Factors associated with failure to receive oral anticancer drugs.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 41-41
Author(s):  
Sahil D Doshi ◽  
Morgan RL Lichtenstein ◽  
Melissa Parsons Beauchemin ◽  
Rohit R. Raghunathan ◽  
Cynthia Law ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Prior Authorization ◽  
Transfer Of Care ◽  
Factors Associated ◽  
Lost To Follow Up ◽  
Directed Change ◽  
To Receive

41 Background: Oral anti-cancer drugs (OACDs) have become increasingly prescribed over the last 10 years and require a significant amount of care coordination. Preliminary administrative database studies have shown that 10-15% of prescriptions are never received by the patient, but the reasons behind this are poorly understood. In this study, we prospectively identified failure to receive (FR) cases in which OACD prescriptions were never received by patients, examined underlying reasons for FR, and assessed clinical and process-related factors associated with FR. Methods: We prospectively collected data on new OACD prescriptions for adult oncology patients at a large, urban academic cancer center from 1/1/2018 to 12/31/2019. We collected patient demographic, clinical, and insurance data, OACD delivery date, and interactions with payers and financial assistance groups. FR was defined as failure to receive a prescribed OACD. Reasons for FR were confirmed by manual chart review and classified into seven categories: clinical deterioration, financial access, provider-driven clinical decision making, patient-directed change, transfer of care, lost to follow up, and other. We calculated the relative proportion of each FR category and used multivariable logistic regression to identify factors associated with FR, including initiation of a prior authorization and drug class. Results: The cohort included 1,080 patients who were prescribed 1,269 new OACDs. Of these prescriptions, 13% (N=163) were categorized as FR. Among the 158 patients with FR, average patient age was 66 years, 55% identified as non-Hispanic white, 61% had any Medicare plan, 11% had Medicaid only, and 25% had commercial insurance. Overall, 18% of FR cases were attributed to clinical deterioration, 13% to financial access, 29% to provider-driven clinical decision making, 17% to patient-directed change, 13% to transfer of care, and 5% were lost to follow up. Univariate analysis showed that FR was less likely in cases where prior authorization was initiated (p < 0.001) and multivariate analysis confirmed this result (OR 0.47 [CI 0.33-0.66], p < 0.001). Conclusions: Though the majority of oncology patients prescribed OACDs received the drug, 13% of patients in our study experienced FR. FR is associated with a lack of prior authorization initiation, which may reflect barriers to access, a change in clinical decision-making, or patient choice. Ultimately, FR is multifactorial and may be appropriate in some cases. More work is needed to determine whether improved access would increase uptake in some patients. [Table: see text]

Reversibility of Delirium in Palliative Care (DRAFT)

2018 ◽  
Author(s):  
Tiffany Shaw ◽  
Eric Prommer
Keyword(s):  
Risk Factors ◽  
Decision Making ◽  
Palliative Care ◽  
Clinical Case ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Factors Associated ◽  
Frequent Event ◽  
Study Intervention

Delirium is a frequent event in patients with advanced cancer. Untreated delirium affects assessment of symptoms, impairs communication including participation in clinical decision-making. This study used specific diagnostic criteria for delirium and prospectively identified precipitating causes of delirium. The study identified factors associated with reversible and irreversible delirium. Impact of delirium on prognosis was evaluated. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case. Topics covered include delirium, neoplasms, palliative care, polypharmacy, risk factors, and therapeutics.

The Statistical Fragility of Platelet-Rich Plasma in Rotator Cuff Surgery: A Systematic Review and Meta-analysis

2021 ◽  
pp. 036354652198997
Author(s):  
Robert L. Parisien ◽  
Cooper Ehlers ◽  
Antonio Cusano ◽  
Paul Tornetta ◽  
Xinning Li ◽  
...  
Keyword(s):  
Systematic Review ◽  
Decision Making ◽  
Rotator Cuff ◽  
Clinical Decision Making ◽  
Platelet Rich Plasma ◽  
Meta Analysis ◽  
Clinical Decision ◽  
Statistical Stability ◽  
Lost To Follow Up

Background: The practice of evidence-based medicine relies on objective data to guide clinical decision-making with specific statistical thresholds conveying study significance. Purpose: To determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating the utilization of platelet-rich plasma (PRP) in rotator cuff repairs (RCRs). Study Design: Systematic review and meta-analysis. Methods: RCTs pertaining to the utilization of PRP in surgical RCRs published in 13 peer-reviewed journals from 2000 to 2020 were evaluated. The FI was determined by manipulating each reported outcome event until a reversal of significance was appreciated. The associated FQ was determined by dividing the FI by the sample size. Results: Of the 9746 studies screened, 19 RCTs were ultimately included for analysis. The overall FI incorporating all 19 RCTs was only 4, suggesting that the reversal of only 4 events is required to change study significance. The associated FQ was determined as 0.092. Of the 43 outcome events reporting lost to follow-up data, 13 (30.2%) represented lost to follow-up >4. Conclusion: Our analysis suggests that RCTs evaluating PRP for surgical RCRs may lack statistical stability with only a few outcome events required to alter trial significance. Therefore, we recommend the reporting of an FI and an FQ in conjunction with P value analysis to carefully interpret the integrity of statistical stability in future comparative trials. Clinical Relevance: Clinical decisions are often informed by statistically significant results. Thus, a true understanding of the robustness of the statistical findings informing clinical decision-making is of critical importance.

Cancer Consultation Preparation Package: Changing Patients but Not Physicians Is Not Enough

2004 ◽  
Vol 22 (21) ◽  
pp. 4401-4409 ◽  
Author(s):  
Phyllis Butow ◽  
Rhonda Devine ◽  
Michael Boyer ◽  
Susan Pendlebury ◽  
Michael Jackson ◽  
...  
Keyword(s):  
Decision Making ◽  
Patient Involvement ◽  
Clinical Decision Making ◽  
Response Rate ◽  
Clinical Decision ◽  
Consultation Intervention ◽  
To Receive ◽  
Question Prompt

Purpose This study evaluated a cancer consultation preparation package (CCPP) designed to facilitate patient involvement in the oncology consultation. Patients and Methods A total of 164 cancer patients (67% response rate) were randomly assigned to receive the CCPP or a control booklet at least 48 hours before their first oncology appointment. The CCPP included a question prompt sheet, booklets on clinical decision making and patient rights, and an introduction to the clinic. The control booklet contained only the introduction to the clinic. Physicians were blinded to which intervention patients received. Patients completed questionnaires immediately after the consultation and 1 month later. Consultations were audiotaped, transcribed verbatim, and coded. Results All but one patient read the information. Before the consultation, intervention patients were significantly more anxious than were controls (mean, 42 v 38; P = .04); however anxiety was equivalent at follow-up. The CCPP was reported as being significantly more useful to family members than the control booklet (P = .004). Patients receiving the intervention asked significantly more questions (11 v seven questions; P = .005), tended to interrupt the physician more (1.01 v 0.71 interruptions; P = .08), and challenged information significantly more often (twice v once; P = .05). Patients receiving the CCPP were less likely to achieve their preferred decision making style (22%) than were controls (35%; P = .06). Conclusion This CCPP influences patients' consultation behavior and does not increase anxiety in the long-term. However, this intervention, without physician endorsement, reduced the percentage of patients whose preferred involvement in decision making was achieved.

Between a logic of disruption and a logic of continuation: Negotiating the legitimacy of algorithms used in automated clinical decision-making

2021 ◽  
pp. 136345932199674
Author(s):  
Rikke Torenholt ◽  
Henriette Langstrup
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Patient Reported Outcomes ◽  
Patient Involvement ◽  
Clinical Decision Making ◽  
Diagnostic Procedures ◽  
Clinical Decision ◽  
Patient Reported ◽  
Pro Tools

In both popular and academic discussions of the use of algorithms in clinical practice, narratives often draw on the decisive potentialities of algorithms and come with the belief that algorithms will substantially transform healthcare. We suggest that this approach is associated with a logic of disruption. However, we argue that in clinical practice alongside this logic, another and less recognised logic exists, namely that of continuation: here the use of algorithms constitutes part of an established practice. Applying these logics as our analytical framing, we set out to explore how algorithms for clinical decision-making are enacted by political stakeholders, healthcare professionals, and patients, and in doing so, study how the legitimacy of delegating to an algorithm is negotiated and obtained. Empirically we draw on ethnographic fieldwork carried out in relation to attempts in Denmark to develop and implement Patient Reported Outcomes (PRO) tools – involving algorithmic sorting – in clinical practice. We follow the work within two disease areas: heart rehabilitation and breast cancer follow-up care. We show how at the political level, algorithms constitute tools for disrupting inefficient work and unsystematic patient involvement, whereas closer to the clinical practice, algorithms constitute a continuation of standardised and evidence-based diagnostic procedures and a continuation of the physicians’ expertise and authority. We argue that the co-existence of the two logics have implications as both provide a push towards the use of algorithms and how a logic of continuation may divert attention away from new issues introduced with automated digital decision-support systems.

scholarly journals Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study

2018 ◽  
Vol 57 (5) ◽  
pp. 957-960 ◽  
Author(s):  
Pieter van Gerven ◽  
Nikki L. Weil ◽  
Marco F. Termaat ◽  
Sidney M. Rubinstein ◽  
Mostafa El Moumni ◽  
...  
Keyword(s):  
Decision Making ◽  
Observational Study ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Ankle Fractures ◽  
Retrospective Observational Study

scholarly journals INNV-34. PATTERNS OF FAILURE AND DEVELOPMENT OF A NOVEL PROGNOSTIC SCORING SYSTEM IN ELDERLY PATIENTS WITH GLIOBLASTOMA – FOLLOW UP ON 10 YEAR ANALYSIS OF THE BC CANCER AGENCY POPULATION

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi137-vi137
Author(s):  
Jonathan Zeng ◽  
Kimberly DeVries ◽  
Andra Krauze
Keyword(s):  
Decision Making ◽  
Scoring System ◽  
Clinical Decision Making ◽  
Radiographic Progression ◽  
Clinical Decision ◽  
Patient Stratification ◽  
Patterns Of Failure ◽  
Resection Status ◽  
Cancer Agency

Abstract PURPOSE Glioblastomas (GBM) are the most common primary brain tumour recurring in most patients despite maximal management. Patient selection for appropriate treatment modality remains challenging resulting in heterogeneity in management. We examined the patterns of failure and developed a scoring system for patient stratification to optimise clinical decision making. METHODS 822 adults (BC Cancer Agency registry) diagnosed 2005–2015 age ≥60 with histologically confirmed GBM ICD-O-3 codes (9440/3, 9441/3, 9442/3) were reviewed. Univariate and Kaplan-Meier analysis were performed. Performance status (PS), age and resection status were assigned a score, cummulative maximal (favorable) score of 10 and minimum (unfavorable) score of 3. Patterns of failure were further analysed in the subset of patients with radiographic follow-up. RESULTS PS score of 3(KPS >80, ECOG 0/1), 2 (KPS 60–70, ECOG 2), 1 (KPS < 60, ECOG 3/4) (median OS 11, 6, 3 months respectively), age score and resection status were prognostic for OS with PS resulting in the most significant curve separation (p< 0.0001). Biopsy as compared to STR/GTR resulted in poorer OS in patients over 70 (age score 1/2) but had less impact in patients younger than 70 (age scores 3/4). The median OS for cumulative scores of 9/10 (123 patients), 7/8 (286 patients), 5/6 (313 patients), and 3/4 (55 patients) were 14, 8, 4 and 2 months respectively (p< 0.0001) allowing for stratification into 4 prognostic groups. 133 patients had >3 MRIs following diagnosis allowing for clinical and radiographic analysis of progression. Clinical/radiographic progression occurred within 3 months (29%/45%), 6 months (50%/66%), 9 months (70%/81%). Progression type (radiographic, clinical, both was not associated with OS. CONCLUSION Our novel prognostic scoring system is effective in achieving patient stratification and may guide clinical decision making. Early radiographic progression appears to precede clinical deterioration and may represent true progression in the elderly.

scholarly journals Influence of Prior Authorization Requirements on Provider Clinical Decision Making

2021 ◽  
Author(s):  
Stephen Salzbrenner ◽  
Maxwell Lydiatt ◽  
Brandon Heldin ◽  
Lawrence M. Scheier ◽  
Harrison Greene ◽  
...  
Keyword(s):  
United States ◽  
Decision Making ◽  
Health Plan ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
The United States ◽  
Trial Registration ◽  
Prior Authorization ◽  
Step Therapy ◽  
Effective Use

Abstract Background: Prior authorization (PA) of medications is widely used by payers in the United States as a way to promote safe and effective use of medications and to control costs. However, PA-related tasks such as completing forms, submitting forms, researching medical history and submitting required documentation can all contribute to burden on healthcare providers. This study examines how such tasks and affect provider burden and treatment decisions. Methods: We developed and administered a nationwide, cross-sectional online survey of medical providers in the United States in 2020 based on a convenience sample of 100,000 providers (physicians, nurse practitioners, and physician assistants). Path analysis was used to test the associations between provider practice characteristics, step therapy and other health plan requirements, perceived burdens of PA, and communication issues with insurers on prescribing behaviors, which included prescribing a different medication, avoiding prescribing of newer medications, and modifying a diagnosis. Weighted analyses were also conducted to account for sample bias due to non-response. Results: A total of 1173 providers (1.2% response rate) provided 1147 usable surveys. The sample was 49.6% female, and a majority were MD/DO providers (85%). Step therapy requirements had the largest influence on prescribing a different medication than planned (b = .22, 95% CI = .160-.285) and avoiding prescribing a newer medication despite meeting evidence-based guidelines (b = .24, 95% CI = .181-.309). A unit-weighted index of perceived PA burden risk was associated with prescribing a different medication (b = .09, 95% CI = .012-.128) and modifying a diagnosis to obtain PA approval (b = .14, 95% CI = .065-.195). Communication issues were associated with prescribing a different medication (b = .11, 95% CI = .029-.186), while health plan requirements (e.g., clinical documentation) was significantly associated with all three prescribing outcomes. Weighted analyses showed that the study conclusions were unlikely to have been biased by nonresponse. Conclusions: Providers report altering prescribing and modifying diagnoses to avoid PA requirements and related burdens. Processes that reduce the administrative burden of PA through improved communication and transparency as well as standardized documentation may help ensure that PA more seamlessly achieves its goals of safe and effective use of medications. Trial Registration: NA Keywords: clinical decision making, health plan, prior authorization, provider burden, specialty types, workaroundsTrial Registration: NA

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