Health Center System Research Articles

1185. Oseltamivir Prescribing Patterns for Infants with Influenza and Factors Associated with Guideline Adherence

Abstract Background The Centers for Disease Control and Prevention (CDC) recommends oseltamivir be given to children < 2 years old with confirmed or suspected influenza as they are at high risk for complications. We sought to analyze oseltamivir prescribing patterns and to describe factors associated with adherence and non-adherence to CDC guidelines. Methods We used a retrospective cohort of infants ≤ 12 months old born from January 1, 2011 to December 31, 2019 within the University of Pittsburgh Medical Center health system in Southwestern Pennsylvania and who had ≥ 2 well-child visits during their first year. Infants with laboratory-confirmed influenza from January 1, 2011 to April 30, 2020 were included. Electronic health records were reviewed to describe oseltamivir prescriptions and influenza-related characteristics. Factors associated with adherence and non-adherence to CDC influenza treatment guidelines were assessed with univariate logistic regression. Results Of 422 infants with laboratory-confirmed influenza, 86% were prescribed oseltamivir. The proportion of infants prescribed oseltamivir increased from an average of 63% during 2011-2016 to 90% during 2016-2020 (OR:5.2; 95%CI: 2.9-9.5). 96% of prescriptions instructed twice daily dosing, 2% had once daily, and 2% were unknown frequency. 91% of prescriptions were for 5 days, 7% had no duration, and 2% were for > 5 days. Infants ≥ 6 months of age compared to < 6 months were less likely to be prescribed oseltamivir (83.3% vs. 100%; p< 0.001); tested for influenza in the emergency room/urgent care (OR: 0.3; 95%CI: 0.2-0.6), or admitted to the hospital (OR:0.5; 95%CI:0.2-0.9). Infants were more likely to be treated with oseltamivir if they had a known influenza positive contact (OR:2.3; 95%CI:1.0-5.2) or had fever ≥ 38.0C (OR:2.0; 95%CI:1.2-3.5). There was no difference in prescribing practices based on history of prematurity or chronic medical conditions. Conclusion Adherence to CDC influenza treatment guidelines for infants is high and has improved over time. However, targeted education at high-risk contact points may further improve guideline adherence. Disclosures John V. Williams, MD, GlaxoSmithKline (Advisor or Review Panel member, Independent Data Monitoring Committee)Quidel (Advisor or Review Panel member, Scientific Advisory Board) Judith M. Martin, MD, Merck Sharp and Dohme (Consultant)

Pediatric to Adult Hydrocephalus

Pediatric patients treated for hydrocephalus, regardless of etiology, require continuous access to care to address the long-term sequelae from the disease progression itself and from the interventions undertaken. The challenge for all pediatric neurosurgeons is providing comprehensive and coordinated care for these patients in order to achieve a smooth and seamless transition into adult health care. A review of the literature was conducted regarding the overall concept of pediatric patients with chronic conditions transitioning to adult care. We also specifically reviewed the pediatric hydrocephalus literature to investigate the barriers of transition, models of success, and specific elements required in a transition policy. The review identified several barriers that hamper smooth and successful transition from pediatric to adult care within the hydrocephalus population. These included patient-related, cultural/society-related, healthcare provider-related, and healthcare system-related barriers. Six elements for successful transitions were noted: transition policy, tracking and monitoring, transition readiness, transition planning, transfer of care, and transition completion stemming from the Got Transition center. A successful patient transition from pediatric neurosurgical care to adult neurosurgical care is very center-specific and depends on the available resources within that center's hospital, health system, and geo-economic environment. Six recommendations are made for transition policy implementation in resource-poor environments, including beginning the process early, preferably at age 14 years.

To Test or Not to Test: COVID-19 Prevention Strategies to Keep Large Gatherings Safe

To Test or Not to Test: COVID-19 Prevention Strategies to Keep Large Gatherings Safe

Prediction Model Using Machine Learning for Mortality in Patients with Heart Failure

Heart Failure (HF) is a major cause of morbidity and mortality in the US. With aging of the US population, the public health burden of HF is enormous. We aimed to develop an ensemble prediction model for 30-day mortality after discharge using machine learning. Using an electronic medical records (EMR) database, all patients with a non-elective HF admission over 10 years (January 2001 - December 2010) within the Montefiore Medical Center (MMC) health system, in the Bronx, New York, were included. We developed an ensemble model for 30-day mortality after discharge and employed discrimination, range of prediction, Brier index and explained variance as metrics in assessing model performance. A total of 7,516 patients were included. The discrimination achieved by the ensemble model was higher 0.83 (95% CI: 0.80 to 0.87) compared to the benchmark model 0.79 (95% CI: 0.75 to 0.84). The ensemble model also exhibited a better range of prediction as well as a favorable profile with respect to the other metrics employed. In conclusion, an ensemble machine learning approach exhibited an improvement in performance compared to the benchmark logistic model in predicting all-cause mortality among HF patients within 30-days of discharge. Machine learning is a promising alternative approach for risk profiling of HF patients, and it enhances individualized patient management.

Elastase Activity From Pseudomonas aeruginosa Respiratory Isolates and ICU Mortality

Pseudomonas aeruginosa (PA) is a common cause of respiratory infection and morbidity. Pseudomonas elastase is an important virulence factor regulated by the lasR gene. Whether PA elastase activity is associated with worse clinical outcomes in ICU patients is unknown. Is there an association between PA elastase activity and worse host outcomes in a cohort of ICU patients? PA respiratory isolates from 238 unique ICU patients from two tertiary-care centers within the University of Pittsburgh Medical Center health system were prospectively collected and screened for total protease and elastase activity, biofilm production, antimicrobial resistance, and polymicrobial status. The association between pathogen characteristics and 30-day and 90-day mortality was calculated using logistic regression. For subgroup analysis, two patterns of early (≤72 h) and late sample (>72 h) collection from the index ICU admission were distinguished using a finite mixture model. Lung inflammation and injury was evaluated in a mouse model using a PA high elastase vslow elastase producer. PA elastase activity was common in ICU respiratory isolates representing 75%of samples and was associated with increased 30-day mortality (adjusted OR [95% CI]: 1.39 [1.05-1.83]). Subgroup analysis demonstrated that elastase activity was a risk factor for 30- and 90-day mortality in the early sample group, whereas antimicrobial resistance was a risk factor for 90-day mortality in the late sample group. Whole genome sequencing of high and low elastase producers showed that predicted loss-of-function lasR genotypes were less common among high elastase producers. Mice infected with a high elastase producer showed increased lung bacterial burden and inflammatory profile compared with mice infected with a low elastase producer. Elastase activity is associated with 30-day ICU mortality. A high elastase producing clinical isolate confers increased lung tissue inflammation compared with a low elastase producer invivo.

AB002. Quality of life is inversely related to income in patients with cutaneous lupus

Recent studies demonstrated cutaneous lupus erythematosus (CLE)’s profound impact on quality of life (QoL), but few have examined the association between income and QoL in CLE patients. To address this knowledge gap, we performed a cross-sectional analysis of 238 patients with CLE from outpatient dermatology clinics at University of Texas Southwestern Medical Center and Parkland Health and Hospital System, a safety-net hospital in Dallas, TX, from November 2008 to December 2018. First, we investigated differences in overall QoL, as measured by the four SKINDEX 29+3 subdomain scores (emotions, function, symptoms and lupus-specific), amongst CLE patients of different income groups (<$10,000/year, $10,000–$50,000/year, >$50,000/year). Next, we identified which aspects of QoL, as specified by individual SKINDEX 29+3 questions, were most frequently impaired in CLE patients of various incomes. Chi-squared tests were used to assess how responses to each question varied across income groups. Of the 238 patients, the majority of patients earned between $10,000–$50,000/year (n=88) or <$10,000/year (n=85). The four SKINDEX 29+3 subdomain scores decreased as annual income increased. In all cases, the lowest income group had higher scores (or worse QoL) than the other two groups (P<0.05 for lupus-specific, P<0.01 for function and symptoms, P<0.001 for emotions). Chi-square results of all SKINDEX 29+3 questions with annual income revealed 9 significant questions. Compared with patients with $10,000–$50,000/year, and >$50,000/year, those with <$10,000/year more often reported impairment in aspects regarding emotion, such as anger and embarrassment, as well as general function, particularly pertaining to isolation and desire to be with others (P≤0.001 for all questions). In conclusion, we have shown that annual income has an inverse relationship to QoL in patients with CLE. Poor QoL, particularly in the context of social detachment, may hinder patients of low socioeconomic status to seek out necessary care, follow physician recommendations and communicate freely about changes in their disease state. We recommend clinicians remain cognizant of the socioeconomic status of patients with CLE, given its effects on their QoL.

Access to consultative dermatologic care via physician-to-physician asynchronous outpatient teledermatology.

To determine whether physician-to-physician outpatient asynchronous store-and-forward teledermatology can be a portal for patient access to consultative dermatologic care and decrease primary care physician referrals to dermatology. Retrospective study. Reviewed outpatient teledermatology consults completed within a shared Epic electronic health record at the University of Pittsburgh Medical Center (UPMC) Health System between August 4, 2013, and December 19, 2019. Study data were reviewed for consult response time and triage percentage. Patient and physician experiences were collected by satisfaction surveys. This study reviewed 1581 teledermatology consults that originated from UPMC primary care provider (PCP) appointments. The average response time for a completed consult was 1 hour, 13 minutes for same-day consult submissions. The majority of consults, 63%, were completed online, whereas only 37% of patients were recommended for an in-person referral visit to the dermatology clinic. Surveyed patients (81%) and PCPs (90%) responded positively to their teledermatology experience. Physician-to-physician outpatient asynchronous teledermatology consults can provide a model for rapid consultation and decreased primary care referral to dermatology.

Improvement in Clinic Efficiency, Patient Satisfaction, and Overcoming Unique Challenges in the Era of COVID-19 with Implementation of Subcutaneous Daratumumab in Patients with Multiple Myeloma (MM) and Light Chain (AL) Amyloidosis

IntroductionIntravenous (IV) daratumumab has become a standard in the treatment of MM and AL amyloidosis largely due to its significant clinical benefit. Due to the high risk of infusion-related reactions (IRRs), it is associated with prolonged infusion times. These lengthy administrations can limit clinic capacity, require split dose infusions, increase chair time, decrease patient satisfaction, and create access barriers in the era of COVID-19. Recently, a fixed-dose subcutaneous (SC) formulation of daratumumab was approved for the treatment of MM, and the safety-run in results (N=28 patients) from a phase III, randomized trial in AL amyloidosis using the SC formulation were published. The SC formulation has the potential to mitigate some of the setbacks from IV formulation and help improve efficiency in the era of COVID-19, where most clinics are faced with limiting and spreading out volume due to space constraints and social distancing requirements. We present real world evidence from a large academic center's experience with adoption of SC formulation to help overcome current challenges.MethodsWe prospectively reviewed all patients being treated with IV daratumumab for MM and/or AL amyloidosis at Boston Medical Center Health System (a 500+ bed integrated delivery network) that would be candidates for the SC formulation. A protocol was designed to switch patients that were currently on IV daratumumab as well as patients newly initiating daratumumab to the SC formulation. Patients deemed eligible were switched to the SC formulation under pharmacy benefit (pending insurance authorization by a pharmacy liaison) at their next scheduled infusion visit. Rationale for switching patients to pharmacy benefit was to support home administration during future surge from COVID-19, using our specialty pharmacy travel RN program. Patients that were naïve to daratumumab, started their first dose as a SC injection. Patients were monitored for 30 minutes following the first SC dose and were pre-medicated with oral acetaminophen, dexamethasone, and diphenhydramine. Patient and nursing satisfaction were assessed after switching to SC daratumumab, using internally developed surveys. Using wholesale acquisition cost, cost analysis was performed between the two formulations. Infusion chair time, improvement in clinic efficiency (using our standard infusion time of 90 minutes for IV daratumumab infusions after the 2nd dose), and safety were assessed and compared.ResultsA total of 26 patients were treated with daratumumab for MM and AL amyloidosis from June 1, 2020 to August 1, 2020. 85% (22/26) of patients were administered the SC formulation. Of these 22 patients, 68% of patients were switched from the IV formulation (15/22) and 32% (7/22) were naïve to daratumumab. The majority (14/22) of SC administrations were patients receiving daratumumab monotherapy for relapsed MM. A breakdown of patient regimens and insurance type is seen in table 1. IRRs were reported in 0 patients starting [or transitioning to] SC daratumumab. Injection site reactions were not reported in any patient. One patient had facial and neck swelling 2 days after administration of SC daratumumab (with no other symptoms) but resolved within 24 hours of an additional dose of dexamethasone and did not recur upon re-challenge of SC daratumumab. Severe neutropenia (ANC less than 500) was reported in 9% of patients (2/22), both patients in the group naïve to daratumumab. Febrile neutropenia was not seen. One patient was being treated with concomitant pomalidomide and the second was treated with lenalidomide and had a baseline ANC of 500 prior to initiation of therapy. Adoption of SC daratumumab led to elimination of 133 hours of chair time and nursing time, or 1260 hours annualized for the year. Cost savings with the elimination of nursing time translates to approximately $100,000 to the institution and approximately $230,000 to the payer. The results compiled from patient and nursing satisfaction surveys are being analyzed and will be presented.ConclusionWe report a successful conversion and adoption of SC daratumumab at our ambulatory hematology/oncology clinic. Insurance authorization does not appear to limit the adoption of this therapy in clinic irrespective of diagnosis or regimen used. Furthermore, the reduction in chair time and patient convenience was largely beneficial in light of COVID-19 to minimize patient exposure in clinic.DisclosuresHughes:Rigel: Other: advisory board; Abbvie: Speakers Bureau; Amgen: Speakers Bureau; Karyopharm: Speakers Bureau. Blevins:Epizyme: Other: Focus Group. Sarosiek:Spectrum: Research Funding. Sloan:Abbvie: Consultancy; Stemline: Consultancy. Sanchorawala:Celgene: Research Funding; Takeda: Research Funding; Caleum: Other: advisory board; Proclara: Other: advisory board; Regeneron: Other: advisory board; Abbvie: Other: advisory board; Janssen: Research Funding; UpToDate: Patents & Royalties; Oncopeptide: Research Funding; Prothena: Research Funding; Caelum: Research Funding.

Consolidation of Cancer Registry and Administrative Claims Data on Cancer Diagnosis and Treatment in the US Military Health System.

Linked cancer registry and medical claims data have increased the capacity for cancer research. However, few efforts have described methods to select information between data sources, which may affect data use. We developed a systematic process to evaluate and consolidate cancer diagnosis and treatment information between the linked Department of Defense Central Cancer Registry (CCR) and Military Health System Data Repository (MDR) administrative claims database, called Military Cancer Epidemiology Data System (MilCanEpi). MilCanEpi contains information on cancer diagnosis and treatment of patients receiving care from 1998 to 2014. We used an iterative process guided by knowledge of data features, current literature, and logical comparisons between the CCR and MDR data to evaluate and consolidate cancer diagnosis and treatment received (yes or no) and their dates. We applied the processes to breast cancer data as an example. Agreement between diagnosis and treatment dates in the two data sources was evaluated using Cohen's κ with 95% CIs. In MilCanEpi, we identified 15,965 patients with a breast cancer diagnosis and 15,145 patients who underwent breast cancer surgery; 97.9% and 84.1% of patients had records in both CCR and MDR for diagnosis and surgery, respectively. Exact agreement was 13.7% for diagnosis dates (Cohen's κ = 0.14; 95% CI, 0.13 to 0.14) and 68.9% for surgery dates (Cohen's κ = 0.69; 95% CI, 0.68 to 0.70) between the two data sources. After applying systematic processes, 98.1% of patients with a breast cancer diagnosis and 99.7% of patients with surgery had information selected for analytic data sets. The developed processes resulted in high consolidation rates of breast cancer data in MilCanEpi and may serve as a data selection template for other tumor sites and linked data sources.

Utilization of Asynchronous and Synchronous Teledermatology in a Large Health Care System During the COVID-19 Pandemic.

Background: Teledermatology offers an opportunity to continually deliver care during the coronavirus disease 2019 pandemic. Objective: To provide quantitative data about the use of teledermatology. Methods: Retrospective analysis of teledermatology consultations was performed from March 16 to May 1, 2020. The number/type of encounters, differences in diagnoses, and prescriptions between asynchronous and synchronous teledermatology visits were analyzed. Results: A total of 951 visits (36.2%) were asynchronous whereas 1,672 visits (63.8%) were synchronous. Only 131 (<5%) visits required an acute in-person follow-up. The diagnosis of acne was more frequent with asynchronous visits (p < 0.002, Bonferroni corrected). Antibiotics and nonretinoid acne medications were prescribed more with asynchronous visits, whereas immunomodulators and biologics were more commonly prescribed with synchronous visits (p < 0.02, Bonferroni corrected). Providers at our institution were split on preferred mode (54.2% synchronous, 45.8% asynchronous); however, synchronous visits were preferred for complex medical dermatology patients and return patients (p < 0.05). Limitations: This study is limited by being a single-center study. Conclusions: Asynchronous teledermatology was used more for acne management, whereas synchronous teledermatology was preferable to providers for complex medical dermatology. Postanalysis of the data collected led us to institute a hybridization of our asynchronous and synchronous teledermatology.

Psychiatric Emergencies During the Height of the COVID-19 Pandemic in the Suburban New York City Area

Background: This report characterizes patients presenting for psychiatric emergencies during the COVID-19 pandemic and describes COVID-19-related stressors.Methods: Medical records of 556 patients that received emergency psychiatric evaluation January 1-April 30, 2020 were reviewed. Patient seen during COVID-19 (N=201) were compared with those prior (N=355), on sociodemographic characteristics, psychiatric diagnoses, symptoms, and disposition. Patients tested positive for COVID-19 were compared with those that tested negative. Prevalence and nature of COVID-19-stressors that influenced the emergency presentation were rated.Outcome: A significant decline in emergency psychiatric volume was observed in children and adolescents (C/A), but not adults. COVID-19 period C/A patients had more new onset disorders and were more likely to be admitted to inpatient care, but were less likely to present with suicide attempts, impulse control disorders and agitation/aggression. Adults were more likely to have no access to outpatient care, present with anxiety disorders, and were also more likely to be admitted for inpatient care. COVID-19 directly affected the psychiatric emergency in 25% of patients, with the more severe stressors triggered by fear of COVID infection (including psychosis), actual COVID infection in self or family members, including death of a loved one. COVID-positive patients were more likely to have psychosis, including new-onset, and were less likely to be depressed/ suicidal compared to their COVID-negative counterparts.Interpretation: This report demonstrates the need for emergency psychiatric services throughout the COVID-19 pandemic. New and severe pathology underscore the need for enhanced outpatient access and inpatient services with capacity to care for COVID-19 patients.Funding Statement: No external funding.Declaration of Interests: The authors have no conflicts of interest to disclose.Ethics Approval Statement: This study was approved by the institutional review board of New York Medical College and Westchester Medical Center Health System, Valhalla, New York.

Risk of Severe Coronavirus Disease 2019 in Patients With Inflammatory Bowel Disease in the United States: A Multicenter Research Network Study

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Incidence Rates of Gynecologic Cancers in the U.S. Active Duty Military Population.

Despite an increasing number of female service members, incidence rates of gynecologic cancers (other than cervical cancer) have not been previously documented in the U.S. active duty military population. This study sought to determine the incidence rates of all gynecologic, including peritoneal, malignancies in the U.S. Active Duty population compared to the general US population as reported in the Surveillance, Epidemiology, and End Results Program database. Gynecologic cancers diagnosed in U.S. Active Duty women aged 20-59 between 2004 and 2013 were retrospectively ascertained. Cancer cases were identified in both the Automated Central Tumor Registry and the Military Health System Data Repository. All cases in Automated Central Tumor Registry plus cases recorded in Military Health System Data Repository, but not duplicative of Automated Central Tumor Registry cases, were included. Age-specific and age-adjusted incidence rates were calculated in military and Surveillance, Epidemiology, and End Results cases. In U.S. Active Duty women, 327 incident cases of gynecologic cancer were identified. There were 110 cases of cervical cancer, 40 cases of endometrial cancer, 152 cases of ovarian cancer, and 25 other gynecologic malignancies. Of the 327 cases, 154 were ascertained from the Automated Central Tumor Registry database and the remainder from Military Health System Data Repository claims data. The age-adjusted rate of all gynecologic cancers for U.S. Active Duty women was 49.17 per 105 (95%CI 37.58, 65.12), while the age-adjusted rate for Surveillance, Epidemiology, and End Results -18 was 42.09 per 105 (95%CI 41.83, 42.35). The kappa coefficient assessing the overlap between the data sources was -0.1937. Though insufficient in numbers for statistical analysis, the observed proportion of ovarian to cervical cancer cases in active duty women < 45years of age was substantially greater than in the general population. U.S. Active Duty women exhibited a similar age-adjusted rate of gynecologic cancer as the general US population. There was suboptimal overlap between the Automated Central Tumor Registry and Military Health System Data Repository databases, indicating the necessity of using both databases in order to obtain reliable data in the active duty population. This study is the current best estimate of a baseline rate of gynecologic cancer in U.S. active duty military women. This rate might change over time as women's roles and exposures in recent and future military conflicts evolve.

Clinical Outcomes and Economic Impact of Oritavancin for Gram-Positive Infections: A Single Academic Medical Center Health System Experience.

BackgroundVancomycin treatment of complicated Gram-positive infections is associated with laboratory monitoring, nephrotoxicity, and multiple daily dosing. Oritavancin, a lipoglycopeptide antibiotic with a once-weekly dosing strategy and similar but slightly broader spectrum of activity, presents several opportunities over vancomycin to improve compliance and convenience for the patient. Minimal real-world clinical and acquisition cost data in the inpatient setting and clinical data surrounding multiple dosing in the outpatient setting have limited oritavancin use despite its potential logistic advantages.ObjectivesWe describe inpatient and outpatient oritavancin administration, clinical outcomes, and economic impact.MethodsThis was a single-center, retrospective case series of patients treated with at least one dose of oritavancin between May 2015 and September 2017 at an academic medical center in the USA. A simplified cost-avoidance analysis was conducted assuming the patient had a national health insurance plan and focused on hospital days prevented.ResultsSeventy-five patients received oritavancin during the study period. The most common use of oritavancin was in patients with acute bacterial skin and skin structure infections (ABSSSI), defined as cellulitis, abscess or non-surgical wounds (n = 25, 33%), followed by surgical wound infections (n = 12, 16%) and osteomyelitis or septic arthritis (n = 10, 13%). Clinical cure or improvement was achieved in 68 patients (93.2%), while five patients (6.8%) failed treatment; adverse reactions were reported in nine patients (12%). Thirty-five patients received oritavancin as inpatients; 20 patients (57%) had at least one hospital day avoided due to inpatient oritavancin administration resulting in a total cost avoidance of US$343,654.ConclusionIn this series of 75 patients with Gram-positive infections, oritavancin treatment resulted in clinical cure or improvement in most patients, and was generally well tolerated. Inpatient administration may avoid costs and outpatient administration is a reasonable consideration for patients in which prolonged antibiotic therapy is necessary.

Impact of the European General Data Protection Regulation (GDPR) on Health Data Management in a European Union Candidate Country: A Case Study of Serbia

As of May 2018, all relevant institutions within member countries of the European Economic Area are required to comply with the European General Data Protection Regulation (GDPR) or face significant fines. This regulation has also had a notable effect on the European Union (EU) candidate countries, which are undergoing the process of harmonizing their legislature with the EU as part of the accession process. The Republic of Serbia is an example of such a candidate country, and its 2018 Personal Data Protection Act mirrors the majority of provisions in the GDPR. This paper presents the impact of the GDPR on health data management and Serbia’s capability to conduct international health data research projects. Data protection incidents reported in Serbia are explored to identify common underlying causes using a novel taxonomy of contributing factors across aspects and health system levels. The GDPR has an extraterritorial application for the non-EU data controllers who process the data of EU citizens and residents, which mainly affects private practices used by medical tourists from the EU, public health care institutions frequented by foreigners, as well as expatriates, dual citizens, tourists, and other visitors. Serbia generally does not have well-established procedures to support international research collaborations around its health data. For smaller projects, contractual arrangements can be made with health data providers and their ethics committees. Even then, organizations that have not previously participated in similar ventures may require approval or support from health authorities. Extensive studies that involve multisite data typically require the support of central health system institutions and relevant research data aggregators or electronic health record vendors. The lack of a framework for preparation, anonymization, and assurance of privacy preservation forces researchers to rely heavily on local expertise and support. Given the current limitation and potential issues with the legislation, it remains to be seen whether the move toward the GDPR will be beneficial for the Serbian health system, medical research, protection of personal data and privacy rights, and research capacity. Although significant progress has been made so far, a strategic approach is needed at the national level to address insufficient resources in the area of data protection and develop the personal data protection environment further. This will also require a targeted educational effort among health workers and decision makers, aiming to improve awareness and develop skills and knowledge necessary for the workforce.

Comparison of Accuracy of Patient and Physician Scar Length Estimates Before Mohs Micrographic Surgery for Facial Skin Cancers

Patients are satisfied when surgical outcomes meet their expectations. Dissatisfaction with surgical scars is one of the most common reasons that patients sue surgeons who perform Mohs micrographic surgery (MMS). To measure the accuracy of patient and physician estimations of scar length prior to skin cancer removal with MMS. This cross-sectional study was conducted between December 1, 2017, and February 28, 2018, at the MMS clinic of a single tertiary referral center health system. A total of 101 adults presenting for MMS for treatment of facial skin cancers volunteered for this study, and 86 surgeons who performed the MMS procedure participated. Patients and physicians independently drew the anticipated scar length on the patients' skin prior to surgery. Preoperative estimates by patients and surgeons were compared with actual postoperative scar length. Of the 101 patients who participated, 57 patients (56.4%) were men and 57 patients (56.4%) were aged 65 years or older. Eighty-four patients (83.2%) underestimated scar length, whereas 67 of the 86 surgeons (77.9%) correctly estimated the scar length (P < .001). The actual postoperative scar length was 2.2 (interquartile range, 1.5-3.6) times larger than the patients' preoperative estimate but only 1.1 (interquartile range, 1.0-1.2) times larger than the surgeons' preoperative estimate (P < .001). Preoperative consultation with the surgeon, a personal history of MMS, or patient-directed research about MMS were not associated with improvement of patients' estimations of scar length. This study's findings suggest that patients with facial skin cancers have unrealistic expectations regarding scars that measure, on average, less than half the length of the actual postoperative scars. Surgeons appear to accurately estimate the length of most surgical scars and have an opportunity to set realistic patient expectations about scar length before surgery.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement.

The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. Retrospective analysis of overall means and clinician-level variation in performance on three new measures. Adults aged 65years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Hypomethylating Agent and Venetoclax Combination Therapy Yields Superior Outcomes When Compared to Hypomethylating Agent Monotherapy in Patients ≥70 Years with Acute Myeloid Leukemia

Hypomethylating Agent and Venetoclax Combination Therapy Yields Superior Outcomes When Compared to Hypomethylating Agent Monotherapy in Patients ≥70 Years with Acute Myeloid Leukemia

Successful Transition from Bortezomib Subcutaneous (SubQ) to Generic Intravenous (IV) Bortezomib: Cost Savings Initiative with Global Economic Impact

Background: It is estimated that the U.S. will spend $370 billion in 2019 on pharmaceuticals and by 2020 the cost of cancer care will be approximately 158 billion. Cost containment strategies for high cost drugs are needed. In 2019 global sales from subcutaneous (SubQ) bortezomib manufactured by Takeda® will exceed $1 billion. There exists an opportunity to decrease overall cost related to bortezomib by $300-400 million across the globe by switching patients to bortezomib intravenous (IV) (manufactured by Fresenius Kabi®). Generic bortezomib was first approved by the FDA in January 2018 but it can only be administered intravenously. A phase 3 randomized controlled trial of twice weekly SubQ vs IV bortezomib showed no difference in time to progression or 1 year overall survival, however rate of Grade 3 peripheral neuropathy doubled in the IV arm compared to SubQ (Moreau et al, 2011). Although twice weekly bortezomib has fallen out of favor and there are retrospective data suggesting that neuropathy from weekly subQ and weekly IV bortezomib may be similar, there exist no prospective data to date to confirm this. Bortezomib induced peripheral neuropathy (BIPN) typically occurs by cycle 4 of twice weekly therapy, and the majority of cases are partially reversible (Dimopolous et al, 2011). We hypothesized that patients who have not developed neuropathy after or during 4 cycles of subcutaneous bortezomib could be switched to IV bortezomib without greatly increasing neuropathy. Methods: Boston Medical Center Health System is a 500 plus bed integrated delivery network which not only functions as payer but also as a provider. A protocol was implemented to switch patients from SubQ to IV bortezomib. Patients had to complete 4 cycles of SubQ bortezomib and have either Grade 1 or no BIPN to qualify to switch to IV bortezomib generic formulation. Patients were eligible to be switched regardless of indication or dose, if other criteria were met. After approval from the hematology/oncology providers and nursing department, this protocol was implemented to start accrual in November 2018. Patients eligible for the switch were identified primarily by pharmacists. After provider approval, pharmacists would update the treatment plan orders and also notify nursing and patients of the change. Nursing and patient satisfaction surveys were also administered to obtain input from all stakeholders. Results: Eleven patients have received at least 1 cycle of IV generic bortezomib for various indications from Nov 2018 to June 2019, with minimum of 2 doses and maximum of 16 doses. The diseases for which bortezomib was being used included multiple myeloma (n= 6) and AL amyloidosis (n= 2), renal transplant rejection and thrombotic thrombocytopenic purpura (TTP). One of the 11 patients had Grade 1 BIPN prior to switching, while all others reported no neuropathy prior to the switch. None of the patients have developed new neuropathy after making the switch from subQ to IV bortezomib. Results of the nursing and patient satisfaction surveys are being collected and will be presented. Conclusion: We describe a method to switch from subcutaneous bortezomib to generic IV bortezomib instituted at a large academic medical center as a cost containment strategy. This has resulted in no new cases of neuropathy in our growing data set. Global adoption of this protocol has the potential to substantially reduce drug costs related to multiple myeloma. Disclosures Sanchorawala: Celgene: Research Funding; Takeda: Research Funding; Proclara: Consultancy, Honoraria; Caelum: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Prothena: Research Funding. Sloan:Merck: Other: endpoint review commitee; Abbvie: Other: Endpoint Review Committee; Stemline: Consultancy. Sarosiek:Acrotech: Research Funding. Shah:Rigel Pharmaceutical: Consultancy, Speakers Bureau.

Real-World Experience with Fostamatinib in Patients with Immune Thrombocytopenia at an Academic Medical Center

Introduction Fostamatinib is a first in its class oral inhibitor of spleen tyrosine kinase (Syk) pathway for treatment of adults with immune thrombocytopenia (ITP) with insufficient response to previous treatment. Choice of treatment for relapsed ITP varies greatly according to clinician and patient preference. It is common for patients to switch between available thrombopoietin (TPO) agonists and now fostamatinib. Titration of these agents is often cumbersome and labor intensive; romiplostim in particular requires weekly visits with lab draws and consumes nurse, pharmacy and provider effort. Here we present real world experience with fostamatinib use in an academic medical center. Methods. We retrospectively identified four patients who were prescribed fostamatinib within the past nine months at Boston Medical Center Health System. All patients had a diagnosis of chronic ITP and were previously treated with corticosteroids, intravenous immunoglobulin (IVIG), and rituximab. With respect to previous TPO receptor use, two of four patients had received both eltrombopag and romiplostim. Patients were started on fostamatinib at a dose of 100 mg by mouth twice daily and titrated up to 150 mg by mouth twice daily if platelet counts were &lt;50 10x9 /L after 4 weeks of therapy. All patients were seen by a pharmacist and provider for initiation of the drug and seen in clinic weekly for the first month on therapy to assess toxicity and efficacy. The duration of follow up for the patients is between 2 and 9 months on therapy. Results. Three of four patients initiated on fostamatinib had a baseline platelet count 100K or greater and the fourth patient had ITP refractory to multiple lines of therapy with a baseline platelet count of 7K at therapy initiation. Three patients sought alternative therapy given side effects from TPO agonists or inconvenience of romiplostim. Three patients had platelets counts &gt;50K at 4 weeks and one patient had a platelet count &lt;30K. Recent platelet counts of the two patients that have been on therapy for 7 and 8 months were 123K and 108K, respectively. The third patient that responded initially discontinued therapy due to lack of stable response. Both of the patients with stable responses were well controlled on previous therapy with romiplostim. One patient required rescue therapy with IVIG and romiplostim due to petechiae 15 days after therapy initiation but continued on therapy thereafter. Two patients that discontinued therapy had platelet counts of 10K and 88K upon discontinuation due to inadequate response and toxicity, respectively. One patient was romiplostim naïve and the other patient had not received romiplostim for four years prior. Two patients developed diarrhea that was managed with loperamide and one led to treatment discontinuation (in combination with insufficient response). One patient experienced hypertension that was managed accordingly. Conclusion. The ideal place in therapy for fostamatinib in ITP therapy is not yet clear. However, the availability as an oral option for patients with refractory disease is appealing. One of our patients required rescue therapy which should be considered when transitioning patients to fostamatinib from TPO agonists. Additionally, side effect management with anti-hypertensives and anti-diarrheal agents may be required to continue therapy. Effectiveness of romiplostim may predict responsiveness to fostamatinib, although additional data are needed. Table Disclosures Shah: Rigel Pharmaceutical: Consultancy, Speakers Bureau. Sarosiek:Acrotech: Research Funding. Sloan:Merck: Other: endpoint review commitee; Abbvie: Other: Endpoint Review Committee; Stemline: Consultancy.