2017 Spring Meeting Innovative Posters

Degree of and reasons for pre-operative anxiety differ in patients undergoing surgery for benign or malignant diagnoses

Karin Cole, MD, Portland Surgical Associates, Kristen Lehmann, RN/BSN, Portland Surgical Associates

Background: The perioperative period has been identified as a key time for identifying emotional distress in cancer patients, as interventions may have an impact on post-op recovery.  The purpose of this study is to determine the self-reported anxiety level and sources of anxiety identified by patients undergoing surgery at our institution.  Patients with both benign and malignant diagnoses were included for purposes of comparison.

Methods: The study period was the calendar year 2016, and the study population was all patients undergoing elective surgery by a single surgeon.  Pre-operatively, patients completed a one-page assessment with a visual analog anxiety scale and indicated sources of anxiety from a list of choices.  Patients completed the same visual analog scale on the day of surgery.

Results: There were 95 patients in the benign disease group and 49 in the malignant group.  The average pre-op anxiety score was 2.9 in the benign group and 4.5 in the malignant group (p<0.05).  Most common causes for anxiety in the benign disease group were the recovery period (31%), pain after surgery (29%), and complications (25%).  In the malignant group, the most common causes were unexpected findings during surgery (61%), worries about future health (49%), and pain after surgery (41%).  The average day of surgery anxiety score was 3.4 in the benign group and 4 in the malignant group (p=NS).

Conclusions: Patients undergoing surgery for cancer report a higher pre- op anxiety level and different causes for anxiety than patients with benign disease.

A demonstration project: Providing Colon Cancer Screening to Homeless people–Capitalizing Community Partnerships

Donna Green, BSN, RN , OCN, Maine Medical Center, Maine Medical Center,  Donna A. Green RN,BSN,OCN, Leslie Foreman RN,BSN,OCN, Beverly Thorpe MSW, Casco Bay Surgery, M. Parker Roberts, MD, Preble Street, Bill Burns, Homeless Health Partners,  Malia Haddock

Background: Homeless people encounter many barriers to healthcare and preventative services, while having an increased prevalence of most risk factors for cancer. A group of homeless adults (40) receiving services from Preble Street in Portland Maine were successfully provided access, support and coaching to participate in colon cancer screening using Fecal Immunochemical Test (FIT) over a period of six weeks. Maine Medical Center Cancer Institute (MMCCI) recruited a Physician champion, while Preble Street gathered multiple internal and external community partners and together help plan the project, identify resources needed, plan for data collection and address potential barriers for participation.

Methods: Community partners (MMCCI, Preble Street, Casco Bay Surgery, NorDx, MaineHealth Care Partners and Homeless Health Partners Case Managers, Me Health LRC, and Maine Medical Center Magnet Council) created a detailed protocol to be used to overcome barriers and facilitate screening. The combination of a simple screening tool and caseworker relationship proved to be an effective strategy. Community Partners were used to identify barriers in the process, monitor all test results and navigate patients testing positive to colonoscopy. Small incentives of $10 food cards were provided for those participating in the screening event.

Results: Of the 40 participants who were screened 8 (20%) tested positive and are in colonoscopy follow-up, with ages ranging from 50-74 years. The majority of participants 28 (70%) reported never having a provider conversation about colon cancer screening.

Conclusions: Providing cancer prevention education and access to screening can have a positive impact on early detection in the homeless population.  Identifying practical barriers and solutions are essential to improving cancer screening participation for homeless people.

Electronic Consultations (eConsults) in Hematology: An Evaluation for Effectiveness

Joshua Hickman, MHA, DHMC - Norris Cotton Cancer Center, Megan M. Colgan, Kenneth R. Meehan, John M. Hill, Jr.

Background: In September 2014, the AAMC received a grant from CMS to examine manners to optimize patient referrals to specialists. DHMC is one of five academic medical centers participating in this project.

Methods: To understand referrals to Hematology and Oncology (H/O) all primary care referrals generated from October 2015 through August 2016 were evaluated. Four primary care geographic locations within the DHMC system (Manchester, Nashua, Concord, and Lebanon) referred 1,780 patients for H/O services. Of these 1,780 patients, 299 patients (17%) were referred to non-DH H/O practices. In general, 84 patients each month were referred to H/O by primary care providers.

Results:  In an attempt to improve the ease of patient referrals to Hematology and reduce costs associated with patient care, electronic consults (eConsults) were initiated within DHMC system. A Hematology eConsult allows the primary care physician to consult a hematologist to determine if a formal in-person consultation is needed and/or if additional patient testing is required. From April 2015 to December 2016, 241 Hematology eConsults were generated. The majority of the eConsults were generated from primary care providers (PCPs) in the Lebanon area (52% of eConsults), followed by the Nashua area (34%) and the Manchester area (12%). The eConsults referral system began slowly but has increased rapidly, resulting in 5 to 8 Hematology eConsults each week, in the last 3 months.In addition,  84% of all hematology eConsults were completed within 48 hours of the PCPs’ request.

Conclusions: Due to the large number of referrals generated to Hematology, the eConsult is an easy and rapid method to assist PCPs in identifying possible patient evaluations required and provides a rapid entry into the consult system. For the specialists, a rapid review, generally 20 minutes or less, offers guidance to the PCP and also determines that those patient seen in consultation are warranted.

Enhancing the Effectiveness of Communication in the Rural Oncology Healthcare Setting.

Rachel Hough, RN,  Norris Cotton Cancer Center Kingsbury Pavilion, Rivier University

Background: Patients with cancer diagnoses receiving dual therapy treatment in radiation and medical oncology are at increased vulnerability for developing side effects and complications altering their overall ability to meet daily needs. Effective interdisciplinary communication can often identify and prevent complications, thus improving patient safety. Staff at a satellite oncology facility undertook a quality improvement project to identify potential areas for improvement in communication and several possible areas were identified. With today's healthcare challenges, it was determined that a standardized communication tool is imperative in the rural oncology setting where multiple electronic health records without interface are used, posing a risk of missing data or corresponding decision support that may impact patient safety.

Methods: A systematic review of literature published between 2010 to the present was performed to identify fundamental themes for effective communication and best practices for establishing a standardized communication tool. Evidence-based models for effective communication were then defined and applied to the rural oncology setting. Practical strategies to structure a toolkit serving as a standardized process were derived.

Results: The Institute of Medicine (2001) noted that poor communication during transitional care has primary unintended safety consequences. Evidence supports the use of standardized communication models to improve safety and quality of care.

Conclusions: Although this evidence based project is in its beginning stages, the benefits are noted in other fast paced complex care environments (e.g. nephrology). Adapting and implementing a more robust standardized tool to ensure the exchange of critical patient information may improve cancer care for patients in the rural oncology setting.

The development of algorithms for rehabilitation of cancer treatment-related sequale

Stacey Howard, SPT, Heather Brabec, SPT, Katherine Michelsen, SPT, Mary Bergman, SPT, Elyse Detweiler, SPT, Jeanine Manubay, SPT, Carly Scheid, SPT, Anna Sidloski, SPT, Morgan Wilson, SPT, Amy Litterini, PT, DPT. n*All coauthors represent the University of New England

Background: Common cancer treatment-related sequelae secondary to chemotherapy, radiation, and/or surgery including breast cancer-related lymphedema (BCRL), chemotherapy-induced peripheral neuropathy (CIPN), and cancer-related fatigue (CRF) continue to be studied extensively in the breast cancer survivor population. A surveillance model exists as a guideline for healthcare practitioners and survivors regarding BCRL and demonstrates advantages related to decreased healthcare costs and patient burden, and improved early detection. The purpose of this project was to create algorithms for early screening and detection of common cancer treatment-related sequelae, and to identify appropriate triggers for referral to rehabilitation professionals.

Methods: A group of University of New England doctor of physical therapy students conducted needs assessments and a focus group with two local oncology providers and survivors at a local Cancer Community Center as part of a community health and wellness project. The information collected was used to create three algorithms for BCRL, CIPN, and CRF using current evidence, existing surveillance models as conceptual framework, and feedback from survivors. A strategic plan was also developed illustrating the cost savings and other benefits of implementing the algorithms.

Results: Three unique and innovative algorithms provide a pathway demonstrating when appropriate screenings should occur, specific screening recommendations, and triggers for appropriate rehabilitation referrals. The strategic plan in addition to the algorithms were presented to key stakeholders.

Conclusions: Implementation of the algorithms has the potential to bridge the current gap between traditional oncology care and access to timely rehabilitation intervention in addition to improving the quality of care across the breast cancer survivorship continuum.

Evaluation of calcitonin utilization in a tertiary healthcare setting

Nicolas LaPlante, Pharm.D. Candidate, Eastern Maine Medical Center, Bret LaForge, Pharm.D. Candidate, Matthew J. Marston, Pharm.D., BCPS

Background: Calcitonin is an effective method for treating hypercalcemia. However, dramatic increases in cost in recent years have created a significant financial burden to medical facilities and patients if the drug is used improperly. A drug-use evaluation was completed with the objective of guiding appropriate calcitonin use.

Methods: A retrospective analysis was conducted for all patients who had a calcitonin order entered during a 2.5 year period. Patients receiving the drug were categorized by the following indications: hypercalcemia, osteoporosis vertebral compression fractures (OVCF) and osteoporosis. The cost savings that would have resulted from preventing unnecessary use were calculated.

Results: There were 68 calcitonin orders placed over the 2.5 year study period, and 32 patients received at least 1 documented dose. Of these, 24 patients were treated for hypercalcemia, 7 for OVCF, and 1 for osteoporosis. It was estimated that if calcitonin use was restricted to the treatment of hypercalcemia and limited to a default treatment duration of 48 or 72 hours, the hospital could have benefited from a savings of $98,700 or $81,900, respectively. Following the study, an order set was developed to implement prescribing restrictions and encourage responsible use of calcitonin in hypercalcemia of malignancy. This placed a 72 hour default duration on injectable calcitonin and reserved its use for only severe cases of hypercalcemia.

Conclusions: An order set was developed for hypercalcemia of malignancy, based on a medication-use evaluation estimating an $81,900 cost savings over a 2.5 year period with appropriate use of calcitonin.

BREAST CANCER SCREENING IN PATIENTS WITH CANCERS OTHER THAN BREAST

Robin Leopold, Alexander W Thomas, Medical student UVM, Kyle F Concannon, Medical student UVM, Alissa D Correll, Medical student UVM, Catherine M LaPenta, Medical student UVM, Stephen M Maurer, Medical student UVM, Brian L Sprague, PhD, Epidemiologist, UVM,Sally D Herschorn, MD, Radiologist, UVM, Claire F Verschraegen, MD, Oncologist, UVM

Background: Screening mammography can detect early breast cancers and reduce subsequent cancer mortality. However, there is a lack of consensus as to what should trigger screening discontinuation. This absence of clear-cut guidelines means that many patients with advanced malignancies continue screening despite unclear benefit.

Methods: We performed a retrospective cohort study of female patients diagnosed with a non-breast malignancy to explore the incidence and effects of screening mammography. Female patients, who were diagnosed between 2007 and 2012 with a non-breast malignancy stage II or higher, were cross-referenced with the Vermont mammography screening logs from January 1, 2007 to September 30, 2014. Additional data was collected through chart reviews, in May 2016.

Results: Of 1501 women, 398 (26%) who met the above criteria had a screening mammogram within first 5 years of their cancer diagnosis. Of these 398 women, 193 (48.5%) were alive without cancer, 132 (33.2%) had died, and 73 (18.3%) were alive with cancer at the time of chart review. Of those who died, 84 (63.6%) had a stage III or IV cancer. Eighteen (4.5%) had a breast biopsy following a suspicious screening mammogram, resulting in 13 (3.3%) benign diagnoses and 5 (1.3%) breast cancer diagnoses. No patient died of breast cancer.

Conclusions: Female patients diagnosed with an advanced non-breast malignancy have a mortality risk that outweighs the known breast cancer mortality benefit from screening mammography.

A Pilot Home Exercise Program for Individuals with Advanced Cancer: A Case Series

Amy Litterini, PT, DPT, University Of New England, Emily Wallingford, DPT; UNE; Molly Thornton, DPT; UNE; Taylor LaCouture, DPT; UNE; Michael Kilgas, DPT; UNE; Elizabeth Kelly, DPT; UNE; Christian Thomas, MD, New England Cancer Specialists

Background: Individuals with advanced cancer experience a multitude of cancer and cancer treatment-related sequelae which can limit functional mobility.  The study purpose was to explore the potential benefits of a home-based resistance and pedometer-monitored walking program on functional outcomes and quality of life in individuals with advanced cancer.

Methods: A within-subjects design of adult volunteers with advanced cancer (n=9, mean age: 63, males: 8, females: 1) were recruited through the local cancer center and treated by supervised physical therapy students in a community-based fitness and rehabilitation facility with Institutional Review Board approval.  Outcome measures included the Timed Up and Go Test (TUG); usual gait speed; the FACIT-Pal; the FACIT-F; and pain on a visual analog scale.  The intervention included eight weeks of individualized home-based resistance exercise via the R.E.S.T. Protocol and a walking program monitored on a pedometer.

Results:  Of the nine patients who entered, four completed the study (44.4%).  No participant withdrew because of study adverse events; however, participation was discontinued for the following reasons: cancer treatment-related side effects (n=3); hospitalization (n=1); and death (n=1). Outcomes for those with both pre- and post-intervention data (n=4) included: a decrease in pain on the VAS (mean: -24.3/100); increased gait speed (mean speed change: +.16m/s, MCID: .13m/s), and reduced TUG time (mean: -3.4s).  Meaningful change was not appreciated on the FACIT-Pal or FACIT-F.

Conclusions: Advanced cancer survivors may benefit from individually prescribed home-based exercise for improving functional mobility.  Further research is needed to validate results in larger, randomized trials.

Pharmacists improve the quality of patient care through optimized medication review at Southcoast’s Outpatient Oncology Center

Heather McCarthy, PharmD, Southcoast Centers for Cancer Care, Pistorino L, Haynes L, Skeffington P, Santos A and Raymond D

Background: Patients are regularly prescribed oral anticancer medications by their Oncologist and have their prescriptions processed by outpatient and/or specialty pharmacies that may not have access to complete medication lists to perform comprehensive drug utilization review.   We identified this as an opportunity to improve the quality of care by involving front-line oncology pharmaceutical experts.

Methods: Cancer Center pharmacists in Fairhaven and Fall River, Massachusetts, have been engaged in an ongoing initiative, reviewing every new oral treatment plan for patients at Southcoast Centers for Cancer Care.  Patients are identified via reports run out of Mosaiq or Epic.  The pharmacist reviews the patient’s current medication list and runs an interaction check through Micromedex with the new oral agent.  If an interaction is identified, the pharmacist contacts the prescriber via email and offers suggestions to resolve the interaction.  Within the email, the prescriber is asked to reply with the action that they will be taking in response to the suggestions.

Results: From January 2015 to August 2016, 217 reviews were completed.  Of those, 80 (37%) resulted in identifying one or more interactions.  The three most frequent causes for concern related to QTc prolongation, chemotherapy drug efficacy being decreased by other medications and “Other,” which included cytochrome p450 enzyme issues.

Conclusions: Oral chemotherapy is associated with a significant number of drug interactions.  Cancer Center pharmacists can play an important role in prospectively identifying these interactions and working with prescribers to prevent and minimize them, and monitor patients to maximize effectiveness of their drug therapy.

Screening for Chemotherapy-Induced Peripheral Neuropathy

Elizabeth McGrath, DNP, AGACNP-BC, AOCNP, ACHPN, DHMC - Norris Cotton Cancer, Center, Elizabeth B. McGrath DNP, APRN, Dartmouth Hitchcock Department of Hematology-Oncology, Norris Cotton Cancer Center, Lara Ronan MD, Dartmouth Hitchcock Department of Neurology, Victoria Lawson MD, Dartmouth Hitchcock Department of Neurology

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is defined as the presence of signs or symptoms of peripheral nerve dysfunction, as a consequence of damage to the peripheral or autonomic nervous system caused by chemotherapeutic agents. It is a common, potentially severe and dose-limiting adverse effect of cancer treatment. The reported incidence of CIPN ranges from 0%-70% in patients receiving chemotherapy. CIPN can lead to dose reductions of chemotherapy, discontinuation of treatment, and ultimately affect overall survival. Due to lack of evidence for effective management of CIPN, regular assessment of neurological function is recommended. However no standardized measurement for CIPN exists.

Methods: A quality Improvement project was undertaken at the Norris Cotton Cancer Center to integrate screening for CIPN into the routine care of patients at risk for CIPN. A literature search was done to select an evidenced based screening tool and data was collected on patients with breast, colon, and head and neck cancers.

Results: Twenty-eight patients were screened prior to initiation of treatment. Six of these patients have been screened mid-cycle. Time to complete survey is brief, i.e. 2-5 minutes. Only one patient refused to complete the survey. Time of entry into data base is less than 5 minutes. Disruption to flow of care minimal.

Conclusions: The project demonstrates screening for CIPN can be easily accomplished in the routine care of patients receiving chemotherapy. The next steps are to educate staff and expand screening to all patients at risk of CIPN and develop a process to ensure screening is done at the proper intervals.

Minimizing variability in available information to safely treat oncology patients in an ambulatory setting

Elizabeth Walsh, MD, Massachusetts General Hospital/North Shore Cancer Center, Antoinette Lavino RPH, Mass General Hospital/North Shore Cancer Center, Jean Treacy NP,Mass General Hospital/North Shore Cancer Center

Background: Over a 2-week period at an academic community based practice, 25% of encounters were reported to have missing or unclear information (n=408).  The top categories of missing data were 1) missing labs/tests, 2) no orders and 3) absent /unclear communication, accounting for 64.3% of cases.

Methods: We proposed a process change with a goal of decreasing encounters with missing /unclear information to 10% by focusing on these deficiencies.  After process mapping, stakeholder analysis and stakeholder input, we developed interventions to address the infusion center and the laboratory/ clinical practice elements of the system.

Results:  In the infusion center, we developed Pre-Treatment Checklists to standardize treatment prerequisites.  In the laboratory and clinical practice, we developed a new workflow to “delink” laboratory, treatment clearance and infusion appointments, meaning the laboratory/clearance appointment are 24-72 hours prior to infusion appointment. These iterative process changes will be fully implemented by March 3, 2017.   As an ongoing evaluation of improvement, we are measuring time from infusion center check-in to medication release by nurses.  We will reassess missing prerequisite data from March 6 to 17.

Conclusions: Oncologic infusion centers require a complex operational flow with multiple role groups working together to deliver safe and efficient care.   Identification of actual and potential process inefficiencies requires input from and analysis of all role groups.  Interventions should be targeted at multiple levels to affect change.

A Comparison of Brief Cognitive Screening Tools for Use in Cancer Survivorship Programs

Heather Wishart, PhD, Department of Psychiatry, Dartmouth Hitchcock, Nichole Miller, Clinical Post Doctoral Fellow, Department of Psychiatry,  Dartmouth Hitchcock, Elizabeth B. McGrath DNP, APRN, Department of Medicine- Hematology-Oncology, Dartmouth Hitchcock

Background: Up to 75% of cancer patients experience cognitive impairment during or after treatment of their cancer. Screening for cognitive deficits is an important part of cancer care, but there is no broadly agreed-upon and well-validated screening approach doing so.

Methods: A quality improvement methodology was utilized to identify and systematically compare available tools with a focus on brief self-report questionnaires, including the Neuro-Quality of Life Scale (Neuro-QOL), the Functional Assessment of Cancer Therapy-Cognition (FACT-COG), the MS-Quality of Life Scale (MS-QOL), and a questionnaire developed based on National Comprehensive Cancer Network guidelines (NCCN-COG).  Participants included 47 patients (Mean age = 61.07 ± 10.7 years) in our gastrointestinal cancer clinic who completed all four questionnaires.  All questionnaires except the Neuro-QOL covered the main domains of cognitive function affected by cancer.

Results:  Symptom severity ratings showed high inter-scale correlations (Spearman Rank-Order Correlation Coefficients (rS) = 0.78 to 0.0.89, p < 0.001).  Symptom interference ratings were moderately correlated (rS = 0.64 to 0.66, p < 0.001).  Only the FACT-COG included items related to others’ perceptions.  Only the Neuro-QOL provided healthy adult control data, but age-adjusted normative data were not provided.

Conclusions: Three of the four questionnaires covered the cognitive domains important for cancer cognition screening and assessed both symptom severity and degree of interference.  Limitations included weak to no normative data or validated cut-off scores.  In the next stages of our QI project, we plan to evaluate these and other brief screening tools in relation to formal neurocognitive assessment, identify sources of normative data, and develop specific practical screening recommendations.