Bracing for infantile scoliosis: no sedation needed

Mehta casting technique applied under anesthesia is standard treatment for infantile scoliosis (IIS). However, concern has been raised about frequent anesthesia in children less than three years. The development of a customized thoracolumbar sacral orthosis (TLSO) could avoid the risks of Mehta casting. To develop a bracing technique for IIS that achieves patient compliance and scoliosis correction. Nine patients with ISS were offered a custom TLSO as an alternative to Mehta casting. One patient declined due to an insurance issue. No anesthesia was required for measurement or fitting of the TLSO. A temperature sensitive monitor recorded wear time. Brace success was determined by radiographic correction and adherence to prescription of greater than 18 hours per day. Eight patients had brace treatment with mean(range): age 19(12–44) months, curve magnitude 34° (22–44°), rib vertebral angle of greater than 20° with follow-up 17(3–28) months. In brace correction was less than 15 degrees in 6 of 8 patients. Compliance monitor recorded wear: 4 patients ≥ 18 hours, 2 patients 16–18 hours, 1 had 14 hours, and 1 monitor malfunctioned and could not be read. Brace design evolved to maximize ipsilateral abdominal relief away from the lateral apical shift of the design. Foam lining was added to prevent skin irritation through the relief opening. Average number of braces per year =2.2. A customized TLSO can achieve in brace correction comparable to Mehta casting with acceptable compliance and without the need for general anesthesia, while allowing bathing and skin care.

Identifying resources available to physicians for management of financial toxicity: A Fellow-driven QI initiative.

294 Background: Insufficient patient-physician cost communication stems in part from limited physician awareness of actionable interventions when cost issues arise. Oncologists report low awareness of resources to help patients with financial toxicity and often feel underprepared to discuss and navigate this issue. Methods: All oncology fellows (n = 19) at the University of California, Los Angeles were invited to participate in QI project during the fall of 2019. As part of the curriculum, fellows were individually paired with an experienced attending and asked to review a hypothetical case of financial toxicity. The case described an elderly widow on Medicare, living hours from the cancer center who was non-adherent to her oral cancer therapy due to high copays. Participants were asked to identify at least four financial toxicity risk factors in the case, and to identify resources and strategies that a physician could use help navigate her financial concerns. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Results: Of 19 participants, 16 completed the case based scenario. Nine categories of risk factors were identified (63% of participants identified an insurance issue, 44% lack of social support, 44% drug cost, 50% fixed income, 50% distance from treatment center, 31% logistical transportation concern). Physician directed solutions were primarily focused on three categories: drug cost, insurance issue, and transportation concerns. Together, an institutional specific financial toxicity tip sheet was generated for further dispersal at the cancer center. After participation in the intervention, more fellows agreed/strongly agreed that they could help a patient experiencing financial toxicity (62% v 6%, p = 0.005). Conclusions: A focused intervention can increase awareness of resources and strategies available to physicians in the management of patient financial concerns, which may impact physician engagement with issues of financial toxicity. Standardized education programs to further educate physicians on financial toxicity management strategies is warranted.

PRUDENT DECISIONS TO ESTIMATE THE RISK OF LOSS IN INSURANCE

The directive 2009/138/EC „Solvency II”, provides the determination of insurance capital requirements based either on a standard formula or an internal model built by the company and approved by the regulatory authority. The build of an internal model involves the determination of an extreme quantile from the empirical distribution of portfolio. An estimate of this quantile, with a 99.5% confidence level, requires a large number of simulations, each taking into account different scenarios as: insufficient reserves, unfavourable developments of financial assets, etc. The present paper proposes to argue the necessity of the extreme value theory approach in order to estimate the risk of loss for the insurance issue, in accordance with European Directive „Solvency II”, from the perspective of making prudent decisions for the assessment of insurance capital requirements.