Clinical Care Team Research Articles

Adopting a model of antimicrobial stewardship program to anti-tubercular treatment stewardship: A single-centre experience from a private tertiary care hospital in South India.

Tuberculosis (TB) remains a significant public health challenge in Low- and Middle-Income Countries (LMIC). Inappropriate use of Anti-Tubercular Treatment (ATT) undermines treatment efficacy and could contribute to drug resistance. While antimicrobial stewardship programs (AMSP) are well established, anti-tubercular treatment stewardship programs (ATTSP) in private hospitals do not have an established model. An AMSP model in a private tertiary care hospital in South India was repurposed to monitor the prescription appropriateness of ATT. A multidisciplinary team evaluated the ATT prescription appropriateness among inpatients over a one-year period with the 4R's criteria: Right Indication, Right Drug, Right Dose, and Right Frequency. The ATTSP team filed recommendations for inappropriate prescriptions to the primary clinical care team, and compliance to the recommendations was documented within 48 hours. During the study period, 172 ATT prescriptions were evaluated. Inappropriate dose and drug prescriptions were found in 16% and 7%, respectively. The primary clinical care teams complied with 83% of the recommendations within 48 hours. The potential impact of implementing the ATTSP model nationwide was assessed using published data, suggesting that the opportunities to correct inappropriate prescriptions could reach a quarter million. The study provides a proof of concept that an ATTSP can be successfully implemented in a TB endemic, resource-constrained setting. Extrapolation for implementing ATTSP across the country has the potential for huge public health benefits.

Trajectory of symptoms reported in remote symptom monitoring over the course of oncology treatment for lung cancer.

250 Background: Electronic patient reported outcomes (ePROs) enable patients to report symptoms from treatment in real time using their mobile device. This analysis sought to better understand the trajectory of reported symptoms via remote symptom monitoring (RSM) during treatment for patients with lung cancer. Methods: We approached patients with lung cancer initiating treatment at the Mitchell Cancer Institute (MCI) between March 2022-October 2023 to participate in an RSM program. Patients were eligible if they were initiating treatment (chemotherapy, targeted therapy, or immunotherapy) for the first time at MCI. Patients seeking a second opinion were excluded. Enrolled patients received a symptom survey (PRO-CTCAE questions) once a week via text or email. Alerts were forwarded to the clinical care team for symptom management. Patients completed symptom assessments for 24 weeks or until withdrawal. At 24 weeks, patients were given the ability to continue symptom assessments if they were continuing treatment. Patient demographics including age at enrollment, race, sex, cancer type, cancer stage, and PRO data were collected from electronic health records and the PRO platform (Carevive). Descriptive statistics were calculated using frequencies and percentages for categorical variables and median and interquartile ranges (IQR) for continuous variables. Results: Of 80 patients approached, a total of 57 (71%) patients with lung cancer were enrolled in RSM; 20% were Black or African American and 80% were White; median age was 66 (IQR 61-73). Over 24 weeks, 732 symptom alerts were reported; 75% considered moderate and 25% considered severe. Overall, the most frequently reported symptom was pain (29%), followed by dyspnea/cough (25%) and constipation (13%). At baseline (week 0), 78 moderate symptoms and 39 severe symptoms alerts were reported. At week 24, 10 moderate symptoms and 4 severe symptoms alerts were reported. Overall, there was a decrease in symptom alerts over time for both moderate and severe alerts. Specific symptom trajectories followed similar patterns. Conclusions: In our sample, most symptoms were reported during the initial three months of treatment with a subsequent decrease in symptom alerts over time, indicating effective monitoring and management by clinical teams engaged in RSM. Future research is needed to understand if symptom improvement correlates with enhanced quality of life, reduced hospitalizations, and prolonged survival, as well as a lessened burden of call volume on the clinical team. Future analyses should also be done to compare similar results of different disease types.

Implementation of INEWS to Improve Patient Outcomes in a Community Hospital

Abstract Background It is imperative to identify at risk older patients with clinical deterioration as soon as possible. The Irish National Early Warning System (INEWS)1 is used to detect clinical deterioration at an early stage based on each patient's vital sign records. It can then initiate a communication mechanism between nurses and doctors to enable early patient care. Data on the effectiveness of the INEWS in patients admitted to community rehabilitation wards, the barriers and difficulties encountered during implementation, are still scarce, despite the development and implementation in acute settings. There are not enough standardised tool available to identify patients' deterioration for community hospitals. Methods This pilot quality improvement programme was conducted in a community hospital's rehabilitation section. Data were gathered seven weeks after the deployment of INEWS and fourteen weeks before. Issues were studied to determine the underlying cause, created a driver diagram to comprehend the factors that lead to unexpected outcomes, educated and gathered feedback from the clinical care teams involved, measured adherence to the INEWS during the six-week pilot project implementation period, and assessed results by looking back at the deteriorating patient data and INEWS compliance using Plan, Do, Study, Act cycles. Results During the pre-INEWS introduction phase (14 weeks), there were 11.9 events per week (7.8 events with infection or septic workups, 9.6 events with onsite management, 1.0 acute care transfers, 0.28 per week unexpected deaths). In the post-INEWS piloting phase (6 weeks), there were 3.6 events per week (2.5 infection or septic workup, 1.8 onsite management and 1.1 acute care transfers per week with no unexpected deaths). Conclusion Conclusion Early detection and rapid management through the INEWS can enhance patient care; however, increased stakeholder engagement in escalation response may enhance patient outcome in resource limited community setting. Reference https://www2.healthservice.hse.ie/organisation/qps-improvement/deteriorating-patient-improvement-programme-partnership-dpipp/

Abstract P318: English and Spanish-Speaking Patient Preferences on Home Blood Pressure Monitors: A Qualitative Study in an Urban Safety Net Setting

Background: Self-measured blood pressure (SMBP) monitoring improves hypertension (HTN) control. Adoption of SMBP monitoring is lower among low-income or minoritized patients, who have higher rates of uncontrolled HTN. Little is known about these patients’ preferences for or challenges with SMBP monitoring. Objective: We explored patient perspectives on SMBP monitoring among patients receiving care at an urban safety-net system. Methods: We interviewed English and Spanish-speaking patients with HTN about preferences for different BP monitoring devices and their accompanying mobile apps, past experiences sharing BP data with their clinical care team, and knowledge about home BP monitoring. Interviews were conducted in the participants’ preferred language. We also asked participants to demonstrate a home BP measurement to evaluate their measurement technique. We presented two BP monitoring devices: a Bluetooth-enabled device and a cellular-enabled device. Rapid qualitative data analysis was used to analyze data. Results: Of the 15 participants (8 English-speaking; 7 Spanish-speaking), eight identified as Latine, four as Black or African American, one as American Indian/Native American, one as Asian/Pacific Islander, and one as multi-ethnic. Highest educational attainment varied: five less than high school, five high school/GED, and five college. Most required assistance with Bluetooth pairing to share data and navigating app features. All participants valued tracking their BP and were motivated to engage in SMBP monitoring but desired more training. Nearly all participants demonstrated inadequate BP knowledge and incorrect BP measurement techniques based on AHA/AMA recommendations. Few reported receiving training on SMBP monitoring techniques. Spanish speakers reported that using apps was challenging due to language discordance and wanted translated apps and resources. Costs related to device features were a key factor in preferences. Conclusions: Patient-reported barriers to SMBP adoption include cost, insufficient training, digital exclusion, and language discordance. Addressing these challenges may increase adoption of SMBP monitoring in safety-net populations. Clinicians should consider patients’ preferences when recommending SMBP monitoring. Cellular SMBP devices that automatically transmit BP readings may mitigate challenges with digital literacy and promote data sharing with clinical care teams, though future studies are needed to evaluate usability.

Abstract P326: Measuring Health Equity Gaps for a Blood Pressure Control Quality Improvement Program: Results from Cook County Health

Background: High blood pressure (BP) affects nearly half of U.S. adult population and was responsible for 13.0 deaths per 100,000 in 2022, with significant differences in age-adjusted mortality rates by sex, race, and ethnicity. Previous research has also highlighted that lower BP control rates are more prominent in Hispanic and Non-Hispanic Black patients, and well as those 60 years or older. This study assesses the role of the AMA MAP™ Hypertension quality improvement (QI) program to improve potential inequities in blood pressure control at a large public health care institution. Methods: 18,252 patients diagnosed with hypertension were identified at Cook County Health. BP values were obtained for patients in the 2 -years prior to implementation of the QI program (July 2019 to June 2021) compared to BP in the 2-years after implementation (July 2021 to July 2023). A multivariable logistic regression model of BP control status, paired t-tests, and ANCOVA analyses, stratified by race, ethnicity, sex, and age are conducted to assess SBP and measure the gaps by demographic characteristics. Results: Prior to the QI program, BP control (<140/<90) was significantly less for Black as compared to White patients (OR 0.82 [0.74-0.92]). The racial difference remained after the program, although it was slightly diminished (OR 0.86 [0.76 – 0.97]). Patients who were older were less likely to have controlled BP prior to the program, but these differences were no longer evident following the QI program. The QI program led to a decline in SBP in all demographic groups, including between ethnicity as shown in Figure 1 (Hispanic: -5.74 [CI:6.19- -5.29] vs Non-Hispanic -4.92 [-5.21- -4.63]), White (-5.96 [CI: -6.45- -5.47]) and Black (-4.80 [CI: -5.11- -4.49]) patients, and by age as shown in Figure 2 between 45-64 years ( -5.79 [CI: -6.12- -5.46] and 65-85 years (-4.31 [CI: -4.68- -3.94]). Conclusion: The results indicate an overall improvement in BP control and SBP, however, gaps persisted in SBP across ethnicity, race, and certain age groups. Quality improvement coaching and dashboards may support clinical care teams in addressing inequities in patient BP control.

Clinical profiles, incidence and predictors of early neonatal mortality at Mbarara Regional Referral Hospital, south-western Uganda

BackgroundThe current neonatal mortality rate in Uganda is high at 22 deaths per 1000 live births, while it had been stagnant at 27 deaths per 1000 live births in the past decade. This is still more than double the World Health Organization target of < 12 deaths per 1,000 live births. Three-quarters of new born deaths occur within the first week of life, which is a very vulnerable period and the causes reflect the quality of obstetric and neonatal care. At Mbarara Regional Referral Hospital (MRRH), the modifiable contributors and predictors of mortality remain undocumented, yet neonates make the bulk of admissions and contribute significantly to the overall infant mortality rate. We therefore examined the clinical profiles, incidence and predictors of early neonatal mortality of neonates admitted at MRRH in south-western Uganda.MethodsWe conducted a prospective cohort study at the Neonatal Unit of MRRH between August – November, 2022 among neonates. We consecutively included all live neonates aged < 7 days admitted to neonatal unit and excluded those whose outcomes could not be ascertained at day 7 of life. We obtained baseline data including; maternal social-demographic and obstetric information, and performed neonatal physical examinations for clinical profiles. We followed up neonates at 24 and 72 h of life, and at 7 days of life for mortality. We summarized the clinical profiles and incidence of mortality as frequencies and percentages and performed modified Poisson regression analysis to identify the predictors of early neonatal mortality.ResultsWe enrolled 384 neonates. The majority of neonates were in-born (68.5%, n = 263) and were admitted within 24 h after birth (54.7%, n = 210). The most common clinical profiles at admission were prematurity (46%, n = 178), low birth weight (LBW) (44%, n = 170), sepsis (36%, n = 139), hypothermia (35%, n = 133), and birth asphyxia (32%, n = 124). The incidence of early neonatal mortality was at 12.0%, 46 out of the 384 neonates died. The predictors of early neonatal mortality were hypothermia, [adjusted Risk Ratio: 4.10; 95% C.I (1.15–14.56)], birth asphyxia, [adjusted Risk Ratio: 3.6; 95% C.I (1.23–10.73)] and delayed initiation of breastfeeding, [adjusted Risk Ratio: 7.20; 95% C.I (1.01–51.30)].ConclusionPrematurity, LBW, sepsis, birth asphyxia and hypothermia are the commonest admission diagnoses. The incidence of early neonatal mortality was high, 12.0%. We recommend targeted interventions by the clinical care team at MRRH to enable timely identification of neonates with or at risk of hypothermia to reduce incidence of adverse outcomes. Intrapartum care should be improved in order to mitigate the risk of birth asphyxia. Breastfeeding within the first hour of birth should be strengthened were possible, as this is associated with vast benefits for the baby and may reduce the incidence of complications like hypothermia.

Extraction of Substance Use Information From Clinical Notes: Generative Pretrained Transformer-Based Investigation.

Understanding the multifaceted nature of health outcomes requires a comprehensive examination of the social, economic, and environmental determinants that shape individual well-being. Among these determinants, behavioral factors play a crucial role, particularly the consumption patterns of psychoactive substances, which have important implications on public health. The Global Burden of Disease Study shows a growing impact in disability-adjusted life years due to substance use. The successful identification of patients' substance use information equips clinical care teams to address substance-related issues more effectively, enabling targeted support and ultimately improving patient outcomes. Traditional natural language processing methods face limitations in accurately parsing diverse clinical language associated with substance use. Large language models offer promise in overcoming these challenges by adapting to diverse language patterns. This study investigates the application of the generative pretrained transformer (GPT) model in specific GPT-3.5 for extracting tobacco, alcohol, and substance use information from patient discharge summaries in zero-shot and few-shot learning settings. This study contributes to the evolving landscape of health care informatics by showcasing the potential of advanced language models in extracting nuanced information critical for enhancing patient care. The main data source for analysis in this paper is Medical Information Mart for Intensive Care III data set. Among all notes in this data set, we focused on discharge summaries. Prompt engineering was undertaken, involving an iterative exploration of diverse prompts. Leveraging carefully curated examples and refined prompts, we investigate the model's proficiency through zero-shot as well as few-shot prompting strategies. Results show GPT's varying effectiveness in identifying mentions of tobacco, alcohol, and substance use across learning scenarios. Zero-shot learning showed high accuracy in identifying substance use, whereas few-shot learning reduced accuracy but improved in identifying substance use status, enhancing recall and F1-score at the expense of lower precision. Excellence of zero-shot learning in precisely extracting text span mentioning substance use demonstrates its effectiveness in situations in which comprehensive recall is important. Conversely, few-shot learning offers advantages when accurately determining the status of substance use is the primary focus, even if it involves a trade-off in precision. The results contribute to enhancement of early detection and intervention strategies, tailor treatment plans with greater precision, and ultimately, contribute to a holistic understanding of patient health profiles. By integrating these artificial intelligence-driven methods into electronic health record systems, clinicians can gain immediate, comprehensive insights into substance use that results in shaping interventions that are not only timely but also more personalized and effective.

Optimal presence: enhancing parent integration to maximize neurodevelopmental outcomes in preterm infants.

Preterm birth disrupts the natural progression of events in the parent-infant relationship and bestows many of the typical parent responsibilities to the clinical care team. In turn, the neonatal intensive care environment (NICU) introduces obstacles to parents that would not otherwise be encountered and forces parents to adapt to this artificial environment as they seek to bond with and care for their newborn. Facilitating parent presence at the bedside and incorporating them into the care of their preterm infant is critical for lessening the immediate burden to both the parent and offspring while also ensuring the best possible outcome for preterm infants. In this review, we explore the impact that parents exert on the neurodevelopmental outcome of preterm infants and identify several barriers and facilitators to parent presence.

Prevalence of Lassa Fever Infections in Ondo State, Nigeria

Emerging and re-emerging infectious diseases have been of immense threat to public health in this 21st century. Among these diseases are COVID-19, Lassa fever, monkeypox, yellow fever, ebola, chicken pox disease and many others. Out of all the above mentioned diseases, Lassa fever is the most recurrent and trending infectious disease in Nigeria which affects many states. It is of great concern that Ondo State is one of the major epicentres of the virus. The objective was to examine the incidence of Lassa fever in Ondo State, Nigeria. A descriptive research design using a purposive sampling technique was used to collect data. Findings revealed that in 2018, Ondo State accounted for 25% of total Lassa fever incidence cases in Nigeria, which suggests that Ondo State was one of the major epicentres of the virus in 2018. As of March 19, 2022, the figure rose to 28% of total Lassa fever incidence. This implies that Ondo State was also the major epicentre of the virus as of March 19, 2022. Furthermore, in the 42nd week of 2022, the predominant age group of the patients affected by Lassa fever in Ondo State was 21–30 years. There has been a significant increase in the number of suspected and confirmed cases as compared with 2021. The factors contributing to the reemergence of LF epidemics in Nigeria are nosocomial transmission, travel and migration, the public health system, socio-cultural factors, conflicts and the COVID-19 pandemic. In conclusion, health education of indigenous people at the community levels (especially residents of Owo and Ose Local Government Areas) about LF causes, preventive measures and avoidance of cultural practices that could predispose them to Lassa fever infection should be given priority. Also, case management capacity and contact tracing must also be strengthened through the establishment of well-equipped and dedicated treatment/referral centers in the epicentre. Training and re-training of clinical care teams should also be given priority.

Clinical Impact of Standardized Interpretation and Reporting of Multimodality Neuromonitoring Data.

Evaluate the consistency and clinical impact of standardized multimodality neuromonitoring (MNM) interpretation and reporting within a system of care for patients with severe traumatic brain injury (sTBI). Retrospective, observational historical case-control study. Single-center academic level I trauma center. Standardized interpretation of MNM data summarized within daily reports. Consecutive patients with sTBI undergoing MNM were included. Historical controls were patients monitored before implementation of standardized MNM interpretation; cases were defined as patients with available MNM interpretative reports. Patient characteristics, physiologic data, and clinical outcomes were recorded, and clinical MNM reporting elements were abstracted. The primary outcome was the Glasgow Outcome Scale score 3-6 months postinjury. One hundred twenty-nine patients were included (age 42 ± 18 yr, 82% men); 45 (35%) patients were monitored before standardized MNM interpretation and reporting, and 84 (65%) patients were monitored after that. Patients undergoing standardized interpretative reporting received fewer hyperosmotic agents (3 [1-6] vs. 6 [1-8]; p = 0.04) and spent less time above an intracranial threshold of 22 mm Hg (22% ± 26% vs. 28% ± 24%; p = 0.05). The MNM interpretation cohort had a lower proportion of anesthetic days (48% [24-70%] vs. 67% [33-91%]; p = 0.02) and higher average end-tidal carbon dioxide during monitoring (34 ± 6 mm Hg vs. 32 ± 6 mm Hg; p < 0.01; d = 0.36). After controlling for injury severity, patients undergoing standardized MNM interpretation and reporting had an odds of 1.5 (95% CI, 1.37-1.59) for better outcomes. Standardized interpretation and reporting of MNM data are a novel approach to provide clinical insight and to guide individualized critical care. In patients with sTBI, independent MNM interpretation and communication to bedside clinical care teams may result in improved intracranial pressure control, fewer medical interventions, and changes in ventilatory management. In this study, the implementation of a system for management, including standardized MNM interpretation, was associated with a significant improvement in outcome.

Evaluation of a Cardiovascular Disease/Diabetes Mellitus Expansion Program for Community Health Workers Employed by Rhode Island Community Health Teams.

The integration of certified community health workers (CCHWs) with specialty chronic disease training into clinical care teams has demonstrated improvements in chronic disease quality of care, management, and outcomes. Rhode Island Department of Health's Diabetes, Heart Disease, and Stroke Program expanded the roles of CCHWs employed by Community Health Teams for chronic disease with a focus on cardiovascular disease (CVD) and diabetes mellitus (DM) from 2020 to 2023. Rhode Island Department of Health's Diabetes, Heart Disease, and Stroke Program sought to determine whether patient health behaviors and clinical outcomes improved with specialty trained CCHW support. Community Health Teams identified high-risk or rising-risk patients with hypertension, high cholesterol, and/or diabetes. During an infrastructure phase, patients were assigned a CCHW who had not received CVD/DM specialty training. During a performance phase, a separate cohort of patients was assigned a CVD/DM specialty-trained CCHW. In each phase, patients were seen by the CCHWs at least twice and completed baseline and follow-up health assessments. The trained CCHWs utilized the baseline assessment to offer health coaching specific to the patient's chronic disease-related needs. Improvements in blood pressure readings and cholesterol were observed at an individual level for CVD patients. However, a significant difference was not observed for hypertension or high cholesterol when comparing phases. Individual-level results indicated improved HbA1c values for DM patients; however, the differences in clinical values were not significant. Although there were no significant differences for clinical values between the phases, the proportion of patients who reported confidence in managing their condition(s) increased from baseline to follow-up for both phases. It cannot be concluded that specialty-trained CCHWs have significant impact on patient behaviors and clinical outcomes. However, overall CCHW intervention did result in improved self-efficacy in patients to manage their chronic conditions. Further evaluation is needed to understand what factors led to improved patient confidence levels.

Cardiovascular Magnetic Resonance Before Invasive Coronary Angiography in Suspected Non–ST-Segment Elevation Myocardial Infarction

BackgroundIn suspected non–ST-segment elevation myocardial infarction (NSTEMI), this presumed diagnosis may not hold true in all cases, particularly in patients with nonobstructive coronary arteries (NOCA). Additionally, in multivessel coronary artery disease, the presumed infarct-related artery may be incorrect. ObjectivesThis study sought to assess the diagnostic utility of cardiac magnetic resonance (CMR) before invasive coronary angiogram (ICA) in suspected NSTEMI. MethodsA total of 100 consecutive stable patients with suspected acute NSTEMI (70% male, age 62 ± 11 years) prospectively underwent CMR pre-ICA to assess cardiac function (cine), edema (T2-weighted imaging, T1 mapping), and necrosis/scar (late gadolinium enhancement). CMR images were interpreted blinded to ICA findings. The clinical care and ICA teams were blinded to CMR findings until post-ICA. ResultsEarly CMR (median 33 hours postadmission and 4 hours pre-ICA) confirmed only 52% (52 of 100) of patients had subendocardial infarction, 15% transmural infarction, 18% nonischemic pathologies (myocarditis, takotsubo, and other forms of cardiomyopathies), and 11% normal CMR; 4% were nondiagnostic. Subanalyses according to ICA findings showed that, in patients with obstructive coronary artery disease (73 of 100), CMR confirmed only 84% (61 of 73) had MI, 10% (7 of 73) nonischemic pathologies, and 5% (4 of 73) normal. In patients with NOCA (27 of 100), CMR found MI in only 22% (6 of 27 true MI with NOCA), and reclassified the presumed diagnosis of NSTEMI in 67% (18 of 27: 11 nonischemic pathologies, 7 normal). In patients with CMR-MI and obstructive coronary artery disease (61 of 100), CMR identified a different infarct-related artery in 11% (7 of 61). ConclusionsIn patients presenting with suspected NSTEMI, a CMR-first strategy identified MI in 67%, nonischemic pathologies in 18%, and normal findings in 11%. Accordingly, CMR has the potential to affect at least 50% of all patients by reclassifying their diagnosis or altering their potential management.

Decision making factors regarding hospice care: A qualitative exploration in patients with recurrent ovarian cancer.

e24035 Background: Women with recurrent ovarian cancer (ROC) often must make end-of-life choices involving hospice care. We qualitatively explored patients’ (pt) understanding of hospice, and main decision-making factors. Methods: Pts were recruited by purposive sampling for semi-structured interviews, which were recorded, transcribed, and consensus coded. Results: 40 pts completed interviews. Median age = 63.4 yrs and time since diagnosis = 5.5 yrs. Important facilitators and barriers to hospice emerged. Key facilitators included: 1) desire to reduce care burden on family; 2) desire for a high quality death; and 3) acceptance (not afraid to die). On reducing care burden, one pt noted: “ I would think that the single most important factor would be the relief that it would give my family members. That they would not bear nearly as large a burden if hospice were to pick up part of that...” On desire for a high quality death, and acceptance: “ I’d wanna go out with as much dignity as possible...if it’s my time to go, let me go. I don’t wanna be...connected to all kinds of IVs and tubes and things just to keep my heart beating .”. Key barriers were: 1) lack of knowledge about hospice; 2) equating hospice to ‘giving up’; 3) loss of faith; and 4) letting go of perceived life-extending medical care like hydration or nutrition. Lack of knowledge was a prevalent theme: “ You only do hospice when it’s at the very end of the road. But maybe that’s not true. Maybe you do that to get some special care for a couple of months to get you through a tough...time. I guess I don’t know.” On giving up: “I would not say I'm a fan of it (hospice) at all...I would rather go out fighting....to me it's like giving up...I can't really imagine that I would actually do that.’Regarding loss of faith or letting go of perceived life-extending care: “ Well, my thoughts on how it works is I'm really not sure. They're there to keep you comfortable in your last days, but I don't know because I've heard so many horror stories with hospice...yeah they keep your pain down, but they don't give you faith. They don't give you hydration... it's like, God, pretty much starving you to death. But I don't know if that's true. I mean, that's just what I've heard.” A pivotal decision making factor that could be either a facilitator or barrier was family support for hospice, reinforcing the need for shared decision-making among the pt, family and clinical care team. One pt stated: “ It's an emotional toll, financial toll, it’s a physical toll on the family...and I would just want to talk to my family about all aspects of it, and then they would go from there, what they would want to do, or what I would want to.” Conclusions: Understanding perceived barriers and facilitators to hospice care through elicitation of pt beliefs and values and focusing efforts on educating pts and their support systems about the role of hospice can empower women with ROC to make informed pt-centered decisions about their end-of-life care.

Access for adolescents and young adults with hard-to-cure cancer to PROFYLE: The pan-Canadian precision oncology pipeline.

10012 Background: Cancer is the most common cause of disease-related death in children, adolescents and young adults (CAYA). Approximately, 1.5% of patients with cancer in Canada are adolescents and young adults (AYAs) (age 15-29). AYAs often present with advanced disease and limited access to clinical trials including genomic testing. The PRecision Oncology For Young peopLE (PROFYLE) national, collaborative program, was created to provide equitable access to molecular profiling to identify novel targeted treatment options for CAYA with hard-to-cure cancers. The AYA node of PROFYLE aims to enhance the inclusion of AYAs across Canada at pediatric and adult centers while raising awareness of improving cancer outcomes of this underserved population. Methods: Building upon 3 pre-existing regional precision oncology programs, PROFYLE was implemented as the first pan-Canadian precision oncology pipeline. The PROFYLE study is multi-centred, non-randomized, interventional, and qualitative. Inclusion criteria: ≤29y; treatment at a Canadian center; diagnosis of a hard-to-cure cancer. It includes genomic and transcriptomic sequencing of paired germline and cancer fresh/frozen samples. Actionable findings, potential targeted therapy options including available clinical trials, clarification of diagnosis, and genetic counseling recommendations are provided to the clinical care team. Results: To date, &gt; 1,200 CAYA are included from all provinces. Of these, 33% were AYAs. Cancer diagnoses included: 47% sarcoma, 15% leukemia/lymphoma, 13% CNS tumor, 25% other. Of the AYAs enrolled, 53% had ≥1 significant tumour profiling finding (48% specific mutations/fusions; 6% DNA repair defect signature, hypermutation, microsatellite instability, chromosomal instability; 3% predictors of therapeutic resistance; 5% outliers in gene expression). 71% had potentially useful findings (15% diagnostic; 9% prognostic; 59% therapeutic; 2% etiologic; 15% cancer predisposition; 2% secondary germline; 0.5% pharmacogenetic). 23% had a pathogenic/likely pathogenic germline variant. 60% had ≥1 potentially actionable somatic alteration. 64% of clinicians indicated that molecular findings impacted clinical management (12% diagnostic; 6% prognostic, 60% therapeutic; 16% germline genetic). 24% indicated a change in treatment planning in response to these findings. Conclusions: The goal of developing a national precision oncology pipeline that provides equitable access to molecular profiling in a clinically relevant timeframe has been realized through the establishment of PROFYLE. Findings demonstrate that the sequencing platform provided medically informative results in the majority of enrolled AYAs. The success of PROFYLE underscores the importance of the continuing efforts to increase the access to this precision oncology initiative for all AYAs with cancer in Canada.

#2103 Accuracy of a continuous glucose monitor in people with diabetes on peritoneal dialysis

Abstract Background and Aims Globally 40% of people receiving peritoneal dialysis (PD) have a diagnosis of diabetes. Good glycaemic control can by complicated by the obligate glucose load associated with PD. Monitoring and treatment of people with diabetes (PwD) on PD has been limited by reduced reliability of traditional markers of glycaemia such as HbA1c in end-stage kidney disease. Continuous glucose monitors (CGMs) have been increasingly used in the care of PwD over the last 20 years. Monitors worn on the upper arm or abdomen measure glucose in interstitial fluid at regular intervals over the 24 hour period. CGMs are currently unlicensed in PD populations as they have not been tested in large scale studies. Concerns remain around accuracy in the presence of potentially interfering substances generated by the breakdown of osmotic agents used in PD fluid (e.g. Icodextrin). We aimed to assess the analytical and clinical accuracy of the FreeStyle Libre(FSL) CGM system in PwD on maintenance PD. Method We conducted a single centre observational study of 10 PwD who had been on PD for at least 3 months. For the 10 day study period participants wore a blinded research model FSL monitor which measured interstitial glucose levels every 15 minutes. Results from the FSL were compared with; Analytical accuracy was assessed using three methods; Clinical accuracy was assessed using the Parkes consensus error grid to assign each pair of readings to one of five risk zones and quantify the clinical implications of any difference between the two measurements. The International Organisation for Standardisation guidelines stipulates 99% of pairs should be in zones A and B, denoting little or no effect on clinical actions. Results Of 11 recruited participants, 10 completed the 10 day study period resulting in 76 paired CGM-YSI measurements and 375 paired CGM-CBG measurements. 7 participants were on APD and 3 on CAPD. All participants were prescribed a PD regime that included one daily dwell with Icodextrin. The aggregate MARD was 9.4% (95% CI 7.9, 10.4) for CGM-YSI matched pairs and 17.6% (95% CI 17, 19.3) for CGM-CBG matched pairs. Spearman's r was 0.94 (p &amp;lt; 0.0001) for CGM-YSI and 0.89 (p &amp;lt; 0.0001) for CGM-CBG. From Bland-Altman analysis, the systematic error of the CGM compared with YSI and CBG was −0.81 mmol/l (SD 0.81) and −1.6 mmol/l (SD 1.9) respectively. Parkes consensus error grid analysis showed that compared with YSI and CBG respectively, 100% and 99.9% of sensor values were in the clinically acceptable zones A and B (Fig. 1). Conclusion We have demonstrated satisfactory performance of the FSL monitoring system by both analytical and clinical metrics in this cohort of PD patients using treatment regimens including Icodextrin based fluids. CGMs provide much more information for the PwD and their clinical care team compared with random CBGs (which in themselves have been shown to exhibit significant between user variability) and time averaged markers such as HbA1c. They allow detection of asymptomatic hypoglycaemia and direct monitoring of the systemic effects of any change to the PD prescription resulting in a larger or smaller glucose load. These results should be reassuring for clinicians wishing to utilise the greater depth of information provided by CGMs to improve clinical care for their patients with diabetes on PD.

Abstract PO5-12-01: Characteristics of Patients Served by Participants in a Survivorship Navigator Learning Collaborative

Abstract Patient navigation is demonstrated to be a successful model for improving breast cancer screening and early detection, particularly for women in under-resourced communities. The effectiveness of this model has not yet been explored in cancer survivorship. Our research assesses the feasibility of community-based patient navigation after a breast cancer diagnosis. This analysis focuses on the role of patient navigators in providing community-based peer support for women living with breast cancer. We conducted an analysis of data from the Breast Cancer Survivorship Patient Navigator Virtual Learning Collaborative (VLC), a case-based, iterative, virtual training program designed to increase capacity of community-based patient navigators to support women diagnosed with breast cancer. Navigators participated in a 14-week practice-based curriculum focused on improving community support for breast cancer survivors. Each session included a brief lecture followed by a case presentation by a participant. Lecture topics include Breast Cancer 101, Psychosocial support, Treatment options, Clinical trials, Sexual Health, Palliative Care, Genetic Testing, and Trauma. All participants were asked to present at least one de-identified case for discussion, using an 55-item case presentation template. The template included data on patient demographics, diagnosis, treatment, and support. To encourage active learning, navigators were encouraged to present challenging cases for discussion focused on identifying solutions and providing peer support. This analysis focuses on the characteristics of patients presented by community navigators from January 2021 to May 2023. A total of 92 de-identified patient cases were presented by 71 patient navigators and community health workers. (Table 1) The majority of patients were diagnosed within 12 months (62%), with early stage (Stages I-III) disease (78%), and were in active treatment or had not yet started treatment (67%). More than half of the cases had tumors that were HR+ (54%) and nearly half were HER2- (43%); 9% of cases were triple negative and 9% were triple positive. Tumor characteristics were not reported for 27% of cases. Individuals diagnosed with metastatic breast cancer (MBC) compared with those diagnosed with early stage disease were more likely to be Black (59% v 39%), single (56% v 31%), not currently employed (100% v 46%), younger (average age 52 v 55 years old) and insured through Medicaid (56% v 17%) Individuals living with MBC relied more heavily on professional support compared to those diagnosed with early stage disease. The majority of MBC patients relied on the clinical care team (67%) and friends and family (67%) for support, with a large number also receiving support from faith-based organizations (56%), compared to those with early stage disease who relied on friends and family (90%) and the clinical care team (54%). Both groups relied on navigators (33% v 35%) and social workers (44% v 34%), while those with MBC relied more frequently on paid caregivers (44% v 3%), disability services (22% v 6%). The data indicates that individuals with MBC had more unmet needs, including practical support (55% v 33%) and disability (55% v 14%). Supportive care needs vary considerably based on stage of diagnosis, while community-based supportive services are often designed to meet the needs of those diagnosed with early stage disease. Community-based survivorship navigators more readily engage with patients with early stage disease who are newly diagnosed or in active treatment. Individuals with MBC have fewer community-based resources and are less likely to connect with a community-based navigator. Data from our Breast Cancer Survivorship Patient Navigator VLC points to the potential to identify gaps in community-based survivorship care. Future research should focus on expanding the reach of community navigators and ensuring community-based support for patients across all stages. Table 1 Demographics of Patients Presented at VLC Citation Format: Tamara Hamlish, Talia Holzman Castetllands. Characteristics of Patients Served by Participants in a Survivorship Navigator Learning Collaborative [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-12-01.

Abstract PO2-10-02: 'Sharing Our Own Experience': A Qualitative Study of Black Women Diagnosed with Triple-Negative Breast Cancer

Abstract Introduction: Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer that is disproportionately prevalent among U.S. Black women. Black women diagnosed with TNBC are less likely to receive the primary treatment options for TNBC, and more likely to die from the disease compared to white patients with the same diagnosis. Given TNBC’s impact on Black women, there is an urgent need to better understand their needs for information and support and any unique barriers to care they may face. Thus, this study explored the perspectives, needs, and lived experiences of Black women diagnosed with TNBC. Methods: Our study was guided by the transformative paradigm and used a multi-method approach. Study-eligible participants self-identified as: a) Black or African American; b) 18 years or older; c) being diagnosed with TNBC within the previous 5-7 years; d) receiving TNBC treatment in the U.S.; and e) English-speaking. From August-October 2022, SHARE Cancer Support (a national nonprofit focused on cancer) and 15 partner organizations used social media and listservs to recruit potential participants from their constituencies to complete a quantitative survey (n=49). From the survey participants, a stratified, purposeful sample of 20 Black women diagnosed with TNBC completed in-depth interviews from November 2022-February 2023. Two Black women researchers conducted virtual interviews with the participants via Zoom. The research team performed thematic analysis on the professionally transcribed data using NVivo 12. A Black Feminist lens was used to analyze codes and interpret emerging themes present across the interviews. The University of South Carolina's Institutional Review Board approved this study. Results: About half of those interviewed were between 35 and 44 years old, had a bachelor's degree or higher, and their annual household income ranged from less than $25,000 to $175,000. Eight major themes emerged from the personal stories of Black women diagnosed with TNBC. From diagnosis to survivorship, Black women discussed the importance of advocacy, including self-advocacy, others advocating on their behalf, and being motivated to become an advocate for others. The participants shared the significance of their identity as Black women and desired that cancer care team members acknowledge their identity and subsequently culturally tailor their care needs. Some participants also noted instances of racism and discrimination that occurred during their TNBC diagnosis or treatment experience. Participants overwhelmingly stressed the vital nature of having “someone who looks like me” to inform them about treatment options and existing resources, as well as to provide emotional support through their shared lived experiences with TNBC. Additionally, participants recognized the importance of embracing the uncertain yet inevitable future. They also emphasized that mental health support is not uniformly provided in care settings but should be an essential component of the TNBC treatment plan. Having support was essential to all the women, but they noted that support can look different for everyone and many existing support resources need to be improved. The themes were adapted into a list of recommended action steps for support organizations, clinical care team members, and TNBC patients to help improve the quality of life for Black women diagnosed with TNBC. Conclusions: The lived experiences of Black women diagnosed with TNBC can serve as a meaningful source of data and provide solutions to addressing persistent health disparities these women face. Findings from this study can inform future research and clinical practice about how to support the holistic needs of Black women diagnosed with TNBC. Recommendations for improving the quality of life for Black women diagnosed with triple-negative breast cancer. The 8 major themes that emerged in the qualitative study were adapted into a list of actionable recommendations for key interest groups to improve the lives of Black women diagnosed with triple-negative breast cancer. Citation Format: Tisha Felder, Lucy Ingram, Megan Austin, Victoria Burke, Stephanie Poland, Megan-Claire Chase, Christine Benjamin. 'Sharing Our Own Experience': A Qualitative Study of Black Women Diagnosed with Triple-Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-10-02.

P050 Determining the feasibility of a multi-centre randomised clinical trial to test the effectiveness of integrated symptom tracking for managing rheumatoid arthritis

Abstract Background/Aims In a series of studies, we co-developed and piloted the remote monitoring of rheumatoid arthritis (REMORA) system. REMORA enables patients to daily track symptoms via their smartphone and integrates this data into their electronic health record for discussion during routine clinic visits. This offers the opportunity to make better, and shared, treatment decisions and improve disease management. The effectiveness of integrated daily symptom tracking on clinical and patient-reported outcomes will be tested in a multi-centre stepped wedge randomised clinical trial (RCT). Here, we present the results of the REMORA feasibility study to test trial procedures and intervention delivery. Methods Across two NHS sites in the Northwest of England we aimed to recruit 60 patients, aged ≥18 years with rheumatoid arthritis (RA) or inflammatory arthritis (IA), and access to an Android/iOS smartphone with daily internet access. Participants were asked to complete a baseline web-survey and use the REMORA app to collect daily symptom reports for up to six months. Clinical care teams extracted data from participants’ medical records for all baseline and follow-up appointments, including disease activity scores. To assess feasibility, we reported recruitment rates, participants’ uptake of and adherence to daily symptom tracking, and outcome data completeness. We also compared characteristics of a) those who consented vs. trackers (defined as submitting ≥1 symptom report, i.e., successful intervention uptake), and b) high adherers (symptoms reported on &amp;gt; 60% days) vs. low adherers (symptoms reported on &amp;lt; 25% days). Results A total of 130 patients were screened across study sites, and 52 were eligible and provided consent to take part (40.0%). Of those, 32 (61.5%) initiated symptom tracking; their demographic characteristics were broadly similar to those who consented, though more people of white ethnicity appeared higher in the tracker group (93.8% (95% CI 79.2-99.2) vs 86.5% (74.2-94.4), respectively). Participants completed at least one symptom report on 63.2% of study days (2384/3771 days). We observed few differences between low vs high adherers, though low adherers (n = 6) were younger (median (IQR) years: 41.5 (34.5-55.3)) than the high engagers (n = 20; 61.0 (50.5-65.3)) and had a shorter disease duration (years: 1.0 (0-5.8) vs 3.0 (0.8-10.8)). In total, 48 consented participants had at least one follow-up appointment during the study window; 46 (95.8%) had complete primary outcome data. Conclusion Across two clinical sites, we determined that the procedures and intervention delivery designed for use within a future multi-centre stepped wedge RCT of the REMORA system were feasible for recruitment, adherence to the intervention and completion of the primary outcome. However, uptake of the intervention was lower than we hoped. To enhance intervention uptake in the main trial, we clarified inclusion criteria, improved patient information on what is required to initiate symptom tracking and modified our supporting materials. Disclosure K.L. Druce: None. M. Parkes: None. R. Bravo: None. D. Griffiths-Jones: None. S.N. van der Veer: None. W. Dixon: Consultancies; consultancy fees from Google unrelated to this work. J. McBeth: None.

A Tracheostomy Support Device to Reduce Tracheostomy-Related Pressure Injury.

Tracheostomies provide many advantages for the care of patients who are critically ill but may also result in complications, including tracheostomy-related pressure injuries. Research efforts into the prevention of these pressure injuries has resulted in specialized clinical care teams and pathways. These solutions are expensive and labor intensive, and fail to target the root cause of these injuries; namely, pressure at the device-skin interface. Here we measure that pressure directly and introduce a medical device, the tracheostomy support system, to reduce it. This was a cross-sectional study of 21 subjects in the ICU, each with a tracheostomy tube connected to a ventilator. A force-sensing resistor was used to measure baseline pressures at the device-skin interface along the inferior flange. This pressure was then measured again with the use of the tracheostomy support system in the inactive and active states. Resultant pressures and demographics were compared. Fifteen male and 6 female subjects, with an average age of 47 ± 14 (mean ± SD) years, were included in this study. Average pressures at the tracheostomy-skin interface at baseline in these 21 ICU subjects were 273 ± 115 (mean ± SD) mm Hg. Average pressures were reduced by 59% (median 62%, maximum 98%) with the active tracheostomy support system to 115 ± 83 mm Hg (P < .001). All the subjects tolerated the tracheostomy support system without issue. Despite best clinical practice, pressure at the tracheostomy-skin interface can remain quite high. Here we provide measures of this pressure directly and show that a tracheostomy support system can be effective at minimizing that pressure.

Improvements in appropriate placement of dental sealants after implementation of a clinical decision support system

BackgroundDental sealants are effective for the prevention of caries in children at elevated risk levels, and increasing the proportion of children and adolescents who have dental sealants on 1 or more molars is a Healthy People 2030 objective. Electronic health record (EHR)-based clinical decision support systems (CDSSs) have the ability to improve patient care. A dental quality measure related to dental sealant placement for children at elevated risk of caries was targeted for improvement using a CDSS. MethodsA validated dental quality measure was adapted to assess a patient’s need for dental sealant placement. A CDSS was implemented to advise care team members whether a child was at elevated risk of developing caries and had sealant-eligible first or second molars. Data on dental sealant placement at examination visits during a 5-year period were analyzed, including 32 months before CDSS implementation and 28 months after CDSS implementation. ResultsFrom January 1, 2018, through December 31, 2022, the authors assessed 59,047 examination visits for children at elevated risk of developing caries and with sealant-eligible teeth. With the implementation of a CDSS and training to support the clinical care team members in September 2020, the appropriate placement of dental sealants at examination visits increased from 27% through 60% (P < .00001). ConclusionsIntegration of a CDSS into the EHR as part of a quality improvement program was effective in increasing the delivery of sealants in eligible first and second molars of children aged 5 through 15 years and considered at high risk of developing caries. Practical ImplicationsAn EHR–based CDSS can be implemented to improve standardization and provide timely and appropriate patient care in dental practices.