PURPOSE Several allelic variants of the gene DPYD encoding dihydropyrimidine dehydrogenase (DPD) are associated with impaired metabolism of the systemic fluoropyrimidine fluorouracil (5FU) and its oral prodrug, capecitabine, which elevates the risk for severe toxicity. Following a patient death related to capecitabine toxicity in which DPD deficiency was suspected, a multidisciplinary advisory panel was convened to develop an institution-wide approach to future patients planned for a systemic fluoropyrimidine. METHODS The panel selected an opt-out testing strategy which focused on developing reliable processes to collect and report test results and targeted education. An electronic health record–based automated reminder was designed to activate when a 5FU- or capecitabine-containing chemotherapy regimen was ordered for a patient without prior exposure to either agent and without a prior DPYD sequencing test result. DPYD testing was standardized across all sites of care, and a closed loop reporting system for abnormal test results was created. Before implementation, targeted education was provided to providers, pharmacists, and nurses, and a failure mode and effects analysis was performed. Program rollout was staged over a 6-month period. RESULTS At 10 months, the rate of preemptive testing increased from a baseline of 26% to a sustained rate of >90%. In the six network sites, the testing rate increased from 9% to 96%. A total of 1,043 patients have been tested preemptively; allelic variants have been identified in 43 (4.1%). Among 25 evaluable patients, dose reduction or change to a non–fluoropyrimidine-based regimen was accomplished in 96%. CONCLUSION Preemptive DPYD testing is feasible, and high rates of testing can be achieved using an opt-out, reminder-based program. We provide the details of the implementation and encourage others to emulate it.
11011 Background: Fellowship training is largely rooted in academic medical centers, though many graduates will ultimately pursue careers in community-based settings. We initiated a national survey of hematologists/oncologists practicing in community or academic-community hybrid settings to understand providers’ educational needs. We hypothesized that the current model of fellowship training is not optimized for those pursuing community-based hematology/oncology careers. Methods: An electronic questionnaire was developed surveying current attitudes and practices of community-based hematologists/oncologists. Survey participants from across the United States were contacted via professional organizations. We primarily assessed whether survey participants received any specific training during fellowship for community-based practice. Participants were also surveyed regarding whether such training may have affected their preparation. Relative risk (RR) and 95% confidence intervals (CI) were calculated using modified Poisson regression with robust error variance adjusted for: time in clinical practice ( < 10 years), size of graduating fellowship training program ( > 5), board certification (hematology and oncology vs. either), and training program geographic location (by region) to identify factors associated with receiving community oncology-specific training. Results: Of the preliminary cohort of 120 participants from across 25 states, 66% were male, 69% identified as White, and 69% had been in practice for > 10 years. Less than half (43.2%, binomial 95% CI 34.6%-52.2%) received any training for a career in a community-based setting. Participants identified rotations in community settings (48%), direct mentorship from community-based physicians (41%), and longitudinal clinic in a community setting (39%) as experiences that would have been valuable. Specific curricula of interest included: medical operations and administration (67%), health policy (38%), and quality improvement (30%). Respondents in clinical practice for < 10 years were more likely to have received any community oncology-specific training (RR 2.02, 95% CI 1.10–3.72); other factors were not significantly associated with the primary outcome (P > 0.05). Conclusions: National trends indicate a growing need for hematology/oncology graduates in community-based settings. Our study demonstrates substantial unmet needs as they relate to training fellows destined for careers in community-based practice. Prospective design of clinical training and curricula emphasizing longitudinal exposures to and key aspects of health care delivery in the community setting are paramount to achieving optimal, goal-concordant hematology and oncology training.
254 Background: Oral chemotherapy is becoming more widely utilized within oncology. Concerns regarding poor adherence and toxicity may be addressed by providing patient education. Methods: We developed and implemented a pharmacist-led initial education session for patients newly prescribed oral chemotherapy in both an academic medical center gastrointestinal oncology clinic and an affiliated community oncology cancer center. We provided an education packet including drug-specific information, clinic contact telephone numbers, and a drug schedule calendar. Standardized teaching and documentation templates were used. Patients completed each education session with the MOATT teaching tool for patients receiving Oral Agents for Cancer V1.2. Assessment of compliance with the ASCO/ONS Chemotherapy Administration Safety Standards on Oral Chemotherapy Education was assessed through use of Quality Oncology Practice Initiative (QOPI) quality measures where applicable and compared to historical QOPI data from the academic medical center from 2015-2017. Results: Thirty-one patients were newly prescribed oral chemotherapy and received the initial education session from November 2017 through May 2018. Based on a monthly report generated of new oral chemotherapy prescriptions, after a seven-month run-in, the rate reached 100% of patients at both sites for the most recent month. When comparing the intervention cohort to the historical QOPI cohort using a one-sided P value of 0.017 with bonferroni correction, there was improvement in safe handling/storage (pre: 19%, post 100%, P = 0.0001), drug-drug and food interactions (pre: 31%, post 100%, P = 0.0001), and plan for missed doses (pre: 37%, post: 97%, P = 0.0001). A trend toward improvement was found for schedule/start date discussion (pre: 87%, post: 100% P = 0.018) and side effect/toxicities (pre: 87%, post: 100% P = 0.018). Conclusions: Implementation of an oral chemotherapy education session in both an academic and community setting was feasible and improved adherence to QOPI measures of oral chemotherapy education and ASCO/ONS standards for oral chemotherapy. Further data regarding time to clinical outcomes is forthcoming.
Cytomegalovirus (CMV) is a major cause of infection-related morbidity and mortality in kidney transplantation. The most significant risk for developing CMV infection after transplant depends upon donor (D) and recipient (R) CMV serostatus. In 2012, our Organ Procurement Organization (OPO) began a novel pretransplant CMV prevention strategy via matching deceased kidney donors and recipients by CMV serostatus. Prior to the matching protocol, our distribution of seropositive and seronegative donors and recipients was similar to the United States at large. After the matching protocol, high-risk D+R- were reduced from 18.5% to 2.9%, whereas low-risk D-R- were increased from 13.5% to 24%. There was no adverse effect on transplant rates and no differential effect on waiting times for R+ vs R- after the protocol was implemented. This protocol could be implemented on a regional or national level to optimize low and high-risk CMV seroprofiles and potentially improve CMV-related outcomes in kidney transplantation.
