Lauren S. Prescott

Perioperative blood transfusion in gynecologic oncology surgery: Analysis of the National Surgical Quality Improvement Program Database

OBJECTIVE To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fishers exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay. RESULTS A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-2.24), surgical site infections (OR 1.80, 95% CI 1.39-2.35), mortality (OR 3.38, 95% CI 1.80-6.36) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001). CONCLUSIONS Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.

How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology

BACKGROUND Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.

Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients

OBJECTIVES To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. METHODS Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007-2011 were identified. Statistical analyses included Wilcoxon-Mann-Whitney, Chi-square analysis, and multivariate analysis. RESULTS 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378days prior to death, respectively. CONCLUSIONS Many ovarian cancer patients underwent some form of aggressive medical care in the last 30days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.

Fighting cancer together: Development and implementation of shared medical appointments to standardize and improve chemotherapy education

OBJECTIVE Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. METHODS We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. RESULTS From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. CONCLUSIONS This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.

Dying well: How equal is end of life care among gynecologic oncology patients?

OBJECTIVE To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients. METHODS This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fishers exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis. RESULTS Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007). CONCLUSIONS Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.

Improved compliance with venous thromboembolism pharmacologic prophylaxis for patients with gynecologic malignancies hospitalized for nonsurgical indications did not reduce venous thromboembolism incidence.

Objective National guidelines recommend prophylactic anticoagulation for all hospitalized patients with cancer to prevent hospital-acquired venous thromboembolism (VTE). However, adherence to these evidence-based recommended practice patterns remains low. We performed a quality improvement (QI) project to increase VTE pharmacologic prophylaxis rates among patients with gynecologic malignancies hospitalized for nonsurgical indications and evaluated the resulting effect on rates of development of VTE. Materials and Methods In June 2011, departmental VTE practice guidelines were implemented for patients with gynecologic malignancies who were hospitalized for nonsurgical indications. A standardized VTE prophylaxis module was added to the admission electronic order sets. Outcome measures included number of admissions receiving VTE pharmacologic prophylaxis within 24 hours of admission; and number of potentially preventable hospital-acquired VTEs diagnosed within 30 and 90 days of discharge. Outcomes were compared between a preguideline implementation cohort (n = 99), a postguideline implementation cohort (n = 127), and a sustainability cohort assessed 2 years after implementation (n = 109). Patients were excluded if upon admission they had a VTE, were considered low risk for VTE, or had a documented contraindication to pharmacologic prophylaxis. Results Administration of pharmacologic prophylaxis within 24 hours of admission increased from 20.8% to 88.2% immediately following the implementation of guidelines, but declined to 71.8% in our sustainability cohort (P < 0.001). There was no difference in VTE incidence among the 3 cohorts [n = 2 (4.2%) vs n = 3 (3.9%) vs n = 3 (4.2%), respectively; P = 1.00]. Conclusions Our QI project improved pharmacologic VTE prophylaxis rates. A small decrease in prophylaxis during the subsequent 2 years suggests a need for continued surveillance to optimize QI initiatives. Despite increased adherence to guidelines, VTE rates did not decline in this high-risk population.

The advance care planning readiness scale: Development and validation of a measure of willingness to discuss and acceptance of end-of-life care in gynecologic cancer patients

Objective The objective of this article was to develop and validate a scale that assesses the readiness of gynecologic oncology patients to engage in advance care planning. Methods The Advance Care Planning Readiness Scale (ACPRS) was validated across 3 independent samples of gynecologic oncology patients. In step I, patients underwent cognitive interviewing to determine if the scale items were comprehensible and applicable to patients. Based on this, modifications to the scale (addition, removal, and merger of items) were completed. In step II, the revised scale was administered to a new sample of patients to assess scale reliability and validity. An exploratory factor analysis determined if the scale loaded onto unique factors. In step III, the revised scale was administered to a third sample of patients, and a confirmatory factor analysis was conducted to test the factor structure proposed in step II. Associations between ACPRS score and completion of advance directives were evaluated. Results Based on patients’ responses, the original ACPRS used in step I was modified to the ACPRS used in step II. The final 8-item ACPRS is a valid, reliable (Cronbach &agr; = 0.81) scale and has 2 primary factors. Women with medical power of attorney documents and living wills had higher ACPRS total scores than those who did not have these advance directives (P = 0.0030). Women with do-not-resuscitate (DNR) orders had higher ACPRS total scores than women without DNRs (P = 0.0176). Conclusions The ACPRS is a valid and reliable 8-item scale that assesses the readiness of gynecologic oncology patients to discuss advance care planning issues.

Unusual indolent behavior of leiomyosarcoma of the vagina: Is observation a viable option?

Highlights • Primary leiomyosarcoma of the vagina is a rare disease.• We identified a case of unanticipated indolent behavior of vaginal leiomyosarcoma.• Observation or hormonal therapy may be viable option for select patients.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

Abstract Objective To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery. Methods We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematologys Choosing Wisely ® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost. Results We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P P P Conclusions Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

Transfusion utilization at the end of life.

303 Background: Both the AMAs Consortium for Performance Improvement and the Joint Commission have identified blood transfusions as one of the top 5 treatments that are over-utilized. We sought to quantify packed red blood cell transfusion (PRBT) utilization among ovarian cancer (OCa) pts in the last 6 months of life and identify risk factors for PRBT. METHODS We performed a retrospective cohort study of deceased OCa pts treated at our institution in their last 6 months of life from 2007-2011. Pts who underwent emergent procedures for bleeding were excluded. Demographic and end of life-interventions were compared between transfusion and non-transfusion groups using chi-squared and univariate analysis. End-of-life interventions included anti-cancer treatment (chemotherapy radiation, or hormonal therapy), invasive procedure or abdominal surgery, as well as aggressive end-of-life care as defined by the NQF. RESULTS Of the 182 pts who met inclusion criteria, 59.9% received a PRBT in the last 6 months of life. Of those pts, 54.1% received a PRBT in the last 30 days of life. Mean hgb level at which pts were transfused was 8.4 ± 0.9 g/dL. Pts received a combined total of 436 units of PRBC. The majority of pts received 1 transfusion (n=50, range 1-16). Mean number of total units transfused was 4 (range 1-25). The most common indication for PRBT was hgb < 9 g/dL (61.1%), followed by symptomatic anemia (21.9%). There was no difference in PRBT rate between pts who received medical interventions in the last 6 months of life v. those who did not. Specifically, transfusion rate was not correlated with: anti-cancer treatments (93.2% v. 92.7%, OR 0.93; 95% CI (0.29, 2.96)), invasive procedures (82.2% v. 81.7%, OR 0.96; CI (0.45,2.08)), abdominal surgery (11.0% v. 11.0%, OR 1.01; 95% CI(0.39,2.59)), or aggressive end-of-life care (46.6% v. 56.9%, OR 1.51; 95% CI (0.83,2.74)). CONCLUSIONS The majority of our pts received a PRBT in the last 6 months of life. We did not identify significant differences in clinical interventions between pts who received a PRBT and those who did not. Based on our analysis, transfusion practices in terminally ill OCa pts should be reevaluated. Creation of transfusion guidelines for cancer pts could potentially result in better utilization of blood bank resources.