Ambulatory Oncology Setting Research Articles

Improving the assessment and documentation of systemic cancer therapy–related toxicity in the ambulatory oncology setting.

221 Background: Accurate documentation of systemic cancer therapy toxicity is crucial for patient safety and effective treatment management. However, achieving consistent and comprehensive documentation remains challenging. While the use of electronic patient-reported outcomes (ePROs) is becoming standard in clinical practice, small community-based practices lack the resources to implement this strategy. This project aims to offer alternative methods for implementing patient-reported outcomes in such practices and utilize this information to enhance the documentation of systemic cancer therapy toxicities using the CTCAE (Common Terminology Criteria for Adverse Events). Methods: We conducted a quality improvement project targeting the adequate assessment and documentation of graded toxicity assessments among healthcare providers. Interventions included implementing a patient-reported outcome survey created using the National Cancer Institute PRO-CTCAE form builder, which patients completed while waiting to be seen by the provider. Additionally, we educated providers on how to use the CTCAE grading tool available in Cerner. Rates of documented graded toxicity assessment using the CTCAE system were evaluated among 71 patients aged 18 years or older receiving systemic cancer therapy and attending follow-up appointments at the Seton Cancer Clinic. Data were collected from electronic medical records both before and after the intervention, with 50 patients assessed pre-intervention and 21 patients assessed post-intervention. Results: The implementation of the patient-reported outcome survey and the utilization of the CTCAE grading tool available in Cerner facilitated a more consistent and comprehensive assessment and documentation process. Post-intervention, the rate of documented graded toxicities increased significantly; the percentage of patients with documented graded toxicities increased from 4% pre-intervention to 80% post-intervention. The intervention also improved the workflow efficiency and the accuracy of toxicity assessments in the oncology clinic. Conclusions: These findings highlight the importance of implementing strategies to improve the assessment and documentation of systemic cancer therapy-related toxicity, especially in small community-based practices where resources may be limited. Continued monitoring and periodic data collection will be essential for sustaining these improvements.

Oncology Clinical Nurse Specialists Practice in the Outpatient Setting.

With rapidly evolving oncology care, the role of the outpatient clinical nurse specialist is most valuable and essential. The purpose of this article is to describe the role of the clinical nurse specialist in the ambulatory oncology settings and highlight the clinical nurse specialists' unique influence across the spheres of impact. This article shares several contributions of an outpatient clinical nurse specialist, which include ways this role impacts nursing practice, patient care, and standardizing organizational guidelines. A method of recording the clinical nurse specialists' encounters or indirect consults was also utilized to provide a process to log consultation received in the day-to-day practice. Work exemplars were included to further demonstrate the impact of this role in this setting. Outpatient clinical nurse specialist need is rising especially in the oncology setting where the majority of cancer care and treatment is delivered. It is important to continue to disseminate and highlight the value it brings to the organization.

Development and evaluation of a data-driven virtual interdisciplinary workshop to facilitate communication and teamwork in ambulatory medical oncology settings.

551 Background: While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. Our objective was to determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Methods: Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. Workshop content was tailored to address key findings from the patient and clinician survey data, including addressing quality, safety, teamwork, communication, and conflict issues. Results: 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team. Clinicians perceived a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by summative data, along participant suggestions for improvement for the Workshop and a desire for long-term partnership in quality improvement. Conclusions: The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable in an ambulatory oncology setting. The Workshop identified opportunities for individual- and system-level improvements in interdisciplinary clinical team communication. This promising strategy—incorporating clinic-specific data and communication techniques in a virtual interdisciplinary communication Workshop—requires replication in larger, more diverse practice samples.

Self-reported health-related social needs screening for new adult patients in an ambulatory oncology setting.

194 Background: Health-related social needs (HRSN) are strongly associated with patient health outcomes, making screening for HRSN a critical component to providing patient-centered oncology care. In April 2023, the Dana-Farber Cancer Institute (DFCI) Patient Reported Data (PRD) Program led the deployment of an EHR-integrated HRSN screening tool. Embedded within our New Patient Intake Questionnaire, the screening supports early identification of and response to needs, informs care planning and delivery, and aims to improves outcomes. Methods: PRD, in collaboration with DFCI’s Patient & Family Advisory Council and others, elected to use an HRSN screening tool deployed across the Mass General Brigham healthcare system (with which DFCI shares an EHR). HRSNs assessed include transportation, housing security, food security, medication costs, utility costs, family and childcare, education, and employment. New adult oncology patients (and/or proxy) were offered the HRSN questionnaire in multiple languages on any internet-enabled device via the patient portal or on a tablet in clinic. Responses were immediately available in the EHR for care team review with needs highlighted to support clinical decision making. Aggregate data is available within the DFCI electronic data warehouse and disseminated for internal use via a Tableau dashboard. Results: Between April 23 and May 31, 2023, 1,842 patients completed the HRSN screening questionnaire. Of responders, 246 (13.4%) were non-white, 725 (39.4%) were male, 72 (4.0%) had a non-English preferred language, and the mean age was 57 years at time of response. 12.8% (251) reported at least one HRSN. Reported HRSNs are described in Table 1. Among those reporting at least one need, the most frequently reported HRSNs are food insecurity (38.7%), utility costs (33.5%), and employment (20.7%). Conclusions: Even when considering much of the population seen at our comprehensive cancer center are relatively well-resourced, we find a meaningful proportion (12.8%) of patients reported HRSNs, demonstrating the importance of screening patients to ensure patient-centered care. Future work will determine additional points for rescreening of HRSNs and focus on improving patient’s access and uptake of screening. We will continue socializing and analyzing HRSN data to improve clinical practice and support the development of interventions to connect patients with available resources.[Table: see text]

What You See is Not What You Get: One Health System’s Improvement of Pain Assessment in the Ambulatory Oncology Setting

What You See is Not What You Get: One Health System’s Improvement of Pain Assessment in the Ambulatory Oncology Setting

An integrative review of adult cancer patients’ experiences of nursing telephone and virtual triage systems for symptom management

PurposeTelephone and virtual triage services are becoming increasingly common in ambulatory oncology settings. Few studies have evaluated their implementation from the perspective of service users. This study aims to evaluate the experiences of engaging with nurse-delivered telephone and virtual triage systems for symptom management among people undergoing cancer treatment. MethodsAn integrative review was undertaken. MEDLINE, CINAHL, PsycInfo, Academic Search Complete and Scopus were systematically searched. Twelve publications met the inclusion criteria, and data related to cancer patients’ perceptions of the triage process were extracted and analysed. ResultsTelephone-based (n=7), app-based (n=5) and video-based teleconferencing (n=2) triage systems were evaluated positively overall, enhancing ease of health system navigation, avoidance of emergency department for consultation, and the information, reassurance and support provided to support self-management of symptoms. However, several factors influenced the users’ engagement with triage services, including confidence to articulate symptoms, limited opening hours, waiting times for initial triage or follow-up and digital literacy. Collectively, these factors contributed to delayed reporting or under-reporting of symptoms, undermining the potential impact of services. Studies included variable reporting of intervention characteristics, including the qualification of nurses delivering and leading services. ConclusionsFuture evaluations of triage services must give greater consideration to the characterisation of interventions to ensure transferability, including nursing roles and qualifications. To ensure effective intervention and optimal supportive care for symptom management, patients must be prepared to engage triage services early. Future evaluations must ensure the impact of digital literacy on engagement with, and experience of, virtual triage is investigated.

Development and Evaluation of a Data-Driven, Interactive Workshop to Facilitate Communication and Teamwork in Ambulatory Medical Oncology Settings.

While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. To determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team, and clinicians perceiving a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by formative and summative data, along with suggestions for improvement. The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable. The Workshop identified opportunities for individual- and system-level improvements in clinical team communication. This promising strategy requires replication in larger, diverse practice samples. Clinicians accepted an interactive workshop that incorporated clinic-specific data and communication strategies. The program is feasible and acceptable in ambulatory oncology settings.

Value Assessment of Oncology Pharmacist Interventions.

A review of the published literature confirms the challenge in quantifying the value of oncology pharmacists. This editorial expands on a 2020 study by Meleis and colleagues published in the Journal of the Advanced Practitioner in Oncology and seeks to correlate pharmacist interventions to cost-saving and cost-avoidance measures to show the value of ambulatory oncology clinical pharmacists in patient care. A total of 4,686 interventions were reviewed. The 6-month intervention data demonstrate an annualized value of approximately $1.1 million dollars from nine ambulatory oncology clinical pharmacists showcasing the essential role of the clinical pharmacist in ambulatory oncology settings.

Symptoms and Needs Monitoring in Diverse Ambulatory Oncology Patients: Usage Characteristics and Impact on Emergency Room Visits and Hospitalization.

Symptoms and needs monitoring using patient-reported outcomes (PRO) is associated with improved clinical outcomes in cancer care. However, these improvements have been observed predominantly in non-Hispanic White patients using English assessments with high completion rates. The documented impact of such monitoring on system-level outcomes including emergency room (ER) visits and hospitalizations remains limited. We explored factors affecting the completion of PRO measures and evaluated clinical outcomes in an ambulatory oncology setting with a diverse racial, ethnic, and linguistic population. A retrospective analysis (October 2019-February 2022) was performed for patients with cancer assigned to My Wellness Check (MWC), a patient-portal-administered and electronic health record-based PRO assessment that generates automated alerts to oncology providers. Patient demographics, clinical characteristics, and clinical outcomes were collected. Logistic regression models examined factors affecting the completion of MWC questionnaires. Cumulative incidence of ER visits and hospitalization were assessed by Cox proportional hazards regression models adjusting for demographics. We identified 9,553 patients; 43.1% (n = 4,117) answered one or more questions. Patients age 65 years or older (adjusted odds ratio [aOR], 0.77; P < .0001), male (aOR, 0.81; P < .0001), Hispanic/Latino ethnicity (aOR, 0.70; P < .0001), living without partners (aOR, 0.75; P < .0001), or receiving no treatment (aOR, 0.76; P < .0001) were less likely to answer MWC questionnaires. Patients who completed the entire MWC questionnaires had a reduced risk of an ER visit (adjusted hazard ratio, 0.78; P < .0001) and hospitalization (adjusted hazard ratio, 0.80; P = .0007) relative to patients who did not. Completing electronic health record-based PRO assessments was associated with significantly better clinical outcomes in a diverse cancer population. Specific patient groups were less likely to participate. Further research is needed to identify barriers to completing PRO measures and the long-term benefits of such programs.

Development of PharmPAL: A Collaborative Practice Pharmacy Clinic in Ambulatory Palliative Care.

Increased access to interprofessional palliative care is needed in ambulatory oncology settings. To achieve this, Dana-Farber Cancer Institute launched a collaborative drug therapy management clinic, PharmPAL, where credentialed advanced practice pharmacists lead independent patient visits. As part of a pilot project focused on clinical innovation, we analyzed PharmPAL referrals and pharmacist interventions between July 2020 and June 2021. We extracted referral patterns, patient hospitalizations, and deaths from the electronic medical record. Outpatient palliative care clinicians completed a survey to determine pharmacist needs and overall satisfaction with PharmPAL. From July 2020 to June 2021, PharmPAL constituted 4.7% (299/6305) of all outpatient palliative care encounters. Most palliative care clinicians (86% [6/7]) reported a desire to increase PharmPAL availability. No patient hospitalizations or deaths were attributed to PharmPAL visits. PharmPAL increased access to palliative care services. All clinicians reported satisfaction with PharmPAL. We continue to assess the impact PharmPAL has on clinic operations and provider satisfaction.

The Impact of an Embedded Oncology Pharmacist in an Outpatient Oncology Center in the Treatment of Hematologic Malignancies.

Background:The growing demand for clinicians in the ambulatory oncology setting to reduce fragmentation of care and improve patient outcomes represents a need for oncology pharmacists as advanced practitioners in the provision of direct patient-centered care. These provisions can include supportive care management, drug-drug interaction evaluation, and selection of appropriate chemotherapy regimens to reduce physician workload in a cost-effective manner, while increasing physician and patient satisfaction. However, robust data are currently lacking to support the impact of pharmacists in the ambulatory oncology setting. The primary objective of this study is to justify the benefit of a full-time clinical pharmacist in the ambulatory oncology setting through documenting pharmacist-driven clinical interventions, correspondence of those interventions with cost avoidance, and perceived benefit from provider and patient satisfaction surveys.Methods:In this observational single-center pilot study, pharmacist interventions were documented and quantified from March 4, 2019, to March 9, 2021. This study evaluated the impact of these interventions through correlating cost avoidance and overall patient and provider satisfaction surveys regarding oncology pharmacists embedded in the outpatient clinic.Results:During the study period, a total of 545 diverse interventions were made by pharmacists. The estimated cost avoidance during the study period was $363,760, resulting in a net benefit of $753,150 per year. Both provider (n = 5) and patient (n = 8) surveys indicated strong agreement to the benefits of an oncology pharmacist’s involvement in clinic.Conclusion:This study demonstrates the clinical impact, financial benefit, and positive humanistic outcomes of an embedded oncology pharmacist within the ambulatory oncology setting.

Clinical Pharmacy Services in Ambulatory Oncology: An Environmental Scan of the Canadian Practice Landscape.

Canadian clinical pharmacy key performance indicators (cpKPIs) have been developed for inpatient hospital practice but are not established for ambulatory oncology. This study represents the first step in developing cpKPIs for ambulatory oncology. To describe the current landscape of pharmacy services in ambulatory oncology in Canada and to identify perspectives related to the development and implementation of cpKPIs in this practice setting. In this national cross-sectional study, a web-based questionnaire was distributed to pharmacists working in ambulatory oncology settings. Potential participants who self-identified as pharmacists practising in an ambulatory oncology setting were eligible. Survey questions focused on participants' demographic characteristics, oncology pharmacy services provided, metrics captured, and pharmacists' perceptions of cpKPIs. All data were analyzed using descriptive statistics. A total of 44 responses were received, with most respondents practising in community hospitals in British Columbia, Ontario, and Atlantic Canada. The services most commonly provided were chemotherapy order verification, laboratory monitoring, identification and resolution of drug therapy problems, and counselling on anticancer medications. Twenty-six of the 44 respondents (59%) indicated that performance metrics or patient outcomes were tracked at their respective institutions, with none being universally captured. Overall, 43 (98%) of the respondents favoured the development of cpKPIs for ambulatory oncology practice. Despite growing patient care needs in ambulatory oncology, there is significant heterogeneity in the scope of pharmacy services offered and the outcomes used to qualify their impact within this setting across Canada. This study demonstrates a clear need for national consensus cpKPIs to inform pharmacy resource utilization and patient-centred quality improvement initiatives.

Evaluation of antibiotic appropriateness at an outpatient oncology centre.

Current evidence supporting antimicrobial stewardship programs focused largely in inpatient setting. With the shift in cancer management from inpatient to ambulatory setting, it is crucial to examine the prevalence and predictors of inappropriate antibiotics prescribing. This is a retrospective cross-sectional study conducted at the National Cancer Centre Singapore (NCCS). Patients at least 21 years, with an active or past cancer diagnosis and prescribed with at least one oral antibiotic by a NCCS physician from 1st July to 30th September 2019 were included. Antibiotic appropriateness was assessed using institutional antibiotic guidelines or published clinical practice guidelines. For cases where antibiotics appropriateness cannot be ascertained using these guidelines, an independent three-member expert panel was consulted. A total of 815 patients were screened; 411 (59.4% females) were included with mean age of 62.4 years. The top three cancer diagnoses were breast (26.5%), lung (15.6%) and head and neck (13.6%). More than half (58.6%) received appropriate antibiotic choice. Of which, 235 (97.5%), 238 (98.8%) and 194 (80.5%) received appropriate dose, frequency and duration respectively. The presence of non-oncologic immunosuppressive comorbidities (OR 4.890, 95% CI 1.556-15.369, p-value = 0.007), antibiotic allergy (OR 2.352, 95% CI 1.178-4.698, p-value = 0.015) and skin and soft tissue infections (OR 2.004, 95% CI 1.276-3.146, p-value = 0.003) were associated with a higher incidence of inappropriate antibiotic choice. This study highlighted that inappropriate antibiotic prescribing is prevalent in the ambulatory oncology setting. Predicators identified can aid in the design of targeted strategies to optimise antibiotic use in ambulatory oncology patients.

Abstract P1-18-23: Implementation and evaluation of a shared care model between oncologists and pharmacists for advanced breast cancer patients on cyclin-dependent kinase (CDK) 4/6 inhibitors

Abstract Background: The introduction of CDK4/6 inhibitors for advanced hormone receptor positive, HER2 negative, breast cancer patients has contributed to increased ambulatory patient visits for oncologists. Oncology clinical pharmacists have training and expertise in medication management and adherence. The aim of the Medication Assessment by Pharmacist (MAP) program is to evaluate the impact of clinical pharmacists performing medication assessment follow-up visits. Methods: Metastatic breast cancer patients on a CDK4/6 inhibitor (palbociclib or ribociclib) deemed suitable for pharmacist assessment were identified by medical oncologists at British Columbia (BC) Cancer Surrey. Oncologists can book the patient for a pharmacist medication assessment appointment at alternate cycles. The clinical pharmacist uses standardized medication assessment forms, provincial protocols and toxicity management guidelines. Results: Between April 2018 to December 2019, 82 patients were initiated on a CDK 4/6 inhibitor at BC Cancer Surrey. Of these, 12 patients (14.6%) were selected for the MAP program for a total of 17 pharmacist visits. This resulted in 340 minutes of clinic time savings for physicians. Patients who underwent the MAP program were more likely to follow provincial and regional protocols for scheduling clinic visits (99%) as compared to those who did not (96%). Rates of monitoring investigations adhering to provincial protocols were similar between those in the MAP program or not (97.6% versus 97.7%). There was a 100% physician and pharmacist survey response rate with a total of 9 physicians and 9 pharmacists participating. 100% of surveyed pharmacists agreed or strongly agreed when asked whether MAP increased job satisfaction. 100% of physicians indicated that MAP reduced physician workload. Physicians and pharmacists who participated in MAP all agreed or strongly agreed when asked if patients were receptive to meeting with a pharmacist. Only 33% of physicians routinely ask about medication adherence, newly started medications or natural health supplements at each visit, as compared with 100% of pharmacists. 100% of physicians reported that they wanted to see MAP expanded to include additional oncology drugs. Conclusions: This study demonstrates that expanding the role of clinical oncology pharmacists and their integration in a shared care model with oncologists can reduce ambulatory patient visits for oncologists without compromising clinical care. Additionally, leveraging pharmacist expertise helps to enhance care by evaluating medication adherence and concurrent drug therapies. Based on this program, MAP has expanded to include additional cancer centres and other oral cancer therapies. This shared care model in the ambulatory oncology setting may be a way to help alleviate projected shortages of oncology providers. Citation Format: Angela Chan, Sylvie Labelle, Elaine Goh. Implementation and evaluation of a shared care model between oncologists and pharmacists for advanced breast cancer patients on cyclin-dependent kinase (CDK) 4/6 inhibitors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-18-23.

Predictors of adherence to patient reported outcomes and psychosocial needs questionnaire in a culturally diverse ambulatory oncology setting: The My Wellness Check Program.

173 Background: Electronic health record (EHR) integrated symptom monitoring using patient reported outcomes (PRO) has been associated with improved outcomes, including health-related quality of life (HRQoL), in cancer survivors. However, these improvements have been documented through reasonably high completion rates of PRO measures in predominantly non-Hispanic White patient populations using only English language assessments. This study aimed to 1) examine factors associated with the completion of PRO assessments and 2) test differences in referrals to cancer support services between PRO responders and non-responders in a cohort of cancer survivors with significant racial, ethnic, and primary language diversity. Methods: A retrospective analysis (October 2019-February 2021) was performed for patients who were assigned the My Wellness Check (MWC) program at a tertiary, comprehensive cancer center. MWC is an EHR-based PRO assessment and referral program that uses PROMIS computer adaptive tests for depression, anxiety, pain, fatigue, and physical function as well as a psychosocial needs assessment. MWC PRO questionnaire is available in English or Spanish based on patient preference. Demographic and clinical characteristics of patients were collected and incorporated in multivariable binary logistic regression model to examine factors associated with completion of the MWC PRO questionnaires. The frequency of referrals to cancer support services was compared by Chi-square test between MWC PRO responders and non-responders. Adjusted odds ratio (aOR) and 95% confidence interval (95%CI) were calculated. Results: Of the 5306 patients eligible to complete MWC PRO questionnaire, the majority were female (64.1%), White (86.9%), Hispanic (65.8%), English speaker (55.4%), and 46.0% were responders. Patients who were younger than 65 (aOR 1.39; 95%CI 1.22-1.59; p &lt; 0.0001), female (1.23; 1.09-1.41; p = 0.0019), non-Hispanic/Latino (1.43; 1.25-1.64; p &lt; 0.0001), living with partners ( = 1.28; 1.13-1.46; p = 0.0001), and receipt of active treatment (1.37; 1.18-1.58; p &lt; 0.0001) were significantly associated with MWC PRO completion. Responders were referred to cancer support services more often than non-responders (16.6% vs 5.4%, p &lt; 0.0001). Conclusions: Patient-level and clinical factors predict completion of PRO measures, and responders were more likely to have a referral to cancer support services. To optimize supportive care for ambulatory cancer patients, further research is needed to identify factors that can promote patient engagement, particularly in patients who are under-utilizers of such services.

Implementing the cancer and aging research group (CARG) tool in the ambulatory oncology setting to drive informed treatment selection.

209 Background: Smilow Cancer Hospital is a NCI designated cancer center in Connecticut that has built a network of 15 community-based oncology (CBO) clinics. Older patients present with unique clinical challenges including multiple comorbidities, decreased functional status, and cognitive impairment. ASCO Geriatric Oncology guidelines recommend completing both a comprehensive geriatric assessment and a chemotherapy toxicity risk assessment on all oncology patients ≥65 years old for informed treatment selection. The CARG calculator is a simple, validated tool to assess chemotherapy toxicity risk in older patients with solid tumors. Despite ASCO guidelines, the existence of validated tools, and literature confirming improved patient outcomes, oncologists’ utilization of risk calculators is limited; therefore, we conducted a pilot CARG quality improvement initiative throughout our CBO network. Methods: 36 CBO physicians agreed to complete five CARG tools, document toxicity scores in the EMR, and complete a post-survey between March and June 2021. PDSA cycles included interventions of a hyperlink to the CARG tool incorporated in the EMR and creating a dot phrase built to simplify documentation. Education was provided on both the CARG and the survey. The survey captured perceived clinical value, time commitment, and barriers to implementation. Baseline data was collected during February 2021 and included geriatric patients receiving a new chemotherapy regimen for a solid tumor. Results: 180 consecutive new chemotherapy starts in geriatric patients were monitored. The CARG score utilization in new chemotherapy starts increased from 6.5% of new cases during the first month, to 26.4% in the third month. 82% of providers found the CARG score helpful in discussing chemotherapy risks with patients. In 32% of cases, the CARG score led to a decision to dose attenuate, and in 15% of cases, the CARG score led to a different treatment regimen. Most oncologists (65%) reported spending ≤5 minutes calculating toxicity, and 88% spent ≤10 minutes. 89% of oncologists reported the CARG score was worth the added time. Conclusions: This QI initiative demonstrates feasibility and increased use of the CARG geriatric chemotherapy toxicity tool in accordance with ASCO geriatric guideline-based care. Physician education and EMR workflow modification were utilized. In the CBO setting, oncologists found the CARG tool to be quick and helpful in discussing treatment risks with patients. Use of the CARG tool led to meaningful changes in treatment, including chemotherapy dose attenuation. Further study metrics such as palliative and supportive care referrals, ED visits, and hospitalizations will fuel sustainability.

Symptom Burden of Patients with Advanced Pancreas Cancer (APC): A Provincial Cancer Institute Observational Study.

Patients with advanced pancreatic cancer (APC) experience many disease-related symptoms. ESAS-r measures the severity of 9 symptom domains and has been validated for use in the ambulatory oncology setting. We aimed to describe symptom burden at baseline for patients with APC treated with modern chemotherapy (CT), and to determine whether symptom burden at baseline is prognostic. Patients diagnosed with APC between 2012–2016, treated with ≥1 cycle of CT, who completed ≥1 ESAS-r were identified. Descriptive statistics were used to report symptom burden and common moderate-to-severe symptoms. A joint model was used to describe the trajectory of ESAS-r during follow-up while controlling for death. Multivariable Cox regression was used to identify independent predictors of death. Of 123 patients identified, the median age was 65 and 61% had metastatic disease. The median baseline ESAS-r total symptom distress score (TSDS) was 24. A total of 86% of patients had at least one symptom score of ≥4 at baseline, with the most common being: fatigue, nausea, anxiety, and shortness of breath. Median overall survival was 10.2 months. Baseline TSDS was not predictive for worse survival in the era of modern CT. Patients with APC have a high burden of cancer-associated symptoms and a high prevalence of moderate-to-severe symptoms. Early intervention has the potential to improve quality of life in this group of patients and should be investigated.

Implementation of an Electronic Medical Record Tool for Early Detection of Deep Vein Thrombosis in the Ambulatory Oncology Setting: The Cleveland Clinic Experience

BACKGROUND:Venous thromboembolism (VTE) is a major cause of morbidity, and the second leading cause of mortality in cancer patients. VTE is associated with delay in cancer directed therapy, increased frequency and duration of hospitalization and overall healthcare costs. However, validated scoring systems for assessing risk of VTE are not widely used in clinical practice. We hypothesized that creation of a computerized risk calculator could help identify at-risk individuals in the ambulatory oncology setting; further, screening for VTE in high risk patients could lead to early detection of deep vein thrombosis (DVT) and avoid potential emergent consequences, including hospitalization.METHODS:A computerized alert was built into the electronic medical record system (EPIC) that automatically calculates a score using a validated risk tool [Khorana Score (KS), Blood 2008] based on the primary site of cancer, leukocyte and platelet counts, hemoglobin, and body mass index. During silent lead-in phase I (8/2016-1/17), we evaluated the accuracy of the electronic alert to detect high-risk patients and prospectively followed them for events. During this period, we limited the test to patients presenting to gastrointestinal, thoracic, genitourinary and lymphoma clinics. Patients presenting for consultation without planned treatment/follow up of at least 3 months at our institution were excluded. In phase II (6/17-12/17), we improved the electronic alert to warn physicians in real time about high risk patients and offered lower extremity ultrasonography as a screening test for early detection. In this phase, we only included patients with KS ≥ 3, and an available CBC <2 weeks from alert.RESULTS:During phase I, the alert identified 194 consecutive patients as being at risk (see table 1). The majority of the patients with a positive alert were male (54%) with the most prevalent malignancy being lung and pancreatic adenocarcinomas. The subsequent rate of DVTs at 6 months in patients with a KS of 4 was 18.75% (3/17), patients with KS of 3 was 16.9% (11/65), KS of 2, 13.1% (8/61), and KS of 1, 6.25% (3/48) (Figure 1). See table 1.Time from score calculation to DVT was an average of 33.2 days. 30% of patients developed a DVT within 4 weeks of alert, 50% within 60 days, and 65% within 90 days. 45% of patients diagnosed with DVT were alerted during their initial or second clinic visit. 55% of patients were diagnosed while inpatient and another 30% in the emergency room. Mean emergency room visits for patients with DVT were 1.75 compared to 0.89 for all patients. Mean all cause admissions and length of stay during this period were 2.43 and 15.01 days for patients with DVT, compared to 0.93 and 5.06 respectively for all 194 patients. Mortality rates were 45% for patients with DVT compared to 17% for the study population.In phase II, 59 patients have been identified as high risk by the alert. Of these, 6 were already on therapeutic anticoagulation or had a recent history of DVT. Of the remainder, screening lower extremity ultrasonography was ordered on 10 patients; three (30%) had a LE DVT and were started on therapeutic anticoagulation. One other patient did not have screening ultrasonography ordered, and was diagnosed with DVT within 14 days and started on therapeutic anticoagulation. Additional data collection is ongoing and will be presented at the meeting.CONCLUSION:An electronic medical record risk calculator can be a valuable clinical tool in earlier detection of DVTs in high-risk cancer patients. An initial silent run-in phase demonstrates the ability of this tool to identify high-risk patients at substantially increased risk for VTE, emergency room visits, hospitalization and mortality. An ongoing phase II pilot of early screening demonstrates high rates of subclinical DVT but low rates of ordering screening tests by providers. Ongoing efforts to increase acceptance of screening ultrasonography and data collection may potentially reduce subsequent hospitalization and other adverse consequences for cancer patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Factors Associated With Job Satisfaction in Medical Oncology Practices: Results From a Multisite Survey.

The aim of this study was to examine the factors influencing job satisfaction of nurses, physicians, and advanced practice providers in ambulatory oncology settings. Job satisfaction is essential to clinician well-being and quality of care. In 2017, clinicians from 29 ambulatory medical oncology practices completed anonymous paper questionnaires that examined job satisfaction, clinician-to-clinician communication, and perceptions of patient safety. Linear regression, adjusted for clustered observations, examined the relationship between job satisfaction, clinician communication, and patient safety perceptions. Of 280 respondents (response rate of 68%), 85% reported that they were satisfied or very satisfied with their current position. Patient safety and accuracy of clinician communication were positively and significantly associated with job satisfaction. Although most surveyed clinicians were satisfied, 15% were dissatisfied and reported communication and safety concerns. Leadership efforts to strengthen clinician communication actions and develop positive safety cultures are promising strategies to promote clinician well-being and high-quality cancer care.

Monitoring Rates of Malnutrition Risk in Outpatient Cancer Centers Utilizing the Malnutrition Screening Tool Embedded into the Electronic Health Record

BackgroundThe risk of malnutrition in patients with cancer is well documented. However, screening to identify patients at risk in ambulatory cancer centers is not standardized nor uniform. The 2-question Malnutrition Screening Tool (MST) is validated in the ambulatory oncology setting and endorsed by the Academy of Nutrition and Dietetics. ObjectiveTo test the feasibility of operationalizing and standardizing malnutrition risk assessment across 2 large ambulatory cancer centers by embedding the MST into the electronic health record (EHR) with the goal of identifying and quantifying the prevalence of malnutrition risk in outpatient settings. DesignA Quality Assurance Performance Improvement project was conducted to evaluate malnutrition screening practices by leveraging the EHR. Work standards were developed, implemented, and evaluated to assess the feasibility of utilizing de-identified MST data, entered as discrete variables in an EHR flowsheet, to track monthly MST completion rates and to identify and quantify patients being treated for cancer scoring at risk for impaired nutritional status. Participants/settingData from 2 large adult ambulatory community cancer centers in the upper Midwest were collected between April 2017 and December 2018. ResultsOver a 20-month period, the average monthly MST completion rate was 74%. Of those with completed MST screens, the average percentage of patients identified at nutritional risk (MST score ≥2) was 5% in medical oncology and 12% in radiation oncology. ConclusionIt is feasible to (1) integrate and standardize data collection of the MST into existing EHR flowsheets and (2) identify and quantify patients at risk for malnutrition on a consistent basis.