20 Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy is not reimbursed because of diagnosis-related group codes. We have previously reported inpatient chemotherapy and immunotherapy (IC) is associated with poorer outcomes for patients with advanced stage solid tumor (ST) vs hematologic malignancy (HM) patients. 1 We piloted the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of inpatient administration of costly therapies in patients especially at the end of life. Methods: Using an iterative process, an interdisciplinary group of physicians, nurses and pharmacists developed objective criteria of patient, cancer and treatment factors to guide chemotherapy stewardship. IC that is on formulary and being given as standard of care (i.e., induction of leukemia) are automatically approved. IC that is non-formulary requires evaluation using the developed criteria. Treatment factors include information on the level of existing evidence to support use: type and phase of trial, FDA and NCCN approvals. Patient factors include: performance status, line and goal of therapy. The scoring rubric positively weights regimens with strong levels of evidence or positive patient factors and negatively weights regimens with poor levels of evidence and adverse patient factors. Clinicians must complete the criteria via a form in RedCap. Upon completion, a score is automatically calculated by the tool and 2 disease specific physicians and a clinical pharmacist review for accuracy. If the threshold score is met, IC is approved for inpatient administration and if it is not met, IC is not approved for administration. Results: From January 2022 until May 2022 there have been 30 cases reviewed. 50% were ST requests and 50% were for HM requests. 20 cases (67%) were approved and 8 cases (26%) were not. Two cases were retracted by the requestor. This resulted in cost savings of $63,920. Table illustrates clinical outcomes and characteristics of the approved cases. Conclusions: This pilot illustrates that 67% of the time our cancer physicians chose the administration of inpatient chemotherapy that aligned with objective criteria which is reassuring and serves to validate the use of this tool. Alternatively, this objective rubric prevented inappropriate administration of chemotherapy 26% of the time. Our pilot indicates that there is a role for an objective tool for automated inpatient chemotherapy stewardship. Reference: Evaluation of inpatient chemotherapy among patients with cancer. Petrone G et al. JCO.2022.40.16_suppl.6566.[Table: see text]
e24074 Background: Early integration of palliative care (PC) into advanced cancer care has been shown to improve quality of life and prognostic understanding. However, there is a paucity of data on utilization of inpatient PC consultation and survival outcomes in patients (pts) receiving inpatient chemotherapy (IC). Methods: A retrospective review was performed at a single academic center of pts receiving IC between Jan 2016 and Dec 2017. We evaluated utilization of PC services, reasons for consult, code status, disposition, and 60-day mortality. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect, taking into account correlations from multiple admissions per patient. Cumulative incidence plot and Cox proportional hazard regression models were used to assess the association between mortality and study covariates. Results: Of 880 admissions, 733 (83%) were hematologic malignancies (HM) and 147 (17%) were solid tumors (ST). PC consults were more likely in ST than HM (OR 3.19, 95% CI 1.85 - 5.50) and for KPS ≤50% (OR 22.20, 95% CI 11.51- 42.79). Of 159 PC consults, 91 (57%) were for pain and 25 (16%) for goals of care. 66 pts (10%) who received IC died within 60 days of admission, 44 (67%) HM and 22 (33%) ST (p = 0.002). In pts who died within 60 days, 63% had PC consult. Median time from admission to PC consult was 2 days for ST and 9 for HM. Of those with PC consult, 40% had a change from full code to DNR/DNI and were more likely to have a health care proxy (HCP) assigned (OR 7.31, p = 0.001). PC consults were also associated with significantly higher odds of discharge to hospice (OR 10.52, 95% CI: 4.3-25.6; p = < 0.0001; Table). Mortality risk was higher in those admitted for symptoms/complications related to their disease or with progression (HR 3.24, 95% CI (2.50-4.19), p < 0.001) and in those with advanced stage disease: Stage 3 (p = 0.033); Stage 4 (p = 0.0003). Of the pts who died within 60 days, 33 (50%) died during the admission and 24 (36%) in hospice. Conclusions: Significant 60-day mortality after receiving IC is consistent with aggressive end-of-life care. Pts with ST and those with poor performance status more frequently utilized inpatient PC services; however, there is opportunity to increase utilization amongst pts with HM and introduce PC earlier in the inpatient clinical course. PC consultations improve advanced care planning with appropriate transitions in code status, HCP assignments, and discharge to hospice.[Table: see text]
6566 Background: Administration of inpatient chemotherapy (IC) is associated with more aggressive end of life care, reduced use of palliative care (PC) and decreased quality of life (QOL). This study aims to identify risk factors associated with overutilization of IC. Methods: We conducted a retrospective chart review of all admissions where IC was administered at an academic center between January 2016 and December 2017. Patients (pts) were stratified by solid tumors (ST) versus hematologic malignancies (HM) and urgency for IC was assessed. We evaluated other variables which can impact patient care such as length of stay (LOS), reason for admission and for IC. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect taking into account correlations from multiple admissions per patient. All tests were two-sided and statistical significance was considered when p<.05. Results: We analyzed 880 admissions (17% ST). Table 1 summarizes outcomes. HM pts required frequent direct admission for IC compared to ST. ST pts (p<.0001), pts >65 years (p=0.004) and pts with KPS ≤50% (p<.0001) were most likely admitted for cancer complications rather than for IC. LOS (>7 days) was significantly longer in HM admissions (p=0.0001), among pts with stage 4 cancer (p=0.014) and KPS ≤50% (p=0.0001). ST (p=0.006) and pts with KPS ≤50% (p=0.0001) received IC for a non-urgent indication significantly more often than HM. In 20% of ST admissions, pts received IC because the admission coincided with a non-urgent planned cycle compared to 3% of HM. In the adjusted analysis, tumor type was the most important factor correlated with urgency of IC (OR 0.42, 95% CI: 0.25-0.72; p=0.001). ST pts (p=0.0001), older pts (p=0.004) and pts with KPS ≤50% (p=0.0001) were less likely to respond to chemotherapy. Only 15% of HM admissions and 46% of ST admissions had a PC consult. 60-day mortality was significantly higher in ST pts than HM (p=0.002). Conclusions: IC is associated with poorer outcomes for pts with advanced stage ST, pts with poor functional status and pts admitted for acute indications. Additionally, ST pts have a higher mortality after IC compared to HM. Utilization of IC should be standardized to account for different patient characteristics and to reduce the incidence of non-urgent administration. Based on this data, we created a standardized protocol to better assess the appropriateness of IC to improve patient care, QOL, and reduce chemotherapy and healthcare utilization at the end of life. [Table: see text]
e13535 Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy (IC) is not reimbursed because of diagnosis-related group codes. We implemented the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of costly inpatient therapies in patients especially at the end of life. Methods: We created a scoring rubric based on treatment and regimen specific criteria. IC that is on formulary and standard of care is automatically approved. IC that is non-formulary requires evaluation using the developed criteria. Treatment factors include: type and phase of trial, and FDA and NCCN approvals. Patient factors include: performance status, line and goal of therapy. Clinicians must complete the criteria via a form in RedCap which then automatically calculates a score which is then reviewed by 2 disease specific physicians and a clinical pharmacist for accuracy. If the threshold score is met, IC is approved and if it is not met, IC is not approved for administration. Our primary outcome is cost savings and clinical outcomes. Results: Pre-implementation the cost of IV NF chemotherapy from 3/2021-10/2021 was $744,105 and post –implementation from 3/2022-10/2022 was $549,363 which is a 26% ($194,741) reduction in cost. 98 cases were reviewed over this time period. 82 (84%) cases were approved and 16 (16%) were disproved. The total cost of approved cases was $482,694 and the cost savings of disproved cases was $68,121 (14%). 51 were Solid Tumor (ST) requests and 47 were for Heme Malignancy (HM) requests. Clinical outcomes of the approved cases are illustrated. 16% of cases were submissions for immunotherapy (nivolumab, pembrolizumab) and 81% of those patients died. Conclusions: 84% of the time our cancer physicians chose the administration of IC that aligned with objective criteria which is reassuring and serves to validate the use of this tool. Alternatively, this tool prevented inappropriate administration of chemotherapy 16% of the time. Our pilot indicates that there is a role for an objective tool for automated IC stewardship.[Table: see text]
325 Background: The Mount Sinai Health System oncology service line initiated a patient safety solution (PSS) committee to comprehensively review reported safety events in order to provide safe and high-quality care. This multi- and interdisciplinary committee creates a safe space to report events that caused harm, near misses and empowers all staff to be part of a just culture of safety. Here we describe the process and report on outcomes. Methods: The committee consists of nurses, advanced practice providers, physicians, pharmacists, social workers, IT analysts, and administrative staff, representing the oncology service line across inpatient and outpatient. Any staff member can enter incident reports that they believe warrant review into a software application. Our quality team reviews all events and then selects cases in which harm or near-harm was involved, for in-depth investigation to be presented at bi-weekly PSS meetings where cases are discussed, root causes are evaluated, and solutions are proposed. For each case, the committee votes on standard of care using the Continuous Quality Improvement (CQI) Classifications tool. Often, smaller workgroups are formed to carry out quality improvement (QI) projects and corrective action plans (CAPs). All case data, including patient demographics, case summaries, outcomes, and ongoing plans are tracked using a custom REDCap survey. A question about the role of bias was added in December 2020 (yes/no/not enough information). Results: From January 2021 until March 2022, a total of 115 events were reviewed with an average of 23 events reviewed each quarter. Sociodemographic information on patients reviewed is in table. 41% of cases involved the inpatient setting. Issues with medication comprised 47% of cases, followed by patient identification (11%) and lack of escalation (10%). The most common CAPs involved education and counselling (47%), development of new policies (22%) and escalation to leadership (8%). In total, we have developed 29 new workflows, policies, and guidelines. Bias was felt to be involved 25% of the time, no bias 5% and not enough information 43% of the time. Conclusions: This process illustrates the importance of a multi- and interdisciplinary and transparent approach to clinical case and peer review to ensure the highest level of care. The outcomes of this committee have led us to optimize current policies, create new policies and procedures, new rounding structures and place a renewed focus on bias and discrimination.[Table: see text]
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