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Quality improvement (QI) initiatives and health services research (HSR) are commonly used to target health care quality. These disciplines are increasingly important because of the movement toward value-based health care as alternative payment and care delivery models drive institutions and investigators to focus on reducing unnecessary health care use and improving care coordination. QI efforts frequently target medical error and/or efficiency of care through the Plan-Do-Study-Act methodology. Within the QI framework, strategies for data display (e.g., Pareto charts, run charts, histograms, scatter plots) are leveraged to identify opportunities for intervention and improvement. HSR is a multidisciplinary field of study that seeks to identify the most effective way to organize, deliver, and finance health care to maximize the quality and value of care at both the individual and population levels. HSR uses a diverse set of quantitative and qualitative methodologies, such as case-control studies, cohort studies, randomized control trials, and semistructured interview/focus group evaluations. This manuscript provides examples of methodologic approaches for QI and HSR, discusses potential challenges associated with concurrent quality efforts, and identifies strategies to successfully leverage the strengths of each discipline in care delivery.

234 Background: Optimal prevention and safe management of febrile neutropenia (FN) in the outpatient setting, when clinically appropriate, can help to keep vulnerable patients from experiencing severe complications requiring hospitalization. Variation in the prevention and outpatient management of FN was identified as a quality and safety gap by Ontario clinicians. This initiative aimed to facilitate a standardized approach to prevention and outpatient management of FN through the development of practical, evidence-based health-care provider and patient resources. Methods: A clinical practice guideline was developed by a 15-member multidisciplinary Working Group (WG) consisting of physicians, pharmacists, nurses, and administrators who are knowledgeable in the areas of prevention and management of FN. The WG reviewed current relevant international guidelines and available literature on primary and secondary FN prophylaxis and FN management, with an emphasis on the optimal use of granulocyte colony-stimulating factor (G-CSF) and appropriate FN management in the outpatient setting. The 2016 Cancer Care Ontario recommendations on the use of G-CSF were used as a foundation for the prevention of FN content. Key clinical questions were identified by the WG, and content was approached with an Ontario-specific lens. Recommendations were developed using an iterative consensus-building process over six WG meetings. The guideline report was reviewed by external clinical experts who validated final content. Accompanying patient information was informed by health literacy best practices, existing symptom management resources, and input from patient education experts, patients, and caregivers. Results: A user-friendly clinical practice guideline was created. Definitions, risk factors, FN prophylaxis strategies based on risk/treatment intent, and appropriate outpatient management of FN are described. Key clinical questions are reviewed and a total of 25 evidence-informed consensus-based recommendations are presented. The guideline includes FN risk assessment and outpatient FN management algorithms, as well as summaries of available literature and WG discussion. The accompanying patient information explains what neutropenia and neutropenic fever are, lists potential symptoms, and describes management strategies in patient-friendly language. All resources are publicly available on the Ontario Health-Cancer Care Ontario website and have been disseminated broadly to relevant stakeholders via email, social media, and webinars. Conclusions: Review of current evidence and expertise from oncology and infectious disease clinicians resulted in an evidence-informed, consensus-based guideline. This clinical practice guideline and accompanying patient information resource can help to facilitate safe, standardized prevention and appropriate outpatient management of FN.

BACKGROUND: People with cancer are at risk for initial, late, and long-term effects of cancer and its treatments. Cancer rehabilitation (CR) focuses on prevention/treatment of these sequelae and optimization of physical, social, and vocational functioning. Our center has a multidisciplinary impairment-driven outpatient CR program, but referrals of patients with GI cancer were low. AIMS: We aimed (for 2019, relative to 2018) (1) to increase CR referrals of patients with GI cancer by 50% and (2) to increase the proportion of referrals coming from oncologists. Balancing measures included inappropriate referrals and cancellations. METHODS: A rapid cycle improvement approach was used to optimize GI referrals to the CR program. Barriers to CR referral were identified through a literature review and informal interviews of GI clinicians. Barriers included (a) knowledge of CR program existence, (b) awareness of the referral process, (c) time, and (d) lack of CR program exposure. The team used Plan-Do-Study-Act (PDSA) cycles every 2 months from January to December 2019 to address barriers. A p-chart was used to analyze the results. RESULTS: PDSA cycles included CR program advertisement, a presentation to GI staff, nurse-led patient identification, patient-facing posters, and clinician thank-you emails. The p-chart showed a 100% relative increase in referral numbers and an improvement in the percentage of patients referred by oncologists from 51% to 75%. There was no significant change in inappropriate referrals or cancellations. CONCLUSION: Through PDSA cycles, we improved the total number of patients with GI cancer and percentage referred by an oncologist to a CR program. Future work will assess sustainability.

Although medical products that are of sound quality are fundamental to the delivery of healthcare, so too is their availability, affordability, accessibility and acceptability. However, achieving all of these aims consistently and simultaneously may be unfeasible due to a host of barriers—no matter the country. If uncertainty, constraints and conflicting priorities also threaten their delivery, not only does the situation becomes yet more challenging, the morally just course of action becomes yet more opaque. While global health organisations, supply chains and projects are heterogenous, international non-governmental organisations (iNGOs) responding to humanitarian crises or delivering development assistance in low-income and middle-income countries are undoubtedly prone to this issue. In a novel framing of the problem of substandard and falsified medicines, this article explores some ethical dilemmas that, directly or indirectly, could result in the quality of medical products in iNGO health projects to be compromised. Drawing on a broad literature base and years of experience as a senior humanitarian pharmacist, the author reflects on the barriers, culture and system that contributes to the existence and persistence of substandard and falsified medical products in global assistance projects. The paper offers an in-depth examination of pressures that may arise in four key areas (capacity, supply chain, bureaucracy and quality assurance) and postulates on the myriad ways in which this may alter the attitudes, behaviours and decision-making of iNGOs in a manner that disincentivises the prioritisation of medical product quality. This paper does not seek to excoriate the aid sector, but rather to lend a new perspective: that such predicaments are overlooked, real-world ethical dilemmas in urgent need of greater openness, research, debate and guidance, for the benefit of moral decision-making and patient care.

Dust from Saharan Africa commonly blows across the Atlantic Ocean and into the Caribbean. Most methods for measuring this dust either are expensive if collected directly from the atmosphere, or depend on very small concentrations that may be chemically altered if collected from soil. Tank bromeliads in the dwarf forest of El Yunque National Forest, Puerto Rico, have a structure of overlapping leaves used to capture rainwater and other atmospheric inputs. Therefore, it is likely that these bromeliads are collecting in their tanks Saharan dust along with local inputs. Here we analyze the elemental chemistry, including rare earth elements (REEs), of tank contents in order to match their chemical fingerprint to a provenance of the Earth's crust. We find that the tank contents differ from the local soils and bedrock and are more similar to published values of Saharan dust. Our study confirms the feasibility of using bromeliad tanks to trace Saharan dust in the Caribbean.

ObjectiveTo evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer.DesignPragmatic, cluster randomised trial.Setting20 cancer centres in Ontario, Canada, allocated by covariate constrained randomisation to remote management of toxicities or routine care.ParticipantsAll patients starting adjuvant or neoadjuvant chemotherapy for early stage breast cancer at each centre. 25 patients from each centre completed patient reported outcome questionnaires.InterventionsProactive, standardised, nurse led telephone management of common toxicities at two time points after each chemotherapy cycle.Main outcome measuresThe primary outcome, cluster level mean number of visits to the emergency department or admissions to hospital per patient during the whole course of chemotherapy treatment, was evaluated with routinely available administrative healthcare data. Secondary patient reported outcomes included toxicity, self-efficacy, and quality of life.ResultsBaseline characteristics of participants were similar in the intervention (n=944) and control arms (n=1214); 22% were older than 65 years. Penetration (that is, the percentage of patients who received the intervention at each centre) was 50-86%. Mean number of visits to the emergency department or admissions to hospital per patient was 0.91 (standard deviation 0.28) in the intervention arm and 0.94 (0.40) in the control arm (P=0.94); 47% (1014 of 2158 patients) had at least one visit to the emergency department or a hospital admission during chemotherapy. Among 580 participants who completed the patient reported outcome questionnaires, at least one grade 3 toxicity was reported by 48% (134 of 278 patients) in the intervention arm and by 58% (163 of 283) in the control arm. No differences in self-efficacy, anxiety, or depression were found. Compared with baseline, the functional assessment of cancer therapy trial outcome index decreased by 6.1 and 9.0 points in the intervention and control participants, respectively.ConclusionsProactive, telephone based management of toxicities during chemotherapy did not result in fewer visits to the emergency department or hospital admissions. With the rapid rise in remote care because of the covid-19 pandemic, identifying scalable strategies for remote management of patients during cancer treatment is particularly relevant.Trial registrationClinicalTrials.govNCT02485678.

Purpose Routine evaluation of quality measures (QMs) can drive improvement in cancer systems by highlighting gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact at the population level. We developed an approach that uses both variation in performance and number of patients affected by the QM to set priorities for improving the quality of systemic therapy for women with early-stage breast cancer (EBC). Patients and Methods Patients with EBC diagnosed from 2006 to 2010 in Ontario, Canada, were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. Individual QMs within a panel of 15 QMs previously developed to assess the quality of systemic therapy across four domains (access, treatment delivery, toxicity, and safety) were ranked on interinstitutional variation in performance (using interquartile range) and the number of patients who were affected; then the two rankings were averaged for a summative priority ranking. Results We identified 28,427 patients with EBC who were treated at 84 institutions. The use of computerized physician electronic order entry for chemotherapy, emergency room visits or hospitalizations during chemotherapy, and timely receipt of chemotherapy were identified as the QMs that had the largest potential to improve quality of care at a system level within this cohort. Conclusion A simple ranking system based on interinstitutional variation in performance and patient volume can be used to identify high-priority areas for quality improvement from a population perspective. This approach is generalizable to other health care systems that use QMs to drive improvement.

BACKGROUND Setting realistic targets for performance is a consistent challenge in quality improvement. In the current study, the authors used administrative data to define achievable targets for a panel of 15 previously developed quality indicators (QIs) focusing on systemic therapy in patients with early-stage breast cancer. METHODS Deterministically linked administrative databases were used to identify patients with TNM stage I to stage III breast cancer who were diagnosed between 2006 and 2010 in Ontario, Canada. For each individual indicator, data-driven empirical benchmarks were calculated using the pared-mean benchmark approach. Variation in institution-level performance for each indicator was examined through the construction of funnel plots. RESULTS A total of 28,303 patients with early-stage breast cancer were identified, 43% of whom received adjuvant chemotherapy. For the 9 QIs for which receiving the service or outcome was desirable (ie, consultation with a medical oncologist), the benchmark varied from 40.9% to 100%. For the 6 indicators for which not receiving the service or outcome was desirable (ie, incidence of febrile neutropenia), the benchmark varied from 0% to 49.0%. There was substantial variation noted with regard to the number of institutions meeting the target and the amount of interinstitution variation between the QIs. Top performing institutions varied by indicator, with no individual institution meeting the benchmark for all indicators. For the majority of indicators, institution size was not found to be correlated with performance. CONCLUSIONS Data-derived benchmarking can be used to facilitate quality improvement by identifying areas of both good as well as suboptimal performance while defining an achievable target for which to strive. Cancer 2017. © 2017 American Cancer Society.

We used administrative health data to explore the impact of primary care physician (pcp) visits on acute-care service utilization by women receiving adjuvant chemotherapy for early-stage breast cancer (ebc). Our population-based retrospective cohort study examined pcp visits and acute-care use [defined as an emergency room (er) visit or hospitalization] by women diagnosed with ebc between 2007 and 2009 and treated with adjuvant chemotherapy. Multivariate regression analysis was used to identify the effect of pcp visits on the likelihood of experiencing an acute-care visit. Patients receiving chemotherapy visited a pcp significantly more frequently than they had before their diagnosis [relative risk (rr): 1.48, 95% confidence interval (ci): 1.44 to 1.53, p < 0.001] and significantly more frequently than control subjects without cancer (rr: 1.51, 95% ci: 1.46 to 1.57, p < 0.001). More than one third of pcp visits by chemotherapy patients were related to breast cancer or chemotherapy-related side effects. In adjusted multivariate analyses, the likelihood of experiencing an er visit or hospitalization increased in the days immediately after a pcp visit (rr: 1.92, 95% ci: 1.76 to 2.10, p < 0.001). During chemotherapy treatment, patients visited their pcp more frequently than control subjects did, and they visited for reasons related to their breast cancer or to chemotherapy-related side effects. Visits to a pcp by patients receiving chemotherapy were associated with an increased frequency of er visits or hospitalizations in the days immediately after the pcp visit. Those results suggest an opportunity to institute measures for early detection and intervention in chemotherapy side effects.

Background Population-based studies suggest that emergency department visits and hospitalizations are common among patients receiving chemotherapy and that rates in routine practice are higher than expected from clinical trials. Chemotherapy-related toxicities are often predictable and, consequently, acute care visits may be preventable with adequate treatment planning and support between visits to the cancer centre. We will evaluate the impact of proactive telephone-based toxicity management on emergency department visits and hospitalizations in women with early stage breast cancer receiving chemotherapy. Methods In this pragmatic covariate constraint-based cluster randomized trial, 20 centres in Ontario, Canada are randomly allocated to either proactive telephone toxicity management (intervention) or routine care (control). The primary outcome is the cluster-level mean number of ED + H visits per patient evaluated using Ontario administrative healthcare data. Participants are all patients with early stage (I-III) breast cancer commencing adjuvant or neo-adjuvant chemotherapy at participating institutions during the intervention period. At least 25 patients at each centre participate in a patient reported outcomes sub-study involving the collection of standardized questionnaires to measure: severity of treatment toxicities, self-care, self-efficacy, quality of life, and coordination of care. Patients participating in the patient reported outcomes (PRO) sub-study are asked to provide written consent to link their PRO data to administrative data. Unit costs will be applied to each per person resource utilized, and a total cost per population and patient will be generated. An incremental cost-effectiveness analysis will be undertaken to compare the incremental costs and outcomes between the intervention and control groups from the health system perspective. Discussion This study evaluates the effectiveness of a proactive toxicity management intervention in a routine care setting. The use of administrative healthcare data to evaluate the primary outcome enables an evaluation in a real world setting and at a much larger scale than previous studies. Trial registration Clinicaltrials.gov, NCT02485678. Registered 30 June 2015. Electronic supplementary material The online version of this article (10.1186/s12885-019-6099-x) contains supplementary material, which is available to authorized users.

Purpose: We aimed to improve the time to antibiotics (TTA) for patients treated with chemotherapy who present to the emergency department (ED) with febrile neutropenia (FN) by using standardized fever advisory cards (FACs). Methods: Patients treated with chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada, with suspected FN were identified, before (April 2012 to March 2013) and after (October 2013 to March 2014) FAC implementation. The primary outcome of interest was TTA. Additional process measures included Canadian Triage and Acuity Scale score, time to physician assessment, and FAC compliance. Outcomes were analyzed with descriptive statistics and control charts to determine whether the change in primary measures were within statistical control over time. Results: Between the pre-FAC cohort (n = 239) and post-FAC cohort (n = 69), TTA did not change significantly post-FACs (195 v 244 min, P = .09), with monthly averages demonstrating normal variation by statistical process control methodology. The introduction of FACs increased the percentage of patients with correctly assigned Canadian Triage and Acuity Scale scores (87% v 100%) but did not affect time to physician assessment. Compliance with FACs among patients was not ideal, with only 62.5% using them as intended. Conclusion: The distribution of FACs was associated with an improved incidence of correct FN triaging but did not demonstrate a meaningful improvement in the quality of FN management. This may be explained by FAC use among patients not being ideal. Next steps in the continued effort toward high-quality FN care include redesign of FACs, reinforcement of provider and patient education, and ED outreach.

21 Background: Cancer prevalence is rising and there is a corresponding increase in hospitalizations across the cancer continuum. However, little is known about the patterns of care and outcomes of cancer inpatients as administrative data may not capture in-hospital details including investigations and medications required for characterization. Understanding how cancer inpatients are managed and their outcomes can help to optimize care delivery. Methods: We conducted a multicenter study of all patients admitted to GIM at seven hospitals (Toronto, Canada) from 2010 to 2017 where we deterministically linked administrative data with each hospital’s electronic information (pharmacy, orders, notes, laboratory/imaging and results) at the patient level. Multivariable regression models compared characteristics and outcomes between cancer and non-cancer patients for the top 5 non-cancer patient discharge diagnoses. Results: Among 230,040 hospitalizations, 15% had cancer listed as an ICD-10 comorbidity. The most common cancer disease sites were gastrointestinal (20%), lung (13%) and leukemia (11%). The most common discharge diagnoses for cancer patients were disease progression (9%), palliative care (6%), pneumonia (4%), leukemia (4%) and lung cancer (4%), while for non-cancer patients were: heart failure (5%), pneumonia (5%), stroke (5%), COPD (5%) and urinary tract infections (5%). In general, compared to non-cancer patients, cancer patients were younger (70 vs 72), had greater length of stay (LOS; 6.4 vs 4.6 days), in-hospital mortality (16% vs 5%), ICU use (12% vs 11%), 30 day re-admission rate (17% vs 10%) and were more likely to receive CTs (64% vs 52%), MRIs (14% vs 12%) and interventional procedures (22% vs 8%) (p < 0.001, all comparisons). When evaluating the top 5 non-cancer patient discharge diagnoses, results (adjusted for age, gender, Charlson comorbidity score and hospital) were similar wherein cancer patients had a higher in-hospital mortality (aOR = 2.02 p < 0.001), 30 day re-admission rate (aOR = 1.09 p = 0.08) and were more likely to receive CTs (aOR = 1.88 p < 0.001), MRIs (aOR = 1.66 p < 0.001) or interventional procedures (aOR = 1.78 p < 0.001), despite similar mean LOS (5.7 vs 5.1 days p = 0.35). Results were similar across discharge diagnoses. Conclusions: Cancer patients represent a unique population on GIM and have higher resource use, mortality and LOS compared to non-cancer patients, with similar trends even for the same non-cancer diagnoses. Specialized models of care for hospitalized cancer patients may be warranted.

184 Background: Oral systemic therapy (ST) presents unique care delivery challenges. Gaps in patient education and monitoring for patients on oral ST delivery are well documented and can result in decreased adherence or increased toxicity. Within Ontario, cancer care is provincially coordinated through Ontario Health- Cancer Care Ontario (OH-CCO), but locally implemented by 14 Regional Cancer Programs (RCPs). Using a centrally coordinated, but regionally implemented quality improvement (QI) approach, we aimed to improve the quality of oral ST delivery across Ontario by enabling the use of patient specific monitoring plans to optimize treatment adherence and toxicity management. Methods: Between 2018 and 2020 a 2 year focused QI project was undertaken. A suite of 19 quality measures were developed to measure different quality domains for oral ST delivery including treatment plan documentation, patient education, toxicity/adherence monitoring and toxicity outcomes. In year 1, all regions used the suite of quality measures to establish baseline performance and develop a QI plan using rapid cycle improvement methodology to improve performance in at least 1 domain based on regional gaps and priorities. Projects were implemented and evaluated during year 2. OH-CCO provided QI coaching through dissemination of standardized QI tools, a monthly discussion forum and project specific feedback. At the end of year 2, a post-implementation evaluation was performed for each region. Results: 15 centers participated, representing all RCPs across Ontario. The participating centers implemented QI projects focused on treatment plan documentation (N = 3), patient education (N = 10) and toxicity/adherence management (N = 5), with some focusing on multiple domains. All centers reported an improvement in at least 1 domain (see Table). Key enablers identified include engagement with a multi-disciplinary team and the use of technology, while barriers include lack of onsite dispensing pharmacy. Future work will continue to focus on quality of oral ST delivery and better pharmacy integration. Conclusions: Through a centrally coordinated, locally implemented QI project, improvement in quality of oral ST care was achieved across Ontario. This model of QI focus has the potential to be adaptable across health systems. [Table: see text]

Background: Overuse of surveillance imaging in patients after curative treatment for early breast cancer (EBC) was recently identified as one of the Choosing Wisely Canada initiatives to improve the quality of cancer care. We undertook a population-level examination of imaging practices in Ontario as they existed before the launch of that initiative. Methods: Patients diagnosed with ebc between 2006 and 2010 in Ontario were identified from the Ontario Cancer Registry. Records were linked deterministically to provincial health care databases to obtain comprehensive follow-up. We identified all advanced imaging exams [aies: computed tomography (CT), bone scan, positron-emission tomography] and basic imaging exams (bies: ultrasonography, chest radiography) occurring within the first 2 years after curative treatment. Poisson regression was used to assess associations between patient or provider characteristics and the rate of AIES. Results: Of 30,006 women with ebc, 58.6% received at least 1 BIE, and 30.6% received at least 1 AIE in year 1 after treatment. In year 2, 52.7% received at least 1 BIE, and 25.7% received at least 1 AIE. The most common AIES were chest CTS and bone scans. The rate of AIES increased with older age, higher disease stage, comorbidity, chemotherapy exposure, and prior staging investigations (p < 0.001). Imaging was ordered mainly by medical oncologists (38%), followed by primary care physicians (23%), surgeons (13%), and emergency room physicians (7%). Conclusions: Despite recommendations against its use, imaging is common in EBC survivors. Understanding the factors associated with aie use helps to identify areas for further research and is required to lower imaging rates and to improve survivorship care.

Purpose: There is increasing interest in using administrative data to examine treatment-related complications that lead to emergency department (ED) visits or hospitalizations (H). The purpose of this study was to evaluate the reliability of billing codes for identifying chemotherapy-related acute care visits (CRVs) among women with early-stage breast cancer. Materials and Methods: The cohort was identified by using deterministically linked health databases and consisted of women who were diagnosed with early-stage breast cancer who started adjuvant chemotherapy between 2007 and 2009 in Ontario, Canada. A random sample of 496 patient cases was chosen as the validation cohort. Sensitivity (SN) and specificity (SP) were calculated for three scenarios: chemotherapy-related ED visit, chemotherapy-related H, and febrile neutropenia (FN)–related visit. For FN-related visits, three definitions were considered: general, moderate, and strict. Results: The administrative cohort consisted of 8,359 patients, 43.4% of whom had at least one ED or H, including 1,496 women who had multiple visits that resulted in 6,293 unique visits. Of these, 73.1% were considered CRVs. The algorithm performed well in identifying CRVs that included H either from ED (SN, 90%; SP, 100%) or directly from home (SN, 91%; SP, 93%), but less well for ED visits that did not result in H (SN, 65%; SP, 80%). Depending on which FN algorithm was used, 4.8% to 24% of visits were considered related. The moderate FN algorithm provided the best tradeoff between SN (69% to 97%) and SP (83% to 98%). Conclusion: Administrative data can be valuable in evaluating chemotherapy-related serious events. Algorithm validation in other cohorts is needed.

The purpose of this study was to evaluate the efficacy of platinum-based chemotherapy (PBC) versus conventional non-PBC regimens in a metastatic triple-negative breast cancer (TNBC) setting. We reviewed the electronic patient records of patients with confirmed metastatic TNBC at four major cancer centres in Canada. All patients were allocated into two groups based on type of chemotherapy received (PBC vs. non-PBC) and line of treatment (first-, second-, or third-line). The primary objective of this study was to evaluate the efficacy of PBC in metastatic TNBC in terms of median duration of overall survival (OS) from diagnosis of distant metastatic disease and compare it with the efficacy of conventional non-platinum-based chemotherapy in metastatic TNBC after controlling for known prognostic factors. A total of 153 metastatic TNBC patients were identified, 58 treated with PBC and 95 with non-PBC. The median time in first-line PBC versus non-PBC was not different between the two groups (2 vs. 2 months, p = 0.9), the median time on treatment in second and third-line therapy was longer for the PBC group compared to the conventional treated group (4 vs. 1 months, p = 0.004; 4 vs. 0.5 months, p = 0.004, respectively). Patients who received PBC had a longer OS compared to those managed conventionally (14.5 vs. 10 months, p = 0.041). This study evaluates the survival outcomes in a homogenous group of TNBC metastatic patients treated with or without PBC. Our results confirmed our hypothesis of a better OS among PBC-treated TNBC patients compared to conventionally managed TNBC patients. Currently ongoing Phase III trials assessing the benefit of PBC versus other chemotherapeutic regimens in advanced TNBC will help define the role of these agents for the management of this breast cancer subtype.

255 Background: Cancer medication-related infusion reactions (CMIRs) can lead to treatment delays, switching to less optimal therapy, or discontinuation. Variation in the prevention, management and reporting of CMIRs was identified as a quality and safety gap by Ontario clinicians. This initiative aimed to facilitate a standardized approach to CMIRs in Ontario through the development of user-friendly health-care provider and patient resources. Methods: A multidisciplinary working group of 15 oncology clinicians (oncologists, pharmacists, nurses, administrators) with experience in the management of CMIRs reviewed available literature on CMIR assessment, prevention and management. Recommendations were based on best available evidence and group consensus when only low-level evidence was available. Final guideline content was reviewed and validated by external experts. Complementary patient information was created based on best practices in health literacy and input from patient education experts, patients and caregivers. A mechanism for system-wide reporting to track CMIRs was explored. Results: A CMIR clinical practice guideline was created. Definitions, risk factors, prophylaxis strategies, an acute management algorithm and desensitization protocols are described. A CMIR severity grading system was proposed. A toolkit was developed and contains a table outlining risk factors, mechanism, incidence, symptoms, onset, prophylaxis, acute management and re-challenge by specific drug and a tool for calculating a three-bag 12-step desensitization. Patient-friendly information was also created. A new data element for collection of CMIR incidence and severity was added to the provincial Activity Level Reporting (ALR) data set to track CMIR trends. Conclusions: A review of current evidence and expertise from oncology clinicians resulted in an evidence-informed, consensus-based guideline. This guideline and the accompanying resources can help to facilitate safe and standardized prevention and management of CMIRs across Ontario. The collection of system-wide CMIR data based on the proposed grading system will inform future quality and safety improvement initiatives.

Background: Cancer patients receiving chemotherapy have high symptom needs that can negatively impact quality of life and result in high rates of unplanned acute care visits. Remote monitoring tools may improve symptom management in this patient population. Objective: This study aimed to design a prototype tool to facilitate remote management of chemotherapy-related toxicities. Methods: User needs were assessed using a participatory, user-centered design methodology that included field observation, interviews, and focus groups, and then analyzed using affinity diagramming. Participants included oncology patients, caregivers, and health care providers (HCPs) including medical oncologists, oncology nurses, primary care physicians, and pharmacists in Ontario, Canada. Overarching themes informed development of a Web-based prototype, which was further refined over 2 rounds of usability testing with end users. Results: Overarching themes were derived from needs assessments, which included 14 patients, 1 caregiver, and 12 HCPs. Themes common to both patients and HCPs included gaps and barriers in current systems, need for decision aids, improved communication and options in care delivery, secure access to credible and timely information, and integration into existing systems. In addition, patients identified missed opportunities, care not meeting their needs, feeling overwhelmed and anxious, and wanting to be more empowered. HCPs identified accountability for patient management as an issue. These themes informed development of a Web-based prototype (bridges), which included toxicity tracking, self-management advice, and HCP communication functionalities. Usability testing with 11 patients and 11 HCPs was generally positive; however, identified challenges included tool integration into existing workflows, need for standardized toxicity self-management advice, issues of privacy and consent, and patient-tailored information. Conclusions: Web-based tools integrating just-in-time self-management advice and HCP support into routine care may address gaps in systems for managing chemotherapy-related toxicities. Attention to the integration of new electronic tools into self-care by patients and practice was a strong theme for both patients and HCP participants and is a key issue that needs to be addressed for wide-scale adoption.

Safe administration of oral chemotherapy is a complex process that represents a potential threat to patient safety. Clear documentation of the plan of care for patients receiving oral chemotherapy can improve patient safety by ensuring complete health information is available to the health care team.We undertook a rapid-cycle improvement project to improve documentation of oral chemotherapy by increasing the number of components of an oral chemotherapy care plan (as outlined by American Society of Clinical Oncology and Oncology Nursing Society) documented in the medical record before starting a new oral chemotherapy drug. Three improvement cycles were implemented, including: introduction of a standardized nursing flow sheet, use of computerized physician order entry for oral chemotherapy prescribing, and a review of computerized physician order entry to ensure all oral chemotherapy regimens were included.Our intervention resulted in a meaningful and sustained improvement in the number of components of oral chemotherapy care plans documented in the medical record, from a mean of 67% (eight of 12 components) to a mean of 92% (11 of 12).We are hopeful that this improvement project will enhance patient safety by improving communication within the health care team regarding the details of the chemotherapy care plan.

Background: There is increasing evidence that DNA repair defects characteristic of BRCA1-related cancers and triple negative breast cancer (TNBC) confer sensitivity to certain chemotherapeutic agents, such as platinums. However, prospective and retrospective studies comparing the efficacy of these agents versus conventional treatment in TNBC are lacking. The aim of this study was to evaluate the efficacy of platinum-based chemotherapy (PBC) in metastatic TNBC in terms of median duration of treatment and overall-survival (OS) and compare it to patients treated with conventional chemotherapy. Methods: We performed a retrospective chart review of patients with metastatic TNBC who received PBC from January 2007 to June 2010 treated at the Sunnybrook Odette Cancer Center and the Ottawa Hospital Cancer Centre. This cohort was compared to a control group that included metastatic TNBC treated with conventional agents that included anthracyclines, taxanes, capecitabine, and vinorelbine. Results: A total of 166 metastatic TNBC patients were analyzed: 60 treated with PBC and 106 managed with conventional treatment. Median age at diagnosis was 48 years and distant disease-free interval was 26 months (m) for both groups. Patients on both groups had multiple sites of metastases at diagnosis of recurrence than a single site of metastasis (69% for both groups). Of the 60 patients treated with PBC, 90% received a combination regimen, most commonly weekly cisplatin plus gemcitabine in 37% of patients and cisplatin plus vinorelbine in 17% of patients. The median number of cycles delivered was 4 (1-24). 33% received the PBC as first-line treatment, 38% as second-line, 18% as third-line, 7% as fourth line, and 3% as fifth-line. Only 8 patients (5%) discontinued PBC secondary to toxicity. The median time on treatment in first, second and third-line therapy was longer for the PBC group compared to the conventional group (5 vs. 2 m, p=0.108; 5 vs. 2 m, p=0.01; and 4 vs. 1 m, p=0.026). Patients treated with PBC had a longer OS compared to those managed conventionally (16 vs. 10 m, p=0.039). Conclusions: PBC appears to improve clinical outcomes in patients with metastatic TNBC compared to those treated with conventional chemotherapy regimens. Although this is a retrospective study with its obvious limitations, it adds to the growing body of literature, suggesting the benefit of PBC in TNBC. Prospective trials are needed to confirm its benefit in order to integrate it as part of the routine management of these patients. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-19-14.

148 Background: Smoking cessation is integral to cancer care. Active smoking is associated with increased toxicity of treatment, poorer response to therapy and is associated with worse overall survival. Patients who quit smoking at diagnosis have better survival outcomes. Cancer Care Ontario has aimed to improve rates of smoking screening and referral to smoking cessation programs based on the validated Ottawa model. Methods: We aimed to implement an “opt-out” referral process for recent or current smokers to a smoking cessation program at the Credit Valley Hospital. We aimed to achieve a referral rate of 20%, based on an institutional baseline of 8.5% and a provincially defined target of 20%. Key stakeholders targeted included nursing, administration, physicians, smoking cessation counsellors and patients. Sequential education interventions were delivered to address gaps in patient and provider knowledge; these included grand rounds, an informal lecture and an educational pamphlet. Results: After the initiative was launched, the referral rate increased from 8.5% to 14.3%. The impact of each intervention is summarized in Table 1. Conclusions: Smoking cessation referrals increased with new process but not to target. Patient refusals lead to a low rate of referral, warranting efforts aimed at addressing patient barriers. Future outcome measures may include smoking cessation rates. [Table: see text]

233 Background: Trillium Health Partners (THP) is a large community oncology practice that has a culture of quality and safety. An investigation was triggered by a perceived increase in the rate of P-HSR during a weekly quality huddle in the chemotherapy suite. At the time THP had no formal hypersensitivity reaction tracking process. A retrospective review of P-HSR over the preceding 18 months identified an increase in reaction rates from a baseline of 1% to 4.5% that started 3 months prior to the raised concern. Methods: A systematic quality review was undertaken to identify triggers for the change and to identify steps to decrease P-HSR to baseline. There was no identified change in premedication, administration or compounding practice and no association with drug or lot number was identified. The increase in P-HSR was coincident with a change in the intravenous (IV) pumps and tubing system across the hospital. The change in IV pumps introduced several potential triggers including: a change in the options for priming the IV tubing which introduced a potential for variable concentrations of drug reaching the patient at the outset of the infusion, an interaction between drug and IV tubing, and a doubling of the IV tubing length which could result in incomplete delivery of the premedication. Results: Sequential practice changes were introduced to address each potential driver including i) a slow infusion protocol for first 2 cycles, ii) alternative tubing sets, iii) practice alert regarding potential for under-delivery of premedication. Over time P-HSR trended down towards the historic baseline, no single intervention had a sustained impact, although the practice alert regarding the administration of premedication seemed to induce the most change. A step wise withdrawal of interventions that were felt to be non impactful is underway. Conclusions: Although no clear cause for the increase in P-HSR was identified the systematic quality review resulted in improved standardization of nursing practice for chemotherapy delivery and the methodical approach also lead to the establishment of a more comprehensive hypersensitivity reporting system at THP.

To compare the quality of informed consent forms (ICF) for different trial phases, funding sources, oncology subspecialties, disease settings, and intervention modalities.ICF for prospectively conducted clinical trials were examined for their descriptions of benefits and risks, study alternatives, voluntary participation, and confidentiality. Readability was assessed with Flesch Reading Ease (FRE) score and Flesch-Kincaid Reading Grade Level.Among 262 evaluable trials, ICF contained an average of 3982 words, 379 sentences, and 10.5 pages. The mean FRE score and Reading Grade Level were 61.2 and 7.4, respectively. All ICF explicitly stated that the intervention was investigational. Only 2 (1%) promised direct personal benefits, 16 (6%) suggested the chance of cure or prolonged survival, and 89 (34%) indicated a potential for tumor response. Conversely, 239 (91%) mentioned the risk of serious harms, 217 (83%) admitted that some side effects could be unknown or unpredictable, and 126 (48%) reported hospitalization or death as a possibility. Alternatives to participation, right to withdraw from study, and data confidentiality were addressed in 242 (92%), 254 (97%), and 260 (99%) ICF, respectively. Hematology, industry-funded, metastatic, and systemic therapy trials were most likely to highlight major risks (P0.05). Readability was better in phase I trials and in studies, which were performed by medical oncologists, sponsored by governmental agencies, conducted in the metastatic setting, and involved systemic therapy (P0.05).ICF had acceptable readability and provided a realistic overview of the benefits and risks of clinical trials, but the potential for hospitalization or fatality was underreported.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in cancer survivors, with the risk increasing significantly with the presence of multiple cardiac risk factors (RF). The proportion of cancer survivors at elevated risk of CVD on the basis of multiple RF is unknown.The National Health and Nutrition Examination Survey (NHANES 1999-2006) was used to examine the proportion of cancer survivors with multiple RF (≥2RF) and those at high cardiac risk (≥4 RF) compared with matched controls. RF (hypertension, hypercholesterolemia, weight, exercise, smoking) were defined according to AHA/ACC.A total of 1,227 cancer survivors and 4,782 controls were identified. The majority of both cancer survivors and controls had multiple RF (91.5 vs. 89.9%) with a substantial proportion at high cardiac risk (35.2 vs. 32.6%). Compared to controls, survivors were more likely to be smokers (34.5 vs. 25.7%, p = 0.001), but less likely be overweight (67.2 vs. 72.0%, p = 0.02). There was no significant difference in the proportion with hypertension (30.6 vs. 30.8%), hypercholesterolemia (52.4 vs. 54.7%) or low exercise (75.6 vs. 73.0%). Among survivors, only age was associated with RF; with older survivors significantly more likely to have poor control than younger survivors (p = 0.005).The prevalence of multiple RF was similar but suboptimal among cancer survivors and controls. Cardiac RF control, particularly among older survivors, is an important area of focus for improvement in survivorship care.

Adjuvant chemotherapy is considered standard care for patients with lymph node (LN) -positive and high-risk LN-negative early breast cancer (EBC). Although chemotherapy-associated toxicities are documented in clinical trials, the impact of toxicities on emergency room (ER) visits and hospitalizations (ER + Hs) at a population level with contemporary chemotherapy is unknown. We undertook a population-based study of ER + Hs in patients with EBC receiving adjuvant chemotherapy compared with noncancer controls (NCCs).All patients diagnosed with EBC between January 2007 and December 2009 in Ontario, Canada, were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. All patients received ≥ one cycle of adjuvant chemotherapy. Patient cases of EBC (n = 8,359) were matched to NCCs (n = 8,359) on age, comorbidity, and geographic location. ER + Hs within 30 days of chemotherapy were identified. If the primary reason for the visit was a common chemotherapy toxicity, the visit was considered chemotherapy associated. All-cause and chemotherapy-associated visits were compared between patient cases and controls. Logistic regression models were used to identify covariates associated with ER + Hs.The proportion of patients with at least one ER + H was significantly higher in patients with EBC undergoing chemotherapy compared with NCCs (43.4% v 9.4%; P.001). Patients with EBC were also more likely to have multiple ER + Hs (17.9% v 2.4%; P.001). On multivariable analysis, comorbidity, receiving a regimen containing docetaxel, and certain geographic regions were associated with increased odds of ER + Hs.ER + Hs are common among patients with EBC receiving chemotherapy and significantly higher than among controls. This represents a potential opportunity for quality improvement.

The study by O’Neill et al adds to the growing number of population studies that have reportedhigh rates of emergency room visits and hospitalizations in patients with cancer treated with chemotherapy in both the curative and metastatic setting. In the study by O’Neill et al, 92% of patients receiving chemotherapy for advanced cancers had an unplanned hospitalization, a rate that was up to 1.9 times higher than the matched nonchemotherapy control group and much higher than would be expected from clinical trial reports. This not only raises a significant concern regarding quality of care of patients with advanced cancers but also has important implications for health care use at the end of life. The use of administrative databases to study chemotherapy toxicities is both powerful and limited. On the one side, administrative data reflect the real-world experience of patients being treated in nontrial settings. Patients on clinical trials represent a minority of all patients with cancer; they are usually younger, healthier, and have higher socioeconomic status than thegeneral cancerpopulationand therefore are less likely to experience serious toxicity of chemotherapy. The outcomes reported in large administrative database studies such as O’Neill et al are more informative of the expected outcomes of the majority of patients seen in daily practice and are important for patients, providers, and health systems to understand some of the risks and health-system implications of therapy. Such information is important for both individual decision making regarding therapy and to assist with health-system planning and quality improvement. However, administrative data contain limited clinical information, which can make it challenging to attribute negative outcomes (such as hospitalizations) to the chemotherapy as opposed to other unmeasured clinical confounders, such as performance status or symptom burden, or to understand how to prevent future events. In the study by O’Neill and colleagues, the matched patients receiving chemotherapy hadworse survival thanunmatchedpatients receiving chemotherapy and thus may reflect the sickest patients treated with chemotherapy. In an attempt to determine the role of chemotherapy in driving hospitalization rates in patients with cancer, studies have used various approaches and algorithms to define hospitalizations that are likely chemotherapy associated. In general, these algorithms have been generated to reflect the common toxicities of chemotherapy using clinical experience and consensus. Although the algorithms used in the literature in general reflect the same scope of toxicities, they each vary in the complement of diagnoses considered, and

e18269 Background: There is ongoing interest in leveraging administrative data to examine quality but methodological concerns persist. We evaluated the reliability of a previously established panel of administrative data derived quality measures for systemic treatment. Methods: The cohort consisted of women diagnosed with early stage (stage I-III) breast cancer (ESBC) in Ontario, Canada, in 2010. Performance on 11 quality indicators evaluated using deterministically linked healthcare administrative databases has been reported previously. Sensitivity and specificity were examined using the chart as the gold standard. Results: The administrative cohort consisted of 6,795 women with ESBC from which a validation cohort of 705 patients was randomly selected from among patients who underwent cancer surgery at one of five hospitals chosen to balance feasibility and institutional characteristics.Sensitivity and specificity varied by indicator (Table 1). Reliability of some indicators may have been affected by suboptimal chart documentation in instances where care spanned multiple settings or the medical record was fragmented, or where the number of eligible patients for that indicator was low. Conclusions: Administrative data can be used to evaluate quality of systemic cancer therapy but understanding the reliability characteristics of individual indicators is essential to inform their appropriate use and interpretation. [Table: see text]

208 Background: There is ongoing interest in leveraging administrative data to examine quality but methodological concerns persist. We evaluated the reliability of a previously established panel of administrative data derived quality measures for systemic cancer treatment. Methods: The study cohort consisted of women diagnosed with early stage (stage I-III) breast cancer (ESBC) in Ontario, Canada, in 2010. Performance on 11 quality indicators evaluated using deterministically linked healthcare administrative databases has been reported previously. The sensitivity and specificity of these 11 indicators were examined using the chart as the gold standard. Results: The administrative cohort consisted of 6,795 women with ESBC from which a validation cohort of 705 patients was randomly selected from among patients who underwent cancer surgery at one of five hospitals chosen to balance feasibility and institutional characteristics.Sensitivity and specificity varied by indicator (Table). Reliability of some indicators may have been affected by suboptimal chart documentation in instances where care spanned multiple settings or the medical record was fragmented, or where the number of eligible patients for that indicator was low. Conclusions: Administrative data can be used to evaluate quality of systemic cancer therapy but understanding the reliability characteristics of individual indicators is essential to inform their appropriate use and interpretation. [Table: see text]

6603Background: The overuse of imaging scans to detect recurrence in curatively treated EBC patients was recently identified as one of ASCO’s top five opportunities to improve the quality of cancer...

e21586Background: There is growing interest in leveraging technology to solve clinical problems in healthcare. Patients (pts) receiving chemotherapy have high symptom needs that can negatively impa...

299 Background: Routine evaluation of evidence informed quality measures (QM) can drive improvement in cancer systems by highlighting potential gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact on quality at a population level. We aimed to use variation in performance to set priorities for improving the quality of ST for women with EBC. Methods: EBC cases diagnosed 2006 – 2010 in Ontario, Canada were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. A panel of QMs, previously developed to be operationalized for administrative data, was applied to reflect the quality of ST. Each QM was evaluated in all patients who met the inclusion criteria for the individual measure. QMs were ranked based on institutional variation in performance using the mean absolute difference (MAD). Results: We identified 28,303 patients, treated at 84 institutions. The performance of each QM is listed in Table 1. Timely receipt of ST, febrile neutropenia (FN) secondary prophylaxis, emergency room visits or hospitalizations, receipt of hormonal therapy (HT) and the use of surveillance imaging represented the 5 QM that demonstrated the greatest variation. Conclusions: Considerable institutional-level variation highlights potentially actionable areas of improvement [Table: see text]

157 Background: Cancer drugs are associated with toxicities which can negatively impact patients’ (pts) quality of life, outcomes and increase acute care use (ACU). There is increasing interest in leveraging technology to solve clinical problems in healthcare. We hypothesized that an electronic tool (toxicity module) targeting management of chemotherapy toxicities could decrease ACU by facilitating more effective symptom management. Methods: Participatory design methodology consisting of end user needs assessment through ethnographic field study (shadowing and in-depth interviews) and focus groups was used to inform design of an interactive prototype toxicity module. Oncology pts and their caregivers, and health care providers (HCPs) including oncologists, oncology nurses and primary care providers were included in all stages of development. Contemporaneous notes were taken during ethnography while focus groups were also audio recorded. Thematic analysis through ideation sessions and time-of-day exercises allowed identification of overarching issues. Results: Eight pts and 8 HCPs participated in the ethnographic field study. Two focus groups, one with 7 pts, one with 4 HCPs were held. Most themes were common to both pts and HCPs; gaps and barriers in the current system, need for decision aids, improved HCP communication and options in care delivery, and access to credible information delivered in a timely, secure manner and integrated into existing systems. Additionally, pts further identified missed opportunities, care not meeting their needs, feeling overwhelmed and anxious and wanting to be more empowered; HCPs identified accountability as an issue. These themes informed development of a prototype for a web-based toxicity management tool, which has served the purpose of defining user needs for symptom tracking, self-management advice, and timely communication with an oncology provider. Iterative evaluation over 2 rounds of usability testing is currently underway. Conclusions: An electronic tool that integrates just-in-time self-management advice and oncology provider support into routine care may address some of the gaps identified in the current system for managing chemotherapy toxicity.

220 Background: Chemotherapy induced nausea and vomiting (CINV) remains one of the most feared treatment-related toxicities in cancer patients. CINV has been shown to decrease quality of life and to increase dose modifications and unplanned hospital visits. Cancer Care Ontario (CCO) and the American Society of Clinical Oncology (ASCO) updated their CINV guidelines in 2013. These changes included a reclassification of many regimens from moderate (MEC) to highly emetogenic (HEC) and a decrease in the duration of serotonin inhibitors (5HT3i). Uptake of the new guidelines at Trillium Health Partners has been slow. We aimed to improve CINV by increasing the percentage of patients who received guideline concordant anti-emetics with their first cycle of HEC/MEC chemotherapy. Methods: The first 25 patients started on MEC/HEC chemotherapy during 3 time periods (pre-guidelines, 6 months post guidelines, 1.5 years post guidelines) were identified. The primary measure of interest was the percentage of patients receiving MEC/HEC who were treated in concordance with the updated CINV guidelines. Secondary measures included the percentage of MEC/HEC patients who experienced grade 2+ CINV. The collected data was used with quality improvement techniques to guide the development of interventions to improve guideline concordance. Results: The concordance of anti-emetics on the day of chemotherapy improved over time, but post-chemotherapy concordance remained at 0% (table). The primary driver for concordance was the use of NK1inhibitors on chemotherapy day, and the duration of 5HT3i post-chemotherapy. Using quality improvement methodology, the highest impact intervention was identified as changing the default settings in the computerized order entry system (CPOE) to reflect the updated guidelines. These changes are currently in progress and a test of this change will be presented. Conclusions: Concordance with CINV guidelines improved over time resulting in lower CINV and less need for reactive CINV interventions. Further work to target duration of 5HT3i is ongoing. [Table: see text]

263 Background: Setting realistic targets for performance on quality indicators (QI) is a consistent challenge in quality improvement. The purpose of this study was to utilize administrative data to define achievable targets for QI in the early stage breast cancer (EBC) population in relation to systemic therapy (ST) delivery based on best performers. Methods: Deterministically linked administrative healthcare databases were used to identify EBC cases diagnosed 2006 – 2010 in Ontario, Canada. Panel of previously established QIs for systemic therapy was applied to patients who met eligibility criteria for the individual indicators. Institutions with less than 10 eligible patients for a specific indicator were excluded. An empiric benchmark was defined as the proportion of patients meeting the indicator from institutions accounting for the top decile of eligible patients. Results: We identified 28,303 EBC patients who received surgery of which 12,252 received adjuvant chemotherapy. Benchmark results are summarized in Table. Conclusions: Many institutions fell considerably below the benchmark. Further analysis of institution-level drivers of high quality care is required to help characterize high performing institutions. [Table: see text]

90 Background: Oral chemotherapy (OC) presents unique challenges to patient safety. In contrast with parenteral chemotherapy, patient education and comprehension are crucial to the safe administration of OC, appropriate toxicity interventions and patient adherence. At Trillium Health Partners we identified a lack of standardization to OC education and monitoring, that resulted in gaps in patient care. Using the American Society of Clinical Oncology/Oncology Nursing Society 2013 chemotherapy safety standards as guidance, we developed and piloted a multi-disciplinary oral chemotherapy care pathway (OCCP) to improve the approach to education and monitoring of patients newly started on OC. Methods: Patients newly started on OC between 03/15–06/15 were enrolled by 2 participating physicians representing a predominantly lung/GI practice. Baseline data was abstracted retrospectively in the 3 months prior to the pilot to reflect all study participants. The OCCP included in-person and telephone assessments by an oncology pharmacist and nurse over 2 cycles of OC. Pilot outcomes included pharmacy interventions, dose modification for toxicity, medication errors, the percent of prescriptions on computerized physician order entry (CPOE), adherence documentation and comprehension of treatment plan. Results: The pilot enrolled 20 patients and compared them against 21 baseline patients. During the pilot there were improvements in the percentage of patients who had pharmacy interventions, documentation of adherence and assessment of comprehension of the treatment plan as well as a reduction in dose modifications due to toxicity (Table 1). Conclusions: Use of a newly developed oral chemotherapy care pathway demonstrated both feasibility as well as improvements in a variety of key patient safety indicators. These results suggest that implementation of a standardized oral chemotherapy care pathway can feasibly improve patient safety outcomes. [Table: see text]

e17620 Background: Defining quality care is a particular challenge in older women with EBC given the under representation of these patients in clinical trials. In the absence of level one evidence,...

The use of bisphosphonates for the prevention of skeletal related events in women with bone metastases from breast cancer is well established. We undertook an evaluation of bisphosphonate use in clinical practice in three Canadian cancer centres. In addition we assessed whether or not physicians at these centres are following their local treatment guidelines and funding policies.Charts and electronic files of patients who had received either clodronate or pamidronate at any time between January 2000 and December 2001 at three Canadian cancer centres were retrospectively reviewed.There has been a marked improvement in the time between the diagnosis of bone metastases and the commencement of bisphosphonates from a median of 155 days in 1998 to 24 days in 2001. However, despite a local funding policy requiring that oral clodronate be the first bisphosphonate used, this was the case in only 67% of patients. In addition, despite one centre's guidelines recommending that bisphosphonates be stopped once the patient was progressing, 90% of their patients remained on bisphosphonates until they died.A considerable amount of effort is spent on the creation of "evidence based" treatment guidelines. Funding agencies develop policies based on these treatment guidelines, but often funding is more restrictive than the treatment guideline would suggest. It is clear from this review that physicians still appear to manage a substantial proportion of patients outside of funding policies, but within evidence based recommendations. Therefore, a need exists for either the creation of guidelines and policies that physicians will follow or the implementation of methods to ensure that restrictive policies are actually followed.

The use of both bisphosphonates and palliative radiotherapy for the prevention and treatment of skeletal complications in women with bone metastases from breast cancer is well established. We undertook an evaluation of palliative radiotherapy utilization rates in breast cancer patients who received bisphosphonates for the treatment of bone metastases in a major Canadian cancer center.Charts and electronic files of breast cancer patients with bone metastases who had received either clodronate or pamidronate at any time between January 2000 and December 2001 at our center were retrospectively reviewed. The utilization rates of palliative radiotherapy in these patients were examined.The percentage of patients receiving bisphosphonates for the treatment of bone metastases who also received palliative radiotherapy to bone remained relatively constant over our study period in the range of 70%. In patients commenced on bisphosphonates before 1998, 42.9% received palliative radiotherapy as initial therapy for bone metastases, whereas in 2001 only 27.8% of patients received palliative radiotherapy before commencing bisphosphonate therapy. There has been a marked improvement in the time between the diagnosis of bone metastases and the commencement of bisphosphonates from a median of 446 days before 1998 to 21 days in 2001. At the same time, there was also an improvement in time between diagnosis of bone metastases and initiation of palliative radiotherapy from a median of 265 days before 1998 to 49 days in 2001.Use of bisphosphonates has not reduced the utilization rates of palliative radiotherapy in breast cancer patients with bone metastases. There is a trend of initiating bisphosphonates before delivery of palliative radiotherapy. The latter was also delivered earlier in the course of bone metastases.

104 Background: ASCO's current guidelines for febrile neutropenia (FN) management support antibiotic administration within one hour of presentation to the emergency department (ED). Prompt initiation of antibiotic therapy is vital to decrease the likelihood of adverse outcomes. Many studies, however, have reported significant delays in antibiotic initiation with mean wait times far exceeding ASCO's guidelines. We aimed to assess the quality of FN management at a regional cancer centre ED. Methods: Patients undergoing chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada between 04/12 - 03/13 were identified using electronic medical records. Patients were excluded if there was no record of chemotherapy delivery within 30 days prior to ED visit. ICD-10 codes and chart data were used to identify patients who had presented for either fever or infection. The primary outcome measures were three major quality of health indicators; time to assessment by a physician, Canadian Triage and Acuity Scale (CTAS) score, and time to initiation of intravenous antibiotics. Results: In total 239 records were included in the analysis. CTAS score was concordant with recommendation for FN (level 1-2) in 85% of patients and did not vary based on primary cancer site (p = 0.17). The mean time to physician assessment was 97.2 min and the mean time to initiation of IV antibiotics was 194.7 min. Overall, 14.6% of patients received their first dose of antibiotic therapy within the recommended 1 hour window. Conclusions: Our audit identified a large margin for improvement in the time to initiation of antibiotic therapy for chemotherapy patients with suspected FN. Prompt recognition and initiation of standardized treatment pathways for FN in the ED may improve the time to initiation of antibiotic therapy. In an attempt to address this gap in quality we have developed and distributed a standardized wallet-sized fever card to all patients receiving cytotoxic chemotherapy within our regional cancer program. This card contains information pertaining to the current chemotherapy treatment and recommended ED treatment protocols for FN. An evaluation of the impact of these cards is ongoing.

106 Background: Multiple studies have found that cancer patients undergoing cytotoxic chemotherapy have a high rate of emergency department (ED) utilization throughout the course of their treatment and up to 20% of patients have recurrent ED visits. We assessed the effect of socioeconomic status (SES) on recurrent ED visits for infectious causes amongst chemotherapy patients. Methods: All patients who visited the Peel Regional Cancer Centre ED within 30 days of receiving cytotoxic chemotherapy between 04/12 - 3/13 were identified. Patients were included in the study if their primary reason for presentation was either fever or infection. Postal codes were cross-matched against 2011 census data from Statistics Canada to obtain estimates of income, education, and occupation. The impact of SES factors on the likelihood of multiple ED visits was analyzed. Results: 239 patients with at least 1 visit to the ED for infection were identified. Of these patients 103 (43.1%) had recurrent ED visits. Patients from areas with a higher proportion of arts, sports, culture, recreation, agriculture, and natural resources employment had a significantly (p

185 Background: Administrative data is increasingly being used to study treatment related complications that lead to acute care visits such as emergency department visits or hospitalizations (ED+H). We evaluated the accuracy of diagnosis codes for identifying chemotherapy related acute care visits (CRVs) among women with breast cancer. Methods: We prospectively developed algorithms to identify CRVs from administrative data in women receiving adjuvant chemotherapy for breast cancer in Ontario, Canada. Sensitivity (SN) and specificity (SP) were calculated for 3 scenarios: chemotherapy related ED visit, chemotherapy related H, and febrile neutropenia (FN) related visit using the chart as the gold standard. Since there is no specific diagnosis code for FN, three definitions of FN were considered: general (defined as fever or infection or neutropenia as main reason for visit), moderate (neutropenia as main reason for visit) or strict (fever or infection plus neutropenia). The population based cohort was generated by linking several health databases to identify women who had at least one ED+H during adjuvant chemotherapy for breast cancer between 2007-2009. The validation cohort consisted of 490 randomly selected cases from this cohort. Results: The population-based cohort consisted of 8,359 patients of whom 43.4% had at least one ED+H including 1,496 women who had multiple visits resulting in 6,293 unique ED+H. Of these, 73.1% were considered CRVs based on our algorithm. The algorithm performed well in identifying CRVs that included an H either from ED (SN 90%, SP 100%) or directly from home (SN 91%, SP 93%) but less well for ED visits that did not result in H (SN 65%, SP 80%). Depending on which FN algorithm was used, 1.4-24% of visits were considered FN related. The general FN algorithm had excellent SN regardless of whether the visit involved H (94-98%) but SP was moderate (66-80%). The strict FN algorithm had good SP (78-99%) but SN was highly variable (13-89%). The moderate FN algorithm provided the best tradeoff between SN (69-97%) and SP (76-98%). Conclusions: CRVs can be identified from administrative data with reasonable confidence, obviating the need for chart abstraction to evaluate chemotherapy related serious events.

115 Background: Over use of routine surveillance imaging to detect recurrence in women with EBC was recently identified as one of the top five opportunities to improve the quality of cancer care by the American Society of Clinical Oncology. We undertook a population level assessment of the current practice of surveillance imaging in EBC women treated in Ontario Canada. Methods: Incident EBC patients diagnosed 01/07 – 12/09 in Ontario, Canada were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. Basic (chest x-ray, abdominal x-ray and abdominal ultrasound) and advanced (computed tomography [CT] or bone scans) surveillance imaging scans completed during the first and second year of follow-up (starting 6 months after surgery or upon completion of chemotherapy) were identified. Logistic regression models were used to identify covariates associated with advanced surveillance imaging. Results: 16,981 EBC patients were included in the analysis of which 7,907(46.6%) received chemotherapy. In the first year of follow up care, 8,311 (48.9%) had at least 1 basic imaging test, while 4,916 (29.0%) had advanced imaging. This fell to 45.7% (basic) and 25.1% (advanced) in the second year of follow-up. Bone scans were the most common advanced imaging test (14.5%), followed by CT thorax (10.8%). On multivariable analysis age, stage, the use of chemotherapy and comorbidity were associated with increased use of advanced surveillance imaging (Table). Conclusions: Surveillance imaging was common in the first two years of follow-up for EBC patients. While appropriate for symptom driven investigation, the high rate of advanced imaging scans suggests an opportunity for improvement with the Ontario cancer system. [Table: see text]

e17503 Background: The standard of care for stage III colon cancer remains 5FU based AC. In clinical trial settings, this begins within 56 days of surgery. Recently a meta-analysis suggested that delays to starting chemotherapy are associated with inferior outcomes and the goal should be to commence AC as soon as feasible. Our objective was to assess the time to starting AC for referred patients to our center and to identify modifiable factors which may be improve upon to reduce delays. Methods: All patients referred to our center with stage III colon cancer who received at least 1 cycle of intravenous AC between Jan.1, 2010 and Dec.31, 2010 were identified. Patient characteristics and time intervals between surgery, Medical Oncology referral, Medical Oncology consultation and initiation of AC were assessed. Results: The total number of patients is 43. Median time to initiation of AC from surgery was 60 days with a range of 29-118 days. Only 32% of patients commenced AC within 56 days of surgery. The intervals of time from surgery to Medical Oncology referral and Medical Oncology consultation to initiation of AC were similar with a median of 25 and 26 days respectively. The median time interval from Medical Oncology referral to Medical Oncology consultation was only 9 days. The bulk of the interval for initiation of AC after seeing a Medical Oncologist was for placement of central intravenous (CIV) devices which took a median of 19 days. Conclusions: The majority of our patients do not start AC within an accepted timeframe. Most of the delay is related to the interval taken to request a consultation to Medical Oncology by the surgeon and to Medical Oncology access to CIV devices. Educational programs geared to referring surgeons which stress the importance of timely AC can help and are being initiated. Further options such as pre booking CIV devices and colon cancer patient-specific nurse navigators to try and streamline the processes and reduce their delays are being explored. [Table: see text]

6628 Background: Over use of routine surveillance imaging to detect recurrence in women with EBC was recently identified as one of the top five opportunities to improve the quality of cancer care by the American Society of Clinical Oncology. We undertook a population level assessment of the current practice of surveillance imaging in EBC women treated in Ontario Canada. Methods: Incident early breast cancer patients diagnosed 01/07 – 12/09 in Ontario, Canada were identified from the Ontario Cancer Registry. Patient records were linked deterministically to provincial health care databases to provide comprehensive medical follow-up. Basic (chest x-ray, abdominal x-ray and abdominal ultrasound) and advanced (computed tomography [CT] or bone scans) surveillance imaging scans completed during the first and second year of follow-up care (starting 6 months after surgery or upon completion of adjuvant chemotherapy) were identified. Logistic regression models were used to identify covariates associated with advanced surveillance imaging. Results: 16,981 EBC patients were included in the analysis of which 7,907(46.6%) received chemotherapy. In the first year of follow up care, 8,311 (48.9%) had at least 1 basic imaging test, while 4,916 (29.0%) had advanced imaging. This fell to 45.7% (basic) and 25.1% (advanced) in the second year of follow-up. Bone scans were the most common advanced imaging test (14.5%), followed by CT thorax (10.8%). On multivariable analysis age, stage, the use of chemotherapy and comorbidity were associated with increased use of advanced surveillance imaging (Table). Significant geographic variation was also demonstrated. Conclusions: Surveillance imaging was common in the first two years of follow-up for EBC patients. While appropriate for symptom driven investigation, attention should be paid to the routine use of surveillance imaging in EBC women during follow-up care. [Table: see text]