Substantial Variation in Peripherally Inserted Central Catheter Use and Outcomes in Patients with Hematologic Malignancies: A Multi-Center Study

Abstract Background: Use of peripherally inserted central catheters (PICCs) has grown rapidly in patients with hematologic malignancies. Studies demonstrating the safety of PICCs in hematologic malignancies, however, are largely single-center, retrospective designs focused on the outpatient setting. Little is known about inpatient PICC use in patients with hematologic malignancies and how such use varies across hospitals. Methods: Data was prospectively collected between November 2013 and December 2019 from a cohort of patients admitted at one of 42 Michigan hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Patients had a diagnosis of a hematologic malignancy and had a PICC placed during their hospital stay. Adult medical patients admitted to a general ward or intensive care unit were eligible for data collection and data were collected from the medical record using a standardized template. The indications for PICC placement, catheter characteristics, and associated complications from 17 hospitals with more than 25 discrete patients with hematologic malignancy were included in a comparative analysis. Major complications were defined as central line associated bloodstream infection (CLABSI), catheter occlusion, and venous thromboembolism (VTE). Differences across hospitals were tested using the Kruskal-Wallis test for continuous variables and Pearson chi-square test for categorical variables. Results: A total of 2092 PICCs placed in 1798 patients were included in the analysis with a median (IQR) dwell time of 15 (6-30) days. Most patients were male (n=1242, 59.4%), white (n=1720, 82.2%), and 50 to 69 years old (n=950, 45.4%). Patients were primarily admitted to large hospitals (≥375 beds: n=1429, 68.8%) that were teaching centers (n=1600, 76.5%) in metropolitan locations (n=2000, 95.6%). Leukemia (n=752, 36.0%) and non-Hodgkin's lymphoma (n=409, 19.6%) were the most represented malignancies. The most common primary indication for PICC placement was administration of chemotherapy (n=1180, 56.4%). The majority of PICCs were double lumen (n=1457, 69.6%), most often placed by vascular access nurses (n=1520, 72.7%). A concurrent central venous catheter was present at the time of PICC placement in 12.2% (n=264) of patients. A major complication event occurred in over 1 in 4 PICCs placed (n=562, 26.9%). Catheter occlusion occurred in 17.8% (n=372), CLABSI in 8.2% (n=171), and VTE in 3.8% (n=80) of PICCs respectively. There was wide variation in PICC indications, characteristics, and outcomes across hospitals. Placement of PICCs for chemotherapy varied from 33.3% to 85.3% (p<0.001). Similarly, there was a wide range of placement for antibiotics (2.8% to 32.4%, p<0.001), transfusion of blood products (0.0% to 9.7%, p<0.001), medications requiring central access (0% to 26.7%, p<0.001), difficult access and blood draws (1.8% to 33.3%, p<0.001), and administration of total parenteral nutrition (0.0% to 14.3%, p=0.002). There was significant variation in the number of lumens used: single (5.6% to 37.9%, p<0.001), double (51.9% to 93.0%, p<0.001), or triple (0.0% to 30.8%, p<0.001). The incidence of major complications spanned from 9.7% to 40.8% (p=0.001). Rate of catheter occlusion had the widest range (0.0% to 36.7%, p<0.001). The differences between rates of VTE (0.0% to 8.7%, p=0.29) and CLABSI (1.4% to 15.9%, p< 0.20) were not statistically significant. Patient mortality ranged from 2.8% to 19.4% (p<0.001). Conclusion: Appropriate venous access is critical to the care of patients with hematologic malignancy. This study demonstrates wide variation in the practice patterns and outcomes for PICCs in patients with hematologic malignancies across hospitals in Michigan. Further work is necessary to further understand and improve decision making around choosing vascular access in this vulnerable population. Figure 1 Figure 1. Disclosures Zhang: SIMR, Inc: Ended employment in the past 24 months, Research Funding; AmerisourceBergen: Current Employment. Sood: Bayer: Consultancy.

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0798 “Uncovering My Feet Alleviates My Restless Legs”: Impact of Different Activities and Conditions on Restless Legs Symptoms

SLEEP ◽

10.1093/sleep/zsaa056.794 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A303-A304

Author(s):

E G Karroum ◽

S Leu-Semenescu ◽

R Amdur ◽

I Arnulf

Keyword(s):

Ambient Temperature ◽

Categorical Variables ◽

Sign Test ◽

Fisher Exact Test ◽

Continuous Variables ◽

Exact Test ◽

Restless Legs ◽

Professional Activities ◽

Wide Range ◽

Activity Condition

Abstract Introduction The restless legs syndrome (RLS) is a resting wake state disorder with inactivity/decreased movement as an aggravating factor and activity/increased movement as an alleviating factor. Other activities and conditions may impact RLS symptoms but have not been systematically studied. Methods Fifty-six patients with primary severe RLS (age: 64.1±11.3; 66% women) responded about the effect of 20 activities/conditions on their RLS symptoms. Responses were assigned a numerical value: Aggravation (-1), No effect/Don’t know (0), Alleviation (+1), with calculating a mean effect score for each activity/condition and using a sign test to determine if that score was significantly above or below zero (no effect). Responses were further analyzed based on age, age at RLS onset, duration of RLS, RLS severity, gender, Familial/Non-familial RLS, and Painful/Non-Painful RLS. Association of continuous variables and categorical variables with each activity/condition was examined using Spearman correlation test and Fisher exact test, respectively. Bonferroni p threshold was set at p=0.00036. Results Activities/conditions with significant (p<0.0001) positive mean effect scores were: Feet uncovering (0.70); Leg massaging (0.63); Cold showers (0.54); and Manual activities (0.46). Activities with significant negative mean effect scores were: Vehicle passenger (-0.80); Show attendance (-0.70); Bedsheets weight on legs (-0.57); Watching TV (-0.54); High ambient temperature (-0.45); During meals (-0.39) (all p<0.0001); and Bedsheets rubbing on legs (-0.34; p=0.0002). Activities/conditions with no significant (all p>0.00036) mean effect scores were: Driving (0.00); Gambling (0.02); Professional activities (0.13); Hot showers (0.13); Using computer (0.14); Low ambient temperature (0.21); Sexual activities (0.27); Mental activities (0.29); and Sports activities (0.34). There was no significant association between each activity/condition and age, age at RLS onset, duration of RLS, RLS severity, gender, Familial/Non-familial RLS, or Painful/Non-Painful RLS. Conclusion There is a wide range of impact of different activities/conditions on RLS symptoms. These could be further considered in the non-pharmacological treatment or prevention of RLS symptoms. Support This study was not funded.

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Clinical Characteristics and Outcomes of Hematologic Malignancy Patients with Clostridium difficile Toxin EIA vs. PCR Positive Test Results

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.987 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S396-S396

Author(s):

Matthew Ziegler ◽

Daniel Landsburg ◽

David Pegues ◽

Kevin Alby ◽

Cheryl Gilmar ◽

...

Keyword(s):

Hematologic Malignancy ◽

Tertiary Care ◽

Positive Test ◽

Categorical Variables ◽

Continuous Variables ◽

Test Results ◽

Exact Test ◽

Academic Center ◽

Chi Squared ◽

Record Review

Abstract Background C. difficile infection is common in patients with hematologic malignancy. There is increasing recognition that molecular (polymerase chain reaction, PCR) based testing lacks specificity for infection, while detecting patients with colonization. The objective of our study was to evaluate characteristics of patients with toxin enzyme immunoassay (EIA) vs. PCR positive C. difficile test results. Methods A retrospective review of inpatients at a tertiary care academic center with hematologic malignancy and a positive C. difficile test from 1/2015 to 1/2016 was performed. Data on demographics, comorbidities, clinical features, and outcomes were collected using medical record review. Characteristics were compared between patients with EIA vs. PCR positive test results using chi-squared or Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. Results A total of 130 patients were included: 51% and 49% had a PCR positive and EIA positive result, respectively. Diagnoses included AML (42%), multiple myeloma (22%), and Non-Hodgkin’s lymphoma (13%). Antibiotic exposure was similar, with a median of 4 days of anti-pseudomonal antibiotics received in the prior 30 days. There was no difference in history of a positive C. difficile test in the prior year (12% in the EIA group, 10% in the PCR group, P = 0.71). Patients with EIA positive results were more likely to have a WBC ≥15/mm3 (18% vs. 6%, P = 0.02). However, there were no differences in presence of fever, stool frequency, or imaging evidence of colitis at the time of testing. Medications in the prior 72 hours were similar, including the use of proton pump inhibitors of ~40% and of laxatives of 28%. Clinical outcomes were also similar between patients with EIA vs. PCR positive tests: all-cause death (22% vs. 20%), recurrent CDI (9% vs. 13%), colectomy (1% vs. 4%), and megacolon (0% vs. 3%). Most patients received treatment with oral vancomycin for a median duration of 14 days. Conclusion In patients with hematologic malignancy, those with EIA vs. PCR positive C. difficile test results were clinically similar. These findings suggest that algorithms for testing and treatment of C. difficile in hematologic malignancy patients will need to be specifically targeted towards this immunocompromised population. Disclosures All authors: No reported disclosures.

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Abstract 17321: Aspirin Use is Associated With Improved Survival in Severely Thrombocytopenic Cancer Patients With Acute Myocardial Infarction

Circulation ◽

10.1161/circ.132.suppl_3.17321 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Attila Feher ◽

Rekha Parameswaran ◽

Eytan M Stein ◽

Dipti Gupta

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cancer Patients ◽

Major Bleeding ◽

Hematologic Malignancy ◽

Hematologic Malignancies ◽

Categorical Variables ◽

Cancer Center ◽

Rank Statistic ◽

Severe Thrombocytopenia

Objective: Patients with hematologic malignancies are at risk for severe thrombocytopenia (sTP). The risk and benefit of aspirin therapy is not known in thrombocytopenic cancer patients who experience an acute myocardial infarction (AMI). Methods: Medical records of patients with hematologic malignancies diagnosed with AMI at Memorial Sloan Kettering Cancer Center during 2005-2014 were reviewed. sTP was defined as platelet count <50 cells k/μL within 7 days of AMI. Demographics, aspirin use, survival and bleeding outcomes were collected. T-tests and Fisher exact tests were used to compare continuous and categorical variables. Survival rates were calculated using the Kaplan-Meier product limit method; groups were compared with log-rank statistic. Results: 118 patients with hematologic malignancies had AMI. 58/118 (49%) had sTP. 25/58 (43%) of those with sTP received aspirin. Patients were mostly male (70%, n=83), mean age 69±11 years, mean follow up 3.6 years. Non-Hodgkin’s lymphoma was the most common hematologic diagnosis (36%, n=42). Survival was significantly worse in patients with sTP vs. no sTP (23% vs. 50% at 1 year, log rank p=0.008). When compared to no sTP with AMI, patients with sTP and AMI were less likely to receive aspirin (83% vs 43%, p=0.0001), thienopyridine (27% vs 3%, p=0.0005) and to undergo coronary angiography (30% vs. 5%, p=0.0005) and revascularization (17% vs. 3%, p=0.03). Cancer patients with sTP and AMI who received aspirin had improved survival when compared to those not treated with aspirin, (92% vs. 70% at 7 days, 72% vs. 33% at 30 days and 32% vs. 13% at 1 year, log rank p=0.008). No fatal bleeding events occurred. Thrombolysis in Myocardial Infarction (TIMI) major bleeding occurred in one patient without sTP. Conclusions: In hematologic malignancy patients with AMI and sTP the use of aspirin was associated with improved survival without increase in major bleeding.

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En route intraosseous access performed in the combat setting

American Journal of Disaster Medicine ◽

10.5055/ajdm.2016.0243 ◽

2016 ◽

Vol 11 (4) ◽

pp. 225-231 ◽

Cited By ~ 3

Author(s):

Shelia Savell, PhD, RN ◽

Alejandra G. Mora, BS ◽

Crystal A. Perez, RN, BSN ◽

Vikhyat S. Bebarta, MD ◽

Joseph K. Maddry, MD

Keyword(s):

Success Rate ◽

Outcome Measures ◽

Vascular Access ◽

Categorical Variables ◽

Continuous Variables ◽

Care Providers ◽

Success Rates ◽

Intraosseous Access ◽

Chi Square ◽

Medical Evacuation

Objective: To describe and compare vascular access practices used by en route care providers during medical evacuation (MEDEVAC). Design: This was a retrospective cohort study. Medical records of US military personnel injured in combat and transported by MEDEVAC teams were queried.Patients: The subjects were transported by military en route care providers, in the combat theater during Operation Enduring Freedom (OEF) between January 2011 and March 2014. The authors reviewed 1,267 MEDEVAC records of US casualties and included 832 subjects that had vascular access attempts.Main outcome measures: The outcome measures for this study were vascular access success rates, including intravenous (IV) and intraosseous (IO) attempts. Subjects were grouped by type of vascular access: None, peripheral intravenous (PIV), IO, and PIV + IO (combination of PIV and IO) and by vascular access (PIV or IO) success (No versus Yes). Survival rate, in-flight events, ventilator, intensive care and in hospital days, and 30-day outcomes were compared among groups. Statistical analysis: The authors used chi-square or Fisher's exact tests to evaluate categorical variables. Analysis of variance (ANOVA) or Kruskal-Wallis tests were used for continuous variables. Results: Vascular access was attempted in 832 (66 percent) of the 1,267 subjects transported by MEDEVAC during this study period. The majority (n = 758) of the access attempts were PIV of which 93 percent (706/758) were successful. In 74 subjects, IO was the only access attempted with an 85 percent (n = 63) success rate. The overall success rate with IO placement was 88 percent. Conclusions: Intraosseous access has been used successfully in the combat setting and accounts for approximately 12 percent of vascular access in the MEDEVAC population the authors studied.

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2596. Invasive Fungal Disease in Patients with GATA2 Variant Hematologic Malignancy

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2274 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S902-S902

Author(s):

Tyler D Bold ◽

Rahul S Vedula ◽

Matthew P Cheng ◽

Francisco M Marty ◽

R Coleman Lindsley

Keyword(s):

Hematologic Malignancy ◽

Retrospective Chart Review ◽

Invasive Fungal Disease ◽

Hematologic Malignancies ◽

Fungal Disease ◽

Infectious Complications ◽

Genetic Diagnostics ◽

Cancer Center ◽

Sequence Variant ◽

Wide Range

Abstract Background Patients with hematologic malignancies (HM) are at risk of invasive fungal disease (IFD). Identification of those patients at the highest risk for IFD would help optimize prophylactic or preemptive treatment decisions in this population. We previously found that among patients with myeloid malignancies who develop invasive aspergillosis, 15% had a mutation in the gene GATA2. Here, we report the incidence of IFD in a cohort of patients with HM related to a pathogenic sequence variant of GATA2. Methods We identified 6343 patients cared for at Dana-Farber/Brigham and Women’s Cancer Center between January 2014 and August 2018 who underwent a next-generation sequencing assay of 95 genes recurrently mutated in hematologic malignancy. Those found to have a pathogenic GATA2 sequence variant were selected for retrospective chart review with respect to serious infectious complications including IFD. Results We identified 54 patients with a pathogenic GATA2 variant. 5 had a germline mutation related to familial GATA2 deficiency. The other 49 had a HM, mostly (41/49) acute myeloid leukemia or myelodysplastic syndrome. The frequency of the variant GATA2 allele in this group ranged from 2.5 to 92.0% of sequencing reads. 14 patients were excluded due to lack of sufficient follow-up, often related to treatment at another institution. Of the remaining 35 patients, 13 (37%) had proven/probable invasive fungal infection (IFI). Fourteen others had syndromes consistent with possible IFD. In total, 16 of these 35 patients (46%) received antifungal therapy for proven, probable or possible IFD. Four of the patients not treated with antifungals were diagnosed with a serious infection including 2 cases of Staphylococcus aureus bacteremia, and one case of disseminated Mycobacterium avium complex. Conclusion We identified a high incidence of IFD among patients with HM related to a pathogenic sequence variant of GATA2. The wide range of variant allele frequency observed raises the possibility that either inherited or acquired GATA2 dysfunction could incur predisposition to infection. These data suggest that personalized genetic diagnostics of patients with HM may be useful for assessment of infectious risk. Disclosures All authors: No reported disclosures.

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Characteristics of patients infected with SARS COVID-19 admitted at COVID health facilities in one of the aspirational district of India: a retrospective study

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20204741 ◽

2020 ◽

Vol 7 (11) ◽

pp. 4435

Author(s):

Ekta Sharma ◽

Gurmeet Katoch ◽

Rajesh Guleri ◽

Jalam Bhardwaj

Keyword(s):

Large Scale ◽

Clinical Laboratory ◽

Descriptive Analysis ◽

Laboratory Data ◽

Age Groups ◽

The Elderly ◽

Categorical Variables ◽

Close Monitoring ◽

Continuous Variables ◽

Wide Range

Background: COVID-19 is the third corona virus that has emerged among the human population in the last two decades. The main aim of this study was to describe the epidemiologic features, clinical presentation of first 52 patients diagnosed with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection admitted at COVID health facilities.Methods: A retrospective descriptive study was conducted over a period of three months from 1st April 2020 to 30th June 2020. We obtained demographic, epidemiological, clinical, laboratory data from the medical records of patients infected with SARS-Cov-2. The categorical variables were expressed in terms of frequency and percentages and the continuous variables were expressed as mean and standard deviation. In addition to descriptive analysis, Pearson’s chi- square test was applied to ascertain the associations between certain variables.Results: The mean age of participants was 29±11.67 years with a male preponderance. Forty three (83%) patients had travel history within India in the previous 30 days i.e. from Delhi (35%), Haryana (15%), Tamilnadu (11%), Himachal Pradesh (8%), Maharashtra (1.9%), Punjab (8%), and Uttar Pradesh (4%). Majority of the patients (90%) were asymptomatic. The age group of 21-30 years was the most affected group (44%) as comparison to the other age groups. No mortality was reported and 100% recovery rate was found.Conclusions: In conclusion, COVID-19 affects a wide-range of patients, from youth to the elderly. In this study, all the COVID-19 infected patients were classified as mild as most were asymptomatic. Close monitoring and large-scale control strategies will be needed to prevent widespread transmission within the community.

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Analysis of Patient Handoff between Providers at a Tertiary Urban Medical Center

Kansas Journal of Medicine ◽

10.17161/kjm.vol1415170 ◽

2021 ◽

Vol 14 ◽

pp. 192-196

Author(s):

Candice Metzinger ◽

Samer Antonios ◽

K James Kallail ◽

Hayrettin Okut ◽

Rosey Zackula ◽

...

Keyword(s):

Nurse Practitioners ◽

Medical Center ◽

Hospital Medicine ◽

Physician Assistants ◽

Categorical Variables ◽

Inpatient Stay ◽

Continuous Variables ◽

Medical Patients ◽

Provider Type ◽

Attending Physicians

Introduction. Few studies have quantified the total number of attending and consulting physicians involved in inpatients’ care, and no other research quantifies the total number of all providers participating in inpatients’ care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients’ care for all admitted patients at a tertiary urban medical center. Methods. The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 01, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation. Results. The sample included information from 200 patient charts. Patients’ ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients’ stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties for medical patients were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care. Conclusions. Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care.

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Representation on feature and patient levels from structured Electronic Medical Records based on Skip-gram algorithm (Preprint)

10.2196/preprints.19905 ◽

2020 ◽

Author(s):

Yanqun Huang ◽

Ni Wang ◽

Zhiqiang Zhang ◽

Honglei Liu ◽

Xiaolu Fei ◽

...

Keyword(s):

Data Representation ◽

Primary Diagnosis ◽

Machine Learning Algorithms ◽

Categorical Variables ◽

Continuous Variables ◽

Stroke Patients ◽

Feature Representations ◽

Wide Range ◽

Silhouette Index ◽

Discrete Values

BACKGROUND The secondary utilization of the structured electronic medical record (sEMR) data has become a challenge due to the diversity, sparsity, and high-dimensionality of the data representation. OBJECTIVE We aimed to explore the feasibility of the embedding-based feature and patient representation for sEMR data and demonstrate the efficiency and superiority of the embedding-based patient representation. METHODS The entire training corpus consisted of records of 104752 hospitalized patients with 21 variables, including demographic characteristics, disease diagnoses, procedures, medications, laboratory tests, and other hospitalization indicators. Discrete values for original categorical variables and binned continuous variables were considered as words (concepts), and thus a record as a sentence in a text. To eliminate the influence the concept sequence played on the embedding algorithm, we randomly shuffled the concepts within a sentence 20 times. For a patient record, each feature concept was embedded into a 200-dimensional real number vector using the Skip-gram algorithm. Then the average of all the embedding concept vectors represented the patient. To assess the effectiveness of these embedding-based feature representations, we used the cosine distances among features’ embedding vectors to capture the latent relationship among the concepts of different features. We further conducted cluster analysis on stroke patients to evaluate and compare the efficiency and superiority of the embedding-based patient representation, where the embedding vectors were trained using the overall patients and just the stroke patients with and without the concept shuffling respectively. The representations of both multi-hot codes and one-hot codes plus original continuous numbers were used as the benchmark representations. RESULTS According to the Silhouette index, stroke patients were clustered into two groups, characterizing in patients with a primary diagnosis of hemorrhage stroke (HS) and ischemic stroke (IS), respectively. Cluster analyses conducted on patients with the embedding representations showed higher applicability (Hopkins Statistics, 0.925), higher aggregation (Silhouette index, 0.862), and lower dispersion (Davies Bouldin index, 0.551) than those conducted on patients with the benchmark representations. The two clusters for patients with the embedding-based representation learned from all the records after the concept shuffling achieved the highest F1-scores of 0.944 for IS and 0.717 for HS, respectively. CONCLUSIONS The feature-level embeddings can reflect the potential associations among medical concepts to some degree. The patient-level embeddings can be easily used as continuous input to standard machine learning algorithms and bring performance improvement. We expect that the embedding-based representation will be helpful in a wide range of the secondary use of the sEMR data.

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255. Breakthrough Mucormycosis (BT-MCR) on Antifungals Having Mucorales Activity Portrays Worse Prognosis compared with BT-MCR on Mold-Active Antifungals with no Mucorales Activity

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.330 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S142-S142 ◽

Cited By ~ 2

Author(s):

Dierdre B Axell-House ◽

Ying Jiang ◽

Andreas Kyvernitakis ◽

Russel E Lewis ◽

Issam I Raad ◽

...

Keyword(s):

Stem Cell ◽

Stem Cell Transplant ◽

Cox Regression ◽

Hematologic Malignancies ◽

Categorical Variables ◽

Cancer Center ◽

Cell Transplant ◽

Continuous Variables ◽

Group A ◽

Group B

Abstract Background BT-MCR is known to develop in the setting of agents having Aspergillus but no Mucorales activity. However, BT-MCR can occur even with the use of antifungals having with Mucorales activity in patients with hematologic malignancies and or stem cell transplant (HM). Methods We reviewed the records of HM patients treated for MCR (1994 to 2019) at MD Anderson Cancer Center. We identified patients with BT-MCR on antifungals having Mucorales activity: posaconazole (POSA), isavuconazole (ISA), and amphotericin B (AMB) (group A), and patients with BT-MCR on agents having Aspergillus but no Mucorales activity: voriconazole (VRC), itraconazole (ITZ), echinocandins (group B). BT-MCR was defined as MCR diagnosis (dx) after ≥7days (d) of antifungal use. The primary outcome was 42d mortality after the BT-MCR dx. Chi-square or Fisher’s exact test was used for categorical variables and Wilcoxon rank-sum test used for continuous variables. Cox regression model was used to evaluate the independent variables on outcome. Results We identified 11 patients in group A (3 POSA, 5 ISA, 3 AMB) and 81 patients in group B (61 VRC, 13 echinocandins, 7 ITZ). Both groups were not different in terms of age, sex, underlying HM (AML/MDS in 100% vs. 88% in groups A and B, respectively), status of HM (active disease in 82% vs. 67%), prior stem cell transplant (45% vs. 54%) or GvHD (80% vs. 84%), neutropenia at dx (55% vs. 42%), prior receipt of >600 mg of prednisone (45% vs. 41%) or ICU at MCR dx (36% vs. 26%). Similarly, Mucorales species (Rhizopus spp. in 55% vs. 49%) and type of infection (sino-pulmonary in 73% vs. 68%) were no different between the groups. However, both d42 (82% vs. 46%, P = 0.025) and d84 (100% vs. 60%, P = 0.007) mortality was worse in group A. Similarly, median time to death was faster in patients in group A (26d, range 7-80d), vs. group B (42d, range 4–3146d, P = 0.031). Kaplan–Meier analysis showed a similar difference (Figure 1). In multivariate analysis, neutropenia (P = 0.038) and ICU at dx (P = 0.002) were independent factors on day 42d mortality in all 92 patients with prior Mucorales–active antifungals showing a trend associated with poor outcome (P = 0.17). Conclusion BT-MCR on agents having Mucorales activity is a marker of poor prognosis in HM patients. Early use of investigational immunotherapy and salvage antifungal chemotherapy studies is needed in that subgroup of patients. Disclosures All authors: No reported disclosures.

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988. Overcoming Prescriber Concerns through Successful Access and Affordability of PrEP

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1174 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S522-S523

Author(s):

Kristen Whelchel ◽

Autumn Zuckerman ◽

Josh DeClercq ◽

Leena Choi ◽

Shahristan Rashid ◽

...

Keyword(s):

Treatment Initiation ◽

Patient Characteristics ◽

Initial Evaluation ◽

Categorical Variables ◽

Continuous Variables ◽

Financial Barriers ◽

Entire Study ◽

Medication Costs ◽

Primary Indication ◽

Insurance Approval

Abstract Background Increasing the number of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) providers expands PrEP access to more eligible patients and aids in ending the HIV epidemic. Non-prescribers of PrEP have noted perceived financial barriers as a limitation to prescribing. The purpose of this study is to describe the PrEP medication access process and outcomes in patients seen at a multidisciplinary PrEP clinic. Methods We conducted a single-center, retrospective, cohort study of patients prescribed PrEP with emtricitabine-tenofovir disoproxil fumarate from a multidisciplinary clinic with prescriptions filled by Vanderbilt Specialty Pharmacy between 9/1/2016 and 3/31/2019. Patient data were gathered from the electronic health records and pharmacy claims data. We evaluated three different time periods: patient initial evaluation to PrEP initiation, prescription of PrEP to insurance approval, and PrEP insurance approval to initiation. Treatment initiation was considered a delay of > 7 days from initial evaluation, and reasons for delay were recorded. Continuous variables are presented as median (interquartile range, IQR) and categorical variables are presented as percentages. Results Characteristics of the 63 included patients are in Table 1; most were male (97%), white (84.%), commercially insured (94%) with a median age of 38 years (IQR 29—47). The primary indication for PrEP was men who have sex with men at high risk for acquiring HIV (97%). The median time from initial appointment to treatment initiation was 7 days (IQR 4—8); Figure 1. Treatment delays were observed in 25% of patients and were mostly driven by patient preference (50% of delays). Insurance prior authorization was required in 27% of patients, all of which were approved. Median total out of pocket medication costs for the entire study period were $0 (IQR $0 – $0); Figure 2. Most patients (86%) used a manufacturer copay card. Table 1 Patient Characteristics Figure 1 Time to Treatment Initiation Figure 2 Patient Out of Pocket Cost and Savings Conclusion In our cohort of mostly commercially insured men, the majority were able to access PrEP with low out of pocket costs facilitated by manufacturer assistance. Though generalizability beyond this population is limited, these results contradict perceived financial barriers to PrEP access. Disclosures All Authors: No reported disclosures

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