Baseline characterization of nutrition counseling and modifiable cardiovascular risk factors among childhood cancer survivors through EHR-linked data analytics Free

Background:

Approximately 50% of childhood cancer survivors (CCS) will develop therapy-related cardiovascular (CV) dysfunction. Targeting of modifiable CV risk factors with exercise and physical activity has been extensively researched with limited success. Additionally, successful intervention studies are extremely limited in CCS. The Children's Oncology Group (COG) Long-Term Follow-up guidelines recommend nutrition referral for relevant abnormalities (BMI, lipids, etc…), though the interplay between nutrition interventions in CCS and reduction of cardiac disease rates later in life is not well explored. As a preface to the development of nutrition-focused interventions in CCS, an understanding of the baseline characteristics, rates of nutrition counseling, and modifiable CV risk factors at our survivorship clinic was necessary. Given the wealth of information possessed by modern-day electronic health records (EHRs), effective data analysis can provide actionable insights and critical understandings of patient populations as demonstrated in our study.

Methods:

This is a single-center retrospective longitudinal study that analyzed all CCS seen within the survivorship program at Nemours Children's Hospital – Delaware (NCH-DE) from 2023 through 2024. Baseline data was collected through use of Qlik Sense®, a data analytics platform integrated within the Epic Hyperspace® EHR, as well as through interdisciplinary collaboration with the Nemours Quality & Safety Data Analytics team. Metrics of interest included rates of visits, BMI, hypertension, diabetes, and dyslipidemia. Unique patients, as well as unique visits occurring on or after the first survivorship visit, were calculated. Overweight BMI was defined as 85^th to less than the 95^th percentile in CCS less than 18 years old, and 25 to 29.9 kg/m² in CCS 18 years or older. Obese BMI was defined as greater than or equal to the 95^th percentile in CCS less than 18 years old, and 30.0 kg/m² or greater in CCS 18 years or older. Hypertension was based on presence on the problem list or anti-hypertensives being prescribed irrespective of a patient's entry into survivorship. Diabetes and pre-diabetes were defined as hemoglobin A1c greater than or equal to 6.5% and 5.7-6.4%, respectively. Dyslipidemia was defined as possessing any one or more abnormal values on or after the first survivorship visit for the following defined lipid markers: total cholesterol (TC, greater than or equal to 200 mg/dL), low density lipoprotein (LDL-C, greater than or equal to 130 mg/dL), and triglycerides (TG; greater than or equal to 100 mg/dL and 140 mg/dL if less than and greater than/equal to 10 years of age, respectively). The Qlik Sense® electronic dashboard was confirmed for accuracy with manual chart reviews. Patients who relapsed during this timeframe were excluded.

Results:

A total of 292 unique CCS encompassing 603 unique survivorship visits were evaluated at NCH-DE from 2023 through 2024. The majority diagnosis was B-ALL. Thirty-one (10.6%) CCS completed a visit with nutrition during the aforementioned timeframe. Seventy-six (26.0%) CCS were overweight, whereas 67 (22.9%) were obese. Interestingly, although 22 (7.5%) CCS received a diagnosis of hypertension and were prescribed an anti-hypertensive irrespective of their entry into survivorship, 0 CCS were reported to have hypertension and/or had an anti-hypertensive prescribed at their survivorship visits specifically. Ten (3.4%) CCS met criteria for diabetes, with an additional 14 (4.7%) having pre-diabetes. Dyslipidemia was noted in 33 (11.3%) CCS, accounting for 15 (5.1%) with elevated TC, 12 (4.1%) with elevated LDL-C, and 24 (8.2%) with elevated TG. 67 (22.9%) CCS received care with cardiology.

Conclusion:

Our study established important baseline data and revealed lower rates for all CV risk factors except overweight BMI compared to previously-published CCS data. It also highlighted opportunities for optimizing care delivery for CCS, including increasing nutrition and sub-specialist referrals, improving documentation of CV risk diagnoses, and improving rates of relevant screenings that play a role in cardiovascular health. Additionally, successful integration and utilization of an EHR-based data analytics engine for patient population and outcomes characterization was demonstrated – a method that can be duplicated at other institutions. Next steps will focus on the development of nutrition-focused interventions in CCS.