Outpatient Program Research Articles

A pilot study of trauma-sensitive yoga and Breathe2Relax among service members in an intensive outpatient program

ABSTRACT Emerging research indicates that yoga is a promising adjunct to psychological trauma treatment. The current pilot study examined the associations between psychophysiological stress, diaphragmatic breathing (DB), and a trauma-sensitive yoga (TSY) regimen developed specifically for trauma-exposed service members in alignment with recent calls for precision in reporting therapeutic yoga protocols. Participants were 31 service members enrolled in a trauma-focused intensive outpatient program (IOP). Service members participated in a brief diaphragmatic breathing (DB) session using the Breathe2Relax (B2R) app followed by the TSY session. Heart rate (HR) and perceived stress were measured at baseline and after both the DB practice and the TSY session. We assessed Yoga and DB expectancies at baseline and post TSY. Participants also rated the acceptability and usability of the B2R app. Results of linear mixed effects regression models showed decreases in HR and perceived stress, compared to baseline, following DB (HR, b = −8.68, CI 95% = −13.34, −4.02; perceived stress, b = −1.77, CI 95% = −2.35, −1.18) and TSY (HR, b = −12.44, CI 95% = −17.15, −7.73; perceived stress b = −3.69, CI 95% = −4.29, −3.08). Higher levels of expectancies, compared to lower levels, related to stronger decreases in HR and perceived stress, particularly after TSY. Overall, participants rated the B2R usability as high; virtually all participants reported that “most would learn to use the app quickly,” and 76.6% reported that they would use it frequently.

Implementation of telehealth and hybrid service delivery of interdisciplinary rehabilitation for military populations withtraumatic brain injury.

The COVID-19 pandemic necessitated the implementation of telehealth and hybrid service delivery models and provided an opportunity to study the impact of this care model in military populations with history of traumatic brain injury (TBI). To present telehealth service utilization rates across rehabilitation specialties, treatment outcome indicators, and patient satisfaction outcomes from a retrospective clinical sample. The study sample consists of 34 patients who underwent telehealth/hybrid Intensive Outpatient Programming (IOP) at a major rehabilitation hospital. Retrospective chart review and clinical data extraction were performed. A historical cohort receiving in-person care was used as a comparison group. Statistical analyses included partial correlations, mixed method analysis of variance (ANOVA), and independent sample t-tests. Medical, behavioral health, physical, occupational, and speech-language therapy providers exhibited similar rates of telehealth service delivery (35 to 41% of all sessions). No significant association was found between percent telehealth sessions and the global treatment outcome indicator. Comparison of treatment effects across cohorts revealed similar benefits of IOP. No between-group differences were noted in satisfaction ratings. The comparable treatment-related gains and reports of positive patient experience support the use of a telehealth and hybrid delivery model for military service members and veterans with TBI.

Low-load blood flow restriction strength training in patients with COPD: a randomised single-blind pilot study

ObjectiveThe objective of this study is to compare the effectiveness of lower limb low-load blood flow restriction training (LL-BFRT) with high-load strength training (HL-ST) as part of an outpatient pulmonary...

Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms

Objective Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are costly and highly co-occurring diagnoses, particularly among veterans, suggesting a need to understand this comorbidity and effectively treat both disorders among this population. Methods The current study aimed to examine substance use outcomes among post-9/11 veterans and service members (N = 48) who completed a two-week intensive outpatient program with concurrent treatment for and PTSD using Prolonged Exposure and substance use. Substance use was assessed at two weeks and three months posttreatment. Results The intensive program had high completion rates and demonstrated decreases in substance use at two weeks and three months posttreatment. Additionally, lower PTSD symptoms at treatment completion were related to less substance use posttreatment. Conclusions Concurrent intensive treatment of PTSD and SUDs can lead to symptom improvement in a short period of time. Findings support the self-medication model, such that PTSD symptoms at treatment completion were related to substance use at follow-up.

Social Support and Associated Factors Among Men and Women in Pre-COVID Substance Use Treatment.

Low levels of social support are related to negative health outcomes, representing further obstacles to recovery from substance use disorder (SUD). This study examined relationships among stressors, symptoms and social support in 124 women and 102 men engaged in two outpatient public sector substance use treatment programs. Multiple linear regression analyses were utilized to assess relationships between variables of interest and social support. Men reported significantly lower social support than women. Food insecurity was associated with lower social support for men (β= -13.6 [95% CI -26.7, -0.4], p = 0.04). When examining emotional support and tangible aid, victimization history was related to lower support (both types) for women while food insecurity was associated with lower support (both types) for men. Depression was related to lower emotional support among both men and women. Substance use treatment programs should explicitly target social support and related stressors to facilitate recovery for the individuals they serve.

Pharmacotherapy for attention deficit/hyperactivity disorder in youth with avoidant restrictive food intake disorder: a case series of patients prescribed stimulant medication in a partial hospitalization program for eating disorders

BackgroundAppetite suppression and weight loss are established potential side effects of most medications for attention deficit/hyperactivity disorder (ADHD). These side effects may be especially problematic when using stimulants to treat ADHD in the context of a restrictive eating disorder, such as avoidant restrictive food intake disorder (ARFID), although these diagnoses are often comorbid in children. This paper presents a combined approach to treating ADHD comorbid with ARFID using stimulant medication and behavior management within a partial hospitalization program (PHP) and intensive outpatient program (IOP)for eating disorders. The aim of this paper is to determine if the continued or new use of stimulant medication allows for adequate weight restoration by reviewing a series of cases receiving the combined treatment.Case presentationsConsecutive patients with a historical or new diagnosis of ADHD when presenting for treatment for ARFID were included in this case series. This series included 10 patients (8 male, 2 female) who received pharmacotherapy using stimulants and behavior management interventions involving structured mealtimes and contingency management. All treatment occurred within the context of a PHP/IOP for childhood eating disorders. All youth were able to effectively continue on stimulant medication, show clinical benefit in core ADHD symptoms, and able to gradually restore weight. In all cases, stimulant medications were not discontinued, but in some cases, doses were optimized (increased or decreased), switched to a different stimulant, or augmented with non-ADHD medication, such as mirtazapine, to support the management of ADHD while concurrently assisting in weight gain as necessary for the treatment of ARFID. Only one patient was newly started on a stimulant medication; as this was near the end of her treatment stay, limited conclusions can be drawn from this case.ConclusionsThese findings support the use of pharmacotherapy, including continuing stimulant medication, when combined with behavior management strategies as a potentially effective treatment approach for ADHD in youth with ARFID in the PHP/IOP setting. Future studies using more rigorous methodology, longer follow-up times, and within other treatment settings are needed.

Routine outcomes and evaluation of an 8-week outpatient multidisciplinary rehabilitative therapy program for functional neurological disorder

ObjectivesWe report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND).MethodsThe program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman’s ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up).ResultsAnalyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up.DiscussionThis outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures.

Clinical stakeholders' perceptions of patient engagement in outpatient medication treatment for opioid use disorder: A qualitative study

IntroductionMedications for opioid use disorder (MOUD) reduce risk of opioid overdose and promote recovery from opioid use disorder, but poor retention in MOUD limits these positive effects. This study explored patient engagement in MOUD from the perspective of clinical stakeholders within an outpatient addiction medicine program to identify program factors influencing patient engagement with treatment. MethodsWe conducted a qualitative case study of a multi-clinic outpatient addiction medicine program embedded within an integrated health system that serves a geographically diverse area of Pennsylvania. Collectively, the program's clinics provide MOUD (primarily buprenorphine) to ~2000 patients annually. From January to March 2021, we conducted semi-structured telephone/video interviews with three stakeholder groups involved in delivering MOUD: administrators (n = 4), providers (n = 7), and addiction care coordinators (n = 5). Data analysis utilized the framework method. ResultsWe identified five themes related to patient engagement. First, participants described health system integration as enhancing quality and offering opportunities for addressing patients' comprehensive health care needs. However, lack of knowledge about addiction and stigma among health system providers was felt to limit patient benefits from this integration, including access to MOUD. Second, participants viewed patient engagement as central to the program's policies, practices, and clinical environment. Adoption of a harm reduction approach and maintenance of a non-stigmatizing clinic environment were described as essential facilitators of engagement. Third, while clinics followed uniform operations, physician leads expressed differing philosophical approaches to treatment, which participants associated with variations in clinical practice and patient engagement. Fourth, participants identified key services that bolstered engagement in MOUD, including psychosocial services, psychiatric care, and telemedicine. Finally, staff well-being emerged as a key consideration for patient engagement. ConclusionsUnderstanding perceptions of those who administer and deliver care is critical for identifying barriers and facilitators to patient engagement in MOUD. Findings suggest potential opportunities for addiction treatment programs to improve patient engagement and ultimately MOUD retention, including integration with other healthcare services to meet comprehensive healthcare needs; adoption of a harm reduction approach; creation of non-stigmatizing clinical environments; investment in psychosocial services, psychiatric care, and telemedicine; and prioritization of staff wellness.

Is that a treatment program? Examining the physical landscape of opioid treatment programs in Los Angeles

IntroductionLittle attention has been paid to the built environment of outpatient opioid treatment programs, despite the need to increase access to medications for opioid use disorder, particularly among people of color. The aims of this study were to rate the attractiveness of publicly-funded opioid treatment programs (OTPs) in Los Angeles County and explore whether less attractive OTPs are found in disadvantaged neighborhoods. MethodsWe conducted observations of the exteriors of all OTPs located in specialty substance use disorder treatment clinics in Los Angeles County in 2021 (N = 44). We created an attractiveness index based on attractiveness of the building exteriors and the surrounding grounds, the presence of disorder such as garbage and graffiti, and the presence of bars on the windows. We tested whether less attractive facilities were more likely to be situated in disadvantaged neighborhoods with high concentrations of racial/ethnic minorities. ResultsMost building exteriors were found to have an ordinary level of attractiveness or rated as unattractive. The grounds were largely unattractive. We found a significant negative association between attractiveness and neighborhood disadvantage. ConclusionThis project was a preliminary study of the physical conditions of OTPs in Los Angeles. We found was that the physical conditions of OTPs in LA County were generally poor. Research has identified many individual and structural barriers to treatment for people with opioid use disorders. Future research should empirically test the association between the built environment of treatment clinics and access to treatment, particularly in communities of color.

Evidence-based treatment for posttraumatic stress disorder decreases suicidal ideation by reducing perceived burdensomeness among veterans in an outpatient program.

Evidenced-based posttraumatic stress disorder (PTSD) treatments generally reduce suicidal ideation (SI), and the interpersonal theory of suicide (ITS) may theoretically account for this finding. The ITS posits that SI stems from feeling like a burden (i.e., perceived burdensomeness) and a lack of belonging (i.e., thwarted belongingness). Previous research suggests that change in PTSD severity has a significant indirect effect on change in SI through changes in perceived burdensomeness, but not thwarted belongingness, among patients receiving residential PTSD treatment in a Veterans Affairs (VA) medical center; however, no research has investigated these associations in an outpatient VA setting with fewer confounding factors that might affect ITS constructs. Therefore, the current sample included veterans (N = 126) who completed PTSD treatment and pre- and posttreatment assessments in a VA outpatient clinic. Results from parallel models of multiple indirect effects suggest that change in PTSD severity was indirectly associated with change in SI through changes in perceived burdensomeness, B = 0.35, p < .001; β = .36, p < .001, SE = .10, 95% CI [.15, .54], but not thwarted belongingness, B = 0.14, p = .146; β = .14, p = .161, SE = .10, 95% CI [-.05, .33]. Additional models were examined using PTSD cluster scores for exploratory purposes. The results indicate that PTSD treatment reduces the perceived and objective burden of PTSD to decrease SI. Study findings support the importance of access to evidence-based care to treat PTSD and alleviate burdensomeness for suicide prevention.

Identification of Persons Living with Dementia Using the Electronic Health Record

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) are underdiagnosed in the primary care setting. Proactive screening for cognitive impairment and subsequent evaluation and diagnosis of patients who screen positive are not routinely and reliably performed. As a result, identification of persons living with dementia (PLWD) for enrollment in clinical programs, clinical trials, and research studies can be challenging. The electronic health record (EHR) represents a potentially viable tool to efficiently and accurate identify PLWD.MethodsIn a large academic health care system in the U.S., we performed an EPIC EHR search for PLWD with the intent of enrolling them in an outpatient dementia care management program. The EHR algorithm used the following criteria for dementia: (1) an ICD‐10 dementia diagnosis in the problem list or past medical history or (2) an FDA‐approved drug on their active medication list. We performed chart review for patients who were identified to have potential dementia using this algorithm to confirm dementia diagnosis is documented in clinical notes.ResultsA total of 985 patients were identified by EHR criteria as potentially having dementia. After chart review, 747 (75.8%) were confirmed to have dementia documented in their clinical history and progress notes. One hundred thirty (13.2%) did not have a confirmed dementia diagnosis, 58 (5.9%) had an incomplete dementia evaluation, and 50 (5.0%) had only mild cognitive impairment. In addition, 55 (5.6%) were deceased.ConclusionWe found that an EHR algorithm can identify patients with dementia in a health plan population. This model may be a useful tool for a focused recruitment of potential participants in clinical trials, research studies, and clinical programs.

Preliminary Investigation of the Influence of Treatment Regimen on Outcomes in Behavioral Parent Training

Caregiver engagement and implementation of behavioral strategies are essential to effective interventions targeting childhood behavior problems. The aim of this preliminary investigation was to better understand caregiver decision-making when selecting different treatment regimens in an open trial format. Treatment packages included: (1) an intensive treatment program (ITP), involving a compressed 20-hour intervention occurring 2 hours per day for 10 days; and (2) a standard dosage treatment as usual (TAU) behavioral treatment program, involving weekly 50-minute appointments. Sixty-seven families with a child between 4–11 years old (M age = 5.82) with clinically significant problem behaviors self-referred to a hospital-based outpatient behavior therapy program. Results suggest that while caregivers chose a standard treatment regimen at a ratio of 2:1, compressed treatment (ITP) was associated with increased caregiver engagement and more significant reductions in child target behavior using both direct and indirect measures. Findings provide preliminary support for the use of high dosage treatment regimens as a means of increasing caregiver engagement and in the reduction of problem behavior in young children.

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study

BackgroundHypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl−) and mortality in incident chronic hemodialysis (HD) patients. MethodRetrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan–Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. ResultsDuring the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl− and interdialytic weight gain (r=−0.15) (p=0.0038). Patients belonging to the quartile with lower Cl− levels had less probability of survival than patients in the quartile with higher Cl− levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl− levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77–0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83–0.97; p<0.0057). ConclusionsLower Cl− levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

A Community-Engaged Process for Adapting a Cardiovascular Health Intervention for Persons with Serious Mental Illness.

People with serious mental illness experience grave disparities in cardiovascular disease risk factors. To promote scale-up of effective cardiovascular disease risk reduction interventions from clinical trials, it is important to involve end-users in adapting interventions to fit the needs of community-based settings. We describe a novel, theory-informed process of garnering community input to adapt IDEAL Goals, an evidence-based intervention for improving cardiovascular disease risk factors in persons with serious mental illness. Outpatient community mental health programs in Maryland and Michigan implementing behavioral health homes, which provide enhanced support to people living with both physical and mental illnesses. Clinicians, frontline staff, and administrators from community mental health organizations and persons with serious mental illness. Our approach to community engagement is based on the Replicating Effective Programs (REP) framework. During the REP preimplementation phase, we used 2 community engagement activities: (1) a "needs assessment" to identify anticipated implementation barriers and facilitators, and (2) "community working groups" to collaboratively engage with end-users in adapting the intervention and implementation strategies. We used the Stakeholder Engagement Reporting Questionnaire to describe our processes for conducting a needs assessment, involving site-level surveys (N=26) and individual interviews (N=94), and convening a series of community working groups with clinicians and staff (mean, 24 per meeting) and persons with serious mental illness (mean, 8 per meeting). By specifying the nature and extent of our community engagement activities, we aim to contribute to the evidence base of how to better integrate and measure community-engaged processes in the adaptation of evidence-based interventions.

Employment outcome among cardiac patients following phase two intensive outpatient cardiac rehabilitation program in Sarawak Heart Centre

Employment outcome among cardiac patients following phase two intensive outpatient cardiac rehabilitation program in Sarawak Heart Centre

Preliminary feasibility, acceptability, and effectiveness of a pilot telehealth-based intensive outpatient program incorporating acceptance and commitment therapy for adolescents with obsessive compulsive disorder

Pediatric obsessive compulsive disorder (OCD) is a significantly impairing disorder. Given the impact of pediatric OCD, it is important to consider how to best adapt treatments for OCD, particularly for more severe youth that may not respond to traditional outpatient formats. Understanding how to implement such treatments via telehealth can improve access to care and reduce treatment burden on families. The current study therefore evaluates preliminary feasibility, acceptability, and effectiveness of delivering a pilot intensive, group-based telehealth treatment combining acceptance-based skills with exposure and response prevention (ERP) for pediatric OCD. Participants (N = 25) received two to 3 h of individual, family, and/or group treatment per day, four days per week, for a total of 10 h of treatment per week. Following the intensive outpatient program (IOP), adolescents reported large decreases in OCD symptoms, and small to large decreases in anxiety and depression. Parents reported similar outcomes, with small to large improvements in the impact of OCD on their child, anxiety, and familial accommodation. This pilot study thereby presents promising results and adds to the growing evidence base of acceptance-based interventions for adolescents with OCD, anxiety, and other mental health concerns.

Outpatient Management of Sickle Cell Vaso-Occlusive Crisis As a Strategy of Decreasing Emergency Department Visits

Background: Complications of sickle cell disease (SCD), including vaso-occlusive crises (VOC), usually require emergency room visits or even hospitalization for management. Outpatient treatment programs have been developed for management of VOC, however the literature is limited as to the efficacy of these models. Previously, patients in Edmonton, Canada followed by the Hemoglobinopathy Clinic would have to present to the emergency department (ED) for assessment of and management of VOC. Since 2019, patients experiencing early VOC symptoms were able to present to the Medical Outpatient Unit (MOU), an infusion clinic shared with other benign and malignant hematology conditions, to be assessed and receive treatment. This study retrospectively evaluated the outcomes of this treatment strategy. Hypothesis: Outpatient management of VOC is an effective way to assess patients and provide appropriate treatment, thereby reducing the frequency of ED presentations for SCD patients. Methods: Patients were able to schedule their own appointments and were encouraged to present early before they developed severe symptoms. They would be assessed by a nurse, who could then release orders from their personalized pain plan, which is a standing set of orders from an SCD clinic physician. Examples of orders include intravenous fluids and pain medications. Based on the severity of symptoms, patients could also be referred to the ED or for assessment by a physician or nurse practitioner. Chart review of patients aged 18 years or older with SCD followed by the Edmonton Hemoglobinopathy Clinic and who presented to MOU from November 2019 to December 2022 for management of VOC was completed. Information gathered included if the patient was on hydroxyurea at the time, investigations ordered, treatments administered, if NP or physician assessment was required, and disposition following the encounter. Encounters within 7 days were counted as one episode and assumed to be the same VOC event. Visits to ED for this cohort were counted and compared to the number of ED visits from 2016 to 2018. Results: 26 SCD patients had at least one MOU encounter for VOC or prophylaxis resulting in a total of 136 encounters (median 2, maximum 25). These accounted for 96 separate episodes of VOC (median 2, maximum 19), with a median of 1 encounter to MOU per episode (maximum 5). Patient demographics had a mean age of 32 years as of the beginning of the study (maximum 65, minimum 16) with 14 males (54%) and 12 females (46%). Patient diagnoses included 10 with HbSS (38%), 12 with HbSC (46%), 3 with HbSD (12%), and 1 with HbSB° (4%). 21 of 26 patients (81%) were on hydroxyurea at some point during this time period. IV fluids were administered in 129 encounters (95%), and pain medications were given in 64 encounters (47%), with opioid medications being given in 24 encounters (18%). 109 encounters had assessment by a nurse only (80%), while 24 were also assessed by a nurse practitioner (18%) and only 3 required assessment by a physician (2%). Patients were discharged home in 134 of 136 encounters (99%), with only 2 encounters resulting in assessment in ED. 70 of 96 episodes of VOC treated in MOU did not have presentation to ED within 30 days (73%). Total ED visits for this cohort decreased from 59 in 2016-2018 to 38 during the time of this study. Conclusion: Treatment of VOC in an outpatient setting was effective for assessment and treatment and decreased ED visits in our cohort. While retrospective, these results suggest outpatient treatment of VOC can be completed safely and efficiently in a shared infusion unit and may be generalized to other centres with outpatient IV infusion programs.

Trends in Access to Cellular Therapies in Multiple Myeloma (TACTUM): Perspectives of Treating Versus Referring Physicians

Introduction: Approved BCMA-directed cellular therapies (BDCT) for multiple myeloma (MM) include chimeric antigen receptor T cell therapies (CART): idecabtagene vicleucel (ide-cel), ciltacabtagene autoleucel (cilta-cel), and T cell engagers (TCE) such as teclistamab (tec). Despite promising efficacy and safety profiles, limited access is a challenge since the first BDCT approval in 2021. We conducted this TACTUM-23 survey to gain insights into the practices and perspectives of oncologists from BDCT-referring and treating centers and identify potential areas of improvement. Methods: The cross-sectional survey was developed with input from BDCT-prescribing oncologists, referring oncologists, and a biostatistician. “ BDCT centers” were centers administering BDCT and included “CART-centers” and TCE-Centers“ where these respective therapies were administered, while others were grouped as ”BDCT-referring centers“ including ”CART/ TCE- referring centers“. Three sections were included: demographics, choice of BDCT in real-world scenarios, and logistical barriers to managing adverse effects at referring centers. The survey was administered electronically from 6/16/23-6/27/23 to a diverse sample of practicing US oncologists from various medical institutions collaborating with USMIRC. Only those who completed 100% of the survey by 7/1/23 were included in the interim analysis. Results: The survey was distributed to 247 oncologists of which 66 (27%) responses were recorded. 37(15%) completed 100% of the survey and were included in this analysis. 73% of oncologists were from academic institutions, and 54% treated plasma cell disorders only. Most oncologists (70%) were from CART-centers. Similarly, most (81%) were from TCE-centers. 11% of centers offered only TCE and not CART while none exclusively offered CART alone. Among CART-centers, 54% offered both approved therapies (ide-cel/cilta-cel). Oncologists practiced in the Midwest (43%), South (22%), West (19%), and Northeast (16%). Choice of BDCT in Real-World Scenarios: TCE was the favored BDCT for patients meeting criteria but with either significant comorbidity, renal failure, poor performance status, mild cognitive impairment, age &amp;gt;75yr, rapidly progressive disease, or post-CART relapse. CART was preferred only for scenarios of extramedullary disease, allogeneic stem cell transplant recipients, and renal failure on dialysis. Respondents ranked choices of potential barriers to access based on their order of importance as below ( Figure 1) Barriers to CART access: Financial burden was the top-ranking barrier (45%) by oncologists from CART-referring centers, while the number of production slots allocated per month was the top barrier (69%) by oncologists from CART-centers. Notably, relocation and caregiver requirements were ranked as top barriers by 27% of oncologists from CART-referring centers but by none of the oncologists from CART-centers. Barriers to TCE access: Among oncologists from TCE-referring centers, the majority (43%) felt that financial burden was the top barrier to access for TCE while most oncologists (63%) from TCE-centers identified hospitalization requirements as the top barrier. Infrastructure for side effect management in BDCT-referring centers: Most oncologists at BDCT-referring centers reported the ability to manage low-grade cytokine release syndrome (CRS), immune effector cell therapy associated neurotoxicity syndrome (ICANS), infections and cytopenia, as shown in Figure 2 Conclusions: While limited by the relatively low number of responses, this survey is the first to specifically delineate barriers to BDCT access by treating versus referring centers in MM. The primary concerns are financial burden, relocation requirements for CART, and hospitalization for TCE. Most oncologists at BDCT-referring centers expressed comfort with identifying and managing low-grade CRS and ICANS, suggesting the readiness of referring oncologists to engage in toxicity management. Future steps to increase collaboration between treating and referring centers include outpatient BDCT programs and clearer guidelines for transferring patients after the initial month of BDCT therapy. Relocation and caregiver requirements, which were perceived as barriers by referring but not treating centers, need to be addressed as well.

FAST4TMA - Rapid Hospital-Based and out-Patient ADAMTS13 Testing

Introduction: Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy caused by the severe deficiency of ADAMTS13 ( a disintegrin and metalloproteinase with a thrombo spondin type 1 motif, member 13). The rapid recognition of a patient with iTTP is critical to starting effective treatment 1, with ADAMTS13 testing results in &amp;lt;72 hours considered “ideal” for diagnosing TTP 2 and is cost-effective when performed at a laboratory that can turn-around testing in &amp;lt;24 hours 3. In a patient in remission from iTTP, recommendations for surveillance ADAMTS13 testing are unclear, with ISTH guidelines offering no explicit time frame 1 but the USTMA (United States Thrombotic Microangiopathy Alliance) recommending testing every 3 months once in remission 4. However, many hospitals are unable to provide ADAMTS13 testing in-house and patients may not have access to regular out-patient ADAMTS13 monitoring. As part of the USMTA's grassroots efforts to serve patients with TMA, a first-ever program was launched to provide a free and rapid ADAMTS13 testing, i.e., &amp;lt;24-hours upon sample receipt. Both hospitalized and out-patients are eligible, including an option for mobile phlebotomy for patients unable to have testing performed through a laboratory. This abstract represents the preliminary results of this ground-breaking program. Methods: The USTMA was founded in 2019 and is currently the only organization serving patients with TMA, composed of 20 academic research sites. Following a survey of member patients asking if free ADAMTS13 testing would be beneficial that was overwhelmingly positive, a collaborative partnership with Machaon Diagnostics was established. ADAMTS13 activity with reflex inhibitor and antibody testing occurs the same day upon sample receipt, with results made immediately available to the ordering physician. Out-patient testing is performed either through the request of an iTTP patient (and ordered through their treating physician) or made by an ordering physician. In the out-patient setting, either a kit is mailed to the patient to be drawn at their local laboratory, or in cases of iTTP patients who are unable to travel to a laboratory, a mobile phlebotomy unit can be dispatched to their residence. Results: An initial survey asking, “If you could get ADAMTS13 drawn at home, for free, would you?” elicited a response of “Yes” from 90% of respondents (n=104/130) within 72 hours. Following the creation of the “FAST4TMA” (Fast, Accurate, Simple Testing for TMA) program, it was announced on the USTMA website and through social media. Currently n=22 patients have requested out-patient ADAMTS13 testing, n=20/22 already diagnosed with iTTP, consisting of 5/22 males, 14/22 females, 3/22 declining to answer, with n=9/22 requests occurring on the first day of the FAST4TMA program (06/25/23). The majority of patients, n-17/22, requested ADAMTS13 testing via a mobile phlebotomy unit. Discussion: In this initial analysis of the FAST4TMA program, we show that a patient-centered out-patient program that is free and able to provide testing at home is eagerly desired by patients. This will have the potential to detect early immunologic relapses, preventing clinical relapses. While in-patient testing has not yet been performed at the time of writing, it is anticipated that this will also provide benefits to TMA patients, particularly in removing barriers to rapid ADAMTS13 testing.

The Development and Implementation of an Effective Outpatient Oncology New Graduate Nurse Orientation Program.

Historically, outpatient oncology settings have not hired new graduate RNs (NG-RNs). However, with staffing shortages, outpatient oncology clinics have hired NG-RNs who required orientation from formal onboarding programs. Us.