The Importance of Redefining Geriatric Expertise in Nursing Homes to Reduce Unnecessary Hospitalizations

Unplanned transfers from nursing homes (NHs) are burdensome, associated with adverse outcomes for residents and costly for health care systems. Internationally, NHs are facing similar issues whereby a lack of geriatric expertise combined with a shortage of NH general practitioners require innovative and adaptable models of care tailored to the organizational context. In this symposium, we will present studies from the MOQI project from the United States, which successfully reduced unnecessary hospitalizations by embedding advanced practice registered nurses (APRN) in 16 US NHs over a 6-year period. We will discuss the influence of race on multiple hospital transfers and present possible interventions to reduce transfers. Next, we will present finding from a study with MOQI APRNs that highlighted their contributions to the COVID-19 pandemic response in NHs and discuss the broader implication or infection control practices. In addition, we will present the INTERCARE project which successfully reduced unplanned hospitalizations in 11 Swiss NHs, by implementing a registered nurse with an expanded role, to compensate for the very limited access to APRNs; which is the case for many European countries. Both MOQI and INTERCARE pinpoint the importance of strategies to support the introduction of a new role in NHs. Both projects will give examples of different models of care which can be feasibly implemented to sustainably decrease unnecessary hospitalizations, in different contexts and with different resources. Finally, data from the INTERCARE study will address the issue of potentially avoidable fall-related transfers and which resources are deemed appropriate to mitigate these.

Defining Appropriate Resources for Nursing Homes to Reduce Potentially Avoidable Transfers After a Fall

Falls are common in nursing home (NH) residents and are the predominant reason for an emergency department (ED) transfer. Falls are responsible for 25% - 87% of ED transfers, a proportion of which are potentially avoidable. INTERCARE – an implementation science study reducing unplanned hospitalizations (2018 – 2020) – involved experts to identify potentially avoidable fall-related transfers. Focus group and stakeholder survey enabled identification of resources to safely manage some falls in NHs. 25.9% of fall-related transfers were potentially avoidable based on using root-cause analysis and discharge reports. Avoidability was associated to ED visit, compared to hospitalizations. Appropriate resources identified by stakeholders included timely access to outpatient services for diagnostic imaging (e.g., X-Ray) and clinical skills’ training in suturing and wound care for registered or specialist nurses. Although NHs are striving for a home-like environment, better access to basic diagnostic and treatment services within NHs should be possible.

Very Few Interventions after Tumor Lysis Monitoring in Patients with Chronic Lymphocytic Leukemia Who Are Started on Venetoclax in the Real-World Setting- Suggests Less Intensive Monitoring Maybe Safe for Low-Risk Patients

Background: Chronic lymphocytic leukemia (CLL) is one of the most common lymphoid malignancies in adults. Venetoclax, an orally administered B-cell lymphoma 2 (BCL2) inhibitor, is a FDA approved therapy offering durable responses. Due to risk of tumor lysis syndrome (TLS) upon venetoclax initiation, a strict dose escalation schedule with frequent laboratory monitoring is recommended in the package insert (PI). Real world data reflecting adherence to this schedule and frequency of interventions resulting from intense monitoring are not described. Methods: Retrospective review of the Levine Cancer Institute database identified 73 consecutive patients with CLL who were initiated on venetoclax between July 2017 and March 2021. This included those initiated at the central academic site and regional academic-hybrid community sites. In the first two weeks of venetoclax, ramp up dosing and TLS labs (creatinine, potassium, calcium, phosphorous and uric acid) were evaluated for compliance consistent with the PI. Compliance required labs to be performed pre-dose, and at 6-8 hours and 24 hours after the initial 20 mg and 50 mg doses on weeks 1 and 2. The consequent interventions within these first 2 weeks, based on TLS labs, were then recorded. Patients who strictly adhered to all these laboratory checks at the various timepoints were considered compliant. Those who missed even a single lab or time point were considered non-compliant. Tumor lysis was measured by standard criteria using the Cairo-Bishop definition. The following Interventions were recorded: rasburicase administration, renal replacement therapy, ED visits, unplanned hospitalizations, ICU admissions, unplanned administration of IV fluids, the use of calcium supplementation, phosphate binders, treatment for hyperkalemia, dose reduction or holding of venetoclax. Baseline patient, disease, and treatment characteristics were summarized and described; rates of compliance were compared between tumor burden categories using Fisher's Exact test. Results : Baseline characteristics of the 73 identified patients were: 64% male, 79% white and 19% black, median age at venetoclax initiation was 67 (44 - 84). There were 49% of patients in the low tumor burden category, 44% in the medium tumor burden category and 6% in the high tumor burden category. Compliance with TLS labs during the first 2 weeks was 66% overall (n=48), with compliance between the tumor burden categories being 75% in high, 66% in medium and 67% in low (P>0.99). Interventions occurred in 6 (8%) of the patients, with all interventions occurring in the medium or high tumor burden group. These interventions included administration of IV fluids (n=2), calcium supplementation (n=1), phosphate binders (n=2) and holding of venetoclax (n=1). None of these 6 patients requiring an intervention had clinical or laboratory TLS. None of the 73 patients required rasburicase administration, renal replacement therapy, ED visits, unplanned hospitalizations, or ICU admissions during this 2 week ramp up period. Of the 6 patients requiring interventions, 4 patients had TLS labs performed by the PI versus 2 patients who did not. Clinical and laboratory TLS in the PI-compliant group was recorded. None of these patients had clinical TLS and 1 patient met the criteria for laboratory criteria TLS based on a 25% change from baseline in phosphorus and uric acid, however, labs remained in normal range. There were no deaths during the venetoclax ramp up. Conclusion: Compliance with the strict TLS lab monitoring during venetoclax initiation is not universal, likely due to real world patient and institutional barriers. The intervention rates during the first 2 weeks were low, with no patients in the low tumor burden category requiring an intervention. These results suggest that a less strict laboratory monitoring schedule may be safe in patients with low tumor burden CLL. If the safety is confirmed prospectively, it would make the venetoclax initiation less cumbersome and result in increased access to venetoclax for patients with low burden CLL. Disclosures Hu: Kite: Membership on an entity's Board of Directors or advisory committees; BeiGene: Membership on an entity's Board of Directors or advisory committees; Cellectar: Membership on an entity's Board of Directors or advisory committees. Moyo: Seattle Genetics: Consultancy. Park: Teva: Consultancy, Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees, Research Funding; G1 Therapeutics: Consultancy; Morphosys: Membership on an entity's Board of Directors or advisory committees; Rafael Pharma: Membership on an entity's Board of Directors or advisory committees, Other: Advisory Board; Gilead: Speakers Bureau; Seattle Genetics: Research Funding, Speakers Bureau; Takeda: Research Funding. Copelan: Amgen: Consultancy. Avalos: Juno Therapeutics: Membership on an entity's Board of Directors or advisory committees; BMJ Best Practice: Patents & Royalties: Royalties from a co-authored article on evaluation of neutropenia. Symanowski: Carsgen: Consultancy; Immatics: Consultancy, Other: DSMB Member; Eli Lilly: Consultancy, Other: DSMB Member. Jacobs: AbbVie: Consultancy, Speakers Bureau; AstraZeneca: Consultancy, Speakers Bureau; Pharmacyclics LLC, an AbbVie Company: Consultancy, Research Funding, Speakers Bureau; TG Therapeutics: Research Funding, Speakers Bureau; Verastem: Consultancy; ADC Therapeutics: Consultancy; Adaptive Biotechnologies: Consultancy; MEI Pharma: Research Funding; TeneoBio: Research Funding; SecuraBio: Consultancy, Speakers Bureau; Genentech: Consultancy; Jannsen: Speakers Bureau. Ghosh: Genmab: Consultancy, Honoraria; Pharmacyclics LLC, an AbbVie Company: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; AstraZeneca: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Speakers Bureau; Bristol Myers Squibb: Consultancy, Honoraria, Research Funding, Speakers Bureau; Epizyme: Honoraria, Speakers Bureau; Incyte: Consultancy, Honoraria; Adaptive Biotech: Consultancy, Honoraria; TG Therapeutics: Consultancy, Honoraria, Research Funding; Seattle Genetics: Consultancy, Honoraria, Speakers Bureau; ADC Therapeutics: Consultancy, Honoraria; AbbVie: Honoraria, Speakers Bureau; Karyopharma: Consultancy, Honoraria; Genentech: Research Funding.

Impact of the COVID-19 Pandemic on Primary Care Access for Patients with Hematologic Malignancies

Introduction: Primary care physicians are essential to cancer care. They frequently identify signs and symptoms leading to a diagnosis of cancer, and provide ongoing support and management of non-cancer health conditions during cancer treatment. Both primary care and cancer care have been greatly affected by the COVID-19 pandemic. In the United States, cancer-related patient encounters and cancer screening decreased over 40% and 80% respectively in January to April 2020 compared to 2019 (London et al. JCO Clin Cancer Inform 2020). However, the impact of the COVID-19 pandemic on primary care access for cancer patients remain unclear. Methods: We undertook a population-based, retrospective cohort study using healthcare databases held at ICES in Ontario, Canada. Patients with a new lymphoid or myeloid malignancy diagnosed within the year prior to the COVID-19 pandemic, between July 1, 2019 and September 30, 2019 (COVID-19 cohort) were compared to patients diagnosed in years unaffected by the COVID-19 pandemic, between July 1, 2018 - September 30, 2018 and July 1, 2017 - September 30, 2017 (pre-pandemic cohort). Both groups were followed for 12 months after initial cancer diagnosis. In the COVID-19 cohort, this allowed for at least 4 months of follow-up data occurring during the COVID-19 pandemic. The primary outcome was number of in-person and virtual visits with a primary care physician. Secondary outcomes of interest included number of in-person and virtual visits with a hematologist, number of visits to the emergency department (ED), and number of unplanned hospitalizations. Outcomes, reported as crude rates per 1000 person-months, were compared between the COVID-19 and pre-pandemic cohorts using Poisson regression modelling. Results: We identified 2882 individuals diagnosed with a new lymphoid or myeloid malignancy during the defined COVID-19 timeframe and compared them to 5997 individuals diagnosed during the defined pre-pandemic timeframe. The crude rate of in-person primary care visits per 1000 person-months significantly decreased from 574.4 [95% CI 568.5 - 580.4] in the pre-pandemic cohort to 402.5 [395.3 - 409.7] in the COVID-19 cohort (p < 0.0001). Telemedicine visits to primary care significantly increased from 5.3 [4.8 - 5.9] to 173.0 [168.4 - 177.8] (p < 0.0001). The rate of combined in-person and telemedicine visits to primary care did not change from 579.8 [573.8 - 585.8] in the pre-pandemic cohort to 575.5 [566.9 - 584.2] in the COVID-19 cohort (p = 0.43). In-person visits to hematologists decreased from 504.1 [498.5 - 509.7] to 432.8 [425.3 - 440.3] (p < 0.0001), and telemedicine visits to hematologists increased from 6.6 [6.0 - 7.3] to 75.9 [72.8 - 79.1] (p < 0.0001). The rate of combined visits to hematologists did not change from 510.7 [505.1 - 516.4] to 508.7 [500.6 - 516.8] (p = 0.68). The rate of ED visits significantly decreased from 95.1 [92.7 - 97.6] in the pre-pandemic cohort to 84.7 [81.4 - 88.0] in the COVID-19 cohort (p < 0.0001). The rate of unplanned hospitalizations did not change from 64.8 [62.8 - 66.8] to 65.7 [62.9 - 68.7] (p = 0.60). Conclusions: Primary care visits for patients with hematologic malignancies did not significantly change during the pandemic, but there was a sizeable shift from in-person to telemedicine visits. Similar findings were seen for visits to hematologists. While the rate of visits to the ED decreased, potentially due to concern of being exposed to the COVID-19 virus, the shift in ambulatory practices did not seem to impact the rate of unplanned hospitalizations. Disclosures No relevant conflicts of interest to declare.

Excess Mortality Among Patients Hospitalized During the COVID-19 Pandemic

BACKGROUND: The extent to which the COVID-19 pandemic has affected outcomes for patients with unplanned hospitalizations is unclear. OBJECTIVE: To examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020 to December 31, 2020). DESIGN, SETTING, AND PARTICIPANTS: Observational study of adults with unplanned hospitalizations at 51 hospitals across 6 Western states. EXPOSURES: Unplanned hospitalizations occurring during the spring COVID-19 surge (March 4 to May 13, 2020; Period 1), an intervening period (May 14 to October 19, 2020; Period 2), and the fall COVID-19 surge (October 20 to December 31, 2020; Period 3) were compared with a pre-COVID-19 baseline period from January 1, 2019, to March 3, 2020. MAIN OUTCOMES AND MEASURES: We examined daily hospital admissions and in-hospital mortality overall and in 30 conditions. RESULTS: Unplanned hospitalizations declined steeply during Periods 1 and 3 (by 47.5% and 25% compared with baseline, respectively). Although volumes declined, adjusted in-hospital mortality rose from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2, and rose again to 3.4% in Period 3. Elevated mortality was seen for nearly all conditions studied during the pandemic surge periods. CONCLUSION: Pandemic COVID-19 surges were associated with higher rates of in-hospital mortality among patients without COVID-19, suggesting disruptions in care patterns for patients with many common acute and chronic illnesses.

Perioperative respiratory adverse events during ambulatory anesthesia in obese children

Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.

Survival outcomes, treatment toxicity, and healthcare utilization in older adults with aggressive non-Hodgkin lymphoma (NHL).

7557 Background: Aggressive NHLs frequently affect older adults, and are often treated with intensive systemic therapy that is potentially curative but can cause substantial toxicities. Although balancing treatment efficacy with the risk of complications is critically important for older adults with NHL, few studies have described these patients’ survival outcomes, rates of toxicities, and healthcare utilization. Methods: We conducted a retrospective analysis of adults > 65 years diagnosed with aggressive NHL and treated with systemic therapy at Massachusetts General Hospital from 4/2000-7/2020. We abstracted patient demographic and clinical information, survival outcomes, treatment toxicity (rates and grade), and healthcare utilization outcomes (intensive care unit [ICU] admissions and unplanned hospitalizations within six months of treatment initiation) from the electronic health record. Using multivariable logistic regression, we examined patient and disease factors associated with rates of grade 3+ non-hematologic toxicity and unplanned hospitalization. Results: Of 295 patients (median age = 73 years [age 65-69: 32.5%; age 70-74: 26.1%; age 75-79: 20.0%; age 80+: 21.4%], 39.0% female), most had advanced stage disease (59.5%) and an ECOG performance status of 0 or 1 (83.1%). The most common diagnosis was de novo diffuse large B-cell lymphoma (DLBCL) or grade 3B follicular lymphoma (69.2%). Most common therapies were CHOP (65.8%) and EPOCH (17.0%) with or without Rituximab. With a median follow up of 5.9 years, 5-year overall survival (OS) was 74.2%. Among patients age 65-69, 70-74, 75-79, and 80+ years, 5-year OS by age group were 82.1%, 72.2%, 73.5%, and 66.3%, respectively. Overall, 42.4% had grade 3+ toxicity, while 8.1% had grade 4 or 5 toxicity. The rates of unplanned hospitalization and ICU admission during the first 6 months of therapy were 41.0% and 6.1%, respectively. In multivariable analysis, hypoalbuminemia (OR 4.22, 95%, p < 0.001) and number of comorbidities (OR 1.75, p < 0.001) were associated with a greater likelihood of grade 3+ toxicity. Hypoalbuminemia (OR 2.76, p = 0.003), number of comorbidities (OR 1.61, p = 0.001), and receipt of EPOCH (OR 5.41, p = 0.012) were associated with a greater likelihood of unplanned hospitalization. Conclusions: The majority of older adults receiving upfront therapy for aggressive NHL survive beyond 5 years, yet nearly half experience substantial treatment toxicities and unplanned hospitalizations. Our findings underscore the need to develop supportive care interventions to enhance the care experience for older adults with NHL.

Evaluation of Oncology Hospital at Home: Unplanned Health Care Utilization and Costs in the Huntsman at Home Real-World Trial

PURPOSE Patients with cancer experience high rates of morbidity and unplanned health care utilization and may benefit from new models of care. We evaluated an adult oncology hospital at home program's rate of unplanned hospitalizations and health care costs and secondarily, emergency department (ED) use, length of hospital stays, and intensive care unit (ICU) admissions during the 30 days after enrollment. METHODS We conducted a prospective, nonrandomized, real-world cohort comparison of 367 hospitalized patients with cancer—169 patients consecutively admitted after hospital discharge to Huntsman at Home (HH), a hospital-at-home program, compared with 198 usual care patients concurrently identified at hospital discharge. All patients met clinical criteria for HH admission, but those in usual care lived outside the HH service area. Primary outcomes were the number of unplanned hospitalizations and costs during the 30 days after enrollment. Secondary outcomes included length of hospital stays, ICU admissions, and ED visits during the 30 days after enrollment. RESULTS Groups were comparable except that more women received HH care. In propensity-weighted analyses, the odds of unplanned hospitalizations was reduced in the HH group by 55% (odds ratio, 0.45, 95% CI, 0.29 to 0.70; P < .001) and health care costs were 47% lower (mean cost ratio, 0.53; 95% CI, 0.39 to 0.72; P < .001) over the 30-day period. Secondary outcomes also favored HH. Total hospital stay days were reduced by 1.1 days ( P = .004) and ED visits were reduced by 45% (odds ratio, 0.55; 95% CI, 0.33 to 0.92; P = .022). There was no evidence of a difference in ICU admissions ( P = .972). CONCLUSION This oncology hospital at home program shows initial promise as a model for oncology care that may lower unplanned health care utilization and health care costs.

Predictors of Unplanned Hospitalizations Among Older Adults Receiving Cancer Chemotherapy

PURPOSE: Hospitalizations during cancer treatment are costly, can impair quality of life, and negatively affect therapy completion. Our objective was to identify risk factors for unplanned hospitalization among older adults receiving chemotherapy. METHODS: This is a secondary analysis of a multisite cohort study (N = 750) of patients ≥ 65 years of age evaluated with a geriatric assessment (GA) to predict chemotherapy toxicity. The primary outcome of this analysis was unplanned hospitalizations during treatment; the secondary outcome was length of stay (LOS) of the first hospitalization. Independent variables included pretreatment GA measures, laboratory values, cancer type and stage, and treatment intensity characteristics. We used logistic regression to estimate the odds of hospitalization and generalized linear models for LOS in multivariable analyses. RESULTS: The sample median age was 72 years (range, 65-94 years); 59% had stage IV disease. At least one unplanned hospitalization occurred in 193 patients (25.7%) during receipt of chemotherapy. In multivariable analyses controlling for cancer type, the following baseline characteristics were significantly associated with increased odds of hospitalization: needing help bathing or dressing (odds ratio [OR], 1.8; 95% CI, 1.0 to 3.1), polypharmacy (≥ 5 meds) (OR, 1.6; 95% CI, 1.1 to 2.4), more comorbid conditions (OR, 1.1; 95% CI, 1.0 to 1.3), availability of someone to take them to the doctor (OR, 2.0; 95% CI, 1.0 to 4.1), CrCl < 60 mL/min (OR, 1.7; 95% CI, 1.1 to 2.4), and albumin < 3.5 g/dL (OR, 1.8; 95% CI, 1.2 to 2.8). In multivariable analyses, older age, self-reported presence of liver or kidney disease, living alone and depressive symptoms were associated with longer LOS. CONCLUSION: Readily available GA variables and laboratory data, but not age, were associated with unplanned hospitalizations among older adults receiving chemotherapy. If validated, these data can inform prediction models and the design of interventions to decrease unplanned hospitalizations.