scholarly journals Incidence of Neutropenic Fever at a Safety Net Hospital in Cancer Chemotherapy Patients Receiving Prophylactic Pegfilgrastim Manual Injection Compared to the on-Body Auto-Injector

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4709-4709
Author(s):  
Atin Jindal ◽  
Jan Kover ◽  
Vanja Raduka ◽  
Timothy E. O'Brien
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Cancer Chemotherapy ◽  
Safety Net ◽  
Delivery Systems ◽  
Neutropenic Fever ◽  
Cancer Type ◽  
Injection Group ◽  
Safety Net Hospital ◽  
Clinic Visits

Abstract Introduction Febrile neutropenia (FN) is a potentially life-threatening complication of chemotherapy, with increased incidence in pts receiving high risk chemotherapy regimens and/or over age 651. Prophylactic filgrastim given daily or once dosing/cycle pegfilgrastim have been shown to decrease the incidence, duration, and severity of neutropenia, fever and infection in patients receiving high risk cancer chemotherapy. Pegfilgrastim stimulates the production, maturation, and activation of neutrophils. Because of its stimulatory effects on neutrophil precursors, it should be given 24 hours after chemotherapy to reduce paradoxical neutropenia. For many pts, particularly those who are underinsured and who will not have home injection covered, this requires a return visit to the clinic. In 2015, a new device delivery of this medication was introduced called the Neulasta® On-Body Injector (OBI) Onpro®.This is a small, lightweight, waterproof device that is timed to deliver an injection 27 hours after application, resulting in less clinic visits. The on-body injector has been shown to be safe in healthy volunteers2 and have pharmacokinetics similar to manual pegfilgrastim3. However, there is limited clinical efficacy data comparing the 2 delivery systems, particularly in an indigent care setting where adherence to home delivery systems may be an issue. Methods Between May 1, 2016 and May 30, 2017 the use of pegfilgastrim delivery systems as prophylaxis was reviewed at a large, urban cancer center. There were 120 patients identified: 60 returned the next day for manual injection of pegfilgrastim and 60 were ordered the home on-body injector. Primary data collected included the incidence of neutropenic fever, absolute neutrophil count (ANC) on admission, length of hospital stay, and on-body device failures. Results All pts received high risk chemotherapy regimens. Within each group (injection and OBI, respectively): ave age was 55.6 vs 56.1 (p = 0.78); sex 65% vs 92% female (p = 0.02); race 60% vs 68% White, 27% vs 22% African American, 3.3% vs 6.7% Hispanic, 5% vs 3.7% Asian (p = 0.7); cancer type: 38.3% vs 11.7% (p < 0.001) NHLymphoma, 28.3% vs 55% breast (p = 0.003), 8.3% vs 6.7% lung (p = 0.73), 25% vs 26.7% other cancer (p = 0.83); 21.7% vs 33.3% had commercial insurance, 73.3% vs 56.7% had Medicare/Medicaid, 5% vs 10% had self-pay. Overall, 17/120 (14%) patients developed FN: 10/60 (16.7%) from the manual injection group vs 5/60 (8.3%) from the OBI group (p = 0.17). 100% of FN patients were admitted for inpatient care and were treated with intravenous antibiotics in both groups. Of those that developed FN, nadir ANC on average was 160 vs 432 (p = 0.22), length of stay 6.6 vs 4.4 days (p = 0.497), 67% vs 40% had advanced cancer (p = 0.003), 70% vs 0% of patients that developed FN had lymphoma; 16.7% vs 20% were >65 years of age (p = 0.64), 8.3% vs 20% had ECOG ≥2 (p = 0.067), and 25% vs 20% had evidence of kidney or liver dysfunction (p = 0.51). Three patients (5%) reported the on-body injector falling off after attachment. One patient did not pick up the on-body injector. These four patients received a manual injection in clinic the following day. None of these patients had FN within 30 days post chemotherapy. Conclusion Cancer pts at a safety net institution receiving post-chemotherapy prophylactic pegfilgrastim were not found retrospectively to have had an increased incidence of febrile neutropenia when using the OBI compared to the manual subcutaneous injection. There was a non-significant increase in FN in the manual injection group but this may have been due to a significant imbalance of more myelosuppressive NHL regimens. Overall, in pts exposed to high risk chemotherapy, OBI use resulted in a low incidence of FN (8.3%) and fewer return clinic visits but education on handling device failure is vital to the effectiveness of the pegfilgrastim OBI in this patient population. 1Myeloid Growth Factors. National Comprehensive Cancer Guidelines (NCCN), Version 1.2018. http://www.nccn.org/. 2Josh RS et al. Performance of the pegfilgrastim on-body as studied with placebo buffer in healthy volunteers. Curr Med Res Opin. 2017; 33(2): 379-384. 3Yang BB et al. Comparison of pharmacokinetics and safety of pegfigrastim administered by 2 delivery methods: on-body injector and manual injection in a prefilled syringe. Can Chemo Pharmacol. 2015; 75(6): 1199-1206. Disclosures No relevant conflicts of interest to declare.

Abstract 230: Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Jeffrey P Chidester ◽  
Sandeep R Das ◽  
Rebecca Vigen
Keyword(s):  
Internal Medicine ◽  
Decision Making ◽  
Safety Net ◽  
Cost Of Care ◽  
Care Hospital ◽  
Care Clinic ◽  
Significant Difference ◽  
Safety Net Hospital ◽  
Out Of Pocket Costs ◽  
Clinic Visits

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p < 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p <0.005]) Knowledge of cost of care was not an often-considered factor in decision making (27% “Often” or “Always” [43 of 159]). There was no significant difference in response by year of training. Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

Real-Time Risk Tool for Pharmacy Interventions

2020 ◽  
pp. 001857872097388
Author(s):  
Hanh L. Nguyen ◽  
Kristin S. Alvarez ◽  
Boryana Manz ◽  
Arun Nethi ◽  
Varun Sharma ◽  
...  
Keyword(s):  
High Risk ◽  
Prediction Models ◽  
Risk Model ◽  
Hospital Readmissions ◽  
Group Versus ◽  
Safety Net ◽  
Low Risk ◽  
Day Hospital ◽  
Significant Difference ◽  
Safety Net Hospital

Background: Adverse drug events (ADEs) result in excess hospitalizations. Thorough admission medication histories (AMHs) may prevent ADEs; however, the resources required oftentimes outweigh what is available in large hospital settings. Previous risk prediction models embedded into the Electronic Medical Record (EMR) have been used at hospitals to aid in targeting delivery of scarce resources. Objective: To determine if an AMH scoring tool used to allocate resources can decrease 30-day hospital readmissions. Design, Setting, and Participants: Propensity-matched cohort study, Medicine/Surgery patients in large academic safety-net hospital. Intervention or Exposure: Pharmacy-conducted AMHs identified by risk model versus standard of care AMH. Main Outcomes and Measures: A total of 30-day hospital readmissions and inpatient ADE prevention. Results: The model screened 87 240 hospitalizations between June 2017 and June 2019 and 4027 patients per group were included. There were significantly less 30 day readmissions among high-risk identified patients that received a pharmacy-conducted AMH compared to controls (11% vs 15%; P = 0.004) and no significant difference in readmission rates for low-risk patients. While there was significantly higher documentation of major ADE prevention in the pharmacy-led AMH group versus control (1656 vs 12; P < 0.001), there was no difference in electronically-detected inpatient ADEs between groups. Conclusions: A risk tool embedded into the EMR can be used to identify patients whom pharmacy teams can easily target for AMHs. This study showed significant reductions in readmissions for patients identified as high-risk. However, the same benefit in readmissions was not seen in those identified at low-risk, which supports allocating resources to those that will benefit the most.

scholarly journals Healthcare disparities in cardio oncology: patients receive same level of surveillance regardless of race at a safety net hospital

2020 ◽  
Author(s):  
Crystal Chen ◽  
Raj Dalsania ◽  
Eman A Hamad
Keyword(s):  
Breast Cancer ◽  
Ejection Fraction ◽  
Statistical Difference ◽  
Safety Net ◽  
Referral Rate ◽  
Cancer Type ◽  
Racial Groups ◽  
Receptor Antagonists ◽  
Her2 Receptor ◽  
Safety Net Hospital

Abstract Background: Cardiotoxicity remains a dreaded complication for patients undergoing chemotherapy with human epidermal growth factor (HER)-2 receptor antagonists and anthracyclines. Though many studies have looked at racial disparities in heart failure patients, minimal data is present for the cardio-oncology population. Methods: We queried the echocardiogram database at a safety net hospital, defined by a high proportion of patients with Medicaid or no insurance, for patients who received HER2 receptor antagonists and/or anthracyclines from January 2016 to December 2018. Patient demographics, clinical characteristics, and treatment outcomes were collected. Based on US census data in 2019, home ZIP codes were used to group patients into quartiles based on median annual household income. The primary end point studied was referral rate to cardiology for patients undergoing chemotherapy. Results: We identified 149 patients who had echocardiograms and also underwent treatment with HER2 receptor antagonists and/or anthracyclines, of which 70 (47.0%) were referred to the cardio-oncology program at our institution. Basic demographics were similar, but white patients were more likely to live in ZIP codes with higher income quartiles (p<0.00001). Comparing between racial groups, there was no statistical difference in the percentage of patients that had a reduction in ejection fraction (EF) (p=0.75). There was no statistical difference between racial groups in the number of cardiology or oncology appointments attended, number of appointments cancelled, average number of echocardiograms received, additional cardiac imaging received. Black patients were more likely to receive ACEI/ARB post chemotherapy (p=0.047). A logistic regression model was created using race, age, gender, insurance, income quartile by home ZIP code, comorbidities (hypertension, hyperlipidemia, coronary artery disease, arrhythmia, diabetes mellitus, smoking, family history, age >65), procedures (coronary stents, cardiac surgery), medications pre-chemotherapy, cancer type, cancer stage, and chemotherapy. This model found that there was an increased referral rate among patients from higher income quartiles (p=0.017 for quartile 3, p=0.049 for quartile 4), patients with a history of hypertension (p<0.0001), and patients with breast cancer (p=0.02). Conclusions: The results of this study suggest that patients of our cardio-oncology population at a safety net hospital receive the same level of surveillance and treatment, and develop drop in ejection fraction at similar rates regardless of their race. However, patients that reside in ZIP codes associated with higher income quartiles, with hypertension, and with breast cancer, are associated with increased rate of referral.

scholarly journals A Focus Group Exploration of Automated Case‐Finders to Identify High‐Risk Heart Failure Patients within an Urban Safety- Net Hospital

2016 ◽  
Vol 4 (3) ◽  
pp. 11
Author(s):  
Mark E. Patterson ◽  
Derick Miranda ◽  
Gregory L. Schuman ◽  
Christopher M. Eaton ◽  
Andrew J. Smith ◽  
...  
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Focus Group ◽  
Safety Net ◽  
Heart Failure Patients ◽  
Safety Net Hospital ◽  
Urban Safety

Improving oral chemotherapy compliance and documentation in a safety-net oncology clinic.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 263-263
Author(s):  
Robert Harrison Hester ◽  
Lindsey Leigh Farmer ◽  
Rohit Vivek Goswamy ◽  
Natalie Chen ◽  
Sophia Seo-hyeon Lee ◽  
...  
Keyword(s):  
Chart Review ◽  
Safety Net ◽  
Toxicity Assessment ◽  
Oral Chemotherapy ◽  
Post Intervention ◽  
Improvement Project ◽  
Safe Delivery ◽  
Chemotherapy Drugs ◽  
Safety Net Hospital ◽  
Clinic Visits

263 Background: Barriers to safe delivery of oral chemotherapy in a safety net hospital population include lack of health insurance, delays in medication delivery, and language barriers. Baseline chart review at the Lyndon B. Johnson Hospital oncology clinic revealed sparse documentation of oral chemotherapy education and compliance. Our team conducted the present quality improvement project to improve documentation of toxicity assessment, patient education, and compliance with the oral chemotherapy agents capecitabine, palbociclib, and sorafenib by 25% from October through December 2020. Methods: A set of standardized questions designed to assess for the above domains were generated in the form of an auto-populated electronic medical record phrase ("dot phrase," see Figure 1). Using weekly timed email notifications, physicians were reminded to incorporate these questions in their documentation during clinic visits. Chart review was performed to assess usage frequency of the dot phrase. A post-intervention survey was administered to assess providers' experience with use of the dot phrase, and assess barriers to consistent documentation. Results: 41 patients over 3 months were identified as taking the oral chemotherapy drugs capecitabine (68%), palbociclib (29%) or sorafenib (3%). 63% were non-English speakers. 49% had breast cancer, 39% GI cancers, and 12% other cancers. 12% of clinic visits correctly incorporated use of the dot phrase. Education on the dosing and schedule for oral chemo was addressed for 48% of patients, documentation of adverse effects was performed for 34% of patients, and assessment of medication adherence was documented for 22% of patients. While 73% of providers felt that documentation of oral chemotherapy compliance is important, 70% cited failure to remember to incorporate the dot phrase in real time as the primary reason for failure to use the dot phrase for oral chemotherapy documentation. Conclusions: Despite providers' view of documentation of oral chemotherapy toxicities and compliance as important, low uptake of the dot phrase was observed. The main barrier to use of the dot phrase was providers' forgetting to incorporate the dot phrase prior to and during their clinic charting. Future efforts should focus on automated reminders and regular assessments to increase compliance to this important quality domain. [Table: see text]

Personalizing Cancer Supportive Care: Predicting Neutropenic Complications in Patients Receiving Intermediate Risk Cancer Chemotherapy

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1022-1022 ◽  
Author(s):  
Gary H. Lyman ◽  
Eva Culakova ◽  
Marek S. Poniewierski ◽  
Jeffrey Crawford ◽  
David C. Dale ◽  
...  
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Cancer Chemotherapy ◽  
Research Funding ◽  
Risk Model ◽  
Chemotherapy Regimen ◽  
Risk Group ◽  
Low Risk ◽  
Severe Neutropenia ◽  
Intermediate Risk

Abstract Abstract 1022 Background: Neutropenic complications represent important dose-limiting toxicities of cancer chemotherapy. We recently developed and validated a risk model for neutropenic complications in patients with solid tumors or lymphoma receiving cancer chemotherapy (Lyman et al. Cancer 2011). While practice guidelines recommend primary colony-stimulating factor (CSF) prophylaxis for patients at >20% risk of febrile neutropenia (FN), many patients receive chemotherapy regimens associated with an intermediate risk (10–20%) of FN. For these patients, the decision to give or withhold primary CSF prophylaxis is based on clinical judgment. We report here the ability of the risk model to identify patients with individual characteristics placing them at high risk for neutropenic complications among patients receiving intermediate risk chemotherapy regimens. Methods: A prospective cohort study was conducted of consenting patients initiating a new chemotherapy regimen at 115 randomly selected US oncology practices between 2002–2006. The risk of cycle 1 severe or febrile neutropenia was estimated [95% CI] utilizing logistic regression analysis adjusting for key clinical factors including: planned chemotherapy, prior chemotherapy, age, abnormal hepatic or renal function, low pretreatment white blood count, and immunosuppressive medications. The cumulative incidence of severe neutropenia and FN across 4 cycles was estimated by the product limit method of Kaplan and Meier. Results: Among 3,760 patients with cancers of breast, lung, ovary, colon, or lymphoma, 2,270 received an intermediate risk chemotherapy regimen based on NCCN guidelines. Overall, in the subpopulation receiving intermediate risk regimens, severe or febrile neutropenia occurred in cycle 1 in 21.4% while FN over 4 cycles was observed in 11%, and primary CSF prophylaxis was utilized in 16.4%. The performance of the risk model was good in this subgroup with a c-statistic of 0.82 [0.80–0.84]. Among the half of patients classified as high risk based on the model despite receiving an intermediate risk chemotherapy regimen, cycle 1 severe or febrile neutropenia occurred in 38% [35%–41%] compared to 5% [4%–6%] of patients classified as low risk based on the model receiving such regimens. Model sensitivity and specificity were 89% and 61%, respectively. The cumulative risk of FN over 4 cycles of chemotherapy was 20% in predicted high risk group versus 5% in the low risk group (Figure). The majority of severe or febrile neutropenia events (67%) and FN events (55%) were observed in cycle 1. One-half of high risk patients who did not receive primary CSF prophylaxis in cycle 1 received CSF during subsequent cycles following a neutropenic event. Conclusions: Our model for predicting neutropenic complications can identify patients at high individual risk for severe neutropenia in cycle 1 or FN in the first 4 cycles of chemotherapy when receiving intermediate risk chemotherapy. This analysis emphasizes the potential value of determining an individual patient's risk of chemotherapy complications based on a validated risk model. Disclosures: Lyman: Amgen: Research Funding. Crawford:Amgen: Consultancy, Honoraria, Research Funding. Dale:Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kuderer:Amgen: Research Funding.

scholarly journals Evaluation of a Pharmacist-Based Intervention to Reduce Readmissions in Geriatric High-Utilizer Patients: A Pilot Study

2019 ◽  
Vol 10 (2) ◽  
pp. 9
Author(s):  
Sara Turbow ◽  
Kruti Shah ◽  
Katherine Penziner ◽  
Michael Knauss
Keyword(s):  
Pilot Study ◽  
High Risk ◽  
Hospital Admissions ◽  
Safety Net ◽  
High Risk Population ◽  
Original Research ◽  
Beers Criteria ◽  
Southeastern Us ◽  
Safety Net Hospital ◽  
High Utilizer

Purpose: The goal of this study was to determine if a pharmacist-led intervention to improve medication safety at hospital discharge reduced the number of hospital readmissions among geriatric high-utilizer patients. This study is the first to test a pharmacist-based intervention in a high-utilizer population. Methods: This was a quasi-experimental pilot study done at a safety-net hospital in the southeastern US. Fifty-seven patients 65 years old and older who were in the 95th percentile for number of hospital admissions in a year were included. On the day of discharge, one of the study pharmacists reviewed the discharge medication list and calculated the Medication Appropriateness Index (MAI) for each medication and reviewed for Beers Criteria. Any medication identified as potentially high-risk or inappropriate was flagged by the pharmacist and discussed with the team. The primary outcome was the number of admissions in the year following the intervention in the intervention group versus the control group. Results: There were no statistically significant differences in the number of admissions, the MAI scores, or the number of medications meeting Beers Criteria between the two groups. Conclusion: Although this study did not demonstrate a decrease in hospital admissions, it shows that pharmacist review of medications at discharge can identify potentially unnecessary medications that could lead to confusion or adverse events. Further research is necessary to identify interventions to prevent readmissions in this high-risk population.   Article Type: Original Research

scholarly journals Healthcare disparities in cardio oncology: patients receive same level of surveillance regardless of race at a safety net hospital

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Crystal B. Chen ◽  
Raj K. Dalsania ◽  
Eman A. Hamad
Keyword(s):  
Breast Cancer ◽  
Ejection Fraction ◽  
Statistical Difference ◽  
Safety Net ◽  
Referral Rate ◽  
Cancer Type ◽  
Racial Groups ◽  
Receptor Antagonists ◽  
Her2 Receptor ◽  
Safety Net Hospital

Abstract Background Cardiotoxicity remains a dreaded complication for patients undergoing chemotherapy with human epidermal growth factor (HER)-2 receptor antagonists and anthracyclines. Though many studies have looked at racial disparities in heart failure patients, minimal data is present for the cardio-oncology population. Methods We queried the echocardiogram database at a safety net hospital, defined by a high proportion of patients with Medicaid or no insurance, for patients who received HER2 receptor antagonists and/or anthracyclines from January 2016 to December 2018. Patient demographics, clinical characteristics, and treatment outcomes were collected. Based on US census data in 2019, home ZIP codes were used to group patients into quartiles based on median annual household income. The primary end point studied was referral rate to cardiology for patients undergoing chemotherapy. Results We identified 149 patients who had echocardiograms and also underwent treatment with HER2 receptor antagonists and/or anthracyclines, of which 70 (47.0%) were referred to the cardio-oncology program at our institution. Basic demographics were similar, but white patients were more likely to live in ZIP codes with higher income quartiles (p < 0.00001). Comparing between racial groups, there was no statistical difference in the percentage of patients that had a reduction in ejection fraction (EF) (p = 0.75). There was no statistical difference between racial groups in the number of cardiology or oncology appointments attended, number of appointments cancelled, average number of echocardiograms received, additional cardiac imaging received. Black patients were more likely to receive ACEI/ARB post chemotherapy (p = 0.047). A logistic regression model was created using race, age, gender, insurance, income quartile by home ZIP code, comorbidities (hypertension, hyperlipidemia, coronary artery disease, arrhythmia, diabetes mellitus, smoking, family history, age > 65), procedures (coronary stents, cardiac surgery), medications pre-chemotherapy, cancer type, cancer stage, and chemotherapy. This model found that there was an increased referral rate among patients from higher income quartiles (p = 0.017 for quartile 3, p = 0.049 for quartile 4), patients with a history of hypertension (p < 0.0001), and patients with breast cancer (p = 0.02). Conclusions The results of this study suggest that patients of our cardio-oncology population at a safety net hospital receive the same level of surveillance and treatment, and develop drop in ejection fraction at similar rates regardless of their race. However, patients that reside in ZIP codes associated with higher income quartiles, with hypertension, and with breast cancer, are associated with increased rate of referral.

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