Treatment patterns and outcomes of high-grade immune checkpoint inhibitor-related pneumonitis in an oncology hospitalist service.

PURPOSE: Immune checkpoint inhibitors (ICI) have become standard of care for some types of lung cancer. Along with expanding usage comes the emergence of immune-related adverse events (irAEs), including ICI-related pneumonitis (ICI-P). Treatment guidelines for managing irAEs have been developed; however, how clinicians manage irAEs in the real-world setting is less well known. We aimed to describe the outcomes and care patterns of grade ≥ 3 ICI-P in an onco-hospitalist service. PATIENTS AND METHODS: We included patients with lung cancer treated with ICI who were admitted to an oncology hospitalist service with a suspicion of ICI-P. We described the hospitalization characteristics, treatment patterns, discharge practices, and clinical outcomes of patients with confirmed ICI-P. The primary outcome was time to start treatment for ICI-P. RESULTS: Among 49 patients admitted with a suspicion of ICI-P, 31 patients were confirmed to have ICI-P and subsequently received ICI-P directed treatment. Pulmonology was consulted in 97% of patients. Median time to start treatment for ICI-P was 1 day (IQR 0-3.5 days). All 31 patients received corticosteroids. Inpatient mortality was 32%. Majority of patients discharged with steroids were prescribed prophylaxis for gastritis and opportunistic infections. Thirty-eight percent of patients were seen by pulmonology and 86% were seen by the oncology team post-discharge. CONCLUSION: Our study confirms prior findings of high mortality among patients with high-grade ICI-P. Early diagnosis and treatment are key to improving clinical outcomes. Understanding the care patterns and adherence to treatment guidelines of clinicians caring for this patient population may help identify ways to further standardize management practices and improve patient outcomes.

Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic cancer pain.

PURPOSE: Data indicates that clinicians might be under-prescribing opioids for patients with chronic cancer pain, and this could impact adequate pain management. Few studies have sought to understand healthcare provider (HCP) perceptions and practices regarding the prescription of opioids for chronic cancer pain. We assessed HCP perceptions and practices regarding opioid prescription for patients with chronic cancer pain since the onset of the COVID-19 pandemic. METHODS: An anonymous cross-sectional survey was conducted among 186 HCPs who attended an opioid educational event in April 2021 and 2022. RESULTS: Sixty-one out of 143 (44%) opioid prescribers reported reluctance to prescribe opioids for chronic cancer pain. In a multivariate logistic model, younger participants (log OR - 0.04, 95% CI - 0.085, - 0.004; p = 0.033) and pain medicine clinicians (log OR - 1.89, CI - 3.931, - 0.286; p = 0.034) were less reluctant, whereas providers who worry about non-medical opioid use were more reluctant to prescribe opioids (log OR 1.58 95% CI 0.77-2.43; p < 0.001). Fifty-three out of 143 (37%) prescribers had experienced increased challenges regarding opioid dispensing at pharmacies, and 84/179 (47%) of all respondents reported similar experience by their patients. Fifty-four out of 178(30%) were aware of opioid-related harmful incidents to patients or their families, including incidents attributed to opioid misuse by a household or family member. CONCLUSION: A considerable number of opioid prescribers were reluctant to prescribe opioids for patients with chronic cancer pain. Many reported challenges regarding dispensing of opioids at the pharmacies. These may be unintended consequences of policies to address the opioid crisis. Future measures should focus on addressing regulatory barriers without undermining the gains already made to combat the opioid crisis.

Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic pain.

PURPOSE: Data indicates that clinicians might be under-prescribing opioids for patients with chronic cancer pain, and this could impact adequate chronic pain management. Few studies have sought to understand healthcare provider (HCP) perceptions and practices regarding the prescription of opioids for chronic pain. We assessed HCP perceptions and practices regarding opioid prescription for patients with chronic pain since the onset of the COVID-19 pandemic. METHODS: An anonymous cross-sectional survey was conducted among 186 HCPs who attended an opioid educational event in April 2021 and 2022. RESULTS: 61/143(44%) opioid prescribers reported reluctance to prescribe opioids for chronic pain. In a multivariate logistic model, younger participants (log OR -0.04, 95% CI: -0.085, -0.004; p = 0.033) and pain medicine clinicians (log OR -1.89, CI: -3.931, -0.286; p = 0.034) were less reluctant, whereas providers who worry about non-medical opioid use (NMOU) were more reluctant to prescribe opioids (log OR 1.58 95% CI: 0.77-2.43; p < 0.001). 53/143(37%) respondents had experienced increased challenges regarding opioid dispensing at pharmacies, and 84/179(47%) reported similar experience by their patients. 54/178(30%) HCPs were aware of opioid-related harmful incidents to patients or their families, including incidents attributed to opioid misuse by a household or family member. CONCLUSION: A significant number of opioid prescribers were reluctant to prescribe opioids for patients with chronic pain. Many reported challenges regarding dispensing of opioids at the pharmacies. These may be unintended consequences of policies to address the opioid crisis. Future measures should focus on addressing regulatory barriers without undermining the gains already made to combat the opioid crisis.

Medically ready for discharge: A multisite "point-in-time" assessment of hospitalized patients.

BACKGROUND: Time spent awaiting discharge after the acute need for hospitalization has resolved is an important potential contributor to hospital length of stay (LOS). OBJECTIVE: To measure the prevalence, impact, and context of patients who remain hospitalized for prolonged periods after completion of acute care needs. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional "point-in-time" survey at each of 15 academic US hospitals using a structured data collection tool with on-service acute care medicine attending physicians in fall 2022. MAIN OUTCOMES AND MEASURES: Primary outcomes were number and percentage of patients considered "medically ready for discharge" with emphasis on those who had experienced a "major barrier to discharge" (medically ready for discharge for ≥1 week). Estimated LOS attributable to major discharge barriers, contributory discharge needs, and associated hospital characteristics were measured. RESULTS: Of 1928 patients sampled, 35.0% (n = 674) were medically ready for discharge including 9.8% (n = 189) with major discharge barriers. Many patients with major discharge barriers (44.4%; 84/189) had spent a month or longer medically ready for discharge and commonly (84.1%; 159/189) required some form of skilled therapy or daily living support services for discharge. Higher proportions of patients experiencing major discharge barriers were found in public versus private, nonprofit hospitals (12.0% vs. 7.2%; p = .001) and county versus noncounty hospitals (14.5% vs. 8.8%; p = .002). CONCLUSIONS: Patients experience major discharge barriers in many US hospitals and spend prolonged time awaiting discharge, often for support needs that may be outside of clinician control.

Hospitalization characteristics and outcomes of patients with cancer and COVID-19 at a comprehensive cancer center.

PURPOSE: Several studies have confirmed increased mortality among patients with both COVID-19 and cancer. It remains important to continue to report observations of morbidity and mortality from COVID-19 in this vulnerable population. The purpose of this study is to describe the hospitalization characteristics and outcomes of patients with both cancer and COVID-19 admitted to our comprehensive cancer center. METHODS: This was a descriptive study of the first COVID-19-related hospitalization among adult patients with cancer admitted to our institution. Descriptive statistics were used to summarize patient demographics, clinical as well as hospitalization characteristics. Overall survival (OS) was estimated using the Kaplan-Meier method. RESULTS: A total of 212 patients were included in our cohort with a mean age of 59 years. Fifty-four percent of patients had history of solid tumor malignancy and 46% had hematologic malignancies. Eighty-five percent of our cohort had active malignancy. The mean length of stay (LOS) for hospitalization was 11.2 days (median LOS of 6 days). Twenty-five percent had severe disease and 10.8% died during their initial hospitalization. Those who had severe disease had worse survival at the end of the observation period. CONCLUSIONS: COVID-19 among cancer patients causes significant morbidity and mortality as well as repeat hospitalizations. Continued study of COVID-19 in this vulnerable population is essential in order to better inform evolving treatment algorithms, public health policies, and infection control protocols, especially for institutions caring for patients with cancer.

Risks, diagnosis, and management of recurrent cancer-associated thrombosis (CAT): a narrative review.

This paper aims to provide a narrative review of the risks, diagnosis, and management of recurrent venous thromboembolism (VTE) in cancer patients. There is an established association between cancer and VTE, with cancer being a major risk factor for VTE. A history of VTE, short duration of oral anticoagulation, and a proximal DVT are all associated with increased risk for recurrent VTE. Studies have shown that certain cancers (e.g., metastatic genitourinary, lung, and colorectal cancers) are associated with recurrent VTE. Published literature shows that cancer is prothrombotic, and various mechanisms have been postulated as pathways for increased thrombogenesis and hence recurrent VTE in cancer. The symptoms, signs, laboratory information, and imaging results for the diagnosis of recurrent VTE are similar to those of an initial VTE. Management of recurrent VTE involves using low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). Vitamin K antagonists (VKA) or inferior vena cava (IVC) filters are less commonly used.