Impact of the COVID-19 Pandemic on in-Person Visit Rates Among Patients with Hematologic Malignancies in the United States

Background/objectives: The COVID-19 pandemic led to a dramatic reduction of in-person medical care in the general population; however, impacts have not been well-characterized for patients with hematologic malignancies. This study assessed the impact of COVID-19 on healthcare delivery for patients with hematologic malignancies with documented active treatment. Methods: Patients from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, and age ≥ 18 years at initial diagnosis were included. To be included in the study, documented receipt of at least one systemic, non-maintenance line of therapy between March 1, 2016 - February 28, 2021 was required. Patients were categorized into treatment types within lines of therapy: Oral therapy (OralTx); outpatient infusions (OutPtTx); and inpatient infusions, including hematopoietic transplants and CAR-T cell therapy (InPtTx). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month. Only visits occurring within a line of therapy were included (i.e. during active therapy, excluding surveillance). Telemedicine was only available for abstraction during the pandemic period. We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual visit rates between March 2020 - February 2021 (expected in-person visit rates if the pandemic had not occurred) for all diseases combined, each disease, and each treatment type. Differences between projected and actual monthly visit rates during the pandemic period were considered statistically significant and related to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. Results: A total of 22,559 patients were included in this analysis (6,241 OralTx, 14,501 OutPtTx, 7,675 InPtTx): 4,069 AML, 3,641 DLBCL, 2,004 FL, 1,899 MCL, 4,574 CLL and 6,701 MM. There was a gradual downward trend in in-person visit rates across all diseases over the study period (March 2016 - February 2021, Figure) and general visit frequencies were lower for OralTx and higher for OutPtTx and InPtTx overall. For all diseases combined, early pandemic months (March - May 2020) saw an 18% (95% PI 8.9% - 25%) reduction in in-person visit rates averaged across OralTx and OutPtTx, with the projected rate being 1.5 (95% PI 1.3 - 1.6) visits per patient per month, compared to an actual rate of 1.2. Reductions in the in-person visit rates were significant for all 3 treatment types for MM, for OralTx for CLL, and for OutPtTx for MCL and CLL. Telemedicine visit rates were greatest for patients who received OralTx, followed by OutPtTx, then InPtTx, with greater use in the early pandemic months and subsequent decrease in later months. All in-person visit rates increased close to predicted rates in the later half of the pandemic period. Conclusions: In treatment of hematologic malignancies, overall documented in-person visit rates for patients on OralTx and OutPtTx significantly decreased during early pandemic months, but returned close to the projected rates later in the pandemic. There were no significant reductions in the overall in-person visit rate for patients on InPtTx. Variability in these trends by disease type was observed, with significant reductions in in-person visits impacting MM, CLL, and MCL. Figure. Visit rates over time according to treatment category Figure 1 Figure 1. Disclosures Lau: Roche: Current equity holder in publicly-traded company; Flatiron Health Inc: Current Employment. Wang: Roche: Current equity holder in publicly-traded company; Flatiron Health: Current Employment. Davidoff: AbbVie: Other: Family member consultancy; Amgen: Consultancy. Huntington: Bayer: Honoraria; Thyme Inc: Consultancy; Novartis: Consultancy; Flatiron Health Inc.: Consultancy; Genentech: Consultancy; SeaGen: Consultancy; Servier: Consultancy; AstraZeneca: Consultancy, Honoraria; TG Therapeutics: Research Funding; DTRM Biopharm: Research Funding; AbbVie: Consultancy; Pharmacyclics: Consultancy, Honoraria; Celgene: Consultancy, Research Funding. Calip: Pfizer: Research Funding; Roche: Current equity holder in publicly-traded company; Flatiron Health Inc: Current Employment. Shah: AstraZeneca: Research Funding; Seattle Genetics: Research Funding; Epizyme: Research Funding. Stephens: CSL Behring: Consultancy; TG Therapeutics: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Consultancy; Celgene: Consultancy; JUNO: Research Funding; Mingsight: Research Funding; Abbvie: Consultancy; Arqule: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding; Epizyme: Membership on an entity's Board of Directors or advisory committees; Beigene: Membership on an entity's Board of Directors or advisory committees; Innate Pharma: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company; Roche: Current equity holder in publicly-traded company. Parikh: GNS Healthcare: Current holder of individual stocks in a privately-held company; Onc.AI: Current holder of individual stocks in a privately-held company; Humana: Honoraria, Research Funding; Nanology: Honoraria; Thyme Care: Honoraria; Flatiron Health Inc: Honoraria. Takvorian: Pfizer: Research Funding; Genentech: Consultancy. Neparidze: GlaxoSmithKline: Research Funding; Janssen: Research Funding; Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees. Seymour: Flatiron Health Inc: Current Employment; Janssen: Membership on an entity's Board of Directors or advisory committees; Roche: Current equity holder in publicly-traded company; Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees.

Racial Disparities in Telemedicine Uptake during the COVID-19 Pandemic Among Patients with Hematologic Malignancies in the United States

Background/objectives: The COVID-19 pandemic impacted healthcare visit trends, propelling healthcare systems to reduce in-person visits and hospital admissions and increasingly rely on telemedicine; whether there are differences in these trends across racial groups is unknown. This study investigated potential racial disparities in visits during the pandemic for patients with documented active treatment for hematologic malignancies. Methods: We used the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database to select patients with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, at least 18 years old at initial diagnosis, and documented race in the EHR as Black/African American or White were included. Patients were categorized into treatment types within lines of therapy: Orals (orals + outpatient infusions with orals) vs. Inpatient treatments (chemotherapy, hematopoietic transplants & CAR-T cell therapy). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month, except for months in which the patient was considered not active (e.g. no documented therapy, surveillance). We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual monthly visit rates (expected rates if the pandemic did not occur) between March 2020 - February 2021 for all diseases combined, for each disease, each treatment type, and each race. Differences between projected and actual monthly visit rates during the pandemic period were considered significant and related due to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. We used cross-correlation analysis to test for significant differences in visit rates between Black and White patients. Results: The analysis included 17,621 patients (2,225 Black, 15,396 White): 3,041 AML, 2,715 DLBCL, 1,558 FL, 1,511 MCL, 3,813 CLL and 5,244 MM (1,166 Black, 4078 White). Across all diseases and treatment categories, Black patients had no significant reductions in in-person visit rates throughout the pandemic period compared to the projected rates. There was, however, an 18% statistically significant reduction (95% PI 9.9% - 25%) in in-person visit rates for White patients on orals during early pandemic months (March - May 2020) from a projected visit rate of 2.0 (95% PI 1.8 - 2.2) visits per patient per month to an actual visit rate of 1.61. There was no significant reduction in in-person visit rates for White patients on inpatient treatments. Telemedicine uptake was significantly higher for White patients compared with Black patients for all diseases combined across all treatment categories (Figure A & B) (t = 9.5, p < 0.01), AML inpatient treatments (t = 2.4, p = 0.04), MM orals (Figure C) (t = 6.0, p < 0.01) and MM inpatient treatments (Figure D) (t = 2.3, p = 0.04). Conclusions: A tradeoff in reductions in in-person visits and uptake of telemedicine use was observed overall. White patients had significantly higher telemedicine uptake compared with Black patients for both oral and inpatient treatments. In-person visit rates for Black patients were unchanged regardless of treatment category. These in-person visit rates reflect documented telemedicine use disparities, which requires further study into possible compound causes, including economic and societal factors. Figure. Trends over time in telemedicine visit rates for White patients (blue line) and Black patients (black line) Figure 1 Figure 1. Disclosures Neparidze: Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Research Funding; Janssen: Research Funding. Lau: Flatiron Health Inc: Current Employment; Roche: Current equity holder in publicly-traded company. Wang: Flatiron Health: Current Employment; Roche: Current equity holder in publicly-traded company. Davidoff: Amgen: Consultancy; AbbVie: Other: Family member consultancy. Huntington: Bayer: Honoraria; Servier: Consultancy; Pharmacyclics: Consultancy, Honoraria; Thyme Inc: Consultancy; Genentech: Consultancy; AbbVie: Consultancy; SeaGen: Consultancy; Celgene: Consultancy, Research Funding; Flatiron Health Inc.: Consultancy; DTRM Biopharm: Research Funding; TG Therapeutics: Research Funding; AstraZeneca: Consultancy, Honoraria; Novartis: Consultancy. Calip: Flatiron Health Inc: Current Employment; Roche: Current equity holder in publicly-traded company; Pfizer: Research Funding. Shah: AstraZeneca: Research Funding; Seattle Genetics: Research Funding; Epizyme: Research Funding. Stephens: Adaptive: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy; Abbvie: Consultancy; CSL Behring: Consultancy; Novartis: Research Funding; Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding; JUNO: Research Funding; Mingsight: Research Funding; AstraZeneca: Consultancy; Innate Pharma: Membership on an entity's Board of Directors or advisory committees; Beigene: Membership on an entity's Board of Directors or advisory committees; TG Therapeutics: Membership on an entity's Board of Directors or advisory committees; Epizyme: Membership on an entity's Board of Directors or advisory committees; Arqule: Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company; Roche: Current equity holder in publicly-traded company. Parikh: Onc.AI: Current holder of individual stocks in a privately-held company; Humana: Honoraria, Research Funding; Flatiron Health Inc: Honoraria; Thyme Care: Honoraria; Nanology: Honoraria; GNS Healthcare: Current holder of individual stocks in a privately-held company. Takvorian: Genentech: Consultancy; Pfizer: Research Funding. Seymour: Janssen: Membership on an entity's Board of Directors or advisory committees; Roche: Current equity holder in publicly-traded company; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; Flatiron Health Inc: Current Employment; Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Clinical Profile, Drug Utilization Pattern and Adverse Drug Reactions of Anti-tubercular Drugs at DOTS Center in a Tertiary Hospital

Most of anti-tubercular drugs (ATD) cause various adverse drug reactions (ADRs) leading to significant morbidity which may have negative consequences on drug adherence and treatment outcome. The objectives of the study were to know the clinical profile of patients receiving ATD, to identify the pattern of ADRs caused by ATD and to know the drug utilization pattern (DUP) in different types of tuberculosis (TB). A prospective observational study was conducted among patients diagnosed with TB at DOTS center in BPKIHS from June 2017 to May 2018 and occurrence of any ADRs were detected during their monthly visit. Descriptive statistics were used to analyze the data. A total of 126 tuberculosis patients were on ATD therapy during the study period. Seventy five patients (59.5%) were male. Most of the patients (44.4%) belonged to age group 21-40 year. Pulmonary TB (66.7%) was more common than extra-pulmonary TB. Multi-drug resistant TB was detected in 4 patients (3.2%). Seventy one patients (56.3%) were found to be smear positive for acid fast bacilli. First line ATD was given to 122 patients (96.8%). Out of 126 patients, 116 (92.1%) reported occurrence of at least one ADR. A higher number of ADRs were observed in male (68.3%). Change in urine color was the most common ADR (92.9%) followed by nausea and vomiting (39.7%). Further studies covering different regions of Nepal are needed to generalize the findings.

Pendampingan Ustaż dan Tuan Guru Pesantren Melalui Penguatan Nilai-nilai Multikultural Untuk Mencegah Radikalisme Islam Berbasis Pesantren di Kota Bima

Bima city has been called “Red Zone” area for radicalism dissemination. Prior reasearch indicated that the Islamic radicalism in Bima appeared from Islamic institution such as pesantren. This community service aimed at preventing Islamic radicalism in pesantren by sharing, educating and giving reinforcement of multicultural values to ustaż and Tuan Guru Pesantren (TGP). Community-Based Research (CBR) approach was employed because ustaż and TGP are the prior of pesantren’s community who can developed and transfer their understanding and religious perception to the students (santri). The results showed that ustaż and TGP had been more inclusive in their religion understanding, they transformed multicultural values to their student and all of pesantren’s community until this preventive step can prohibit the Islamic radicalism. They were also willing to involve the community service team in composing pesantren’s learning program. The team also give monthly visit for sharing idea about multicultural values.

Health plan expenditures young adults with newly-diagnosed Hodgkin lymphoma (HL) by care at NCI-designated comprehensive cancer centers (CCC) vs. other treatment sites (non-CCC).

7081 Background: Patients diagnosed with HL between 22-39y have worse outcomes than younger patients (≤21y); we previously reported that treatment at a CCC mitigates these disparities [Wolfson, Leukemia 2017]. While there is general consensus that CCC care is expensive, expenditures for managing young adults with HL in CCC vs. non-CCC are not known. Methods: Cancer-related expenditures were examined in HL patients diagnosed between 2001-2014 at age 22-39y and treated at CCC and non-CCC sites using commercial insurance claims data (OptumLabs Data Warehouse). Multivariable generalized linear models with log link modeled average monthly health plan paid expenditures, adjusting for sociodemographics, stage, adverse events, pre-existing comorbidities, and diagnostic era. Results: Of the 1501 HL patients, 33% (n = 489) were treated at a CCC. Patients treated at CCC vs. non-CCC did not differ with respect to race, sex, income, diagnostic era or comorbidities (p≥0.3). Mean duration of enrollment was longer in CCC than non-CCC (25 vs. 23 mos; p < 0.001) patients. During the first year after HL diagnosis, total average monthly expenditures were higher in CCC ($9,111) than non-CCC ($7,834, p = 0.001), including those related to inpatient (CCC: $1,790 vs. non-CCC: $1,011; p = 0.001) and outpatient (CCC: $6,971 vs. non-CCC: $6,487; p = 0.001) expenditures. The higher CCC expenditures were associated with higher monthly rates of inpatient admissions (IRR = 1.3, p = 0.001) and outpatient visits (IRR = 1.1, p = 0.02) at CCC. Rates of chemotherapy-related inpatient admissions were higher (IRR = 2.3, p = 0.001) in CCC than non-CCC patients, while outpatient chemotherapy visit rates were lower (IRR = 0.9, p = 0.001) in CCC. During Years 2-3, total average monthly expenditures were higher in CCC ($19,259) than non-CCC ($4,145, p = 0.002) patients. Outpatient expenditures were higher in CCC ($10,164) vs. non-CCC ($2,901, p = 0.001), with higher monthly outpatient visit rates (IRR = 1.7, p = 0.001) at CCC. Conclusions: Inpatient and outpatient cancer-related expenditures in young adults with HL were higher at CCC than non-CCCs. Higher outpatient expenditures at CCC were associated with only higher monthly visit rates. Higher inpatient expenditures were in the setting of higher admission rates, including those related to chemotherapy. Additional work is necessary to understand whether these higher expenditures at CCC are related to supportive care and/or differences in facility structure and billing practices.

FAKTOR – FAKTOR YANG BERHUBUNGAN DENGAN PEMANFAATAN BUKU KIA TERHADAP IBU HAMIL DI WILAYAH KERJA PUSKESMAS TIGO BALEH KOTA BUKITTINGGI TAHUN 2018

<em>KIA Book is a tool to detect early the presence of maternal and child health problems or problems. An initial survey conducted in the work area of the Tigo Baleh health center in Bukittinggi, researchers asked several questions regarding the use of MCH books on 10 pregnant women. 4 pregnant women utilize and 6 pregnant women only save, the KIA book is used only when they want to do a checkup at the midwife's home. This study aims to determine the factors associated with the use of MCH books in the work area of Tigo Baleh Health Center in Bukittinggi City in 2018. Population of all pregnant women in 2018, a sample of an average monthly visit at the Tigo Baleh health center in Bukittinggi city in 2018 was 60 people, purposive sampling technique was taken. Implemented in the work area of Tigo Baleh Health Center, Bukittinggi City. Data analysis in this research uses univariate and bivariate. The results of this study showed that 31 respondents (52%) had a large number of respondents with poor knowledge, 35 respondents (58%) had a low motivation level, 33 respondents (55%) had the most role as health workers, most of them Primigravida parity respondents were 43 respondents (72%), most respondents did not use 27 KIA books (45%). There is a meaningful relationship to knowledge, motivation, the role of health workers and parity in the use of MCH books The conclusion in this study there is a relationship between knowledge, motivation, the role of health workers and parity on the use of MCH books on pregnant women in the work area of Tigo Baleh Health Center in Bukittinggi City in 2018. understand, bring the KIA Book so that the mother knows very much the benefits that exist in the KIA Book from pregnancy to 5 years old child.</em>

Telehealth awareness in a US urban peritoneal dialysis clinic: From 2018 to 2019

The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient’s home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.

Comparison of self-ligating Damon3 and conventional MBT brackets regarding alignment efficiency and pain experience: A randomized clinical trial

Background. Self-ligating brackets might be more efficient than conventional appliance systems during the initial alignment stage of orthodontic treatment due to reduced frictional resistance. This study aimed to compare the alignment efficiency and pain experience of Damon3 self-ligating and MBT pre-adjusted brackets in the initial alignment stage. Methods. In this randomized clinical trial, 30 patients aged 14‒20 years, who needed non-extraction treatment in both maxillary and mandibular arches, were randomly assigned to two groups; 15 patients were treated with MBT pre-adjusted brackets, and 15 patients received Damon3 self-ligating brackets, both with 0.022-in slots. Alginate impressions were taken at the start of treatment (T0) and four monthly visits (T1, T2, T3, and T4). Little’s irregularity index (LII) was used to assess the tooth displacements. The patients rated their pain experience immediately after the insertion of the archwire, 4 hours, 24 hours, 3 days, 7 days, and at each monthly visit using a visual analog scale (VAS). Results. The rate of upper dental alignment between T0 and T4 was significantly higher with the Damon3 compared to MBT brackets (P=0.015). Although significantly more changes in the lower LII scores were observed during the first three months with the Damon3 system, the rate of improvement in the irregularity of lower teeth over the 4-month period was not significantly different between the two groups (P=0.50). The patients’ pain experience was not significantly different between the bracket groups (P=0.29). Conclusion. During the four-month alignment stage, significantly more improvement in the upper dental irregularity was observed with self-ligating compared to conventional brackets. The bracket type had no effect on pain experience during the alignment stage.

QOLP-15. LONGITUDINAL PERCEPTION OF PROGNOSIS OF PATIENTS WITH HIGH GRADE GLIOMA COMPARED TO THEIR CAREGIVERS AND CLINICIANS

BACKGROUND Treatment options and prognosis are limited for patients with high grade glioma (pwHGG), underscoring the importance of patient and caregiver understanding to prioritize goals of care and quality of life (QOL). Although addressed by multiple providers, patients and caregivers may experience discordance in understanding the prognosis. This may be related to patient/caregiver perception, cognitive decline as a result of the tumor and/or treatment, or failure by the clinician to clearly articulate this information under emotional circumstances. AIMS: To evaluate the longitudinal perception of prognosis of patients compared to their caregivers and their providers during the adjuvant treatment of newly diagnosed HGG. METHODS After IRB approval, 16 pwHGG, their caregivers and their providers reported an overall survival estimate at each monthly visit during adjuvant treatment, as part of a larger survey. Options included “weeks,” “weeks to several months,” “several months to years,” “indefinite number of years”, or “I do not wish to answer.” RESULTS Seven of the sixteen patient/caregiver clusters have completed the appropriate duration of the study with the remaining completing in November. The perception of the patient differs from the caregiver at almost each visit. Regardless of the counseling provided by provider, the perception of both tends to change at each visit and can vary from dismal to overtly optimistic. There does not appear to be discrepancy between the neuro-oncology and palliative care provider’s perception of prognosis. CONCLUSION Newly diagnosed pwHGG and caregivers vary in their perception of prognosis, deviating not only from each other but also differing at each visit throughout the course of their illness. The providers’ perception appeared to remain consistent but often varied from that of the patient and caregiver. Providers need to be aware that prognostic understanding appears to fluctuate throughout the course of illness and cannot be clarified via a single discussion.

Assessment of topiramate’s efficacy and safety in epilepsy

ABSTRACT Objective: To study the significance of topiramate (TPM) addition on seizure control in treatment of epilepsy. Design: A prospective open label add-on trial of TPM addition in patients with epilepsy was done. The events of baseline phase of 12 weeks followed by titration and maintenance phases were recorded. Assessment of the number of seizure and emergent adverse effects was done by a monthly visit for each case. Main Outcome Measures: Reduction of more than 50% mean seizure frequency or response ratio of 0.33 was taken as the criteria for responders. Statistical Analysis: Normal Z-test for significance of differences between two proportions and Chi-square test for presence of association was applied and mean age, median duration, sex ratio, percentage prevalence were depicted. Results: Significant responses to TPM in both partial as well as generalized seizures were observed (Z = 6.66, P < 0.001 and Z = 4.185, P < 0.01). The effect was more pronounced in patients with partial seizures. However, the overall response was highly significant (Z = 7.839, P < 0.001). The best response was noted at the dose of 200-300 mg/day (Z = 6.708, P < 0.001). More than 35% cases of partial and generalized seizures reported more than 75% reduction levels. The drug was well tolerated in more than 65% cases for side effects on psychosis, giddiness, and anorexia. Mild side effects were seen only in about less than 35% cases. Conclusions: TPM was found as a significantly effective add-on anticonvulsant with some limitation or mild side effects.