Impact of a best practice alert on transfusion practices for solid tumor oncology patients.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 57-57
Author(s):  
Ryan Buck ◽  
Kelley Wachsberg ◽  
Charlotta Weaver ◽  
Lyndsey Dombrowski ◽  
Madeleine Ma ◽  
...  
Keyword(s):  
Solid Tumor ◽  
Best Practice ◽  
Inpatient Mortality ◽  
Post Intervention ◽  
Oncology Patients ◽  
Restrictive Transfusion ◽  
Packed Red Blood Cells ◽  
Comorbidity Index ◽  
Best Practice Alert ◽  
Restrictive Transfusion Strategy

57 Background: Recent evidence supports a restrictive transfusion strategy in the majority of hospitalized patients, though transfusion practices for oncology patients remain highly variable. We evaluated whether use of a best practice alert for solid tumor oncology inpatients would result in more restrictive transfusion practices and impact patient outcomes. Methods: We conducted a retrospective, historical control analysis at a large academic hospital in Chicago, IL. We compared transfusion utilization among solid tumor oncology patients before and after implementation of a transfusion alert. Patients with active bleeding, hematologic malignancies and those undergoing surgical procedures were excluded. A best practice alert with clinical decision support encouraging use of a restrictive transfusion strategy (Hgb < 7 g/dL) was implemented 6/14 with phase-in completed by 9/14. We abstracted PRE intervention medical records of patients hospitalized from 5/1/13 to 4/30/14 and POST intervention records from 9/1/14 to 8/31/15. Readmission rates, incidence of ICU transfer and inpatient mortality were also compared using multiple linear regression. Outcomes were adjusted for age, gender, race, BMI, smoking status and Charlson comorbidity index. Results: 1296 total patients were included in the analysis (PRE, n = 685; POST, n = 611). There were no differences in age, gender, BMI or Charlson comorbidity index among cohorts, although the PRE cohort included more Caucasians (60.2% vs. 46.8%, p < 0.0001) and smokers (6.0% vs. 2.5%, p = 0.002). Packed red blood cells transfused per 100 patient-days were significantly lower in the POST-intervention cohort (3.8 vs. 6.4, p = 0.01). The POST-intervention cohort also had fewer 30-day emergency department visits (3.3% vs. 5.1%, p = 0.03). There were no significant differences in rates of 30-day readmission (34.6 % vs. 37.3%, p = 0.19), ICU transfer (0.5% vs. 1.1%, p = 0.08) or inpatient mortality (1.7% vs. 1.8%, p = 0.96). Conclusions: Implementation of a best practice alert among solid tumor oncology patients effectively reduced utilization of packed red blood cells without affecting patient outcomes.

Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse

2019 ◽  
Vol 152 (5) ◽  
pp. 544-557
Author(s):  
James H Derzon ◽  
Nicole Clarke ◽  
Aaron Alford ◽  
Irwin Gross ◽  
Aryeh Shander ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Best Practice ◽  
Clinical Decision ◽  
Transfusion Practice ◽  
The Body ◽  
Transfusion Strategy ◽  
Restrictive Transfusion ◽  
Restrictive Transfusion Strategy ◽  
Rbc Transfusion

Abstract Objectives Assess support for the effectiveness of two separate practices, restrictive transfusion strategy and computerized physician order entry/clinical decision support (CPOE/CDS) tools, in decreasing RBC transfusions in adult surgical and nonsurgical patients. Methods Following the Centers for Disease Control and Prevention Laboratory Medicine Best Practice (LMBP) Systematic Review (A-6) method, studies were assessed for quality and evidence of effectiveness in reducing the percentage of patients transfused and/or units of blood transfused. Results Twenty-five studies on restrictive transfusion practice and seven studies on CPOE/CDS practice met LMBP inclusion criteria. The overall strength of the body of evidence of effectiveness for restrictive transfusion strategy and CPOE/CDS was rated as high. Conclusions Based on these procedures, adherence to an institutional restrictive transfusion strategy and use of CPOE/CDS tools for hemoglobin alerts or reminders of the institution’s restrictive transfusion policies are effective in reducing RBC transfusion overuse.

scholarly journals 36. Evaluation of a Best Practice Alert (BPA) to Improve Pneumocystis jirovecii Prophylaxis Prescribing in Cancer Patients Receiving High-dose Corticosteroids in an Outpatient Setting

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S140-S140
Author(s):  
Justine Abella Ross ◽  
Bernard Tegtmeier ◽  
Deron Johnson ◽  
Deepa Nanayakkara ◽  
Alfredo Puing ◽  
...  
Keyword(s):  
Best Practice ◽  
Fluorescent Antibody ◽  
Immunosuppressive Drugs ◽  
Outpatient Setting ◽  
Pneumocystis Jirovecii ◽  
High Dose ◽  
Pneumocystis Jirovecii Pneumonia ◽  
Cell Transplant ◽  
Post Intervention ◽  
Best Practice Alert

Abstract Background In patients (pts) with cancer, the risk of Pneumocystis jirovecii pneumonia (PJP) is a function of dose and duration of corticosteroids (CS), underlying immunodeficiency, and immunosuppressive drugs. Trimethoprim/sulfamethoxazole (TMP/SMX) and atovaquone (ATO) are effective prophylaxis (ppx) agents against PJP. Guidelines recommend PJP ppx for pts on &gt; 20 mg /day of prednisone or its equivalent for ≥ 1 month. A best practice alert (BPA) to identify pts receiving CS may assist with improving PJP ppx prescribing in cancer pts. Methods PJP BPA was created to identify pts on CS (excluding hydrocortisone) with no active prescription for TMP/SMX or ATO ppx in EMR. Dapsone and pentamidine excluded since not preferred agents at our institution. PJP case: positive PJP polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) &gt; 84 copies or positive PJP direct fluorescent antibody (DFA) or cytology with clinical and radiographic suspicion. PJP PCR from BAL &lt; 84 copies/ml with negative DFA and cytology excluded. Preventable PJP (P-PJP): pts after CS &gt; = 30 days without PJP ppx. Non-preventable PJP (NP-PJP) : pts after CS &lt; 30 consecutive days, or on PJP ppx (non-compliance, failure), or day +1 to +30 post hematopoietic cell transplant (HCT). Pre-intervention (pre-i) PJP pts 3/1/2018 to 7/31/19 (17 months), post-intervention (post-i) PJP pts 8/1/19 to 2/1/20 (18 months) evaluated to assess BPA impact on PJP inpatient (inpt) admissions. Results In the post-i, the BPA fired 3,588 times in 1,302 pts. Pre-i: 20 P-PJP, 13 NP-PJP out of 33 pts. Post-i: 6 P-PJP, 25 NP-PJP out of 31 pts. The BPA fired in 4/31 PJP pts in the post-i period: 2/6 of P-PJP, 2/25 NP-PJP. The number of P-PJP decreased from 20 to 6 in the post-i period (p=0.0097). Conclusion Implementation of a decision support tool significantly decreased the number of P-PJP. The BPA was limited by identifying pts after CS were prescribed after the initial visit leading to periods of CS use without ppx and inability to calculate CS dosing and length of prescription. BPA provided passive education in the outpatient setting and future opportunities include refining the EMR to better identify pts at risk for developing PJP. Disclosures All Authors: No reported disclosures

scholarly journals 2362. Back to the Future: The Impact of Multi-Step Algorithm C. difficile Testing at a Large Tertiary Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S813-S814
Author(s):  
Jacqueline Bork ◽  
Kimberly C Claeys ◽  
J Kristie Johnson ◽  
Jennifer Jones ◽  
Uzoamaka Obiekwe ◽  
...  
Keyword(s):  
Best Practice ◽  
Medical Center ◽  
Hospital Setting ◽  
Nucleic Acid Amplification ◽  
Oral Vancomycin ◽  
Post Intervention ◽  
Days Of Therapy ◽  
Step Algorithm ◽  
Best Practice Alert ◽  
The Impact

Abstract Background Antibiotic stewardship and infection control programs rely on C. difficile infection (CDI) test results to measure CDI incidence in the hospital setting. C. difficile carriage is common and distinguishing infection from colonization is difficult with the highly sensitive nucleic acid amplification testing (NAAT) commonly used. Current guidelines recommend a multi-step algorithm for testing. The impact on patient outcomes and CDI metrics are largely unknown. Methods This was a pre-post study at the University of Maryland Medical Center, evaluating the impact of a CDI testing strategy (introduced October 2018) that simultaneously reported NAAT and confirmatory enzyme immunoassay (EIA) when used with existing best practice alerts for appropriate testing. Pre-intervention (November 2017–September 2018) and post intervention (October 2018–March 2019) periods were compared for mean CDI incidence (CDI per 10,000 admissions) defined by: (1) positive NAAT, (2) reported CDI (last positive test), and (3) treated CDI (receiving oral vancomycin). Both community and hospital-onset cases were included. The NAAT CDI incidence was used as the pre-intervention comparison for all 3 measures. In addition, oral vancomycin days of therapy (DOT) per 1,000 patient-days (PD) was compared. Pre–post comparisons of mean CDI incidence and mean DOT rates were done using Student t-test. Results There were 3,237 samples tested (2,269 pre and 968 post-intervention) with 376 NAAT positive (262 pre and 114 post-intervention). Of the 99 tests with reflex EIA, there were 74 discordant tests (NAAT +/EIA -) with 35 (47%) treated for CDI. Mean NAAT CDI incidence pre-intervention was 54 per 10,000 admissions. Post-intervention mean CDI incidence decreased as follows: 45 NAAT CDI per 10,000 admissions (P = 0.13), 15 reported CDI per 1000 admissions (P < 0.0001), and 28 treated CDI per 10,000 admissions (P = 0.0007). Oral vancomycin DOT per 1,000 PD decreased from 16 to 9 (P = 0.0002). Conclusion C. difficile NAAT testing with confirmatory EIA, in combination with best practice alert, decreased reported and treated cases of CDI, which may distinguish infection vs. colonization and avoid unnecessary treatment, beyond that achieved with alerts that improve appropriate patient selection for testing. Disclosures All authors: No reported disclosures.

Best practice alert and cost transparency information for high cost oncology medications.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 323-323
Author(s):  
Pelin Cinar ◽  
Tracy Lin ◽  
Kevin Rodondi
Keyword(s):  
Treatment Cost ◽  
Best Practice ◽  
Small Sample ◽  
Medication Cost ◽  
Financial Toxicity ◽  
Post Intervention ◽  
Cost Transparency ◽  
Significant Difference ◽  
Best Practice Alert ◽  
Total Payment

323 Background: Oncology medication cost is often absent from therapy decision process until issues arise with payer denial resulting in potential patient financial toxicity. To incorporate cost, Best Practice Alert (BPA) and Cost Transparency Information (CTI) for high cost oncology medication (HCOM) were implemented into prescribing platform as care coordination tools. Methods: Ten HCOM were identified in gastrointestinal (GI) and breast oncology groups for which BPA and CTI were developed. Over a 6 month period, HCOM prescriptions triggered BPAs to alert providers and to place automated referrals to social work (SW). CTI – with drug costs and comparable treatment plan(s) – were posted in prescribing platform. Descriptive analyses examined differences in total payment to hospital and patients out-of-pocket payments (OPP) between treatment plans. Pre- and post-intervention surveys evaluated oncologists’ perception and behavior toward treatment cost. Results: The analysis included 162 patients and 1406 medication claims. In the GI group, BPAs effectively identified treatments incurring higher mean total payment (diff = 46733, p < 0.001) and higher mean OPP (diff = 115, p < 0.001). For the breast group, the impact was mixed. BPAs identified treatments with higher total payment at the 90% quantile (p < 0.001) and higher mean total payment (diff = 72612, p < 0.001), but there was no statistically significant difference in OPP between treatments. Pre-intervention survey (n = 26, 50% response rate) indicated 46% of oncologists rarely discuss medication cost with patients and 35% rarely refer patients to SW. Only 4% of oncologists strongly agreed that they could easily acquire cost information. Post-intervention survey highlighted that CTI improved oncologists’ awareness of medication costs, but BPA exerted no substantial influence on provider behaviors. Conclusions: BPA intervention effectively highlighted treatment cost and accurately identified patients at risk for financial toxicity. The lack of statistically significant difference in oncologists’ behavior and perception may be due to a small sample size. Comments from providers suggest that BPA combined with OPP would be more useful in reducing financial toxicity.

Using blood wisely in oncology patients: An institutional analysis of the Choosing Wisely Canada restrictive transfusion strategy guidelines.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 10-10
Author(s):  
Megan Elizabeth Tesch ◽  
Mae Alghawas ◽  
Alina S. Gerrie
Keyword(s):  
Single Unit ◽  
Hematological Malignancies ◽  
Choosing Wisely ◽  
High Rate ◽  
Transfusion Strategy ◽  
Oncology Patients ◽  
Restrictive Transfusion ◽  
Solid Malignancies ◽  
Audit Period ◽  
Restrictive Transfusion Strategy

10 Background: Numerous studies support the safety of single-unit red red blood cell (RBC) transfusions and restrictive pre-transfusion hemoglobin (Hg) thresholds (≤ 70-80 g/L) among diverse populations of hospitalized patients, including those with malignancies on myelosuppressive systemic therapy. Using Blood Wisely is a national Choosing Wisely Canada (CWC) initiative that challenges hospitals to benchmark themselves on evidence-informed restrictive transfusion strategies, with the aim to decrease inappropriate RBC transfusions in Canada. We assessed transfusion practices among oncology inpatients at BC Cancer Vancouver Centre as part of this initiative and performed an exploratory analysis among outpatients. Methods: BC Cancer Vancouver RBC transfusion records were obtained for the period of October 2019-September 2020. The percentage of single-unit transfusions and transfusions for Hg ≤ 80 g/L were measured, to assess adherence to CWC targets of ≥ 65% and ≥ 80%, respectively, for these metrics. Univariate analyses were used to compare treatment variables and transfusion outcomes. Results: During the 1-year audit period, 120 inpatient and 586 outpatient RBC transfusions occurred. For inpatient transfusions, 40.8% (n = 49) were single-unit and 79.2% (n = 95) were for Hg ≤ 80 g/L. For outpatient transfusions, 11.8% (n = 69) were single-unit and 65.7% (n = 304) were for Hg ≤ 80 g/L. Outpatients and patients with solid malignancies were more likely to receive multiple-unit transfusions, compared to inpatients (p < 0.001) and patients with hematological malignancies (p < 0.001), respectively. Patients with solid malignancies and those on active treatment were more likely to be transfused when Hg was > 80 g/L, compared to patients with hematological malignancies (p = 0.004) and those off treatment (p = 0.003), respectively. Multiple RBC units were more likely to transfused when the interval from pre-transfusion bloodwork to receipt of transfusion was > 3 days (p = 0.029). Conclusions: A high rate of inappropriate RBC transfusions are being ordered for oncology patients at our institution, in discordance with CWC restrictive transfusion strategy guidelines. Quality improvement interventions are planned to adopt best practices in transfusion medicine in this high-use population.[Table: see text]

scholarly journals Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

BMJ Open ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. e037238
Author(s):  
Mineji Hayakawa ◽  
Takashi Tagami ◽  
Hiroaki IIjima ◽  
Daisuke Kudo ◽  
Kazuhiko Sekine ◽  
...  
Keyword(s):  
Emergency Department ◽  
Severe Bleeding ◽  
Transfusion Strategy ◽  
Ethical Guidelines ◽  
Restrictive Transfusion ◽  
Cluster Randomised ◽  
Transfusion Requirements ◽  
Injured Patients ◽  
Restrictive Transfusion Strategy ◽  
Rbc Transfusion

IntroductionResuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies.Methods and analysisThis is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70–90 or 100–120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician’s judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages.Ethics and disseminationThe trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses.Trial registration numberUMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

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