Pre- and Post-Implementation Evaluation of a Systematized Order Set for Inpatient Hypercalcemia Management
Introduction/Background/Significance: At Mount Sinai Health System (MSHS), hypercalcemia is defined as a corrected serum calcium (CSC) level of at least 10.5 mg/dL or an ionized calcium level of at least 1.1 mmol/L. Mild hypercalcemia is usually asymptomatic, but moderate to severe hypercalcemia can lead to renal, gastrointestinal, neurologic, and / or cardiac complications. In Dec 2020, MSHS developed internal guidelines for hypercalcemia management. In Mar 2024, a systematized order set for inpatient hypercalcemia treatment was created to enhance medication selection and provider education.
Materials and Methods/Case Presentation/Objective: To analyze trends in drug utilization and laboratory outcomes for each hypercalcemia severity, we performed a retrospective chart review of adult patients (age >= 18 years) who were treated inpatient for hypercalcemia within MSHS before order set implementation (Sep 1, 2023 to Feb 29, 2024) and after order set implementation (Mar 1, 2024 to Dec 31, 2024). Drugs evaluated were intravenous fluid (e.g., sodium chloride 0.9%, Isolyte), bisphosphonate (e.g., zoledronic acid, pamidronate), calcitonin, steroid (e.g., prednisone, dexamethasone), and denosumab. Key secondary outcomes of interest were laboratory value changes (e.g., serum creatinine, estimated glomerular filtration rate [eGFR], CSC).
Results/Description/Main Outcome Measures: Of 202 patients included, 89 were in the pre-implementation group and 113 were in the post-implementation group. Baseline patient characteristics of age (67 vs. 69 years), gender (52.8% vs. 52.2% male), and underlying etiology (17% vs. 18 % non-malignant; 67.4% vs. 70% malignant; 16% vs. 12% other / unknown) were similar. There were 19.1% vs. 18.6% with multiple myeloma and 7.9% vs. 10.6% with lymphoma.
In the post-implementation group, there were more patients with severe hypercalcemia (51.7% vs. 77.9%; p < 0.05), correlating to enhanced utilization of calcitonin (66% vs. 90%; p < 0.05) and intravenous fluid (87% vs. 98%; p < 0.05). Calcitonin doses per patient were 2.5 vs. 2.8, which remained appropriate.
For patients with severe hypercalcemia, numerically more in the post-implementation period achieved CSC < = 11.5 or < = 10.8 mg/dL at all follow-up time points, and additional study power is needed for inferential statistics. CSC < = 11.5 mg/dL was achieved in 15.6% vs. 26.7% at 24 hours; 45.7% vs. 50.8% at 48 hours; 59.4% vs. 62.5% at 72 hours; and 63% vs. 75% at 168 hours. CSC < = 10.8 mg/dL was achieved in 6.3% vs. 10.7% at 24 hours; 17.1% vs. 27% at 48 hours; 28.1% vs. 44.6% at 72 hours; and 63% vs. 67.5% at 168 hours.
There were fewer patients with ongoing CTCAE Grade 1 to 2 serum creatinine elevations (1.2 to 3.39 mg/dL) in the post-implementation group at 24 hours (60% vs. 39%; p < 0.05) and at 72 hours (61% vs. 35%; p < 0.05). There were fewer patients with ongoing eGFR 15 to 29 mL/min/1.73 m2 in the post-implementation group at 24 hours (29% vs. 12%; p < 0.05) and at 48 hours (26% vs. 11%; p < 0.05).
Conclusions: In the post-implementation period, there were several positive trends in drug prescribing, as well as CSC and renal outcomes, supporting continued utilization of the order set.
