Asante, Dennis

In 2013, the American Society of Hematology (ASH) published recommendations with Choosing Wisely to limit surveillance imaging in aggressive lymphoma. We studied surveillance imaging practice patterns for diffuse large B-cell lymphoma (DLBCL) before and after the ASH Choosing Wisely campaign. We used OptumLabs Data Warehouse, a national insurance claims database, to retrospectively study imaging frequency in survivors of DLBCL from 2008 to 2016. Three time periods were defined: Period 1 (2008 to 2010), Period 2 (2011 to 2013), and Period 3 (2014 to 2016). One thousand four hundred seventy-two patients were included. Median follow up was approximately 2 years. During the first and second years of surveillance, imaging remained stable between Period 1 (years 1 and 2: 199 [91%] and 137 [83%], respectively) and Period 2 (years 1 and 2: 257 [88%] and 172 [77%], respectively; P = .38), but decreased in Period 3 (years 1 and 2: 315 [78%] and 83 [61%], respectively; P < .01). In a multivariable logistic regression, year after 2012 was a significant predictor of decreased overuse (more than two scans per year in the first year of surveillance; [odds ratio, 0.49 for 2013 v 2008; P = .02]). Our study demonstrated the rate of surveillance scans—both computed tomography and positron emission tomography imaging—in DLBCL decreased after the ASH Choosing Wisely campaign. Multiple factors, such as changes in recommendations, reimbursement, and provider knowledge base, may have all contributed and should be studied further.

AbstractIntroductionTreatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.MethodsData from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.ResultsOf 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).ConclusionOne in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow‐up to minimize readmission.

Background: Adherence to surveillance guidelines in resected colon cancer has significant implications for patient morbidity, cost of care, and healthcare utilization. This study measured the underuse and overuse of imaging for staging and surveillance in stage I–II colon cancer. Methods: The OptumLabs database was queried for administrative claims data on adult patients with stage I–II colon cancer who underwent surgery alone in 2008 through 2016. Use of PET and CT imaging was evaluated during both initial staging (n=6,921) and surveillance for patients with at least 1 year of follow-up (n=5,466). “High use” was defined as >2 CT abdominal/pelvic (CT A/P) or PET scans per year during surveillance. Results: Overall, 27% of patients with stage I–II colon cancer did not have a staging CT A/P or PET scan and 95% did not have a CT chest scan. However, rates of staging CT A/P and CT chest scans increased from 62.0% (2008) to 74.8% (2016) and from 2.3% (2008) to 7.1% (2016), respectively. Staging PET use was overall very low (5.2%). During surveillance, approximately 30% of patients received a CT A/P or PET and 5% received a CT chest scan within the first year after surgery. Of patients who had surveillance CT A/P or PET scans, the proportion receiving >2 scans within the first year (high use) declined from 32.4% (2008) to 9.6% (2016) (P = .01). Conclusions: Although PET use remains appropriately low, many patients with stage I–II colon cancer do not receive appropriate staging and surveillance CT chest scans. Among those who do receive these scans during surveillance, high use has declined significantly over time.

Abstract Introduction: The role of surveillance imaging in diffuse large B-cell lymphoma (DLBCL) after treatment with curative intent is debated. In 2013, the American Society of Hematology (ASH) Choosing Wisely® campaign (Hicks LK, et al. Blood 2013) released a recommendation to "limit surveillance CT scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma." This was based on previous studies demonstrating a lack of survival benefit as well as a significant impact on the patient in terms of cost, anxiety, incidental findings and radiation exposure. Similar findings have been described regarding the use of PET imaging, especially in low risk patients. We aimed to study the changes in practice patterns of surveillance imaging for DLBCL survivors treated with curative intent before and after the publication of the ASH Choosing Wisely® campaign. Methods: Administrative claims data from a large U.S commercial insurance database (OptumLabs Data Warehouse) were used to retrospectively identify adult patients with an incident diagnosis of DLBCL between 2008 and 2016 and at least one year of follow-up. We excluded those who did not receive treatment with curative intent: RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) x 6 cycles or RCHOP x 3-5 cycles plus radiation. Patients were also excluded if they had a co-existing or second cancer, or if they received any chemotherapy/radiation during their surveillance period, as to exclude anyone with a recurrence of their lymphoma. The surveillance period started 90 days after the last chemotherapy or radiation and continued for the duration of follow-up. Surveillance imaging was defined as any PET, PET-CT, CT chest, CT abdomen, and/or CT pelvis. To examine trends over time, three time periods were defined: 2008-2010, 2011-2013 and 2014-2016. The Cochran Armitage test was used to test the trend hypothesis. Results: A total of 1,472 patients were included. Cohort characteristics by time period are described in Table 1. Surveillance imaging frequency decreased from 84% in Year 1 of surveillance to 43% in Year 5 (Figure 1). Overall, surveillance imaging during the first 3 surveillance years significantly decreased over the three time periods (Figure 2) (P<0.01 for Years 1 and 2, P=0.04 for Year 3). Imaging surveillance for the first two years of surveillance did not significantly decrease from 2008-2010 to 2011-2013 (P>0.05), but significantly decreased from 2011-2013 to 2014-2016 (P<0.01). Of the groups that received imaging surveillance during year 1, the median number of scans during the first year was 2 (inter-quartile range, 1-2) and did not significantly change over time. In addition, PET/PET-CT surveillance decreased from 49% in Year 1 to <10% in Year 5. PET/PET-CT also decreased over the three time periods, from 62% (2008-2010) to 48% (2011-2013) to 43% (2014-2016) during the first year of surveillance and 40% to 31% to 25% during the second year. Younger age (<65 years versus ≥65 years) was associated with higher imaging utilization (86% versus 81%, respectively), and specifically PET/PET-CT utilization (55% versus 43%, respectively), during the first year of surveillance. However, race (white versus non-white) did not significantly affect imaging (85% versus 83%) or PET utilization (50% versus 47%) during the first year of surveillance. Conclusions: Our study demonstrates that the rate of surveillance CT and PET imaging in DLBCL patients treated with curative intent decreased significantly in the years after the publication of the ASH Choosing Wisely® campaign. However, over half of the DLBCL patients diagnosed in 2014-2016 continued to undergo surveillance imaging, indicating either incomplete guideline dissemination or ongoing debate regarding optimal surveillance practice. Future studies are necessary to determine whether such a decline in surveillance imaging is sustained and to examine factors (patient, provider, and payer) associated with surveillance imaging in DLBCL. Disclosures No relevant conflicts of interest to declare.

Abstract Introduction Anticoagulant therapy in individuals with cirrhosis is challenging, as their risk of hemorrhage is significant due to concomitant alterations in primary hemostasis, secondary hemostasis and fibrinolysis. For many years, warfarin and heparin (including low molecular weight heparin) were the only treatment options for patients with thrombosis. Since 2010, novel, direct-acting oral anticoagulants (DOAC) that inhibit either thrombin (dabigatran) or factor Xa (e.g., rivaroxaban, apixaban, edoxaban, and betrixaban) are available. These direct-acting oral anticoagulants do not require laboratory monitoring and have minimal food and drug interactions, which makes them appealing to use for many patients. Unfortunately, there is inadequate data about efficacy and safety of these direct oral anticoagulants in cirrhotic patients as this group was commonly excluded from clinical trials evaluating these medications. In our study we aim to describe a large single institution experience with use of DOACs in patients with cirrhosis and explore clinical characteristics as potential predictors for bleeding and thrombosis. Methods: We conducted a retrospective cohort study of patients with cirrhosis who were seen in our institution between September 1, 2010 and June 30, 2017 and were treated with a DOAC utilizing a database search tool, called the Advanced Cohort Explorer that allows electronic records to be reviewed in a time efficient manner through text search or code search functionality. Only patients with cirrhosis diagnosed by histopathologic evaluation or with clinical presentation consistent with cirrhosis and confirmed by a gastroenterologist or by radiologic imaging (MRI, CT) were included in the study. Results: In our study, 106 individuals (male=72) met the inclusion criteria. Ninety three (88%) patients were treated with an anti-Xa inhibitor (rivaroxaban or apixaban), and remaining 13 (12%) with direct thrombin inhibitor (dabigatran). Median age at starting anticoagulant was 66 (range 24-89) years. The most common indication for anticoagulation was atrial fibrillation/flutter (54%), followed by pulmonary embolism/deep vein thrombosis (19%) and splanchnic vein thrombosis (15%). At the time of DOAC initiation, the median Charlson comorbidity index (CCI) was 7 (range 3-15); MELD score was 10 (range 6-24); and platelet count 150,000/ul (range 50,000-432,000). Thirty six (34%) patients had objectively diagnosed varices. Median follow up was 563 days (range: 7-2646). Bleeding requiring medical evaluation occurred in 32 (30.2%) patients. Major bleeding as defined by ISTH was experienced by 12 (11.3%) individuals. The most common source of bleeding was gastrointestinal tract (21.7%); other organs were less commonly affected (table 1). Hemorrhagic complication usually occurred early after starting anticoagulation (median 101 days; range 4-1356), and was the most common reason for discontinuation of anticoagulant treatment (14%), followed by completion of treatment (10%). On Cox proportional hazard modeling, rising BMI (HR: 1.032 per unit increase in BMI; p<0.05) and elevated bilirubin (HR: 1.223 per 1 mg/dL increase) were associated with increased risk of bleeding. Other clinical factors, including sex, type of anticoagulant used, platelet count, PT/INR, albumin, MELD score, varices, portal hypertension, concomitant aspirin use, and Charlson comorbidity index were not associated with bleeding risk. Thrombotic events while on DOAC affected 7 (6.7%) individuals, which included venous thrombosis in 4 (3.8%) and arterial thrombosis in 3 (2.9%) patients. No clinical factors were associated with increased risk of thrombosis. Conclusions: Our study is the largest series of patients with cirrhosis treated with DOACs. Bleeding complications with DOAC use in this population is high. Providers considering starting DOACs in patients with cirrhosis should consider the risk of bleeding in this population. Disclosures No relevant conflicts of interest to declare.

Abstract Background: Proteasome inhibitors and immunomodulatory drugs are currently an integral part of the management of multiple myeloma. Pre-clinical and clinical studies suggest that bortezomib, the first approved proteasome inhibitor for the management of multiple myeloma, may be associated with an increased risk of cardiac events such as heart failure (HF), acute myocardial infarction (MI), and arrhythmia. The goal of this study was to evaluate the rate of adverse cardiac events in patients treated with bortezomib compared to lenalidomide. Methods: This retrospective, propensity-matched study using a large, national administrative claims database included multiple myeloma patients who initiated bortezomib and a comparison group (matched on age, sex, year of drug initiation, baseline HF, hyperlipidemia, hypertension, history of MI, arrhythmia and Charlson comorbidity index) who initiated lenalidomide between January 2008 and December 2014. Those who received both bortezomib and lenalidomide were excluded from the analysis. The primary endpoints were time to hospitalization for HF, acute MI and arrhythmia. Rates of hospitalizations were computed per 100 patient years (PY). Cox proportional hazard models were used to obtain hazard ratios (HR) and 95% confidence intervals (CI). Results: A total of 1,128 patients (564 bortezomib users and 564 lenalidomide users, mean age of 69, 47% female, and average follow-up time of 438 days) were included in the analysis. The rate of hospitalization for HF, acute MI, and arrhythmia was 5.76/100 PY, 2.57/100 PY, and 3.10/100 PY respectively among bortezomib users and 2.45/100 PY, 1.47/100 PY, and 2.85/100 PY respectively among lenalidomide users. In the propensity score matched models, the risk of hospitalization for acute MI and arrhythmia with bortezomib was similar to lenalidomide (HR 1.60 [95% CI 0.73-3.49] and HR 1.01 [95% CI 0.54-1.90] respectively). The risk of hospitalization for HF with bortezomib use was significantly higher compared to lenalidomide (HR 2.10 [95% CI 1.18-3.74], Figure 1). Further stratification of the patient population by baseline HF status showed that those with baseline HF (n=212) were significantly more likely to be hospitalized for HF following treatment with bortezomib compared to lenalidomide. The rate of hospitalization for HF in the population with baseline HF was 24.12/100 PY among bortezomib users and 8.77/100 PY among lenalidomide users (HR 2.24 [95% CI 1.04-4.83]). Those without baseline HF (n=916) had similar rates of hospitalization for HF when treated with bortezomib and lenalidomide (2.83/100 PY and 1.29/100 PY respectively, HR 2.05 [95% CI 0.86-4.91]). Conclusion: The current study shows that bortezomib use in patients treated for multiple myeloma is associated with an increased risk of hospitalization for heart failure, but not acute MI or arrhythmia. Those with HF prior to initiating therapy with bortezomib had a significantly increased risk of hospitalization for HF when compared to those treated with lenalidomide. There was no significant difference in the rate of hospitalization for HF in those without a baseline diagnosis of HF. Collectively, these data have important implications for the management of patients with multiple myeloma, especially those with a history of HF at the time of therapy initiation. Figure 1. Kaplan Meier plot for HF hospitalizations. Figure 1. Kaplan Meier plot for HF hospitalizations. Disclosures No relevant conflicts of interest to declare.

Purpose: Differentiating between systemic sclerosis-related interstitial lung disease (SSc-ILD) and idiopathic pulmonary fibrosis (IPF) is important because of the differences in workup, prognosis, and treatment. However, there is much overlap in the appearance of these 2 entities on high-resolution computed tomography. We propose that inflammation and/or fibrosis focally or disproportionately involving the bilateral anterolateral upper lobes and posterosuperior lower lobes [“Four Corners” Sign (FCS)] is specific for SSc-ILD. Materials and Methods: Randomized high-resolution computed tomography studies from 74 IPF and 73 SSc-ILD cases were evaluated by 2 thoracic radiologists blinded to all patient data. For each case the reviewers noted whether the FCS was present and assigned a confidence level on the basis of a 7-point Likert scale. The same process was then performed on a randomized external validation group of 42 SSc-ILD and 42 IPF cases. Results: For Likert scores of 6 or 7 (“mostly agree” or “entirely agree” that the FCS is present, respectively) the sensitivity in SSc was 16.4% (95% confidence interval, 9.7%, 26.6%), specificity 100.0% (95% confidence interval, 95.1%, 100.0%). There was a significant association between a confidently present FCS and SSc compared with a confidently present FCS and IPF (P=0.0003). Analysis on an external validation group of 42 SSc and 42 IPF cases conferred similarly high specificity for SSc in cases characterized as FCS with high confidence. Conclusion: The FCS, a pattern of focal or disproportionate inflammation and/or fibrosis involving the bilateral anterolateral upper lobes and posterosuperior lower lobes, is specific for SSc-ILD when readers are confident of its presence.

Abstract Background While several studies have identified risk factors for PJI using insurance claims data, these data sets have been limited to a single regional insurance dataset or to the Medicare population. We sought to investigate risk factors for early PJI among patients undergoing total hip or knee arthroplasty (THKA). Methods All patients who underwent primary THKA between January 1, 2004 and July 31, 2014 with 12 months of continuous preceding medical and pharmacy insurance coverage were included in the study. The primary outcome of PJI required both a compatible procedure code and a diagnostic code during an inpatient stay from the time of THKA through 90 days after discharge. Comorbidities were based on ICD-9 codes in the preceding 12 months and patients with a prior diagnosis of PJI during that time period were excluded. Univariate and multivariate analysis was performed using logistic regression. Results A total of 147,053 patients underwent THKA during the study period, including 97,448 patients with TKA and 49,605 with THA. PJI occurred in 754 (0.5%) patients. Female gender was independently associated with lower odds of PJI (Figure). A number of biologically plausible factors were associated with increased risk, including chronic skin ulcer, obesity, substance use disorders, joint sarcoma, and malnutrition. The adjusted odds of PJI increased in a stepwise fashion with each increase in the Charlson comorbidity index (CCI), with those with a score of 4 or more having a nearly 2-fold adjusted odds of PJI compared with a score of 0 (OR 1.91; 95% CI 1.29 −2.82). Previously observed risk factors diabetes mellitus, rheumatoid arthritis, and chronic renal failure were associated with increased odds of PJI on univariate analysis, but not after adjustment. Conclusion These data identify several potentially modifiable risk factors for preoperative optimization, including obesity, malnutrition, chronic skin ulcers, and substance-use disorders. The level of comorbidity as assessed by the CCI provides a rough estimate of the increasing risk of PJI. The pathobiology of additional risk factors observed here deserves further study. Disclosures All authors: No reported disclosures.