Clustering and Stochastic Simulation Optimization for Outpatient Chemotherapy Appointment Planning and Scheduling

Outpatient Chemotherapy Appointment (OCA) planning and scheduling is a process of distributing appointments to available days and times to be handled by various resources through a multi-stage process. Proper OCAs planning and scheduling results in minimizing the length of stay of patients and staff overtime. The integrated consideration of the available capacity, resources planning, scheduling policy, drug preparation requirements, and resources-to-patients assignment can improve the Outpatient Chemotherapy Process's (OCP's) overall performance due to interdependencies. However, developing a comprehensive and stochastic decision support system in the OCP environment is complex. Thus, the multi-stages of OCP, stochastic durations, probability of uncertain events occurrence, patterns of patient arrivals, acuity levels of nurses, demand variety, and complex patient pathways are rarely addressed together. Therefore, this paper proposes a clustering and stochastic optimization methodology to handle the various challenges of OCA planning and scheduling. A Stochastic Discrete Simulation-Based Multi-Objective Optimization (SDSMO) model is developed and linked to clustering algorithms using an iterative sequential approach. The experimental results indicate the positive effect of clustering similar appointments on the performance measures and the computational time. The developed cluster-based stochastic optimization approaches showed superior performance compared with baseline and sequencing heuristics using data from a real Outpatient Chemotherapy Center (OCC).

Strategies to Mitigate Chemotherapy and Radiation Toxicities That Affect Eating

Background: Cancer and its therapy is commonly associated with a variety of side effects that impact eating behaviors that reduce nutritional intake. This review will outline potential causes of chemotherapy and radiation damage as well as approaches for the amelioration of the side effects of cancer during therapy. Methods: Information for clinicians, patients, and their caregivers about toxicity mitigation including nausea reduction, damage to epithelial structures such as skin and mucosa, organ toxicity, and education is reviewed. Results: How to anticipate, reduce, and prevent some toxicities encountered during chemotherapy and radiation is detailed with the goal to improve eating behaviors. Strategies for health care professionals, caregivers, and patients to consider include (a) the reduction in nausea and vomiting, (b) decreasing damage to the mucosa, (c) avoiding a catabolic state and muscle wasting (sarcopenia), and (d) developing therapeutic alliances with patients, caregivers, and oncologists. Conclusions: Although the reduction of side effects involves anticipatory guidance and proactive team effort (e.g., forward observation, electronic interactions, patient reported outcomes), toxicity reduction can be satisfying for not only the patient, but everyone involved in cancer care.

Similar Quality of Life and Safety in Patients Receiving Inpatient or Outpatient Chemotherapy: A Focus on Esophageal Squamous Cell Carcinoma

Quality of life (QoL) is a particularly important issue for cancer patients. This study was designed to investigate the differences in QoL in esophageal squamous cell carcinoma (ESCC) patients who underwent inpatient chemotherapy (IPCT) or outpatient chemotherapy (OPCT). A total of 107 ESCC patients were enrolled, including 53 patients in the IPCT group and 54 patients in the OPCT group. The widely used and well-validated instruments European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 Items (EORTC QLQ-C30) and Oesophageal Cancer Module (EORTC QLQ-OES18) were used to examine the QoL of the two groups. In addition, the differences in adverse events (AEs) were evaluated. The results of QLQ C-30 analysis showed that mean global quality of life scores were similar between IPCT and OPCT groups, as were functional and symptom scales. There were no significant differences in the functional and symptom scales in the analysis of QLQ OES18 either. Most AEs of chemotherapy were grades 1–2, and the majority of patients tolerated the side effects; no statistically significant difference in AEs between these two groups was mentioned. Our study suggests that the health-related QoL and adverse events in ESCC patients who received IPCT or OPCT are similar. OPCT is reasonable and safe in clinical practice.

Response rates, long term outcomes and toxicity profile of gemcitabine and vinorelbine based outpatient chemotherapy regimen in primary progressive and relapsed childhood Hodgkin lymphoma

This study aimed to determine response rates, overall survival (OS), event-free survival (EFS) and toxicity profile of an outpatient chemotherapy regimen based on gemcitabine and vinorelbine (GV) for relapsed childhood Hodgkin lymphoma (HL). This was a retrospective study that included 41 patients up to the age of 18 years with relapsed HL. Twelve patients (29%) had primary progressive disease (PPD), 6 (15%) had early relapse (ER) and 23 (56%) had late relapse (LR). The overall initial response rate was 83% (LR: 87%, ER: 83%, PPD: 75%. p-value: .2). Three-year combined OS was 80% (LR: 89%, ER: 80%, PPD: 65%. p-value: .07) and EFS 71% (LR: 86%, ER: 62%, PPD: 47%. p-value: .01). There were no toxic deaths. Febrile neutropenia was observed in four patients (9.6%) and lung toxicity in 1 patient (2.4%). This study suggests that outpatient GV is an effective and low toxicity salvage regimen for relapsed childhood HL.

Impact of transitioning inpatient chemotherapy regimens to the outpatient setting

BACKGROUND

Chemotherapy regimens historically have required admission of the patient to the hospital for extended infusions running over multiple days to complete each cycle of therapy. With the evolution of monitoring strategies readily available, a renaissance in patient care and healthcare cost utilization is necessary as transitioning the administration of these agents to the outpatient setting is seemingly achievable and is potentially more cost-effective.

PURPOSE

This evaluation sought to primarily measure cost-savings for an institution by transitioning inpatient chemotherapy regimens to the outpatient setting. Secondary outcomes evaluated the effect of this transition on overall patient length of stay, prevalence of adverse effects, and overall chemotherapy schedule adherence as a result of implementing transitions in sites of care. Barriers to receiving care in the outpatient setting were assessed by evaluating the acuity of performance status as well as distance from the hospital.

METHODS

This single-center retrospective, quantitative chart and expense analysis evaluated patients receiving rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) or rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) chemotherapy regimens based on treatment setting at a single institution. Included patients were treated at the University of Chicago Medical Center. Those receiving inpatient-only management as compared with patients who received therapy in outpatient settings were compared in a matched cohort analysis. The control group was matched from the period before transition of therapy was instituted between November 2014 and November 2015, with those patients transitioned to outpatient therapy (December 2015 to November 2016), using demographic, diagnostic, treatment, and clinical status data to assure group similarity. Mean cost of therapy was compared between inpatient and outpatient regimens. Descriptive and demographic categorical data were compared using the Fisher's exact test. Continuous data were evaluated using the Student's t test. A significance level of alpha <0.05 was used for all analysis.

RESULTS

The cost of R-EPOCH therapy represented a significant difference across groups. R-ICE therapy similarly saw significant cost differences between inpatient and outpatient groups. If this was made standard of care for qualifying patients a retrospective annualized estimation of $466,507.85 with R-EPOCH therapy and $205,977.60 for R-ICE therapy could have been saved if this was utilized for patients who previously received their therapy as an inpatient.

CONCLUSION

The population of patients cared for at the University of Chicago Medicine during this time-period qualified for outpatient treatment for those treated with R-EPOCH and R-ICE regimens with no significantly identifiable prohibitive barriers between groups. As no significant complications manifested, it is reasonable to continue transitioning patients receiving these regimens to the outpatient setting where appropriate. R-EPOCH and R-ICE therapies were shown to be reasonable outpatient therapy while providing significant cost-savings for the institution.

Trend of salvage treatment in diffuse large B cell lymphoma in the outpatient chemotherapy era

Patients with diffuse large B cell lymphoma (DLBCL) who have failed to achieve complete remission with first-line therapy can subsequently receive salvage therapy. However, there is no definite consensus on the use of salvage therapy, and little information on the optimal treatment regimen. The present study retrospectively analyzed data from 131 patients diagnosed with DLBCL between April 2002 and November 2017 who relapsed and received salvage therapy. Primary treatment included R-CHOP or R-CHOP-like regimens. The most common salvage regimen was R-DeVIC (42%), followed by R-ESHAP (23%), other aggressive regimens (12%) and palliative therapy (23%). The median overall survival (OS) was 45.7 months for R-DeVIC, 41.8 months for palliative therapy, 29.4 months for R-ESHAP, and 28.5 months for aggressive regimens (P=0.937). A total of 25 patients underwent autologous stem cell transplantation (ASCT), and the OS was 75.6 months for these patients compared with 33.5 months (range, 25.6–45.6 months) for patients who did not undergo ASCT (P=0.033). Following the establishment of an outpatient chemotherapy unit in 2014, R-DeVIC use became more common, increasing from 37% prior to 2014 to 46% after 2014, whereas R-ESHAP use decreased (31 to 17%). The present study did not identify the optimal salvage regimen for patients with DLBCL. However, salvage ASCT improved the outcome, and regimens administered via peripheral veins were demonstrated to be more common in outpatient chemotherapy settings.

Influence of demographıc factors on perceıved socıal support among adult cancer patients in Turkey

Background

Social support, acknowledged as a protective factor against diseases, produces positive results in the prognosis of cancer patients.

Objective

There is no relevant studies on perceived social support and factors related to Turkish cancer patients. Hence, the present study aimed to determine the demographic characteristics that affect the perceived social support in cancer patients undergoing chemotherapy in Turkey.

Patients and Methods

This study was designed as a descriptive cross-sectional study. The sample included 423 adult cancer patients who admitted to the Outpatient Chemotherapy Unit of three hospitals in Turkey between March 2014 and August 2014. The data were collected through Demographic Characteristics Form and Cancer-Specific Social Support Scale (CPSSS).

Results

Patients were between 19 and 85 years of age with a mean 51.75 years. Almost half of them (40.7%) were primary school graduates, 53.2% were female, 84.6% were married and 85.8% had children. It was found that the patients generally received a high score (127.86 ± 17.44) from the CPSSS scale. The highest scores were obtained on the Confidence Support sub dimension. It was revealed that women and married patients needed more confidence support and general social support (P < 0.05). Social support perceived by primary school graduates was statistically significant to a great extent (P < 0.05). In spite of the difference between the patients with metastasis and their perceived social support grade averages (P > 0.05), it was seen that patients with multiple children utilized more confidence support and general social support in social support reception (P < 0.05).

Conclusion

The study showed that study participants received a high amount of social support. Age, gender, marital status, number of children, and educational status were determined to affect perceived social support. It is recommended to support the patients who do not receive sufficient social.

Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting

PURPOSE

Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting is described.

SUMMARY

The University of Arizona Cancer Center and Banner-University Medical Center Tucson are affiliated not-for-profit academic medical centers in Tucson, Arizona, whose facilities include a hospital and ambulatory care clinics that maintain 3 outpatient infusion centers. The cancer center pharmacy currently employs 25 pharmacists, with 4 clinical pharmacists serving both the inpatient and outpatient treatment sites. A multidisciplinary team of staff members was assembled to address the transition of chemotherapy from inpatient to outpatient that included physicians, ambulatory clinical oncology pharmacists, finance, social workers, pharmacy staff, nursing staff, and information technology. The program was initiated in May 2014, with a 2-year postimplementation evaluation of our transition of chemotherapy to the outpatient setting. Chemotherapy order sets were developed in our electronic medical record for transitioning rituximab to the outpatient setting for inpatient chemotherapy orders as well as transitioning leukemia, lymphoma, and solid tumor chemotherapy regimens to be administered in the outpatient setting. Eighteen rituximab-containing regimens and 14 chemotherapy protocols were switched to the outpatient setting, with numerous variants of these regimens also created for outpatient only administration. The realized savings for high-cost chemotherapy transitioned to the outpatient setting with rituximab and clofarabine was $1,902,890. Over 747 inpatient bed days were saved, with an approximated cost savings to the health system of $1,402,866, with a cumulative cost savings to our health system of $3,305,756.

CONCLUSION

This model for transitioning chemotherapy from the hospital to the outpatient setting enhanced access to care, decreased bed utilization in the hospital, and improved clinical and financial metrics.

Concerns and Returns to Work in Patients with Breast Cancer Receiving Outpatient Chemotherapy: a Pilot Study

Objective

Breast cancer survivors are increasing in number among survivors of all types of cancer, and survivors returning to work are extremely important. The development of outpatient chemotherapy has increased the working population of patients undergoing cancer therapy. Consequently, a significant number of breast cancer survivors experience physical, psychological, and social problems. This study aimed to clarify differences in concerns among patients with breast cancer receiving outpatient chemotherapy according to their employment status.

Methods

Twenty-eight patients with breast cancer undergoing outpatient chemotherapy were recruited. A questionnaire was used to survey the attributes, employment status, and levels of concern in these patients based on the Cancer-chemotherapy Concerns Rating Scale (CCRS). Data from three groups (employed full time, employed part-time, and unemployed) were analyzed using multiple comparison tests.

Results

The patients' mean age was (55.1 ± 9.9) years. According to the CCRS findings, the following three parameters differed between the three groups: scores for the items "I always think about my disease" (employed vs. unemployed, P = 0.005) and "I can't work (housework/schoolwork)" (employed full time vs. part time, P = 0.045), and scores for the "self-existence" subscale (employed vs. unemployed, P = 0.024).

Conclusions

This study revealed the characteristics of concerns in patients with breast cancer according to their employment status. Being able to continue working is considered to enhance the social health of these patients. Predicting concerns in employed patients will help gain perspective in early nursing interventions.

[Survey of the Efficacy of Long-term and Successive Pharmaceutical Care in Outpatient Chemotherapy by Oncology Pharmacy Specialists]

It is important that pharmacists ensure safe chemotherapy implementation. In addition to inspecting chemotherapeutic prescriptions according to patient condition and drug-drug interactions, the management of chemotherapy-induced adverse effects and associated pharmaceutical intervention is one of the most important responsibilities of pharmacists in medical care teams. In May 2016, an oncology pharmacist was set responsible for the specialized, long-term, and successive pharmaceutical care, including instructions about appropriate use of medication at an outpatient chemotherapy center. We evaluated the effectiveness of the continuous pharmaceutical care. The number of medication counseling and associated pharmaceutical interventions increased with time. Specifically, the number of pharmaceutical interventions (prescription questions and pharmaceutical proposals) was 745 (459 and 286, respectively) in the surveillance period, which significantly increased compared to that observed within the same duration before posting an oncology pharmacist. The adoption rate was approximately 70% for prescription questions and 98% for pharmaceutical proposals. We also found that approximately 70% of the proposals attenuated the painful symptoms. Furthermore, approximately 60% of all pharmaceutical interventions were established after the third visit; in particular, approximately 20% of the pharmaceutical proposals were suggested after the sixth visit, indicating that continuous medication counseling results in an increase in pharmaceutical proposals. In conclusion, long-term and successive pharmaceutical care by oncology pharmacy specialists in outpatient chemotherapy contributes to a safe and less onerous chemotherapy implementation, as it has been highly adopted, is effective in many cases, and has been proven to be important for risk management in chemotherapy.

[A Questionnaire Survey on Cooperation between Community Pharmacies and Hospitals in Outpatient Chemotherapy-Comparison of Roles of Pharmacists in Community Pharmacy and Hospitals]

　Previous reports suggested that sharing outpatient information during chemotherapy is very important for managing pharmaceutical usage between community pharmacies and hospitals. We herein examined using a questionnaire survey whether pharmaceutical management for outpatient chemotherapy is desired by community and hospital pharmacists. The response rates were 44.3% (133/300) for pharmacists in community pharmacies and 53.7% (161/300) for pharmacists in hospitals. Prescriptions for outpatients during chemotherapy were issued at 88.2% of the hospitals. Currently, 28.9% of hospital pharmacists rarely provide pharmaceutical care, such as patient guidance and adverse effect monitoring, for outpatients receiving oral chemotherapy. Furthermore, whereas 93.7% of hospital pharmacists conducted prescription audits based on the chemotherapy regimen, audits were only performed by 14.8% of community pharmacists. Thus, outpatients, particularly those on oral regimens, were unable to receive safe pharmaceutical care during chemotherapy. Community pharmacists suggested that hospital pharmacists should use "medication notebooks" and disclose prescription information when providing clinical information to community pharmacists. They also suggested sending clinical information to hospital pharmacists by fax. On the other hand, hospital pharmacists suggested the use of "medication notebooks" and electronic medical records when providing clinical information to community pharmacists. In addition, they suggested for community pharmacists to use electronic medical records when providing clinical information to hospital pharmacists. As there may be differences in opinion between community and hospital pharmacists, mutual preliminary communication is important for successful outpatient chemotherapy.

Physical and chemical stability of high-dose ifosfamide and mesna for prolonged 14-day continuous infusion

PURPOSE

Ifosfamide plus mesna have been used recently in a high-dose regimen that allows this chemotherapy to be given to outpatients with less toxicity over 14 days using a portable pump. However, there is a need for published stability information. The aim of this study was to investigate the physicochemical stability of ifosfamide with mesna in normal saline at room temperature over a prolonged period of 14 days.

METHODS

Infusion solutions of 1:1 ifosfamide and mesna at final concentrations of 10, 20 and 30 mg/mL were prepared with 0.9% sodium chloride in PVC bags. Solutions were stored at room temperature. Concentrations of ifosfamide and mesna were measured at 0 and 1, 3, 7 and 14 days using a stability-indicating reversed phase high-performance liquid chromatography (HPLC) assay with ultraviolet detection.

RESULTS

Ifosfamide and mesna were both physicochemically stable (>94%) for 14 days in all tested infusion solutions (10, 20 and 30 mg/mL).

CONCLUSIONS

Our stability data indicate that ifosfamide and mesna (1:1) combination can be administered as a prolonged continuous infusion with portable pump in an outpatient setting without replacement of the infusion bag. We suggest 20 mg/mL as a reasonable concentration for infusion rates of about 2-4 cc/hr over prolonged periods of time.