Community-based Healthcare System Research Articles

Enhanced Recovery After Surgery Orthopaedics Program in a Community-Based Health Care System.

Enhanced Recovery After Surgery programs are common among healthcare systems and various surgical disciplines. Although evidence supporting the physiological rationale of multiple nutrition, physical activity, and pain control strategies before, during, and after surgical procedures is accumulating, implementing such strategies may pose a substantial challenge. The purpose of this quality improvement initiative was to outline the development, workflow, and implementation of an Enhanced Recovery After Surgery program for same-day total joint replacement procedures in a rural healthcare setting. This was not just an academic exercise. Our leadership had a strong desire to support our patients by identifying ways to hasten their recovery so that they can return to their preferred activities.

NCPD Tests: Enhanced Recovery After Surgery Orthopedics Program in a Community-Based Health Care System.

NCPD Tests: Enhanced Recovery After Surgery Orthopedics Program in a Community-Based Health Care System.

Trends in Detection of Adenoma and Sessile Serrated Lesions Over a Decade in a Community-Based Healthcare System.

Adenoma detection rate (ADR) is an accepted benchmark for screening colonoscopy. Factors driving ADR and its relationship with sessile serrated lesions detection rate (SSLDR) over time remain unclear. We aim to explore patient, physician, and procedural influences on ADR and SSLDR trends. Using a large healthcare system in northern California from January 2010 to December 2020, a total of 146,818 screening colonoscopies performed by 33 endoscopists were included. ADR and SSLDR were calculated over time using natural language processing. Logistic regression was used to calculate the odd ratios of patient demographics, physician attributes, and procedural details over time. Between 2010 and 2020, ADR rose from 19.4% to 44.4%, whereas SSLDR increased from 1.6% to 11.6%. ADR increased by 2.7% per year (95% confidence interval 1.9%-3.4%), and SSLDR increased by 1.0% per year (95% confidence interval 0.8%-1.2%). Higher ADR was associated with older age, male sex, higher body mass index, current smoker, higher comorbidities, and high-risk colonoscopy. By contrast, SSLDR was associated with younger age, female sex, white race, and fewer comorbidities. Patient and procedure characteristics did not significantly change over time ( P -interaction >0.05). Longer years in practice and male physician were associated with lower ADR and SSLDR in 2010, but significantly attenuated over time ( P -interaction <0.05). Both ADR and SSLDR have increased over time. Patient and procedure factors did not significantly change over time. Male endoscopist and longer years in practice had lower initial ADR and SSLDR, but significantly lessened over time.

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System.

To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system. We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system. A large community-based healthcare system. In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread. We used evidence-based strategies to implement the bundle in all 34 hospitals. We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs. The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.

Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors.

Community-based healthcare delivery systems frequently lack cancer-specific survivorship support services. This leads to a burden of unmet needs that is magnified in rural areas. Using sequential mixed methods we assessed unmet needs among rural cancer survivors diagnosed between 2015 and 2021. The Supportive Care Needs Survey (SCNS) assessed 5 domains; Physical and Daily Living, Psychological, Support and Supportive Services, Sexual, and Health Information. Needs were analyzed across domains by cancer type. Survey respondents were recruited for qualitative interviews to identify care gaps. Three hundred and sixty two surveys were analyzed. Participants were 85% White (n = 349) 65% (n = 234) female and averaged 2.03 years beyond cancer diagnosis. Nearly half (49.5%) of respondents reported unmet needs, predominantly in physical, psychological, and health information domains. Needs differed by stage of disease. Eleven interviews identified care gap themes regarding; Finding Support and Supportive Services and Health Information regarding Care Delivery and Continuity of Care. Patients experience persistent unmet needs after a cancer diagnosis across multiple functional domains. Access to community-based support services and health information is lacking. Community based resources are needed to improve access to care for long-term cancer survivors.

30 by 2030 campaign

Primary Health Care (PHC) is a cornerstone of universal health coverage (UHC). To prevent diseases and holistically treat people, community-based primary healthcare systems need to be strengthened. PHC is an approach that aims to address physical, mental, and social health and well-being, and to provide comprehensive care for a person's health needs throughout life rather than focus on treating a specific set of diseases. To achieve this approach, we must strengthen horizontal PHC systems and encourage vertical programmes, including disease-specific programmes, to be developed, integrated, and implemented in the context of integrated Primary Health Care.&#x0D; In early 2020 the WHO Collaborating Centre on Family Medicine and Primary Health Care launched the 30by2030 campaign (https://www.30by2030.net), whereby signatories are asking donors of vertical disease-oriented projects to invest at least 30% of their budgets for vertical programs in strengthening coordinated and integrated primary health care. The initiative is a pull of efforts of different organizations such as Wonca: World Organisation of Family Doctors, The Network: Towards Unity for Health (TUFH), African Forum for Primary Health Care, European Forum for Primary Care, PRIMAFAMED network, among others.&#x0D; The 30 by 2030 has two aims: the first one is to inform and raise awareness of the impact of vertical programs on health systems. Most of the private and external funds, which represent one-third of the total spending of PHC, are channelled through programmes that focus on the health problems of specific population subgroups (e.g., HIV, tuberculosis, malaria) which also leads to inequity by disease. The second aim is to call for international donors to assign 30% of their vertical top-down, disease-oriented budgets to strengthen primary healthcare services through coordination, increased human resources and improved infrastructure.

Abstract 16845: Heart Failure Hospitalist Service Line Have Decrease All Cause Readmission, Length of Stay and Cost at 3 UPMC Hospitals in Central Pennsylvania in 2022

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Methods: Patients with both primary diagnosis HF at UPMC Harrisburg/West Shore/Community General totaled to 1574 in 2022. Hospitalist, Cardiologist, teaching service N= 547 (36%); CHF hospitalist Team N=1027 (64%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups for 2022. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all other providers (Hospitalist, Cardiologist, teaching service) is 32%. HF Hospitalist team at 3 UPMC hospitals had lower 30 day all cause readmission rates: 8.46%. All other providers length of stay was 7.7 days while length of stay while on HF hospitalist service was 6.3 days. Potential cost savings to UPMC hospitals greater than $2.3 million dollars since start of HF Hospitalist service line. Conclusions: HF patients rarely have a consistent provider when readmitted. To address this health care priority at a system level, UPMC Central Pennsylvania’s strategy of creating a HF hospitalist service line has shown to be a unique method to not only develop trusting relationships with our patients but also attain impressive results. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. At this community-based healthcare system, HF Hospitalist outcomes include decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 5yrs of the HF Hospitalist service line now at 3 hospitals at UPMC.

Early detection of lung cancer through programmatic management of pulmonary nodules in the Mississippi Delta.

126 Background: Lung cancer (LC) causes the most cancer deaths in the US, but early detection improves outcomes. Uptake of Low-Dose CT screening (LDCT) has been low, contributing to race-based disparities. Programmatic management of incidentally detected pulmonary nodules (PN) provides a complementary avenue for early detection which could address disparities. In our PN cohort, Detecting Early LC in the Mississippi Delta (DELUGE), we provide broad access to early detection across a region fraught with geographic, socioeconomic, and race-based disparities. However, many detected PN will not result in LC. After successful implementation at the program level, we seek to evaluate individual-level factors important for early-detection. We evaluated how individuals with small PN identified in DELUGE differ between those who were and were not diagnosed with LC. Methods: DELUGE is a prospective cohort study where we systematically manage incidentally detected PN with trained navigators and evidence-based risk stratification. We constructed DELUGE in a community-based healthcare system across the mid-south with some of the highest per-capita LC incidence and mortality rates in the US. We evaluated all PN ≤30mm in DELUGE from 2015-2022. We compared clinical and demographic characteristics between individuals who were or were not diagnosed with LC within 24 months. Primary analysis used logistic regression, reporting odds ratios (OR) with 95% confidence intervals. Results: From 2015-2022, 17,945 individuals with PN ≤30 mm (71% of the total cohort of 25,339) were identified and enrolled in DELUGE. They had median age of 65 years, were 56% female, and 27% Black / 69% White. 853 (4.8%) patients were diagnosed with LC within two years. PN size significantly predicted LC diagnosis. For every 1 mm increase in nodule size the odds of LC increased by 15% (OR: 1.15 [1.14-1.16]); PN in an upper lobe (OR: 2.0 [1.7-2.2]) and those with cavitation also increased the odds of LC (OR: 2.9[1.9-4.2]). Sex, rural/urban residence, and number of PN were not associated with LC. The most predictive individual level characteristics were age, prior cancer history (OR: 1.3 [1.1-1.5], family cancer history (OR: 1.7 [1.5-2.0], COPD (OR: 3.3 [2.9-3.8]), and smoking history (OR: 6.6 [5.3-8.4]). In the multiple variable model, the most significant associations with LC diagnosis included PN size, age, insurance, family cancer history, COPD, and smoking history (all p&lt;0.0001). This model could provide estimated sensitivity 0.81 and specificity 0.81 for predicting LC (AUC= 0.88). Conclusions: Factors measurable at baseline have predictive ability, and predictive modeling may be useful in management of small PN. More focused follow-up could improve programmatic efficiency, targeting the alleviation of geographic, socioeconomic, and race-based health disparities in this high poverty region of the US.

S438 A Survey of Advanced Colorectal Cancer in Elderly Patients in a Large Community-Based Healthcare System

S438 A Survey of Advanced Colorectal Cancer in Elderly Patients in a Large Community-Based Healthcare System

S444 Molecular Tumor Testing on Colorectal Adenocarcinoma Specimens in a Large Community-Based Healthcare System

S444 Molecular Tumor Testing on Colorectal Adenocarcinoma Specimens in a Large Community-Based Healthcare System

Lung Cancer Yield Among Those Undergoing Lung Cancer Screening in Community-based Healthcare Systems

Lung Cancer Yield Among Those Undergoing Lung Cancer Screening in Community-based Healthcare Systems

Extracting patient-level data from the electronic health record: Expanding opportunities for health system research.

Epidemiological studies of interstitial lung disease (ILD) are limited by small numbers and tertiary care bias. Investigators have leveraged the widespread use of electronic health records (EHRs) to overcome these limitations, but struggle to extract patient-level, longitudinal clinical data needed to address many important research questions. We hypothesized that we could automate longitudinal ILD cohort development using the EHR of a large, community-based healthcare system. We applied a previously validated algorithm to the EHR of a community-based healthcare system to identify ILD cases between 2012-2020. We then extracted disease-specific characteristics and outcomes using fully automated data-extraction algorithms and natural language processing of selected free-text. We identified a community cohort of 5,399 ILD patients (prevalence = 118 per 100,000). Pulmonary function tests (71%) and serologies (54%) were commonly used in the diagnostic evaluation, whereas lung biopsy was rare (5%). IPF was the most common ILD diagnosis (n = 972, 18%). Prednisone was the most commonly prescribed medication (911, 17%). Nintedanib and pirfenidone were rarely prescribed (n = 305, 5%). ILD patients were high-utilizers of inpatient (40%/year hospitalized) and outpatient care (80%/year with pulmonary visit), with sustained utilization throughout the post-diagnosis study period. We demonstrated the feasibility of robustly characterizing a variety of patient-level utilization and health services outcomes in a community-based EHR cohort. This represents a substantial methodological improvement by alleviating traditional constraints on the accuracy and clinical resolution of such ILD cohorts; we believe this approach will make community-based ILD research more efficient, effective, and scalable.

Increased Risk of Hospitalization, Surgery, and Venous Thromboembolism Among Patients With Inflammatory Bowel Disease and Malnutrition in a Large, Community-Based Health Care System.

Patients with inflammatory bowel disease (IBD) constitute a high-risk population for malnutrition. Routine screening with standardized tools is recommended but can be challenging. Outcome data specific to IBD are sparse. We performed a retrospective cohort study (2009-2019) and electronically screened a large community-based population with IBD for malnutrition risk by extracting height and longitudinal weight, data elements used in the Malnutrition Universal Screening Tool (MUST). We used Cox proportional hazards regression to evaluate whether an electronic medical record-derived modified MUST malnutrition risk score was associated with IBD-related hospitalization, surgery, and venous thromboembolism. Malnutrition risk was categorized as low in 10,844 patients with IBD (86.5%), medium in 1,135 patients (9.1%), and high in 551 patients (4.4%). In the 1-year follow-up period, medium and high malnutrition risks, compared with low risk, were associated with IBD-related hospitalization (medium-risk adjusted hazard ratio [aHR] 1.80, 95% confidence interval [CI] 1.34-2.42; high-risk aHR 1.90, 95% CI 1.30-2.78) and IBD-related surgery (medium risk aHR 2.28, 95% CI 1.60-3.26; high risk aHR 2.38, 95% CI 1.52-3.73). Only high malnutrition risk was associated with venous thromboembolism (aHR 2.79, 95% CI 1.33-5.87). Malnutrition risk is significantly associated with IBD-related hospitalization, surgery, and venous thromboembolism. Application of the MUST score to the electronic medical record can efficiently identify patients at risk for malnutrition and adverse outcomes, permitting concentration of nutritional and nonnutritional resources to those at greatest risk.

Change of home visit frequency by public health nurses predicts emergency escorts for psychiatric patients living in the community: A retrospective medical record review.

Improper or insufficient treatment of mental health illness harms individuals, families, and society. When psychiatric treatment shifts from a hospital-based to a community-based health care system, risk management is essential to the provision of effective care. We examine whether an upgrade in home visit frequency of psychiatric patients as identified by public health nurses can predict the subsequent need for emergency escort services for medical treatment. A 2-year retrospective medical record review. A district of New Taipei City in Taiwan. A total of 425 patients with a diagnosed mental health illness cared for through home visits by public health nurses from January 2018 to December 2019. We accessed the Ministry of Health and Welfare's psychiatric care management information system to identify a set of medical records, and analyzed these records using chi-square and regression analyses. The analyses indicated that the groups experiencing the greatest need for emergency escort services were: male, 35-49 years old, with a senior high school level of education, without a disability identification card, with a schizophrenia diagnosis, and had been reported by the nurse as having progressed to a serious level. Nurses' increased frequency of home visits (an indicator that the patient's overall condition was worsening) and nurses' reports of increased severity of problems were significant predictors of the need for emergency escort services. The nurses' adjustment of visit frequency based on the results of the visit assessment predicts the need for emergency escort services for mental patients. The findings support not only the professional roles and functions of public health nurses, but also the importance of strengthening psychiatric health community support services.

Recent Developments in Community-Based Mental Health Care in Japan: A Narrative Review

BACKGROUND: Since the 1950s, mental health care in Japan has been hospital-centered. A set of legislative initiatives were undertaken in 1995, emphasizing the importance of community-based mental health care. However, despite these attempts to develop a community-based mental health care system, the rate of inpatient-based treatment has remained high and the shift from hospital-centered care to community-based has still not fully materialized.&#x0D; AIM: This study aims to conduct a review of the available literature on the development of community-based mental health care in Japan between 2010 and 2020.&#x0D; METHODS: We conducted a standardized literature search in the electronic database Igaku Chuo Zasshi, aiming to identify original studies published between 2010 and 2020 that explored community mental health care in Japan. The included studies outcomes were categorized as performance surveys, service user reports, service provider reports, and educational activities. A descriptive-analytical method was implemented in the current review.&#x0D; RESULTS: A total of 25 studies were examined. Six studies reported surveys assessing the performance of community-based mental health care on the assertive community treatment (ACT), compulsory treatment, home-visit nursing care, physical complications, and a welfare medicine collaboration on a remote islands. Four studies investigated the perspectives of service users or their families on home-visit nursing care, social participation, community program, and legislative revision. Ten studies focused on social withdrawal, service providers perspectives on local population needs, supporting skills, care programs, and the professional growth of psychiatric social workers. Five studies focused on educational approaches for future healthcare professionals and efforts to improve mental health literacy among adolescents.&#x0D; CONCLUSION: This paper provided the first comprehensive review of Japans community-based mental health care. Between 2010 and 2020, community mental health care in Japan evolved in many directions, with the understanding that various needs should be met. Home-visit nursing care and ACT can be considered as the most thoroughly investigated and better developed. Research that adopt rigorous methodologies such as randomized controlled trials is required if the goal is to achieve solid conclusions.

28 Factors impacting genomic testing rates among epithelial ovarian cancer patients across a large community-based healthcare system

28 Factors impacting genomic testing rates among epithelial ovarian cancer patients across a large community-based healthcare system

Abstract 14287: Development of an Innovated Heart Failure Hospitalist Program Drives Best Practice and Exceptional Outcomes From 2018-2021

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Hypothesis: The UPMC Hospitalist and Cardiology leadership recognized the need to foster consistent inpatient hospitalist providers, which was lacking in the current model. The concept of a dedicated Heart Failure Hospitalist service line emerged. Methods: Patients with both primary HF: UPMC Hospitalist, Cardiologist, teaching service N= 4192 (70%); CHF hospitalist Team N=1785 (30%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups from 2018-2021. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all providers is 21% from 2018-2021, matching the national average. HF Hospitalist team (only at Harrisburg Hospital) has consistently lower readmission rates: 9% (2018), 8.34% (2019), 8.6% (2020), 6.95% (2021). HF hospitalist length of stay was also consistently lower, by 0.5 to 0.9 days. Potential cost savings to UPMC hospitals is $1.5 million dollars since start of HF Hospitalist service line. Conclusions: Heart failure is a major health care issue. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. The HF Hospitalists provide quality care with frequent daily rounding, optimization of HF medications, providing education to the patient and family to improve treatment plan adherence, as well as engaging in early discussion of palliative and hospice transition. At this community-based healthcare system, HF Hospitalist outcomes include decreasing length of stay; decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 4yrs of the HF Hospitalist service line at UPMC.

Factors impacting genomic testing rates among epithelial ovarian cancer patients across a large community-based healthcare system (595)

<b>Objectives:</b> To determine the rates of germline and somatic testing for epithelial ovarian cancer (EOC) patients and identify factors that impact testing rates across a large community-based healthcare system operating in seven states across WA, OR, CA, AK, MT, NM, and TX. The system is comprised of over 100,000 caregivers, 51 hospitals, and 829 physician clinics. The aim was to identify fixed barriers to testing, including region, hospital type, insurance status, racial/ ethnic disparities, and stage of diagnosis. <b>Methods:</b> Clinical, pathologic, demographic, and genomic testing information was obtained from the diverse dataset within the Providence St. Joseph Health Electronic Medical Records and the system-wide cancer registry for all patients with an EOC diagnosis (ICD C56.x) between January 2015 and January 2020. Structured genomic data was sourced from laboratory information systems and manual abstraction of molecular sequencing reports. This dataset encompasses patient population data among diverse hospital settings and urban/rural environments. Hospital types were broken down into academic settings, which contain residency programs (Academic), Commission on Cancer (CoC) accredited programs or smaller community sites (Community) without CoC accreditation. Descriptive statistics and logical regression were utilized to summarize key findings. <b>Results:</b> Within this EOC cohort (3,007 patients), 34% (<i>n</i>=1,027 patients) completed some type of genomic testing (GT). The percentage of patients tested increased from 31% in 2015 to 46% in 2019, reflecting the uptake of testing guidelines. The increase in GT rates was largely attributable to an increase in somatic tumor testing (14-39%), while germline testing rates were stable across the interval (25-33%). Patients were more likely to receive testing if they received care at an academic or CoC institution versus a community institution (p=0.0001). Logistic regression analysis demonstrated the following factors impacted tested rates: institution type, insurance, and stage at diagnosis (p=0.001, p=0.0019 and p < 0.0001, respectively). Race/ethnicity did not contribute significantly to the model but did have a significant effect when analyzed independently. <b>Conclusions:</b> This study is the first to analyze practice patterns in GT for EOC across a broad community-based healthcare system servicing seven states. The data highlight discrepancies in GT heavily influenced by practice setting, insurance status, and stage of diagnosis (likely reflecting payer coverage/ increased need for information in advanced-stage disease). There is a need for a universally defined testing approach to provide equitable access to evidence-based cancer care.

Implementation of patient-reported outcomes for symptom management in oncology practice through the SIMPRO research consortium: a protocol for a pragmatic type II hybrid effectiveness-implementation multi-center cluster-randomized stepped wedge trial

BackgroundMany cancer patients experience high symptom burden. Healthcare in the USA is reactive, not proactive, and doctor-patient communication is often suboptimal. As a result, symptomatic patients may suffer between clinic visits. In research settings, systematic assessment of electronic patient-reported outcomes (ePROs), coupled with clinical responses to severe symptoms, has eased this symptom burden, improved health-related quality of life, reduced acute care needs, and extended survival. Implementing ePRO-based symptom management programs in routine care is challenging. To study methods to overcome the implementation gap and improve symptom control for cancer patients, the National Cancer Institute created the Cancer-Moonshot funded Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium.MethodsSymptom Management IMplementation of Patient Reported Outcomes in Oncology (SIMPRO) is one of three research centers that make up the IMPACT Consortium. SIMPRO, a multi-disciplinary team of investigators from six US health systems, seeks to develop, test, and integrate an electronic symptom management program (eSyM) for medical oncology and surgery patients into the Epic electronic health record (EHR) system and associated patient portal. eSyM supports real-time symptom tracking for patients, automated clinician alerts for severe symptoms, and specialized reports to facilitate population management. To rigorously evaluate its impact, eSyM is deployed through a pragmatic stepped wedge cluster-randomized trial. The primary study outcome is the occurrence of an emergency department treat-and-release event within 30 days of starting chemotherapy or being discharged following surgery. Secondary outcomes include hospitalization rates, chemotherapy use (time to initiation and duration of therapy), and patient quality of life and satisfaction. As a type II hybrid effectiveness-implementation study, facilitators and barriers to implementation are assessed throughout the project.DiscussionCreating and deploying eSyM requires collaboration between dozens of staff across diverse health systems, dedicated engagement of patient advocates, and robust support from Epic. This trial will evaluate eSyM in routine care settings across academic and community-based healthcare systems serving patients in rural and metropolitan locations. This trial’s pragmatic design will promote generalizable results about the uptake, acceptability, and impact of an EHR-integrated, ePRO-based symptom management program.Trial registrationClinicalTrials.gov NCT03850912. Registered on February 22, 2019. Last updated on November 9, 2021.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System.

Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.