List Of Problems Research Articles

Impact on End‐of‐life Planning of a Care Coordination Program for persons living with dementia

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and have worse health outcomes compared to those without ADRD. We developed a population‐based dementia care management program to support the care of PWLD in a large U.S. healthcare system.MethodsIn a large multi‐specialty medical group practice, we identified patients enrolled in a value‐based insurance program (Medicare Advantage) using the EPIC electronic health record (EHR), and eligible patients were invited to enroll in the CARES dementia care program. Patients were eligible if they had an ICD‐10 diagnosis of ADRD in the EHR problem list and/or past medical history, or currently taking an FDA‐approved medication for ADRD. We additionally included patients with ADRD who have a primary care provider in the affiliated academic health system. During an in‐person intake visit, a study‐assigned nurse practitioner (NP) engaged in advance care planning discussion with patients and caregivers and completed advance directives (AD) and Physician Order for Life Sustaining Treatment (POLST). We assessed the rate of completion of the AD and POLST pre‐program and post‐enrollment.ResultsWe enrolled 195 patients in the CARES dementia care program. After enrollment, participants increased completion of advanced directives from 27.7% to 30.8% (p = 0.25) and the POLST from 13.3% to 23.1% (p = 0.006). Of the POLST forms completed, 70.7% indicated that the patient was ‘do not attempt resuscitation’ (DNAR) (65.2% of those who completed the POLST pre‐program, 77.8% for those who completed after enrollment, p = 0.19). Among those who completed the POLST, 55.0% indicated selective medical interventions (63.6% pre‐program, 47.1% post‐enrollment, p = 0.15), 40.0% wanted full medical interventions (31.8% pre‐program, 52.9% post‐enrollment, p = 0.10), and 5.0% wanted comfort‐focused interventions (4.5% pre‐program, 5.9% post‐enrollment, p = 0.43). Trial period of nutritional supports was indicated by 69.2% (72.7% pre‐program, 64.7% post‐enrollment, p = 0.28), while 28.2% wanted no artificial treatment (27.2% pre‐program, 29.4% post‐enrollment, p = 0.45), and 2.6% wanted long‐term nutritional support (0% pre‐program, 5.9% post‐enrollment, p = 0.13).ConclusionA dementia care coordination program shows signs of increased completion of end‐of‐life planning, with the majority choosing ‘do not attempt resuscitation’ (DNAR).

The Correlation of Pain, Psychological Aspects, and Sleep in Fibromyalgia: A Cross-Sectional Analysis.

This pilot study measures pain perception, somatosensory amplification and its relationship to health anxiety in patients with fibromyalgia (FM) and patients with FM and obstructive sleep apnea (OSA); this study also examines the effects of OSA on pain perception in patients with FM. In this pilot study, patients diagnosed with FM or FM and OSA, completed three self-reported questionnaires: Short-Form McGill Pain Questionnaire (SF-MPQ), Somatosensory Amplification Scale (SSAS), and Illness Behavior Questionnaire (IBQ). Sleep study results were analyzed. Scores were summarized using medians and interquartile ranges and are compared using Wilcoxon rank sum tests. Overall FM (n = 25), female n=23 male n=3 mean age, 57.48 years. OSA n=17 (68%) and 8 (32%) were not. The SF-MPQ Sensory sub-scale scores and the SF-MPQ overall scores differed significantly between patients with and without OSA. The SF-MPQ Sensory sub-scale scores were significantly lower for patients with OSA (p=0.03), as were SF-MPQ overall scores (p=0.04). SSAS overall scores and IBQ overall scores did not differ significantly by OSA diagnosis. Correlations of the different dimensions of IBQ with SSAS and mean number of diagnoses in FM and FM+OSA, mean number of diagnoses in problem list of SSAS ≤30 was 29.5, mean number of diagnoses in SSAS ≥30 was 34.9. Developing a better understanding of the effects of OSA on pain perception in patients with FM is needed for improved health status. More research is needed to see if higher pain perception and SSAS score lead to increased health care utilization and to evaluate the relationship between untreated disordered sleeping and pain perception in patients with FM. Our findings highlight the need for more research to evaluate the relationship between treated and untreated disordered sleeping, pain perception, somatization and illness behavior in the health status of individuals with FM.

Impact of Cancer Diagnosis on Appropriate Use of Antithrombotic Medications in Individuals with Cardiovascular Diseases

Introduction: Cancer and Cardiovascular disease (CVD) often coexist and CVD is the leading cause of non-cancer mortality in people with cancer. Antithrombotic medications used to manage CVD are associated with increased bleeding risk, particularly in people with cancer. Appropriate management of CVD is therefore essential in individuals with cancer, both to decrease recurrent CVD as well as to prevent bleeding. In this study, we assessed utilization patterns of antithrombotic medications for CVD following a new diagnosis of cancer. Methods: Among people receiving primary care at the University of Vermont Medical Center from 2010 to 2019, we identified a cohort of 4,010 subjects with baseline CVD, identified from problem lists or billing codes within the first year of follow-up. Exclusion criteria included baseline cancer diagnosis (cancer known at the time of inclusion in the cohort or within the first year of follow-up) or a known history of venous thrombosis. Incident cancer was defined as new diagnosis of cancer after the first year of follow-up and did not include people with non-melanomatous skin cancers. We used the National Cancer Institute list of ICD-9 and ICD-10 codes for different cancer diagnoses. Patient's use of antithrombotics, prescribed or non-prescribed, were captured using computable phenotypes developed from the electronic outpatient medication reconciliation record and validated using chart review. People with baseline CVD who were diagnosed with cancer after the first year of follow up were matched 1:1 by sex and age with people with CVD and no cancer. We used logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) of persistent guideline-directed use of antithrombotic medications for 6 months after a new cancer diagnosis versus a matched time-period in those without incident cancer (use of antiplatelets in those with a history of atherosclerotic CVD and use of anticoagulation in those with a history of atrial fibrillation). Results: We identified 4,010 individuals with baseline CVD, 841 of whom (20%) developed incident cancer during follow-up. Distribution of CVD and antithrombotic use in the age- and sex-matched population are presented in Table 1. 2/3 of the population had coronary artery disease and about 30% had atrial fibrillation or flutter. About 65% of individuals were on any antiplatelet therapy and 18% were on anticoagulation for CVD. 41% of people with baseline CVD, and incident cancer diagnosis were still on antiplatelet therapy 6 months after their cancer diagnosis as opposed to 38 % in the matched population without a cancer diagnosis. 33% of individuals with incident cancer were still on anticoagulation for atrial fibrillation or flutter as opposed to 28% of the matched population without cancer. Both of these differences were statistically significant with OR=1.55 (95% CI, 1.15-2.1) for antiplatelets, and OR=1.56 (95% CI, 1.05,2.31) for anticoagulants, compared to those with no cancer diagnosis (Table 2). Conclusion: Surprisingly, our study found that incident cancer in individuals with baseline CVD was associated with increased adherence to antithrombotic therapy. We had hypothesized that incident cancer would be associated with lower use of antithrombotic therapy. This result could be related to increased interaction with medical specialists following a cancer diagnosis. The impact of increased adherence to antithrombotics on bleeding however, will need to be further investigated.

A Comprehensive Investigation into the Underlying Etiology of Massive Splenomegaly

Background: Massive Splenomegaly is commonly encountered in routine hematology practice. However, a comprehensive analysis of the underlying pathologies driving splenomegaly is lacking and few studies have investigated the epidemiology of this finding. In many cases, splenomegaly is detected incidentally in asymptomatic patients. The numerous potential causes of massive splenomegaly can pose a challenge when evaluating a patient. This study aims to identify the most prevalent etiologies among patients who initially exhibited massive splenomegaly. The objective is to determine outcomes and provide insights to guide clinical decision-making. Methods: We undertook a retrospective cohort study at the Oregon Health & Science University in Portland OR, including adults between ages of 18-89 years who had documented splenomegaly on their medical problem list or imaging within the last 10 years (January 2012-June 2023). Massive splenomegaly was defined as spleen measuring greater than 20 cm in its largest dimension. The presence of massive splenomegaly was confirmed by direct review of the medical record and available imaging modalities including ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI). Splenic pathology results and splenectomy outcomes were obtained if available. Results: We identified 224 patients with massive splenomegaly with a mean age of 52.6 years. Of the 224 patients, 113 (50.4%) were ultimately found to have a hematological diagnosis underlying the splenomegaly, while 93 (41.5%) ultimately had a diagnosis related to liver dysfunction. 18 (8%) were idiopathic or representative of a rare disease. Among those with hematologic diagnosis, myeloproliferative neoplasms accounted for 40.7% followed by Leukemia (23%) and lymphoma (21.2%). Among those ultimately diagnosed with some form of liver pathology driving their presentation, cirrhosis was the most common etiology, encompassing 79.6% while the remaining 20.4% had non-cirrhotic pathology including non-alcoholic fatty liver disease without overt cirrhosis (NAFLD), Primary sclerosing cholangitis (PSC), Autoimmune hepatitis or others. Chronic Hepatitis C related cirrhosis (32.3%) followed by Non-alcoholic Steatohepatitis (NASH) related cirrhosis (19.4%) were the most common forms of cirrhosis. Of the 18 cases not specifically related to hematologic or liver disease, 5 (2.2%) were of an unknown etiology, 6 (2.7%) were due to solid organ cancers or metastases and 3 (1.3%) appeared to be related to sequalae of Cystic Fibrosis. The remaining 4 cases were attributed to singular cases of Type 2 Glycogen Storage Disease causing cirrhosis, Autosomal Recessive Polycystic Kidney Disease, Felty Syndrome, and sequelae of motor vehicle accident, respectively. Conclusion: This large cohort of patients with massive splenomegaly offers many insights into the epidemiology of the underlying differential diagnosis. We found that approximately half of cases involved a hematologic disorder with myeloproliferative neoplasms being the most common etiology. Liver pathology was also a common driver, accounting for approximately 40% of cases. These findings underscore the necessity for appropriate diagnostic workup to better address the diverse etiologies contributing to massive splenomegaly.

Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

To qualitatively assess surgeons' decision making for lip surgery in patients with cleft lip/palate (CL/P). Prospective, non-randomized, clinical trial. Clinical data institutional laboratory setting. The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the 'Standardized Assessment for Facial Surgery (SAFS)' for systematic viewing by the surgeons. The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either 'in person' or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. In general, there was surgeon agreement for the diagnoses/treatments. The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Modifications for Quasi-Newton Method and Its Spectral Algorithm for Solving Unconstrained Optimization Problems

In this paper, two modifications for spectral quasi-Newton algorithm of type BFGS are imposed. In the first algorithm, named SQNEI, a certain spectral parameter is used in such a step for BFGS algorithm differs from other presented algorithms. The second algorithm, SQNEv-Iv, has both new parameter position and value suggestion. In SQNEI and SQNEv-Iv methods, the parameters are involved in a search direction after an approximated Hessian matrix is updated. It is provided that two methods are effective under some assumptions. Moreover, the sufficient descent property is proved as well as the global and superlinear convergence for SQNEv-Iv and SQNEI. Both of them are superior the standard BFGS (QNBFGS) and previous spectral quasi-Newton (SQNLC). However, SQNEv-Iv is outstanding SQNEI if it is convergent to the solution. This means that, two modified methods are in the race for the more efficiency method in terms less iteration numbers and consuming time in running CPU. Finally, numerical results are presented for the four algorithms by running list of test problems with inexact line search satisfying Armijo condition.

An audit on problem lists transfers in general practice in Leeds, United Kingdom

Background: Problem-oriented medical records are the standard among electronic health records (EHR) but after 50 years of use, problem lists (PL) do not seem to be the solution to clinicians' information needs. Objectives: To perform a quality improvement evaluation of PL content, considering available guidelines on its characteristics (accuracy, clarity, concision, currency) when transferring patients from one primary care organisation in England to another in Leeds. The standard should simply be the need to confirm currency. PL should be ready to be used safely after a brief check-up. Methods: During six months, all patients registering at a primary care setting in Leeds had their PL updated when they were transferred with an existing English electronic medical record. The content of the PL was later analysed by looking for the number of items in both lists (active and inactive), for the presence of duplicates and synonyms, and for items that needed to be added. It is normal practice to review the records at the time of transfer, usually by a nurse or healthcare assistant, but it was done by a general practitioner (GP) aiming to maximise the quality of the final PL. Results: Of the 175 newly registered patients studied, 3077 PL items were collected. Active PL included an average of 5.7 entries per patient, while inactive PL had an average of 11.8 entries. The number of duplicates per patient was about 1.8, while the number of synonyms was around 1.2. Unnecessary items were common. When records were reconciled, there was a 66.7% reduction in active PL entries and an 86.4% reduction in inactive entries. Discussion: Handover of PL among family physicians fails to transfer high-quality data. Different organisations follow distinct patterns in the use of PL. Major changes may be required to improve the flow of accurate, concise and up-to-date information. It could be argued that without further training, the use of clear guidelines or better support from health informatics, the PL will not provide the important summary information that clinicians need, which will affect clinicians' decision-making and to the detriment of patients.

NCOG-32. THE SPECIFIC PSYCHOSOCIAL BURDEN OF CAREGIVERS OF ADULT NEURO-ONCOLOGICAL PATIENTS - A PROSPECTIVE STUDY

Abstract OBJECTIVE The diagnosis of a brain tumor represents high burden for the patients’ caregivers (CG). Psychosocial screening tools adapted to the burden profile of CG are urgently required but do not exist. The aim was to develop a problem list for neuro-oncological CGs’ unmet needs for an application in combination to the Distress Thermometer scale. METHODS CG were prospectively assessed regarding changes in everyday life, relationship, social life, emotional, physical problems, and support needs, either via questionnaire (Center A) or by a qualitative interview (center B). A qualitative content analysis was performed by an inductive/deductive approach using MAXQDA® software. RESULTS A total of 50 caregivers were assessed (25 in center A via questionnaire, 25 in center B via interviews) during outpatient visits. Most frequently reported need was the need for psychological support (29/50, 58%). This was true after initial diagnosis (26/50, 52%) as well as in case of clinical deterioration of their loved-one (30/50, 60%). The results leaded to problem categories, congruent to the NCCN distress thermometer categories for cancer patients (practical, social, emotional, physical, and spiritual/existential problems). We detected new topics including “constraints/organization of (medical) appointments” (25/50, 50%) or “constant availability required for partner” (21/50, 42%). Also, 70% (35/50) put their own interests last or adapted their leisure activities. In the qualitative interviews (Center B), further items were identified, e.g., “dealing with psychological problems of the patient” (3/25, 12%), “different coping strategies among patient/caregiver” (4/25, 16%). We defined additional problem categories specifically adapted to CG of neurooncological patients, e.g., “problems due to neurocognitive/neuropsychological symptoms of the loved-one” and “problems with role as a caregiver”. CONCLUSION The interviews reflected the unmet needs of brain tumor caregivers. Our problem list developed for CG of neurooncological patients might allow for the targeted assessment and optimization of care.

Alerting providers to hospitalized persons with dementia using the electronic health record.

While patients with dementia entering the hospital have worse outcomes than those without dementia, early detection of dementia in the inpatient setting is less than 50%. We developed and assessed the positive predictive value (PPV) and feasibility of a novel electronic health record (EHR) banner to identify patients with dementia who present to the inpatient setting using data from the medical record. We developed and implemented an EHR algorithm to flag hospitalized patients age ≥65 years with potential cognitive impairment in the Epic EHR system using dementia ICD-10 codes, FDA-approved medications, and the use of the term "dementia" in the emergency department physician note. Medical records were reviewed for all patients who were flagged with an EHR banner from October 2022 to May 2023. A total of 344 individuals were identified who had a banner on their chart of which 280 (81.4%) were either diagnosed with dementia or were on an FDA-approved dementia medication. Forty-three individuals who had confirmed dementia were identified by a medication only (15.4%). Of the patients without confirmed dementia, the majority (N = 33, 9.6%) had a diagnosis of altered mental status, cognitive dysfunction, or mild cognitive impairment. Only 31 individuals (9.0%) had no indication of dementia or cognitive decline in their problem list, past medical history, or medication list. We found that it was feasible to implement an EHR algorithm for prospective dementia identification with a high PPV. These types of algorithms provide an opportunity to accurately identify hospitalized older individuals for inclusion in quality improvement projects, clinical trials, pay-for-performance programs, and other initiatives.

Abstract 16090: Human Chart Abstraction Combined With Electronic Medical Record Programmed Queries Improves Identification of Patients With Cardiac Implanted Electronic Devices

Background The Society of Thoracic Surgery cardiac surgery database (STSD) is used for quality improvement and research. The STSD relies on human chart abstraction (STS-HA) to accurately identify cardiac patients with existing Cardiac Implanted Electronic Devices (CIED’s). Perioperative CIED management may impact surgical outcomes, yet the sensitivity of the STS-HA for CIED patients is unknown. Methods All 7 major STS cardiac surgeries performed at Johns Hopkins Hospital (JHH) and Temple University Hospital (TUH), between 7/2017 and 6/2022, were assessed for the presence of a CIED. CIED patients were identified using both STS-HA and a programmed EMR (Epic) reports (EMR-pro) relying on CPT codes, problem lists, structured data elements, and CIED interrogation reports. The presence of existing CIED in patients was confirmed by same-day chest imaging, which is not uniformly searchable using EMR-pro. McNemar’s chi square test was used to compare the sensitivity of STS-HA with EMR-pro to identify preoperative patients with existing CIED’s. Results Using the STSD, we identified 4770 surgical patients across both institutions during the study period (JHH n= 2627, TUH n=2143), of whom 167 patients had CIED’s (3.5%; JHH 77 (2.9%), TUH 90 (4.2%). Of these, STS-HA identified 144 (86.2% pooled sensitivity) as having existing CIED’s (JHH 69, 89.6%; TUH 75, 83.3%). EMR-pro identified 164 patients (98.2% pooled sensitivity; JHH 77, 100%; TUH 87, 96.7%). Each of the 3 TUH patients identified by STS-HA but not by the EMR-pro had CIED documentation in paper chart scans. The pooled sensitivity of EMR-pro was better than that of STS-HA in identification of CIED’s at the time of surgery (p<0.0001). Discussion The programmed EMR algorithm’s superior sensitivity to human abstraction in identifying cardiac surgical patients with existing CIED’s is an important enhancement in identifying this population. This improvement in sensitivity illustrates the power of EMR programmed reports to address the unreliability of human chart abstraction. Understanding the inherent limitations of the STS database and improving it are essential to the interpretation of past STSD based research and improving the reliability of STSD based studies performed in the future.

Abstract 16282: Incident Heart Failure With Preserved Ejection Fraction in a Cohort of Patients With Biopsy-Proven Non-Alcoholic Fatty Liver Disease

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with heart failure with preserved ejection fraction (HFpEF), independent of shared risk factors. The aim of this study was to determine the prevalence, clinical, and echocardiographic (TTE) features of HFpEF in patients with biopsy-proven NAFLD. Methods: We performed a retrospective single-center cohort study of patients with biopsy-proven NAFLD in the Duke NAFLD Biorepository and Clinical Database. Study entry was at the time of liver biopsy and patients were followed until death or 5/1/2023. Clinical and echocardiographic data were abstracted via manual chart review. HFpEF was defined as: at least one TTE characteristic (left atrial volume index ≥ 29 ml/m 2 , septal wall thickness ≥ 1 cm, or evidence of diastolic dysfunction) and signs or symptoms of heart failure (diagnosis of heart failure on problem list, hospitalization for heart failure, elevated NT pro-BNP level, jugular venous distention, use of loop diuretics, pulmonary or peripheral edema, fatigue, or exertional symptoms). Descriptive statistics were evaluated. Results: A total of 742 patients were included in the study. The mean age of the cohort was 50 +/- 12 years, and 83% were White. 95 (13%) had TTE both prior to study entry and during follow up, while 279 patients (38%) had TTE only during follow up. A total of 185 patients met criteria for HFpEF during follow up. After removing patients with TTE evidence of HFpEF prior to study entry, there were 132 cases of incident HFpEF over a mean follow up of 9.1 years, representing 47% of those with TTE after liver biopsy, and 18% of the overall cohort. Considering only TTE criteria, 142 patients had incident HFpEF. During follow up, 12 patients were hospitalized for heart failure. Conclusions: HFpEF is common in patients with NAFLD and a small percentage of patients do not have a chart diagnosis despite meeting echocardiographic criteria, suggesting that HFpEF may be under-recognized. Screening for HFpEF and/or formal care pathways to address early heart failure will be important to prevent morbidity and mortality in this population.

Abstract 16120: Efficacy of an Electronic Medical Record Alert System in Identifying Cardiac Implantable Electronic Device Infection

Introduction: Cardiac Implantable Electronic Device infection (CIED-I) is common, morbid, and frequently under recognized. Electronic Medical Record (EMR) based alerts have been proposed as a solution to improve detection of CIED-I. Hypothesis: Development of a real-time EMR algorithm to identify CIED-I can improve recognition of patients with CIED-I. Methods: An EMR (Epic, Verona, WI) alert system to identify inpatients with CIED-I was developed based on the presence of CIED and positive blood cultures. The presence of CIED was determined using patient problem list, structured data elements describing device implantation, and prior device interrogation. Alerts were generated each time a patient with CIED had a positive blood culture. We examined patients admitted between January 2020 - March 2023. Identified patients were adjudicated manually to confirm: (1) the presence of CIED and (2) true bacteremia versus contaminant based on patient and microbiological characteristics. Results: The algorithm generated 255 alerts, corresponding to 100 unique patients over 142 hospitalizations. Of these alerts, 213 appropriately identified 88 unique patients with positive blood cultures and CIEDs, resulting in an alert specificity of 84% and patient specificity of 88%. The remaining 42 (16.6%) alerts occurred in 10 patients who no longer had CIED due to prior CIED extraction (6 at the time of heart transplant and 4 with extraction without reimplantation) as well as 2 patients with erroneous blood culture identification (one positive syphilis antibody test and one lab documentation error). In patients with appropriate alerts, 27 patients had 4/4 positive blood culture bottles, 5 patients had 3/4, 10 patients had 2/4, 41 patients had 1/4, 2 patients had 2/2, and 1 patient had 1/2. The positive predictive value of the algorithm to identify true bacteremia was 0.65 (138/213). Conclusions: The algorithm has high specificity to identify patients with possible CIED infection. Improving the accuracy of device detection, by incorporating radiology imaging or history of extraction, could further improve specificity. Positive predictive value and alert fatigue could be improved by stratifying alerts by blood culture species and total number of positive blood cultures.

Building Quality Improvement Initiatives through Anti-Cancer Stewardship in the Veterans Health Administration (VHA): CML Pilot

The Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Services created a national stewardship with focus on anti-cancer therapeutics within a disease-specific cohort . Directing stewardship initiatives to a cohort of Veterans with a common malignancy is a novel approach. A multidisciplinary team with National PBM and VISNs (Veterans Integrated Service Network) promotes standardization of practice with accountability to monitor outcomes as a continual quality improvement process. A toolkit was built to support stewardship activities and includes: near-real-time process to identify a national disease-specific Veteran cohortdisease validation processcentralized MUE data collectioneducational resourcessite for communication and training materials Tyrosine Kinase Inhibitors (TKIs) account for the second highest utilization among outpatient oral anti-cancer therapies in VHA . Imatinib has demonstrated persistent efficacy and is the preferred TKI on the VA National Formulary. Utilizing our toolkit, we developed two MUEs for our national CML cohort to determine why Veterans were not prescribed imatinib as 1L therapy and reasons for switching from first to second line therapy. Methods Business rules identified VISN CML cohorts by using data sources and diagnostic coding from the VA Electronic Health Record (EHR): primary care and hematology/oncology visits (ICD-10), inpatient stays (ICD-10), and problem lists (ICD-10; SNOMED CT). Retrospective chart review of two subsets: Veterans who received a drug other than imatinib as their initial VA prescriptionVeterans who received at least two unique drugs to treat CML Data abstracted for MUE #1: Disposition of TKI prescriptionIf new initiation, documented reason(s) for drug selectionIf continuation, prior drug therapy history Data abstracted for MUE #2: Documented reason(s) for switch to 2LIf adverse drug reaction (ADR) included as a reason, is it documented in the EHR? Analysis combined responses with prescription data from the EHR. Results Of the 18 VISNs, 9 participated in MUE data collection. 365 patients were identified as not having received imatinib 1L and 360 were identified as having received at least two unique drugs to treat CML. These counts are each approximately 30% of the total CML patient cohort. In the total cohort, ~50% of patients received imatinib 1L and have not switched to 2L. Responses for 1L TKI therapy (N=365) 199 (55%) continued therapy originally started outside VA with 67% of these patients (n=133) without documentation of prior imatinib therapy166 (45%) were newly initiating CML therapy with top documented reasons for drug selection: Intermediate or high risk (e.g., SOKAL risk scoring): 77 (46%)46 (28%)18 (11%)Dasatinib was the most prescribed 1L therapy in this cohort (64%; 235), followed by nilotinib (23%; 85), which had a higher prevalence when therapy was continuation (30%).53 patients (15%) had subsequent imatinib therapyResponses for switch from 1L to 2L therapy (N=360) Top documented reasons for switch from 1L to 2L therapy 215 (60%)81 (23%)Resistance / inadequate response: 69 (19%)Only 37 (17%) who experienced an ADR had it documented in the EHRThe most common 2L drug was dasatinib (55%;198). The median number of days between 1L and 2L initiation was 275 (range: 7 - 2, 573)136 patients (38%) received third line therapy or beyond Conclusions A formalized oncology stewardship with focus on disease-specific initiatives within a national healthcare system is feasible. Responses from our 1L MUE indicate that despite geography, imatinib remains the preferred TKI and accounts for the highest utilization. Most veterans not receiving imatinib as 1L therapy, received dasatinib or nilotinib. Continuation of therapy due to transition of care to VA was the primary reason for 1L therapy with a non-preferred TKI. Other reasons included: FDA indication and SOKAL risk scoring. In our pilot 1L to 2L MUE, ADRs were the most common reason for CML patients to be switched to 2L (45%) followed by resistance/inadequate response and disease progression . Most ADRs were not documented in the EHR. Further interventions in TKI prescribing may be instituted in select sites . Following initiatives for CML, Anti-Cancer Stewardship will be expanded to other oncologic diseases.

The National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List as a screening tool for sexual problems in adults with cancer.

295 Background: Cancer diagnosis and treatment adversely affect sexuality, which often remains unaddressed. Few clinic-based, easily administrable tools exist to identify sexual problems in patients with cancer. The National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List (NDT) is frequently used to measure distress in oncology clinics. This study explored the prevalence and associative factors for sexual problems and their overlap with reported distress in cancer patients using NDT screening data. Methods: This retrospective cohort study included adults with cancer receiving oncology care at the University of Alabama at Birmingham from March 2017 through April 2023. Participants completed a lay navigator-administered NDT around their first visit. Participants reported their distress levels in a score of 0 (no distress) and 10 (extreme distress) and checked their problems from a 42-item Problem List, sexual problems being one of them. Distress was categorized as mild (0-3), moderate (4-7), and severe (8-10) distress. Patient age, sex, race, tumor type, and stage were captured. Frequencies of reported sexual problems were calculated and compared by patient characteristics and reported distress using Cohen’s d (0.2 small, 0.5 medium, 0.8 large effect) or Cramer’s V (0.1 small, 0.3 medium, 0.5 large effect) effect sizes. Results: Of patients completing an NDT survey (N=2821), 62% were female, 22% were Black, and 30% had a diagnosis of breast cancer. A total of 4% (n=99) expressed sexual problems. Compared to those reporting no sexual concerns, patients who reported sexual concerns were younger (median age 56 [interquartile range, IQR: 48-66] vs. 64 [IQR: 57-72], d=0.6) and more often had a breast cancer diagnosis (45% vs. 29%, V: 0.10), (V=0.2). Participants reporting sexual problems more often reported moderate to severe distress than those who did not (64% vs. 34%, V=0.1). Conclusions: Though the percentage of participants reporting sexual problems was low compared to historical data on sexual dysfunction in patients with cancer, the NCCN Distress Thermometer and Problem List could be a helpful screening tool for identifying sexual problems in adults with cancer. Sexual problems reported by patients with cancer differed by age, cancer types, and distress levels. More research is needed to understand best practices for capturing and responding to sexual concerns in patients with cancer during clinical encounters.

ACS CARES: A digital approach to supporting health information and social needs among people with cancer and caregivers.

548 Background: ACS CARES (The American Cancer Society Community Access to Resources, Education, and Support) is the first nationwide non-clinical navigation program for people with cancer and caregivers. ACS CARES is a multi-channel approach providing direct, individualized, non-clinical assistance through a native app, telephonic or in-person support. Here we examine preliminary feasibility and acceptability of digital navigation through the ACS CARES app. Methods: The ACS CARES app became available for download on June 1, 2023. It includes sociodemographic and cancer-related questions, and a health information and social needs assessment adapted from the NCCN distress thermometer and problem list. Based on patient or caregiver responses, the app curates information and resources tailored to each user’s cancer journey and endorsed concerns. The aim is to deliver timely information to reduce distress, resources to mitigate social determinants of health, and emotional support to improve the cancer experience. Results: In the first three weeks, 349 people downloaded the app and 231 individuals (45% people with cancer, 55% caregivers) created profiles. Users represented 39 different cancer types across all stages, with 54% currently receiving treatment. Users are 75% white, 11% Hispanic, 63% female, with an average age of 55 (SD: 15). 11% of users are military/veteran, 15% rural, and from 43 states and US territories. The average initial distress screening was 4.0 on a scale of 0-10. Practical concerns were most frequently endorsed (n = 380, 36%). Cancer or health-related information was the most frequently endorsed practical concern with information on ‘Treatments, medications, procedures, and other therapies’ being the most common health information need. Fatigue, and worry, anxiety or fear were the most frequently endorsed physical and emotional concerns, respectively. Virtual support from someone with a similar cancer experience was the most commonly endorsed social concern. Users have accessed 357 health information or social needs resources in the app. Conclusions: Preliminary data suggest feasibility and acceptability of using a native app to access information and resources for cancer support. ACS has targeted efforts planned to support diverse user engagement. Peer support within the app and in-person support at four pilot cancer centers will begin in September.

CHIPping in: Clonal hematopoiesis clinics in community oncology.

499 Background: Clonal hematopoiesis of indeterminate prognosis (CHIP) is recently recognized as a pre-malignant condition and independent cardiovascular risk factor with doubled risk of coronary heart disease, cerebrovascular events, and worsened heart failure outcomes. Despite this recognition, multidisciplinary CHIP clinics are near-uniformly associated with tertiary centers where only a minority of oncology patients receive care. Tennessee Oncology is a large community oncology practice with over 200 providers at 35 sites of care throughout Tennessee and North Georgia. Here, we report the characteristics of two years of patients with common CHIP mutations as we prepare to launch our CHIP clinic. Methods: Patients with solid tumors who underwent either tissue- or blood-based comprehensive genomic profiling from May 2021 to May 2023 were reviewed. Patients with incidental discovery of DNMT3A, ASXL1, TET2, JAK2, IDH1/2, SRSF2, U2AF1, SF3B1, and ZRSR2 mutations are classified as having CHIP. High-risk mutation profile was defined as >1 mutation or a single mutation with variant allele frequency (VAF) of ≥10%. In patients sequenced >1x, only initial sequencing was used. The presence of cardiovascular disease or traditional risk factors was based entries into the patients’ “problem list” or use of medications commonly used to treat these conditions. Results: Over a two-year period, 3599 patients underwent sequencing and CHIP mutations were identified in 1069 (29.7%) patients. The median VAF was 1.58% and 585 patients had at least one mutation with a VAF of ≥2%. Median age at sequencing was 69.6 years. Distribution between males/females was similar. Lung cancer was the most common histology (n=328) followed by breast (n=122) and colon (n=121). DNMT3A mutations (n=829) were most frequently seen followed by TET2 (n=353), ASXL1 (n=335), SRSF2/U2AF1/SF3B1/ZRSR2 (n=147), JAK2 (n=138), and IDH1/2 (n=104). Nearly two-thirds of patients had a high-risk mutational profile with >1 mutation (n=479) or VAF ≥10% (n=185). Assessing traditional risk factors for cardiovascular and cerebrovascular disease, essential hypertension and type 2 diabetes were present in 56.4% (n=603) and 30.1% (n=322) of patients, respectively, and a minority of patients had established coronary disease (n=181) or heart failure (n=74). Twenty-three percent (245/1069) had no cardiovascular risk factors. Conclusions: In a large community practice, 29.7% of patients have common CHIP mutations – most of whom are considered high-risk based on current risk stratification criteria. Many patients also have traditional risk factors or established cardiac disease underscoring the strong association between CHIP and cardiovascular disease. A community-based, multi-disciplinary CHIP clinic would enhance these patients’ care and potentially lead to improved outcomes.

An analysis of Plan, Do, Study, Act for a supportive care program for patients with metastatic breast cancer.

376 Background: Patients with metastatic cancer have unique survivorship needs. Recent studies show patients with advanced cancer have unmet needs in the following categories: health information (31%), psychosocial support (27%), symptom management and general wellness support (23%) (Hart, et al., 2022). The Living Well with Advanced Breast Cancer Clinic (LWABC) was established in 2017 to address these unmet needs. This multidisciplinary clinic provides the patient and caregiver(s) an individual visit with a medical oncologist, integrative medicine physician, palliative medicine physician, dietitian, and nurse navigator. The patient is provided in-depth education and personalized supportive care plans. Methods: Over recent years, clinic staff have utilized the Plan, Do, Study, Act (PDSA) (Taylor, et al., 2014 ) methodology to refine operations and improve patient care. In 2021, the plan phase was initiated with incorporation of a nurse navigator and program manager for the clinic. Nurse navigation services have been shown to improve patient and caregiver knowledge as well as quality of life and was deemed an important addition to the program (Oncology Nursing Society, 2018). At the beginning of calendar year 2022, in the “do” phase, the nurse navigator/program manager was hired and implemented pre-visit phone calls as well as navigation services for patients. These services include assessment of needs, patient education, provision of community resources, and assistance with scheduling referrals. At the beginning of calendar year 2023, use of the NCCN distress thermometer and problem list was initiated. The current phase, “study,” includes development of a dashboard for monitoring clinic operations. Review and assessment of distress thermometer data is ongoing. Results: When comparing calendar year 2021 to 2022, the clinic has seen increases in referrals (40 in 2021 to 65 in 2022), number of patients seen (31 in 2021 to 46 in 2022), and unique patient zip codes (28 in 2021 to 42 in 2022). There was also a reduction in late cancellation rates from 15.9% (2021) to 7.2% (2022). Late cancellation is defined as any appointment cancelled 24 hours or less prior to scheduled visit. Conclusions: Utilizing the PDSA cycle clinic staff have seen operational improvements over the last two years. Currently, this supportive care program remains in a “study” phase and will continue to evaluate progress and patient outcomes. Results from the act phase will be utilized to continue expansion of the clinic and services in the future. Further aiding this endeavor is an embedded patient advocate and ongoing outreach and collaboration with patient support organizations.

4 Characterizing Cognitive Profiles and Postoperative Cognitive Risk in Older Adults Presenting for Elective Surgery

Objective:Older adults represent 50% of surgical patients and are disproportionately at risk of poor cognitive outcomes after surgery including delirium, accelerated cognitive decline, and dementia. Delirium alone is estimated to occur in up to 50% of older adults postoperatively, while research indicates it is preventable in 30-40% of cases. Individuals with pre-existing cognitive impairments or neurodegenerative diseases are at the highest risk of such outcomes, but (1) cognitive diagnoses are grossly underrepresented in patients' medical records, and (2) routine preoperative cognitive clearance remains rare. The purpose of this presentation is to demonstrate the extent and nature of cognitive vulnerability in older adults preparing for elective surgery within a tertiary care hospital. A case series is also reviewed to illustrate varying surgical outcomes with and without consideration of preoperative cognitive risk.Participants and Methods:This presentation incorporated IRB-approved and data honest broker management to assess diagnoses and cognitive profiles of adults age 65 and older electing surgery with anesthesia between January 2018 and December 2019. Data were assessed across two phases of the Perioperative Cognitive Anesthesia Network (PeCAN) program within the University of Florida and UF Health. First, data from the preoperative anesthesia clinic were reviewed for the percentage of patients with cognitive difficulties within the patient problem list. Second, based on neuropsychological domains, the cognitive profiles of patients assessed by neuropsychologists within the preoperative anesthesia clinic were divided into primary attention, primary memory, or combined memory attention. From these patients, the presenter highlight cases to demonstrate how individuals with cognitive difficulties can be provided care by a multidisciplinary team to mitigate the presence of postoperative complications.Results:Of 14,794 older adults entering the tertiary care medical center for surgical procedures, 4% (n=591) of the sample had ICD cognitive or neurodegenerative codes in the record. When a comprehensive neurobehavioral assessments were conducted on 1,363 of these presurgical patients, 70% had confirmed cognitive deficits on neuropsychological testing. These deficits included primary attention and executive deficits (12%), primary memory impairment (27%), or both attention and memory impairment (31%). Cases from these patients are reviewed and highlight how preoperative cognitive risk status can inform conservative perioperative practices including opioid-sparing analgesia, depth of anesthesia monitoring, and postoperative inpatient geriatric medicine consultation.Conclusions:Medical records listed cognitive diagnoses in 4% of hospital preoperative medical records, yet neuropsychological assessment of a subset of cases revealed a markedly higher rate of impairment. Patients with preoperative cognitive assessment show cognitive symptoms consistent with known neurological disorders of aging including Alzheimer's disease and cerebrovascular disease. Appreciation of pre-existing neurocognitive disorders can alter perioperative practices to prevent or reduce the risk of delirium and other postoperative neurocognitive changes. These data and cases reviewed will highlight how neuropsychology can be involved in perioperative care and champion perioperative interventions for perioperative "rescues".

Correctly structured problem lists lead to better and faster clinical decision-making in electronic health records compared to non-curated problem lists: A single-blinded crossover randomized controlled trial

BackgroundCorrectly structured problem lists in electronic health records (EHRs) offer major benefits to patient care. Without structured lists, diagnosis information is often scatteredly documented in free text, which may contribute to errors and inefficient information retrieval. This study aims to assess whether EHRs with correctly structured problem lists result in better and faster clinical decision-making compared to non-curated problem lists. MethodsTwo versions of two patient records (A and B) were created in an EHR training environment: one version included diagnosis information structured and coded on the problem list (“correctly structured problem list”), the other version had missing problem list diagnoses and diagnosis information partly documented in free text (“non-curated problem list”). In this single-blinded crossover randomized controlled trial, healthcare providers, who can prescribe medications, from two Dutch university medical center locations first evaluated a randomized version of patient A, then B. Participants were asked to motivate their answer to two medication prescription questions. One (test) question required information similarly presented in both record versions. The second (comparison) question required information documented on problem lists and/or in notes. The primary outcome measure was the correctness of the motivated answer to the comparison question. Secondary outcome measure was the time to answer and motivate both questions correctly. ResultsAs planned, 160 participants enrolled. Two were excluded for not meeting inclusion criteria. Correctly structured problem lists increased providers’ ability to answer the comparison question correctly (56.3 % versus 33.5 %, McNemar odds ratio 2.80 (1.65–4.93) 95 %-CI). Median time to answer both questions correctly was significantly lower for EHRs with correctly structured problem lists (Wilcoxon-signed-rank test p = 0.00002, with incorrect answers coded equally at slowest time). ConclusionsCorrectly structured problem lists lead to better and faster clinical decision-making. Increased structured problem lists usage may be warranted for which implementation policies should be developed.

Ability of machine-learning based clinical decision support system to reduce alert fatigue, wrong-drug errors, and alert users about look alike, sound alike medication

Background and objectiveThe overall benefits of using clinical decision support systems (CDSSs) can be restrained if physicians inadvertently ignore clinically useful alerts due to “alert fatigue” caused by an excessive number of clinically irrelevant warnings. Moreover, inappropriate drug errors, look-alike/sound-alike (LASA) drug errors, and problem list documentation are common, costly, and potentially harmful. This study sought to evaluate the overall performance of a machine learning-based CDSS (MedGuard) for triggering clinically relevant alerts, acceptance rate, and to intercept inappropriate drug errors as well as LASA drug errors. MethodsWe conducted a retrospective study that evaluated MedGuard alerts, the alert acceptance rate, and the rate of LASA alerts between July 1, 2019, and June 31, 2021, from outpatient settings at an academic hospital. An expert pharmacist checked the suitability of the alerts, rate of acceptance, wrong-drug errors, and confusing drug pairs. ResultsOver the two-year study period, 1,206,895 prescriptions were ordered and a total of 28,536 alerts were triggered (alert rate: 2.36 %). Of the 28,536 alerts presented to physicians, 13,947 (48.88 %) were accepted. A total of 8,014 prescriptions were changed/modified (28.08 %, 8,014/28,534) with the most common reasons being adding and/or deleting diseases (52.04 %, 4,171/8,014), adding and/or deleting drugs (21.89 %, 1,755/8,014) and others (35.48 %, 2,844/ 8,014). However, the rate of drug error interception was 1.64 % (470 intercepted errors out of 28,536 alerts), which equates to 16.4 intercepted errors per 1000 alerted orders. ConclusionThis study shows that machine learning based CDSS, MedGuard, has an ability to improve patients’ safety by triggering clinically valid alerts. This system can also help improve problem list documentation and intercept inappropriate drug errors and LASA drug errors, which can improve medication safety. Moreover, high acceptance of alert rates can help reduce clinician burnout and adverse events.