Differences in Radiotherapy-Treated Members with Cancer during COVID-19 Pandemic Using Nationwide Claim Data

PURPOSE/OBJECTIVE(S)

This study aimed to identify the impact of the pandemic on radiotherapy activity among members with cancer.

MATERIALS/METHODS

This retrospective study included fully-insured commercial members of a large national payor with cancer aged ≥18 years undergoing radiotherapy from March 1, 2018 to February 28, 2022. Radiotherapy activity was defined as the mean weekly number of treatment courses and attendances (fractions) per month pre-COVID (March 2018 to February 2020); during COVID (March 2020 to February 2021); and post-COVID (March 2021 to February 2022). T-tests assessed differences between pre-COVID and post-COVID on radiotherapy activity by age, gender, and cancer type. Interrupted time series analysis (ITS) assessed change in activity overtime, controlling for pre-COVID trends and other potential confounders. A p-value of <0.05 was considered significant.

RESULTS

The study included 9,275 members, 10,121 courses, and 169,257 fractions; most members were female (57%), the mean age was 57 years (SD = 12). Overall, there was a decline in mean weekly number of courses from the pre-COVID to post-COVID (-18%, p<0.05) timeframe. Females < 70 years experienced the largest decline in mean weekly number of courses (-23%, p<0.05) followed by males aged 70+ (-16%, p<0.05) and males < 70 years (-16%, p<0.05). All cancer types saw a significant decline (p<0.05); breast cancer reported the largest decline (-21%, p<0.05). Fraction numbers significantly declined overall by 27% (p<0.05) from the pre-COVID to post-COVID timeframe. The largest decline in fraction numbers was observed in females < 70 (-28%, p<0.05) followed by males < 70 years (-24%, p<0.05) and males aged 70+ (-22%, p<0.05). No difference between COVID and pre-COVID weeks for courses was observed once pre-COVID trends were accounted for using ITS. Females aged 70+ received 25% (p<0.05) fewer fractions during COVID compared to pre-COVID; a decline which continued to grow even as the pandemic eased (March 2021 to February 2022). Males aged 70+ also experienced a decreased level of fractions during the pandemic (-30%, p<0.05), but increased in the recovery period (+24%, p<0.05). Males < 70 years had an increased level of fractions during the pandemic (+14%, p<0.05).

CONCLUSION

Radiation mean weekly number of courses and fractions between pre-COVID and post-COVID declined with the effect more pronounced in females < 70 years. A decrease in fraction number was observed in all cancer types; specifically, breast cancer had the largest decline. ITS analysis revealed no difference between COVID and pre-COVID weeks for courses as the downward trend was already present prior to the pandemic. These findings suggest while radiotherapy courses and fractions were significantly impacted, fractionation was decreased to a greater extent, indicating an increased adoption of hypofractionation during the pandemic.

Saxitoxin Exposure Confirmed by Human Urine and Food Analysis

A case of an elderly female with suspected paralytic shellfish poisoning (PSP) is presented. The patient shared a meal of recreationally-harvested shellfish with her family and soon began to experience nausea and weakness. She was taken to the local emergency department and then transported to a larger hospital in Anchorage where she was admitted to the intensive care unit with respiratory depression and shock. Her condition improved, and she was discharged from the hospital 6 days later. No others who shared the meal reported symptoms of PSP. A clam remaining from the meal was collected and analyzed for paralytic shellfish toxins (PST) by the Alaska Department of Environmental Conservation Environmental Health Laboratory; the clam tested positive for saxitoxin (STX; 277 μg/100 g), neosaxitoxin (NEO; 309 μg/100 g), multiple gonyautoxins (GTX; 576-2490 μg/100 g), decarbamoyl congeners (7.52-11.3 μg/100 g) and C-toxins (10.8-221 μg/100 g) using high-pressure liquid chromatography with post-column oxidation (AOAC Method 2011.02). Urine from the patient was submitted to Centers for Disease Control for analysis of selected PSTs and creatinine. STX (64.0 μg/g-creatinine), NEO (60.0 μg/g-creatinine) and GTX1-4 (492-4780 μg/g-creatinine) were identified in the urine using online solid phase extraction with HPLC and tandem mass spectrometry. This was the first time GTX were identified in urine of a PSP case from Alaska, highlighting the need to include all STX congeners in testing to protect the public's health through a better understand of PST toxicity, monitoring and prevention of exposures.

PCR typing of tetracycline resistance determinants (Tet A-E) in Salmonella enterica serotype Hadar and in the microbial community of activated sludges from hospital and urban wastewater treatment facilities in Belgium

The distribution of tetracycline resistance determinants Tet A-E was studied by PCR in 40 tetracycline-resistant Salmonella enterica serotype Hadar (S. hadar) isolates collected from human patients in 1996 and 1997, as well as in the microbial community originating from activated sludges of hospital and urban wastewater treatment facilities. A fast DNA extraction and purification method from activated sludges was used to provide amplifiable DNA. The method is based on the direct lysis of bacteria improved by bead-beating followed by DNA purification on polyvinylpolypyrrolidone spin columns to remove PCR inhibitors. The purified DNAs from salmonellae and activated sludges were characterized for the presence of tetracycline determinants with specific primer pairs designed on the basis of published sequences. The Tet A determinant was present in all clinical isolates and DNAs extracted from the bacterial community of the selected activated sludges. The Tet C determinant was identified in only one of the 40 clinical isolates and in six of the seven environmental samples. No signal was detected for Tet B, D and E determinants. This study revealed a high and stable prevalence of the Tet A determinant in both salmonellae clinical isolates and the microbial community of activated sludges from hospital and urban wastewater treatment facilities over a 2-year period.

The effect of patient size and dose of recombinant human erythropoietin therapy on red blood cell volume expansion in autologous blood donors for elective orthopedic operation

BACKGROUND

Recombinant human erythropoietin (EPO) therapy has been known to enhance erythropoiesis and facilitate autologous blood donation before elective orthopedic operations. However, the optimal EPO dose in this setting remains undefined. To help determine this, we have examined the effect of patient weight and EPO dose on red blood cell (RBC) volume expansion.

STUDY DESIGN

Forty-six nonanemic autologous blood donors enrolled at our institution in two previously reported multicenter clinical trials were analyzed. Patients received either placebo or EPO (150, 300, or 600 units [U] per kg) given intravenously at each of six AB blood type donation visits.

RESULTS

Total preoperative RBC volume expansion over a 22 day period was 465 +/- 135 mL (mean +/- SD) in patients receiving a placebo and 588 +/- 201 mL, 735 +/- 144 mL, and 881 +/- 292 mL in patients receiving graded concentrations of EPO. When RBC volume increase was corrected for patient weight and EPO dose, patients receiving placebo or EPO (150, 300, and 600 U per kg) expanded RBC volume by 5.9 mL per kg in patients receiving placebo and 7.9, 9.1, and 10.9 mL per kg in patients receiving EPO, respectively (p < 0.02 for each EPO group compared with placebo group). A direct relationship between EPO dose and RBC volume increase (response) over 22 days was determined by the linear regression equation: RBC volume (mL per kg) = 6.34 + 0.0013X, r = 0.98, where X equals total units EPO administered (per kg body weight).

CONCLUSIONS

We conclude that EPO dose can be based on anticipated blood losses and transfusion needs in autologous blood donors before orthopedic operation.

Has recombinant human erythropoietin therapy minimized red-cell transfusions in hemodialysis patients?

We have conducted a six-year (1986-1991) review of our transfusion service to identify the frequency of blood transfusions in patients undergoing chronic hemodialysis, before and after availability of recombinant human erythropoietin (EPO) as an alternative to allogeneic blood. Four hundred forty-nine patients who underwent a total of 54,929 dialysis events were reviewed. Overall, 343 (76%) of 449 patients received 4,864 red-cell transfusions during 54,929 dialysis events. Red-cell units transfused per patient were significantly lower in 1991 compared to the year (1988) prior to EPO (5.3 +/- 4.5, M+SD, vs 8.6 +/- 13.4, p = 0.02) but not compared to 1986 (6.4, p = 0.11). The frequency of red-cell transfusions per 100 dialysis events declined substantially when 1991 was compared to 1988 (4.11 vs 13.35, p < 0.01) but less so when 1991 was compared to 1986 (4.11 vs 6.20, p < 0.01). Overall, 4864 red-cell units transfused to dialysis patients accounted for 4.46% of 109,159 red-cell units released by our transfusion service, decreasing from 7.3% in 1988 to 2.0% in 1991. We conclude 1) the availability of EPO in 1989 was accompanied by a significant reduction in the frequency of red-cell exposure in patients undergoing dialysis from 1988, but the reduction was less impressive when compared to 1986. 2) Attention to EPO dosage, concomitant causes of anemia, and resistance to EPO therapy in this setting may be required to take full advantage of this biotechnologic alternative to blood transfusion.

The impact of autologous blood ordering and blood procurement practices on allogeneic blood exposure in elective orthopedic surgery patients

The contribution of autologous blood ordering and blood procurement practices on subsequent allogeneic blood exposure in elective orthopedic surgery must be understood to address the role of aggressive autologous blood procurement in blood conservation strategies. The authors examined the relationship between autologous blood ordering, blood collection, and subsequent allogeneic blood transfusion in orthopedic surgical patients. Of 263 consecutive autologous blood donors reviewed, 179 (68%) successfully donated the number of units requested (blood ordering cohort). Of these, 17 (9.5%) received allogenic blood. Of 84 patients unable to donate the units requested, 23 (27%) received allogeneic blood (blood procurement cohort). Allogeneic blood exposure in the blood ordering cohort occurred at the same prevalence for patients asked to donate < or = 3 units or > or = 4 units (10[6.8%] of 146 patients and 7[6%] of 116 patients, respectively). In contrast, only 3 (2%) of 146 patients asked to donate < or = 3 units received allogeneic blood in the blood procurement cohort, compared with 20 (17%) of 116 patients asked to donate > or = 4 units (P < .01). The greatest prevalence of allogeneic blood exposure occurred in 13 (35%) of 37 anemic (hematocrit level 39% at first donation) patients in the blood procurement cohort who could not donate > or = 4 units as requested. The study indicated that both blood ordering and blood procurement practices in autologous blood donation programs are important factors in blood conservation efforts to minimize allogeneic blood exposure.

Blood transfusions in hip fracture patients: implications for blood conservation programs

To address the potential role of innovative blood conservation interventions in nonelective surgery, we reviewed blood transfusions and blood losses during hospitalization of patients undergoing open reduction internal fixation of an intratrochanteric hip fracture. Sixty-four orthopaedic patients consecutively admitted over a 3-year interval were analyzed for transfusion needs by calculating red blood cell (RBC) volume lost during hospitalization. Overall, 39 (61%) patients received blood. We found that the "transfusion-trigger" was higher for females compared to males. Fifteen (23%) of 64 patients were identified to have been transfused with RBC volumes in excess of RBC volumes lost. The remaining 49 patients determined to be untransfused or to be transfused appropriately received 1.4 +/- 2.1 blood units (M +/- SD). Of these, 30 (60%) received < or = 1 U. We found no evidence that patients who received blood transfusions in excess of blood losses benefited compared to those whose blood replacement was less than blood lost. We conclude that innovative blood conservation interventions such as recombinant human erythropoietin (EPO) therapy can be incorporated into this nonelective surgical setting and may permit a significant percentage of hip fracture patients to avoid homologous blood transfusion. An algorithm for physician education programs that can address blood transfusion practices is provided so that patients can benefit from new blood conservation approaches.

Identifying elective orthopedic surgical patients transfused with amounts of blood in excess of need: the transfusion trigger revisited

The discharge hematocrit has been analyzed as a clinical indicator of the transfusion trigger by which to identify patients undergoing elective orthopedic surgery who were transfused with blood in excess of need. The volume of red cells lost by each patient during surgical hospitalization was compared to the volume of red cells transfused. Three clinical indicator levels were considered. Red cell losses of 10, 20, and 30 percent of each patient's baseline red cell volume at admission were considered to be appropriate before subsequent blood transfusion replacement, representing generous, intermediate, or strict clinical indicator levels, respectively. With Level I as a generous clinical indicator, 110 (25%) of 525 patients were transfused in excess of blood needs; by Level II (intermediate) and Level III (strict) criteria, 221 (42%) and 314 (60%) of 525 patients, respectively, were transfused in excess of blood needs. Significant differences were found for transfused patients analyzed by gender (26% of women vs. 13% of men; Level I, p less than 0.001) and preoperative autologous blood donation (25% of autologous blood donors vs. 11% of those who did not donate autologous blood; Level I, p less than 0.001). It can be concluded that the discharge hematocrit and amount of blood lost during hospitalization can be used as clinical indicators with which to identify patients receiving transfusions in excess of needs in the elective surgical setting. With this method, it was found that the transfusion trigger is different for women and for men as well as for autologous blood donors and those who did not donate autologous blood undergoing elective orthopedic surgery [corrected].