Outpatient Oncology Services Research Articles

Effect of COVID-19 Pandemic on Oncology Services and the Impact of Specific Measures in Reducing the Delays

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused disruption of oncology services, but data on actual delays are lacking. We sought to study the delays faced by the cancer patients during the COVID-19 pandemic and the impact of measures carried out to reduce the delays. METHODS: We carried out a review of inpatient and outpatient oncology services from March 15 to June 15, 2020, at our institution. We obtained data on delays in referrals, diagnosis, chemotherapy, and treatment delivery for cancer patients. To examine the delays, patients were assessed in the inpatient and outpatient settings and according to cancer types. RESULTS: A total of 505 patients' events were included in the study, with 136 referral delays, 167 diagnostic delays, 121 chemotherapy delays, and 81 treatment delays. In the outpatient settings, maximum referral delays were faced by breast cancer patients (9.5 ± 3.3 days, range 7–14), followed by hematologic malignancy (hematology) patients (8.4 ± 4.5 days, range 0–14). Maximum diagnosis delay was faced by hematology patients (11.75 ± 5 days, range 0–14), followed by breast cancer patients (11.2 ± 3.4 days, range 7–14). Breast and colorectal cancer patients faced maximum chemotherapy delays (9.5 ± 6.6 days, range 0–14), followed by hematology patients (7.3 ± 6.6 days, range 0–14). In the inpatient setting, maximum diagnosis delays were faced by hematology patients (11 ± 2 days, range 10–14), followed by gastrointestinal cancers (8 ± 2.4 days, range 5–10). Maximum chemotherapy delays were faced by hematology patients (8.5 ± 5.9 days, range 0–14) and breast cancer patients (8 ± 2.4 days, range 5–10). Hematology patients were most affected by treatment-delays (6.75 ± 4.7 days, range 0–10). Comparison of delays during the earlier part of the study with the later part showed that referral delays improved by 3.5 days (P = 0.02), diagnosis delays improved by 6.1 days (P < 0.001), chemotherapy delays improved by 7.7 days (P < 0.001), and treatment delays improved by 8 days (P < 0.001). CONCLUSIONS: COVID-19 pandemic caused delays in the diagnosis and management of most cancer patients. Measures adopted to overcome delays resulted in a significant reduction in delays.

Emotional impact of COVID-19 preparations on metro and regional cancer workforces in Queensland Australia: "We are all in this together".

44 Background: Australia has achieved a “flattening of the curve” with a sustained COVID-19 roadmap to recovery in place. We explored the emotional impact of COVID-19 on our cancer workforce, during the preparation phase of the pandemic. Methods: We developed and pilot-tested an online survey to capture the emotional impact on cancer care staff during the COVID-19 health system response. Two large cancer centres were identified for study sample, one metropolitan and one regional, in Queensland, Australia. All cancer care staff with patient-facing roles were invited via all-staff email to participate on a weekly basis, uniquely also including ancillary and administrative workers. The final survey questionnaire included qualitative domains with open text responses for reflections on difficult decisions and subsequent emotional impacts. At the same time, a prospective diary of organizational developments was independently maintained by two investigators in order to contextualize changing survey responses over time. Qualitative data analyses by four investigators included independent, multiple cross-coding, memos, dataset review and member-checking to ensure methodological rigour. Data were synthesised into key themes utilising the Framework Method (Gale, 2013). Results: 117 metropolitan and 59 regional staff were surveyed over a 6-week period. Participants were medical, nursing, allied health, administrative and ancillary staff, working across inpatient and outpatient oncology services. Four key themes were emergent across the trajectory of the COVID preparation phase; ‘Strategies for protection’ (self-isolation, using PPE, protecting patients, families and each other), ‘Navigating rules and keeping up’ (compliance, exceptions, conflict and complex decision fatigue), ‘Tempered optimism’ (this is grief, strategies for coping, pride in one’s place), and ‘Framing the new normal’ (using new technology, second wave, uncertainty). At different time points, one theme dominated more than others. Conclusions: Despite rapid adaptations to system changes, staff responses highlight that it was their sense of connectedness that had the greatest influence on their reflections during the COVID-19 pandemic, but also underpinned the humanistic aspects of their responses. Staff perceptions of feeling supported and prepared, permeated through the duration of the survey. Results from the recovery phase are awaited.

Impact of clinical pharmacists in outpatient oncology practices: A review

Published literature describing the effectiveness of outpatient oncology services delivered by clinical pharmacists is summarized. Peer-reviewed articles on studies evaluating the provision of outpatient oncology services by licensed clinical pharmacists in the United States were identified and screened according to a study-specific protocol. Only research publications focused on the care of oncology patients and indicating the evaluation of measurable services and outcomes were selected for review. Data from eligible studies were extracted using a standardized tool, and agreement by a majority of the investigators was required for inclusion of articles in the final review. Eight publications were included in the review; nearly all were published since 2010. All of the included articles reported on results of observational studies in which data sourced from surveys, existing medical or prescription records, or medical cost information were analyzed to measure patient or provider satisfaction (or both) or patient-reported health outcomes. The evaluated evidence indicated that pharmacists were effective in identifying treatment issues and medication misuse, delivering satisfactory and valued services, and finding mechanisms to reduce medical costs or generate revenue to justify continuation or support expansion of clinical pharmacy services. Moreover, in two instances, pharmacists' services were associated with improvements in symptoms reported by oncology patients. Available evidence suggests that outpatient oncology practices may benefit from integrating pharmacists into care models in order to more effectively, efficiently, and holistically address the needs of patients with cancer.

Factors associated with use of falls risk-increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross-sectional study.

Older people with cancer are at increased risk of falling. Falls risk-increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n=293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n=120) and medications causing orthostatic hypotension (69.9%, n=269). In total, 24.0% (n=92) patients reported falling in the previous 6months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64-68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06-127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high-risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.

Evaluation of Outpatient Oncology Services Using Lean Methodology

Evaluation of Outpatient Oncology Services Using Lean Methodology

Smoking Cessation Counseling Beliefs and Behaviors of Outpatient Oncology Providers

Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the "teachable moment" of cancer diagnosis to provide smoking cessation assistance. PROVIDERS AND METHODS: Physicians and midlevel providers (n = 74) who provide outpatient oncology services completed an online survey regarding smoking cessation counseling behaviors, beliefs, and perceived barriers. Outpatient medical records for 120 breast, lung, head and neck, colon, prostate, and acute leukemia cancer patients were reviewed to assess current smoking cessation assessment and intervention documentation practices. Providers reported commonly assessing smoking in new patients (82.4% frequently or always), but rates declined at subsequent visits for both current smokers and recent quitters. Rates of advising patients to quit smoking were also high (86.5% frequently or always), but <30% of providers reported frequently or always providing intervention to smoking patients (e.g., nicotine replacement therapy or other medications, self-help materials, and/or referrals). Only 30% of providers reported that they frequently or always followed up with patients to assess progress with quitting. Few providers (18.1%) reported high levels of confidence in their ability to counsel smoking patients. Patients' lack of motivation was identified as the most important barrier to smoking cessation. Although beliefs about providing cessation services to smoking patients were generally positive, few providers reported commonly providing interventions beyond advice to quit. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.

Meanings and aspects of quality of life for cancer patients: A descriptive exploratory qualitative study

Given the importance of quality of life (QoL) for cancer patients, it is important to work out what this concept means not only for cancer patients, and for the nurses who care for them, but also the aspects of which it is composed. Therefore, an interpretive research study was conducted to explore in-depth meanings and aspects of QoL as expressed by cancer nurses. Participants were selected from different inpatient and outpatient oncology services and a palliative setting in Adelaide, South Australia. Results showed that many aspects contribute to an individual’s QoL. These include the physical, the psychological, the spiritual, and both environmental and social interactions. More importantly, participants stated that spirituality is multifaceted and that there may be aspects in life that may be taken for granted. The meaning of patients’ QoL was viewed by nurses as a patient’s overall happiness and satisfaction. Also, nurses identified that providing choices to patients made an important contribution to a patient’s QoL. Therefore, this exploration into the in-depth meanings and aspects of QoL for cancer patients from nurses’ perspectives identifi ed that, in addition to the aspects related to QoL that have been identified previously in the literature, aspects related to spirituality would need to be extensively covered, and providing choices to patients would be important in patients’ QoL in an Australian setting.

How do nurses assess quality of life of cancer patients in oncology wards and palliative settings?

PurposeHow Quality of Life (QoL) assessment is conducted across different oncology wards and palliative settings is a challenging issue and needs to be searched further. There is a lack of interpretive research study in Australian populations in which QoL assessment for cancer patients in oncology and palliative areas has deeply been explored. Therefore, an interpretive research study was conducted to explore in-depth nurses’ QoL assessment conducted in oncology wards and palliative settings. MethodThe study was completed in 2007 in two major public hospitals in Adelaide, South Australia. Ten nurses were selected from different inpatient and outpatient oncology services and a palliative setting to take part in semi-structured interviews. The study was a ‘grounded theory approach’ in which some aspects of the grounded theory were used to gain a fundamental understanding and broad description of the experience of QoL assessment as conducted by nurses. ResultsAfter the data collection and analysis six main themes were identified. Four of the themes are presented as: a) Cues-based QoL assessment, and b) Purpose-based QoL assessment, c) Facilitators of QoL assessment, and d) Barriers of QoL assessment. ConclusionsFindings of the research study generally supported the notion that nurses mainly pick up on patients’ cues as a way for QoL assessment when they communicate with patients in the clinical area rather than using QoL tools. Also, nurses are, at times, uncertain if they are doing a QoL assessment and if their assessment of patients’ QoL is correct or not. Therefore, this supports a need for nurses to develop a more holistic relationship and stronger rapport with patients which underpins the assessment of cancer patients’ QoL through various cues.

Medicare's Hospital Outpatient Prospective Payment System: OPPS 101 (part 2 of 2).

There are many obvious differences for billing and reimbursement for outpatient oncology services in the hospital outpatient department versus in the office-based setting. The details can be difficult for hospitals to master because outpatient oncology is just one of many service lines to be billed. And the coding, billing, and payment details represent only part of the challenge for hospitals. Institutions are large and complex organisms, with many departments handling components of the entire continuum of delivering and billing for services. This often leads to significant fragmentation or miscommunication. For example, if the department responsible for maintaining the system to record charges (the charge master) is not well informed regarding changes in coding and billing requirements, important codes or code definitions may not be current and accurate, making it impossible for charge entry staff to choose the correct items. Or if the department responsible for patient registration is not aware of payer nuances regarding the use of specific drugs for certain diagnoses, they will not know that a predetermination of insurance coverage is needed. Finally, the pharmacy charge entry system may record the units of drug dispensed, but if those units do not match the Healthcare Common Procedure Coding System unit definition of billable dose, then drug charges can be grossly under- or overstated. Thus, hospitals frequently find it extremely difficult to match the detailed expertise that most office-based practices have developed through years of specialty focus.

The Cancer Pain Inventory: preliminary development and validation

The purpose of this study was to develop a Cancer Pain Inventory (CPI) that measures cancer patients' beliefs and concerns about pain. This paper describes development and pilot testing of a preliminary version of the CPI and describes its psychometric properties including its reliability and validity relative to established pain measures. Subjects were recruited from inpatient and outpatient oncology services of an NCI-designated comprehensive cancer center. Participants completed the 50 potential CPI items and these standard measures-Orientation-Memory-Concentration Test, Survey of Pain Attitudes, Brief Pain Inventory, Pain Disability Index, and Center for Epidemiological Studies-Depression Scale. The magnitude and significance of associations between the CPI and the other measures were examined. Of 366 patients who were eligible and agreed to participate in the study, 262 completed the questionnaires. Principal components analyses were used to select items most appropriate for retention in the preliminary version of the CPI and to describe its factor structure. Based on the content of items that loaded on each factor, the five factors were labeled as Catastrophizing, Interference with Functioning, Stoicism, Social Aspects, and Concerns about Pain Medication. Correlations between the CPI and other measures supported construct validity of the five CPI factors. The results supported the validity of the CPI as a measure of five constructs relevant to the experience of pain in the cancer setting. The results also underscored the presence of unique features of cancer-related pain that clearly differ from commonly recognized dimensions of chronic, non-cancer-related pain.

Caregiver satisfaction with out-patient oncology services: utility of the FAMCARE instrument and development of the FAMCARE-6

To evaluate caregivers' experience of oncology services for ambulatory patients and to develop a short instrument (FAMCARE-6) suitable for computerised administration in the clinical setting. A sample of 234 caregivers recruited from 388 ambulatory oncology patients completed a computerised version of the 20-item family satisfaction with advanced cancer care (FAMCARE) instrument, which was originally developed for use in palliative care settings. Caregivers reported generally high satisfaction with all aspects of ambulatory oncology services: overall score; mean, 3.96 (SD, 0.67); information giving, 3.88 (0.78); physical patient care, 4.00 (0.71); availability of care, 3.89 (0.77); and psychosocial care, 4.05 (0.72), from a possible score of 5. Factor analyses identified a single factor structure; the items were reduced to six (FAMCARE-6), which yielded a scale with adequate psychometric properties (completion rates over 90% for every item, correlation of 0.7 or above with the factor identified in the individual item factor analysis, and internal reliability of α = 0.85). The overall mean score was 3.91 (SD, 0.73) for the FAMCARE-6. FAMCARE-6 can be used to assess caregiver satisfaction with ambulatory oncology services and may be suitable to be included as part of a computerised screening system for the psychological care of oncology patients.

Documentation of Chemotherapy Infusion Preparation Costs in Academic- and Community-Based Oncology Practices

Significant changes in Medicare reimbursement for outpatient oncology services were proposed as part of the Medicare Modernization Act of 2003. The purpose of this study was to identify the "true cost" associated with drug-related handling for the preparation and delivery of chemotherapy doses to estimate the impact of changing reimbursement schema by Medicare. Two academic medical outpatient infusion centers and 2 community cancer centers provided data used to estimate all costs (excluding drug cost) associated with the preparation of chemotherapy doses. The data included both fixed costs (drug storage, space, equipment, and information resources) and variable costs (insurance management, inventory, waste management, pharmacy staff payroll, supplies, and shipping). The average cost for the preparation of chemotherapy doses across all sites was dollar 34.27 (range, dollar 32.08-dollar 41.23). A time-and-motion study was also performed to determine what tasks were conducted by pharmacy staff and how much time was spent in the preparation of the top 15 chemotherapeutic drugs and regimens used in the 4 sites. Data from the 4 centers was projected to show that if 3,990,495 million chemotherapy infusions were administered to a national Medicare population in 2003, when multiplied by the average cost of preparation for infusions determined by the current study (dollar 34.27), the estimated total annual cost to Medicare for chemotherapy preparation by pharmacists is dollar 136,754,263.65. The pharmacists spent most of their days (90% or more) performing tasks directly related to the preparation of these agents. These data provide scientific support for the consideration of appropriate reimbursement for chemotherapy services provided by pharmacists to Medicare beneficiaries.

Developing an Ambulatory Care Productivity &amp; Patient Charge System

Click to increase image sizeClick to decrease image size Additional informationNotes on contributorsMargaret A. RileyMargaret A. Riley, M.N., R.N., C.N.A.A., is Director of Outpatient Oncology Services at Saint Joseph's Hospital of Atlanta in Atlanta, Ga. Siobhan Seidner, M.S.H.S., is Management Engineer in the Department of Operations Analysis at the same institution. The authors would like to thank the staff at the Outpatient Oncology and Treatment Center for their support and guidance in this project.Siobhan SeidnerMargaret A. Riley, M.N., R.N., C.N.A.A., is Director of Outpatient Oncology Services at Saint Joseph's Hospital of Atlanta in Atlanta, Ga. Siobhan Seidner, M.S.H.S., is Management Engineer in the Department of Operations Analysis at the same institution. The authors would like to thank the staff at the Outpatient Oncology and Treatment Center for their support and guidance in this project.

Implementing and Marketing a Cancer Prevention and Screening Program

Click to increase image sizeClick to decrease image size Additional informationNotes on contributorsMargaret A. RileyMaggie A. Riley, M.N., R.N., is Director of Outpatient Oncology Services at Saint Joseph's Hospital of Atlanta in Atlanta, Ga.