Posttraumatic stress symptoms and financial toxicity among adolescent and young adult oncology patients and their caregivers at cancer diagnosis.

BACKGROUND: Adolescent and young adult oncology (AYAO) patients and caregivers may experience significant psychosocial dysfunction and financial toxicity. Understanding early risk factors is critical to improving survivorship trajectories. METHODS: The authors conducted a cross-sectional study of baseline survey data from a prospective cohort of AYAO patient-caregiver dyads enrolled within 1 month of medical oncology treatment initiation. Posttraumatic stress symptoms (PTSS) were measured by the Impacts of Events Scale-Revised, and financial toxicity was measured with the Comprehensive Score (COst). The authors fit models of linear association between PTSS, financial toxicity, and other end points and pairwise associations of PTSS and financial toxicity within dyads. RESULTS: The analytic cohort contained 41 patients, 37 caregivers, and 34 complete dyads. Clinically-concerning PTSS were observed among patients (44%) and caregivers (52%). The median COst scores were 20.0 for patients (quartiles, 12.5-29.5) and 22.0 for caregivers (quartiles, 12.8-26.0), which were consistent with high financial toxicity (patients, 46%; caregivers, 44%). PTSS were positively associated with financial toxicity (P = .013 for patients, P = .039 for caregivers), subjective distress (P < .001 for all), depressive (P < .001 for all) and anxiety symptoms (P = .005 for patients, P = .024 for caregivers), and poorer quality of life (P < .001 for patients, P = .003 for caregivers). A significant paired association was not found in PTSS (Pearson correlation coefficient [PCC], 0.23; 95% confidence interval [CI], -0.15 to 0.56). Financial toxicity was positively associated within dyads (PCC, 0.65; 95% CI, 0.36-0.83). CONCLUSIONS: At diagnosis, AYAO patients and caregivers exhibit substantial PTSS, which are associated with greater financial toxicity and other psychosocial distress.

Enhancing Cancer care of rural dwellers through telehealth and engagement (ENCORE): protocol to evaluate effectiveness of a multi-level telehealth-based intervention to improve rural cancer care delivery.

BACKGROUND: Despite lower cancer incidence rates, cancer mortality is higher among rural compared to urban dwellers. Patient, provider, and institutional level factors contribute to these disparities. The overarching objective of this study is to leverage the multidisciplinary, multispecialty oncology team from an academic cancer center in order to provide comprehensive cancer care at both the patient and provider levels in rural healthcare centers. Our specific aims are to: 1) evaluate the clinical effectiveness of a multi-level telehealth-based intervention consisting of provider access to molecular tumor board expertise along with patient access to a supportive care intervention to improve cancer care delivery; and 2) identify the facilitators and barriers to future larger scale dissemination and implementation of the multi-level intervention. METHODS: Coordinated by a National Cancer Institute-designated comprehensive cancer center, this study will include providers and patients across several clinics in two large healthcare systems serving rural communities. Using a telehealth-based molecular tumor board, sequencing results are reviewed, predictive and prognostic markers are discussed, and treatment plans are formulated between expert oncologists and rural providers. Simultaneously, the rural patients will be randomized to receive an evidence-based 6-week self-management supportive care program, Cancer Thriving and Surviving, versus an education attention control. Primary outcomes will be provider uptake of the molecular tumor board recommendation and patient treatment adherence. A mixed methods approach guided by the Consolidated Framework for Implementation Research that combines qualitative key informant interviews and quantitative surveys will be collected from both the patient and provider in order to identify facilitators and barriers to implementing the multi-level intervention. DISCUSSION: The proposed study will leverage information technology-enabled, team-based care delivery models in order to deliver comprehensive, coordinated, and high-quality cancer care to rural and/or underserved populations. Simultaneous attention to institutional, provider, and patient level barriers to quality care will afford the opportunity for us to broadly share oncology expertise and develop dissemination and implementation strategies that will enhance the cancer care delivered to patients residing within underserved rural communities. TRIAL REGISTRATION: Clinicaltrials.gov , NCT04758338 . Registered 17 February 2021 - Retrospectively registered, http://www.clinicaltrials.gov/.

A Time and Motion Analysis of Nursing Workload and Electronic Health Record Use in the Emergency Department.

INTRODUCTION: The use of an electronic health record may create unanticipated consequences for emergency care delivery. We sought to describe emergency department nursing task distribution and the use of the electronic health record. METHODS: This was a prospective observational study of nurses in the emergency department using a time-and-motion methodology. Three trained research assistants conducted 1:1 observations between March and September 2019. Nurse tasks were classified into 6 established categories: electronic health record, direct/indirect patient care, communication, personal time, and other. Nurses' perceived workload was assessed using the National Aeronautics and Space Administration (NASA) Task Load Index. RESULTS: Twenty-three observations were conducted over 46 hours. Overall, nurses spent 27% of their time on electronic health record tasks, 25% on direct patient care, 17% on personal time, 15% on indirect patient care, and 6% on communication. During morning (7 am-12 pm) and afternoon shifts (12 pm-3 pm), the use of the health record was the most commonly performed task, whereas indirect patient care was the task most performed during evening shifts (3 pm-12 pm). Using the National Aeronautics and Space Administration (NASA) Task Load Index, nurses reported an increase in mental demand and effort during afternoon shifts compared with morning shifts. DISCUSSION: We observed that emergency nurses spent more time using the electronic health record as compared to other tasks. Increased usability of the electronic health record, particularly during high occupancy periods, may be a target for improvement.

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement.

BACKGROUND: Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS: A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS: Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION: Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE: IV.

Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery.

OBJECTIVE: The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room. METHODS: A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability. RESULTS: One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases. CONCLUSIONS: The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.

Efficacy, Toxicity, and Pharmacokinetics of Intra-Arterial Chemotherapy Versus Intravenous Chemotherapy for Retinoblastoma in Animal Models and Patients.

Purpose: Through controlled comparative rabbit experiments and parallel patient studies, our purpose was to understand mechanisms underlying differences in efficacy and toxicity between intra-arterial chemotherapy (IAC) and intravenous chemotherapy (IVC). Methods: In rabbits, ocular tissue drug levels were measured following IAC and IVC. Retinal toxicity was assessed using electroretinography, fluorescein angiography, optical coherence tomography (OCT) and OCT angiography. Efficacy to eradicate retinoblastoma orthotopic xenografts was compared. In IAC and IVC patients, we measured blood carboplatin pharmacokinetics and compared efficacy and toxicity. Results: In rabbits receiving IAC, maximum carboplatin levels were 134 times greater in retina (P = 0.01) and 411 times greater in vitreous (P < 0.001), and total carboplatin (area under the curve) was 123 times greater in retina (P = 0.005) and 131 times greater in vitreous (P = 0.02) compared with IVC. Melphalan levels were 12 times greater (P = 0.003) in retina and 26 times greater in vitreous (P < 0.001) for IAC. Blood levels were not different. IAC melphalan (but not IV melphalan or IV carboplatin, etoposide, and vincristine) caused widespread apoptosis in retinoblastoma xenografts but no functional retinal toxicity or cytopenias. In patients, blood levels following IVC were greater (P < 0.001) but, when adjusted for treatment dose, were not statistically different. Per treatment cycle in patients, IVC caused higher rates of anemia (0.32 ± 0.29 vs. 0.01 ± 0.04; P = 0.0086), thrombocytopenia (0.5 ± 0.42 vs. 0.0 ± 0.0; P = 0.0042), and neutropenia (0.58 ± 0.3 vs. 0.31 ± 0.25; P = 0.032) but lower treatment success rates (P = 0.0017). Conclusions: The greater efficacy and lower systemic toxicity with IAC appear to be attributable to the greater ocular-to-systemic drug concentration ratio compared with IVC. Translational Relevance: Provides an overarching hypothesis for a mechanism of efficacy/toxicity to guide future drug development.

Modeling Care Team Structures in the Neonatal Intensive Care Unit through Network Analysis of EHR Audit Logs.

BACKGROUND: In the neonatal intensive care unit (NICU), predefined acuity-based team care models are restricted to core roles and neglect interactions with providers outside of the team, such as interactions that transpire via electronic health record (EHR) systems. These unaccounted interactions may be related to the efficiency of resource allocation, information flow, communication, and thus impact patient outcomes. This study applied network analysis methods to EHR audit logs to model the interactions of providers beyond their core roles to better understand the interaction network patterns of acuity-based teams and relationships of the network structures with postsurgical length of stay (PSLOS). METHODS: The study used the EHR log data of surgical neonates from a large academic medical center. The study included 104 surgical neonates, for whom 9,206 unique actions were performed by 457 providers in their EHRs. We applied network analysis methods to model EHR provider interaction networks of acuity-based teams in NICU postoperative care. We partitioned each EHR network into three subnetworks based on interaction types: (1) interactions between known core providers who were documented in scheduling records (core subnetwork); (2) interactions between core and noncore providers (extended subnetwork); and (3) interactions between noncore providers (extended subnetwork). For each core subnetwork, we assessed its capability to replicate predefined core-provider relations as documented in scheduling records. We further compared each EHR network, as well as its subnetworks, using standard network measures to determine its differences in network topologies. We conducted a case study to learn provider interaction networks taking care of 15 neonates who underwent gastrostomy tube placement surgery from EHR log data and measure the effectiveness of the interaction networks on PSLOS by the proportional-odds model. RESULTS: The provider networks of four acuity-based teams (two high and two low acuity), along with their subnetworks, were discovered. We found that beyond capturing the predefined core-provider relations, EHR audit logs can also learn a large number of relations between core and noncore providers or among noncore providers. Providers in the core subnetwork exhibited a greater number of connections with each other than with providers in the extended subnetworks. Many more providers in the core subnetwork serve as a hub than those in the other types of subnetworks. We also found that high-acuity teams exhibited more complex network structures than low-acuity teams, with high-acuity team generating 6,416 interactions between 407 providers compared with 931 interactions between 124 providers, respectively. In addition, we discovered that high-acuity and low-acuity teams shared more than 33 and 25% of providers with each other, respectively, but exhibited different collaborative structures demonstrating that NICU providers shift across different acuity teams and exhibit different network characteristics. Results of case study show that providers, whose patients had lower PSLOS, tended to disperse patient-related information to more colleagues within their network than those who treated higher PSLOS patients (p = 0.03). CONCLUSION: Network analysis can be applied to EHR log data to model acuity-based NICU teams capturing interactions between providers within the predesigned core team as well as those outside of the core team. In the NICU, dissemination of information may be linked to reduced PSLOS. EHR log data provide an efficient, accessible, and research-friendly way to study provider interaction networks. Findings should guide improvements in the EHR system design to facilitate effective interactions between providers.