Neeta K. Venepalli

Identifying Clinically Disruptive International Classification of Diseases 10th Revision Clinical Modification Conversions to Mitigate Financial Costs Using an Online Tool

PURPOSE To quantify coding ambiguity in International Classification of Diseases Ninth Revision Clinical Modification conversions (ICD-9-CM) to ICD-10-CM mappings for hematology-oncology diagnoses within an Illinois Medicaid database and an academic cancer center database (University of Illinois Cancer Center [UICC]) with the goal of anticipating challenges during ICD-10-CM transition. METHODS One data set of ICD-9-CM diagnosis codes came from the 2010 Illinois Department of Medicaid, filtered for diagnoses generated by hematology-oncology providers. The other data set of ICD-9-CM diagnosis codes came from UICC. Using a translational methodology via the Motif Web portal ICD-9-CM conversion tool, ICD-9-CM to ICD-10-CM code conversions were graphically mapped and evaluated for clinical loss of information. RESULTS The transition to ICD-10-CM led to significant information loss, affecting 8% of total Medicaid codes and 1% of UICC codes; 39 ICD-9-CM codes with information loss accounted for 2.9% of total Medicaid reimbursements and 5.3% of UICC billing charges. CONCLUSION Prior work stated hematology-oncology would be the least affected medical specialty. However, information loss affecting 5% of billing costs could evaporate the operating margin of a practice. By identifying codes at risk for complex transitions, the analytic tools described can be replicated for oncology practices to forecast areas requiring additional training and resource allocation. In summary, complex transitions and diagnosis codes associated with information loss within clinical oncology require additional attention during the transition to ICD-10-CM.

Conducting Retrospective Ontological Clinical Trials in ICD-9-CM in the Age of ICD-10-CM

Objective To quantify the impact of International Classification of Disease 10th Revision Clinical Modification (ICD-10-CM) transition in cancer clinical trials by comparing coding accuracy and data discontinuity in backward ICD-10-CM to ICD-9-CM mapping via two tools, and to develop a standard ICD-9-CM and ICD-10-CM bridging methodology for retrospective analyses. Background While the transition to ICD-10-CM has been delayed until October 2015, its impact on cancer-related studies utilizing ICD-9-CM diagnoses has been inadequately explored. Materials and Methods Three high impact journals with broad national and international readerships were reviewed for cancer-related studies utilizing ICD-9-CM diagnoses codes in study design, methods, or results. Forward ICD-9-CM to ICD-10-CM mapping was performing using a translational methodology with the Motif web portal ICD-9-CM conversion tool. Backward mapping from ICD-10-CM to ICD-9-CM was performed using both Centers for Medicare and Medicaid Services (CMS) general equivalence mappings (GEMs) files and the Motif web portal tool. Generated ICD-9-CM codes were compared with the original ICD-9-CM codes to assess data accuracy and discontinuity. Results While both methods yielded additional ICD-9-CM codes, the CMS GEMs method provided incomplete coverage with 16 of the original ICD-9-CM codes missing, whereas the Motif web portal method provided complete coverage. Of these 16 codes, 12 ICD-9-CM codes were present in 2010 Illinois Medicaid data, and accounted for 0.52% of patient encounters and 0.35% of total Medicaid reimbursements. Extraneous ICD-9-CM codes from both methods (Centers for Medicare and Medicaid Services general equivalent mapping [CMS GEMs, n = 161; Motif web portal, n = 246]) in excess of original ICD-9-CM codes accounted for 2.1% and 2.3% of total patient encounters and 3.4% and 4.1% of total Medicaid reimbursements from the 2010 Illinois Medicare database. Discussion Longitudinal data analyses post-ICD-10-CM transition will require backward ICD-10-CM to ICD-9-CM coding, and data comparison for accuracy. Researchers must be aware that all methods for backward coding are not comparable in yielding original ICD-9-CM codes. Conclusions The mandated delay is an opportunity for organizations to better understand areas of financial risk with regards to data management via backward coding. Our methodology is relevant for all healthcare-related coding data, and can be replicated by organizations as a strategy to mitigate financial risk.

Features of hepatocellular carcinoma in Hispanics differ from African Americans and non-Hispanic Whites

AIM To compare features of hepatocellular carcinoma (HCC) in Hispanics to those of African Americans and Whites. METHODS Patients treated for HCC at an urban tertiary medical center from 2005 to 2011 were identified from a tumor registry. Data were collected retrospectively, including demographics, comorbidities, liver disease characteristics, tumor parameters, treatment, and survival (OS) outcomes. OS analyses were performed using Kaplan-Meier method. RESULTS One hundred and ninety-five patients with HCC were identified: 80.5% were male, and 22% were age 65 or older. Mean age at HCC diagnosis was 59.7 ± 9.8 years. Sixty-one point five percent of patients had Medicare or Medicaid; 4.1% were uninsured. Compared to African American (31.2%) and White (46.2%) patients, Hispanic patients (22.6%) were more likely to have diabetes (P = 0.0019), hyperlipidemia (P = 0.0001), nonalcoholic steatohepatitis (NASH) (P = 0.0021), end stage renal disease (P = 0.0057), and less likely to have hepatitis C virus (P < 0.0001) or a smoking history (P < 0.0001). Compared to African Americans, Hispanics were more likely to meet criteria for metabolic syndrome (P = 0.0491), had higher median MELD scores (P = 0.0159), ascites (P = 0.008), and encephalopathy (P = 0.0087). Hispanic patients with HCC had shorter OS than the other racial groups (P = 0.020), despite similarities in HCC parameters and treatment. CONCLUSION In conclusion, Hispanic patients with HCC have higher incidence of modifiable metabolic risk factors including NASH, and shorter OS than African American and White patients.

Early identification of high-risk neutropenia in the ambulatory setting.

87 Background: The University of Illinois Cancer Center (UICC) utilizes nurse (RN) visits for laboratory review and toxicity evaluations for patients (pts) receiving chemotherapy. Upon review of nursing visits, we observed that RN visit documentation for neutropenia was variable without standard language, communication with physicians (MD), or requirement for MD evaluation. We sought to implement an early intervention strategy to prevent morbidity and mortality from high risk neutropenia (HRN). METHODS A multidisciplinary task force of oncology RNs and MDs created actual and ideal process maps, from identification of neutropenia to patient disposition. We developed a Standard Operating Protocol (SOP) involving a HRN checklist (created based on NCCN and ISDA guidelines) and new process for triage of HRN pts. RNs were required to complete the HRN checklist within the electronic health record for all pts with ANC < 1,000. If high risk features were identified, MD evaluation was required within 1 hour of RN call, with SOAP note and attending notification. RESULTS Over an 8 week period, 17 HRN templates were generated. The process and checklist were adjusted after the first 4 weeks with clinic wide feedback. Within the first 4 weeks, 8 templates were generated (5 MD, 3 RN); no patients met high risk neutropenia criteria and all were discharged home. Within the second 4 weeks, 9 templates were generated (3 MD, 6 RN); 3 HRN pts were identified with two direct admissions and one home discharge with favorable outcomes. Clinic staff reported greater understanding of HRN, increased satisfaction with multidisciplinary interactions, and more comfort with calling MDs for prompt patient evaluation. CONCLUSIONS UICC successfully piloted the creation and implementation of an early identification and intervention strategy for HRN with strong multidisciplinary support. Compared to the prior 6 month period, we found that use of the SOP and checklist resulted in improvement in evaluation of quality and timeliness of HRN pts and prevented morbidity and mortality. Additionally, the checklist provoked critical thinking from end users with more thorough patient evaluations and improved documentation, resulting in aggressive intervention and better outcomes.

Adherence to Oral Anticancer Medications: Evolving Interprofessional Roles and Pharmacist Workforce Considerations

Interprofessional care is exhibited in outpatient oncology practices where practitioners from a myriad of specialties (e.g., oncology, nursing, pharmacy, health informatics and others) work collectively with patients to enhance therapeutic outcomes and minimize adverse effects. Historically, most ambulatory-based anticancer medication therapies have been administrated in infusion clinics or physician offices. Oral anticancer medications (OAMs) have become increasingly prevalent and preferred by patients for use in residential or other non-clinic settings. Self-administration of OAMs represents a significant shift in the management of cancer care and role responsibilities for patients and clinicians. While patients have a greater sense of empowerment and convenience when taking OAMs, adherence is a greater challenge than with intravenous therapies. This paper proposes use of a qualitative systems evaluation, based on theoretical frameworks for interdisciplinary team collaboration and systems science, to examine the social interactionism involved with the use of intravenous anticancer treatments and OAMs (as treatment technologies) by describing patient, organizational, and social systems considerations in communication, care, control, and context (i.e., Kaplan’s 4Cs). This conceptualization can help the healthcare system prepare for substantial workforce changes in cancer management, including increased utilization of oncology pharmacists.

Documentation of pharmacist-provided patient education for oral chemotherapy.

237 Background: Pharmacist-provided patient education for oral chemotherapy is poorly documented in patient electronic medical records (EMR) at UIC Oncology Pharmacy. At baseline, 41% of patients who started new therapy with selected oral chemotherapies had a patient education note documented by a pharmacist in their EMR. Our aim is to provide and document patient education for at least 90% of patients who start new oral chemotherapy and fill their prescriptions at UIC Oncology Pharmacy over three months. The importance of patient counseling and documentation is recognized by the Quality Oncology Practice Initiative (QOPI) group. Approximately 25% of patients undergoing chemotherapy are on oral chemotherapy. (Deutsch S, Koerner P, Miller RT, Craft Z, Fancher K. Utilization patterns for oral oncology medications in a specialty pharmacy cycle management program. J Oncol Pharm Pract. 2014;0:1-8.) Methods: A multi-disciplinary team performed an affinity sort and created a process map to identify areas of intervention. The first intervention was labelling prescription bags to identify them as oral chemotherapy prescriptions that require counseling by a pharmacist. Data was collected after two weeks. RESULTS At the completion of the first PDSA cycle, 40% of patients who started new oral chemotherapy had a documented patient education note written by a pharmacist in their EMR. Documentation of education was performed on the day of pick-up in 89% of cases. Table 1 shows the percentage of notes that included the elements recognized by QOPI standards: documentation of start date, adherence, and adverse effects. CONCLUSIONS Documentation of patient education for oral chemotherapy should be a well-integrated component of ambulatory pharmacy practice. A second PDSA cycle is planned to increase rates of documentation by utilizing the pharmacy resident to perform patient counseling and documentation. Future interventions will be aimed at improving the quality of the data included in the documented notes. [Table: see text].

A novel auditing procedure for an oral chemotherapy process improvement project.

164 Background: A process to standardize ordering, documentation, and administration of inpatient oral chemotherapy was implemented at the University of Illinois Hospital and Health Sciences System. The process requires oncology clinician review and endorsement of inpatient oral chemotherapy drug orders via an oral chemotherapy note within the electronic health record. Pharmacists are instructed to reject oral chemotherapy drug orders that lack this required documentation. A novel auditing procedure was established in order to track adherence to these new requirements and provide real time and adaptable feedback to front-line staff critical to the projects success. METHODS To support continuous quality improvement (QI) with this project, an auditing tool was developed in REDCap, a secure, web-based data management application. The auditing tool was originally developed as a traditional web-based data collection instrument with the primary purpose of tracking performance. By utilizing more advanced features offered by the REDCap platform, the auditing tool generated automated follow-up surveys to pharmacists involved in non-adherent outlier cases. The survey solicited information on the root cause of non-adherence, and based on the end-user response, provided adaptable continuing education tailored to this root cause. RESULTS Between June and September 2015, a total of 67 orders for oral chemotherapy were audited. Compliance with process improvement requirements was noted in 58%, 100%, 78%, and 93% of cases in June, July, August, and September, respectively. Outlier surveys were sent to 12 pharmacists in the non-adherent cases; of 11 responses, the most common response reflected an unfamiliarity with the process. Following targeted education, through September 2015, no single pharmacist has been involved in more than one non-adherent case. CONCLUSIONS The novel auditing tool supported the continuous quality improvement process by engaging front-line staff, generating automated and real time surveys for outlier responses, and providing targeted and personalized education aimed at resolving the root cause in non-adherent cases. As such, it can be applied towards any REDCap QI projects.

A multidisciplinary quality improvement project to improve the safety of oral chemotherapy in hospitalized patients.

110 Background: At the University of Illinois Hospital and Health Sciences System (UIC), inpatient IV chemotherapy administration occurs in the setting of specific protocols and multidisciplinary safety assessments while oral chemotherapy agent (OCA) inpatient administration occurs less formally. Baseline 8 week review of 174 admissions to the oncology service revealed that of 16 patients (9.2%) on outpatient OCA, 50% received OCAs while inpatient, with 12. 55% having a formal chemotherapy note in place. We aimed to increase the percentage of administered OCAs with associated provider generated chemotherapy notes from 12.5% to 75% over 16 weeks. METHODS A multidisciplinary task force comprised of oncology providers, clinical pharmacy, nursing leadership, and information technology was assembled. An actual and ideal process map was created, and using tools such as affinity sorting and root cause analysis, interventions were implemented focusing on residents (knowledge of OCA), nurses (documentation and policy adherence), pharmacists (education, policy adherence) and IT team (order modification). A standardized multidisciplinary hospital wide process was implemented for OCA ordering, administration, documentation, and patient education. A novel REDCap (research electronic data capture) auditing procedure was designed by which a weekly pharmacy report of every oral chemotherapy order at UI Health is automatically generated. RESULTS Between June and September 2015, a total of 67 OCA administration reports were audited. OCA notes were associated with OCA administration in 58% of cases in June, 100% in July, 78% in August and 93% in September. Furthermore, OCA notes were entered within 4 hours of OCA ordering in 58% of cases in June, 54% in July and 78% of the cases in August and September. No adverse events were reported. CONCLUSIONS At the University of Illinois Hospital and Health Sciences System, a multidisciplinary team designed and implemented a standardized OCA administration, ordering, and documentation process focused on safe, appropriate and timely inpatient OCA administration. A novel REDCap auditing process assisted the team to identify the areas in need of optimization.

Phase Ib study of PGG beta glucan in combination with anti-MUC1 antibody (BTH1704) and gemcitabine for the treatment of advanced pancreatic cancer.

TPS493 Background: Mucin 1 (MUC1) is a tumor associated membrane-bound glycoprotein that promotes oncogenesis through promotion of epithelial cell polarity loss, anti-apoptosis, and hypoxia driven angiogenesis. MUC1 overexpression is associated with aggressive behavior and poor outcomes in pancreatic ductal adenocarcinoma (PDAC), and increased resistance to gemcitabine (G) in vitro. BTH1704 (BTH) is a humanized monoclonal antibody (MAb) targeting aberrantly glycosylated MUC1. Imprime PGG (PGG) is a soluble yeast-derived b 1,3/1,6 glucan that binds complement receptor 3 (CR3) on innate immune cells priming them to exert anti-tumor activity against complement (iC3b) opsonized tumor cells. Following incubation of PGG with whole blood from healthy subjects, variability in PGG binding to neutrophils and monocytes has been observed, with higher binding and functional changes correlating with higher levels of endogenous anti-b glucan antibodies. BTH binds to antigens (MUC1), leading to iC3b opsonization of tumor...

Improving advance care planning for UICC Oncology patients.

234 Background: Advance care planning (ACP) in the ambulatory setting is underutilized and poorly documented at the University of Illinois Cancer Center (UICC). A baseline 8 week review noted 8.8% of metastatic solid tumor patients had ACP documentation in the electronic medical record (EMR) by the third visit and 23% in the previous two visits. Our aim was to increase ACP documentation to 75% of UICC metastatic solid tumor patient charts by the third visit through development of a standardized process for ACP discussion and documentation. METHODS A multidisciplinary team of oncology physicians, nurses, social workers (SW), and palliative care created a process map of ACP discussion. A new process for SW consults was piloted over 6 weeks. Additionally, all clinic staff participated in a standardized curriculum for ACP discussions. Post intervention data was prospectively collected over six weeks. RESULTS Total 94 encounters occurred during the pilot evaluating ACP in metastatic solid tumor patients of which 37/55 (39.4%) had documented ACP discussion. SW consults occurred in 18/94 (19.1%), leading to 18/18 (100%) with Power of Attorney (POA) forms in EMR. Evaluation by tumor subtypes showed 14/21 (66.7%) of gastrointestinal patients had ACP documentation with 9/21 (42.9%) with SW consults leading to 11/21 (52.4%) with POA forms in EMR. Of 39 total thoracic patients, 19/39 (48.7%) had ACP documentation of which 9/39 (23%) with SW consults and 7/39 (17.9%) with POA forms in EMR. CONCLUSIONS UICC successfully piloted the creation and implementation of a process for ACP consults and standardization of ACP discussion and EMR documentation. While our initial aim of 75% a chart was not reached, the piloted process increased SW consults and completion of POA forms, as well as greater multidisciplinary effort and patient engagement. Compared to the pilot period, a multidisciplinary approach and use of the new process did improve ACP documentation. We plan to expand to all metastatic patients. [Table: see text].