Abstract P4-03-22: Linking Internal Medicine Care to Metastatic Breast Cancer Patients for Success: LIMBS

Background: The Advanced Breast Cancer (ABC) program at The University of Texas MD Anderson Cancer Center was created by metastatic breast cancer (MBC) patients for MBC patients. The ABC Program seeks to improve quantity and quality of life for patients living with MBC. MD Anderson actively treats 2,076 patients living with MBC. ABC program patient advocates voiced the need to increase MBC patients’ access to internal medicine services coordinated with oncology care.

Significance: Previous literature suggests patients living with MBC have difficulty receiving oncology coordinated internal medicine services due to their terminal diagnosis and indefinite prescription of anti-cancer treatment. Comorbidities in this setting are known to be associated with inferior outcomes. ABC Program patient advocates reported various challenges seeking care from community based medical professionals including, timely awareness of their local provider on the status of their cancer. Other challenges included the lack of familiarity of some providers with novel MBC cancer treatment, side effects, and interactions of their cancer treatment with non-cancer conditions and treatment. Therefore, with the increasing life expectancy of MBC patients, there is a growing realization of the importance of managing the medical comorbidities in coordination with the MBC patient’s cancer treatment.

Purpose: To increase access and coordinate internal medicine services for MBC patients with medical comorbidities.

Interventions: In partnership with ABC Program patient advocates, the Linking Internal Medicine and Metastatic Breast cancer for Success (LIMBS) clinic was created in February 2021. The LIMBS clinic aimed to bridge the gap in lack of oncology coordinated internal medicine service for MBC patients.

Evaluation: Breast Medical Oncology providers requested LIMBS clinic consults for 108 patients for comorbidity management since the clinic inception. This is a 44% increase in internal medicine consultations prior to LIMBS clinic creation (60 vs 108). The LIMBS clinic consults resulted in 474 follow up visits. Compared to MBC patients at MD Anderson, LIMBS patients were more likely to be African American (20% vs 13%) and were more likely to be older (59 years vs 57 years). Gender, marital status, and clinical trial enrollment did not differ between LIMBS patients and MBC patients. LIMBS patients had significantly higher rates of hypertension (46% vs 19%), Type II DM (19% vs 6%), hyperlipidemia (13% vs 10%), and hypothyroidism (13% vs 6%) compared to MBC patients in general. LIMBS patients had lower rates of anxiety (8% vs 11%) and depression (2% vs 7%) when compared to the MBC patients in general. The top 10 comorbidities for all MBC patients versus LIMBS patients are listed in Table 1.

Discussion: It is feasible to build and integrate internal medicine with breast medical oncology services for patients with metastatic breast cancer. Future research should focus on exploring, describing, and meeting the internal medicine needs of MBC patients. Future initiatives are needed to bridge the gap in care for oncology coordinated internal medicine services between community and tertiary care centers.

Table 1. Top 10 Comorbidities of all MBC patients versus LIMBS clinic patients Note. This table demonstrates the top 10 comorbidities for MBC population and the LIMBS population.

Citation Format: Abbey Kaler, Akshara Singareeka Raghavendra, Ginny T. Kirklin, Dawn Cunningham, Ellen Manzullo, Debu Tripathy, Zayd Razouki. Linking Internal Medicine Care to Metastatic Breast Cancer Patients for Success: LIMBS [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-22.

Electronic health records analytics to identify cancer patients with metabolic syndrome

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Background: Metabolic syndrome, defined as the presence of at least 3 of 5 clinical factors including hypertension, elevated triglyceride levels, low high-density lipoprotein level, insulin resistance, and central obesity, increases the risk of heart disease, fatty liver, and multiple cancers. Metabolic syndrome in cancer patients has been associated with poor cancer-specific and overall survival. Lifestyle modification in patients with metabolic syndrome may reduce the risk of poor outcomes. In this quality improvement project, we aimed to determine the prevalence of metabolic syndrome among cancer patients and survivors seen in an outpatient general internal medicine (GIM) clinic and to determine the feasibility of using electronic health records (EHR) analytics to systematically identify such patients and refer them to lifestyle interventions and liver imaging. Methods: Study period was January-December 2021. During this period, an EHR algorithm was used to identify patients with metabolic syndrome based on the presence of ICD-10 diagnoses of metabolic conditions (diabetes, hypertension, lipid disease, and obesity). This algorithm was used to direct data from patient visits into an interactive dashboard to track metabolic syndrome prevalence and continuously monitor referrals to interventions. In September 2021, a best practice alert based on the EHR algorithm was created to identify patients with metabolic syndrome and prompt providers to refer them to nutrition counseling, liver ultrasound with elastography, and/or a community-based active-living support group for cancer survivors. GIM clinic nurses also reviewed medications and utilized an EPIC SmartPhrase that incorporated laboratory values (e.g., glucose, A1c, and lipids), blood pressure, and body mass index to confirm whether patients actually met the criteria for metabolic syndrome, and if so, they notified medical providers who then ordered the interventions. Patients confirmed to have metabolic syndrome received educational materials about lifestyle modifications. Data extracted from the dashboard were analyzed using Minitab 17 statistical software. Results: Among 1133 patients seen in the GIM clinic during 2021, 609 (54%) had metabolic syndrome. A total of 1045 patients (92%) had hypertension, 802 (71%) had hyperlipidemia, 571 (50%) had obesity, and 483 (43%) had diabetes. Among the 609 patients with metabolic syndrome, 148 (24%) were referred to liver ultrasound with elastography, 124 (20%) to nutrition counseling, and 21 (3%) to the support group. Beginning September 1, the best practice alert was triggered for 1131 clinical encounters meeting criteria for metabolic syndrome. Conclusions: The prevalence of metabolic syndrome among cancer patients seen in a GIM clinic was high. EHR analytics can lead to systematic identification and referral of patients with metabolic syndrome to lifestyle interventions and liver imaging.

Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing

Background

Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices.

Methods

A web-based survey of clinicians at a multispecialty medical practice.

Results

Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08–1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03–1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01–1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13–1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25–0.65). Highly concerned clinicians were more likely to work in clinics which engage in “best practices” for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51–8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84–4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64–9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction.

Conclusions

Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.

A Systematic Review of Patient- and Family-Level Inhaled Corticosteroid Adherence Interventions in Black/African Americans

BACKGROUND

Inhaled corticosteroid (ICS) adherence rates are suboptimal among adult black/African Americans. Comprehensive studies characterizing the effectiveness and the methodological approaches to the development of interventions to improve ICS adherence in adult black/African Americans have not been performed.

OBJECTIVES

Conduct a systematic review of patient/family-level interventions to improve ICS adherence in adult black/African Americans.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and CINAHL from inception to August 2017 for English-language US studies enrolling at least 30% black/African Americans comparing patient/family-level ICS adherence interventions with any comparator. Two investigators independently selected, extracted data from, and rated risk of bias. We collected information on intervention characteristics and outcomes, and assessed whether studies were informed by behavior theory, stakeholder engagement, or both.

RESULTS

Among 1661 abstracts identified, we reviewed 230 full-text articles and identified 4 randomized controlled trials (RCTs) and 1 quasi-experimental (pre-post design) study meeting criteria. Study participants (N range, 17-333) varied in mean age (22-47 years), proportion black/African Americans studied (71%-93%), and sex (69%-82% females). RCTs evaluated problem-solving classes, self-efficacy training, technology-based motivational interviewing program, and the use of patient advocates. The RCT testing self-efficacy training was the only intervention informed by both behavior theory and stakeholder engagement. All 4 RCTs compared interventions with active control and rated as medium risk of bias. No RCTs found a statistically significant improvement in adherence.

CONCLUSIONS

Few studies assessing asthma adherence interventions focused on adult black/African-American populations. No RCTs demonstrated improved ICS adherence in participants. Future studies that are informed by behavior change theory and stakeholder engagement are needed.

Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study

OBJECTIVE

To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials.

METHODS

We identified randomized controlled trials (RCTs) evaluating a drug or device in patients with chronic medical conditions through meta-analyses (MAs) published between January 1, 2007, and June 23, 2015, in the 10 general medical journals with highest impact factor. We estimated the prevalence of having the largest effect size or heterogeneity in the first 2 published trials. We evaluated the association of the exaggerated early effect with several a priori hypothesized explanatory variables.

RESULTS

We included 70 MAs that had included a total of 930 trials (average of 13 [range, 5-48] RCTs per MA) with average follow-up of 24 (range, 1-168) months. The prevalence of the exaggerated early effect (ie, proportion of MAs with largest effect or heterogeneity in the first 2 trials) was 37%. These early trials had an effect size that was on average 2.67 times larger than the overall pooled effect size (ratio of relative effects, 2.67; 95% CI, 2.12-3.37). The presence of exaggerated effect was not significantly associated with trial size; number of events; length of follow-up; intervention duration; number of study sites; inpatient versus outpatient setting; funding source; stopping a trial early; adequacy of random sequence generation, allocation concealment, or blinding; loss to follow-up or the test for publication bias.

CONCLUSION

Trials evaluating treatments of chronic medical conditions published early in the chain of evidence commonly demonstrate an exaggerated treatment effect compared with subsequent trials. At the present time, this phenomenon remains unpredictable. Considering the increasing morbidity and mortality of chronic medical conditions, decision makers should act on early evidence with caution.

Improving Anticoagulation Measurement Novel Warfarin Composite Measure

BACKGROUND

Percent time in therapeutic range (TTR) and international normalized ratio (INR) variability both measure warfarin control and are associated with outcomes independently. Here, we examine the advantages of a warfarin composite measure (WCM), which summarizes the 2 when measuring patient outcomes. We also examine how the measure chosen would affect anticoagulation clinic performance rankings.

METHODS AND RESULTS

We constructed WCM using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability using 103 897 warfarin-experienced patients from 100 anticoagulation clinics. We examined the association of WCM with ischemic stroke, major bleeding, and fatal bleeding, using a subset of patients with atrial fibrillation (n=40 404). We divided patients into quintiles based on their level of control for TTR, log INR variability, and WCM. We calculated the hazard ratios for ischemic stroke, major bleeding, and fatal bleeding stratified by these quintiles. WCM hazard ratios for stroke and fatal bleeding showed the largest difference between excellent control and poorest control quintile compared with TTR and log INR variability, but not for major bleeding. In addition, we compared site rankings obtained using each of our 3 performance measures. Kappa scores for identifying outlier and nonoutlier clinics between WCM and its components were moderate (κ=0.56 for TTR and κ=0.62 for log INR variability) but was weak between TTR and log INR variability (κ=0.13).

CONCLUSIONS

WCM produces the largest range of risk for warfarin complications, widening the floor ceiling effects that limit the use of TTR and INR variability as separate measures. Anticoagulation clinics ranking changed considerably according to the anticoagulation measure that was selected.

Organizational factors associated with Health Care Provider (HCP) influenza campaigns in the Veterans health care system: a qualitative study

Background

It is an important goal to vaccinate a high proportion of health care providers (HCPs) against influenza, to prevent transmission to patients. Different aspects of how a HCP vaccination campaign is conducted may be linked to different vaccination rates. We sought to characterize organizational factors and practices that were associated with vaccination campaign success among six sites within the Veterans Health Administration, where receipt of flu-vaccination is voluntary.

Method

We conducted a total of 31 telephone interviews with key informants who were involved with HCP flu vaccination campaigns at three sites with high-vaccination rates and three sites with low-vaccination rates. We compared the organization and management of the six sites’ campaigns using constant comparison methods, characterzing themes and analyzing data iteratively.

Results

Three factors distinguished sites with high flu vaccination rates from those with low vaccination rates. 1) High levels of executive leadership involvement: demonstrating visible support, fostering new ideas, facilitating resources, and empowering flu team members; 2) Positive flu team characteristics: high levels of collaboration, sense of campaign ownership, sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign; and 3) Several concrete strong practices emerged: advance planning, easy access to the vaccine, ability to track employee vaccination status, use of innovative methods to educate staff, and use of audit and feedback to promote targeted efforts to reach unvaccinated employees.

Conclusion

Successful HCP flu campaigns shared several recognizable characteristics, many of which are amenable to adoption or emulation by programs hoping to improve their vaccination rates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1462-y) contains supplementary material, which is available to authorized users.

Percent Time in Range with Warfarin as a Performance Measure: How Long a Sampling Frame Is Needed?

BACKGROUND

Warfarin is received by millions of patients in the United States and elsewhere and will remain the most commonly used anticoagulant for the foreseeable future. Percent time in therapeutic range (TTR) with warfarin is increasingly used as a performance measure. However, stakeholders have expressed concern that TTR lags behind changes in performance. Work in a larger study focused on the impact of shortening the conventional measurement period for TTR.

METHODS

Some 124 sites within the Department of Veterans Affairs (VA) were examined during a seven-year period (fiscal years [FYs] 2008-2014 (April 1, 2007-September 30, 2014). The duration of time segments (2, 3, 4, 6 months) used to calculate TTR were varied, and these four durations were compared in terms of the number of patients retained per site, mean and median site TTR, and site performance rankings.

RESULTS

Data were obtained on 295,237 unique patients who received anticoagulation. As the calculation window shortened, patients with better control (that is, higher TTR) were selectively excluded from the measurement because their laboratory values were more widely spaced. Site mean TTR was highest when the most patients were included (6 months: 950 patients; TTR 65.2%) and lowest when the fewest patients were included (2 months: 567 patients; TTR 60.0%). However, the 3-, 4-, and 6-month segments achieved similar results, each of which included more than 800 patients per site, with mean TTR across a narrow range (64.9%-65.2%). Site rankings were less highly correlated between the 2-month period and longer periods (r = 0.7- 0.8) but were otherwise 0.95 or higher, with a nearly perfect correlation (0.985) between the 4- and 6-month periods.

CONCLUSIONS

When TTR is used to measure site-level performance, comparable results can be achieved using a 4- or a 6-month measurement period. On the basis of these results, the use of a 4-month period for future measurement efforts is recommended.

Pathways to poor anticoagulation control

BACKGROUND

While a considerable amount is known about which patient-level factors predict poor anticoagulation control with warfarin, measured by percent time in therapeutic range (TTR), less is known about predictors of time above or below target.

OBJECTIVE

To identify predictors of different patterns of international normalized ratio (INR) values that account for poor control, including 'erratic' patterns, where more time is spent both above and below INR target, and unidirectional patterns, where time out of range is predominantly in one direction (low or high).

METHODS

We studied 103 897 patients receiving warfarin with a target INR of 2-3 from 100 Veterans Health Administration sites between October 2006 and September 2008. Our outcomes were percent time above and below the target range. Predictors included patients' demographics, comorbidities, and other clinical data.

RESULTS

Predictors of erratic patterns included alcohol abuse (5.2% more time below and 3.7% more time above, P < 0.001 for all results), taking > 16 medications (4.6% more time below and 1.8% more time above compared to taking seven or fewer medications), and four or more hospitalizations during the study (6.6% more time below and 2% more time above compared to no hospitalization). In contrast, predictors like cancer, non-alcohol drug abuse, dementia, and bipolar disorder were associated with more time below the target range (3.4%, 5.2%, 2.6%, and 3.2%, respectively) and less (or similar) time above range.

CONCLUSION

Different patient-level factors predicted unidirectional below-target and 'erratic' patterns of INR control. Distinct interventions are necessary to address these two separate pathways to poor anticoagulation.