Michigan Market Referral Coordination Initiative: a Regional Market Approach to VA Specialty Care.

BACKGROUND: The Maintaining Internal Systems and Integrated Outside Networks (MISSION) Act of 2018 was created in response to reports of prolonged wait times for veterans accessing health care within the Veterans Affairs (VA) system. In Michigan, the MISSION Act Community Care Program led to an increased number of veterans receiving specialty care outside the VA system, in part due to the complicated process of coordinating specialty care within the VA system. From 2018 to 2020, the percentage of veterans referred to the VA Ann Arbor Healthcare System (AA) for specialty care from its two referring facilities, Battle Creek VA Medical Center (BC) and Saginaw VA Healthcare System (SAG), decreased from 54.4 to 27%. OBJECTIVE: Improve the number of Michigan veterans choosing VA specialty care. INTERVENTION: In 2021, three VA facilities in Michigan (AA, BC, and SAG) created a market-level referral system named the Michigan Market Referral Initiative (MMRCI). This unique approach used a centralized nurse-driven team to manage specialty referrals, working directly with the veteran to explore both VA and community care (CC) options. MAIN MEASURES: Referrals triaged and acceptance rates for VA care were tracked. The localized Standard Episode of Care model was used to estimate cost savings. Post-intervention AA patient wait times were compared to local CC wait times. KEY RESULTS: In the 14 months after implementation of the MMRCI, the rate of veteran retention increased by 32.4%. The estimated dollars retained within the VA by MMRCI efforts was $24,105,251 as of 7/1/2022. Post-intervention AA wait times were superior to community care except in 3 specialties. CONCLUSIONS: This multifacility effort is an example of a highly coordinated, veteran-centered collaboration that has led to successful retention of veterans within the VA system with resultant large-scale cost avoidance and comparable clinic wait times. Focusing on central care coordination and veteran engagement in the referral process are keys to its success, along with leveraging existing referral patterns between nearby VA facilities. This model could be extrapolated to other VA markets throughout the country where similar relationships exist.

Ruxolitinib in adult patients with secondary haemophagocytic lymphohistiocytosis: an open-label, single-centre, pilot trial.

BACKGROUND: Hemophagocytic lymphohistiocytosis is a cytokine-driven inflammatory syndrome that is associated with substantial morbidity and mortality. Overall survival in adult patients with secondary haemophagocytic lymphohistiocytosis remains suboptimal, and novel therapeutic strategies are needed. The phosphorylation-dependent activation of the Janus family kinases JAK1 and JAK2 are hallmarks of the final common pathway in this disease. We therefore aimed to determine the activity and safety of ruxolitinib, a JAK inhibitor, in adults with secondary haemophagocytic lymphohistiocytosis. METHODS: We performed an open-label, single-centre, pilot study of ruxolitinib in adults with secondary haemophagocytic lymphohistiocytosis at the University of Michigan Rogel Cancer Center (Ann Arbor, MI, USA). We included patients aged 18 years or more who fulfilled at least five of the eight HLH-2004 criteria for hemophagocytic lymphohistiocytosis. Discontinuation of corticosteroids was not required for enrolment in this study. Patients received oral ruxolitinib (15 mg twice a day) on a continuous 28-day cycle, or until disease progression or unacceptable toxicity. The primary endpoint was overall survival at 2 months from the first dose of ruxolitinib. Secondary endpoints included the assessment of adverse events, response (defined as the assessment of all quantifiable signs and laboratory abnormalities included in the diagnostic criteria for haemophagocytic lymphohistiocytosis), and pharmacodynamic biomarkers. Analyses were done in all treated patients with available data. This study is registered with ClinicalTrials.gov, number NCT02400463, and is still recruiting. FINDINGS: As of Feb 7, 2019, five patients had been enrolled. The first patient was enrolled in February, 2016. No deaths were recorded, with a median follow-up of 490 days (IQR 190-1075). 2-month overall survival was 100% (95% CI 57-100). Regarding response, resolution of symptoms (either partial or complete) and disease-associated laboratory abnormalities was observed in all five patients. Cytopenias improved in all patients within the first week of treatment, leading to relatively rapid transfusion independence, discontinuation of corticosteroids, and hospital discharge. A single serious adverse event (ie, grade 4 febrile neutropenia) was reported. One patient discontinued treatment because of grade 2 extremity pain and no treatment-related deaths were observed. Improvements in inflammatory markers (eg, ferritin, soluble IL-2 receptor) and T cells and monocytes activation (ie, decreased STAT1 phosphorylation) were observed following treatment. INTERPRETATION: These preliminary data suggest that ruxolitinib is active, well tolerated, and manageable in the outpatient setting in patients with secondary haemophagocytic lymphohistiocytosis. Given the paucity of effective, non-myelosuppressive therapies, these preliminary findings have important therapeutic implications for patients with haemophagocytic lymphohistiocytosis and other cytokine-release syndromes and warrant further investigation. FUNDING: National Cancer Institute, the University of Michigan Rogel Cancer Center, and Incyte Corporation.