Identifying resources available to physicians for management of financial toxicity: A Fellow-driven QI initiative.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 294-294
Author(s):  
Katrina Fischer ◽  
Sidharth Anand ◽  
Anne M. Walling ◽  
Sarah Marie Larson ◽  
John Glaspy
Keyword(s):  
Risk Factors ◽  
Los Angeles ◽  
Drug Cost ◽  
Management Strategies ◽  
Treatment Center ◽  
Cancer Center ◽  
Financial Toxicity ◽  
Physician Engagement ◽  
The Impact ◽  
Insurance Issue

294 Background: Insufficient patient-physician cost communication stems in part from limited physician awareness of actionable interventions when cost issues arise. Oncologists report low awareness of resources to help patients with financial toxicity and often feel underprepared to discuss and navigate this issue. Methods: All oncology fellows (n = 19) at the University of California, Los Angeles were invited to participate in QI project during the fall of 2019. As part of the curriculum, fellows were individually paired with an experienced attending and asked to review a hypothetical case of financial toxicity. The case described an elderly widow on Medicare, living hours from the cancer center who was non-adherent to her oral cancer therapy due to high copays. Participants were asked to identify at least four financial toxicity risk factors in the case, and to identify resources and strategies that a physician could use help navigate her financial concerns. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Results: Of 19 participants, 16 completed the case based scenario. Nine categories of risk factors were identified (63% of participants identified an insurance issue, 44% lack of social support, 44% drug cost, 50% fixed income, 50% distance from treatment center, 31% logistical transportation concern). Physician directed solutions were primarily focused on three categories: drug cost, insurance issue, and transportation concerns. Together, an institutional specific financial toxicity tip sheet was generated for further dispersal at the cancer center. After participation in the intervention, more fellows agreed/strongly agreed that they could help a patient experiencing financial toxicity (62% v 6%, p = 0.005). Conclusions: A focused intervention can increase awareness of resources and strategies available to physicians in the management of patient financial concerns, which may impact physician engagement with issues of financial toxicity. Standardized education programs to further educate physicians on financial toxicity management strategies is warranted.

scholarly journals Nephrectomy Delay of More than 10 Weeks from Diagnosis Is Associated with Decreased Overall Survival in pT3 RCC

2021 ◽  
Vol 8 (2) ◽  
pp. 27-33
Author(s):  
Jiping Zeng ◽  
Ken Batai ◽  
Benjamin Lee
Keyword(s):  
Risk Factors ◽  
Overall Survival ◽  
Logistic Regression ◽  
Proportional Hazards ◽  
Surgical Margin ◽  
Cox Proportional Hazards ◽  
Cancer Center ◽  
Integrated Network ◽  
Factors Associated ◽  
The Impact

In this study, we aimed to evaluate the impact of surgical wait time (SWT) on outcomes of patients with renal cell carcinoma (RCC), and to investigate risk factors associated with prolonged SWT. Using the National Cancer Database, we retrospectively reviewed the records of patients with pT3 RCC treated with radical or partial nephrectomy between 2004 and 2014. The cohort was divided based on SWT. The primary out-come was 5-year overall survival (OS). Logistic regression analysis was used to investigate the risk factors associated with delayed surgery. Cox proportional hazards models were fitted to assess relations between SWT and 5-year OS after adjusting for confounding factors. A total of 22,653 patients were included in the analysis. Patients with SWT > 10 weeks had higher occurrence of upstaging. Using logistic regression, we found that female patients, African-American or Spanish origin patients, treatment in academic or integrated network cancer center, lack of insurance, median household income of <$38,000, and the Charlson–Deyo score of ≥1 were more likely to have prolonged SWT. SWT > 10 weeks was associated with decreased 5-year OS (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.15–1.33). This risk was not markedly attenuated after adjusting for confounding variables, including age, gender, race, insurance status, Charlson–Deyo score, tumor size, and surgical margin status (adjusted HR, 1.13; 95% CI, 1.04–1.24). In conclusion, the vast majority of patients underwent surgery within 10 weeks. There is a statistically significant trend of increasing SWT over the study period. SWT > 10 weeks is associated with decreased 5-year OS.

Cost-health literacy training in fellowship: A QI initiative.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 80-80
Author(s):  
Katrina Fischer ◽  
Sidharth Anand ◽  
Anne M. Walling ◽  
Sarah Marie Larson ◽  
John Glaspy
Keyword(s):  
Health Literacy ◽  
Los Angeles ◽  
Literacy Skills ◽  
Direct Patient Care ◽  
Financial Toxicity ◽  
Subjective Distress ◽  
Communication Practices ◽  
The Cost ◽  
The Impact ◽  
Case Based

80 Background: Limited cost-health literacy is a significant factor in the physicians ability to discuss and navigate patient financial concerns. Because these skills are not formally taught during training, the cost-health literacy of graduate medical trainees is unknown. This study describes a QI initiative to measure and improve upon the cost-health literacy skills of oncology fellows as it pertains to objective knowledge and self-perceived cost communication practices. Methods: All oncology fellows (n = 19) at the University of California, Los Angeles were invited to participate in QI project during the fall of 2019. Fellows participated in a case-based curriculum over three months, consisting of a group didactic on financial toxicity (45 minutes) and an interactive case based learning scenario that highlighted financial toxicity risk factors and areas for intervention (30 minutes). We concluded with a group discussion (30 minutes) to review and consolidate strategies, identfying internal and external resources that enable physicians to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Results: Of 19 participants, 17 participated and 16 completed both the pre and post survey. These 16 were included in the analysis. After the intervention, participants were more likely to report comfort discussing out of pocket costs (50% v 19%, p = 0.005) and to feel they could help a patient experiencing financial toxicity (62% v 6%, p = 0.005). Fellows were more likely to report awareness of resources that were available to them to help patients manage financial toxicity (69% v 19%, p 0.003) but were no more likely to report asking patients about their subjective distress due to treatment related costs (57% v 50%, p = 0.759). Conclusions: We can teach and improve upon cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and how it objectively impacts cost communication practices.

scholarly journals Do Patients and Oncologists Discuss the Cost of Cancer Treatment? An Observational Study of Clinical Interactions Between African American Patients and Their Oncologists

2017 ◽  
Vol 13 (3) ◽  
pp. e249-e258 ◽  
Author(s):  
Lauren M. Hamel ◽  
Louis A. Penner ◽  
Susan Eggly ◽  
Robert Chapman ◽  
Justin F. Klamerus ◽  
...  
Keyword(s):  
Social Support ◽  
African American ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Financial Toxicity ◽  
Younger Patients ◽  
Patients With Cancer ◽  
The Cost ◽  
Clinical Interactions ◽  
The Impact

Purpose: Financial toxicity negatively affects patients with cancer, especially racial/ethnic minorities. Patient-oncologist discussions about treatment-related costs may reduce financial toxicity by factoring costs into treatment decisions. This study investigated the frequency and nature of cost discussions during clinical interactions between African American patients and oncologists and examined whether cost discussions were affected by patient sociodemographic characteristics and social support, a known buffer to perceived financial stress. Methods Video recorded patient-oncologist clinical interactions (n = 103) from outpatient clinics of two urban cancer hospitals (including a National Cancer Institute–designated comprehensive cancer center) were analyzed. Coders studied the videos for the presence and duration of cost discussions and then determined the initiator, topic, oncologist response to the patient’s concerns, and the patient’s reaction to the oncologist’s response. Results: Cost discussions occurred in 45% of clinical interactions. Patients initiated 63% of discussions; oncologists initiated 36%. The most frequent topics were concern about time off from work for treatment (initiated by patients) and insurance (initiated by oncologists). Younger patients and patients with more perceived social support satisfaction were more likely to discuss cost. Patient age interacted with amount of social support to affect frequency of cost discussions within interactions. Younger patients with more social support had more cost discussions; older patients with more social support had fewer cost discussions. Conclusion: Cost discussions occurred in fewer than one half of the interactions and most commonly focused on the impact of the diagnosis on patients’ opportunity costs rather than treatment costs. Implications for ASCO’s Value Framework and design of interventions to improve cost discussions are discussed.

Effects of Multiple Myeloma (MM) Therapy and Type of Thromboprophylaxis On the Incidence and Timing of Venous Thromboembolism (VTE) and Factors Predictive of VTE.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2244-2244
Author(s):  
Jatin J. Shah ◽  
Aparna Hegde ◽  
Xiao Zhou ◽  
Sheeba K. Thomas ◽  
Michael Wang ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Conflicts Of Interest ◽  
Univariate Analysis ◽  
Cancer Center ◽  
Hematopoietic Stem ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
Multivariate Proportional Hazard ◽  
The Impact

Abstract Abstract 2244 Background: Patients (pts) with MM are at increased risk for VTE due to various risk factors related to the host, disease, and treatment. Immunomodulatory drugs (IMiDs) such as thalidomide and lenalidomide have further increased the risk of VTE. Several studies have shown the VTE risk can be reduced with the use of low molecular weight heparin (LMWH) or aspirin thromboprophylaxis. Based on these findings, VTE thromboprophylaxis has been recommended in pts receiving IMiDs + Dexamethasone (Dex), but the impact of these guidelines on patient outcomes in clinical practice is unclear. The objective of this observational study was to evaluate the incidence, timing and risk factors of VTE and the impact of different types of thromboprophylaxis on the incidence of VTE. Methods: This was a retrospective cohort study, and included all MM pts newly referred to the M.D. Anderson Cancer Center in 2006. Medical records of these pts were reviewed for the type and site of VTE, the incidence and timing of VTE during the five-year period from the referral date, and the risk factors, including pt demographics, co-morbidities, baseline laboratory values, types of MM and treatment, and types of thromboprophylaxis. Univariate and multivariate proportional hazard models were fitted to find the independent risk factors predictive of VTE. The stepwise selection method was employed to build a multivariate model using variables with p<0.15 in univariate analysis. Results: The cumulative incidence of VTE was 24% (38/159 pts) during the 5-year follow up period. Of the 38 pts with VTE, 25 (66%) had deep vein thrombosis (DVT), 11 (29%) had pulmonary embolus (PE), and 2 had concurrent DVT and PE. Most of the pts (32/38, 84%) had VTE within 1 year from the referral date. The incidence of recurrent VTE among these pts was 27.5% (11/38 pts), for a total of 52 episodes. Since the majority of VTEs and recurrences were within one year, we examined the risk factors for VTE during this period. Treatment with IMiDs + Dex and thromboprophylaxis with LMWH or Coumadin were independent predictive factors as shown below. The incidence of VTE was highest in pts exposed to IMiDs + Dex (30/38 pts), even after discontinuation of treatment, with most episodes (17/30) occurring during the preparation (7/30) or within 30 days (10/30) following hematopoietic stem cell transplantation (HSCT), when most (16/17) pts were not receiving anti-coagulants. Conclusions: These findings suggest that patients treated with IMiDs + Dex are at high risk for VTE, even after discontinuation of this treatment, especially, during and after the HSCT period. Future studies are needed to investigate VTE prevention strategies for this high-risk pt population. Disclosures: No relevant conflicts of interest to declare.

The effect on financial toxicity and well-being of cancer trial patients through the reimbursement of ancillary costs by the lazarex care program (LCP).

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e19030-e19030
Author(s):  
Dana Dornsife ◽  
Robert G. Johnson
Keyword(s):  
Care Program ◽  
Well Being ◽  
Equal Treatment ◽  
Cancer Center ◽  
Financial Toxicity ◽  
Cancer Trial ◽  
Black African ◽  
Important Barrier ◽  
Asian Pacific ◽  
The Impact

e19030 Background: Financial toxicity is a significant issue for many cancer patients (pts) and an even greater concern for pts considering a cancer clinical trial (CT) given the potential issues of distance to the trial site, additional trips to the cancer center, etc. Lazarex Cancer Foundation (LCF) has developed an efficient mechanism to quickly evaluate pts who are economically challenged and often underserved and to efficiently reimburse the non-clinical expenses (i.e. travel, lodging). Reimbursement (RI) of ancillary CT expenses can help to remove this important barrier and effect CT enrollment, retention, and diversity. Methods: Data was retrospectively reviewed from the LCP for years 2015 to 2019, and assessed for age, gender, race/ethnicity, household income (HI), type of assistance, and compared with trends from the prior 5 years. In addition, information was obtained concerning whether the RI was an important determinant in the decision to enroll or remain enrolled, the impact of RI on the pts’ well-being, and the ease/difficulty of the application and RI process. Results: During this period, 2,911 pts were approved for RI: 45% male, 55% female; 12.2% Latino/Hispanic, 7.6% black/African-American, 3.8% Asian/Pacific Islander, 72% white, and 4.3% multi-ethnic/other. The median HI was $35,000-$49,000 with 32% of the HI at less than $25,000, and 17% less than $15,000. RI expenses were distributed: 37% airfare, 37% lodging, and 26% ground transportation. There were increases in the % of minority pts and decreases in the median HI when compared with the five years prior. Questionnaires with 65% return rate of active pts indicated that 38% of pts stated that RI contributed to their positive CT decision, 92% of pts indicated RI had a significant impact (moderate to extremely high) on their sense of well-being with 82% in the high to extremely high category. 96% reported the application as not difficult to easy and only 4% noted the RI process itself as difficult. Conclusions: Accumulating data indicates that the socioeconomic financial toxicities are a significant root cause of inequitable access to CT. RI for pts upon whom the costs of participation place an undue burden, decreases their vulnerability, increases their well-being, and helps protect their rights to equal treatment. The LCF with more than ten years of experience with pt RI is currently expanding its efforts into targeted major cancer centers where all eligible pts will be enabled: the IMPACT (Improving Patient Access to Cancer Clinical Trials) Program.

Real-world outcomes in patients with metastatic renal cell carcinoma according to risk factors: Analysis of the STAR TOR registry.

2020 ◽  
Vol 38 (6_suppl) ◽  
pp. 628-628
Author(s):  
Michael Moran ◽  
Marcus Hubbe ◽  
Michael Rink ◽  
Lothar Bergmann ◽  
Arne Strauss ◽  
...  
Keyword(s):  
Risk Factors ◽  
Renal Cell Carcinoma ◽  
Cell Carcinoma ◽  
Metastatic Renal Cell Carcinoma ◽  
Real World ◽  
Renal Cell ◽  
Risk Group ◽  
Prognostic Models ◽  
Cancer Center ◽  
The Impact

628 Background: Metastatic renal cell carcinoma (mRCC) treatment is partly informed by risk group. The two most commonly used prognostic models, the International Metastatic RCC Database Consortium (IMDC) and the Memorial Sloan-Kettering Cancer Center (MSKCC), stratify patients (pts) into favorable (0 risk factors [RFs]), intermediate (1–2 RFs) or high risk (≥3 RFs) groups. This study examined real-world outcomes according to IMDC and MSKCC RFs in sunitinib-treated pts with mRCC. Methods: Data were extracted on 19 June 2019 from a large, prospective German multicenter registry (STAR-TOR). Only pts with sufficient data for risk stratification by IMDC and MSKCC were included in this analysis. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The impact of RFs on survival was assessed using Cox’s regression analysis and the chi square test. Results: According to IMDC or MSKCC, 16.7% and 15.3%, 26.2% and 30.8%, 18.7% and 24.7%, and 38.5% and 29.2 of pts had 0, 1, 2 and ≥3 RFs, respectively. In IMDC intermediate pts, only < 1 year diagnosis to therapy (24.8%) was the most common RF; in MSKCC intermediate pts, < 1 year diagnosis to therapy with low hemoglobin (19.9%) were the most common. OS was not significantly different for pts with 0 vs 1 (p = 0.24), or 2 vs ≥3 (p = 0.16) IMDC RFs, but was significant according to MSKCC RFs (0 vs 1, p = 0.04; 2 vs ≥3, p < 0.01). OS was significantly longer for pts with 1 vs 2 RFs for IMDC (p = 0.03) and MSKCC (p = 0.04), but PFS was not (IMDC, p = 0.29; MSKCC, p = 0.12). OS was significantly longer for 0 vs 2, 0 vs ≥3, and 1 vs ≥3 RFs for IMDC and MSKCC RFs (all comparisons, p < 0.01). Similar results were observed for PFS with the exception of 0 vs 1 IMDC RF (p = 0.01). Conclusions: The intermediate risk group appears to be heterogeneous. OS for pts with 1 RF may align with the favorable risk group and pts with 2 RFs may align with the poor risk group.[Table: see text]

scholarly journals Effects of Rain on Freeway Traffic in Southern California

2017 ◽  
Vol 2616 (1) ◽  
pp. 69-80 ◽  
Author(s):  
Sawanpreet Singh Dhaliwal ◽  
Xinkai Wu ◽  
John Thai ◽  
Xudong Jia
Keyword(s):  
Los Angeles ◽  
Traffic Management ◽  
Southern California ◽  
Management Strategies ◽  
Heavy Rain ◽  
Flow Speed ◽  
Free Flow ◽  
Light Rain ◽  
Free Flow Speed ◽  
The Impact

A number of studies in the past quantified the effect of rain on traffic parameters but were limited to wet areas. This research expands the literature by studying the effect of rain in a dry area such as Southern California and considering regional differences in the impact. Traffic data (loop detectors) and precipitation data (rain gauges) from the Los Angeles, California, metropolitan area were analyzed to access the effect of rain on traffic stream parameters such as free-flow speed, speed at capacity, and capacity. Rainfall events were categorized as light, medium, and heavy as discussed in the 2010 Highway Capacity Manual. Density plots and fundamental diagrams for rain types proved that free-flow speed, speed at capacity, and capacity were reduced by 5.7%, 6.91%, and 8.65%, respectively, for light rain; 11.71%, 12.34%, and 17.4%, respectively, for medium rain; and 10.22%, 11.85%, and 15.34%, respectively, for heavy rain. The reductions for free-flow speed were lower, whereas for speed at capacity and for capacity, they were higher than those reported in the 2010 manual. Moreover, headway increased during rain; this finding shows cautious driving behavior. Multiplicative weather adjustment factors were computed to compensate for the loss of speed and capacity. Also demonstrated was the spatial and temporal effect of rain on traffic. Downstream traffic was not much affected by a rainfall event, whereas the upstream traffic was negatively affected. This study is expected to support weather-responsive traffic management strategies for dry areas.

The Doctor Faustus Dossier

2018 ◽  
Author(s):  
Adrian Daub
Keyword(s):  
Twentieth Century ◽  
Los Angeles ◽  
Primary Source ◽  
Music And Literature ◽  
Twentieth Century Music ◽  
Private And Public ◽  
Doctor Faustus ◽  
Public Lives ◽  
Nazi Era ◽  
The Impact

Arnold Schoenberg and Thomas Mann, two towering figures of twentieth-century music and literature, both found refuge in the German-exile community in Los Angeles during the Nazi era. This complete edition of their correspondence provides a glimpse inside their private and public lives and culminates in the famous dispute over Mann's novel Doctor Faustus. In the thick of the controversy was Theodor Adorno, then a budding philosopher, whose contribution to the Faustus affair would make him an enemy of both families. Gathered here for the first time in English, the letters are complemented by diary entries, related articles, and other primary source materials, as well as an introduction that contextualizes the impact that these two great artists had on twentieth-century thought and culture.

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