Background Limited data is available on how the timing and setting of palliative care referral can affect end-of-life care. In this retrospective cohort study, we examined how the timing and setting of palliative care (PC) referral were associated with the quality of end-of-life care. Methods All adult patients residing in the Houston area who died of advanced cancer between 9/1/2009 and 2/28/2010 and had a PC consultation were included. We retrieved data on PC referral and quality of end-of-life care indicators. Results Among 366 decedents, 120 (33%) had early PC referral (>3 months before death) and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs. 68%, P<0.001), hospitalizations (48% vs. 81%, P<0.003), and hospital deaths (17% vs. 31%, P=0.004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs. 68%, P<0.001), hospital admissions (52% vs. 86%, P<0.001), hospital deaths (18% vs. 34%, P=0.001) and intensive care unit admissions (4% vs. 14%, P=0.001). In multivariate analysis, outpatient PC referral (odds ratio [OR]=0.42, 95% confidence interval [CI] 0.28-0.66; P<0.001) was independently associated with less aggressive end-of-life care. Male sex (OR=1.63, 95%CI 1.06-2.50; P=0.03) and hematologic malignancy (OR=2.57, 95%CI 1.18-5.59; P=0.02) were associated with more aggressive end-of-life care. Conclusion Patients referred to outpatient PC had improved end-of-life care compared to inpatient PC. Our findings support the need to increase the availability of PC clinics and to streamline the process of early referral.

Background Limited data is available on the quality of end-of-life care for patients with hematologic malignancies. In this retrospective cohort study, we compared the quality of end-of-life care between patients with hematologic malignancies and those with solid tumors. Methods All adult patients who died of advanced cancer between 9/1/2009 and 2/28/2010 while under the care of our institution were included. We collected baseline demographics and end-of-life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life. Results 113/816 (14%) decedents had hematologic malignancies. In the last 30 days of life, hematologic patients were more likely to have emergency room visits (54% vs. 43%, P=0.03), hospital admissions (81% vs. 47%, P<0.001), >=2 admissions (23% vs. 10%, P<0.001), >14 days of hospitalization (38% vs. 8%, P<0.001), intensive care unit admissions (39% vs. 8%, P<0.001) and death (33% vs. 4%, P<0.001), chemotherapy use (43% vs. 14%, P<0.001), and targeted therapy use (34% vs. 11%, P<0.001) compared to patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs. 17%, P=0.02). The composite score for aggressiveness of care (0=best, 6=worst) was significantly higher among patients with hematologic malignancies than those with solid tumors (median 2 vs. 0, P<0.001). In multivariate analysis, hematologic malignancy was a significant factor associated with aggressive end-of-life care (odds ratio 6.6, 95% confidence interval 4.1–10.7, P<0.001). Conclusions Patients with hematologic malignancies received more aggressive care at the end-of-life.

Purpose. Safety concerns raised in the recent oncology trials with erythropoiesis-stimulating agents (ESAs) have led to regulatory restrictions on their use. We wished to determine the impact of these changes on the use of ESAs and RBC transfusions. Conclusions. Recent ESA safety concerns and regulatory restrictions have significantly decreased ESA use. The lack of a significant impact on transfusions may be related to a lower hemoglobin threshold used to initiate ESAs or treatment of patients less likely to respond. The Oncologist

247 Background: Recently, a 30-day all-cause readmission rate has been proposed as a measure of quality of care. Readmissions are assumed to reflect failure by the discharging physician, hospital, or post acute care. These rates are generally easily calculated from available administrative data, and classifiable as "related to the previous discharge diagnosis" or not. Present on admission modifiers may enhance classification and assignment to "preventable" or "non-preventable," "expected or non-expected." This methodology is not generally applicable to the oncology population. The experience with one major cancer center is presented as an example of the limitations of such an approach. Methods: We analyzed 52,097 oncology admissions in an all-payer population that occurred between January 2010 and January 2012. Results: A mean of 32.5% (n=16,918) were readmitted within 30 days, compared to a "peer" group in the database of the University Health Consortium, median of 15%. The attached graph demonstrates the stability of this proportion. Leukemia, lymphoma, stem cell patients (46%), all patients with intense medical needs and frequent readmissions, n=7,635, were the largest subgroup. 42% (n=7,099) were readmissions for chemotherapy or immunotherapy, both planned and expected, and 11% (n=1,803) due to neutropenic fever, pneumonia, or sepsis, all common in this population and neither unexpected nor usually preventable. The most preventable, unexpected, and unplanned readmissions were for postoperative infection, dehydration, and urinary tract infection, accounting for 3.6% (n=609). Thus, the majority of readmissions were planned, expected, or not preventable. Conclusions: In a cancer population at an academic cancer hospital, the majority of readmission are not only planned, but also expected for this population of patients and should not be construed as representative of a quality of care issue. Proper stratification and classification of readmissions is essential to the interpretation of such a measure.

Safety signals raised in the recent oncology clinical trials have led to various regulatory restrictions including FDA black-box warning, National Coverage Determination (NCD), and updated ASCO/ASH guidelines in 2007. The purpose of this study was to determine the impact of these changes on the utilization of ESAs and on transfusion (Tx) of RBCs in 2006 (prior to changes) and 2007. We identified the total number of unique patients that received any treatment including chemotherapy, radiation, transfusions, or any treatment in the out-patient and in-patient settings during this 2 year time period. All the data on the ESA doses dispensed by the hospital pharmacy and all the RBC transfusions dispensed by the Blood bank were also analyzed. The ESA units were calculated by converting 40,000 units of epoetin alfa or 100 mcg of darbepoetin alfa to one unit of ESA. When comparing 2007 to 2006, the number of patients that received ESAs decreased by 26% and the total ESA units decreased by 30%. The overall usage of ESAs decreased by 55%, from 2398 units in 1/2006 to 1080 units in 12/2007. However, the number of pts that received RBC transfusions increased only by 6% and the total number of RBC units transfused by 2% (from 38,218 units in 2006 to 38,948 units in 2007). The median Hgb on the day of transfusion was same for each year (Hgb 8.2 g/dL for both 2006 and 2007), suggesting that the lack of impact on RBC Tx may not be due to a change in Tx threshold. The total number of unique patients referred and treated at MDACC during 2007 (24,356) increased by 13% from 2006 (21,619), not accounting for a lack of impact on transfusions. We therefore examined Hgb at the initiation of ESAs in a subset of pts (n=212) that had not received ESA for at least 3 months. The median Hgb/HCT values at the initiation of ESAs were 9.5 g/dL/27.4. The most frequent utilization of ESAs and transfusions was in patients with hematological malignancies. Conclusion: These findings indicate that the recent ESA safety concerns and related regulatory changes have significantly affected the ESA utilization. The lack of significant impact of reduced ESA usage on RBC transfusions may be related to a lower Hgb threshold used at initiation of ESAs and/or the targeted patient population (less likely to respond) treated with ESAs. Further research is needed to establish the factors contributing to the lack of correlation and to optimize the use of ESAs.

277 Background: Reviewing clinical practice by provider has been an ongoing process for quite some time. The metrics reviewed and how the review was conducted were not clearly defined and, as a result, has varied widely between organizations. Recredentialing or some self-imposed process were the main drivers until The Joint Commission required a more regular review of the clinicians’ practice in a hospital and clinics setting. MD Anderson embraced the requirement as an opportunity to improve its clinical review process and create a more robust infrastructure. Methods: Organizational and technological support was critical for success. The OPPE effort is led by the V.P. for Medical Affairs. A new faculty role, Quality Officer (QO), was established in each clinical department. The Office of Performance Improvement (OPI) was enlisted for data support and provided educational resources to the QOs. The Information Services staff maintains the technology to support the project long term. The Medical Staff Office has administrative responsibility for the program. Results: Two bi-annual OPPE reviews for credentialed providers (physicians and mid-levels) have been completed under the new process. Electronic display and processing has eliminated volumes of paper needed to track OPPE for 1,000+ faculty. External audit requirements are easily supported. Early adopters of the new OPPE tools have been complimentary of the support provided by display of values in control chart versus table formats. The application of statistical process control rules help QOs understand variation in performance among faculty and aid in identifying statistically valid quality issues. Conclusions: MD Anderson leveraged the OPPE requirements to make organizational changes and create processes that enhance review of clinical practice with electronic tools that improve decision making and analytical capabilities. The implementation of clinical quality metrics has made it clearer to see how each practice is doing based on criteria they defined, as well as create a path towards developing oncology performance metrics that can be considered nationally.

A large academic cancer center devised a performance improvement plan for special procedures and sedation. A group of interdisciplinary professionals convened to address data collection, complications, and outcomes for non-surgical procedures and sedation. Administrative, medical, and nursing representatives from all areas in which these procedures are performed gathered to assess existing data and data collection methods and to develop an improvement plan. Gastroenterology, pulmonary, diagnostic imaging, intensive care, gynecology, genitourinary, hematology, and anesthesiology specialties were represented. The group was facilitated by staff from the institution's Office of Performance Improvement and co-chaired by an anesthesiologist and a pulmonary specialist. A representative from the Practice Outcomes Department was also an active participant. This article describes group process, design efforts, pilot testing, and analyses for this project. Pilot data are presented as well as a discussion of staff involvement.