Paula A. Lewis-Patterson

Improving Wait Time for Chemotherapy in an Outpatient Clinic at a Comprehensive Cancer Center

PURPOSE We conducted our study at the Ambulatory Treatment Center (ATC) of the MD Anderson Cancer Center, a network of six outpatient treatment units for patients receiving infusion therapies. Excessive patient wait time for chemotherapy was a primary source of ATC patient dissatisfaction. ATC employees expressed frustration, because often, patients arrived physically on time but were not treatment ready. Additionally, ATC staff emphasized challenges associated with obtaining finalized treatment orders for prescheduled appointments (ie, placeholder appointments without associated physician treatment orders). We aimed to decrease mean patient wait time from check-in to treatment in one ATC unit by 25%. METHODS We studied appointment cycle time in the ATC Green Unit, stratifying appointments by type (ie, prescheduled [no finalized treatment orders] and scheduled [finalized treatment orders]). We obtained mean wait times at baseline (control) and again after our intervention period. We conducted interviews and observations in ATC Green, from which we developed a three-part plan to reduce wait time: increase process efficiency within ATC Green, enhance communications with MD Anderson clinics and centers, and incorporate information technology applications. RESULTS After our intervention, we observed a 15% decrease in wait time for patients with prescheduled appointments and a 29% decrease for those with scheduled appointments. Overall, there was a 26.8% reduction in mean patient wait time relative to baseline (control). CONCLUSION We observed a significantly decreased mean patient wait time after implementing our intervention. This decrease may improve patient satisfaction, relieve employee frustration with appointment scheduling, and create opportunities for increasing institutional revenue.

Abstract 3464: Low concordance with CEA tumor marker monitoring in colorectal cancer survivors

Purpose: To assess providers’ concordance with surveillance and risk reduction recommendations for colorectal cancer (CRC) survivors after completion of their curative treatment. Patients and Methods: This was a longitudinal study of survivors who met the following eligibility criteria: diagnosed with a primary colon or rectal cancer before their first visit (V) to the CRC Survivorship Clinic, adult survivor ≥ 18 years old, no evidence of disease, alive at the time of data abstraction, and 1-3 clinic visits between 9/01/2011 and 8/31/2014. Data were collected at V1 scheduled between 9/1/2011 and 8/31/2012. V2 was scheduled 9-15 months after the first visit. V3 was also scheduled 9-15 months after V2. Data sources were survivorship care plans, electronic medical records, and CRC survivorship algorithms. For an annual visit, CRC algorithms recommended history/physical exams (H & PEs), carcinoembryonic antigen (CEA) testing when previously elevated, and colonoscopies for surveillance of cancer recurrence. Concordance rates (CR) were measured as the percent of yes/no responses to whether the providers followed minimum standards for the 3 procedures. Demographic and clinical characteristics were also collected. Descriptive statistics were used to summarize all data. Results: 81 of 117 CRC survivors who met all eligibility criteria were included in this sub-analysis. The number of survivors visits varied across time, V1 = 81, V2 = 56, and V3 = 36. Most survivors were male (51.9%) and Caucasian (66.7%). 67.9% reported being 5-8 years post-treatment. 58% were diagnosed with colon cancer and of those 61.7% were Stage IIIA-IV compared to 55.8% of rectal cancer survivors with advanced disease. Table 1 summarizes the percentage of CR rates across the 3 visits. Conclusion: CRs for H & PEs and colonoscopies remained high across the 3 visits. CRs were lowest for CEA recommendations. These low rates suggest further work is needed to determine barriers in clinical practice that limit use of CEA tumor marker monitoring in CRC survivors. Citation Format: Guadalupe Palos, Katherine R. Gilmore, Patricia Chapman, Paula Lewis-Patterson, Weiqi Bi, Maria Alma Rodriguez. Low concordance with CEA tumor marker monitoring in colorectal cancer survivors. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3464.

Changing Nursing Practice in Survivorship Care With Clinical Decision Tools

The paradigm shift to include survivorship care as part of the cancer care continuum underscores the critical need for a change in nursing practice. One way to ensure that change in practice is delivered in a safe and efficient manner is through the use of clinical decision tools (CDTs). Such tools can be used to increase relevant knowledge and skills of nurses and patients. Despite the widespread recognition of their value, CDTs to educate providers on cancer survivors’ care are limited and, when available, often are not used. Clinical practice algorithms were developed for disease-specific survivorship clinics in a cancer academic center. This article reviews the conceptual framework of the survivorship algorithms, describes the application of the algorithms in multidisciplinary disease-specific survivorship clinics, and discusses the implementation strategies used to promote clinicians’ adoption and implementation of the algorithms. At a Glance • The authors found that algorithms can be successfully used as clinical decision tools(CDTs) to deliver survivorship care. • Algorithms and other CDTs are powerful tools to enhance professional practice. • Additional studies are needed to assess their effect on clinical practice and survivor outcomes.

Ethical Issues in Cancer Survivorship

Abstract Ethical issues challenge the medical decisions made by oncology health care providers in their day-to-day clinical practice. Ethical issues differ across the continuum of the cancer experience, particularly in the case of long-term cancer survivors. This group of survivors enters the cancer experience, exit, and often re-enter that continuum across their lifespan. Thus, it is clear that caring for a survivor is a dynamic process, which can lead to a myriad of ethical challenges. In this chapter, we will define who is a cancer survivor and present basic concepts of cancer survivorship. Next, the role of communication, worldviews, and ethical decision-making will be explored in relationship to cancer survivorship. Then we will discuss the impact of ethical principles on discussions related to late and long-term effects on the survivorship trajectory. Throughout the chapter, clinical vignettes will be used to demonstrate how ethical theories are linked to daily clinical practice within a survivorship paradigm.

Cancer Prevention in the Survivorship Setting

OBJECTIVES To describe how nurses can use risk reduction and health promotion activities to facilitate surveillance of late effects and secondary cancers in long-term cancer survivors. DATA SOURCES Literature review on survivorship, nursing practice, cancer prevention, and survivorship; articles published in peer-reviewed scientific journals; and Web-based or professional organization resources. CONCLUSION Appropriate participation in screening activities, early detection of cancer, and further advances in treatment have contributed to the rise in cancer survivors. A demand for nurses with clinical experience and competence in survivorship care will follow. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses have an essential role in providing safe and high-quality care throughout the survivorship experience, which can contribute to better long-term outcomes.

Application of a standard practice-based system to measure and compare quality of cancer survivorship care.

239 Background: Despite the growing committment to improve survivorship care, measuring its quality remains difficult. In 2006, the American Society of Clinical Oncologists (ASCO) launched a practice-based system known as the Quality Oncology Practice Initiative (QOPI) to measure the quality of cancer care. Here, we demonstrate the use of QOPI procedures to compare compliance with survivorship care plans (SCPs) across different disease-specific clinics. METHODS Measures based on survivorship clinical practice guidelines were abstracted from SCPs issued to survivors scheduled for appointments in site-specific clinics. Following QOPI procedures, we identified the target condition as cancer, selected data collection methods, and determined core measures for abstraction. Procedures included; identifying the number of survivors arriving for appointments within the specified time period, standardizing denominators and numerators used per clinic, determining the number of full-time providers per clinic, and calculating the number of records to audit per clinic. All data were obtained from completed care plans, institutional electronic medical records, and scheduling systems. Descriptive statistics were used to conduct aggregate analyses of de-identified data. The same procedures were followed in each clinic. RESULTS From September 1, 2014, to August 31, 2015, we used a standard process to assess compliance for issuing survivorship care plans across 9 clinics. There were a total of 8864 arrived appointments; 46 providers completed a total of 7448 electronic survivorship care plans over the time period. Analysis of compliance rates indicated broad variation across clinics, including: breast (85.3%), gastrointestinal (80.2%), genitourinary (88.5%), gynecology (78.6%), head/neck (96.8%), lymphoma (99.3%), melanoma (62.2%), thyroid (75.4%) and thoracic (63.3%). CONCLUSIONS Establishing uniform procedures, such as the QOPI process, to measure and compare compliance with SCPs will help achieve high quality standards of care for long-term cancer survivors. Further examination is warranted to determine longitudinal trends and factors contributing to variation in compliance rates.

SMART chemotherapy: A comprehensive cancer center’s journey to shared medical appointments.

135 Background: Shared medical appointments (SMA) offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. To our knowledge, there are no established SMA models for oncology patients undergoing treatment. Our objective was to develop and implement a SMA for chemotherapy education and clearance for women with gynecologic cancer. METHODS We first assessed the level of interest in SMAs among our patients and providers through qualitative interviews. We subsequently created a multidisciplinary team comprised of physicians, mid-level providers, nurses, pharmacists, administrators, health education specialists and members of the QI Department. Our project consisted of several phases: 1) provider buy-in, 2) program development, 3) staff education, 4) implementation; and 5) patient recruitment. A plan-do-study-act cycle was performed following each SMA, using patient and provider feedback. Appropriate modifications were made before the subsequent SMA. RESULTS Both patients and providers identified pre-chemotherapy as an optimal area to pilot SMAs. We established a multidisciplinary Shared Medical Appointment and Readiness Teaching (SMART) clinic for all gynecologic oncology patients initiating chemotherapy with platinum- and taxane-based regimens. This model of care provides patient education within a framework of social support that empowers patients. We developed a standardized chemotherapy education presentation, and also provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advanced directives and center contact information. Surveyed patients reported being highly satisfied with the group visit and would recommend SMA to other patients. Our preliminary data analysis revealed that SMART visits decreased wait time and increased value-added time for patients. CONCLUSIONS SMAs for oncology patients initiating chemotherapy is both novel and feasible. A patient centric model, collaboration of multidisciplinary team members, and timely responsiveness to constructive feedback are essential to the successful integration of SMAs in an academic center.