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Keating NL, Cleveland JLF, Wright AA, Brooks GA, Meneades L, Riedel L, Zubizarreta JR, Landrum MB. Evaluation of Reliability and Correlations of Quality Measures in Cancer Care. JAMA Netw Open 2021; 4:e212474. [PMID: 33749769 PMCID: PMC7985722 DOI: 10.1001/jamanetworkopen.2021.2474] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Measurement of the quality of care is important for alternative payment models in oncology, yet the ability to distinguish high-quality from low-quality care across oncology practices remains uncertain. OBJECTIVE To assess the reliability of cancer care quality measures across oncology practices using registry and claims-based measures of process, utilization, end-of-life (EOL) care, and survival, and to assess the correlations of practice-level performance across measure and cancer types. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the Surveillance, Epidemiology, and End Results (SEER) Program registry linked to Medicare administrative data to identify individuals with lung cancer, breast cancer, or colorectal cancer (CRC) that was newly diagnosed between January 1, 2011, and December 31, 2015, and who were treated in oncology practices with 20 or more patients. Data were analyzed from January 2018 to December 2020. MAIN OUTCOMES AND MEASURES Receipt of guideline-recommended treatment and surveillance, hospitalizations or emergency department visits during 6-month chemotherapy episodes, care intensity in the last month of life, and 12-month survival were measured. Summary measures for each domain in each cohort were calculated. Practice-level rates for each measure were estimated from hierarchical linear models with practice-level random effects; practice-level reliability (reproducibility) for each measure based on the between-measure variance, within-measure variance, and distribution of patients treated in each practice; and correlations of measures across measure and cancer types. RESULTS In this study of SEER registry data linked to Medicare administrative data from 49 715 patients with lung cancer treated in 502 oncology practices, 21 692 with CRC treated in 347 practices, and 52 901 with breast cancer treated in 492 practices, few practices had 20 or more patients who were eligible for most process measures during the 5-year study period. Patients were 65 years or older; approximately 50% of the patients with lung cancer and CRC and all of the patients with breast cancer were women. Most measures had limited variability across practices. Among process measures, 0 of 6 for lung cancer, 0 of 6 for CRC, and 3 of 11 for breast cancer had a practice-level reliability of 0.75 or higher for the median-sized practice. No utilization, EOL care, or survival measure had reliability across practices of 0.75 or higher. Correlations across measure types were low (r ≤ 0.20 for all) except for a correlation between the CRC process and 1-year survival summary measures (r = 0.35; P < .001). Summary process measures had limited or no correlation across lung cancer, breast cancer, and CRC (r ≤ 0.16 for all). CONCLUSIONS AND RELEVANCE This study found that quality measures were limited by the small numbers of Medicare patients with newly diagnosed cancer treated in oncology practices, even after pooling 5 years of data. Measures had low reliability and had limited to no correlation across measure and cancer types, suggesting the need for research to identify reliable quality measures for practice-level quality assessments.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. F. Cleveland
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laurie Meneades
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lauren Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Statistics, Harvard Faculty of Arts and Sciences, Cambridge, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Duggan C, Dvaladze A, Rositch AF, Ginsburg O, Yip CH, Horton S, Rodriguez RC, Eniu A, Mutebi M, Bourque JM, Masood S, Unger-Saldaña K, Cabanes A, Carlson RW, Gralow JR, Anderson BO. The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview. Cancer 2020; 126 Suppl 10:2339-2352. [PMID: 32348573 PMCID: PMC7482869 DOI: 10.1002/cncr.32891] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice. METHODS In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening. RESULTS Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits. CONCLUSIONS Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.
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Affiliation(s)
| | | | - Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ophira Ginsburg
- Perlmutter Cancer Center, Section for Global Health, Division of Health and Behavior, Department of Population Health, New York University Langone Health, NY, USA
| | | | - Susan Horton
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Alexandru Eniu
- Hopital Riviera Chablais, Vaud-Valais, Rennaz, Switzerland
| | - Miriam Mutebi
- Breast Surgical Oncology, Aga Khan University Hospital, Nairobi, Kenya
| | - Jean-Marc Bourque
- Department of Radiation Oncology, University of Ottawa, Ottawa, Canada
- Department of Medicine, McGill University, Montreal, Canada
| | - Shahla Masood
- University of Florida Health Jacksonville Breast Center, Jacksonville, FL, USA
| | | | | | - Robert W. Carlson
- National Comprehensive Cancer Center, Plymouth Meeting, Pennsylvania, USA
| | | | - Benjamin O Anderson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Pluchino LA, D'Amico TA. National Comprehensive Cancer Network Guidelines: Who Makes Them? What Are They? Why Are They Important? Ann Thorac Surg 2020; 110:1789-1795. [PMID: 32298647 DOI: 10.1016/j.athoracsur.2020.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 11/29/2022]
Abstract
The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 28 leading cancer centers dedicated to improving and facilitating quality, effective, efficient, and accessible cancer care so that patients can live better lives. The NCCN offers a number of programs and resources to give clinicians access to tools and knowledge that can help guide decision making in the management of cancer, including the flagship product, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). The NCCN Guidelines provide evidence-based, consensus-driven guidance for cancer management to ensure that all patients receive preventive, diagnostic, therapeutic, and supportive services that are most likely to lead to optimal outcomes. They are intended to assist all individuals who impact decision making in cancer care, including physicians, nurses, pharmacists, payers, patients and their families, and many others. The development of the NCCN Guidelines is an ongoing and iterative process based on a critical review of the best available evidence and the consensus recommendations made by a multidisciplinary panel of oncology experts. The NCCN Guidelines are the most detailed and frequently updated clinical practice guidelines available in any area of medicine and are the recognized standard for cancer care throughout the world. NCCN Guidelines are used by clinicians, payers, and other health care decision makers around the world to ensure delivery of high-quality, accessible, patient-centered care aimed at optimizing patient outcomes.
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Affiliation(s)
- Lenora A Pluchino
- Clinical Information Operations, National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | - Thomas A D'Amico
- Division of Thoracic Surgery, Duke Cancer Institute, Durham, North Carolina.
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Gockley A, Melamed A, Cronin A, Bookman MA, Burger RA, Cristae MC, Griggs JJ, Mantia-Smaldone G, Matulonis UA, Meyer LA, Niland J, O'Malley DM, Wright AA. Outcomes of secondary cytoreductive surgery for patients with platinum-sensitive recurrent ovarian cancer. Am J Obstet Gynecol 2019; 221:625.e1-625.e14. [PMID: 31207237 DOI: 10.1016/j.ajog.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most women with advanced epithelial ovarian cancer develop recurrent disease, despite maximal surgical cytoreduction and adjuvant platinum-based chemotherapy. In observational studies, secondary cytoreductive surgery has been associated with improved survival; however its use is controversial, because there are concerns that the improved outcomes may reflect selection bias rather than the superiority of secondary surgery. OBJECTIVE To compare the overall survival of women with platinum-sensitive recurrent ovarian cancer treated at National Cancer Institute-designated cancer centers who receive secondary surgery vs chemotherapy. STUDY DESIGN This retrospective cohort study included women from 6 National Cancer Institute-designated cancer centers diagnosed with platinum-sensitive recurrent ovarian cancer between January 1, 2004, and December 31, 2011. The primary outcome was overall survival. Propensity score matching was used to compare similar women who received secondary surgery vs chemotherapy. Additional analyses examined how these findings may be influenced by the prevalence of unobserved confounders at the time of recurrence. RESULTS Among 626 women, 146 (23%) received secondary surgery and 480 (77%) received chemotherapy. In adjusted analyses, patients who received secondary surgery were younger (P = 0.001), had earlier-stage disease at diagnosis (P = 0.002), and had longer disease-free intervals (P < 0.001) compared with those receiving chemotherapy. In the propensity score-matched groups (n = 244 patients), the median overall survival was 54 months in patients who received secondary surgery and 33 months in those treated with chemotherapy (P < 0.001). Among patients who received secondary surgery, 102 (70%) achieved optimal secondary cytoreduction. There were no significant differences in complication rates between the 2 groups. In sensitivity analyses, the survival advantage associated with secondary surgery could be explained by the presence of more multifocal recurrences (if 4.3 times more common), ascites (if 2.7 times more common), or carcinomatosis (if 2.1 times more common) among patients who received chemotherapy instead of secondary surgery. CONCLUSION Patients with platinum-sensitive recurrent ovarian cancer who received secondary surgery had favorable surgical characteristics and were likely to have minimal residual disease following secondary surgery. These patients had a superior median overall survival compared with patients who received chemotherapy, although unmeasured confounders may explain this observed difference.
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Affiliation(s)
- Allison Gockley
- Division of Gynecologic Oncology, Department of Obstetrics Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA.
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA
| | - Angel Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Michael A Bookman
- Division of Medical Oncology, Kaiser Permanente Northern California, San Francisco, CA
| | - Robert A Burger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Jennifer J Griggs
- Department of Health Management and Policy, Division of Internal Medicine, Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Gina Mantia-Smaldone
- Department of Surgical Oncology, Division of Gynecologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Ursula A Matulonis
- Division of Gynecologic Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, MD Anderson Cancer Center, Houston, TX
| | - Joyce Niland
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | - David M O'Malley
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alexi A Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA; Division of Gynecologic Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Powis M, Groome P, Biswanger N, Kendell C, Decker KM, Grunfeld E, McBride ML, Urquhart R, Winget M, Porter GA, Krzyzanowska MK. Cross-Canada differences in early-stage breast cancer treatment and acute-care use. Curr Oncol 2019; 26:e624-e639. [PMID: 31708656 PMCID: PMC6821122 DOI: 10.3747/co.26.5003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Chemotherapy has improved outcomes in early-stage breast cancer, but treatment practices vary, and use of acute care is common. We conducted a pan-Canadian study to describe treatment differences and the incidence of emergency department visits (edvs), edvs leading to hospitalization (edvhs), and direct hospitalizations (hs) during adjuvant chemotherapy. Methods The cohort consisted of women diagnosed with early-stage breast cancer (stages i-iii) during 2007-2012 in British Columbia, Manitoba, Ontario, or Nova Scotia who underwent curative surgery. Parallel provincial analyses were undertaken using linked clinical, registry, and administrative databases. The incidences of edvs, edvhs, and hs in the 6 months after treatment initiation were examined for patients treated with adjuvant chemotherapy. Results The cohort consisted of 50,224 patients. The proportion of patients who received chemotherapy varied by province, with Ontario having the highest proportion (46.4%), and Nova Scotia, the lowest proportion (38.0%). Age, stage, receptor status, comorbidities, and geographic location were associated with receipt of chemotherapy in all provinces. Ontario had the highest proportion of patients experiencing an edv (36.1%), but the lowest proportion experiencing h (6.4%). Conversely, British Columbia had the lowest proportion of patients experiencing an edv (16.0%), but the highest proportion experiencing h (26.7%). The proportion of patients having an edvh was similar across provinces (13.9%-16.8%). Geographic location was associated with edvs, edvhs, and hs in all provinces. Conclusions Intra- and inter-provincial differences in the use of chemotherapy and acute care were observed. Understanding variations in care can help to identify gaps and opportunities for improvement and shared learnings.
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Affiliation(s)
- M Powis
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - P Groome
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON
| | - N Biswanger
- Epidemiology and Cancer Registry Department, CancerCare Manitoba, Winnipeg, MB
| | - C Kendell
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, NS
| | - K M Decker
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
- Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB
| | - E Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
| | - M L McBride
- Cancer Control Research, BC Cancer, Vancouver, BC
| | | | - M Winget
- Stanford University School of Medicine, Stanford, CA, U.S.A
| | - G A Porter
- Department of Surgery, Queen Elizabeth ii Health Sciences Centre, Halifax, NS
| | - M K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON
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When oncologic treatment options outpace the existing evidence: Contributing factors and a path forward. J Cancer Policy 2019. [DOI: 10.1016/j.jcpo.2019.100188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Neuner JM, Kong A, Blaes A, Riley D, Chrischilles E, Smallwood A, Lizarraga I, Schroeder M. The association of socioeconomic status with receipt of neoadjuvant chemotherapy. Breast Cancer Res Treat 2019; 173:179-188. [PMID: 30232683 PMCID: PMC6687292 DOI: 10.1007/s10549-018-4954-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/01/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are advantages to neoadjuvant chemotherapy in operable breast cancer, particularly for those with higher-risk cancers, but little is known about factors that are associated with the use of neoadjuvant chemotherapy outside of clinical trials. We examined whether use of neoadjuvant chemotherapy instead of adjuvant chemotherapy varies by nonclinical factors such as patient socioeconomic status or rural residence. METHODS Women diagnosed with breast cancer in 2013-2014 at eight medical institutions were surveyed by mail regarding their experiences with breast cancer treatment, and this information was linked to hospital-based cancer registries. We examined the use of neoadjuvant chemotherapy among women with histologically confirmed invasive stage I-III breast cancer and used regression models to examine the association of socioeconomic status with chemotherapy timing. We also explored potential mechanisms for those differences. RESULTS Over 29% of the chemotherapy sample overall received neoadjuvant chemotherapy. Neoadjuvant receipt was lower for those with income < $100,000 (AOR 0.56, 95% CI 0.2-0.9) even with adjustment for other demographics, stage, and biomarker status, and findings for education and a variable for both lowest education and income < $100,000 were similar. Rural/urban residence was not associated with neoadjuvant receipt. Differences by income in perceptions of the importance of neoadjuvant chemotherapy advantages and disadvantages did not appear to explain the differences in use by income. CONCLUSIONS In a multicenter sample of breast cancer patients, lower income was strongly associated with less receipt of neoadjuvant chemotherapy. Since patients with lower socioeconomic status are more likely to present with later-stage disease, this pattern has the potential to contribute to breast cancer outcome disparities.
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Affiliation(s)
- Joan M Neuner
- Medical College of Wisconsin, Milwaukee, USA.
- Department of Medicine and Center for Advancing Population Science, Medical College of Wisconsin, HRC, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Amanda Kong
- Medical College of Wisconsin, Milwaukee, USA
| | - Ann Blaes
- University of Minnesota, Minneapolis, USA
| | - Danielle Riley
- University of Iowa College of Public Health, Iowa City, USA
| | | | | | | | - Mary Schroeder
- University of Iowa College of Public Health, Iowa City, USA
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Ho G, Wun T, Muffly L, Li Q, Brunson A, Rosenberg AS, Jonas BA, Keegan TH. Decreased early mortality associated with the treatment of acute myeloid leukemia at National Cancer Institute-designated cancer centers in California. Cancer 2018; 124:1938-1945. [PMID: 29451695 PMCID: PMC6911353 DOI: 10.1002/cncr.31296] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/11/2018] [Accepted: 01/19/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND To the authors' knowledge, few population-based studies to date have evaluated the association between location of care, complications with induction therapy, and early mortality in patients with acute myeloid leukemia (AML). METHODS Using linked data from the California Cancer Registry and Patient Discharge Dataset (1999-2014), the authors identified adult (aged ≥18 years) patients with AML who received inpatient treatment within 30 days of diagnosis. A propensity score was created for treatment at a National Cancer Institute-designated cancer center (NCI-CC). Inverse probability-weighted, multivariable logistic regression models were used to determine associations between location of care, complications, and early mortality (death ≤60 days from diagnosis). RESULTS Of the 7007 patients with AML, 1762 (25%) were treated at an NCI-CC. Patients with AML who were treated at NCI-CCs were more likely to be aged ≤65 years, live in higher socioeconomic status neighborhoods, have fewer comorbidities, and have public health insurance. Patients treated at NCI-CCs had higher rates of renal failure (23% vs 20%; P = .010) and lower rates of respiratory failure (11% vs 14%; P = .003) and cardiac arrest (1% vs 2%; P = .014). After adjustment for baseline characteristics, treatment at an NCI-CC was associated with lower early mortality (odds ratio, 0.46; 95% confidence interval, 0.38-0.57). The impact of complications on early mortality did not differ by location of care except for higher early mortality noted among patients with respiratory failure treated at non-NCI-CCs. CONCLUSIONS The initial treatment of adult patients with AML at NCI-CCs is associated with a 53% reduction in the odds of early mortality compared with treatment at non-NCI-CCs. Lower early mortality may result from differences in hospital or provider experience and supportive care. Cancer 2018;124:1938-45. © 2018 American Cancer Society.
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Affiliation(s)
- Gwendolyn Ho
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
- Kaiser Permanente North Valley, Department of Hematology Oncology, Sacramento, CA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Lori Muffly
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Aaron S. Rosenberg
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Brian A. Jonas
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Theresa H.M. Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California
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Meyer LA, Cronin AM, Sun CC, Bixel K, Bookman MA, Cristea MC, Griggs JJ, Levenback CF, Burger RA, Mantia-Smaldone G, Matulonis UA, Niland JC, O'Malley DM, Wright AA. Use and Effectiveness of Neoadjuvant Chemotherapy for Treatment of Ovarian Cancer. J Clin Oncol 2017; 34:3854-3863. [PMID: 27601552 DOI: 10.1200/jco.2016.68.1239] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose In 2010, a randomized clinical trial demonstrated noninferior survival for patients with advanced ovarian cancer who were treated with neoadjuvant chemotherapy (NACT) compared with primary cytoreductive surgery (PCS). We examined the use and effectiveness of NACT in clinical practice. Patients and Methods A multi-institutional observational study of 1,538 women with stages IIIC to IV ovarian cancer who were treated at six National Cancer Institute-designated cancer centers. We examined NACT use in patients who were diagnosed between 2003 and 2012 (N = 1,538) and compared overall survival (OS), morbidity, and postoperative residual disease in a propensity-score matched sample of patients (N = 594). Results NACT use increased from 16% during 2003 to 2010 to 34% during 2011 to 2012 in stage IIIC disease ( Ptrend < .001), and from 41% to 62% in stage IV disease ( Ptrend < .001). Adoption of NACT varied by institution, from 8% to 30% for stage IIIC disease (P < .001) and from 27% to 61% ( P = .007) for stage IV disease during this time period. In the matched sample, NACT was associated with shorter OS in stage IIIC disease (median OS: 33 v 43 months; hazard ratio [HR], 1.40; 95% CI, 1.11 to 1.77) compared with PCS, but not stage IV disease (median OS: 31 v 36 months; HR, 1.16; 95% CI, 0.89 to 1.52). Patients with stages IIIC and IV disease who received NACT were less likely to have ≥ 1 cm postoperative residual disease, an intensive care unit admission, or a rehospitalization (all P ≤ .04) compared with those who received PCS treatment. However, among women with stage IIIC disease who achieved microscopic or ≤ 1 cm postoperative residual disease, NACT was associated with decreased OS (HR, 1.49; 95% CI, 1.01 to 2.18; P = .04). Conclusion Use of NACT increased significantly between 2003 and 2012. In this observational study, PCS was associated with increased survival in stage IIIC, but not stage IV disease. Future studies should prospectively consider the efficacy of NACT by extent of residual disease in unselected patients.
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Affiliation(s)
- Larissa A Meyer
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Angel M Cronin
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Charlotte C Sun
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Kristin Bixel
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Michael A Bookman
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Mihaela C Cristea
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Jennifer J Griggs
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Charles F Levenback
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Robert A Burger
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Gina Mantia-Smaldone
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Ursula A Matulonis
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Joyce C Niland
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - David M O'Malley
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
| | - Alexi A Wright
- Larissa A. Meyer, Charlotte C. Sun, and Charles F. Levenback, The University of Texas MD Anderson Cancer Center, Houston, TX; Angel M. Cronin, Ursula A. Matulonis, and Alexi A. Wright, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Kristin Bixel and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Michael A. Bookman, US Oncology Research and Arizona Oncology, Tucson, AZ; Mihaela C. Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; Robert A. Burger, University of Pennsylvania; and Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA
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10
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Abstract
BACKGROUND Overuse, the provision of health services for which harms outweigh the benefits, results in suboptimal patient care and may contribute to the rising costs of cancer care. We performed a systematic review of the evidence on overuse in oncology. METHODS We searched Medline, EMBASE, the Cochrane Library, Web of Science, SCOPUS databases, and 2 grey literature sources, for articles published between December 1, 2011 and March 10, 2017. We included publications from December 2011 to evaluate the literature since the inception of the ABIM Foundation's Choosing Wisely initiative in 2012. We included original research articles quantifying overuse of any medical service in patients with a cancer diagnosis when utilizing an acceptable standard to define care appropriateness, excluding studies of cancer screening. One of 4 investigator reviewed titles and abstracts and 2 of 4 reviewed each full-text article and extracted data. Methodology used PRISMA guidelines. RESULTS We identified 59 articles measuring overuse of 154 services related to imaging, procedures, and therapeutics in cancer management. The majority of studies addressed adult or geriatric patients (98%) and focused on US populations (76%); the most studied services were diagnostic imaging in low-risk prostate and breast cancer. Few studies evaluated active cancer therapeutics or interventions aimed at reducing overuse. Rates of overuse varied widely among services and among studies of the same service. CONCLUSIONS Despite recent attention to overuse in cancer, evidence identifying areas of overuse remains limited. Broader investigation, including assessment of active cancer treatment, is critical for identifying improvement targets to optimize value in cancer care.
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11
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Affiliation(s)
- Michael J Hassett
- Michael J. Hassett, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
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12
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Powis M, Sutradhar R, Gonzalez A, Enright KA, Taback NA, Booth CM, Trudeau M, Krzyzanowska MK. Establishing achievable benchmarks for quality improvement in systemic therapy for early-stage breast cancer. Cancer 2017; 123:3772-3780. [PMID: 28678343 DOI: 10.1002/cncr.30804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Setting realistic targets for performance is a consistent challenge in quality improvement. In the current study, the authors used administrative data to define achievable targets for a panel of 15 previously developed quality indicators (QIs) focusing on systemic therapy in patients with early-stage breast cancer. METHODS Deterministically linked administrative databases were used to identify patients with TNM stage I to stage III breast cancer who were diagnosed between 2006 and 2010 in Ontario, Canada. For each individual indicator, data-driven empirical benchmarks were calculated using the pared-mean benchmark approach. Variation in institution-level performance for each indicator was examined through the construction of funnel plots. RESULTS A total of 28,303 patients with early-stage breast cancer were identified, 43% of whom received adjuvant chemotherapy. For the 9 QIs for which receiving the service or outcome was desirable (ie, consultation with a medical oncologist), the benchmark varied from 40.9% to 100%. For the 6 indicators for which not receiving the service or outcome was desirable (ie, incidence of febrile neutropenia), the benchmark varied from 0% to 49.0%. There was substantial variation noted with regard to the number of institutions meeting the target and the amount of interinstitution variation between the QIs. Top performing institutions varied by indicator, with no individual institution meeting the benchmark for all indicators. For the majority of indicators, institution size was not found to be correlated with performance. CONCLUSIONS Data-derived benchmarking can be used to facilitate quality improvement by identifying areas of both good as well as suboptimal performance while defining an achievable target for which to strive. Cancer 2017;123:3772-3780. © 2017 American Cancer Society.
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Affiliation(s)
- Melanie Powis
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Katherine A Enright
- Trillium Health Partners, Mississauga, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan A Taback
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | - Maureen Trudeau
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Odette Cancer Centre, Toronto, Ontario, Canada
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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Weingart SN, Stoffel EM, Chung DC, Sequist TD, Lederman RI, Pelletier SR, Shields HM. Working up rectal bleeding in adult primary care practices. J Eval Clin Pract 2017; 23:279-287. [PMID: 27436515 DOI: 10.1111/jep.12596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation. METHODS We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups. RESULTS Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance. CONCLUSION Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.
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Affiliation(s)
- Saul N Weingart
- Tufts Medical Center, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | | | - Daniel C Chung
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Thomas D Sequist
- Harvard Medical School, Boston, MA, USA.,Partners Healthcare System, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Data Management Core, Dana-Farber Cancer Institute Boston, Boston, MA, USA
| | | | - Helen M Shields
- Harvard Medical School, Boston, MA, USA.,Division of Medical Communications, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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14
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Becerra AZ, Aquina CT, Berho M, Boscoe FP, Schymura MJ, Noyes K, Monson JR, Fleming FJ. Surgeon-, pathologist-, and hospital-level variation in suboptimal lymph node examination after colectomy: Compartmentalizing quality improvement strategies. Surgery 2017; 161:1299-1306. [PMID: 28088321 DOI: 10.1016/j.surg.2016.11.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/05/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and to examine if this variation affects 5-year, disease-specific survival. METHODS A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I-III colon cancer from 2004-2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses. RESULTS The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival. CONCLUSION There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.
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Affiliation(s)
- Adan Z Becerra
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mariana Berho
- Department of Laboratory Medicine, Cleveland Clinic Florida, Weston, FL
| | - Francis P Boscoe
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Maria J Schymura
- New York State Cancer Registry, Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, Division of Health Services Policy and Practice, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - John R Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, Florida Hospital, Orlando, FL
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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15
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Pellet AC, Erten MZ, James TA. Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost. Am J Surg 2015; 211:1084-8. [PMID: 26545344 DOI: 10.1016/j.amjsurg.2015.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/23/2015] [Accepted: 08/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients. METHODS A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded. RESULTS From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905. CONCLUSIONS Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost.
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Affiliation(s)
- Andrew C Pellet
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Mujde Z Erten
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Ted A James
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA.
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16
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Beeler PE, Orav EJ, Seger DL, Dykes PC, Bates DW. Provider variation in responses to warnings: do the same providers run stop signs repeatedly? J Am Med Inform Assoc 2015; 23:e93-8. [PMID: 26499104 DOI: 10.1093/jamia/ocv117] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/30/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Variation in the use of tests and treatments has been demonstrated to be substantial between providers and geographic regions. This study assessed variation between outpatient providers in overriding electronic prescribing warnings. METHODS Responses to warnings were prospectively logged. Random effects models were used to calculate provider-to-provider variation in the rates for the decisions to override warnings in 6 different clinical domains: medication allergies, drug-drug interactions, duplicate drugs, renal recommendations, age-based recommendations, and formulary substitutions. RESULTS A total of 157 482 responses were logged. Differences between 1717 providers accounted for 11% of the overall variability in override rates, so that while the average override rate was 45.2%, individual provider rates had a wide range with a 95% confidence interval (CI) (13.7%-76.7% ). The highest variations between providers were observed in the categories age-based (25.4% of total variability; average override rate 70.2% [95% CI, 29.1%-100% ]) and renal recommendations (24.2%; average 70% [95% CI, 29.5%-100% ]), and provider responses within these 2 categories were most often clinically inappropriate according to prior work. Among providers who received at least 10 age-based recommendations, 64 of 238 (27%) overrode ≥ 90% of the warnings and 13 of 238 (5%) overrode all of them. Of those who received at least 10 renal recommendations, 36 of 92 (39%) overrode ≥ 90% of the alerts and 9 of 92 (10%) overrode all of them. CONCLUSIONS The decision to override prescribing warnings shows variation between providers, and the magnitude of variation differs among the clinical domains of the warnings; more variation was observed in areas with more inappropriate overrides.
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Affiliation(s)
- Patrick E Beeler
- Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Research Center for Medical Informatics, University Hospital Zurich, Switzerland
| | - E John Orav
- Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Diane L Seger
- Partners Healthcare Systems, Inc, Wellesley, Massachusetts, USA
| | - Patricia C Dykes
- Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Partners Healthcare Systems, Inc, Wellesley, Massachusetts, USA
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17
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Stienen JJC, Hermens RPMG, Wennekes L, van de Schans SAM, van der Maazen RWM, Dekker HM, Liefers J, van Krieken JHJM, Blijlevens NMA, Ottevanger PB. Variation in guideline adherence in non-Hodgkin's lymphoma care: impact of patient and hospital characteristics. BMC Cancer 2015; 15:578. [PMID: 26253203 PMCID: PMC4529707 DOI: 10.1186/s12885-015-1547-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 07/14/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The objective of this observational study was to assess the influence of patient, tumor, professional and hospital related characteristics on hospital variation concerning guideline adherence in non-Hodgkin's lymphoma (NHL) care. METHODS Validated, guideline-based quality indicators (QIs) were used as a tool to assess guideline adherence for NHL care. Multilevel logistic regression analyses were used to calculate variation between hospitals and to identify characteristics explaining this variation. Data for the QIs regarding diagnostics, therapy, follow-up and organization of care, together with patient, tumor and professional related characteristics were retrospectively collected from medical records; hospital characteristics were derived from questionnaires and publically available data. RESULTS Data of 423 patients diagnosed with NHL between October 2010 and December 2011 were analyzed. Guideline adherence, as measured with the QIs, varied considerably between the 19 hospitals: >20 % variation was identified in all 20 QIs and high variation between the hospitals (>50 %) was seen in 12 QIs, most frequently in the treatment and follow-up domain. Hospital variation in NHL care was associated more than once with the characteristics age, extranodal involvement, multidisciplinary consultation, tumor type, tumor aggressiveness, LDH level, therapy used, hospital region and availability of a PET-scanner. CONCLUSION Fifteen characteristics identified at the patient level and at the hospital level could partly explain hospital variation in guideline adherence for NHL care. Particularly age was an important determinant: elderly were less likely to receive care as measured in the QIs. The identification of determinants can be used to improve the quality of NHL care, for example, for standardizing multidisciplinary consultations in daily practice.
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Affiliation(s)
- Jozette J C Stienen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Rosella P M G Hermens
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Lianne Wennekes
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Saskia A M van de Schans
- Netherlands Comprehensive Cancer Organisation, Department of Registry and Research, PO box 19079, 3501 DB, Utrecht, the Netherlands.
| | | | - Helena M Dekker
- Department of Radiology, Radboud university medical center, Nijmegen, the Netherlands.
| | - Janine Liefers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | | | - Nicole M A Blijlevens
- Department of Hematology, Radboud university medical center, Nijmegen, The Netherlands.
| | - Petronella B Ottevanger
- Department of Medical Oncology, Radboud university medical center, Nijmegen, the Netherlands.
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18
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Wright AA, Cronin A, Milne DE, Bookman MA, Burger RA, Cohn DE, Cristea MC, Griggs JJ, Keating NL, Levenback CF, Mantia-Smaldone G, Matulonis UA, Meyer LA, Niland JC, Weeks JC, O'Malley DM. Use and Effectiveness of Intraperitoneal Chemotherapy for Treatment of Ovarian Cancer. J Clin Oncol 2015; 33:2841-7. [PMID: 26240233 DOI: 10.1200/jco.2015.61.4776] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A 2006 randomized trial demonstrated a 16-month survival benefit with intraperitoneal and intravenous (IP/IV) chemotherapy administered to patients who had ovarian cancer, compared with IV chemotherapy alone, but more treatment-related toxicities. The objective of this study was to examine the use and effectiveness of IP/IV chemotherapy in clinical practice. PATIENTS AND METHODS Prospective cohort study of 823 women with stage III, optimally cytoreduced ovarian cancer diagnosed at six National Comprehensive Cancer Network institutions. We examined IP/IV chemotherapy use in all patients diagnosed between 2003 and 2012 (N = 823), and overall survival and treatment-related toxicities with Cox regression and logistic regression, respectively, in a propensity score-matched sample (n = 402) of patients diagnosed from 2006 to 2012, excluding trial participants, to minimize selection bias. RESULTS Use of IP/IV chemotherapy increased from 0% to 33% between 2003 and 2006, increased to 50% from 2007 to 2008, and plateaued thereafter. Between 2006 and 2012, adoption of IP/IV chemotherapy varied by institution from 4% to 67% (P < .001) and 43% of patients received modified IP/IV regimens at treatment initiation. In the propensity score-matched sample, IP/IV chemotherapy was associated with significantly improved overall survival (3-year overall survival, 81% v 71%; hazard ratio, 0.68; 95% CI, 0.47 to 0.99), compared with IV chemotherapy, but also more frequent alterations in chemotherapy delivery route (adjusted rates discontinuation or change, 20.4% v 10.0%; adjusted odds ratio, 2.83; 95% CI, 1.47 to 5.47). CONCLUSION Although the use of IP/IV chemotherapy increased significantly at National Comprehensive Cancer Network centers between 2003 and 2012, fewer than 50% of eligible patients received it. Increasing IP/IV chemotherapy use in clinical practice may be an important and underused strategy to improve ovarian cancer outcomes.
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Affiliation(s)
- Alexi A Wright
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Angel Cronin
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dana E Milne
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael A Bookman
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert A Burger
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Cohn
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mihaela C Cristea
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jennifer J Griggs
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy L Keating
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles F Levenback
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gina Mantia-Smaldone
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ursula A Matulonis
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joyce C Niland
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane C Weeks
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David M O'Malley
- Alexi A. Wright, Angel Cronin, Dana E. Milne, Nancy L. Keating, Ursula A. Matulonis, and Jane C. Weeks, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Robert A. Burger, University of Pennsylvania; Gina Mantia-Smaldone, Fox Chase Cancer Center, Philadelphia, PA; David E. Cohn and David M. O'Malley, The Ohio State University Comprehensive Cancer Center, Columbus, OH; Mihaela Cristea and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte, CA; Jennifer J. Griggs, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; and Charles F. Levenback and Larissa A. Meyer, The University of Texas MD Anderson Cancer Center, Houston, TX
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Fred HL. Good doctors and the State of Missouri: a connection worth remembering. Tex Heart Inst J 2015; 41:571-2. [PMID: 25593516 DOI: 10.14503/thij-14-4818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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