PURPOSE The COVID-19 pandemic created an imperative to re-examine the role of telehealth in oncology. We studied trends and disparities in utilization of telehealth (video and telephone visits) and secure messaging (SM; ie, e-mail via portal/app), before and during the pandemic. METHODS Retrospective cohort study of hematology/oncology patient visits (telephone/video/office) and SM between January 1, 2019, and September 30, 2020, at Kaiser Permanente Northern California. RESULTS Among 334,666 visits and 1,161,239 SM, monthly average office visits decreased from 10,562 prepandemic to 1,769 during pandemic, telephone visits increased from 5,114 to 8,663, and video visits increased from 40 to 4,666. Monthly average SM increased from 50,788 to 64,315 since the pandemic began. Video visits were a significantly higher fraction of all visits ( P < .01) in (1) younger patients (Generation Z 48%, Millennials 46%; Generation X 40%; Baby Boomers 34.4%; Silent Generation 24.5%); (2) patients with commercial insurance (39%) compared with Medicaid (32.7%) or Medicare (28.1%); (3) English speakers (33.7%) compared with those requiring an interpreter (24.5%); (4) patients who are Asian (35%) and non-Hispanic White (33.7%) compared with Black (30.1%) and Hispanic White (27.5%); (5) married/domestic partner patients (35%) compared with single/divorced/widowed (29.9%); (6) Charlson comorbidity index ≤ 3 (36.2%) compared with > 3 (31.3%); and (7) males (34.6%) compared with females (32.3%). Similar statistically significant SM utilization patterns were also seen. CONCLUSION In the pandemic era, hematology/oncology telehealth and SM use rapidly increased in a manner that is feasible and sustained. Possible disparities existed in video visit and SM use by age, insurance plan, language, race, ethnicity, marital status, comorbidities, and sex.
6578 Background: The ECOG-PS (Eastern Cooperative Oncology Group Performance Status) scale is often used to guide cancer care, but the degree to which it predicts contemporary real-world clinical outcomes, in general and within certain patient groups, is relatively unknown. This retrospective cohort study examined associations between ECOG-PS levels and adverse outcomes in cancer patients with diverse patient characteristics. Methods: Various patient characteristics and nurse-rated ECOG-PS scores (range: 0-4) were recorded for all 21,730 adult patients with cancer receiving intravenous systemic therapy between 01/01/2017 and 12/31/2019 at 18 Kaiser Permanente Northern California cancer centers. Differences in baseline characteristics by ECOG-PS scores were evaluated using chi-square tests for categorical variables and ANOVA for continuous variables. Univariable and multivariable Cox Proportional Hazard models were used to test the ability of ECOG-PS to predict the occurrence of adverse clinical outcomes, including 1-month emergency department (ED) visits and hospitalizations, and 6-month mortality. Results: Overall, 42.5% of patients had ECOG-PS = 0, 42.5% had ECOG-PS = 1, 10.5% had ECOG-PS = 2, 4% had ECOG-PS = 3 and 0.4% had ECOG-PS = 4. Most patients were women (58%), non-Hispanic White (61%), English speakers (93%) and married/domestic partners (63%). African Americans, men, older patients, and those with higher Charlson comorbidity index or Stage IV cancer were found to have higher ECOG-PS levels (all p < 0.001). In multivariable analysis, ECOG-PS of 3-4 were associated with higher ED visits (HR 3.85, 95% CI [3.47-4.26]), hospitalizations (HR 4.7, [4.12-5.36]) and mortality (HR 7.34, [6.64-8.11]), compared with ECOG-PS = 0. Upper gastrointestinal (GI) and Stage IV cancers were associated with a higher risk of ED (upper GI: HR 2.39, [2.12-2.68], (stage IV: HR 1.31, [1.21-1.42]), hospitalization (HR 2.67, [2.27-3.13], (HR 1.51, [1.35-1.68]), and mortality rates (HR 3.37, [2.97-3.81], (HR 1.82, [1.68-1.98]), compared to Breast and Stage I cancers; however, advanced age was not associated with these outcomes. Interactions between ECOG-PS and cancer type as well as ECOG-PS and age group were statistically significant (p < 0.001), such that ECOG-PS was more predictive of adverse outcomes in younger patients and those with breast cancer. Conclusions: In this contemporary real-world cohort, multivariable analysis showed that ECOG-PS, cancer type and stage were strong predictors of ED visits, hospitalizations and mortality; however, advanced age was not. These results also show that ECOG-PS is more predictive of clinical outcomes in certain patient groups. Our findings may have implications on the use of ECOG-PS for clinical decision making.
12055 Background: ASCO and NCCN guidelines recommends Geriatric Screening (G8) and CARG chemotherapy toxicity tool assessment for all older patient before receiving chemotherapy as high risk G8 (< 14) and CARG (≥10) are associated with increased chemotherapy toxicities. We conducted a pilot to understand predictors of high risk G8/CARG and if high risk G8/CARG can predict ER/hospitalization and mortality in community-based Oncology clinics in Kaiser Permanente Northern California. Methods: G8 and CARG were administered to all patients ≥65 years with newly diagnosed cancer from 5/1/21 to 12/31/21. Patients were followed for at least 30 days after assessment for ER/hospitalization and mortality. The median follow-up days from referral to ER/hospitalization was 96 days (range 0-273 days). Chi-Square tests were applied for G8/CARG risk category with demographic and utilization variables. Cox proportional-hazards models were performed to see the association between G8/CARG score and days from referral to ER/hospitalization, and days from referral to death, adjusted for age, sex, race, and cancer type. Results: During this pilot 1082 patients (52% female) completed G8, and 516 patients (57% female) completed CARG. Percentage of patients with high risk G8/CARG increased with each decade (G8: < 70 yrs (58%), 70-79 (63%), 80-89 (90%), ≥ 90 (100%); p < 0.001); (CARG: < 70 yrs (19%), 70-79 (43%), 80-89 (65%), 90 and above (81%); p < 0.001). More men than women had high risk CARG (48% vs. 39%, p = 0.012). Ethnicity was not associated with high risk G8 / CARG. Upper GI cancers (UGI) were associated with highest proportion of patients with high risk G8 (88%) and CARG (58%) whereas breast cancer (BC) had the lowest proportion of patients with high risk G8 (46%) and CARG (14%); p < 0.001. In the adjusted G8 model for ER/hospitalization, high risk G8 vs low risk (HR 1.58, CI 1.23-2.03, p = 0.0003) was related to ER/hospitalization. In the adjusted CARG model for ER/ hospitalization, high risk CARG vs low risk (HR 2.42, CI 1.37-4.29, p = 0.0024) and medium risk CARG vs low risk (HR 2.17, CI 1.23-3.83, p = 0.0074) were related to ER/hospitalization. In the adjusted G8 model for mortality, high risk G8 vs low risk (HR 4.52, CI 2.28-8.97, p < 0.0001) were related to mortality. In the adjusted CARG model for mortality, high risk CARG vs low risk (HR 3.92, CI 1.21-12.74, p = 0.023) and medium risk CARG vs low risk (HR 1.59, CI 0.48-5.33, p = 0.45) were related to mortality. Conclusions: This community-based pilot shows that increasing age is associated with high risk G8 / CARG. G8 and CARG assessment at the time of initial cancer diagnosis can predict early ER/hospitalization and mortality in older adults with cancer and should be included as a part of initial assessment.
12051 Background: As the number of older adults with cancer continues to grow, there is an urgent and unmet need to implement geriatric assessments and toxicity screening tools (G8 and CARG toxicity tool) for patients 65 and older with a cancer diagnosis in real-world settings. Studies of these tools show completion rates of 20-35% when administered by a physician. To determine if nurse navigators could increase completion rates, we implemented a pilot in seven community cancer centers within an integrated health system. Methods: A pilot project of G8 and CARG toxicity tool implementation was completed at seven community cancer centers from May 1,2021 to December 31,2021 in patients age ≥ 65 years, with solid or malignant hematologic cancer diagnosis. G8 was administered at seven sites and CARG was assessed in addition to G8 on solid tumor patients undergoing chemotherapy at four of the seven sites. Referrals to nutrition, audiology, physical therapy, psychiatry, and neurology were sent by nurse navigators based on assessment results. Results: The total number of eligible patients for G8 was 1372, with 1082 (78.9 %) successfully completing assessment, and the total number of eligible patients for CARG toxicity tool was 563 with 516 (91.6%) successfully completing assessment. The median age of patients completing assessment was 74 years old (range 65-100) and 52% were female. The cohort included Asian / Pacific Islanders (23%), Black (15%), Hispanic White (8%), and Non-Hispanic Whites (51%). Most common cancers included genitourinary cancer (18%), breast cancer (17%), upper GI cancer (15%), and thoracic cancer (13%). The assessments resulted in referrals to multiple services including nutrition (193 referrals), audiology (30), physical therapy (18), psychiatry (5), and neurology (5). Conclusions: Nurse navigators can successfully implement G8 and CARG toxicity tool in hematology-oncology clinics in a broad range of cancer types at a high rate with resultant referrals to multiple supportive services in real-world settings.
1606 Background: While the COVID pandemic elevated the usage of telehealth to unprecedented levels, it remains unclear whether telehealth use is sustained after the initial pandemic era, and whether there remain demographic differences in telehealth utilization. In this study, we compared telehealth trends amongst different demographic populations in a large integrated healthcare system. Methods: Utilization of various visit types (office, video, telephone) was investigated in this population-based retrospective cohort study at 22 Kaiser Permanente Northern California Hematology and Oncology clinics from 10/1/2020 to 6/1/2022. We explored trends associated with the COVID 19 pandemic and after the initial pandemic era as well as demographic differences, using Chi-square for categorical and the Mann-Whitney U Test for non-parametric comparisons. Results: During the study period, there were 341,089 hematology/oncology visits with MD/DO providers, including 83,756 (24.5%) office, 125,162 (36.7%) video, and 132,171 (38.7%) telephone. Total monthly visits remained stable, with a monthly average of 1,765 (10.9%) for new visits and 14,476 (89.1%) for return visits. Monthly telehealth visits (telephone + video) peaked in January, 2021 (85.6% of total visits) and subsequently declined by June, 2022 (68.7% of total visits). Telephone visits increased from 46.1% of telehealth visits to 58.9% over the study period. Amongst telehealth visits, video visits remained popular for new appointments (56.9%) while telephone visits were more common for return appointments (60.7%). After the initial pandemic era, telehealth utilization continued to differ amongst different demographic populations. Video visits remained a significantly higher fraction of all visits (p<0.01) in: (1) less than 45 year-old (60.0%) compared to older than 80 year-old (33.2%); (2) primary English speakers (50.7%) compared to those who require an interpreter (41.5%); (3) patients with commercial insurance (58.2%) compared to those with Medicaid (47.0%) or Medicare (45.2%); (4) non-Hispanic Whites (51.4%) and Asians (52.2%) compared to Hispanic Whites (45.0%) and Blacks (43.6%); (5) patients with the lowest neighborhood deprivation index (NDI) quartile (living in the least deprived neighborhood) (54.0%) vs the highest quartile (46.1%). Conclusions: After the initial pandemic era, telehealth utilization declined slightly over time but remained a common method of providing oncology care. Video visits continued to be widely utilized for initial visits whereas there was a shift to telephone visits for follow up appointments over time. Disparities in telehealth, especially in video visits, continued to be seen in various demographic populations by age, English proficiency, insurance plan, race/ethnicity and neighborhood deprivation index. Continued high utilization of telehealth should inform policy and practices in the post-pandemic era.
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