Factors and Costs Associated With Delay in Treatment Initiation and Prolonged Length of Stay With Inpatient EPOCH Chemotherapy in Patients With Hematologic Malignancies

An economic evaluation of fine-needle cytology as the primary diagnostic tool in the diagnosis of lymphadenopathy

Fine-needle aspiration cytology (FNAC) is commonly used to obtain a pre-surgical pathological diagnosis in many organs, but its cost-effectiveness in lymphadenopathy has not been studied yet. We calculated the cost and diagnostic accuracy of a diagnostic algorithm that uses FNAC as a first-line procedure and compared it to a purely surgical approach in 545 consecutive lymphadenopathies. In 74% of the cases, FNAC alone can obtain a sufficiently detailed diagnosis, avoiding the surgical biopsy. In doing so, the average cost of diagnosis is cut to less than one-third, the patient avoids an invasive procedure and the diagnosis is reached earlier. In conclusion, the systematic use of lymph node-FNAC in the initial assessment of lymphadenopathy is clinically and economically advantageous as it avoids surgical biopsies in cases where cytology can suffice.

Utilization of an Outpatient Integrated Infusion Suite to Decrease Length of Stay, Increase Revenue, and Improve Patient Experience for Elective Chemotherapy Admissions

PURPOSE

Reduction of chemotherapy start times (CST) and length of stay (LOS) for elective chemotherapy admissions is a priority. The aim of this project was to improve efficiency of patient care while simultaneously increasing revenue by reducing LOS and transitioning high-cost chemotherapy to the outpatient setting.

METHODS

A multidisciplinary quality improvement team proposed building a new outpatient infusion suite in close proximity to the inpatient unit. This suite was then integrated into the flow of elective inpatient chemotherapy admissions and discharges for etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R). Quality measures such as CST, LOS, and revenue were used to evaluate the new infusion suite.

RESULTS

In the pilot phase of the study, the average CST improved by approximately 1 hour 45 minutes (P = .0218). The mean LOS was reduced from 4.3 to 4.1 midnights (P = .0214). In terms of hours, LOS was reduced from 105.8 to 95.5 hours (P < .0001). A mean quarterly revenue of $309,410 US dollars was noted during the pilot that had not been previously billed. These improvements were sustained throughout the control phase.

CONCLUSION

Delays in CST and prolonged LOS lead to patient dissatisfaction and increased cost to the health care system. Focus groups and patient feedback are important when designing and implementing new workflows. The creation of an outpatient integrated infusion suite allows medical centers to meet patients' expectations of reducing number of visits while also reducing LOS and capturing new revenue. Adherence to scheduling guidelines further reduces the CST for elective chemotherapy administration.

Radiology-pathology correlation for bone and soft tissue tumors or tumor-like masses: single institutional experience after implementation of a weekly conference

OBJECTIVES

To determine the frequency of non-diagnostic and discordant results from bone and soft tissue biopsies performed at our institution over a 3-year period and to investigate whether implementation of a weekly musculoskeletal radiology-pathology correlation conference decreased the time to appropriate patient management in cases of discordance.

METHODS

Consecutive image-guided core needle biopsy results obtained over a 12 month period of time were reviewed in a retrospective fashion. Following implementation of the correlation conference, subsequent consecutive image-guided core needle biopsy results obtained over a 26 month period of time were reviewed in a prospective fashion. For non-diagnostic and discordant cases, the time in days from date of availability of the biopsy result to date of documentation of a specific follow-up action plan was recorded.

RESULTS

Diagnostic yield was 96.5% and 94.9% for the retrospective and prospective periods, respectively. There were four discordant results in the retrospective cohort (1.7%) and seven discordant results in the prospective cohort (2.1%). Following implementation of the weekly correlation conference, there was significant decrease (p < 0.05) in median time from a discordant biopsy result to follow-up action plan. There were no unnecessary surgeries, litigation, or other unfavorable consequences in either cohort.

CONCLUSION

Image-guided core needle biopsies of bone and soft tissue provide high diagnostic yield, often with specific diagnoses. The statistically significant decrease in number of days to follow-up action plan for discordant results suggests radiology-pathology review has a positive impact on patient care. Subjective benefits from communication and educational standpoints are also noteworthy.

Reducing chemotherapy administration time on an inpatient oncology unit

PURPOSE

Due to the multifaceted chemotherapy workflow within the hospital, many patients often experience delays in receiving their treatment. This study aims to evaluate the causes for chemotherapy administration delays and implement new methods to reduce delays from order release to chemotherapy administration on an inpatient oncology unit at a community-focused academic medical center.

METHODS

In this prospective quality improvement study, we developed a process map to track baseline time stamps and utilized performance improvement tools to identify causes for chemotherapy delays. Based on recognized areas for improvement, the Plan-Do-Study-Act (PDSA) model was used to implement one cycle of interventions. Chemotherapy orders were collected, and benchmark time stamps were documented from the electronic medical record.

RESULTS

The primary outcome for the number of chemotherapy delays, based on compliance rate, was reduced from 63/100 (63.0%) to 48/100 (48.0%), a 15% reduction (p = 0.046). Our primary outcome of chemotherapy delays, based on our institutional benchmark of <3 hours, did not show statistical significance. Median time from chemotherapy order release to administration decreased from 7.08 hours at baseline to 6.10 hours post-intervention, a 13.8% reduction (p < 0.0001). Median verification, preparation, and delivery times were all reduced post-intervention by 13.0% (p < 0.0001), 3.9% (p = 0.024), and 14.8% (p < 0.0001) respectively.

CONCLUSIONS

This study allowed our institution to evaluate our current practice and reformulate the chemotherapy administration process. With the continuing education on the chemotherapy administration process and additional PDSA cycle interventions, it will help standardize our process and ultimately continue to reduce chemotherapy delays.

Clinical process optimization of transfemoral transcatheter aortic valve implantation

Background: The avoidance of prolonged hospital stay is a major goal in the management of transcatheter aortic valve implantation (TAVI) - medically and economically. Materials & methods: We compared the time range of the preprocedural length of stay in 2014/2015 with 2016/2017, after the implementation of the TAVI coordinator in 2016. This included restructured pathways for screening and pre-interventional diagnosis, performed examinations during the inpatient stay and major outcome variables. Results: After 2016, we observed a significant reduction in preprocedural length of stay (admission to procedure) compared with 2014/2015 (11.3 ± 7.9 vs 7.5 ± 5.6 days, p = 0.001). There was no difference in other major outcome variables. Conclusion: The introduction of the TAVI coordinator caused a shortening of preprocedural length of stay.

Decreasing Time to Initiation of Chemotherapy for Patients Electively Admitted to a Hematologic Malignancy Service

PURPOSE

Delays in initiating elective inpatient chemotherapy can decrease patient satisfaction and increase length of stay. At our institution, we observed that 86% of patients who were admitted for elective chemotherapy experienced a delay-more than 6 hours-with a median time to chemotherapy of 18.9 hours. We developed a process improvement initiative to improve time to chemotherapy for elective chemotherapy admissions.

METHODS

Our outcome measure was the time from admission to chemotherapy administration in patients who were admitted for elective chemotherapy. Process measures were identified and monitored. We collected baseline data and used performance improvement tools to identify key drivers. We focused on these key drivers to develop multiple plan-do-study-act cycles to improve our outcome measure. Once we started an intervention, we collected data every 2 weeks to assess our intervention.

RESULTS

At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 18.9 hours to 8.85 hours (P = .005). Median time to laboratory results resulted decreased from 3.17 hours to 0.00 hours. There was no change in time from signing chemotherapy to nurse releasing the chemotherapy. We noted that more providers were signing the chemotherapy before patient admission.

CONCLUSION

By implementing new admission workflows, optimizing our use of the electronic medical record to communicate among providers, and improving preadmission planning we were able to reduce our median time to chemotherapy for elective admissions by 53.2%. Improvement is still needed to meet our goals and to ensure the sustainability of these ongoing efforts.

Reducing Wait Time Between Admission and Chemotherapy Initiation

PURPOSE

Reducing the length of stay is a high-priority objective for all health care institutions. Delays in chemotherapy initiation for planned preadmissions lead to patient dissatisfaction and prolonged length of stay.

PATIENTS AND METHODS

A multidisciplinary team was formed as part of the ASCO Quality Training Program. We aimed to reduce the time to initiation of chemotherapy from patient arrival at Parkland Hospital from a median of 6.2 hours at baseline to 4 hours over a 6-month period (35% reduction). The team identified inconsistency in blood work requirements, poor communication, and nonstandard patient arrival times as key causes of delay in the process. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified improvement opportunities. The outcome measure was time from arrival to chemotherapy start. Data were obtained from time stamps in the electronic health record.

RESULTS

The first PDSA cycle included patient reminders to arrive at specific times, improved communication using a smartphone secure messaging application, and preadmission notes by oncology fellows detailing whether fresh blood work were needed on admission. Baseline data from 36 patients and postimplementation data from 28 patients were analyzed. Median time from admission to chemotherapy initiation preprocess change was 6.2 hours; it was 3.2 hours postchange. A sustained shift in the process was apparent on a control chart.

CONCLUSION

Delays in initiation of chemotherapy can be prevented using classic quality improvement methodology and a multidisciplinary team. We aim to further refine our PDSA cycles and ensure sustainability of change.