The impact of an oncology urgent care center on health-care utilization.

INTRODUCTION: Studies suggest that many emergency department (ED) visits and hospitalizations for patients with cancer may be preventable. The Centers for Medicare & Medicaid Services has implemented changes to the hospital outpatient reporting program that targets acute care in-treatment patients for preventable conditions. Oncology urgent care centers aim to streamline patient care. Our cancer center developed an urgent care center called the direct referral unit in 2011. METHODS: We abstracted visits to our adjacent hospital ED and direct referral unit from January 2014 to June 2018. Patient demographics, cancer and visit diagnoses, visit charges, and 30-day therapy utilization were assessed. RESULTS: An analysis of 13 114 visits demonstrated that increased direct referral unit utilization was associated with decreased monthly ED visits (P < .001). Common direct referral unit visit diagnoses were dehydration, nausea and vomiting, abdominal pain, and fever. Patients receiving active cancer treatment more frequently presented to the direct referral unit (P < .001). The average charges were $2221 for the direct referral unit and $10 261 for the ED. CONCLUSION: The association of decreased ED visits with increased direct referral unit utilization demonstrates the potential for urgent care centers to reduce acute care visits. Many patients presented to our direct referral unit with preventable conditions, and these visits were associated with considerable cost savings, supporting its use as a cost-effective method to reduce acute care costs.

Transition to Value-based Healthcare: Development, Implementation, and Results of an Optimal Surgical Care Framework at a National Cancer Institute-designated Comprehensive Cancer Center.

BACKGROUND: The continued rise in healthcare expenditures has not produced commensurate improvements in patient outcomes, leading US healthcare stakeholders to emphasize value-based care. Transition to such a model requires all team members to adopt a new strategic and organizational framework. OBJECTIVE: To describe and report a strategy for the implementation of a novel patient-centered value-based "optimal surgical care" (OSC) framework, with validation and cost analysis in kidney surgery. DESIGN, SETTING, AND PARTICIPANTS: An observational study of care episodes at a single institution from 2014 to 2019 was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multidisciplinary teams defined OSC by core and procedure-specific metrics using a combination of provider-based ("bottom-up") and "clinical leadership"-based ("top-down") strategies. Baseline OSC rates across were established, while identifying proportions of OSC achieved by coefficient of variation (CV) in total direct costs. Multivariable linear regression comparing cost between OSC and non-OSC encounters was performed, adjusting for patient characteristics. RESULTS AND LIMITATIONS: An analysis of 30 261 perioperative care episodes was performed. Following the implementation of an OSC framework, there was an increase in OSC rates across all procedure buckets using core (25%) and procedure-specific (26%) metrics. Among the tumors tested, kidney cancer surgical episodes held the highest OSC rate improvement (67%) with lowest variability in cost (CV 0.5). OSC was associated with significant total cost savings across all tumor types after adjusting for inflation (p < 0.05). Compared with non-OSC episodes, a significant reduction in the cost ratio of OSC was noted for renal surgery (p < 0.01), with estimated costs savings of $2445.87 per OSC encounter. CONCLUSIONS: Institutional change directing efforts toward optimizing surgical care and emphasizing value rather than focusing solely on expense reduction is associated with improved outcomes, while potentially reducing costs. The strategy for implementation requires serial performance analyses, engaging and educating providers, and continuous ongoing adjustments to achieve durable results. PATIENT SUMMARY: In this study, we report our strategy and outcomes for transitioning to a value-based healthcare model using a novel "optimal surgical care" framework at a National Cancer Institute-designated comprehensive cancer center. We observed an increase in optimal surgical care episodes across all specialties after 5 yr, with a potential associated reduction in cost expenditure. We conclude that the key to a successful and sustained transition is the implementation strategy, focusing on continual review and provider engagement.

Adverse Events Reported by Patients With Cancer After Administration of a 2-Dose mRNA COVID-19 Vaccine.

BACKGROUND: Most safety and efficacy trials of the SARS-CoV-2 vaccines excluded patients with cancer, yet these patients are more likely than healthy individuals to contract SARS-CoV-2 and more likely to become seriously ill after infection. Our objective was to record short-term adverse reactions to the COVID-19 vaccine in patients with cancer, to compare the magnitude and duration of these reactions with those of patients without cancer, and to determine whether adverse reactions are related to active cancer therapy. PATIENTS AND METHODS: A prospective, single-institution observational study was performed at an NCI-designated Comprehensive Cancer Center. All study participants received 2 doses of the Pfizer BNT162b2 vaccine separated by approximately 3 weeks. A report of adverse reactions to dose 1 of the vaccine was completed upon return to the clinic for dose 2. Participants completed an identical survey either online or by telephone 2 weeks after the second vaccine dose. RESULTS: The cohort of 1,753 patients included 67.5% who had a history of cancer and 12.0% who were receiving active cancer treatment. Local pain at the injection site was the most frequently reported symptom for all respondents and did not distinguish patients with cancer from those without cancer after either dose 1 (39.3% vs 43.9%; P=.07) or dose 2 (42.5% vs 40.3%; P=.45). Among patients with cancer, those receiving active treatment were less likely to report pain at the injection site after dose 1 compared with those not receiving active treatment (30.0% vs 41.4%; P=.002). The onset and duration of adverse events was otherwise unrelated to active cancer treatment. CONCLUSIONS: When patients with cancer were compared with those without cancer, few differences in reported adverse events were noted. Active cancer treatment had little impact on adverse event profiles.

Clinical Validation of an Alternative Specimen Collection Kit for SARS-CoV-2 Testing at Fox Chase Cancer Center.

Background: Supply chain disruptions during the COVID-19 pandemic have affected the availability of components for specimen collection kits to detect SARS-CoV-2. Plastic injection molding offers a rapid and cheap method for mass production of swabs for upper respiratory tract sampling. Local production of virus transport medium increases flexibility to assemble sample collection kits if the medium provides appropriate stability for SARS-CoV-2 detection. Methods: A locally produced virus transport medium and a novel injection molded plastic swab were validated for SARS-CoV-2 detection by reverse-transcription quantitative polymerase chain reaction. Both components were compared to standard counterparts using viral reference material and representative patient samples. Results: Clinical testing showed no significant differences between molded and flocked swabs. Commercial and in-house virus transport media provided stable test results for over 40 days of specimen storage and showed no differences in test results using patient samples. Conclusions: This collection kit provides new supply chain options for SARS-CoV-2 testing.

Is there a benefit to frozen section analysis at the time of partial nephrectomy?

INTRODUCTION: The utility of frozen section performance during partial nephrectomy (PN) is controversial. We assessed the predictive value of frozen sections on final margin status for patients undergoing PN for localized renal tumors. MATERIALS AND METHODS: We queried our prospectively maintained kidney cancer database for patients undergoing PN with localized renal tumors from 2005-2011. Patients were stratified based on the receipt of frozen section analysis into 'frozen' and 'no frozen' groups. Groups were compared using ANOVA, Chi-square, and Wilcoxon's tests. RESULTS: A total of 537 patients (mean age 58.1 years ± 12.0 years, 64.2% male) underwent PN (mean tumor size 3.7 cm ± 2.0 cm; mean Nephrometry score 7.5 ± 1.8) from 2005-2011. Comparing tumor characteristics between patients undergoing frozen sections (83.1%) and those who did not (16.9%), no differences in histology, Fuhrman grade, pathologic stage, or Nephrometry Score were observed between groups. Final margins were positive in 10 patients (11.0%) in the 'no frozen' group compared to 20 patients (4.5%) in the 'frozen' section group (p = 0.01) but in patients with a documented malignancy on final pathology, final margins were positive in 5.5% and 2.9% respectively (p = 0.16). Four patients (0.7%) had local recurrences, all of whom had negative frozen and final pathologic margins. There was no correlation between positive surgical margins and local recurrence (p = 1.0) at a median follow up of 21 months (IQR = 9-31months). CONCLUSIONS: In our institutional cohort, frozen section analysis failed to impact final margin status in patients with documented renal cell carcinoma. Given the oncologic uncertainty of positive surgical margins, further prospective evaluation is necessary to determine the clinical utility of frozen section analysis.

Diagnosing metabolic acidosis in the critically ill: bridging the anion gap, Stewart, and base excess methods.

PURPOSE: Metabolic acid-base disorders are common in critically ill patients. Clinicians may have difficulty recognizing their presence when multiple metabolic acid-base derangements are present in a single patient. Clinicians should be able to identify the components of complex metabolic acid-base disorders since metabolic acidoses due to unmeasured anions are associated with increased mortality in critically ill patients. This review presents the derivation of three commonly used methods of acid-base analysis, which include the anion gap, Stewart physiochemical, and modified base excess. Clinical examples are also provided to demonstrate the subtleties of the different methods and to demonstrate their application to real patient data. PRINCIPAL FINDINGS: A comparison of these methods shows that each one is equally adept at identifying a metabolic acidosis due to unmeasured anions; however, the Stewart physiochemical and the modified base excess methods better evaluate complex metabolic acid-base disorders. CONCLUSIONS: While all three methods correctly identify metabolic acidosis due to unmeasured anions, which is a predictor of mortality, it remains unclear if further delineation of complex metabolic acid-base disorders using the Stewart physiochemical or the modified base excess methods is clinically beneficial.