Objective: Retrospective review of Veterans diagnosed with MPM looking at history of exposure to asbestos, military occupation, active duty service branch, and compensation for disability or ‘service connection’ (SC).

Background: Malignant Pleural Mesothelioma (MPM) is a rare disease that disproportionately affects Veterans. Untreated, this is a rapidly fatal disease with a 6 month median survival. Traditionally, an association between Navy service and MPM in veterans is well established. The Veterans Healthcare Administration (VHA) rewards a full, 100%, compensatory benefit known as SC disability for pleural neoplasms in the setting of asbestos exposure during military service. In 2012, Kuschner et al. from the Palo Alto VA reported that 6% (1/16) of MPM patients at their VA were even told about the possibility of compensation.

Methods: We offer open access, in-network, advice and therapy for Veterans within VHA nationally. After initial phone triage or e-consult, qualified Veterans register at the VABHS. A multidisciplinary team, including experienced MPM thoracic surgeons, pathologists and radiologists, reviews each case and tailor individual treatment plans.

Results: Between 2011 and 2016, we phone-triaged 73 Veterans with suspected MPM. 56 had confirmed MPM and half (50%) served in the U.S. Navy. 39% (16 Army, 3 Marines, 3 Air Force) served in ground or air combat units. There were 2 Veterans from the Coast Guard (4%) and 4 Veterans with unknown service branches (7%). 43 Veterans travelled an average of 1,031 miles to VABHS. 38 of these Veterans have biopsy-proven MPM, which the VHA defines as a disease rewarded 100% SC disability compensation. 3 Veterans are currently being processed by the VHA. There are still significant numbers of Veterans with MPM without SC (see Table 1.)

Conclusion: The majority of Veterans evaluated at the VABHS served in the Navy or Coast Guard, however 39% served in branches not traditionally associated with MPM. Surprisingly, many did not serve in traditional military occupations associated with asbestos exposure. There is an opportunity for improvement in recognizing a ‘service connection’ for veterans with MPM.

Objective: Retrospective review of Veterans diagnosed with MPM looking at history of exposure to asbestos, military occupation, active duty service branch, and compensation for disability or ‘service connection’ (SC).

Background: Malignant Pleural Mesothelioma (MPM) is a rare disease that disproportionately affects Veterans. Untreated, this is a rapidly fatal disease with a 6 month median survival. Traditionally, an association between Navy service and MPM in veterans is well established. The Veterans Healthcare Administration (VHA) rewards a full, 100%, compensatory benefit known as SC disability for pleural neoplasms in the setting of asbestos exposure during military service. In 2012, Kuschner et al. from the Palo Alto VA reported that 6% (1/16) of MPM patients at their VA were even told about the possibility of compensation.

Methods: We offer open access, in-network, advice and therapy for Veterans within VHA nationally. After initial phone triage or e-consult, qualified Veterans register at the VABHS. A multidisciplinary team, including experienced MPM thoracic surgeons, pathologists and radiologists, reviews each case and tailor individual treatment plans.

Results: Between 2011 and 2016, we phone-triaged 73 Veterans with suspected MPM. 56 had confirmed MPM and half (50%) served in the U.S. Navy. 39% (16 Army, 3 Marines, 3 Air Force) served in ground or air combat units. There were 2 Veterans from the Coast Guard (4%) and 4 Veterans with unknown service branches (7%). 43 Veterans travelled an average of 1,031 miles to VABHS. 38 of these Veterans have biopsy-proven MPM, which the VHA defines as a disease rewarded 100% SC disability compensation. 3 Veterans are currently being processed by the VHA. There are still significant numbers of Veterans with MPM without SC (see Table 1.)

Conclusion: The majority of Veterans evaluated at the VABHS served in the Navy or Coast Guard, however 39% served in branches not traditionally associated with MPM. Surprisingly, many did not serve in traditional military occupations associated with asbestos exposure. There is an opportunity for improvement in recognizing a ‘service connection’ for veterans with MPM.

Objective: Retrospective review of Veterans diagnosed with MPM looking at history of exposure to asbestos, military occupation, active duty service branch, and compensation for disability or ‘service connection’ (SC).

Background: Malignant Pleural Mesothelioma (MPM) is a rare disease that disproportionately affects Veterans. Untreated, this is a rapidly fatal disease with a 6 month median survival. Traditionally, an association between Navy service and MPM in veterans is well established. The Veterans Healthcare Administration (VHA) rewards a full, 100%, compensatory benefit known as SC disability for pleural neoplasms in the setting of asbestos exposure during military service. In 2012, Kuschner et al. from the Palo Alto VA reported that 6% (1/16) of MPM patients at their VA were even told about the possibility of compensation.

Methods: We offer open access, in-network, advice and therapy for Veterans within VHA nationally. After initial phone triage or e-consult, qualified Veterans register at the VABHS. A multidisciplinary team, including experienced MPM thoracic surgeons, pathologists and radiologists, reviews each case and tailor individual treatment plans.

Results: Between 2011 and 2016, we phone-triaged 73 Veterans with suspected MPM. 56 had confirmed MPM and half (50%) served in the U.S. Navy. 39% (16 Army, 3 Marines, 3 Air Force) served in ground or air combat units. There were 2 Veterans from the Coast Guard (4%) and 4 Veterans with unknown service branches (7%). 43 Veterans travelled an average of 1,031 miles to VABHS. 38 of these Veterans have biopsy-proven MPM, which the VHA defines as a disease rewarded 100% SC disability compensation. 3 Veterans are currently being processed by the VHA. There are still significant numbers of Veterans with MPM without SC (see Table 1.)

Conclusion: The majority of Veterans evaluated at the VABHS served in the Navy or Coast Guard, however 39% served in branches not traditionally associated with MPM. Surprisingly, many did not serve in traditional military occupations associated with asbestos exposure. There is an opportunity for improvement in recognizing a ‘service connection’ for veterans with MPM.

Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.

We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.

22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).

Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.

Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.

We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.

22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).

Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.

Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.

We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.

22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).

Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.

Background: EGFR and ALK gene mutations differ in frequency in various populations, are more common in young, non-smoking women, and are predictors for response to targeted therapy. The objective of this study was to analyze the clinical characteristics of patients with these mutations, and to compare them to other lung cancer patients.

Methods: We identified 154 lung adenocarcinoma cases diagnosed from 2009-2015, here we present interim data on 100 patients. Baseline demographics, smoking history, exposure to agent orange, pathologic diagnoses, AJCC stage, treatment, and survival data were collected.

Results: At diagnosis, median age was 67 (46-90) years; 96 were male. AJCC stage was 1a (n = 3), 1b (n = 1), 2a (n = 3), 2b (n = 6), 3a (n = 16), 3b (n = 10), 4 (n = 61). 92 were white, 6 African American, and 2 Native American. 95% were smokers; 25 had multiple malignancies and, 22 were exposed to Agent Orange. 84 tumors were tested for EGFR; 78% were negative, 7.5% were positive, and 15% had insufficient material. None of 54 tumors tested for ALK had rearrangement. 68 received chemotherapy. Average survival was 20.7 (range 0-90) months; 16 patients remain alive.

EGFR positive patients includes 4 males and 2 females. 5 were smokers. None was exposed to Agent Orange or had other malignancies. Average age was 66 years (54-79). 3 were AJCC stage IV, 2 stage IIIb and 1 stage IIa. EGFR inhibitor treatment was given to 4 patients, 1 received conventional chemotherapy, and 1 declined treatment. Average survival was 19.6 ( 6-35)months; 2 remain alive.

Conclusions: In our population only a low percentage of patients has EGFR mutation and even fewer have ALK rearrangement. However, a greater proportion of patients with EGFR positive tumors are women (33% vs 4%). Smoking history should not exclude patients from evaluation for targeted therapy. While no difference in survival was observed, this may be due to the small number of patients in the EGFR-inhibitor treated group. A larger study using The National VA Tumor Registry may provide more information to help guide testing and treatment of these patients. Updated data will be presented at the AVAHO Annual Meeting.

Background: EGFR and ALK gene mutations differ in frequency in various populations, are more common in young, non-smoking women, and are predictors for response to targeted therapy. The objective of this study was to analyze the clinical characteristics of patients with these mutations, and to compare them to other lung cancer patients.

Methods: We identified 154 lung adenocarcinoma cases diagnosed from 2009-2015, here we present interim data on 100 patients. Baseline demographics, smoking history, exposure to agent orange, pathologic diagnoses, AJCC stage, treatment, and survival data were collected.

Results: At diagnosis, median age was 67 (46-90) years; 96 were male. AJCC stage was 1a (n = 3), 1b (n = 1), 2a (n = 3), 2b (n = 6), 3a (n = 16), 3b (n = 10), 4 (n = 61). 92 were white, 6 African American, and 2 Native American. 95% were smokers; 25 had multiple malignancies and, 22 were exposed to Agent Orange. 84 tumors were tested for EGFR; 78% were negative, 7.5% were positive, and 15% had insufficient material. None of 54 tumors tested for ALK had rearrangement. 68 received chemotherapy. Average survival was 20.7 (range 0-90) months; 16 patients remain alive.

EGFR positive patients includes 4 males and 2 females. 5 were smokers. None was exposed to Agent Orange or had other malignancies. Average age was 66 years (54-79). 3 were AJCC stage IV, 2 stage IIIb and 1 stage IIa. EGFR inhibitor treatment was given to 4 patients, 1 received conventional chemotherapy, and 1 declined treatment. Average survival was 19.6 ( 6-35)months; 2 remain alive.

Conclusions: In our population only a low percentage of patients has EGFR mutation and even fewer have ALK rearrangement. However, a greater proportion of patients with EGFR positive tumors are women (33% vs 4%). Smoking history should not exclude patients from evaluation for targeted therapy. While no difference in survival was observed, this may be due to the small number of patients in the EGFR-inhibitor treated group. A larger study using The National VA Tumor Registry may provide more information to help guide testing and treatment of these patients. Updated data will be presented at the AVAHO Annual Meeting.

Background: EGFR and ALK gene mutations differ in frequency in various populations, are more common in young, non-smoking women, and are predictors for response to targeted therapy. The objective of this study was to analyze the clinical characteristics of patients with these mutations, and to compare them to other lung cancer patients.

Methods: We identified 154 lung adenocarcinoma cases diagnosed from 2009-2015, here we present interim data on 100 patients. Baseline demographics, smoking history, exposure to agent orange, pathologic diagnoses, AJCC stage, treatment, and survival data were collected.

Results: At diagnosis, median age was 67 (46-90) years; 96 were male. AJCC stage was 1a (n = 3), 1b (n = 1), 2a (n = 3), 2b (n = 6), 3a (n = 16), 3b (n = 10), 4 (n = 61). 92 were white, 6 African American, and 2 Native American. 95% were smokers; 25 had multiple malignancies and, 22 were exposed to Agent Orange. 84 tumors were tested for EGFR; 78% were negative, 7.5% were positive, and 15% had insufficient material. None of 54 tumors tested for ALK had rearrangement. 68 received chemotherapy. Average survival was 20.7 (range 0-90) months; 16 patients remain alive.

EGFR positive patients includes 4 males and 2 females. 5 were smokers. None was exposed to Agent Orange or had other malignancies. Average age was 66 years (54-79). 3 were AJCC stage IV, 2 stage IIIb and 1 stage IIa. EGFR inhibitor treatment was given to 4 patients, 1 received conventional chemotherapy, and 1 declined treatment. Average survival was 19.6 ( 6-35)months; 2 remain alive.

Conclusions: In our population only a low percentage of patients has EGFR mutation and even fewer have ALK rearrangement. However, a greater proportion of patients with EGFR positive tumors are women (33% vs 4%). Smoking history should not exclude patients from evaluation for targeted therapy. While no difference in survival was observed, this may be due to the small number of patients in the EGFR-inhibitor treated group. A larger study using The National VA Tumor Registry may provide more information to help guide testing and treatment of these patients. Updated data will be presented at the AVAHO Annual Meeting.

Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.

Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status,  chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.

To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.

Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.

Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.

Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.

Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.

Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status,  chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.

To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.

Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.

Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.

Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.

Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.

Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status,  chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.

To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.

Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.

Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.

Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.

Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.

Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.

Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).

Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.

Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.

Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.

Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).

Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.

Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.

Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.

Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).

Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.

Background: There are a variety of treatments available for patients with stage IV colon cancer. Chemotherapy is the usual treatment, with greater amounts of surgery being associated with more aggressive hospitals. Income can play a role in the type of treatment a patient receives, or if they even receive treatment at all (Baldwin et al. 2005).

Methods: First course treatment received by stage IV colon cancer patients of Veterans Affair Hospitals (VAH) and all other hospital types were compared using the National Cancer Data Base (NCDB). Patient’ 2012 income and type of treatment provided were examined. Treatment types included chemotherapy, surgery, no treatment, etc. Data from 45 VAH with 2,667 patients and 1,543 non-VA affiliated hospitals with 144,575 patients were utilized. Chi-squared analysis was conducted to calculate statistical significance.

Results: The NCDB reveals noticeable differences between VAH and all other hospitals in percentages of stage IV colon cancer patients receiving treatment. 25.3% of VAH patients received no treatment while 16.9% of patients at all other hospitals received no treatment (P < .05). More VAH patients received solely chemotherapy compared to patients at other hospitals (21.2% vs 15.9%, P < .05). VAH patients had less surgery compared to patients at all other hospitals (47.2% vs 59.4%, P < .05). These effects were present at all income levels.

Implications: VAH patients were more likely to receive no treatment compared to patients at all other hospitals. Furthermore, VAH patients were less likely to receive aggressive surgical care compared to other hospitals. These results imply that VAH patients are more likely to receive no treatment in comparison to other hospitals, as well as less likely to receive aggressive care when treatment is given. Differences in care seen between hospital types were not influenced by income.

Background: There are a variety of treatments available for patients with stage IV colon cancer. Chemotherapy is the usual treatment, with greater amounts of surgery being associated with more aggressive hospitals. Income can play a role in the type of treatment a patient receives, or if they even receive treatment at all (Baldwin et al. 2005).

Methods: First course treatment received by stage IV colon cancer patients of Veterans Affair Hospitals (VAH) and all other hospital types were compared using the National Cancer Data Base (NCDB). Patient’ 2012 income and type of treatment provided were examined. Treatment types included chemotherapy, surgery, no treatment, etc. Data from 45 VAH with 2,667 patients and 1,543 non-VA affiliated hospitals with 144,575 patients were utilized. Chi-squared analysis was conducted to calculate statistical significance.

Results: The NCDB reveals noticeable differences between VAH and all other hospitals in percentages of stage IV colon cancer patients receiving treatment. 25.3% of VAH patients received no treatment while 16.9% of patients at all other hospitals received no treatment (P < .05). More VAH patients received solely chemotherapy compared to patients at other hospitals (21.2% vs 15.9%, P < .05). VAH patients had less surgery compared to patients at all other hospitals (47.2% vs 59.4%, P < .05). These effects were present at all income levels.

Implications: VAH patients were more likely to receive no treatment compared to patients at all other hospitals. Furthermore, VAH patients were less likely to receive aggressive surgical care compared to other hospitals. These results imply that VAH patients are more likely to receive no treatment in comparison to other hospitals, as well as less likely to receive aggressive care when treatment is given. Differences in care seen between hospital types were not influenced by income.

Background: There are a variety of treatments available for patients with stage IV colon cancer. Chemotherapy is the usual treatment, with greater amounts of surgery being associated with more aggressive hospitals. Income can play a role in the type of treatment a patient receives, or if they even receive treatment at all (Baldwin et al. 2005).

Methods: First course treatment received by stage IV colon cancer patients of Veterans Affair Hospitals (VAH) and all other hospital types were compared using the National Cancer Data Base (NCDB). Patient’ 2012 income and type of treatment provided were examined. Treatment types included chemotherapy, surgery, no treatment, etc. Data from 45 VAH with 2,667 patients and 1,543 non-VA affiliated hospitals with 144,575 patients were utilized. Chi-squared analysis was conducted to calculate statistical significance.

Results: The NCDB reveals noticeable differences between VAH and all other hospitals in percentages of stage IV colon cancer patients receiving treatment. 25.3% of VAH patients received no treatment while 16.9% of patients at all other hospitals received no treatment (P < .05). More VAH patients received solely chemotherapy compared to patients at other hospitals (21.2% vs 15.9%, P < .05). VAH patients had less surgery compared to patients at all other hospitals (47.2% vs 59.4%, P < .05). These effects were present at all income levels.

Implications: VAH patients were more likely to receive no treatment compared to patients at all other hospitals. Furthermore, VAH patients were less likely to receive aggressive surgical care compared to other hospitals. These results imply that VAH patients are more likely to receive no treatment in comparison to other hospitals, as well as less likely to receive aggressive care when treatment is given. Differences in care seen between hospital types were not influenced by income.

Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.

Methods: Standard project management techniques and descriptive statistics were used.

Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.

Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.

Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.

Methods: Standard project management techniques and descriptive statistics were used.

Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.

Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.

Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.

Methods: Standard project management techniques and descriptive statistics were used.

Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.

Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

I sit down at patients’ eye level during patient visits and use a team brochure/personal business card for all new patients.

Why I Do It

One of the major concerns expressed by patients is the time spent with them by their provider. Sitting down at patients’ eye level lets them know that you are not in a hurry and you are there to give them whatever time they need. Sitting also causes your patients to perceive that you spent more time with them than if you spent the same amount of time while standing. This practice is not only advocated by patient-care consultants but is something I had reinforced during my firsthand experience as a patient several years ago when I had a surgical procedure. Every time the surgeon came into my hospital room, he sat in the chair, leisurely crossed his legs, and spoke to me from that position while writing in the chart. I knew exactly what he was doing, and it still made a difference to me! It put me more at ease and made me feel that he was there for me, ready to give me whatever time I needed and answer any questions that I had (and I had them). Sitting also puts you on an even level with your patients so they feel that you are talking with them, not down to them. This eases tension, adds comfort and trust to the situation, and is much more engaging.

How I Do It

After I greet patients, I look for a place to sit. If there is a chair, I pull it over to the bedside, sit in a relaxed manner, and continue the visit. If there is no chair in the room, I will sit on the windowsill, the bedside table (I have even been known to lower the bedside tray table and sit on the end with the support post if there is room on it), or whatever I can utilize to physically put myself on patients’ level. As a last resort, as long as there is not an isolatable infection, I will ask permission to sit on the edge of the bed. I make a point of telling them during this process that I am looking for a place to sit and talk so that they know this is my goal.

After the initial conversation and exam, if the patients are new to the service, I walk them through our team brochure and reiterate how we act as their PCP in the hospital and how we communicate with their PCP. I also make a point to show the team photo roster, which personalizes our team to patients, and say, “I also want you to have one of my baseball cards. We call our business cards ‘baseball cards’ because they have our pictures and a lot of ‘stats’ on them: our training, personal interests. That way, you know more about the person who is helping to take care of you.” I almost always see these cards out on patients’ trays or bedside tables on subsequent visits. Patients seem appreciative of the cards and the information. If I see another provider’s baseball card, I will ask patients a question about that provider as a way to continue to foster relations between our patients and our team. The more our patients can relate to us, the more they will trust us and the better their experience will be. TH

Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

I sit down at patients’ eye level during patient visits and use a team brochure/personal business card for all new patients.

Why I Do It

One of the major concerns expressed by patients is the time spent with them by their provider. Sitting down at patients’ eye level lets them know that you are not in a hurry and you are there to give them whatever time they need. Sitting also causes your patients to perceive that you spent more time with them than if you spent the same amount of time while standing. This practice is not only advocated by patient-care consultants but is something I had reinforced during my firsthand experience as a patient several years ago when I had a surgical procedure. Every time the surgeon came into my hospital room, he sat in the chair, leisurely crossed his legs, and spoke to me from that position while writing in the chart. I knew exactly what he was doing, and it still made a difference to me! It put me more at ease and made me feel that he was there for me, ready to give me whatever time I needed and answer any questions that I had (and I had them). Sitting also puts you on an even level with your patients so they feel that you are talking with them, not down to them. This eases tension, adds comfort and trust to the situation, and is much more engaging.

How I Do It

After I greet patients, I look for a place to sit. If there is a chair, I pull it over to the bedside, sit in a relaxed manner, and continue the visit. If there is no chair in the room, I will sit on the windowsill, the bedside table (I have even been known to lower the bedside tray table and sit on the end with the support post if there is room on it), or whatever I can utilize to physically put myself on patients’ level. As a last resort, as long as there is not an isolatable infection, I will ask permission to sit on the edge of the bed. I make a point of telling them during this process that I am looking for a place to sit and talk so that they know this is my goal.

After the initial conversation and exam, if the patients are new to the service, I walk them through our team brochure and reiterate how we act as their PCP in the hospital and how we communicate with their PCP. I also make a point to show the team photo roster, which personalizes our team to patients, and say, “I also want you to have one of my baseball cards. We call our business cards ‘baseball cards’ because they have our pictures and a lot of ‘stats’ on them: our training, personal interests. That way, you know more about the person who is helping to take care of you.” I almost always see these cards out on patients’ trays or bedside tables on subsequent visits. Patients seem appreciative of the cards and the information. If I see another provider’s baseball card, I will ask patients a question about that provider as a way to continue to foster relations between our patients and our team. The more our patients can relate to us, the more they will trust us and the better their experience will be. TH

Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

I sit down at patients’ eye level during patient visits and use a team brochure/personal business card for all new patients.

Why I Do It

One of the major concerns expressed by patients is the time spent with them by their provider. Sitting down at patients’ eye level lets them know that you are not in a hurry and you are there to give them whatever time they need. Sitting also causes your patients to perceive that you spent more time with them than if you spent the same amount of time while standing. This practice is not only advocated by patient-care consultants but is something I had reinforced during my firsthand experience as a patient several years ago when I had a surgical procedure. Every time the surgeon came into my hospital room, he sat in the chair, leisurely crossed his legs, and spoke to me from that position while writing in the chart. I knew exactly what he was doing, and it still made a difference to me! It put me more at ease and made me feel that he was there for me, ready to give me whatever time I needed and answer any questions that I had (and I had them). Sitting also puts you on an even level with your patients so they feel that you are talking with them, not down to them. This eases tension, adds comfort and trust to the situation, and is much more engaging.

How I Do It

After I greet patients, I look for a place to sit. If there is a chair, I pull it over to the bedside, sit in a relaxed manner, and continue the visit. If there is no chair in the room, I will sit on the windowsill, the bedside table (I have even been known to lower the bedside tray table and sit on the end with the support post if there is room on it), or whatever I can utilize to physically put myself on patients’ level. As a last resort, as long as there is not an isolatable infection, I will ask permission to sit on the edge of the bed. I make a point of telling them during this process that I am looking for a place to sit and talk so that they know this is my goal.

After the initial conversation and exam, if the patients are new to the service, I walk them through our team brochure and reiterate how we act as their PCP in the hospital and how we communicate with their PCP. I also make a point to show the team photo roster, which personalizes our team to patients, and say, “I also want you to have one of my baseball cards. We call our business cards ‘baseball cards’ because they have our pictures and a lot of ‘stats’ on them: our training, personal interests. That way, you know more about the person who is helping to take care of you.” I almost always see these cards out on patients’ trays or bedside tables on subsequent visits. Patients seem appreciative of the cards and the information. If I see another provider’s baseball card, I will ask patients a question about that provider as a way to continue to foster relations between our patients and our team. The more our patients can relate to us, the more they will trust us and the better their experience will be. TH

Dr. Sharp is a chief hospitalist with Sound Physicians at UF Health in Jacksonville, Fla.

Purpose: To disseminate information regarding the Louis Stokes Cleveland VAMC process for CT guided bone marrow aspiration and biopsies (BMAB).

Relevant Background/Problem: With timely access to quality care at the forefront of many VA-based initiatives we sought to decrease wait times for new patients with hematology concerns. Upon review of clinic utilization we recognized that many established patients requiring BMAB were scheduled into a new patient slot to allow enough time for the procedure. At the same time, our colleagues in Interventional Radiology (IR) approached us regarding the feasibility of performing BMAB using CT guidance.

Methods: We performed a retrospective review of all BMAB done between September 2014 and August 2015 before the IR guided procedure was offered to determine number of procedures performed. We then examined those cases performed from September 2015 to June 2016 after rollout of IR guided BMAB to determine numbers of cases, location of procedure (IR versus Hematology/Oncology), operator (IR versus staff versus fellow), and complications.

Data Analysis: From September 2014 to August 2015, 211 BMAB were performed, averaging 17 per month. From September 2015 to June 2016, 207 BMAB were performed with an average of 20 per month. During the latter time period, 50% of BMAB were performed using IR guidance with the other 50% performed by either Hematology/Oncology staff or fellows. There were no complications reported regardless of location and operator. Exposure to radiation dose was extremely low.

Results: IR guided BMAB is a safe and feasible option for patients and Hematology/Oncology providers.

Implications: IR guided BMAB can be one option to decompress already overbooked Hematology/Oncology clinics and to provide quicker access to care for patients with newly diagnosed hematologic and oncologic conditions.

Purpose: To disseminate information regarding the Louis Stokes Cleveland VAMC process for CT guided bone marrow aspiration and biopsies (BMAB).

Relevant Background/Problem: With timely access to quality care at the forefront of many VA-based initiatives we sought to decrease wait times for new patients with hematology concerns. Upon review of clinic utilization we recognized that many established patients requiring BMAB were scheduled into a new patient slot to allow enough time for the procedure. At the same time, our colleagues in Interventional Radiology (IR) approached us regarding the feasibility of performing BMAB using CT guidance.

Methods: We performed a retrospective review of all BMAB done between September 2014 and August 2015 before the IR guided procedure was offered to determine number of procedures performed. We then examined those cases performed from September 2015 to June 2016 after rollout of IR guided BMAB to determine numbers of cases, location of procedure (IR versus Hematology/Oncology), operator (IR versus staff versus fellow), and complications.

Data Analysis: From September 2014 to August 2015, 211 BMAB were performed, averaging 17 per month. From September 2015 to June 2016, 207 BMAB were performed with an average of 20 per month. During the latter time period, 50% of BMAB were performed using IR guidance with the other 50% performed by either Hematology/Oncology staff or fellows. There were no complications reported regardless of location and operator. Exposure to radiation dose was extremely low.

Results: IR guided BMAB is a safe and feasible option for patients and Hematology/Oncology providers.

Implications: IR guided BMAB can be one option to decompress already overbooked Hematology/Oncology clinics and to provide quicker access to care for patients with newly diagnosed hematologic and oncologic conditions.

Purpose: To disseminate information regarding the Louis Stokes Cleveland VAMC process for CT guided bone marrow aspiration and biopsies (BMAB).

Relevant Background/Problem: With timely access to quality care at the forefront of many VA-based initiatives we sought to decrease wait times for new patients with hematology concerns. Upon review of clinic utilization we recognized that many established patients requiring BMAB were scheduled into a new patient slot to allow enough time for the procedure. At the same time, our colleagues in Interventional Radiology (IR) approached us regarding the feasibility of performing BMAB using CT guidance.

Methods: We performed a retrospective review of all BMAB done between September 2014 and August 2015 before the IR guided procedure was offered to determine number of procedures performed. We then examined those cases performed from September 2015 to June 2016 after rollout of IR guided BMAB to determine numbers of cases, location of procedure (IR versus Hematology/Oncology), operator (IR versus staff versus fellow), and complications.

Data Analysis: From September 2014 to August 2015, 211 BMAB were performed, averaging 17 per month. From September 2015 to June 2016, 207 BMAB were performed with an average of 20 per month. During the latter time period, 50% of BMAB were performed using IR guidance with the other 50% performed by either Hematology/Oncology staff or fellows. There were no complications reported regardless of location and operator. Exposure to radiation dose was extremely low.

Results: IR guided BMAB is a safe and feasible option for patients and Hematology/Oncology providers.

Implications: IR guided BMAB can be one option to decompress already overbooked Hematology/Oncology clinics and to provide quicker access to care for patients with newly diagnosed hematologic and oncologic conditions.

Background: CSP 380-Risk Factors for Large Colonic Adenomas, a screening colonoscopy study, enrolled 3,121 patients from 1994-97 at 13 VA sites. We report 10 year outcomes based on risk group after baseline colonoscopy.

Methods: Asymptomatic veterans age 50-75 who had not undergone colorectal cancer (CRC) screening in the prior 10 years underwent colonoscopy and were classified into 6 risk groups: no neoplasia, 1-2 small adenomas, 3-10 adenomas, > 10 adenomas, advanced adenoma (polyp ≥ 1 cm, villous histology, or high grade dysplasia), and CRC. Subjects were followed for 10 years until death or last colonoscopy. We report the proportions who developed advanced neoplasia (AN, defined as advanced adenoma or CRC) and CRC.

Results: Of the patients enrolled, 1,917 had at least one follow-up colonoscopy. Of these 1,917, 933 had no neoplasia at baseline; 4.0% developed AN, including 0.8% with CRC. At baseline, 560 patients had 1-2 small adenomas; 5.9% developed AN, including 0.9% with CRC. For those with 3-10 adenomas (134), 15.7% developed AN, including 0.7% with CRC. Two had > 10 adenomas; neither developed AN or CRC. At baseline, 265 patients had advanced adenoma; 19.2% developed AN, including 1.9% with CRC. Twenty-three patients had baseline CRC; 34.8% developed AN, including 21.7% with CRC. Patients with baseline CRC were at highest risk of developing AN. Those with advanced adenoma or 3-10 adenomas were at moderate risk. Those with no neoplasia or 1-2 small adenomas were at lowest risk. Except for those with baseline CRC, all risk groups showed a dramatic decline in CRC incidence after 3 years, with 10-year CRC risk similar to those with no neoplasia at baseline.

Conclusion: 1) Baseline colonoscopy result is a predictor of future risk for AN. 2) Those with baseline CRC remain at risk for recurrence. Intensive surveillance is warranted. 3) Those with 1-2 small adenomas or no adenomas at baseline have a low risk of AN after 2-3 years, and may not need surveillance. 4) Those with baseline advanced adenoma or > 3 adenomas show a dramatic decline in CRC risk after 3 years, suggesting that frequent surveillance may only be necessary in the first 5 years.

Background: CSP 380-Risk Factors for Large Colonic Adenomas, a screening colonoscopy study, enrolled 3,121 patients from 1994-97 at 13 VA sites. We report 10 year outcomes based on risk group after baseline colonoscopy.

Methods: Asymptomatic veterans age 50-75 who had not undergone colorectal cancer (CRC) screening in the prior 10 years underwent colonoscopy and were classified into 6 risk groups: no neoplasia, 1-2 small adenomas, 3-10 adenomas, > 10 adenomas, advanced adenoma (polyp ≥ 1 cm, villous histology, or high grade dysplasia), and CRC. Subjects were followed for 10 years until death or last colonoscopy. We report the proportions who developed advanced neoplasia (AN, defined as advanced adenoma or CRC) and CRC.

Results: Of the patients enrolled, 1,917 had at least one follow-up colonoscopy. Of these 1,917, 933 had no neoplasia at baseline; 4.0% developed AN, including 0.8% with CRC. At baseline, 560 patients had 1-2 small adenomas; 5.9% developed AN, including 0.9% with CRC. For those with 3-10 adenomas (134), 15.7% developed AN, including 0.7% with CRC. Two had > 10 adenomas; neither developed AN or CRC. At baseline, 265 patients had advanced adenoma; 19.2% developed AN, including 1.9% with CRC. Twenty-three patients had baseline CRC; 34.8% developed AN, including 21.7% with CRC. Patients with baseline CRC were at highest risk of developing AN. Those with advanced adenoma or 3-10 adenomas were at moderate risk. Those with no neoplasia or 1-2 small adenomas were at lowest risk. Except for those with baseline CRC, all risk groups showed a dramatic decline in CRC incidence after 3 years, with 10-year CRC risk similar to those with no neoplasia at baseline.

Conclusion: 1) Baseline colonoscopy result is a predictor of future risk for AN. 2) Those with baseline CRC remain at risk for recurrence. Intensive surveillance is warranted. 3) Those with 1-2 small adenomas or no adenomas at baseline have a low risk of AN after 2-3 years, and may not need surveillance. 4) Those with baseline advanced adenoma or > 3 adenomas show a dramatic decline in CRC risk after 3 years, suggesting that frequent surveillance may only be necessary in the first 5 years.

Background: CSP 380-Risk Factors for Large Colonic Adenomas, a screening colonoscopy study, enrolled 3,121 patients from 1994-97 at 13 VA sites. We report 10 year outcomes based on risk group after baseline colonoscopy.

Methods: Asymptomatic veterans age 50-75 who had not undergone colorectal cancer (CRC) screening in the prior 10 years underwent colonoscopy and were classified into 6 risk groups: no neoplasia, 1-2 small adenomas, 3-10 adenomas, > 10 adenomas, advanced adenoma (polyp ≥ 1 cm, villous histology, or high grade dysplasia), and CRC. Subjects were followed for 10 years until death or last colonoscopy. We report the proportions who developed advanced neoplasia (AN, defined as advanced adenoma or CRC) and CRC.

Results: Of the patients enrolled, 1,917 had at least one follow-up colonoscopy. Of these 1,917, 933 had no neoplasia at baseline; 4.0% developed AN, including 0.8% with CRC. At baseline, 560 patients had 1-2 small adenomas; 5.9% developed AN, including 0.9% with CRC. For those with 3-10 adenomas (134), 15.7% developed AN, including 0.7% with CRC. Two had > 10 adenomas; neither developed AN or CRC. At baseline, 265 patients had advanced adenoma; 19.2% developed AN, including 1.9% with CRC. Twenty-three patients had baseline CRC; 34.8% developed AN, including 21.7% with CRC. Patients with baseline CRC were at highest risk of developing AN. Those with advanced adenoma or 3-10 adenomas were at moderate risk. Those with no neoplasia or 1-2 small adenomas were at lowest risk. Except for those with baseline CRC, all risk groups showed a dramatic decline in CRC incidence after 3 years, with 10-year CRC risk similar to those with no neoplasia at baseline.

Conclusion: 1) Baseline colonoscopy result is a predictor of future risk for AN. 2) Those with baseline CRC remain at risk for recurrence. Intensive surveillance is warranted. 3) Those with 1-2 small adenomas or no adenomas at baseline have a low risk of AN after 2-3 years, and may not need surveillance. 4) Those with baseline advanced adenoma or > 3 adenomas show a dramatic decline in CRC risk after 3 years, suggesting that frequent surveillance may only be necessary in the first 5 years.