897 Infusion episode-related benefits of pembrolizumab Q6W dosing schedule for patients with melanoma treated in the adjuvant and metastatic settings in the United States (US)

BackgroundA new dosing schedule for pembrolizumab (400 mg every six weeks (Q6W)) received accelerated FDA approval in 2020 across all approved adult indications. The Q6W dosing schedule provides an opportunity to reduce the number of infusions required over the treatment course, thereby decreasing time and costs for health care providers, patients and their caregivers. This study quantified the potential infusion episode-related benefits of pembrolizumab Q6W regimen for the treatment of patients with melanoma in the adjuvant and metastatic settings in the US.MethodsAn Excel-based tool was developed to quantify the infusion episode-related time and cost of using pembrolizumab Q6W compared to available nivolumab dosing regimens (Q4W/Q2W) to treat patients with melanoma in the adjuvant and metastatic settings from the patient, caregiver, provider, and payer perspectives. The number of infusion visits, time and costs were estimated considering a hypothetical infusion center. Time-related inputs were based on a survey of patients, physicians and nurses; cost-related inputs were obtained from published sources. Sensitivity analyses were performed to assess the robustness of results. Additional analyses assessed the impact of using alternative regimens with different frequencies of administration.ResultsBased on the tool, pembrolizumab Q6W reduced the number of infusion visits (31%), time at the infusion center (41%) and chair time (31%) in total, over one year, versus nivolumab Q4W. Because fewer visits are needed, travel time is estimated to decrease by 31%. The infusion-related direct and indirect costs borne by patients and caregivers are projected to decrease by $1,095 and $2,272, respectively over a treatment course. For a typical US infusion center treating 169 melanoma patients per week over a 1-year period, using pembrolizumab Q6W rather than nivolumab Q4W is estimated to reduce the number of infusions by 2,729 (31% reduction) for a total of 3,802 fewer hours of infusion chair time, allowing the infusion center to increase patient capacity by up to 45% using currently available resources. Time and cost savings are more prominent when comparing with nivolumab Q2W: 5,757 fewer infusion events (66% reduction) and 8,062 less hours of chair time, which would increase the patient capacity by 2.9 times.ConclusionsUtilizing pembrolizumab Q6W to treat patients with melanoma in the US is expected to substantially reduce the number of infusion visits and associated chair time required over the duration of treatment, reducing the time and monetary burden for patients and their caregivers. Additionally, it may also improve system capacity.

Self-management interventions for Type 2 Diabetes: systematic review protocol focusing on patient workload and capacity support

Introduction: People living with type 2 diabetes undertake a range of tasks to manage their condition, collectively referred to as self-management. Interventions designed to support self-management vary in their content, and efficacy. This systematic review will analyse self-management interventions for type 2 diabetes drawing on theoretical models of patient workload and capacity. Methods and analysis: Five electronic databases (Medline, Embase, CENTRAL, CINAHL and PsycINFO) will be searched from inception to 27th April 2021, supplemented by citation searching and hand-searching of reference lists. Two reviewers will independently review titles, abstracts and full texts. Inclusion criteria include Population: Adults with type 2 diabetes mellitus; Intervention: Randomised controlled trials of self-management support interventions; Comparison: Usual care; Outcomes: HbA1c (primary outcome) health-related quality of life (QOL), medication adherence, self-efficacy, treatment burden, healthcare utilization (e.g. number of appointment, hospital admissions), complications of type 2 diabetes (e.g. nephropathy, retinopathy, neuropathy, macrovascular disease) and mortality; Setting: Community. Study quality will be assessed using the Effective Practice and Organisation of Care (EPOC) risk of bias tool. Interventions will be classified according to the EPOC taxonomy and the PRISMS self-management taxonomy and grouped into similar interventions for analysis. Clinical and methodological heterogeneity will be assessed within subgroups, and random effects meta-analyses performed if appropriate. Otherwise, a narrative synthesis will be performed. Interventions will be graded on their likely impact on patient workload and support for patient capacity. The impact of these theoretical constructs on study outcomes will be explored using meta-regression. Conclusion This review will provide a broad overview of self-management interventions, analysed within the cumulative complexity model theoretical framework. Analyses will explore how the workload associated with self-management, and support for patient capacity, impact on outcomes of self-management interventions. Registration number: PROSPERO CRD42021236980.

1077 TELP In Urology: Hindrance or A Help During Covid-19 Pandemic? A Closed Loop Audit

Aim TELP (Treatment Escalation/Limitation Plan) form is a novel clinical decision-making tool introduced during the COVID-19 pandemic in our health board to provide a standardised patient management plan in case of patient deterioration. A closed loop audit of its compliance in Urology patients was performed. Method Patient medical records were analysed over two periods (Cycle 1: 5/10/20 - 11/10/20 and Cycle 2: 23/11/20 – 29/11/20) for all Urology patients in our institution. Cycle 1 audit findings were presented at the Departmental Education Meeting. During Cycle 1, an anonymous questionnaire was sent to all Urology Medical and Nursing staff to gather their opinion on TELP. Results In total 100 patients were analysed. 66 were male and 34 females. Age ranged from 15 to 91 years. TELP form completion rate improved from 48% (Cycle 1) to 68% (Cycle 2), however, correct completion remained poor at 11.1% and 16.7% in Cycle 1 and Cycle 2 respectively. Commonly, there was no reporting of ‘discussion with patient or family’ or ‘patient capacity’. Majority of patients with a completed TELP had one to four underlying co-morbidities and were emergency admissions (65%). The questionnaire reported barriers to compliance including, time for completion, document size, and the feeling it was inappropriate for certain patient groups. Most felt it did not represent patients’ wishes (73%) or improved discussion regarding escalation status (50%). Conclusions TELP forms have sub-optimal correct completion rates and may not always represent patient’s wishes. Inherent barriers to its use need to be addressed, given limited resources during the COVID pandemic.

Multimorbidity and its effect on perceived burden, capacity and the ability to self-manage in a low-income rural primary care population: A qualitative study

Introduction Multimorbidity is increasing in prevalence, especially in low-income settings. Despite this, chronic conditions are often managed in isolation, potentially leading to burden-capacity imbalance and reduced treatment adherence. We aimed to explore, in a low-income population with common comorbidities, how the specific demands of multimorbidity affect burden and capacity as defined by the Cumulative Complexity Model. Materials and methods Qualitative interviews with thirteen rural community health centre patients in Victoria, Australia. Participants were aged between 47–72 years and reported 3–10 chronic conditions. We asked about perceived capacity and burden in managing health. The Theory of Patient Capacity was used to analyse capacity and Normalisation Process Theory to analyse burden. All data specifically associated with the experience of multimorbidity was extracted from each burden and capacity domain. Results The capacity domains of biography, resource mobilisation and work realisation were important in relation to multimorbidity. Conditions causing functional impairment (e.g. chronic pain, depression) interacted with physical, psychological and financial capacity, leading to biographical disruption and an inability to realise treatment and life work. Despite this, few people had a treatment plan for these conditions. Participants reported that multimorbidity affected all burden domains. Coherence and appraisal were especially challenging due to condition interactions, with clinicians providing little guidance. Discussion The capacity and burden deficits highlighted by participants were not associated with any specific diagnosis, but were due to condition interactions, coupled with the lack of health provider support to navigate interactions. Physical, psychological and financial capacities were inseparable, but rarely addressed or understood holistically. Understanding and managing condition and treatment interactions was a key burden task for patients but was often difficult, isolating and overwhelming. This suggests that clinicians should become more aware of linkages between conditions, and include generic, synergistic or cross-disciplinary approaches, to build capacity, reduce burden and encourage integrated chronic condition management.

Key elements in selection of pre-dialysis patients for home dialysis

Background: Most pre-dialysis patients are medically eligible for home dialysis, and home dialysis has several advantages over incentre dialysis. However, accurately selecting patients for home dialysis appears to be difficult, since uptake of home dialysis remains low. The aim of this study was to investigate which medical or psychosocial elements contribute most to the selection of patients eligible for home dialysis. Methods: All patients from a Dutch teaching hospital, who received treatment modality education and subsequently started dialysis treatment, were included. The pre-dialysis programme consisted of questionnaires for the patient, nephrologist and social worker, followed by an assessment of eligibility for home dialysis by a multidisciplinary team. Clinimetric assessment and logistic regression were used to identify domains and questions associated with home dialysis treatment. Results: A total of 135 patients were included, of whom 40 were treated with home dialysis and 95 with incentre haemodialysis. The key elements associated with long-term home dialysis treatment were part of the domains ‘suitability of the housing’, ‘self-care’, ‘social support’ and ‘patient capacity’, with adjusted odds ratios ranging from 0.13 for negative to 18.3 for positive associations. Conclusion: The assessment of contraindications by a nephrologist followed by the assessment of possibilities by a social worker or dialysis nurse who investigates four key elements, ideally during a home visit, and subsequent detailed education offered by specialized nurses is an optimal way to select patients for home dialysis.

Qualitative analysis of reasons for hospitalization for severe hypoglycemia among older adults with diabetes

Background Hospital admissions for severe hypoglycemia are associated with significant healthcare costs, decreased quality of life, and increased morbidity and mortality, especially for older adults with diabetes. Understanding the reasons for hypoglycemia hospitalization is essential for the development of effective interventions; yet, the causes and precipitants of hypoglycemia are not well understood. Methods We conducted a qualitative study of non-nursing home patients aged 65 years or older without cognitive dysfunction admitted to a single tertiary-referral hospital with diabetes-related hypoglycemia. During the hospitalization, we conducted one-on-one, in-depth, semi-structured interviews to explore: (1) experiences with diabetes management among patients hospitalized for severe hypoglycemia; and (2) factors contributing and leading to the hypoglycemic event. Major themes and sub-themes were extracted using the constant comparative method by 3 study authors. Results Among the 17 participants interviewed, the mean age was 78.9 years of age, 76.5% were female, 64.7% African American, 64.7% on insulin, and patients had an average of 13 chronic conditions. Patients reported: (1) surprise at hypoglycemia despite living with diabetes for many years; (2) adequate support, knowledge, and preparedness for hypoglycemia; (3) challenges balancing a diet that minimizes hyperglycemia and prevents hypoglycemia; (4) the belief that hyperglycemia necessitates medical intervention, but hypoglycemia does not; and (5) tension between clinician-prescribed treatment plans and self-management based on patients’ experience. Notably, participants did not report the previously cited reasons for hypoglycemia, such as food insecurity, lack of support or knowledge, or treatment errors. Conclusions Our findings suggest that some hypoglycemic events may not be preventable, but in order to reduce the risk of hypoglycemia in older individuals at risk: (1) healthcare systems need to shift from their general emphasis on the avoidance of hyperglycemia towards the prevention of hypoglycemia; and (2) clinicians and patients need to work together to design treatment regimens that fit within patient capacity and are flexible enough to accommodate life’s demands.

Neuro-Oncology Clinicians’ Attitudes and Perspectives on Medical Assistance in Dying

IntroductionMedical assistance in dying (MAiD), also known as physician-assisted death, is currently legal in several locations across the globe. Even more jurisdictions are considering legalizing MAiD. Brain cancer or its treatments can lead to cognitive impairment, which can impact decision-making capacity. In most jurisdictions patients are assessed for mental capacity to inform MAiD eligibility. We sought to explore worldwide neuro-oncology clinicians’ attitudes and perspectives on MAiD, including interpretation of decision-making capacity for patient MAiD eligibility.MethodsAn online survey was distributed to members of national and international neuro-oncology societies. We asked questions about decision-making capacity and MAiD, in part using hypothetical patient scenarios. Multiple choice and free-text responses were captured.ResultsThere were 125 survey respondents. Impaired cognition was identified as the most important factor that would signal a decline in patient capacity. At least 26% of survey respondents had moral objections to MAiD. Fewer clinicians were willing to support a MAiD decision for patients with lower-grade tumors and better performance status.Conclusionshile there are differing opinions on the moral permissibility of MAiD in general and for neuro-oncology patients, most clinicians agree that capacity must be assessed carefully before a decision is made. Further, some patients with brain tumors are not generally thought to be MAiD-eligible due to the nature of their specific diseases. These results can inform assessments of patient capacity in neuro-oncological practice in jurisdictions where MAiD is legal.

Optimizing Operating Room Throughput

Practice Problem: Throughput is an instrumental aspect for hospitals to maximize patient capacity; therefore, methods to improve patient flow should be consistently implemented. Surgical areas are a major contributor to inpatient admissions and the subsequent revenue; however, without the appropriate oversight, patient throughput can be negatively impacted. PICOT: The PICOT question that guided this project was: In operating room patients who require inpatient admission (P), how does the implementation of a standardized bed flow process (I), compared to the current methods for care transitions (C), reduce perioperative delays and improve hospital financial metrics (O), over a three-month period (T)? Evidence: A review of the evidence revealed that streamlining operating room throughput was essential to the quality of clinical care and patient safety as well as to improve efficiencies associated with patient volumes, lengths of stay and hospital census. Intervention: A dedicated bed flow manager was implemented in the project setting with the overall goal to enhance throughput measures within the operating room. Outcome: While the intervention did not achieve statistical significance as determined by the data analysis, the results did demonstrate clinical significance as the organization was able to maximize capacity and throughput during the Covid-19 pandemic. Conclusion: The addition of a dedicated surgical bed flow manager was beneficial to the optimization, standardization and systemization of the perioperative throughput process.

Healthcare professionals’ perspective on treatment burden and patient capacity in low-income rural populations: challenges and opportunities

Background The challenges of chronic disease self-management in multimorbidity are well-known. Shippee’s Cumulative Complexity Model provides useful insights on burden and capacity factors affecting healthcare engagement and outcomes. This model reflects patient experience, but healthcare providers are reported to have a limited understanding of these concepts. Understanding burden and capacity is important for clinicians, since they can influence these factors both positively and negatively. This study aimed to explore the perspectives of healthcare providers using burden and capacity frameworks previously used only in patient studies. Methods Participants were twelve nursing and allied health providers providing chronic disease self-management support in low-income primary care settings. We used written vignettes, constructed from interviews with multimorbid patients at the same health centres, to explore how clinicians understood burden and capacity. Interviews were recorded and transcribed verbatim. Analysis was by the framework method, using Normalisation Process Theory to explore burden and the Theory of Patient Capacity to explore capacity. Results The framework analysis categories fitted the data well. All participants clearly understood capacity and were highly conscious of social (e.g. income, family demands), and psychological (e.g. cognitive, mental health) factors, in influencing engagement with healthcare. Not all clinicians recognised the term ‘treatment burden’, but the concept that it represented was familiar, with participants relating it both to specific treatment demands and to healthcare system deficiencies. Financial resources, health literacy and mental health were considered to have the biggest impact on capacity. Interaction between these factors and health system barriers (leading to increased burden) was a common and challenging occurrence that clinicians struggled to deal with. Conclusions The ability of health professionals to recognise burden and capacity has been questioned, but participants in this study displayed a level of understanding comparable to the patient literature. Many of the challenges identified were related to health system issues, which participants felt powerless to address. Despite their awareness of burden and capacity, health providers continued to operate within a single-disease model, likely to increase burden. These findings have implications for health system organisation, particularly the need for alternative models of care in multimorbidity.

Association between Emergency Department Overcrowding and Mortality at a Teaching Hospital in Saudi Arabia

Introduction: Emergency Departments (ED) are highly important in hospital settings because they offer 24-hour professional assistance to patients in need of healthcare. However, ED overcrowding has started to become a global healthcare crisis, such that the patient capacity of EDs is no longer sufficient to meet patient demand. Aim: Thus, this study aimed to determine the relationship between ED overcrowding and the mortality rate of patients to draw the attention of decision makers in Saudi Arabia toward this issue, with the hope of ultimately attaining a solution to this problem. Methods: Using patients’ electronic health records that were stored in the Quadra Med system in 2018, we calculated the occupancy rates of the ED of a target teaching hospital at different quarters and associated those figures with the mortality rates for the same quarters. Results: Our results showed that there was no significant association between mortality rate and crowding status in the ED. Nonetheless, we recommend increasing public awareness and bed capacity at EDs in Saudi Arabia because overcrowded EDs can lead to adverse patient outcomes. Conclusion: The present study showed that the highest percentage (38%) of deaths that occurred during the overcrowded period were mostly of patients between 30 and 44 years of age, while patients between 60 and 74 years of age accounted for 36% of deaths. The current study also assessed patient triaging, revealing that the highest number of patients was associated with level four (62.7% of the total patients in the overcrowded ED) and level five (33.1% in the overcrowded ED) triaging. We also discovered higher levels of admission in the critical care unit during the ED overcrowding period compared with other periods.