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PURPOSE Among patients receiving chemotherapy, symptom monitoring with electronic patient-reported outcomes (ePROs) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established, warranting evaluation in community cancer practices. We present implementation findings of ePRO symptom monitoring across a large multisite community oncology practice network. METHODS Patients initiating a new systemic therapy at one of the 210 practice sites at Texas Oncology were invited to use the Navigating Cancer ePRO platform, with stepped-wedge implementation from July to December 2020. Participating patients received a weekly prompt by text message or e-mail to self-report common symptoms and well-being. Severe self-reported symptoms triggered a real-time notification to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability. RESULTS Four thousand three hundred seventy-five patients planning systemic treatment were enrolled and participated. Seventy-three percent (1,841 of 2,522) of enrolled patients completed at least one ePRO assessment. Among these individuals, 64% (16,299 of 25,061) of available weekly ePRO assessments were completed. Over a 10-week period, compliance declined from 72% to 52%. Barriers currently being addressed include lack of a second reminder text or e-mail prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included ease of use and patient and staff engagement on the importance of PROs for symptom management. CONCLUSION ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.

This study describes the prevalence and persistence of fatigue among a cohort of long-term non-Hodgkin lymphoma (NHL) survivors. Mailed surveys assessed quality-of-life including fatigue (SF-36) at baseline and five years. Logistic regression was used to identify factors associated with prevalence of fatigue at baseline and persistence of fatigue across timepoints. More than one-quarter (27.7%) of the 555 NHL survivors reported clinically meaningful fatigue at baseline and 18.7% reported persistent fatigue at five years. One-third (34.4%) reported clinically meaningful worsening of fatigue over time. Independent associations with persistent fatigue included female gender, less education, past chemotherapy, increased comorbidities, and posttraumatic stress symptoms (P

e16249 Background: Patients with pancreatic cancer face many nutrition-related concerns, although few guidelines exist to direct clinical nutrition services in this population. Examining quality outcomes for patients in clinics with and without access to a Registered Dietitians (RD’s) can help examine the contributions of RD’s in this area. Methods: A retrospective cohort design was used to compare Total Cost of Care (TCOC), hospital admissions and Length of Stay (LOS), and Emergency Department (ED) and Observation visits for patients with pancreatic cancer who were enrolled in the Oncology Care Model (OCM) during Performance Periods (PP) 1-6 (July 1, 2016–June 30, 2019). Patient deaths during the initial episode of care were also examined. Patients from a geographically concentrated metropolitan hub were divided into cohorts based on clinic access to an RD. Each patient’s initial six-month OCM episode of care was used for analysis. Results: Of the 389 OCM patients identified with pancreatic cancer from PP1-6, 203 were treated at 10 clinics with an RD and 186 in 17 clinics without an RD. In the RD cohort, 43.3% of patients were admitted to the hospital with an average LOS of 8.9 days. By contrast, 52.2% of patients in the non-RD cohort were admitted to the hospital with an average LOS of 10.0 days. TCOC for the 6-month episode was lower in the RD cohort at $37,185 versus the non-RD cohort at $40,907. During the initial 6-month episode of care, 37% of patients in the non-RD cohort died during the initial 6-month episode vs only 28% in the RD cohort. A higher percentage of patients in the RD cohort (35%) had ED or Observation visits, compared with the non- RD cohort (32%). Conclusions: Amongst OCM patients with pancreatic cancers, treatment at a clinic with an RD was associated with lower TCOC, reduced LOS for patients that were admitted to the hospital, and lower percentage of deaths in the first 6-month episode of care. The percentage of patients with ED and Observational visits was slightly higher in the cohort that had access to an RD. This analysis shows the potential benefit of RD services in an outpatient setting and justifies further study. Future multilevel modeling will evaluate the statistical significance of these results.[Table: see text]

1575 Background: Digital health solutions (DHS) allow for enhanced remote communication between patients and clinical staff and the COVID-19 pandemic has brought these tools to the forefront of care delivery. Once adopted, barriers to adequate utilization still exist. Given the important need to decrease digital divides, and the diversity of patients and care settings across our clinic’s 220 sites of service, we sought to understand how utilization of oncology DHS may be limited among certain populations. Methods: We investigated utilization among cancer patients who enrolled and engaged with a portfolio of DHS between March 1, 2019 and January 15, 2022. This portfolio includes three tools: (1) an electronic patient-reported outcomes (ePRO) remote monitoring program for tracking symptoms and oral adherence, (2) a patient portal (PP) for securely accessing patient health records, and (3) digital education (DE) for patients regarding disease and treatments. ePRO completion rate, average number of PP logins, and DE read rate were used as measures of utilization for each tool, respectively, and compared among patients with different age (< 65 and ≥65 years), language preference [English (EL) or Spanish (SL)], and distance from clinic (non-rural: < 20 miles OR rural: ≥20 miles). Mann-Whitney U and Chi-Square tests were used to compare continuous and categorical variables, respectively. Results: This study included a total of 77,347 unique patients representing 651,004 digital encounters. 9,938 patients engaged in ePRO, 49,771 patients in PP, and 12,044 patients in DE. Engagement across all DHS was high in patients of age group < 65 (ePRO: 72.7%, PP: 79.67% and PE 54.7%) as compared to ≥65 years, but the ePRO completion rate is high in ≥65 age group (59.0% vs 55.6%), whereas no significant difference was observed in the PP login activity and DE read rate. EL patients were significantly (p-value < 0.01) more engaged (ePRO 68% vs. 54%, PP: 80% vs. 62%, DE: 57% vs. 37%) and had higher digital utilization (ePRO completion rate: 57.31% vs 53.23%, average PP logins: 7.48 vs 7.14 and DE read rate: 96.2% vs 90.8%) than SL patients across the DHS. Patients living in rural areas comprised roughly 25% of the population and participated across tools similarly as patients living in non-rural areas (ePRO 67% vs. 69%, PP: 79% vs. 79%, DE: 56.9% vs. 56.8%). Utilization of the portfolio was variable based on rural vs non-rural status (ePRO completion rate: 56.3% vs. 57.4%, average PP logins: 7.9 vs. 7.3, DE read rate: 96.02.7% vs 96.3%). Conclusions: Despite variable engagement based on age, language, and rural status across the portfolio, patients within these populations continue to utilize the DHS. How we understand and explore enhancements to DHS remain under investigation for tool optimization for patient-specific barriers to care.

1507 Background: There is a priority to accelerate the delivery of digital health solutions (DHS) to provide patients with enhanced means for accessing care, but lack of understanding of their utility in certain populations. There are concerns that equitable adoption translate into disparities. We sought to implement a portfolio of DHS across a large practice and characterize engagement across populations to enhance clinical informatics solutions that support care delivery. Methods: This is a retrospective evaluation of cancer patients who engaged with a portfolio of DHS between March 1, 2019 and January 15, 2022. We included four tools with opt-in and opt-out functionality: (1) a care management (CM) platform utilized by clinical staff to manage patient activities, (2) an electronic patient-reported outcomes (ePRO) remote monitoring program for tracking symptoms and oral adherence, (3) a patient portal (PP) for securely accessing patient health records, and (4) digital education (DE) for patients regarding disease and treatments. The engaged population was defined as the number of enrolled patients with at least one (1) record of triage activity, (2) completed ePRO assessment, (3) PP login, and (4) DE read activity, for each tool, respectively. The start of the index period was adjusted based on the first go-live date of each tool. We evaluated factors (age, gender, race/ethnicity, preferred-language, marital status, and distance from clinic) associated with patient engagement using Chi-Square test and multivariate logistic regression. Results: This analysis included a total of 267,375 unique patients. Of the enrolled population per tool, 172,840 (73.6%), 9,938 (67.7 %), 49,771 (79.2%), and 12,044 (56.9%) patients were engaged in CM, ePRO, PP and DE, respectively. The majority (>50%) of engaged patients were female, White and non-Hispanic/Latino, English-language, and aged 61-80 yrs. After adjusting for covariates, we observed that White and non-Hispanic/Latino [(CM: OR 1.15, ePRO OR 1.46, PP: OR 1.48, and DE: OR 1.36) and English-language (CM: OR 1.2, ePRO OR 1.67, PP: OR 1.8 and DE: OR 1.89) patients were significantly (p-value 80 years as compared to reference age of 0-20 years for any digital tools except CM. Conclusions: DHS can be used to support the cancer patient journey and we demonstrated high utilization in an array of sociodemographic variables in our population. However, tools designed and implemented with different populations in mind to reduce staff burden and lessen the digital divide should be further explored.

264 Background: Patients with gastric and esophageal cancers are at high risk for malnutrition. Appropriate nutrition care provided by a registered dietitian (RD) as part of a multidisciplinary care team is supported by evidenced-based guidelines and clinical studies focused on surgical outcomes. However, Medicare does not routinely cover outpatient RD services for oncology patients which limits access to this care. Examining quality outcomes for patients in clinics with and without access to a RD can help define the value of this service. Methods: We used a retrospective cohort design to analyze Total Cost of Care (TCOC), hospital admissions and Length of Stay (LOS), and Emergency Department (ED) and Observation visits for patients with gastric and esophageal cancer who were enrolled in the Oncology Care Model (OCM) during Performance Periods (PP) 1-6 (July 1, 2016 – June 30, 2019). We divided patients from a geographically concentrated metropolitan hub into cohorts based on clinic access to a RD. Each patient’s initial OCM episode of care was used for analysis. Results: We identified 253 OCM patients with gastric or esophageal cancer from PP1-6. Of these, 109 were treated at 9 clinics with an RD and 144 in 16 clinics without a RD. In the RD cohort 42.2% of patients were admitted to the hospital with a LOS of 6.8 days. In the non-RD cohort 45.8% of patients were admitted to the hospital with a LOS of 9.4 days. TCOC for the 6-month episode was lower in the RD cohort at $ 39,033 vs the non-RD cohort at $49,359. There were 0.56 ED and observation visits per patient in the RD cohort and 0.8 ED and observation visits per patient in the cohort without a RD. Conclusions: Amongst OCM patients with gastric and esophageal cancers, treatment at a clinic with a RD was associated with lower TCOC, reduced LOS for patients that were admitted to the hospital and fewer ED and observational visits. This analysis shows the potential benefit of RD services in an outpatient setting and justifies further study. Future prospective studies will need to evaluate which interventions are most impactful.[Table: see text]

49 Background: Oncology providers and patients benefit from evidence-based nutritional resources to support cancer care. For patients, proper nutrition care can prevent inappropriate weight loss, improve treatment tolerance, and improve quality of life. Recent literature has noted the lack of both adequate dietitian resources at outpatient centers and comprehensive nutrition guidelines in cancer care. At a large community practice with 210 locations across Texas and Oklahoma, a survey was developed and administered to assess nutrition practices. Methods: Clinic directors in the practice completed a survey to assess for the presence or absence of a malnutrition screen; how nutrition concerns are addressed; and the availability of a dietitian. Results: A total of 26 responses detailed the nutrition processes at 50 unique locations. At 37 (74%) locations, a malnutrition screening tool was utilized and of these, 30 (81%) locations reported utilizing the Malnutrition Screening Tool (MST), a brief, validated tool for outpatient settings including oncology. Seven (19%) sites did not specify what tool was used. Of the clinics that reported completing a malnutrition screen for patients, the screen was completed by the advanced practice provider (APP)/physician in 18 (49%) clinics, a nurse in 4 (11%) clinics, a dietitian in 4 (11%) clinics and a medical assistant in 1 (3%) clinic. At 10 sites more than one provider type was responsible for completing the screen. Nutrition issues were addressed by physicians, APPs, and nurses in 15 (50%), 35 (70%), and 9 (14%) sites respectively (see table). Twenty-two locations (44%) reported referring patients to a dietitian and 10 sites (20%) had a dietitian available in clinic. Forty-one (82%) clinics employed more than one method for addressing nutrition issues. Sixteen of 26 respondents (62%) reported that increased dietitian access would be helpful; this included respondents whose locations already had a dietitian available. Conclusions: Overall, 74% of reporting locations used a malnutrition screening tool and 20% had access to a dietitian on site. Forty-four percent of sites referred to a dietitian if there was a need. This indicates that multiple providers are involved in the nutritional care of oncology patients. In response to these findings, the multidisciplinary PECAN Taskforce was created to develop comprehensive malnutrition screening, implement a referral process for all at-risk patients, enhance nutrition education, and expand dietitian services. Further study will measure the impact of expanded nutrition access on patient outcomes.[Table: see text]

1578 Background: Value-based care models such as the Oncology Care Model incentivize practices to reduce hospitalizations and emergency department (ED) visits. Texas Oncology found that most ED visits occurred during regular business hours. Prolonged patient call back times were consistently rated poorly on satisfaction surveys and often led to ED visits for symptoms that could be managed in our offices. We partnered with Navigating Cancer (NC) to implement an electronic patient management technology solution. Methods: For each of our 200 locations, call volume was estimated based on clinic volume. We then reallocated or hired dedicated triage nurses and operators. Incoming calls were entered into the NC dashboard by operators as incidents which were routed based on symptom priority following system generated prompts. Incident volumes and resolution times were tracked. We instituted PDSA cycles at all locations with a goal of less than 90-minute resolution of symptom-related incidents Utilizing the electronic dashboard allowed us to continue this initiative during the COVID-19 public health emergency as our staff could work remotely. Nurses were able to document if a potential ED visit was avoided. These data points allowed our practice to establish comprehensive and strategic actions plans for quality improvement. Results: We finalized implementation of the system in February of 2020. Total incidents for 2020 were over 1 million, averaging over 5000 per location. Resolution time for all incidents started at 3.2 hours pre-implementation and improved to 2.2 hours in December of 2020. Resolution times for symptom-related incidents started at 2.3 hours pre-implementation and ended at 1.5 hours in December of 2020 with over 60% resolved under one hour. 8% of symptom-related incidents resulted in definite or probable ED avoidances by nursing assessment. Shortness of breath, vomiting, chills, and weakness were the top symptom types addressed for ED avoidances. Conclusions: An electronic patient management solution with PDSA cycles of quality improvement can markedly reduce call back times, especially for symptom related calls. We believe managing symptoms in a timely fashion will lower ED visits and hospitalizations as well as improve patient satisfaction. We will report on these outcomes once available.[Table: see text]

12103 Background: Among patients receiving chemotherapy, symptomatic adverse event monitoring with electronic patient-reported outcomes (ePRO) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established warranting evaluation in community cancer practices. Objective: Evaluate implementation of ePRO symptom monitoring across a large multi-site community oncology practice network. Methods: Patients initiating a new systemic therapy at one of 210 practice sites in the Texas Oncology Practice were invited to use in the Navigating Cancer ePRO platform, with rolling implementation from July-December 2020. Participating patients received a weekly prompt by text message or email (patient choice) to self-report common symptoms and well-being via web or smartphone. Severe self-reported symptoms triggered a real-time notification alert to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability. Results: 4375 patients planning systemic treatment enrolled and participated, with baseline characteristics are shown in Table 1. 73% (1841/2522) of enrolled patients with follow up completed at least one ePRO assessment, and among these individuals, 65% (8762/25061) of all available weekly ePRO assessments were completed. Over a 10-week period, compliance with weekly symptom reporting declined from 72% to 52%. Patients on oral therapy had higher compliance rates overall. Barriers currently being addressed include lack of a second reminder text/email prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included patient and staff engagement on the importance of PROs for symptom management. Conclusions: ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high, but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.[Table: see text]

e20053 Background: Fatigue is a common and distressing effect of cancer and its treatment. Prior research suggests fatigue persists long after diagnosis and treatment in non-Hodgkin lymphoma (NHL) survivors. This study aimed to identify distinct trajectories of fatigue in NHL survivors and predictors of trajectories that could inform clinical care. Methods: Our secondary analysis used data from a longitudinal study of NHL survivors (n = 886) at least 2 years post-diagnosis. Fatigue was measured using the SF-36 vitality subscale across three time points. Prior literature informed the selection of baseline demographic (e.g. age, gender, race) and disease characteristics [e.g. NHL type, comorbidities, post-traumatic stress disorder (PTSD)] explored as possible predictors of fatigue trajectories. We used group-based trajectory modeling to identify distinct groups of patients experiencing similar patterns of fatigue. Variables significant in bivariate analysis were included in a stepwise multinomial logistic regression to identify factors predictive of group membership. Results: We identified four distinct trajectories that suggest levels of fatigue persist unchanged over time. The Low Fatigue Group (15.6%) experienced less fatigue than the general population. The Population Norm Group (42.5%) experienced a similar level of fatigue to the general population mean. The Significant Fatigue Group (27.5%) experienced fatigue levels almost one standard deviation worse than the general population. The Worst Fatigue Group (14.3%) experienced fatigue almost two standard deviations worse than the population norm. PTSD symptoms and comorbidity scores were predictive of levels of fatigue over time. Greater age at diagnosis increases the odds survivors experienced worse fatigue than the population mean (Table). Conclusions: Levels of fatigue experienced early in an NHL patients’ disease trajectory may persist for many years. Higher levels of PTSD symptoms and comorbidities were predictive of worse fatigue over time. Early interventions addressing PTSD symptoms and comorbidities may improve long term fatigue outcomes. [Table: see text]

Background: Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer. Objective: To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs. Design: Prospective cohort study and long-term follow-up. Setting/Subjects: From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year. Measurements: We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes. Results: Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p

As patients are living longer after a cancer diagnosis, survivorship is becoming increasingly important in cancer care. The sequelae of multimodality therapies include weight gain and decreased cardiorespiratory fitness, which increase cardiovascular risk. Evidence suggests that physical activity reduces the risk of breast cancer recurrence and death. Avoidance of weight gain after therapy also improves outcomes after a diagnosis of breast cancer. Prospective randomized trials must be performed to determine the benefits of specific physical activity and dietary habits for survivors of breast cancer. This review outlines the important physiologic changes that occur with antineoplastic therapy and the important role of exercise and diet.

97 Background: For cancer patients, the impact of pruritus is not well known, and may be increasing in incidence and severity for those receiving targeted agents. We aimed to describe pruritus in patients with solid tumors, assessing the incidence, pattern, treatments, and associations with cancer types and therapies. Methods: From 2009-2011, patients seen in the Duke Cancer Institute solid tumor clinics directly reported their symptoms on electronic tablets as part of routine care, using Patient Care Monitor 2.0. Of the resulting 17,338 encounters, >1,000 patients reported moderate-severe itching (score of >3 out of 10). The analysis cohort included 215 patients who reported severe itching (>6 out of 10) on at least one visit (total visits = 536). We reviewed charts to abstract demographics, diagnosis, stage, cancer therapy, comorbidities, anti-pruritus therapy, and provider response, and applied descriptive statistics and chi-square analyses. Results: Most patients had advanced disease (56% stage IV), and had breast (36%), lung (23%), kidney (8%), colorectal (6%), or prostate cancer (5%). Thirty percent were not on active therapy, 27% were receiving a targeted therapy, 29% were receiving cytotoxic chemotherapy, and 14% were receiving both. Pruritus persisted in 56% of patients, and resolved but recurred in 10%. Patients receiving chemotherapy were more likely to have severe rather than moderate pruritus (p 0.01), while those receiving targeted drugs were more likely to have persistent pruritus (p 0.03). Potentially high-risk targeted therapies including EGFR inhibitors, multi-kinase inhibitors, and mTOR inhibitors were not associated with severity or persistence of pruritus. Only 20% of patients were receiving an anti-pruritus treatment. Clinicians documented discussing pruritus in just 28% of cases, and addressed it directly only 10% of the time. Only 5% of patients were started on a new anti-pruritus treatment. Conclusions: Pruritus is common among patients with advanced cancer, and occurs across a range of cancer types and treatments. Pruritus is frequently not recognized or addressed by clinicians, and appears to be an unmet palliative care need in oncology.

9525 Background: Hospitalized cancer patients are more likely to have advanced disease and are at risk for poor outcomes, yet little is known about their quality of life (QOL) and rates of depressi...