Establishing survivorship care planning in a comprehensive cancer center to meet clinic needs and accreditation standards

59 Background: Standard 3.3 of the American College of Surgeons Commission on Cancer (CoC) patient-centered care guidelines requires that accredited institutions deliver SCPs to all patients completing cancer treatment with curative intent (10% of eligible patients in 2015 and increasing incrementally to 100% in 2019). Implementation of SCP delivery has been challenging and limited to date. We describe our implementation process at the Robert H. Lurie Comprehensive Cancer Center. Methods: We established a multidisciplinary working group that developed and administered a survey of providers’ attitudes towards SCPs and preferences for delivery, assessed clinical workflows, then developed and vetted customized SCP templates within the electronic health record (EHR) and two complimentary SCP delivery models. Results: Twelve providers completed the survey (6 physicians, 5 advanced practice providers [APPs], 1 nurse). 67% viewed SCPs as feasible within workflows, 75% felt designated survivorship clinicians were best equipped to deliver SCPs; All reported SCPs were beneficial to patients; and 92% felt SCPs were beneficial to inter-provider communication. Cited barriers were: time and staff required and non-optimal billing. To harmonize with existing workflows, we established two delivery models: (1) clinical groups with a low volume of survivors relative to available nursing staff complete and deliver SCPs themselves; (2) clinical groups with high volumes of survivors relative to available nursing staff refer patients to a centralized survivorship clinic where SCPs are delivered by designated survivorship APPs. All elements of the ASCO templates were incorporated into our EHR templates. We reduced free-text data entry by designing templates where 20% of the fields are auto-populated from existing EHR data and another 65% use drop-down menus. Mean completion time is 12 minutes (range 10-30 minutes; n= 30). Conclusions: CoC-accredited institutions across the nation are working to meet Standard 3.3. We present our experiences developing and implementing SCP delivery models, including lessons learned to inform models of survivorship care under development at other institutions

An effectiveness-implementation hybrid trial for informatics-based cancer symptom management

236 Background: Oncology outpatients can facesignificant cancer- and treatment-related symptoms that compromise health related quality of life and quality health care. Although the burden of symptoms on patients’ lives are well-known, most health care systems are not ideally set up to relieve them. Patients are not typically drawn into meaningful engagement with the health care team in ways that enable symptom self-management. As a result, opportunities for early identification and treatment are lost, causing avoidable human suffering and cost. The Northwestern University IMPACT (NU IMPACT) project aims to evaluate the effectiveness and implementation of an informatics-driven symptom monitoring and web-based self-management intervention. The project uses PROMIS measures, integrated into the EHR, to trigger response and intervention. This presentation describes the effectiveness-implementation hybrid trial design and measurement of implementation. Methods: NU IMPACT will test the effectiveness and implementation of a system-wide symptom management intervention, across six adult hematology/oncology and gynecologic oncology outpatient clinics at Northwestern Memorial HealthCare, using a cluster randomized pragmatic roll-out implementation trial with an embedded individual-level randomized clinical trial. This unique design allows for a fully-powered randomized trial to establish the efficacy of the intervention, as well as a randomized test of implementation. We are enrolling approximately 6,000 patients in pre-implementation and 6,000 in post-implementation, with half of the latter group randomly assigned to enhanced symptom management, and the other half to usual care. Results: Implementation process is guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) model with evaluation following the RE-AIM framework. Particular focus is paid to adoption at the clinic and provider levels, the extent to which the intervention achieves meaningful reach to cancer patients, and the potential for sustainment. Additionally, we are testing and validating a newly developed method for tracking and reporting dynamic changes to implementation strategies. Conclusions: Achieving the aims of the NU IMPACT project is a critical step in the advancement of informatics-driven symptom management interventions for cancer patients. The innovative implementation trial design and measurement approach will aid in the rapid translation of findings to other healthcare systems. Clinical trial information: NCT03988543

Piloting a screening tool in a breast cancer survivorship clinic

66 Background: Breast cancer survivors experience physical, psychosocial, and practical concerns. Our Adult Survivorship Clinic provides patients a comprehensive survivorship visit following curative intent therapy to identify and address these needs. This study assessed patient and staff feasibility, usefulness, and burden of a screening tool. Methods: Patients seen in the Robert H. Lurie Breast Cancer Survivorship Clinic were randomly assigned to receive a screener (Coleman Supportive Oncology Tool including a concerns checklist & the 4-item Patient Health Questionnaire [PHQ-4]) versus no screener prior to their survivorship clinic appointment. All patients were asked to complete the FACIT-TS-PS to assess treatment satisfaction following the appointment. The screener group also completed an additional set of screener acceptability questions. The survivorship clinician completed a questionnaire after each patient visit. Results: Patients with breast cancer (n = 100) were randomized. Twenty-six (52%) of the participants not given a screener and 26 (52%) of the participants given a screener completed the FACIT TS-PS. 48% of participants were age 55 years or older and 54% received chemotherapy. While there were no statistically significant differences between the groups, both groups scored high on the FACIT TS-PS. Screener patients provided high ratings for the satisfaction survey with 100% of the respondents reporting the screener was “probably” or “definitely” clear and relevant. 85% reported that the questions provided little or no distress. The median time to complete the tool was 4 to 5 minutes. The survivorship provider reported that in 47% of patients (23/49) the screener uncovered an additional significant concern. In 35% of screened patients (17/49), the provider felt the screener prompted an additional referral to supportive oncology services or a medical specialist. Conclusions: A comprehensive and brief screener for patient concerns was feasible and acceptable for both patients and provider. Even in the context of a comprehensive survivorship visit, a screening tool uncovered additional concerns that led to supportive care referrals

Piloting a supportive oncology screener with adult survivors of childhood cancers

9 Background: Adult survivors of childhood cancers experience a host of late effects. Our Survivors Taking Action and Responsibility (STAR) clinic treats those needs. Methods: We piloted the Coleman Supportive Oncology Tool (CSOT, which includes a concerns checklist & the 4-item Patient Health Questionnaire [PHQ-4]) that patients completed before STAR visits. We used chi-square, T-tests, and logistic regression to identify differences in CSOT scores associated with patient characteristics. Results: Patients (n = 115) completed the CSOT: 54% women; 81% White; 34% leukemias, 30% lymphomas, 10% brain tumors, 8% sarcomas, and 18% other cancers. Mean years: current age = 33.48 (SD = 7.71) and age at diagnosis = 9.8 (SD = 5.84). The majority had chemotherapy (95%) and radiation (74%). A minority underwent surgery (38%) and transplant (22%); experienced a cancer recurrence or second malignancy (each 20%). We assessed 21 potential late effects; the mean number per patient was 1.92 (range = 0-9); most frequent were cardiologic (23%), endocrine (17%), musculoskeletal (17%) and infertility (16%). Controlling for current age, each 13 years (a) since diagnosis was associated with roughly 1 more long term effect (β = 1.02, p = 300 mg anthracycline was associated with a nearly 8-fold increase in cardiologic late effects (OR = 7.94, p < .01). Recurrence, second malignancy, and age < 10 years at diagnosis were associated with significantly more late effects (p = < .001, 01, < .01, and .02 respectively); those variables were not associated with greater CSOT concerns. We assessed 32 CSOT supportive care concerns; the mean number per patient was 3.23 (range = 0-18); the most frequent were difficulties with body weight (34%), sleep (19%), work / school (18%), concentration and health insurance (each 17%). On an item assessing fear of recurrence (FoR) frequency, most (74%) endorsed “not at all” but any FoR was associated with endorsing a greater number of CSOT concerns (p < .0001). Conclusions: Using a brief screener was feasible in a clinic providing follow-up care to adult survivors of childhood cancers to identify patients’ current medical and supportive care needs

Use of a best-practice advisory to increase survivorship clinic referrals

53 Background: The American College of Surgeons Commission on Cancer require accredited institutions to give patients a survivorship care plan (SCPs) within six months of completing curative intent therapy. However, only a minority are receiving SCP’s. Some institutions have survivorship clinics to deliver comprehensive care, including SCP’s. Insufficient referrals to such clinics are a common barrier due to survivorship not being integrated into oncology workflows. To address this, we developed and implemented a best practice advisory (BPA) alert within our EMR to identify eligible patients and facilitate referrals to the survivorship clinic. Methods: Our pilot included breast cancer patients within medical oncology. The BPA electronic alert criteria included: stage 0-III, new patient encounter within 12 months, no SCP completed or previous referral. Upon triggering, the BPA asks “Does your patient require a SCP?” followed by 3 options: 1) SCP needed- an automatic order is generated, if signed, the BPA will not fire again, if unsigned, it will fire at the next encounter (no sooner than 30 days) and will continue until an order is placed or the response “ SCP not needed” is selected. 2) SCP not needed- the BPA will never trigger again for that patient. 3) Don’t know/still on treatment-the BPA will re-fire in 30 days. Data on frequency of BPA firing and number of referrals was compared 90 days prior and post implementation. Chi-square analysis was used. Results: Between 4/1/2015-3/31/2016, 902 patients were seen with stage 0-III breast cancer at Northwestern. Ninety days prior to implementation of the BPA, 30 patients (3.3%) were referred by 8 oncology providers. In the 90 days following implementation, the BPA fired 845 times (48.5% option 1, 24.8% option 2, 26.6% option 3) and 198 patients (22%) were referred. The difference was statistically significant ( χ2 = 141.7, p < 0.0001). Conclusions: The implementation of BPAs within an EMR is an effective way to increase referrals to a survivorship clinic, thus increasing the number of patients given SCPs. Challenges identified were having enough staff availible to deal with a rapid increase in referrals, need for refinement of BPA criteria to more precisely identify eligible patients, and provider burden