Leveraging Electronic Health Record Data and Measuring Interdependence in the Era of Precision Education and Assessment.

PURPOSE: The era of precision education is increasingly leveraging electronic health record (EHR) data to assess residents' clinical performance. But precision in what the EHR-based resident performance metrics are truly assessing is not fully understood. For instance, there is limited understanding of how EHR-based measures account for the influence of the team on an individual's performance-or conversely how an individual contributes to team performances. This study aims to elaborate on how the theoretical understandings of supportive and collaborative interdependence are captured in residents' EHR-based metrics. METHOD: Using a mixed methods study design, the authors conducted a secondary analysis of 5 existing quantitative and qualitative datasets used in previous EHR studies to investigate how aspects of interdependence shape the ways that team-based care is provided to patients. RESULTS: Quantitative analyses of 16 EHR-based metrics found variability in faculty and resident performance (both between and within resident). Qualitative analyses revealed that faculty lack awareness of their own EHR-based performance metrics, which limits their ability to act interdependently with residents in an evidence-informed fashion. The lens of interdependence elucidates how resident practice patterns develop across residency training, shifting from supportive to collaborative interdependence over time. Joint displays merging the quantitative and qualitative analyses showed that residents are aware of variability in faculty's practice patterns and that viewing resident EHR-based measures without accounting for the interdependence of residents with faculty is problematic, particularly within the framework of precision education. CONCLUSIONS: To prepare for this new paradigm of precision education, educators need to develop and evaluate theoretically robust models that measure interdependence in EHR-based metrics, affording more nuanced interpretation of such metrics when assessing residents throughout training.

Trends and variations in utilization and costs of radiotherapy for prostate cancer: A SEER medicare analysis from 2007 through 2016.

OBJECTIVE: To assess recent changes and disparities in utilization and costs of radiotherapy in Medicare beneficiaries with prostate cancer. METHODS: Surveillance, Epidemiology and End Results (SEER) -Medicare linked data from 2006-2016 were used to identify continuously enrolled Medicare beneficiaries with a first-time diagnosis of prostate cancer who, within 12 months of diagnosis, underwent at least one radiotherapy related service. Trends in the utilization of different radiotherapy techniques over time, yearly changes in per-patient costs of radiotherapy, and effect of socio-demographic and clinical characteristics on total cost were measured. Per patient annual costs, annual incidence of prostate cancer, and utilization of radiotherapy were used to estimate total costs of radiotherapy to the Medicare program. RESULTS: For Medicare beneficiaries with a first-time diagnosis of prostate cancer, the utilization of intensity modulated radiation therapy (IMRT), proton therapy, and stereotactic body radiation therapy (SBRT) increased 23.62%, 0.74% and 1.61% respectively (p <0.0001) while brachytherapy decreased 17.04% (p <0.0001). Cost per beneficiary decreased $340.24 (95% CI: $136.05 - $544.43) annually (p = 0.0065). Age, registry region, and Gleason score were all associated with expenditures. The total cost to the Medicare program was estimated at US $1.16 billion in the year 2016. DISCUSSION: In Medicare beneficiaries with prostate cancer treated with radiotherapy, IMRT is the primary mode of treatment. Utilization of brachytherapy decreased significantly despite the efficacy and cost-effectiveness. Although per patient costs have decreased, the share of patient responsibility remained unaltered across years. The current costs to Medicare of radiotherapy for newly diagnosed prostate cancer patients is substantial.

Dosimetric assessment of brass mesh bolus and transparent polymer-gel type bolus for commonly used breast treatment delivery techniques.

We investigated skin dose enhancements of brass mesh bolus (BMB) and a recently developed transparent polymer-gel bolus (PGB) for clinically relevant breast treatment delivery techniques. The dose enhancement of the breast surface with BMB and PGB were compared to that of tissue-equivalent bolus. Three breast treatment plans were generated on CT scans of an anthropomorphic chest phantom: tangential step-and-shoot 3D conformal (3DCRT) planned using Field-in-Field (FiF), tangential sliding-window 3DCRT using Electronic Compensator (EC), and volumetric modulated arc therapy (VMAT). All plans were created using 6 MV photons and a prescription dose (Rx) of 180 cGy per fraction. Skin doses of all 3 plans were measured with radiochromic films, separately delivered in triplicate. Each plan was delivered to the phantom without bolus, and then with BMB (1 or 2 layers; 3 or 10 mm tissue-equivalent), PGB, and Superflab (3, 5, and 10 mm tissue-equivalent). Doses were determined by reading the radiochromic films with a flatbed scanner, and analyzing the images using a calibration curve for each specific batch. For all bolus types and plans, surface doses averaged over the 3 measurements were between 88.4% and 107.4% of Rx. Without bolus, average measured skin doses were between 51.2% and 64.2% of Rx. Skin doses with BMB and PGB were comparable to that with tissue-equivalent bolus. Over all 3 treatment delivery techniques, using BMB resulted in average skin doses of 92.8% and 102.1% for 1- and 2 layers, respectively, and using PGB results in average skin doses of 94.8%, 98.2%, and 99.7% for 3, 5, and 10-mm tissue-equivalent, respectively. The average measured skin doses with BMB and PGB agreed within ± 3% compared to the tissue-equivalent thickness bolus. We concluded that BMB and PGB are clinically equivalent in skin dose enhancement for breast treatment as the 3, 5, and 10 mm tissue-equivalent bolus.

A Medicare cost analysis of MRI- versus CT-based high-dose-rate brachytherapy of the cervix: Can MRI-based planning be less costly?

PURPOSE: While some institutions deliver multiple fractions per implant for MRI-based planning, it is common for only one fraction to be delivered per implant with CT-based cervical brachytherapy. The purpose of this study was to compare physician costs, hospital costs, and overall costs for cervical cancer patients treated with either CT-based or MRI-based high-dose-rate (HDR) cervical brachytherapy to determine if MRI-based brachytherapy as described can be financially feasible. METHODS AND MATERIALS: We identified 40 consecutive patients treated with curative intent cervical brachytherapy. Twenty patients underwent CT-based HDR brachytherapy with five fractions delivered in five implants on nonconsecutive days in an outpatient setting with the first implant placed with a Smit sleeve under general anesthesia. Twenty patients received MRI-based HDR brachytherapy with four fractions delivered in two implants, each with MRI-based planning, performed 1-2 weeks apart with an overnight hospital admission for each implant. We used Medicare reimbursements to assess physician costs, hospital costs, and overall cost. RESULTS: The median cost of MRI-based brachytherapy was $14,248.75 (interquartile range [IQR]: $13,421.32-$15,539.74), making it less costly than CT-based brachytherapy with conscious sedation (i.e., $18,278.85; IQR: $17,323.13-$19,863.03, p < 0.0001) and CT-based brachytherapy with deep sedation induced by an anesthesiologist (i.e., $27,673.44; IQR: $26,935.14-$29,511.16, p < 0.0001). CT-based brachytherapy with conscious sedation was more costly than CT-based brachytherapy with deep sedation (p < 0.001). CONCLUSIONS: MRI-based brachytherapy using the described treatment course was less costly than both methods of CT-based brachytherapy. Cost does not need to be a barrier for MRI-based cervical brachytherapy, especially when delivering multiple fractions with the same application.

Cost in perspective: direct assessment of American market acceptability of Co-60 in gynecologic high-dose-rate brachytherapy and contrast with experience abroad.

PURPOSE: While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru's National Cancer Institute, which uses both isotopes. MATERIAL AND METHODS: A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers' WTP. Using activity-based costing, we note the Peruvian fiscal experience. RESULTS: Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent's department but not time in practice or the American Brachytherapy Society membership. Peru's experience noted cost savings with Co-60 of $52,400 annually. CONCLUSIONS: By comparing the cost of additional shielding for a sample institution's HDR suite with radiation oncologists' WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations.

Improving the Accessibility of Patient Care Through Integration of the Hospital and Radiation Oncology Electronic Health Records.

PURPOSE: Radiation therapy (RT)-specific aspects of a patient's cancer care commonly are documented and scheduled through a radiation oncology electronic health record (rEHR). However, patients who receive RT also receive multidisciplinary care from providers who use the hospital EHR (hEHR). We created an electronic interface to integrate our hEHR and rEHR to improve communication of the RT aspects of care between our department and the rest of the hospital. The objective of this study was to assess the impact of rEHR and hEHR integration on the accessibility of the RT-specific aspects of patient care to providers. METHODS AND MATERIALS: We performed a preintegration and postintegration survey of 175 staff members at our academic cancer center. Respondents rated the importance and accessibility of several RT encounters and documents on a Likert scale. The Wilcoxon-Mann-Whitney, χ2, and Fisher's exact tests were used to compare preintegration and postintegration responses. RESULTS: There were 32 and 19 responses to the pre- and postintegration surveys, respectively. rEHR items most commonly reported to be at least moderately important were the dates of first treatment (n = 29 [91%]), last treatment (n = 29 [91%]), brachytherapy (n = 22 [69%]), radiosurgery (n = 22 [69%]), and computed tomography simulation (n = 21 [66%]). A drastic improvement was found in most items made visible in the hEHR through the interface. CONCLUSION: By integrating our hEHR and rEHR, we improved the communication of patient care between the RT department and the multidisciplinary team. Institutions should pursue and support integration of the EHRs to improve the quality of care provided to patients with cancer.

Clinical trials in low and middle-income countries - Successes and challenges.

Gynecologic malignancies affect women in low and middle-income countries (LMICs) at equal or higher rates compared to high income countries (HICs), yet practice guidelines based on clinical trials performed in HICs do not routinely account for resource disparities between these regions. There is a need and growing interest for executing clinical trials in LMICs. This has led to the creation of multinational cooperative groups and the initiation of several ongoing clinical trials in Mexico, China, and Korea. In this article we describe the challenges involved in initiating clinical trials in LMICs, review current efforts within surgical, medical, and radiation oncology, and introduce high priority topics for future research.

Sister Society Meeting on Global Education Development and Collaboration: Meeting Report.

OBJECTIVES: To identify common barriers to teaching and training and to identify strategies that would be useful in developing future training programs in gynecologic oncology in low- and middle- income countries. METHODS: There is a lack of overall strategy to meet the needs of education and training in gynecologic oncology in low- and middle- income countries, the leaderships of sister societies and global health volunteers met at the European Society of Gynecologic Oncology in October 23, 2015. The challenges of the training programs supported by gynecologic oncology societies, major universities and individual efforts were presented and discussed. Strategies to improve education and training were identified. RESULTS: Major challenges include language barriers, limited surgical equipment, inadequate internet access, lack of local support for sustainability in training programs, inadequate pathology and radiation oncology, finance and a global deficiency in identifying sites and personnel in partnering or developing training programs. The leaderships identified various key components including consultation with the local Ministry of Health, local educational institutions; inclusion of the program into existing local programs, a needs assessment, and the development of curriculum and regional centers of excellence. CONCLUSIONS: Proper preparation of training sites and trainers, the development of global curriculum, the establishment of centers of excellence, and the ability to measure outcomes are important to improve education and training in gynecologic oncology in low- and middle- income countries.

Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline.

PURPOSE: To provide evidence-based, resource-stratified global recommendations to clinicians and policymakers on the management and palliative care of women diagnosed with invasive cervical cancer. METHODS: ASCO convened a multidisciplinary, multinational panel of cancer control, medical and radiation oncology, health economic, obstetric and gynecologic, and palliative care experts to produce recommendations reflecting resource-tiered settings. A systematic review of literature from 1966 to 2015 failed to yield sufficiently strong quality evidence to support basic- and limited-resource setting recommendations; a formal consensus-based process was used to develop recommendations. A modified ADAPTE process was also used to adapt recommendations from existing guidelines. RESULTS: Five existing sets of guidelines were identified and reviewed, and adapted recommendations form the evidence base. Eight systematic reviews, along with cost-effectiveness analyses, provided indirect evidence to inform the consensus process, which resulted in agreement of 75% or greater. RECOMMENDATIONS: Clinicians and planners should strive to provide access to the most effective evidence-based antitumor and palliative care interventions. If a woman cannot access these within her own or neighboring country or region, she may need to be treated with lower-tier modalities, depending on capacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care. For women with early-stage cervical cancer in basic settings, cone biopsy or extrafascial hysterectomy may be performed. Fertility-sparing procedures or modified radical or radical hysterectomy may be additional options in nonbasic settings. Combinations of surgery, chemotherapy, and radiation therapy (including brachytherapy) should be used for women with stage IB to IVA disease, depending on available resources. Pain control is a vital component of palliative care. Additional information is available at www.asco.org/rs-cervical-cancer-treatment-guideline and www.asco.org/guidelineswiki. It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Decision Trees Predicting Tumor Shrinkage for Head and Neck Cancer: Implications for Adaptive Radiotherapy.

OBJECTIVE: To develop decision trees predicting for tumor volume reduction in patients with head and neck (H&N) cancer using pretreatment clinical and pathological parameters. METHODS: Forty-eight patients treated with definitive concurrent chemoradiotherapy for squamous cell carcinoma of the nasopharynx, oropharynx, oral cavity, or hypopharynx were retrospectively analyzed. These patients were rescanned at a median dose of 37.8 Gy and replanned to account for anatomical changes. The percentages of gross tumor volume (GTV) change from initial to rescan computed tomography (CT; %GTVΔ) were calculated. Two decision trees were generated to correlate %GTVΔ in primary and nodal volumes with 14 characteristics including age, gender, Karnofsky performance status (KPS), site, human papilloma virus (HPV) status, tumor grade, primary tumor growth pattern (endophytic/exophytic), tumor/nodal/group stages, chemotherapy regimen, and primary, nodal, and total GTV volumes in the initial CT scan. The C4.5 Decision Tree induction algorithm was implemented. RESULTS: The median %GTVΔ for primary, nodal, and total GTVs was 26.8%, 43.0%, and 31.2%, respectively. Type of chemotherapy, age, primary tumor growth pattern, site, KPS, and HPV status were the most predictive parameters for primary %GTVΔ decision tree, whereas for nodal %GTVΔ, KPS, site, age, primary tumor growth pattern, initial primary GTV, and total GTV volumes were predictive. Both decision trees had an accuracy of 88%. CONCLUSIONS: There can be significant changes in primary and nodal tumor volumes during the course of H&N chemoradiotherapy. Considering the proposed decision trees, radiation oncologists can select patients predicted to have high %GTVΔ, who would theoretically gain the most benefit from adaptive radiotherapy, in order to better use limited clinical resources.

Markov model and cost-effectiveness analysis of bevacizumab in HER2-negative metastatic breast cancer.

PURPOSE: Metastatic breast cancer (MBC) remains an incurable disease despite advances in treatment modalities. In 2008, the FDA approved bevacizumab with paclitaxel for the initial treatment of HER2-negative MBC. The approval was then officially revoked by the FDA in November 2011. However, both the European Medicines Agency and NCCN still endorse bevacizumab for this indication. One of the greatest challenges facing health care worldwide is reconciling incremental clinical benefits with exponentially rising costs. This study aimed to assess the cost-effectiveness of bevacizumab with paclitaxel for HER2-negative MBC. METHODS: A Markov decision tree using Data 3.5 (TreeAge Software Inc.) was created for decision and cost-effectiveness analyses of using bevacizumab plus paclitaxel versus paclitaxel alone as first-line chemotherapy in HER2-negative MBC using efficacy and toxicity data from the E2100 study. The model was designed from the patient and payer perspectives and sensitivity analyses were run. RESULTS: The marginal cost between paclitaxel alone versus bevacizumab and paclitaxel was 86k with a marginal efficacy of 0.369 quality-adjusted life-years and marginal cost effectiveness of 232,720.72 USD. The expected outcome value was 1.86 for bevacizumab and paclitaxel and 1.67 for paclitaxel alone. The combination was not cost effective and only a marginal survival advantage was observed. CONCLUSIONS: This study demonstrates that, despite a significant progression-free survival advantage, the addition of bevacizumab to paclitaxel is not cost effective for the cohort of patients with HER2-negative MBC included in our analysis. Such data could be informative to policymakers who consider the health economics and incremental cost-effectiveness of medical therapies.