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Jed A Gorden



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    MA02 - Improving Outcomes for Patients with Lung Cancer (ID 895)

    • Event: WCLC 2018
    • Type: Mini Oral Abstract Session
    • Track: Advanced NSCLC
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/24/2018, 10:30 - 12:00, Room 201 BD
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      MA02.02 - Multistate Healthcare Network Underutilizes Valuable End-of-Life Resources in Stage IV Non-Small Cell Lung Cancer (ID 13935)

      10:35 - 10:40  |  Author(s): Jed A Gorden

      • Abstract
      • Presentation
      • Slides

      Background

      Early implementation of outpatient palliative care (OPC) in stage IV non-small cell lung cancer (NSCLC) patients has been associated with increased survival, improved quality of life and reduction in unnecessary health care. However, medical systems have struggled with the adoption of end-of-life resources. We aimed to determine the utilization of OPC services in stage IV NSCLC patients within our multistate, community-based healthcare network.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      We reviewed 4,298 stage cIV NSCLC patients diagnosed between 1/2013-12/2017, in a community-based healthcare network encompassing 34 centers in Alaska, California, Montana, Oregon and Washington. We excluded 899 patients managed at 9 sites without OPC services, and 92 patients who received inpatient palliative care only. Eligible patients were stratified by whether or not they received OPC; then further by early OPC, which was defined as within 11 weeks of diagnosis. Survival was compared using Kaplan-Meier with log rank tests.

      4c3880bb027f159e801041b1021e88e8 Result

      Of the 3,307 patients reviewed, only 8% (252/3,307) received OPC and 6% (182/3,307) early OPC. Median time from diagnosis to death was significantly longer for OPC patients (347 days, 95% CI 273-421) versus no PC (151 days, 95% CI 138-164), p<0.001; and similarly for early OPC (216 days, 95% CI 167-265) versus no PC, p=0.008. Documentation of advance directive/living will/power of attorney was low in all categories, with rates of documentation at 32%, 31% and 27% for patients receiving OPC, early OPC and no OPC, respectively.

      figure iaslc days dx to death.png

      8eea62084ca7e541d918e823422bd82e Conclusion

      We identified that OPC services are broadly underutilized in stage cIV NSCLC patients across our multistate, community-based healthcare network. In addition, end-of-life documents were rarely completed in all clinical settings regardless of OPC. We confirmed prolonged survival associated with OPC in the community setting, but greater utilization is required to increase this benefit. These findings, as well as the additional benefits/value of OPC, require further study.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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    P2.01 - Advanced NSCLC (Not CME Accredited Session) (ID 950)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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      P2.01-80 - Performance Status and Resource Utilization in Patients Receiving Palliaitve Care with Stage IV Non-Small Cell Lung Cancer (ID 11323)

      16:45 - 18:00  |  Author(s): Jed A Gorden

      • Abstract
      • Slides

      Background

      Palliative care (PC) services assist with the end-of-life needs of patients with advanced cancer; and clinical trials have associated early implementation of outpatient PC with increased survival, improved quality of life and reduction in healthcare utilization in stage IV non-small cell lung cancer (NSCLC). However, these studies only included patients with Eastern Cooperative Oncology Group (ECOG) performance status scores of 2 or less, which does not fully represent the spectrum of patients with stage IV NSCLC. The National Quality Forum (NQF) endorses metrics to measure quality and aggressiveness of end-of-life care. We aimed to determine the overall utilization of PC and the performance status of patients receiving outpatient versus inpatient PC and their resource utilization based on the NQF elements.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      We reviewed patients diagnosed with cIV NSCLC between 6/1/2013-6/1/2017, managed at 7 sites with access to dedicated PC services. Patients were initially categorized by whether or not they received PC consultation, and then further stratified into outpatient and inpatient PC.

      4c3880bb027f159e801041b1021e88e8 Result

      We analyzed 445 patients, of which 19% (86/445) received a PC consultation. Of the 86 patients receiving PC, 47% (40/86) were outpatient and 53% (46/86) were inpatient. Median (25th-75th interquartile range) ECOG scores at PC consultation were 1 (1-3) and 4 (3-4) for outpatient and inpatient PC, respectfully (p<0.001). The NQF’s endorsed data elements for each group are shown in the figure.

      iaslc 2018 nqf.png

      8eea62084ca7e541d918e823422bd82e Conclusion

      Patients receiving inpatient PC had a significantly worse performance status with higher emergency department and intensive care unit usage than outpatient PC, suggesting inpatient PC accesses a different, sicker population with greater clinical needs. Comprehensive multidisciplinary initiatives focused on increased outpatient PC utilization and targeting the NQF metrics of quality and resource utilization are needed.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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    P2.11 - Screening and Early Detection (Not CME Accredited Session) (ID 960)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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      P2.11-21 - Factors Predicting Attrition in Community-Based Healthcare Network Lung Cancer Screening Programs (ID 13952)

      16:45 - 18:00  |  Author(s): Jed A Gorden

      • Abstract
      • Slides

      Background

      Since publication of the National Lung Screening Trial, the national focus has been on implementation of Lung Cancer Screening Programs (LCSPs). However, lung cancer screening (LCS) is a continuum where the benefits are derived from long-term engagement and, to date, little is known about attrition in LCS. We aimed to identify the rate of attrition within two of our healthcare network, community-based LCSPs and identify the factors predictive of attrition.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      We reviewed 2364 individuals who underwent LCS within two of our healthcare network LCSPs from 01/01/2012-03/31/2017. One LCSP is centralized (shared decision making/evaluation/management at a single site) and the other is decentralized (shared decision making/evaluation/management occur in geographically diverse community care settings with support from a central LCSP coordinator). Attrition was defined as declining further screening or lost to follow-up. Continuous data reported as median and 25th-75th interquartile range, and univariate/multivariable logistic regression analyses was performed to identify predictors of attrition.

      4c3880bb027f159e801041b1021e88e8 Result

      We identified an attrition rate of 15% (351/2364) with median time to attrition of 15 (12-20) months. Patients who underwent attrition tended to be younger [62 (58-67) versus 65 (60-69) years, p<0.001], smoking on first visit (61% versus 55%, p=0.05), in the decentralized program (74% versus 67%, p=0.01), and less likely to have a nodule on first CT scan (48% versus 64%, p<0.001). Multivariable logistic regression demonstrated a younger age, decentralized program type, and the absence of a nodule on first CT scan to be significant predictors of attrition (p<0.05) [Table].

      Predictors of Attrition
      UNIVARIATE ANALYSIS
      Characteristic Odds Ratio Lower 95% C. I. Upper 95% C. I. P Value
      Age, years 0.95 0.93 0.97 <0.001
      Gender
      Female
      Male 0.88 0.70 1.11 0.29
      Race
      White
      Black 1.19 0.68 2.06 0.54
      Native Hawaiian/Asian 1.74 1.03 2.95 0.04
      American Indian 0.49 0.12 2.08 0.33
      Declined/Other 0.97 0.58 1.62 0.90
      Smoking Status on 1st Visit
      Former
      Current 1.28 1.01 1.61 0.04
      Distance to CT scan, miles 1.00 1.00 1.00 0.70
      Program
      Centralized
      Decentralized 1.41 1.09 1.82 0.01
      Nodule on 1st CT scan
      No
      Yes 0.53 0.42 0.67 <0.001
      Nodule Size on 1st CT scan 0.99 0.97 1.02 0.53
      MULTIVARIABLE ANALYSIS
      Characteristic Odds Ratio Lower 95% C. I. Upper 95% C. I. P value
      Age, years 0.96 0.94 0.98 <0.001
      Program
      Centralized
      Decentralized 1.37 1.04 1.79 0.02
      Nodule on 1st CT scan
      No
      Yes 0.58 0.46 0.73 <0.001

      8eea62084ca7e541d918e823422bd82e Conclusion

      Overall attrition is low at 15%. Factors that correlated with failure to follow-up were young age, active smoking, being in a decentralized program, and lack of nodule on first scan. Ongoing efforts are necessary to ensure that screening is a continuum, particularly in populations of individuals at high-risk of attrition.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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