Provider Differences in Use of Implanted Ports in Older Adults With Cancer

Identification and classification of principal features for analyzing unwarranted clinical variation

RATIONALE, AIMS, AND OBJECTIVE

Unwarranted clinical variation (UCV) is an undesirable aspect of a healthcare system, but analyzing for UCV can be difficult and time-consuming. No analytic feature guidelines currently exist to aid researchers. We performed a systematic review of UCV literature to identify and classify the features researchers have identified as necessary for the analysis of UCV.

METHODS

The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We looked for articles with the terms 'medical practice variation' and 'unwarranted clinical variation' from four databases: Medline, Web of Science, EMBASE and CINAHL. The search was performed on 24 March 2023. The articles selected were original research articles in the English language reporting on UCV analysis in adult populations. Most of the studies were retrospective cohort analyses. We excluded studies reporting geographic variation based on the Atlas of Variation or small-area analysis methods. We used ASReview Lab software to assist in identifying articles for abstract review. We also conducted subsequent reference searches of the primary articles to retrieve additional articles.

RESULTS

The search yielded 499 articles, and we reviewed 46. We identified 28 principal analytic features utilized to analyze for unwarranted variation, categorised under patient-related or local healthcare context factors. Within the patient-related factors, we identified three subcategories: patient sociodemographics, clinical characteristics, and preferences, and classified 17 features into seven subcategories. In the local context category, 11 features are classified under two subcategories. Examples are provided on the usage of each feature for analysis.

CONCLUSION

Twenty-eight analytic features have been identified, and a categorisation has been established showing the relationships between features. Identifying and classifying features provides guidelines for known confounders during analysis and reduces the steps required when performing UCV analysis; there is no longer a need for a UCV researcher to engage in time-consuming feature engineering activities.

Implanted Port Access in the Emergency Department: A Unit-Level Feasibility Study of a Nurse-Led Port Access Algorithm

INTRODUCTION

The objective of this study was to determine the impact of an emergency nurse-led implanted port access algorithm for ED patients with implanted ports admitted to the hospital.

METHODS

A feasibility study evaluated the implementation of a central line-associated bloodstream infection algorithm in the emergency department over a 1-month study period. Emergency nurses received central line-associated bloodstream infection education and training for port access algorithm implementation. Pre- and postimplementation surveys measured the nurses' knowledge, attitudes, and behaviors regarding central line-associated bloodstream infections. The nurses' perceptions of the algorithm were assessed pre- and postimplementation. ED patient port access and central line-associated bloodstream infection rates were compared with preimplementation rates.

RESULTS

Emergency nurses (N = 32) received central line-associated bloodstream infection education and algorithm training. Pre- and postimplementation as well as knowledge, attitude, and behavior surveys were completed by 59% (n = 19) of the nursing staff. Knowledge regarding central line-associated bloodstream infections significantly improved, t₍₁₉₎ = -4.8, P < .001. The nurses' pre- and postimplementation attitude and behavior scores did not differ significantly. They expressed no concerns regarding implementation of the algorithm; 89% (n = 17) reported that the algorithm "fit well" with the ED workflow, and 21% (n = 4) integrated the patient's decision regarding venous access into their shift report. The ED port access incidence during the study period was 17.6% (n = 3), compared with 83.3% (n = 15) in the month before the study.

DISCUSSION

The emergency nurse-led port access algorithm decreased ED port access rates. The nurses' pre- and postimplementation knowledge of central line-associated bloodstream infections increased. The emergency nurse-led port access algorithm empowered emergency nurses to educate their patients on implanted port access and decreased central line use.

Use of High-Cost Cancer Treatments in Academic and Nonacademic Practice

BACKGROUND

Academic physicians, such as those affiliated with National Cancer Institute (NCI)-designated Comprehensive Cancer Centers, may have different practice patterns regarding the use of high-cost cancer drugs than nonacademic physicians.

MATERIALS AND METHODS

For this cohort study, we linked cancer registry, administrative, and demographic data for patients with newly diagnosed cancer in North Carolina from 2004 to 2011. We selected cancer types with multiple U.S. Food and Drug Administration-approved, National Comprehensive Cancer Network-recommended treatment options and large differences in reimbursement between higher-priced and lower-priced options (stage IV colorectal, stage IV lung, and stage II-IV head-and-neck cancers). We assessed whether provider's practice setting-NCI-designated Comprehensive Cancer Center ("NCI") versus other location ("non-NCI")-was associated with use of higher-cost treatment options. We used inverse probability of exposure weighting to control for patient characteristics.

RESULTS

Of 800 eligible patients, 79.6% were treated in non-NCI settings. Patients treated in non-NCI settings were more likely to receive high-cost treatment than patients treated in NCI settings (36.0% vs. 23.2%), with an unadjusted prevalence difference of 12.7% (95% confidence interval [CI], 5.1%-20.0%). After controlling for potential confounding factors, non-NCI patients remained more likely to receive high-cost treatment, although the strength of association was attenuated (adjusted prevalence difference, 9.6%; 95% CI -0.1%-18.7%). Exploratory analyses suggested potential heterogeneity across cancer type and insurance status.

CONCLUSION

Use of higher-cost cancer treatments may be more common in non-NCI than NCI settings. This may reflect differential implementation of clinical evidence, local practice variation, or possibly a response to the reimbursement incentives presented by chemotherapy billing.

IMPLICATIONS FOR PRACTICE

Oncology care delivery and practice patterns may vary between care settings. By comparing otherwise similar patients treated in National Cancer Institute (NCI)-designated Comprehensive Cancer Centers with those treated elsewhere, this study suggests that patients may be more likely to receive treatment with certain expensive cancer drugs if treated in the non-NCI setting. These practice differences may result in differences in patient costs and outcomes as a result of where they receive treatment.

Pembrolizumab microgravity crystallization experimentation

Crystallization processes have been widely used in the pharmaceutical industry for the manufacture, storage, and delivery of small-molecule and small protein therapeutics. However, the identification of crystallization processes for biologics, particularly monoclonal antibodies, has been prohibitive due to the size and the flexibility of their overall structure. There remains a challenge and an opportunity to utilize the benefits of crystallization of biologics. The research laboratories of Merck Sharp & Dome Corp. (MSD) in collaboration with the International Space Station (ISS) National Laboratory performed crystallization experiments with pembrolizumab (Keytruda^®) on the SpaceX-Commercial Resupply Services-10 mission to the ISS. By leveraging microgravity effects such as reduced sedimentation and minimal convection currents, conditions producing crystalline suspensions of homogeneous monomodal particle size distribution (39 μm) in high yield were identified. In contrast, the control ground experiments produced crystalline suspensions with a heterogeneous bimodal distribution of 13 and 102 μm particles. In addition, the flight crystalline suspensions were less viscous and sedimented more uniformly than the comparable ground-based crystalline suspensions. These results have been applied to the production of crystalline suspensions on earth, using rotational mixers to reduce sedimentation and temperature gradients to induce and control crystallization. Using these techniques, we have been able to produce uniform crystalline suspensions (1–5 μm) with acceptable viscosity (<12 cP), rheological, and syringeability properties suitable for the preparation of an injectable formulation. The results of these studies may help widen the drug delivery options to improve the safety, adherence, and quality of life for patients and caregivers.

Practice Patterns for Older Adult Patients With Advanced Cancer: Physician Office Versus Hospital Outpatient Setting

PURPOSE

A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments.

METHODS

This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians.

RESULTS

Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting.

CONCLUSION

We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.

Optimal vascular access strategies for patients receiving chemotherapy for early-stage breast cancer: a systematic review

IMPORTANCE

Systemic chemotherapy can be administered either through a peripheral vein (IV), or centrally through peripherally inserted central catheter (PICC), totally implanted vascular access devices (PORTs) or tunnelled cuffed catheters. Despite the widespread use of systemic chemotherapy in patients with breast cancer, the optimal choice of vascular access is unknown.

OBJECTIVE

This systematic review evaluated complication rates and patient satisfaction with different access strategies for administering neo/adjuvant chemotherapy for breast cancer.

EVIDENCE REVIEWED

Ovid Medline, EMBASE and the Cochrane Central Register of Controlled Trials were searched from 1946 to September 2017. Two reviewers independently assessed each citation. The Newcastle-Ottawa scale was used to assess the quality of cohort and case-control studies.

FINDINGS

Of 1584 citations identified, 15 unique studies met the pre-specified eligibility criteria. There were no randomised studies comparing types of vascular access. Reports included six single-institution retrospective cohort studies, one retrospective multi-institution cohort, one retrospective cohort database study, five prospective single-institution studies, one prospective multi-institution study and one nested case-control study. Median complication rates were infection: 6.0% PICC (2 studies) versus 2.1% PORT (8 studies); thrombosis: 8.9% PICC (2 studies) versus 2.6% PORT (9 studies); extravasation: 0 PICC (1 study) versus 0.4% PORT (4 studies) and mechanical issues: PICC 3.8% (1 study) versus 1.8% PORT (9 studies). Satisfaction/quality of life appeared high with each device.

CONCLUSION

In the absence of high-quality data comparing vascular access strategies, randomised, adequately powered, prospective studies would be required to help inform clinical practice and reduce variation.

Upper-Extremity Deep Vein Thrombosis in Patients With Breast Cancer With Chest Versus Arm Central Venous Port Catheters

Most of the patients undergoing treatment for cancer require placement of a totally implantable venous access device to facilitate safe delivery of chemotherapy. However, implantable ports also increase the risk of deep vein thrombosis and related complications in this high-risk population. The objective of this study was to assess the incidence of upper-extremity deep vein thrombosis (UEDVT) in patients with breast cancer to determine whether the risk of UEDVT was higher with chest versus arm ports, as well as to determine the importance of previously reported risk factors predisposing to UEDVT in the setting of active cancer. We retrospectively reviewed the medical records of 297 women with breast cancer who had ports placed in our institution between the dates of December 1, 2010, and December 31, 2016. The primary outcome was the development of radiologically confirmed UEDVT ipsilateral to the implanted port. Overall, 17 of 297 study subjects (5.7%) were found to have UEDVT. There was 1 documented case of associated pulmonary embolism. Fourteen (9.5%) of 147 subjects with arm ports experienced UEDVT compared with only 3 (2.0%) of 150 subjects with chest ports (P = .0056). Thus, implantation of arm ports as opposed to chest ports may be associated with a higher rate of UEDVT in patients with breast cancer.

Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer

IMPORTANCE

Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions.

OBJECTIVE

To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases.

MAIN OUTCOME AND MEASURES

To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use.

RESULTS

Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively).

CONCLUSIONS AND RELEVANCE

Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.