VHA-Wide Automated Assessment of EGFR Mutation Testing in Advanced Stage, Non-Squamous, Non-Small Cell Lung Cancer (nsNSCLC)

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Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.

Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.

Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.

Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.

Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.

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Correspondence: Jennifer Smith (jennifer.smith11436b@va.gov)

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Correspondence: Jennifer Smith (jennifer.smith11436b@va.gov)

Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.

Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.

Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.

Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.

Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.

Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.

Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.

Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.

Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.

Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.

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Safety of Nivolumab: A Medication Use Evaluation

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Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

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Correspondence: Emily Weigand (emily.weigand@va.gov)

Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

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Use of the Community Needs Assessment (CNA) to Identify Barriers and Improve Access to Cancer Care for Veterans

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Abstract 31: 2016 AVAHO Meeting

Purpose: To disseminate information regarding The American College of Surgeons Commission on Cancer (ACOS COC) requirements of Patient Navigation that can be used across VAMCs.

Background: The ACOS COC requires that each facility determine a patient navigation process. The process must focus on a barrier to care identified within a Community Needs Assessment (CNA) that is administered at least every 3 years. From the results of the CNA, a patient navigation process can be developed to address patient, provider, or system barriers to care. These results are also presented to the Cancer Committee (CC) to compile a report summarizing the findings and implementing a plan to improve the quality of cancer care delivered.

Methods: A CNA questionnaire was reviewed by an interdisciplinary group consisting of oncology social worker, oncology psychologist, medical oncologist, survivorship advanced practice nurse, 3 oncology nurse care coordinators and the Cancer Center Program Administrator. The questionnaire was formatted for ease of reading and comprehension. The group presented the CNA questionnaire to the CC for review and approval. The questionnaire was distributed and completed by Veteran’s at varying stages along the cancer trajectory.

Data Analysis: The questionnaire was distributed and completed by 50 Veterans from Feb 2014-Sept 2014. The questionnaires were distributed and collected in the chemotherapy infusion clinic, during outpatient clinic visits, and during the Louis Stokes Cleveland VAMC (LSCVAMC) annual Cancer Fair.

Results: The top rated concern was found to be travel. According the National Cancer Data Base (NCDB) generated in May 2015 shows that from the years of 2007-2012, 34% of Veterans receiving their care at the LSCVAMC traveled between 50-99 miles to receive their cancer care. The data were presented to the CC, and plans were made to further look at travel resources and community services available to our Veterans. A comprehensive report addressing resources was compiled and presented to the CC.

Implications: Identifying and breaking down barriers to transportation is vital to improving access to Veteran’s cancer care.

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Abstract 31: 2016 AVAHO Meeting
Abstract 31: 2016 AVAHO Meeting

Purpose: To disseminate information regarding The American College of Surgeons Commission on Cancer (ACOS COC) requirements of Patient Navigation that can be used across VAMCs.

Background: The ACOS COC requires that each facility determine a patient navigation process. The process must focus on a barrier to care identified within a Community Needs Assessment (CNA) that is administered at least every 3 years. From the results of the CNA, a patient navigation process can be developed to address patient, provider, or system barriers to care. These results are also presented to the Cancer Committee (CC) to compile a report summarizing the findings and implementing a plan to improve the quality of cancer care delivered.

Methods: A CNA questionnaire was reviewed by an interdisciplinary group consisting of oncology social worker, oncology psychologist, medical oncologist, survivorship advanced practice nurse, 3 oncology nurse care coordinators and the Cancer Center Program Administrator. The questionnaire was formatted for ease of reading and comprehension. The group presented the CNA questionnaire to the CC for review and approval. The questionnaire was distributed and completed by Veteran’s at varying stages along the cancer trajectory.

Data Analysis: The questionnaire was distributed and completed by 50 Veterans from Feb 2014-Sept 2014. The questionnaires were distributed and collected in the chemotherapy infusion clinic, during outpatient clinic visits, and during the Louis Stokes Cleveland VAMC (LSCVAMC) annual Cancer Fair.

Results: The top rated concern was found to be travel. According the National Cancer Data Base (NCDB) generated in May 2015 shows that from the years of 2007-2012, 34% of Veterans receiving their care at the LSCVAMC traveled between 50-99 miles to receive their cancer care. The data were presented to the CC, and plans were made to further look at travel resources and community services available to our Veterans. A comprehensive report addressing resources was compiled and presented to the CC.

Implications: Identifying and breaking down barriers to transportation is vital to improving access to Veteran’s cancer care.

Purpose: To disseminate information regarding The American College of Surgeons Commission on Cancer (ACOS COC) requirements of Patient Navigation that can be used across VAMCs.

Background: The ACOS COC requires that each facility determine a patient navigation process. The process must focus on a barrier to care identified within a Community Needs Assessment (CNA) that is administered at least every 3 years. From the results of the CNA, a patient navigation process can be developed to address patient, provider, or system barriers to care. These results are also presented to the Cancer Committee (CC) to compile a report summarizing the findings and implementing a plan to improve the quality of cancer care delivered.

Methods: A CNA questionnaire was reviewed by an interdisciplinary group consisting of oncology social worker, oncology psychologist, medical oncologist, survivorship advanced practice nurse, 3 oncology nurse care coordinators and the Cancer Center Program Administrator. The questionnaire was formatted for ease of reading and comprehension. The group presented the CNA questionnaire to the CC for review and approval. The questionnaire was distributed and completed by Veteran’s at varying stages along the cancer trajectory.

Data Analysis: The questionnaire was distributed and completed by 50 Veterans from Feb 2014-Sept 2014. The questionnaires were distributed and collected in the chemotherapy infusion clinic, during outpatient clinic visits, and during the Louis Stokes Cleveland VAMC (LSCVAMC) annual Cancer Fair.

Results: The top rated concern was found to be travel. According the National Cancer Data Base (NCDB) generated in May 2015 shows that from the years of 2007-2012, 34% of Veterans receiving their care at the LSCVAMC traveled between 50-99 miles to receive their cancer care. The data were presented to the CC, and plans were made to further look at travel resources and community services available to our Veterans. A comprehensive report addressing resources was compiled and presented to the CC.

Implications: Identifying and breaking down barriers to transportation is vital to improving access to Veteran’s cancer care.

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Fed Pract. 2016 September;33 (supp 8):29S-30S
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