263 INFORMING INTERVENTION DESIGN IN COGNITIVELY IMPAIRED POPULATIONS: LESSONS LEARNED FROM THE OPTIMIZE DEPRESCRIBING INTERVENTION

Background

Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions increasing their risks of adverse drug events, hospitalization, further cognitive decline and death and leading to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes. The OPTIMIZE trial examined whether educating and activating patients, family and clinicians about deprescribing reduces number of medications for older adults with cognitive impairment and multiple chronic conditions. Acceptability and challenges of intervention delivery in this vulnerable population are not well understood.

Methods

We explored mechanisms of intervention effectiveness through post hoc qualitative interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. We assessed accessibility and delivery of materials as well as the ability of the materials to facilitate conversations and influence decisions around deprescribing.

Results

Acceptance of the intervention was affected by contextual factors including cognition and prior knowledge of deprescribing. Positive effects of the intervention included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials by patients was inconsistent but highest shortly after intervention delivery. Short clinic visit times remained the largest clinician barrier to deprescribing.

Conclusion

Our work identifies key learnings in intervention roll out which can guide future scaling of our intervention and other pragmatic deprescribing intervention studies in patients with cognitive impairment. We highlight the critical roles of both timing and repetition in intervention delivery to cognitively impaired populations as well as the barrier to deprescribing posed by short clinic consultation time. Our success in activating deprescribing conversations in this population highlights the need to incentivize medical professionals and health systems to incorporate deprescribing into routine clinical practice and expand proven interventions to other vulnerable populations.

The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial

Background

Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI.

Methods

With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions.

Discussion

The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC.

Trial registration

NCT03984396. Registered on 13 June 2019

Abstract P6-02-02: Increased interval cancers after the 2009 U.S. preventive services task force guidelines: A single-center, retrospective analysis

Background: In late 2009, the U.S. Preventive Services Task Force (USPSTF) increased the recommended time between screening mammography from one year to two years. We examined the effect of USPSTF recommendations in an integrated safety-net system whose patients often have intermittent access to care. The purpose of this study was to determine if changes in screening guidelines were associated with stage migration or changes in rate of interval cancers.

Methods: We conducted a retrospective cohort analysis of breast cancer patients diagnosed between 2005-2013 at one safety-net hospital. We abstracted stage at diagnosis, time intervals between screening and diagnostic imaging, as well as BIRADS classification from clinical and administrative billing data. We divided patients into two cohorts: Those diagnosed with breast cancer "pre-2010" (2005 – 2010) and "post-2010" (2011-2013). We compared stage of diagnosis between cohorts using Chi-Square tests. In a subset of patients for whom we had prior screening imaging information, we determined the rate of interval cancers. Interval cancers were defined as patients whose diagnosis occurred within 14 months (pre-2010) or within 26 months (post-2010) of normal screening mammography. Logistic regression was used to determine the unadjusted odds of interval cancer as a function of being post-2010 versus pre-2010.

Results: There were 521 unique, breast cancer patients between 2005-2013,

Distribution of Breast Cancer by Stage Stage 0Stage IStage IIStage IIIStage IVTotal2005-200941816142242492010-20134679824421272

249 in the 'pre-2010' cohort, and 272 in the 'post-2010' cohort. In the 2005-2009 cohort, 32.5% and 24.5% of patients were stage I and Stage II respectively. In 2010-2013, 29.0% and 30% were stage I and stage II, respectively. The difference in stage at diagnosis was not statistically significant (p=0.62). In a subset of 178 patients with available screening imaging data, we determined the rate of interval cancers. Pre-2010, 7.4% (8/108) of patients had an interval cancer. Post-2010, 20% (14/70) patients had an interval cancer. Patients diagnosed post-2010 had three times the odds of having an interval cancer compared to pre-2010 patients (OR = 3.13, 95% CI 1.24-7.91, p=0.01).

Discussion: The USPSTF 2009 recommendation is associated with a statistically significant increase in interval cancers in a safety-net population, but we cannot conclude that this contributes to stage migration in this limited population. Investigation of larger groups is needed to further assess how USPSTF guidelines affect outcomes in underserved populations.

Citation Format: Townsend NT, Everhart RM, Bayliss EA, Jaiswal K. Increased interval cancers after the 2009 U.S. preventive services task force guidelines: A single-center, retrospective analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-02.

Abstract P6-12-03: Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile

Background: Timely detection and treatment of breast cancer patients is important in survival and recurrence. Given disparities in breast cancer outcomes based on socioeconomic status, we examined the time to diagnosis and treatment in a safety net hospital.

Methods: We conducted a retrospective review of all breast cancer patients identified by cancer registry records from 7/1/2010 to 6/30/2012 (n=124). We excluded patients with primary stage IV (n=8) and those with recurrent breast cancer within 5 years of primary diagnosis (n=4). We determined intervals between presentation to diagnosis, diagnosis to first treatment, last surgery to chemotherapy start, and last surgery to radiation start. We used logistic regression to calculate unadjusted odds of receiving timely treatment (&lt; median time) versus more delayed treatment (≥ median time) as a function of age, language, ethnicity, insurance, Charlson co-morbidity index, cancer stage, method of first presentation (screening mammography vs. care provider), symptoms at presentation, and type of surgical treatment.

Results: Of 112 patients, the median age was 59. 42.9% were Hispanic, 29.5% were White, and 24.1% were African American. Clinical stage distribution was 20.0% stage 0, 31.8% stage I, 40.9% stage II, and 8% stage III. 83.9% of patients had surgery, of which 51.1% had breast conservation. The median time from presentation to diagnosis, time from diagnosis to first treatment, and time from surgery to chemotherapy start, fell within recommended intervals (Table 1). The time from last surgery to radiation start was greater than recommended intervals. Variables with significantly increased odds of taking longer than the median time include: stage, method of presentation, language, Charlson index, surgical treatment, ethnicity, symptoms at presentation (Table 2).

Conclusion: Acceptable diagnosis and treatment intervals were obtained for disadvantaged patients, except for time to radiation therapy. Room for improvement exists: focused interventions to facilitate access to radiation therapy, aid providers in accessing imaging more quickly, aid non-English speaking and Hispanic patients could lead to improved breast cancer care.

Table 1. Intervals of CareMeasure: Time From...Median (days)25th, 75th % (days)Recommended Intervals (days)Presentation to Diagnosis197, 4360Diagnosis to 1st Treatment3730, 4821-60Presentation to 1st Treatment6247, 83n/aLast Surgery to Chemo Start4831, 5928-90Last Surgery to Radiation Start*6853,7942-56* for patients needing surgery and radiation only

Table 2. Un-adjusted Odds Ratio of Taking Longer than Median TimeIntervalVariableReferenceO.R.p-valuePresentation to DiagnosisStage II or IIIStage 0 or I2.880.008 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram4.270.0004Diagnosis to First TreatmentAge&lt; 55Age ≥ 552.180.070 English-speakingNon-English speaking0.220.005 Charlson Index ≥ 3Charlson Index &lt;30.420.040 Symptomatic PresentationAsymptomatic Presentation2.830.040 Breast ConservationMastectomy2.840.020Presentation to First TreatmentHispanicNon-Hispanic2.650.022 Charlson Index ≥ 3Charlson Index &lt;30.520.120 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram3.160.008

Citation Format: Jaiswal KR, Furniss A, Doyle R, Gayou N, Bayliss EA. Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-03.

Observation versus late reintroduction of letrozole as adjuvant endocrine therapy for hormone receptor-positive breast cancer (ANZ0501 LATER): an open-label randomised, controlled trial

BACKGROUND

Despite the effectiveness of adjuvant endocrine therapy in preventing breast cancer recurrence, breast cancer events continue at a high rate for at least 10 years after completion of therapy.

PATIENTS AND METHODS

This randomised open label phase III trial recruited postmenopausal women from 29 Australian and New Zealand sites, with hormone receptor-positive early breast cancer, who had completed ≥4 years of endocrine therapy [aromatase inhibitor (AI), tamoxifen, ovarian suppression, or sequential combination] ≥1 year prior, to oral letrozole 2.5 mg daily for 5 years, or observation. Treatment allocation was by central computerised randomisation, stratified by institution, axillary node status and prior endocrine therapy. The primary outcome was invasive breast cancer events (new invasive primary, local, regional or distant recurrence, or contralateral breast cancer), analysed by intention to treat. The secondary outcomes were disease-free survival (DFS), overall survival, and safety.

RESULTS

Between 16 May 2007 and 14 March 2012, 181 patients were randomised to letrozole and 179 to observation (median age 64.3 years). Endocrine therapy was completed at a median of 2.6 years before randomisation, and 47.5% had tumours of >2 cm and/or node positive. At 3.9 years median follow-up (interquartile range 3.1-4.8), 2 patients assigned letrozole (1.1%) and 17 patients assigned observation (9.5%) had experienced an invasive breast cancer event (difference 8.4%, 95% confidence interval 3.8% to 13.0%, log-rank test P = 0.0004). Twenty-four patients (13.4%) in the observation and 14 (7.7%) in the letrozole arm experienced a DFS event (log-rank P = 0.067). Adverse events linked to oestrogen depletion, but not serious adverse events, were more common with letrozole.

CONCLUSION

These results should be considered exploratory, but lend weight to emerging data supporting longer duration endocrine therapy for hormone receptor-positive breast cancer, and offer insight into reintroduction of AI therapy.

CLINICAL TRIALS NUMBER

Australian New Zealand Clinical Trials Registry (www.anzctr.org.au), ACTRN12607000137493.

Supporting self-management for patients with complex medical needs: recommendations of a working group

Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.

Hepatic concentrations of zinc, copper and manganese in infants with extrahepatic biliary atresia

The objective of this study was to determine the concentration of Zinc (Zn), Copper (Cu) and Manganese (Mn) in hepatic tissue from extrahepatic biliary atresia (EHBA). Liver biopsy samples were obtained at time of portoenterostomy from 49 infants ages 1.1 to 20.7 months (median 2.1) with EHBA. Samples were dry ashed and analyzed by flame (Zn) or flameless (Cu and Mn) atomic absorption spectrophotometry. Hepatic Cu concentrations are physiologically elevated at birth and decline rapidly during the first 2 month of life, therefore only samples from 29 infants, ages greater than 8 weeks were considered for Cu. Concentrations (mg/kg dry weight, mean and range) were: Zn 142 (70-507), Cu 204 (19-570), Mn 9.1 (2.8-21.8) vs. literature controls in the same age range: Zn 262 (82-543), Cu 92, Mn 4.3 (3.3-11.5). No correlations were found between serum alkaline phosphatase, AST or total bilirubin and hepatic trace element concentrations, between trace element concentrations and age, or between Cu and Mn. Decreased bile flow with intrahepatic cholestasis may result in hepatic accumulation of Mn as well as Cu. The low hepatic Zn concentrations indicate the need for further study of Zn metabolism in this population.

Thyroid involvement in multiple myeloma

Involvement of the thyroid gland by plasma cell neoplasms is a rare occurrence. Two modes of presentation are described; firstly as part of disseminated myeloma and secondly, as an isolated plasma cell neoplasm of the thyroid as the only evidence of disease. We wish to describe two cases of thyroid involvement as part of disseminated disease.

Spinal-cord syndrome due to non-compressive Paget's disease of bone: a spinal-artery steal phenomenon reversible with calcitonin

A 76-year-old man had progressive low back pain, leg weakness, and sensory loss. Radiology showed changes consistent with wide-spread Paget's disease, but no cord compression or involvement of nerve roots was detected by myelography or computerised axial tomography. His symptoms were relieved within 12 days of starting 100 MRC units of subcutaneous salmon calcitonin and recurred when calcitonin was discontinued for 5 days. The improvement continued on calcitonin treatment for 1 year, with falls in serum alkaline phosphatase and urinary hydroxyproline excretion. It is suggested that calcitonin treatment, in reducing the abnormally high metabolic activity of the diseased bone, and hence its vascular perfusion, allows more blood to reach the spinal cord.