Carole Kathleen Dalby

The ASCO Quality Training Program: Designing and Implementing a Medical Specialty Society-Based Quality Improvement Training Program

The mission of ASCO”s Quality Training Program is “to teach oncology providers to engage in successful quality improvement activities in their practice settings and to train oncologists to assume quality leadership positions and champion quality initiatives.”

Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non–Small-Cell Lung Cancer

PURPOSE Increasing costs and medical complexity are significant challenges in modern oncology. We explored the use of clinical pathways to support clinical decision making and manage resources prospectively across our network. MATERIALS AND METHODS We created customized lung cancer pathways and partnered with a commercial vendor to provide a Web-based platform for real-time decision support and post-treatment data aggregation. Dana-Farber Cancer Institute (DFCI) Pathways for non-small cell lung cancer (NSCLC) were introduced in January 2014. We identified all DFCI patients who were diagnosed and treated for stage IV NSCLC in 2012 (before pathways) and 2014 (after pathways). Costs of care were determined for 1 year from the time of diagnosis. RESULTS Pre- and postpathway cohorts included 160 and 210 patients with stage IV NSCLC, respectively. The prepathway group had more women but was otherwise similarly matched for demographic and tumor characteristics. The total 12-month cost of care (adjusted for age, sex, race, distance to DFCI, clinical trial enrollment, and EGFR and ALK status) demonstrated a

Implementation of chemotherapy treatment plans (CTP) in a large comprehensive cancer center (CCC): The key roles of infrastructure and data sharing.

15,013 savings after the implementation of pathways (

Standardization of initial chemotherapy teaching to improve care.

67,050 before pathways v

An Assessment of the Quality Oncology Practice Initiative: Lessons Learned From a Detailed Assessment of a Well-established Profession-based Performance Measurement Program

52,037 after pathways). Antineoplastics were the largest source of cost savings. Clinical outcomes were not compromised, with similar median overall survival times (10.7 months before v 11.2 months after pathways; P = .08). CONCLUSION After introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly, with no compromise in survival. In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of clinical pathways may provide a means to coalesce and disseminate institutional expertise and track and learn from care decisions.

The Intensive Palliative Care Unit (IPCU): Changing outcomes for hospitalized cancer patients in an academic medical center.

20 Background: ASCO recommends that prior to initiating chemotherapy, a synoptic CTP should be created. At a large CCC, there was no tool to consistently or clearly communicate chemotherapy plans within the electronic health record (EHR). METHODS In 2011, a structured tool was created in the EHR to document patient diagnosis, tumor characteristics, planned regimen, side effects, performance status, and other elements when starting a new chemotherapy. Completion of a CTP generates a synoptic note in the EHR, pre-populates a chemotherapy consent form and computerized chemotherapy ordering template, helping to integrate CTPs into normal workflow and removing steps for possible errors. Completed CTPs can be accessed by care team members and sent to external referring providers. Implementation strategy included education on the importance of and how to complete CTPs and sending monthly compliance reports to disease centers (DC) and regional sites (RS). Compliance was defined as number completed CTPs / number new chemotherapy starts. RESULTS The CTP tool was introduced in a staggered rollout in mid-2011 (compliance reporting began in 2012). Six DC and 3 RS presently complete and use CTPs. 3,569 CTPs were completed since 2012. The table shows compliance by quarter, demonstrating significant variation among DC and RS. We attribute increased compliance to introduction of formal feedback reports that allow for identification of high-volume providers not completing CTPs, triggering individual interventions, especially targeted re-education. We also suspect shared reporting led to competition among providers, further improving performance. No incentives were provided for CTP completion. CONCLUSIONS By creating a tool within the existing workflow and providing formal feedback, CTPs have been implemented as a communication tool at a CCC. [Table: see text].

Challenges of implementing the ASCO/ONS oral chemotherapy standards in a community practice network.

Recognizing that each nurse approaches patient education differently, a team of nurses at Dana-Farber Cancer Institute satellite facilities employed quality improvement strategies to develop a standardized approach to patient education. The goal was to eliminate variation in teaching and improve patient satisfaction scores.

Potential pitfalls of binary reporting metrics using a QOPI end-of-life (EOL) sample.

Background: National performance measurement programs used to improve quality and/or accountability are prevalent. Professional society-based programs largely assess practice or provider performance. We tested the limitations of the Quality Oncology Practice Initiative (QOPI), a well-established program. Methods: We investigated the potential limitations of the QOPI limited sampling strategy and end-of-life (EOL) metrics through a retrospective review of all decedents meeting the QOPI eligibility criteria at a large three-site community oncology practice. Relative precision for each EOL metric was measured and simulated scenarios modeled via log-normal distributions were compared. Results: A total of 246 deaths were identified; only 14% of decedents were included in the QOPI limited sample. Important differences in relative precision between samples were evident. Chemotherapy administered at the EOL was 2.8 times greater among the full cohort compared to the sample. Conclusion: The limited sampling strategy demonstrated the lack of precision explained by sampling variability confounded in smaller sample sizes. Our analyses demonstrated that practices reporting the same metric may stem from very different underlying distributions, which limits the ability to understand complex practice patterns and improve care. These findings may be of significance to other performance measurement programs that utilize similar testing strategies.

Standardizing risk: Development of disease and regimen-specific side effect language to enhance consent and chemotherapy treatment plan.

135 Background: Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Womens Cancer Center, the intensive palliative care unit (IPCU) admits oncology patients with uncontrolled symptoms throughout the trajectory of illness. A DNR/DNI is not required for admission. These patients are managed by an interdisciplinary team of palliative care clinicians who focus on symptom management and advanced care planning. The purpose of our analysis was to investigate goals of care outcomes and healthcare utilization after admission to the IPCU. METHODS We retrospectively reviewed patient, diagnosis, IPCU admission, and code status characteristics among 74 oncology patients admitted to the IPCU in August and September 2013. We examined the distribution of goals of care pre- and post-index IPCU admission. RESULTS A total of 67 IPCU patients received palliative chemotherapy and/or radiation while seven patients received curative intent treatment. All patients had documented goals of care discussion during the IPCU admission. Of the palliative intent treatment patients, 58% of patients were transferred to the IPCU from medical oncology and 42% were directly admitted. The median age was 64 (range: 25-90 years), and 57% were female. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint and all patients documented multiple symptoms (median = two). Twenty-five patients (37%) experienced a change in code status from FULL to DNR/DNI. A total of eight patients died in the IPCU and 50% of these experienced a code status change during the index admission. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30 day readmission was 4% (95% CI -1%-9%) adjusted for the competing risk of death. CONCLUSIONS Our findings suggest the inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases unnecessary hospital readmissions among advanced cancer patients.

Limitations of QOPI end-of-life (EOL) data use for purposes of accountability: Comparison of sample versus full cohort analysis.

93 Background: In March 2013, The American Society of Clinical Oncologists and the Oncology Nursing Society published standards for the safe administration of oral chemotherapy. Gap analysis at Dana-Farber Cancer Institute (DFCI) Satellites revealed opportunities in planning, education, and monitoring of patients prescribed oral chemotherapy. As a quality improvement initiative, the DFCI Satellites designed and implemented a multidisciplinary approach to oral chemotherapy administration. METHODS The Model for Improvement was employed. A process map highlighted gaps in oral chemotherapy. Several improvement opportunities were identified. 1) Pharmacists developed oral chemotherapy treatment algorithms in the EMR. 2) Providers adapted the parenteral chemotherapy treatment plan (CTP) for use with oral chemotherapy. 3) A nursing education program was created, and implemented following completion of the CTP and consent. 4) Continuous monitoring for toxicity and adherence was initiated by providers via clinic visits and telephone screening. RESULTS Monthly compliance reports measured CTP completion, consent, initial education, and monitoring for adherence. Aggregated rates indicate practice variability. Some sites perform well, while others continue to show room for improvement. CONCLUSIONS Developing a process for oral chemotherapy is challenging. Systems are not set up for oral drug safety. Although we had success with introduction of the intervention, results have not yet demonstrated sufficient reliability. System limitations and human factor challenges have impeded progress. Given the risk potential of oral chemotherapy, adopting a robust process to deliver oral chemotherapy is essential for safe patient care. Oral chemotherapy administration is a work in progress that must be refined to achieve high reliability. [Table: see text].