Peter G. Ellis

Care Management by Oncology Nurses To Address Palliative Care Needs: A Pilot Trial To Assess Feasibility, Acceptability, and Perceived Effectiveness of the CONNECT Intervention

BACKGROUND Specialty palliative care is not accessible for many patients with advanced cancer. There is a need to find alternative palliative care strategies in oncology clinics. OBJECTIVE The objective of the study was to assess the feasibility, acceptability, and perceived effectiveness of an oncology nurse-led care management approach to improve primary palliative care. METHODS The study design was a single-arm pilot trial of the Care Management by Oncology Nurses (CONNECT) intervention, in which registered oncology nurses receive specialized training and work closely with oncologists to (1) address symptom needs; (2) engage patients and caregivers in advance care planning; (3) provide emotional support; and (4) coordinate care. The subjects were 23 patients with advanced cancer, 19 caregivers, and 5 oncologists from a community oncology clinic in western Pennsylvania. Feasibility was assessed through enrollment rates, outcome assessment rates, and visit checklists. Patients, caregivers, and oncologists completed three-month assessments of acceptability and perceived effectiveness. RESULTS The consent-to-approach rate was 86% and enrolled-to-consent rate, 77%. CONNECT was implemented according to protocol for all participants. No participants withdrew after enrollment. Four patients died during the study; three-month outcome assessments were completed with all remaining participants (83%). Patients and caregivers reported high satisfaction with CONNECT and perceived the intervention as helpful in addressing symptoms (85%), coping (91%), and planning for the future (82%). Oncologists unanimously agreed that CONNECT improved the quality of care provided for patients with advanced cancer. CONCLUSION An oncology nurse-led care management intervention is feasible, acceptable, and was perceived to be effective for improving provision of primary palliative care. A randomized trial of CONNECT is warranted.

Development and implementation of oncology care pathways in an integrated care network: the Via Oncology Pathways experience.

Physician involvement is integral to a successful clinical pathways program. The Via Pathways model used at the UPMC CancerCenter, in which the oncologists developing the clinical content are ultimately the oncologists who use the Pathways Portal, has proven to be successful in ensuring physician participation. In addition, an agile user interface and pragmatic layout of the tool are essential for incorporating pathways into the daily workflow of physicians. When appropriately developed and implemented, clinical pathways are an effective tool for standardizing care and ensuring quality.

Clinical Pathways: Management of Quality and Cost in Oncology Networks in the Metastatic Colorectal Cancer Setting

PURPOSE Via Pathways (clinical pathways for cancer) provide evidence-based guidance for specific patient presentations based on the merit of efficacy, then toxicity, and finally cost (if efficacy and toxicity are comparable). We evaluated the impact of a change to the guidance in the metastatic colorectal cancer (mCRC) setting across two large, integrated health networks. METHODS Cetuximab and panitumumab were determined to have equal efficacy in the treatment of mCRC with no significant difference in toxicity based on recent data from key clinical studies. A cost analysis using Centers for Medicare and Medicaid Services average sales data determined a cost advantage for panitumumab. A substitution of panitumumab for cetuximab in the clinical pathway for all mCRC lines of therapy was initiated as of August 2014. RESULTS In the preimplementation period, 86 (93.5%) and six (6.5%) treatment selections were for cetuximab and panitumumab, respectively. After the pathway change was implemented, 13 (18.1%) and 59 (81.9%) treatment selections were for cetuximab and panitumumab, respectively. The change in prescribing habits was rapidly altered by the pathway change. The estimated annualized cost savings for the two health networks resulting from the response to the pathway change was

Pathways Clinical Decision Support for Appropriate Use of Key Biomarkers.

711,021. CONCLUSION This study demonstrates that clinical pathways can act as a tool to assist oncology practices in decreasing costs and quickly responding to changing treatment paradigms by providing clinicians with consensus-driven treatment recommendations that incorporate the most up-to-date clinical trial results, toxicity considerations, and regimen cost information.

Actionable biomarkers in a non-small cell lung cancer (NSCLC) clinical pathway (CP).

PURPOSE Breast cancer diagnostics have the ability to predict disease recurrence and the benefit of chemotherapy. This study measures the use of a diagnostic assay, Oncotype DX, when embedded in a breast cancer decision support algorithm and, on the basis of the assay results, the use of chemotherapy in the adjuvant setting. METHODS UPMC CancerCenter retrospectively reviewed patients with estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)Neu-negative disease with zero to three positive nodes navigated in the Via Pathways decision support portal during a 12-month period. The breast algorithm prompted input of the assay recurrence score (RS) and then recommended hormonal therapy alone (HT) for low RS, or chemotherapy followed by HT for high RS. The patients RS was correlated with the treatment decision. RESULTS During this time period, 643 patients had ER-positive, HER2Neu-negative disease with zero to three positive nodes. Of those, 596 (92.7%) had diagnostic testing to determine chemotherapy plus HT versus HT alone, and 47 had chemotherapy followed by HT without an RS. For node-negative patients classified with low or high RS, pathway treatment adherence rates were 99.7% and 96.6%, respectively; node-positive patients had 95.7% and 87.5% adherence rates, respectively. CONCLUSION This analysis demonstrates the use of a clinical pathway to measure the adoption of a diagnostic test, the Oncotype DX breast assay, and the use of the appropriate therapy on the basis of the RS. As more diagnostics are established to aid in the personalized treatment of diseases, pathways may be important in maintaining clinician awareness of the appropriate disease presentations where these tests should be used, measuring usage of these tests, and tracking the treatment decisions on the basis of test results.

Developing and piloting an electronic telephone triage application.

155 Background: Oncologists use Via Pathways (VP) to drive standardization to best evidence-based cancer care. VP include guidance for biomarker testing and associated treatments. Practices collaborated to analyze the first line non squamous carcinoma NSCLC VP. An unexpectedly large percentage of treatment decisions captured by oncologists in the VP portal had unknown ALK translocation or EGFR mutation test results. The VP was modified to require input of whether or not the test was ordered. This analysis examines the impact of this change. METHODS ALK and EGFR testing responses from the VP database were analyzed pre and post implementation of the change. Treatment decisions were reviewed to analyze prescribing patterns. RESULTS From 1/1/2014 to 1/29/2015, ~40% of EGFR or ALK testing responses were unknown. Post-implementation (1/30/2015 to 5/31/2015), 29.8% were charted as awaiting ALK results and 9.4% did not order the test; 29.5% were charted as awaiting EGFR results and 7.6% did not order the test. For the combined period, appropriate targeted agents were selected for 91.9% (n = 37) and 86.5% (n = 133) of patients who were ALK translocation positive and EGFR sensitizing mutation positive, respectively. CONCLUSIONS Results demonstrate the ability of CP to promote testing of key biomarkers and use of appropriate targeted agents. Frequent evaluation and modification of pathway content is needed to ensure practice patterns are accurately captured. [Table: see text].

Frequency of efficacy, toxicity and cost as the deciding factor when determining clinical pathways.

68 Background: Telephone triage is a vital part of todays oncology practice and is often not standardized and measured to allow for quality improvement. UPMC CancerCenter (UPMC) has 31 outpatient clinics and is in need of a tool to streamline the current telephone triage process. UPMC and Via Oncology collaborated to develop and pilot a prototype of an electronic telephone triage application. The key components of the prototype were defined as decision support, EHR integration, reporting and workflow management. METHODS A prototype application, Symptom Manager (SM), was developed and piloted with 4 nurses at 3 outpatient clinics. Front office staff registered inbound calls in SM, which populated a phone triage queue. The nurse was prompted to enter information about the call. Decision support materials were displayed for reference, including algorithms for symptom assessment, adjudication and treatment. The output was a structured summary of the encounter that was copied to the patients chart. From the queue, the nurse was prompted to make outbound calls for symptom reassessment. A feedback session with nurse users and institution leadership was held following the pilot. RESULTS A total of 235 inbound calls were captured in the application, of which 74 (31.5%) were symptom-related. Additional data fields collected during the pilot included symptom, adjudication, time elapsed for callback, and symptom status at follow up. The ability to extract and report on data of this type was viewed as valuable for quality and process improvement. The nurse users praised SMs ease of use, but prototype performance issues shortened the pilot. When referencing the decision support materials, nurses felt more confident consulting providers and during independent decision-making. They indicated that the standardized documentation increased efficiency. Requests for future enhancements included deeper EHR integration and additional fields for data capture. CONCLUSIONS This prototype fulfilled the defined key components of a tool of this type. SM is currently being refined and incorporated into the Via Portal, Via Oncologys decision support software. An update on the software and additional data captured during the pilot will be provided at presentation.

The usefulness of clinical pathways (CP) in managing quality and cost in oncology networks.

e18169Background: The cost of cancer care has been of increasing concern to patients, payers and providers. There is general agreement that, when clinical outcomes are comparable, the least costly ...

Incorporation of a patient question prompt list into a pancreatic cancer pathway.

715 Background: UPMC CancerCenter (UPMC) and Indiana University Health (IUH) utilize Via Pathways (VP) for their CP initiative. VP are developed and maintained by disease committees that evaluate therapies on merit of efficacy, then toxicity, and finally cost (if efficacy and toxicity are comparable) to provide a recommendation for specific patient presentations. Recent data from key studies regarding the use of panitumumab (PAN) or cetuximab (CET) in the setting of metastatic colo-rectal cancer by the colo-rectal committee led to the determination that both treatments were equally effective with no significant difference in toxicity (Price et al., 2014; Peeters et al., 2014). A subsequent cost comparison utilizing CMS average sales prices demonstrated an approximate 14% monthly cost advantage for PAN. A substitution of PAN for CET across all metastatic lines of therapy in the pathway was initiated as of August 2014. This analysis was undertaken to understand the impact of this change. Methods: We reviewe...

Clinical pathways and quality metrics.

20 Background: Metastatic pancreatic cancer is an aggressive disease affording a life expectancy of less than 6 months (Worni et al., 2013). Timely end-of-life discussions are critical. Patient question prompt lists (QPL) have been shown to facilitate discussions around distressing topics and increase patient satisfaction (Brandes et al., 2014; Clayton et al., 2007). We evaluated the use of a QPL embedded in a pancreatic pathway provided by Via Pathways (VP) to enhance communication between oncologists and patients with metastatic disease. METHODS VP are disease-specific decision support algorithms delivered in a web-based portal and used by oncologists at the point of care. Through a committee of oncologists and palliative care specialists, a QPL was developed and incorporated into the VP pancreatic pathway. The goal of the QPL was to empower patients to have informed discussions of available cancer therapies, treatment goals, and personal preferences. Users of the pathway were required to indicate if the QPL was used, then had to provide it to the patient. The QPL prompt was placed in the first line metastatic branch of the pancreatic pathway and piloted from 12/1/14 to 2/28/15. Following the pilot, users were surveyed through email. RESULTS Results are shown in the table. CONCLUSIONS Based on the results, the pilot had limited success. Although there was an even distribution of those indicating the QPL was and was not provided to the patient, survey results suggested the majority of providers were unaware of the QPL. Our conclusion is that our approach must be less of a burden to the oncologist. Current focus is on automated delivery of advance care planning materials directly to the patient, removing that task from the oncologist workflow. [Table: see text].