My Life, My Story: Patient Experience Evaluation in Palliative Care

Lauren Rosenberg, PhD, Andrea Ruskin, MD, Margaret Bauer, PhD

VA Connecticut Healthcare System, West Haven, CT

Purpose of project: To assess palliative care patients' experience completing the My Life, My Story (MLMS) program.

Relevant background: MLMS was developed in 2013 at William S. Middleton Memorial Veterans Hospital. Previous research on MLMS shows benefits for both providers and patients. The program involves working with Veterans to write their personal narrative story. VA Connecticut Palliative Care Team has applied the MLMS program in their clinical care with Veterans.

Methods: Veterans were administered a 5-point Likert scale questionnaire two weeks following completion of the MLMS program. Participants were asked one open ended question assessing effects of MLMS participation, and information on dissemination of their story. Demographic data was collected via chart review.

Data analysis: Descriptive statistics were run to evaluate participant's responses to Likert scale items. Thematic analysis was used to assess participant's qualitative responses.

Results: Participants (N = 19) were largely male (n = 18, 94.7%), White (n = 18, 94.7%), Not Hispanic or Latino (n = 19, 100%), with a cancer diagnosis (n = 14, 73.7%). Most participants agreed or strongly agreed that completing MLMS was a good use of time with their provider (n = 19, 100%), would recommend MLMS to other Veterans (n = 19, 100%), felt more understood by providers (n = 13, 68.4%), felt more connected to family/friends (n = 16, 84.2%), provided sense of meaning/purpose (n = 15, 78.9%), and felt the process of completing MLMS was easy (n = 17, 89.5%). Veterans shared their story with family (n = 13), friends (n = 6), providers (n = 3), or did not share their story with others (n = 4). The following seven major themes emerged when asking participants how the process of creating their life story affected them: Reflection on life, overall positive experience, cathartic to tell story, foster sense of pride, family legacy, increased provider insight, and negative feedback.

Conclusions: Veterans had an overall positive experience participating in the MLMS program in palliative care.

Implications: MLMS is a low budget, low risk intervention with positive outcomes for implementation into oncology and palliative care programs across VA healthcare centers.

"Close to Me" CBOC Infusion Program

Jenna Shields, PharmD, BCOP; Brittney Worth, PharmD; Andrea Stone, RN; Vida Almario Passero, MD, MBA

VA Pittsburgh Healthcare System, Pittsburgh, PA; Minneapolis VA Healthcare System, Minneapolis, MN; National Oncology Program, VHA Specialty Care Services (11SPEC17)

Currently, within the Veterans Affairs Healthcare System, anti-cancer therapy infusions and injections are primarily offered at VA Medical Centers (VAMC) in urban areas. The time and out of pocket expenses related to travel present a barrier to care, often leading Veterans to seek cancer care in the community.
The Minneapolis VA developed a "Remote Infusion" program that deploys a chemotherapy certified RN to administer anti-cancer and supportive therapies at surrounding Community Based Outpatient Clinics (CBOC). The program expanded in October 2021, and since, they have provided 259 infusions and injections to 145 Veterans at 16 CBOCs. These efforts have saved at least 20,000 miles of travel for Veterans in the Minneapolis/St. Cloud catchment area. Building off the success of this program, the National Oncology Program Integrated Project Team has developed the "Close to Me" CBOC infusion program.

The "Close to Me" CBOC infusion program utilizes VAMCs to compound treatments. Then a chemotherapy certified RN is deployed to the surrounding CBOCs to administer treatments. Veterans eligible for this program must have received and tolerated their first dose of treatment at a VAMC. Medications included in this program have low risk of reaction, short infusion time, and at least 8 hours of drug stability. Treatments include immune check point inhibitors, leuprolide, octreotide, IV fluids, and iron infusions. Additional treatments continue to be evaluated and added. Telehealth modalities are utilized for patient visits with their oncology provider for treatment clearance. An implementation toolkit, including a library of standard operating procedures, note templates, and staffing models has been developed for VAMCs interested in replicating this program. The Pittsburgh VA launched the first "Close to Me" CBOC infusion program on June 8, 2022.

The "Close to Me" CBOC infusion program optimizes current VA infrastructure and processes to expand access to the world class oncology care VA provides by reducing travel burden for the Veterans. Additional areas of novel solutions under development to provide expanded access points to anti-cancer therapies include mobile infusion units, mobile compounding units, and home administration.

Myeloid neoplasm masquerading as hypereosinophilia and sweet syndrome

Oday Elmanaseer, Amin Azem, Syed Mehdi

Albany Stratton VA (Albany, NY), Albany Medical Center (Albany, NY)

Introduction:
Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.

Case Presentation:
A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.

Discussion:
Hematological malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated.

Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2.

Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.

Conclusion:
Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.

Implementation of Clinical Triggers for Palliative Care Consultation on the Edward Hines Jr. VA Hematology/Oncology Inpatient Service

Glenda M. Delgado-Ramos (1,2), Jean Alyxa F. Vendiola (1,2), Alexi Vahlkamp (1), Amanda Bowers (1), Cheryl Czerlanis (1,2), Seema Limaye (1,2)

(1) Edward Hines Jr. VA Hospital, Hines, IL (2) Loyola University Medical Center, Maywood, IL

Purpose: Hospitalized patients with advanced malignancies often have high symptom burden and poor quality of life, which are frequently under-recognized or under-treated. Accordingly, the integration of specialty palliative care (PC) in this population is imperative. Unfortunately, a sustainable referral model to capture patients for timely PC involvement is lacking. This quality improvement study evaluated the implementation of a clinical trigger-based referral process to PC for inpatients on the Hematology/Oncology (HO) service at Hines VA Hospital.

Clinical outcomes studied included: Life-Sustaining Treatment (LST) note completion rates; measurement of overall survival at 3, 6, and 12 months; rate of re-hospitalization within 30 days; and venue of death and treating specialty of deceased patients.

Methods: House staff received a weekly email that included the clinical PC triggers. Admitted patients who met trigger criteria would prompt consultation to PC. Clinical triggers included: metastatic oncologic disease or relapsed hematologic disease; uncontrolled symptoms; >2 unscheduled hospitalizations in the prior 30 days; and unscheduled hospitalizations lasting >7 days.

Results: A total of 63 patients were admitted to the HO service between December 2020 through February 2021. Of those, 53 (84.1%) met at least 1 trigger and 36 (68%) received PC consultation. Of the patients that met trigger criteria and received a PC consult, 85.7% died with hospice compared to 44.4% in the group who did not receive a PC consult (p <0.01). Nineteen (51.3%) died within 6 months of discharge compared to 7 (26.9%) who did not receive a PC consult (p =0.08). Twelve (33.3%) had recurrent hospitalizations compared to 5 (29%) who did not receive a PC consult (p =0.38), and 20 (55.6%) had a new or updated LST note compared to 2 (11.8%) who did not receive PC consultation (p <0.01).

Conclusion: This study demonstrated the feasibility of implementing a trigger-based system for PC consultation in a Veteran inpatient HO population. Notably, a large majority of HO inpatients met criteria for at least 1 PC trigger. No significant difference was found in overall survival at 6 months; however, patients who received PC consultation were more likely to receive hospice services at the end of life.