Faculty Bibliography

BACKGROUND:Medication adherence after myocardial infarction remains low. Pharmacy claims have typically been used to measure medication adherence, but electronic pill bottles may offer additional information. OBJECTIVE:The main objectives of this study were to compare the association of adherence measured by prescription claims and remote monitoring technologies with cardiovascular events. RESEARCH DESIGN/METHODS:This study was a secondary analysis of a remote monitoring intervention to increase medication adherence in myocardial infarction patients. SUBJECTS/METHODS:In total, 682 myocardial infarction patients were randomized to the intervention group with both medical and pharmacy benefits. MEASURES/METHODS:Pharmacy claims adherence was measured using proportion of days covered (PDC) and GlowCap adherence (GC) was measured as the proportion of days the pill bottle was opened. We compared the association of PDC and GC adherence for statins with time to first vascular readmission or death and assessed model fit using Akaike information criterion and Bayesian information criterion and the likelihood ratio test. RESULTS:Higher PDC was significantly associated with a lower hazard rate for vascular readmissions or death (hazard ratio=0.435; P=0.009). There was also an association between GC adherence and vascular readmissions or death (hazard ratio=0.313; P≤0.001). Adding the GC adherence variable to the model using only PDC improved the model fit (likelihood ratio test, P=0.001), as well as vice versa (P=0.050). CONCLUSIONS:Pharmacy claims data provide useful but not complete data for medication adherence monitoring. New wireless technologies have the potential to provide additional data about clinical outcomes.

Background/UNASSIGNED:Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden. Methods/UNASSIGNED: = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics. Discussion/UNASSIGNED:We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

Metaplastic breast cancer (MPBC) is a rare subtype that accounts for <1% of all breast cancers. Although these are typically "triple negative," they are relatively chemotherapy-refractory compared to conventional triple negative invasive breast cancers with more aggressive features and an overall poor prognosis. MPBC is a heterogeneous group of tumors that are enriched for TP53 and PIK3CA mutations, and have been found to have high PD-L1 expression though the mechanisms underlying its immunogenicity remain unclear. We perform comprehensive genomic profiling in the largest MPBC dataset (n = 192) to date and assess for other potential biomarkers of immune response.

Background First-line PD-1 checkpoint inhibition (CI) in cisplatin-ineligible advanced UC represents a new treatment standard based on single arm trials [1,2], leaving uncertainty regarding role of chemotherapy. Describing utilization and corresponding outcomes with second-line treatment will provide guidance in this new sequence. We present the outcomes of these patients treated at our institution. Methods 43 patients with advanced UC received 1st-line CI from 6/2014 - 6/ 2018 on or off protocol. Clinical, laboratory and imaging data within 30 days of 1st-line initiation were gathered and clinical outcomes were analyzed including response by RECIST v1.1 and survival (OS). Disposition and treatment post- CI were also analyzed. Clinical outcomes were analyzed for the entire study population as well as known prognostic subgroups. A multivariable analysis was used to determine the prognostic value of baseline factors, and a log rank test was used to compare outcomes in prognostic subgroups. Results 43 patients were treated with 1st-line CI (atezolizumab or pembrolizumab) from 6/2014 until 6/2018. Median age was 77 (range 34 - 89), (74% male) (26% prior BCG), (60% visceral metastases, 19% liver), (reason for cisplatin ineligibility: ECOG PS =2 30%, Impaired renal function 44%, both 21%). ORR to first-line CI was 30.2% (95% CI 28% - 32%), CR 14%. Median OS and PFS was 11.7 mos (95% CI 7.6 - 19.8) and 3.0 mos (95% CI 2 - 11.2), respectively (median follow up 11.7 mos). OS was negatively correlated with visceral metastases at baseline. Of 29 patients who progressed, 17 received 2nd-line treatment (71% chemotherapy (most commonly Gem/Carbo (10 pts)) or 29% immunotherapy). Patients on chemotherapy had an RR of 38.46% while those on immunotherapy had an RR of 20.0%. Combined, 2nd-line treatment resulted in a median OS of 6.2 months (95% CI of 2.9-12.66), an ORR of 11.1% (95% CI of 8.0% to 15.0%) and an RR of 33.3% (95% CI of 28% - 39%). Conclusions In our single institution experience, OS and ORR with 1st-line CI are similar to outcomes reported in single arm trials. RR to 2nd-line chemotherapy is comparable to historical rates with gem/carbo in the first-line, however 12 of 29 progressing patients did not receive 2nd-line treatment, highlighting the importance of patient selection for first- line CI. Outcomes by PD-L1 status will be presented