Journal articles: 'Standardized care information utility' – Grafiati (2025)

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Introduction: Older adults living with frailty and multimorbidity interact with multiple care providers across different health settings increasing the risk for fragmented care and information discontinuity. Information discontinuity results in workforce inefficiencies and adverse health events, including duplication of assessment and diagnostics, medication errors and increased health service use. Standardized assessments potentiate integrated care by communicating consistent measures of health information between health care sectors and providers. InterRAI assessments facilitate integration through promoting a common language and aligning successive assessments across the care continuum. Description: We used a pragmatic case example of a theoretical medically-complex older adult to illustrate effective use of interRAI standardized assessments throughout the health care journey. The interRAI suite of instruments spans across the age continuum, from pediatrics to geriatrics, and is designed to be used across diverse care settings, including community services, primary care, home care, long-term care, acute care, inpatient and community mental health, and palliative services. The case example represents one patient’s assessment findings, derived from standardized assessment instruments, such as the contact assessment, home care assessment and long-term care facility assessment. Automated and embedded risk algorithms are generated as outputs from the assessment, acting as decision support tools to inform care planning for clinical, functional, and social support needs. Process schematics depict potential workflows, where instruments can guide care strategies and facilitate the flow of information between the care team members. Discussion: Integrating elements such as using a common language, standardized assessment items, and embedded decision support algorithms, can support effective communication and collaboration in the care of older adults between clinical settings. Risk algorithms and scales support real-time identification of care issues, with standardized assessment items allowing for changes in health status to be easily recognized. Operationalizing a suite of standardized assessment instruments across the health system offers advantages for the individual including improved continuity of care, as well as for organizations and the system through use of a consistent measurement of health metrics between health providers and sectors, and evaluating health system performance. Successful adoption of comprehensive assessment tools to support integration requires training, stakeholder engagement and time to embed work and care processes into practice. Conclusion: Standardized language and algorithms used in interRAI comprehensive assessments can increase capacity for integration and continuity of care across the full spectrum of health sectors and settings. Findings from this pragmatic case example demonstrate real-world application and utility of standardized assessments to support an integrated workforce.

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9593 Background: Survivorship care plans have strong face validity, but individualizing plans to each patient’s needs can be resource intensive. At our institution, a 1-page standardized letter that outlines the essential components of follow-up care is mailed to PCPs at the time of a patient’s discharge. This letter highlights the recommended frequency and interval of tests and physician visits. Our study aims were to 1) characterize PCPs’ attitudes regarding these letters and 2) identify potential strategies to improve this channel of communication with PCPs. Methods: Self-administered surveys were mailed to high-volume PCPs in British Columbia, defined as those whose practices followed >/=5 breast or colorectal CS in the preceding year. The survey asked about practice characteristics and PCPs’ views towards the content and format of these standardized letters. Logistic regression models were constructed to delineate factors associated with follow-up preferences. Results: Among 787 PCPs, 507 (64%) responded: median year since graduation was 27 (range 1-62), 67% were men, 38% had a faculty appointment, 71% practiced in a group, and 92% were paid fee-for-service. When asked about their perspectives regarding the care of CS, 388 (77%) indicated they were comfortable providing follow-up with 299 (74%) reporting that the standardized letter contained adequate information. In regression models, PCPs who were comfortable with cancer surveillance and those who graduated greater than 30 years ago were more likely to view the standardized letter as useful (OR 2.50, 95% CI 1.41-4.43 and OR 2.31, 95% CI 1.24-4.33, respectively) and important (OR 4.07, 95% CI 1.80-9.19 and OR 3.14, 95% CI 1.01-9.74, respectively). Among 103 (26%) PCPs who found the letter to be insufficient, most wanted additional details about the cancer diagnosis (88%), specific information on the toxicities of therapy (88%), and the estimated risk of recurrence (84%). Conclusions: Most PCPS were satisfied with a simple, standardized letter that outlines the necessary components of cancer follow-up. PCPs with less familiarity with cancer surveillance may be a target group that benefits most from individualized survivorship care plans.

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Introduction: Health Management Information System (HMIS) is a coordinated effort to improve the decision making for reorienting health care services to a large populace. Since its adoption and its revitalization its use in primary health care was assessed for usefulness and utility. Methods: Study was carried out at Community Health Centre (CHC), Haroli, Una, Himachal Pradesh. Standardized reporting formats for every month was collated and analyzed at Primary Health Centre (PHC) Level for year 2011, 2012, and 2013. Results: In year 2003 with an average pregnancy registration of 20/1000 population study area exhibited high rate and an increasing trend across all the PHCs. An interesting mismatch was observed when the reported birth rate was 3.2/1000 population in year 2013 which was relatively very low against pregnancy registration. Most of the deliveries have happened at home and have been conducted by the Non-Skill Birth Attendants. Overall and even across all the PHCs, the poor sex ratio (number of females per 1000 males) at birth is reported. Conclusion: Good maternal and child health (MCH) and sex ratio at birth were observed. Computed indicators revealed a mismatch like low birth rate despite the high rate of antenatal registration and care over three years which required to be studied for underlying determinants.

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Objective: Assessing barriers to adherence provides helpful information to clinicians. The objective of this study was to describe the clinical utility of the Barriers Assessment Tool (BAT) using clinical data for a large, midwestern U.S. pediatric kidney transplant program. Methods: Focus group and clinical data were obtained during post-transplant medical visits. Qualitative and quantitative assessment methods were utilized to describe patient and caregiver feedback on the BAT, clinical utility, concordance between reporters, and the effect of interventions on subsequent assessment and electronically measured adherence. Results: Patients were willing to discuss adherence issues with their care team. There was substantial agreement between patients and caregivers at two timepoints. If a barrier was not addressed, 89.6% (43/48) of patients and 85.9% (67/78) of caregivers reported the same BAT scores from the first to second assessment. When barriers were addressed with a clinic-based intervention, 82% of caregivers reported no adherence barriers. No significant change was found for patient-reported barriers. Conclusions: Standardized assessment of barriers to medication adherence provides actionable information to clinicians. Standardized assessment of adherence barriers may give clinicians opportunities to help patients and caregivers overcome these barriers which can decrease risk of rejection.

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Abstract The feasibility and utility of measuring social networks of people living with mild to moderate stage dementia to improve care quality was examined by comparing information obtained using Antonucci’s social network mapping approach and through information elicited through a series of open-ended questions regarding life story and well-being. Data were obtained from 24 interviews with 12 people belonging to one or more networks of people living with dementia receiving care in adult day programs. Concurrently we obtained measures of health and well-being using validated symptom checklists and the ICE-CAP suite of well-being measures. Parallel interviews were conducted with social network members who were in a care partner role, either paid or unpaid. Respondents were able to map social networks, and preferred open-ended questions to more standardized measures of quality of life and well-being. Findings from both sources were generally convergent, with open-ended questions providing richer information to guide care.

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Objective: To construct a needs assessment instrument for older people using a standardized terminology (International classification of functioning, disability, and health [ICF]) and assess its psychometrical properties. Method: An instrument was developed comprising questions to older people regarding their perceived care needs. The instrument’s reliability, validity, and utility were tested. Forty-one social workers and 251 older people participated. Results: The questions were sufficiently unambiguous (inter-rater reliability, intraclass correlation = .60–.80); measured a person’s care and service needs to a satisfactory extent (criteria validity, agreement between social workers’ and older people’s assessments = 72–94%); both social workers and older people considered the questions useful; and the needs of older people were documented in social records to a greater extent when the instrument was used. Conclusion: The psychometric properties of the instrument support its use by social workers to gain relevant information on elder care needs.

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Abstract Purpose Formalized handoff procedures have been shown to increase patient safety and quality of care across multiple medical and surgical specialties,1–4 but literature regarding handoffs in ophthalmology remains sparse. We instituted a standardized handoff utilizing an electronic medical record (EMR) system to improve care for patients shared by multiple resident physicians across weekday, weeknight, and weekend duty shifts. We measured efficiency, efficacy, and resident satisfaction before and after the standardized handoff was implemented. Methods Resident physicians surveyed were primarily responsible for patient care on consult and call services at two quaternary academic medical centers in a major metropolitan area. Patient care was performed in outpatient, emergency, and inpatient settings. Annual anonymous questionnaires consisting of 6 questions were used to collect pre- and postintervention impressions of the standardized EMR handoff process from ophthalmology resident physicians (9 per year; 3 preintervention years and 1 postintervention year). An additional anonymous postintervention questionnaire consisting of 12 questions was used to further characterize resident response to the newly implemented handoff procedure. Results Prior to implementation of a standardized EMR-based handoff procedure, residents unanimously reported incomplete, infrequently updated handoff reports that did not include important clinical and/or psychosocial information. Following implementation, residents reported a statistically significant increase in completeness and timeliness of handoff reports. Additionally, resident perception of EMR handoff utility, efficiency, and usability were comprehensively favorable. Residents reported handoffs only added a mean of 6.5 minutes to a typical duty shift. Conclusion Implementation of our protocol dramatically improved resident perceptions of the handoff process at our institution. Improvements included increased quality, ease-of-use, and efficiency. Our standardized EMR-based handoff procedure may be of use to other ambulatory-based services.

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Background Long-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists. Objective The aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR. Methods We used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout. Results This multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs. Conclusions Our generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.

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Objective To explore how placental pathology is currently used by clinicians and what placental information would be most useful in the immediate hours after delivery. Study design We used a qualitative study design to conduct in-depth, semi-structured interviews with obstetric and neonatal clinicians who provide delivery or postpartum care at an academic medical center in the US (n = 19). Interviews were transcribed and analyzed using descriptive content analysis. Results Clinicians valued placental pathology information yet cited multiple barriers that prevent the consistent use of pathology. Four main themes were identified. First, the placenta is sent to pathology for consistent reasons, however, the pathology report is accessed by clinicians inconsistently due to key barriers: difficult to find in the electronic medical record, understand, and get quickly. Second, clinicians value placental pathology for explanatory capability as well as for contributions to current and future care, particularly when there is fetal growth restriction, stillbirth, or antibiotic use. Third, a rapid placental exam (specifically including placental weight, infection, infarction, and overall assessment) would be helpful in providing clinical care. Fourth, placental pathology reports that connect clinically relevant findings (similar to radiology) and that are written with plain, standardized language and that non-pathologists can more readily understand are preferred. Conclusion Placental pathology is important to clinicians that care for mothers and newborns (particularly those that are critically ill) after birth, yet many problems stand in the way of its usefulness. Hospital administrators, perinatal pathologists, and clinicians should work together to improve access to and contents of reports. Support for new methods to provide quick placenta information is warranted.

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e18757 Background: Next-generation sequencing (NGS) has the potential to accelerate precision medicine in oncology by informing efficient and improved clinical treatment decision-making. However, discussions on the utility of NGS in clinical practice are ongoing. This survey study examined clinical utility barriers to adoption of NGS into oncologic care. Methods: A cross-sectional online survey was sent to a nationally representative sample of oncologists/hematologists, surgeons, and pathologists (N=201). The survey gathered information on physician demographics, practice characteristics, perceived barriers to NGS testing, and potential strategies for increasing adoption. Results: Almost all physicians in the sample (99.5%) reported using NGS. Physicians reported the following aspects of NGS as the most valuable: ability to guide decision-making (73.1%), more accurate identification of corresponding treatment (56.7%), comprehensive genomic coverage (54.2%), efficient technology with faster turnaround time (49.8%), and more accurate diagnosis or prognosis (41.3%). Physicians reported that NGS results guided treatment decisions for 63% of patients (Range: 2% - 100%). Over 85% of physicians reported that confidence in interpreting results and availability of clinical guidelines were important in undertaking NGS. Correspondingly, limited evidence of clinical utility was a top barrier to testing (80.1%), with pathologists and surgeons more likely than oncologists/hematologists to consider this. Overall, 76% of physicians shared that strategies to alleviate these clinical utility barriers included increased evidence, standardized guidelines, and interpretation support. Conclusions: Given the high uptake of NGS testing in this physician sample, but the lower rates of application of test results to guide treatment, the clinical impact of NGS may not be fully optimized. This discrepancy highlights the ongoing need for real-world evidence to better understand and further optimize the evolving role of NGS in the context of the overall management of the cancer patient. [Table: see text]

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29 Background: First-year pediatric hematology-oncology fellows frequently must deliver difficult news to patients and families, possibly with little prior experience. Training in this area is often via didactic lectures and by “trial and error”. This can lead to significant discomfort on the part of fellows and potentially increased distress on the part of families if information is poorly communicated. Standardized patient (SP) encounters provide a safe environment for fellows to practice effective and compassionate communication skills. SPs can provide feedback to the fellows that may not otherwise be available from patients, families or peers. Methods: During the 4 hour course, fellows receive didactic sessions on delivery of bad news, disclosure of medical errors, and discussion of prognosis and goals of care. Half of the fellows receive the didactic sessions, while the other half participate in the SP cases involving 7-10 minute encounters followed by 10-15 minute confidential debriefings including the fellow, SP and a faculty member. Three cases are completed by each fellow: new diagnosis of an incurable brain tumor, tumor progression and goals of care discussion regarding the same patient 6 months later, and disclosure of a chemotherapy error. At the end, fellows complete an evaluation of the course and their perceived post-course skills. Results: Fellows in the first course (n = 8) strongly agreed that the course improved their ability to deliver bad news (mean = 5 on 5 point scale), was an appropriate method for this material (mean = 4.6) and that the confidential debriefing was useful without being stressful (mean = 4.7). Most comments supported the utility of receiving immediate feedback from the SPs and faculty. The didactic sessions were listed as the least helpful part of the course. Conclusions: Simulated encounters with immediate feedback from SPs and faculty can improve perceived competence in the delivery of bad news. Like many adult learners, course participants did not find the didactic sessions to be as helpful as interactive experiences. Follow-up surveys after the fellows complete the first year of training will further assess the utility of this instructional method.

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ABSTRACTObjectives:The 12-lead electrocardiogram (ECG) can capture valuable information in the prehospital setting. By the time patients are assessed by an emergency department (ED) physician, their symptoms and any ECG changes may have resolved. We sought to determine whether the prehospital electrocardiogram (pECG) could influence ED management and how often the pECG was available to and reviewed by the ED physician.Methods:A retrospective medical record review was conducted on a random sample of patients ≥ 18 years who had a prehospital 12-lead ECG and were transported to one of two tertiary care centres. Data were recorded onto a standardized data extraction tool. Three investigators independently compared the pECG to the first ECG obtained in the ED after patient arrival at the hospital. Any abnormalities not present on the ED ECG were adjudicated to ascertain whether they had the potential to change ED management.Results:Of 115 ambulance runs selected, 47 had no pECG attached to the ambulance call record (ACR) and another 5 were excluded (one ST elevation myocardial infarction, one cardiac arrest, three ACR missing). Of the 63 pECGs reviewed, 16 (25%) showed changes not apparent on the initial ED ECG (κ = 0.83; 95% CI 0.74–0.93), of which 12 had differences that might influence ED management (κ = 0.76; 95% CI 0.72–0.82). Only one hospital record contained a copy of the pECG, despite the current protocol that paramedics print two copies of the pECG on arrival in the ED (one copy for the ACR and one to be handed to the medical personnel). None of 110 ED charts documented that the pECG was reviewed by the ED physician.Conclusion:The pECG has the potential to influence ED management. Improvement in paramedic and physician documentation and a formal pECG handover process appear necessary.

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e23283 Background: In a concerted effort to enhance the quality, accessibility, and effectiveness of comprehensive real-world cancer datasets, CancerX, a public-private partnership announced by the White House recently conducted a demonstration project, the CancerX Data Sprint. CancerX Data Sprint attempted a novel approach to quickly inform collective efforts of the Center for Medicare and Medicaid Innovation (CMMI), the National Cancer Institute (NCI), the US Food and Drug Administration (FDA), and the Office of the National Coordinator for Health Information Technology (ONC) to advance cancer-related data standards. Specifically, at the intersection of CMMI’s Enhancing Oncology Model (EOM) and the development of ONC’s United States Core Data for Interoperability (USCDI+) – Oncology extension, CancerX leveraged its unique model and broad membership to report novel insights to advance data-driven innovations in oncology research, care, and policy. Methods: From Sept to Dec 2023, the Data Sprint convened 150+ member organizations from industry and government partners to 1) Identify the high-value research questions that could be asked about the standardized real-world data (RWD) generated through EOM 2) Supplement the existing data elements with new ones to extend and enhance the ability to conduct scientific, clinical, and research inquiries with comprehensive datasets. The CancerX community opined via surveys, written feedback, and live workshops to identify key data elements, discuss their clinical value and technical feasibility, and consider their use in real-world settings as part of the comprehensive datasets. Results: Building on the current EOM clinical data elements, we identified and reported 15 new clinical data elements for considerations with high clinical utility and ease of technical abstraction. This comprehensive RWD encompasses a diverse range of patient demographics, clinical details, treatment histories, and outcomes, creating a more accurate and inclusive portrayal of cancer treatment effectiveness and patient journeys. This depth of information is crucial for optimizing the personalization of treatment pathways, conducting impact assessments, and addressing healthcare disparities. Essentially, the new datasets serve as a valuable repository of insights, driving advancements in cancer research, treatment and elevating care quality. Conclusions: CancerX remains committed to supporting federal data initiatives like USCDI+ Cancer standards development and others by providing recommendations for essential data elements implementation to enhance clinical utility, technical feasibility, and exchange of standardized cancer data. By adopting a unique approach and assembling an interdisciplinary group, we can ensure that data standardization efforts prioritize high-utility data elements, ultimately maximizing benefits for our patients.

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168 Background: Radiation oncology specific oncology information systems (OIS) are highly specialized and capture large amounts of rich data related to patient care. There is great potential to expand the utility of these systems from data collection and point-of-care documentation to platforms for radiation oncology informatics. To this end, we have begun an effort to consolidate and standardize the OIS within a large network of radiation oncology clinics. We report initial findings from a multi-center OIS standardization pilot involving five clinics. Methods: Five radiation oncology clinics were converted from a paper-based medical record to an electronic medical record (EMR) on a single instance of the OIS. Clinician-led workgroups developed best-practice EMR workflows to ensure high-quality data were input into the OIS. Database configuration, clinical workflows, and documentation were standardized to enable consortium-wide reporting and dashboarding. Results: Standardization for the five radiation oncology centers was completed in September 2014. Clinical and operational dashboards were generated including dashboards to study radiation toxicity, treatment modality utilization, time studies for each task from referral to treatment, SRS/SBRT utilization, follow-up rates, and referral patterns. Consortium-wide analysis revealed substantive differences in operational and clinical practices. For example: IMRT utilization for prostate cancer patients treated with external beam radiotherapy ranged from 83% to 100% amongst facilities; the time required to contour target volumes on 80% of patients ranged from 2 to 10 days amongst physicians; and follow-up rates ranged from 50% to 83% amongst physicians. Conclusions: Standardization and consolidation of the radiation oncology OIS significantly increased reporting capabilities to include measures based on quality, safety, and patient outcomes. Disparate practices amongst radiation oncology clinics were observed and best practices discovered. OIS consolidation and standardization was essential to develop a consortium-wide understanding of clinical and operational quality.

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Abstract Purpose To review the economic evaluation of the guideline implementation in primary care. Data sources Medline and Embase. Study selection Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form. Results of data synthesis Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome. Conclusion Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.

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Abstract Background Predicting bowel prep quality prior to colonoscopy may help improve colonoscopy prep quality by instituting adjunct measures before colonoscopy. This will in turn reduce repeat procedures, complications, and costs. Aims We determined the utility of a standardized method to obtain information from patients on the characteristics of their last bowel movement before colonoscopy by correlating the obtained information to BBPS. We compared this approach to informal/usual descriptions attained by nurses. Methods This is a cross-sectional study with data collected at two tertiary care hospitals. On the day of their colonoscopy, outpatients were asked by an assistant to describe their last bowel movement using a standardized method. The same patients had previously been asked by endoscopy nurses to describe their last bowel movement; the assistant was blind to previous descriptions. Descriptions were assigned a score (Table 1). Following colonoscopy, total and segmental BBPS scores were recorded by the gastroenterologist performing the procedure; the gastroenterologist was blind to the descriptions. Bivariate Pearson’s Correlation was used to separately assess the correlation between descriptions and BBPS. Cohen’s Kappa was used to assess agreement between the two descriptions. Results 121 patients (ages 17–86; 55% Female) with 11% BBPS< 6 were included. For descriptions attained by the assistant, there was a strong correlation with total BBPS score (r = 0.738; p < 0.001); correlation to segmental BBPS was moderate-to-strong (r=0.70, 0.63 and 0.67 right, transverse and left colon respectively). For descriptions attained by endoscopy nurses, there was a moderate correlation with total BBPS score (r = 0.525; p < 0.001); correlation to segmental BBPS was weak-to-moderate (r=0.52, 0.49 and 0.44 right, transverse and left colon respectively). There was weak agreement (K = 0.525) between description attained by assistant and nurses. Conclusions When asked using a standardized method, a patient’s description of their last bowel movement correlates strongly with their total and segmental BBPS score; the correlation is weaker for non-standardized descriptions attained by endoscopy nurses. A standardized questionnaire, including assessing consistency, is valuable in assessing the bowel movement before colonoscopy. Funding Agencies None

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The article is devoted to the study of the system of legal regulation of information security in Ukraine. It has been established that the Constitution is the foundation of the system of legal acts, which is the basis of legal regulation of information security in Ukraine. It is followed by the Laws of Ukraine: On Information, On Protection of Information in Information and Communication Systems, On Protection of Personal Data, On State Secrets, On National Security of Ukraine, On Basic Principles of Ensuring Cyber Security of Ukraine, On Electronic Communications, On Media, On Copyright and related rights, On the protection of rights to the composition of semiconductor products, On the protection of rights to inventions and utility models, On state secrets, etc. Norms defining information security of Ukraine have found further development at the sub-legal level. By­laws are aimed at detailing individual provisions of the Constitution of Ukraine and laws. They have a subject direction and regulate a specific sphere of social relations or areas of work of state administration bodies. At the level of central executive bodies, orders, instructions and orders are issued as by-laws. The documents defining the regulatory and technical basis of information protection in Ukraine also include standards and industry materials. They are of key importance because they ensure uniformity in the field of information security, standardize procedures for protecting information, methods for ensuring confidentiality, integrity and availability of data, as well as measures for preventing and responding to information incidents. We also included international acts: conventions, declarations, resolutions, etc., in the system of legal acts that constitute the basis of legal regulation of information security in Ukraine. It was concluded that today the normative and legal basis of ensuring information security is an extensive network of domestic and international norms of different legal force and focus, which in its totality ensures the comprehensive functioning of the entire system of ensuring information security in Ukraine.

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Abstract Background Children with medical complexity (CMC) are a highly medicalized population of children due to the complexity of their clinical presentations, various diagnoses, and multiple care providers. Real-time health information can inform clinicians to make better recommendations and improve clinical outcomes. In other populations, such as children with Type 1 diabetes, online health symptom trackers (HST) were used to facilitate clinic visits and track symptoms longitudinally. To-date, HSTs have not yet been examined in a clinical setting with CMC and their families. Objectives The aims of our study were to create a standardized online tool, which supports the creation of online HSTs, and to assess their utility in clinical care from a parent and health care provider (HCP) perspective. Design/Methods Parents of CMC were invited to use a standardized online care platform called Connecting2gether for 6-months and create online HSTs that could be shared with their HCPs. Online HSTs could be added by parents from a prepopulated list with an open notes section, and the ‘Signs and Symptoms’ trackers could be customized by parents. A demographic survey was completed at baseline. At 6-months a tracker acceptability survey and in-depth semi-structured qualitative interviews were completed to assess the utility and usability of HSTs. HST usage data were also collected. Interviews were analyzed via thematic analysis whereby codes were generated to inform themes, and surveys were analyzed using descriptive methods. Results Thirty-six parents enrolled on the platform and 21 (57%) created at least one online HST during the study period. The most used HSTs were ‘Signs and Symptoms’, ‘Sleep’, and ‘How I Feel’. Majority of parents (86%) reported finding the trackers useful. Only 55% of HCPs viewed the HSTs and of those, 36% reporting using them in clinical care. Qualitative interviews revealed three themes: 1) HST Usability: HSTs were used in different settings such as in clinic and school, they were used to guide conversation as a visual over time, and they used in decision making; 2) Enhancement to HST Usage: suggestions included having more options of different symptoms; and 3) Challenges and Barriers to HST Usage: including personal preference and medical stability of the patient. Conclusion The ability of online HSTs to visually depict the change in symptoms over time in CMC was found to be a benefit from a parent and HCP perspective. HSTs were identified as a tool used in clinic to guide conversation and decision making, and as a visual to track symptoms longitudinally. However, HCPs need more guidance on how to use trackers. Future directions for online HSTs include integration into the electronic health record to increase accessibility.

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10 Background: Genomic information is increasingly used to personalize health care. One example is gene-expression profiling (GEP) tests that estimate recurrence risk to inform chemotherapy decisions in breast cancer treatment. Recently, GEP tests were publicly funded in Ontario. We assessed the clinical utility of GEP tests, exploring the factors facilitating their use and value in treatment decision-making. Methods: As part of a mixed-methods clinical utility study, we conducted interviews with oncologists (n=14), and focus groups and interviews with breast cancer patients (n=28) who underwent GEP, recruited through oncology clinics in Ontario. Data were analyzed using content analysis and constant comparison. Results: Various factors governing access to GEP have given rise to challenges for patients and oncologists. Oncologists are positioned as gatekeepers of GEP, providing access in medically appropriate cases. However, varying perceptions of appropriateness led to perceived inequities in access and negative impacts on the doctor-patient relationship. Media attention facilitated patient awareness of GEP but complicated gatekeeping. Additional administration burden and long waits for results led to increased patient anxiety and delayed treatment. Collectively, these factors inadvertently heightened GEP’s perceived value for patients relative to other prognostic indicators because of barriers to access. Conclusions: This study delineates the factors facilitating and restricting access to GEP, and highlights the roles of the media and organization of services in GEP’s perceived value and utilization. Results identify a need for administrative changes and practice guidelines to support streamlined and standardized utilization of the test.

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167 Background: Patient demographics, lifestyle factors, and past medical history enable clinicians to optimize care plans, and be useful for health services research. Unfortunately, these data are often recorded inconsistently in the medical chart. In 2015, we tested a paper-form questionnaire to collect such data systematically in the outpatient setting. This current study assessed the feasibility (applicability, acceptability, practicality) of administering the questionnaire via electronic format (iPad). Objectives: To examine whether the electronic format of the questionnaire was (1) applicable (reliable and complete data); (2) acceptable to patients; and (3) practical for clinic utilization. Methods: New adult cancer patients visiting the thoracic cancer clinic at Princess Margaret Cancer Centre in summer, 2016 were asked to complete a Patient Health Questionnaire via iPad devices. This questionnaire was developed through trial testing in addition to literature review, expert opinion, and prior paper-based testing. Results: In 62 new patients (57% male, mean age 66 years old), this electronic questionnaire took on average 25 minutes to complete. The electronic questionnaire was applicable (89% completed the questionnaire, reliable data) and acceptable (69% were happy to complete, 69% found questionnaire useful, 61% thought it asked the right questions, 71% did not think it made clinic visits more difficult). For practicality, although the data were easily interpretable by clinicians, 48% of patients failed to complete the questionnaire before they were seen by their clinicians. Conclusions: Though feasible to collect electronically standardized demographics, lifestyle, and past medical history routinely, timeliness was an issue. Earlier arrival times or completion at home may be necessary to improve clinical utility of the questionnaire.

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Abstract Despite increased risk for negative outcomes, cognitive impairment (CI) is greatly under-detected during hospitalization. While automated EHR-based phenotypes have potential to improve recognition of CI, they are hindered by widespread under-diagnosis of underlying etiologies such as dementia—limiting the utility of more precise structured data elements. This study examined unstructured data on symptoms of CI in the acute-care EHRs of hip and stroke fracture patients with dementia from two hospitals. Clinician reviewers identified and classified unstructured EHR data using standardized criteria. Relevant narrative text was descriptively characterized and evaluated for key terminology. Most patient EHRs (90%) had narrative text reflecting cognitive and/or behavioral dysfunction common in CI that were reliably classified (κ 0.82). The majority of statements reflected vague descriptions of cognitive/behavioral dysfunction as opposed to diagnostic terminology. Findings from this preliminary derivation study suggest that clinicians use specific terminology in unstructured EHR fields to describe common symptoms of CI. This terminology can inform the design of EHR-based phenotypes for CI and merits further investigation in more diverse, robustly characterized samples.

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Background Continuous quality improvement is important for cancer systems. However, collecting and compiling quality indicator data can be time-consuming and resource-intensive. Here we explore the utility and feasibility of linked routinely collected health data to capture key elements of quality of care for melanoma in a single-payer, universal health care setting. Method This pilot study utilized a retrospective population-based cohort from a previously developed linked administrative data set, with a 65% random sample of all invasive cutaneous melanoma cases diagnosed 2007–2012 in the province of Ontario. Data from the Ontario Cancer Registry was utilized, supplemented with linked pathology report data from Cancer Care Ontario, and other linked administrative data describing health care utilization. Quality indicators identified through provincial guidelines and international consensus were evaluated for potential collection with administrative data and measured where possible. Results A total of 7,654 cases of melanoma were evaluated. Ten of 25 (40%) candidate quality indicators were feasible to be collected with the available administrative data. Many indicators (8/25) could not be measured due to unavailable clinical information (e.g. width of clinical margins). Insufficient pathology information (6/25) or health structure information (1/25) were less common reasons. Reporting of recommended variables in pathology reports varied from 65.2% (satellitosis) to 99.6% (body location). For stage IB-II or T1b-T4a melanoma patients where SLNB should be discussed, approximately two-thirds met with a surgeon experienced in SLNB. Of patients undergoing full lymph node dissection, 76.2% had adequate evaluation of the basin. Conclusions We found that use of linked administrative data sources is feasible for measurement of melanoma quality in some cases. In those cases, findings suggest opportunities for quality improvement. Consultation with surgeons offering SLNB was limited, and pathology report completeness was sub-optimal, but was prior to routine synoptic reporting. However, to measure more quality indicators, text-based data sources will require alternative approaches to manual collection such as natural language processing or standardized collection. We recommend development of robust data platforms to support continuous re-evaluation of melanoma quality indicators, with the goal of optimizing quality of care for melanoma patients on an ongoing basis.

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Welfare assessments have been largely successful in improving management and quality of life for animals in human care. This has prompted an increased interest in their use for free-ranging wild animals to assess health, environment, and human-induced impacts that influence policy decisions. The North Atlantic Right Whale (NARW, Eubalaena glacialis) is one of the most endangered whale species. NARWs constantly face serious injuries and mortalities due to human activities, which poses both a species conservation and an individual welfare concern. Establishing a standardized welfare assessment for the NARW is a holistic way to understand the cumulative effects of anthropogenic activities at both the individual and population levels. To investigate the potential use of welfare assessments in NARWs, we performed a brief literature review to explore the history and utility of animal welfare assessments. Following the review, we developed a welfare assessment tool specific to the NARW. The goal is for biologists to apply this tool to understand NARW welfare in conjunction with research in the field. Ultimately, the information gained from this review can aid in public dissemination of the results of human impacts on NARW welfare and may help influence future conservation policies.

Abstract:

Introduction: Increase in functional decline of older adults after discharge from the emergency department (ED) has been reported; however, evaluations of interventions to mitigate this problem are infrequent. Data collected in the ED on older adults may document functional status, yet their utility for research is unknown. This study aimed to assess the usability of data collected by ED Transition Coordinators (EDTC) during routine assessments for functional decline research. Methods: EDTCs assess all patients 75 years old presenting to the ED and complete a standardized Transitional Assessment Referral (TAR) form that documents patients independence and daily functioning. To measure the utility of these forms for research purposes, trained research staff evaluated the TARs completed in April 2017 by TCs in the University of Alberta Hospital ED by extracting data from the TARs into a purpose-built REDCap database. Researchers selected and assessed for completeness and clarity the following variables unique to the TARs: facility vs. non-facility living, goals of care and personal directive, fall history, falls in the past 90 days, independence in 14 activities of daily living (ADLs)/instrumental activities of daily living (IADLS), community services in place, and homecare referrals for discharged patients. The proportion of TARs with data for each variable and the proportion of forms with unambiguous responses in each section are reported. Results: Overall, 500 forms were analysed; patients were 41% male with a mean age of 82 (SD=11.2). Homecare referrals, facility vs. non-facility living, and independence with 14 ADLs/IADLs were the most frequently documented variables (81%, 78%, and 79%, respectively); however for ADLs/IADLs, 59% of the 79% had one or more missing components. While fall history was reported in 301 forms (60%), only 107/301 (36%) reported the number of falls in the last 90 days. The referral to homecare variable was complete in 217/268 (81%) forms; however, 99% of files were missing data about goals of care, personal directives, and receipt of community services. Conclusion: Although some information on elderly patients is consistently reported, many of the social service/human factors associated with functional decline are not recorded. While data on the TARs may be useful for studying functional decline in the ED, exploring the barriers to form completion may improve adherence thereby increasing their research utility.

Abstract:

Interactive patient portals are a valuable tool for engaging patients in their healthcare, with various functionalities including viewing laboratory results, refilling prescriptions and communicating directly with nurses, physicians and other healthcare providers via electronic messaging. The utility of patient portals is limited primarily from lack of patient uptake and enrolment due to a variety of factors including lack of awareness, low health literacy, poor technology mastery, lack of availability of a smartphone or computer and distrust of the security of their personal health information. We aimed to increase enrolment in the Epic (O2) MyChart patient portal among patients receiving HIV care through our Infectious Diseases clinic via a standardised sign-up protocol during their clinic visits. This intervention resulted in a modest increase in enrolled patients. However, the factors preventing a more dramatic increase in patient uptake remain unclear.

Abstract:

Objective:The current guidance for the management of women with stage IA2 cervical carcinoma is that whatever the primary surgical intervention, pelvic lymphadenectomy should be included. The role of lymphadenectomy in the management of cervical carcinoma remains somewhat confused, as the procedure has not been proven to be therapeutic, although it is claimed that the information gained is valuable in determining the need for adjuvant therapy.For lymphadenectomy to have clinical utility in the care of women with stage IA2 cervical carcinoma, a sufficiently high incidence of node positivity would be required to justify the morbidity of the procedure for the whole group.The objective of this paper was to establish the incidence of pelvic lymph node positivity in stage IA2 cervical carcinoma.Methods:A PubMed search using the words "stage IA2 cervical carcinoma," "microinvasive cervical carcinoma," "stage IA cervical carcinoma," "stage I cervical carcinoma," and "lymphadenectomy in cervical carcinoma" was performed; the articles were divided into those that adhered to the International Federation of Gynecology and Obstetrics (FIGO) definition of a stage IA2 tumor and those that did not. Sentinel node studies were not included, as this procedure does not form part of the FIGO guidelines.Results:Studies adhering to the FIGO definition showed a 0.5% incidence of lymph node metastases in stage IA2 cervical carcinomas, which is not as high as was previously believed (7.3%).Conclusions:The very low rate of positive lymph nodes in correctly staged IA2 cases cannot justify the inclusion of lymphadenectomy as part of standardized care for these patients.

Abstract:

e21152 Background: The medical community is continually searching for the best way to treat cancer. The value and utility of biomarkers in guiding treatment decisions is widely accepted but remains a challenge for the bedside clinician and requires ongoing validation and correlation to clinical outcomes. Caris Life Sciences has a dedicated team of scientists who study volumes of scientific literature, synthesize biomarker research and by way of an evidence-based electronic rules engine, translates the application of the literature to biomarker analysis of tumor tissue (The Target Now Report) in support of biomarker-drug association evidence useful in clinical decision-making. Subsequently, Caris initiated the Caris Registry to capture clinical disease, treatment and outcome data from patients who have a Target Now Report. Methods: The Caris Registry is a web-based data entry platform based on an IRB approved protocol. The eligible subject for the Registry will have a qualified Target Now Report. All clinical data elements are defined and supported by the NCI caBIG standardized data dictionary. Disease history/status, treatments and outcomes are captured at enrollment with Day 1 defined as the date of the Target Now Report and every 9 months for 5 years or death whichever is first. Results: As of January 19, 2012, there are 68 participating centers across the country and 43 centers pending IRB submission. There are 852 Target Now cases enrolled with the following cancer lineage distribution: Breast 209, Ovary 169, Lung 117, Colon 79, Endometrium 33, and other 245. There are 323 completed follow up reports and 175 completed end of study reports capturing vital status and cancer related deaths. Conclusions: Caris has successfully launched a scientifically valid and regulatory compliant Registry and database intended to become a robust library of tumor biomarker results linked to clinical outcomes data. As the library grows, data mining could provide vital information access to researchers, pharmaceutical firms, government, academia and insurers for use in drug development, molecular and biomarker research, economic impact assessments, healthcare policy discussion and most importantly directing personalized cancer treatment.

Abstract:

Summary Objectives: To report the lessons learned from eight years of feeding back routinely collected cardiovascular data in an educational context Methods: There are distinct educational and technical components. The educational component provides peer-led learning opportunities based on comparative analysis of quality of care, as represented in computer records. The technical part ensures that relevant evidence-based audit criteria are identified; an appropriate dataset is extracted and processed to facilitate quality improvement. Anonymised data are used to provide inter-practice comparisons, with lists of identifiable patients who need interventions left in individual practices. Results: The progressive improvement in cholesterol management in ischaemic heart disease (IHD) is used as an exemplar of the changes achieved. Over three iterations of the cardiovascular programme the standardised prevalence of IHD recorded in GP computer systems rose from 3.8% to 4.0%. Cholesterol recording rose from 47.6% to 89.0%; and the mean cholesterol level fell from 5.18 to 4.67 mmol/L; while statin prescribing rose from 46% to 57% to 68%. The atrial fibrillation, heart failure and renal programmes (more people with chronic kidney disease go on to die from cardiovascular cause than from end-stage renal disease) are used to demonstrate the range of cardiovascular interventions amenable to this approach. Conclusions: Technical progress has meant that larger datasets can be extracted and processed. Feedback of routinely collected data in an educational context is acceptable to practitioners and results in quality improvement. Further research is needed to assess its utility as a strategy and cost-effectiveness compared with other methods.

Abstract:

Background Dementia disease is a chronic condition that leads a person with dementia (PwD) into a state of progressive deterioration and a greater dependence in performing their activities of daily living (ADL). It is believed nowadays that PwDs and their informal caregivers can have a better life when provided with the appropriate services and support. Connected Health (CH) is a new technology-enabled model of chronic care delivery where the stakeholders are connected through a health portal, ensuring continuity and efficient flow of information. CH has demonstrated promising results regarding supporting informal home care and Aging in Place, and it has been increasingly considered by researchers and health care providers as a method for dementia home care management. Objective This study aims to describe the development and implementation protocol of a CH platform system to support informal caregivers of PwDs at home. Methods This is a longitudinal observational mixed methods study where quantitative and qualitative data will be combined for determining the utility of the CH platform for dementia home care. Dyads, consisting of a PwD and their informal caregiver living in the community, will be divided into 2 groups: the intervention group, which will receive the CH technology package at home, and the usual care group, which will not have any CH technology at all. Dyads will be followed up for 12 months during which they will continue with their traditional care plan, but in addition, the intervention group will receive the CH package for their use at home during 6 months (months 3 to 9 of the yearly follow-up). Further comprehensive assessments related to the caregiver’s and PwD’s emotional and physical well-being will be performed at the initial assessment and at 3, 6, 9, and 12 months using international and standardized validated questionnaires and semistructured individual interviews. Results This 3-year funded study (2016-2019) is currently in its implementation phase and is expected to finish by December 2019. We believe that CH can potentially change the PwD current care model, facilitating a proactive and preventive model, utilizing self-management–based strategies, and enhancing caregivers’ involvement in the management of health care at home for PwDs. Conclusions We foresee that our CH platform will provide knowledge and promote autonomy for the caregivers, which may empower them into greater control of the care for PwDs, and with it, improve the quality of life and well-being for the person they are caring for and for themselves through a physical and cognitive decline predictive model. We also believe that facilitating information sharing between all the PwDs’ care stakeholders may enable a stronger relationship between them, facilitate a more coordinated care plan, and increase the feelings of empowerment in the informal caregivers. International Registered Report Identifier (IRRID) DERR1-10.2196/13280

Abstract:

17035 Background: Recent advances in information technology have made the goal of incorporating patient-reported symptoms possible. Initial studies have examined the validity of these systems but no systematic work has been done to examine the impact on overall practice efficiency. The PACE (Patient Assessment, Care, and Education) System captures patient-reported symptoms, quality of life, social and family history changes, and other clinical data at every office visit. The PACE System includes the Patient Care Monitor (PCM), a standardized, comprehensive assessment of a patient's condition that allows for a self-reported review of systems (ROS) via a wireless, touch screen computer tablet. The purpose of this study was to determine if implementation of the PCM had an impact on total transcription length. Methods: The study utilized a retrospective within subjects control design comparing transcription length by physicians practicing both with and without the PCM. The PACE System was implemented in October 2004 in a main outpatient oncology site in Billings, MT (PACE site). The analysis compared transcription length by physicians who practice in the Billings office where the PACE system was available, and also in four sites in Montana and Wyoming where the PACE system was not available during the same time period (January to October 2006). All available, consecutive physician notes were analyzed from eligible physicians during the analysis period. Results: Four physicians met inclusion criteria and 8,150 notes were analyzed. The average number of dictation words at PCM sites was 406.7 as compared to 485.5 at non- PCM sites (a 16% reduction). The average number of dictation lines at the PCM sites was 54.0 as compared to 58.5 at non-PCM sites (an 8% reduction). Conclusions: Increases in the use of information technology in outpatient oncology necessitate increased understanding of the validity and utility of these systems. This study of the PACE system suggests that there may be an efficiency benefit by implementing patient self-reporting systems. No significant financial relationships to disclose.

Abstract:

12010 Background: Despite high prevalence of functional status (FS) and physical performance (PP) impairments among older adults with cancer, standardized assessments and interventions are not routinely used in oncology care. This study characterized how oncologist knowledge of Geriatric Assessment (GA) results influenced conversations and GA-guided recommendations addressing FS and PP concerns. Methods: Data were from a NCORP funded (UG1CA189961) nationwide cluster randomized controlled trial (ClinicalTrials.gov: NCT02107443; PI: Mohile), with inclusion criteria: age ≥70, stage III/IV solid tumor or lymphoma with palliative treatment intent, and ≥1 GA domain impairment. All subjects underwent baseline GA including standardized FS ([instrumental] activities of daily living) and PP (Timed Up and Go, Short Physical Performance Battery, Older Americans Resources and Services Physical Health scale, falls in past 6 months) measures. Oncologists in Intervention arm practices received full GA results and validated recommendations for each patient, while those in the usual care (UC) arm were only notified of depression or severe cognitive impairment. One clinical encounter per patient within 4 weeks of GA was audio-recorded, transcribed and blind coded using a priori content-analysis scheme to categorize conversations and oncologist response (dismissed, acknowledged, or addressed with recommendation) by GA domain. Frequencies, raw and adjusted (for site using generalized linear mixed models) proportions were compared using the Chi square test. Results: 541 patients (mean age: 77, range 70-96) were included. More FS and PP conversations occurred in Intervention (PP=532, FS=164) than UC (PP=183, FS=87) arm (p<.0001). The adjusted proportion of all patients having one or more FS or PP conversations reached 85.8% in the Intervention arm but only 58.6% in UC (p<.0001). Intervention oncologists were more likely to address FS and PP concerns than UC oncologists (42.6% vs 16.5%, p=0.0003), and to use referrals (Intervention=23.5%, UC=5.0%, p<.0001) or information (Intervention=22.3%, UC=3.8%, p=0.0006) to address them. Conclusions: Providing oncologists a GA report with recommended interventions enhances oncologist-patient communication regarding FS and PP-related concerns in older adults with advanced cancer. FS and PP-related issues were more likely to be addressed by those oncologists receiving the GA report, demonstrating the utility of GA as a tool in creating tailored interventions for FS and PP concerns. Our findings support use of GA as an important tool in caring for patients with impairments in physical performance and function. Funding: NIH/NCI UG1CA189961, T32CA102618. Clinical trial information: NCT02107443.

Abstract:

Purpose With prospective clinical sequencing of tumors emerging as a mainstay in cancer care, an urgent need exists for a clinical support tool that distills the clinical implications associated with specific mutation events into a standardized and easily interpretable format. To this end, we developed OncoKB, an expert-guided precision oncology knowledge base. Methods OncoKB annotates the biologic and oncogenic effects and prognostic and predictive significance of somatic molecular alterations. Potential treatment implications are stratified by the level of evidence that a specific molecular alteration is predictive of drug response on the basis of US Food and Drug Administration labeling, National Comprehensive Cancer Network guidelines, disease-focused expert group recommendations, and scientific literature. Results To date, > 3,000 unique mutations, fusions, and copy number alterations in 418 cancer-associated genes have been annotated. To test the utility of OncoKB, we annotated all genomic events in 5,983 primary tumor samples in 19 cancer types. Forty-one percent of samples harbored at least one potentially actionable alteration, of which 7.5% were predictive of clinical benefit from a standard treatment. OncoKB annotations are available through a public Web resource ( http://oncokb.org ) and are incorporated into the cBioPortal for Cancer Genomics to facilitate the interpretation of genomic alterations by physicians and researchers. Conclusion OncoKB, a comprehensive and curated precision oncology knowledge base, offers oncologists detailed, evidence-based information about individual somatic mutations and structural alterations present in patient tumors with the goal of supporting optimal treatment decisions.

Abstract:

Background. Consensus on standardized active surveillance or follow-up care by clinicians is lacking leading to considerable variation in practice across countries. An important structural modelling consideration is that self-examination by patients and their partners can detect melanoma recurrence outside of active surveillance regimes. Objectives. To identify candidate melanoma surveillance strategies for American Joint Committee on Cancer (AJCC) stage I disease and compare them with the current recommended practice in a cost-utility analysis framework. Methods. In consultation with UK clinical experts, a microsimulation model was built in TreeAge Pro 2019 R1.0 (Williamstown, MA, USA) to evaluate surveillance strategies for AJCC stage IA and IB melanoma patients separately. The model incorporated patient behaviors such as self-detection and emergency visits to examine suspicious lesions. A National Health Service (NHS) perspective was taken. Model input parameters were taken from the literature and where data were not available, local expert opinion was sought. Probabilistic sensitivity analysis, one-way sensitivity analysis on pertinent parameters and value of information was performed. Results. In the base-case probabilistic sensitivity analysis, less intensive surveillance strategies for AJCC stage IA and IB had lower total lifetime costs than the current National Institute for Health and Care Excellence (NICE) recommended strategy with similar effectiveness in terms of quality-adjusted life years and thereby likely to be cost-effective. Many strategies had similar effectiveness due to the relatively low chance of recurrence and the high rate of self-detection. Sensitivity and scenario analyses did not change these findings. Conclusions. Our model findings suggest that less resource intensive surveillance may be cost-effective compared with the current NICE surveillance guidelines. However, to advocate convincingly for changes, better evidence is required.

Abstract:

Background: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. Aim: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. Design: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. Setting/participants: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). Results: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10–20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. Conclusion: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.

Abstract:

Introduction: Apixaban 2.5mg twice daily has been shown to significantly reduce the risk of venous thromboembolism (VTE) compared to placebo for the primary thromboprophylaxis of VTE in ambulatory cancer patients initiating chemotherapy, who are at intermediate-high risk of VTE, with a Khorana score of ≥2 (hazard ratio, 0.41; 95% confidence interval, 0.26 to 0.65; P&lt;0.001). In this study, we estimated whether the health benefit gained from apixaban justified its costs. Method: We conducted a cost-utility analysis of apixaban (2.5mg twice daily) compared to usual care, whereby no apixaban is prescribed, from the perspective of Canada's healthcare system. Our target population was ambulatory cancer patients starting chemotherapy with an intermediate-high risk of VTE. We developed a Markov model with a cycle length of 1-week to simulate costs and quality-adjusted life years (QALYs) for patients receiving either apixaban or usual care over 6 months (Figure 1). To estimate the baseline time varying risk of VTE among ambulatory cancer patients undergoing chemotherapy, we created pseudo patient-level data from survival curves reported for patients in the placebo arm of the AVERT trial using 'WebPlotDigitizer'. We fitted parametric survival models to the patient-level data points to extrapolate VTE risk beyond the trial follow-up period (median follow-up 183 days). The best model was selected based on a visual inspection and the Akaike Information Criterion. The relative risk of VTE, clinically relevant non-major bleeding, and major bleeding (using the International Society of Thrombosis and Haemostasis criteria) as a result of apixaban was obtained from the AVERT trial using the on-treatment analysis. We conducted a targeted literature search to obtain the risk of complications among cancer patients receiving low-molecular-weight heparin for the initial treatment and secondary prevention of VTE using a meta-analysis technique. Hazard ratio for increased risk of death due to cancer was estimated as a weighted average of the age-standardized mortality rate by tumor type, based on the proportion of patients with each tumor type in the AVERT trial. Costs were obtained from published Canadian sources. Baseline health utility values for patients on chemotherapy and in remission were calculated as a weighted average of utility values by tumour type, also based on the proportion of patients with each tumour type in the AVERT trial. Utility values for chemotherapy and remission for each tumour type, as well as event specific disutility values, were obtained from the published literature. Both costs and QALYs were discounted using an annual rate of 1.5%, as recommended by the Canadian Agency for Drugs and Technologies in Health. We conducted deterministic and probabilistic sensitivity analyses to assess robustness of study findings. Results: Over a 6-month period, apixaban was associated with a lower health system cost (C$25,987 vs C$26,268) and a slight increase in QALYs (0.3339 vs 0.3337) compared to usual care (Table 1). The probability that apixaban was cost-saving compared to usual care was 90%; however, this probability decreased with the greater willingness to pay (WTP) values partly due to the high uncertainty in the difference in QALYs. At a WTP threshold of C$50,000/QALY, the probability of apixaban being cost effective was 57% (Figure 2). Over 1 year, apixaban reduced health care system costs by C$1,113 and improved QALYs by 0.0005 units compared to usual care. At a WTP threshold of C$50,000/QALY, the probability of apixaban being cost effective increased to 70%. Our results were robust to the change in time horizon; however, they were more sensitive to the relative risk of VTE, the relative risk of major bleeding, the costs amassed in the post-VTE period, and the treatment cost of acute VTE. Probabilistic sensitivity analysis indicated a high-level uncertainty around cost effectiveness estimates, which may be driven by the wide confidence intervals around estimates for relative risk of complications in patients receiving thromboprophylaxis with apixaban. Conclusion: From a publicly funded health system's perspective apixaban is a cost saving option for thromboprophylaxis among ambulatory cancer patients initiating chemotherapy. Disclosures Wells: BMS/Pfizer: Honoraria, Research Funding; Bayer: Honoraria; Sanofi: Honoraria; Daiichi Sankyo: Honoraria. Carrier:Servier: Honoraria; Bayer: Honoraria; Pfizer: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Leo Pharma: Honoraria, Research Funding. OffLabel Disclosure: Apixaban can be used as postoperative prophylaxis of DVT/PE and for treatment of DVT/PE. We performed a cost-utility analysis of apixaban 2.5mg BID for the primary thromboprophylaxis of ambulatory cancer patients initiating chemotherapy, at intermediate-high risk of venous thromboembolism.

Abstract:

Background:In IgG4-related diseases (IgG4-RD), usefulness of18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging for detecting the organ involvement of IgG4-RD have been shown and,18FDG PET/CT was more accurate and appeared to be more sensitive as compared to other imaging technics1,2. However, until now, the studies regarding about quantitative analysis of PET/CT imaging in IgG4-RD were few. To avoid unnecessary biopsy and select suitable lesion for biopsy on multi-organ involvement disease such as IgG4-RD, the information which lesion is suspected as disease-involvement lesion in a non-invasive test is important.Objectives:The purpose of this work is to evaluate the usefulness of18FDG-PE/CT imaging in management of IgG4-RD using quantitative analysis of PET/CT imaging.Methods:21 patients with IgG4-RD, in whom PET/CT was undertaken at the time of diagnosis between December 2009 and July 2018, were enrolled. We retrospectively investigated the association between histological findings in which biopsy was performed for diagnosis of IgG4-RD and findings of PET/CT.18FDG uptake was assessed in site of major organ involvement of IgG4-RD which could be differentiated from the normal uptake of background tissue with18FDG-PET/CT. For quantitative analysis, we measured the highest standardized uptake value (SUV) of the pixels within the region of interest (ROI) (SUVmax) and the average SUV within ROI (SUVmean). We also measured SUVmeanof liver as reference tissue. Then, we calculated ratio between SUVmeanof ROI and SUVmean/liver.Results:The age at diagnosis was 64.5 ± 11.9 years, serum IgG4 was 743.8 ± 584.1 mg/dl, and biopsy was performed at 24 sites (Submandibular gland 10, prostate gland 4, pancreas 2, thyroid gland 1, lung 1, retroperitoneum 1, kidney 1). Histological findings were consistent with IgG4RD (positive) at 19 sites.Although SUVmaxat the biopsy site was not correlated with the biopsy results, SUVmeanat the biopsy site were significantly higher in the biopsy-positive group (figure 1). As similar, SUVmean/liver SUVmeanwere also higher in the biopsy-positive group (2.17 vs 1.52, respectively P<0.05). To establish cut-off value of SUVmeanto consider biopsy, A receiver operating characteristics (ROC) curve was constructed. ROC curve analysis indicated SUVmean=4.074 as cut-off value which discriminate IgG4-RD related lesion.Conclusion:Our present study suggested that quantitative analysis of18FDG-PET/CT imaging is useful for selecting the biopsy site in IgG4-related disease.Figure 1.XXXXXReferences:[1]Ebbo M, Grados A, Guedj E, et al. Usefulness of 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography for staging and evaluation of treatment response in IgG4-related disease: a retrospective multicenter study. Arthritis Care Res (Hoboken) 2014; 66(1): 86-96.[2]Zhang J, Chen H, Ma Y, et al. Characterizing IgG4-related disease with (1)(8)F-FDG PET/CT: a prospective cohort study. Eur J Nucl Med Mol Imaging 2014; 41(8): 1624-34.Disclosure of Interests:None declared

Abstract:

Objective: The purpose of this research is to ascertain the frequency of deeper sections and the diagnostic utility of these sections in non-cutaneous tiny biopsies obtained from a hospital setting. Study Design: Cross-sectional study Place and Duration: This study was carried out at Shaukat Khanum Memorial Hospital Peshawar, Jan 2022 to April 2022 Methods: In this study, there were a total of 100 patients, ranging in age from 16 to 50 years old. Patients who were hospitalized to the oral and maxillofacial department and who had deeper section procedures were considered for inclusion. Following the acquisition of informed and written consent, complete demographic information was obtained. The locations of organs and the levels at which leaks were found were documented for each and every instance. The mean, standard deviation, frequency, and percentages were the metrics that were used to evaluate the categorical variables. All of the data was analysed with SPSS version 22.0. Results: Among the deeper sections, we discovered that cervix cases accounted for 50%, stomach cases accounted for 25%, endometrial cases accounted for 15%, and colorectal cases accounted for 10%. Twenty-six instances 26%, had a deeper section done, with level 4 being the most prevalent. Although in most cases a diagnosis could be determined from the initial slide, in 55 of these cases (55%), further slides were reviewed to look for additional histological features. The goal was to either confirm the diagnosis obtained from the initial slide or raise confidence in that diagnosis. In 55 cases, 39 (70.9%) showed new pathological abnormalities in deeper sections, whereas 16 (29.1%) showed no change in histological features. Conclusion: A more in-depth examination is typically required in order to arrive at a certain diagnosis. Because of this, it is recommended that, regardless of the extent of the lesion, deeper sections be conducted on samples that cannot be consistently detected on ordinary levels, and this approach need to be standardized everywhere in the globe. Keywords: Histopathology, Deeper Sections, Non-cutaneous, Biopsy

Abstract:

228 Background: Genomic profiling (GP) plays an important role in the care of patients diagnosed with advanced cancer, and has been used to guide clinical decision making. As age has been associated with low health literacy, we sought to determine comprehension of the goals and objectives of GP between younger (age < 65) and older (age ≥65) with genitourinary cancers. Methods: Eligible patients had agreed to receive somatic GP as a part of routine clinical care through a CLIA-certified commercially available platform. Participating physicians conducted a standardized dialogue with patients pertaining to the rationale for and clinical utility of somatic GP. Patients then received an in-person survey lasting approximately 10-15 min and assessing a broad range of perceptions related to GP. Results: Among 47 patients, 62% were characterized as older adults. Diagnoses encountered included kidney (43%), prostate (32%), and bladder (25%). Only older adults perceived any shortcomings in the description of GP. These shortcomings related to the clarity of the descriptions of genomic data, as well as the accuracy, detail and compassion with which this information was conveyed. Older adults demonstrated a very strong reliance on physician input in their decision to obtain somatic GP - 42% of older adults suggested that trust in their physician was among the top three reasons for which they opted to do genomic testing, in contrast to just 10% of younger patients (P = 0.04). Both older and younger patients demonstrated frequent misconceptions pertaining to the role of GP. For example, the majority of younger (78%) and older (52%) patients suggested the test was being performed for prognostic purposes. Both groups also frequently held the notion that somatic testing could identify hereditary cancer-related disorders (younger: 78% vs older: 66%). Conclusions: Detailed surveys of patients with genitourinary cancers reveal varied comprehension of somatic GP between younger and older patients. Interventions to enhance understanding of the principles of GP may be helpful in facilitating shared decision-making, particularly among older patients.

Abstract:

Context.— Digital pathology (DP) implementations vary in scale, based on aims of intended operation. Few laboratories have completed a full-scale DP implementation, which may be due to high overhead costs that disrupt the traditional pathology workflow. Neither standardized criteria nor benchmark data have yet been published showing practical return on investment after implementing a DP platform. Objective.— To provide benchmark data and practical metrics to support operational efficiency and cost savings in a large academic center. Design.— Metrics reviewed include archived pathology asset retrieval; ancillary test request for recurrent/metastatic disease; cost analysis and turnaround time (TAT); and DP experience survey. Results.— Glass slide requests from the department slide archive and an off-site surgery center showed a 93% and 97% decrease, respectively. Ancillary immunohistochemical orders, compared in 2014 (52%)—before whole slide images (WSIs) were available in the laboratory information system—and 2017 (21%) showed $114 000/y in anticipated savings. Comprehensive comparative cost analysis showed a 5-year $1.3 million savings. Surgical resection cases with prior WSIs showed a 1-day decrease in TAT. A DP experience survey showed 80% of respondents agreed WSIs improved their clinical sign-out experience. Conclusions.— Implementing a DP operation showed a noteworthy increase in efficiency and operational utility. Digital pathology deployments and operations may be gauged by the following metrics: number of glass slide requests as WSIs become available, decrease in confirmatory testing for patients with metastatic/recurrent disease, long-term decrease in off-site pathology asset costs, and faster TAT. Other departments may use our benchmark data and metrics to enhance patient care and demonstrate return on investment to justify adoption of DP.

Abstract:

Background:Antinuclear Antibody (ANA) testing forms the basis on which many rheumatological diseases are subsequently diagnosed. ANA testing quantifies the dilution of plasma to produce the titer and staining pattern and this can be a part of an ANA order set that reflexively cascades to sub-serology if positive. Studies have shown that a low titer ANA may potentially translate into an erroneous diagnosis: if one estimates a 1 percent prevalence of ANA associated disease in the general population then 30% of those individuals would have a false positive result of ANA detected at 1:40 titer [1]. We theorized that there is no need for several methods to coexist within a single inpatient hospital setting especially since diagnostic value of staining patterns alone is limited.Objectives:To compare the utility and yield of “ANA screening reflex to profile” (ARP) and “ANA reflex to titer” (ART) order sets in the inpatient setting of a community tertiary care hospital. We aim to identify the appropriateness of the ANA testing ordered including cost-effectiveness of ordering ARP over ART in order to implement the identified quality measures towards improving utilization of ANA testing.Methods:We identified all inpatient ANA reflex testing orders performed at Community Regional Medical Center, Fresno, California completed between 11/2018 till 07/2019. This included ART and ARP orders with 6 sub-serologies: SSA, SSB, dsDNA, Smith, Scl-70 and U1RNP. A Health Information Management report was generated which included patient’s age, gender, length of hospital stay, dates of testing ordered, principal diagnosis and type of ANA testing ordered. Descriptive statistics were computed and analyzed.Results:We reviewed a total of 1,012 ANA lab orders performed between 11/01/2018 until 07/30/2019 performed on 700 patients. According to the laboratory standard using Immunofluorescence Assay, an ANA titer starting from 1:40 is reported as positive. Out of the 1,012 tests, 334 tests were positive i.e. 33%. The ART order by itself contributed to 29.9% of the positive testing while ARP formed 70% of the positive testing. 56 of the 910 ARP (6%) performed had one or more sub-serology antibody positive while in 178 ARP orders (20%) only the ANA titer was positive with negative serology. The most common sub-serology antibody noted positive was dsDNA forming 54% of the positive serology results. Multiple testing was noted with 218 orders of ARP and ART being ordered on the same patient within the same week, which shows 21.5% of ANA lab orders were repetitive. Length of stay was noted to be more than 3 days for 89% of the patients who had repetitive testing, majority of those tests (99%) on the same day by the same medical provider. It cost $5.0 for an ART order that resulted negative and $5.0 for an ARP panel that resulted negative. It cost $10.0 for those patients who had both ART and ARP ordered with negative results. A positive ART result added $12.0 additional to the cost of each positive ANA profile ($67.36) when both tests were ordered together.Conclusion:Our study findings reflect the need for using higher yield ANA testing that has been standardized. It demonstrated that physicians ordering the testing were not familiar with the ART vs. ARP, and the laboratory orders needed to be re-structured. We removed the ART from the inpatient Electronic Medical Record i.e. Epic system so that only the ARP order remained. This would prevent repetitive testing and reduce healthcare costs through reduction by at least $12.0 per positive ANA result and may also translate into reduced length of hospital stay. We were able to add Centromere Antibody (Ab) to the ANA profile sub serologies to standardize it further as it is an important part of Scleroderma diagnosis.References:[1]Range of antinuclear antibodies in “healthy” individuals. AU, Tan EM, et al. Arthritis Rheum. 1997; 40(9):1601Disclosure of Interests:None declared

Abstract:

Automated algorithms for identifying potential pre-exposure prophylaxis (PrEP) candidates are effective among men, yet often fail to detect cisgender women (hereafter referred to as “women”) who would most benefit from PrEP. The emergency department (ED) is an opportune setting for implementing automated identification of PrEP candidates, but there are logistical and practical challenges at the individual, provider, and system level. In this study, we aimed to understand existing processes for identifying PrEP candidates and to explore determinants for incorporating automated identification of PrEP candidates within the ED, with specific considerations for ciswomen, through a focus group and individual interviews with ED staff. From May to July 2021, we conducted semi-structured qualitative interviews with 4 physicians and a focus group with 4 patient advocates working in a high-volume ED in Chicago. Transcripts were coded using Dedoose software and analyzed for common themes. In our exploratory study, we found three major themes: 1) Limited PrEP knowledge among ED staff, particularly regarding its use in women; 2) The ED does not have a standardized process for assessing HIV risk; and 3) Perspectives on and barriers/facilitators to utilizing an automated algorithm for identifying ideal PrEP candidates. Overall, ED staff had minimal understanding of the need for PrEP among women. However, participants recognized the utility of an electronic medical record (EMR)-based automated algorithm to identify PrEP candidates in the ED. Facilitators to an automated algorithm included organizational support/staff buy-in, patient trust, and dedicated support staff for follow-up/referral to PrEP care. Barriers reported by participants included time constraints, hesitancy among providers to prescribe PrEP due to follow-up concerns, and potential biases or oversight resulting from missing or inaccurate information within the EMR. Further research is needed to determine the feasibility and acceptability of an EMR-based predictive HIV risk algorithm within the ED setting.

Abstract:

Background There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. Objective This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. Methods Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. Results A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. Conclusions Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. Trial Registration International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184

Abstract:

Adequate health literacy is a necessity to enable effective decision making to seek, access and utilise appropriate health care service. Evidence exists indicating a low level of general health literacy among Black African women, especially those with a refugee background. Breast and cervical are the most common cancers, with Black African women or women with African ethnicity being disproportionately overrepresented. The level of health literacy specific to breast and cervical cancer among Black African women, especially those with a refugee background, has not been reviewed systematically. The present study describes a protocol for a systematic review of the available evidence on the level of health literacy specific to breast and cervical cancer among Black African women globally. We will perform a systematic review of the available quantitative and qualitative studies. The search will include studies that describe the level of health literacy specific to breast and cervical cancer among Black African women. We will conduct a preliminary search on Google scholar to build the concepts for search terms, and a full search strategy using the identified concepts and keywords across four databases namely PubMed, SCOPUS, CINAHL and Web of Sciences. We will use Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to schematically present the search strategy. We will use the standardized Joanna Briggs Institute quality appraisal and selection tool to recruit studies, and the data extraction tool to synthesise the information extracted from the recruited studies. We will be guided by socioecological theory and Indigenous epistemology to synthesise the non-quantifiable information thematically, and pool the quantitative information using meta-analysis, based on the availability of information.

Abstract:

Objectives. To evaluate the utility of fetal abdominal wall thickness (AWT) for predicting intrapartum complications amongst mothers with pregestational type 2 diabetes. Methods. This was a historical cohort study of pregnant mothers with pregestational type 2 diabetes delivering at a Canadian tertiary-care center between January 1, 2014, and December 31, 2018. Delivery records were reviewed to collect information about demographics and peripartum complications. Stored fetal ultrasound images from 36 weeks’ gestation were reviewed to collect fetal biometry and postprocessing measurement of AWT performed in a standardized fashion by 2 blinded and independent observers. The relationship between fetal AWT was then correlated with risk of intrapartum complications including emergency Caesarean section (CS) and shoulder dystocia. Results. 216 pregnant women with type 2 diabetes had planned vaginal deliveries and were eligible for inclusion. Mean maternal age was 31.3 years, and almost all were overweight or obese at the time of delivery (96.8%). Overall, the incidence of shoulder dystocia and emergency intrapartum CS was 7.4% and 17.6%, respectively. There was no difference in mean fetal AWT between those having a spontaneous vaginal delivery (8.2 mm (95% CI 7.9-8.5)) and those needing emergency intrapartum CS (8.1 mm (95% CI 7.4-8.8); p = 0.71 ) or shoulder dystocia (8.7 mm (95% CI 7.9-9.5); p = 0.23 ). There was strong interobserver correlation of AWT measurements ( r = 0.838 ; p < 0.00001 ). The strongest association with intrapartum complications was birthweight ( p = 0.003 ): with birthweight > 4000 grams, the relative risk of shoulder dystocia or CS is 2.75 (95% CI 1.74-4.36; p < 0.001 ). Conclusions. There was no obvious benefit of AWT measurement at 36 weeks for predicting shoulder dystocia or intrapartum CS amongst women with type 2 diabetes in our population. The strongest predictor of intrapartum complications remained birthweight, and so studies for improving estimation of fetal weight and evaluating the role of intrapartum ultrasound for predicting risk of delivery complications are still needed.

Abstract:

e18318 Background: Decision making in precision oncology relies on the timeliness of diagnostic testing. Uncertainty surrounding the clinical utility of laboratory developed molecular and next generation sequencing (NGS) tests (LDTs) has engendered a predominantly manual claims review process. Denials and delays may create hurdles for optimally treating patients, and denials may contribute to financial toxicity. ASCO’s CancerLinQ aggregates clinical data from EHRs of participating oncology practices to improve the quality of care for patients. We hypothesized that standardized clinical data could be used in the short term to appeal denials of NGS LDTs and in the long run, lead to evidence-based coverage decisions. Methods: Using National Provider Index IDs, CancerLinQ participating physicians were cross-walked to ordering physicians of tests offered from 100 U.S. laboratories using XIFIN for billing services in 2018 to evaluate the feasibility of using CancerLinQ clinical data for claims adjudication. We determined the proportion of molecular and NGS tests (based on CPT coding) initially denied and the proportion of successful appeals through a manual submission process for clinical documentation (not including CancerLinQ data). CancerLinQ clinical data were evaluated for key elements necessary for successful appeals. Results: Sixty-five percent of CancerLinQ participating physicians ordered tests from the laboratories identified. Approximately 80% of NGS and 40% of molecular services were initially denied. After appealing with clinical information through the manual process, 55% of denials were successfully overturned. Key clinical data provided manually could be automatically extracted from CancerLinQ at high rates, such as ICD-9/ICD-10 cancer diagnosis (100% of 1,082,606 patients), Stage Group (47.6 %), and treatment plan (35.9%). Metastatic disease status is available through M1-stage (23.2% of total M-Stage), AJCC Stage IV (29.0% of total AJCC Stage) and Metastatic diagnosis codes (17.2%). Conclusions: CancerLinQ contains key data elements necessary for successful appeals and can streamline the claims adjudication process, ultimately helping to build the evidence base for coverage decisions.

Abstract:

Background: The rise in the number of caesarean section (CS) deliveries worldwide has raised questions about its suitability and effects on the health outcomes of mothers and newborns. Consequently, healthcare professionals have been exploring standardized approaches for assessing the necessity of CS procedures to promote efficient use of this surgical intervention. The Robson Classification System has become a beneficial resource for classifying CS indications and supporting efforts to enhance the quality of obstetric care. Objective: To evaluate the utility of the Robson Classification System in assessing caesarean section indications and its implications at LUMHS. Study Design: Cross-sectional study. Settings: This study was done at Gynae and OBS department of Liaquat University of Medical & Health Sciences (LUMHS), Jamshoro Pakistan. Duration: Three-month period from November 2020 to February 2021. Methods: Women who underwent CS deliveries with available data necessary for categorizing them into the ten groups of the Robson Classification System were included. After undergoing cesarean sections, patients were screened to classify them according to the Robson 10-group system. The information obtained was strictly used for the study's objectives and treated with confidentiality. Subsequently, the collected data were inputted into SPSS version 26 for analysis. Results: The overall rate of CS was 51.2%. Mean age of the patients was 36.73+2.43 years. The highest contributors to the CS rate were in women with preterm singleton cephalic term pregnancies (group 10) 31.7% and multiparous; single term pregnancy with one and more previous caesarean section around 5 a and b) 31.9%, followed by nulliparous, single, cephalic, ≥37 weeks, spontaneous labor (group 1) 11.2%, (group 2b) 8.1%, (group 3) 5.7% and (group 4) 4.0%. Conclusion: The CS rate was observed to the highly frequent, with Robson groups 5 and 10 being the primary drivers of this heightened rate. Initiatives aimed at decreasing the initial CS occurrence by enhancing the management of both spontaneous and induced labors, as well as strengthening clinical protocols to promote vaginal birth after CS, are anticipated to yield the most substantial impact on reducing the CS rate.

Abstract:

Abstract Most skin artificial intelligence (AI) classifiers are trained only on images with diagnostic labels. However, the addition of clinical information can improve predictive accuracy. Recent interest has been stimulated in incorporating clinical data into image files, using the well-established international Digital Imaging and Communication in Medicine (DICOM) standards (Caffery L, Weber J, Kurtansky N et al. DICOM in dermoscopic research: experience report and a way forward. J Digit Imaging 2021; 34: 967–73). We have developed an automated process of creating metadata-embedded DICOM files, directly from a live teledermatology system, described below. Through our Community and Locality Imaging Centre (CLIC) model, patients referred from primary care are triaged to CLIC for high-quality image capture. There, trained health professionals use a mobile application to capture standardized DICOM information for each lesion. Each lesion dataset contains images (macroscopic, dermoscopic) and clinical metadata (patient and lesion information). Datasets are transferred to an image management system, for teledermatology and verification of ground-truth diagnoses by a consultant dermatologist. On completion of diagnoses, datasets are flagged for conversion into DICOM format, where metadata are embedded in the image files. Flagged datasets are cleaned and clinical metadata are mapped to DICOM attributes. Datasets are converted into metadata-embedded DICOM files, and reviewed for conformance to the DICOM standard using the open-source fo-dicom library (v5). These files are further tested for conformance to DICOM standard using the dciodvfy validator tool. Compliant DICOM files are then transferred to a trusted research environment for research. To test whether these DICOM files are usable for AI research, they are examined using the DICOM viewing software 3D Slicer (https://www.slicer.org/), ensuring images are usable and metadata are correctly translated. Image pixel data and clinical metadata are extracted using pydicom, into a format suitable for AI algorithm development. In our pilot work, 658 lesion datasets have been converted into metadata-embedded DICOM files. Conversion on existing hardware [virtual Intel central processing units with 2.60 GHz (two processors) and 8 GB of memory] took &lt; 1 s per image. Metadata-embedded DICOM files were approximately 0.2 kB bigger than the original JPEG files. For 3-MB images, this represented a negligible 0.003% increase in storage requirement. Testing has shown that these files can be successfully handled by algorithms within an AI research environment. In summary, we have demonstrated the feasibility of automating the conversion of routine teledermatology data into AI-ready image files encoded with clinical metadata. Future work is planned to evaluate the utility of this output on the performance of AI classifiers.

Abstract:

Abstract Introduction Burn injuries continue to be prevalent in the pediatric population and are the fifth most common cause of non-fatal injury according to the World Health Organization. Unlike the adult population, most pediatric burns in the United States are small in size and are often the result of scalds. Despite the high incidence of small burns, a standardized treatment algorithm does not currently exist, and care is often influenced by clinical judgement and resource availability. As a result, various techniques to close the burn wound and promote further healing are currently utilized. This study explores the utility of a multi-stage grafting technique, involving allograft and autograft, for treating small burns (≤ 10% total body surface area (TBSA)) in pediatric patients. Methods A retrospective review of patients aged 0-18 years who had a burn that was ≤ 10% TBSA and underwent a multi-stage grafting procedure involving the use of allograft and autograft between 09-01-2018 and 09-01-2022 was conducted. Demographic information including data pertaining to the burn injury was collected for all patients. The primary outcome measure for this study was the percentage of graft take at the graft dressing takedown procedure. All variables were summarized using descriptive statistics. P values &lt; 0.05 indicated statistical significance. Results One hundred and sixty-eight patients met the inclusion criteria for this study. The mean time from presentation to allograft surgery was 10.8 days (SD 5.6) followed by autograft surgery approximately one week later. Most patients were discharged within 24 hours following allograft surgery (88.1%) and autograft surgery (80.9%). Mean autograft take was 97.7% (SD 11.1%) with only four patients experiencing significant graft loss requiring subsequent re-grafting. The main causes of graft loss were infection and inadequate excision of the wound bed. Conclusions This analysis revealed that patients who underwent a multi-stage grafting procedure involving the use of allograft and autograft experienced minimal graft loss. These positive outcomes demonstrate that the multi-stage grafting technique, which has traditionally been employed for larger burn injuries, can be successfully adapted for smaller burns in children. Moreover, the findings from this study help to address the significant knowledge gap regarding the optimal approach to treating small burn wounds. Further research in this area is warranted to learn more about cosmetic outcomes following multi-stage grafting and determine how it compares to other techniques for treating small burns. Applicability of Research to Practice The findings from this study will allow us to begin benchmarking our treatment of small burn wounds with other centers resulting in improvements in patient care and outcomes.

Abstract:

Artificial Intelligence (AI) essentially refers to various types of machine learning, often involving deep neural networks. It autocompletes our ideas as we write, enables us to communicate with our phones, and supports language translation.1 According to the 2019 Global Burden of Disease Study, the estimated age-standardized incidence of cardiovascular disease (CVD) in Pakistan was 918.8 per 100,000 people (global: 684.33 per 100,000), and the age-standardized death rate was 357.88 per 100,000 (global: 239.85 per 100,000).2 With AI, new analytical and data-driven approaches could lead to significant advances in understanding multimorbid groups of cardiology patients and potentially improve therapeutic strategies.3 AI has been used to interpret echocardiograms and heart rhythms from ECGs, and to detect indicators of heart disease, such as left ventricular dysfunction, from surface ECGs and nuclear cardiology.4-6 It is a misconception that AI will replace cardiologists. Instead, skilled practitioners will be able to expand their clinical capabilities, make more accurate and prompt diagnoses, and improve management decisions in patient care. As with any statistical application, it is important to understand AI's strengths and limitations. To understand the basics of AI, it starts with developing an algorithm based on human expertise. Programmers create relationships between input and output, known as expert systems. In machine learning, a general algorithm, such as a neural network, approximates a mathematical relationship between input data and expected outputs. In unsupervised learning, such as clustering, only the inputs are fed into the algorithm, which then finds insights in the data using its inner structure and statistics. An AI model can discover new relationships in data that have previously eluded human discovery.1 For research purposes, cardiologists using AI may follow these steps: Type and collection of data. Preprocessing of data. Choosing the right machine learning approach. Validating and evaluating methods and results.3 The application of AI techniques in the healthcare system is still in its infancy and requires more understanding through workshops and integrated learning.7 In conclusion, AI represents a new development in the field of medicine, especially cardiology. However, it is susceptible to significant errors in interpretation and raises safety and ethical concerns. References Lopez-Jimenez F, Attia Z, Arruda-Olson AM, Carter R, Chareonthaitawee P, Jouni H, et al. Artificial Intelligence in Cardiology: Present and Future. Mayo Clin Proc. 2020;95(5):1015-39. Samad Z, Hanif B. Cardiovascular Diseases in Pakistan: Imagining a Postpandemic, Postconflict Future. Circulation. 2023;147(17):1261-3. Gill SK, Karwath A, Uh HW, Cardoso VR, Gu Z, Barsky A, et al. Artificial intelligence to enhance clinical value across the spectrum of cardiovascular healthcare. Eur Heart J. 2023;44(9):713-25. Cheng LT, Zheng J, Savova GK, Erickson BJ. Discerning tumor status from unstructured MRI reports--completeness of information in existing reports and utility of automated natural language processing. J Digit Imaging. 2010; 23(2):119-32. Narula S, Shameer K, Salem Omar AM, Dudley JT, Sengupta PP. Machine-learning algorithms to automate morphological and functional assessments in 2D echocardiography. J Am Coll Cardiol. 2016;68(21):2287-95. Garcia EV, Klein JL, Taylor AT. Clinical decision support systems in myocardial perfusion imaging. J Nucl Cardiol. 2014;21(3):427-39. Gama F, Tyskbo D, Nygren J, Barlow J, Reed J, Svedberg P. Implementation frameworks for artificial intelligence translation into health care practice: scoping review. J Med Internet Res 2022;24:e32215.

Abstract:

Abstract Background Inflammatory bowel disease is a chronic medical condition requiring regular clinical assessment and evaluation. Specialist involvement often occurs regularly to determine disease activity, progression, and consider therapeutic changes for disease control. The rapid advancement of scientific evidence and addition of novel medications have combined to make IBD care increasingly complex. Moreover, evolving standards of care have led to an increased burden of documentation. Synoptic reporting is a novel documentation method that standardizes the input of clinical data and generates comprehensive reports based on that data. It has yet to be widely accepted throughout medicine, but is commonly used in surgery and diagnostics. Advancements within IBD have amplified the need for meticulous reporting of patients' previous therapies and preventative health care: areas synoptic reporting excels in. Aims We analyzed for the presence of disease-related, treatment-based, and preventative health elements in consultation reports across standard of care and synoptic reporting methods. Methods We identified consecutive IBD consultations from Jan 1 2023 onwards for participating gastroenterologists, up to 10 reports for most clinicians, if available. Each report was labeled synoptic or standard reporting. Manual review was used to determine whether each element was present and coded in binary fashion, except for female reproductive health, which was absent, present, or N/A. For analysis, data was partitioned based on whether synoptic reporting was used, with the percentage of reports including each element being calculated based on this data. Comparisons for inclusion were then completed between the groups. Results We identified a total of 62 consultations with 19 utilizing synoptic reporting. Reporting methods fared similarly for age, sex, year of diagnosis, and summary of course. Synoptic reporting performed significantly better in reporting vaccinations, marijuana use, as well as B12, vitamin D, and ferritin levels. Differences exceeding 20% were found in the reporting of EIMs, CRC screening, and female reproductive health, though these were not at a level of statistical significance in this preliminary study. Conclusions We found through our analysis that synoptic reporting is a simple tool that creates reports with a greater inclusion of elements important for disease management and health maintenance. Relaying this information back to patients' practitioners can theoretically improve outcomes through better preventative care, active monitoring, and awareness of patients’ disease history by future consultants. Future research will focus on expanding the study population as well as gaining further insight into the utility of synoptic reporting in improving clinical communication and disease management. Funding Agencies None