F. Marc Stewart

Implementing a Death with Dignity Program at a Comprehensive Cancer Center

BACKGROUND The majority of Death with Dignity participants in Washington State and Oregon have received a diagnosis of terminal cancer. As more states consider legislation regarding physician-assisted death, the experience of a comprehensive cancer center may be informative. METHODS We describe the implementation of a Death with Dignity program at Seattle Cancer Care Alliance, the site of care for the Fred Hutchinson-University of Washington Cancer Consortium, a comprehensive cancer center in Seattle that serves the Pacific Northwest. Institution-level data were compared with publicly available statewide data from Oregon and Washington. RESULTS A total of 114 patients inquired about our Death with Dignity program between March 5, 2009, and December 31, 2011. Of these, 44 (38.6%) did not pursue the program, and 30 (26.3%) initiated the process but either elected not to continue or died before completion. Of the 40 participants who, after counseling and upon request, received a prescription for a lethal dose of secobarbital (35.1% of the 114 patients who inquired about the program), all died, 24 after medication ingestion (60% of those obtaining prescriptions). The participants at our center accounted for 15.7% of all participants in the Death with Dignity program in Washington (255 persons) and were typically white, male, and well educated. The most common reasons for participation were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%). Eleven participants lived for more than 6 months after prescription receipt. Qualitatively, patients and families were grateful to receive the lethal prescription, whether it was used or not. CONCLUSIONS Overall, our Death with Dignity program has been well accepted by patients and clinicians.

Responsibility for Costs Associated With Clinical Trials

Medicare and coverage requirements in the Patient Protection and Affordable Care Act (ACA) have improved access to clinical trials, but major obstacles persist. First, access to participation in studies can be limited if networks established by insurance plans do not include providers involved in clinical trials. Second, certain details of the relationship between the clinical trials provisions of the ACA and state laws have not been defined. Third, consensus regarding the scope of insurance coverage for costs in clinical trials has not been reached. We discuss each of these problems and offer suggestions for resolution. These obstacles must be addressed to improve access for patients and to advance medical care through research.

Value in cancer care: Regional initiative to improve care through data reporting and interventions.

34 Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR), partnered with community members to launch a regional, stakeholder-driven initiative to define and report value metrics for cancer care for Washington State. Region-wide Summits were held in 2014 and 2015. Participants included local healthcare delivery organizations, patient advocacy groups, payers, and policymakers. The 2014 Summit identified priority metrics; these metrics were reported at the 2015 Summit. METHODS For the 2015 Summit, HICOR staff developed algorithms to measure adherence to the community-prioritized metrics using a claims-registry linked database. Metrics spanned diagnosis, treatment, continuing, and end-of-life (EOL) phases of care. After reviewing adherence at the clinic-level and for the region, attendees were invited to attend break-out sessions for metrics where there was the largest variation: hospital and ED use during treatment, hospital and ED use at EOL, and breast cancer surveillance. Within the breakout sessions, participants were asked to identify barriers to adherence and possible interventions to improve care. After discussion, participants individually ranked the top 3 interventions and estimated expected improvement to be gained by successful implementation of the intervention Results: Table. Working groups were formed to develop detailed protocols for implementable interventions. CONCLUSIONS Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus to identify and prioritize value metrics in cancer care, and to develop consensus regarding approaches to improve adherence to those metrics. [Table: see text].

Regional initiative to use data transparency to improve cancer care.

39 Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR) has adopted a multi-stakeholder approach to characterize oncology care, prioritize areas for improvement, design programs, and evaluate outcomes. Beginning in 2014, HICOR initiated a process to move towards data transparency in the reporting of regional quality and value metrics. METHODS The HICOR team constructed clinic-level adherence reports for community-prioritized metrics and the 2012 ASCO Choosing Wisely recommendations using a registry-claims linked database. In the fall of 2014, a national external advisory board reviewed methodology for measuring adherence. De-identified regional results were presented at a provider meeting in late 2014 to elicit provider feedback on methodology and on strategies for reporting clinic-identified adherence. Clinics were privately given their own adherence data. In 2015, revised de-identified regional reports were presented at a Value in Cancer Care Summit poster session and made available through HICOR IQ, a regional oncology informatics platform, for further discussion. RESULTS Results show that no clinic was also the best or worst performing clinic. The table shows the performance by clinic for the 5 Choosing Wisely recommendations. There is now increased demand by clinics to view their own adherence benchmarked with the region as a next step in moving towards full data transparency. Additionally, there is support from provider members in the community to re-identify clinics in order to compare results against their peers. CONCLUSIONS Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus towards releasing clinic-level adherence to quality and value metrics. By consulting trusted experts in the field and allowing multiple opportunities to provide feedback, providers are requesting even more transparency in order use the oncology measures to improve care in their practice and the region. [Table: see text].

Measuring adherence to a Choosing Wisely recommendation in a regional oncology clinic.

196 Background: Natural language processing (NLP) has the potential to significantly ease the burden of manual abstraction of unstructured electronic text when measuring adherence to national guidelines. We incorporated NLP into standard data processing techniques such as manual abstraction and database queries in order to more efficiently evaluate a regional oncology clinics adherence to ASCOs Choosing Wisely colony stimulating factor (CSF) recommendation using clinical, billing, and cancer registry data. METHODS Database queries on the clinics cancer registry yielded the study population of patients with stage II-IV breast, non-small cell lung (NSCL), and colorectal cancer. We manually abstracted chemotherapy regimens from paper prescription records. CSF orders were collected through queries on the clinics facility billing data, when available; otherwise through a custom NLP program and manual abstraction of the electronic medical record. The NLP program was designed to identify clinical note text containing CSF information, which was then manually abstracted. RESULTS Out of 31,725 clinical notes for the eligible population, the NLP program identified 1,487 clinical notes with CSF-related language, effectively reducing the number of notes requiring abstraction by up to 95%. Between 1/1/2012-12/31/2014, adherence to the ASCO CW CSF recommendation at the regional oncology clinic was 89% for a population of 322 patients. CONCLUSIONS NLP significantly reduced the burden of manual abstraction by singling out relevant clinical text for abstractors. Abstraction is often necessary due to the complexity of data collection tasks or the use of paper records. However, NLP is a valuable addition to the suite of data processing techniques traditionally used to measure adherence to national guidelines.

Measuring baseline adherence to Choosing Wisely recommendations in regional oncology clinics: Challenges and strategies.

133 Background: ASCO launched the Choosing Wisely campaign to reduce the use of interventions lacking evidence of benefit to cancer patients, but implementation may be a challenge. This project develops a stakeholder-informed process to prioritize and implement the 2012 ASCO Choosing Wisely (CW) recommendations in oncology clinic settings. METHODS Medical directors from 6 network-affiliated oncology clinics in the Puget Sound region selected 2 CW measures for implementation: (1) No biomarkers/advanced imaging following early breast cancer treated for cure, and; (2) No colony stimulating factor use for low FN risk chemotherapy. RESULTS Adherence is measured with data from each clinics tumor registry, billing records, lab results, pathology reports, and clinic notes. Challenges to measuring baseline adherence included translating non-specific guidelines into discrete data elements (e.g. when does surveillance start?) or required measuring the absence of something, presenting quality control challenges to distinguish between adherence and missing data. Additional challenges are shown in the Table. To address these challenges, the team developed these strategies: (1) creation of specific data elements, (2) mapping clinics separately to the criteria and (3) employing methods such as Natural Language Processing to efficiently collect data from EMR. CONCLUSIONS It is feasible to measure adherence to ASCO CW recommendations with data sources available at oncology clinics. Variability in data platforms among clinics is inherent to the current medical landscape and must be accounted for in successful implementation of cross-clinic programs. [Table: see text].

Stakeholder-informed “Choosing Wisely” implementation project in regional oncology clinics.

207 Background: ASCO launched the Choosing Wisely campaign to reduce the use of interventions that lack evidence for their use in clinical cancer care. The recommendations have strong support, but lack an implementation plan. The objective of this project is to develop a stakeholder-informed process to improve adherence to ASCO Choosing Wisely within an experimental context. METHODS Participants include Medical Directors from 7 oncology clinics and 1 commercial insurer within the Puget Sound region, and the SEER Puget Sound Cancer Registry. The project consists of 3 phases (1) prioritization, (2) design, (3) implementation and monitoring. For phase 1, Medical Directors were surveyed via e-mail to prioritize the recommendations with the following criteria: importance for improving the value of cancer care; impact of adherence; urgency; and feasibility of implementing an intervention. Participants met via teleconference to discuss survey results, review regional utilization data, and design of interventions. Participants were surveyed again for a final ranking. In phase 2, participants discussed options for interventions and study designs. RESULTS Initially, the highest ranked recommendations were advanced imaging in staging of local stage prostate cancer, surveillance of local and regional stage breast cancer, and colony stimulating factor (CSF) use for low risk chemotherapy. After discussion, breast cancer surveillance and CSF prescribing ranked the highest. Participants requested utilization and cost-impact data from the health insurer for the top 2 choices. CONCLUSIONS Using a transparent, multi-stakeholder process, it is feasible to implement programs to improve adherence to ASCO Choosing Wisely.