Trainee-led quality improvement (QI) project examining PCP prophylaxis in patients on chronic, high-dose corticosteroids.

Abstract

e23211 Background: Patients with cancer who develop Pneumocystis pneumonia (PCP) have 30-day mortality rates estimated to be > 50%. Despite consensus guidelines from the American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA), appropriate PCP prophylaxis is reported as low as 3.9% for patients with solid malignancies on chronic, high-dose corticosteroids. In this trainee-led QI initiative, we investigated rates of appropriate PCP prophylaxis at a tertiary care cancer center and surveyed clinicians regarding barriers to prescribing prophylaxis. Methods: An interprofessional, multidisciplinary team consisting of hematology-oncology fellows and cancer-center level QI staff was established. This analysis combined a retrospective chart review and survey at a tertiary care center. Retrospective chart review examined PCP prophylaxis rates among patients with solid malignancies prescribed high dose/duration corticosteroids per ASCO/IDSA guidelines (≥20mg prednisone equivalents daily for ≥1 month) between May 1, 2022 and May 31, 2023. The survey, conducted between December 2022 and May 2023, assessed prescriber knowledge of, and attitudes towards, appropriate PCP prophylaxis prescription. The survey was open to clinicians across oncology specialties. Results: Over the study period, 297 patients met inclusion criteria for PCP prophylaxis (median age 62, 178 (60%) were male, 212 (71%) were White, and 55 (18%) were Black). Fewer than half of eligible patients were prescribed prophylactic antibiotics (n = 140, 47%). There were no sociodemographic differences between patients prescribed prophylaxis and those not prescribed prophylaxis. Survey responses (n = 71) included 33 (46%) attending physicians, 21 (30%) advanced practice providers, 8 (11%) residents/fellows, and 9 (13%) unknown. Thirty participants (42%) had cared for a patient who developed PCP while on corticosteroids. While 62 participants (87%) had experience prescribing PCP prophylaxis, only 18 (25%) accurately identified the dose and duration of corticosteroids at which prophylaxis is needed. Lack of guideline knowledge/education was the most commonly cited barrier to prophylaxis (Table). Conclusions: Our study shows strikingly fewer than half of eligible patients on chronic, high-dose steroids were prescribed PCP prophylaxis. Lack of provider knowledge and systems-related obstacles were noted as primary barriers. Based on these findings, an urgent QI intervention is underway to address each barrier, increase rates of PCP prophylaxis, and reduce rates of PCP incidence towards the broader goal of improving outcomes in this at-risk patient population. [Table: see text]