Care Patterns and Barriers to Outpatient Care for Adults With AML Following Intensive Chemotherapy at NCCN Member Institutions.

BACKGROUND: Prolonged hospitalization following intensive (re)induction chemotherapy for acute myeloid leukemia (AML), while standard, is costly and resource intense, limits inpatient bed capacity, and negatively impacts quality of life. Early hospital discharge (EHD) following completion of chemotherapy has proven safe as an alternative at select institutions, but is not widely implemented. PATIENTS AND METHODS: From February 2023 through May 2023, the NCCN Best Practices Committee conducted a survey evaluating AML hospitalization patterns, care models, and barriers to EHD at its 33 member institutions. RESULTS: A total of 30 (91%) institutions completed the survey; two-thirds treat >100 patients with AML annually and 45% treat more than half of these with intensive chemotherapy. In the (re)induction setting, 80% of institutions keep patients hospitalized until blood count recovery, whereas 20% aim to discharge patients after completion of chemotherapy if medically stable and logistically feasible. The predominant reasons for the perceived need for ongoing hospitalization were high risk of infection, treatment toxicities, and lack of nearby/accessible housing. There was no significant association between ability to practice EHD and annual AML volume or treatment intensity patterns (P=.60 and P=.11, respectively). In contrast, in the postremission setting, 87% of centers support patients following chemotherapy in the outpatient setting unless toxicities arise requiring readmission. Survey responses showed that 80% of centers were interested in exploring EHD after (re)induction but noted significant barriers, including accessible housing (71%), transportation (50%), high toxicity/infection rate (50%), high transfusion burden (50%), and limited bed availability for rehospitalization (50%). CONCLUSIONS: Hospitalization and care patterns following intensive AML therapy vary widely across major US cancer institutions. Although only 20% of surveyed centers practice EHD following intensive (re)induction chemotherapy, 87% do so following postremission therapy. Given the interest in exploring the EHD approach given potential advantages of EHD for both patients and health care systems, strategies to address identified medical and logistical barriers should be explored.

Clinician Perspectives Regarding the Impact of Information Technology on Multidisciplinary Tumor Boards: A National Comprehensive Cancer Network Survey.

PURPOSE: Multidisciplinary tumor boards (MTBs) support high-quality cancer care. Little is known about the impact of information technology (IT) tools on the operational and technical aspects of MTBs. The National Comprehensive Cancer Network EHR Oncology Advisory Group formed a workgroup to investigate the impact of IT tools such as EHRs and virtual conferencing on MTBs. METHODS: The workgroup created a cross-sectional survey for oncology clinicians (eg, pathology, medical, surgical, radiation, etc) participating in MTBs at 31 National Comprehensive Cancer Network member institutions. A standard invitation e-mail was shared with each EHR Advisory Group Member with a hyperlink to the survey, and each member distributed the survey to MTB participants at their institution or identified the appropriate person at their institution to do so. The survey was open from February 26, 2022, to April 26, 2022. Descriptive statistics were applied in the analysis of responses, and a qualitative thematic analysis of open-ended responses was completed. RESULTS: Individuals from 27 institutions participated. Almost all respondents (99%, n = 764 of 767) indicated that their MTBs had participants attending virtually. Most indicated increased attendance (69%, n = 514 of 741) after virtualization with the same or improved quality of discussion (75%, n = 557 of 741) compared with in-person MTBs. Several gaps between the current and ideal state emerged regarding EHR integration: 57% (n = 433 of 758) of respondents noted the importance of adding patients for MTB presentation via the EHR, but only 40% (n = 302 of 747) reported being able to do so most of the time. Similarly, 87% (n = 661 of 760) indicated the importance of documenting recommendations in the EHR, but only 53% (n = 394 of 746) reported this occurring routinely. CONCLUSION: Major gaps include the lack of EHR integration for MTBs. Clinical workflows and EHR functionalities could be improved to further optimize EHRs for MTB management and documentation.

A Survey of the National Comprehensive Cancer Network on Approaches Toward Addressing Patients' Transportation Insecurity.

BACKGROUND: Addressing patients' social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied. METHODS: In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN's 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future. RESULTS: A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients' transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%). CONCLUSIONS: Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients' transportation needs.

Measuring Advanced Practice Provider Productivity at the National Comprehensive Cancer Network's Member Institutions.

Introduction: The utilization of advanced practice providers (APPs) in oncology has been growing over the last decade; however, there is no standard method for assessing an APP's contributions to oncology care. Methods: The NCCN Best Practices Committee (BPC) created an APP Workgroup to develop recommendations to support the roles of APPs at NCCN Member Institutions. The Workgroup conducted surveys to understand how NCCN centers measure productivity. This article will review the survey results and provide recommendations for measuring APP productivity. Results: Although 54% of responding centers indicated they utilize relative value units (RVU) targets for independent APP visits, 88% of APPs are either unsure or do not believe RVUs are an effective measurement of overall productivity. Relative value units do not reflect non-billable hours, and APPs perform a significant number of non-billable tasks that are important to oncology practices. Sixty-six percent of APPs believe that measuring disease-based team productivity is a more reasonable assessment of APP productivity than measuring productivity at the individual level. Conclusion: Our recommendation for cancer centers is to focus on the value that APPs provide to overall care delivery. Advanced practice provider productivity metrics should consider not only the number of patients seen by APPs, but also the high quality and thorough care delivered that contributes to the overall care of the patient and practice. Advanced practice providers can help improve access to care, deliver improved outcomes, and increase patient and provider satisfaction. Reducing the focus on RVUs, accounting for important non-RVU-generating activities, and incorporating quality and team metrics will provide a better overall picture of APP productivity.

COVID-19 and Cancer Center Operations: Lessons Learned From the NCCN Best Practices Committee.

The NCCN Best Practices Committee, which is composed of senior physician, nursing, and administrative leaders from NCCN Member Institutions, evaluated the status of cancer center operations after 1 year of operating during the COVID-19 pandemic. Two major initiatives stood out: the increase in the utilization of network sites, and the gains made in telemedicine operations and reimbursement. Experts from NCCN Member Institutions participated in a webinar series in June 2021 to share their experiences, knowledge, and thoughts on these topics and discuss the impact on the future of cancer care.

Adoption of Patient-Generated Health Data in Oncology: A Report From the NCCN EHR Oncology Advisory Group.

BACKGROUND: Collecting, monitoring, and responding to patient-generated health data (PGHD) are associated with improved quality of life and patient satisfaction, and possibly with improved patient survival in oncology. However, the current state of adoption, types of PGHD collected, and degree of integration into electronic health records (EHRs) is unknown. METHODS: The NCCN EHR Oncology Advisory Group formed a Patient-Reported Outcomes (PRO) Workgroup to perform an assessment and provide recommendations for cancer centers, researchers, and EHR vendors to advance the collection and use of PGHD in oncology. The issues were evaluated via a survey of NCCN Member Institutions. Questions were designed to assess the current state of PGHD collection, including how, what, and where PGHD are collected. Additionally, detailed questions about governance and data integration into EHRs were asked. RESULTS: Of 28 Member Institutions surveyed, 23 responded. The collection and use of PGHD is widespread among NCCN Members Institutions (96%). Most centers (90%) embed at least some PGHD into the EHR, although challenges remain, as evidenced by 88% of respondents reporting the use of instruments not integrated. Forty-seven percent of respondents are leveraging PGHD for process automation and adherence to best evidence. Content type and integration touchpoints vary among the members, as well as governance maturity. CONCLUSIONS: The reported variability regarding PGHD suggests that it may not yet have reached its full potential for oncology care delivery. As the adoption of PGHD in oncology continues to expand, opportunities exist to enhance their utility. Among the recommendations for cancer centers is establishment of a governance process that includes patients. Researchers should consider determining which PGHD instruments confer the highest value. It is recommended that EHR vendors collaborate with cancer centers to develop solutions for the collection, interpretation, visualization, and use of PGHD.

Preferences in Oncology History Documentation Styles Among Clinical Practitioners.

PURPOSE: Clinical notes function as the de facto handoff between providers and assume great importance during unplanned medical encounters. An organized and thorough oncology history is essential in care coordination. We sought to understand reader preferences for oncology history organization by comparing between chronologic and narrative formats. METHODS: A convenience sample of 562 clinicians from 19 National Comprehensive Cancer Network Member Institutions responded to a survey comparing two formats of oncology histories, narrative and chronologic, for the same patient. Both histories were consensus-derived real-world examples. Each history was evaluated using semantic differential attributes (thorough, useful, organized, comprehensible, and succinct). Respondents choose a preference between the two styles for history gathering and as the basis of a new note. Open-ended responses were also solicited. RESULTS: Respondents preferred the chronologic over the narrative history to prepare for a visit with an unknown patient (66% preference) and as a basis for their own note preparation (77% preference) (P < .01). The chronologic summary was preferred in four of the five measured attributes (useful, organized, comprehensible, and succinct); the narrative summary was favored for thoroughness (P < .01). Open-ended responses reflected the attribute scoring and noted the utility of content describing social determinants of health in the narrative history. CONCLUSION: Respondents of this convenience sample preferred a chronologic oncology history to a concise narrative history. Further studies are needed to determine the optimal structure and content of chronologic documentation for oncology patients and the provider effort to use this format.

A Study of Advanced Practice Provider Staffing Models and Professional Development Opportunities at National Comprehensive Cancer Network Member Institutions.

INTRODUCTION: The National Comprehensive Cancer Network (NCCN) Best Practices Committee created an Advanced Practice Provider (APP) Workgroup to develop recommendations to support APP roles at NCCN Member Institutions. METHODS: The Workgroup conducted three surveys to understand APP program structure, staffing models, and professional development opportunities at NCCN Member Institutions. RESULTS: The total number of new and follow-up visits a 1.0 APP full-time equivalent conducts per week in shared and independent visits ranged from 11 to 97, with an average of 40 visits per week (n = 39). The type of visits APPs conduct include follow-up shared (47.2%), follow-up independent (46%), new shared (6.5%), and new independent visits (0.5%). Seventy-two percent of respondents utilize a mixed model visit type, with 15% utilizing only independent visits and 13% utilizing only shared visits (n = 39). Of the 95% of centers with APP leads, 100% indicated that leads carry administrative and clinical responsibilities (n = 20); however, results varied with respect to how this time is allocated. Professional development opportunities offered included posters, papers, and presentations (84%), leadership development (57%), research opportunities (52%), writing book chapters (19%), and other professional development activities (12%; n = 422). Twenty percent of APPs indicated that protected time to engage in development opportunities should be offered. CONCLUSION: As evidenced by the variability of the survey results, the field would benefit from developing standards for APPs. There is a lack of information regarding leadership structures to help support APPs, and additional research is needed. Additionally, centers should continuously assess the career-long opportunities needed to maximize the value of oncology APPs.

Oncologist Perspectives on Telemedicine for Patients With Cancer: A National Comprehensive Cancer Network Survey.

PURPOSE: The use of telemedicine expanded dramatically in March 2020 following the COVID-19 pandemic. We sought to assess oncologist perspectives on telemedicine's present and future roles (both phone and video) for patients with cancer. METHODS: The National Comprehensive Cancer Network (NCCN) Electronic Health Record (EHR) Oncology Advisory Group formed a Workgroup to assess the state of oncology telemedicine and created a 20-question survey. NCCN EHR Oncology Advisory Group members e-mailed the survey to providers (surgical, hematology, gynecologic, medical, and radiation oncology physicians and clinicians) at their home institution. RESULTS: Providers (N = 1,038) from 26 institutions responded in Summer 2020. Telemedicine (phone and video) was compared with in-person visits across clinical scenarios (n = 766). For reviewing benign follow-up data, 88% reported video and 80% reported telephone were the same as or better than office visits. For establishing a personal connection with patients, 24% and 7% indicated video and telephone, respectively, were the same as or better than office visits. Ninety-three percent reported adverse outcomes attributable to telemedicine visits never or rarely occurred, whereas 6% indicated they occasionally occurred (n = 801). Respondents (n = 796) estimated 46% of postpandemic visits could be virtual, but challenges included (1) lack of patient access to technology, (2) inadequate clinical workflows to support telemedicine, and (3) insurance coverage uncertainty postpandemic. CONCLUSION: Telemedicine appears effective across a variety of clinical scenarios. Based on provider assessment, a substantial fraction of visits for patients with cancer could be effectively and safely conducted using telemedicine. These findings should influence regulatory and infrastructural decisions regarding telemedicine postpandemic for patients with cancer.

Creative Strategies Implemented During the Coronavirus Pandemic That Will Impact the Future of Cancer Care.

The coronavirus pandemic has significantly impacted operations at leading cancer centers across the United States. In the midst of the chaos, at least one silver lining has emerged: the development of new, creative strategies for delivering cancer care that are likely to continue post pandemic. The NCCN Best Practices Committee, which is composed of senior physician, nursing, and administrative leaders at NCCN Member Institutions, conducted a webinar series in June 2020 highlighting the most promising and effective strategies to date. Experts from NCCN Member Institutions participated in the series to share their experiences, knowledge, and thoughts about the future of cancer care.

Current Practices for Screening and Management of Financial Distress at NCCN Member Institutions.

BACKGROUND: Financial distress from medical treatment is an increasing concern. Healthcare organizations may have different levels of organizational commitment, existing programs, and expected outcomes of screening and management of patient financial distress. PATIENTS AND METHODS: In November 2018, representatives from 17 (63%) of the 27 existing NCCN Member Institutions completed an online survey. The survey focused on screening and management practices for patient financial distress, perceived barriers in implementation, and leadership attitudes about such practices. Due to the lack of a validated questionnaire in this area, survey questions were generated after a comprehensive literature search and discussions among the study team, including NCCN Best Practices Committee representatives. RESULTS: Responses showed that 76% of centers routinely screened for financial distress, mostly with social worker assessment (94%), and that 56% screened patients multiple times. All centers offered programs to help with drug costs, meal or gas vouchers, and payment plans. Charity care was provided by 100% of the large centers (≥10,000 unique annual patients) but none of the small centers that responded (<10,000 unique annual patients; P=.008). Metrics to evaluate the impact of financial advocacy services included number of patients assisted, bad debt/charity write-offs, or patient satisfaction surveys. The effectiveness of institutional practices for screening and management of financial distress was reported as poor/very poor by 6% of respondents. Inadequate staffing and resources, limited budget, and lack of reimbursement were potential barriers in the provision of these services. A total of 94% agreed with the need for better integration of financial advocacy into oncology practice. CONCLUSIONS: Three-fourths of NCCN Member Institutions reported screening and management programs for financial distress, although the actual practices and range of services vary. Information from this study can help centers benchmark their performance relative to similar programs and identify best practices in this area.

Psychology Staffing at Cancer Centers: Data From National Comprehensive Cancer Network Member Institutions.

PURPOSE: The field of psycho-oncology is relatively undeveloped, with little information existing regarding the use of psychologists at cancer centers. Comprising 30 leading cancer centers across the United States, the National Comprehensive Cancer Network (NCCN) set out to understand the trends in its Member Institutions. METHODS: The NCCN Best Practices Committee surveyed NCCN Member Institutions regarding their use of psychologists. The survey was administered electronically in the spring/summer of 2017. RESULTS: The survey was completed by 18 cancer centers. Across institutions, 94% have psychologists appointed to provide direct care to their cancer center patients. The number of licensed psychologist full-time equivalents (FTEs) on staff who provide direct patient care ranged from < 1.0 FTE (17%) to 17.0-17.9 FTEs (6%). Regarding psychologist appointments, 41% have both faculty and staff appointments, 41% have all faculty appointments, and 18% have all staff appointments. Forty-three percent of institutions indicated that some licensed psychologists at their centers (ranging from 1%-65%) do not provide any direct clinical care, and 57% indicated that all licensed psychologist on staff devote some amount of time to direct clinical care. The percent of clinical care time that is spent on direct clinical care ranged from 15%-90%. CONCLUSION: There is great variability in psychology staffing, academic appointments, and the amount of direct patient care provided by on-staff psychologists at cancer centers.

Mitigation strategies for anti-D alloimmunization by platelet transfusion in haematopoietic stem cell transplant patients: a survey of NCCN® centres.

BACKGROUND AND OBJECTIVES: D-negative patients are at risk of developing an alloantibody to D (anti-D) if exposed to D during transfusion. The presence of anti-D can lead to haemolytic transfusion reactions and haemolytic disease of the newborn. Anti-D alloimmunization can also complicate allogeneic haematopoietic stem cell transplantation (HSCT) with haemolysis and increased transfusion requirements. The goal of this study was to determine whether cancer centres have transfusion practices intended to prevent anti-D alloimmunization with special attention in patients considered for HSCT. METHODS AND MATERIALS: To understand transfusion practices regarding D-positive platelets in D-negative patients with large transfusion needs, we surveyed the 28 cancer centres that are members of the National Comprehensive Cancer Network® (NCCN® ). RESULTS: Nineteen centres responded (68%). Most centres (79%) avoid transfusing D-positive platelets to RhD-negative patients when possible. Four centres (21%) avoid D-positive platelets only in D-negative women of childbearing age. If a D-negative patient receives a D-positive platelet transfusion, 53% of centres would consider treating with Rh immune globulin (RhIg) to prevent alloimmunization in women of childbearing age. Only one centre also gives RhIg to all D-negative patients who are HSCT candidates including adult men and women of no childbearing age. CONCLUSION: There is wide variation in platelet transfusion practices for supporting D-negative patients. The majority of centres do not have D-positive platelet transfusion policies focused on preventing anti-D alloimmunization specifically in patients undergoing HSCT. Multicentre, longitudinal studies are needed to understand the clinical implications of anti-D alloimmunization in HSCT patients.

National Comprehensive Cancer Network Infusion Efficiency Workgroup Study: Optimizing Patient Flow in Infusion Centers.

PURPOSE: The National Comprehensive Cancer Network (NCCN) formed an Infusion Efficiency Workgroup to determine best practices for operating efficient and effective infusion centers. METHODS: The Workgroup conducted three surveys that were distributed to NCCN member institutions regarding average patient wait time, chemotherapy premixing practices, infusion chair use, and premedication protocols. To assess chair use, the Workgroup identified and defined five components of chair time. RESULTS: The average patient wait time in infusion centers ranged from 25 to 102 minutes (n = 23; mean, 58 minutes). Five of 26 cancer centers (19%) routinely mix chemotherapy drugs before patient arrival for patients meeting specified criteria. Total planned chair time for subsequent doses of the same drug regimens for the same diseases varied greatly among centers, as follows: Administration of doxorubicin and cyclophosphamide ranged from 85 to 240 minutes (n = 22); of FOLFIRINOX (folinic acid, fluorouracil, irinotecan hydrochloride, and oxaliplation) ranged from 270 to 420 minutes (n = 22); of rituximab ranged from 120 to 350 minutes (n = 21); of paclitaxel plus carboplatin ranged from 255 to 380 minutes (n = 21); and of zoledronic acid ranged from 30 to 150 minutes (n = 22) for planned total chair time. Cancer centers were found to use different premedication regimens with varying administration routes that ranged in administration times from zero to 60 minutes. CONCLUSION: There is a high degree of variation among cancer centers in regard to planned chair time for the same chemotherapy regimens, providing opportunities for improved efficiency, increased revenue, and more standardization across centers. The NCCN Workgroup demonstrates potential revenue impact and provides recommendations for cancer centers to move toward more efficient and more standard practices.

Risk of Surgical Site Infection (SSI) following Colorectal Resection Is Higher in Patients With Disseminated Cancer: An NCCN Member Cohort Study.

BACKGROUNDSurgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.OBJECTIVETo examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRSDESIGNAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011-2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.SETTINGMulticenter studyPARTICIPANTSOf 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.MAIN OUTCOMEThe primary outcome of interest was 30-day SSI rate.RESULTSA total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23-2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09-1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06-2.53; P=.02), and longer duration of procedure were associated with development of SSI.CONCLUSIONSPatients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.Infect Control Hosp Epidemiol 2018;39:555-562.

NCCN's Commitment to Medication Safety: The Vincristine Initiative.

The mission of NCCN is to improve the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Improving medication safety is an important aspect of fulfilling this mission. In September 2014, the NCCN Best Practices Committee began a medication safety initiative to improve the safe use of vincristine. This article describes and discusses this initiative.

The Current State of Palliative Care for Patients Cared for at Leading US Cancer Centers: The 2015 NCCN Palliative Care Survey.

BACKGROUND: ASCO and IOM recommend palliative care (PC) across health care settings for patients with serious illnesses, including cancer. This study provides an overview of the current availability, structure, and basic quality of PC services within NCCN Member Institutions. METHODS: A PC survey was developed by NCCN staff and a working group of PC experts from 11 NCCN Member Institutions under the auspices of the NCCN Best Practices Committee. The survey was piloted and refined by 3 working group members and sent electronically to all 26 NCCN Member Institutions. NCCN staff and working group leaders analyzed the survey data. RESULTS: A total of 22 of 26 institutions responded (85%). All respondents (100%) reported an inpatient PC consult service (staffed by an average of 6.8 full-time equivalents [FTEs], seeing 1,031 consults/year with an average length of stay [LOS] of 10 days). A total of 91% of respondents had clinic-based PC (with an average of 469 consults/year, staffed by an average of 6.8 FTEs, and a 17-day wait time). For clinics, a comanagement care delivery model was more common than strict consultation. Home-based PC (23%) and inpatient PC units (32%) were less prevalent. Notably, 80% of institutions reported insufficient PC capacity compared with demand. Across PC settings, referrals for patients with solid tumors were more common than for hematologic malignancies. Automatic or "triggered" referrals were rare. The most common services provided were symptom management (100%) and advance care planning (96%). Most programs were funded through fee-for-service billing and institutional support. Partnerships with accountable care organizations and bundled payment arrangements were infrequent. PC program data collection and institutional funding for PC research were variable across institutions. CONCLUSIONS: Despite the prevalence of PC inpatient and clinic services among participating NCCN Member Institutions, PC demand still exceeds capacity. Opportunities exist for expansion of home-based PC and inpatient PC units, optimizing referrals, research, and payer collaborations.