Impact of immunotherapy best practice alert on physician awareness of immune-related adverse events and patient outcomes in the urgent and emergent care setting.

Abstract

e13540 Background: Immune checkpoint inhibitors (ICI) are used to treat a wide range of malignancies and can provoke inflammatory side effects in any organ system. These immune-related adverse events (irAEs) are graded in severity according to the Common Terminology Criteria for Adverse Events (CTCAE) which serves as the basis for strategic toxicity management. Cancer patients treated with ICIs often present to urgent care (UC) and emergency room (ER) settings for CTCAE grade 2-4 irAEs. Providers in these settings need to recognize these irAEs as the treatment differs from chemotherapy toxicity management. Best practice alerts (BPAs) have been integrated in the electronic health record (EHR) to raise provider awareness to patients’ unique risk factors and improve patient outcomes. For example, a BPA for patients prescribed second generation antipsychotics led to more in-hospital providers ordering the appropriate laboratory studies to screen for metabolic derangements. Here, we describe our retrospective institutional protocol for the assessment of provider awareness and patient outcomes prior to and after the implementation of a BPA for patients receiving ICIs and presenting to an UC or ER with symptoms attributable to irAEs. Methods: Our institution will implement a BPA that identifies patients treated with ICIs within 6 months of presentation to an institutional UC or ER. The BPA will require providers to check a yes/no box asking if they considered an irAE in the differential diagnosis for the patient’s presenting symptom prior to advancing in the EHR. The BPA will include a hyperlink to the current American Society of Clinical Oncology guidelines for management of irAEs. After BPA implementation we will retrospectively analyze the EHR of patients treated with ICIs who presented to an institutional UC or ER for the time periods of 6-months prior to and after the implementation of the BPA. Our analysis will include review of the UC/ER providers’ differential diagnoses, imaging and laboratory studies, subspecialty consultations, and treatments provided. Our primary endpoint will be the quantification of patients diagnosed with an irAE at presentation both prior to and after implementation of the BPA. The secondary endpoints will include quantification of patients who received guideline-based management of irAEs in the UC/ER setting, time to resolution of symptoms to CTCAE grade 1 or less, and analysis of subspecialist involvement in the management of an identified irAE. We plan to use the Chi-squared method to observe for statistical significance of endpoints between the pre- and post- periods of BPA implementation. Our aim is to demonstrate the utility of a BPA in promoting the appropriate assessment and management of irAEs in cancer patients receiving checkpoint immunotherapies.