Lung Cancer Screening in the Community Setting.

BACKGROUND: Lung cancer has high incidence and high mortality burden, particularly because it is typically diagnosed in later stages. The National Lung Screening Trial demonstrated a lung cancer-specific mortality benefit in high-risk current and former smokers with yearly low-dose chest computed tomography (CT). Lung cancer screening is thus recommended, but it is unclear whether the results of the National Lung Screening Trial can be replicated in community settings. METHODS: A retrospective review was performed of the lung screening program over its first 5 years, 2012 to 2016. Patients' demographics, initial screening results, follow-up, and management results were analyzed in relation to the National Lung Screening Trial results. Annual adherence was defined as returning for imaging within 1 year + 90 days. RESULTS: A total of 1,241 persons underwent initial screening over the 5-year period; 78.6% of findings were benign, and only annual repeat low-dose chest CT was recommended. A total of 29 cancers were identified in 26 participants (2%), of which 72% were stage I. The annual adherence rate to repeat imaging after a low-risk baseline scan was 37%, and the any follow-up rate was 51% despite programmatic efforts to follow screening recommendations. When positive findings required more intensive evaluation, most commonly by repeat chest CT scan, adherence was 88%. A total of 1.1% of all participants had invasive biopsies for benign results. Complications of biopsy were minimal. CONCLUSIONS: This review demonstrates that a community-based program can approximate the results of the National Lung Screening Trial in detecting early lung cancers. Further study of the adherence phenomenon is essential.

Measuring end-of-life care in oncology practices: learning from the care of the dying.

BACKGROUND: There is increased interest among oncology and palliative professionals in providing appropriately timed hospice services for cancer patients. End of life (EoL) metrics have been included in oncology quality programs, but accurate EoL data and benchmarks are hard to obtain. OBJECTIVE: To improve EoL care by measuring patterns of care among recently deceased patients. METHODS: Care utilization among deceased patients was analyzed by using software integrated with patient electronic health records. The data was verified by chart review. RESULTS: Of 179 cancer deaths, tumor registry data differed from chart review in 7% of cases with regard to dates and/or location of death. Institutional EoL metrics were significantly affected by a large number of patients (37%) with advanced illnesses who had clinical diagnoses of cancer made at the end of life, but who had not been managed by oncologists. This population of patients who had not been managed by oncologists was older, less likely to use hospice, and more likely to use the intensive care unit than were oncologist-managed cancer patients. Among the patients of individual oncologists, the median stay in hospice ranged from 6-28 days. Data collection and chart review took an average of 27 minutes per case with combined efforts by a data analyst and oncology practitioner. LIMITATIONS: Single institution with comprehensive electronic medical record; some patients were treated outside of the system. CONCLUSION: Acquiring accurate data on EoL metrics is time consuming. Compared with chart review, other data sources have inaccuracies and include some patients who have not been managed by oncologists. Accurate attribution to individual physicians requires chart review by an experienced clinician.

Reduction in chemotherapy order errors with computerized physician order entry.

PURPOSE: To measure the number and type of errors associated with chemotherapy order composition associated with three sequential methods of ordering: handwritten orders, preprinted orders, and computerized physician order entry (CPOE) embedded in the electronic health record. MATERIALS AND METHODS: From 2008 to 2012, a sample of completed chemotherapy orders were reviewed by a pharmacist for the number and type of errors as part of routine performance improvement monitoring. Error frequencies for each of the three distinct methods of composing chemotherapy orders were compared using statistical methods. RESULTS: The rate of problematic order sets-those requiring significant rework for clarification-was reduced from 30.6% with handwritten orders to 12.6% with preprinted orders (preprinted v handwritten, P < .001) to 2.2% with CPOE (preprinted v CPOE, P < .001). The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders (preprinted v handwritten, P < .001) to 0.1% with CPOE (CPOE v preprinted, P < .001). CONCLUSION: The number of problem- and error-containing chemotherapy orders was reduced sequentially by preprinted order sets and then by CPOE. CPOE is associated with low error rates, but it did not eliminate all errors, and the technology can introduce novel types of errors not seen with traditional handwritten or preprinted orders. Vigilance even with CPOE is still required to avoid patient harm.

A supportive care clinic for cancer patients embedded within an oncology practice.

BACKGROUND: Most cancer patients have symptoms from their disease or treatment. Symptoms are not ideally managed in the context of busy clinics, resulting in potentially avoidable emergency department (ED) visits and hospitalizations. Adjunct supportive care clinics (SCCs) may more effectively address patient needs, but they contribute to fractionation of care if different personnel are involved. OBJECTIVE: We describe an SCC embedded within a physician practice in which an employed nurse practitioner delivered most of the care. We measured the disposition of patients from the SCC to the ED, and the effect on ED visits and admissions for symptom management. METHODS: We conducted a retrospective review of the patients attending the SCC over a period of 11 months. Demographics and disposition outcomes were tracked and compared with pre-intervention controls. RESULTS: In all, 340 visits were recorded from 330 unique patients. Same-day and next-day appointments with a nurse practitioner were arranged for 62% and 25% of patients, respectively. The most common complaints related to pain and gastrointestinal issues. Most of the patients were discharged home. A few needed hospitalization or ED-level care. Admissions for symptom-related care fell by 31%. An estimated 66 ED visits were avoided by patients accessing the SCC. LIMITATIONS: The study was retrospective. It did not include detailed fnancial data. Results may not be generalizable because of the high level of central planning and use of a shared electronic medical record system, which may be lacking in some practices. CONCLUSIONS: An embedded supportive care clinic allowed rapid access to experienced oncology care under supervision by the patient's own oncologists. The clinic was associated with less use of the ED and need for hospitalization. New methods of reimbursing medical care will increasingly require oncology practices to improve patient access to symptom-related care to avoid unnecessary admissions. An embedded SCC can accomplish these goals while avoiding further fractionation of care.