Identify Practice Patterns Research Articles

Perceptions of Dysphagia Evaluation and Treatment Among Individuals with Parkinson's Disease.

Dysphagia is a leading cause of morbidity and mortality among individuals with Parkinson's disease (PD). The primary objectives of the present study were to explore patients' narrative reports focused on what information and evaluation and treatment experiences they identified as they manage dysphagia, and to identify practice patterns relevant to dysphagia management. A secondary objective was to produce an educational resource for this population that addressed their questions about dysphagia. A sample of individuals with oropharyngeal dysphagia secondary to PD (n = 25) across all regions of the United States were interviewed using open- and closed questions and a written questionnaire. Verbatim interview transcripts were interrogated using qualitative content analysis (QCA) with an inductive approach to identify themes from the participants' reported knowledge of dysphagia and experiences with swallowing evaluation and treatment. Authors developed a pamphlet addressing common questions that participants posed in the interviews and conducted a member check to revise it with their feedback. Most participants reported having been asked about their swallowing function by a healthcare professional. 60% of the sample reported having had a swallowing evaluation. Only 20% (5/25) of participants reported having completed swallowing therapy. Some participants did not know that swallowing therapy exists. Nearly all participants reported having a strong desire to know more about dysphagia and preferred a pamphlet as a resource format. Few of the study participants had received swallowing therapy, and nearly all participants were eager to learn about the nature of dysphagia, its progression, and treatment options. Given the physical, emotional, and social ramifications of living with dysphagia, access to swallowing education and treatment needs to be a stronger focus of PD management.

Practice patterns in prostate cancer therapy among healthcare professionals: Comparison with expert recommendations from an online tool.

e13549 Background: The treatment landscape of prostate cancer (PC) is complex, and recent approvals of new agents and regimens further challenge healthcare professionals (HCPs) to select optimal therapy for patients with PC. We sought to identify practice patterns among community HCPs for PC by comparing HCP and key opinion leader (KOL) treatment recommendations using an online decision support tool. Methods: The online decision support tool was developed with 5 KOLs who provided therapy recommendations for 96 patient case scenarios encompassing mHSPC, nmCRPC, and mCRPC based on factors including disease volume and symptoms, comorbidities, previous therapy, and biomarker status. HCPs entered specific patient and disease factors into the tool along with their intended treatment plan and were shown the 5 individual KOL recommendations for the patient case. An analysis of HCP selected therapy compared with KOL recommendations was performed. Results: Between September 2023 and January 2024, 286 patient cases were entered by 100 HCPs. KOL consensus defined as ≥3 in agreement. HCP therapy selection discordance with KOL recommendations was 69% for nmCRPC (n = 64 cases), 42% for mHSPC (n = 125 cases), and 46% for mCRPC (n = 97 cases). The level of discordance was 63% (n = 43 cases) for nmCRPC with a PSADT <10 months and 81% (n = 21 cases) with a PSADT ≥10 months (Table). Regardless of PSADT, selection of therapy for nmCRPC without listed comorbidities was highly discordant 82% (n = 34 cases). In mHSPC, the highest level of discordance was seen in cases with de novo, symptomatic, high-volume disease, and diabetes at 73% (n = 11). Discordance was 54% for de novo mHSPC with symptomatic disease (n = 52 cases). HCP selection of 1L, 2L, or 3L therapy for mCRPC was 44% to 47% discordant with KOL recommendations regardless of prior therapy. Selection of therapy for mCRPC with HRR mutations including BRCA (n = 29) was 48% discordant. Among HCPs who initially selected treatment options that diverged from expert recommendations or were uncertain about therapy selection, 48% (n/N = 75/157) intend to change their therapy selection to align with the experts. Detailed data analysis with KOL recommendations will be presented. Conclusions: This analysis suggests differences in clinical practice between HCPs and KOLs for multiple case scenarios in PC and suggests that use of the decision tool may lead to increased alignment of treatment choices with KOLs. [Table: see text]

Discharge of Acute Coronary Syndrome Patients on Sub-Optimal Dual Anti-Platelet Therapy: A Single Center Experience.

To identify and quantify the reasons why acute coronary syndrome (ACS) patients undergoing stenting at the University of New Mexico Hospital (UNMH) were prescribed sub-optimal dual antiplatelet therapy (DAPT) at discharge, and to identify practice patterns that could potentially lead to improved DAPT treatment for these patients. We reviewed electronic medical records and cardiac catheterization records of 326 patients who underwent percutaneous coronary intervention (PCI) at UNMH between January 1, 2021, and June 30, 2022 and identified 229 ACS patients who survived until discharge. Demographic and clinical characteristics relevant to P2Y12 inhibitor selection were obtained from a review of medical records. Pharmacists' notes documenting their efforts to secure appropriate insurance coverage and reasons for discharging patients on clopidogrel rather than ticagrelor/prasugrel were reviewed. Patients discharged on aspirin and clopidogrel underwent review of medical records and cardiac catheterization lab records to determine if the discharge P2Y12 drug was appropriate. Reasons for inappropriate discharge on clopidogrel were categorized as cost/insurance, patient preference, concern for daily adherence to a twice-daily medication, and maintenance of pre-hospital clopidogrel therapy rather than switch to ticagrelor after PCI. The 229 ACS patients included 87 (38.0%) appropriately discharged on ticagrelor/prasugrel, 63 (27.5%) appropriately discharged on clopidogrel, 75 (32.8%) discharged on sub-optimal clopidogrel, and 4 (1.7%) not discharged on a P2Y12 inhibitor. For patients inappropriately discharged on clopidogrel (n = 75), the most common reasons were cost or lack of insurance (n = 56) and clinical inertia (taking clopidogrel before PCI and maintained on it afterward) (n = 17). Sub-optimal P2Y12 therapy at discharge was significantly associated with lack of insurance (odds ratio 21.5, 95% confidence interval 5.33-156,p < 0.001) but not with ethnicity, age, sex, or diabetes. At the University of New Mexico, a safety-net hospital, increasing financially restricted access to ticagrelor/prasugrel could help up to 24.5% of ACS patients reduce their risk of ischemic events. For patients admitted on clopidogrel DAPT, escalating to ticagrelor/prasugrel could reduce ischemic risk in 7.4%. Expanding and improving healthcare insurance coverage might reduce the frequency of discharge on sub-optimal P2Y12 therapy.

The Pediatric Dermatologist's View of Pediatric Vitiligo.

No guidelines exist for pediatric vitiligo. To identify practice patterns of pediatric dermatologists treating vitiligo. A PeDRA survey was completed online by 56 pediatric dermatologists. Practitioners reported feeling most comfortable treating 13- to 17-year-olds and least comfortable treating infants. Quality of life was assessed by interview in 89.3%. Topical calcineurin inhibitors (TCIs), topical corticosteroids (TCSs), narrowband UVB, coverup makeup, topical JAK inhibitors (tJAKis), and 308-nm laser were the leading vitiligo therapeutics chosen. 94.5% of practitioners reported experiencing frustration due to difficulties procuring therapies. Pediatric vitiligo has notable effects on quality of life. Some therapeutic options exist which are preferred by pediatric&nbsp;dermatologists. There is a need for more data on therapeutics in infants and young children, J Drugs Dermatol. 2024;23(2): doi:10.36849/JDD.7572e.

MP67-14 VARIATION OF HORMONAL AGENT USAGE WITH POSTOPERATIVE RADIATION THERAPY: RESULTS FROM A POPULATION BASED COHORT OF PROSTATE CANCER PATIENTS IN COMMUNITY ONCOLOGY PRACTICES

You have accessJournal of UrologyCME1 Apr 2023MP67-14 VARIATION OF HORMONAL AGENT USAGE WITH POSTOPERATIVE RADIATION THERAPY: RESULTS FROM A POPULATION BASED COHORT OF PROSTATE CANCER PATIENTS IN COMMUNITY ONCOLOGY PRACTICES Rodrigo R Pessoa, Tyler Robin, Thomas Flaig, Elizabeth Molina, Boris Gershman, Eric Ballon-Landa, Corbin Eule, Elizabeth Kessler, Brian Chapin, Marc C Smaldone, and Simon P Kim Rodrigo R PessoaRodrigo R Pessoa More articles by this author , Tyler RobinTyler Robin More articles by this author , Thomas FlaigThomas Flaig More articles by this author , Elizabeth MolinaElizabeth Molina More articles by this author , Boris GershmanBoris Gershman More articles by this author , Eric Ballon-LandaEric Ballon-Landa More articles by this author , Corbin EuleCorbin Eule More articles by this author , Elizabeth KesslerElizabeth Kessler More articles by this author , Brian ChapinBrian Chapin More articles by this author , Marc C SmaldoneMarc C Smaldone More articles by this author , and Simon P KimSimon P Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003330.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The optimal hormonal agent for postoperative radiation therapy remains to be defined with either LH-RH agents or androgen receptor blockers. Androgen deprivation therapy appears to be important for some patients receiving postoperative radiation therapy but there are differences in side effects and quality of life. Thus, we used a large national database of community practices to identify practice patterns with hormonal agents in the postoperative radiation therapy settings. METHODS: From the CancerLinQ database, which represents more than a 100 community oncology practices in the U.S., we included all men who underwent radical prostatectomy and then received adjuvant or salvage radiation therapy from 2000 to 2021. The primary outcome was concomitant use of hormonal therapy including luteinizing hormone – releasing hormone (LH-RH) agents or androgen receptor blockers. Multivariable logistic regression analyses were used to elucidate patient characteristics associated with use of each class of hormonal agents. RESULTS: Among the 390 surgically treated patients receiving postoperative radiation therapy, 50.7%(n=198) received no hormonal agents, 23.6 % (n=92) received LH-RH agents, and 22.82% (n=89) received both LH-RH agents and androgen receptor blocker. Only 2.8% (n=11) received androgen receptor blocker alone. Among patients with salvage radiation therapy at PSA>0.7 ng/dl, 51.6% did not receive any form of hormonal therapy. On multivariable analysis, patients with pN1+ compared with pN0 had higher odds of receiving LH-RH agents (OR: 3.21; p=0.01) during postoperative radiation therapy. Conversely, African American men were less likely to receive androgen receptor blockers compared to white men (OR: 0.24; p=0.004). Use of hormonal agents were not associated with postoperative radiation therapy intent. CONCLUSIONS: Among patients treated in community-based oncology practices in the U.S., most are not receiving any form of hormonal agents with postoperative radiation therapy. Racial disparities also exist in the use of androgen receptor blockers during post-prostatectomy radiation therapy. Increased attention is needed to disseminate evidence into clinical practice. Source of Funding: Schramm Foundation © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e948 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rodrigo R Pessoa More articles by this author Tyler Robin More articles by this author Thomas Flaig More articles by this author Elizabeth Molina More articles by this author Boris Gershman More articles by this author Eric Ballon-Landa More articles by this author Corbin Eule More articles by this author Elizabeth Kessler More articles by this author Brian Chapin More articles by this author Marc C Smaldone More articles by this author Simon P Kim More articles by this author Expand All Advertisement PDF downloadLoading ...

Perceptions of Paris: an international survey in preparation for The Paris System for Reporting Urinary Cytology 2.0 (TPS 2.0).

An international panel of experts in the field of urinary cytopathology conducted a survey, supported by the American Society of Cytopathology, to seek opinions, gather evidence, and identify practice patterns regarding urinary cytology before and after the introduction of The Paris System for Reporting Urinary Cytopathology (TPS). Results from this survey were utilized in the development of the second edition of TPS (TPS-2.0). The study group, originally formed during the 2013 International Congress of Cytology, reconvened at the 2019 annual meeting of the American Society of Cytopathology. To prepare for the second edition of TPS, the group generated a survey that included 43 questions related to the taxonomy and practice of urinary cytology. A total of 523 participant responses were collected, and 451 from 54 countries passed a qualifying screen. Three hundred ninety-four participants provided information about their work settings. Eighty-two percent (218/266) of responding participants use TPS. One hundred sixty-eight people who responded on their urinary cytology atypia rates reported an average decrease from 21.6% to 16%. Over three fourths of participants felt that the same criteria should be used for upper and lower tract interpretations and for instrumented and voided samples. There were varied opinions on addressing atypical squamous cells and suggestions for an expanded discussion of the issue to be included in TPS 2.0. Results of the survey demonstrate strong support for TPS and show a decreased self-reported atypia rate in the laboratories using TPS. The majority of participants related that the criteria put forth for the reporting categories were user-friendly and applied with relative ease. The comment section of the survey included suggestions from the participants for further improvement of TPS. Results of this survey have been useful in fine-tuning and advancing TPS. They were considered along with recent literature to generate the second edition of TPS.

996: MAXIMIZING THE GOLDEN HOUR IN CRITICALLY ILL PATIENTS: ASSESSMENT GAPS AT THE TIME OF ADMISSION

Introduction: The “golden hour” is the concept that timely assessment and resuscitation can improve outcomes in the critically ill. These principles are well-established in trauma patients, and rapid administration of evidence-based interventions has also been shown to improve outcomes in patients with sepsis. The best approach to perform this rapid evaluation and treatment, however, has not been previously evaluated in the ICU. Our aims are to observe common approaches to the assessment of critically ill patients upon ICU admission, to compare them to the established Checklist for Early Recognition and Treatment of Acute Illness and iNjury (CERTAIN) that has been associated with improved patient outcomes, and to examine the impact of observed variations in practice. Methods: We conducted a prospective observational study in Mayo Clinic ICUs. We recorded ICU team actions during patient admissions, including performance of primary assessment, vital signs, IV access confirmation, labs and ultrasound, differential diagnosis, and plan by systems, including code status. Data were analyzed to identify practice patterns, assessment gaps, and length of stay. Results: Data on 16 MICU patient observations has been analyzed to date. The patient median age was 65.5 years, 40% were female, and the mean ICU length of stay was 2.7 days. Recorded frequency of airway assessment was 73%, breathing 73%, circulation 93%, disability 33%, and exposure 80%. 73% of patients had their vital signs evaluated, and 60 % had IV/IO access obtained. 62% had cardiac POCUS, while only 31% had lung ultrasound and 25% had an abdominal ultrasound. The most frequently addressed systems during the discussion of plans were cardiovascular and pulmonary at 62% and 75%, with neurologic and hematologic discussed in 25%. The least commonly discussed system was endocrine (12.5%). Nurses completed 36% of admission tasks, while 50% of plan by system tasks were completed by residents. Conclusions: We describe variations in assessment during admission. Gaps in assessment are frequently observed during the golden hour compared to the CERTAIN checklist, arguing that a systematic approach is necessary to avoid errors of omission. Additional research is needed to determine the impact of these variations in practice on ICU patient outcomes.

Diagnosis and Management of Isolated Neutropenia: A Survey of Pediatric Hematologists Oncologists

Background: Isolated neutropenia is a common referral to pediatric hematology oncology. Guidelines exist regarding the management of severe congenital neutropenia as well as the differential diagnosis for isolated neutropenia. However, no expert guidelines exist to inform practice patterns on the diagnosis and management of patients with asymptomatic neutropenia or individuals with typical neutrophil counts associated with the Duffy null phenotype (Fy[a-/b-]). Understanding the practice patterns of pediatric hematologists oncologists may inform future efforts to reduce unnecessary medical testing and follow-up in these patient populations. Methods: We distributed a twenty-one-question electronic survey to pediatric hematologists oncologists through the American Society of Pediatric Hematology Oncology's member discussion board from March 2022 until April 2022. The purpose of the survey was to identify practice patterns regarding patients referred for isolated neutropenia. Eligible participants included attending physicians and those who regularly see referrals for neutropenia. All trainees, advanced care providers, and individuals who do not regularly see patients with neutropenia were excluded. The survey explored: 1) common diagnostic studies physicians use to evaluate patients referred with asymptomatic and isolated neutropenia, 2) frequency of patient follow-up, 3) use of limited red cell phenotyping in pediatric patients with isolated neutropenia, 4) common terminology used to describe isolated neutropenia, and 5) whether physicians support removal of the term "benign ethnic neutropenia" from practice. We also presented two clinical case vignettes of asymptomatic and isolated neutropenia in a one-year-old male and a twelve-year old female. We compared management responses to the two vignettes to general neutropenia practice patterns. Results: One hundred and twenty-six pediatric hematology oncology attending physicians who regularly see neutropenia referrals completed the survey and were included in the analysis. Selected survey responses are shown in the Table. The most common tests ordered for pediatric patients with isolated neutropenia include complete blood cell count (CBC) (98%), peripheral smear (75%), anti-neutrophil antibody testing (29%), and immunoglobulins (24%). In the clinical vignettes, providers were more likely to order an anti-neutrophil antibody in toddlers (p=0.0085), and antinuclear antibody (ANA) panels in adolescents (p<0.001). Half of providers ask for additional CBCs prior to their initial consultation. Most respondents suggest referring patients with mild neutropenia after demonstrating a decline in absolute neutrophil count (ANC) (51%). For patients with mild neutropenia, most providers order an additional CBC to ensure resolution of their neutropenia or do not follow after their initial evaluation (87%). For patients with moderate neutropenia, most providers continue to follow patients even after their initial evaluation (46%). The three most important factors that influence continued follow-up of patients with isolated neutropenia include: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with the term "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with limited red cell phenotyping. Conclusion: We identify the common practice patterns of pediatric hematologists oncologists caring for patients referred for asymptomatic and isolated neutropenia. Data from this study is providing the framework for a cost-effectiveness study aimed to reduce the healthcare and family burden of referrals for isolated neutropenia to pediatric hematologists oncologists. Furthermore, this survey demonstrates support for replacement of the term "benign ethnic neutropenia" with "typical neutrophil count with Fy(a-/b-) status" in applicable patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Retrospective Review of the Safety of Osimertinib with Thoracic Radiotherapy

<h3>Purpose/Objective(s)</h3> Tyrosine Kinase inhibitor [TKI] therapy is the backbone of treatment for patients who progress after definitive treatment for EGFR mutated non-small cell lung carcinoma [NSCLC], or those who are diagnosed with metastatic disease. Evidence from phase II and III clinical trials have suggested that ablative consolidation of oligometastatic or progressive sites leads to improved progression-free, and overall survival. For patients on TKI therapy, there is little information regarding the safety of combining therapy with radiation therapy [RT]. There are 5 FDA approved EGFR TKI's but simertinib is most used today and is the focus of this review. We present the risk of toxicity of concurrent simertinib and thoracic RT in a large institutional cohort. <h3>Materials/Methods</h3> A prospectively collected database of patients treated with simertinib from September 2014 through March of 2021 was reviewed to identify those who had RT at some point in their treatment. 206 individual patients were identified of whom 60 had treatment directed to a thoracic target. 13 patients were treated to 2 metachronous thoracic sites yielding 73 individual treatments. Patient records were retrospectively reviewed to identify practice patterns regarding sequencing of RT and TKI, and the incidence of toxicity. <h3>Results</h3> In these 73 targets, most volumes were treated with SBRT [3-5 fractions] 42(57%). Twenty-one targets (29%) were treated with hypofractionation [8-20 fractions; HFRT], 8(11%) were treated with conventional radiation, [200cGY per fraction; CFR] and 2 with quad shot fractionation [QS]. The median PTV size was 91.25cc (range 8.55cc – 767.95cc). In 43 treatments radiation was delivered concurrently with simertinib, drug was held for 20 radiation treatments, and 10 treatments were delivered before simertinib initiation. Of those tumors treated with continuous simertinib dosing, 28 tumors were treated with SBRT, 13 with HFRT, 1 CFR and 1 with QS. 24 patients were diagnosed with radiation pneumonitis following thoracic RT; 4/11(36%) tumors treated prior to TKI; 6/20(30%) treatments when medication was held; and 14/44(32%) tumors when simertinib was continued through radiation (p=0.14). Most cases of pneumonitis were grade 1-2 and only 2 patients developed grade 3 pneumonitis. Grade 3 pneumonitis was not associated with continuous simertinib dosing. The median PTV for any grade pneumonitis was 112.27cc. Institutional V20 planning constraints were met in all but 1 patient who was treated with CFR. Other toxicities reported included 7 events of esophagitis, and 4 events of dermatitis all of which were grade 1-2. <h3>Conclusion</h3> Patients receiving osimertininb concurrently with thoracic RT did not appear to have higher rates of pneumonitis relative to those who held drug during RT or initiated it after RT. This suggests it is safe to continue simertinib concurrently with thoracic RT when standard planning dose limits are followed.

Human Papillomavirus Impact on Temporal Treatment Trends in Oropharyngeal Carcinoma: 2010–2016

Introduction: The study objective was to identify practice patterns in oropharyngeal cancer management from 2010 to 2016 among human papillomavirus (HPV)-associated and non-HPV-associated oropharyngeal squamous-cell carcinoma (OPSCC) patients. Methods: The National Cancer Database was utilized to identify OPSCC patients from 2010 to 2016. Frequency distributions and multivariable analyses were generated to identify practice patterns and predictors of treatment modality. Results: A total of 35,956 patients with nonmetastatic OPSCC were included. HPV status was not associated with a treatment modality preference. At academic centers, the proportion of HPV-associated OPSCC patients versus non-HPV-associated OPSCC patients undergoing surgical management was similar (35.7%; 35.9%). Community cancer programs treated patients less often surgically but with no significant treatment preference based on HPV status. Within each facility type, HPV status was not a predictor of surgical or nonsurgical management. Conclusion: HPV association does not appear to significantly influence treatment modality preference among OPSCC patients. The proportion of OPSCC patients undergoing surgical treatment declined from 2010 to 2016.

Acceptability of medical immobilization: Results from a pilot international survey.

Controversy exists on the acceptability of medical immobilization (MI). To identify regulations, professional conventions, and opinions on the acceptability of MI and to identify practice patterns through a pilot study of members of the International Association of Paediatric Dentistry (IAPD) and their colleagues. A 22-item questionnaire was developed and electronically distributed to 1191 members of the IAPD. Responses were received from 182 dentists in 45 countries. The majority (74.9%) of respondents use MI, and 29.1% use an immobilization device. MI with an immobilization device was reported as professionally acceptable (58.1%) and permitted by medicolegal regulations (70.8%) in their countries of practice. Dentists rated acceptability of MI higher than they perceived parents would overall and perceived MI to be more acceptable by parents for emergency situations and for children with special healthcare needs but 19.8% of respondents found it totally unacceptable in all scenarios. Use and opinions of acceptability varied by geographical location with respondents from North America being more accepting of MI. Most dentists felt that the use of an immobilization device could lead to lasting psychological trauma (72.3%) and violation of the rights of the child (55.4%) but that it improves access to care (58.5%). The acceptability of MI remains an area of controversy for paediatric dentists internationally.

Physical therapy within US HTCs: A multicentre survey of utilization, practice patterns and pain management approaches.

Practice patterns and utilization of physical therapists (PTs) affiliated with Hemophilia Treatment Centers (HTCs) in the United States (US) are not well known. Describe utilization, role responsibilities and practice patterns of US HTC PTs. Identify practice patterns specifically focusing on assessment and treatment of pain. Recognize gaps in utilization and role responsibilities of PTs as part of the multidisciplinary team and suggest guidelines for PT involvement within the HTC. Respondents were a subset of a convenience sample of healthcare providers who responded to a non-validated survey developed by a multi-disciplinary panel of haemophilia experts. A 33.0% response-rate (n=59) representing all regions of US HTCs was achieved. Those working ≥10hours per week were more likely to provide nutrition education (P=.026) and surgical options education (P<.001). Those who billed insurance for their services during comprehensive visits were more likely to provide education regarding surgical options (P=.046). The majority of PTs (95.0%) evaluated pain regardless of time spent in clinic and felt comfortable treating pain. Fifty-eight percent used a formal pain measurement tool and more likely to use a formal pain measurement tool if billing insurance (P=.004). Top five non-pharmacologic treatments recommended for pain management included splints/braces (84.8%), aquatic therapy (74.6%), orthotics (71.2%), surgical options (47.5%) and yoga (32.2%). This study demonstrated PT utilization across HTC centres varies widely. Gaps in care may be addressed through salary support, funded education, greater regional/national collaboration of PTs specializing in bleeding disorders and advocacy for insurance coverage for appropriate services.

Signal from the noise: A mixed graphical and quantitative process mining approach to evaluate care pathways applied to emergency stroke care

ObjectiveMapping real-world practice patterns vs. deviations from intended guidelines and protocols is necessary to identify and improve the quality of care for emergent medical conditions like acute ischemic stroke. Most status-quo process identification relies on expert opinion or direct observation, which can be biased or limited in scalability. We propose a mixed graphical and quantitative process mining approach to Electronic Health Record (EHR) event log data as a unique opportunity not only to more easily identify practice patterns, but also to compare real-world care processes and measure their conformance or variability. MaterialsData was obtained from the event log of a major EHR vendor (Epic) for Stanford Health Care Hospital patients aged 18 years and older presenting to the ED from January 1, 2010 through December 31, 2018 and receiving tPA (tissue plasminogen activator) within 4.5 h of presentation. MethodsWe developed an unsupervised process-mining algorithm to create a process map from clinical event logs. The method first identifies the most common events across the cohort. Then, all possible ordered events are recorded, and a summarized vector of nodes (events) and edges (events occurring in series) are mapped by their timing and probability. The highest probability ordered pairs are used to identify the most common path. We define measures for individual pathways conformity and average conformity across all encounters. ResultsAutomatically generated process mining graphs, and specifically it’s the most common path, mimicked our institutions recommended “code stroke” clinical pathway. The average conformity score for our cohort was 0.36 (i.e. paths had an average of 36% overlap with all possible paths), with a range from high of 0.64 and low of 0.20. DiscussionThis method allows for unsupervised visualization of the current state of common processes as well as their most common path, which can then be used to calculate the conformity of individual pathways through this process. These results may be used to evaluate the consistency of quality care at a given institution. It may also be extended to other common processes like sepsis or myocardial infarction care or even those which currently lack standardized clinical pathways. ConclusionOur mixed graphical and quantitative process mining approach represents an essential data analysis step to improve complex care processes by automatically generating qualitative and quantitative process measures from existing event log data which can then be used to target quality improvement initiatives.

ANEMIA TREATMENT PATTERNS AND OUTCOMES AMONG A NATIONAL COHORT OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Anemia is a common complication of inflammatory bowel disease (IBD) and can have a significant negative impact on quality of life by causing fatigue and reduced exercise tolerance. However, system wide patterns of anemia recognition and treatment are lacking. The aim of our study is to identify practice patterns of screening for anemia, assessment of iron stores, and administration of iron repletion therapy among a national cohort of patients with IBD. METHODS We conducted a retrospective cohort study of patients with IBD in the national Veterans Affairs (VA) dataset from 2000-2017. IBD patients were identified using a previously validated algorithm using administrative codes for Crohn’s disease (CD) and ulcerative colitis (UC). Laboratory values, patient demographics, and medical treatment data were extracted from the national VA datasets. Anemia was defined as hemoglobin &amp;lt; 13 g/dL in males and &amp;lt; 12g/dL in females. Initial observation of anemia during the study period was considered index anemia date. Analyses were descriptive of proportion of IBD patients with anemia, treatment, or outcomes. Temporal trends were presented as number patients by calendar year. RESULTS Of the 89,687 patients with IBD identified from 2000-2017, 50,781 (56%) were found to have anemia at least once during the study period. The number of IBD patients with anemia increased five-fold during the study period from 3,260 to 15,579 unique patients per calendar year. Testing for iron deficiency among patients with anemia was low- only 36% of anemic patients had iron studies completed within 6 months of anemia result. Of anemic patients who completed iron studies, the vast majority (89%) were consistent with iron deficiency anemia. Of patients with low iron stores, only 23% of patients received iron therapy within 6 months of lab result. Of patients with anemia, only 19% had anemia resolve within 1 year. Hospitalization within 5 years was observed in 30% of patients with anemia, with 60% of hospitalizations occurring within 1 year of index anemia date. IBD-associated surgery within 5 years of index anemia date was observed in only 2% of patients. CONCLUSIONS In a large national cohort of IBD patients, anemia is a common and undertreated complication, and is frequently followed by hospitalization and steroid use. Although iron deficiency is the most common cause of anemia, adequate iron testing and treatment is lacking, which may contribute to the low rates of anemia resolution. Interventions to improve anemia testing and treatment for iron deficiency anemia are needed.

ANEMIA TREATMENT PATTERNS AND OUTCOMES AMONG A NATIONAL COHORT OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Anemia is a common complication of inflammatory bowel disease (IBD) and can have a significant negative impact on quality of life by causing fatigue and reduced exercise tolerance. However, system wide patterns of anemia recognition and treatment are lacking. The aim of our study is to identify practice patterns of screening for anemia, assessment of iron stores, and administration of iron repletion therapy among a national cohort of patients with IBD.

Surgical Management of Patients with Complex Perianal Fistula: Results of a US National Case-based Survey to Determine Future Educational Needs

Introduction: Crohn’s-related perianal fistulas (CPF) are major contributors to lowered quality of life (QoL) for patients with Crohn’s disease. This study aimed to identify practice patterns and knowledge gaps in CPF management. Methods: To understand the perspectives of colorectal surgeons (CRS) managing patients with CPF, we developed a case-based survey related to management of initial presentation and recurrence of CPF. Surveys were distributed online during Sep/Oct 2020 to US CRS experienced with CPF (≥1 CPF patient/month). Results: Seventy-eight CRS responses were collected. In patients who initially presented with fistula, there was no standardized approach for CPF evaluation or classification. While the majority (71%) chose seton plus medical management as initial intervention, there was no standard approach to seton removal. No consensus existed on preferred medical/surgical treatment in patients with a partial biologic response or for recurrent fistula. CRS prioritized long-term CPF goals of improved QoL and avoiding major surgery/preserving continence, while fistula healing had the lowest priority. COVID-19 did not have a major effect on patient management. Barriers to optimal CPF management were perceived to be lack of effective medical therapies, poor surgical outcomes/complication risks, patient reluctance, delayed referral/diagnosis, and lack of guidelines/treatment algorithms. Significant barriers to multidisciplinary management included lack of access to CPF specialists and treatment plan communication, and difficulty coordinating care between specialists/centers. A lack of familiarity exists with newer/potential treatments. Conclusion: There is no consensus on how to best manage CPF. Education is needed to improve outcomes in CPF treatment.

S818 Medical Management of Patients With Complex Perianal Fistula: Results of a U.S. National Case-Based Survey to Determine Future Educational Needs

Introduction: Crohn's-related perianal fistulas (CPF) contribute to lowered quality of life for patients with Crohn's disease (CD). This study aimed to identify practice patterns and knowledge gaps in CPF management. Methods: To understand perspectives of gastroenterologists (GIs) and GI nurse practitioners/physician assistants (NP/PAs) managing patients with CPF, a case-based survey was developed related to management of initial presentation and CPF recurrence. Surveys were distributed online to GIs/NPs/PAs with CPF experience (at least 1 CPF patient per month) in Sep/Oct 2020. Results: Surveys were collected from 127 gastroenterologists and 63 GI NP/PA;24% of GIs and 35% of GI NPs/PAs were from academic settings. There was little agreement in CPF classification/scoring tools, with many GI NP/PAs (39%) and GIs (44%) choosing no classification system, and ways to distinguish simple versus complex CPF was inconsistent. Most participants agreed that controlling CD activity was very important, and most recommended an anti-TNF as initial pharmacotherapy. Thereafter, there was no agreement on next steps including medication adjustments, how long to leave a seton in place or when to refer to surgery. GIs and NP/PAs differed on whether fistula healing or improved quality of life was the most important long-term CPF goal. GIs were likely or very likely to discuss quality of life issues and general information about surgical management options with patients, but fewer discussed medication adverse effects or investigational options. Familiarity of investigational treatments was low, including 86% of HCPs not at all or slightly familiar with stem cell treatments. Barriers to optimal management of CPF were lack of effective medicines (64%), patient reluctance (49%), delayed referral/diagnosis (43%), and lack of guidelines/treatment algorithms (41%). COVID-19 did not have a major effect on patient management. Collaboration with colorectal surgeons on management plans occurred with 42% of GIs and 32% of NP/PAs. Barriers to effective multidisciplinary CPF management included logistical difficulty in coordinating care (40%), lack of access to specialists (38%), lack of communication of treatment plans (30%). Patient involvement in management decisions was considered by 47% of GIs and 60% of NPs/PAs. Conclusion: There is no consensus on how to best manage CPF. Education is needed to improve outcomes in CPF treatment.

The gynecologic oncologist as the HPV champion: missed opportunities for cancer prevention

Objectives: The Human Papillomavirus (HPV) vaccine is FDA approved up to age 45 and emerging evidence suggests it may prevent recurrent infections. This has important implications for patients commonly seen by gynecologic oncologists. Our objective was to describe factors that influence HPV vaccine recommendation amongst gynecologic oncologists and identify barriers and missed opportunities for vaccination. Methods: A pilot-tested online survey was electronically sent to all members of the Society of Gynecologic Oncology in the U.S. Questions evaluated the following domains: demographics, practice patterns, barriers and knowledge regarding the HPV vaccine. We defined HPV vaccine champions as providers who both recommended and either administered, stocked or prescribed the vaccine in the outpatient setting, and surveyed their practice patterns to identify possible missed opportunities for vaccination. Descriptive statistics were used to calculate the rate of HPV vaccine recommendation, explore barriers to vaccination and identify practice patterns. Univariate logistic regression was used to identify factors associated with vaccine recommendation. Results: A total of 183 gynecologic oncology providers completed the survey, representing 10% of invitations sent. Most were ≤ 45 years old (65%, n=99), practicing in urban (57%, n=105) and academic settings (67%, n=122). Eighty-one percent (n=147) had completed training, and of these, 68% (n=101) had been in practice for > 5 years. Ten percent (n=18/174) of respondents had not recommended the HPV vaccine in the past 12 months. Vaccine recommendation was associated with better HPV vaccine knowledge (Odds Ratio (OR) 1.7, 95% Confidence Interval (CI) 1.0-2.9), being a non-trainee (OR 3.8, CI 1.3-11.2) and practicing in the South (OR 10.8, CI 1.3-90.7). Among all providers, the most commonly reported barriers to vaccinating were that the patient's cancer diagnosis took precedence (88%, n=146/165), the cost to the clinic (48%, n=79/165), uncertainty about insurance coverage (43%, n=71/165) and that the vaccine history was not asked (48%, n=79/165). Forty eight percent (n=87) met criteria as HPV vaccine champions. Of those, 96% (n=78/81) at least sometimes offer the HPV vaccine at a visit for vulvar or cervical dysplasia. Eighty-three percent (n=67/81) offer it to patients with an HPV-related cancer diagnosis. In contrast, only 35% (n=29/82) were likely to offer it in a consultation for BRCA management and 28% (n=23/82) were likely to offer it at a surgical consultation for fibroids (Figure). Download : Download high-res image (89KB) Download : Download full-size image Conclusions: Gynecologic oncologists have a unique opportunity to educate and increase vaccination rates in eligible women. There are significant barriers to HPV vaccine administration in the gynecologic oncology office, and we identify examples of missed opportunities to vaccinate in non-HPV related clinical scenarios.

Treatment patterns for patients with metastatic or recurrent head and neck cancer in a large integrated health-care system.

e18015 Background: Since publication of the landmark KEYNOTE-048 Trial, pembrolizumab alone or with platinum-based chemotherapy and 5-fluorouracil (5FU) was established as a standard of care for the frontline treatment of patients with recurrent or metastatic head and neck squamous cell cancer (HNSCC), replacing the EXTREME regimen of Cetuximab with platinum and 5FU. In clinical practice, some clinicians modify the KEYNOTE-048 regimen by substituting a taxane for 5FU (i.e., Paclitaxel + Carboplatin + Pembrolizumab, PCT). Within the Kaiser Permanente Northern California (KPNCAL) network, we identified a cohort of 123 patients who received palliative first-line therapy for metastatic HNSCC to identify practice patterns in a real-world setting within a large health care delivery system. Methods: This is a data-only cohort study of all adult KPNCAL members diagnosed with metastatic HNSCC treated with palliative combination chemotherapy and/or immunotherapy between January 1, 2018 and July 31, 2020. Results: Among a cohort of 123 patients, 28 patients received the EXTREME regimen (platinum + 5FU + cetuximab), 10 received modified EXTREME (platinum + taxane + cetuximab), 14 received platinum + 5FU + pembrolizumab, 9 received platinum + taxane + pembrolizumab and 62 received single agent immunotherapy. From 2018 through mid-2020, there was an apparent shift away from cetuximab based regimens and a concurrent rise in immunotherapy-based regimens. By mid-2020, the majority of patients received an immunotherapy-based regimen (28 patients), while only 5 patients received a cetuximab based regimen (Table). Conclusions: Data from our cohort reported clinical practice patterns within a large multispecialty integrated health-care system in Northern California. Our findings highlight the marked variability in practice patterns within a single health care system for first-line metastatic therapy. While we identified trends away from cetuximab based therapy and toward immunotherapy-based therapy in clinical practice there remained wide practice variations among clinical oncologist treating patients with newly diagnosed metastatic HNSCC. This further emphasizes the need for prospective clinical trials to identify the optimal regimen or to confirm clinical equipoise between regimens among patients with metastatic or recurrent head and neck cancer. [Table: see text]

Patterns of breast cancer radiotherapy practices among Saudi radiation oncologists.

Objectives:To identify practice patterns among radiation oncologists in Saudi Arabia.Methods:A questionnaire comprising 27 scientific questions and 6 demographic questions was created in 2019 by a faculty member at King Abdulaziz University, Jeddah, Saudi Arabia, and distributed among radiation oncologists in Saudi Arabia between February and April 2019.Results:Twenty-four responses were received. Regarding chest wall treatment after mastectomy, 100% of the respondents offered postmastectomy radiotherapy (PMRT) for tumor stage 3 node 1 (T3N1) or T4 disease, while 87.5% offered PMRT for T2N1, and 83.3% offered PMRT for T3N0 disease. In contrast, there was a lack of consensus regarding treatment planning and coverage criteria for internal mammary lymph nodes and contouring.Conclusion:Variations in breast radiotherapy practices in Saudi Arabia exist due to the lack of clinical evidence and national guidelines, as well as potential variations in health resources allocation. Resource allocations and the establishment of national guidelines are recommended to decrease this variation and allow for data exchange and the development of national research collaborations.