Coordinating an Oncology Precision Medicine Clinic Within an Integrated Health System: Lessons Learned in Year One

Precision medicine is a term describing strategies to promote health and prevent and treat disease based on an individual’s genetic, molecular, and lifestyle characteristics. Oncology precision medicine (OPM) is a cancer treatment approach targeting cancer-specific genetic and molecular alterations. Implementation of an OPM clinical program optimally involves the support and collaboration of multiple departments, including administration, medical oncology, pathology, interventional radiology, genetics, research, and informatics. In this review, we briefly introduce the published evidence regarding OPM’s potential effect on patient outcomes and discuss what we have learned over the first year of operating an OPM program within an integrated health care system (Aurora Health Care, Milwaukee, WI) comprised of multiple hospitals and clinics. We also report our experience implementing a specific OPM software platform used to embed molecular panel data into patients’ electronic medical records

Identifying care-home residents in routine healthcare datasets:a diagnostic test accuracy study of five methods

Background: there is no established method to identify care-home residents in routine healthcare datasets. Methods matching patient’s addresses to known care-home addresses have been proposed in the UK, but few have been formally evaluated. Study design: prospective diagnostic test accuracy study. Methods: four independent samples of 5,000 addresses from Community Health Index (CHI) population registers were sampled for two NHS Scotland Health Boards on 1 April 2017, with one sample of adults aged ≥65 years and one of all residents. To derive the reference standard, all 20,000 addresses were manually adjudicated as ‘care-home address’ or not. The performance of five methods (NHS Scotland assigned CHI Institution Flag, exact address matching, postcode matching, Phonics and Markov) was evaluated compared to the reference standard. Results: the CHI Institution Flag had a high PPV 97–99% in all four test sets, but poorer sensitivity 55–89%. Exact address matching failed in every case. Postcode matching had higher sensitivity than the CHI flag 78–90%, but worse PPV 77–85%. Area under the receiver operating curve values for Phonics and Markov scores were 0.86–0.95 and 0.93–0.98, respectively. Phonics score with cut-off ≥13 had PPV 92–97% with sensitivity 72–87%. Markov PPVs were 90–95% with sensitivity 69–90% with cut-off ≥29.6. Conclusions: more complex address matching methods greatly improve identification compared to the existing NHS Scotland flag or postcode matching, although no method achieved both sensitivity and positive predictive value > 95%. Choice of method and cut-offs will be determined by the specific needs of researchers and practitioners

Implementation of pharmacy services in 22 oncology clinics

Background: Our integrated health care system consisted of 15 hospitals and 159 clinics. Since 2011, 22 private practice oncology clinics transitioned to hospital-based clinics. This presented an opportunity to standardize safe and effective pharmacy services at these locations. Methods: Using patient volumes, system leaders determined six pharmacists would serve the 22 new clinics via telepharmacy. Baseline pharmacy services to be offered were prospective order verification, product checking and drug information dissemination. To prepare for the transition, over 25 physicians agreed to standardize electronic order sets and develop one formulary. Vial sizes were consolidated and a uniform way to prepare each chemotherapy agent was designated. Over 75 policies were reviewed and updated. Education was provided to all caregivers prior to the transition. Once baseline services were integrated, additional patient-focused services such as supportive care counseling, follow-up phone calls, medication reconciliation and chemotherapy education were offered. Results: Pharmacists verified over 66,000 physician-ordered chemotherapy prescriptions in 2013, intervening on about 6% by suggesting adjustments for potential organ dysfunction or toxicity. For the past year pharmacists counseled nearly 90 patients a month regarding their supportive care medications. Survey results revealed a consistent increase in overall understanding, although the sample size did not allow for statistical significance. In addition, pharmacists made about 25 follow-up phone calls to patients to assess control of nausea and vomiting, completed medication histories for about 10 patients new to chemotherapy and were consulted for about 5 chemotherapy teachings per month. Conclusions: Integration of pharmacy services in our oncology clinics has allowed for development of a streamlined and safe process for ordering and preparing chemotherapy. It also has increased patient access to pharmacists and education related to supportive care medications

A standardized approach for managing chemotherapy-induced rash

Background: Chemotherapy-induced rash can lead to disruptions or discontinuation of therapy, potentially leading to a poorer prognosis for patients. Methods: A retrospective chart review was performed at selected clinics to determine rash incidence, current rash management, and dose reductions, disruptions, and discontinuation of therapy due to rash for epidermal growth factor receptor-inhibitors (EGFR-I) during August and September 2013. A rash management algorithm containing preventative and treatment recommendations was created for selected EGFR-I (cetuximab, panitumumab, erlotinib) and implemented in the clinics’ electronic medical record as part of a pilot study from February through May 2014. When the EGFR-I were ordered, electronic alerts reminded providers of the algorithm. Pharmacists received electronic messages to ensure algorithm compliance. Nurses provided patients with a rash information sheet and preventative prescriptions. Providers assessed patients for rash during follow-up and instituted the rash treatment algorithm, if indicated. Through a chart review, rash incidence, and dose reductions, disruptions, and discontinuation of therapy due to rash were determined. Results: The retrospective chart review revealed 7 of 9 (78%) patients, in whom preventive medications were not utilized, developed rash with the selected EGFR-I. Treatment medications were required in 6 of 7 (86%) patients with rash. Even with treatment, 3 of 7 (43%) patients had a severe rash, making therapy modification necessary. A dose reduction was ordered for 1 patient, a disruption for another, and discontinuation of therapy for a third. During the pilot period, 6 of 7 (86%) patients developed rash, but none required dose reductions or discontinuation of therapy. Of the 6 patients who developed rash, 4 were adequately managed with preventive measures alone. Of the 2 patients who started rash treatment, 1 patient had rash resolution and the other patient continued treatment without any therapy modifications. Conclusions: An algorithm containing preventive and treatment recommendations for EGFR-I-induced rash may be more beneficial than reactive therapy alone in attenuation of dose reductions, disruptions, and discontinuation of therapy

AES prescription scores

Data in this file were used to address the following: To what extent is AES agreement wording fit for purpose

Conservation grazing aspect scores

Data in this file were used to address the question: Are sites achieving conservation grazing

AES delivery scores

Data in this file were used to address this question: Are AES a successful mechanism for delivering conservation grazing

At-risk Youth Find Work Hope in Work-Based Education

The transition from school to the workplace has been identified as challenging for at-risk youth who have already disengaged from learning and feel disenfranchised in the context of school. Work-based education (WBE), including co-operative education, has been recognized in recent years as an effective strategy for enabling at-risk youth to re-engage with learning and to make more successful transitions to the workplace and to further education. Not all at-risk youth thrive in WBE, even in programs that are judged to be effective for most. What remains unclear is what changes for those previously disengaged youth, as a product of participation in WBE, that enables them to shift their perspective and re-engage with learning. The purpose of this paper is to describe the experiences and changes in perspectives, in their own words, of seven previously disengaged youth while they were participating in WBE. Their teachers recommended these youth because they had made a “turnaround” since beginning WBE. The experiences and changed perspectives reported by these seven youth suggest that they found work hope through their success in WBE, and were beginning to set goals, view themselves as agents, and seek pathways to reach their goals. We discuss implications for increasing the effectiveness of WBE to re-engage even greater numbers of at-risk youth and to facilitate their transition to work by enhancing work hope