Evolving assessment pathways for precision oncology medicines to improve patient access: a tumor-agnostic lens

BACKGROUND

Genomic and molecular alterations are increasingly important in cancer diagnosis, and scientific advances are opening new treatment avenues. Precision oncology (PO) uses a patient's genomic profile to determine optimal treatment, promising fewer side effects and higher success rates. Within PO, tumor-agnostic (TA) therapies target genomic alterations irrespective of tumor location. However, traditional value frameworks and approval pathways pose challenges which may limit patient access to PO therapies.

OBJECTIVES

This study describes challenges in assessing PO and TA medicines, explores possible solutions, and provides actionable recommendations to facilitate an iterative life-cycle assessment of these medicines.

METHODS

After reviewing the published literature, we obtained insights from key stakeholders and European experts across a range of disciplines, through individual interviews and an industry workshop. The research was guided and refined by an international expert committee through 2 sounding board meetings.

RESULTS

The current challenges faced by PO and TA medicines are multiple and can be demonstrated through real-world examples of the current barriers and opportunities. A life-cycle approach to assessment should be taken, including key actions at the early stages of evidence generation, regulatory and reimbursement stage, as well as payment and adoption solutions that make use of the evolving evidence base. Working toward these solutions to maximize PO medicine value is a shared responsibility and stands to benefit all stakeholders.

CONCLUSIONS

Our call to action is to expand access to comprehensive genomic testing, foster a learning health care system, enable fast and equitable access to cost-effective treatments, and ultimately improve health outcomes.

People get ready! A new generation of Alzheimer's therapies may require new ways to deliver and pay for healthcare

The development of disease-modifying therapies (DMTs) for Alzheimer's disease (AD) has progressed over the last decade, and the first-ever therapies with potential to slow the progression of disease are approved in the United States. AD DMTs could provide life-changing opportunities for people living with this disease, as well as for their caregivers. They could also ease some of the immense societal and economic burden of dementia. However, AD DMTs also come with major challenges due to the large unmet medical need, high prevalence of AD, new costs related to diagnosis, treatment and monitoring, and uncertainty in the therapies' actual clinical value. This perspective article discusses, from the broad perspective of various health systems and stakeholders, how we can overcome these challenges and improve society's readiness for AD DMTs. We propose that innovative payment models such as performance-based payments, in combination with learning healthcare systems, could be the way forward to enable timely patient access to treatments, improve accuracy of cost-effectiveness evaluations and overcome budgetary barriers. Other important considerations include the need for identification of key drivers of patient value, the relevance of different economic perspectives (i.e. healthcare vs. societal) and ethical questions in terms of treatment eligibility criteria.

A potential biomarker of radiosensitivity in metastatic hormone sensitive prostate cancer patients treated with combination external beam radiotherapy and radium-223

PURPOSE

The ADRRAD trial reported the safety and feasibility of the combination of external beam radiotherapy and radium-223 in the treatment of de novo bone metastatic prostate. This study aimed to determine if any biomarkers predictive of response to these treatments could be identified.

EXPERIMENTAL DESIGN

30 patients with newly diagnosed bone metastatic hormone sensitive prostate cancer were recruited to the ADRRAD trial. Blood samples were taken pre-treatment, before cycles 2 to 6 of radium-223, and 8 weeks and 6 months after treatment. Mononuclear cells were isolated and DNA damage was assessed at all timepoints.

RESULTS

DNA damage was increased in all patients during treatment, with bigger increases in foci observed in patients who relapsed late compared to those who relapsed early. Increases in DNA damage during the radium-223 only cycles of treatment were specifically related to response in these patients. Analysis of hematology counts also showed bigger decreases in red blood cell and hemoglobin counts in patients who experienced later biochemical relapse.

CONCLUSIONS

While some patients responded to this combination treatment, others relapsed within one year of treatment initiation. This study identifies a biomarker based approach that may be useful in predicting which patients will respond to treatment, by monitoring both increases in DNA damage above baseline levels in circulating lymphocytes and decreases in red blood cell and hemoglobin counts during treatment.

Staff Perceptions on the Effectiveness of GRiP-S, a New Approach to Clinical Supervision Incorporating Safewards: An Interpretive Phenomenological Analysis

This study explored the impact of an innovative approach to clinical supervision for mental health nurses which integrates Safewards, named Group Reflective integrated Practice with Safewards - GRiP-S. Qualitative data was collected through 10 individual semi-structured interviews with nursing staff who had participated within the clinical supervision approach. Interviews provided insights into the nursing staff's perception and experience of the clinical supervision approach. Through interpretive phenomenological analysis six themes emerged (i) illuminating embodied practice of Safewards, (ii) building confidence through empowering connections, (iii) creating a culture of positive change, (iv) identifying internal motivation for and external barriers to supervision engagement, (v) navigating a global pandemic, and (vi) the transformative role of reflection. Findings demonstrated that the GRiP-S approach assisted mental health nurses' adoption of Safewards interventions in practice, while supporting the development of a cohesive staff team. The impact of COVID-19 within the study setting was addressed and nurses identified how the Safewards model assisted in navigating challenges during this time. Findings further supported prior research on the role of the supervisor and supervisee relationship. This study supports the integration of Safewards within reflective clinical supervision for mental health nursing staff to assist in Safewards fidelity and nursing staff personal and professional development.

Inter-comparison of measurements of inorganic chemical components in precipitation from NADP and CAPMoN at collocated sites in the USA and Canada during 1986-2019

Wet deposition monitoring is a critical part of the long-term monitoring of acid deposition, which aims to assess the ecological impact of anthropogenic emissions of SO2 and NOx. In North America, long-term wet deposition has been monitored through two national networks: the Canadian Air and Precipitation Monitoring Network (CAPMoN) and the US National Atmospheric Deposition Program (NADP), for Canada and the USA, respectively. In order to assess the comparability of measurements from the two networks, collocated measurements have been made at two sites, one in each country, since 1986 (Sirois et al., in Environmental Monitoring and Assessment, 62, 273-303, 2000; Wetherbee et al., in Environmental Monitoring and Assessment, 1995-2004, 2010). In this study, we compared the measurements from NADP and CAPMoN instrumentation at the collocated sites at the Pennsylvania State University (Penn State), USA, from 1989 to 2016, and Frelighsburg, Quebec, Canada, from 2002 to 2019. We also included in the study the collocated daily-vs-weekly measurements by the CAPMoN network during 1999-2001 and 2016-2017 in order to evaluate the differences in wet concentration of ions due to sampling frequency alone. The study serves as an extension to two previous CAPMoN-NADP inter-comparisons by Sirois et al. (Environmental Monitoring and Assessment, 62, 273-303, 2000) and Wetherbee et al., in (Environmental Monitoring and Assessment, 1995-2004, 2010). At the Penn State University site, for 1986-2019, CAPMoN was higher than NADP for all ions, in terms of weekly concentration, precipitation-weighted annual mean concentration, and annual wet deposition. The precipitation-weighted annual mean concentrations were higher for SO42- (2%), NO3- (12%), NH4+ (16%), H+ (6%), and base cations and Cl- (11-15%). For annual wet deposition, CAPMoN was higher for SO4-2, NO3-, NH4+ and H+ (5-17%), and base cations and Cl- (12-17%) during 1986-2019. At the Frelighsburg site, NADP changed the sample collector in October 2011. For 2002-2011, the relative differences at the Frelighsburg site were positive and similar in magnitude to those at the Penn State site. For 2012-2019, the precipitation-weighted annual mean concentrations were 5-27% lower than NADP, except for H+, which was 23% higher. The change in sample collector by NADP had the largest effect on between-network biases. The comparisons of daily-vs-weekly measurements conducted by the CAPMoN network during 1999-2001 and 2016-2017 show that the weekly measurements were higher than the daily measurements by 1-3% for SO42-, NO3-, and NH4+; 3-9% for Ca2+, Mg2+, Na+, and Cl-; 10-24% for K+; and lower for H+ by 8-30% in terms of precipitation-weighted mean concentration. Thus, differences in sampling frequencies did not contribute to the systematically higher CAPMoN measurements. Understanding the biases in the data for these networks is important for interpretation of continental scale deposition models and transboundary comparison of wet deposition trends.

Simulation CT Features and Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation cardiotoxicity is a significant clinical dilemma in non-small cell lung cancer (NSCLC) radiation therapy (RT). Baseline cardiovascular (CV) status may influence the risk of cardiotoxicity, and may be ascertainable from the appearance of the heart on simulation computed tomography (CT). We examined the association of CT features with incidental heart dose and risk of cardiac events in NSCLC.

MATERIALS/METHODS

Patients treated with curative-intent RT between 2015 and 2020 at a regional center were identified. Clinical notes were interrogated for baseline patient and CV health details, and follow-up CV events. Cardiac events were verified by a cardiologist. A deep learning-based auto-segmentation tool was applied, allowing extraction of a pre-specified list of volume parameters in a programming environment. CAC was graded as none, mild, moderate and severe in patients with a non-contrast scan. The craniocaudal relationship of the PTV and heart (Feng atlas) were annotated.

RESULTS

A total of 478 patients were included, with a median age of 70 and Charlson Index of 5. The median mean heart dose was 6.3 Gy (IQR 2.7-11.4). The median lung V20 was 20.0% (IQR 14.8-27.1). Cardiovascular risk factors were common, with most patients having 2 (39%) or 3 (31%). A history of previous cardiac events was common, including myocardial infarction (14%), arrhythmia (11%) or heart failure (9%). A total of 6.9% and 7.1% patients developed a new atrial arrhythmia (AA) or heart failure (HF) after completing RT. The volume metrics with the highest AUC for AA and HF events were the left atrium (LA) (AUC 0.67, p = 0.0002) and left ventricle:right ventricle (LV:RV) ratio (AUC 0.66, p = 0.0021). Kaplan-Meier analysis for cardiac events dichotomizing at the optimal cut-point for maximum sensitivity and specificity demonstrated significantly different rates for both AA (LA 109cc, HR 3.35, 95% CI 1.64-6.83, p = 0.0009) and HF (LV:RV ratio 1.61, HR 2.37, 95% CI 1.19-4.74, p = 0.0143). Only 2 patients with non-contrast scans developed a myocardial infarction, both had mild CAC. The incidence of pooled cardiac events was not significantly different between patients with no (n = 2/21, 9.5%), mild (n = 10/38, 26.3%), moderate (n = 8/53, 15.1%) and severe (n = 7/24, 29.2%) CAC (p = 0.3916). Where the inferior border of the PTV was above the superior border of the heart, mean heart dose was significantly lower than compared with overlap of levels (1.9 Gy v 9.7 Gy, p<0.0001), and this was true for 3DCRT (n = 139, p<0.001), IMRT (n = 94, p<0.001) and VMAT (n = 145, p<0.001) patients.

CONCLUSION

LA volume and LV:RV volume ratio are predictive for the development of AA and HF respectively. CAC grade did not differentiate patients by risk of cardiac events. Where the craniocaudal level of the PTV doesn't overlap with the level of the heart, the cardiac dose is likely to be very low. Several simulation CT features are associated with cardiac events following treatment for NSCLC and prospective evidence of cardiac risk could enable medical optimization prior to RT.

Patient-Level and Endpoint-Specific Clinico-Dosimetric Analysis of the Cardiac Base as a Mediator of Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer (NSCLC) radiation therapy. Radiation dose to the cardiac base is associated with poor overall survival in several clinical studies, but has not been validated in a non-dose escalated cohort, or with individual patient delineations. In this study we examined the impact of cardiac base dose on overall survival (OS) and cardiac events (CEs), and interrogated the relationships of the substructures comprising the heart base with OS and CEs.

MATERIALS/METHODS

Patients with stage I-III NSCLC treated with curative-intent radiation therapy between 2015 and 2020 at a regional cancer center were identified. Clinical notes were examined for baseline patient, tumor and cardiac details, and both cancer and cardiac outcomes. Three cardiologists verified CEs. Cardiac delineations were completed using a validated deep learning-based autosegmentation tool. Cox and Fine and Gray regressions were undertaken for the risk of death and CEs respectively, accounting for pre-specified evidence-based dose metrics and clinically relevant cardiac covariates.

RESULTS

Most patients received 55 Gy/20# (n = 461/478, 96%) without chemotherapy (58%), planned with VMAT (51%) or IMRT (20%). Pre-existing cardiovascular morbidity was common, with 78% having ≥2 risk factors, and 46% having >1 established cardiac disease. The median follow-up was 21.1 months. Dichotomized at the median, higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (21.6 months (95% CI 19.3-24.9) versus 29.4 months (95% CI 21.6-36.6), p = 0.021), and remained significant when statistically compared in published multivariate models. In a multivariate analysis for pooled acute CEs, heart base Dmax was associated with CEs (HR 1.75, 95% CI 1.01-1.06, p = 0.04), but this was not the case for individual CEs. Using Fine and Gray models to account for the competing risk of death, left main coronary maximum dose was associated with atrial fibrillation (p = 0.024), proximal right coronary artery V15 (p = 0.023) and mean dose (p = 0.032), and the right atrium mean dose (p = 0.029) were associated with heart failure. No dose-volume metrics were significantly associated with acute coronary syndrome. None of the constituent base substructures dose were significantly associated with death.

CONCLUSION

Dose to the heart base was associated with increased mortality and an increased pooled cardiac event rate. Accounting for endpoint-specific clinical covariates, only select constituent substructures of the heart base were associated with CEs and no substructures were independently associated with survival. Together, these findings are suggestive of possible interplay between the constituent base substructures in their mediation of radiation cardiotoxicity.

Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review

BACKGROUND

While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings.

AIM

To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care.

METHODS

Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies.

RESULTS

A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations.

CONCLUSION

All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience.

PATIENT AND PUBLIC CONTRIBUTION

Patient or public contribution was not possible because of the type of the variables being explored.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

A randomized, double-blind, single-dose study to assess bioequivalence of MB02 biosimilar after manufacturing iteration and reference bevacizumab

To investigate and compare the pharmacokinetic (PK) profiles of MB02 products, before and after optimizing the manufacturing process, and reference bevacizumab to establish bioequivalence between them. In this randomized, double-blind, single dose, parallel study, 114 healthy male volunteers were randomized 1:1:1 to receive a 1 mg/kg intravenous dose of MB02-SP, MB02-DM, or US-bevacizumab. The follow-up period was 100 days. PK similarity between them was determined using the standard bioequivalence criteria (0.80-1.25) for the area under the serum concentration-time curve from time 0 extrapolated to infinity and the maximum observed serum concentration. Study results showed that the PK profiles of bevacizumab were similar. Statistical analysis demonstrated that for each pairwise comparison there were no differences. The 90% CIs for the ratios of geometric least squares means were fully contained within the predefined similarity acceptance limits and ranged from 0.899 to 1.12 for area under the curve and from 0.887 to 1.11 for maximum concentration. A total of 159 adverse events were reported by 76 subjects who received the study drug. The majority (90.6%) of the reported adverse events were grade 1 in severity, with 9.4% as grade 2 in severity. None were considered as grade 3, 4, or 5. Treatment-induced anti-drug antibodies incidence was 21.6%, 33.3%, and 23.7% for the treatment of MB02-SP, MB02-DM, and US-bevacizumab, respectively. No subjects showed treatment-induced neutralizing anti-drug antibodies. This study demonstrates the PK, safety, and immunogenicity similarity and bioequivalence of MB02-SP, MB02-DM, and the reference product bevacizumab.

Getting a grip on Safewards: The cross impact of clinical supervision and Safewards model on clinical practice

The Safewards model is used across various mental health settings to reduce incidents of conflict and containment and its efficacy in reducing the use of seclusion and restraint, improving patients' experiences of care, and enhancing safety within clinical settings is well documented (Bowers, Journal of Psychiatric & Mental Health Nursing, 21, 2014, 499). However, there are barriers to successful implementation, including level of staff buy-in (Baumgardt et al., Frontiers in Psychiatry, 10, 2019, 340; Price et al., Mental Health Practice, 19, 2016, 14). This mixed-method study assessed the impact of adopting a Safewards model within a clinical supervision framework in an approach, named Group Reflective integrated Practice with Safewards (GRiP-S), which integrates Safewards theory within the clinical supervision framework. Both quantitative and qualitative data were collected using the questions derived from the Manchester Clinical Supervision Scale -26© (Winstanley & White, The Wiley International Handbook of Clinical Supervision. John Wiley & Sons Ltd, 2014). A total of 67 surveys and eight interviews were completed by nursing staff. Overall, the results showed that the GRiP-S approach improves the implementation of Safewards and nurses' clinical practice. Nursing staff satisfaction with clinical supervision and Safewards improved post GRiP-S pre-GRIP-S- 69.54 (SD 16.059); post-GRIP-S 71.47 (SD 13.978). The survey also identified nursing staff's perception of GRiP-S in the restorative and formative domains of clinical supervision improved. The restorative mean score pre-GRiP-S was 28.43 (SD 5.988) and post-GRiP-S 29.29 (SD 3.951). The formative mean score pre-GRiP-S was 20.10 (SD 5.617) and post-GRiP-S 20.63 (SD 13.978). The qualitative results further explained the satisfaction levels and the changes seen in perception domains. The GRiP-S approach reported (i) improved therapeutic relationships and patient centred care, (ii) improved staff communication and teamwork, (iii) barriers to GRiP-S engagement, and (iv) assistance with the change process. The results indicate that the GRiP-S approach had a positive impact on Safewards delivery and supports ongoing change of practice.

POS0481 DEFINING DISTINCT RESIDENT AND MIGRATORY FIBROBLAST POPULATIONS FROM SKIN BIOPSIES IN SYSTEMIC SCLEROSIS

Background

Recent studies using single cell RNA sequencing have delineated distinct subpopulations of fibroblasts in skin and other organs. To improve understanding of functional differences between fibroblast subpopulations, we have developed a novel technique to selectively isolate “migratory” fibroblasts, and non-migratory “resident” fibroblasts from heathy control (HC) and SSc skin.

Objectives

To compare migratory and resident populations of dermal fibroblasts in systemic sclerosis by their differential gene or protein expression, and through functional assays of fibrotic potential.

Methods

Forearm skin punch biopsies were collected from dcSSc(n=3), and healthy control skin(n=3).

Migratory fibroblasts were first isolated by standard explant culture, then the residual biopsy fragments underwent collagenase digestion to yield a population of resident fibroblasts that retained in the biopsy fragments. These populations were further expanded for use at passage 3-6.

Functional characterisation included 3-D collagen gel contraction, and migratory scratch-wound assays. Expression of pro-collagen I (Col1), CTGF and αSMA was compared by western blot. Bulk RNAseq on each fibroblast population was performed. Statistical analysis was carried out using Rsoftware “tidyverse”. Criteria for significant differences in gene expression were a fold change of ≥1.5, and adjusted p-value (FDR) of <0.05

Results

Compared with HC, all SSc fibroblast populations showed a hallmark fibrotic phenotype with increased gel contraction, faster migration, and overexpression of Col1, CTGF and αSMA compared with HC. However, SSc resident fibroblasts showed attenuated contraction, migration, and reduced levels of αSMA compared to migratory SSc fibroblasts. Bulk RNAseq performed on each fibroblast population confirmed 5579 significantly differentially expressed genes between SSc resident and SSc migratory fibroblasts, whereas no genes were significantly differentially expressed between HC resident and migratory fibroblasts.

SSc and HC migratory fibroblasts and resident fibroblasts were then compared, to understand disease-related differences between the two fibroblast populations. 739 genes were significantly overexpressed in the migratory fibroblast population (including ASPM, TRIP3), whereas 745 genes were significantly upregulated in the resident fibroblast population. The genes upregulated in resident fibroblasts included CCL2, CXCL8, and ICAM1.

Many genes typically associated with SSc (such as SERPINE1, COMP), were not significantly different between the SSc fibroblast subpopulations, but were significantly elevated in both SSc subpopulations compared to HC fibroblast populations, suggesting that these reflect a more generic SSc phenotype.

Conclusion

Migratory and resident SSc fibroblast populations exhibit distinct functional and transcriptional differences that are much less apparent for HC biopsies. Further work is required to understand the precise contribution these distinct SSc fibroblast populations in pathogenesis, and how they might be targeted therapeutically. Our findings also highlight that conventional explant culture techniques may ignore important fibroblasts populations and highlight the importance of more detailed analysis such as single cell analysis to better understand pathobiology of SSc.

Table 1.

Table of the most significantly differentially expressed genes with highest fold change and adjusted p-value (FDR) between the migratory and resident SSc fibroblast population

Significantly upregulated genes in SSc migratory fibroblastsSignificantly upregulated genes in SSc resident fibroblastsFold changeAdjusted p valueFold changeAdjusted p valueGPR15.990.01CCL238.66<0.0001PPME14.860.011CXCL824.360.0001KIF20A4.340.015ICAM115.38<0.0001CENPF4.310.018EGR115.190.0002STC24.180.01EGR212.770.0002ASPM3.880.02IFI44L11.50.002TRIB33.600.011CXCL611.43<0.0001HAPLN13.360.039PDGF-D10.140.0003CCNB23.290.025OAS38.940.0009KIF143.240.027IFIT18.580.004

Disclosure of Interests

Kristina Clark: None declared, Alice Cole: None declared, Xu Shiwen: None declared, Voon Ong: None declared, Christopher D Buckley Employee of: founder of Mestag Therapeutics https://mestagtherapeutics.com/, Christopher P Denton: None declared.

Improving Estimates of Sulfur, Nitrogen, and Ozone Total Deposition through Multi-Model and Measurement-Model Fusion Approaches

Earth system and environmental impact studies need high quality and up-to-date estimates of atmospheric deposition. This study demonstrates the methodological benefits of multimodel ensemble and measurement-model fusion mapping approaches for atmospheric deposition focusing on 2010, a year for which several studies were conducted. Global model-only deposition assessment can be further improved by integrating new model-measurement techniques, including expanded capabilities of satellite observations of atmospheric composition. We identify research and implementation priorities for timely estimates of deposition globally as implemented by the World Meteorological Organization.

Factors Affecting Citizen Trust and Public Engagement Relating to the Generation and Use of Real-World Evidence in Healthcare

The potential for the use of real-world data (RWD) to generate real-world evidence (RWE) that can inform clinical decision-making and health policy is increasingly recognized, albeit with hesitancy in some circles. If used appropriately, the rapidly expanding wealth of health data could improve healthcare research, delivery of care, and patient outcomes. However, this depends on two key factors: (1) building structures that increase the confidence and willingness of European Union (EU) citizens to permit the collection and use of their data, and (2) development of EU health policy to support and shape data collection infrastructures, methodologies, transmission, and use. The great potential for use of RWE in healthcare improvement merits careful exploration of the drivers of, and challenges preventing, efficient RWD curation. Literature-based research was performed to identify relevant themes and discussion topics for two sets of expert panels, organized by the European Alliance for Personalised Medicine. These expert panels discussed steps that would enable a gradual but steady growth in the quantity, quality, and beneficial deployment of RWE. Participants were selected to provide insight based on their professional medical, economic, patient, industry, or governmental experience. Here, we propose a framework that addresses public trust and access to data, cross-border governance, alignment of evidence frameworks, and demonstrable improvements in healthcare decisions. We also discuss key case studies that support these recommendations, in accordance with the discussions at the expert panels.

Animal and translational models of SARS-CoV-2 infection and COVID-19

COVID-19 is causing a major once-in-a-century global pandemic. The scientific and clinical community is in a race to define and develop effective preventions and treatments. The major features of disease are described but clinical trials have been hampered by competing interests, small scale, lack of defined patient cohorts and defined readouts. What is needed now is head-to-head comparison of existing drugs, testing of safety including in the background of predisposing chronic diseases, and the development of new and targeted preventions and treatments. This is most efficiently achieved using representative animal models of primary infection including in the background of chronic disease with validation of findings in primary human cells and tissues. We explore and discuss the diverse animal, cell and tissue models that are being used and developed and collectively recapitulate many critical aspects of disease manifestation in humans to develop and test new preventions and treatments.

The frequent user’s decision-making process when contacting urgent and/or emergency services

Background

There is a lack of qualitative research that has been undertaken which has captured the perspective of frequent users to urgent and emergency healthcare services. Previous research has viewed and studied this population largely by using retrospective routine data, which focuses on the patient's demographic, presenting symptom or demand implication. Current research now advocates that these vulnerable and complex individuals are using these services due to their unmet needs or multiple comorbidities. The aim of this research was to explore the patient's decision-making process and their motivations for repeatedly contacting urgent and emergency services.

Methods

Semi-structured interviews were undertaken with a small cohort of six previously identified frequent users to urgent and emergency healthcare services. These participants were recruited into the study by a third sector organisation, due to the vulnerabilities and complexities of these individuals' lifestyles. A framework analysis was used to code and extract relevant themes and concepts from the interviews.

Results

Social prescribing through a named support worker enables navigation and re-engagement into a range of services that benefits this population and reduces their demand upon other services. The support given through social prescribing organisations can counteract the lack of personal support networks and resilience factors that these individuals experience. In addition, individuals who have been re-referred into substance misuse services should be offered alternative engagement programmes, which differ from their initial programme.

Conclusions

Current inequities of outcomes and access to services should be examined, in relation to vulnerable and complex individuals who have reduced support networks and limited resilience factors. Future research should be undertaken regarding the benefits for frequent users of social prescribing to support patient outcomes and re-integration into services.

Key messages

Social prescribing is the link that enables complex and vulnerable frequent users to navigate and re-engage into a range of health and social care services. Examining the inequities faced by frequent users to urgent and emergency healthcare services.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

1173 Reducing Cancellation and Improving the Patient’s Experience Through Quality Improvement Process

Introduction

Sleep study volume in our system has increased by 23% from 2017 to 2019 which makes unfilled sleep beds a significant concern. Cancellation rate impacts our sleep bed access. We hypothesized cancellation can be improved through quality improvement process which could ultimately lead to improve patient satisfaction.

Methods

A multi-disciplinary team was assembled to examine potential contributing factors. Using the Model for Improvement we developed, tested and implemented interventions using tools such as PDSA cycles, process map and a simplified FMEA (Failure Modes and Effects Analysis). A Key Driver Diagram helped guide our journey to improve the cancellation rate. We developed a Parent Advisory Group to help us with ideas to identify how we could improve the cancellation rate.

Results

The cancellation was 21% prior to the implementation of our interventions. To improve these measures, we have implemented several interventions. The content of our sleep study preparation handbook was improved, increased distribution of the education handbook and developed a series of sleep study videos which are available for viewing prior to the study to prepare patients and families. In addition, we standardized our process of reminder calls in the call center and sleep lab by defining roles and responsibilities. This improved our ability to answer questions and identify and mitigate barriers they may have. We implemented transportation assistance to patients who have transportation barriers and created a waitlist protocol to assist families with a preferred date. After 2 years of interventions, the cancellation rate has decreased from 21% to 14.7%. Interestingly, as we improved our cancellation rate, the overall patient satisfaction has been improved from 83% to 88%.

Conclusion

Using the Model for Improvement, we improved education, communication and scheduling processes, which has reduced cancellation rate and consequently improved patient satisfaction.

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Toward the improvement of total nitrogen deposition budgets in the United States

Frameworks for limiting ecosystem exposure to excess nutrients and acidity require accurate and complete deposition budgets of reactive nitrogen (Nr). While much progress has been made in developing total Nr deposition budgets for the U.S., current budgets remain limited by key data and knowledge gaps. Analysis of National Atmospheric Deposition Program Total Deposition (NADP/TDep) data illustrates several aspects of current Nr deposition that motivate additional research. Averaged across the continental U.S., dry deposition contributes slightly more (55%) to total deposition than wet deposition and is the dominant process (>90%) over broad areas of the Southwest and other arid regions of the West. Lack of dry deposition measurements imposes a reliance on models, resulting in a much higher degree of uncertainty relative to wet deposition which is routinely measured. As nitrogen oxide (NOx) emissions continue to decline, reduced forms of inorganic nitrogen (NHx = NH3 + NH4+) now contribute >50% of total Nr deposition over large areas of the U.S. Expanded monitoring and additional process-level research are needed to better understand NHx deposition, its contribution to total Nr deposition budgets, and the processes by which reduced N deposits to ecosystems. Urban and suburban areas are hotspots where routine monitoring of oxidized and reduced Nr deposition is needed. Finally, deposition budgets have incomplete information about the speciation of atmospheric nitrogen; monitoring networks do not capture important forms of Nr such as organic nitrogen. Building on these themes, we detail the state of the science of Nr deposition budgets in the U.S. and highlight research priorities to improve deposition budgets in terms of monitoring and flux measurements, leaf- to regional-scale modeling, source apportionment, and characterization of deposition trends and patterns.

Aspects of uncertainty in total reactive nitrogen deposition estimates for North American critical load applications

Determination of the amount of reactive nitrogen (Nr) deposition in excess of the ecosystem critical load (CL) requires an estimate of total deposition. Because the CL exceedance is used to inform policy decisions, uncertainty in both the CL and the exceedance itself must be understood. In this paper we review the state of the science with respect to the sources of uncertainty in total Nr deposition budgets used for CL assessments in North America and put forth recommendations for research and monitoring to improve deposition measurements and models. In the absence of methods to rigorously quantify uncertainty in total Nr deposition, a simple weighted deposition uncertainty metric (WDUM) is introduced as a tool for scientists and decision makers to use in assessing CL exceedances. Maps of the WDUM applied to National Atmospheric Deposition Program (NADP) Total Deposition (TDep) estimates show greater uncertainty in areas of the U.S. where dry deposition makes a larger contribution to the deposition budget, particularly ammonia (NH3) in agricultural areas and oxidized nitrogen (NOx) in urban areas. Organic N deposition is an important source of uncertainty over much of the U.S. Our analysis illustrates how the WDUM can be used to assess spatial patterns of deposition uncertainty and inform actions to improve deposition budgets for CL assessments at the local scale.

Late presentation of spinal cord compression in hereditary multiple exostosis: case reports and review of the literature

INTRODUCTION

Osteochondromas are usually found in the long bones of patients with hereditary multiple exostoses (HME). The spine is reported to be involved in over 50% of cases, but few of these patients are symptomatic as the result of an existing spinal exostosis.

METHODS

We reviewed the current literature in order to find the right approach to patients with HME-complicated spinal exostosis and describe three paediatric patients that were diagnosed late with spinal cord compression due to cervical exostosis.

RESULTS

Our three cases were all late presentations with neurology and unfortunately had minimal improvement of neurology after the lesion was surgically removed. There is general agreement that late presentation of spinal cord injury due to osteochondromas involving the cervical spine may cause severe and irreversible neurological sequelae. Our literature review revealed that there are no clear-cut guidelines to develop more comprehensive screening measures for these patients.

CONCLUSIONS

A high index of suspicion is the most important factor for correct diagnosis and appropriate management. Physicians who treat HME should bear in mind that thorough history taking and a neurological examination at follow up are essential for these patients. Clearer guidelines for the development of more comprehensive screening programmes are essential.

LEVEL OF EVIDENCE

IV.

Policy perspectives on alternative models for pharmaceutical rebates: a report from the Institute for Clinical and Economic Review Policy Summit

Alternative approaches to the current rebate system are being considered by policymakers and stakeholders in the private insurance market. This paper presents an analysis of three alternative options to the current rebate model: retaining retroactive rebates but requiring 100% pass-through of rebates and fees to plan sponsors; retaining retroactive rebates but requiring that patients share in rebates at the point of sale; and eliminating retroactive rebates and replacing the current structure with upfront discounts. Each alternative approach presents a balance of potential advantages and disadvantages. Policymakers should not assume that switching to an alternative rebate model will deliver unalloyed benefits for patients and the health system.

Valuation of EuroQol Five-Dimensional Questionnaire, Youth Version (EQ-5D-Y) and EuroQol Five-Dimensional Questionnaire, Three-Level Version (EQ-5D-3L) Health States: The Impact of Wording and Perspective

BACKGROUND

Valuations of health states were affected by the wording of the two instruments (EQ-5D-3L and EQ-5D-Y) and by the perspective taken (child or adult).

OBJECTIVES

There is a growing demand for value sets for the EQ-5D-Y (EQ-5D instrument for younger populations). Given the similarities between EQ-5D-Y and EQ-5D-3L, we investigated whether valuations of health states were affected by the differences in wording between the two instruments and by the perspective taken in the valuation exercise (child or adult).

STUDY DESIGN

Respondents were randomly assigned to EQ-5D-3L or EQ-5D-Y (instrument) and further into two groups that either valued health states for an adult or for a 10-year-old child (perspective). The valuation tasks were composite time trade-off (C-TTO) and discrete choice experiments (DCE), including comparisons with death (DCE + death). Members of the adult general population in four countries (Germany, Netherlands, Spain, England) participated in computer-assisted personal interviews.

METHODS

Two-way multivariate analysis of variance (MANOVA) and post hoc tests were used to compare C-TTO responses and chi-square tests were conducted to compare DCE + death valuations.

RESULTS

A significant interaction effect between instrument and perspective for C-TTO responses was found. Significant differences by perspective (adult and child) occurred only for the EQ-5D-3L. Significant differences in values between instruments (EQ-5D-3L and EQ-5D-Y) occurred only for the adult perspective. Both significant results were confirmed by the DCE + death results. When comparing EQ-5D-3L for adult perspective and EQ-5D-Y for child perspective, values were also significantly different.

CONCLUSIONS

The results identified an interaction effect between wording of the instrument and perspective on elicited values, suggesting that current EQ-5D-3L value sets should not be employed to assign values to EQ-5D-Y health states.

Search for Boosted Dark Matter Interacting with Electrons in Super-Kamiokande

A search for boosted dark matter using 161.9 kt yr of Super-Kamiokande IV data is presented. We search for an excess of elastically scattered electrons above the atmospheric neutrino background, with a visible energy between 100 MeV and 1 TeV, pointing back to the Galactic center or the Sun. No such excess is observed. Limits on boosted dark matter event rates in multiple angular cones around the Galactic center and Sun are calculated. Limits are also calculated for a baseline model of boosted dark matter produced from cold dark matter annihilation or decay. This is the first experimental search for boosted dark matter from the Galactic center or the Sun interacting in a terrestrial detector.

Valuing EQ-5D-5L health states 'in context' using a discrete choice experiment

BACKGROUND

In health state valuation studies, health states are typically presented as a series of sentences, each describing a health dimension and severity 'level'. Differences in the severity levels can be subtle, and confusion about which is 'worse' can lead to logically inconsistent valuation data. A solution could be to mimic the way patients self-report health, where the ordinal structure of levels is clear. We develop and test the feasibility of presenting EQ-5D-5L health states in the 'context' of the entire EQ-5D-5L descriptive system.

METHODS

An online two-arm discrete choice experiment was conducted in the UK (n = 993). Respondents were randomly allocated to a control (standard presentation) or 'context' arm. Each respondent completed 16 paired comparison tasks and feedback questions about the tasks. Differences across arms were assessed using regression analyses.

RESULTS

Presenting health states 'in context' can significantly reduce the selection of logically dominated health states, particularly for labels 'severe' and 'extreme' (χ² = 46.02, p < 0.001). Preferences differ significantly between arms (likelihood ratio statistic = 42.00, p < 0.05). Comparing conditional logit modeling results, coefficients are ordered as expected for both arms, but the magnitude of decrements between levels is larger for the context arm.

CONCLUSIONS

Health state presentation is a key consideration in the design of valuation studies. Presenting health states 'in context' affects valuation data and reduces logical inconsistencies. Our results could have implications for other valuation tasks such as time trade-off, and for the valuation of other preference-based measures.

Oral literacy demand in the pediatric dental clinic: a pilot study

BACKGROUND

The parent's ability to obtain, process, and understand important oral health information (i.e., their oral health literacy) is directly related to their child's oral health status.

AIM

To assess the relationship between oral literacy demands placed on parents by dentists and parents' understanding of dental information given to them.

DESIGN

Thirty-one consenting primary caregivers of children attending their first dental visit completed a demographic survey, a REALD-30 test, and a survey to test understanding of dental information. Dental appointments, performed by eight pediatric dental residents, were audio-recorded and transcribed for qualitative analysis and descriptive statistics.

RESULTS

Factors associated with language complexity were significantly higher in dental residents (R) than participants (P), that is, total number of words spoken (R: 1615.09 + 859.91 vs P: 480.68 + 232.034) and words per sentence (R: 8.82 + 1.74 vs P: 4.91 + 1.71). Speaking turns did not differ between resident and parent (R: 94.64 vs P: 83.27).

CONCLUSIONS

Although the dialogue between the participating dentists and parents was highly unequal, parents understood about 86% of the information provided by the resident. Future studies are needed to identify factors associated with gaps in the educational process of parents in the dental setting.

A Review of NICE Methods and Processes Across Health Technology Assessment Programmes: Why the Differences and What is the Impact?

BACKGROUND

Decisions made by the National Institute for Health and Care Excellence (NICE) exert an influence on the allocation of resources within 'fixed' National Health Service budgets. Yet guidance for different types of health interventions is handled via different 'programmes' within NICE, which follow different methods and processes.

OBJECTIVE

The objective of this research was to identify differences in the processes and methods of NICE health technology assessment programmes and to explore how these could impact on allocative efficiency within the National Health Service.

METHODS

Data were extracted from the NICE technology appraisal programme, medical technologies guidance, diagnostic assessment programme, highly specialised technologies programme, and clinical guidelines process and methods manuals to undertake a systematic comparison. Five qualitative interviews were carried out with NICE members of staff and committee members to explore the reasons for the differences found.

RESULTS

The main differences identified were in the required evidence review period, or lack thereof, mandatory funding status, the provision of a reference case for economic evaluation, the requirement for and the type of economic analysis undertaken, and the decision making criteria used for appraisal.

CONCLUSION

Many of the differences found can be justified on grounds of practicality and relevance to the health technologies under assessment. Nevertheless, from a strict utilitarian view, there are several potential areas of inefficiency that could lead to the misallocation of resources within the National Health Service, although some of these might be eliminated or reduced if an egalitarian view is taken. The challenge is determining where society is willing to trade health gains between different people.