ABSTRACT
STATEMENT OF PROBLEM/QUESTION: How to effectively and efficiently administer ambulatory COVID-19 monoclonal antibodies to the underserved patient population in a Federally Qualified Health Center clinical setting. DESCRIPTION OF PROGRAM/INTERVENTION: Ambulatory administration of monoclonal antibody (mAb) for COVID-19 was shown to be extremely effective at decreasing symptom duration, hospitalization and death from COVID-19. The challenge with this treatment is that it needs to be administered either IV or SQ and has a required observation period. The Denver Health Federico F. Peña Southwest Urgent Care Clinic (UC), located within the Denver Health Federico F. Peña Family Health Center in Southwest Denver, is a Federally Qualified Health Center (FQHC) serving the underserved patients in urban Denver where mAb is administered. Qualifying patients were identified via internal system referrals, external state referrals and active review of COVID-19 positive patients who resulted within the hospital system. Patients were scheduled following education regarding the treatment and consent. mAb was initially supervised by UC providers and administered by RNs. In an effort to expand services as patient demand grew, a community meeting room was converted to an infusion center where more patients could be treated utilizing a physician standing order. MEASURES OF SUCCESS: The operational process of this service was mapped and is utilized by multiple sites throughout Colorado as a reference. The quantitative metrics include the number of patients treated, patient demographics and patient outcomes. The qualitative metrics that will be used include comments from patients regarding their experience of the treatment and their description of their clinical course. FINDINGS TO DATE: Clinic leadership has participated in statewide presentations to ∼1500 providers to discuss the process/implementation in the clinical setting. This clinic has administered mAb therapies to ∼2500 patients to date, ages 12 and older. The patients identify predominately Hispanic or other non-white race/ethnicity. Analysis of outcomes is currently pending and will be available at the time of presentation. Patients are extremely grateful to have this treatment in their community and feel improvement generally within 1-2 days of receiving the treatment. Based on the clinical trial data (the NNT is ∼20), this FQHC clinic has prevented 125 hospitalizations/ deaths in just over one year by offering this treatment. KEY LESSONS FOR DISSEMINATION: mAb therapy can present some operational challenges including separation of COVID-19 positive patients from non-COVID-19 patients, staffing, space for treatment/observation, etc. However, thinking creatively to utilize resources available within the FQHC clinic can result in a significant improvement in patient health and reduction in poor outcomes from SARS-CoV-2 infection. Ensuring access to this treatment for underserved patients, whom are harder his by COVID-19, should be prioritized.
ABSTRACT
The value of genetic counseling and testing to cancer prevention, early detection, and treatment options to ensure optimal outcomes is widely acknowledged by providers, payers and patients. However, many individuals who should receive genetic counseling are never offered this service. All patients with early onset (<=age 45), triple negative (<=60) and metastatic HER2 negative breast cancer should be offered genetic counseling and testing (GC/GT) per National Comprehensive Cancer Network guidelines. A quality improvement project to actively identify and offer genetic counseling to all women with early onset, triple negative and metastatic breast cancer was implemented. Baseline information on the number of early onset (<=45), triple negative and metastatic HER2 negative breast cancers diagnosed January 2018-June 2019 was collected and cross-referenced with the Cancer Genetics Risk Assessment patient database and the electronic health record (EHR) to see how many had GC/GT in our department or the breast surgeons' office. We developed questions for an electronic screening tool used by the navigation team when meeting with patients for the first time, screening for personal or family history criteria that would flag patients at increased risk for hereditary cancer. If any questions were flagged, the patient was asked by the navigator if they would be interested in a genetic counseling appointment to consider genetic Stesting. Training was provided to the navigation team so that they could answer basic questions, biweekly meetings were set up to discuss patients, and a flier and informational videos were made available to patients who wanted more information about GC/GT. If a patient was agreeable to genetic counseling, an automated email was triggered to the genetics team, who contacted the patient for an appointment. A standing order was obtained from willing breast surgeons and oncologists within our network to streamline the referral process. In the 18-month baseline period, there were 126 patients diagnosed with early onset, 36 with triple negative <=60 and 30 with metastatic HER2 negative breast cancer. Of these, 57.1% of early onset, 66.7% triple negative and 3.3% of those with metastatic breast cancer had documentation of GC/GT. A paper screening tool was implemented in July 2019 with implementation of an electronic version in November 2019. In the 18-month intervention period, there were 100 patients diagnosed with early onset, 39 with triple negative and 22 patients with metastatic breast cancer. Of these, 86% of early onset, 87.2% of triple negative and 31.8% of metastatic breast cancer patients had documented GC/GT.A limitation of this project is that some patients leave the system to be treated elsewhere after diagnosis and some may have been tested in their private practitioner's office that does not connect with our EHR. Additionally, some may have been offered GC/GT but declined or were unwilling/unable to complete an appointment. Finally, the pandemic likely had an impact on this project, since fewer women were undergoing mammography screening due to COVID-19 restrictions, resulting in fewer diagnoses of breast cancer. By leveraging the navigation team's interaction with breast cancer patients, we were able to improve identification and referral of more patients with early onset, triple negative <=60 and metastatic HER2 negative breast cancer for GC/GT. One barrier to genetic counseling that has been previously identified is a lack of physician referral. Active engagement with a breast navigator can circumvent this barrier. De-identified aggregate data from this quality improvement project was shared with the Association for Community Cancer Centers as part of a larger project, supported by a grant from Pfizer.
ABSTRACT
Background. Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of studies that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infections. Methods. An anonymous 10-question survey was distributed to 125 physicians (Infectious Diseases, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results. Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3-10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents;93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusion. Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.