The Impact of Socioeconomic Deprivation on Clinical Outcomes for Pancreatic Adenocarcinoma at a High-volume Cancer Center

Abstract Background NHS was created in 1948 to redress the healthcare inequality through provision of universal healthcare service in the UK. However even of late, significant health inequality persists. Socioeconomic deprivation is known to result in increased overall morbidity and mortality. Aim To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with ACS (NSTEMI/STEMI) who were treated with PCI Methods A retrospective study of NSTEMI/NSTEMI patients after inpatient treatment with coronary angiogram and PCI. The parameters include basic demographics, risk factors, LV EF on echocardiogram, lipid profile and discharge medication. Individual's socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1–2, 3–4, 5–6,7 –8, 9–10). Follow-up for 24 months. Clinical outcome assessed was composite endpoint event of MACE. Results 357 from the lowest quintile (SIMD 1–2), 319 from SIMD 3–4, 191 from SIMD 5–6, 120 from SIMD 7–8, and 99 from the highest quintile (SIMD 9–10) were included. No statistical difference exists between age or gender. No difference in past medical history (inclusive of hypertension, diabetes, dyslipidemia, family history. No difference in incidence of nicotine use. Prescription of aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel) as well as secondary prevention medications (such as ace inhibitor/angiotensin II receptor blocker, beta blocker, statin and GTN) were good and not statistically different between all groups. No statistical difference exists between all groups relating to pre-discharge LV ejection fraction on echocardiogram or random cholesterol level check on admission. 24 months follow-up demonstrated composite endpoint of MACE was statistically higher among patients of lowest socioeconomic quintile (Kaplan Meier plot, p<0.001). Step-wise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcomes (p<0.001, R2=14.5%). Patients from the least deprived quintile possess survival advantage almost 14-folds as compared to those of most deprived group (Odd-ratio 13.8 (95% CI: 39.4–48.5)). Summary After an ACS event, despite initial coronary intervention and subsequent optimal prescription of prognostically beneficial secondary prevention medications, patients from the lower socioeconomic group (as described by SIMD) are still more likely to experience readmission for cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. Socioeconomic deprivation has been shown to be an independent predictor of adverse clinical outcome for those who survived initial ACS. Acknowledgement/Funding None

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Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process

Journal of Oncology Practice ◽

10.1200/jop.2016.017756 ◽

2017 ◽

Vol 13 (4) ◽

pp. e273-e282 ◽

Cited By ~ 10

Author(s):

Ankit Agarwal ◽

Rachel A. Freedman ◽

Felicia Goicuria ◽

Catherine Rhinehart ◽

Kathleen Murphy ◽

...

Keyword(s):

Care Delivery ◽

High Volume ◽

Cancer Center ◽

Prior Authorization ◽

Patient Demographics ◽

Approval Rate ◽

Decision Points ◽

Oncology Practice ◽

The Cost ◽

The Impact

Introduction: The cost and burden associated with prior authorization (PA) for specialty medications are concerns for oncologists, but the impact of the PA process on care delivery has not been well described. We examined PA processes and approval patterns within a high-volume breast oncology clinic at a major academic cancer center. Methods: We met with institutional staff to create a PA workflow and process map. We then abstracted pharmacy and medical records for all patients with breast cancer (N = 279) treated at our institution who required a PA between May and November 2015 (324 prescriptions). We examined PA approval rates, time to approval, and associations of these outcomes with the type of medication being prescribed, patient demographics, and method of PA. Results: Seventeen possible process steps and 10 decision points were required for patients to obtain medications requiring a PA. Of the 324 PAs tracked, 316 (97.5%) were approved on the first PA request after an average time of 0.82 days (range, 0 to 14 days). Approximately half of PAs were for either palbociclib (26.5%) or pegfilgrastim (22.2%), and 13.6% of PAs were for generic hormonal therapy. Requirements to fax PA requests were associated with greater delay in approval time (1.31 v 0.17 days for online requests; P < .001). The use of specialty pharmacies increased staff burden and delays in medication receipt. Conclusion: The PA process is complicated and labor intensive. Given the high PA approval rate, it is unlikely that PA requirements reduce medication utilization in practice, and these requirements may impose unnecessary burdens on patient care. The goals and requirements for PAs should be readdressed.

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Factors affecting the administration of adjuvant therapy in patients with pancreatic adenocarcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.e15087 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. e15087-e15087

Author(s):

Pablo Emilio Serrano Aybar ◽

Peter Tae Wan Kim ◽

Kenneth Leung ◽

Sean P. Cleary ◽

Steven Gallinger ◽

...

Keyword(s):

Adjuvant Therapy ◽

Pancreatic Adenocarcinoma ◽

Multivariate Logistic Regression Analysis ◽

Major Complication ◽

High Volume ◽

Lower Probability ◽

Node Negative ◽

Factors Affecting ◽

Major Complications ◽

The Impact

e15087 Background: Adjuvant therapy for pancreatic adenocarcinoma is now considered standard of care. The proportion of patients receiving adjuvant therapy (ADT) following pancreatic resection is a good quality indicator of cancer care. The aim of this study was to evaluate factors associated with receiving ADT in patients with pancreatic cancer. Methods: Between years 2000-2010, all patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma at a single high-volume hepatotopancreatobiliary center were evaluated. The impact of demographic, peri-operative and pathological risk factors affecting the administration of ADT were analyzed using univariate and multivariate logistic regression analysis. Results: There were 258 patients identified. Median age was 65 (37-84) years, 54% were females. There was a 15% margin positivity rate, 14% pancreatic leak rate, 14.7% major complication rate, and 1.2% 90 day/in-hospital mortality rate. Overall, 160/258 (70%) of patients received adjuvant therapy. On multivariate analysis; age, presence of major complications, node-negative disease and earlier era (2000-2004) were significantly associated with a lower probability of receiving ADT. Reasons for not receiving ADT were; patient preference: 20/67 (32%), not recommended: 14/67 (23%), disease recurrence: 12/67 (9.5%) and being medically unfit for ADT: 18/67 (11.5%). None of these reasons were different between time-periods except for fewer patients being offered ADT from 2000-2005 (15.4% vs. 2.5%, p <0.001). Conclusions: Thirty percent of patients do not receive ADT following pancreatectomy. Those with advanced age; node-negative disease and those who had major complications after pancreaticoduodenectomy were less likely to receive ADT. The impact of these factors should be taken into account when considering the administration of ADT.

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Preoperative Chemoradiation for Patients With Pancreatic Cancer: Toxicity of Endobiliary Stents

Journal of Clinical Oncology ◽

10.1200/jco.2000.18.4.860 ◽

2000 ◽

Vol 18 (4) ◽

pp. 860-860 ◽

Cited By ~ 61

Author(s):

Peter W. T. Pisters ◽

Wayne A. Hudec ◽

Jeffrey E. Lee ◽

Isaac Raijman ◽

Sandeep Lahoti ◽

...

Keyword(s):

Pancreatic Cancer ◽

Pancreatic Adenocarcinoma ◽

Tertiary Care ◽

Hepatic Abscess ◽

Preoperative Chemoradiation ◽

Biliary Stent ◽

Cancer Center ◽

Hepatic Toxicity ◽

Biliary Decompression ◽

The Impact

PURPOSE: A recent multicenter study of preoperative chemoradiation and pancreaticoduodenectomy for localized pancreatic adenocarcinoma suggested that biliary stent–related complications are frequent and severe and may prevent the delivery of all components of multimodality therapy in many patients. The present study was designed to evaluate the rates of hepatic toxicity and biliary stent–related complications and to evaluate the impact of this morbidity on the delivery of preoperative chemoradiation for pancreatic cancer at a tertiary care cancer center. PATIENTS AND METHODS: Preoperative chemoradiation was used in 154 patients with resectable pancreatic adenocarcinoma (142 patients, 92%) or other periampullary tumors (12 patients, 8%). Patients were treated with preoperative fluorouracil (115 patients), paclitaxel (37 patients), or gemcitabine (two patients) plus concurrent rapid-fractionation (30 Gy; 123 patients) or standard-fractionation (50.4 Gy; 31 patients) radiation therapy. The incidences of hepatic toxicity and biliary stent–related complications were evaluated during chemoradiation and the immediate 3- to 4-week postchemoradiation preoperative period. RESULTS: Nonoperative biliary decompression was performed in 101 (66%) of 154 patients (endobiliary stent placement in 77 patients and percutaneous transhepatic catheter placement in 24 patients). Stent-related complications (occlusion or migration) occurred in 15 patients. Inpatient hospitalization for antibiotics and stent exchange was necessary in seven of 15 patients (median hospital stay, 3 days). No patient experienced uncontrolled biliary sepsis, hepatic abscess, or stent-related death. CONCLUSION: Preoperative chemoradiation for pancreatic cancer is associated with low rates of hepatic toxicity and biliary stent–related complications. The need for biliary decompression is not a clinically significant concern in the delivery of preoperative therapy to patients with localized pancreatic cancer.

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Impact of trainee involvement in esophagectomy on clinical outcomes: a narrative systematic review of the literature

Diseases of the Esophagus ◽

10.1093/dote/doz063 ◽

2019 ◽

Vol 32 (10) ◽

pp. 1-8

Author(s):

P Prasad ◽

M Navidi ◽

A Immanuel ◽

S M Griffin OBE ◽

A W Phillips

Keyword(s):

Systematic Review ◽

Clinical Outcomes ◽

Meta Analysis ◽

Neoadjuvant Treatment ◽

Length Of Hospital Stay ◽

High Volume ◽

Cochrane Library ◽

Published Data ◽

Meta Analyses ◽

The Impact

SUMMARY Changes in the structure of surgical training have affected trainees’ operative experience. Performing an esophagectomy is being increasingly viewed as a complex technical skill attained after completion of the routine training pathway. This systematic review aimed to identify all studies analyzing the impact of trainee involvement in esophagectomy on clinical outcomes. A search of the major reference databases (Cochrane Library, MEDLINE, EMBASE) was performed with no time limits up to the date of the search (November 2017). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Four studies that included a total of 42 trainees and 16 consultants were identified, which assessed trainee involvement in open esophagogastric resectional surgery. A total of 1109 patients underwent upper gastrointestinal procedures, of whom 904 patients underwent an esophagectomy. Preoperative characteristics, histology, neoadjuvant treatment, and overall length of hospital stay were comparable between groups. One study found higher rates of anastomotic leaks in procedures primarily performed by trainees as compared to consultants (P < 0.01)—this did not affect overall morbidity or survival; however, overall anastomotic leak rates from the published data were 10.4% (trainee) versus 6.3% (trainer) (P = 0.10). A meta-analysis could not be performed due to the heterogeneity of data. The median MINORS score for the included studies was 13 (range 11–15). This study demonstrates that training can be achieved with excellent results in high-volume centers. This has important implications on the consent process and training delivered, as patients wish to be aware of the risks involved with surgery and can be reassured that appropriately supervised trainee involvement will not adversely affect outcomes.

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A retrospective review of borderline resectable-locally advanced pancreatic adenocarcinoma (BR-LAPC) undergoing neoadjuvant chemotherapy followed by stereotactic body radiation therapy (SBRT) at the University of Colorado Cancer Center.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.436 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 436-436

Author(s):

Claymore Joey Cuny ◽

John Hoyle ◽

Cindy L. O'Bryant ◽

Cheryl Lauren Meguid ◽

Christopher Hanyoung Lieu ◽

...

Keyword(s):

Clinical Outcomes ◽

Surgical Resection ◽

Locally Advanced ◽

Neoadjuvant Treatment ◽

Dose Intensity ◽

Cancer Center ◽

University Of Colorado ◽

Number Of Patients ◽

The University ◽

The Impact

436 Background: Metastatic pancreatic chemotherapy regimens are often used as neoadjuvant treatment in the LAPC setting. The University of Colorado has a treatment paradigm for BR-LAPC which consists of 2-4 months of chemotherapy followed by SBRT then reevaluated for surgical resection. Methods: Retrospective analysis of patients with pathologically confirmed BR-LAPC who received all neoadjuvant treatment (chemotherapy and SBRT) with intention of undergoing surgical resection at the University of Colorado Cancer Center from 2012 to 2017. Baseline data collected includes demographics, comorbidities, disease characteristics and chemotherapy regimen FOLFIRINOX or Gemcitabine/Nab-Paclitaxel (GNP). The objective of the study is to describe the correlation of neoadjuvant regimens and clinical outcomes. Results: A total of 100 patients were identified with 40 patients collected for the interim analysis. Of these patients 82.5% (N = 33) received FOLFIRINOX and 17.5% (N = 7) received GNP. Patients who received FOLFIRINOX, 78.8% went for surgical resection compared to 85.7% in the GNP group. The number of patients who had a reported College of American Pathology (CAP) grade ≤1, representing no or minimal residual disease, was 3 for the FOLFIRINOX group and no patients in the GNP group. The percent of patients in the FOLFIRINOX group who achieved R0 resections was 90% compared to 83% for the GNP group. Mean initial CA 19-9 was 38.5U/ml, 386.7U/ml, and 1799.8U/ml in CAP grade 1, 2, 3 respectively, while percent reduction in CA 19-9 level during neoadjuvant was 33.3%, 69.7%, and 72.4% respectively. Assessment of the impact of relative dose intensity for each neoadjuvant regimen on clinical outcomes is ongoing. Conclusions: FOLFIRINOX neoadjuvant treatment was associated with improved surgical outcomes including an increased rate of R0 and CAP grade ≤1 resections. Low initial CA 19-9 levels were associated with favorable surgical and pathologic outcomes whereas absolute or relative CA 19-9 reductions with neoadjuvant were not. Final analysis of all 100 patients will be reported.

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Socioeconomic deprivation and 1 year clinical outcomes after cryablation for atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.189 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

Y Lau ◽

O Cimpeanu ◽

GE Marshall ◽

GJ Padfield ◽

GA Wright ◽

...

Keyword(s):

Heart Failure ◽

Clinical Outcomes ◽

Alcohol Misuse ◽

Socioeconomic Deprivation ◽

Socioeconomic Group ◽

Bleeding Diathesis ◽

Lower Socioeconomic ◽

All Cause Mortality ◽

The Impact

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Socioeconomic deprivation has previously been demonstrated to result in worse heart failure and myocardial infarction outcomes. Published studies shown lower socioeconomic group to associate with higher prevalence of atrial fibrillation (AF), increased mortality and morbidity. However, the impact of socioeconomic deprivation on clinical outcomes post AF cryoablation has yet to be investigated. AIM To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with AF treated by cryoablation. METHODS A retrospective study of paroxysmal or persistent AF patients after cryoablation. The parameters included basic demographics, weight, past medical history (inclusive of hypertension, heart failure, diabetes, stroke or transient ischaemic attacks, prior myocardial infarction, obstructive sleep apnoea) and alcohol misuse. Medical treatment post AF ablation (Beta blocker, non-dihydropyridine calcium channel blocker, flecainide, amiodarone, dronaderone, sotolol, anticoagulant use) were also recorded. Individual’s socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1-2,3-4,5-6,7-8, 9-10). Follow-up for 12 months. Clinical outcome assessed was rate of readmission for symptomatic documented AF, rate of heart failure admission, stroke, bleeding diathesis and all-cause mortality. RESULTS 312 patients were identified: 65 from the lowest quintile (SIMD 1-2), 57 from SIMD 3-4, 54 from SIMD 5-6, 52 from SIMD 7-8, and 84 from the highest quintile (SIMD 9-10). No statistical difference exists between age, gender or weight. Lowest socioeconomic quintile has higher incidence of heart failure (p =0.018) but other past medical history was no different. No difference in incidence of alcohol misuse. Prescription rate/rhythm control agents and anticoagulant use post ablation was not statistically different between all groups. 12 months follow-up demonstrated readmission for symptomatic documented AF was statistically higher among patients of lowest socioeconomic quintile (Keplan Meier plot, p = 0.001). Stepwise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcome (p = 0.02). Risk of readmission for AF in patients from the wealthiest socioeconomic group is almost a quarter as compared to those of most deprived social group (Odd-ratio 0.273 (95% CI 0.122 – 0.607)). Other clinical outcomes including risk of admissions for heart failure, stroke, bleeding diathesis and all-cause mortality was not statistically different across all groups. Summary After cryoablation for AF, patients from the lower socioeconomic group are still more likely to experience readmission for symptomatic AF at 12-month, despite similar post-procedure pharmaceutical agents utilised.

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Influence of the First Wave of the COVID-19 Pandemic on Cancer Care in a German Comprehensive Cancer Center

Frontiers in Public Health ◽

10.3389/fpubh.2021.750479 ◽

2021 ◽

Vol 9 ◽

Author(s):

Johanna Kirchberg ◽

Anke Rentsch ◽

Anna Klimova ◽

Vasyl Vovk ◽

Sebastian Hempel ◽

...

Keyword(s):

High Volume ◽

Tumor Stage ◽

Tumor Board ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Tertiary Referral Center ◽

Tract Cancer ◽

Oncological Patients ◽

Tumor Entity ◽

The Impact

Introduction: During the first wave of the COVID-19 pandemic in 2020, the German government implemented legal restrictions to avoid the overloading of intensive care units by patients with COVID-19. The influence of these effects on diagnosis and treatment of cancer in Germany is largely unknown.Methods: To evaluate the effect of the first wave of the COVID-19 pandemic on tumor board presentations in a high-volume tertiary referral center (the German Comprehensive Cancer Center NCT/UCC Dresden), we compared the number of presentations of gastrointestinal tumors stratified by tumor entity, tumor stage, and treatment intention during the pandemic to the respective data from previous years.Results: The number of presentations decreased by 3.2% (95% CI −8.8, 2.7) during the COVID year 2020 compared with the pre-COVID year 2019. During the first shutdown, March–May 2020, the total number of presentations was 9.4% (−18.7, 1) less than during March–May 2019. This decrease was significant for curable cases of esophageal cancer [N = 37, 25.5% (−41.8, −4.4)] and colon cancer [N = 36, 17.5% (−32.6, 1.1)] as well as for all cases of biliary tract cancer [N = 26, 50% (−69.9, −15)] during the first shutdown from March 2020 to May 2020.Conclusion: The impact of the COVID-19 pandemic on the presentation of oncological patients in a CCC in Germany was considerable and should be taken into account when making decisions regarding future pandemics.

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Modeling and improving chemotherapy patient flow.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.30_suppl.175 ◽

2014 ◽

Vol 32 (30_suppl) ◽

pp. 175-175 ◽

Cited By ~ 1

Author(s):

Inga Tolin Lennes ◽

Ana Cecelia Zenteno Langle ◽

Michael Duk ◽

Avital Levy Carlis ◽

Mara Bloom ◽

...

Keyword(s):

Operations Management ◽

Patient Flow ◽

Tracking System ◽

Physical Space ◽

High Volume ◽

Change Implementation ◽

Phase Iii ◽

Cancer Center ◽

Patient Tracking ◽

The Impact

175 Background: Chemotherapy administration scheduling is dependent on infusion room hours of operation, availability of oncologist, capacity for treatment, pharmacy hood time, nursing and pharmacy staffing, and physical space limitations. In 2013, the main infusion center at MGH Cancer Center had 45% room/chair utilization reported by the Ambulatory Patient Tracking System and 33% exam room utilization in the clinics. However our infusion center experienced extremely high volume during peak hours, 10am to 2pm, but was underutilized before 10am and after 2pm, making it difficult to add on additional patients. Methods: In November 2013, MGH Cancer Center began collaboration with MIT Operations Management experts to ultimately improve patient flow through the Cancer Center by flattening the bottleneck at peak hours of operation and improving utilization of the infusion area and clinics. In phase I of the project, data was reviewed and refined. Key role groups of schedulers, prescribers, pharmacists and infusion nurses were shadowed by collaborators to gain insight into complex scheduling practices. A multidisciplinary working group met weekly to discuss the progress and suggest areas for further investigation. In phase II, optimization models testing the impact of alternative scheduling practices, physical space changes and alternative clinic configurations will be created. Finally, in phase III, change implementation and measurement will take place. Results: Process flow maps of patient movement through the cancer center were created. Patient tracking data was manipulated to understand key operational metrics. Several insights include an overall same-day chemotherapy cancellation rate of 10.7%, with the majority of cancellations from thoracic, GI and GU disease centers. Our mean scheduled infusion treatment length was 2.13 hours and 25% of appointments booked into infusion are not linked with a same-day clinic appointment. Conclusions: Understanding and refining incomplete or problematic data was a key part of understanding the issues contributing to the middle of the day bottleneck in the infusion area. Future work on this project will include optimization modeling and change implementation.

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Impact of geography and travel distance on outcomes in epithelial ovarian cancer: a national cancer database analysis

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2020-001807 ◽

2020 ◽

pp. ijgc-2020-001807

Author(s):

Ava Daruvala ◽

F Lee Lucas ◽

Jesse Sammon ◽

Christopher Darus ◽

Leslie Bradford

Keyword(s):

Ovarian Cancer ◽

Overall Survival ◽

Healthcare Delivery ◽

High Volume ◽

Cox Proportional Hazards ◽

Travel Distance ◽

Cancer Center ◽

National Cancer Database ◽

Significant Difference ◽

The Impact

BackgroundAs ovarian cancer treatment shifts to provide more complex aspects of care at high-volume centers, almost a quarter of patients, many of whom reside in rural counties, will not have access to those centers or receive guideline-based care.ObjectiveTo explore the association between proximity of residential zip code to a high-volume cancer center with mortality and survival for patients with ovarian cancer.MethodsThe National Cancer Database was queried for cases of newly diagnosed ovarian cancer between January 2004 and December 2015. Our predictor of interest was distance traveled for treatment. Our primary outcomes were 30-day mortality, 90-day mortality, and overall survival. The effect of treatment on survival was analyzed with the Kaplan-Meier method. Multiple logistic regression for binary outcomes and Cox proportional hazards regression for overall survival were used to assess the effect of distance on outcome, controlling for potential confounding variables.ResultsA total of 115 540 patients were included. There was no statistically significant difference in 30- or 90-day mortality among any of the travel distance categories. A statistically significant decrease in 30-day re-admission was found among patients who lived further away from the treating facility. A total of 105 529 patients were available for survival analysis, and survival curves significantly differed between distance strata (p<0.0001). The adjusted regression models demonstrated increased long-term mortality in patients who lived farther away from the treating facility after controlling for potential confounding.ConclusionAlthough 30- and 90-day mortality do not differ by travel distance, worse survival is observed among women living >50 miles from a high-volume treatment facility. With a national policy shift toward centralization of complex care, a better understanding of the impact of distance on survival in patients with ovarian cancer is crucial. Our findings inform the practice of healthcare delivery, especially in rural settings.

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