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Importance: Initial approval for immune checkpoint inhibitors (ICIs) for treatment of advanced non-small cell lung cancer (NSCLC) was limited to patients with high levels of programmed cell death ligand 1 (PD-L1) expression. However, in the period after approval, it is not known how new evidence supporting efficacy of these treatments in patients with low or negative PD-L1 expression was incorporated into real-world practice., Objective: To evaluate the association between PD-L1 testing and first-line ICI use., Design, Setting, and Participants: This retrospective cohort study (January 1, 2011, to December 31, 2018) used a deidentified nationwide electronic health record-derived database reflecting real-world care at more than 280 US community and academic cancer clinics (approximately 800 sites of care). Patients included those with advanced NSCLC without other identifiable variations diagnosed in the period after the US Food and Drug Administration's initial first-line approval of ICIs for patients with high PD-L1 expression (≥50%)., Exposure: First-line ICI treatment., Main Outcomes and Measures: Patterns of PD-L1 testing and first-line ICI treatment among all patients and patients stratified by tumor histologic type (squamous vs nonsquamous)., Results: A total of 45 631 patients (mean [SD] age, 68.4 [9.6] years; 21 614 [47.4%] female) with advanced NSCLC were included in the study. PD-L1 testing increased from 468 (7.2%) in 2015 to 4202 (73.2%) in 2018. Within a subset of 7785 patients receiving first-line treatment in the period after first-line approval of pembrolizumab, those who received PD-L1 testing had a greater odds of receiving an ICI (odds ratio, 2.11; 95% CI, 1.89-2.36). Among patients with high PD-L1 expression (≥50%), 1541 (83.5%) received first-line ICI treatment; 776 patients (40.3%) with low PD-L1 expression (1%-49%) and 348 (32.3%) with negative PD-L1 expression (0%) also received ICIs. In addition, 755 untested patients (32.8%) were treated with a first-line ICI. The proportion of patients who received ICIs without PD-L1 testing increased during the study period (59 [17%] in quarter 4 of 2016 to 141 [53.8%] in quarter 4 of 2018)., Conclusions and Relevance: In this study, use of first-line ICI treatment increased among patients with advanced NSCLC with negative, low, or untested PD-L1 expression status in 2016 through 2018. These findings suggest that national practice was rapidly responsive to new clinical evidence rather than adhering to regulatory guidance in place at the time.

Purpose: Electronic health records have changed providers' workflow. Epic's InBasket supplants traditional communication and is a central hub for clinical information. Failure to promptly complete records impairs communication and revenue collection. By tracking providers' InBasket activities and offering feedback, we hoped to improve InBasket management and interdisciplinary communication., Methods: We created a report to track 273 providers' InBasket activities, including ambulatory transcriptions, chart cosignatures, order cosignatures, patient calls, results, and billable encounters. The report showed how often and for how long each activity was delinquent. We completed three Plan-Do-Study-Act cycles. During cycle 1 (November to December 2015), we sent all providers automated e-mails with their monthly results. During cycle 2 (January to April 2016), we focused solely on billable encounter closure and sent targeted e-mails to providers with > 50 delinquent encounters. The e-mails stated that providers had 30 days to complete encounters or their practices would be closed to new patients; at 30 days, noncompliant providers had 60 days before practice suspension. During cycle 3 (May to September 2016), we continued to monitor and send targeted e-mails to providers who accumulated > 50 encounters. We modeled the financial impact of the intervention using net closure data, the report's aging function, and billing logs., Results: InBasket monitoring with structured feedback decreased open encounters by 53.43%. We did not see improvements in the other metrics that the report tracked. We estimate that $231,724 was saved as a result of the intervention and $349,179 was lost to filing deadlines., Conclusion: Automated e-mails did not reduce open encounters; targeted e-mails to providers improved InBasket management.

Purpose: The 21-gene recurrence score (RS) assay is used to help formulate adjuvant chemotherapy recommendations for patients with estrogen receptor-positive, early-stage breast cancer. Most frequently, medical oncologists order RS after surgery. Results take an additional 2 weeks to return, which can delay decision making. We conducted a prospective quality-improvement project to assess the impact of early guideline-directed RS ordering by surgeons before the first visit with a medical oncologist on adjuvant therapy decision making., Materials and Methods: Surgical oncologists ordered RS testing following National Comprehensive Cancer Network guidelines at time of diagnosis or at time of surgery between July 1, 2015 and December 31, 2015. We measured the testing rate of patients eligible for RS, time to chemotherapy decisions, rates of chemotherapy use, accrual to RS-based clinical trials, cost, and physician acceptance of the policy and compared the results to patients who met eligibility criteria for early guideline-directed testing during the 6 months before the project., Results: Ninety patients met eligibility criteria during the testing period. RS was ordered for 91% of patients in the early testing group compared with 76% of historical controls ( P < .001). Median time to chemotherapy decision was significantly shorter in the early testing group (20 days; 95% CI, 17 to 23 days) compared with historical controls (32 days; 95% CI, 29 to 35 days; P < .001). There were no significant differences in time to chemotherapy initiation, chemotherapy use, RS-based trial enrollment, or calculated costs between the groups., Conclusion: Early guideline-directed RS testing in selected patients is an effective way to shorten time to treatment decisions.

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population's cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

Purpose: The degree to which electronic health records (EHRs) enhance the quality of patient care depends on use of the system to monitor and improve practice. In planning the transition to Epic's Beacon electronic chemotherapy ordering platform, we saw an opportunity to measure our performance and increase evidence-based practice., Methods: Advanced planning began 2 years before implementation and included formation of a chemotherapy council charged with reviewing references and approving each chemotherapy protocol; a readiness assessment; design of electronic flow-sheet adherent with Oncology Nursing Society guidelines. To monitor use of evidence-based treatments, we created a novel quality metric: the rate of evidence-based adherence (REBA)., Results: A full infusion schedule was maintained through implementation, with a transient 1-month increase in wait time. Our overall REBA of 0.86 significantly exceeded our prespecified goal of 0.80 (P = .001). REBA varied from 0.50 to 0.95 between disease groups. Antiemetic use increased by 20% after Beacon implementation. Provider satisfaction at 8 months ranged from 76% to 80%., Conclusion: The transition to electronic chemotherapy ordering offers an institution the chance to develop evidence-based oncology practice, standardize supportive care, and enhance patient safety. The key elements that made our transition so successful were (1) extensive involvement of oncology leadership, (2) use of a chemotherapy council to enforce evidence-based practice, (3) ongoing collaboration between clinical operations and information technology. Finally, the REBA is a powerful tool to monitor adherence to evidence-based chemotherapy prescribing.