PROJECT LEAD(S): Jessica Reeves, PharmD and Aida Venado, MD
EXECUTIVE SPONSOR(S): Steven Hays, MD; Lori Coleman, RN; Ashley Thompson, PharmD; David Quan, PharmD
ABSTRACT Cytomegalovirus (CMV) infection is a prevalent and serious opportunistic infection in immunocompromised solid organ transplant (SOT) recipients, with significant impacton graft survival, morbidity, and mortality. Valganciclovir, the first-line agent for prevention and treatment of CMV, requires precise dosing to avoid breakthrough infection and development of resistance due to underdosing and myelosuppression from overdosing. With the growth of our transplant program, admissions for CMV have increased from 13 in 2020 to 30 in 2024. Correspondingly, the average length of stay has risen from 69 days to 438 days, resulting in a significant increase in cost from $358,549 in 2020 to $2,470,406 in 2024.To address these challenges, we propose the implementation of a pharmacist-led CMV stewardship program utilizing existing tools within the Apex system to optimize medication dosing and monitoring. Literature supports that pharmacist-led stewardship programs can reduce the incidence of CMV viremia, prevent breakthrough infections, accelerate time to viral eradication, lower resistance rates, and decrease CMV-related hospital admissions by shifting from reactive to proactive care.1-3 Utilizing published strategies, the proposed pharmacist-led CMV stewardship program aims to reduce inpatient days due to CMV infection by 25%, achieve cost savings exceeding $500,000 annually, and minimize CMV resistance, thereby improving patient outcomes, morbidity, and mortality in SOT recipients.
TEAM We plan to initially implement the stewardship program within the lung transplant group, with the intention of expanding it to other SOT teams, all eager to improve CMV outcomes.Given that all SOT groups have similar outpatient lab review workflows and a dedicated pharmacist in clinic, this model will be easily applicable across other transplant populations. The initiative has the full support of both pharmacy and lung transplant leadership.
Transplant pulmonologist: Aida Venado, MD, MAS
Lung Transplant Pharmacists: Jessica Reeves, PharmD, Rebecca Florez, PharmD, Rachael Gordon, PharmD, Bo Yen, PharmD
Heart Transplant Pharmacist: Jose Lazo, PharmD, Victoria Nguyen, PharmD, Brandon Martinez, PharmD
Abdominal Transplant Pharmacists: Althea Han, PharmD, Melanie Mascetti, PharmD, KevenGomez, PharmD, David Quan, PharmD, Jennifer La, PharmD
PROBLEM CMV infections are common in the general population, typically causing mild illness in healthy individuals. However, CMV is a major complication in SOT recipients and is associated with significant healthcare costs, morbidity,and mortality. Once exposed, CMV remains latentand can reactivate during immunocompromised states. Risk stratification in SOT recipients is based on CMV serostatus: CMV IgG positive indicates prior exposure, and CMV IgG negative indicates no exposure. SOT recipients who are CMV mismatch (donor IgG positive, recipient IgG negative) are at the highest risk for infection. Additionally, the profound immunosuppressionrequired to prevent allograft rejection increases the risk for CMV reactivation which can lead tointense viral replication and life-threatening infection.
Valganciclovir is an oral antiviral that is the first-line standard of care for both the prevention and treatment of CMV infection. Dosing requires careful adjustment based on renal function, as underdosing increases the risk of breakthrough infection and the development of refractory or resistant disease, while overdosing can lead to myelosuppression, potentially exacerbating complications in immunocompromised patients. When refractory or resistant CMV infection is suspected, a genotyping test is performed to detect mutations and confirm antiviral resistance. This test is typically not available at labs outside of UCSF and can only be performed when CMV viral loads exceed 1,000 copies.
While close attention must be paid to renal dose adjustments, clinical expertise and individualized, comprehensive patient evaluation should be considered before implementing a dosing change considering factors such as recent VL, serostatus, presence of neutropenia or thrombocytopenia, and level of immunosuppression.
Within the lung transplant program, lab results are reviewed collaboratively by nurse coordinators with an advanced practice provider (APP), fellow, or attending pulmonologist. Similar workflows are followed in the outpatient management of other SOT patients. During lab review, renal function and CMV VL are briefly assessed, and dosing changes to valganciclovir are made accordingly. Due to the high volume of patients, there is often insufficient time to conduct a comprehensive assessment of each case leading to instances of inappropriate dose reductions, contributing to breakthrough viremia or development of CMV resistance, which requires hospitalization for IV therapies.Furthermore, a lack of standardization in the formulas used to assess renal function among providers has led to dosing discrepancies, confusion about when to initiate treatment versus continue prophylactic dosing for low-level CMV viremia, and inconsistent use of CMV genotyping.This has resulted in increased burden to patients, such as the need to travel to long distances to UCSF for CMV genotyping, as well as increased costs to both UCSF and patients.
Rural and underserved communities can face disparities in care. Patients in communities that do not have LabCorp or Quest and rely on alternative facilities for lab work can experience significant delays in time to reporting of their labs, leading to delays in adjustment of dosing, initiation of treatment, or assessment for resistant disease. If resistant disease is suspected, these patients must travel to UCSF for CMV genotyping, as it is generally unavailable at outside laboratories.
Over the past five years, UCSF has seen a notable increase in inpatient admissions for the management of CMV infections, rising from 13 in 2020 to 30 in 2024, with the rate of CMV admissions per 1000 admissions increasing from 3.2 in 2021 to 8.1 in 2024. This has also been accompanied by a substantial rise in total inpatient days from 69 to 438 (with a median lengh of stay ranging from 4 in 2020 to 7 in 2024), suggesting a trend toward more severe or refractory cases. The financial impact of these admissions has also escalated exponentially, with total costs increasing from $358,549 in 2020 to $2,470,406 in 2024 with a median cost of $16,619 in 2020 and $31,075 in 2024. Please see attached document 'hospitalizations, length of stay, and costs' attached for further details and breakdown by organ group. Furthermore, multiple incident reports (IRs) have been filed concerning missed or delayed CMV lab results, as well as the development of severe, resistant CMV disease linked to the underdosing of valganciclovir. With regard to lab tests, the number of CMV genotyping tests performed has increased, from 22 tests in 2020 to 33 in 2024. Specifically, within the lung transplant group, 26 genotyping tests have been sent from 2020 to 2024. Confirmed CMV resistance has increased from 50% (1 out of 2 tests) in 2020 to 75% (6 out of 8 tests) in 2024. Additionally, eight of the 26 genotyping tests were sent inappropriately with insufficient VL for the test to be run.
This concerning trend of escalating inpatient days, costs, and increased morbidity and mortality is expected to persist as our annual transplant volume continues to grow. As of December 2024, UCSF ranks as the second all-time highest volume transplant center in the United States, having performed a total of 18,449 organ transplants, according to the Organ Procurement and Transplantation Network (OPTN).
TARGET Published literature supports that pharmacist-led CMV stewardship initiatives can reduce CMV infection rates, CMV-related hospital admissions, and CMV resistance rates by over 40%.1-3 Furthermore, when patients develop (val)ganciclovir resistance, literature suggests that there is a ten-fold increase in associated total hospital costs ($200,000 vs $20,000).4 Based on published literature and success of these pharmacist-led initiatives, our goal is to implement a pharmacist-run CMV stewardship program aimed at reducing CMV-related hospital admissions, inpatient days, associated costs, and the development of CMV resistance by 25%. This would result in a reduction of annual CMV-related hospital admissions from 30 to 22 and a decrease in inpatient days from 438 to 328. With an estimated direct variable cost of $1,688 per bed for the 2023-2024 academic year, we anticipatecost savings of at least $183,992 (excluding ICU bed costs) from a 25% reduction in patient days.
In 2024, the total cost associated with CMV infection admissions was $2,470,406. We project a 25% reduction in costs, resulting in total savings of $617,601. Lastly, we anticipate a 25% reduction in the development of CMV resistance. In 2024, 33 CMV genotyping tests were ordered at a cost of $1,945 per test. With a 25% reduction in resistance and the subsequent need for fewer genotyping tests, we expect to save $16,000.
We utilized Slicer Dicer within Apex to determine the number of admissions, total length of stay, and total associated costs for CMV infection as the principal problem for admission.
GAPS Currently, the primary gap is significant variability in CMV management within the lung transplant program at UCSF, as well as across other organ transplant groups. In the existing workflow, CMV viral load results are reviewed alongside renal function during daily lab review (Monday through Friday) with nurse coordinators and an APP, fellow, or attending. Due to the high volume of labs reviewed, there is often insufficient time to individualize and comprehensively assess each CMV result and corresponding change in renal function. Additional challenges include the absence of updated, standardized protocols regarding when to initiate treatment dosing of valganciclovir versus when to continue monitoring, resulting in confusion and inconsistent practices.
Within Apex, there has been the use of different creatinine clearance calculators that may utilize an inappropriate patient weight leading to under or over estimating creatinine clearance, further complicating dosing decisions. Additionally, if a patient has not had a weight or serum creatine in the past twenty-one days, Apex will not calculate a creatinine clearance, leading providers to potentially calculate it incorrectly. Moreover, there has been an overuse of CMV genotyping in patients without clinical suspicion of resistant or refractory disease, or without sufficient viral load for the test to be run, leading to unnecessary costs and increased patient burden due to the need to travel long distances to UCSF for testing.
Lastly, some patients routinely have laboratory tests conducted at non-UCSF facilities or facilities that do not result within Apex (i.e. NOT UCSF, Labcorp or Quest), requiring manual entry of results into the Apex system.This process introduces equity gaps, resulting in delays in receiving test results, adjusting valganciclovir dosing, and initiating timely treatment for breakthrough CMV infections.These delays contribute to the emergence of resistant CMV strains, which may ultimately necessitate inpatient treatment with intravenous foscarnet or maribavir. Patients who are most adversely affected are those residing in remote communities with limited access to local laboratory services.
INTERVENTION We propose the implementation of a pharmacist-led CMV stewardship initiative, modeled after successful programs at other institutions, which have demonstrated reductions in the incidence of CMV viremia and breakthrough infection, faster time to CMV eradication, lower rates of CMV resistance, and a decrease in CMV-related hospital admissions.1-3 Furthermore, these stewardship models have facilitated a shift in patient-centered care from reactive to proactive, leading to improved patient outcomes and a reduction in the duration of valganciclovir therapy needed to achieve viral clearance, which can help reduce risk of myelosuppression in an already vulnerable population.1
This pharmacist led initiative will be implemented in the outpatient setting and integrated into the workflow of the covering outpatient pharmacist for each respective organ group.First, an updated UCSF CMV protocol will be developed in collaboration with Infectious Disease Specialists, Lung Transplant Specialists, and Transplant Pharmacists to align with current practices and streamline CMV management. To ensure the sustainability and long-term success of the initiative, we will initially focus on the highest-risk populations, including CMV mismatch patients (donor CMV IgG positive, recipient CMV IgG negative), individuals with an active CMV viral load, and those receiving alternative therapies for CMV (such asletermovir,maribavir, foscarnet, or cidofovir).
Working with Phoenix and informatics teams, an Episode of Care Encounter will be created to facilitate the enrollment and monitoring of these high-risk patients. A daily report (Monday through Friday) will be generated within Apex, enabling the covering clinic pharmacist to review enrolled patients. The pharmacist will clinically assess the patients' new lab results and may take one of the following actions, as clinically appropriate: adjust the dose of valganciclovir, modify the frequency of CMV viral load monitoring, or order CMV resistance genotyping. Additionally, the pharmacist will communicate with the covering attending physician and make recommendations regarding changes to immunosuppression, admission for intravenous therapies in cases of suspected refractory or resistant CMV, or switching to alternative therapies due to adverse effects.
Through the Episode of Care, the pharmacist will be able to document a concise, standardized note utilizing DOT phrases, which will be routed to the nurse coordinator and sent to the patient via MyChart. The nurse coordinator will then follow up with the patient to ensure the necessary changes are implemented. Communication of medication changes with patients by the nurse coordinator is already a standard of practice within our workflows. The pharmacist will also assign a follow-up date to the encounter, and the daily report will allow sorting based on the next follow-up date, enabling timely review of labs and ensuring that the pharmacist can reach out if labs are not completed as expected.
All high-risk CMV patients will be enrolled in the CMV initiative during their index hospitalization for transplantation by the covering inpatient transplant pharmacist. In the outpatient setting, when an CMV VL is detected, an alert will be triggered in Apex and sent to the respective pharmacist’s pooled in-basket. The pharmacist will then enroll the patient for ongoing management. Additionally, patients currently receiving alternative therapies will be enrolled for monitoring of CMV VL to detect any breakthrough viremia, or at the time of transitioning to alternative therapies.
This initiative has been discussed with our informatics and Phoenix teams and we believe the intiative to be feasible within the Caring Wisely year. We don't anticipate that this will be affected by the Beaker lab build freeze. The data we will need to utilize for this initiative is already available and will only require creation of a dashboard to track and monitor patients within Apex.
Potential barriers to implementation include ongoing challenges in obtaining lab results promptly for patients in remote areas whose EHRs do not integrate with ours, as well as difficulties in obtaining CMV resistance genotyping at outside hospitals or labs. Additional challenges include medication non-compliance leading to breakthrough CMV infection and insurance authorization for alternative therapies such as maribavir or letermovir. While we anticipate staffing coverage of this initiative to assimilate into our current workflow, there is a potential barrier for staffing gaps if a pharmacist(s) is on vacation and may require the inpatient pharmacist to review the daily report.
With regard to implementing this initiative within our respective teams, we plan to develop provider-facing material in the form of an updated CMV prophylaxis and treatment protocol for each solid organ transplant organ group as well as a written protocol detailing the CMV initiative and outlining the changes in workflow. We can also hold a Zoom meeting with the respective parties involved in lab review to educate on the workflow changes.
PROPOSED EHR MODIFICATIONS We need to develop a new workflow for CMV monitoring for transplant recipients at UCSF within Apex utilizing Episodes of Care Encounters. This platform will facilitatetimely, reliable, and closed-loop communication among multiple stakeholders—patients, transplant pharmacists, and nurse transplant coordinators—from laboratory result review to patient instructions. Please see the attached document outlining specific EHR modifications.
RETURN ON INVESTMENT (ROI) Based on our goal of a 25% reduction in CMV-related hospital admissions, inpatient days, associated costs, and the development of CMV resistance, the following cost savings and revenue enhancement would be achieved:
Reduction of annual CMV-related hospital admissions from 30 to 22
Decrease in inpatient days from 438 to 328
Cost savings of $16,00 for reduced CMV genotyping tests, based on CMV genotyping test of $1,945
Cost savings of at least $183,992 in bed costs (excluding ICU bed costs) based on estimated variable cost of $1,688 per bed for the 2023-2024 academic year
Total hospital-admission cost savings of $617,601 based on total annual cost of $2,470,406 in 2024
SUSTAINABILITY Within the transplant programs, pharmacists and nurse coordinators are already established members of the team. With lung transplant pharmacists in clinic five days per week, we believe that this model will be sustainable, requiring approximately 1 to 1.5 hours of review time per day, Monday through Friday, based on the time commitment described by other institutions and estimated volume of labs to be reviewed. We believe that funding for this initiative would allow this project to be created, which would then be assimilated into pre-existing workflows allowing for sustainability and longevity beyond the funding year while improving patient care and resulting in cost savings.
Supervisors, managers, and transplant pharmacists are all in support of integrating this into their existing outpatient roles. The initial idea for implementation of this project arose from within our pharmacy group in response to incident reports. Additionally, this CMV stewardship initiative has support from our infectious disease colleagues and respective solid organ transplant teams. We expect that the success of this initiative will have a profound positive impact on patient care and reduce morbidity and mortality post-solid organ transplant. The additional workload is anticipated to be feasible and can be incorporated into existing clinic workflows. Typically, clinic days are only half day in regard to actively seeing patients. The pharmacist spends the other half of the day answering inbasket messages, reviewing patients for the following days clinic, providing medication access, etc. During this second half of the day, the pharmacist will be able to incorporate this new CMV workflow into their day.
Reviewing high-risk CMV patients through this protocolized initiative will also allow for improved workflow efficiency. In the current state, the pharmacist receives in basket messages when providers have questions about CMV medication dosing. This initiative will reduce these in basket requests and create a platform for a more streamlined, efficient approach for monitoring patients. With the buildout of a more systematic report within Apex, this would make our time, review and follow up of these patients more efficient and consistent providing equitable care to all solid organ transplant recipients.
Lastly, with this initiative we plan to build a dashboard within Apex that will be managed by the team and allow us to monitor and sustain the process measures, which will be integral to the success and longevity of this initiative. We anticipate that the build of this initiative would only take a couple of months (2-3) and first tests of change could be performed within the following six months.
BUDGET
Salary support for project lead: $50,000
Comments
Thank you for submitting this
Thank you for submitting this compelling proposal. A few requests to better understand your target metrics:
1. Hospitalizations should be compared as rates... number of hospitalizations per total number of eligibles. Can you better define the numerator and denominator in these rates?
2. In addition to total costs and hospital days, can you also show the average costs and hospital days (with standard deviations)? There's a good chance you will have outliers, so you might also show these as medians with IQRs.
3. Process Measures. The pharmacist will clinically assess the patients' new lab results and may take one of the following actions, as clinically appropriate: adjust the dose of valganciclovir, modify the frequency of CMV viral load monitoring, or order CMV resistance genotyping.
**can you estimate current/baseline values of these actions, and what you propose will happen with the intervention in place?
Thank you, Dr. Gonzales, for
Thank you, Dr. Gonzales, for your valuable feedback and insights. I apologize for the delayed response, as we have been actively gathering additional data to ensure a comprehensive answer to your questions. Please see a response for question 1 below. I will be in touch soon with responses to questions 2 and 3.
1. Rates of hospitalizations
From 2020 to 2024, there were 12536 hospitalizations from 6662 patients to the solid organ transplant (SOT) services, including Advanced Lung Disease, Advanced Heart Failure, Kidney Transplant, and Liver Transplant. To calculate the rate of CMV admissions in SOT patients, we considered the number of hospitalizations for management of CMV infection as the primary diagnosis as the numerator and the total number of hospitalizations to the SOT services as the denominator. Overall, the rate of CMV admissions in SOT patients has increased over time (Table 1), being the highest in the Advanced Lung Disease Service and the Kidney Transplant service.
Table 1. Hospital Admissions in Solid Organ Transplant Patients by Primary Diagnosis
Year
Non-CMV
CMV
Rate of CMV admissions per 1000 admissions
2021
2519
8
3.2
2022
2421
4
1.6
2023
2456
14
5.7
2024
2569
21
8.1
2025
2505
19
7.5
Table 2. Rate of Hospital Admissions for CMV Infection in Advanced Heart Failure Patients
Year
Non-CMV
CMV
Rate of CMV admissions per 1000 admissions
2021
233
2
8.5
2022
205
0
0
2023
284
1
3.5
2024
314
4
12.6
2025
296
1
3.4
Table 3. Rate of Hospital Admissions for CMV Infection in Advanced Lung Disease Patients
Year
Non-CMV
CMV
Rate of CMV admissions per 1000 admissions
2021
206
0
0
2022
210
0
0
2023
218
4
18
2024
202
3
14.6
2025
236
13
52.2
Table 4. Rate of Hospital Admissions for CMV Infection in Kidney Transplant Patients
Year
Non-CMV
CMV
Rate of CMV admissions per 1000 admissions
2021
1172
3
2.6
2022
1132
3
2.6
2023
1111
9
8
2024
1124
12
10.6
2025
1091
5
4.6
Table 5. Rate of Hospital Admissions for CMV Infection in Liver Transplant Patients
Year
Non-CMV
CMV
Rate of CMV admissions per 1000 admissions
2021
908
3
3.3
2022
874
1
1.1
2023
843
0
0
2024
929
2
2.1
2025
882
0
0
Hi Dr. Gonzales, In response
Hi Dr. Gonzales,
In response to questions 2 and 3, please see below.
#2 Average costs and hospital days
The mean and average length of stay for admissions for CMV infection has increased over time (Table 6) since 2020, unlike for admissions for non-CMV diagnosis, which has remained stable (Table 7).
To estimate the hospitalization cost, we used the Payments and Refunds slice in Slicer Dicer that displays the total payment amount less any refunds associated with the account. This includes bad debt and external AR payments and refunds. This field shows payments as a positive amount. Based on the data available, the cost appears skewed (Table 8 and 9). Though, among CMV admissions, 23 (33.82%) were on the lowest quartile of cost, 20 (29.4%) in the second quartile, 16 (23.5%) in the third quartile, and 9 (13.2%) in the highest quartile. Using a linear regression model, with diagnosis and length of stay as predictors, we estimated the cost of a 7-day admission for CMV infection, the median duration in 2024, to be $30,171.52. We are open to feedback on how to better track hospital admission costs and would appreciate if the reviewers could suggest another metric we could analyze.
Table 6. Length of Stay for Hospital Admissions for CMV Infection in Solid Organ Transplant Patients
Year
Mean
SD
Median
Interquartile Range
2020
5.1
3.5
4
8, 2.5
2021
4.3
3.2
3
6, 2.5
2022
9.3
11.7
4
9, 4
2023
7.3
7.5
5
8.5, 2.5
2024
13.3
14.5
7
15, 4
2025
7
7.1
7
12, 2
Table 7. Length of Stay for Hospital Admissions for Non-CMV diagnosis in Solid Organ Transplant Patients
Year
Mean
SD
Median
Interquartile Range
2020
6.4
9.6
4
7, 2
2021
7.4
17
4
7, 2
2022
6.8
8.3
4
7, 2
2023
6.5
8.7
4
7, 2
2024
7.9
13
4
8, 3
2025
6.3
7.5
4
7, 2
Table 8. Payments for Hospital Admissions for CMV Infection in Solid Organ Transplant Patients
Year
Mean
SD
Median
Interquartile Range
2020
$17714.6
11403
$16619
25708.9, 11302.6
2021
$12565.3
1980.4
$12480
13841.3, 11289.2
2022
$96632.1
276544.6
$12663.4
29409.5, 11192.4
2023
$44776.4
60141.2
$15735.6
36610.8, 14307.5
2024
$47133.1
49534.1
$31075.7
62671.1, 14744.2
2025
$7162.5
10129.3
$7162.5
14325, 0
Table 9. Payments for Hospital Admissions for Non-CMV diagnosis in Solid Organ Transplant Patients
Year
Mean
SD
Median
Interquartile Range
2020
$76646.6
161222
$26296.6
67205.1, 13440
2021
$94808.5
243343.6
$32963.5
83945, 15057.3
2022
$93199.3
175289.9
$33091
87237.3, 15338.2
2023
$87114.5
174118.6
$31777.6
76509.8, 15947.4
2024
$102606
208362.2
$29475
87866.3, 13004.8
2025
$16544.5
51553.2
$0
13039.5, 0
#3 Process Measures
Currently, pharmacists perform these actions on an ad hoc basis, typically in response to inbasket messages from providers requesting a more detailed review of a patient's therapy—including dose adjustments, renal function, viral load (VL), and other clinical parameters. These reviews may also occur as part of routine inpatient clinical assessments. This makes it challenging to estimate current/baseline values. With the implementation of the proposed intervention, pharmacists will have dedicated time to conduct more comprehensive and consistent assessments. Furthermore, the development and implementation of a standardized CMV protocol will support reduced variability in the management of CMV across solid organ transplant organ groups. With the additional Apex support, we will be able to develop a dashboard to track metrics moving forward and better gauge the impact of this initiative. Based on other large academic medical centers who have implemented similar initiatives with success, I propose that we will reduce the incidence of CMV viremia, prevent breakthrough and resistant infections, and decrease CMV-related hospital admissions.
Thank you for your submission
Thank you for your submission of this excellent proposal. A few questions and feedback.
1) Can you prioritize the gaps listed in the current state that are contributing to your problem of increasing CMV resistance, genotype testing, and inpatient hospitalizations? For instance, one of the gaps listed is that patients frequently use outside labs to do their testing, and there are delays in uploading and reviewing those results. If this turns out to be a large contributing factor to your quality gap, I'm not sure if I see how your proposal would address this gap.
2) It is helpful that an outside AMC has shared their EHR modifications with you. Have you socialized this with our informatics and Pheonix teams to see if building these functionalities is feasible within a Caring Wisely year. Approximately how long would this build take and would this be impacted at all by the Beaker lab build freeze or not impacted? When would first tests of change in this proposal be able to be rolled out?
3) Thank you for sharing your projected sustainablity plan. Are the supervisors, managers, and transplant pharamacists themselves bought into adding this to their existing job descriptions? Would this additional 1-1.5 hrs of work per day be feasible?
Hi Dr. Lau,Thank you for the
Hi Dr. Lau,
Thank you for the insightful comments and questions!
1. Prioritize current gaps
To prioritize the gaps contributing to increased CMV resistance, genotype testing variability, and inpatient hospitalizations, the most critical issues include inconsistent CMV management, limited time for assessing high-risk cases, and the absence of a dedicated review team across organ transplant groups. Based on published literature, we believe the implementation of a pharmacist-led CMV stewardship program will enhance oversight, provide dedicated time for comprehensive evaluation of high-risk patients, and ultimately reduce these existing gaps in care. With funding and support, we would be able to create this stewardship initiative and will allow for a more structured approach to patient monitoring, reducing variability in treatment strategies and improving outcomes.
The second gap is the absence of an updated, standardized CMV prophylaxis and treatment protocol across each organ group. We plan to create a protocol for each organ alongside infectious disease specialists, transplant pharmacists, and the respective attending specialty.
We are able to see lab results in a timely manner in Apex for patients who have their labs drawn at UCSF facilities, LabCorp or Quest. A small portion of patients utilize non-UCSF facilities and face delays in care. Our proposal will address this gap by providing proactive follow up when labs are anticipated. High risk patients, patients with a detectable VL or those on non-traditional therapies, will be enrolled in an Episode of Care. If a patient has their labs drawn at non-UCSF facilities, the pharmacist will be able to assign follow up for the anticipated lab. If results are not in the Apex at the expected follow up, the pharmacist will then perform outreach to the lab to obtain the results. This will result in expedited lab review and patient management until more permanent automated lab result retrieval is implemented in the future.
2. Yes, this has been socialized with our informatics and Phoenix teams. Efforts have already been made to explore building these functionalities within Apex and Phoenix and we believe it to be feasible within the Caring Wisely year. With our baseline work that has already been done, we believe the funding for protected time and additional support will allow us to build these functionalities faster so we may implement our intervention sooner and begin assessing tests of change.
We do not anticipate that this initiative will be affected by the Beaker lab build freeze. The data we will need to utilize for this initiative is already available and will just require creation of a dashboard to track and monitor patients.
I anticipate it would take a month or two to build out the functionalities in Apex and we could have first tests of change within 6 months after to determine the impact of the intervention on CMV viremia, admissions, length of stay, reduced testing, etc.
#3
Supervisors, managers, and transplant pharmacists are all in support of integrating this into their existing outpatient roles. The initial idea for implementation of this project arose from within our pharmacy group in response to filed incident reports. Additionally, this CMV stewardship initiative has support from our infectious disease colleagues and respective solid organ transplant teams. Additionally, we anticipate that this could be an intiative that could be utilized at the other UC transplant centers to improve post-transplant CMV outcomes. We expect that the success of this initiative will have a profound positive impact on patient care and reduce morbidity and mortality post-solid organ transplant. The additional workload is anticipated to be feasible and can be incorporated into existing clinic workflows. Typically, clinic days are only half day in regard to actively seeing patients. The pharmacist spends the other half of the day answering inbasket messages, reviewing patients for the following days clinic, providing medication access, etc. During this second half of the day, the pharmacist will be able to incorporate this new CMV workflow into their day.
Reviewing high-risk CMV patients through this protocolized initiative will also allow for improved workflow efficiency. In the current state, the pharmacist receives in basket messages when providers have questions about CMV medication dosing. This initiative will reduce these in basket requests and create a platform for a more streamlined, efficient approach for monitoring patients. With the buildout of a more systematic report within Apex, this would make our time, review and follow up of these patients more efficient and consistent providing equitable care to all solid organ transplant recipients.
Great proposal! I think this
Great proposal! I think this will really help our transplant patients and improve outcomes!
Thank you for submission of
Thank you for submission of this great proposal!
I'm in agreement with Ralph and Cat's question; additional questions/feedback:
(1) What are your plans to monitor and sustain process measures, i.e, building out a dashboard or reportwork bench that will be managed by the team?
(2) Related to Cat's question #2, do you have available data that shows the number of patients that use outside labs and why that causes delays in the workflow?
(4) Do you have any plans to develop patient-facing or provider-facing material to help educate these proposed changes?
Hi Rasmyah, Thank you for
Hi Rasmyah,
Thank you for these great questions/comments.
1. Monitoring and sustaining process measures
To monitor and sustain process measures, we plan to build out a dashboard that will be managed by the team. Measuring the outcomes and continuing ongoing quality improvement assessments will be integral to the success and longevity of this initiative.
2. Outside labs
I am still awaiting the data of how many patients receive labs at facilities outside of UCSF, LabCorp, and Quest; however, this is not a large percentage of our patient population. We are able to see lab results in a timely manner in Apex for patients who have their labs drawn at UCSF facilities, LabCorp or Quest. It is patients who receive labs outside of these facilities that are affected. I can update you if I receive these numbers prior to Friday. The delays in workflow are created because labs from faciltiies not listed above must be manually faxed to UCSF, then manually entered into Apex. There can be delays receiving the fax from outside facility, entering it into Apex and thus delays in acting on the resulted lab leading to delays in care.
Our proposal will address this gap by providing proactive follow up when labs are anticipated from these patients who receive labs at these facilities (i.e. non-UCSF, LabCorp, Quest facilities). The pharmacist will be able to assign follow up for the anticipated lab. If results are not in the Apex at the expected follow up, the pharmacist will then perform outreach to the lab to obtain the results. This will result in expedited lab review and patient management until more permanent automated lab result retrieval is implemented in the future.
3. Patient/Provider Facing Materials
We plan to develop a couple forms of provider-facing material. First, we plan to develop an updated CMV prophylaxis and treatment protocol for each solid organ transplant organ group. This will be created alongside infectious disease specialists, transplant pharmacists and the appropriate organ-specific attending physicians. We also plan to develop a written protocol detailing the CMV initiative and outlining the changes in workflow that will be disseminated to each of the respective teams. We can also hold a Zoom meeting with the respective teams and care team memebers involved in lab review to educate on the workflow changes.
This sounds like a great
This sounds like a great proposoal - I am very hopeful that it will optimize outcomes for the transplant patient population!
Thank you for putting
Thank you for putting together this proposal and gathering input from the various individuals listed. I hope this leads to a positive change in the transplant clinics to help our patients.
This is a fantastic proposal
This is a fantastic proposal and has massive implications throughout the enterprise. CMV is one of our biggest post transplant complications and in my tenure at UCSF we have been seeing a pretty significant increase in resistance. Streamlining the CMV management has direct impact on the inpatient capacity/throughput, strategic growth, and quality/safety. I think this is an excellent idea. Well done Jess!