Das D

Background: The utilization of oral chemotherapy agents is becoming increasingly widespread due to expanding indications in the oncology world. This change represents a shift in managing patients with cancer from intermittent intravenous therapy to self-administered chronic oral therapy which presents unique issues regarding patient safety. A previous study conducted in Toronto, Canada showed that the formation of a multidisciplinary oral chemotherapy clinic helped improve patient outcomes (Disperati et al, 2017).

To address these concerns at our facility, an oral chemotherapy clinic was implemented to provide closer monitoring of patients on oral chemotherapeutic agents. The pharmacy driven oral chemotherapy clinic includes a multidisciplinary team of an oncology pharmacist, oncology physicians, and support staff. The oncology pharmacist provides counseling on proper medication administration, ensures medication adherence, and manages adverse drug events.

Physicians collaborate with the oncology pharmacist to enroll patients into the clinic by placing an intrafacility consult. Referred patients may be newly starting oral chemotherapy or continuing an oral chemotherapy regimen. Patients are not eligible if partial care is provided by a community oncologist. Pharmacist appointments may be face to face or telephone and are in addition to routine physician provider visits.

Results: After the first 4 months of initiating the oral chemotherapy clinic, there were 10 patients enrolled. There were 22 documented interventions, 16 pharmacist interventions and 6 physician interventions. The most common pharmacist interventions included medication adjustments and initiation of supplemental medications to treat adverse events. Patients engaged in 49 encounters, including 17 traditional visits, 21 oral chemotherapy clinic visits, 8 scheduled telehealth visits, and 3 unscheduled telehealth visits with only 1 emergency department visit. Notably, no emergency visits were due to a patient’s oral chemotherapy regimen.

Additional outcomes were analyzed showing 100% patient compliance, 100% proper renal/hepatic dosing and the oral chemo clinic achieved 84% appropriate lab monitoring (improved from 36% in the control group).

Implications: A multidisciplinary approach and integrating the pharmacist run oral chemotherapy clinic improved patient monitoring, drug compliance and patient access to care. With these positive results, we hope to expand the program and incorporate a fulltime pharmacist.

Background: The utilization of oral chemotherapy agents is becoming increasingly widespread due to expanding indications in the oncology world. This change represents a shift in managing patients with cancer from intermittent intravenous therapy to self-administered chronic oral therapy which presents unique issues regarding patient safety. A previous study conducted in Toronto, Canada showed that the formation of a multidisciplinary oral chemotherapy clinic helped improve patient outcomes (Disperati et al, 2017).

To address these concerns at our facility, an oral chemotherapy clinic was implemented to provide closer monitoring of patients on oral chemotherapeutic agents. The pharmacy driven oral chemotherapy clinic includes a multidisciplinary team of an oncology pharmacist, oncology physicians, and support staff. The oncology pharmacist provides counseling on proper medication administration, ensures medication adherence, and manages adverse drug events.

Physicians collaborate with the oncology pharmacist to enroll patients into the clinic by placing an intrafacility consult. Referred patients may be newly starting oral chemotherapy or continuing an oral chemotherapy regimen. Patients are not eligible if partial care is provided by a community oncologist. Pharmacist appointments may be face to face or telephone and are in addition to routine physician provider visits.

Results: After the first 4 months of initiating the oral chemotherapy clinic, there were 10 patients enrolled. There were 22 documented interventions, 16 pharmacist interventions and 6 physician interventions. The most common pharmacist interventions included medication adjustments and initiation of supplemental medications to treat adverse events. Patients engaged in 49 encounters, including 17 traditional visits, 21 oral chemotherapy clinic visits, 8 scheduled telehealth visits, and 3 unscheduled telehealth visits with only 1 emergency department visit. Notably, no emergency visits were due to a patient’s oral chemotherapy regimen.

Additional outcomes were analyzed showing 100% patient compliance, 100% proper renal/hepatic dosing and the oral chemo clinic achieved 84% appropriate lab monitoring (improved from 36% in the control group).

Implications: A multidisciplinary approach and integrating the pharmacist run oral chemotherapy clinic improved patient monitoring, drug compliance and patient access to care. With these positive results, we hope to expand the program and incorporate a fulltime pharmacist.

Background: The utilization of oral chemotherapy agents is becoming increasingly widespread due to expanding indications in the oncology world. This change represents a shift in managing patients with cancer from intermittent intravenous therapy to self-administered chronic oral therapy which presents unique issues regarding patient safety. A previous study conducted in Toronto, Canada showed that the formation of a multidisciplinary oral chemotherapy clinic helped improve patient outcomes (Disperati et al, 2017).

To address these concerns at our facility, an oral chemotherapy clinic was implemented to provide closer monitoring of patients on oral chemotherapeutic agents. The pharmacy driven oral chemotherapy clinic includes a multidisciplinary team of an oncology pharmacist, oncology physicians, and support staff. The oncology pharmacist provides counseling on proper medication administration, ensures medication adherence, and manages adverse drug events.

Physicians collaborate with the oncology pharmacist to enroll patients into the clinic by placing an intrafacility consult. Referred patients may be newly starting oral chemotherapy or continuing an oral chemotherapy regimen. Patients are not eligible if partial care is provided by a community oncologist. Pharmacist appointments may be face to face or telephone and are in addition to routine physician provider visits.

Results: After the first 4 months of initiating the oral chemotherapy clinic, there were 10 patients enrolled. There were 22 documented interventions, 16 pharmacist interventions and 6 physician interventions. The most common pharmacist interventions included medication adjustments and initiation of supplemental medications to treat adverse events. Patients engaged in 49 encounters, including 17 traditional visits, 21 oral chemotherapy clinic visits, 8 scheduled telehealth visits, and 3 unscheduled telehealth visits with only 1 emergency department visit. Notably, no emergency visits were due to a patient’s oral chemotherapy regimen.

Additional outcomes were analyzed showing 100% patient compliance, 100% proper renal/hepatic dosing and the oral chemo clinic achieved 84% appropriate lab monitoring (improved from 36% in the control group).

Implications: A multidisciplinary approach and integrating the pharmacist run oral chemotherapy clinic improved patient monitoring, drug compliance and patient access to care. With these positive results, we hope to expand the program and incorporate a fulltime pharmacist.

Introduction: Advancements in genomic profiling now allow for routine comprehensive somatic genomic alteration testing in all patients with advanced cancer. A subset of patients will have targetable genomic alterations, though the frequency of these alterations and the efficacy of the matched treatments have varied amongst published data. Several commercially available platforms exist, but the ideal method to appropriately interpret and apply this data across various clinical tumor types and disease stages is still unclear.

Methods: We obtained a list of all the next generation sequencing (NGS) panels submitted from our center to the National Precision Oncology Program (NPOP). A total of 53 patients were included in the analysis. We analyzed the most frequently altered genes, the tumor types most frequently profiled, the frequency of cases with targetable alterations, and the efficacy of the matched treatments in individual patients. We also compared the number and types of alterations reported as well as the length of reports generated by the three different commercial NGS platforms used in our cohort.

Results: A total of 19/53 (35.8%) patients had targetable alterations. Five out of 21 (23.8%) received a targeted therapy. Non-small cell lung cancer [NSCLC] (n = 14; 26%) and prostate cancer (n=9; 17%) were the most frequently profiled tumors. In the NSCLC cohort, 7/14 (50%) had targetable alterations, including two patients in whom a prior single gene test for the specific alteration [EGFR, BRAF] was negative. NGS panels produced on average 6.6-13.0 alterations per patient, and average report length ranged from 8.3-19.0 pages.

Conclusions: NGS testing has been implemented by providers across a variety of tumor types at our institution, though the number of patients receiving matched treatments is low. Reflexive serial single-gene testing in NSCLC for EGFR, ALK, ROS1, and BRAF is likely reducing the number of NGS panels sent in these patients. Two false-negative single gene tests in our small cohort suggests we are underdiagnosing driver alterations in these patients with this approach. We would suggest exploring decision support tools and provider education in order to encourage judicious and clinically meaningful use of this valuable resource.

Introduction: Advancements in genomic profiling now allow for routine comprehensive somatic genomic alteration testing in all patients with advanced cancer. A subset of patients will have targetable genomic alterations, though the frequency of these alterations and the efficacy of the matched treatments have varied amongst published data. Several commercially available platforms exist, but the ideal method to appropriately interpret and apply this data across various clinical tumor types and disease stages is still unclear.

Methods: We obtained a list of all the next generation sequencing (NGS) panels submitted from our center to the National Precision Oncology Program (NPOP). A total of 53 patients were included in the analysis. We analyzed the most frequently altered genes, the tumor types most frequently profiled, the frequency of cases with targetable alterations, and the efficacy of the matched treatments in individual patients. We also compared the number and types of alterations reported as well as the length of reports generated by the three different commercial NGS platforms used in our cohort.

Results: A total of 19/53 (35.8%) patients had targetable alterations. Five out of 21 (23.8%) received a targeted therapy. Non-small cell lung cancer [NSCLC] (n = 14; 26%) and prostate cancer (n=9; 17%) were the most frequently profiled tumors. In the NSCLC cohort, 7/14 (50%) had targetable alterations, including two patients in whom a prior single gene test for the specific alteration [EGFR, BRAF] was negative. NGS panels produced on average 6.6-13.0 alterations per patient, and average report length ranged from 8.3-19.0 pages.

Conclusions: NGS testing has been implemented by providers across a variety of tumor types at our institution, though the number of patients receiving matched treatments is low. Reflexive serial single-gene testing in NSCLC for EGFR, ALK, ROS1, and BRAF is likely reducing the number of NGS panels sent in these patients. Two false-negative single gene tests in our small cohort suggests we are underdiagnosing driver alterations in these patients with this approach. We would suggest exploring decision support tools and provider education in order to encourage judicious and clinically meaningful use of this valuable resource.

Introduction: Advancements in genomic profiling now allow for routine comprehensive somatic genomic alteration testing in all patients with advanced cancer. A subset of patients will have targetable genomic alterations, though the frequency of these alterations and the efficacy of the matched treatments have varied amongst published data. Several commercially available platforms exist, but the ideal method to appropriately interpret and apply this data across various clinical tumor types and disease stages is still unclear.

Methods: We obtained a list of all the next generation sequencing (NGS) panels submitted from our center to the National Precision Oncology Program (NPOP). A total of 53 patients were included in the analysis. We analyzed the most frequently altered genes, the tumor types most frequently profiled, the frequency of cases with targetable alterations, and the efficacy of the matched treatments in individual patients. We also compared the number and types of alterations reported as well as the length of reports generated by the three different commercial NGS platforms used in our cohort.

Results: A total of 19/53 (35.8%) patients had targetable alterations. Five out of 21 (23.8%) received a targeted therapy. Non-small cell lung cancer [NSCLC] (n = 14; 26%) and prostate cancer (n=9; 17%) were the most frequently profiled tumors. In the NSCLC cohort, 7/14 (50%) had targetable alterations, including two patients in whom a prior single gene test for the specific alteration [EGFR, BRAF] was negative. NGS panels produced on average 6.6-13.0 alterations per patient, and average report length ranged from 8.3-19.0 pages.

Conclusions: NGS testing has been implemented by providers across a variety of tumor types at our institution, though the number of patients receiving matched treatments is low. Reflexive serial single-gene testing in NSCLC for EGFR, ALK, ROS1, and BRAF is likely reducing the number of NGS panels sent in these patients. Two false-negative single gene tests in our small cohort suggests we are underdiagnosing driver alterations in these patients with this approach. We would suggest exploring decision support tools and provider education in order to encourage judicious and clinically meaningful use of this valuable resource.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Purpose: To streamline the diagnostic evaluation of lung cancer.

Background: Lung cancer remains the leading cause of cancer death in the United States. Although more than half of cases present with metastatic disease, prognosis is still poor for earlier stage tumors. While most guidelines recommend a multidisciplinary approach to the diagnostic evaluation, recommendations and data for the timeliness of the process are lacking. Highly specialized diagnostic imaging tests and procedures are required to make the diagnosis, which can result in delays in the initiation of treatment. In the metastatic setting, the emergence of immunotherapies and targeted therapies requires additional tissue testing for predictive biomarkers and molecular alterations, increasing the importance of adequate biopsy specimens and tissue preservation. We reviewed the diagnostic evaluation process at our hospital in order to formulate a Plan, Do, Study, Act (PDSA) quality improvement project aimed at improving the efficiency of our process.

Methods: We performed a retrospective analysis of all cases of non-small cell lung cancer (NSCLC) diagnosed at the Birmingham VA Medical Center (BVAMC) from 2015-2017. Cases for which the entire evaluation was not performed at BVAMC were excluded. Outcomes of interest were time from imaging suggestive of lung cancer (T1) to pathologic diagnosis (T2) and to date of first treatment (T3).

Results: At the time of data submission, 171 cases had been analyzed. Mean time from suspicious imaging to pathologic diagnosis (T1-T2) was 59.5 days. Mean time from pathologic diagnosis to treatment initiation (T2-T3) was 69.4 days. Mean time spent in the diagnostic evaluation
(T1-T3) was 128.9 days. The data will be stratified further to identify opportunities for improvement. We have since instituted a multidisciplinary lung tumor board and are using CPRS-based tracking software to prospectively analyze cases and improve the efficiency of our process.

Conclusions: The diagnostic evaluation of lung cancer is a multi-step process, and unique factors contribute to delays at each step. It is essential to have a multidisciplinary team to help identify, predict and alleviate these barriers. Analysis of other variables including age, performance status, pulmonary function tests (PFTs), smoking, number of biopsies performed and utilization of positive emission tomography (PET) scans is underway.

Purpose: To streamline the diagnostic evaluation of lung cancer.

Background: Lung cancer remains the leading cause of cancer death in the United States. Although more than half of cases present with metastatic disease, prognosis is still poor for earlier stage tumors. While most guidelines recommend a multidisciplinary approach to the diagnostic evaluation, recommendations and data for the timeliness of the process are lacking. Highly specialized diagnostic imaging tests and procedures are required to make the diagnosis, which can result in delays in the initiation of treatment. In the metastatic setting, the emergence of immunotherapies and targeted therapies requires additional tissue testing for predictive biomarkers and molecular alterations, increasing the importance of adequate biopsy specimens and tissue preservation. We reviewed the diagnostic evaluation process at our hospital in order to formulate a Plan, Do, Study, Act (PDSA) quality improvement project aimed at improving the efficiency of our process.

Methods: We performed a retrospective analysis of all cases of non-small cell lung cancer (NSCLC) diagnosed at the Birmingham VA Medical Center (BVAMC) from 2015-2017. Cases for which the entire evaluation was not performed at BVAMC were excluded. Outcomes of interest were time from imaging suggestive of lung cancer (T1) to pathologic diagnosis (T2) and to date of first treatment (T3).

Results: At the time of data submission, 171 cases had been analyzed. Mean time from suspicious imaging to pathologic diagnosis (T1-T2) was 59.5 days. Mean time from pathologic diagnosis to treatment initiation (T2-T3) was 69.4 days. Mean time spent in the diagnostic evaluation
(T1-T3) was 128.9 days. The data will be stratified further to identify opportunities for improvement. We have since instituted a multidisciplinary lung tumor board and are using CPRS-based tracking software to prospectively analyze cases and improve the efficiency of our process.

Conclusions: The diagnostic evaluation of lung cancer is a multi-step process, and unique factors contribute to delays at each step. It is essential to have a multidisciplinary team to help identify, predict and alleviate these barriers. Analysis of other variables including age, performance status, pulmonary function tests (PFTs), smoking, number of biopsies performed and utilization of positive emission tomography (PET) scans is underway.

Purpose: To streamline the diagnostic evaluation of lung cancer.

Background: Lung cancer remains the leading cause of cancer death in the United States. Although more than half of cases present with metastatic disease, prognosis is still poor for earlier stage tumors. While most guidelines recommend a multidisciplinary approach to the diagnostic evaluation, recommendations and data for the timeliness of the process are lacking. Highly specialized diagnostic imaging tests and procedures are required to make the diagnosis, which can result in delays in the initiation of treatment. In the metastatic setting, the emergence of immunotherapies and targeted therapies requires additional tissue testing for predictive biomarkers and molecular alterations, increasing the importance of adequate biopsy specimens and tissue preservation. We reviewed the diagnostic evaluation process at our hospital in order to formulate a Plan, Do, Study, Act (PDSA) quality improvement project aimed at improving the efficiency of our process.

Methods: We performed a retrospective analysis of all cases of non-small cell lung cancer (NSCLC) diagnosed at the Birmingham VA Medical Center (BVAMC) from 2015-2017. Cases for which the entire evaluation was not performed at BVAMC were excluded. Outcomes of interest were time from imaging suggestive of lung cancer (T1) to pathologic diagnosis (T2) and to date of first treatment (T3).

Results: At the time of data submission, 171 cases had been analyzed. Mean time from suspicious imaging to pathologic diagnosis (T1-T2) was 59.5 days. Mean time from pathologic diagnosis to treatment initiation (T2-T3) was 69.4 days. Mean time spent in the diagnostic evaluation
(T1-T3) was 128.9 days. The data will be stratified further to identify opportunities for improvement. We have since instituted a multidisciplinary lung tumor board and are using CPRS-based tracking software to prospectively analyze cases and improve the efficiency of our process.

Conclusions: The diagnostic evaluation of lung cancer is a multi-step process, and unique factors contribute to delays at each step. It is essential to have a multidisciplinary team to help identify, predict and alleviate these barriers. Analysis of other variables including age, performance status, pulmonary function tests (PFTs), smoking, number of biopsies performed and utilization of positive emission tomography (PET) scans is underway.