Division Of Gynecologic Oncology Research Articles

Implementation of a validated post-operative opioid nomogram into clinical gynecologic surgery practice: A quality improvement initiative

ObjectivesThe Gynecologic Oncology Postoperative Opioid use Predictive (GO-POP) calculator is a validated tool to provide evidence-based guidance on post-operative opioid prescribing. The objective of this study was to evaluate the impact of the implementation of GO-POP within an academic Gynecologic Oncology division. MethodsTwo cohorts of patients (pre-implementation and post-implementation) who underwent surgery were compared with reference to GO-POP calculator implementation. All patients were included in the post-implementation group, regardless of GO-POP calculator use. An additional expanded-implementation cohort was used to compare pain control between GO-POP users and non-GO-POP users prospectively. Wilcoxon rank sum tests or ANOVA for continuous variables and Chi-square or Fisher’s exact tests were used to categorical variables. ResultsThe median number of pills prescribed post-operatively decreased from 15 pills (Q1: 10, Q3: 20) to 10 pills (Q1: 8, Q3: 14.8) after implementation (p < 0.001). In the expanded-implementation cohort (293 patients), 41% patients were prescribed opioids using the GO-POP calculator. An overall median of 10 pills were prescribed with no difference by GO-POP calculator use (p = 0.26). Within the expanded-implementation cohort, refill requests (5% vs 9.2%; p = 0.26), clinician visits (0.8% vs 0.6%, p = 1), ED or urgent care visits (0% vs 2.3%, p = 0.15) and readmissions (0% vs 1.7%, p = 0.27) for pain did not differ between those prescribed opioids with and without the GO-POP calculator. ConclusionsA 33% reduction in post-operative opioid pills prescribed was seen following implementation of the GO-POP calculator into the Gynecologic Oncology division without increasing post-operative pain metrics or encounters for refill requests.

Factors Associated with Inpatient Narcotic Medication Usage after Robotic-assisted Laparoscopy

Describe factors that contribute to an increased narcotic medication use after robotic-assisted laparoscopic (RAL) surgery. A retrospective cohort. A teaching hospital. All patients undergoing RAL surgery by gynecologist oncologists at St. Joseph's Hospital and Medical Center over a 3-year period. RAL by gynecologist oncologists. Using retrospective chart review, patients who underwent RAL surgery from 2012 to 2015 in the division of gynecologic oncology were identified; 757 patients were eligible for inclusion in the study. Total narcotic use during the postoperative hospital stay was converted to oral morphine milligram equivalents (OME). Bivariate correlations of total OME narcotics to multiple variables were evaluated using Spearman's rho. The average age, body mass index, and length of stay were 53.76 years (17-92), 31.75 kg/m2 (17-56), and 1.56 days (range, 0-19), respectively. Increased OME correlated positively with body mass index (Spearman's rho=.077, p=.036), any intraoperative complication (Spearman's rho=.05, p=.886), any postoperative complication (Spearman's rho=.16, p <.0001), length of stay in days (Spearman's rho=.282, p <.0001), procedure time (Spearman's rho .023, p=.52), and total anesthesia time (Spearman's rho, .032). Total OME narcotics were correlated negatively with age of 65 years or older (Spearman's rho, -.144, p <.0001) and use of patient-controlled analgesia (Spearman's rho, -.185, p <.0001). Age younger than 65 years seems to be a predictor for increased requirement of total morphine equivalent medication after RAL surgery, whereas patient-controlled analgesia use had a negative association.

Implementation of an enhanced recovery after surgery (ERAS) protocol for total abdominal hysterectomies in the division of gynecologic oncology: a network-wide quality improvement initiative.

Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the non-ERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). A large-scale quality improvement (QI) initiative is feasible utilizing a multidisciplinary team to implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scale QI result was comparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.

The Pelvic Surgeon

Journal of Gynecologic SurgeryVol. 39, No. 3 EditorialFree AccessThe Pelvic SurgeonMitchel S. HoffmanMitchel S. Hoffman—Mitchel S. Hoffman, MD, Editor-in-Chief Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA.Search for more papers by this authorPublished Online:1 Jun 2023https://doi.org/10.1089/gyn.2023.0035AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail At the turn of the 20th century, a number of advances made surgery much safer for patients. These were: antisepsis; anesthesia; and eventual introduction of antibiotics and blood banking. Formal surgical training in the United States began in the early part of that century. Expertise in gynecologic surgery in the United States also arose from and in tandem with general surgery. The American Board of Obstetrics and Gynecology was established in 1930 as departments of obstetrics and gynecology continued to develop and expand their training programs. Eventually, training in gynecologic surgery became distinct from that of general surgery. Surgical specialization (including gynecologic) followed, a trend that continues in parallel with advances in medical knowledge and complexity.The pelvis is a confined space where portions of the urinary, genital, and intestinal tracts become intimately associated. For that reason, diseases and other abnormalities in the pelvis may involve multiple organ systems and other neurovascular structures. Therefore, urology, gynecology, and colorectal surgery may all be involved in procedures within the confines of the pelvis. As pelvic diseases and abnormalities cross organ systems and disciplines, so must their surgical management.There are ranges of expertise within each pelvic surgical discipline and, while a multidisciplinary approach may be required at times, the gynecologic surgeon must be able to manage the treatment of extended pelvic disease or related pelvic disorders. In some instances, the various surgical disciplines have developed specialty-specific methodology for managing similar conditions. For the reasons described, pelvic surgery by its very nature is multidisciplinary.Two articles in the current issue address gynecologic surgical management of disease extension or related disorders. Drs. Simone Fertel (MD) and Katie Propst (MD), from the University of South Florida Morsani College of Medicine, in Tampa, FL, USA, discuss the historical background of assessment and management of fecal incontinence and the surgical treatment options for patients who suffer with this condition. The Mayo Clinic's (Rochester, MN, USA) gynecologic oncology division investigated specific procedures that might be associated with postoperative complications occurring with ovarian cancer cytoreductive surgery, and identified the contribution of some nongynecologic procedures. Most importantly, surgery must always be done by appropriately trained and skilled individuals. There is a critical consequence arising from the issues that face surgical training competency, particularly as it affects general gynecologic surgery. General gynecologic surgery especially is in danger of becoming boxed into an increasingly narrower scope of capability. Our specialty must train individuals to be pelvic surgeons. I would be most interested in hearing from you, the readers of this journal, regarding your thoughts on the future of general gynecologic surgery. The best format for doing this would be a Letter to the Editor.FiguresReferencesRelatedDetails Volume 39Issue 3Jun 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.The Pelvic Surgeon.Journal of Gynecologic Surgery.Jun 2023.107-107.http://doi.org/10.1089/gyn.2023.0035Published in Volume: 39 Issue 3: June 1, 2023PDF download

Apixaban for extended postoperative thromboprophylaxis in gynecologic oncology patients undergoing laparotomy

IntroductionVenous thromboembolic events represent the second most frequent cause of mortality in cancer patients. Recent literature shows that direct oral anticoagulants (DOAC) are at least as effective and safe as low molecular weight heparin for postoperative thromboprophylaxis. However, this practice has not been broadly adopted in gynecologic oncology. The aim of this study was to evaluate clinical effectiveness and safety of apixaban for extended thromboprophylaxis in comparison to enoxaparin after laparotomies for gynecologic oncology patients. MethodsThe Gynecologic Oncology Division at a large tertiary center transitioned from enoxaparin 40 mg daily to apixaban 2.5 mg BID for 28 days after laparotomies for gynecologic malignancies in November 2020. This real-world study compared patients post-transition (November 2020 to July 2021 (n = 112)) to a historical cohort (January to November 2020 (n = 144)), using the institutional National Surgical Quality Improvement Program (NSQIP) database. All Canadian gynecologic oncology centers were surveyed to assess postoperative DOAC utilization. ResultsPatient characteristics were similar between groups. No difference was found between total venous thromboembolism rates (4% vs. 3%, p = 0.49). No difference was found in postoperative readmission (5% vs. 6%, p = 0.50). Of the 7 readmissions in the enoxaparin group, one was due to bleeding requiring transfusion; there were no readmissions for bleeding in the apixaban group. No patient required a reoperation for bleeding. Thirteen percent of the 20 Canadian centers have transitioned to extended apixaban thromboprophylaxis. ConclusionsApixaban for 28-day postoperative thromboprophylaxis was found to be an effective and safe alternative to enoxaparin after laparotomies in a real-world cohort of gynecologic oncology patients.

Editorial introductions.

Editorial introductions.

43 Implementation of a standard same day discharge protocol for minimally invasive hysterectomies in the division of gynecologic oncology: a quality improvement project

43 Implementation of a standard same day discharge protocol for minimally invasive hysterectomies in the division of gynecologic oncology: a quality improvement project

Telemedicine and gynecologic oncology: caring for patients remotely during a global pandemic

Telemedicine uses technology to deliver medical care remotely and has been shown to provide similar patient satisfaction and care outcomes compared with in-person visits. This study aimed to assess the gynecologic oncology patient telehealth experience. All patients receiving telehealth care between March 23, 2020, to May 14, 2020, from a single institution's gynecologic oncology division were offered postvisit surveys to assess satisfaction. Basic demographic and clinical data were collected and analyzed with descriptive statistics. Patient zip code data were correlated with Community Need Index scores and visualized using heat maps. Of 286 telehealth visits, 112 postvisit surveys (39.2%) were collected. Survey responses demonstrated high patient satisfaction with responders agreeing that privacy was respected (97.3%), diagnosis and treatment options were adequately explained (92%), they could easily ask questions (97.3%), and they established a good rapport with their provider (96.4%). Additional benefits included reduced travel (92.9%), time (83.0%), cost (67.9%), and family interruption (57.1%). Among 11 patients receiving treatment on a clinical trial, 10 (90.9%) were able to continue on trial without disruption. Most responders (87.5%) preferred future visits to occur via telehealth or a mixture of telehealth and in-person visits. No difference in satisfaction was found among patients residing in zip codes associated with higher Community Need Index scores or increased distance from the institution. The use of telemedicine in providing gynecologic oncology care was associated with high patient satisfaction and had the benefits of reduced time, cost, travel, and interruption to family time.

TOGETHER Care: PatienT-tailOred GynEcologic Oncology posT discHargE caRe (290)

TOGETHER Care: PatienT-tailOred GynEcologic Oncology posT discHargE caRe (290)

Just text me: A feasibility study of postoperative texting evaluations for gynecologic oncology patients (291)

<b>Objectives:</b> Postoperative recovery is a stressful time for patients. As part of the standard of care, postoperative gynecologic oncology patients at the University of Pennsylvania Health System receive post-discharge phone calls by gynecologic oncology nurses to evaluate and recommend intervention as needed during patients' postoperative recovery. Given the high clinical volume, we aimed to determine if an automated text messaging program and healthcare innovation strategies, in lieu of routine telephonic nursing evaluations, could provide postoperative patient assessments that were comprehensive, were satisfactory to patients, and decreased provider clinical workload. <b>Methods:</b> English speaking patients undergoing surgery with four providers in the Division of Gynecologic Oncology at the University of Pennsylvania Health System from February 2021 to June 2021 were eligible for enrollment. Patients were offered routine telephonic evaluations by the gynecologic oncology nurses versus text message-based evaluations. Enrolled patients were texted 48 hours following discharge using an algorithm based on the Division's routine telephonic script. A "fake back end", i.e. a care team member who sent and responded to patient text messages, was utilized given the pilot nature of this study. Patients who did not respond were called by the nursing team to complete the remaining questions for evaluation. Patients with responses requiring further assessment were called by the nursing team for triage. Over the course of the pilot study, the algorithm was edited in response to patient and provider feedback. This program was approved by the Penn Medicine Institutional Review Board Quality Initiative and supported by the Center for Health Care Innovation. <b>Results:</b> Sixty-nine patients were approached for the program with 56 patients enrolling. Median age of enrollees was 54 years (IQR= 45.1-62.5). Basic demographics are provided in Table 1. The most common reason for declining the program was patient preference of telephone call. Of enrollees, 41 (73%) initiated the program. Of the 41 active enrollees, 18 (44%) completed the entire algorithm. Median time to completion of the algorithm was 34 (IQR 20-81) minutes. The 18 completed algorithms saved an estimated 4.5 hours of provider time. Reasons for non-completion were: 5 (22%) response indicated need for provider assessment, 3 (13%) algorithm error, and 15 (65%) patient non-response. Of the 17 enrollees who answered "On a scale of 0-10, how likely are you to recommend this texting program to a friend if they were getting the same procedure as you?" there were 13 promoters (9-10), 1 neutral participant (7-8), and 3 detractors (6 or less). Twelve participants responded with a score of 10/10. The lowest score was a 5 from a single patient. <b>Conclusions:</b> Text messaging programs for gynecologic oncology patients are feasible in providing efficient postoperative care and are satisfactory to patients. Further study is needed to determine the safety and scalability of automated patient evaluation text messaging platforms.

Evaluating differences in enhanced recovery after surgery (ERAS) implementation and its effects on opioid use by race (571)

<b>Objectives:</b> The purpose of this study was to determine if there was a difference in postoperative opioid use based on race after surgery for gynecologic cancers. <b>Methods:</b> The electronic medical record (EMR) was used to identify patients undergoing major surgery within the Division of Gynecologic Oncology at a single institution from July 1, 2019, to June 30, 2020. Descriptive data and prognostic factors were collected. The EMR and state prescription drug monitoring systems were used to collect information on filled opioid prescriptions. Opioid use was standardized to morphine milligram equivalents (MMEs). The effect of perioperative enhanced recovery after surgery (ERAS) implementation on postoperative opioid use was assessed. SAS Version 9.4 was used for statistical analyses. <b>Results:</b> A total of 160 patients met the inclusion criteria. Among the patients, 51.9% were White, 41.2% Black, and 6.9% others. Of the included patients, 81% received some component of ERAS. Implementation of ERAS components was variable, with 58.1% of patients receiving preoperative acetaminophen, 52.5% receiving preoperative gabapentin, and 54.7% receiving pre or postoperative Transversus Abdominis Plane (TAP) blocks. Analyses compared postoperative opioid use between Blacks and White patients. There was no difference in opioid use during the last 24 hours of hospitalization (25.5 vs 21.7 MMEs, p=0.46). There was a trend towards increased opioids prescribed at discharge (343 vs 206 MMEs, p=0.086) and total opioids prescribed in the 30-day postoperative period (538 vs 327 MMEs, p=0.59) in Black than White patients. There was no difference in ERAS implementation between Black and White patients. For Black patients, preoperative acetaminophen was associated with a statistically significant reduction in inpatient opioid use in the last 24 hours of hospitalization (17.8 vs 36.7 MMEs, p=0.041) and opioids prescribed at discharge (189 vs 568 MMEs, p=0.047). However, this difference was not observed for White patients. Preoperative gabapentin demonstrated similar trends. The effect of TAP blocks on postoperative narcotic use was not significant in either group. <b>Conclusions:</b> Preoperative acetaminophen use in Black patients was associated with decreased postoperative opioid use. This information can be used to improve counseling for patients on home-going pain management regimens.

Malignant Bowel Obstruction in Ovarian Cancer Recurrence: The Role of Palliative Surgery in a Decision-Making Process

Background: Malignant bowel obstruction (MBO) is often the latest stage in ovarian cancer (OC). The therapy of this condition ranges from medical waiting to surgery. The objective of this pilot study is to compare the two strategies so that we can provide a path forward for future studies. Methods: From 700 women diagnosed with OC in the database of the Division of Gynecologic Oncology we crossed the names of those admitted by the emergency services of the IRCSS Azienda Ospedaliero Universitaria of Bologna, Italy. We selected MBO patients with a history of OC as the only neoplastic condition and compared the results between medical conduct and surgery to restore intestinal transit. Results: Of the 700 women in our database, 36 were eligible for study according to the inclusion and exclusion criteria: 9 in surgery group and 27 in medical group. Surgical conduct (tumor biopsy and stoma) appears to be resolutory for the obstruction and have a better result than medical therapy regarding recurrence of MBO, despite the development of greater complications. Relapses of MBOs occurred in 11% of surgical patients and 44% of medical patients (p = 0.0714). Furthermore, after surgical treatment, five patients (55%) experienced postoperative complications; in four cases, severe anemia requiring blood transfusion, while one patient developed post-surgical sepsis, which evolved into multiple organ failure and death. Of the 9 patients treated surgically, 2 (22%) were given surgery as a first choice. In most cases (78%), surgery was decided upon when medical treatment failed. The only discriminative factor appears to be age. The length of hospitalization increased with the patient’s age (p = 0.0181) as statistically significant factors for a worse outcome in surgery. Conclusions: MBO requires complex and multidisciplinary management where different factors need to be considered before initiating surgical therapy. Future studies are needed to deal with this complex problem.

Use of Laparoscopic and Laparotomic J-Plasma Handpiece in Gynecological Malignancies: Results From A Pilot Study in A Tertiary Care Center

IntroductionThe J-Plasma has recently been introduced into the surgical community with different intrinsic characteristics aimed to further reduce the thermal effect and enhance precision when compared to standard radiofrequency. This study aimed to investigate the role of this new technology in different conditions of gynecological carcinomatosis characterized by the indication for regional peritonectomy and/or ablation, either in laparotomy (LPT) or in laparoscopy (LPS), in the context of a modern personalized approach to the surgical management of gynecological malignancies.Material and MethodsFrom January 2019 to April 2019, 12 patients were selected for this prospective pilot study at the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. In this single surgeon experience, the inclusion criteria were: histologically proven advanced ovarian/endometrial cancer, primary or interval debulking surgery, and intraoperative indication for regional peritonectomy. Six patients were treated by LPS (Group 1) and 6 by LPT (Group 2).ResultsIn Group 1 the indication for debulking surgery was in 4 cases an interval debulking surgery and 2 advanced endometrial cancer. All patients in Group 2 underwent primary debulking surgery for advanced ovarian cancer. The whole cohort achieved a complete tumor excision after surgery. The median OT and median EBL were 195 min and 100 ml in Group 1, and 420 min and 500 ml in Group 2. The median hospital stay was 4 days in Group 1 and 13 days in Group 2, respectively. No intra and postoperative complications were registered within 60 days after surgery.ConclusionsJ-Plasma allows to approach delicate maneuvers on viscera, mesentery, and blood vessels with a high degree of safety and precision thanks to its limited vertical and lateral thermal spread, favoring the surgeon to push ever higher the cytoreduction/morbidity tradeoff. The use of J-Plasma in cytoreductive surgery could also increase the range of possible minimally invasive procedures, narrowing the technical distance with the open technique and thus contributing to designing a personalized surgical strategy for each patient in different scenarios of peritoneal carcinomatosis.

The first European gynaecological procedure with the new surgical robot Hugo™ RAS. A total hysterectomy and salpingo-oophorectomy in a woman affected by BRCA-1 mutation.

The benefits of minimally invasive surgery are well known in gynaecology. Robotic-assisted surgery has gained widespread acceptance within the surgical community and seems to be the most rapidly developing sector of minimally invasive surgery. This video shows the salient steps of total hysterectomy with new robotic technology, Hugo™ RAS. The objectives were to introduce and demonstrate the feasibility, efficacy, and safety of this new advanced device. A sixty-two years-old woman affected by BRCA-1 mutation underwent the first European gynaecological surgical procedure using the new surgical robot Hugo™ RAS in the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Docking and operative times. The docking time was 6 minutes and the total operative time was 58 minutes. There were no system errors and faults in the robotic arms. The surgeon found no friction or rasping in the arms. The estimated blood loss was 30 mL. No intraoperative complications were recorded. Gynaecological surgery with Hugo™ RAS seems feasible, safe and effective as shown by initial experiences in urological surgery. A larger case series would confirm the current experience and determine whether this technology could offer any additional benefit.

Needleoscopic-assisted risk-reducing bilateral salpingo-oophorectomy in BRCA1/2 mutation carriers: Peri-operative outcomes and psychological impact

ObjectiveTo investigate the role of needleoscopic-assisted laparoscopy in terms of surgical impact and psychological outcomes in RR-BSO for BRCA1/2 patients. Study designProspective monocentric trial conducted at the Division of Gynecologic Oncology, “Fondazione Policlinico Universitario A. Gemelli” IRCSS in Rome.Between March 2016 and March 2018, 26 consecutive patients were prospectively enrolled in the study and underwent RR-BSO. Peri-operative surgical variables were collected.The psychological interview was performed at the discharge and during the first post-operative follow-up visit (between 30 and 60 days after surgery). ResultsWe reported a median OT of 18.5 min (range, 15–37), a median EBL of 0 mL (0–20), and no conversion to laparoscopy or laparotomy.The median VAS score was “at rest” of 2, 3, and 1; while under “Valsalva maneuver” was 4, 3, 2, respectively at 2, 4, and 24 h.77% (20/26) of the whole population had a previous diagnosis of breast cancer.All patients expressed great cosmetic satisfaction both at discharge and after 30/60 days, with an 84.6% of score 5 and a 15.4% of score 4.The highest number of “score 5”, concerning the cosmetic outcomes, were clustered in the subgroup of breast cancer survivors with a 95% of score 5 versus 50% of score 5 in patients with no previous breast cancer (p = 0.0073).Similarly, the maximal psychological advantage of the ultra-MIS approach was revealed in the breast cancer survivors (70% of score 5 versus 16% of score 5, p = 0.02). ConclusionsThe use of 2.4 mm instruments raises the possibility of decreasing post-operative incisional pain, reducing hospitalization, and ensuring better cosmetic and psychological outcomes without increasing complications.The full psychosomatic benefit of ultra-MIS within BRCA mutation carriers is revealed in breast cancer survivors, probably due to the comparison with the mutilating and invasive previous breast surgery.

Editorial introductions.

Editorial introductions.

The ABCs of ACPs: perspectives from gynecologic oncology clinicians on an advance care planning initiative

Objectives: There are many advance care planning (ACP) initiatives for patients, however little is known on the clinician experience around these initiatives. Clinician experience can affect provider adoption of the initiative and willingness to utilize and engage in advance care planning. Our goal was to evaluate the attitudes and experience of Gynecologic Oncology clinicians utilizing an electronic health record (EHR) ACP notification in clinical practice to identify barriers and facilitators to use. Methods: Starting in 2017, an academic medical center Gynecologic Oncology division implemented a quality improvement project to increase ACP conversations and EHR documentation. Patients with high risk of death within 1 year, defined as a diagnosis of platinum-resistant ovarian cancer, recurrent endometrial cancer, or metastatic/recurrent cervical or vulvar cancer were identified in the outpatient setting by clinic staff and ACP discussion recommended. A template was provided to facilitate documentation in the medical record. Providers were notified by email and/or paper if a patient met ACP criteria. In 2019, an inpatient ACP project combined similar diagnostic criteria along with an unplanned hospital admission to identify patients appropriate for ACP. An EHR alert notified clinicians upon chart opening if inclusion criteria were met. At the completion of the quality improvement project, clinicians were surveyed on their experiences with these two interventions. Results: Nine out of 12 (75%) clinicians responded to the survey. Respondents were physicians (n=7, 78%) and advanced practice providers (n=2, 22%) with a median of 4 (IQR 2 -14) years in practice. Most participants agreed the notification in either setting improved delivery of patient care (88%) and was valuable to the care provided (88%). The notification was not burdensome in the daily work (88%) nor was it difficult to navigate (75%). A majority of respondents would continue to use the notifications (88%) and recommend the notification to other specialties (88%). While most (63%) felt that the notification was accurate in its identification of eligible patients, noticeable gaps include patients with new or undocumented serious illnesses or who had received care outside of the health system. Conclusions: Implementation of a system to identify patients at highest risk of death to facilitate advanced care planning discussions is not only feasible, but also viewed positively by the clinicians involved. Further work to better refine eligibility criteria as well as EHR integration is needed to optimize the delivery of goal concordant patient care.

Challenges with increased utilization of clinical tumor testing in ovarian cancer

Challenges with increased utilization of clinical tumor testing in ovarian cancer

Retrospective analysis of oncologic outcomes by germline and somatic genetic status in patients with ovarian cancer

Retrospective analysis of oncologic outcomes by germline and somatic genetic status in patients with ovarian cancer

Sociodemographic Disparities in Outpatient Cardiology Telemedicine During the COVID-19 Pandemic

Sociodemographic Disparities in Outpatient Cardiology Telemedicine During the COVID-19 Pandemic