Phase I study of procaspase-activating compound-1 (PAC-1) in the treatment of advanced malignancies

BACKGROUND

Procaspase-3 (PC-3) is overexpressed in multiple tumour types and procaspase-activating compound 1 (PAC-1) directly activates PC-3 and induces apoptosis in cancer cells. This report describes the first-in-human, phase I study of PAC-1 assessing maximum tolerated dose, safety, and pharmacokinetics.

METHODS

Modified-Fibonacci dose-escalation 3 + 3 design was used. PAC-1 was administered orally at 7 dose levels (DL) on days 1-21 of a 28-day cycle. Dose-limiting toxicity (DLT) was assessed during the first two cycles of therapy, and pharmacokinetics analysis was conducted on days 1 and 21 of the first cycle. Neurologic and neurocognitive function (NNCF) tests were performed throughout the study.

RESULTS

Forty-eight patients were enrolled with 33 completing ≥2 cycles of therapy and evaluable for DLT. DL 7 (750 mg/day) was established as the recommended phase 2 dose, with grade 1 and 2 neurological adverse events noted, while NNCF testing showed stable neurologic and cognitive evaluations. PAC-1's t1/2 was 28.5 h after multi-dosing, and systemic drug exposures achieved predicted therapeutic concentrations. PAC-1 clinical activity was observed in patients with neuroendocrine tumour (NET) with 2/5 patients achieving durable partial response.

CONCLUSIONS

PAC-1 dose at 750 mg/day was recommended for phase 2 studies. Activity of PAC-1 in treatment-refractory NET warrants further investigation.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov: NCT02355535.

Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19

Importance

Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation.

Objective

To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings.

Exposures

Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO).

Main Outcomes and Measures

The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm.

Results

The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79).

Conclusions and Relevance

This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm.

Trial Registration

ClinicalTrials.gov Identifier: NCT04354701.

Racial Disparities in COVID-19 Outcomes Among Black and White Patients With Cancer

IMPORTANCE

Non-Hispanic Black individuals experience a higher burden of COVID-19 than the general population; hence, there is an urgent need to characterize the unique clinical course and outcomes of COVID-19 in Black patients with cancer.

OBJECTIVE

To investigate racial disparities in severity of COVID-19 presentation, clinical complications, and outcomes between Black patients and non-Hispanic White patients with cancer and COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the COVID-19 and Cancer Consortium registry from March 17, 2020, to November 18, 2020, to examine the clinical characteristics and outcomes of COVID-19 in Black patients with cancer. Data analysis was performed from December 2020 to February 2021.

EXPOSURES

Black and White race recorded in patient's electronic health record.

MAIN OUTCOMES AND MEASURES

An a priori 5-level ordinal scale including hospitalization intensive care unit admission, mechanical ventilation, and all-cause death.

RESULTS

Among 3506 included patients (1768 women [50%]; median [IQR] age, 67 [58-77] years), 1068 (30%) were Black and 2438 (70%) were White. Black patients had higher rates of preexisting comorbidities compared with White patients, including obesity (480 Black patients [45%] vs 925 White patients [38%]), diabetes (411 Black patients [38%] vs 574 White patients [24%]), and kidney disease (248 Black patients [23%] vs 392 White patients [16%]). Despite the similar distribution of cancer type, cancer status, and anticancer therapy at the time of COVID-19 diagnosis, Black patients presented with worse illness and had significantly worse COVID-19 severity (unweighted odds ratio, 1.34 [95% CI, 1.15-1.58]; weighted odds ratio, 1.21 [95% CI, 1.11-1.33]).

CONCLUSIONS AND RELEVANCE

These findings suggest that Black patients with cancer experience worse COVID-19 outcomes compared with White patients. Understanding and addressing racial inequities within the causal framework of structural racism is essential to reduce the disproportionate burden of diseases, such as COVID-19 and cancer, in Black patients.

Chasm Between Cancer Quality Measures and Electronic Health Record Data Quality

PURPOSE

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires eligible clinicians to report clinical quality measures (CQMs) in the Merit-Based Incentive Payment System (MIPS) to maximize reimbursement. To determine whether structured data in electronic health records (EHRs) were adequate to report MIPS CQMs, EHR data aggregated by ASCO's CancerLinQ platform were analyzed.

MATERIALS AND METHODS

Using the CancerLinQ health technology platform, 19 Oncology MIPS (oMIPS) CQMs were evaluated to determine the presence of data elements (DEs) necessary to satisfy each CQM and the DE percent population with patient data (fill rates). At the time of this analysis, the CancerLinQ network comprised 63 active practices, representing eight different EHR vendors and containing records for more than 1.63 million unique patients with one or more malignant neoplasms (1.73 million cancer cases).

RESULTS

Fill rates for the 63 oMIPS-associated DEs varied widely among the practices. The average site had at least one filled DE for 52% of the DEs. Only 35% of the DEs were populated for at least one patient record in 95% of the practices. However, the average DE fill rate of all practices was 23%. No data were found at any practice for 22% of the DEs. Since any oMIPS CQM with an unpopulated DE component resulted in an inability to compute the measure, only two (10.5%) of the 19 oMIPS CQMs were computable for more than 1% of the patients.

CONCLUSION

Although EHR systems had relatively high DE fill rates for some DEs, underfilling and inconsistency of DEs in EHRs render automated oncology MIPS CQM calculations impractical.

Assessment of Regional Variability in COVID-19 Outcomes Among Patients With Cancer in the United States

IMPORTANCE

The COVID-19 pandemic has had a distinct spatiotemporal pattern in the United States. Patients with cancer are at higher risk of severe complications from COVID-19, but it is not well known whether COVID-19 outcomes in this patient population were associated with geography.

OBJECTIVE

To quantify spatiotemporal variation in COVID-19 outcomes among patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This registry-based retrospective cohort study included patients with a historical diagnosis of invasive malignant neoplasm and laboratory-confirmed SARS-CoV-2 infection between March and November 2020. Data were collected from cancer care delivery centers in the United States.

EXPOSURES

Patient residence was categorized into 9 US census divisions. Cancer center characteristics included academic or community classification, rural-urban continuum code (RUCC), and social vulnerability index.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality. The secondary composite outcome consisted of receipt of mechanical ventilation, intensive care unit admission, and all-cause death. Multilevel mixed-effects models estimated associations of center-level and census division-level exposures with outcomes after adjustment for patient-level risk factors and quantified variation in adjusted outcomes across centers, census divisions, and calendar time.

RESULTS

Data for 4749 patients (median [IQR] age, 66 [56-76] years; 2439 [51.4%] female individuals, 1079 [22.7%] non-Hispanic Black individuals, and 690 [14.5%] Hispanic individuals) were reported from 83 centers in the Northeast (1564 patients [32.9%]), Midwest (1638 [34.5%]), South (894 [18.8%]), and West (653 [13.8%]). After adjustment for patient characteristics, including month of COVID-19 diagnosis, estimated 30-day mortality rates ranged from 5.2% to 26.6% across centers. Patients from centers located in metropolitan areas with population less than 250 000 (RUCC 3) had lower odds of 30-day mortality compared with patients from centers in metropolitan areas with population at least 1 million (RUCC 1) (adjusted odds ratio [aOR], 0.31; 95% CI, 0.11-0.84). The type of center was not significantly associated with primary or secondary outcomes. There were no statistically significant differences in outcome rates across the 9 census divisions, but adjusted mortality rates significantly improved over time (eg, September to November vs March to May: aOR, 0.32; 95% CI, 0.17-0.58).

CONCLUSIONS AND RELEVANCE

In this registry-based cohort study, significant differences in COVID-19 outcomes across US census divisions were not observed. However, substantial heterogeneity in COVID-19 outcomes across cancer care delivery centers was found. Attention to implementing standardized guidelines for the care of patients with cancer and COVID-19 could improve outcomes for these vulnerable patients.

External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline

PURPOSE

This guideline provides evidence-based recommendations for the indications and technique-dose of external beam radiation therapy (EBRT) in hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC).

METHODS

The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the indications, techniques, and outcomes of EBRT in HCC and IHC. This guideline is intended to cover the definitive, consolidative, salvage, preoperative (including bridge to transplant), and adjuvant settings as well as palliative EBRT for symptomatic primary lesions. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.

RESULTS

Strong recommendations are made for using EBRT as a potential first-line treatment in patients with liver-confined HCC who are not candidates for curative therapy, as consolidative therapy after incomplete response to liver-directed therapies, and as a salvage option for local recurrences. The guideline conditionally recommends EBRT for patients with liver-confined multifocal or unresectable HCC or those with macrovascular invasion, sequenced with systemic or catheter-based therapies. Palliative EBRT is conditionally recommended for symptomatic primary HCC and/or macrovascular tumor thrombi. EBRT is conditionally recommended as a bridge to transplant or before surgery in carefully selected patients. For patients with unresectable IHC, consolidative EBRT with or without chemotherapy should be considered, typically after systemic therapy. Adjuvant EBRT is conditionally recommended for resected IHC with high-risk features. Selection of dose-fractionation regimen and technique should be based on disease extent, disease location, underlying liver function, and available technologies.

CONCLUSIONS

The task force has proposed recommendations to inform best clinical practices on the use of EBRT for HCC and IHC with strong emphasis on multidisciplinary care. Future studies should focus on further defining the role of EBRT in the context of liver-directed and systemic therapies and refining optimal regimens and techniques.

Chemotherapy Knowledge Base Management in the Era of Precision Oncology

Cancer medicine has grown increasingly complex in recent years with the advent of precision oncology and wide utilization of multidrug regimens. Representing this increasingly granular knowledge is a significant challenge. As users and managers of a freely available chemotherapy drug and regimen database, we describe the changes we have made to accommodate these challenges. These include the development of a domain ontology and increased granularity in the classification of cancer types on the website.

Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline

PURPOSE

To develop an evidence-based clinical practice guideline to assist in clinical decision making for patients with advanced hepatocellular carcinoma (HCC).

METHODS

ASCO convened an Expert Panel to conduct a systematic review of published phase III randomized controlled trials (2007-2020) on systemic therapy for advanced HCC and provide recommended care options for this patient population.

RESULTS

Nine phase III randomized controlled trials met the inclusion criteria.

RECOMMENDATIONS

Atezolizumab + bevacizumab (atezo + bev) may be offered as first-line treatment of most patients with advanced HCC, Child-Pugh class A liver disease, Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0-1, and following management of esophageal varices, when present, according to institutional guidelines. Where there are contraindications to atezolizumab and/or bevacizumab, tyrosine kinase inhibitors sorafenib or lenvatinib may be offered as first-line treatment of patients with advanced HCC, Child-Pugh class A liver disease, and ECOG PS 0-1. Following first-line treatment with atezo + bev, and until better data are available, second-line therapy with a tyrosine kinase inhibitor may be recommended for appropriate candidates. Following first-line therapy with sorafenib or lenvatinib, second-line therapy options for appropriate candidates include cabozantinib, regorafenib for patients who previously tolerated sorafenib, or ramucirumab (for patients with α-fetoprotein ≥ 400 ng/mL), or atezo + bev where patients did not have access to this option as first-line therapy. Pembrolizumab or nivolumab are also reasonable options for appropriate patients following sorafenib or lenvatinib. Consideration of nivolumab + ipilimumab as an option for second-line therapy and third-line therapy is discussed. Further guidance on choosing between therapy options is included within the guideline. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.

Seven decades of chemotherapy clinical trials: a pan-cancer social network analysis

Clinical trials establish the standard of cancer care, yet the evolution and characteristics of the social dynamics between the people conducting this work remain understudied. We performed a social network analysis of authors publishing chemotherapy-based prospective trials from 1946 to 2018 to understand how social influences, including the role of gender, have influenced the growth and development of this network, which has expanded exponentially from fewer than 50 authors in 1946 to 29,197 in 2018. While 99.4% of authors were directly or indirectly connected by 2018, our results indicate a tendency to predominantly connect with others in the same or similar fields, as well as an increasing disparity in author impact and number of connections. Scale-free effects were evident, with small numbers of individuals having disproportionate impact. Women were under-represented and likelier to have lower impact, shorter productive periods (P < 0.001 for both comparisons), less centrality, and a greater proportion of co-authors in their same subspecialty. The past 30 years were characterized by a trend towards increased authorship by women, with new author parity anticipated in 2032. The network of cancer clinical trialists is best characterized as strategic or mixed-motive, with cooperative and competitive elements influencing its appearance. Network effects such as low centrality, which may limit access to high-profile individuals, likely contribute to the observed disparities.

Trends in FDA cancer registration trial design over time, 1969-2020

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Background: The FDA has issued hundreds of cancer drug indications, with many new drugs, expanded indications, and biosimilars approved in recent years. While the gold standard for regulatory approval is the randomized controlled trial (RCT), RCT design including selection of control arms can differ considerably. We sought to investigate trends and patterns in RCT trial design used to support FDA approvals in oncology. Methods: We reviewed the available FDA package inserts of oncology drugs (N=258) for RCTs cited to support initial and expanded indication approvals as of January 2020; biosimilars were excluded. RCTs were linked to the HemOnc ontology, which contains trial-level metadata including publication year, endpoints, and trial design. Log-linear regression was performed to evaluate trends in approvals over time by endpoint. Study drugs were categorized as cytotoxic therapy, targeted therapy, or immunotherapy. RCTs were categorized by four designs: escalation (adding a drug or increasing the drug dose in an established regimen), in-class comparison (comparing two drugs in the same therapeutic class), out-of-class switch (comparing drugs in distinct therapeutic classes), and de-escalation (removing a drug or reducing the drug dose in an established regimen). Results: We identified 556 registration trials, 372 (67%) of which were RCTs. Approvals have been increasing exponentially over time (R2 0.9, p<0.001), both for RCTs reporting overall survival (OS) endpoints (R2 0.77, p<0.001), and non-OS endpoints (R2 0.67, p<0.001). Of the three most common trial designs (Table), in-class comparisons were least likely to report OS (28%; escalations 47%; out-of-class switches 43%, p=0.01 by Chi-squared). Class switches were common in immunotherapy trials compared to targeted or cytotoxic therapy. Conclusions: Despite growth in FDA approvals, a minority of registration trials report paradigmatic shifts in therapeutic approach (out-of-class switches), with the relative exception of immunotherapy trials. Escalation is the most common route to FDA approval, even though this design inevitably increases cost and toxicity. This suggests that new oncology drug approvals are not alone a useful metric of practice-changing innovation. [Table: see text]

A case report of paraneoplastic syndrome in β-hCG-secreting duodenal adenocarcinoma

Human chorionic gonadotropin (hCG) is a glycoprotein hormone that is used in clinical practice to detect pregnancy and serves as a sensitive marker for trophoblastic tumors. Other organs besides placental trophoblasts naturally express the hormone at low levels, which can be elevated in nontrophoblastic malignancies. Some studies have suggested that elevated β-hCG levels in nontrophoblastic tumors are a sign of aggressive disease and strongly associated with poor prognosis. We describe a case of a 50-year-old post-menopausal woman with metastatic duodenal adenocarcinoma who presented with a negative pregnancy test that later changed to positive. Biopsy of the primary duodenal mass showed positive immunohistochemical expression of β-hCG. The patient was also found to have multiple brain metastases, which is uncommon in gastrointestinal cancer. This is a rare case of paraneoplastic syndrome in a β-hCG-secreting duodenal adenocarcinoma.

Timely administration of antibiotics in febrile neutropenia per updated ASCO/IDSA guidelines

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Background: Current ASCO guidelines for management of febrile neutropenia (FN) recommend initial antibiotic administration within one hour of triage, and initial assessment within 15 minutes of triage for patients presenting with FN within 6 weeks of chemotherapy. The University of Illinois Cancer Center (UICC) implemented an early identification and management strategy in the ambulatory setting for FN in 2017, with success in increasing the percentage of FN patients receiving antibiotics within 2 hours from 50% to 92% over a 6 months (05/2017-11/2017) period. Given updated joint ASCO/IDSA guidelines, we aimed to increase percentage of FN patients receiving antibiotics within 1 hour from 56% to more than 90% over 16 months. Methods: A multidisciplinary team involving oncology, hematology (attendings and fellows), pharmacy, and nursing met quarterly to review FN cases including time to antibiotic administration and documentation of prompt assessment. Two Plan-Do-Study-Act (PDSA) cycles were completed, including development and deployment of an electronic medical record automated order set and targeted education for fellows and nurses. Results: Between 12/17 and 04/19, of 7 patients with FN, 100% (N = 7) received antibiotics in clinic. The percentage of FN patients receiving antibiotics within 1 hour of triage post first and second interventions was as follows: 25% (N = 1), 100% (N = 4). 100% (N = 7) of FN patients had documentation of prompt assessment, but time from triage was not specified. Conclusions: We were successful in improving the percentage of FN patients receiving antibiotics from 56% to more than 90% over 16 months. We are targeting our next PDSA cycle to increase assessments within 15 minutes of triage. Additional future interventions include tailoring antibiotics based on FN with low or high risk of complication via focus group and root case analyses discussion with our attendings, fellows, and nurses, and collaborating with ED on a standard care pathway for FN management.

Universal hepatitis B screening in a high risk community

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Background: 2015 ASCO guidelines for Hepatitis B (HBV) screening in patients (pts) receiving chemotherapy recommend a risk-adaptive strategy considering patient and treatment-specific factors. The University of Illinois Cancer Center (UICC) is an academic center with largely underserved, minority and socioeconomically disadvantaged pts. UICC implemented a universal HBV screening policy in 2016. We aimed to increase HBV screening from 60% to 95% over 18 months. Methods: A multidisciplinary team of oncologists, hepatologists, fellows, nurses and pharmacists created an ideal process map for universal HBV screening in all pts starting chemotherapy outlining screening parameters, laboratory tests required and follow-up for positive screens. Four Plan-Do-Study-Act cycles were tested. Interim analysis was done targeting specific providers for additional education. Results of screening were analyzed by chart review. Results: A total of 589 treatment-naive pts were screened for HBV between Aug 2017 and Feb 2019. Educational sessions were held for nurses, pharmacists and fellows to review ideal process maps between Jan and March 2018. 0% of pts had insurance denials for HBV screening coverage. Screening rates improved from 65% in Aug 2017 to 100% in Feb 2019. Positive HBV screen rate was 3% (N = 18) and all were new diagnoses. 61% (N = 11) of positive screens had no risk factors for HBV exposure and would not have met risk adaptive criteria for screening. 27% (N = 3) of positive screens without prior risk factors were initiated on prophylactic ART. 50% (N = 9) of all new HBV diagnoses initiated prophylactic ART to prevent reactivation, while 50% received active surveillance on chemotherapy. 0% of pts on active surveillance developed reactivation. Conclusions: Implementing and sustaining a universal HBV screening program was feasible and effective in identifying pts at risk for reactivation in a high risk population. 61% of positive screens lacked traditional risk factors. Risk-adaptive screening may miss cases in diverse populations where HBV is not endemic, precluding appropriate management. Further evaluation will include expanding screening to inpatient chemotherapy starts and cost-benefit analysis of universal screening in this unique population.

Increasing fertility preservation counseling prior to chemotherapy

225

Background: The 2018 ASCO Guidelines recommend that physicians document discussions about fertility with all female patients < 49 years old at the time of cancer diagnosis. Patients interested in fertility preservation (FP) should be referred to Reproductive Endocrinology and Infertility (REI) prior to chemotherapy. Retrospective review of oncology patients at our academic medical center over 6 months found that 33% of females < 49 years old had FP discussion documented. We aimed to increase FP discussions and help expedite referrals to REI from 33% to 75% within 5 months. Methods: All new chemotherapy orders were reviewed weekly. Female patients between ages 18-49 were identified and charts were abstracted for the following: age, race, diagnosis, stage, type and line of chemotherapy, and FP discussion. If FP was not discussed, the physician was contacted in real time via email to address FP with the patient and document the discussion. Charts were reviewed 2-4 weeks later to determine if FP was documented. To better understand barriers to FP documentation, fellows and attendings were surveyed to target future interventions. Results: From Dec. 2018 to Apr. 2019, 6/27 (22%) patients had documented discussions of FP. Post intervention, this number increased to 17/27 (63%) with one referral to REI. Intent of chemotherapy was curative in 56% of patients, and 67% were receiving their first line of chemotherapy. 2/15 (13%) patients receiving curative treatment and 4/12 (33%) patients receiving palliative chemotherapy had documentation of FP, both of which increased with intervention to 8/15 (53%) and 9/12 (75%), respectively. Conclusions: Our intervention successfully increased FP discussion from 33% to 63%, but we did not meet our goal of 75%. Per our survey results, the most common barriers to FP discussion were time constraints, inexperience discussing FP, and perception of prohibitive cost to the patient. We are designing our next intervention to address provider inexperience with FP discussion. This will include education regarding the financial aspects of REI and discussion of the new Oncofertility law in Illinois (HB2617), which ensures insurance coverage for oncofertility as of Jan 2019.

The Spectrum of Pulmonary Toxicity in Pancreatic Cancer Patients Receiving Gemcitabine Combination Chemotherapy

Gemcitabine is widely utilized in the treatment of pancreatic, ovarian, and non small cell lung cancers. Gemcitabine is associated with a wide spectrum of lung toxicities, ranging from dyspnea 25% of patients to severe pulmonary toxicity in up to 5% of patients. There is a dearth of information specific to pulmonary toxicity in the setting of gemcitabine combination chemotherapy. Given the potential severity, it is important to identify it early by excluding more common etiologies. We share two case reports of patients with pancreatic cancer who developed severe pulmonary toxicity during gemcitabine combination chemotherapy. Both cases emphasize the heightened risk of pulmonary toxicity in patients receiving gemcitabine chemotherapy combinations, and a need to be vigilant to initiate appropriate therapies immediately.

Electronic but overly eclectic: Disciplined EHR data management is needed to automate MIPS reporting

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Background: Physician reimbursement for care delivered to Medicare beneficiaries fundamentally changed with the 2015 MACRA legislation, requiring eligible clinicians to report quality measures in the Merit-Based Incentive Payment System (MIPS). To determine whether structured data in electronic health records (EHRs) were adequate to report MIPS results, EHR data ingested by ASCO’s CancerLinQ (CLQ) was analyzed. Methods: Nineteen MIPS measures specified for medical oncology, including 8 shared by other specialties, were retrieved from qpp.cms.gov and systematically evaluated to determine data elements necessary to satisfy each measure. The existence of corresponding data fields and completion of these fields with clinical data was analyzed according to EHR implementation in de-identified and aggregated CLQ data. Results: Five clinician informaticists reviewed the 19 oncology MIPS measures, and identified a consensus list of 52 discrete EHR data elements (DEs) that would be needed. CLQ-processed data from 4 commercial EHR systems implemented at 47 CLQ practices found structured data fields for 84% (43 of 52) of the DE, but fewer than half (46%) of these fields were ever populated and only 32% (17 of 52) of DE were recorded for > 20% of cases. Only 3-5 of 19 MIPS measures could be reliably reported based on data element availability by most practices in this sample set. There were minimal differences between the EHRs ability to encode MIPS DE. Elements most likely to be encoded were those for registration (birthdate, gender), billing (diagnosis, meds), vital signs and smoking status, while those seldom or never encoded related to care plans (tobacco, alcohol, pain management). Other DE rarely encoded were patient events occurring outside the oncology practice (receipt/completion of consultations, dates of hospice enrollment and death), which would be dependent on data exchange between work units and practice entities or, more likely, re-entry by oncology practices. Conclusions: Only a minority of DE required to satisfy MIPS criteria are available as discrete data fields in current EHRs, limiting automated reporting efforts. Improved data quality and completeness is needed to satisfy mandated reporting.

Patient-centered design in developing a mobile application for oral anticancer medications

OBJECTIVES

To develop and test the usability and feasibility of a customizable mobile application (app) designed to help educate patients about their oral anticancer medications (OAMs) and regimens.

SETTING

Outpatient cancer center and oncology pharmacy for urban, Midwestern academic health system.

PRACTICE DESCRIPTION

Clinically-supervised educational intervention to support patients learning about OAMs.

PRACTICE INNOVATION

With input from patient partners, our interdisciplinary team designed the first known tablet-based educational app that can interface with a patient's electronic medical record. The app is based on learning style and adherence theories and is customizable for individually prescribed OAMs. The app can accommodate multiple learning styles through text at 6th-grade reading level, pictures, animations, and audio voiceovers. Functionalities include interactive educational modules on 11 OAMs and case-based patient stories on common barriers to OAM adherence.

EVALUATION

Early phase testing provided the opportunity to observe the user interface with the app and app functionality. Data were summarized descriptively from observations and comments of patient subjects.

RESULTS

Thirty patient subjects provided input-19 in phase 1 usability testing and 11 in phase 2 feasibility testing. Comments provided by patient subjects during usability testing were largely positive. Responses included self-identification with patient stories, usefulness of drug information, preferences for text messages, and app limitations (e.g., perceived generational digital divide in technology use and potential patient inability to receive text messages). Using their feedback, modifications were made to the prototype app. Responses in feasibility testing demonstrated the app's usefulness across a wide range of ages. Highest opinion ratings on app usefulness were stated by patients who were newer to OAM therapy.

CONCLUSION

User feedback suggests the potential benefit of the app as a tool to help patients with cancer, particularly after the first months for those starting new OAM regimens. Processes and lessons learned are transferable to other settings.

Design of Customized Mobile Application for Patient Adherence to Oral Anticancer Medications Utilizing User-Centered Design

Adherence and compliance to oral anticancer medications (OAMs) can be challenging for patients due to their complex regimens. The goal of this research project was to design an effective and engaging user interface (UI), based on user-centered design (UCD) and incorporate animations, to reinforce and improve patient's understanding of the key aspects of taking OAMs. This current paper encompasses the development process and describes the initial phase of the project, which focused on the design and development of the tablet-based educational application (app). A UCD approach was implemented by consulting with oncology clinicians and patients at an early stage of development. Animations were developed and incorporated to convey complex medical concepts and information. An iterative design process will help ensure that the tool is customized for patient engagement.

Timely antibiotic administration in febrile neutropenia

204

Background: The University of Illinois currently lacks a standard process to ensure timely antibiotic administration for patients with febrile neutropenia. The Infectious disease society of America (IDSA) guidelines recommend administration of antibiotics within two hours. Given the variability in patient encounters, we sought to implement an early identification and interventional strategy in the ambulatory setting for febrile neutropenic patients. A retrospective chart review over 10 weeks demonstrated that of 40 patients diagnosed with neutropenia 15 % (N = 6) had febrile neutropenia. Of these 6 patients, 50% (N = 3) received antibiotics within the IDSA time frame. We aimed to increase the percentage of febrile neutropenic patients receiving antibiotics within 2 hours from 50% to 100% in 8 weeks. Methods: A focus group at our quarterly morbidity mortality and improvement conference brainstormed a list of causes of delay in antibiotic initiation based on an index case discussion. A task force generated a pareto chart after affinity sorting the prior list, and created actual and ideal process maps, from identification of neutropenic patients to patient disposition. A standard operative protocol (SOP) was developed involving the creation and implementation of an electronic provider generated neutropenia check list triggering specific actions per IDSA recommendations, and a standardized order set including STAT cultures, and STAT antibiotics. Results: The febrile neutropenia SOP will be piloted over an 8 week period starting in early November in four ambulatory settings. The primary outcome data is the time from event to antibiotic administration. Process data will include time from event to antibiotic order, time from antibiotic order to administration and compliance with high risk neutropenic check list. We plan to assess our interventions every 3-4 weeks, and pilot at least 2 PDSA cycles within the next 8 weeks. Conclusions: Although febrile neutropenia is a recognized medical emergency with clear guidelines on treatment, not all patients may receive antibiotics within the appropriate time frame. It is therefore imperative for institutions to be aware of their level of IDSA compliance and implement appropriate quality improvements as required.

Hepatitis B virus screening in patients receiving intravenous chemotherapy

205

Background: Patients with chronic hepatitis B (HBV) who undergo chemotherapy without antiviral prophylaxis may develop HBV reactivation, hepatitis, liver injury, and even death. The University of Illinois Cancer Center (UICC) lacks a standardized guideline for screening patients for HBV prior to chemotherapy initiation. A retrospective chart review was conducted on chemotherapy orders submitted to UICC pharmacy over 4 weeks for both hematological and solid tumor malignancies. Of 63 new orders for intravenous chemotherapy, only 14 patients (22%) underwent HBV screening prior to chemotherapy initiation. We aimed to increase HBV screening from 22% to 50% over 2 months. Methods: A multidisciplinary taskforce comprised of hematology/oncology and hepatology physicians, clinical pharmacy, and nursing was created. An ideal process map was created identifying a clear management schema for HBV screening including differences in screening tests for various populations and management recommendations for positive test results. Two Plan-Do-Study-Act (PDSA) cycles were tested with post intervention data collected over eight weeks. Results: Of 192 chemotherapy orders submitted to outpatient pharmacy over 8 weeks, 62 patients (32%) were determined to be appropriate for HBV screening prior to initiation of chemotherapy. Of these, 36 patients (58%) were screened appropriately for HBV. Additionally, a subset analysis revealed 100% of patients successfully screened for HBV prior to initiation of anti-CD20 therapies. Conclusions: At UICC, a multidisciplinary team created and successfully piloted the implementation of a HBV screening policy in both hematological and solid tumor malignancies. Our initial aim was reached after 8 weeks of implementation, and ongoing efforts are being conducted to further improve HBV screening rates to 90%.

Features of hepatocellular carcinoma in Hispanics differ from African Americans and non-Hispanic Whites

AIM

To compare features of hepatocellular carcinoma (HCC) in Hispanics to those of African Americans and Whites.

METHODS

Patients treated for HCC at an urban tertiary medical center from 2005 to 2011 were identified from a tumor registry. Data were collected retrospectively, including demographics, comorbidities, liver disease characteristics, tumor parameters, treatment, and survival (OS) outcomes. OS analyses were performed using Kaplan-Meier method.

RESULTS

One hundred and ninety-five patients with HCC were identified: 80.5% were male, and 22% were age 65 or older. Mean age at HCC diagnosis was 59.7 ± 9.8 years. Sixty-one point five percent of patients had Medicare or Medicaid; 4.1% were uninsured. Compared to African American (31.2%) and White (46.2%) patients, Hispanic patients (22.6%) were more likely to have diabetes (P = 0.0019), hyperlipidemia (P = 0.0001), nonalcoholic steatohepatitis (NASH) (P = 0.0021), end stage renal disease (P = 0.0057), and less likely to have hepatitis C virus (P < 0.0001) or a smoking history (P < 0.0001). Compared to African Americans, Hispanics were more likely to meet criteria for metabolic syndrome (P = 0.0491), had higher median MELD scores (P = 0.0159), ascites (P = 0.008), and encephalopathy (P = 0.0087). Hispanic patients with HCC had shorter OS than the other racial groups (P = 0.020), despite similarities in HCC parameters and treatment.

CONCLUSION

In conclusion, Hispanic patients with HCC have higher incidence of modifiable metabolic risk factors including NASH, and shorter OS than African American and White patients.

Documentation of pharmacist-provided patient education for oral chemotherapy

237

Background: Pharmacist-provided patient education for oral chemotherapy is poorly documented in patient electronic medical records (EMR) at UIC Oncology Pharmacy. At baseline, 41% of patients who started new therapy with selected oral chemotherapies had a patient education note documented by a pharmacist in their EMR. Our aim is to provide and document patient education for at least 90% of patients who start new oral chemotherapy and fill their prescriptions at UIC Oncology Pharmacy over three months. The importance of patient counseling and documentation is recognized by the Quality Oncology Practice Initiative (QOPI) group. Approximately 25% of patients undergoing chemotherapy are on oral chemotherapy. (Deutsch S, Koerner P, Miller RT, Craft Z, Fancher K. Utilization patterns for oral oncology medications in a specialty pharmacy cycle management program. J Oncol Pharm Pract. 2014;0:1-8.) Methods: A multi-disciplinary team performed an affinity sort and created a process map to identify areas of intervention. The first intervention was labelling prescription bags to identify them as oral chemotherapy prescriptions that require counseling by a pharmacist. Data was collected after two weeks. Results: At the completion of the first PDSA cycle, 40% of patients who started new oral chemotherapy had a documented patient education note written by a pharmacist in their EMR. Documentation of education was performed on the day of pick-up in 89% of cases. Table 1 shows the percentage of notes that included the elements recognized by QOPI standards: documentation of start date, adherence, and adverse effects. Conclusions: Documentation of patient education for oral chemotherapy should be a well-integrated component of ambulatory pharmacy practice. A second PDSA cycle is planned to increase rates of documentation by utilizing the pharmacy resident to perform patient counseling and documentation. Future interventions will be aimed at improving the quality of the data included in the documented notes. [Table: see text]

A multidisciplinary quality improvement project to improve the safety of oral chemotherapy in hospitalized patients

110

Background: At the University of Illinois Hospital and Health Sciences System (UIC), inpatient IV chemotherapy administration occurs in the setting of specific protocols and multidisciplinary safety assessments while oral chemotherapy agent (OCA) inpatient administration occurs less formally. Baseline 8 week review of 174 admissions to the oncology service revealed that of 16 patients (9.2%) on outpatient OCA, 50% received OCAs while inpatient, with 12. 55% having a formal chemotherapy note in place. We aimed to increase the percentage of administered OCAs with associated provider generated chemotherapy notes from 12.5% to 75% over 16 weeks. Methods: A multidisciplinary task force comprised of oncology providers, clinical pharmacy, nursing leadership, and information technology was assembled. An actual and ideal process map was created, and using tools such as affinity sorting and root cause analysis, interventions were implemented focusing on residents (knowledge of OCA), nurses (documentation and policy adherence), pharmacists (education, policy adherence) and IT team (order modification). A standardized multidisciplinary hospital wide process was implemented for OCA ordering, administration, documentation, and patient education. A novel REDCap (research electronic data capture) auditing procedure was designed by which a weekly pharmacy report of every oral chemotherapy order at UI Health is automatically generated. Results: Between June and September 2015, a total of 67 OCA administration reports were audited. OCA notes were associated with OCA administration in 58% of cases in June, 100% in July, 78% in August and 93% in September. Furthermore, OCA notes were entered within 4 hours of OCA ordering in 58% of cases in June, 54% in July and 78% of the cases in August and September. No adverse events were reported. Conclusions: At the University of Illinois Hospital and Health Sciences System, a multidisciplinary team designed and implemented a standardized OCA administration, ordering, and documentation process focused on safe, appropriate and timely inpatient OCA administration. A novel REDCap auditing process assisted the team to identify the areas in need of optimization.

A novel auditing procedure for an oral chemotherapy process improvement project

164

Background: A process to standardize ordering, documentation, and administration of inpatient oral chemotherapy was implemented at the University of Illinois Hospital and Health Sciences System. The process requires oncology clinician review and endorsement of inpatient oral chemotherapy drug orders via an oral chemotherapy note within the electronic health record. Pharmacists are instructed to reject oral chemotherapy drug orders that lack this required documentation. A novel auditing procedure was established in order to track adherence to these new requirements and provide real time and adaptable feedback to front-line staff critical to the project’s success. Methods: To support continuous quality improvement (QI) with this project, an auditing tool was developed in REDCap, a secure, web-based data management application. The auditing tool was originally developed as a traditional web-based data collection instrument with the primary purpose of tracking performance. By utilizing more advanced features offered by the REDCap platform, the auditing tool generated automated follow-up surveys to pharmacists involved in non-adherent outlier cases. The survey solicited information on the root cause of non-adherence, and based on the end-user response, provided adaptable continuing education tailored to this root cause. Results: Between June and September 2015, a total of 67 orders for oral chemotherapy were audited. Compliance with process improvement requirements was noted in 58%, 100%, 78%, and 93% of cases in June, July, August, and September, respectively. Outlier surveys were sent to 12 pharmacists in the non-adherent cases; of 11 responses, the most common response reflected an unfamiliarity with the process. Following targeted education, through September 2015, no single pharmacist has been involved in more than one non-adherent case. Conclusions: The novel auditing tool supported the continuous quality improvement process by engaging front-line staff, generating automated and real time surveys for outlier responses, and providing targeted and personalized education aimed at resolving the root cause in non-adherent cases. As such, it can be applied towards any REDCap QI projects.

Phase Ib study of PGG beta glucan in combination with anti-MUC1 antibody (BTH1704) and gemcitabine for the treatment of advanced pancreatic cancer

TPS493

Background: Mucin 1 (MUC1) is a tumor associated membrane-bound glycoprotein that promotes oncogenesis through promotion of epithelial cell polarity loss, anti-apoptosis, and hypoxia driven angiogenesis. MUC1 overexpression is associated with aggressive behavior and poor outcomes in pancreatic ductal adenocarcinoma (PDAC), and increased resistance to gemcitabine (G) in vitro. BTH1704 (BTH) is a humanized monoclonal antibody (MAb) targeting aberrantly glycosylated MUC1. Imprime PGG (PGG) is a soluble yeast-derived b 1,3/1,6 glucan that binds complement receptor 3 (CR3) on innate immune cells priming them to exert anti-tumor activity against complement (iC3b) opsonized tumor cells. Following incubation of PGG with whole blood from healthy subjects, variability in PGG binding to neutrophils and monocytes has been observed, with higher binding and functional changes correlating with higher levels of endogenous anti-b glucan antibodies. BTH binds to antigens (MUC1), leading to iC3b opsonization of tumor cells thus, allowing PGG-primed leukocytes to kill the iC3b-opsonized tumor cells. This forms the rationale for testing BTH1704 combined with G + PGG. Methods: This is a single institution Phase 1b dose escalation study with a standard 3x3 design to determine the maximal administered dose (MAD) of BTH combined with G + PGG in patients with previously treated advanced PDAC.Each dose cohort includes at least one subject with high and one low PGG binding capability. Primary objectives: establish MAD of BTH combined with G + PGG. Secondary objectives: characterize adverse effects, clinical response, time to progression, progression free and overall survival. Correlative objectives: quantify PGG binding, MDSC phenotyping of PBMC, anti b glucan antibody levels, MUC1 IHC. Inclusion criteria: confirmed advanced PDAC, ECOG PS 0-2, rest period 2-6 weeks from prior first- or second-line treatment. Exclusion criteria: uncontrolled chronic illness. Administration and design: BTH and PGG are administered on days 1, 8, 15, and 22 of a 28-day cycle; G is administered on days 1, 8, and 15. The study is currently enrolling patients. Clinical trial information: NCT02132403. Clinical trial information: NCT02132403.

Conducting Retrospective Ontological Clinical Trials in ICD-9-CM in the Age of ICD-10-CM

OBJECTIVE

To quantify the impact of International Classification of Disease 10th Revision Clinical Modification (ICD-10-CM) transition in cancer clinical trials by comparing coding accuracy and data discontinuity in backward ICD-10-CM to ICD-9-CM mapping via two tools, and to develop a standard ICD-9-CM and ICD-10-CM bridging methodology for retrospective analyses.

BACKGROUND

While the transition to ICD-10-CM has been delayed until October 2015, its impact on cancer-related studies utilizing ICD-9-CM diagnoses has been inadequately explored.

MATERIALS AND METHODS

Three high impact journals with broad national and international readerships were reviewed for cancer-related studies utilizing ICD-9-CM diagnoses codes in study design, methods, or results. Forward ICD-9-CM to ICD-10-CM mapping was performing using a translational methodology with the Motif web portal ICD-9-CM conversion tool. Backward mapping from ICD-10-CM to ICD-9-CM was performed using both Centers for Medicare and Medicaid Services (CMS) general equivalence mappings (GEMs) files and the Motif web portal tool. Generated ICD-9-CM codes were compared with the original ICD-9-CM codes to assess data accuracy and discontinuity.

RESULTS

While both methods yielded additional ICD-9-CM codes, the CMS GEMs method provided incomplete coverage with 16 of the original ICD-9-CM codes missing, whereas the Motif web portal method provided complete coverage. Of these 16 codes, 12 ICD-9-CM codes were present in 2010 Illinois Medicaid data, and accounted for 0.52% of patient encounters and 0.35% of total Medicaid reimbursements. Extraneous ICD-9-CM codes from both methods (Centers for Medicare and Medicaid Services general equivalent mapping [CMS GEMs, n = 161; Motif web portal, n = 246]) in excess of original ICD-9-CM codes accounted for 2.1% and 2.3% of total patient encounters and 3.4% and 4.1% of total Medicaid reimbursements from the 2010 Illinois Medicare database.

DISCUSSION

Longitudinal data analyses post-ICD-10-CM transition will require backward ICD-10-CM to ICD-9-CM coding, and data comparison for accuracy. Researchers must be aware that all methods for backward coding are not comparable in yielding original ICD-9-CM codes.

CONCLUSIONS

The mandated delay is an opportunity for organizations to better understand areas of financial risk with regards to data management via backward coding. Our methodology is relevant for all healthcare-related coding data, and can be replicated by organizations as a strategy to mitigate financial risk.

Improving advance care planning for UICC Oncology patients

234

Background: Advance care planning (ACP) in the ambulatory setting is underutilized and poorly documented at the University of Illinois Cancer Center (UICC). A baseline 8 week review noted 8.8% of metastatic solid tumor patients had ACP documentation in the electronic medical record (EMR) by the third visit and 23% in the previous two visits. Our aim was to increase ACP documentation to 75% of UICC metastatic solid tumor patient charts by the third visit through development of a standardized process for ACP discussion and documentation. Methods: A multidisciplinary team of oncology physicians, nurses, social workers (SW), and palliative care created a process map of ACP discussion. A new process for SW consults was piloted over 6 weeks. Additionally, all clinic staff participated in a standardized curriculum for ACP discussions. Post intervention data was prospectively collected over six weeks. Results: Total 94 encounters occurred during the pilot evaluating ACP in metastatic solid tumor patients of which 37/55 (39.4%) had documented ACP discussion. SW consults occurred in 18/94 (19.1%), leading to 18/18 (100%) with Power of Attorney (POA) forms in EMR. Evaluation by tumor subtypes showed 14/21 (66.7%) of gastrointestinal patients had ACP documentation with 9/21 (42.9%) with SW consults leading to 11/21 (52.4%) with POA forms in EMR. Of 39 total thoracic patients, 19/39 (48.7%) had ACP documentation of which 9/39 (23%) with SW consults and 7/39 (17.9%) with POA forms in EMR. Conclusions: UICC successfully piloted the creation and implementation of a process for ACP consults and standardization of ACP discussion and EMR documentation. While our initial aim of 75% a chart was not reached, the piloted process increased SW consults and completion of POA forms, as well as greater multidisciplinary effort and patient engagement. Compared to the pilot period, a multidisciplinary approach and use of the new process did improve ACP documentation. We plan to expand to all metastatic patients. [Table: see text]

Data accuracy and financial cost of conducting retrospective ontological clinical trials using ICD-9-CM in the age of ICD-10-CM

229

Background: Estimates of the 1 year implementation delay of ICD-10-CM (I10) range upto $6.6 billion with the majority of cost attributable to I10 implementation. Little attention has been paid to post implementation costs and management strategies for data accuracy within longitudinal cancer related databases spanning both ICD-9-CM (I9) and I10. The objective of our study was to quantify financial impact and compare data quality of I10 transition in cancer clinical trials through backward I10 to I9 mapping via two tools. Methods: Cancer related original research articles published in NEJM, Blood and JCO between Jan 1st 2013 and Dec 31st 2013 were reviewed for I9 utilization. Each I9 code was mapped forward to I10 via the Motif web portal tool. The I10 codes were manually reviewed with additional clinically relevant I10 codes added. The final I10 code list was mapped backward to I9 using two tools, the Motif web portal and CMS GEMs. Generated I9 codes were compared to the original I9 list to identify ‘lost’ codes. To assess financial implications of lost data, lost I9 codes were assessed in 2010 Illinois Medicaid data. Results: Of 1,567 original articles reviewed, 7 articles were included and yielded 412 I9 codes which mapped to 1437 I10 codes. Upon manual review, 416 I10 codes were added. Backward mapping by Motif web and CMS GEMs respectively yielded 652 and 551 I9 codes; 16 of the original I9codes were absent from the CMS GEMs list while Motif tool yielded 100% of original codes. Of these 16, 12 codes were present in 2010 Illinois Medicaid data, and accounted for 7,490 patient encounters (0.52%) and $1.1 million (0.35%) of total Medicaid reimbursements. Conclusions: We report significant differences in data quality of I9 generated by backward coding via CMS GEMs and the Motif web tool, with major financial impact. Longitudinal data analyses upto 5 years post ICD-10-CM transition will require backward coding, and comparison of ICD-9-CM codes for accuracy. The bridging methodology and analytic tools presented can be replicated by organizations and clinical researchers to increase data fidelity spanning the upcoming transition.

Early identification of high-risk neutropenia in the ambulatory setting

87

Background: The University of Illinois Cancer Center (UICC) utilizes nurse (RN) visits for laboratory review and toxicity evaluations for patients (pts) receiving chemotherapy. Upon review of nursing visits, we observed that RN visit documentation for neutropenia was variable without standard language, communication with physicians (MD), or requirement for MD evaluation. We sought to implement an early intervention strategy to prevent morbidity and mortality from high risk neutropenia (HRN). Methods: A multidisciplinary task force of oncology RNs and MDs created actual and ideal process maps, from identification of neutropenia to patient disposition. We developed a Standard Operating Protocol (SOP) involving a HRN checklist (created based on NCCN and ISDA guidelines) and new process for triage of HRN pts. RNs were required to complete the HRN checklist within the electronic health record for all pts with ANC < 1,000. If high risk features were identified, MD evaluation was required within 1 hour of RN call, with SOAP note and attending notification. Results: Over an 8 week period, 17 HRN templates were generated. The process and checklist were adjusted after the first 4 weeks with clinic wide feedback. Within the first 4 weeks, 8 templates were generated (5 MD, 3 RN); no patients met high risk neutropenia criteria and all were discharged home. Within the second 4 weeks, 9 templates were generated (3 MD, 6 RN); 3 HRN pts were identified with two direct admissions and one home discharge with favorable outcomes. Clinic staff reported greater understanding of HRN, increased satisfaction with multidisciplinary interactions, and more comfort with calling MDs for prompt patient evaluation. Conclusions: UICC successfully piloted the creation and implementation of an early identification and intervention strategy for HRN with strong multidisciplinary support. Compared to the prior 6 month period, we found that use of the SOP and checklist resulted in improvement in evaluation of quality and timeliness of HRN pts and prevented morbidity and mortality. Additionally, the checklist provoked critical thinking from end users with more thorough patient evaluations and improved documentation, resulting in aggressive intervention and better outcomes.

Identifying clinically disruptive International Classification of Diseases 10th Revision Clinical Modification conversions to mitigate financial costs using an online tool

PURPOSE

To quantify coding ambiguity in International Classification of Diseases Ninth Revision Clinical Modification conversions (ICD-9-CM) to ICD-10-CM mappings for hematology-oncology diagnoses within an Illinois Medicaid database and an academic cancer center database (University of Illinois Cancer Center [UICC]) with the goal of anticipating challenges during ICD-10-CM transition.

METHODS

One data set of ICD-9-CM diagnosis codes came from the 2010 Illinois Department of Medicaid, filtered for diagnoses generated by hematology-oncology providers. The other data set of ICD-9-CM diagnosis codes came from UICC. Using a translational methodology via the Motif Web portal ICD-9-CM conversion tool, ICD-9-CM to ICD-10-CM code conversions were graphically mapped and evaluated for clinical loss of information.

RESULTS

The transition to ICD-10-CM led to significant information loss, affecting 8% of total Medicaid codes and 1% of UICC codes; 39 ICD-9-CM codes with information loss accounted for 2.9% of total Medicaid reimbursements and 5.3% of UICC billing charges.

CONCLUSION

Prior work stated hematology-oncology would be the least affected medical specialty. However, information loss affecting 5% of billing costs could evaporate the operating margin of a practice. By identifying codes at risk for complex transitions, the analytic tools described can be replicated for oncology practices to forecast areas requiring additional training and resource allocation. In summary, complex transitions and diagnosis codes associated with information loss within clinical oncology require additional attention during the transition to ICD-10-CM.

Racial differences in patients with hepatocellular carcinoma: A large single-institution experience

318

Background: Hepatocellular carcinoma (HCC) disproportionately affects minorities with higher age-adjusted incidence and mortality rates in Hispanics (H) and blacks (B) versus non-Hispanic whites (C). While H have the fastest rising rates of HCC of all ethnic groups per SEER analysis, little is known about race specific risk factors and disease characteristics. Methods: We retrospectively reviewed HCC patients (pts) treated at University of Illinois-Chicago between 1998 and 2005. Demographics, disease characteristics, treatment patterns, and survival were analyzed with descriptive statistics and chi-square p values. Results: Mean age of HCC pts (N=195) at diagnosis was 59.7 years + 9.8 (19.5% female; 22% aged 65 or older; 61.5% Medicare or Medicaid; 4.1% without insurance; 22.6% H; 31.2% B). Compared to C and B, H pts were more likely to have ascites and NASH and less likely to have ever smoked or have hepatitis C. Compared to B, H pts were more likely to have metabolic syndrome, diabetes, and encephalopathy (HE). Compared to C, B pts had lower MELD scores. Conclusions: In our patient population, Hispanic patients were significantly more likely to have diabetes and NASH, and lower frequency of tobacco use, HCV, and elevated AFP levels at diagnosis. [Table: see text]