Higher Cancellation Rate Research Articles

Predictors of Patient Experience for 89,205 Physical and Occupational Therapy Patients Seen for Musculoskeletal Disorders: A Retrospective Cohort Study

OBJECTIVE: To identify predictors of patient experience among a cohort of 89,205 individuals who sought physical and occupational therapy services for musculoskeletal disorders. DESIGN: Retrospective cohort. METHODS: Patient experience was measured using a previously validated tool, the Select Medical Patient Reported Experience Measure (SM-PREM©), for physical and occupational therapy outpatient clinics. Linear and logistic regression models measured the association between demographic, clinical, and payment-related variables and SM-PREM© scores at discharge. RESULTS: Multiple variables that were statistically significantly associated with SM-PREM scores across regression analyses (p<0.05); 4 predictors consistently emerged from the regression analyses. The use of paper outcomes capture (OR=1.21, 95%CI 1.17, 1.26), higher cancellation rates (OR=1.00, 95%CI 1.00, 1.01), higher percent out-of-pocket costs (OR=1.00, 95%CI 1.00, 1.01), and failure to meet the outcomes MCID (OR=0.76, 95%CI 0.73, 0.78) were predictors of a less favorable patient experience. CONCLUSION: Outcome capture methods, managing cancellation rates, and addressing financial barriers were important for improving patient experiences. More research is needed to investigate the underlying mechanisms driving these associations, explore interventions to mitigate their negative impacts and consider additional variables that may further explain variations in SM-PREM scores.

Three years of COVID-19-related school restrictions and mental health of children and adolescents in Japan

During the 3 years of the COVID-19 pandemic, Japanese children had to live with strict mitigation measures at school, such as eating school lunches silently and wearing masks during physical exercise classes, even after those mitigation measures have been relaxed worldwide. Excursions and other school events were frequently cancelled, especially in 2020 and 2021. This study conducts a retrospective survey on school experiences to understand how the strict mitigation measures were related to children's mental health and well-being. Results revealed school excursion cancellation to be associated with a higher risk of developing depressive symptoms {odds ratio [OR] 1.543 [95% confidence interval (CI) 1.109–2.148]}, and high cancellation rate of other school events to be associated with dissatisfaction in school experience [OR 1.650 (95% CI 1.222–2.228)]. In the subsample analysis, we found that girls and children with no extracurricular activities tended to exhibit depressive symptoms due to the cancellation of school excursions. Overall, the study demonstrated that persistent strict mitigation measures at schools might be a key factor in understanding children’s mental health and psychological well-being during a long-lasting pandemic.

O-206 Natural, modified natural or artificial endometrial preparation strategies for frozen embryo transfer in ovulatory women (MONART): a randomized controlled trial

Abstract Study question Are live birth rates after natural (NC), modified natural (mNC) endometrial preparation superior to artificial cycle (AC) strategies for ovulatory women undergoing frozen embryo transfer? Summary answer Live birth rates were comparable between NC, mNC, and AC. However, NC and mNC resulted in a significantly higher cycle cancellation rate. What is known already The number of frozen embryo transfer (FET) cycles has increased dramatically. In ovulatory women undergoing FET, three common strategies can be used for endometrial preparation: NC, mNC (NC + human chorionic gonadotropin trigger), and AC protocols. Previous studies comparing the effectiveness of these strategies had several drawbacks, including small sample size, lack of consistency between studies in the assessment and reporting of outcomes, and the retrospective origin, which introduced potential biases. Therefore, there is a lack of consensus on the optimal endometrial preparation protocol for FET. Study design, size, duration This single-center, open-label, randomized controlled trial was conducted at IVFMD, My Duc Hospital in Ho Chi Minh City, Vietnam. From March 2021 to March 2022, a total number of 1,428 participants were randomized (476 per group). The primary outcome of the study was live birth after one FET. Secondary outcomes were fertility outcomes, early pregnancy complications, obstetrical outcomes, perinatal and neonatal complications, and endometrial preparation cycle cancellation rates. Participants/materials, setting, methods Eligible participants were ovulatory women aged 18–45 with FET treatment, underwent no more than three IVF/intracytoplasmic sperm injection-FET cycles, had no more than two day-3 or one blastocyst transferred. Women with menopause/anovulation, contraindications for hormonal administration, uterine abnormalities who underwent in-vitro maturation, pre-implantation genetic testing, oocyte donation cycles were excluded. The FET strategies included FET after the first endometrial preparation cycles with AC, mNC, or NC, as per randomization, and the second with AC. Main results and the role of chance A total of 4,779 participants were screened, of whom 1,428 eligible individuals (476 per group) were randomized after written informed consent. The live birth rate after one FET was 36.6% (174/476) in the natural cycle strategy group, 33.4% (159/476) in the modified natural cycle strategy group, and 34.0% (162/476) in the artificial cycle strategy group (relative risk [95% confidence interval] for natural versus artificial cycle strategy: 1.07 [0.87–1.33] and for modified natural versus artificial cycle strategy: 0.98 [0.79–1.22]). Maternal and neonatal outcomes were comparable between groups, in particular,hypertensive disorders in pregnancy. For both natural and modified cycle groups, 20.08% (99/476) of the first FET cycles were canceled before subsequent successful ET versus none in the artificial cycle group. Limitations, reasons for caution Due to the nature of the intervention, blinding was not possible. The study was conducted in ovulatory women in a single center in Vietnam, which may limit the generalisability of the findings. Wider implications of the findings Live birth rates and obstetric/neonatal outcomes after the natural cycle, modified natural cycle, or artificial cycle strategies for ovulatory women undergoing FET are comparable, with higher cancellation rates in both the natural cycle and the modified natural cycle groups. Trial registration number NCT04804020

When and why does customization reduce booking cancellations? Field evidence from two hotels

PurposeThis study employs S-D Logic to examine the hotel booking behaviors of individuals, with a focus on the impact of service customization on service cancellation. Additionally, the moderating role of social co-creation is explored to provide further insight.Design/methodology/approachThe paper draws on booking data from two hotels: a resort hotel with 40,060 recorded bookings, including 11,122 cancellations, and bookings from a city hotel with 79,330 bookings, including 33,102 cancellations.FindingsThe result reveals that bookings with higher levels of initial customization, such as special requests, are more likely to be modified later and less likely to be canceled. Interestingly, while multi-adult bookings were found to have a higher cancellation rate than individual bookings, the effects of customization commitment were more pronounced for multi-adult bookings.Originality/valueThis paper is the first to establish a connection between service customization, the number of adults on a booking and the likelihood of cancellation, thus providing new empirical evidence for the emergence of customization effects in services. Additionally, the study identifies important contingencies based on the number of consumers in a booking.

Recruiting refugees and migrants as potential hematopoietic stem cell donors to serve patients of comparable ethnicities with rare human leucocyte antigen patterns - The BluStar.NRW project in North Western Germany

Currently, approximately 19 million people with a migration background live in Germany. The majority of those descend from regions where the population has a genetically different distribution of HLA antigens when compared to the HLA frequencies usually found in North Western Europe. In case of severe haematological disorders of these individuals, allogeneic stem cell transplantation may be the treatment of choice. However, finding appropriate histocompatible hematopoietic stem cell donors continues to be a major challenge. If no matching sibling donors are available, there are only few suitable donors with a similar genetic background available in international blood stem cell donor registries.The “BluStar.NRW” project aimed to recruit new blood and hematopoietic stem cell donors with a migration background and to noticeably increase the number of suitable donors for patients within this group. Since December 2017, a total number of 9100 blood and stem cell donors with a migration background were recruited and typed for this project. HLA typing for HLA-A, -B, -C, -DRB1, -DQB1, and -DPB1 was performed by Next Generation Sequencing. We assessed the proportion of rare alleles according to HLA frequency tables, as defined by a frequency of <1:1000. The rare HLA allele frequencies according to HLA frequency tables of the BluStar.NRW cohort were compared with a matched control donor cohort: Rare HLA-A, -B, -C, -DRB1 and -DQB1 alleles occurred three times more frequent than in the control group, but rare HLA-DPB1 alleles occurred more frequently in the control cohort. This difference was highly significant for all HLA alleles (p < 0.0001 for HLA-A, -B, -C, -DRB1, -DPB1; p = 0.0002 for HLA-DQB1). In addition, the distribution of rare alleles differed between the two groups. To date, 29 work-ups were initiated, 12 PBSC, one BM and three DLI were collected so far out of the BluStar.NRW cohort. The apheresis probability is twofold higher (0.18% vs. 0.07%) compared to the control group which clearly shows a serious medical need. However, 13 work-ups were cancelled in the BluStar.NRW donor cohort which represents an almost twice as higher cancellation rate (45% vs. 25%).This single registry analysis with a large sample cohort clearly indicates that hematopoietic stem cell donors with a migration background represent an adequate donor pool to serve patients of comparable ethnicity.

Trends of Ophthalmic Surgery Cancellations at a County Hospital Before and During COVID-19: A 10-Year Retrospective Study

ABSTRACT Purpose Despite several publications on ophthalmic surgical cancellations discussing preventative causes in academic institutions, there remains a paucity of similar studies for safety-net hospitals. This study analyzed cancellation rates at a county hospital over a 10-year period. Methods This retrospective, open cohort study investigated a total of 11,350 surgeries scheduled at a tertiary-level county hospital between January 1, 2012 and December 31, 2021. Surgical cancellation reasons were collected from chart review and categorized into eight groups to allow for analyses. Cancellation rates were then calculated per year and per subspecialty. The primary statistical analyses were paired, 2-tailed t test and χ2 test. Results The most common reason for cancellation overall was institution-related (1065 surgeries), which was also the most common reason per year from 2012 to 2019 (range: 37.4% − 60.6%). In 2020, during COVID-19 stay-at-home mandates, the most common reason became COVID-related rescheduling, and in 2021, it was patient-driven. The cancellation rate in 2020 was significantly higher than 2019 (+9.27%,95% CI:4.96%-13.6%,p = .05), and significantly lower from 2021 to 2020 (−22.8%,95% CI:-26.8%-(-)18.7%,p = .001). Pediatric surgery had the highest cancellation rate overall (36.4%), but oculoplastics had the highest cancellation rate in 2020 (48.9%). Conclusion The most common reason for cancellation over the 10-year period was institution-related, in contrast to other publications based in academic centers. The study also had a higher cancellation rate than previously reported, again suggesting the difference between county and academic centers. The COVID-19 pandemic had a significant impact on cancellations, even after the COVID-19 stay-at-home orders were eased.

P-130 Progesterone-primed cycles result in slower embryos without compromising the implantation potential, with the advantage of oral administration and potential cost reduction: A time-lapse imaging study

Abstract Study question Could exogenous progestin replace the use of an antagonist of GnRH (GNRH-antagonist) without any effects on embryo morphokinetics and implantation rate in freeze-all cycles? Summary answer Exogenous progestin leads to slower embryo development and increased cyclés cancellation rate, with increased implantation rate when compared to cycles using an GnRH-antagonist. What is known already Improvements in cryopreservation techniques associated with the expansion of elective-single embryo transfer have steadily increased the use of deferred embryo transfers. This gives the opportunity to break away from the standard sequence of stimulation–retrieval–transfer, and to consider new strategies for pharmacological control of follicle growth. Usual ovarian stimulation regimens use an analog of the GnRH to prevent the LH surge and premature ovulation. Since progesterone is able to block the LH surge question remains on whether exogenous progesterone may replace the use of an GnRH analogue without compromising embryo development, in cycles followed by embryo cryopreservation. Study design, size, duration This cohort study, performed in a private university-affiliated IVF center, from Mar/2019 - Mar/2021, included 288 freeze-all ICSI cycles and its 2,768 respective embryos. Patients were age matched, according to the age, into groups depending on the protocol used to prevent the LH surge: Progestin-Primed-Group (n = 144 cycles and 1,360 embryos) and GnRH-Antagonist-Group (n = 144 cycles and 1,408 embryos). Embryos were cultured in a time-lapse imaging incubation system (TLI) and embryo morphokinetics were compared among the groups Participants/materials, setting, methods Evaluated kinetic markers were timing to pronuclei appearance (tPNa) and fading (tPNf), to two, three, four, five, six, seven, and eight cells (t2 - t8), to morulation (tM), start of blastulation (tSB) and blastulation (tB). Durations of the second (t3-t2) and third (t5-t3) cell cycles (cc2 and cc3) and timing to complete synchronous divisions s1 (t2-tPNf), s2 (t4-t3), and s3 (t8-t5) were also calculated. The KID-Score ranking, laboratorial and clinical outcomes were also evaluated. Main results and the role of chance Mean maternal and paternal ages were 37.0 ± 3.8 and 39.0 ± 6.4 years old. Slower tPNa (6.2 ± 0.2 vs. 7.0 ± 0.2, p = 0.008), t2 (27.2 ± 0.3 vs. 26.2 ± 0.3, p = 0.045), t7 (56.4 ± vs. 54.7 ± 0.5, p = 0.046), tM (89.3 ± 0.8 vs. 87.1 ± 0.6, p = 0.045), tSB (101.5 ± 0.8 vs. 110.8 ± 0.1, p = 0.012), tB (111.0 ± 0.8 vs. 108.5 ± 0.7, p = 0.034), were observed among embryos derived from Progestin-Primed cycles. Similar tPNf, t3, t4, t5, t6, t8, timing to cc2, cc3, s1, s2, and s3 were observed among the groups. No significant differences were noted in the Kid-score D5, number of aspirated follicles, retrieved oocytes, oocyte yield, mature oocytes, and rates of mature oocytes, fertilization, and blastocyst formation. The cyclés cancelation (15.7% vs. 2.0%, p = 0.004) and implantation rates (63.1% ± 6.1 vs. 44.4% ± 6.3, p = 0.004) were increased in the Progestin-Primed-Group, however no significant differences were noted in the cumulative pregnancy (64.4% vs. 49.0%, p = 0.104) and miscarriage rate (2.6% vs. 8.6%, p = 0.554) for Progestin-Primed and GnRH-Antagonist groups, respectively. The expense for the ovulation prevention using the GnRH-Antagonist was U$318.18, while by using progestins U$ 11.05 was sufficient to inhibit the premature LH surge. Limitations, reasons for caution This study has limitations, such as the retrospective design and small sample size. Wider implications of the findings Despite the increased implantation rate and potential cost reduction, the high cancellation rate and slower embryo development in the progestin-protocol cannot be ignored. Delayed embryo transfer due to the freeze-only approach may also be inconvenient. Before considering any protocols for LH surge prevention, pros and cons must be carefully evaluated. Trial registration number N/A

O-295 Dual trigger does not improve reproductive outcomes in advanced maternal age women

Abstract Study question Could dual trigger increase oocyte yield and maturation rate in women of advanced maternal age (≥ 40) undergoing IVF? Summary answer Dual trigger does not result in higher oocyte yield or maturation rates compared to hCG monotrigger What is known already Advanced maternal age is related to poor ovarian response (POR) and remains a major therapeutic challenge in routine IVF practice, because of the association with low live birth rates and high cancellation rates. hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome (by improving oocyte quantity and quality) in normal responders, while evidence in poor responders remains controversial. Study design, size, duration This is a retrospective cohort study including patients attending a private IVF clinic from 1st January 2018 until 1st June 2022. Participants/materials, setting, methods All women who underwent IVF/ICSI in antagonist protocol in our center were included. Patients may have undergone triggering of the final oocyte maturation either with 250mcg of rhCG or 0.2 mg of GnRH agonist. Mature oocytes were inseminated using ICSI. Main results and the role of chance In total, 2242 patients were included, 454 (20.2%) in the rhCG group and 1788 (79.8%) in the dual trigger group. There was no significant difference in female age [41.3 (1.12) vs 41.3 (1.19), p value 0.94]. Total stimulation units and duration were also comparable between groups. The number of oocytes and MII oocytes did not differ significantly between rhCG and dual trigger group [5.8 (4.1) vs 6.3 (4.7) and 4.7 (3.3) vs 4.9 (3.4), p = 0.15 and 0.49, respectively]. Maturation rates were similar 81.7% (22.4) and 79.8% (23.5), p = 0.15, as well as fertilization rates (defined as the number of oocytes fertilized divided by the total number of cumulus-oocyte complexes recruited) [57% (29.7) vs 58.8% (29.4), p value=0.2]. Embryo utilization rates (defined as the total number of embryos transferred and cryopreserved divided by the number of oocytes fertilized) were comparable between the two arms: 69.7% (34.2) vs 70% (33.9), p value =0.22. Multivariate Poisson regression analysis adjusting for relevant confounders (AMH, total stimulation units) showed that the type of triggering strategy (dual trigger vs rhCG) was not associated with either the number of MII oocytes (coefficient 0.2, p value=0.24) or maturation rates (coefficient -1.8, p value 0.12). Limitations, reasons for caution The main limitation is the retrospective design of our study, with an inherent risk of bias. Wider implications of the findings To the best of our knowledge, this is the largest study evaluating dual trigger strategy in advanced maternal age women. Our data demonstrate that dual trigger cannot improve the outcome of low prognosis women and should not be used as a panacea for all IVF patients. Trial registration number NA

Retrospective study of ovarian reaction and fertility in women with discordant antimullerian hormone and follicle-stimulating hormone/luteinizing hormone ratios during in vitro fertilization.

The objective of this study was to examine the predictive ability of follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratio and antimullerian hormone (AMH) levels in the same cohort when both are inconsistent and to identify which has an excellent ability to predict live birth and ovarian response to in vitro fertilization (IVF). A retrospective cohort study was performed within 6096 IVF cycles executed between January 2016 and August 2019 at the Center for Assisted Reproduction, The Third Affiliated Hospital of Zhengzhou University, and Jiaozuo Maternity and Child Health Care Hospital. Initially, IVF cycles were classified according to basal FSH/LH ratio and AMH values, and the primary outcome was a comparison of live birth rate per cohort. Secondary outcomes included characteristics of the study individuals such as body mass index (BMI), age, antral follicle count, ovarian sensitivity index, cycle cancellation rate, and cycle outcome data. Women with FSH/LHhigh ratio and AMHnormal levels had a meaningly higher live birth rate compared with those with FSH/LHnormal ratio and AMHlow levels (46.59% vs. 21.21%, p < 0.001). In addition, women with FSH/LHnormal ratio and AMHlow levels were found to have a higher cancellation rate in their IVF cycles (80.98%). In women with FSH/LHnormal ratio, further multivariate analysis revealed that AMH level, age, number of retrieved oocytes, and FSH dosage were relevant risk factors for live birth. The relative risk of live birth was 0.11 (95% [CI] 0.06-0.20, p < 0.001) in patients with AMHlow compared with patients with AMHnormal . It also suggested that the probability of AMHlow level may be higher as the women's age (≥35 years, odd ratio [OR] 1.94, 95% [CI] 1.44-2.61; p < 0.001) and increasing BMI (≥28 kg/m2 , OR 2.38, 95% [CI] 1.33-4.27; p=0.004). Receiver operating characteristic curve analysis indicated that AMH had higher sensitivity and specificity to predict live birth compared with FSH/LH (AUC 0.627 vs. 0.539). AMH levels can be an excellent predictor of the discrepancy between FSH/LH ratio and AMH levels regarding living birth rates in women undergoing IVF.

HPB P54 General surgery telemedicine clinics: here to stay post-pandemic?

Abstract Background The telemedicine clinic in general surgery has become widespread since the onset of the COVID-19 pandemic and has remained so following relaxation of restrictions on conventional face-to-face appointments. However, there has been significant scepticism regarding its continued utility. In particular, there is a concern that patients cannot be adequately assessed and counselled for invasive procedures, which may result in high cancellation rates on the day of procedure. The aim of this study was to assess the cancellation rate on the day of surgery for procedures booked in telemedicine clinics. Methods We conducted a retrospective analysis of surgical procedures booked via hepatopancreatobiliary (HPB) and general surgery telemedicine clinics from March 2020 to November 2021. From September 2020 onwards, telemedicine clinics were only run for laparoscopic cholecystectomies for benign gallbladder disease. The primary outcome was the cancellation rate of surgical cases booked from telemedicine clinics. Statistical analysis was done using JASP 0.16.2 software. Results We identified 240 cases booked for surgery from telemedicine clinic. 162 patients (68%) were female; the median age of the study population was 51 (16–81). 186 (78%) patients had gallstones, 19 (8%) gallbladder polyps, 13 (5%) secondary liver tumour, 5 (2%) liver cyst, 5 (2%) pancreatic tumour, 4 (1.7%) primary liver tumour, 2 (0.8%) gallbladder tumour and 6 (2.5%) other pathologies. 225 patients (94%) underwent surgery on their first admission. Procedures included 192 cholecystectomies, 10 open segmental liver resections, 6 laparoscopic segmental liver resections, 4 distal pancreatectomies, 3 open right hepatectomies, 2 Whipple procedures, 2 laparoscopic deroofing of the liver cyst, 2 laparoscopic lymph node biopsy, 1 extended right hepatectomy, 1 left hepatectomy, 1 small bowel resection and 1 exploratory laparotomy. 15 (6%) patients had surgery cancelled on the day of surgery, 14 of those were for laparoscopic cholecystectomy, 1 for laparoscopic liver resection. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. The majority 212 (88%) of patients were ASA class 1–2; only 28 (12%) were ASA class 3. There was no significant association between high ASA (3) and cancellation rate (Chi square test 5% vs 14% p=0.062). Conclusions Telemedicine clinic in general surgery was often the only option to assess and plan operative management for newly referred patients during the COVID-19 pandemic. Our series showed that it was feasible to assess and counsel patients on the phone even for major HPB procedures with a minimal cancellation rate on the day of operation.

Association of Medical Appointment Cancellation Rates on Survival After Esophagectomy for Esophageal Cancer

BackgroundCancelled healthcare appointments, especially in patients with complex cancers, such as esophageal cancer, risk delayed treatment and adverse outcomes. We hypothesized that patients with greater rates of healthcare appointment cancellations would have decreased survival after esophagectomy for esophageal cancer. MethodsA retrospective analysis of patients from a single institution who underwent esophagectomy for esophageal cancer between 2004 and 2020 was performed. Appointment cancellations were queried 2 years pre-/post-esophagectomy and categorized as medical or ancillary. Continuous and categorical variables were compared by Mann–Whitney and chi-squared analyses, respectively. Survival associations post-esophagectomy were made by Kaplan–Meier analysis. ResultSeventy-six patients were identified. Total medical and ancillary appointments post-esophagectomy increased by 188% and 136%, respectively. Per patient, there was a median increase of 57.5 medical appointments in the post-esophagectomy period. Of medical appointments, 23.7% were cancelled pre-esophagectomy but 33.4% post-esophagectomy (p < 0.001). This trend held true for ancillary appointments. Patients with increased medical cancellation rates post-esophagectomy had shortened recurrence-free (p = 0.09) and overall survival (p < 0.01) versus patients with low cancellation rates. ConclusionA significant increase in healthcare appointments is seen after esophagectomy. Patients with increased healthcare appointment cancellations have decreased post-esophagectomy survival which presents an opportunity to intervene in patients who historically have a high cancellation rate.

A novel role of follicle-stimulating hormone (FSH) in various regeneration-related functions of endometrial stem cells

Follicle-stimulating hormone (FSH) promotes the production and secretion of estrogen, which in turn stimulates the growth and maturation of ovarian follicles. Therefore, consecutive FSH treatment to induce ovarian hyperstimulation (superovulation) is still considered the most cost-effective option for the majority of assisted reproductive technologies (ARTs). However, a relatively high cancellation rate and subsequent low pregnancy outcomes (approximately 15%) are the most challenging aspects of this FSH-based ART. Currently, the main cause for this low implantation rate of FSH-based ART has not yet been revealed. Therefore, we hypothesized that these high cancellation rates with FSH-based superovulation protocols might be associated with the harmful effects of consecutive FSH treatment. Importantly, several recent studies have revealed that tissue-resident stem cell deficiency can significantly reduce cyclic endometrial regeneration and subsequently decrease the pregnancy outcome. In this context, we investigated whether FSH treatment could directly inhibit endometrial stem cell functions and consequently suppress endometrial regeneration. Consistent with our hypothesis, our results revealed for the first time that FSH could inhibit various regeneration-associated functions of endometrial stem cells, such as self-renewal, migration, and multilineage differentiation capacities, via the PI3K/Akt and ERK1/2 signaling pathways both in vitro and in vivo.

Impact of personalized care discussions on advance care planning.

e18619 Background: Advanced Care Planning (ACP) involves learning about decisions that may need to be made during care so they are known to family and providers. ACP has been associated with less aggressive medical care near death and improved quality of life.However, despite evidence for their benefit, ACP is inconsistent among patients with advanced cancer. At our institution, only 52% of patients with cancer undergoing palliative intent treatment had an ACP at the time of death. We sought to increase ACP through a quality improvement project intended to proactively identify and introduce patients to Personalized Care Discussions (PCDs). PCDs engage oncology patients and palliative care providers in ACP to articulate goals of care. Methods: A team of palliative care providers, medical oncologists, and administrative staff designed each phase of the intervention. Inclusion criteria to proactively identify patients eligible for a PCD were created along with a workflow to introduce PCDs and schedule a PCD appointment. A plan-do-study-act (PDSA) model was used to test impact of change to the PCD referral workflow and patient inclusion criteria. Each PDSA cycle lasted between 4 and 9 weeks between 6/1/2021 and 1/31/2022. PDSA 1: Oncologist referral to PCD for new patients. PDSA 2: Oncologist referral to PCD for Stage IV patients. PDSA 3: Automatic referral to PCD of Stage IV patients. PDSA 4: Pancreatic patients, any stage, added to PDSA 3 criteria. Results: During the measurement period, 68 patients completed a PCD. While changes to the inclusion criteria throughout PDSA cycles resulted in more total unique patients completing PCDs, the completion rate of eligible patients did not vary significantly across cycles. However, the proportion of patients completing PCDs for oncologists engaged in the project increased during the eight-month QI period (92%) from the previous eight-month period (86%). Conclusions: This project sought to identify and introduce patients to PCDs to improve ACP. We found that access to PCDs was not sufficient to increase completion of PCDs, since fewer than half completed the appointment. However, 68 patients who otherwise may not have completed a PCD did so because of this intervention. Misperceptions of palliative care may contribute to high cancellation rates of PCD appointments. This pattern is seen in the overall low completion rate of palliative care appointments (56% in same timeframe). Informal patient feedback often indicated a preference for care discussions to be with the primary oncologist, whereas our intervention introduced a new provider. These results demonstrate that a trigger to identify patients for PCDs without primary oncologist engagement falls short. Continued focus is needed to determine a proactive approach to identify patients who will benefit most from PCDs to complete ACP proactively.[Table: see text]

Short-notice cancellations of laparoscopic permanent contraception

ObjectivePermanent contraception through tubal sterilization is the preferred contraceptive method for 25% of women in the United States. Laparoscopic permanent contraception has an anecdotally high cancellation rate. Cancellations affect operating room utilization and may reflect barriers to care. We aimed to identify the short-notice cancellation (≤7 days from scheduled surgery) rate for laparoscopic permanent contraception, reasons for cancellation, and postcancellation outcomes. Study DesignWe performed a retrospective chart review of patients aged 18 to 50 who canceled or no-showed a scheduled laparoscopic permanent contraception surgery between May 2016 and May 2019 at an academic tertiary care hospital and academic county hospital in Denver, Colorado. We reviewed electronic health records to determine the time between cancellation and surgery date and documented reasons for cancellation. We evaluated contraceptive methods used and pregnancies within a year after the canceled surgery. ResultsThe overall surgery cancellation rate for scheduled laparoscopic permanent contraception was 22% (123 of 558). Short-notice cancellation occurred for 71.5% of patients and 32.5% (40 of 123) canceled same day. The most common reason for cancellation was patient choice (74%) followed by financial/insurance issues (11.4%). In the year after their canceled surgery, 22% (27 of 123) of patients obtained permanent contraception and 5.7% (7 of 123) had a subsequent pregnancy. ConclusionsAmong patients who canceled their laparoscopic permanent contraception, the vast majority canceled their surgery a week or less from their scheduled date. These short-notice cancellations may adversely affect both patients and the health care system. More research is needed on institutional policies to reduce laparoscopic permanent contraception cancellations while helping patients who want effective contraception find an option that works best for them. ImplicationsOur retrospective cohort study found that laparoscopic permanent contraception surgeries have an overall high cancellation rate at both an academic tertiary and an academic county hospital, with most cancellations occurring less than 7 days prior to surgery. Future research will be used to reduce barriers to permanent contraception while developing clinical tools to reduce surgery cancellation rates.

Ovarian Reserve and ART Outcomes in Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome Patients With FOXL2 Mutations.

ObjectiveTo characterize the status of ovarian reserve and ART outcomes in BPES women and provide informative reference for clinical diagnosis and treatment.MethodsTwenty-one women with BPES were screened for mutations in the FOXL2 gene and underwent assisted reproductive technology (ART) treatment. Indicators for ovarian reserve and ART outcomes were compared between patients with and without FOXL2 mutations. Additionally, ART outcomes were compared among patients with different subtypes of FOXL2 mutations.ResultsA total of 13 distinct heterozygous variants in the FOXL2 gene were identified in 80.95% of BPES women, including 4 novel mutations with plausible pathogenicity (c.173_175dup, c.481C>T, c.576del and c.675_714del). Compared to non-mutation group, patients with FOXL2 mutations had elevated levels of FSH (P=0.007), decreased AMH levels (P=0.012) and less AFC (P=0.015). They also had worse ART outcomes with large amount of Gn dosage (P=0.008), fewer oocytes (P=0.001), Day3 good quality embryos (P=0.001) and good quality blastocysts (P=0.037), and a higher cancellation rate (P=0.272). High heterogeneity of ART outcomes existed in BPES patients with different FOXL2 mutation types.ConclusionsBPES patients with FOXL2 mutations had diminished ovarian reserve and adverse ART outcomes. The genotype-reproductive phenotype correlations were highly heterogeneous and cannot be generalized. Genetic counseling for fertility planning and preimplantation or prenatal genetic diagnosis to reduce offspring inheritance are recommended.

Operating room efficiency in a low resource setting: a pilot study from a large tertiary referral center in Ethiopia

BackgroundThe operating room (OR) is one of the most expensive areas of a hospital, requiring large capital and recurring investments, and necessitating efficient throughput to reduce costs per patient encounter. On top of increasing costs, inefficient utilization of operating rooms results in prolonged waiting lists, high rate of cancellation, frustration of OR personnel as well as increased anxiety that negatively impacts the health of patients. This problem is magnified in developing countries, where there is a high unmet surgical need. However, no system currently exists to assess operating room utilization in Ethiopia.MethodologyA prospective study was conducted over a period of 3 months (May 1 to July 31, 2019) in a tertiary hospital. Surgical case start time, end time, room turnover time, cancellations and reason for cancellation were observed to evaluate the efficiency of eight operating rooms.ResultsA total of 933 elective procedures were observed during the study period. Of these, 246 were cancelled, yielding a cancellation rate of 35.8%. The most common reasons for cancellation were related to lack of OR time and patient preparation (8.7% and 7.7% respectively). Shortage of facilities (instrument, blood, ICU bed) were causes of cancelation in 7.7%. Start time was delayed in 93.4% (mean 8:56 am ± 52 min) of cases. Last case completion time was early in 47.9% and delayed in 20.6% (mean 2:54 pm ± 156 min). Turnover time was prolonged in 34.5% (mean 25 min ± 49 min). Total operating room utilization ranged from 10.5% to 174%. Operating rooms were underutilized in 42.7% while overutilization was found in 14.6%.ConclusionWe found a high cancellation rate, most attributable to late start times leading to delays for the remainder of cases, and lack of preoperative patient preparation. In a setting with a high unmet burden of surgical disease, OR efficiency must be maximized with improved patient evaluation workflows, adequate OR staffing and commitment to punctual start times. We recommend future quality improvement projects focusing on these areas to increase OR efficiency.

A real-life overview of a hematopoietic cell transplant program throughout a four-year period, including prospective registry, exclusion causes and final donor selection.

Traceability of patients who are candidates for Hematopoietic cell transplant (HCT) is crucial to ensure HCT program quality. Continuous knowledge of both a detailed registry from a HCT program and final exclusion causes can contribute to promoting a real-life vision and optimizing patient and donor selection. We analyzed epidemiological data reported in a 4 year-monocentric prospective registry, which included all patients presented as candidates for autologous (Auto) and/or allogeneic (Allo) HCT. A total of 543 patients were considered for HCT: 252 (42.4%) for Allo and 291 (57.6%) for Auto. A total of 98 (38.9%) patients were excluded from AlloHCT due to basal disease progression more commonly (18.2%). Seventy-six (30.2%) patients had an HLA identical sibling, whereas 147 (58.3%) patients had only Haplo. UD research was performed in 106 (42%) cases, significantly more often in myeloid than lymphoid malignancies (57% vs 28.7%, p < 0.001) but 61.3% were finally canceled, due to donor or disease causes in 72.4%. With respect to Auto candidates, a total of 60 (20.6%) patients were finally excluded; progression was the most common cause (12%). Currently, Haplo is the most frequent donor type. The high cancellation rate of UD research should be revised to optimize further donor algorithms.

P–707 Does the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing modified natural cycle IVF (MNC-IVF)?

Abstract Study question Does the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing MNC-IVF? Summary answer Neither the type nor the dose of gonadotropins affects the reproductive outcomes of poor responders undergoing MNC-IVF. What is known already Poor ovarian response (POR) to ovarian stimulation remains a major therapeutic challenge in routine IVF practice, because of the association with low live birth rates and high cancellation rates. Although high doses of gonadotropins are traditionally used to stimulate the ovaries in women with predicted POR, MNC-IVF has been proposed as a mild-approach alternative in this population. Typically, the MNC protocol includes GnRH-antagonists to avoid premature ovulation and gonadotropin add-back stimulation at the late follicular phase. However, evidence is sparse, and there is no consensus regarding a specific dose or type of gonadotropins in this mild stimulation protocol. Study design, size, duration This is a retrospective cohort study including patients attending a tertiary referral University Hospital from 1st January 2017 until 1st March 2020. Participants/materials, setting, methods All women who underwent MNC-IVF in our center were included. Gonadotropins [recombinant FSH (rFSH), urinary FSH (uFSH) or highly purified human menopausal gonadotrophin (hp-hMG)] were started when a follicle with a mean diameter of 12–14 mm was observed on ultrasound scan, followed by GnRH antagonists (0.25mg/day) from the next day onwards. Mature oocytes were inseminated using ICSI. Main results and the role of chance In total, 484 patients undergoing 1398 cycles were included. Mean (SD) age and serum AMH were 38.2 (3.7) years and 0.46 (0.78) ng/ml, respectively. The daily dose of gonadotropins was either &amp;lt;75 IU/d [11/1398 (0.8%)] or 75 to &amp;lt; 100 IU/d [1303/1398 (93.2%)] or ≥ 100 IU/d [84/1398 (6%)]. Patients were stimulated with: rFSH [251/1398 (18%)], uFSH [45/1398 (3.2%)] or hp-hMG [1102/1398 (78.8%)]. Biochemical and clinical pregnancy rates were 142/1398 (10.1%) and 119/1398 (8.5%). Live birth was achieved in 80/1398 (5.7%) of cycles. Live birth rates (LBR) were similar between the different type and doses of gonadotropins (p-value 0.3 and 0.51, respectively). The GEE multivariate regression analysis adjusting for relevant confounders (age, BMI, number of MII oocytes) showed that the type of treatment strategy (rFSH/uFSH/hp-hMG) and the dose of gonadotropins were not significantly associated with LBR (coefficient 0.01 and –0.02, p value 0.09 and 0.3, respectively). Limitations, reasons for caution The main limitation is the retrospective design of our study, with an inherent risk of bias. Wider implications of the findings: This is the first and largest study evaluating MNC-IVF protocol modalities. Our data demonstrate that any type of gonadotropin can be used and there is no benefit from daily doses beyond 75IU. Trial registration number N/A

P–281 Is it worth to go to blastocyst when there are less than 4 embryos on day 3?

Abstract Study question Are pregnancy rates similar with blastocyst transfer compared to D3 transfer for patient with a poor embryo yield. Summary answer In poor prognosis patients, more D3 embryos are needed to result in similar outcome compared to single blastocyst and it increases the multiple pregnancy risk. What is known already Good prognosis patients benefit from a blastocyst transfer rather than cleavage-stage embryo because day 3 morphology has limited predictive value for subsequent developmental. A Cochrane meta-analysis in 2016 found a higher live birth rate per transfer in the blastocyst group compared to cleavage-stage and no difference in miscarriage and multiple pregnancies. However, in unselected patients, studies have yielded conflicting results and especially in poor prognosis patients at risk of transfer cancellation. A threshold of four good embryos on the third day has been previously correlated with blastocyst yield and live birth rate compared with cleavage-stage embryo transfer. Study design, size, duration We analyzed the outcome of 1115 cycles with less than 4 embryos during 2019–2020 and compared the results between two groups of D3 and D5 transfers. Participants/materials, setting, methods Amongst 1115 study cycles, in 691 cycles a D3 transfer was performed and in 424 cycles a D5 transfer was performed. We compared transfer cancellation rates, mean number of transferred embryos and ongoing pregnancy rates between the two groups and also in subgroups with female age &amp;lt;37 and female age &amp;gt;37. The statistical analyses were done by Chi square and t-test for paired samples. Main results and the role of chance In the overall study population, the mean female age was 36.3 ± 4.3 years, the mean number of obtained embryos was 2.4 ± 1.0, the mean number of transferred embryos was 1.4 ± 0.8. 17.2% of the cycles resulted in transfer cancellation (6.2% in D3 transfer group and 35.0% in D5 transfer group). After D3 transfer the ongoing pregnancy rate (OPR) per transfer was 21.5% compared to 39.7% in D5 transfers (p &amp;lt; 0.05). A similar pattern was observed in subgroups of age &amp;lt;37 years and &amp;gt;37 years with OPR per transfer significantly higher when D5 transfer was performed. Notably more embryos were transferred on D3 compared to D5 (mean number 1.4 for D3 and 1 for D5). Nonetheless, OPR were similar per cycle in both groups and subgroups of different ages. Limitations, reasons for caution A prospective randomized controlled trial is needed to confirm these results that are consistent with previously reports on retrospective and observational studies. Wider implications of the findings: In poor prognosis patients with low embryo yield, D3 and D5 transfers result in similar OPR per cycle. Transferring at blastocyst stage is not inferior to D3, despite the high cancellation rate, and appears safer permitting a single embryo transfer to avoid multiple pregnancy. Trial registration number Not applicable

P–552 Delayed blastocyst development is associated with a higher risk of aneuploidy in patients of advanced maternal age

Abstract Study question Is delayed blastocyst development, assessed by the day of trophectoderm (TE) biopsy, associated with higher rates of aneuploidy? Summary answer Our findings show an association between delayed blastocyst development and poorer prognosis, in terms of euploidy rates, in patients of advanced maternal age. What is known already Extended culture of embryos past day 5 of development has become routine practice in all freeze-all cycles, including those applying preimplantation genetic testing for aneuploidies (PGT-A). As healthy live births have been obtained from day 6 and day 7 blastocysts, increasing the pool of embryos available for PGT-A is beneficial, particularly for patients of advanced maternal age who face higher cancellation rates. Nevertheless, the association between delayed blastocyst development and aneuploidy rates remains unclear. As current studies have reported opposing findings, detailed analysis of the chromosomal constitution of slowly developing embryos remains paramount. Study design, size, duration Retrospective, international, multicentre cohort study of 4211 patients undergoing preimplantation genetic testing for aneuploidy (PGT-A) from January 2016 to July 2020. We evaluated the chromosomal status of 14757 blastocysts tested using TE biopsy and next generation sequencing (NGS). Both autologous and donation cycles were included in the analysis. Cycles were excluded if they utilised preimplantation genetic testing for monogenic disorders (PGT-M) or preimplantation genetic testing for structural rearrangements (PGT-SR). Participants/materials, setting, methods We evaluated euploidy, aneuploidy and mosaicism rates reported in day 5 (n = 9560), day 6 (n = 4753) and day 7 (n = 262) blastocysts, stratified by SART-defined maternal age categories (&amp;lt;35, 35–37, 38–40, 41–42, &amp;gt;42). We further assessed the type and frequency of abnormalities reported in all blastocysts classified as clinically unsuitable, according to the day of biopsy. Finally, we examined the specific chromosomes affected in embryos diagnosed with a single uniform (n = 3882) or single mosaic (n = 518) abnormality. Main results and the role of chance The mean maternal age within our patient cohort was 39.9±3.7. Overall, slowly developing blastocysts were significantly more likely to be classified as clinically unsuitable (60.6%) compared to day 5 embryos (55.2%; p &amp;lt; 0.0001). This correlation was also observed when stratified by age, with the exception of the &amp;lt;35 age group (p = 0.25). Markedly, the risk of aneuploidy in slowly developing blastocysts became progressively higher with advancing maternal age (p &amp;lt; 0.0001). We did not observe any significant differences in the types of abnormalities diagnosed in slowly developing embryos compared to day 5 blastocysts. Nevertheless, abnormalities affecting all chromosomes were present at the blastocyst stage. Single trisomies and monosomies were the most frequent across all age groups, and were equally prevalent in day 5, 6 and 7 blastocysts. These most commonly affected chromosomes 16, 22, 21 and 15. We observed no significant differences in the incidence of segmental aneuploidies in relation to the day of biopsy, across all age groups. When considered separately, day 7 blastocysts presented with higher rates of structural aberrations, however low numbers limited statistical power. Finally, delayed blastocyst development was not associated with higher mosaicism rates (p = 0.79). Interestingly, single mosaic trisomies and monosomies were most frequently associated with chromosome 19. Limitations, reasons for caution Due to the retrospective nature of the study, full elucidation of all potential confounders may not be possible in all instances. The low number of day 7 blastocysts limited statistical power. As such, the results from day 6 and day 7 embryos were evaluated together. Wider implications of the findings: Our findings offer an important clinical resource for counselling patients of advanced maternal age. Maternal aging may be associated with a higher incidence of aneuploidy in slowly developing blastocysts. Nevertheless, extended culture increases the pool of biopsiable blastocysts, ultimately improving the chance of having a euploid embryo for transfer. Trial registration number NA