An Automated, Dynamic Radiation Oncology Prescription Checking System

PURPOSE

Despite serving as a critical communication tool, radiation oncology prescriptions are entered manually and prone to error. An automated prescription checking system was developed and implemented to help address this problem.

METHODS AND MATERIALS

Rules defining clinically appropriate prescriptions were generated, examining specific types of errors: (1) unapproved dose per fraction for a given disease site; (2) dose per fraction too large for nonstereotactic treatment technique; and (3) dose per fraction too low. With a goal of catching errors as upstream as possible to minimize their propagation, a report was created and ran every 30 minutes to check all newly written or approved prescriptions against the 3 rules. When a prescription violated these rules, an automated email was immediately sent to the prescriber alerting them of the potential error. System performance was continuously monitored and the criteria triggering an alert adjusted to balance error detection against false positives. Alerts leading to prescription amendment were considered true errors.

RESULTS

From June 2021 to November 2022, the system checked 24,047 prescriptions. A total of 241 email alerts were triggered, for an average alert rate of 1%. Of the 241 alerts, 198 (82.2%) were unapproved doses per fraction for the disease site, 14 (5.8%) were doses per fraction that were too low, and 29 (12%) were doses too large for nonstereotactic treatment technique. Thirty-one percent of alerts led to a change of prescription, suggesting they were true errors. The baseline rate of erroneous prescription entry was 0.3%. A regression model showed that trainee prescription entry and dose per fraction <150 cGy were significantly associated with true errors.

CONCLUSIONS

Given the significant consequences of erroneous prescription entry, which ranged from wasted resources and treatment delays to potentially serious misadministration, there is significant value in implementing automated prescription checking systems in radiation oncology clinics.

Improving Radiation Oncology Staff Engagement with Quality Improvement and Safety through a QI Committee Visiting Staff Initiative

PURPOSE/OBJECTIVE(S)

An interdisciplinary, team-based approach to safety and quality is a critical value of radiation oncology. Quality Improvement (QI) programs can be meaningful contributors. A visiting staff initiative to the monthly QI meeting was developed, with goals of broadening staff engagement with QI activities, providing transparency, encouraging a culture of reporting, and offering additional perspectives to the standing QI Committee (QIC).

MATERIALS/METHODS

From 5/2021 - 1/2023, 24 staff, including physicians (n = 11), radiation therapists (n = 6), dosimetrists (n = 4), and administrative staff (n = 3) from 4 community-based radiation oncology clinics rotated through the monthly QI meeting as visitors. The meeting was held virtually. Prior to the meeting, visitors were provided with a background on QI operations and encouraged to be active participants. The QIC has 30 standing members including physicians (n = 2), physicists (n = 8), dosimetrists (n = 2), nursing (n = 3), radiation therapists (n = 4), IT (n = 2), administrative staff (n = 4), and QIC support staff (n = 2), out of a total of 115 staff members. Visitors filled out pre- and post-attendance surveys. A survey of the QIC (n = 14) was conducted to assess the value of the program to the committee. Survey responses were on a Likert scale (1 = Strongly Disagree; 5 = Strongly Agree). A 2-tail t-test was used for statistical analysis.

RESULTS

Nearly all visitors stated that they learned something new through participation in the QI meeting (92%), and most said they were interested in future QI participation (63%). Most visitors were familiar with the process of submitting a safety report (75%), and nearly half submitted one in the past year (46%). After the first 10 visitors participated in QIC, the standing QIC was surveyed and agreed that visitors offered new perspective (4.3), and that the visitor program enhanced quality and safety in the department (4.2).

CONCLUSION

The QIC visiting staff initiative was significantly effective in educating interdisciplinary staff members, establishing a safety culture, increasing transparency around QI functions, and providing new perspectives. At baseline, there was appreciation for the role of QI and safety. Implementing a QI visiting staff initiative is feasible and beneficial and may be of even higher impact in less established QI programs.

Radiation Treatment Preparation Safety Risk Prediction

PURPOSE/OBJECTIVE(S)

To determine the effect of delays in radiation treatment preparation task timeliness on reported safety events.

MATERIALS/METHODS

For 2022, all patients treated at four community-based radiation oncology clinics were included for analysis. Safety reports which occurred during treatment preparation tasks (i.e., between CT simulation and the first treatment) were included for this analysis. Patients with a reported safety event were the report cohort and those without were the control cohort. Treatment preparation tasks are completed sequentially and included contouring, treatment planning, Radiation Oncologist review, Medical Physicist review, Therapist quality check. At baseline, each task was scheduled a standard interval for completion based on treatment technique. The time taken to complete each task was captured using ARIA v16.0 Care Path module (Varian Medical Systems, Palo Alto, CA) and extracted through database query. For each task, two metrics were quantified: Task (1) Completion Timeliness: the time (hours) to complete each task, relative to the time allocated to each task. A negative value indicated more time taken than scheduled. (2) Overall Timeliness: specific task timeliness (hours) relative to overall timeliness for the whole Care Path. A negative value indicated the tasks were behind schedule. A student's t-test with an alpha of 0.05 was used to indicate significance.

RESULTS

Over the study period, 66 courses had a reported treatment preparation safety event (report) and 2690 did not (control). Techniques include 54% and 56% 3DCRT, 35% and 35% IMRT, 3% and 3% SRS, and 6% and 8% SBRT, for the report and control groups, respectively. Disease sites include breast, GU, GI, head and neck, CNS, thoracic, skin, secondary, gynecological, sarcoma, and heme. Table 1 displays the timeliness for each of the five tasks. Of the courses with safety events, overall timeliness was significantly behind the control group from the in contouring, treatment planning, Radiation Oncologist review, and Medical Physicist review. Courses with safety events took significantly more time than scheduled early in treatment preparation with a significant increase at treatment planning and significantly less time towards the end with the therapist quality check.

CONCLUSION

Patient courses with reported safety events had significantly longer treatment planning times, and as a result inadequate time to perform each downstream pre-treatment activity. The implication of this analysis is that a flag could be created to indicate risk of a safety event early in the treatment preparation process.

Effective practices during emergency school lockdowns: shared experiences of four Australian schools

This study investigates common features of a set of diverse schools' responses to the initial school lockdown period during the pandemic in 2020, with a focus on practices supporting learning, inclusion and wellbeing. It comprises a collective case study of four Australian schools that were selected based on their reputation for impactful support of students and teachers during the emergency remote teaching period. Methods included interviews and focus groups with school leaders, teachers and students. The schools had widely differing contexts, technology access and student needs. Despite these varied contexts, the findings provided important insights into common practices supporting effective remote teaching. Emerging principles of effective practice illuminate ways forward to mitigate the significant risks accompanying emergency remote teaching, and guide practices in a variety of school contexts.

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Background/Introduction

Targets set by Public Health England (PHE) state that 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc&gt;2) anticoagulated was below the target set by PHE. In addition, optimisation of risk factors can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To provide specialist input from a cardiovascular pharmacist to prevent AF-related strokes through improvement of anticoagulation rates and optimisation of cardiovascular risk factors in patients with AF across three London boroughs over one year, as well as minimising bleed risk in patients on dual antithrombotic therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to identify high-risk AF patients (CHA2DS2VASc&gt;2) by working with primary care clinicians. Utilising “proactive care frameworks” created by UCLPartners and Clinical Effectiveness Group Queen Mary University of London, patients were stratified and prioritised for review. Patients not on anticoagulation were deemed to be at highest risk, requiring an urgent review to assess suitability for anticoagulation. A virtual multidisciplinary team (MDT) would review any complex patients and agree an action plan. Patients on dual antithrombotic therapy were also assessed to determine if antiplatelet therapy was indicated to minimise risk of major bleeding. All AF patients were reviewed for suitability of statin initiation to optimise cardiovascular risk prevention.

Results

At baseline, 86% (7581/8582) of AF patients with a CHA2DS2VASc&gt;2 across the three boroughs were anticoagulated. 1001 patients were reviewed by a specialist pharmacist, with 84% (841/1001) of patients having a CHA2DS2VASc between 2–5, and 28% (280/1001) on antiplatelet monotherapy. Analysis at 12 months following intervention reported that 95% (7888/8280) of AF patients with a CHA2DS2VASc&gt;2 were suitably anticoagulated, an improvement of 9%. 6% (61/1001) of patients were switched from antiplatelets and 25% (246/1001) were newly initiated on anticoagulation. 13% (130/1001) of patients required specialist MDT input to determine appropriateness for anticoagulation initiation. There was also a reduction in dual anticoagulation and antiplatelet therapy from 429 to 252 patients (41% reduction). Lastly of those reviewed, 2609 patients received a recommendation to start a statin for either primary (n=1981) or secondary prevention (n=628).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce to significantly improve and optimise cardiovascular risk, and reduce the risk of stroke in this high-risk population for people with AF across all three boroughs. By extrapolating these results nationally, 3600 strokes could be averted over 18 months.

Funding Acknowledgement

Type of funding sources: None.

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

In England, 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation as part of targets set by Public Health England by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc&gt;2) anticoagulated was 87%, 83% and 84%. This placed two of the three localities in the bottom 10% compared to others in England. In addition, optimising cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To prevent AF-related strokes by improving anticoagulation rates and optimising cardiovascular risk factors in patients with AF in all general practices across three London boroughs over one year, and to minimise risk of bleeding in patients on concurrent anticoagulation and antiplatelet therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to systemically identify high-risk AF patients (CHA2DS2VASc&gt;2) by working with primary care clinicians, including up-skilling of primary care pharmacists. Through utilisation of ‘proactive care frameworks’ created by the Clinical Effectiveness Group Queen Mary University of London and UCL Partners, patients were able to be stratified and prioritised for review. AF patients not on anticoagulation or on antiplatelet monotherapy were deemed to be at highest risk, and these patients were reviewed to assess suitability for anticoagulation. Subsequently, patients on concurrent anticoagulation and antiplatelets were assessed to determine if dual antithrombotic prescribing was still indicated to minimise risk of major bleeding. Lastly, to optimise cardiovascular risk prevention, all AF patients were reviewed for suitability of statin initiation for primary or secondary prevention. A virtual multidisciplinary team was convened for complex patients, which included a cardiologist, haematologist, general practitioner and pharmacist to review and agree an action plan.

Results

An interim analysis at 9 months reported that 94% (6745/7145) of patients with a CHA2DS2VASc&gt;2 across the three boroughs were suitably anticoagulated, an improvement of 6% on the initial 88% (6585/7391). There was a reduction in concurrent anticoagulation and antiplatelet therapy from 381 to 262 patients (31.2% reduction) following specialist review. Lastly 2285 patients were reviewed with a recommendation to start a statin for either primary (n=1783) or secondary prevention (n=502).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce with significant improvement in anticoagulation rates across all three boroughs, reducing the risk of stroke in this high-risk population. In addition, we were able to reduce the risk of bleeding in this cohort of patients by stopping inappropriate antiplatelet therapy, and reduced the risk of cardiovascular disease through statin initiation.

Do you Vape With Aloha?: How culture and place are used to spread misinformation on Instagram

Background

Forty-two percent of high school teens in Hawai'i have tried e-cigarettes, double the United States' national average. Native Hawaiians have higher use than other racial/ethnic groups. While Hawai'i state law prohibits tobacco sales to anyone under 21, many Hawai'i adolescents purchase e-cigarettes on the internet, often through social media.

Methods

We collected 717 public Instagram posts from April and December 2018 geotagged in Hawai'i that mentioned one or more hashtag search terms (e.g., #vape, #ecig). All relevant, working posts (n = 476) were manually coded for text and image characteristics.

Results

Over 80% of posts were from vape shops (n = 389 of 476;81.7%). Caption text commonly mentioned brand names (n = 409;85.9%), vape shop names (n = 379;79.6%), and flavors (n = 103;21.6%). The most frequent image elements were logos (n = 395;82.7%), e-cigarettes (n = 324;68.1%), and flavors (n = 110;23.1%). Less than one in 50 (n = 9;1.8%) included caption text warnings.

One in five posts (n = 94,19.7%%) featured content specific to Hawai'i including references to Native Hawaiian culture, flavors and foods, scenery, plants, animals, and language. For example, “Hawai'i Nei...Stay Blessed n Vape With Aloha” or “Ma'o Hau Hele” is the state flower of Hawaii, combined with a refreshing sweet raspberry it makes the perfect balance of flavor.” User engagement (i.e., likes) varied, with a median of 17 likes per post (range: 0-308). Posts with Hawaiian cultural elements received significantly more likes than other posts (median: 22 versus 16;p=0.0047).

Conclusions

Culture is a critical strength that can support positive health outcomes in many communities. Vape shops and product promoters explicitly misappropriated Native Hawaiian culture to sell e-cigarettes on Instagram, while downplaying known harms. Adolescents and young adults may be particularly vulnerable given social media's role as a powerful health behavior influence and an e-cigarette purchasing source.

Key messages

Health misinformation is contextualized within culture and place in a way that is compelling to users, may put youth at particular risk, and can perpetuate health disparities. Our study supports tailored health campaigns and interventions for local communities and cultures to combat such online misinformation.

P1236Revealing cardiac mechanics with CMR whilst CRT is active: the first step

Introduction

Cardiac resynchronisation therapy (CRT) is a routine treatment for heart failure with reduced ejection fraction and conduction delay to improve symptoms and prognosis. Technological advancements both in cardiac magnetic resonance (CMR) and devices (MRI-conditional modes) now enable investigation of the haemodynamic response to CRT over a range of heart rates.

Methods

Patients with a CRT-D device were enrolled from heart failure clinics at a single tertiary centre. A complete device system assessment and baseline device check was conducted to ensure MRI compatibility and suitability. Left ventricular (LV) volumes and systolic blood pressure were measured at baseline and heart rates of 75, 90, 100, 115, 125, and 140 bpm (randomised order) with CRT active and intrinsic conduction (AOO). MRI conditional mode parameters were replicated through standard parameter modification to ensure biventricular pacing during CRT active scans. All scans were conducted using a 3.0 T Siemens Prisma MRI scanner with analysis on commercially available software. Contractility was derived from the systolic blood pressure and left ventricular end systolic volume. A post scan device and lead assessment was conducted to assess for scanning safety.

Results

Scanning was conducted in 22 patients (safety cohort). Post scan battery voltage reduced by 2.9±1.0%. Mean change in atrial, right ventricular and left ventricular lead impedance was 0.5±0.06%, 3.0±0.04% and −1.7±0.05% respectively. Mean change in atrial, right ventricular and left ventricular pacing threshold was 0.0±0.3%, 8.3±0.3% and 5.6±0.3%. No patient experienced symptoms related to scanning or device failure.

Preliminary data for patients with CRT on and off have been analysed (paired analysis cohort, n=8, 6 men). Mean age was 71.1±8.2, aetiology was primarily ischaemic (62.5%) with the remainder dilated cardiomyopathy. The mean LV ejection fraction at baseline was 29.4±12.9%. Biventricular pacing led to acute improvements in ejection fraction (p=0.005), left ventricular cardiac output (p<0.0001) and contractility (p=0.05) over the entire range of heart rates studied. We also noted an improvement in the force frequency relationship during biventricular pacing with a higher peak contractility (p=0.05), a higher heart rate at which this occurred (HR=130) and a generally up sloping relationship when compared with intrinsic conduction.

Conclusion

We have demonstrated for the first time, the mechanistic improvements in cardiac contractility consequent to CRT using CMR and also that MRI scans of conditional devices can be safe with CRT active.

Acknowledgement/Funding

Dr A Koshy is conducting a PhD supported by grant from Medtronic. Dr Klaus Witte has received honoraria from Medtronic

Recruiting for an Online Survey through Social Media: Testing Variations in Messaging, Compensation, and Platform

To test three recruitment strategies for parents on social media (Facebook and Twitter) to complete a brief survey about the human papillomavirus (HPV) vaccine. Methods: We created three campaigns with ads on Facebook and promoted tweets on Twitter that invited parents of children ages 9–15 to complete a brief survey about the HPV vaccine. Iterative, yet varied, campaigns were conducted to determine the ideal social media platform, compensation amount, and messaging. Ads depicted vaccine-eligible children (11–12 years of age) of various ethnicities. Ad messaging was adapted from social media toolkits at the CDC and the HPV Roundtable. Parents who clicked on our ad were first screened for eligibility. Those who were eligible then completed a 20-item survey via Qualtrics that included questions about HPV, the vaccine, and social media use. Survey compensation was either $5 or $10. At the end of the survey, we provided information about HPV and the vaccine. The campaign was available in English and Spanish. Results: The first campaign was launched on both Facebook and Twitter and offered $5 compensation. The Facebook component yielded 18,527 impressions; two adults were confirmed eligible by the screener and both completed the survey (100% screener to completion rate). Cost per survey was $349.45. The Twitter component received 143,661 impressions and yielded 18 completed surveys, with a screener to completion rate of 26% and a cost of $42.99 per survey. For the second campaign, we dropped Facebook and focused solely on Twitter, offering $10 compensation. We received 50,475 impressions that yielded 55 completed surveys (screener to completion rate = 71%) costing $4.78 each. The final campaign tested simpler messaging on Twitter with $10 compensation, and received 8,897 impressions, 38 survey completions (screener to completion rate = 88%), and cost $1.19 per survey. Conclusions: While Facebook is widely used among Americans, our findings may suggest that Twitter is more engaging and cost-effective. Recent Facebook policy changes may explain the differences seen in cost and survey completion. Understanding the reach and effectiveness of the different platforms will help ensure the success of an intervention using social media.

Association of prenatal exposure to gestational diabetes with offspring body composition and regional body fat distribution

The aim of this cohort study was to compare body composition and regional body fat distribution between children exposed (GDM+) or unexposed (GDM-) in utero to gestational diabetes mellitus (GDM) and to investigate the association with the glycaemic and the insulin profile. Data from 56 GDM+ and 30 GDM- were analysed. Height, weight and waist circumference were measured. Total and regional body composition was measured by dual-energy X-ray absorptiometry. Insulin, glucose and HbA_1c were obtained from a fasting plasma sample, and the HOMA-IR index was calculated. anova was performed to compare adiposity measures between GDM+ and GDM-. Associations between the glycaemic and insulin profile and adiposity measures were studied using partial Pearson correlations. Mean age was 6.6 ± 2.3 years. Waist circumference, fat mass percentage, android fat mass, android fat mass percentage and android-to-gynoid fat mass ratio were higher among GDM+, and lean mass percentage was lower (P < 0.05). Among GDM+ children, body mass index (BMI) z score, waist circumference, fat mass percentage, android fat mass percentage and android-to-gynoid fat mass ratio were all positively correlated with HbA_1C (r = 0.32-0.43, P < 0.05). Prenatal exposure to GDM is associated with increased total and abdominal adiposity. This increased adiposity observed among GDM+ children is associated with an altered glycaemic profile. This study is registered in the Clinical Trials.gov registry (NCT01340924).

Relations between Desire for Early Death, Depressive Symptoms and Antidepressant Prescribing in Terminally Ill Patients with Cancer

Some patients with advanced cancer express the wish for an early death. This may be associated with depression. We examined the relations between depressive symptoms and desire for early death (natural or by euthanasia or physician-assisted suicide) in 142 terminally ill patients with cancer being cared for by a specialist palliative care team. They completed the Hospital Anxiety and Depression Scale questionnaire and answered four supplementary questions on desire for early death.

Only 2 patients expressed a strong wish for death by some form of suicide or euthanasia. 120 denied that they ever wished for early release. The desire for early death correlated with depression scores. Depressive symptoms were common in the whole group but few were on antidepressant therapy.

Better recognition and treatment of depression might improve the lives of people with terminal illness and so lessen desire for early death, whether natural or by suicide.

Fruit and vegetables on prescription: a brief intervention in primary care

BACKGROUND

Increasing fruit and vegetable consumption is a goal for the U.K. Therefore, the effectiveness of a fruit and vegetable voucher scheme coupled with key 'five-a-day' consumption messages as a brief intervention in primary care consultations was assessed in the present study.

METHODS

One thousand one hundred and eighty-eight vouchers as a prescription for fruits and vegetables were routinely distributed to patients attending a primary healthcare centre in a deprived area, and 124 volunteer patients routinely attending the centre were included. Telephone-based questionnaires were used to examine changes in consumption over the short and medium term. Other key aspects assessed in the evaluation related to fruit and vegetable purchasing behaviour, knowledge relating to what constitutes a portion size, the relationship between food and health, and barriers to consumption.

RESULTS

Although 76.2% of participants used the prescription vouchers when purchasing fruits and vegetables, a significant change in the consumption or purchasing behaviour was not observed (P > 0.05). Participants' level of knowledge relating to the number of portions recommended and the portion size of different fruits and vegetables showed a moderate increase from baseline over the short and medium term. The primary barriers to fruit and vegetable consumption were reported as 'the quality of fresh fruits and vegetables' and 'the money available to spend on food'.

CONCLUSIONS

The use of 'the fruit and vegetable on prescription' scheme was an effective method of engaging participants in improving awareness of key diet-related health messages. However, further intervention is required to produce a significant impact on the actual behaviour change.

Effect of potential therapeutic agents in reducing oxidative stress in pulmonary tissues of recurrent airway obstruction-affected and clinically healthy horses

REASONS FOR PERFORMING STUDY

To determine and compare the reactive oxygen and nitrogen species (ROS and RNS) in pulmonary tissues of horses affected with recurrent airway obstruction (RAO) and clinically healthy horses, and to evaluate the effectiveness of potential therapeutic agents in reducing ROS and RNS in the tissues of these horses.

OBJECTIVES

We hypothesised that RAO-affected horses would have high levels of reactive species and that the test agents would reduce them. The objectives were as follows: 1) to determine the level of ROS and RNS in pulmonary tissues (bronchial and arterial rings) of RAO-affected and clinically healthy horses; and 2) to determine the ability of pentoxifylline, pyrrolidine-dithiocarbamate and a combined use of endothelin A and B receptor antagonists (BQ123 and BQ788, respectively) in reducing reactive species.

METHODS

Arterial and bronchial rings were collected from the diaphragmatic lung lobe of each horse immediately after euthanasia. The levels of ROS and RNS were measured in control tissues and those incubated with test agents, using an electron paramagnetic resonance instrument.

RESULTS

The levels of ROS and RNS were significantly greater in arterial and bronchial tissues of RAO-affected than of clinically healthy horses. Pentoxifylline and endothelin antagonists reduced both ROS and RNS in tissues from RAO-affected horses. Basal levels of reactive species in clinically healthy horses were not affected by these agents. No difference in the level of reactive species was observed between arterial and bronchial tissues.

CONCLUSIONS

Horses affected by RAO had higher ROS and RNS than clinically healthy horses. Pentoxifylline and endothelin antagonists effectively reduced ROS and RNS in pulmonary tissues of RAO-affected horses.

POTENTIAL RELEVANCE

The study suggested a potential use for pentoxifylline and endothelin antagonists in treating RAO-affected horses. As endothelin is involved in physiological functions, therapeutic use of its antagonists is cautioned.