Impact of leucovorin shortage on patient treatment.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e17566-e17566
Author(s):  
Mina Samir Erian Hanna ◽  
Peter Kozuch ◽  
Molly Thorn ◽  
Janna Roitman ◽  
Michael L. Grossbard ◽  
...  

e17566 Background: Shortages of intravenous leucovorin were initially reported in late 2008, and availability plummeted nationally and at Continuum Cancer Centers of New York (CCCNY) in late 2011. NCCN guidelines recommend either the use of levoleucovorin or low dose leucovorin during the shortage. The impact of the leucovorin shortage on patient therapy remains unknown. Methods: We reviewed patient charts for all outpatients treated with leucovorin at CCCNY between April and September of 2010, 2011, and 2012. We recorded patient characteristics, and leucovorin use (dose, number of treatments); and calculated descriptive statistics. We classified each dose as either low (20-40 mg/m2) or high (200-500mg/m2) and compared leucovorin use between years with Chi Square and ANOVA tests. We also reviewed pharmacy purchasing data to evaluate the economic effect of the leucovorin shortage. Results: We identified 55 patients treated with 313 doses of leucovorin in 2010, 99 patients treated with 582 doses in 2011 and 118 patients treated with 742 doses in 2012. No patients received levoleucovorin. Patient characteristics, disease and stage were similar between years with colorectal cancer accounting for 78%, 69%, and 70% of patients in 2010, 2011, and 2012 (p=0.87). Low dose leucovorin was used in 30.0% of doses in 2010, 30.4% in 2011, and 99.1% in 2012 (p<0.0001). The mean dose/treatment (SD) was 459 mg (296), 499 mg (328), and 47 mg (89), in 2010, 2011, 2012, respectively (p<0.0001). Among patients treated for colon cancer we found no association between stage (III vs. IV) and use of low dose leucovorin in 2010 or 2011. Quantity of leucovorin purchased at one hospital decreased by 63% from 171.75 g in 2010 and 157.50g in 2011 to 63.00 g in 2012. The price of leucovorin was similar at 0.017 $/mg in 2011 and 0.013 $/mg in 2012. Conclusions: Worsening leucovorin drug shortage was associated with a profound change in leucovorin use at CCCNY between 2011 and 2012. In accordance with NCCN guidelines, physicians used more low dose leucovorin. The price of leucovorin remained constant despite limited supply. Additional patient follow up is warranted to evaluate the outcomes of patients treated during the shortage.

2020 ◽  
Vol 08 (12) ◽  
pp. E1865-E1871
Author(s):  
Srihari Mahadev ◽  
Olga C. Aroniadis ◽  
Luis H. Barraza ◽  
Emil Agarunov ◽  
Michael S. Smith ◽  
...  

Abstract Background and study aims The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020. Participants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Results Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5 % (18 – 84 %) of hospital beds at the time of survey completion, with 14.5 % (2 %-23 %) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90 % (66 %-98 %) and 84.5 % (50 %-97 %) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88 % for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67 % and obstructive jaundice in 20 %); Colonoscopies (4/unit/week for bleeding in 77 % or colitis in 23 %) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44 % performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6 % in the first 2 weeks and up to 19.6 % in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6 % COVID +) and ERCP (10.2 % COVID +). Conclusions COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Leslie Corless ◽  
Tamela L Stuchiner ◽  
Cameron Garvin ◽  
Alexandra C Lesko ◽  
Elizabeth Baraban

Background: Few studies have shown the impact of substance use (SU) on treatment and outcomes of stroke patients. Research suggests stigma related to SU impacts patient experience in healthcare settings. In this study we assessed whether there were differences in patient characteristics and outcomes for stroke patients with SU compared to those with no substance use (NSU). Methods: Retrospective data from two Oregon hospitals included patients admitted with stroke diagnosis, 18 years or older, who discharged between October 2017 and May 2019. Patients with documented SU and specific SU type were compared to patients with NSU with regard to demographics, medical history, stroke subtypes, treatment, discharge disposition and length of stay (LOS). SU was defined as any documented abuse of alcohol (ETOH), methamphetamine (MA), cannabis, opiates, cocaine, benzodiazepines, and Methyl-enedioxy-methamphetamine (MDMA). Non parametric median tests and Pearson’s chi square tests were used. Results: Among 2,030 patients included in the analysis, 13.8% (n=280) were SU and 86.2% (n=1,750) were NSU. Patients with SU were significantly younger, median age (61 vs. 73, p <.001) and less were female (35.4% vs. 53.6%, p <0.001). Those with SU had lower prevalence of dyslipidemia (43.6% vs. 59.5%, p <0.001), AFIB (12.5% vs. 22.2%, p <0.001), and previous TIA (6.1% vs 10.8%, p=0.02), and more smoked (54.3% vs 13.3% p <0.001). More patients with SU arrived via transfer (38.4% vs 27.4%, p=.001). Fewer patients with SU expired or were discharged to hospice (8.9% vs 13.7%) and a greater percent left against medical advice (AMA) (3.2% vs 0.6%) (p<.001). When comparing specific SU types to NSU, all SU groups were younger, had similar medical histories and a greater proportion left AMA. Only MA users had differentiating stroke diagnoses with a higher percent of SAH (14.5% vs 5.6%) (p=.003) in addition to longer LOS (6 vs 4 days, p=.006). No differences were found in acute stroke treatment rates. Conclusion: Patients with SU were demographically different from the NSU population and did differentiate on some stroke care outcomes and processes, potentially indicating opportunities to address stigma around substance use to meet the needs of patients with both stroke and substance use.


2021 ◽  
Vol 12 (05) ◽  
pp. 1101-1109
Author(s):  
Ashley B. Stephens ◽  
Chelsea S. Wynn ◽  
Annika M. Hofstetter ◽  
Chelsea Kolff ◽  
Oscar Pena ◽  
...  

Abstract Background Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. Objective This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). Methods We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was “on” versus “off” for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. Results Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). Conclusion CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.


2020 ◽  
Vol 38 (01) ◽  
pp. 016-022
Author(s):  
Melissa T. Chu Lam ◽  
Emily Schmidt-Beuchat ◽  
Emma Geduldig ◽  
Lois E. Brustman ◽  
Katie Hyewon Choi ◽  
...  

Objective This study aimed to estimate the prevalence of measles immunity in a cohort of pregnant women in New York City and determine if there is a positive correlation of measles immunity with patient demographics, rubella immunity, number of measles, mumps, and rubella vaccine (MMR) doses received, and age at last vaccination. Study Design This is a cross-sectional study of pregnant patients seen at a single institution from January 2019 to May 2019. Patients were classified as measles and rubella immune or nonimmune using commercial immunoglobulin G (IgG) tests. Patient characteristics were compared using t-tests, Chi-square tests, or Fisher's exact tests as appropriate. The association of age at last vaccination with immunity status was assessed using multivariable logistic regression adjusted for age at presentation. The utility of rubella IgG for distinguishing measles immunity was assessed using receiver operating characteristic curve analysis. Results Serologic immunity for measles and rubella was obtained for 1,366 patients. Of these, 1,047 (77%) were measles immune and 1,291 (95%) were rubella immune. Patients born after 1989 were less likely to be immune to measles, while multiparity and private insurance were associated with increased measles immunity. Documentation of MMR vaccination was available for 140 (10%) patients. Of these, 44 (31%) were serologically nonimmune to measles and 9 (6.4%) were nonimmune to rubella. In patients known to have received one dose of MMR, 62% (24/39) were immune to measles with an improvement to 72% (69/96) among those who received two or more doses. Age at last vaccination was not associated with measles immunity. Rubella IgG level was a poor predictor of positive measles titer (area under the curve = 0.59). Conclusion Approximately one of every four pregnant patients is serologically measles nonimmune, even among women with documented MMR vaccination or documented rubella immunity. These findings raise concerns that relying on vaccination history or rubella immune status may not be sufficient to assure protection from infection with measles. If further suggests that measles serology should be added to routine prenatal laboratory testing to identify nonimmune patients that may benefit from postpartum vaccination. Key Points


2009 ◽  
Vol 27 (15_suppl) ◽  
pp. e20509-e20509
Author(s):  
H. M. Holmes ◽  
K. T. Bain ◽  
R. Luo ◽  
A. Zalpour ◽  
E. Bruera ◽  
...  

e20509 Background: Low-molecular weight heparin (LMWH) is preferred over warfarin in patients with thromboembolic disease and active cancer, but no guidelines exist in hospice. Although warfarin may be less safe in hospice patients, hospices may prefer to provide warfarin due to lower cost and less invasiveness compared to LMWHs. We sought to identify disparities in the use of warfarin vs. LMWHs in cancer patients enrolled in hospice. Methods: We analyzed a dataset from a national pharmacy provider for more than 800 hospices. We identified patients with a terminal diagnosis of cancer who were enrolled and died in hospice in 2006 and who were prescribed warfarin or LMWH. Patient characteristics included age, gender, race, cancer diagnosis, length of hospice service, and number of comorbidities. For descriptive comparisons, the Kruskal-Wallis test was used for continuous variables, and the Chi-square test was used for categorical variables. Results: Of 54,764 patients with cancer admitted and deceased in 2006, 3874 (7.1%) were prescribed warfarin, and 1137 (2.1%) were prescribed LMWH. Patients prescribed warfarin (n=576) or enoxaparin (n=5) for treatment of atrial arrhythmias were excluded. The mean age was 70.6 years for warfarin and 64.8 years for LMWH (p<0.0001). The mean and median lengths of service, respectively, were 43.6 days and 23.0 days for warfarin and 35.0 and 18.0 days for LMWH, (p<0.0001). There were no differences for gender, and a higher proportion of white patients were prescribed warfarin. Patients prescribed warfarin had an average of 2.1 comorbid conditions, versus 1.6 conditions for LMWH (p<0.0001). Cancer diagnoses were significantly different between the two groups, with a higher proportion of patients with lung and prostate cancer taking warfarin. Conclusions: Patients prescribed warfarin were older, had more comorbidities, and a longer length of service than patients prescribed LMWHs. Further research is needed to determine the impact of anticoagulation on outcomes, especially cost and quality of life, for cancer patients in hospice. This study raises the need to establish guidelines for the appropriateness of anticoagulation in hospice patients with cancer. No significant financial relationships to disclose.


2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 377-377
Author(s):  
Caitlin Takahashi ◽  
Ravi Shridhar ◽  
Jamie Huston ◽  
Anjan Jayantilal Patel ◽  
Richard H. Brown ◽  
...  

377 Background: Extra-hepatic cholangiocarcinomas (EHC) are low-incidence cancers that are difficult to diagnose and associated with a dismal prognosis. Surgery remains the only option for durable survival however R1 resections are high. We sought to examine the impact of adjuvant therapies on survival in patients with EHC. Methods: Utilizing the National Cancer Database we identified patients who underwent resection for EHC. We then stratified by adjuvant therapy (chemo(AC) or chemoradiation(CRT). Baseline comparisons of patient characteristics were made using Mann-Whitney U, Kruskal Wallis and Pearson’s Chi-square test as appropriate. Survival analyses were performed using the Kaplan-Meier method. Multivariable cox proportional models (MVA) were developed to identify predictors of survival. All statistical tests were two-sided and α < 0.05 was considered significant. Results: We identified 4334 patients who underwent EHC resection: AC = 775, CRT = 1254, no adjuvant (NA) therapy = 2305 and a median age of 67 (18-90) years. R0 resections was performed in 71.6% of patients and the median LN harvest was 9 (3-18). R0 resections and lymph node negative patients demonstrate improved survival p < 0.001 and p < 0.001. Adjuvant therapy did not improve survival in R0 resections, p = 0.2. However survival was benefited in R1 patients, with those receiving CRT demonstrating the most significant improvement: median and overall 5-year survival AC = 16.7 months 8%, CRT = 23.1 months, 20.4%, and NA = 16.1 months and 11.6% p < 0.001. In LN- patients CRT (47.3 months, 47%) but not AC (45 months, 44.5%) demonstrated benefit in survival compared to NA (37.8 months, 40.1) p = 0.04 and p = 0.7. Additionally, patients with LN+ and R1 resection had survival benefit when treated with (CRT 24.9 months and 24.3%), compared to NA (20.2 and 21.1%), p = 0.02. AC (24 months and 24%) did not demonstrate survival in these patients, p = 0.21. MVA demonstrated that age, T-stage, LN+, R0 resection and CRT were predictors of survival. Conclusions: Adjuvant CRT improves survival for patients with EHC who underwent R1 resections, and in LN- and LN+ patients. However, AC only benefited node positive patients with R0 resections. Patients with resected EHC should be referred for adjuvant CRT.


Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 547-547
Author(s):  
Mark A. Crowther ◽  
David Garcia ◽  
Walter Ageno ◽  
Daniel M. Witt ◽  
Sam Schulman ◽  
...  

Abstract The optimal therapy for patients who present with markedly prolonged INR values during warfarin therapy is undefined. Evidence suggests that the risk of bleeding increases directly with the degree of prolongation of the INR. Traditional therapy for patients with excessive warfarin associated anticoagulation has included warfarin withdrawal with or without vitamin K, transfusion therapy and admission to the hospital. As part of an ongoing international study, we prospectively enrolled 32 consecutive warfarin-treated patients presenting with an INR of more than 10.0. Eligible patients had no evidence of active bleeding or need for immediate correction of their INR. All patients received 2.5 mg of oral vitamin K, were not treated with coagulation factor replacement, and were followed over 90 days for clinical events and their INR response. Seventeen of the 32 patients were women, with an average age of 65.8 (range 31 to 89). Treatment of venous thrombosis and atrial fibrillation (12 patients each) were the most common indications for warfarin. Twenty-five patients had a target INR of 2.0 to 3.0; the remainder had a target of 2.5 to 3.5. The mean INR at presentation was 12.9 (range 10.0 to 21.2). Of the 25 patients with a recorded INR value on the day following vitamin K, 19 (76%) had an INR of 6.0 or less (range 1.6 to 17.5, mean 5.0, 2 less than 2.0). On day 7 after study drug, the mean INR was 3.5 (range 1.6 to 17.5). Six (19%) patients reported bleeding over the 90 days after study drug: 1 (3%) bleed was major (retroperitoneal hemorrhage diagnosed the day after study drug) and 3 patients reported epistaxis or bruising within three days of study drug. Two patients reported late bleeding; one had a fall on day 8 at which time the INR was 10.5, and the other had bleeding associated with a surgical procedure 25 days after study drug. No patients had suspected or confirmed thrombosis, and no patients died during follow-up. This the first prospective study of vitamin K monotherapy for patients with INR values above 10, and confirms prior retrospective analyses which suggest that low dose oral vitamin K effectively lowers the INR in such patients. Our preliminary results also suggest that coagulation factor replacement may be unneeded in such patients. The true risk of bleeding, and the impact of degree of prolongation of the INR on the vitamin K response, will require additional patient recruitment.


2012 ◽  
Vol 187 (4S) ◽  
Author(s):  
Howard Korman ◽  
David Wenzler ◽  
Thomas Lanni ◽  
Chirag Shah ◽  
Jan Parslow ◽  
...  

Author(s):  
Emilia Bellucci ◽  
Lasitha Dharmasena ◽  
Lemai Nguyen ◽  
Hanny Calache

This paper reports on the Failure To Attend (FTA) rate of appointments as well as patients following the implementation of SMS reminders in a public dental outpatient service.  Given the ineffectiveness of the intervention and a highly representative patient’s profile, this paper identifies the demographic characteristics of patients who miss all of their appointments.  Data on appointment attendance, patient demographics and dental service type was collected over a time period of 46 consecutive months.  Using descriptive and inferential statistics (chi-square, two sample tests and Marascuilo procedure) we found the SMS intervention was ineffective in reducing the FTA rates. Further, patients associated with high rates of non-attendance exhibited one or more of the following characteristics: male; age 26 – 44; non-concession card holders; a person of Indigenous, local, Asian or African descent, and of refugee status, persons living in low socio-economic areas; and appointments in General Care and Student Clinics. Whilst the literature overwhelmingly attributes SMS reminders to improving the attendance rate of patients in outpatient clinics, our contradictory findings suggest a more targeted approach in settings whose patients exhibit strong characteristics associated with non-attendance. 


2019 ◽  
Vol 101-B (7) ◽  
pp. 800-807 ◽  
Author(s):  
S. N. Hampton ◽  
P. A. Nakonezny ◽  
H. M. Richard ◽  
J. E. Wells

Aims Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures. Patients and Methods Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis. Results A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R2 = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R2 = 0.4985). Age, HADSA, patient’s percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R2 = 0.5802). Conclusion Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800–807.


Sign in / Sign up

Export Citation Format

Share Document