Ensuring Patient Safety and Access in Cancer Care.

The inability to obtain the right high-quality cancer care in a timely and safe manner can have devastating results for patients. As cancer care becomes inundated with cutting edge and novel treatments, such as personalized medicine, oral chemotherapy, biosimilars, and immunotherapy, new safety challenges are emerging at increasing speed and complexity. Moreover, shifting federal healthcare policies could have significant implications for the safety and access to high-quality and effective cancer care for millions of patients with cancer. Challenges and opportunities in ensuring patient access to safe, affordable, and high-quality cancer care remain significant within the policy landscape. To address these concerns, NCCN hosted the Ensuring Safety and Access in Cancer Care Policy Summit in June 2017 to discuss pertinent patient safety issues and access implications under the Trump administration, as well as policy and advocacy strategies to address these gaps and build on opportunities moving forward.

Using mHealth technologies to improve the identification of behavioral health problems in urban primary care settings.

INTRODUCTION: Behavioral health disorders remain under recognized and under diagnosed among urban primary care patients. Screening patients for such problems is widely recommended, yet is challenging to do in a brief primary care encounter, particularly for this socially and medically complex patient population. METHODS: In 2013, intervention patients at an urban Connecticut primary clinic were screened for post-traumatic stress disorder, depression, and risky drinking (n = 146) using an electronic tablet-based screening tool. Screening data were compared to electronic health record data from control patients (n = 129) to assess differences in the prevalence of behavioral health problems, rates of follow-up care, and the rate of newly identified cases in the intervention group. RESULTS: Results from logistic regressions indicated that both groups had similar rates of disorder at baseline. Patients in the intervention group were five times more likely to be identified with depression (p < 0.05). Post-traumatic stress disorder was virtually unrecognized among controls but was observed in 23% of the intervention group (p < 0.001). The vast majority of behavioral health problems identified in the intervention group were new cases. Follow-up rates were significantly higher in the intervention group relative to controls, but were low overall. CONCLUSION: This tablet-based electronic screening tool identified significantly higher rates of behavioral health disorders than have been previously reported for this patient population. Electronic risk screening using patient-reported outcome measures offers an efficient approach to improving the identification of behavioral health problems and improving rates of follow-up care.

Changing physician incentives for affordable, quality cancer care: results of an episode payment model.

PURPOSE: This study tested the combination of an episode payment coupled with actionable use and quality data as an incentive to improve quality and reduce costs. METHODS: Medical oncologists were paid a single fee, in lieu of any drug margin, to treat their patients. Chemotherapy medications were reimbursed at the average sales price, a proxy for actual cost. RESULTS: Five volunteer medical groups were compared with a large national payer registry of fee-for-service patients with cancer to examine the difference in cost before and after the initiation of the payment change. Between October 2009 and December 2012, the five groups treated 810 patients with breast, colon, and lung cancer using the episode payments. The registry-predicted fee-for-service cost of the episodes cohort was $98,121,388, but the actual cost was $64,760,116. The predicted cost of chemotherapy drugs was $7,519,504, but the actual cost was $20,979,417. There was no difference between the groups on multiple quality measures. CONCLUSION: Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction. Eliminating existing financial chemotherapy drug incentives paradoxically increased the use of chemotherapy.

Latent tuberculosis among Latino migrant farmworkers in Connecticut.

STUDY OBJECTIVE: It is estimated that the prevalence rate of latent tuberculosis infection (LTBI) for the United States general population is less than 5%. The prevalence of LTBI among Connecticut migrant workers has not been reported. This study was designed to determine the prevalence of a positive tuberculin skin test (TST), a potential measure of LTBI in migrant workers, at one Connecticut farm. METHODS: A two-step standardized TST was performed on farmworkers recruited in a migrant clinic setting. Those with negative results on the first-step were offered the second. Workers with positive results were referred to community health centers for assessment and examined by a physician investigator. RESULTS: Seventy-nine male workers were recruited from a population of approximately 200. Of these, 57 consented to the first-step TST, and 26% tested positive. Over 96% of the 57 tested workers were from Mexico. None had symptoms or signs of active tuberculosis. CONCLUSION: This study suggests that a high percentage of asymptomatic Connecticut Latino migrant farmworkers have LTBI. This finding has public health implications for TB control strategies in the state.

Weekly docetaxel and bortezomib as first-line treatment for patients with hormone-refractory prostate cancer: a Minnie Pearl Cancer Research Network phase II trial.

BACKGROUND: Docetaxel is currently the standard first-line treatment in patients with hormone-refractory prostate cancer (HRPC). Bortezomib, the first proteasome inhibitor in clinical use, demonstrated activity against prostate cancer in phase I trials. For this reason, we evaluated the efficacy of docetaxel plus bortezomib in the first-line treatment of patients with HRPC. PATIENTS AND METHODS: Between February 2004 and May 2005, 63 eligible patients entered this phase II trial. All patients had metastatic adenocarcinoma of the prostate that had progressed on hormonal therapy. All patients received docetaxel 30 mg/m(2) and bortezomib 1.6 mg/m(2) on days 1, 8, and 15 of a 28-day cycle. Patients were reevaluated after 8 weeks of treatment; responding and stable patients continued treatment until tumor progression. RESULTS: Sixty patients (95%) received > or = 2 courses of treatment and were evaluable for response. Fifteen patients (25%; 95% confidence interval, 15%-38%) had a > 50% decrease in serum prostate-specific antigen level with treatment; the median response duration was 8 months. The median progression-free and overall survival times for the entire group were 4.1 months and 13.8 months, respectively; 20% of patients were alive at 2 years. The regimen was well tolerated, with uncommon grade 3/4 toxicity. CONCLUSION: Treatment with this combination of weekly docetaxel and bortezomib showed no suggestion of improved efficacy versus previous results with docetaxel alone. Bortezomib has minimal activity in patients with HRPC and is unlikely to make any impact on treatment efficacy.

Cotinine levels and green tobacco sickness among shade-tobacco workers.

STUDY OBJECTIVE: Symptoms consistent with Green Tobacco Sickness (GTS) were found in 4% (13/331) to 15% (45/303) of the migrant, mostly Latino, shade-tobacco workers who sought medical care at a Connecticut clinic. The objective of this study was to determine whether or not shade-tobacco farm workers absorb nicotine from the tobacco leaves and have a corresponding increase in both salivary cotinine levels (a breakdown product of nicotine) and symptoms consistent with GTS. METHODS: The study utilized a prospective cohort design to evaluate salivary cotinine and symptoms consistent with GTS in a population of shade tobacco farm workers compared to a control group of nursery workers. The workers were assessed at two points in time, the early tobacco planting season and the harvest season. RESULTS: There was not a significant increase in salivary cotinine levels among shade-tobacco workers. Salivary cotinine levels over the work season did not significantly increase in shade-tobacco workers when compared with nursery workers. During the harvest season, none of the tobacco workers reported symptoms consistent with GTS. CONCLUSIONS: Migrant workers in Connecticut who harvest shade-tobacco appear to have a low-risk of occupational nicotine dermal absorption and a low incidence of GTS. The work practices associated with harvesting shade-tobacco, in addition to the fact that shade tobacco may actually have a lower level of nicotine than either burley or flue cured tobacco, may explain these results. Our study appears to reinforce the GTS prevention recommendations made by investigators in other tobacco growing regions, specifically the importance of minimizing close skin contact with tobacco leaves and avoiding dermal contact with the plants when they are wet.

Training medical providers to conduct alcohol screening and brief interventions.

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Teaching quality measurement and improvement, cost-effectiveness, and patient satisfaction in undergraduate medical education: the UME-21 experience.

BACKGROUND: The health care system in the United States is changing at an ever-increasing rate. Recent reports by the Institute of Medicine raising concerns regarding rates of medical errors and suggesting the need for reengineering of the health care delivery system have focused attention on the need for quality measurement and improvement. METHODS: We abstracted data from final written reports submitted by 18 Undergraduate Medical Education for the 21st Century (UME-21) schools, as well as other materials available from participating UME-21 schools. Specific curricular innovations developed and implemented were identified. Additionally, senior medical students' responses to the annual Graduation Questionnaire administered by the Association of American Medical Colleges (AAMC) were available for analysis. The change from 1999 to 2001 in the proportion of seniors rating instruction in quality assurance as adequate was compared among four groups of UME-21 schools and the other 107 US medical schools. RESULTS: Eleven of the 18 schools specifically addressed the content areas of quality measurement and improvement, including utilization management (27% of schools), cost-effectiveness (45% of schools), use of clinical practice guidelines (73% of schools), and patient satisfaction assessment (45% of schools). Each school developed unique approaches and educational materials pertinent to the content area. Overall, the percentage of seniors rating the relative amount of instructional time devoted to quality assurance in medicine by their school's curriculum as adequate or better rose from 49% to 66% between 1999 and 2001 at the 11 UME-21 schools that introduced initiatives in quality improvement into their curricula. This change was significantly higher than the pattern at other US medical schools between 1999 and 2001, at which seniors' ratings rose only from 43% to 56%. CONCLUSIONS: Curriculum development and implementation addressing quality improvement in medical practice accelerate improvement of students' perception that their education has adequately addressed this subject area. This article summarizes some of the experiences, curricular approaches, successes, failures, and lessons learned in quality improvement by schools participating in the UME-21 project.

UME-21 local evaluation initiatives: contributions and challenges.

BACKGROUND AND OBJECTIVES: The 18 medical schools involved in the UME-21 initiative developed innovative curricula and evaluation strategies. While there was significant variation in how schools approached the evaluation process, there were common methodological issues and challenges affecting the reliability of scores and validity of interpretations regarding outcomes. This paper explores these issues and challenges, using experiences from selected UME-21 schools. METHODS: Four evaluation issues and strategies are discussed: instrument development, study design, process evaluation using formative evaluation methods, and qualitative strategies. Within each discussion, examples from a UME-21 school are presented. RESULTS: The four evaluation strategies offered the flexibility to match local evaluation needs with an effective approach to evaluations. CONCLUSIONS/IMPLICATIONS: The school-level evaluation requirements by the UME-21 initiative provided schools the flexibility to design individualized evaluation strategies, yet also encouraged collaboration among evaluators. While this strategy resulted in many successes at the school level, it also served to identify common methodological challenges that can be used as a guide for other schools in implementing and evaluating curricula.

Shade tobacco and green tobacco sickness in Connecticut.

The prevalence of Green Tobacco Sickness (GTS) among shade tobacco farmworkers in Connecticut is unknown. We conducted a study to determine the prevalence of GTS in farmworkers working in shade tobacco fields who presented for clinical care at medical student-run clinics. A retrospective chart review of the tobacco workers seen at Farmworkers' Clinics during 2001 was instituted in this study. Although GTS was not clinically diagnosed in any of the patients, we found 15% diagnoses that could be attributed to possible GTS by ICD-9 code review. Using a stricter GTS case definition, the frequency rate decreased to 4%. Nonsmokers were significantly more likely than smokers to report GTS-like symptoms (P < 0.01). Isolated symptoms of headache and dizziness were significantly more frequent among nonsmokers than smokers (P < 0.05). In conclusion, cases of possible GTS were found in Connecticut shade tobacco workers. Nonsmokers were more at risk to have possible GTS than smokers.

Improving patient care outcomes by teaching quality improvement to medical students in community-based practices.

PURPOSE: As part of the Undergraduate Medical Education for the 21st Century (UME-21) project, the University of Connecticut School of Medicine developed and implemented a quality improvement curriculum. This study examined its impact on educational outcomes and the effect of the students' continuous quality improvement (CQI) projects on the quality of care delivered at community practice sites. METHOD: Seventy-seven second-year students working in groups of two to four conducted CQI projects on diabetes mellitus at 24 community-based primary care practices. They collected baseline data, implemented a results-specific intervention, and re-assessed quality indicators six months later. Students' knowledge, attitudes, and beliefs were evaluated using Likert-scale rated items as well as open-ended questions. RESULTS: A total of 513 charts were abstracted for the baseline sample, with 380 charts abstracted post-intervention. Attitudinal data revealed students acknowledged the benefit of outcomes measurement in clinical practice despite their frustration with the tedium of the chart-abstraction process. The rate of documentation of performances of foot and eye exams increased significantly from baseline to remeasurement (51.3% to 70.2%; p <.001 and 26.9% to 37.8%; p <.001, respectively). The mean value for glycohemoglobin dropped from 7.71% at baseline to 7.22% at remeasurement (p <.001). CONCLUSIONS: Medical student-driven CQI projects can improve the quality of care for diabetes at practices in which the students participate while introducing them and their preceptors to the process of quality measurement and improvement. Formative input from students should be used to optimize CQI experiences. Using medical students to lead CQI efforts in private practices may represent an underutilized resource to improve the care of patients in community-based practices.