Increasing RAS mutation result availability in newly diagnosed patients with metastatic colorectal cancer by their first outpatient medical oncology clinic visit at a large safety net hospital.
Authors: Patel Viral M , Moscowitz Anna , Cobb Robyn , Balani Jyoti , Jones Amy Little , Henderson Amy , Baker Kristi , Kazmi Syed Mohammad Ali , Verma Nilesh , Brown Timothy J. , Al Mutar Salwan , Kainthla Radhika 
Published: January 2025

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Background:
Rat sarcoma virus mutation testing (RASmt) is critical in guiding systemic therapy selection for patients with metastatic colorectal cancer (mCRC) in the first-line setting. Missing results at the initial medical oncology visit can negatively impact patient outcomes by delaying treatment or leading to inappropriate treatment selection. This quality improvement (QI) project aims to increase the percentage of patients with newly diagnosed mCRC with RASmt results available by their first outpatient medical oncology appointment at a large safety net hospital to 20% over an 8-month period.
Methods:
A multidisciplinary team of key stakeholders including clinicians, a pathologist, and administrators was assembled to determine factors associated with failure to obtain RASmt. A baseline analysis of all patients referred to the gastrointestinal (GI) oncology clinic from June 2022 to April 2023, with manual review of electronic medical records by investigators, showed that only 6% (3/46) of newly diagnosed patients with mCRC had RASmt results available by their first GI oncology appointment. Two Plan-Do-Study-Act (PDSA) cycles were conducted to assess interventions that were implemented based on process mapping and reasons for unavailable test results. To increase the percentage of patients with RASmt results available, starting December 2023, patients initially diagnosed with mCRC as inpatients who were being followed by the oncology consult service had RASmt ordered on the tissue biopsy prior to discharge (PDSA1). Starting April 2024, the medical directorfor outpatient GI oncology clinics ordered RASmt for all patients with mCRC referred to the clinic at the point of referral (PDSA2)
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New patient referrals were reviewed through July 3, 2024.
Results:
At baseline, the most common reason for unavailable RASmt results was the lack of test orders, with 70% (32/46) of new patients with mCRC not having RASmt ordered prior to their first appointment. Once RASmt was ordered, the average time for results was 13 days. After the first intervention, 4% (1/23) of patients with mCRC had RASmt results available at their first appointment. After the second intervention, 42% (5/12) of patients had RASmt results available. Additionally, median time from diagnosis of mCRC to first appointment decreased from 23 days at baseline to 17 days during PDSA1 to 12 days during PDSA2.
Conclusions:
By ordering RASmt at the point of referral, the percentage of patients who had RASmt available at their first appointment markedly increased from 6% to 42%. This QI initiative additionally demonstrates the importance of multidisciplinary teams to enhance patient care efficiency at a large safety net hospital. Further efforts are ongoing to increase RASmt availability beyond 42% with a focus on reducing the turnaround time of the test.