the goal of targeting 10% of eligible patients. Initial focus was on breast cancer patients with some sites also including other cancers. The model of survivorship care is an “embedded consultation” in medical or surgical oncology with an advanced practice provider (APP) completing the care plan and meeting with the patient at the end of first line treatment. Results: Initial required volumes were estimated based on 2013 registry data with a goal of completing approximately 700 care plans in 2015 to meet the 10% CoC standard. During Q1 & Q2 of 2015, 444 care plans were generated and given to patients, mostly for breast cancer survivors. The most significant barrier surrounded retrieving data from the EMR. Conclusions: Data from the first half of 2015 demonstrates success with the approach. Aurora Cancer Care will exceed the benchmark of 700 care plans. There has been a high level of engagement with the APPs who have taken ownership of survivorship care planning, contributing to the success of the program thus far. Because of difficulty retrieving data from the EMR, manual tracking was still required. Future modifications will address this and other barriers.
Importance Cancer screening deficits during the first year of the COVID-19 pandemic were found to persist into 2021. Cancer-related deaths over the next decade are projected to increase if these deficits are not addressed. Objective To assess whether participation in a nationwide quality improvement (QI) collaborative, Return-to-Screening, was associated with restoration of cancer screening. Design, Setting, and Participants Accredited cancer programs electively enrolled in this QI study. Project-specific targets were established on the basis of differences in mean monthly screening test volumes (MTVs) between representative prepandemic (September 2019 and January 2020) and pandemic (September 2020 and January 2021) periods to restore prepandemic volumes and achieve a minimum of 10% increase in MTV. Local QI teams implemented evidence-based screening interventions from June to November 2021 (intervention period), iteratively adjusting interventions according to their MTVs and target. Interrupted time series analyses was used to identify the intervention effect. Data analysis was performed from January to April 2022. Exposures Collaborative QI support included provision of a Return-to-Screening plan-do-study-act protocol, evidence-based screening interventions, QI education, programmatic coordination, and calculation of screening deficits and targets. Main Outcomes and Measures The primary outcome was the proportion of QI projects reaching target MTV and counterfactual differences in the aggregate number of screening tests across time periods. Results Of 859 cancer screening QI projects (452 for breast cancer, 134 for colorectal cancer, 244 for lung cancer, and 29 for cervical cancer) conducted by 786 accredited cancer programs, 676 projects (79%) reached their target MTV. There were no hospital characteristics associated with increased likelihood of reaching target MTV except for disease site (lung vs breast, odds ratio, 2.8; 95% CI, 1.7 to 4.7). During the preintervention period (April to May 2021), there was a decrease in the mean MTV (slope, −13.1 tests per month; 95% CI, −23.1 to −3.2 tests per month). Interventions were associated with a significant immediate (slope, 101.0 tests per month; 95% CI, 49.1 to 153.0 tests per month) and sustained (slope, 36.3 tests per month; 95% CI, 5.3 to 67.3 tests per month) increase in MTVs relative to the preintervention trends. Additional screening tests were performed during the intervention period compared with the prepandemic period (170 748 tests), the pandemic period (210 450 tests), and the preintervention period (722 427 tests). Conclusions and Relevance In this QI study, participation in a national Return-to-Screening collaborative with a multifaceted QI intervention was associated with improvements in cancer screening. Future collaborative QI endeavors leveraging accreditation infrastructure may help address other gaps in cancer care.
196 Background: Oncology quality performance metrics may be improved by establishing a coordinated process for getting data back to providers. However, establishing ownership of quality metric data can be a challenge, especially in a large, integrated health system. Methods: Aurora Cancer Care’s team developed quality charters and a coordinated process for its 15-hospital, integrated health system that outlines a course of action for metric selection, data distribution, peer review and development of process improvement plans. A weighted tool was developed and implemented to prioritize measure selection. The weighted tool described and scored each quality measure against its performance improvement opportunity, ease in data collection, national benchmarks, regulatory and reimbursement impact, value to the patient and consideration of the resources required to implement change. The final score was used to prioritize and select measures. The System Multidisciplinary Disease-Specific Quality Subcommittees established quality measures. Abstraction began, outliers were reviewed and results were disseminated to the System Cancer Leadership Council as well as the 15 hospitals via the Regional Cancer Quality Subcommittees (RCQS). The RCQS chairs and quality directors meet quarterly with the system quality liaison to ensure the communication of data back to the front-line providers. Results: We found a rise in the percentages of invasive rectal cancers diagnosed with endorectal ultrasound or magnetic resonance imaging (no stage IV) (2012: 76%, 2013: 84%) and treated with total mesorectal excision (no stage IV) (2012: 72%, 2013: 87%). In addition, increases in the examination of at least 12 regional lymph nodes for invasive colorectal cancer (2012: 93%, 2013: 98%; p<0.05) and partial, rather than total, nephrectomy for renal cancer patients with T1a tumors (2012: 71%, 2013: 95%; p<0.05) were statistically significant. Conclusions: Though our coordinated process to get quality data back to providers continues to evolve, our front-line providers have shown greater enthusiasm for the data, engaged in behavior modification and become more accountable with process improvement plans that are integral to establishing the best patient outcomes.
143 Background: Managing physicians (medical oncologist, radiation oncologist, surgeons) have a responsibility to clinically stage patients prior to the initiation of cancer treatment. Clinical staging not only directs the treatment plan, but identifies appropriate clinical trials and estimates prognosis. We sought to determine whether engagement of managing physicians would result in increased clinical staging for various types of cancer. Methods: Baseline data on clinical staging for breast, colorectal (colon, rectal, anal, rectosigmoid junction)*, thoracic (lung esophageal)†, genitourinary (prostate, penis, testes)‡, and pancreatic primary cancers were obtained. The data were grouped by disease type and sub-specialty of the managing physicians. Based on that data, several performance improvement initiatives were implemented to provide managing physicians the opportunity to clinically stage the cancer patient prior to the initiation of treatment. The initiatives for completing and documenting staging were: a tutorial on use of Problem List in the electronic medical record (EMR); modification of history & physical and consult notes to include a field for staging; sharing among sub-specialties the smart lists within the template to allow for customization of existing templates; and 1:1 review with physicians who had outliers without clinical staging. Results: Clinical staging documented prior to the initiation of cancer treatment significantly increased in all five types of cancers studied (p < .01; Table). Conclusions: Though collaborative efforts by managing physicians continues to evolve, in many cases, use of the electronic medical record through a variety of performance improvement initiatives has facilitated documentation of clinical staging of cancer patients prior to the initiation of treatment. This engagement changed practice patterns, aligned our institution with best practice guidelines and aided in treatment selection for the best possible patient outcomes. [Table: see text]
