Journal articles: 'Guideline-concordant care'

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Ju, Michelle, James-Michael Blackwell, Patricio Polanco, John C. Mansour, Sam C. Wang, Matthew R. Porembka, Herbert Zeh, and Adam Charles Yopp. "Affordable Care Act Medicaid expansion does not reduce guideline concordant cancer care disparities in vulnerable populations." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 2039. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.2039.

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2039 Background: The receipt of timely, guideline concordant cancer amongst racial/ethnic and socioeconomic vulnerable populations remains a significant health policy issue. The Affordable Care Act (ACA) with implementation of Medicaid Expansion sought to reduce cancer disparities by reducing uninsured rates, theoretically improving healthcare access and delivery. We assessed the impact of Medicaid expansion on racial/ethnic disparities in the receipt of timely guideline concordant cancer care. Methods: We identified patients between 40-64 years of age with all stages of cancer (lung, colorectal, breast, uterine, and cervical) in the National Cancer Database, 2012-2015. Patients were assigned to Medicaid expansion cohort based on state of residence and whether Medicaid expansion was enacted at date of diagnosis in that state. Guideline concordant care was defined based on NCCN guidelines. We constructed an ecological model with multivariate regression analysis on rate of guideline concordant care receipt with covariates including race/ethnicity, Medicaid expansion, SES, gender, Charlson-Deyo score, and treatment facility type. Results: We identified 445,952 patients, 12% Black, 6% Hispanic white, median age 55 years. Patients in the lowest SES quartile following Medicaid expansion had the greatest increase in rates of insured status, although all SES quartiles had increased insured rates compared to non-Medicaid expansion regardless of race/ethnicity. In our ecological model, the rate of receipt of guideline concordant care declined by 0.5% per year between 2012-2015. After adjusting for covariates, Asians were 2.8% less likely to receive guideline concordant care than non-Hispanic whites, Blacks 3.8% less likely, and Hispanics 6.3% less likely (p < 0.0001). Racial/ethnic disparities in receipt of guideline concordant cancer care remained after Medicaid expansion with no differential benefit. Conclusions: Insurance gains under the ACA Medicaid expansion did not affect the rate of guideline concordant care receipt. Significant racial disparities persist in the likelihood of receiving guideline concordant care, particularly among Hispanics. Further studies are needed to determine additional barriers to cancer care access/delivery and identify key targets aimed at improving equity.

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Vyas, Ami M., Hilary Aroke, and Stephen J. Kogut. "HSR19-111: Disparities in Guideline-Concordant Care Among HER2 Positive Metastatic Breast Cancer Patients." Journal of the National Comprehensive Cancer Network 17, no. 3.5 (March 8, 2019): HSR19–111. http://dx.doi.org/10.6004/jnccn.2018.7196.

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Background: We examined guideline-concordant care among women with HER2+ MBC and determined the magnitude of differences in guideline-concordant care between those with positive and negative hormone receptor (HR) status by utilizing a non-linear decomposition technique. Methods: We conducted a retrospective observational cohort study using the Surveillance, Epidemiology, End Results-Medicare linked database. The study cohort consisted of women age >66 years diagnosed with HER2+ MBC in 2010–2013 (N=241). Guideline-concordant initial care within 6 months of cancer diagnosis was defined as per NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). A multivariate logistic regression was performed to identify the significant predictors of guideline-concordant care. A post-regression non-linear decomposition was conducted to examine the magnitude of disparities in guideline concordant care by women’s HR status. Results: 76.8% of the study cohort received guideline-concordant care, while 23.2% did not. As compared to those who did not receive guideline-concordant care, women who received guideline-concordant care were significantly more likely to have positive HR status (adjusted odds ratio (AOR)=2.11; P=.04), had good performance status (AOR=3.46; P=.0008), and had a higher number of oncology visits (AOR=8.05; P<.0001). With 1 year increase in age at cancer diagnosis, there was 5% lesser likelihood of receiving guideline-concordant care (AOR=0.95; P=.04). From the decomposition analysis, 19.0% of the disparity in guideline-concordant care between women with positive and negative HR status was explained by differences in their characteristics. Enabling characteristics (marital status, census-level income, and education) explained the highest (22.8%) proportion of the disparity, followed by external environmental factors (location of residence, SEER region, hospitals offering oncology services) at 5.3%, and need-related factors (tumor grade, comorbidity, performance status, number of metastases) at 3.2%. Conclusion: Almost one quarter of the study cohort did not receive guideline-concordant care. There are opportunities to improve cancer care for women with negative HR status who have lower socioeconomic status. The high unexplained portion of differences in guideline-concordant care (81.0%) can be due to patient preferences for treatment, propensity to seek care, and organizational and physician-level factors not captured in the database.

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Kimmick, Gretchen Genevieve, Steven Fleming, Susan A. Sabatino, Xiao-cheng Wu, Wenke Hwang, J. Frank Wilson, Mary Jo B. Lund, Rosemary Cress, and Roger T. Anderson. "Influence of comorbidity on guideline concordant care for breast cancer: Findings from the Center for Disease Control and Prevention National Program of Cancer Registry (NPCR) patterns of care study." Journal of Clinical Oncology 30, no. 15_suppl (May 20, 2012): 6052. http://dx.doi.org/10.1200/jco.2012.30.15_suppl.6052.

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6052 Background: Comorbidity burden predicts cancer treatment and may influence outcome. We explore the relationship of specific comorbid illnesses with receipt of guideline concordant care for early stage breast cancer. Methods: The NPCR’s Patterns of Care study reabstracted the medical records of breast cancer cases diagnosed in 2004 from 7 cancer registries. We included women with nonmetastatic in situ and invasive breast cancer, known hormone receptor status, node status, and tumor size. Guideline-concordant management, including surgery, radiation, chemotherapy and endocrine components, was based on NCCN guidelines using tumor size, nodal and hormone receptor status. Comorbidity was measured according to the Adult Comorbidity Evaluation Index (ACE). Multivariate logistic regression models were used to determine factors associated with guideline-concordant care, and included overall ACE scores and 26 separate ACE comorbidity categories, as well as age, race, hormone receptor status, and HER2 status. Results: The study sample included 6904 women (mean age 58.7 and range 20-99 years, 76% white, 45% with ACE comorbidity score of 0, 70% ER and/or PR+, 13% HER2+). Overall, 64% received guideline-concordant care. Receipt of guideline-concordant care varied by overall comorbidity burden (71% for none; 65% for minor; 63% for moderate; 50% for severe; p<0.05). The presence of hypertension (OR 1.26, 95% CI 1.08-1.48) predicted receipt of guideline concordant care, whereas, peripheral artery disease (OR 0.44, 95% CI 0.21-0.93), diabetes (OR 0.78, 95% CI 0.63-0.97) and dementia (OR 0.31, 95% CI 0.13-0.74) predicted lack of guideline concordant care. Older age, black race, and hormone receptor positivity were associated with less, and HER2 positivity with receipt of more guideline-concordant care. Conclusions: Overall those with more comorbidity burden received less guideline-concordant care. However, the effects vary by specific conditions. The odds of receiving guideline-concordant care was greater in those with hypertension and less in those with peripheral arterial disease, diabetes, and dementia.

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Fang, P., W. He, S. Giordano, and G. L. Smith. "Racial Disparities in Guideline-Concordant Cancer Care." International Journal of Radiation Oncology*Biology*Physics 99, no. 2 (October 2017): S10. http://dx.doi.org/10.1016/j.ijrobp.2017.06.039.

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Machhi, Rushad, and Amanda Marie Parkes. "Impact of psychosocial factors on the receipt of guideline concordant care in adolescent and young adults with localized Ewing sarcoma and osteosarcoma." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): e18658-e18658. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e18658.

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e18658 Background: Adolescent and young adults (AYAs) experience poorer outcomes, including lower survival improvements, compared to younger and older patients. As higher compliance with National Comprehensive Cancer Network (NCCN) guidelines has been associated with improved outcomes, we sought to understand the influence of psychosocial factors on receipt of care concordant with NCCN guidelines in AYAs with bone sarcomas. Methods: Retrospective chart review was performed on adult AYA patients (18-39 years) with localized Ewing sarcoma (ES) or high-grade conventional osteosarcoma (OS) seen at least once between 2015-2019 at the University of Wisconsin (UW). These tumor types were selected given uniform guideline-based care recommendations. Chart review identified receipt of standard care as per NCCN Bone Cancer guidelines, defined as neoadjuvant chemotherapy, local therapy (surgery/radiation), and adjuvant chemotherapy with receipt of at least 75% of recommended chemotherapy cycles, and compared to interpersonal relationships (marital status and presence of children at cancer diagnosis), changes in school or work following cancer diagnosis, substance use, and residential location. Results: We identified 21 AYA patients with localized ES (10/21, 48%) or OS (11/21, 52%), with 67% (14/21) receiving NCCN guideline concordant care. Receipt of guideline concordant care was associated with interpersonal relationships, with only 33% (1/3) of patients with children versus 72% (13/18) of patients without children receiving guideline concordant care. Additionally, the one patient noted to divorce following cancer diagnosis did not receive guideline concordant care (0/1, 0%) as compared with 67% (10/15) of single patients and 80% (4/5) of married patients. Vocational changes also affected care, with only 56% (5/9) of patients with work change following cancer diagnosis receiving guideline concordant care versus 75% (9/12) without work changes. Guideline concordant care was less common in patients with alcohol use (5/10, 50%) as compared with patients without alcohol use (9/11, 82%). Residential distance to UW was also associated with receipt of guideline concordant care, which was more common in patients living 0-20 miles from UW (86%, 6/7) as compared with those 21-100 miles from UW (60%, 6/10) or > 100 miles from UW (50%, 2/4). Conclusions: Given the occurrence of cancer during a complex developmental time, AYAs have a relatively high occurrence of psychosocial changes and needs, which we found to be associated with receipt of NCCN guideline concordant care in patients with localized ES and OS. While a limited sample size, as the first study to define specific psychosocial factors that affect receipt of guideline concordant care, these finding suggest the need to improve identification and support of these discrete patient factors.

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Clair, Kiran, Jenny Chang, Argyrios Ziogas, Sora Park Tanjasiri, Kari Joanne Kansal, Greg E. Gin, Jason A. Zell, and Robert E. Bristow. "Disparities by race, socioeconomic status, and insurance type in the receipt of NCCN guideline concordant care for select cancer types in California." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 7031. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.7031.

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7031 Background: There are a limited number of studies that have evaluated the association between National Comprehensive Cancer Network (NCCN) guideline adherence and survival across different cancers. We aim to assess the relationship between race/ethnicity, socioeconomic status (SES), insurance type and the receipt of NCCN guideline concordant cancer care and survival. Methods: This is a retrospective population-based cohort study of patients with 7 types of invasive cancer using the California Cancer Registry. Adherence with NCCN guidelines was defined by appropriate surgical, radiation, and chemo- or hormonal therapies. Multivariate logistic regression was used to evaluate the relationship between the patient, insurance type, tumor, and guideline adherence. Disease-specific survival analysis was performed using multivariate proportional hazards model. Results: A total of 543,198 patients were identified with invasive cancer between 2004-2017 (cases by disease type: breast 189,311, prostate 156,502, colon 80,102, liver 25,857, gastric 22,066, ovary 22,551, and cervix 16,691). The proportion of patients receiving NCCN guideline-concordant care varied by disease type. Non-concordant guideline treatment was associated with increased disease-specific mortality across all cancer types: breast (HR 1.28, 95%CI 1.23-1.33), prostate (HR 1.31, 95%CI 1.22-1.41), colon (HR 1.73, 95%CI 1.67-1.78), liver (HR 2.52, 95%CI 2.42-2.63), gastric (HR 2.38, 2.28-2.49), ovary (HR 1.32, 95%CI 1.26-1.38), and cervical cancer (HR 1.17, 95%CI 1.08-1.26). In multivariate models, compared to White, black patients were less likely to receive guideline concordant care for breast (OR 0.88, 95%CI 0.84-0.92), prostate (OR 0.90, 95%CI 0.86-0.93), colon (OR 0.85, 95%CI 0.79-0.92), and ovarian cancer (OR 0.71, 95%CI 0.62-0.82). Compared to Managed care insurance patients, Medicaid payer status was also associated with lower guideline concordant care for breast (OR 0.81, 95%CI 0.78-0.84), prostate (OR 0.91, 95%CI 0.86-0.97), colon (OR 0.70, 95%CI 0.65-0.75), gastric (OR 0.69, 95%CI 0.63-0.75), and liver cancer (OR 0.66, 95%CI 0.61-0.72). Conclusions: Less than half of cancer patients received NCCN guideline concordant care. There was an incremental relationship observed between SES and the likelihood of receiving guideline concordant care. Patients receiving non-guideline concordant care had worse disease-specific survival.

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Knežević, Božidarka, Ljilja Musić, Goran Batrićević, Aneta Bošković, Nebojša Bulatović, Ana Nenezić, Jelena Vujović, and Milovan Kalezić. "Optimizing prevention and guideline-concordant care in Montenegro." International Journal of Cardiology 217 (August 2016): S32—S36. http://dx.doi.org/10.1016/j.ijcard.2016.06.218.

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Cohen-Stavi, Chandra J., Calanit Key, Shmuel Giveon, Tchiya Molcho, Ran D. Balicer, and Efrat Shadmi. "Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting." Family Practice 37, no. 4 (March 27, 2020): 479–85. http://dx.doi.org/10.1093/fampra/cmaa024.

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Abstract Background Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. Objective Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. Methods A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). Measures Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. Results 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. Conclusions Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.

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Kimmick, Gretchen, Steven T. Fleming, Susan A. Sabatino, Xiao-Cheng Wu, Wenke Hwang, J. Frank Wilson, Mary Jo Lund, Rosemary Cress, and Roger T. Anderson. "Comorbidity Burden and Guideline-Concordant Care for Breast Cancer." Journal of the American Geriatrics Society 62, no. 3 (February 10, 2014): 482–88. http://dx.doi.org/10.1111/jgs.12687.

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McBride, Cameron L., Julia M. Akeroyd, David J. Ramsey, Vijay Nambi, Khurram Nasir, Erin D. Michos, Ruth L. Bush, et al. "Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs." Vascular Medicine 23, no. 3 (March 30, 2018): 232–40. http://dx.doi.org/10.1177/1358863x18758914.

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The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.

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Snyder, Rebecca A., Rebecca Wardrop, Alexander Mclain, Alexander A. Parikh, and Anna Cass. "Self-reported patient experience and quality of care among elderly patients with colon cancer." Journal of Clinical Oncology 38, no. 4_suppl (February 1, 2020): 33. http://dx.doi.org/10.1200/jco.2020.38.4_suppl.33.

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33 Background: Although studies have identified demographic and clinical factors associated with quality colorectal cancer care, the association between patient-reported experience of care and quality of care is unknown. Our primary aim was to assess the relationship between patient-reported experience of care and receipt of guideline-concordant colon cancer (CC) treatment. Methods: Fee-For-Service Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER registry and Consumer Assessment of Healthcare Providers and Systems patient experience survey (SEER-CAHPS) dataset. Patient-reported ratings were compared based on receipt of care consistent with recommended treatment guidelines [resection of ≥ 12 lymph nodes (LN) (stage I-III) and receipt of adjuvant chemotherapy (stage III)]. Linear regression was performed to compare mean patient experience scores by receipt of guideline concordant care, adjusting for patient and hospital factors. Results: 1010 patients with stage I-III CC were identified (mean age 76.7, SE 6.9). Of these, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 LN and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported ratings of health care quality, personal and specialty physicians, customer service, physician communication, getting needed care, and getting care quickly were similar among patients who received guideline-concordant treatment compared to those who did not. However, mean ratings of overall health care quality [91.3 (SE 2.0) vs. 82.4 (SE 1.7), p = 0.0004] and getting needed care [92.8 (SE 2.4) vs. 86.8 (SE 2.0), p = 0.047] were higher among stage III patients who received guideline concordant care compared to those who did not. Conclusions: Patient-reported ratings of health care quality and ability to get needed care are associated with guideline concordant cancer care among elderly patients with stage III CC. Further investigation is needed to determine if patient-reported experience correlates with other clinical measures of quality of colorectal cancer care.

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Kim, Bo, Stephanie Rodrigues, Natalie S. Dell, and Rani Elwy. "Process mapping appointments to identify improvements in care delivered to patients who screen positive for depression." European Journal for Person Centered Healthcare 4, no. 3 (September 29, 2016): 433. http://dx.doi.org/10.5750/ejpch.v4i3.1097.

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Rationale, aims and objectives After screening positive for depression, many patients do not receive effective medication or maintain optimal contact with practitioners. Our objective was to examine how appointments that patients have after screening positive may affect the delivery of evidence-based and guideline-concordant depression care. Methods We reviewed treatment records for 271 patients who screened positive for depression in primary care across three United States Veterans Health Administration medical facilities. For each patient, we mapped the process of appointments that took place following the positive screen, noting the number of appointments, the service line in which each appointment was held, as well as whether guideline-concordant depression care was in turn received over four months. Results We found that (i) approximately half of the patients who screened positive had no follow-up appointments, (ii) all patients who had two or more follow-up appointments received some – but not necessarily guideline-concordant – mental health treatment, and (iii) there were distinct patterns across the three facilities regarding which service lines’ appointments most often resulted in treatment. Conclusions Our work offers a novel approach of using data on appointments that patients have after screening positive for depression to shed light on current care practices. The number of post-screening appointments can be an informative process measure for improving depression care to become more guideline-concordant. Facilities vary substantially in terms of which service lines they use to attain guideline-concordance, likely due to notable differences in how their primary care, integrated primary care behavioral health, and mental health services are organized.

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Stahl, Kelly A., Elizabeth J. Olecki, Matthew E. Dixon, June S. Peng, Madeline B. Torres, Niraj J. Gusani, and Chan Shen. "Gastric Cancer Treatments and Survival Trends in the United States." Current Oncology 28, no. 1 (December 24, 2020): 138–51. http://dx.doi.org/10.3390/curroncol28010017.

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Gastric cancer is the third most common cause of cancer deaths worldwide. Despite evidence-based recommendation for treatment, the current treatment patterns for all stages of gastric cancer remain largely unexplored. This study investigates trends in the treatments and survival of gastric cancer. The National Cancer Database was used to identify gastric adenocarcinoma patients from 2004–2016. Chi-square tests were used to examine subgroup differences between disease stages: Stage I, II/III and IV. Multivariate analyses identified factors associated with the receipt of guideline concordant care. The Kaplan–Meier method was used to assess three-year overall survival. The final cohort included 108,150 patients: 23,584 Stage I, 40,216 Stage II/III, and 44,350 Stage IV. Stage specific guideline concordant care was received in only 73% of patients with Stage I disease and 51% of patients with Stage II/III disease. Patients who received guideline consistent care had significantly improved survival compared to those who did not. Overall, we found only moderate improvement in guideline adherence and three-year overall survival during the 13-year study time period. This study showed underutilization of stage specific guideline concordant care for stage I and II/III disease.

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Gomez, Caitlin Laurel, Nicole Ann Dawson, Robyn Lynn Dvorak, Nova Foster, Anne Hoyt, Sara A. Hurvitz, Amy Kusske, Charles Y. Tseng, and Susan Ann McCloskey. "Multidisciplinary breast clinic: Impact on patient satisfaction, timeliness, and guideline concordant care." Journal of Clinical Oncology 32, no. 30_suppl (October 20, 2014): 124. http://dx.doi.org/10.1200/jco.2014.32.30_suppl.124.

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124 Background: After recent implementation of a multidisciplinary breast clinic (MDC) for newly diagnosed women at our institution, we sought to examine the impact of MDC on patient satisfaction, timeliness and guideline concordant care. Methods: Women with newly diagnosed breast cancer at our institution are referred to MDC where they are seen by a team of breast specialists for initial consultation. The MDC model is further facilitated by a patient navigator/coordinator who serves as a single point of contact across disciplines and through the continuum of care. We deployed patient satisfaction surveys querying helpfulness of the care coordinator and satisfaction with seeing breast cancer specialty physicians together in one visit. We further retrospectively analyzed timeliness of care and guideline concordant care since MDC implementation. Results: Patient satisfaction survey response rate was 42% (n=133).On a scale of 1 (very poor) – 5 (excellent), 93% of respondents rated helpfulness of care coordinator as excellent and seeing specialty physicians together in one visit as excellent. 99% of respondents rated these factors as either excellent (5) or good (4). Regarding timeliness, among 202 women with newly diagnosed, non-metastatic breast cancer seen in MDC between June 2012 and April 2014, mean time from neoadjuvant chemotherapy to surgery was 43.1 days (range 26-78 days), from surgery to adjuvant radiation was 39.2 days (range 22-79 days), from surgery to adjuvant chemotherapy was 40.6 days (range 19-89 days), and from adjuvant chemotherapy to radiation was 34.9 days (range 13-67 days). All timeliness metrics well exceeded established national standards of 60-90 days. Regarding guideline concordant care, 94% and 90% respectively received indicated radiation therapy and chemotherapy in accordance with National Comprehensive Cancer Network (NCCN) Guidelines. Those not receiving guideline concordant care either declined, were of advanced age, or had prohibitive co-morbidities. Conclusions: The MDC model, which emphasizes care coordination via a team approach and patient navigation, is associated with excellent patient satisfaction and timely, guideline concordant breast cancer care.

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Hawkins, Brandon K., Mary Joyce B. Wingler, David A. Cretella, Katie E. Barber, Kayla R. Stover, and Jamie L. Wagner. "An evaluation of antipseudomonal dosing on the incidence of treatment failure." SAGE Open Medicine 9 (January 2021): 205031212110009. http://dx.doi.org/10.1177/20503121211000927.

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Introduction: Significant mortality is associated with delays in appropriate antibiotic therapy in Pseudomonas aeruginosa infections. The impact of empiric dosing on clinical outcomes has been largely unreported. Methods: This retrospective cohort compared treatment failure in patients receiving guideline-concordant or guideline-discordant empiric therapy with cefepime, meropenem, or piperacillin/tazobactam. Patients with culture-positive P. aeruginosa between 1 July 2013 and 31 July 2019 were eligible for inclusion. Patients with cystic fibrosis, polymicrobial infection, and urinary or pulmonary colonization were excluded. The composite primary outcome was treatment failure, defined as (1) therapy modification due to resistance/perceived treatment failure, (2) increased/unchanged qSOFA, or (3) persistent fever 48 h after initiating appropriate therapy. Secondary outcomes included rate of infectious diseases consultation, all-cause inpatient mortality, mechanical ventilation requirement, and infection-related intensive care unit and hospital lengths of stay. Results: In total, 198 patients were included: 90 guideline-concordant and 108 guideline-discordant. Baseline characteristics were balanced. Treatment failure was more common in the guideline-discordant than the guideline-concordant group (62% versus 48%; p = 0.04). This remained significant when adjusting for supratherapeutic dosing ( p = 0.02). Infectious diseases consultation was higher in the guideline-discordant group (46% versus 29%, p = 0.01), while intensive care unit length of stay was longer in the guideline-concordant group (4.5 versus 3 days, p = 0.03). Additional secondary outcomes were similar. Conclusion: Treatment failure was significantly higher in patients receiving guideline-discordant empiric antipseudomonal dosing. Guideline-directed dosing, disease states, and patient-specific factors should be assessed when considering empiric antipseudomonal dosing.

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Vyas, Ami M., Hilary Aroke, and Stephen Kogut. "Guideline-Concordant Treatment Among Elderly Women With HER2-Positive Metastatic Breast Cancer in the United States." Journal of the National Comprehensive Cancer Network 18, no. 4 (April 2020): 405–13. http://dx.doi.org/10.6004/jnccn.2019.7373.

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Background: It is crucial to identify whether women with HER2-positive (HER2+) metastatic breast cancer (MBC) are treated according to treatment guidelines and whether treatment disparities exist. This study examined guideline-concordant treatment among women with HER2+ MBC and determined the magnitude of differences in treatment between those with positive and negative hormone receptor (HR) status using a nonlinear decomposition technique. Methods: A retrospective observational cohort study was conducted using the SEER-Medicare linked database. The study cohort consisted of women aged ≥66 years diagnosed with HER2+ MBC in 2010 through 2013 (n=241). Guideline-concordant initial treatment after cancer diagnosis was defined based on the NCCN Clinical Practice Guidelines in Oncology for Breast Cancer. A multivariable logistic regression was performed to identify significant predictors of guideline-concordant treatment. A postregression decomposition was conducted to identify the magnitude of disparities in treatment by HR status. Results: Of 241 women included in the study, a total of 76.8% received guideline-concordant treatment. These women were significantly more likely to have positive HR status (P=.0298), have good performance status (P=.0009), and more oncology visits (P<.0001). With 1-year increments in age at cancer diagnosis, the likelihood of receiving guideline-concordant treatment reduced by 5% (P=.0356). The decomposition analysis revealed that 19.0% of the disparity in guideline-concordant treatment between women with positive and negative HR status was explained by differences in their characteristics. Enabling characteristics (marital status, income, and education) explained the highest (22.8%) proportion of the disparity. Conclusions: Nearly one-quarter of the study cohort did not receive guideline-concordant treatment. Our findings suggest opportunities to improve cancer care for elderly women with negative HR status who are unpartnered or have lower socioeconomic status. The high unexplained portion of the disparity by HR status can be due to patient treatment preferences, propensity to seek care, and organizational and physician-level characteristics that were not included in the study.

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Williams, Courtney P., Andres Azuero, Kelly M. Kenzik, Maria Pisu, Ryan D. Nipp, Smita Bhatia, and Gabrielle B. Rocque. "Guideline Discordance and Patient Cost Responsibility in Medicare Beneficiaries With Metastatic Breast Cancer." Journal of the National Comprehensive Cancer Network 17, no. 10 (October 2019): 1221–28. http://dx.doi.org/10.6004/jnccn.2019.7316.

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Background: Treatment for metastatic breast cancer (MBC) that is not concordant with the NCCN Guidelines for Breast Cancer has been associated with higher healthcare utilization and payer costs. However, a significant knowledge gap exists regarding the impact of guideline-discordant care on patient cost responsibility. This study examined this question among patients with MBC in the year postdiagnosis. Methods: This retrospective cohort study used data from the SEER-Medicare linked database from 2000 through 2013. Guideline discordance, defined by year-specific NCCN Guidelines, was assessed for first-line antineoplastic treatment and grouped into discrete categories. Patient cost responsibility (deductibles, coinsurance, copayments) in women with MBC were summed for all medical care received in the year postdiagnosis. The difference in patient cost responsibility by guideline discordance status was estimated using linear mixed-effect models. Results: Of 3,709 patients with MBC surviving at least 1 year postdiagnosis, 17.6% (n=651) received guideline-discordant treatment. Median cost responsibility in the year postdiagnosis for patients receiving guideline-discordant treatment was $7,421 (interquartile range [IQR], $4,359–$12,983) versus $5,171 (IQR, $3,006–$8,483) for those receiving guideline-concordant care. In adjusted models, guideline-discordant treatment was significantly associated with $1,841 higher patient costs in the first year from index diagnosis date (95% CI, $1,280–$2,401) compared with guideline-concordant care. Patient cost responsibility differed by category of guideline discordance, with those receiving nonapproved bevacizumab having the highest cost responsibility (β=$3,330; 95% CI, $1,711–$4,948). Conclusions: Deviations from current treatment guidelines may have implications on patient healthcare cost responsibility. Additional research is needed to fully understand the mechanisms underlying how guideline deviation leads to greater costs for patients with MBC.

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Wu, Janet, Kaitlyn R. Rivard, Elizabeth A. Neuner, Vasilios Athans, Camille Sabella, Robert Estridge, Robert Curtis, and Thomas G. Fraser. "1958. Assessment of Guideline-Concordant Antimicrobial Prescribing in Urgent Care Centers." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S62. http://dx.doi.org/10.1093/ofid/ofz359.135.

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Abstract Background In the United States in 2014, 266 million outpatient antibiotic prescriptions were dispensed. The Center for Disease Control and Prevention estimates that 30% of outpatient antibiotic prescriptions are inappropriate. These inappropriate prescriptions contribute to increased resistance, adverse events, and healthcare costs. Methods This was a retrospective study of patients presenting to 22 urgent care centers within a large healthcare system between September 1, 2018 and February 28, 2019. Data were collected from a dashboard designed to track antimicrobial prescribing data by indication, location, and provider. ICD-9 and -10 codes associated with otitis media, pharyngitis, sinusitis, cystitis, and upper respiratory infections (URI) were included. Guideline-concordant antimicrobial prescribing was determined based on compliance with national guideline recommendations, after taking patient allergies into account. The URI category includes disease states in which antimicrobials are rarely appropriate (e.g., acute rhinitis, nasopharyngitis, and acute bronchitis). Results A total of 57,799 encounters were included in this analysis (19,242 pediatric and 38,557 adult) and 60% of patients received an antibiotic prescription. Overall antimicrobial guideline concordance was higher in pediatrics (84%) than adults (62%). Rates of guideline-concordant antimicrobial selection are shown in Table 1. The most common guideline-discordant prescriptions were tetracyclines (39%), amoxicillin/clavulanate (26%), and macrolides (17%) in adult patients with sinusitis, pharyngitis, or otitis media. In pediatric patients, the most common discordant prescriptions were macrolides (32%), third-generation cephalosporins (30%), and amoxicillin/clavulanate (19%). Unnecessary antimicrobial prescribing for URI occurred in 23% of pediatric patients and 36% of adult patients. Conclusion Guideline-discordant antimicrobial prescribing is common in urgent care centers, particularly in adult patients. In addition to encouraging utilization of order sets, emphasis on education and feedback may be important to improve and sustain guideline-concordant prescribing rates and reduce prescribing for URI. Disclosures All Authors: No reported Disclosures.

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Zullig, Leah L., William R. Carpenter, Dawn Provenzale, Morris Weinberger, Bryce B. Reeve, and George L. Jackson. "Examining Potential Colorectal Cancer Care Disparities in the Veterans Affairs Health Care System." Journal of Clinical Oncology 31, no. 28 (October 1, 2013): 3579–84. http://dx.doi.org/10.1200/jco.2013.50.4753.

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Purpose Racial disparities in cancer treatment and outcomes are a national problem. The nationwide Veterans Affairs (VA) health system seeks to provide equal access to quality care. However, the relationship between race and care quality for veterans with colorectal cancer (CRC) treated within the VA is poorly understood. We examined the association between race and receipt of National Comprehensive Cancer Network guideline–concordant CRC care. Patients and Methods This was an observational, retrospective medical record abstraction of patients with CRC treated in the VA. Two thousand twenty-two patients (white, n = 1,712; African American, n = 310) diagnosed with incident CRC between October 1, 2003, and March 31, 2006, from 128 VA medical centers, were included. We used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for stages II and III, fluorouracil-based adjuvant chemotherapy for stage III, and surveillance colonoscopy for stages I to III). Explanatory variables included demographic and disease characteristics. Results There were no significant racial differences for receipt of guideline-concordant CRC care. Older age at diagnosis was associated with reduced odds of medical oncology referral and surveillance colonoscopy. Presence of cardiovascular comorbid conditions was associated with reduced odds of medical oncology referral (odds ratio, 0.65; 95% CI, 0.50 to 0.89). Conclusion In these data, we observed no evidence of racial disparities in CRC care quality. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.

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Nadeem, Hasan, John Romley, and Shaneda Warren-Andersen. "Changes in black-white disparity in receipt of guideline concordant treatment for women with early-stage breast tumors." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e19089-e19089. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e19089.

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e19089 Background: Racial disparities are well documented in the treatment of women with breast cancer. Whereas clinical treatment guidelines are established for early stage breast tumors, disparities in guideline-concordant (GC) treatment may influence variation in breast cancer outcomes. As such, we investigated differences in the receipt of GC treatment for black and white women with early-stage breast cancer between 2008 and 2016. Methods: We evaluated the Surveillance, Epidemiology, and End Results Registry (SEER) Incidence database for black and white women aged 20-64 years with stage I / stage II breast tumors. Primary analyses investigated associations between race and receipt of GC treatment in three chronological periods. Potential driving factors for trends in receipt of guideline-concordant treatment were also assessed. Results: Among 145,561 women diagnosed with early stage breast tumors, overall receipt of GC care decreased from 84.58% in 2008 to 83.89% in 2016. In period 1 (2008-2010), there was a prominent disparity between black and white women (81.89% black vs 86.24% white; p < 0.001). By period 3 (2014-2016), GC care increased for black women (84.29%) but decreased for white women (84.82%), eliminating the disparity (p = 0.276). Multivariate logistic regression on changes in the black-white disparity across the study period showed increased receipt of GC treatment for black women relative to white women in period 2 (2011-2013, odds ratio [OR], 1.202; 95% confidence interval [CI], 1.075 – 1.344) and period 3 (OR, 1.376; 95% CI, 1.212 – 1.505). For black women undergoing breast conserving surgery, administration of radiation therapy increased from 44.01% in period 1 to 50.64% in period 3 (p < 0.001) and was a prominent driver for increased GC care. Conclusions: Overall receipt of guideline-concordant treatment decreased from 2008-2016. Black women experienced a substantial increase in receipt of guideline-concordant care in period 2 (2011-2013) and period 3 (2014-2016) relative to white women. Delivery and completion of radiation therapy with breast conserving surgery increased the likelihood of receipt of guideline-concordant treatment.

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Gilani, Fizza, Sumit R. Majumdar, Jeffrey A. Johnson, Ross T. Tsuyuki, Richard Z. Lewanczuk, Richard Spooner, and Scot H. Simpson. "Adding Pharmacists to Primary Care Teams Increases Guideline-Concordant Antiplatelet Use in Patients with Type 2 Diabetes: Results from a Randomized Trial." Annals of Pharmacotherapy 47, no. 1 (January 2013): 43–48. http://dx.doi.org/10.1345/aph.1r552.

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BACKGROUND Antiplatelet therapy is recommended as part of a strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. However, compliance with these guideline-recommended therapies appears to be less than ideal. OBJECTIVE To assess the effect of adding pharmacists to primary care teams on initiation of guideline-concordant antiplatelet therapy in type 2 diabetic patients. METHODS Prespecified secondary analysis of randomized trial data. In the main study, the pharmacist intervention included a complete medication history, limited physical examination, provision of guideline-concordant recommendations to the physician to optimize drug therapy, and 1-year follow-up. Controls received usual care without pharmacist interactions. Patients with an indication for antiplatelet therapy, but not using an antiplatelet drug at randomization were included in this substudy. The primary outcome was the proportion of patients using an antiplatelet drug at 1 year. RESULTS At randomization, 257 of 260 study patients had guideline-concordant indications for antiplatelet therapy, but less than half (121; 47%) were using an antiplatelet drug. Overall, 136 patients met inclusion criteria for the substudy (71 intervention and 65 controls): 60% were women, with mean (SD) age 58.0 (11.9) years, diabetes duration 5.3 (6.0) years, and hemoglobin A1c 7.6% (1.5). Sixteen (12%) had established cardiovascular disease at enrollment. At 1 year, 43 (61%) intervention patients and 15 (23%) controls were using an antiplatelet drug (38% absolute difference; number needed to treat, 3; relative increase, 2.6; 95% CI 1.5–4.7; p < 0.001). Of these 58 patients, 52 (90%) were using aspirin 81 mg daily. CONCLUSIONS Adding pharmacists to primary care teams significantly and substantially increased the proportion of type 2 diabetic patients using guideline-concordant antiplatelet therapy.

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Culpepper, Larry. "Improving Patient Outcomes in Depression Through Guideline-Concordant, Measurement-Based Care." Journal of Clinical Psychiatry 74, no. 04 (April 15, 2013): e07. http://dx.doi.org/10.4088/jcp.12075tx1c.

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Chen, Jenny I., Leonard N. Slater, George Kurdgelashvili, Khawaja O. Husain, and Chris A. Gentry. "Outcomes of Health Care–Associated Pneumonia Empirically Treated with Guideline-Concordant Regimens Versus Community-Acquired Pneumonia Guideline–Concordant Regimens for Patients Admitted to Acute Care Wards from Home." Annals of Pharmacotherapy 47, no. 1 (January 2013): 9–19. http://dx.doi.org/10.1345/aph.1r322.

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BACKGROUND The introduction of the health care–associated pneumonia (HCAP) categorization expanded recommendations for broad-spectrum empiric antibiotics to pneumonia patients presenting from the community with recent health care–system exposure. However, the efficacy of such regimens in improving clinical outcomes in these patients has not been well established. OBJECTIVE To compare the clinical outcomes of HCAP patients treated initially with HCAP guideline–concordant antibiotic regimens to those treated initially with community-acquired pneumonia (CAP) guideline-concordant antibiotic regimens. METHODS This retrospective study included HCAP patients presenting from home and admitted to general medical wards. HCAP regimen patients were treated empirically with at least 1 antipseudomonal agent. All other patients were assigned to the CAP regimen group. The primary end point was clinical cure at 30 days postdischarge. Subgroup analysis was performed in patients hospitalized 1–30 days and 31–90 days before the HCAP admission. RESULTS Of 228 HCAP admissions, 122 patients received CAP regimens and 106 received HCAP regimens. The 2 groups were similar at baseline, including Pneumonia Severity Index scores. Attributable clinical cure occurred in 75.4% of CAP regimen patients and 69.8% of HCAP regimen patients (p = 0.34). Overall clinical cure occurred in 59.8% of CAP regimen patients and 54.7% of HCAP regimen patients (p = 0.44). The CAP regimen group used fewer days of intravenous antibiotics (4.39 vs 7.75, p < 0.0001) and had shorter lengths of stay (6.36 vs 8.58 days, p < 0.0001). For patients hospitalized 31–90 days earlier, clinical cure was higher in the CAP regimen group (attributable, 82.9% vs 60.0%, p = 0.0090; overall, 67.1% vs 47.5%, p = 0.044). CONCLUSIONS Compared to CAP guideline–concordant regimens, treatment of HCAP with HCAP guideline–concordant regimens did not increase clinical cure rates and was associated with lower clinical cure rates in patients hospitalized 31–90 days prior to the HCAP admission. This study suggests that broad-spectrum empiric antibiotics may not be necessary in all HCAP patient groups.

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Attridge, Russell T., Christopher R. Frei, Mary Jo V. Pugh, Kenneth A. Lawson, Laurajo Ryan, Antonio Anzueto, Mark L. Metersky, Marcos I. Restrepo, and Eric M. Mortensen. "Health care–associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes." Journal of Critical Care 36 (December 2016): 265–71. http://dx.doi.org/10.1016/j.jcrc.2016.08.004.

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Wiener, Daniel C., and Renda Soylemez Wiener. "Patient-Centered, Guideline-Concordant Discussion and Management of Pulmonary Nodules." Chest 158, no. 1 (July 2020): 416–22. http://dx.doi.org/10.1016/j.chest.2020.02.007.

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Manning, J. Sloan, and W. Clay Jackson. "Providing Guideline-Concordant Assessment and Monitoring for Major Depression in Primary Care." Journal of Clinical Psychiatry 76, no. 01 (January 28, 2015): e03-e03. http://dx.doi.org/10.4088/jcp.13013tx7c.

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Krebs, Erin E., Alicia A. Bergman, Jessica M. Coffing, Steffanie R. Campbell, Richard M. Frankel, and Marianne S. Matthias. "Barriers to Guideline-Concordant Opioid Management in Primary Care—A Qualitative Study." Journal of Pain 15, no. 11 (November 2014): 1148–55. http://dx.doi.org/10.1016/j.jpain.2014.08.006.

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Goyal, RK, and KL Davis. "Receipt of Guideline-Concordant Surveillance Care in Elderly Patients with Colorectal Cancer." Value in Health 19, no. 3 (May 2016): A39. http://dx.doi.org/10.1016/j.jval.2016.03.1844.

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Javid, Sara H., Thomas K. Varghese, Arden M. Morris, Michael P. Porter, Hao He, Dedra Buchwald, and David R. Flum. "Guideline-concordant cancer care and survival among American Indian/Alaskan Native patients." Cancer 120, no. 14 (April 7, 2014): 2183–90. http://dx.doi.org/10.1002/cncr.28683.

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Gaither, J. R., E. Edelman, W. Becker, S. Crystal, K. Gordon, J. Goulet, R. Kerns, et al. "Receipt of opioid therapy guideline- concordant care among HIV+ and HIV− veterans." Drug and Alcohol Dependence 146 (January 2015): e119. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.242.

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Dang, A. T., J. V. Hegde, N. Dawson, R. Dvorak, A. Hoyt, S. Hurvitz, A. Kusske, E. Silver, C. Tseng, and S. A. McCloskey. "Multidisciplinary Breast Clinic: Impact on Pretreatment Evaluation, Timeliness, and Guideline Concordant Care." International Journal of Radiation Oncology*Biology*Physics 96, no. 2 (October 2016): E11. http://dx.doi.org/10.1016/j.ijrobp.2016.06.623.

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White, Dolly P., Allison W. Kurian, Jennifer L. Stevens, Benmei Liu, Ariel E. Brest, and Valentina I. Petkov. "Receipt of guideline‐concordant care among young adult women with breast cancer." Cancer 127, no. 18 (June 2021): 3325–33. http://dx.doi.org/10.1002/cncr.33652.

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Yao, N., M. M. Hillemeier, and R. T. Anderson. "Breast cancer treatment resources and guideline-concordant treatment in Appalachia." Journal of Clinical Oncology 29, no. 27_suppl (September 20, 2011): 216. http://dx.doi.org/10.1200/jco.2011.29.27_suppl.216.

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216 Background: Appalachia has poorer cancer outcomes, but little research has been done regarding availability of cancer care resources in this region and how resource availability may relate to cancer outcomes. This study 1) examines associations between radiation therapy resources and receipt of radiotherapy after BCS in counties within Kentucky - a SEER state; and 2) describes spatial patterning of breast cancer treatment resources in all 13 Appalachian states. Methods: For the Kentucky analyses, county-level data from the Area Resource File and SEER registry are analyzed. Bivariate analyses and spatial lag regression using a 6-nearest neighboring counties matrix are conducted. The sample includes stage I or II primary breast cancer patients age 18+ years diagnosed in Kentucky during 2000-2007. The dependent variable is the county-level percentage of patients received BCS without radiation; independent variables include density of radiation therapy providers and facilities and other socioeconomic covariates. For the analyses of entire Appalachian region, descriptive analyses and exploratory spatial data analysis are conducted including 420 Appalachian counties and 644 non-Appalachian counties in 13 states. Results: In Kentucky 16.44% of 17,227 early stage breast cancer patients received BCS without radiation therapy (21.08% in Appalachia versus 14.80% in non-Appalachia, p<0.001). Appalachian Kentucky had significantly fewer radiation oncologists and radiation therapy facilities per capita than non-Appalachian Kentucky. The number of radiation therapy facilities per capita is negatively associated with rates of BCS without radiation when controlling for covariates. Analysis of 13 Appalachian states shows that Appalachian counties, especially in the Central and Southern regions, had significant fewer physicians per capita in Surgery, Anesthesia, Clinical Pathology, and Radiation Oncology. Clustering of scarce breast cancer care resources was observed in Central Appalachia. Conclusions: Appalachian counties, especially in central Appalachia, have fewer breast cancer treatment resources than non-Appalachian counties, and resource availability is associated with cancer health disparities.

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Chodoff, Alaina, Katherine Clegg Smith, Aishwarya Shukla, Amanda L. Blackford, Nita Ahuja, Fabian McCartney Johnston, Kimberly S. Peairs, et al. "Variations in recommended surveillance in colorectal cancer survivorship care plans." Journal of Clinical Oncology 38, no. 29_suppl (October 10, 2020): 13. http://dx.doi.org/10.1200/jco.2020.38.29_suppl.13.

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13 Background: Survivorship care plans (SCPs) outline pertinent information about a cancer survivor’s treatment and follow-up care. We describe the content of colorectal cancer (CRC) SCPs, completed as part of a randomized controlled trial of SCPs, and evaluate whether follow-up recommendations are guideline concordant. Methods: We analyzed 74 CRC SCPs from an academic and community cancer center. Frequency distributions and descriptive statistics were calculated for the entire cohort and separately by recruiting site. Follow-up recommendations were compared to American Cancer Society (ACS), American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines (Table). Results: Content routinely provided in SCPs (>80%) included patient demographics, cancer diagnosis, treatment details (surgery, chemotherapy, radiation therapy) as well as treatment-related side effects. SCP content specified less frequently included cancer stage, cancer risk (predisposing conditions), and recommendations for genetic counseling/testing and health promotion. Nearly all SCPs from the community site provided uniform, guideline-concordant follow-up. At the academic site, on average, more than 15 follow-up recommendations were listed for each surveillance modality, except colonoscopy. Among the SCPs that specified the frequency of follow-up care, the rate of guideline-concordant recommendations was 15/42 (36%) for follow-up visits, 29/43 (67%) for imaging, 12/45 (27%) for laboratory and 39/39 (100%) for colonoscopy. Conclusions: SCPs consistently provided information about CRC diagnosis and treatment, but often omitted information about cancer risk, staging and prognosis. There was considerable variation between cancer centers in the follow-up recommendations suggested for CRC survivors. Future work to improve the consistency of SCP follow-up recommendations with guidelines may be needed. Clinical trial information: NCT03035773 . [Table: see text]

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Parker, Nathan H., Katherine R. Arlinghaus, and Craig A. Johnston. "Integrating Physical Activity Into Clinical Cancer Care." American Journal of Lifestyle Medicine 12, no. 3 (March 5, 2018): 220–23. http://dx.doi.org/10.1177/1559827618759478.

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Physical activity is an important target for improving health and well-being among cancer survivors. Cancer clinicians are uniquely positioned to promote physical activity among survivors through follow-up visits for treatment planning and surveillance. Providers should prioritize assessment of guideline-concordant physical activity and facilitate achievement of physical activity guidelines through exercise prescription, goal setting, addressing barriers, and capitalizing on support systems.

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Bailey, Christina E., Chung-Yuan Hu, Y. Nancy You, Harmeet Kaur, Randy D. Ernst, and George J. Chang. "Variation in Positron Emission Tomography Use After Colon Cancer Resection." Journal of Oncology Practice 11, no. 3 (May 2015): e363-e372. http://dx.doi.org/10.1200/jop.2014.001933.

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PET use after colon cancer resection is increasing. Further study is needed to understand the clinical value and effectiveness of PET scans and the reasons for this departure from guideline-concordant care.

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Olson, Jonathan M., Gregory J. Raugi, Viet Q. Nguyen, Onchee Yu, and Gayle E. Reiber. "Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center." Wound Repair and Regeneration 17, no. 5 (September 2009): 666–70. http://dx.doi.org/10.1111/j.1524-475x.2009.00524.x.

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Snyder, Rebecca A., Rebecca Wardrop, Alexander C. McLain, Alexander A. Parikh, and Anna L. Cass. "Association of Patient Experience With Guideline-Concordant Colon Cancer Treatment in the Elderly." JCO Oncology Practice 17, no. 6 (June 2021): e753-e763. http://dx.doi.org/10.1200/op.20.00626.

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PURPOSE: The association between patient-reported experience of care and care quality is not well described. The purpose of this study was to assess the relationship between the patient-reported experience and receipt of guideline-concordant colon cancer (CC) treatment. METHODS: Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER Consumer Assessment of Healthcare Providers and Systems data set. Patient-reported scores were compared by receipt of guideline concordant care (GCC) (resection of ≥ 12 lymph nodes [stage I-III] and adjuvant chemotherapy [stage III]). Linear mixed-effects regression was performed to compare adjusted mean patient experience scores by GCC. RESULTS: Of the 1,010 identified patients, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 lymph node and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported scores of healthcare quality, physicians, physician communication, getting needed care, and getting care quickly were similar among patients who received GCC compared with those who did not. However, mean scores of overall healthcare quality (91.3 v 82.4, P = .0004) and getting needed care (92.8 v 86.8, P = .047) were higher among stage III patients who received GCC compared with those who did not. CONCLUSION: Patient-reported scores of healthcare quality and ability to get needed care are associated with GCC among elderly patients with stage III CC. Further investigation is needed to determine whether patient-reported experience correlates with other clinical measures of quality of CC care.

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Diaz, Maria Carmen G., Lori K. Handy, James H. Crutchfield, Adriana Cadilla, Jobayer Hossain, and Lloyd N. Werk. "Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia." Clinical Pediatrics 59, no. 11 (June 2, 2020): 988–94. http://dx.doi.org/10.1177/0009922820928054.

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Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers’ antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers’ CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non–guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician’s selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.

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Yonts, Alexandra B., Michael Jason Bozzella, Matthew Magyar, Laura O’Neill, and Nada Harik. "1139. Multidisciplinary Initiative to Increase Guideline-Concordant Antibiotic Prescriptions at Discharge for Hospitalized Children with Uncomplicated Community-Acquired Pneumonia." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S405—S406. http://dx.doi.org/10.1093/ofid/ofz360.1003.

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Abstract Background Community-acquired pneumonia (CAP) is the most common diagnosis in hospitalized children. The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published evidenced-based clinical practice guidelines for the management of CAP in children 3 months of age or older in 2011. These guidelines are not consistently followed. Our objective was to evaluate if quality improvement (QI) methods could improve guideline-concordant antibiotic prescribing, specifically addressing the use of oral third-generation cephalosporins, at hospital discharge for children with uncomplicated CAP. Methods QI interventions, implemented at a single tertiary care children’s hospital in Washington, D.C., focused on key drivers targeting hospital medicine resident teams. Multiple plan-do-study-act (PDSA) cycles were performed. Initial interventions included educational sessions (in small group and lecture formats) aimed at pediatric resident physicians, as well as visual job aids (Figure 1) and guideline summaries posted in resident physician work areas. Interventions were implemented in series to allow for statistical analysis via run chart. Medical records of eligible patients were reviewed monthly after each intervention to determine the impact on appropriate discharge antibiotic prescribing. Results At baseline, the median percentage of children with a diagnosis of uncomplicated CAP discharged with guideline-concordant antibiotics was 50%. Median rates of guideline-concordant antibiotic prescribing improved to 87.5% after initial interventions (Figure 2). Conclusion A fellow-led multidisciplinary QI initiative was successful in decreasing rates of non-guideline-concordant antibiotic prescribing at discharge. These interventions can be tailored for use at other institutions and for other infectious processes with established treatment guidelines. To ensure sustained improvement in guideline-concordant prescribing, future planned interventions include additional educational sessions with residents, faculty, and pharmacists, EMR order set modification and physician benchmarking. These tactics are intended to address the anticipated challenge of resident/faculty turnover and automate antibiotic choice for uncomplicated CAP. Disclosures All authors: No reported disclosures.

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Fang, Penny, Weiguo He, Daniel Gomez, Karen E. Hoffman, Benjamin D. Smith, Sharon H. Giordano, Reshma Jagsi, and Grace L. Smith. "Racial disparities in guideline-concordant cancer care and mortality in the United States." Advances in Radiation Oncology 3, no. 3 (July 2018): 221–29. http://dx.doi.org/10.1016/j.adro.2018.04.013.

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Wilson, Andrew M., Nasheed I. Jamal, Eric M. Cheng, Moira Inkelas, Debra Saliba, Andrea Hanssen, Jorge A. Torres, and Michael K. Ong. "Teleneurology clinics for polyneuropathy: a pilot study." Journal of Neurology 267, no. 2 (November 3, 2019): 479–90. http://dx.doi.org/10.1007/s00415-019-09553-0.

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Abstract Introduction Polyneuropathy (PN) is a common condition with significant morbidity. We developed tele-polyneuropathy (tele-PN) clinics to improve access to neurology and increase guideline-concordant PN care. This article describes the mixed-methods evaluation of pilot tele-PN clinics at three community sites within the Greater Los Angeles VA Healthcare System. Methods For the first 25 patients (48 scheduled visits), we recorded the duration of the tele-PN visit and exam; the performance on three guideline-concordant care indicators (PN screening labs, opiate reduction, physical therapy for falls); and patient-satisfaction scores. We elicited comments about the tele-PN clinic from patients and the clinical team. We combined descriptive statistics with qualitative themes to determine the feasibility and acceptability of the tele-PN clinics. Results The average tele-PN encounter and exam times were 28.5 and 9.1 min, respectively. PN screening lab completion increased from 80 to 100%. Opiate freedom improved from 68 to 88%. Physical therapy for patients with recent falls increased from 58 to 100%. The tele-PN clinic was preferred for follow-up over in-person clinics in 86% of cases. Convenience was paramount to the clinic’s success, saving an average of 231 min per patient in round-trip travel. The medical team’s caring and collaborative spirit received high praise. While the clinic’s efficiency was equal or superior to in-person care, the limited treatment options for PN and the small clinical exam space are areas for improvement. Conclusion In this pilot, we were able to efficiently see and examine patients remotely, promote guideline-concordant PN care, and provide a high-satisfaction encounter.

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Altalib, HH, BT Fenton, J. Sico, JL Goulet, H. Bathulapalli, A. Mohammad, J. Kulas, et al. "Increase in migraine diagnoses and guideline-concordant treatment in veterans, 2004–2012." Cephalalgia 37, no. 1 (September 30, 2016): 3–10. http://dx.doi.org/10.1177/0333102416631959.

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Background and aim Health administrators, policy makers, and educators have attempted to increase guideline adherence of migraine medications while reducing inappropriate use of opioid- and barbiturate-containing medications. We evaluated the burden of migraine and proportion of guideline-concordant care in a large, national health care system over time. Methods We conducted a time-series study using data from the Veterans Health Administration (VHA) electronic health record. Veterans with migraines were identified by ICD-9 code (346.X). Prescriptions and comorbid conditions were evaluated before and after migraine diagnosis. Chi-square tests and logistic regression were performed. Results A total of 57,064 veterans were diagnosed with migraine headache (5.3%), with women significantly more likely diagnosed (11.6% vs. 4.4%, p < 0.0001). The number of veterans diagnosed with migraine has significantly increased over the years. By 2012, triptans were prescribed to 43% of people with migraine, with no difference by gender. However, triptan prescriptions increased from 2004 to 2012 in men, but not women, veterans. Preventive medicines showed a significant increase with the year of migraine diagnosis, after controlling for age, sex, race, and for comorbidities treated with medications used for migraine prevention. Conclusions The burden of migraines is increasing within the VHA, with a corresponding increase in the delivery of guideline-concordant acute and prophylactic migraine-specific medication.

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LeMasters, TJ, SS Madhavan, U. Sambamoorthi, and D. Long. "Comparison Of Overall Survival Between Older Women Who Received Guideline-Concordant Care Versus Guideline-Discordant Care For Stage I–Iii Breast Cancer." Value in Health 19, no. 3 (May 2016): A142. http://dx.doi.org/10.1016/j.jval.2016.03.2011.

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Maniago, Rebecca, Sylvia S. Richey, Sarah DeVincenzo, Stephanie Jou, Robin Linzmayer, Janet Donegan, Gregory Sampang Calip, and Ivy Altomare. "Implementation of an EHR-embedded decision support tool in community oncology practices." Journal of Clinical Oncology 39, no. 28_suppl (October 1, 2021): 274. http://dx.doi.org/10.1200/jco.2020.39.28_suppl.274.

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274 Background: Clinical decision support (CDS) tools facilitate value based cancer care delivery and can enable measurement of guideline concordance, but can be challenging to implement. Flatiron Assist is an EHR-embedded and customizable CDS tool which facilitates selection and documentation of NCCN Guideline concordant and NCCN Preferred treatment regimens. We assessed performance metrics after the first year of use of this tool at eleven sites of care. Methods: We reviewed all non-small cell lung cancer (NSCLC) treatment orders as entered at 11 community practice sites of care in the northeast and southeast US from launch May 15, 2020, through May 23, 2021. Use of the CDS tool is not mandatory at these practices, and is deployed via prescriber choice. The tool documents and reports various quality metrics. We describe monthly prevalence of the CDS tool use, proportion of orders documented as guideline concordant, and prescriber-reported reasons for non-concordance. Results: All 954 NSCLC treatment regimen orders by the 89 prescribers who had the option to use the CDS tool were analyzed during the 1 year observation period. 658 regimens (69%) were ordered via the tool. Table describes prescriber users and non-users over time. The tool was deployed for 60% of NSCLC orders at 2 months, 69% at 6 months and 78% at 1 year post launch. Over the observed time period, 92% of treatment regimens ordered via the tool were documented as guideline concordant (94% at 2 months, 96% at 6 months and 85% at 1 year post-launch). Prescriber-reported reasons for ordering non-concordant regimens were “physician choice” (59%), “patient status” (12%), “newly published evidence” (10%), “second opinion from outside institution” (9%), “financial burden on patient/insurance doesn’t cover” (5%), “patient choice” (2%) and “other (allergy, disease progression, atypical disease)” (3%). Conclusions: At the study sites, this EHR-embedded CDS tool was rapidly adopted by most prescribers (approximately two thirds within 6 months of launch), and used for the majority of NSCLC candidate order sets during the 1 year observation period. NCCN concordance among users was empirically high overall and declined slightly over time, perhaps due to increased usage and/or greater comfort with the optional tool with ongoing use. Prescribers most commonly self-attributed the selection of non-concordant therapy to “physician choice” as opposed to factors such as financial hardship or patient choice. Further research will characterize workflow time, predictors of non-use and non-concordant orders, and evaluate whether Flatiron Assist improves clinical outcomes.[Table: see text]

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Moore, Hollis, Amy Trentham-Dietz, Caprice Christian Greenberg, David J. Vanness, John M. Hampton, Xiao-cheng Wu, Roger T. Anderson, et al. "Obesity and guideline-concordant systemic therapy for locoregional breast cancer." Journal of Clinical Oncology 32, no. 26_suppl (September 10, 2014): 145. http://dx.doi.org/10.1200/jco.2014.32.26_suppl.145.

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145 Background: Obese breast cancer patients tend to have higher mortality than non-obese patients. Hypothesizing that differences in receipt of adequate treatment may contribute to this mortality differential, we examined whether breast cancer patients with higher body mass index (BMI) received systemic adjuvant treatment consistent with National Comprehensive Cancer Network guidelines. Methods: Female adult stage I-III breast cancer cases diagnosed in 2004 were identified from population-based cancer registries in 7 states and supplemented with abstracted medical records. Differences in receipt of concordant treatment according to BMI were investigated using logistic regression models adjusted for age and other covariates. Results: Among all women, 57% (2,174 of 3,828) received overall guideline-concordant (GC) adjuvant systemic treatment, meaning treatment adherent in each of 3 defined domains: chemotherapy, chemotherapy regimen, and hormonal therapy. Within the domains, 82% of women received GC chemotherapy, and 93% of those received a GC regimen, and 80% received GC hormonal therapy. Women with higher BMI had greater odds of receiving GC systemic therapy (odds ratio for each 5 kg/m2 increase in BMI 1.07, 95% CI 1.01 to 1.14; p value for trend = 0.04). No significant differences in guideline treatment according to BMI were found in the individual therapy domains (adjuvant chemotherapy, p = 0.18; chemotherapy regimen, p = 0.26), although a borderline significant, nonlinear pattern was seen for hormonal therapy, in which the highest odds of GC treatment were found in the lowest and highest BMI ranges (p = 0.07 from χ2 test). Conclusions: Contrary to our hypothesis, odds of guideline concordant systemic therapy increased with higher BMI, and no significant differences were found within any specific treatment domain. Further research describing how multiple factors including treatment patterns influence outcomes for obese breast cancer patients may identify areas where changes in practice can reduce disease burden and mortality. Our research also suggests further investigation into patterns of care for underweight patients.

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Blaes, Anne Hudson, Maysa M. Abu-Khalaf, Catherine M. Bender, Susan Faye Dent, Chunkit Fung, Sophia Kustas Smith, Samantha Watson, Sweatha Katta, Janette K. Merrill, and Shawna V. Hudson. "Identifying gaps in the coverage of survivorship care services." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): 6583. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.6583.

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6583 Background: Despite advancements in reimbursement, anecdotal evidence suggests patients are not able to access guideline concordant survivorship care services due to a lack of coverage by payers. We present the results of a mixed methods study aimed to determine the practice-reported rates and sources of delay/denial on evidence-based, guideline concordant survivorship care services. Methods: A quantitative survey was developed by ASCO’s Cancer Survivorship Committee (CSC) to assess which services are being denied by payers for coverage/reimbursement. Questions were limited to disease sites for which practice guidelines exist. 533 ASCO members who provide survivorship care were surveyed, with a focus on obtaining representation from rural/urban, academic/private practice, pediatric/adult, and geographic location across the U.S. Semi-structured telephone interviews were conducted in October and November 2020 with geographic sub sample representation to further explore the nature of and extent to which coverage barriers are experienced for guideline-concordant care, specific to the provider or clinic’s primary disease site or specialty. Results: 120 responses from 50 states were included. Respondents were primarily clinicians (88%) with the majority treating patients with Medicare/Medicaid/CHIP (60%), followed by private/employer insurance (38%). There was little issue with coverage of hormone therapies. One-third reported issues some of the time with maintenance chemotherapy (38%) and immunotherapy (35%). Coverage denials for screening for recurrence for breast cancer (MRI, 63.5%), Hodgkin Lymphoma (PET/CT 47%; Breast MRI, 44.4%), and lung cancer (Low-dose CT 37.4%) were common. Half of the survey respondents reported denials for supportive care/symptom management services (Table). Private or employer-based insurance denials were most often the source of barriers (57.7%). Through interviews, denials were found to be the same across sites and not unique to a single payer or region. Most had a process to appeal denials for evidence-based services. Conclusions: Denial for survivorship care, particularly supportive care services, is common. There is a need for better advocacy with payers, improved policy, and support for providers/practices to implement protocols to obtain coverage for services, particularly in the face of burnout.[Table: see text]

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Osarogiagbon, Raymond U., Nicholas Ryan Faris, Matthew Smeltzer, Meredith Ray, Kenneth Daniel Ward, Fedoria Rugless, Bianca Michelle Jackson, et al. "Prospective comparative effectiveness trial of multidisciplinary lung cancer (LC) care." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): 6549. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.6549.

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6549 Background: LC is common and lethal; care-delivery is complex, varies in quality and outcomes, stimulating calls for multidisciplinary treatment planning (MTP) involving key specialists. This much-advocated model lacks rigorous evaluation. We conducted a prospective cohort study of MTP v Serial Care (SC) in a community healthcare system. Methods: Newly-diagnosed LC patients with performance status (PS) 0-2, and their caregivers, were enrolled from a LC multispecialty group clinic (MGC) or single-specialty general oncology clinics. A subset of general oncology clinic patients were discussed in a Multidisciplinary Thoracic Oncology Conference (MTOC), others were not (Serial Care [SC]). In this analysis, we compare MGC and MTOC patients (MTP recipients) to SC patients. Primary endpoint was overall survival (OS); secondary endpoints were measures of quality: staging practices, guideline-concordant treatment, timeliness of care, patient and caregiver satisfaction. We adjusted proportional hazards and logistic models for age, sex, histology, stage, PS, insurance, and race. Results: 254 patients received MTP v 272 SC. After a median 30 months’ follow up, there was no difference in OS (adjusted hazard ratio 1.10 [CI 0.87-1.40], p = .43). Stage-confirmatory biopsy was done in 61% MTP v 45% SC patients (adjusted odds ratio [aOR] 2.59, CI 1.74-3.86, p < .0001); 81% MTP v 68% SC patients received guideline-concordant treatment (aOR 2.04, CI 1.31-3.19, p < .002). Although the time from lesion detection to diagnostic biopsy (25 v 15 days, p = .004) or staging biopsy (29 v 20 days, p = .007) was higher with MTP, there was no difference in time to definitive treatment (60 v 57 days, p = .06). MTP patients and their caregivers reported greater satisfaction with the combined quality of care received from all team members (p < .0001) at baseline, 3 and 6 months. Conclusions: MTP for LC significantly improved the quality of care including the thoroughness of staging, use of guideline-concordant care, and patient satisfaction. Contrary to reports from retrospective analyses, timeliness of care was worse with MTP. Patient and caregiver satisfaction was superior with MTP. Despite improved quality, MTP was not associated with improved LC survival. Clinical trial information: NCT02123797.

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Wu, Jenny, Yongmei Huang, Ana I. Tergas, Alexander Melamed, Fady Khoury-Collado, June Y. Hou, Caryn M. St. Clair, Cande V. Ananth, Dawn L. Hershman, and Jason D. Wright. "The effect of guideline-concordant care in mitigating insurance status disparities in cervical cancer." Gynecologic Oncology 159, no. 2 (November 2020): 309–16. http://dx.doi.org/10.1016/j.ygyno.2020.08.006.

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Prins, M., P. Verhaak, M. Smolders, P. Spreeuwenberg, M. Laurant, K. van der Meer, H. van Marwijk, B. Penninx, and J. Bensing. "P01-83 - Associations between guideline-concordant care and clinical outcomes for depression and anxiety." European Psychiatry 25 (2010): 304. http://dx.doi.org/10.1016/s0924-9338(10)70302-3.

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Journal articles on the topic 'Guideline-concordant care'

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