Array based comparative genomic hybridisation (aCGH) is a powerful technique for detecting clinically relevant genome imbalance and can offer 40 to > 1000 times the resolution of karyotyping. Indeed, idiopathic learning disability (ILD) studies suggest that a genome-wide aCGH approach makes 10–15% more diagnoses involving genome imbalance than karyotyping. Despite this, aCGH has yet to be implemented as a routine NHS service. One significant obstacle is the perception that the technology is prohibitively expensive for most standard NHS clinical cytogenetics laboratories. To address this, we investigated the cost-effectiveness of aCGH versus standard cytogenetic analysis for diagnosing idiopathic learning disability (ILD) in the NHS. Cost data from four participating genetics centres were collected and analysed. In a single test comparison, the average cost of aCGH was £442 and the average cost of karyotyping was £117 with array costs contributing most to the cost difference. This difference was not a key barrier when the context of follow up diagnostic tests was considered. Indeed, in a hypothetical cohort of 100 ILD children, aCGH was found to cost less per diagnosis (£3,118) than a karyotyping and multi-telomere FISH approach (£4,957). We conclude that testing for genomic imbalances in ILD using microarray technology is likely to be cost-effective because long-term savings can be made regardless of a positive (diagnosis) or negative result. Earlier diagnoses save costs of additional diagnostic tests. Negative results are cost-effective in minimising follow-up test choice. The use of aCGH in routine clinical practice warrants serious consideration by healthcare providers.

1508 Background: Previously, among Veterans with cancer, lay health workers (LHWs) trained to discuss patients’ goals of care reduced acute care use, improved patient experiences and reduced total costs of care at the end-of-life. Among Medicare-Advantage beneficiaries with cancer, LHWs trained to proactively assess patient symptoms reduced symptom burden, acute care use and total costs of care. It is unknown whether LHWs can assist with both goals of care and symptom assessments in community settings. The objective of this randomized clinical trial was to determine the effect of a LHW-led goals of care and symptom assessment intervention on acute care use and secondarily goals of care documentation, satisfaction and end-of-life healthcare use among patients with advanced cancer in a community practice. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies who planned to receive care at the oncology practice were randomized from 8/11/2016 through 2/5/2020 into intervention and control groups. Patients completed validated satisfaction surveys at randomization and 9 months follow-up and were followed for 12 months. We compared risk of death using Cox Models, healthcare use and satisfaction using generalized regression models adjusted for length of follow-up. Results: 128 patients were randomized; 64 in the intervention and 64 in the control. The mean age was 67 years; 22% identified as Hispanic/Latino; 57% White, 30% Asian Pacific Islander, 8% Black or African American, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no survival differences. Intervention patients were less likely to utilize the emergency department (OR: 0.35; 95% CI 0.17-0.72) and hospital (OR: 0.48; 95% CI 0.23-0.98) and had lower mean emergency department visits (1.05 +/- 1.74 versus 1.84 +/- 2.55, p = 0.04) and hospitalizations per year (0.63 +/- 1.28 versus 1.26 +/- 2.23, p = 0.04) as compared to control patients. More intervention patients had their goals of care documented (94% versus 52% p < 0.001) and used hospice (35% versus 14% p = 0.004) as compared to control patients. There were no differences in palliative care use (89% versus 77% p = 0.09). At 9 months follow-up as compared to baseline, intervention patients experienced greater improvements in satisfaction with care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p < 0.001). Among 30 patients who died (n = 16 intervention; n = 16 control), more patients in the intervention used hospice (81% versus 43%) and fewer used acute care in the last month (37% versus 81%, p = 0.012) than in the control. Conclusions: An LHW intervention reduced acute care use among patients with cancer, improved patient experiences and end-of-life care. This intervention may be a scalable approach to improve care delivery and experiences for patients after a diagnosis of cancer. Clinical trial information: NCT03154190.

Although care of the family has long been a focus of nursing, there has been an increased emphasis in recent years to provide opportunities for families to be an integral part of the hospitalization experience. This has been difficult for many nurses who perceive themselves as competent to care for a patient in “medical crisis” but feel unqualified to provide family care. This article will address issues related to implementing a family-centered philosophy of care in a critical care unit. Implementation strategies that will be discussed include: formulating a staff-led family support group and family committee, instituting a family visitation contract within open visitation parameters, and developing clinicians with expertise in family care. Tools such as a performance plan for a Clinical Nurse II specializing in family care and the family visitation contract will be shared

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