Clinical Review

BACKGROUND: Timely hospice care in oncology improves end-of-life care, decreases hospitalizations, improves quality of life and satisfaction. However, collaborative practice of palliative care and oncology remains inconsistent, resulting in absent or delayed hospice services. Short hospice length of service is a marker of poor quality of care and end-user dissatisfaction. Most Americans desire end-of-life care in their homes; however, most of them receive their end-of-life care in hospitals.

HYPOTHESIS: A collaborative oncology-palliative care clinic model improves access to hospice care.

INTERVENTION: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:
(1) Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
(2) Shared palliative care and oncology clinic appointments;
(3) Introduction of palliative care for every new oncology clinic patient, for advance care planning;
(4) Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management;
(5) Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

MEASUREMENTS: In December 2019, we conducted a retrospective review of all Veterans seen in oncologypalliative care clinic during FY2018-FY2019 with specific attention to community hospice referrals, hospice length of stay, and location of Veterans’ death.

RESULTS: Of a total of 189 Veterans seen in this clinic in FY18-FY19, at the time of review.
(1) 68 (36%) Veterans accessed hospice care.
(2) Of 71 deceased Veterans, 59 (83%) died on hospice (Medicare data: 50%).
(3) Average length of stay on hospice was 64 days (other studies: 48 days).
(4) Compared to other studies, our longer hospice stay was consistent across various cancers: lung (75 vs. 40 days), prostate (69 vs. 48 days), pancreas (40 vs. 32 days), colorectal (140 vs. 46 days).
(5) Of Veterans who died on hospice care, 30 (51%) died at home (other studies: 25%).

CONCLUSION: Our intervention improved access to hospice care in cancer care.

FUTURE IMPLICATIONS: (1) Impact of this intervention of cost of end-of-life care.
(2) Future innovative clinic models for delivery of collaborative comprehensive care for complex nee

BACKGROUND: Timely hospice care in oncology improves end-of-life care, decreases hospitalizations, improves quality of life and satisfaction. However, collaborative practice of palliative care and oncology remains inconsistent, resulting in absent or delayed hospice services. Short hospice length of service is a marker of poor quality of care and end-user dissatisfaction. Most Americans desire end-of-life care in their homes; however, most of them receive their end-of-life care in hospitals.

HYPOTHESIS: A collaborative oncology-palliative care clinic model improves access to hospice care.

INTERVENTION: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:
(1) Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
(2) Shared palliative care and oncology clinic appointments;
(3) Introduction of palliative care for every new oncology clinic patient, for advance care planning;
(4) Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management;
(5) Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

MEASUREMENTS: In December 2019, we conducted a retrospective review of all Veterans seen in oncologypalliative care clinic during FY2018-FY2019 with specific attention to community hospice referrals, hospice length of stay, and location of Veterans’ death.

RESULTS: Of a total of 189 Veterans seen in this clinic in FY18-FY19, at the time of review.
(1) 68 (36%) Veterans accessed hospice care.
(2) Of 71 deceased Veterans, 59 (83%) died on hospice (Medicare data: 50%).
(3) Average length of stay on hospice was 64 days (other studies: 48 days).
(4) Compared to other studies, our longer hospice stay was consistent across various cancers: lung (75 vs. 40 days), prostate (69 vs. 48 days), pancreas (40 vs. 32 days), colorectal (140 vs. 46 days).
(5) Of Veterans who died on hospice care, 30 (51%) died at home (other studies: 25%).

CONCLUSION: Our intervention improved access to hospice care in cancer care.

FUTURE IMPLICATIONS: (1) Impact of this intervention of cost of end-of-life care.
(2) Future innovative clinic models for delivery of collaborative comprehensive care for complex nee

BACKGROUND: Timely hospice care in oncology improves end-of-life care, decreases hospitalizations, improves quality of life and satisfaction. However, collaborative practice of palliative care and oncology remains inconsistent, resulting in absent or delayed hospice services. Short hospice length of service is a marker of poor quality of care and end-user dissatisfaction. Most Americans desire end-of-life care in their homes; however, most of them receive their end-of-life care in hospitals.

HYPOTHESIS: A collaborative oncology-palliative care clinic model improves access to hospice care.

INTERVENTION: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:
(1) Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
(2) Shared palliative care and oncology clinic appointments;
(3) Introduction of palliative care for every new oncology clinic patient, for advance care planning;
(4) Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management;
(5) Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

MEASUREMENTS: In December 2019, we conducted a retrospective review of all Veterans seen in oncologypalliative care clinic during FY2018-FY2019 with specific attention to community hospice referrals, hospice length of stay, and location of Veterans’ death.

RESULTS: Of a total of 189 Veterans seen in this clinic in FY18-FY19, at the time of review.
(1) 68 (36%) Veterans accessed hospice care.
(2) Of 71 deceased Veterans, 59 (83%) died on hospice (Medicare data: 50%).
(3) Average length of stay on hospice was 64 days (other studies: 48 days).
(4) Compared to other studies, our longer hospice stay was consistent across various cancers: lung (75 vs. 40 days), prostate (69 vs. 48 days), pancreas (40 vs. 32 days), colorectal (140 vs. 46 days).
(5) Of Veterans who died on hospice care, 30 (51%) died at home (other studies: 25%).

CONCLUSION: Our intervention improved access to hospice care in cancer care.

FUTURE IMPLICATIONS: (1) Impact of this intervention of cost of end-of-life care.
(2) Future innovative clinic models for delivery of collaborative comprehensive care for complex nee

A 70-year-old veteran followed in clinic for metastatic castration-resistant prostate cancer (mCRPC) was found to have a new left axillary lymph node conglomerate on routine imaging, despite stable PSA on Enzalutamide therapy. Biopsy of the axillary mass showed metastatic neuroendocrine carcinoma, with a differential diagnosis of small cell carcinoma of unknown primary vs. Merkel Cell Carcinoma (MCC). Given his prostate cancer diagnosis and the rarity of MCC, small cell differentiation of prostate cancer was initially favored. However, the patient appeared well and subsequent PET/CT only showed two subcutaneous hypermetabolic lesions. These findings would be unusual with small cell differentiation of prostate cancer. A second biopsy of a subcutaneous lesion was most consistent with MCC, confirming our diagnosis.

At time of diagnosis, staging MRI Brain revealed 3 parenchymal brain lesions, presumed to be metastatic MCC. As per a landmark trial by Nghiem et al, the patient was started on Pembrolizumab 2 mg/kg every three weeks for treatment of metastatic MCC. Brain lesions were locally treated with stereotactic radiosurgery (SRS).

Although his mCRPC was under good control with Enzalutamide, this drug is associated with increased risk of seizures in clinical trial and is not recommended for those with predisposing seizure risk. In light of MCC brain metastases, we decided to switch mCRPC therapy to Darolutamide, an androgen receptor antagonist that has lower penetration of the blood-brain barrier and less incidence of seizures. He tolerated the combination of Darolutamide with Pembrolizumab well, with only a grade 1 acneiform rash.

After just 1 cycle of Pembrolizumab, the patient’s clinically-evident MCC drastically regressed. After 8 months of treatment, his MCC continues to respond clinically and radiographically. This case emphasizes the importance of not relying on “Occam’s razor” – that one should assume a single diagnosis for multiple findings. The simplest explanation of the patient’s left axillary mass biopsy would have been small cell differentiation of prostate cancer; however, this has proved to be a synchronous MCC, which portends a much more favorable prognosis with immunotherapy treatment. We also demonstrate a successful approach to concurrent treatment of metastatic MCC and mCRPC.

A 70-year-old veteran followed in clinic for metastatic castration-resistant prostate cancer (mCRPC) was found to have a new left axillary lymph node conglomerate on routine imaging, despite stable PSA on Enzalutamide therapy. Biopsy of the axillary mass showed metastatic neuroendocrine carcinoma, with a differential diagnosis of small cell carcinoma of unknown primary vs. Merkel Cell Carcinoma (MCC). Given his prostate cancer diagnosis and the rarity of MCC, small cell differentiation of prostate cancer was initially favored. However, the patient appeared well and subsequent PET/CT only showed two subcutaneous hypermetabolic lesions. These findings would be unusual with small cell differentiation of prostate cancer. A second biopsy of a subcutaneous lesion was most consistent with MCC, confirming our diagnosis.

At time of diagnosis, staging MRI Brain revealed 3 parenchymal brain lesions, presumed to be metastatic MCC. As per a landmark trial by Nghiem et al, the patient was started on Pembrolizumab 2 mg/kg every three weeks for treatment of metastatic MCC. Brain lesions were locally treated with stereotactic radiosurgery (SRS).

Although his mCRPC was under good control with Enzalutamide, this drug is associated with increased risk of seizures in clinical trial and is not recommended for those with predisposing seizure risk. In light of MCC brain metastases, we decided to switch mCRPC therapy to Darolutamide, an androgen receptor antagonist that has lower penetration of the blood-brain barrier and less incidence of seizures. He tolerated the combination of Darolutamide with Pembrolizumab well, with only a grade 1 acneiform rash.

After just 1 cycle of Pembrolizumab, the patient’s clinically-evident MCC drastically regressed. After 8 months of treatment, his MCC continues to respond clinically and radiographically. This case emphasizes the importance of not relying on “Occam’s razor” – that one should assume a single diagnosis for multiple findings. The simplest explanation of the patient’s left axillary mass biopsy would have been small cell differentiation of prostate cancer; however, this has proved to be a synchronous MCC, which portends a much more favorable prognosis with immunotherapy treatment. We also demonstrate a successful approach to concurrent treatment of metastatic MCC and mCRPC.

A 70-year-old veteran followed in clinic for metastatic castration-resistant prostate cancer (mCRPC) was found to have a new left axillary lymph node conglomerate on routine imaging, despite stable PSA on Enzalutamide therapy. Biopsy of the axillary mass showed metastatic neuroendocrine carcinoma, with a differential diagnosis of small cell carcinoma of unknown primary vs. Merkel Cell Carcinoma (MCC). Given his prostate cancer diagnosis and the rarity of MCC, small cell differentiation of prostate cancer was initially favored. However, the patient appeared well and subsequent PET/CT only showed two subcutaneous hypermetabolic lesions. These findings would be unusual with small cell differentiation of prostate cancer. A second biopsy of a subcutaneous lesion was most consistent with MCC, confirming our diagnosis.

At time of diagnosis, staging MRI Brain revealed 3 parenchymal brain lesions, presumed to be metastatic MCC. As per a landmark trial by Nghiem et al, the patient was started on Pembrolizumab 2 mg/kg every three weeks for treatment of metastatic MCC. Brain lesions were locally treated with stereotactic radiosurgery (SRS).

Although his mCRPC was under good control with Enzalutamide, this drug is associated with increased risk of seizures in clinical trial and is not recommended for those with predisposing seizure risk. In light of MCC brain metastases, we decided to switch mCRPC therapy to Darolutamide, an androgen receptor antagonist that has lower penetration of the blood-brain barrier and less incidence of seizures. He tolerated the combination of Darolutamide with Pembrolizumab well, with only a grade 1 acneiform rash.

After just 1 cycle of Pembrolizumab, the patient’s clinically-evident MCC drastically regressed. After 8 months of treatment, his MCC continues to respond clinically and radiographically. This case emphasizes the importance of not relying on “Occam’s razor” – that one should assume a single diagnosis for multiple findings. The simplest explanation of the patient’s left axillary mass biopsy would have been small cell differentiation of prostate cancer; however, this has proved to be a synchronous MCC, which portends a much more favorable prognosis with immunotherapy treatment. We also demonstrate a successful approach to concurrent treatment of metastatic MCC and mCRPC.

PURPOSE: Analysis of data from nearly 150 VA medical centers over a three-year period in 2019 by the Partnership for Public Service and the Boston Consulting Group showed a statistically significant link between employee engagement and patient satisfaction. Schwartz Rounds, sponsored by the national Schwartz Center for Compassionate Healthcare, offer a way to engage providers in an interdisciplinary dialogue and improve communication (the Joint Commission lists Schwartz Rounds as a recommended resource for this purpose). Schwartz Rounds are currently held at a number of VA medical centers, but there is limited data on their effectiveness in the VA. The purpose of this initiative was to establish Schwartz Rounds at VA Connecticut and assess its effectiveness in engaging providers and improving communication.

BACKGROUND: Schwartz Rounds provide an opportunity to discuss the social and emotional issues providers face in caring for patients and families. In contrast to traditional medical rounds, the focus is on the human dimension of medicine. Providers have an opportunity to share their experiences, thoughts and feelings on diverse topics, often drawn from patient cases. Schwartz Rounds have been shown to enhance providers’ teamwork, decrease their perceived stress and improve their ability to cope with the psychosocial demands of care (Lown, 2010).

RESULTS: We initiated quarterly Schwartz Rounds at VA Connecticut in early 2020. They are based in our Cancer Center but coordinated through Hospital Education and open to all employees, and CME is available. We have held two sessions to date, the second via Webex due to COVID-19. We collected detailed survey data from participants after each session. Feedback was positive with 79% and 65% of respondents rating the sessions as excellent, 95% and 90% reporting feeling less isolated, and 100% at both sessions reporting feeling better prepared to understand the experiences of and communicate with colleagues.

CONCLUSIONS: Schwartz Rounds at VA Connecticut have been well received and effective in engaging providers. Preliminary data suggests a positive impact on well-being and relationships with colleagues. This forum may help VA medical centers improve multidisciplinary employee engagement and communication, goals that have become even more important during the recent pandemic.

PURPOSE: Analysis of data from nearly 150 VA medical centers over a three-year period in 2019 by the Partnership for Public Service and the Boston Consulting Group showed a statistically significant link between employee engagement and patient satisfaction. Schwartz Rounds, sponsored by the national Schwartz Center for Compassionate Healthcare, offer a way to engage providers in an interdisciplinary dialogue and improve communication (the Joint Commission lists Schwartz Rounds as a recommended resource for this purpose). Schwartz Rounds are currently held at a number of VA medical centers, but there is limited data on their effectiveness in the VA. The purpose of this initiative was to establish Schwartz Rounds at VA Connecticut and assess its effectiveness in engaging providers and improving communication.

BACKGROUND: Schwartz Rounds provide an opportunity to discuss the social and emotional issues providers face in caring for patients and families. In contrast to traditional medical rounds, the focus is on the human dimension of medicine. Providers have an opportunity to share their experiences, thoughts and feelings on diverse topics, often drawn from patient cases. Schwartz Rounds have been shown to enhance providers’ teamwork, decrease their perceived stress and improve their ability to cope with the psychosocial demands of care (Lown, 2010).

RESULTS: We initiated quarterly Schwartz Rounds at VA Connecticut in early 2020. They are based in our Cancer Center but coordinated through Hospital Education and open to all employees, and CME is available. We have held two sessions to date, the second via Webex due to COVID-19. We collected detailed survey data from participants after each session. Feedback was positive with 79% and 65% of respondents rating the sessions as excellent, 95% and 90% reporting feeling less isolated, and 100% at both sessions reporting feeling better prepared to understand the experiences of and communicate with colleagues.

CONCLUSIONS: Schwartz Rounds at VA Connecticut have been well received and effective in engaging providers. Preliminary data suggests a positive impact on well-being and relationships with colleagues. This forum may help VA medical centers improve multidisciplinary employee engagement and communication, goals that have become even more important during the recent pandemic.

PURPOSE: Analysis of data from nearly 150 VA medical centers over a three-year period in 2019 by the Partnership for Public Service and the Boston Consulting Group showed a statistically significant link between employee engagement and patient satisfaction. Schwartz Rounds, sponsored by the national Schwartz Center for Compassionate Healthcare, offer a way to engage providers in an interdisciplinary dialogue and improve communication (the Joint Commission lists Schwartz Rounds as a recommended resource for this purpose). Schwartz Rounds are currently held at a number of VA medical centers, but there is limited data on their effectiveness in the VA. The purpose of this initiative was to establish Schwartz Rounds at VA Connecticut and assess its effectiveness in engaging providers and improving communication.

BACKGROUND: Schwartz Rounds provide an opportunity to discuss the social and emotional issues providers face in caring for patients and families. In contrast to traditional medical rounds, the focus is on the human dimension of medicine. Providers have an opportunity to share their experiences, thoughts and feelings on diverse topics, often drawn from patient cases. Schwartz Rounds have been shown to enhance providers’ teamwork, decrease their perceived stress and improve their ability to cope with the psychosocial demands of care (Lown, 2010).

RESULTS: We initiated quarterly Schwartz Rounds at VA Connecticut in early 2020. They are based in our Cancer Center but coordinated through Hospital Education and open to all employees, and CME is available. We have held two sessions to date, the second via Webex due to COVID-19. We collected detailed survey data from participants after each session. Feedback was positive with 79% and 65% of respondents rating the sessions as excellent, 95% and 90% reporting feeling less isolated, and 100% at both sessions reporting feeling better prepared to understand the experiences of and communicate with colleagues.

CONCLUSIONS: Schwartz Rounds at VA Connecticut have been well received and effective in engaging providers. Preliminary data suggests a positive impact on well-being and relationships with colleagues. This forum may help VA medical centers improve multidisciplinary employee engagement and communication, goals that have become even more important during the recent pandemic.

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.