Inpatient Administration Research Articles

IMPACT OF TIME-TO-TEST FOR CLOSTRIDIOIDES DIFFICILE INFECTION ON LENGTH OF STAY IN INFLAMMATORY BOWEL DISEASE PATIENTS HOSPITALIZED WITH FLARE

Abstract Background Guidelines recommend testing inflammatory bowel disease (IBD) patients hospitalized with flare for Clostridioides difficile infection (CDI), though little is known about whether a delay in testing for CDI is related to adverse outcomes. We examined the relationship between time-to-C. difficile PCR test order, collection, and result with adverse IBD outcomes. Methods We performed a retrospective cohort study of IBD patients hospitalized with flare through the emergency department (ED) between 2013 and 2020 at an urban academic medical center. The time from ED presentation to C. difficile test order (time-to-order), sample collection (time-to-collection), and test result (time-to-result) were collected. Time-to-result was stratified by within 6 hours, 6–24 hours, and 24 hours or longer. The primary outcome was length of stay (LOS). Secondary outcomes were inpatient anti-TNF administration and surgery. We used hemodynamic and laboratory values at presentation to evaluate disease severity as a confounding variable between length of stay and time-dependent variables. Results We identified 122 IBD patients hospitalized with flare. There were no significant differences in baseline characteristics among time-to-result groups. Despite a shorter time-to-result, the average LOS in the 6 hours group was 7.3 days, longer compared to the 6–24 hours group (4.3 days, p=0.018) and the 24 hours group (4.2 days, p=0.035; Table 1). There were no differences in inpatient anti-TNF administration (p=0.10) or surgery (p=0.08) among time-to-result groups. The markers of disease severity that correlated with longer LOS were C-reactive protein (CRP) (0.28 days, p=0.003), heart rate (0.478 days, p<0.001), diastolic hypotension (0.228 days, p=0.01), and hypoalbuminemia (0.215 days, p=0.02). Higher CRP correlated with earlier time-to-result (-0.218 hours, p=0.02). Patients with more markers of disease severity had earlier times-to-result (12.8 hours vs. 32.2 hours, p=0.014) and had a longer LOS (7.9 vs. 3.4 days, p=0.007) (Table 2). Patients with more severe disease had an earlier time-to-order (4.48 hours) compared to those with less severe disease (17.4 hours), though this difference did not meet statistical significance (p=0.09; Table 2). Conclusion Earlier time-to-result for CDI is associated with longer LOS in IBD patients hospitalized with flare. This inverse relationship is confounded by disease severity at presentation: patients with more severe disease have a shorter time-to-result and a longer LOS. It may be that these patients produce a stool sample more readily; however, the near significance of differences in time-to-order among severity groups suggest a role for provider bias, which must be studied further. Delay in testing was not associated with higher rates of inpatient anti-TNF administration or surgery.

Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management

IntroductionPediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not. MethodsRetrospective cohort study of patients 0–18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred. ResultsA total of 4098 patients with a median age of 6 years old (IQR 4–10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3–8) in the non-ibuprofen group. ConclusionsNo difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.

Medication Use Quality and Safety in Older Adults: 2019 Update.

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

Exploring Cost Savings with Specialty Biologic Drugs Administered to Adult Inpatients with Inflammatory Bowel Disease.

Background: Specialty infusion and self-injectable biologic drugs for the treatment of inflammatory bowel disease (IBD) are high-cost medications. When administered to hospital-admitted patients, these medications are not reimbursed on an individual basis but rolled into a per diem payment by most payers in the United States (US). Therefore, choosing to administer these medications in the inpatient setting may reveal negative financial implications for some health care institutions. Selecting an alternative site of care to administer these medications during the clinical management process may lead to cost savings. Objective: Review the clinical necessity of inpatient specialty biologic administrations for the treatment of IBD to identify and quantify potential cost saving opportunities. Methods: Using patient medical records at a US academic medical center, we retrospectively identified inpatient administrations of specialty infusion and self-injectable biologic medications for IBD treatment from June 1, 2016 to May 31, 2017. Guided by a standardized form, an evaluation team consisting of 3 of the investigators determined the clinical necessity of each specialty biologic medication administration within the inpatient setting. Costs and reimbursement rates for administration in both the inpatient and outpatient settings were procured and tabulated. Results: Seventeen inpatient specialty biologic administrations for IBD during the 12 month study period were identified. Of these, 11 administrations were given for the treatment of Crohn's disease (CD) and 6 for ulcerative colitis (UC). The evaluation team determined that 65% of these administrations were clinically necessary as inpatient administrations, and that 35% were not. The sum of the wholesale acquisition costs (WAC) for clinically necessary inpatient biologic administrations totaled $54 737, and the WAC for those administrations deemed not clinically necessary totaled $43 702. Further analysis of administration events revealed that the institution could have realized an estimated $13 817 in additional revenue above the cost of the drug if eligible inpatient biologic administrations had been received in the institution's outpatient clinic setting instead. Conclusion: Administering specialty biologic drugs for the treatment of IBD in the care setting best aligned with existing reimbursement structures may lead to institutional cost savings.

Options of the placental dysfunction correction in women with preeclampsia

Background. Placental dysfunction (PD) is one of the most common complications of pregnancy, which has not only medical but also social significance. The links of the PD pathogenesis include endothelial dysfunction, hemodynamic disorders of the placental vessels, disorders of arterial and venous blood flow in the placenta.
 Objective. To study diagnostic methods and possibilities of PD correction in women with preeclampsia (PE).
 Materials and methods. The study involved 68 women with PE in the II and III trimesters of pregnancy, treated at the multidisciplinary clinic of the Tashkent Medical Academy during 2017-2019. Patients underwent standard clinical, laboratory and instrumental examination with color Doppler mapping of vessels of the uterine-placental-fetal system and ultrasound evaluation of the fetoplacental system.
 Results and discussion. Premature aging of the placenta was found in 77.3 % of cases, turbid amniotic fluid – in 59.09 %, oligohydramnion – in 27.3 %. Disorders of uteroplacental blood flow were detected in 28.3 % of cases, placentofetal blood flow – in 26.7 %. Impaired blood flow at both levels without critical values occurred in 10 % of pregnant women. In case of insufficiency of a blood circulation of 2nd grade the syndrome of fetal growth restriction was observed in 16,7 % of cases. Compensated forms of PD were subject to the comprehensive treatment with the addition of infusions of L-arginine (Tivortin, “Yuria-Pharm”) in the inpatient phase and oral administration of Tivortin aspartate in the outpatient phase. The length of the fetal thigh in the group of L-arginine at the beginning of treatment was 47.33 mm, which was by 9.04 % less than this parameter in physiological pregnancy. After treatment with Tivortin, in the full-term period, no significant difference was found. In pregnant women who received L-arginine at 25-29 weeks of pregnancy, after 2 weeks, the resistance indices (RI) of the umbilical artery and uterine artery decreased from 0.68±0.09 to 0.58±0.05 and from 0,58±0.16 to 0.43±0.08, respectively. The RI of the middle cerebral artery increased from 1.05±0.23 to 1.27±0.19. Parameters of RI dynamics indicate that the early treatment with Tivortin is more effective than late.
 Conclusions. 1. Regardless of the presence of fetal growth restriction syndrome in women with disorders of uterine-placental-fetal circulation, it is advisable to include L-arginine in the treatment to prevent this condition. 2. Ultrasound examination is a reliable method for evaluating the effectiveness of PD treatment.

Inpatient Therapy With Calcineurin Inhibitors in Severe Ulcerative Colitis.

Inpatient management of severe ulcerative colitis is complicated by the use of prior immunosuppressant therapies. Our aim was to determine the rate of 1-year colectomy among individuals receiving inpatient calcineurin inhibitor (CNI)-based therapy stratified by prior biologic therapy. A retrospective cohort study was performed between January 1, 2013 and April 1, 2018. Only individuals requiring inpatient administration of intravenous cyclosporine or oral tacrolimus were included in the analysis. Individuals were stratified according to prior biologic therapy exposure. The primary outcome of interest was 1-year risk of colectomy. Kaplan-Meier curves were generated for time-to-event data, and regression models were performed to examine the effects of covariates on the clinical endpoint. Sixty-nine (62.3% male) patients were treated with an inpatient CNI-based therapy and were included in the analysis. Fifteen (21.7%) patients were biologic-naïve, 42 (60.9%) patients had prior exposure to 1 class of biologic therapy, and 12 (17.4%) patients had prior exposure to 2 classes of biologic therapy (third-line CNI therapy). Third-line CNI therapy showed a greater risk of 1-year colectomy risk when compared with the risk for patients who were biologic-naïve (hazard ratio, 3.63; 95% confidence interval, 1.17-13.45; P = 0.025). In a multivariate proportional hazards model, third-line CNI therapy remained significantly associated with 1-year colectomy risk (hazard ratio, 7.94; 95% confidence interval, 1.97-39.76; P = 0.003). The use of CNI-based therapy in individuals exposed to multiple classes of prior biologic therapies leads to a significantly increased risk of 1-year colectomy. Future studies will be required to compare inpatient management strategies with the expanding novel therapies in UC.

Assessing opioid administration in pediatric burn patients with nonsurgical management

BackgroundDespite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients. MethodsAdmitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization. ResultsA total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10–18 years; p<0.0001) and larger burns (>5% TBSA burned; p<0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p=0.0103). ConclusionsNonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.

Effects of an anesthesia perioperative surgical home for total knee and hip arthroplasty at a Veterans Affairs Hospital: a quality improvement before-and-after cohort study.

A perioperative surgical home, the Anesthesia Perioperative Care Service (APCS), was created to execute enhanced recovery after surgery pathways for total knee and total hip arthroplasty patients at the Tennessee Valley Health System Nashville VA Medical Center. We hypothesized that the APCS would be associated with reduced length of stay, in-hospital and post-discharge opioid exposure, costs, and hospital readmissions. Data were collected for all patients admitted to the Nashville VA Medical Center following their respective surgery, for 400 days after the initiation of the APCS and for a 400-day period prior. This cohort study was based on a quality improvement project set up at the initiation of the service. The adjusted effect on each quantitative outcome was evaluated using proportional odds logistic regression methods. In addition, each regression analysis was performed in segmented regression fashion to identify changes in the outcomes over time. We included 282 patients in our cohort-96 prior and 186 post-implementation. Median hospital length of stay, intravenous (IV) and per os (PO) inpatient opioid administration, outpatient opioid quantity, and total days of supply were all reduced in the cohort cared for by the APCS. After adjusting for potential cofounders and evaluated outcome over time, the APCS remained independently associated with a reduction of hospital length of stay of one day (95% confidence interval, 0.09 to 1.97; P = 0.05) and with decreasedIV and PO inpatient opioid administration, while continuingto show no increase in hospital readmissions. This cohort study showed significant improvements in important post-surgical outcomes after total knee and hip arthroplasty that were associated with the implementation of an APCS.

AM Versus PM Postoperative Administration of Warfarin With a Mechanical Mitral Valve.

Background: Currently, there are no guidelines regarding the optimal daily timing of inpatient warfarin administration. Objective: The purpose of this study was to determine whether dosing warfarin in the morning will have a significant impact on therapeutic international normalized ratio (INR) achievement compared with evening administration in mechanical mitral valve patients initiated on warfarin following cardiac surgery. Methods: This was a single-center, pre- and post-retrospective cohort conducted between 2014 and 2018. One-hundred fifty-four adult patients who underwent a mechanical mitral valve replacement or alternative cardiac surgery with a history of a mechanical mitral valve were enrolled. The primary outcome was achievement of therapeutic INR at any time point after initiation of warfarin. Pre-intervention administration timing was 6 pm and post-intervention timing was 10 am. Results: Baseline characteristics including age, sex, and race were similar between the 2 groups (P = NS for each characteristic). Therapeutic INR achievement was significantly improved at all time points following 10 am warfarin administration compared with 6 pm (hazard ratio = 1.69; P = .005). Mean time-to-therapeutic INR was 7.37 days in the post-intervention group and 8.39 days in the pre-intervention group (P = .073). There were no significant differences in INR >4, bleeding, or thrombotic complications between groups. Conclusion and Relevance: This retrospective analysis suggests that there may be a postoperative benefit in therapeutic INR achievement in mechanical valve patients when dosing warfarin in the morning compared with evening administration. Large-scale studies should be conducted to further elucidate the potential benefit across more heterogeneous populations.

Identifying and Addressing Barriers to Systemic Thrombolysis for Acute Ischemic Stroke in the Inpatient Setting: A Quality Improvement Initiative.

ObjectivesTo identify barriers to inpatient alteplase administration and implement an interdisciplinary program to reduce time to systemic thrombolysis.Patients and MethodsCompared with patients presenting to the emergency department with an acute ischemic stroke (AIS), inpatients are delayed in receiving alteplase for systemic thrombolysis. Institutional AIS metrics were extracted from the electronic medical records of patients presenting as an inpatient stroke alert. All patients who received alteplase for AIS were included in the analysis. A gap analysis was used to assess institutional deficiencies. An interdisciplinary intervention was initiated to address these deficiencies. Efficacy was measured with pre- and postintervention surveys and institutional AIS metric analysis. Statistical significance was determined using the Student t test. We identified 5 patients (mean age, 73 years; 100% (5/5) male; 80% (4/5) white) who met inclusion criteria for the preintervention period (January 1, 2017, to December 31, 2017) and 10 patients (mean age, 71 years; 50% male; 80% white) for the postintervention period (October 31, 2018, to July 1, 2020).ResultsWe found barriers to rapid delivery of thrombolytic treatment to include alteplase availability and comfort with bedside reconstitution. Interdisciplinary intervention strategies consisted of stocking alteplase on additional floors as well as structured education and hands-on alteplase reconstitution simulations for resident physicians. The mean time from stroke alert to thrombolysis was shorter postintervention than preintervention (57.4 minutes vs 77.8 minutes; P=.03).ConclusionA coordinated interdisciplinary approach is effective in reducing time to systemic thrombolysis in patients experiencing AIS in the inpatient setting. A similar program could be implemented at other institutions to improve AIS treatment.

The use of steroids in cervicofacial infections in UK OMFS departments: a Maxillofacial Surgery Trainees Research Collaborative (MTReC) study.

Defining current inpatient management of cervicofacial infections is key to identifying strategies to optimise care. Steroid use is beneficial in peritonsillar and orbital abscess, but there are few studies of steroid use in odontogenic cervicofacial infections. Our previous research identified widespread variation in practice, necessitating a national audit to define current practice. A multicentre, trainee-led snapshot audit was carried out across 25 hospitals in the UK. Information recorded included demographic features, presentation, surgical and medical management, and steroid administration. One thousand two admissions were recorded. Fifty-five percent were male, with mean age 37.3years (range 0-94years). Steroids were administered to 357 patients (36%), 159 of whom received steroids on admission, and 254 peri-operatively. Patients who were prescribed steroids had significantly higher white cell count (12.4 vs 11.5), CRP (79.5 vs 57) and heart rate (94 vs 88) on admission. Justifications given for administration included swelling (74), dysphagia (21), and airway compromise (7). Three patients (0.8%) reported steroid-related side effects. This study uses the largest recorded cohort of cervicofacial infections to define current inpatient steroid administration. Our results suggest that steroids are targeted towards the most compromised 1/3 of patients. The incidence of steroid-related side effects was low. Defining the characteristics of patients currently receiving steroids will aid in determining whether steroid administration is an effective adjunct in treating odontogenic cervicofacial infection.

Costs of Postinfusion Monitoring By Site of Care for Patients with Relapsed/Refractory (R/R) Large B-Cell Lymphoma (LBCL) Who Received Third-Line or Later Treatment with Lisocabtagene Maraleucel (liso-cel) in the Transcend NHL 001 and Outreach Trials

Background: Chimeric antigen receptor (CAR) T cell therapy is generally limited to inpatient settings; yet, exploration of outpatient infusion and monitoring is ongoing. Information on health care resource utilization (HCRU) and costs associated with CAR T cell therapy administration is limited and may differ by postinfusion monitoring site. Liso-cel is an investigational, CD19-directed, defined composition, 4-1BB CAR T cell product administered at equal target doses of CD8+ and CD4+ CAR+ T cells. An interim analysis from the OUTREACH study (NCT03744676) observed lower HCRU with outpatient vs inpatient administration (Bachier et al. J Clin Oncol 2020;38:8037). The patient journey after CAR T cell therapy administration may differ for patients with outpatient vs inpatient monitoring and may result in varying costs of care. This study estimated the cost of postinfusion monitoring by site of care for patients with R/R LBCL who received third-line or later treatment with liso-cel in the TRANSCEND NHL 001 (TRANSCEND; NCT02631044) and OUTREACH clinical trials. Methods: This retrospective study analyzed HCRU reported in clinical trial databases from TRANSCEND and OUTREACH. A 2-step microcosting method was used to identify key HCRU and to estimate postinfusion costs: (1) HCRU was analyzed from the index date (day of liso-cel infusion) through the 6-month follow-up; and (2) costs were applied to each HCRU. HCRU included standard inpatient and intensive care unit (ICU) length of stay (LOS), diagnostics (laboratory work and imaging), procedures (dialysis and intubation), and medications (supportive care, prophylactic treatment, and adverse event management). Unit costs were obtained from the health care system (provider) perspective and adjusted to 2020 US dollars. Cost per standard inpatient day ($2,542) was estimated from Healthcare Cost and Utilization Project databases, and cost per ICU day ($7,556) was sourced from Dasta et al (Crit Care Med. 2005;33:1266-77). All medication costs were obtained from REDBOOK (IBM Micromedex) using wholesale acquisition costs. Diagnostic and procedure costs were obtained from the Centers for Medicare &amp; Medicaid Services laboratory fee schedule, physician fee schedule, or outpatient prospective payment system. A payment-to-cost ratio was applied to Medicare payment rates to estimate unit costs. Costs were adjusted to reflect the site of care where the HCRU occurred. A cost ratio was applied to adjust costs from the physician's office/community oncology clinic to the hospital outpatient department (Winfield, Muhlestein, Leavitt Partners; 2017) and from outpatient to inpatient (Meisenberg et al. Bone Marrow Transplant. 1998;21:927-32). Costs were aggregated by HCRU category, specifically medications, diagnostics, procedures, and facility costs. An average total cost by post-liso-cel infusion month was calculated for patients with ongoing status in that month (patients censored due to data cutoff were not included). Analyses were stratified by site of postinfusion monitoring (inpatients vs outpatients). Results: A total of 303 patients with R/R LBCL across the 2 trials received liso-cel and postinfusion monitoring (inpatients, n = 256; outpatients, n = 47). HCRU and LOS, including standard inpatient and ICU days, are shown in the Table. Inpatients had higher rates of inpatient stays (&amp;lt;100% vs 62%) and tocilizumab use (for CRS and/or NE; 20% vs 9%) than outpatients, respectively. Rates of ICU admission, corticosteroid use, vasopressor use, dialysis, and intubation were similar between groups. Median and average LOS in standard inpatient and ICU settings were higher among inpatients. Median (range) total LOS for inpatients and outpatients was 15 (0-88) and 4 (0-77) days, respectively. The estimated mean postinfusion cost of care was $89,535 for inpatients and $36,702 for outpatients. Over 6 months, most costs were incurred in the first month after infusion ($50,369 [56%] for inpatients and $19,837 [54%] for outpatients). Costs were largely driven by facility costs, namely standard inpatient and ICU stays (Figure). Conclusions: Lower overall HCRU was observed with outpatient liso-cel postinfusion monitoring, primarily due to hospitalizations, which resulted in a mean 6-month cost savings of $52,833 (59%) compared with inpatient monitoring. These results are based on national average costs and may not be generalizable to specific institutions. Disclosures Palomba: Regeneron: Research Funding; Juno Therapeutics, a Bristol-Meyers Squibb Company: Honoraria, Research Funding; Genentech: Research Funding; Merck: Honoraria; Novartis: Honoraria; Celgene: Honoraria; Pharmacyclics: Honoraria. Jun:Bristol-Myers Squibb Company: Current Employment, Current equity holder in publicly-traded company. Garcia:Bristol-Myers Squibb Company: Current equity holder in publicly-traded company; Juno Therapeutics, a Bristol-Myers Squibb Company: Current Employment. Lymp:Bristol-Myers Squibb Company: Current equity holder in publicly-traded company; Juno Therapeutics, a Bristol-Myers Squibb Company: Current Employment. McGarvey:Pfizer, Inc.: Ended employment in the past 24 months; BluePath Solutions: Current Employment. Gitlin:BMS: Research Funding. Pelletier:BMS: Current Employment, Current equity holder in publicly-traded company. Nguyen:BluePath Solutions: Current Employment.

Clinical Features, Treatments and Outcomes of HIV-Associated Diffuse Large B-Cell Lymphoma: A Single-Center Experience

INTRODUCTION Recent studies have suggested that the prognosis of HIV-associated diffuse large B-cell lymphoma (HIV-DLBCL) may be improving with advances in anti-retroviral therapies (ART). A pooled analysis of clinical trial data showed that EPOCH may be associated with superior outcomes as compared to CHOP (Barta et al. Blood. 2013), but about two-third of patients in the combined analysis were treated without rituximab. A recent French study, however, showed similar overall survival (OS) between R-CHOP and R-EPOCH treated patients (Besson et al. AIDS 2017) and a phase III trial showed similar efficacy of R-CHOP vs. R-EPOCH in HIV-uninfected DLBCL (Bartlett et al. JCO 2019). The optimum frontline therapy in HIV-DLBCL is unknown as most clinical trials exclude HIV-infected patients or restrict accrual to those with undetectable HIV viral load and minimum CD4 count cut-off. Moreover, most existing studies include a majority (&amp;gt;60%) Caucasian population, and there is a paucity of studies on outcomes in African-American population. In this retrospective study, we describe the clinical features and outcomes of HIV-DLBCL patients seen at our institution and compare them with HIV negative DLBCL patients. METHODS We conducted a retrospective review of HIV+ DLBCL cases diagnosed and treated at our institution from 2008-2020. We used the Kaplan-Meier method to assess overall survival (OS). Univariate and multivariate analyses were performed to assess prognostic factors. HIV-DLBCL patients were matched 1:2 with HIV negative DLBCL by age and stage of lymphoma at diagnosis. Comparison of OS analysis was conducted using log-rank method and predictors of progression or death using Cox proportional hazards regression. RESULTS We included a total of 33 patients with HIV-DLBCL in our study. Median age was 46.6 years (IQR 40-53.3), 25 (76%) were males, and 20 (61%) were African-Americans (Table). 28 (85%) patients had stage III/IV and 24 (73%) had extranodal disease at diagnosis. The median CD4 count at diagnosis was 252 (IQR 89.5-409). 6 (18%) had CNS involvement at diagnosis, for which the median OS was 8.3 months. First-line treatment included rituximab-chemotherapy combinations in 25 (76%) patients. All patients continued ART during first line treatment. Median follow up duration of the entire cohort was 2.06 years (IQR 0.53-5.02 years) and 5 (15.2%) were lost to follow up. The 2-year OS for R-CHOP treated patients was 63% vs. 38% for R-EPOCH treated patients, although this failed to reach statistical significance (p=0.125). On multivariate analysis, the only factor significantly associated with difference in event free survival (EFS; progression or death) was female sex (HR 19.86; [2.652-148.7]; p=0.004). Trends were seen towards shorter EFS among patients who were tobacco smokers at time of DLBCL diagnosis (HR 2.69; 0.463-15.6]; p=0.271), CD4+ count &amp;lt;200 at time of DLBCL diagnosis (HR 2.39; [0.519-11.0]; p=0.264), IPI score &amp;gt;3 (HR 2.98; [0.480-18.5]; p=0.241), and presence of MYC gene rearrangement (HR 3.93; [0.569-27.2]; p=0.165). Treatment type (R-CHOP, R-EPOCH), ART use prior to lymphoma diagnosis, race, and insurance status were not correlated with EFS. 11 (33.3%) patients died within 1 year of diagnosis. The 2-year OS for the entire cohort was 64% vs. 68% in matched HIV-negative DLBCL patients (p=0.651). Median OS for HIV+ patients was 2.14 years (IQR 0.23-5.77) vs 2.97 years (IQR 0.76-6.48) in matched HIV-negative DLBCL patients (p=0.3996). One patient died from acute hypoxemic respiratory failure prior to starting treatment. Four patients died of complications during their first inpatient chemotherapy administration. CONCLUSION In our cohort, most HIV-DLBCL patients were African-Americans, presented with advanced stage and extranodal disease. The survival of HIV-associated DLBCL was similar to HIV-negative counterparts. All HIV-DLBCL continued ART during chemotherapy, suggesting the feasibility of this approach. There was no difference in OS between patients treated with R-CHOP vs. R-EPOCH, however there was a trend towards increased OS in patients treated with R-CHOP. CNS involvement at diagnosis was frequently seen. Despite limited sample size, we observed a significant association with gender, and a trend toward significant factors including tobacco use and low CD4 count at time of diagnosis. Disclosures Mehta: TG Therapeutics:Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Merck:Research Funding;Roche-Genentech:Research Funding;Kite/Gilead:Research Funding;Innate Pharmaceuticals:Research Funding;Seattle Genetics:Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Oncotartis:Research Funding;Gelgene/BMS:Research Funding;Juno Parmaceuticals/BMS:Research Funding;fortyseven Inc/Gilead:Research Funding;Takeda:Research Funding;Incyte:Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Affimed:Research Funding.

Tumor Lysis Syndrome Risk in Outpatient Versus Inpatient Administration of Venetoclax and Hypomethlators for Acute Myeloid Leukemia

Introduction Venetoclax (VEN), a BCL-2 inhibitor, along with hypomethylating agents (HMAs) has become standard therapy for older patients (pts) with acute myeloid leukemia (AML) not fit for intensive frontline therapy based on recent Phase 3 data reporting a median overall survival (OS) of 14.7 months. Initially used in CLL, VEN is associated with fatal episodes of tumor lysis syndrome (TLS). Package insert and expert opinion recommendations are for its initiation in the inpatient setting, with a dose escalation of 100mg day 1, 200mg day 2, and 400mg day 3 with IV hydration and close monitoring of TLS markers. In the initial phase 1b trial that resulted in its approval for use in pts with AML all pts were admitted to the hospital for initial venetoclax ramp up and received at least 72 hours of prior TLS prophylaxis, as well as initiation of venetoclax only if the white blood cell count was less than 25,000. No episodes of TLS were documented. Herein, we evaluated the safety of outpatient VEN ramp up when given in addition to HMAs for the treatment of AML. Methods We conducted a retrospective review of pts diagnosed with AML at our institution from 12/1/2016 until 7/1/2020. We identified pts who received HMAs and VEN, either as up-front treatment for newly diagnosed AML or as salvage therapy for relapsed or refractory disease, and stratified pts based on whether venetoclax was initiated in the inpatient or outpatient setting. We then examined baseline AML characteristics including initial blast count, cytogenetics and molecular profiles as well as baseline TLS markers prior to the initiation of VEN. Finally, using the Cairo-Bishop Criteria we examined the number of episodes of laboratory or clinical tumor lysis in all pts. Fisher's exact test and Wilcoxon rank-sum tests were performed to examine differences in categorical and continuous variables. Results Between 12/1/2016 and 7/1/2020 43 pts at received VEN in addition to an HMA for the treatment of AML (Table 1). 39 pts (91%) had VEN initiation and ramp up in the outpatient setting. Amongst all pts 24 received azacitadine, 11 decitabine, and 8 received both HMAs at some point during therapy. Twenty-two pts received HMA and VEN as frontline treatment while the other 21 received it as salvage therapy. There were 28 pts who received venetoclax within 28 days of starting the HMA, 25 of whom received it as an outpatient and 3 as an inpatient. Pretreatment labs were notable for median normal values of potassium, phosphate, uric acid, calcium and creatinine (Table 1). The median pretreatment creatinine levels between the two groups were not significantly different. Median pre-treatment WBC count was noted to be significantly higher in the inpatient cohort (37.9 vs 5.5, p-value of 0.01). Cytogenetic and molecular characteristics are included in the table with the only significant difference being a larger percentage of DNMT3A mutation in the inpatient group. While identification of TLS was somewhat limited by incomplete data on all pts, there was only one identified episode of laboratory TLS (2.5%) with an elevated phosphate and uric acid. This occurred in the outpatient group in a patient whose pretreatment WBC count was greater than 25,000. This pt required admission to the hospital for rasburicase and IV fluids with resolution of the laboratory effects without resultant clinical TLS. There were no episodes of clinical TLS in either group. 30-day mortality from starting VEN was 0% in both groups. While the Cairo-Bishop Criteria require the presence of 2 lab abnormalities to diagnose TLS we did a further analysis to evaluate for the presence of even a single lab abnormality associated with TLS. We identified 3 additional pts (7.5%) in the outpatient cohort who had the presence of only one lab abnormality associated with TLS within the 7 days after initiating treatment. None of these pts required any further TLS directed treatment or hospitalization. Conclusion Our experience with HMAs and VEN showed that outpatient ramp up of venetoclax is safe with a very low risk of laboratory TLS (2.5%) and no evidence of clinical TLS within our cohort. Even with an expanded definition of TLS we only identified 3 additional pts who developed laboratory abnormalities associated with TLS. Our results suggest that, in addition to HMA, VEN ramp up can be safely delivered with monitoring to pts with a WBC count less than 25,000 in the outpatient setting. Disclosures Olszewski: Genentech, Inc.: Research Funding; Spectrum Pharmaceuticals: Research Funding; TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding.

Safety and financial analysis of outpatient dose-adjusted EPOCH for B-cell lymphoma at a tertiary comprehensive cancer center.

Dose-adjusted (DA-) EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) is a front-line treatment option for aggressive B-cell lymphomas. Due to regimen complexity, inpatient administration of DA-EPOCH has been historically required. Moffitt Cancer Center (MCC) developed an Inpatient/Outpatient (IPOP) program to facilitate administration of complicated regimens in the outpatient setting. We hypothesized that outpatient administration of DA-EPOCH at a comprehensive cancer center is both safe and cost-effective. We conducted a single-center, retrospective chart review including B-cell lymphoma patients who were 18 years or older and who had received DA-EPOCH at MCC from April 26, 2017 through August 10, 2019. The primary endpoint was hospital admissions during outpatient chemotherapy administration. Additional safety endpoints included hospitalizations between cycles, infectious complications, extravasations, drug spills, pump-malfunctions, and drug-related adverse events. Financial analysis included drug cost, resource utilization, and impact of hospital bed backfill. 56 patients received 219 cycles of DA-EPOCH with 193 cycles administered outpatient. Zero patients required hospitalization during outpatient administration of DA-EPOCH, resulting in 965 saved hospital days. 23 patients (41%) were hospitalized between cycles, most commonly due to neutropenic fever (52%). No extravasations were documented throughout the study period. There were few incidences of drug spills or pump malfunctions. Based on current regimen utilization, the annual transition of 84 cycles of DA-EPOCH to the outpatient setting has a positive impact on margin of $1,444,548. Routine outpatient administration of DA-EPOCH is both safe and feasible with a positive annual impact on margin of $1,444,548 at a comprehensive cancer center.

Is inpatient chemotherapy overutilized?

215 Background: Inpatient palliative chemotherapy has been associated with more aggressive end of life care, reduced utilization of hospice services and decreased quality of life. The decision to administer chemotherapy in the inpatient setting is not always standardized which may lead to overutilization. Methods: We performed a retrospective chart review of all patients who received inpatient chemotherapy at an Academic center during the year 2016. Patients were stratified by solid tumor (ST) versus hematologic malignancies (HM) and assessed for the urgency of chemotherapy. We also evaluated response to treatment, death within 30 days of chemotherapy administration, and other qualitative and quantitative variables. We used descriptive statistics and odds ratios (OR) were estimated from logistic regression models. Results: We identified 141 patients; 47% HM. Select significant patient outcomes (p-value ≤0.05) are summarized in Table. At the time of admission, the majority of ST patients had stage 4 cancer (71%) with a poorer performance status (p= 0.0005) and were more often admitted due to symptoms related to their cancer (p&lt;0.0001). HM patients were more likely to be directly admitted for chemotherapy (p&lt;0.0001). Among ST patients, 29% received chemotherapy because the admission coincided with a non-urgent planned cycle compared to 11% of HM. Reason for inpatient chemotherapy was documented as urgent for 94% HM and 67% ST patients. ST patients were more likely to receive a palliative care consult (65% vs 24%; p&lt;0.001) and to die within 30 days of index admission (15.8% vs 6.2%; p=0.019). In the adjusted analysis, the most important factor associated with urgent chemotherapy was the cancer type (OR: 8.25, 95% CI 2.13-31.97, p=0.002). Conclusions: Our study indicates that there is an overutilization of inpatient chemotherapy in ST patients as well as increased mortality within 30 days of inpatient chemotherapy administration compared to HM. The administration of inpatient chemotherapy can be avoided in many cases which can lead to improved quality of life and cost savings. Creation of a standardized algorithm on the appropriateness of inpatient chemotherapy may be a useful tool to guide decision making. [Table: see text]

S3197 Impact of Disease Severity and Time-to-Test for Clostridioides difficile Infection on Length of Stay in Inflammatory Bowel Disease Patients Hospitalized With Flare

INTRODUCTION: Guidelines recommend testing inflammatory bowel disease (IBD) patients hospitalized with flare for Clostridioides difficile infection (CDI), though little is known about whether a delay in testing for CDI is related to adverse outcomes. We examined the relationship between time to C. difficile PCR test order, collection, and result with adverse IBD outcomes. METHODS: We performed a retrospective cohort study of IBD patients hospitalized with flare through the emergency department (ED) between 2013 and January 2020 at an urban academic medical center. The time from ED presentation to CDI test order (time-to-order), sample collection (time-to-collection), and test result (time-to-result) were collected. Time-to-result was stratified by within 6 hours, 6–24 hours, and 24 hours or longer. The primary outcome was length of stay (LOS). Secondary outcomes were inpatient anti-TNF administration and surgery. Separately, we used initial hemodynamic and laboratory values to create an IBD hospitalization severity score for evaluation against LOS and time-dependent variables. RESULTS: We identified 122 IBD patients hospitalized with flare. There were no significant differences in baseline characteristics among time-to-result groups. There was no difference in time-to-order between the 6 hours and 6–24 hours groups (Table 1). Despite a shorter time-to-result, the average LOS in the 6 hours group was 7.3 days, longer compared to the 6–24 hours group (4.3 days, P = 0.018) and the 24 hours group (4.2 days, P = 0.035; Table 1). There were no differences in inpatient anti-TNF administration (P = 0.10) or surgery (P = 0.08) among time-to-result groups. Markers of disease severity correlated with longer LOS and earlier time-to-result (Table 2). A composite of these markers was used to stratify patients by disease severity. Those with more severe disease had earlier times-to-result (12.8 hours vs. 32.2 hours, P = 0.014) and had a longer LOS (7.9 vs. 3.4 days, P = 0.007) with no difference in time-to-order compared to patients with less severe disease (P = 0.09; Table 3). CONCLUSION: Earlier time-to-result for CDI is associated with longer LOS in IBD patients hospitalized with flare. This inverse relationship is confounded by disease severity at presentation. Patients with more severe disease have a shorter time-to-result and a longer LOS without any difference in time-to-order. Delay in testing was not associated with higher rates of inpatient anti-TNF administration or surgery.Table 1.: Length of stay is longer in those tested for CDI within 6 hours of presentation compared to those tested after 6 hours. P-value as compared to < 6h group in parentheses.Table 2.: Correlation of markers of disease severity with length of stay and/or time-to-result.Table 3.: Comparing time-to-order, time-to-collection, time-to-result, and length of stay using a composite of severity (CRP >= 10, HR >= 100, diastolic blood pressure <60, or albumin <3.5). P-value for statistical significance in comparison to 1 Marker group in parentheses.

Clinical Team Distribution and Antibiotic Use Patterns at a Tertiary-Care Academic Medical Center

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (&gt;7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.Funding: NoneDisclosures: None

A Clinical Decision Support Intervention to Improve Inpatient Pediatric Influenza Vaccination

Background: Pediatric influenza vaccination rates remain &lt;50% in the United States. Children with chronic medical conditions are at higher risk of morbidity and mortality from influenza, yet most experience missed opportunities for immunization in outpatient settings. In an adult cohort study, 74% of patients who had not received the influenza vaccine before or during hospitalization remained unvaccinated through the rest of the season. Thus, inpatient settings represent another important opportunity for vaccinating an especially susceptible population. In addition, 4 published studies have shown promise in improving inpatient pediatric influenza vaccination. However, these studies had limited effect sizes and included interventions requiring ongoing maintenance with dedicated staff. In this study, we hypothesized that a clinical decision support (CDS) intervention designed with user-centered design principles would increase inpatient influenza vaccine administration rates in the 2019–2020 influenza season. Methods: We performed a workflow analysis of different care settings to determine optimal timing of influenza vaccine decision support. Through formative usability testing with frontline clinicians, we developed electronic health record (EHR) prototypes of an order set module containing a default influenza vaccine order. This module was dynamically incorporated into order sets for patients meeting the following criteria: ≥6 months old, no prior influenza vaccine in the current season in our medical system or the state immunization registry, and no prior anaphylaxis to the vaccine. We implemented the CDS into select order sets based on operational leader support. We compared the proportion of eligible hospitalized patients in which the influenza vaccine was administered between our intervention period and the 2018–2019 season (historical controls). To account for secular trends, we also compared the vaccination rates for hospitalized patients exposed to our CDS to those that were not exposed to the CDS during the intervention period (concurrent controls). Results: During the intervention period (September 5, 2019–November 1, 2019), influenza vaccine was administered to 762 of 3,242 (24%) of eligible patients, compared to 360 of 2,875 (13%) among historical controls (P &lt; .0001). Among the 42% of patients exposed to the CDS, vaccination rates were 33% compared to 9% for concurrent controls (p &lt; .0001). Our intervention was limited by end-user uptake, with some physicians or nurses discontinuing the default vaccine order. In addition, early in the intervention, some vaccines were ordered but not administered, leading to vaccine waste. Conclusions: CDS targeting eligible hospitalized patients for influenza vaccination incorporated early into the workflow of nurses and ordering clinicians can substantially improve influenza vaccination rates among this susceptible and hard-to-reach population.Funding: NoneDisclosures: None

A novel program of self-administration of medications within an acute inpatient rehabilitation unit

Introduction:Self-administration of medications (SAM) is a critical component of independent living in the face of chronic illnesses. The current local practice, where nurses manage all aspects of inpatient medication administration, has significant limitations in promoting this important activity post-discharge. Inpatient SAM is considered novel in Singapore. In this paper, we aim to describe the process of establishing a SAM program in a local rehabilitation inpatient ward.Materials and methods:In 2016, a multidisciplinary workgroup was formed in a local general hospital to develop a SAM protocol to empower participants to better self-manage their medications post-discharge through a series of graduated assessments and targeted education. The program started as a pilot in April 2017, and was eventually expanded to all rehabilitation wards within the hospital. Medication errors and near-misses were tracked, and surveys targeting participating patients and staff were given at the end of each encounter.Results:As of 31 December 2019, 160 patients were enrolled into the SAM program. Of these, 75, 63 and 22 patients were in SAM 1, SAM 2 and SAM 3 (tiers representing differing independence levels), respectively, at discharge. There were no medication errors. One near-miss was reported. The program was well-received by both patients and staff.Conclusions:We present a novel and viable protocol for the inpatient selection and assessment of patients, with the aim of supporting safe SAM post-discharge through educational empowerment and early identification of barriers with interventions.