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Impact of Pharmacist-Driven Telemedicine Services in Hematopoietic Stem Cell Transplant (HSCT) Long-term Care Clinic in a Veteran Population
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Discontinuation of Allopurinol for Tumor Lysis Syndrome Report
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Blood type linked to higher risk for early onset stroke
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
FROM NEUROLOGY
Impact of Insurance Status on Survival in Hurthle Cell Carcinoma: A National Cancer Database (NCDB) Analysis
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Demographics in Early vs Late-Stage Laryngeal Squamous Cell Carcinoma: A NCDB Review
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Disparities in Palliative Care Utilization in Malignant Mixed Mullerian Tumor: A National Cancer Database (NCDB) Study
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Creation of a National Virtual Tumor Board Through the National TeleOncology Service
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.
Development of an Informatics Infrastructure and Frontend Dashboard for Monitoring Clinical Operations of the National TeleOncology Service
Background
Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.
Methods
The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.
Results
The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.
Conclusions
An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.
- Esquer Rochin MA, Gutierrez-Garcia JO, Rosales JH, Rodriguez LF. Design and evaluation of a dashboard to support the comprehension of the progression.
Background
Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.
Methods
The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.
Results
The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.
Conclusions
An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.
Background
Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.
Methods
The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.
Results
The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.
Conclusions
An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.
- Esquer Rochin MA, Gutierrez-Garcia JO, Rosales JH, Rodriguez LF. Design and evaluation of a dashboard to support the comprehension of the progression.
- Esquer Rochin MA, Gutierrez-Garcia JO, Rosales JH, Rodriguez LF. Design and evaluation of a dashboard to support the comprehension of the progression.
Myeloid Neoplasm Masquerading as Hypereosinophilia and Sweet Syndrome
Introduction
Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.
Case Presentation
A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.
Discussion
Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.
Conclusions
Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.
Introduction
Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.
Case Presentation
A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.
Discussion
Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.
Conclusions
Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.
Introduction
Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.
Case Presentation
A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.
Discussion
Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.
Conclusions
Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.
Gastrointestinal Stromal Tumor Arising From the Small Intestine in a Heart Transplant Recipient on Hemodialysis and Chronic Immunosuppression: A Case Report
Background
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.
Presentation
A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.
Diagnosis and Treatment
The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.
After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.
Conclusion
To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.
Background
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.
Presentation
A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.
Diagnosis and Treatment
The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.
After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.
Conclusion
To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.
Background
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.
Presentation
A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.
Diagnosis and Treatment
The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.
After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.
Conclusion
To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.