(70) Improving identification and evaluation of adult cystic fibrosis patients with advanced lung disease to increase timely referral for lung transplantation.

Background: The Cystic Fibrosis (CF) Foundation guidelines for lung transplant evaluation call for systematic referral based on patients’ forced expiratory volume in the first second (FEV1) and markers of shortened survival [1]. Consistent screening for these markers and early referral of eligible patients are essential to improving outcomes in patients with advanced lung disease (ALD). A quality improvement (QI) initiative to identify CF patients with ALD, perform recommended evaluation and refer eligible patients for lung transplantation in a timely manner was developed. The goals were to increase the percentage of those screened for markers of shortened survival and those referred for lung transplant evaluation.

Methods: The multidisciplinary QI team identified adult CF patients who met ALD criteria from January 2021 through March 2022 by utilizing Port CF center specific data, CF Smart Reports, and patient medical records. Patient data included FEV1, body mass index, thoracic procedures, pulmonary rehabilitation, palliative care visit, massive hemoptysis, pneumothorax, pulmonary exacerbations, intensive care unit admissions, echocardiogram (ECHO), right heart catheterization, six-minute walk test (6MWT), oxygen assessment, blood gas, transplant discussion, and transplant referral. The QI team designed a protocol to monitor patients with ALD including evaluation and discussion of lung transplantation starting in 1/2022. Data from 1/2022-3/2022 was used as a comparison to baseline. The proportion of eligible patients who were referred for lung transplantation and who had appropriate assessment for markers of shortened survival based on the CF guidelines for lung transplant [1] were assessed and compared. Data are compared via chi-squared test.

Results: Data from 2021 was used as baseline and identified 35 patients with ALD. Following the usual practice of the clinic during the baseline period, 46.7% of eligible patients were referred for lung transplantation. The proportion of eligible patients evaluated for markers of shortened survival were low for ECHO, 6MWT, blood gas testing and oxygen assessment (13.3-66.7%, Table). Following the onset of intervention, data from the first quarter of 2022 showed a non-significant increase in the proportion of eligible patients referred for lung transplantation to 50.0%. There was an increase noted in the proportion of eligible patients evaluated by ECHO and 6MWT, while there was a non-significant decrease in patients receiving blood gas analysis and no change in those receiving an assessment for oxygen needs. (Table)

Conclusions: The development of a process to identify adult CF patients with ALD and closely follow the CF Foundation guidelines for lung transplant referral led to an increase in the evaluation of some markers of shortened survival in those with ALD. This improvement was made in a short period of time, 3 months, and was accompanied by a non-significant increase in the proportion of eligible patients referred for lung transplantation. The improved adherence to guidelines and increased monitoring for markers of shortened survival is expected to increase the awareness of ALD patients who are appropriate for referral for lung transplant evaluation and increase the proportion referred. The QI team plans to continue this process and analyze data in subsequent 3-month intervals.

Acknowledgements:

References: [1] Ramos KJ et al, Lung transplant referral for individuals with cystic fibrosis: Cystic Fibrosis Foundation guidelines. J Cyst Fibros 2019; 18:321-333.