Oncology Advanced Practice Providers Research Articles

Improving Quality and Cost of the Oncology Advanced Practice Provider Chemotherapy Privileging Process.

Managing antineoplastic orders, side effects, and symptoms is a primary role of oncology advanced practice providers (APPs). Antineoplastic management (ANM) is complex because of risk of medication errors, narrow therapeutic range of agents, frequent dose adjustments, and multiple drug regimens. This article describes an academic institution's review of current practice for ANM privileging and employing Plan-Do-Study-Act (PDSA) cycles to develop a revised process relevant to APP practice, addressing efficiency, accessibility, and cost-effectiveness. Using consecutive PDSA cycles, the team revised the didactic portion of the ANM privileging process and collaborated with nurses, pharmacists, and physicians for mentoring expertise. The revised process resulted in increased relevance of ANM didactic content while requiring 75% less time to complete. To date, all ANM-privileged APPs at the institution (N = 49) have completed the revised ANM privileging process, with a 100% pass rate on the competency assessment.

QIM24-177: Effects of a Music-Based Intervention on Reducing Compassion Fatigue in Oncology Advanced Practice Providers.

QIM24-177: Effects of a Music-Based Intervention on Reducing Compassion Fatigue in Oncology Advanced Practice Providers.

Defining the Role of the Advanced Practice Provider Within the National Cancer Institute Community Oncology Research Program.

Oncology advanced practice providers (APPs), including nurse practitioners, clinical nurse specialists, physician assistants, and clinical pharmacists, contribute significantly to quality cancer care. Understanding the research-related roles of APPs in the National Cancer Institute's (NCI) Community Oncology Research Program (NCORP) could lead to enhanced protocol development, trial conduct, and accrual. The 2022 NCORP Landscape Assessment Survey asked two questions about the utilization and roles of APPs in the NCORP. A total of 271 practice groups completed the 2022 survey, with a response rate of 90%. Of the 259 nonpediatric exclusive practice groups analyzed in this study, 92% used APPs for clinical care activities and 73% used APPs for research activities. APPs most often provided clinical care for patients enrolled in trials (97%), followed by assistance with coordination (65%), presenting/explaining clinical trials (59%), screening patients (49%), ordering investigational drugs (37%), and consenting participants (24%). Some groups reported APPs as an enrolling investigator (18%) and/or participating in institutional oversight/selection of trials (15%). Only 5% of NCORP sites reported APPs as a site primary investigator for trials, and very few (3%) reported APPs participating in protocol development. Practice groups report involving APPs in clinical research within the NCORP network; however, opportunities for growth exists. As team-based care has enhanced clinical practice in oncology, this same approach can be used to enhance successful research. Suggested strategies include supporting APP research-related time, recognition, and education. The findings of this survey and subsequent recommendations may be applied to all adult oncology practices that participate in clinical research.

Developing the Form and Content of Implementation Strategies to Prevent Venous Thromboembolism for Ambulatory Patients with Cancer

Introduction To prevent venous thromboembolism (VTE) in people with cancer, guidelines recommend risk-assessment for those receiving systemic therapy and anticoagulation (AC) prophylaxis for those at high risk of VTE. However, these recommendations are significantly underused in clinical practice. Our prior work demonstrated barriers and facilitators contributing to this underuse and identified potential implementation strategies to address these barriers. The objective of this study was to develop the form and content of targeted implementation strategies promoting the uptake in clinical practice of guideline-recommendations for VTE prevention for ambulatory patients with cancer. Methods We conducted multidisciplinary stakeholder focus group discussions and semi-structured patient interviews to iteratively design the form and content of five implementation strategies (Table 1): (1) Conduct clinician education and training on risk-assessment models and anticoagulation thromboprophylaxis; (2) Adapt electronic health records (EHR) to provide interactive assistance; (3) Develop and distribute educational materials for clinicians about the Khorana score, VTE risk, and AC counseling; (4) Develop and distribute educational materials for patients; and (5) Audit and feedback. Stakeholders included oncologists, classical hematologists, an oncology clinical pharmacist, oncology advanced practice providers, and oncology patients, in academic and community-based settings within a single health care system. We conducted the clinician focus groups iteratively: in the first session we reviewed guidelines and evidence to support the use of risk assessment and AC prophylaxis in patients with cancer and shared barriers and facilitators identified in our earlier work. During subsequent sessions, we iteratively designed the form and content of the implementation strategies. In the final session, clinicians were presented a finalized prototype of the implementation strategies and asked to perform exploratory usability testing through simulated patient care encounters. Individual semi-structured interviews were conducted with patients to obtain feedback on the design of the implementation strategies and patient-education resources. Results A workflow for integration of risk-assessment and relevant prophylaxis in clinical practice was created based on participant feedback. Details for selected implementation strategies are shown in Table 1. For EHR support, stakeholders recommended the risk-assessment component be integrated within chemotherapy order sets. In addition, they recommended incorporating aid for AC management within the EHR, including a method to assess bleeding risk, pre-populated options for AC thromboprophylaxis, provision of easily accessible links to resources for peri-operative/procedure AC management, and a list of interactions between anticoagulants and common drugs used in oncology practice. Clinician stakeholders also recommended - and subsequently approved - standard phrases available to incorporate into the EHR documentation, both to guide decision-making and to serve as a reminder to re-assess in future visits. For education resources (clinician and patient), clinicians wanted education resources to be concise, and for the patient-facing resource, to be provided to patients both in existing “chemotherapy education” booklets and sent in after-visit appointment instructions. Regarding audit and feedback, clinicians recommended a personalized report card comparing their use of appropriate VTE prevention to their peers. After reviewing the patient-facing education documents, patients recommended simpler, straightforward language and clarifications for the VTE and AC patient education resources based on their past experiences. Conclusions With multidisciplinary stakeholder input from clinicians and patients, we developed a set of implementation strategies designed to address barriers to uptake of VTE prevention recommendations in oncology clinics. Next steps are to test the implementation strategies in clinical practice to measure impact on increasing these evidence-based interventions.

The use of simulation-based learning to increase the confidence level of oncology advanced practice providers when discussing palliative care.

265 Background: The increase in cancer cases globally has dramatically strengthened the need in introducing palliative care upon a cancer diagnosis. Oncology advanced practice providers (APPs) are essential in integrating palliative care concurrently with treatment. SinceAPPs have limited to no hands-on training in palliative care, they often feel unprepared and less confident in discussing palliative care with cancer patients, resulting in a gap in care. This can result in a decreased in quality of life (QoL), absence of symptom management, increased healthcare costs and usage of healthcare resources, increased emergency room visits and hospital admissions. This quality improvement (QI) project sought to increase the confidence level of APPs, when discussing palliative care using simulation-based training in an effort to address this educational gap and provide palliative care support alongside standard of care. Methods: The project utilized a sample of 15 APPs working in an academic outpatient oncology facility. Participants completed a pre-and post-survey consisting of 12 Likert-type questions to measure their confidence level in palliative care before and after the simulation training session. Simulation-based learning with standardized participants (SPs) was utilized to increase the confidence level of APPs in the outpatient oncology setting. A pancreatic cancer patient case was utilized for the simulation. The Wilcoxon’s signed-rank test was used to compare the results of the pre and post test scores. Results: The results showed positive changes between the pre- and post-survey results in confidence level. Post-survey results were statistically significant (p value of < 0.05) and respondents reported greater confidence following the simulation-based training. Referrals also increased to palliative care post simulation. Conclusions: Palliative care simulation with SPs closed educational gaps and improved the APPs confidence levels when discussing palliative care with cancer patients. As a result, simulation-based learning is an effective strategy to train newly hired oncology APPs or enhance skill deterioration as needed to integrate palliative care concurrently with treatment as the standard for cancer patients. Furthermore, from this QI project, a computer-based module was developed for new oncology APPs onboarding to the organization. Future directions are to expand to non-oncology APPs that directly care for cancer patients.

Integration of an APP-Led Supportive and Palliative Oncology Care Program: A Quality Improvement Project

Patients with advanced cancer have been found to demonstrate severe symptoms and low quality of life at diagnosis; therefore, it is imperative that they have early access to palliative care services along the continuum of care. Oncology advanced practice providers are uniquely poised to serve as champions for primary palliative care integration within their practice. The purpose of this quality improvement project was to develop and implement an APP-led supportive and palliative oncology care (SPOC) program within routine cancer care. The project design utilized the Plan-Do-Study-Act (PDSA) methodology as the guiding framework for development, implementation, and analysis of the SPOC program. Across 49 participants, there were a total of 239 SPOC encounters during the studied period. Participants had a mean of 4.9 visits (SD = 3.5) with the APP. There was a high prevalence of patient-reported symptom burden, the most frequent of which included pain at 44 (90%), fatigue at 36 (74%), appetite loss at 29 (59%), and weakness at 27 (55%) instances. Ninety-four percent of participants (n = 46) had a structured and documented goals of care conversation with the APP during their participation within the program. A total of seven patients completed their advance directives while receiving SPOC care, which was a 25% completion rate. There was a significant demand for interdisciplinary resources (n = 136). Integration of SPOC principles into routine oncology practice is an opportunity to improve the patient and family experience while demonstrating the value of APPs at the clinical and organizational level.

Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project.

Hospitalized advanced cancer patients and their families are inadequately informed about their cancer diagnosis and prognosis, which limits educated and reasonable decision-making for their care and end-of-life planning. The primary objective of this evidence-based project was to enhance serious illness conversations (SICs) with advanced cancer patients by providing advanced practice providers (APP) training and to increase the frequency of SIC documentation in the electronic medical record (EMR). SIC training included a 45-minute Zoom video recording and 30-minute discussion groups. Advanced practice providers' beliefs and self-efficacy were measured pre- and post-training via a survey. Prior training was queried in the pre-survey. Data from APP discussion groups were summarized and themes identified. Serious illness conversation documentation frequency was measured. Pre- and post-survey differences were assessed using Wilcoxon rank sum tests. 19 inpatient medical oncology nurse practitioners and 6 physician assistants participated. Many reported little formal training yet are engaging in SICs regularly. Scores on both the belief and self-efficacy survey sections were high prior to training and did not significantly change following training. Despite the high pre-survey scores, many of the APPs verbalized the need for more training to improve their confidence and to learn SIC communication skills. Training significantly improved the APP's ability to manage their own emotions and be present. This indicates a trend toward improved APP comfort with SICs. Accessible documentation in the EMR increased with training.

Improving Physician-Patient Decision Making for Treatment of Chronic Lymphocytic Leukemia with BTK Inhibition

Educational Need Advancements in evidence-based treatment strategies with approved BTK inhibitors ibrutinib and acalabrutinib are improving survival of patients with chronic lymphocytic leukemia (CLL). These advances create knowledge and practice gaps as new BTK inhibitors are introduced to the treatment landscape for clinicians and patients. Education is needed to ensure that clinicians can apply current evidence and stratify patients appropriately. As new data emerges regarding long-term adverse events and the relevance of high-risk prognostic features in treatment selection; patient and provider education is warranted for effective integration of BTK inhibitors, evidence-based management strategies, patient understanding of the factors affecting treatment, improving patient-provider communication, and active participation in care decisions. Educational Initiative To meet educational needs, an educational initiative was conducted in August 2020 for HCP and patient/caregiver audiences. Both HCP and patient/caregiver programs feature live-virtual programming with interactive faculty panels, live audience polling, pre-education question submission and live Q&A. All education will remain on-demand for 12 months. HCP Elements The live-virtual CME program targets hematologic oncologists, hematologists, oncology advanced practice providers, oncology nurses, and other clinicians who manage patients with CLL. Faculty include two hematologists/oncologists with expertise in the management of patients with CLL. As a companion resource to the live CME program, expert clinical perspective was provided in the form of a patient decision library featuring four 15-minute cases from real patients, presented with interview vignettes and a focus on alignment with treatment recommendations. Patient/Caregiver Elements The live-virtual patient and caregiver directed program features a three-person panel, including one hematologist/oncologist, one hematology/oncology nurse practitioner, and one CLL patient. The initiative was conducted in partnership with the CLL Society. The full program will be featured online and will be additionally distributed in smaller chapters on social media, including Facebook and YouTube. Patients will also be invited to engage in the patient decision library to hear the stories of the four patients and the expert commentary on treatment decision-making. Methods and Anticipated Results Educational impact evaluation data will be collected through a series of surveys administered to learners prior to and following the educational programs. For the HCP program, questions will be designed to evaluate the effects of learner participation on change in knowledge, competence, and clinical practice behavior parameters. For the patient/caregiver program, questions will be designed to evaluate the effects of participation on change in knowledge, empowerment, and health-related behaviors. Impact, engagement, and attendance data to date will be reported. Some engagement statistics include total learners, target audience learners, average time in session, total in-session polling responses, question count, and total slide downloads. Impact data will be specifically gathered through an activity pretest, posttest (immediately following activity), and a 2-month follow-up posttest. The 2-month follow-up posttest has a strong focus on behavioral impact of the education and will be composed of open- and closed-ended questions. Open-ended qualitative responses will be grouped by theme. McNemar testing will be conducted on responses to knowledge and competence questions that are repeated at 3 timepoints (pre/post/follow-up) to assess statistical significance; effect size (Cohen's D) will also be reported for these questions. Disclosures Davids: TG Therapeutics: Consultancy, Research Funding; Verastem: Consultancy, Research Funding; MEI Pharma: Consultancy, Research Funding; Surface Oncology: Research Funding; AstraZeneca: Consultancy, Research Funding; Ascentage Pharma: Consultancy, Research Funding; Adaptive Biotechnologies: Consultancy; AbbVie: Consultancy; Pharmacyclics: Consultancy, Research Funding; Gilead Sciences: Consultancy; Novartis: Consultancy, Research Funding; BeiGene: Consultancy; Celgene: Consultancy; Eli Lilly: Consultancy; Genentech: Consultancy, Research Funding; Janssen: Consultancy; Bristol Myers Squibb: Research Funding; Merck: Consultancy; Research to Practice: Honoraria; Syros Pharmaceuticals: Consultancy; Zentalis: Consultancy; Sunesis: Consultancy. Mato:AstraZeneca: Consultancy, Research Funding; TG Therapeutics: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Loxo: Consultancy, Research Funding; Adaptive: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Janssen: Consultancy, Research Funding. Koffman:Astra Zeneca: Speakers Bureau; Miragen Therapeutics Inc: Current equity holder in publicly-traded company; Astra Zeneca: Current equity holder in publicly-traded company; Iovance Biotherapeutics: Current equity holder in publicly-traded company; Synairgen Plc: Current equity holder in publicly-traded company; Pfizer: Current equity holder in publicly-traded company; Oncternal Therapeutics Inc: Current equity holder in publicly-traded company; BeiGene: Current equity holder in publicly-traded company; TG Therapeutics: Speakers Bureau; Humanigen: Current equity holder in publicly-traded company; Bristol-Myers Squib: Speakers Bureau; MEI Pharma: Current equity holder in publicly-traded company; Bristol-Myers Squibb: Current equity holder in publicly-traded company; Sunesis Pharmaceuticals: Current equity holder in publicly-traded company; Abbvie: Current equity holder in publicly-traded company; Johnson & Johnson: Current equity holder in publicly-traded company; Verastem Oncology: Current equity holder in publicly-traded company; Inovio Pharmaceuticals Inc: Current equity holder in publicly-traded company.

A survey of oncology advanced practice providers' knowledge and attitudes towards sexual and gender minorities with cancer.

To evaluate the knowledge and attitudes towards sexual and gender minority (SGM) oncology patients' needs among advanced practice providers (APPs). SGM individuals experience health disparities, in part due to lack of access to knowledgeable providers. Despite the important role of APPs in cancer care, less is known about their attitudes and knowledge towards SGM cancer patients. Cross-sectional study. A survey of APPs at a National Cancer Institute-Designated Comprehensive Cancer Center assessed self-reported demographics, attitudes, knowledge and postsurvey confidence in knowledge of SGM oncology patient needs. Reporting of this study adheres to STROBE guidelines. Knowledge of health needs was low with an average of 2.56 (SD=1.27) items answered correctly out of 6. The majority of APPs self-reported being comfortable treating SGM patients (93.6% and 87.2%, respectively), but less confident in knowledge of their health needs (68.0% and 53.8%, respectively). Although less than half of APPs believed education should be mandatory (44.9%), 79.5% were interested in education about SGMs' unique health needs. Political affiliation, medical specialty, licensure, and having SGM friends or family were associated with various attitude items, but not knowledge. Moderation analyses indicated that APPs who had greater overall knowledge scores were more likely to agree, on average, that knowing sexual orientation, gender identity and sex assigned at birth are important to providing quality oncology care. APPs report being comfortable providing care for SGMs with cancer, but knowledge gaps remain that may inhibit the quality of care provided. Given the interest in education, results would support the development of SGM-related healthcare training for oncology APPs. Targeted education for providers during training and continuing education is likely to improve the provision of quality care for SGMs with cancer.

166 Attitudes, Practices, and Barriers to Sexual Health Assessments of Patients Amongst Practicing Oncologists: Survey Data from a Group of Local Oncology Healthcare Providers

Despite the endorsement by national survivorship guidelines, sexual health is infrequently discussed among cancer providers and cancer survivors.1,2 Previous studies evaluating this subject are limited and lack consistency in the attitudes and practice patterns among Oncologists and advanced practice providers (APPs) toward discussing sexuality with their patients.3 The goal of our study was to assess how often practicing oncologists, their nurse practitioners, and their physician assistants are discussing sexual health issues with their cancer patients. We also evaluated how comfortable providers are discussing sexual health, whether they have received formal didactic training in various sexual health issues, and the barriers that they believe prevent them from discussing their sexual health with their patients. We distributed the 18-item, validated Sexual Health Attitudes Questionnaire to 88 practicing Oncologists and Oncology APPs in our geographic region by email. The instrument evaluates: attitudes towards sexuality, education, and barriers to discussion of sexual health with Oncology patients. Stata IC was used for statistical analysis.

Cross training of APPs on inpatient oncology units as a safe and cost-effective model.

56 Background: Oncology Advanced Practice Providers (APPs) have not been optimally trained to care for each other’s sub specialty of patients. In times of high census and/or short staffing, inpatient APPs are left to care for and manage high volumes of acutely ill patients. This is concerning for patient safety, burning out as well as dissatisfactions when vacation and meetings are denied because there is no backup coverage available. Methods: In order to minimize the use of overtime pay, physician moonlighting pay and additional positions in times of short staffing, we proposed to cross train experienced APPs to see if the staffing needs could be met. The disease groups consisted of transplant, leukemia and lymphoma. Each disease group has a lead APP involved in the strategic planning and implementation process. They were instrumental in working through and identifying risks and benefits of this training plan and were the first to be trained, as to lead by example. Buy in from APPs was achieved by promoting the flexibility of scheduling that would result from having more coverage. Some were also motivated to add to their skill set by learning how to care for a new disease group. Results: The APPs felt comfortable taking patients after around 2 training shifts. They felt the patients were more alike than different and the workflow for most job duties were identical, and enjoyed working with fellow oncology APPs they hadn’t interacted much with. Cross training was proposed to add a financial benefit to our institution. Key metrics we monitored were productivity and supplemental pay. The financial savings from avoiding supplemental overtime or fellow moonlighting wages for 2018 was $8,540, and $14,640 for quarter1 2019. The APPs had no decrease in productivity to date, and no decrease in quality metrics and no adverse events related. Conclusions: Cross training as a means to reduce short staffing financial burdens while advancing the scope of practice of APPs is a safe and possible alternative to adding positions, or paying overtime/moonlighting pay. Training of cross covering APPs was not overall a major constraint. Buy-in from leadership as well as APPs is instrumental in not only initiating a cross training program, but maintaining it as well.

Diversity Awareness and Documentation Practices Among Oncology Advanced Practice Providers.

Advanced practice providers (APPs) care for widely diverse populations. The Institute of Medicine (IOM) states that bias, prejudice, and stereotyping by a health-care provider may contribute to disparities, which are associated with worse outcomes. The IOM called for efforts to increase awareness among health-care providers. The objective of this study is to assess the cultural self-awareness of oncology APPs who practice in a community-based outpatient cancer center and investigate the extent to which APPs include cultural care into patient assessments and document this data. Oncology APPs completed a questionnaire evaluating cultural self-awareness. A prospective, quality improvement chart review was performed to analyze the extent to which cultural themes were addressed during oncology clinic visits. A list of cultural keywords was used as a guide. About 10% of the 2015 cancer population at the institution was examined, which included a stratified sample of the top six disease groups. Responses were analyzed. All APPs demonstrated average or above-average cultural awareness. Documentation of cultural assessment was low. Of the 28 cultural keyword items, an average of 4.88 items were addressed during each visit. Multiple cultural items, including literacy, language, insurance status, and belief about the disease were addressed less than 5% of the time.

Meeting the Challenge of Immune-Related Adverse Events With Optimized Telephone Triage and Dedicated Oncology Acute Care.

Immune checkpoint inhibitors (ICIs) have improved outcomes for many patients with advanced cancers. However, managing the immune-related adverse events (irAEs) associated with these agents is challenging. Late recognition and/or inadequate irAE management can result in ICI discontinuation or termination, negatively impacting patient outcomes and increasing unplanned emergency department visits, hospital admissions, and costs of care. Improved clinician training and infrastructure development are needed to adequately address irAEs and maximize the potential benefits of ICIs. Advanced practice providers (APPs) are well positioned to drive these improvements. Two aspects of care may reduce the burden of irAE management: improved telephone triage and the implementation of dedicated oncology acute care services. Evidence-based protocols should be used for telephone triage. Protocol development may benefit from an evaluation of current irAE management guidelines together with resources from the Melanoma Nursing Initiative and Immuno-Oncology Essentials. Patients and their caregivers must be educated to recognize and report early symptoms suggestive of an irAE, thereby supporting triage efforts. Advanced practice providers should also advocate for the development of dedicated oncology acute care facilities staffed with clinicians well trained to recognize, grade, and manage irAEs. This manuscript reviews multiple existing models of telephone triage and dedicated oncology acute care. Oncology APPs are poised to lead the staffing, infrastructure, and educational changes necessary to reduce the burden of irAEs in patients receiving ICI therapy.

Evidence-Based Oncology Practice: Competencies for Improved Patient Outcomes

Oncology advanced practice providers (APP) play a critical role in providing cancer care to patients and families. Given the rate of scientific advancement, APPs are challenged to keep with the pace of science and acquire tools for successful practice. One such tool is evidence-based practice (EBP). Mastery of the competencies is obligatory and will assist APPs with the incorporation of EBP into clinical practice, and thus ensure the highest quality of patient care, forge the best patient outcomes, and reduce health-care expenditures. Advanced practice providers who achieve competency and proficiency have a professional responsibility to mentor others and assume leadership roles to help cement EBP as the standard of care.

Potential of Biosimilars to Increase Access to Biologics: Considerations for Advanced Practice Providers in Oncology

Biosimilars are biologic products that are highly similar, but not identical, to a licensed reference (or "originator") biologic product. These agents have the potential to provide efficiencies and improve access to treatment for patients. Biosimilars are currently available for use in clinical practice, including oncology indications, and several more are in clinical development. Due to several key differences in their fundamental properties, production and manufacturing of biosimilars is more complex compared with that of small-molecule generic drugs. Accordingly, the generic drug approval process is not suitable or transferable to biosimilars, the approval of which involves extensive and thorough comparison with the originator biologic. Advanced practice providers play an important role in evaluating treatment options available to patients, prescribing, patient education, and product monitoring. In order to perform these tasks effectively, advanced practice providers should understand the concepts related to biosimilars in clinical practice, particularly regarding extrapolation to other indications, product labeling, interchangeability between products, and routine pharmacovigilance, among other clinical considerations. However, many health-care providers have limited awareness and minimal experience regarding biosimilars. Thus, the purpose of this review is to provide an overview of biosimilars and discuss the clinical considerations for oncology advanced practice providers concerning these therapies.

Management of Advanced Bladder Cancer: An Update

Bladder cancer is the sixth most common cancer in the United States; therefore, the majority of clinicians working in the oncology setting will care for this patient population. Unfortunately, treatment plans, especially in the advanced setting, lack consistency. This, along with the advanced age and comorbidities of most bladder cancer patients, can provide challenges for clinicians when developing treatment plans. In the past 2 years, new drug approvals, specifically those for immune checkpoint inhibitors, have changed the treatment landscape for bladder cancer for the first time since the 1980s. This review article outlines the current management for muscle-invasive and metastatic bladder cancer, while also highlighting future considerations in this disease space. It is imperative that oncology advanced practice providers are up to date with these new changes and have a sound understanding of treatment principles for patients with advanced bladder cancer in order to deliver the safest and most effective care.

Abstract 15: The Use of Handheld Focused Cardiac Ultrasound (FoCUS) for EF Assessment at Parkland Memorial Hospital: A Quality Improvement Initiative With Novel Applications for Clinical Outcomes

Background: Focused cardiac ultrasound (FCU) has been used to answer clinical questions. Chemotherapy-related cardiotoxicity (CRR) is an entity that requires serial echocardiography. It is unknown whether FCU can be used to screen for CRR using advanced practice providers (APPs). The goal of this study is to determine if FCU can be used to reliably evaluate left ventricular ejection fraction (EF) by an APP to assess for CRR. Methods: The study was conducted at the Echo lab and the Oncology clinic. An Oncology APP was trained on the use of FCU and EF analysis. The APP was trained to obtained standard 2D views for EF assessment and on EF interpretation. The EF assessment was compared to sonographer echocardiogram on the same day. EF was assessed by a cardiologist and this was deemed to be the gold standard. The studies were all analyzed by two separate blinded cardiologists and the degree of correlation was analyzed. Linear regression modeling to analyze correlation between EF interpretation between all blinded observers and Bland Altman analysis was performed. Image quality was evaluated for all FCU images by a single blinded cardiologist and segmental endocardial border delineation was scored. Results: A total of 91 patients were scanned in Phase I of the study. The correlation coefficient between cardiologists was r=0.93. The correlation between cardiologist and APP were r=0.79 and 0.76 respectively. For the images obtained by the APP, the correlation between the APP and cardiologists were =0.83 and re=0.78. The correlation between APP and EF gold standard was r=0.77. The correlation between experienced cardiologists interpreting the FCU images was r=0.87. All images were determined to be interpretable. Conclusions: There was good correlation between cardiologists with respect to EF analysis. There was also good correlation between APP and cardiologists for EF analysis. Image quality from FCU was found to be good and acceptable for interpretation. This study demonstrates it is feasible to train an APP on obtaining images for EF analysis and they can be trained on EF interpretation with good correlation with experienced echocardiographers. We will evaluate outcomes associated with its use including delays to chemotherapy imposed by traditional echocardiography, cost to the health care system and patient-reported outcomes.

Applying Metrics to Outpatient Oncology Advanced Practice Providers

Applying Metrics to Outpatient Oncology Advanced Practice Providers