Health System-Provided Rideshare Is Safe and Addresses Barriers to Colonoscopy Completion

In 2019, nearly 14 million colonoscopies were performed in the United States.1 In these settings, the accepted practice is that a responsible person drives and chaperones patients home after receiving procedural sedation, including colonoscopy.2 Lack of access to transportation and/or a chaperone is a persistent barrier to care in safety-net health systems and federally qualified health centers as a result of lower incomes, underinsurance, and higher social needs.3 Given racial, ethnic, and socioeconomic disparities in many digestive diseases that require colonoscopy for diagnosis and management, innovative solutions are needed to overcome logistical barriers to colonoscopy completion, especially in these settings.

Implementing an Organized Colorectal Cancer Screening Program: Lessons Learned From an Academic-Community Practice

Introduction

The effectiveness of mailed fecal immunochemical test outreach might be enhanced through an organized colorectal cancer screening program, yet published real-world experiences are limited. We synthesized the process of implementing a colorectal cancer screening program that used mailed fecal immunochemical test outreach in a large integrated academic-community practice.

Methods

Data from a pilot mailed fecal immunochemical test program were shared with healthcare system leadership, which inspired the creation of a cross-institutional organized colorectal cancer screening program. In partnership with a centralized population health team and primary care, we defined (1) the institutional approach to colorectal cancer screening, (2) the target population and method for screening, (3) the team responsible for implementation, (4) the healthcare team responsible for decisions and care, (5) a quality assurance structure, and (6) a method for identifying cancer occurrence.

Results

The Fred Hutch/UW Medicine Population Health Colorectal Cancer Screening Program began in September 2021. The workflow for mailed fecal immunochemical test outreach included a mailed postcard, a MyChart message from the patient's primary care provider, a fecal immunochemical test kit with a letter signed by the primary care provider and program director, and up to 3 biweekly reminders. Patients without a colonoscopy 3 months after an abnormal fecal immunochemical test result received navigation through the program. In the first program year, we identified 9,719 patients eligible for outreach, and in an intention-to-treat analysis, 32% of patients completed colorectal cancer screening by fecal immunochemical test or colonoscopy.

Conclusions

Real-world experiences detailing how to implement organized colorectal cancer screening programs might increase adoption. In our experience, broadly disseminating pilot data, early institutional support, robust data management, and strong cross-departmental relationships were critical to successfully implementing a colorectal cancer screening program that benefits all patients.

A proactive financial navigation intervention in patients with newly diagnosed gastric and gastroesophageal junction adenocarcinoma

PURPOSE

Many cancer patients and caregivers experience financial hardship, leading to poor outcomes. Gastric and gastroesophageal junction (GEJ) cancer patients are particularly at risk for financial hardship given the intensity of treatment. This pilot randomized study among gastric/GEJ cancer patients and caregivers tested a proactive financial navigation (FN) intervention to obtain a signal of efficacy to inform a larger, more rigorous randomized study.

METHODS

We tested a 3-month proactive FN intervention among gastric/GEJ cancer patients and caregivers compared to usual care. Caregiver participation was optional. The primary endpoint was incidence of financial hardship, defined as follows: accrual of debt, income decline of ≥ 20%, or taking loans to pay for treatment. Data from participant surveys and documentation by partner organizations delivering the FN intervention was analyzed and outcomes were compared between study arms.

RESULTS

Nineteen patients and 12 caregivers consented. Primary FN resources provided included insurance navigation, budget planning, and help with out-of-pocket medical expenses. Usual care patients were more likely to experience financial hardship (50% vs 40%) and declines in quality of life (37.5% vs 0%) compared to intervention patients. Caregivers in both arms reported increased financial stress and poorer quality of life over the study period.

CONCLUSIONS

Proactive financial navigation has potentially positive impacts on financial hardship and quality of life for cancer patients and more large-scale randomized interventions should be conducted to rigorously explore the impact of similar interventions. Interventions that have the potential to lessen caregiver financial stress and burden need further exploration.

TRIAL REGISTRATION

TRN: NCT03986502, June 14, 2019.

Intervention Nonadherence in the TrACER (S1415CD) Study: A Pragmatic Randomized Trial of a Standardized Order Entry for CSF Prescribing

PURPOSE

We conducted a pragmatic, cluster-randomized trial to test whether a guideline-based standing order entry (SOE) improves use of primary prophylactic CSF (PP-CSF) prescribing for patients receiving myelosuppressive chemotherapy. We investigated variability in adherence to the intervention.

METHODS

We conducted a cluster-randomized trial among 32 oncology clinics from the NCI Community Oncology Research Program. Clinics were randomized 3:1 to a guideline-based PP-CSF SOE or usual care. Among SOE sites, automated orders for PP-CSF were included for regimens at high risk for febrile neutropenia (FN) and an alert not to use PP-CSF for low FN risk. A secondary 1:1 randomization was done among intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF for patients receiving intermediate risk-regimens. Providers were allowed to override the SOE.

RESULTS

Overall, PP-CSF use among patients receiving high FN risk treatment was high and not different between arms; however, rates of PP-CSF use varied widely by site, ranging from 48.6% to 100%. Among those receiving low FN risk regimens, PP-CSF use was low and not different between arms; however, PP-CSF use ranged from 0% to 19.4% across sites. In the intermediate-risk substudy, PP-CSF was five-fold higher among sites randomized to SOE; however, there was considerable variability in adherence to intervention assignment: PP-CSF use ranged from 0% to 75% among sites randomized to SOE. Despite an alert to not prescribe, PP-CSF prescribing ranged from 0% to 33%.

CONCLUSION

In this randomized pragmatic trial aimed at improving PP-CSF prescribing, there was substantial variability in site adherence to the intervention assignment. Although the ability to opt out of the intervention is a feature of pragmatic trials, planning to estimate nonadherence is critical to ensure adequate power.

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System

GOALS

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system.

BACKGROUND

The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings.

STUDY

We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings.

RESULTS

We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women (P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively.

CONCLUSIONS

In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Assessment of financial screening and navigation capabilities at National Cancer Institute community oncology clinics

BACKGROUND

Cancer-related financial hardship is a side effect of cancer diagnosis and treatment, and affects both patients and caregivers. Although many oncology clinics have increased financial navigation services, few have resources to proactively provide financial counseling and assistance to families affected by cancer before financial hardship occurs. As part of an ongoing randomized study testing a proactive financial navigation intervention, S1912CD, among sites of the National Cancer Institute Community Oncology Research Program (NCORP), we conducted a baseline survey to learn more about existing financial resources available to patients and caregivers.

METHODS

The NCORP sites participating in the S1912CD study completed a required 10-question survey about their available financial resources and an optional 5-question survey that focused on financial screening and navigation workflow and challenges prior to starting recruitment. The proportion of NCORP sites offering financial navigation services was calculated and responses to the optional survey were reviewed to determine current screening and navigation practices and identify any challenges.

RESULTS

Most sites (96%) reported offering financial navigation for cancer patients. Sites primarily identified patients needing financial assistance through social work evaluations (78%) or distress screening tools (76%). Sites revealed challenges in addressing financial needs at the outset and through diagnosis, including lack of proactive screening and referral to financial navigation services as well as staffing challenges.

CONCLUSIONS

Although most participating NCORP sites offer some form of financial assistance, the survey data enabled identification of gaps and challenges in providing services. Utilizing community partners to deliver comprehensive financial navigation guidance to cancer patients and caregivers may help meet needs while reducing site burden.

Association between patient, clinic, and geographical-level factors and 1-year surveillance colonoscopy adherence

INTRODUCTION

Surveillance colonoscopy 1-year after surgical resection for patients with stages I-III colorectal cancer (CRC) is suboptimal and data on factors associated with lack of adherence are limited. Using surveillance colonoscopy data from Washington state, we aimed to determine the patient, clinic, and geographical factors associated with adherence.

METHODS

Using administrative insurance claims linked to Washington (WA) cancer registry data we conducted a retrospective cohort study of adult patients diagnosed with stage I-III CRC between 2011 and 2018 with continuous insurance for at least 18 months after diagnosis. We determined the adherence rate to 1-year surveillance colonoscopy and conducted logistic regression analysis to identify factors associated with completion.

RESULTS

Of 4,481 stage I-III CRC patients identified, 55.8% completed a 1-year surveillance colonoscopy. The median time to colonoscopy completion was 370 days. On multivariate analysis, older age, higher stage CRC, Medicare insurance or multiple insurance carriers, higher Charlson Comorbidity Index score and living without a partner were significantly associated with decreased adherence to 1-year surveillance colonoscopy. Among 29 eligible clinics, 51% (n=15) reported lower than expected surveillance colonoscopy rates based on patient mix.

CONCLUSION

Surveillance colonoscopy 1-year after surgical resection is sub-optimal in WA state. Patient and clinic factors, but not geographic factors (Area Deprivation Index), were significantly associated with surveillance colonoscopy completion. This data will inform the development of patient and clinic level interventions to address an important quality of care issue across Washington.

A Pragmatic Cluster-Randomized Trial of a Standing Order Entry Intervention for Colony-Stimulating Factor Use Among Patients at Intermediate Risk for Febrile Neutropenia

PURPOSE

Primary prophylactic colony-stimulating factors (PP-CSFs) are prescribed to reduce febrile neutropenia (FN) but their benefit for intermediate FN risk regimens is uncertain. Within a pragmatic, randomized trial of a standing order entry (SOE) PP-CSF intervention, we conducted a substudy to evaluate the effectiveness of SOE for patients receiving intermediate-risk regimens.

METHODS

TrACER was a cluster randomized trial where practices were randomized to usual care or a guideline-based SOE intervention. In the primary study, sites were randomized 3:1 to SOE of automated PP-CSF orders for high FN risk regimens and alerts against PP-CSF use for low-risk regimens versus usual care. A secondary 1:1 randomization assigned 24 intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF for intermediate-risk regimens. Clinicians were allowed to over-ride the SOE. Patients with breast, colorectal, or non-small-cell lung cancer were enrolled. Mixed-effect logistic regression models were used to test differences between randomized sites.

RESULTS

Between January 2016 and April 2020, 846 eligible patients receiving intermediate-risk regimens were registered to either SOE to prescribe (12 sites: n = 542) or an alert to not prescribe PP-CSF (12 sites: n = 304). Rates of PP-CSF use were higher among sites randomized to SOE (37.1% v 9.9%, odds ratio, 5.91; 95% CI, 1.77 to 19.70; P = .0038). Rates of FN were low and identical between arms (3.7% v 3.7%).

CONCLUSION

Although implementation of a SOE intervention for PP-CSF significantly increased PP-CSF use among patients receiving first-line intermediate-risk regimens, FN rates were low and did not differ between arms. Although this guideline-informed SOE influenced prescribing, the results suggest that neither SOE nor PP-CSF provides sufficient benefit to justify their use for all patients receiving first-line intermediate-risk regimens.

An evaluation of stakeholder engagement in comparative effectiveness research: lessons learned from SWOG S1415CD

Aim: Stakeholder engagement is central to comparative effectiveness research yet there are gaps in definitions of success. We used a framework developed by Lavallee et al. defining effective engagement criteria to evaluate stakeholder engagement during a pragmatic cluster-randomized trial. Methods: Semi-structured interviews were developed from the framework and completed to learn about members' experiences. Interviews were analyzed in a deductive approach for themes related to the effective engagement criteria. Results: Thirteen members participated and described: respect for ideas, time to achieve consensus, access to information and continuous feedback as areas of effective engagement. The primary criticism was lack of diversity. Discussion: Feedback was positive, particularly among themes of respect, trust and competence, and led to development of a list of best practices for engagement. The framework was successful for evaluating engagement. Conclusion: Standardized frameworks allow studies to formally evaluate their stakeholder engagement approach and develop best practices for future research.

Effects of a Guideline-Informed Clinical Decision Support System Intervention to Improve Colony-Stimulating Factor Prescribing: A Cluster Randomized Clinical Trial

IMPORTANCE

Colony-stimulating factors are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia. Research suggests that 55% to 95% of colony-stimulating factor prescribing is inconsistent with national guidelines.

OBJECTIVE

To examine whether a guideline-based standing order for primary prophylactic colony-stimulating factors improves use and reduces the incidence of febrile neutropenia.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial, the Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER), involved 32 community oncology clinics in the US. Participants were adult patients with breast, colorectal, or non-small cell lung cancer initiating cancer therapy and enrolled between January 2016 and April 2020. Data analysis was performed from July to October 2021.

INTERVENTIONS

Sites were randomized 3:1 to implementation of a guideline-based primary prophylactic colony-stimulating factor standing order system or usual care. Automated orders were added for high-risk regimens, and an alert not to prescribe was included for low-risk regimens. Risk was based on National Comprehensive Cancer Network guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was to find an increase in colony-stimulating factor use among high-risk patients from 40% to 75%, a reduction in use among low-risk patients from 17% to 7%, and a 50% reduction in febrile neutropenia rates in the intervention group. Mixed model logistic regression adjusted for correlation of outcomes within a clinic.

RESULTS

A total of 2946 patients (median [IQR] age, 59.0 [50.0-67.0] years; 2233 women [77.0%]; 2292 White [79.1%]) were enrolled; 2287 were randomized to the intervention, and 659 were randomized to usual care. Colony-stimulating factor use for patients receiving high-risk regimens was high and not significantly different between groups (847 of 950 patients [89.2%] in the intervention group vs 296 of 309 patients [95.8%] in the usual care group). Among high-risk patients, febrile neutropenia rates for the intervention (58 of 947 patients [6.1%]) and usual care (13 of 308 patients [4.2%]) groups were not significantly different. The febrile neutropenia rate for patients receiving high-risk regimens not receiving colony-stimulating factors was 14.9% (17 of 114 patients). Among the 585 patients receiving low-risk regimens, colony-stimulating factor use was low and did not differ between groups (29 of 457 patients [6.3%] in the intervention group vs 7 of 128 patients [5.5%] in the usual care group). Febrile neutropenia rates did not differ between usual care (1 of 127 patients [0.8%]) and the intervention (7 of 452 patients [1.5%]) groups.

CONCLUSIONS AND RELEVANCE

In this cluster randomized clinical trial, implementation of a guideline-informed standing order did not affect colony-stimulating factor use or febrile neutropenia rates in high-risk and low-risk patients. Overall, use was generally appropriate for the level of risk. Standing order interventions do not appear to be necessary or effective in the setting of prophylactic colony-stimulating factor prescribing.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02728596.

Can order entry systems improve oncology practice? The TrACER Experience

339

Background: Primary prophylactic colony stimulating factors (PP-CSF) are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia (FN). Prior research suggested poor adherence to PP-CSF prescribing relative to national guidelines. Accordingly, the objective of the TrACER study was to examine whether a guideline-based standing order entry (SOE) system for PP-CSF improves use and reduces FN. TrACER also included a substudy to evaluate the effectiveness of PP-CSF for patients receiving intermediate risk chemotherapy, where evidence of benefit is weaker. Methods: We conducted a patient-informed, cluster randomized trial among 32 oncology clinics from the NCI Community Oncology Research Program. Patients age ≥18 with breast, colorectal or non-small cell lung cancer initiating cancer therapy were enrolled. Clinics were randomized 3:1 to the implementation of a guideline-based PP-CSF SOE or usual care. Automated orders for PP-CSF were added for high-risk regimens and an alert not to use PP-CSF was included for low-risk regimens. Risk was based on National Comprehensive Cancer Network guidelines. A secondary 1:1 randomization for intermediate risk-regimens assigned 16 intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF. Results: 2,946 patients were enrolled (2287 intervention, 659 usual care). PP-CSF use among high-risk patients was high and not significantly different between arms (89.2% SOE; 95.8% usual care). FN rates for the SOE and usual care arms were 6.1% and 4.2% and not significantly different. The FN rate among high-risk patients not receiving PP-CSF was 14.9%. Among the 585 patients receiving low-risk regimens, PP-CSF use was low and not different between arms (6.3% SOE, 5.5% usual care). FN rates did not differ between the SOE system (1.5%) and usual care (0.8%). In contrast, for the intermediate risk substudy, rates of PP-CSF use were substantially higher among sites randomized to SOE (37.1% vs 9.9%, OR = 5.91(95% CI 1.77-19.70; p = 0.0038), and rates of FN were low and identical between arms (3.7% vs 3.7%). Similarly, FN rates did not differ between intermediate-risk patients that did or did not receive PP-CSF, irrespective of assignment. Conclusions: Implementation of a guideline-informed SOE system did not impact PP-CSF use or FN rates in high- and low-risk patients, where evidence supporting PP-CSF is stronger, and had a significant impact on PP-CSF use but not FN rates among intermediate risk patients, where evidence of benefit is weak. Overall, adherence to PP-CSF for low- and high-risk chemotherapy was much better than predicted based on evidence available at trial design. SOE interventions may be more useful in situations where more uncertainty of benefit exists. The pragmatic trial design provides high-quality evidence that had previously been lacking on the use and performance of PP-CSF in real world settings across the spectrum of FN risk. Clinical trial information: NCT02728596.

Intervention non-adherence in a pragmatic randomized trial of a standardized order entry for colony stimulating factor prescribing

374

Background: Pragmatic trials evaluate the effectiveness of interventions in routine practice conditions. Pragmatic trials have high generalizability, but the treatment effect can be influenced by nonadherence to the intervention of interest. We conducted a pragmatic, cluster-randomized trial to test whether a guideline-based standing order entry (SOE) system improves use of primary prophylactic colony stimulating factor (PP-CSF) prescribing for patients receiving myelosuppressive chemotherapy. Clinics were assigned to the SOE or usual care. We investigated variability in adherence to the intervention. Methods: TrACER was a patient-informed, cluster randomized trial among 32 oncology clinics from the NCI Community Oncology Research Program. Clinics were randomized 3:1 to a guideline-based PP-CSF SOE or usual care (primary study). Among SOE intervention sites, automated orders for PP-CSF were included for regimens at high risk for febrile neutropenia (FN) and an alert not to use PP-CSF for low FN risk. A secondary 1:1 randomization assigned the 24 intervention sites to either SOE to prescribe or an alert to not prescribe PP-CSF for patients receiving intermediate FN risk-regimens. Providers were allowed to override the standing orders for individual patients. Results: Overall, 8 sites (659 patients) were randomized to usual care and 24 sites (2287 patients) to the intervention; 12 (1296 patients) were randomized to the intermediated risk SOE intervention and 12 (991 patients) to the alert not to prescribe PP-CSF. PP-CSF use among patients receiving high FN risk treatment was high and not different between arms (89.2% SOE; 95.8% usual care), however rates of PP-CSF use by site ranged from 48.6% to 100%. Among those receiving low FN risk regimens, PP-CSF use was low and not different between arms (6.3% SOE, 5.5% usual care), however PP-CSF use ranged from 0% to 19.4% across sites randomized to the alert to not prescribe. In the intermediate risk sub-study, PP-CSF was higher among sites randomized to SOE vs. the alert not to prescribe PP-CSF (37.1% vs 9.9%, OR = 5.91, 95% CI 1.77-19.70; p = 0.0038). However, there was considerable variability in adherence to intervention assignment: PP-CSF use ranged from 0% to 75% among sites randomized to SOE, and despite an alert to not prescribe, PP-CSF rates ranged among sites from 0% to 33%. FN rates were low and similar in both arms. Conclusions: In this randomized pragmatic trial aimed at improving PP-CSF prescribing, there was substantial variability in site adherence to the intervention assignment. While the ability to opt-out of the intervention is a feature of pragmatic trials, careful pre-study planning to estimate nonadherence is critical to ensure adequate power to detect an effect. Understanding reasons for intervention opt-outs will is also inform future pragmatic studies aimed at improving adherence to practice guidelines. Clinical trial information: NCT02728596.

A pragmatic cluster-randomized trial of a standing physician order entry intervention for colony stimulating factor use among patients at intermediate risk for febrile neutropenia (SWOG S1415CD)

1518

Background: Primary prophylactic colony stimulating factors (PP-CSF) are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia (FN) but their benefit for regimens with intermediate FN risk is uncertain. Within a pragmatic, randomized trial of a standing order entry (SOE) intervention for prescribing PP-CSF, we designed a substudy to evaluate the effectiveness of PP-CSF for patients receiving therapy with intermediate FN risk. Methods: TrACER was a cluster randomized trial where NCI community Oncology Research Program practices were randomized to usual care (UC) or a guideline-based SOE intervention. In the primary study, sites were randomized 3:1 to a SOE of automated PP-CSF orders for NCCN-designated high FN risk chemotherapy regimens and alerts against PP-CSF orders for low FN risk regimens (intervention) versus usual care. A secondary randomization assigned intervention sites to a SOE intervention either to prescribe or not prescribe PP-CSF for patients receiving intermediate FN risk regimens. Clinicians were allowed to override the SOE. Patients age ≥18 with either breast, colorectal or non-small cell lung cancer were enrolled and followed for 12 mo. PP-CSF was defined as initiation within 24-72 hours after systemic chemotherapy. Sample size calculations were based on an FN risk reduction from 15% to 7.5%, and provided 80% power at a planned enrollment of 90 patients per site. Mixed effect logistic regression models were used to test differences between sites randomized to prescribe or not prescribe PP-CSF. Results: Between January 2016 and April 2020, 24 sites (2,287 patients) were randomized to the intervention. Among intervention sites, 12 were randomized to either SOE to prescribe or an alert to not prescribe PP-CSF for the 542 patients receiving intermediate FN risk regimens. Rates of PP-CSF use were higher among sites randomized to prescribe PP-CSF (37.1% vs 9.9%, OR = 5.90 (95% CI 1.72-20.20; p = 0.0048)). Overall, the rates of FN were low and identical between PP-CSF and no PP-CSF arms (3.7% vs 3.7%). Among patients who did not receive PP-CSF, rates of FN were also low and similar between arms (3.8% vs 4.1%). Conclusions: While implementation of a SOE intervention for PP-CSF significantly increased PP-CSF use among patients receiving intermediate risk regimens, FN rates did not differ between arms. Despite SOE, 63% of patients assigned to receive PP-CSF did not receive it. FN rates overall were lower than expected and did not differ between patients that did or did not receive PP-CSF. Although this guideline-informed SOE influenced prescribing, the results suggest that neither the SOE nor PP-CSF itself provide sufficient benefit to justify their use for persons receiving intermediate FN risk regimens. Clinical trial information: NCT02728596.

A pragmatic cluster-randomized trial of a computerized clinical decision support system to improve colony stimulating factor prescribing for patients with cancer receiving myelosuppressive chemotherapy (SWOG S1415CD)

1525

Background: Primary prophylactic colony stimulating factors (PP-CSF) are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia (FN). Prior studies have shown that 55-95% of CSF prescribing is inconsistent with practice guidelines. We conducted a cluster randomized trial to determine if guideline-informed standing orders for PP-CSF improved prescribing and reduced the incidence of FN. Methods: Patients age ≥18 with breast, colorectal or non-small cell lung cancer initiating first cancer-directed therapy with NCCN-recommended regimens were eligible. The intervention consisted of automated PP-CSF orders for high FN risk chemotherapy regimens and an alert not to use PP-CSF for low FN risk regimens. Regimen FN risk was based on NCCN guidelines. Clinicians could override the orders. Primary and secondary outcomes were PP-CSF use among patients receiving high and low risk regimens FN incidence within 6 months of initial therapy. Sample size estimates assumed an FN risk of 25% for high-risk chemotherapy. 32 NCI Community Oncology Research Program (NCORP) practices randomized 3:1 to the order entry system (intervention) versus usual care (UC) provided 90% power to detect a 50% reduction in FN at a planned enrollment of 90 patients per site. Mixed effect logistic regression models were used to test differences among randomized sites. 13 practices with pre-existing PP-CSF order sets enrolled in a parallel cohort study. Patients and other stakeholder groups informed study design, conduct and reporting. Results: Between January 2016 and April 2020, 2,946 patients were randomized (2287 intervention, 659 UC); 718 were enrolled in the cohort. Mean age across arms was 58.1. 77% of patients were female; 61% diagnosed with breast cancer. Among patients receiving high-risk regimens, PP-CSF use did not differ between arms (89.2% intervention; 95.8% UC, adjusted p = 0.21) and was similar to the cohort patients (93.0%). The FN rate for high-risk patients was 5.7% in intervention clinics and 4.2% in UC clinics (adjusted p = 0.26); FN was 14.9% among high-risk patients who did not receive PP-CSF. Among patients receiving low-risk regimens, PP-CSF use did not differ between arms (intervention 6.3%, UC 5.5%, adjusted p = 0.74) and was slightly lower than the cohort (8.3%). FN rates did not differ between low risk groups (intervention 1.5%, UC 0.8%, adjusted p = 0.51). Conclusions: Guideline-informed standing orders did not increase PP-CSF use in high-risk patients, nor did it decrease use in low-risk patients. Adherence to guidelines in both risk groups exceeded historical reports. FN rates among patients not receiving PP-CSF were substantially below those reported in CSF guidelines. Automated standing orders for PP-CSF do not appear to be helpful or necessary. Clinical trial information: NCT02728596.

Barriers Associated with Inadequate Follow-up of Abnormal Fecal Immunochemical Test Results in a Safety-Net System: A Mixed-Methods Analysis

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Less than 50% of patients with an abnormal FIT result had a documented reason.

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Patient-level (e.g., declined colonoscopy) reasons were most frequently documented.

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Interviews revealed discordance in documented and patient-reported reasons.

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Mixed-methods analyses are needed to improve colonoscopy after abnormal FIT results.

In safety-net healthcare systems, colonoscopy completion within 1-year of an abnormal fecal immunochemical test (FIT) result rarely exceeds 50%. Understanding how electronic health records (EHR) documented reasons for missed colonoscopy match or differ from patient-reported reasons, is critical to optimize effective interventions to address this challenge. We conducted a convergent mixed-methods study which included a retrospective analysis of EHR data and semi-structured interviews of adults 50–75 years old, with abnormal FIT results between 2014 and 2020 in a large safety-net healthcare system. Of the 299 patients identified, 59.2% (n = 177) did not complete a colonoscopy within one year of their abnormal result. EHR abstraction revealed a documented reason for lack of follow-up colonoscopy in 49.2% (n = 87/177); patient-level (e.g., declined colonoscopy; 51.5%) and multi-factorial reasons (e.g., lost to follow-up; 37.9%) were most common. In 18 patient interviews, patient (e.g., fear of colonoscopy), provider (e.g., lack of result awareness), and system-level reasons (e.g., scheduling challenges) were most common. Only three reasons for lack of colonoscopy overlapped between EHR data and patient interviews (competing health issues, lack of transportation, and abnormal FIT result attributed to another cause). In a cohort of safety-net patients with abnormal FIT results, the most common reasons for lack of follow-up were patient-related. Our analysis revealed a discordance between EHR documented and patient-reported reasons for lack of colonoscopy after an abnormal FIT result. Mixed-methods analyses, as in the present study, may give us the greatest insight into modifiable determinants to develop effective interventions beyond quantitative and qualitative data analysis alone.

Successes and challenges of implementing a cancer care delivery intervention in community oncology practices: lessons learned from SWOG S1415CD

Background

Cancer Care Delivery (CCD) research studies often require practice-level interventions that pose challenges in the clinical trial setting. The SWOG Cancer Research Network (SWOG) conducted S1415CD, one of the first pragmatic cluster-randomized CCD trials to be implemented through the National Cancer Institute (NCI) Community Oncology Program (NCORP), to compare outcomes of primary prophylactic colony stimulating factor (PP-CSF) use for an intervention of automated PP-CSF standing orders to usual care. The introduction of new methods for study implementation created challenges and opportunities for learning that can inform the design and approach of future CCD interventions.

Methods

The order entry system intervention was administered at the site level; sites were affiliated NCORP practices that shared the same chemotherapy order system. 32 sites without existing guideline-based PP-CSF standing orders were randomized to the intervention (n = 24) or to usual care (n = 8). Sites assigned to the intervention participated in tailored training, phone calls and onboarding activities administered by research team staff and were provided with additional funding and external IT support to help them make protocol required changes to their order entry systems.

Results

The average length of time for intervention sites to complete reconfiguration of their order sets following randomization was 7.2 months. 14 of 24 of intervention sites met their individual patient recruitment target of 99 patients enrolled per site.

Conclusions

In this paper we share seven recommendations based on lessons learned from implementation of the S1415CD intervention at NCORP community oncology practices representing diverse geographies and patient populations across the U. S. It is our hope these recommendations can be used to guide future implementation of CCD interventions in both research and community settings.

Trial Registration

NCT02728596, registered April 5, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07835-4.

Operationalizing a Rideshare Intervention for Colonoscopy Completion: Barriers, Facilitators, and Process Recommendations

INTRODUCTION

Transportation is a common barrier to colonoscopy completion for colorectal cancer (CRC) screening. The study aims to identify the barriers, facilitators, and process recommendations to implement a rideshare non-emergency medical transportation (NEMT) intervention following colonoscopy completion within a safety-net healthcare setting.

METHODS

We used informal stakeholder engagement, story boards - a novel user-centered design technique, listening sessions and the nominal group technique to identify the barriers, facilitators, and process to implementing a rideshare NEMT program following colonoscopy completion in a large safety-net healthcare system.

RESULTS

Barriers to implementing a rideshare NEMT intervention for colonoscopy completion included: inability to expand an existing NEMT program beyond Medicaid patients and lack of patient chaperones with rideshare NEMT programs. Facilitators included: commercially available rideshare NEMT platforms that were lower cost and had shorter wait times than the alternative of taxis. Operationalizing and implementing a rideshare NEMT intervention in our healthcare system required the following steps: 1) identifying key stakeholders, 2) engaging stakeholder groups in discussion to identify barriers and solutions, 3) obtaining institutional sign-off, 4) developing a process for reviewing and selecting a rideshare NEMT program, 5) executing contracts, 6) developing a standard operating procedure and 7) training clinic staff to use the rideshare platform.

DISCUSSION

Rideshare NEMT after procedural sedation is administered may improve colonoscopy completion rates and provide one solution to inadequate CRC screening. If successful, our rideshare model could be broadly applicable to other safety-net health systems, populations with high social needs, and settings where procedural sedation is administered.

Perceptions on Barriers and Facilitators to Colonoscopy Completion After Abnormal Fecal Immunochemical Test Results in a Safety Net System

IMPORTANCE

The effectiveness of stool-based colorectal cancer (CRC) screening, including fecal immunochemical tests (FITs), relies on colonoscopy completion among patients with abnormal results, but in safety net systems and federally qualified health centers, in which FIT is frequently used, colonoscopy completion within 1 year of an abnormal result rarely exceeds 50%. Clinician-identified factors in follow-up of abnormal FIT results are understudied and could lead to more effective interventions to address this issue.

OBJECTIVE

To describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results in a safety net health care system.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted using semistructured key informant interviews with primary care physicians (PCPs) and staff members in a large safety net health care system in Washington state. Eligible clinicians were recruited through all-staff meetings and clinic medical directors. Interviews were conducted from February to December 2020 through face-to-face interactions or digital meeting platforms. Interview transcripts were analyzed deductively and inductively using a content analysis approach. Data were analyzed from September through December 2020.

MAIN OUTCOMES AND MEASURES

Barriers and facilitators to colonoscopy completion after an abnormal FIT result were identified by PCPs and staff members.

RESULTS

Among 21 participants, there were 10 PCPs and 11 staff members; 20 participants provided demographic information. The median (interquartile range) age was 38.5 (33.0-51.5) years, 17 (85.0%) were women, and 9 participants (45.0%) spent more than 75% of their working time engaging in patient care. All participants identified social determinants of health, organizational factors, and patient cognitive factors as barriers to colonoscopy completion. Participants suggested that existing resources that addressed these factors facilitated colonoscopy completion but were insufficient to meet national follow-up colonoscopy goals.

CONCLUSIONS AND RELEVANCE

In this qualitative study, responses of interviewed PCPs and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable. These findings suggest that interventions to improve follow-up of abnormal FIT results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion.

Text Message Preferences for Surveillance Colonoscopy Reminders Among Colorectal Cancer Survivors

Background. Surveillance colonoscopy 1-year after colorectal cancer (CRC) surgery effectively reduces CRC mortality, yet less than half of survivors undergo this procedure. Text message reminders can improve CRC screening and other health behaviors, but use of this strategy to address barriers to CRC surveillance has not been reported. Objectives. The goal of this qualitative study was to assess CRC survivor perspectives on barriers to colonoscopy to inform the design of a theory-based, short message service (SMS) intervention to increase surveillance colonoscopy utilization. Method. CRC survivors in Western Washington participated in one of two focus groups to explore perceived barriers to completing surveillance colonoscopy and preferences for SMS communication. Content analysis using codes representative of the health belief model and prospect theory constructs were applied to qualitative data. Results. Thirteen CRC survivors reported individual-, interpersonal-, and system-level barriers to surveillance colonoscopy completion. Participants were receptive to receiving SMS reminders to mitigate these barriers. They suggested that reminders offer supportive, loss-framed messaging; include educational content; and be personalized to communication preferences. Finally, they recommended that reminders begin no earlier than 9 months following CRC surgery and not include response prompts. Conclusions. Our study demonstrates that CRC survivors perceive SMS reminders as an acceptable, valuable tool for CRC surveillance. Furthermore, there may be value in integrating theoretical frameworks to design, implement, and evaluate SMS interventions to address barriers to CRC surveillance. As physicians play a key role in CRC surveillance, provider- and system-level interventions that could additively improve the impact of SMS interventions are also worth exploring.

Feasibility and Validity of Asking Patients to Define Individual Levels of Meaningful Change on Patient-Reported Outcomes

Purpose

Patient-reported outcomes (PROs) are frequently used in clinical care to monitor treatment response. However, most guidelines on PRO use treat all patients the same. This study tested the feasibility and validity of a method for determining individually meaningful change in PRO measures.

Methods

Participants (n=398) completed 12 pain and distress questions to define individually meaningful change. This mixed-methods study used both quantitative and qualitative analyses, including descriptive statistics, inferential statistics, and content analysis.

Results

Two-thirds (67%) of the sample reported at least one medical condition, including depression and back pain. Most participants (70%-90%) were able to answer the questions as intended. Participants varied widely in the amount of change they considered meaningful (coefficients of variation: 40%-99%). Higher symptom levels were associated with larger amounts of change considered meaningful and with greater likelihood of answering questions as intended. Participants reported a variety of reasons for why they considered an amount of change in pain or distress meaningful. The hypothetical nature of the questions and the need to reference previous questions was found to be confusing.

Conclusions

Asking patients to define an individual level for meaningful change on PROs was feasible and valid. Having patients define their own goals on PROs for treatment of pain or distress could make treatment more patient-centered.

Effective stakeholder engagement: design and implementation of a clinical trial (SWOG S1415CD) to improve cancer care

Background

The Fred Hutchinson Cancer Research Center has engaged an External Stakeholder Advisory Group (ESAG) in the planning and implementation of the TrACER Study (S1415CD), a five-year pragmatic clinical trial assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention. The trial is being conducted by SWOG through the National Cancer Institute Community Oncology Research Program in 45 clinics. The ESAG includes ten patient partners, two payers, two pharmacists, two guideline experts, four providers and one medical ethicist. This manuscript describes the ESAG’s role and impact on the trial.

Methods

During early trial development, the research team assembled the ESAG to inform plans for each phase of the trial. ESAG members provide feedback and engage in problem solving to improve trial implementation. Each year, members participate in one in-person meeting, web conferences and targeted email discussion. Additionally, they complete a survey that assesses their satisfaction with communication and collaboration. The research team collected and reviewed stakeholder input from 2014 to 2018 for impact on the trial.

Results

The ESAG has informed trial design, implementation and dissemination planning. The group advised the trial’s endpoints, regimen list and development of cohort and usual care arms. Based on ESAG input, the research team enhanced patient surveys and added pharmacy-related questions to the component application to assess order entry systems. ESAG patient partners collaborated with the research team to develop a patient brochure and study summary for clinic staff. In addition to identifying recruitment strategies and patient-oriented platforms for publicly sharing results, ESAG members participated as co-authors on this manuscript and a conference poster presentation highlighting stakeholder influence on the trial. The annual satisfaction survey results suggest that ESAG members were satisfied with the methods, frequency and target areas of their engagement in the trial during project years 1–3.

Conclusions

Diverse stakeholder engagement has been essential in optimizing the design, implementation and planned dissemination of the TrACER Study. The lessons described in the manuscript may assist others to effectively partner with stakeholders on clinical research.

Impact of clinic characteristics on the adoption of a guideline-based standing order algorithm and patient accrual in the pragmatic cluster-randomized trial SWOG S1415CD (NCT02728596)

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Background: The S1415CD intervention requires the integration of guideline-based prescribing recommendations and standing orders for primary prophylactic colony stimulating factors into existing chemotherapy order systems at community practices within the National Cancer Institute’s Community Oncology Research Program. We looked at the impact of clinic level characteristics on the length of time needed to successfully adopt the intervention and subsequent patient accrual. Methods: We calculated the length of time between randomization and intervention completion for each intervention arm clinic and classified them as short onset (2-5 months, N = 5), medium onset (6-8 months, N = 12) or long onset (10-12 months, N = 7). We compared baseline survey responses about clinic characteristics to onset times. Results: Type of EMR software and the number of chemotherapy regimens reconfigured for the trial had no effect on onset time. All short and medium onset clinics placed orders through an EMR, while 5 of 7 long onset clinics used paper orders. Long onset clinics had less reported nurse involvement in the reconfiguration workflow (change initiation, approval, fulfillment and dissemination) at 14% of clinics vs. 25% of medium onset and 75% of short onset clinics. The average weekly patient accrual rates observed after intervention completion were 1.0 in the short onset (range 0.6-1.5), 0.8 in the medium onset (0.2-1.3) and 0.6 in the long onset (0.1-2.0). Conclusions: When recruiting clinics for trials that require health record system changes, it may be helpful to consider aspects of the system modification workflow such as type of hospital departments involved, as clinics with less nursing involvement may take longer to complete the changes. The inclusion of clinics using different EMR software did not impede onset, but clinics using paper may require more time. Length of onset had no meaningful impact on weekly accrual rates; however, it did determine when clinics could start recruitment, affecting the total number of months clinics could recruit during the study accrual period. Clinical trial information: NCT02728596.

The influence of patient engagement on the design and implementation of a clinical trial to improve cancer care delivery

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Background: We have engaged 10 patient partners in the development and implementation of S1415CD, a five-year pragmatic clinical trial currently in year 3 assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention (NCT02728596). Patient partners serve as part of a 21-person External Stakeholder Advisory Group (ESAG), which also includes providers, payers and guidelines experts. This abstract explores the influence of patient partners on the design, tools and implementation of S1415CD Methods: Patient partners advise the study team on protocol development, patient-facing materials and implementation challenges over four teleconferences each year, annual in-person meetings and targeted email communication. All patient partner input from 2014-2017 was tracked, collected and reviewed for impact on the trial. Results: Input from patient partners led to the refinement of the study’s patient-reported outcome (PRO) survey questions, the creation of a highly utilized patient brochure, and the formation of talking points for clinic staff to help explain the study. Patient partners in conjunction with high performing sites helped develop strategies for sites with lower patient accrual to optimize the approach and consent of study participants. Conclusions: The sustained engagement of patient partners in S1415CD ensured patient-centeredness in trial design and guided the development of PRO surveys and relevant, high quality patient-facing materials. Drawing on experiential knowledge and insights from their roles as caregivers and advocates, patient partners provided valuable feedback that influenced patient approach and engagement in the study. Embedding patient partners in the research continuum has catalyzed critical discussions and problem solving among the patient partners and study team, which has led to patient-centered solutions to study challenges. Clinical trial information: NCT02728596.

From A to Xeloda: Practical considerations for implementing a chemotherapy regimen ordering system intervention

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Background: SWOG S1415CD (NCT02728596) is a pragmatic trial comparing outcomes of colony stimulating factor (CSF) use in usual care with care that uses guideline-informed standing CSF orders for protocol chemotherapy regimens. To develop the regimen list, we reviewed, reconciled, and compiled a comprehensive list of 77 NCCN-recognized core regimens and 40 biologic variants for breast, non-small cell, and colorectal cancer, meant to capture a broad population and variety of practices and settings. The 24 intervention sites chose regimens representative of the 3 febrile neutropenia (FN) risk categories (high, intermediate, low) from the list to reconfigure in prescription ordering systems. The current analysis seeks to determine whether providing a comprehensive list of regimens resulted in increased enrollment of patients. Methods: For each site, we compared how many core regimens the site reconfigured to their average weekly rate of enrollment from date of first patient enrolled to 4/1/2018, controlled for cooperative group type and site-reported volume of breast, non-small cell lung, and colorectal cancer patients. For each regimen, we determined its relative popularity by tallying how many sites chose to reconfigure it for the trial. Results: Sites reconfigured an average of 56% (range: 19%-100%) of core regimens on our list. The 18 most popular core regimens chosen by 83-96% of sites provided enrollment coverage across all FN risk categories for all intervention sites and accounted for 91% of enrollment, although enrollment among those regimens varied widely (0-18% of all patients enrolled). Reconfiguring more regimens did not correlate with higher average weekly enrollment (r < 0.1). Conclusions: Studies that wish to limit the number of regimens may want to focus on the most popular regimens as identified by committee or preliminary polling. Starting from a comprehensive set of regimens for a pragmatic trial focusing on chemotherapy ordering systems takes more time to compile and vet, is more difficult to implement in databases, is a burden to sites to review and reconfigure in ordering systems, and does not necessarily translate to increased enrollment rates. Clinical trial information: NCT02728596.

Implementing an EHR guideline–based intervention in paper ordering systems

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Background: Studies show Colony Stimulating Factor (CSF) prescribing is inconsistent with national guidelines. SWOG trial S1415CD is a pragmatic study comparing outcomes of CSF use in usual care with care that uses guideline-informed standing CSF orders. The intervention includes embedded CSF orders based on Febrile Neutropenia (FN) risk and system note wording describing guideline recommendations. Of 24 intervention sites, five (20.8%) use paper, presenting the challenge of translating an electronic health record (EHR) intervention to paper order entry systems (OES). Methods: Paper sites were surveyed on their chemotherapy OES to inform translation of the intervention. We worked with sites to develop a workflow consistent with the key principles of the intervention: Recommendation language 1) is present before prescribing CSF, 2) reaches all study-authorized orders, 3) reaches all patients on study-authorized orders, and 4) chemotherapy and CSF are ordered before the patient is enrolled. Results: Each site had a distinct workflow that was reworked (Table 1). Paper sites took 4-10 months (average 7.6) for implementation; EHR sites took 1-10 months (average 4.5). Conclusions: Implementing an EHR-centric intervention in paper sites is feasible with appropriate time and resources built into a project to account for the unique challenges. As paper sites represented one fifth of the intervention sites, it is vital to include paper sites in OES interventions for generalizability of results. Clinical trial information: NCT02728596. [Table: see text]

Abstract 2767: Consistency of standing orders for primary prophylactic CSF within a national network of community oncology practices: SWOG intergroup trial S1415CD

BACKGROUND

Among the 400,000 individuals undergoing chemotherapy for breast, colorectal and lung cancer in the US, many are at risk of febrile neutropenia (FN). Prophylactic colony stimulating factor (CSF) use reduces the risk of FN, yet studies show that 55%-95% of CSF prescribing is inconsistent with clinical practice guidelines. There is lack of evidence and ambiguous guidelines for CSF use in regimens with an intermediate risk of FN. To address these issues, we are conducting a pragmatic trial to assess CSF prescribing and to generate evidence about CSF efficacy with intermediate risk regimens. To inform the design and sample size needs, we conducted a survey of current CSF order system use within a large network of community oncology practices.

METHODS

The study setting are sites within the NCI Community Oncology Research Program (NCORP), a national network across the U.S. and Puerto Rico that conducts multi-site cancer clinical trials. Between January-September 2016, 58 NCORP practices were surveyed on their existing systems for prescribing CSF prophylaxis.

RESULTS

8 clinics (14%) reported that their sites do not use any standing orders for CSF prophylaxis prescribing. Standing order set characteristics for the remaining 50 practices are shown in Table 1.

Table 1Summary of CSF standing order implementation in 50 surveyed NCORP clinicsBreast Cancer RegimensNon-Small Cell Lung Cancer RegimensColorectal Cancer RegimensOrder Set CharacteristicDose DenseHigh RiskIntermediate RiskLow RiskIntermediate RiskLow RiskIntermediate RiskLow RiskN (%)N (%)N (%)N (%)N (%)N (%)N (%)N (%)Automatically Included in Order Set (Standing Orders)46 (82%)31 (62%)7 (14%)08 (16%)07 (14%)0Automatically Excluded in Order Set 006 (12%)19 (38%)5 (10%)19 (38%)8 (16%)19 (38%)No automatic ordering- up to physician discretion to add or exclude orders4 (8%)19 (38%)37 (74%)31 (62%)37 (74%)31 (62%)35 (670%)31 (62%)

CONCLUSIONS

We observed wide variation in the current application of standing orders. Intermediate risk regimens had the most inconsistent practices, with a near equal number of clinics choosing either actively including or excluding CSF order sets. The majority of clinics using standing orders included CSF for dose dense and high risk regimens but only 19 (38%) actively excluded CSF for low risk regimens. These results support the need for more evidence to inform clearer guidelines on CSF use in intermediate risk regimens and studies that evaluate the effects of existing CSF standing orders on guideline adherence and patient outcomes.

Funding:PCORI (PCS-1402-09988) and NCORP grant (5UG1CA189974)

Citation Format: Scott Ramsey, Dawn Hershman, Ari Bell-Brown, Kate Watabayashi, Karma Kreizenbeck, Sean Sullivan, Aasthaa Bansal, William Barlow, Kathryn Arnold, Gary Lyman. Consistency of standing orders for primary prophylactic CSF within a national network of community oncology practices: SWOG intergroup trial S1415CD [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2767. doi:10.1158/1538-7445.AM2017-2767