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Purpose: There is no consensus in the oncology community about the optimal model for anticoagulation management of ambulatory cancer patients. To understand oncologists’ preferences regarding anticoagulation management, we compared the characteristics of patients referred to an oncology-oriented anticoagulation management service with ‘‘usual care’’ patients managed by the patient’s primary oncologist. Methods: We performed a retrospective medical record review of ambulatory oncology patients’ anticoagulation care at a comprehensive cancer center. We examined the characteristics of 33 patients anticoagulated before implementation of a dedicated oncology anticoagulation management service. We compared this group with 33 patients managed by the anticoagulation management service and with 39 usual care patients managed by the primary oncologist after the anticoagulation management service was created. We also examined differences in laboratory test utilization, time in the therapeutic range (for patients anticoagulated with warfarin), and anticoagulation-related adverse events during a 3-month assessment period. Results: Anticoagulation management service patients were more likely to be treated for hematologic malignancies, use erythropoietin stimulating agents, and require warfarin management for previous venous thromboembolic disease compared to usual care patients. In contrast, oncologists were more likely to manage anticoagulation care of patients with advanced solid tumors undergoing active chemotherapy. Anticoagulation management service and usual care patients on warfarin therapy had comparable time in the therapeutic range and complication rates. Conclusion: Oncologists selectively referred patients to the anticoagulation management service. Anticoagulation management service patients’ warfarin control and complication rates were comparable to care provided by the primary oncologist, suggesting that an oncology-specific anticoagulation management service may be a feasible and effective option for anticoagulation management of ambulatory oncology patients. [ABSTRACT FROM AUTHOR]

The article discusses a report on the American Society of Clinical Oncology (ASCO) 2010 provider-payer initiative meeting. It states that the goal of ASCO's Provider-Payer Initiative was to establish a forum for open dialogue between medical oncologists and the payer community to promote enhanced shared understanding of the various challenges each stakeholder currently experiences. The participants of this meeting included individuals from the payer community, leaders in innovative case models and systems analysis and ASCO staff, leadership and membership and the agenda focused on areas where there seems to be a relatively easy opportunity for improvement in the quality, efficiency, or total cost of care. Several key themes that emerged from the presentations are discussed.

Purpose: Intensity-modulated radiation therapy (IMRT) limits the dose of radiation to critical normal tissue structures and can be applied to the management of most cancers treated with radiation therapy. Because of increased treatment planning time and quality assurance, IMRT is costly. Blue Cross Blue Shield of Massachusetts (BCBSMA) and the Massachusetts Radiation Oncology Physicians Advisory Council (PAC) developed a strategy to develop standards for the appropriate use of IMRT. Methods: Normal tissue volume guidelines were established in multiple oncology disease areas and body site regions. Guidelines were activated in September 2011, and the use of IMRT per case was tracked quarterly by BCBSMA staff. Results: During the first year of activation of the volume-based guidelines, use of IMRT decreased by 17% in Massachusetts, in contrast to a 20% increase during the previous year. Conclusions: The normal tissue-based guidelines have decreased the use of IMRT in Massachusetts; increased the use of 3D treatment; continued communication between treating radiation oncologists and an insurance organization responsible for cost and quality in medicine; increased cost savings; enabled an efficient appeal process; and provided optimal, cost-effective patient care. This may prove to be an effective model for other disciplines and other developing and maturing radiation technologies. [ABSTRACT FROM AUTHOR]

Introduction: To prevent oral chemotherapy prescription errors, we enhanced a prescription-writing module in an ambulatory electronic medical record. We sought to describe the enhancement, examine its performance to date, and identify opportunities for improvement. Methods: Enhancements to the oral chemotherapy writing module included weight- and body surface area-based dosing, fields for cancer diagnosis and intent of therapy (curative v palliative), and dose-limit warnings. We studied all prescriptions for 18 oral chemotherapies generated by oncology clinicians during the first 17 months after the safe prescribing enhancements were introduced, from May 1, 2010, to October 1, 2011. We examined the frequency with which clinicians used the new features, the number and type of alerts generated, and clinician actions inresponse to alerts. Results: Six hundred clinicians generated 6,673 prescriptions for 2,043 patients. Six drugs-temozolomide, capecitabine, lenalidomide, hydroxyurea, imatinib, and erlotinib-accounted for 5,512 of all oral chemotherapy prescriptions (83%). Prescribers indicated the intent of therapy 13% of the time and listed thepatient's cancer diagnosis 46% of the time. Prescribers customized their instructions using a free-text field in 64% of prescriptions.Clinicians' 6,673 prescription attempts triggered 395dose-limit warnings (5%), mostly for temozolomide. Clinicians ignored most (96%) warnings, because current dosing recommendations exceeded the dose-limit warnings for the alerted medications. Conclusion: Oncology clinicians readily accepted features designed to enhance oral chemotherapy safety. Additional enhancements are needed to facilitate prescriptions with complex dosing regimens and to provide dose-limit warnings that reflect current clinical practice. [ABSTRACT FROM AUTHOR]

Background: To investigate the incidence, characteristics, and predisposing factors for cerebral white matter lesions in patients with Crohn's disease., Methods: We retrospectively evaluated the incidence and characteristics of cerebral T2 white matter abnormalities in 54 patients with Crohn's disease and compared to 100 age-matched controls. We also investigated potential co-morbidities known to be associated with white matter abnormalities in Crohn's patients with normal and abnormal Magnetic Resonance Imaging (MRI)., Results: Seventy-two percent of patients with Crohn's disease had T2 white matter abnormalities, as compared with 34% of the age-matched controls (P < .001). Lesion severity and size were not significantly different between the two groups; however, periventricular distribution and fulfillment of the Barkhof MRI criteria were overrepresented in Crohn's population. History of hypertension, diabetes, and migraine; gender, duration of disease and prior exposure to anti-tumor necrosis factor were not significantly different between Crohn's patients with and without white matter abnormalities; however, patients with lesions were significantly older than those without., Conclusions: Patients with Crohn's disease have a higher incidence of white matter T2 hyperintensities as compared with controls. Age was the only significant factor for the abnormalities within Crohn's group. White matter T2 hyperintensities are likely another extra-intestinal manifestation of Crohn's disease., (Copyright © 2010 by the American Society of Neuroimaging.)

Background: Few models for medication reconciliation in ambulatory primary or specialty care have been described, perhaps because of the special challenges posed by this environment., Methods: Dana-Farber Cancer Institute (Boston) created a reconciliation program that was designed as a patient-clinician partnership intervention. Policies that require clinicians to review and update medication lists at regular appointments were augmented. Clinic assistants printed patients' medication lists from the electronic medical record and distributed lists to established patients for review. Patients provided updated lists to their oncology clinicians. Clinicians then entered the information or indicated changes to be entered by a pharmacist., Results: At baseline, 81% of patients' medication lists included at least one error or omission. With medication reconciliation, 90% of incorrect medication lists were updated. In contrast, only 2% of medication lists were corrected among patients who received "usual" care (p < .001)., Discussion: From the program's inception in November 2005 through August 2007, patients and staff reconciled 24,148 medication lists by making 53,040 changes to 168,475 listed drugs, a rate of 31 changes per 100 medications. Implementation required broad staff engagement and ongoing attention to operational issues.