Purpose: To conduct a systematic review with meta-analysis to determine the effects of immunosuppression on Group 1 Pulmonary Arterial Hypertension in patients with systemic lupus erythematosus (SLE). Methods:We searched Medline, Embase, Web of Science, Clini caltr ials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) with a search strategy developed by a medical librarian. We included retrospective, cross-sectional, casecontrol, prospective studies, and randomized controlled trials (RCTs) in our analysis and only included studies that contained data for patients with SLE. We included any immunosuppressive agents (including but not limited to cyclophosphamide, glucocorticoids, mycophenolate mofetil, azathioprine, and rituximab) We assessed for risk of bias and certainty of evidence. Outcomes included hemodynamics (as measured by pulmonary arterial hypertension), functional status, 6 minute walk test (6MWT), quality of life, mortality, and serious adverse events. Results:We included three studies. One RCT and two single-arm interventional observational studies. The RCT had a high risk of bias whereas the two single-arm interventional studies were graded as fair quality. Meta-analysis could not be conducted because of insufficient data. The RCT showed significant improvements in hemodynamics (as measured by pulmonary arterial pressures) and functional status.One observational study showed improvements in hemodynamics, functional status, and 6MWT. There were insufficient data for serious adverse events, mortality, and quality of life.Conclusions: Despite a high prevalence and with a poor prognosis, there is a paucity of data for the role of immunosuppression in the treatment of Group 1 Pulmonary Arterial Hypertension in SLE. More high-quality studies are needed, especially to investigate serious adverse events and quality of life.
e18641 Background: There are two million female veterans across the United States, a number increasing by more than 18,000 per year. 1 in 8 women will be diagnosed with breast cancer in their lifetime, and studies have shown that servicewomen are 40% more likely to get breast cancer than civilians. The American Cancer Society (ACS) recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and both primary care physicians and oncologists are now ordering these more frequently. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs screening mammograms and ultrasounds, but breast MRI is not currently available at the facility. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments, the outside MRI facility, and the patient. There are a significant number of MRI order cancellations per month, which can lead to delays in diagnosis or treatment. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We looked at all breast MRI orders starting in 12/2020 at the MEDVAMC and determined the rate of cancellation and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis to determine the most common cancellation reasons and p-charts of the percent of cancelled MRI orders per month and a run chart of the percent due to incorrect verbiage. Results: Of the 243 orders placed for MRI for 124 patients from 12/2020 to 1/2022, 64.2% were cancelled. Of the 57% of patients (71/124) with complete MRIs, 35.2% had non-benign findings requiring follow up, excluding known malignancies. Our Pareto analysis showed that most cancellations were due to incorrect verbiage in the order. An intervention in 6/2021 changed the MRI order from a free text box to clickable options, followed by an educational intervention in 12/2021. Cancellations due to incorrect verbiage decreased overall after June, however it has not yet reached significance. It is too early to determine if the educational intervention caused a significant change, however the cancellation rate has decreased. Conclusions: Providing discrete, clickable options within the MRI order has reduced the number of cancellations due to incorrect verbiage, though we have not yet reached significance. Early data suggests that the educational intervention has improved the cancellation rate. Fewer cancellations will lead to more timely studies, which will in turn lead to faster follow up of non-benign findings. Further directions include using a nurse navigator to reduce confusion and delays, further simplifying the ordering process, checking patient phone numbers in clinic, and sending patients home with information on the importance of screening MRI to reduce veteran cancellation.
371 Background: The number of female veterans is increasing by more than 18,000 per year, and 700 veterans enrolled in VA healthcare are diagnosed with breast cancer each year. The American Cancer Society recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and primary care physicians and oncologists order breast MRIs regularly. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs mammograms and ultrasounds on site, but breast MRI is not currently available. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments at the MEDVAMC, outside MRI facilities, and patients. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We reviewed all breast MRI orders from 1/2019 to 5/2021 at the MEDVAMC and determined the cancellation rate and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis of cancellation reasons. Our process measures were percentage of placed breast MRI orders that were cancelled and delay from MRI order to MRI performed. Our outcome measures were percentage of order cancellations due to incorrect or incomplete orders and delay from MRI order placement to results uploaded. Results: Of the 434 orders that were placed for breast MRIs, 64% were cancelled. Only 117 of the 167 patients that had MRIs ordered ultimately received one. Of the 104 patients without known malignancy who competed an MRI, 45% had non-benign findings requiring follow-up. Our pareto analysis showed that the top cancellation reason was incorrect orders, usually contrast or side verbiage. In June 2021, the CITC order set for MRI was changed from a free text box to discrete, clickable options for side and contrast. In December 2021, we held educational interventions on how to avoid delay or cancellation. Our p-chart of percentage of cancellations due to incorrect ordering shows an extremely promising decrease, with the last seven consecutive subgroups of 15 patients below the mean. The order cancellation percentage is also decreasing. The average delay pre-intervention from MRI order placement to results uploaded was 67 days. In January 2022, we implemented a breast MRI nurse navigator to help acquire results and expedite scheduling. Post-intervention, the average delay has decreased to 38.5 days. Using XmR and S charts, we have also shown an increase in precision. Conclusions: Providing discrete, clickable options within the MRI order set reduced the number of cancellations due to incorrect verbiage. Early data suggests that the educational intervention improved the cancellation rate. Instituting a nurse navigator decreased both the delay and variability for the time from order placement to results received, which will reduce the delay to follow-up of non-benign findings.
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