Quality Improvement Training in a Variety of Cancer Care Delivery Settings: Experiences From a Comprehensive Cancer Center, an Academic Medical Center, and Community Practices.

PURPOSE: Training clinical and supportive staff in quality improvement (QI) theory and use of QI tools has the potential to improve oncology care delivery. We report our combined experience of providing training to oncologists in a variety of local settings and assess the effect of the training on individual participants and for institutions. METHODS: Multidisciplinary oncology teams at a comprehensive cancer center, an academic medical center, and community practices were led through experiential QI training that spanned several months. The curriculum included didactic training sessions that attendees applied to their local project-based work and that required plan-do-study-act cycles. The curriculum was adapted to the smaller practice setting through use of a workbook and a reduced focus on quantitative methods. All teams were supported by coaches and provided final presentations to leadership. The self-rated abilities of trainees to use 15 QI tools were assessed with a pre/post training survey that had five response categories (information, skill, knowledge, understanding, and wisdom). Local institutional and external project presentations were tracked. RESULTS: During 7 years, 129 trainees participated in 56 QI projects. All of the 15 QI tools had 80% of trainees rate themselves in the top three categories (knowledge, understanding, and wisdom) after the training; none met this threshold before. Multiple projects were presented in institutional and external settings. Most projects targeted three of the four domains of the ASCO Quality Oncology Practice Initiative certification program standards. CONCLUSIONS: We implemented and sustained QI training programs in a variety of cancer delivery settings. The flexible training model should be easily adoptable by others.

Developing a model for embedded palliative care in a cancer clinic.

OBJECTIVES: Describe the development and key features of a model for embedded palliative care (PC) for patients with advanced kidney cancer or melanoma seen in a cancer clinic. METHODS: Retrospective chart review of patients following an initial phase and then a prospective review following the implementation of a model for embedded PC. RESULTS: In the initial phase, 18 patients were seen for a total of 53 visits; 78% were seen more than once, with a mean of three visits per patient. In the model phase, 46 patients were seen for a total of 163 visits; 74% were seen more than once, with a mean of 3.5 visits. Demographics were similar between the two groups. Content of the first PC visit in the initial and model phases was symptom management (61% and 57%), psychosocial support/relationship building (28% and 35%) and advance care planning/decision-making support (11% and 8%), respectively. CONCLUSIONS: The initial phase demonstrated acceptability and feasibility of a model for embedded PC for patients and the oncology team. Establishment of specific eligibility criteria and screening to identify eligible patients in the model phase led to an increased uptake of PC for patients with advanced kidney cancer and melanoma in a cancer clinic.

Understanding Oral Chemotherapy Prescribing Patterns at the End of Life at a Comprehensive Cancer Center: Analysis of a Massachusetts Payer Claims Database.

PURPOSE: Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. Specific measures defining appropriate end-of-life use of oral agents have not yet been described, and little is known about prescribing patterns. METHODS: We conducted an exploratory analysis of 371 patients at Dana-Farber Cancer Institute who were covered by the Blue Cross Blue Shield of Massachusetts pharmacy benefit and died during 2012 to 2013. We analyzed processed claims as a surrogate for chemotherapy administration. We compared oral with parenteral chemotherapy claims in the last 6 months of life. RESULTS: In the last 6 months of life, 294 patients (79%) had chemotherapy claims, including 81 (22%) prescribed an oral agent; 20 patients had claims for oral chemotherapy in the last 30 days of life. For eight patients (40%), this was the initial start of that oral agent. In the last 14 days of life, only 23 patients had chemotherapy claims, including six patients prescribed an oral agent. CONCLUSION: The collection of oral chemotherapy use data through insurance claims was feasible. Processed claims for chemotherapy, including oral, sharply declined during the last 30 days of life, consistent with a shift to palliative management. These results highlight the need for a more comprehensive analysis of oral chemotherapy prescribing patterns and development of specific measures to define the appropriate use of oral chemotherapy at the end of life.