Moving Medicine Forward: Dr. Shariff Receives Community Cancer Centers Innovators Award 

See Dr. Shariff's ACCC interview on developing the Duke Endo-Oncology Electronic Consultative Service. Afreen Shariff, MD, assistant professor in the division of Endocrinology, Metabolism and Nutrition, has been selected by the Association of Community Cancer Centers (ACCC) as a 2023 Innovator Award recipient for her work on the effectiveness of electronic consults for immune-related endocrine toxicities. 

Dr. Shariff in 2020 created the acuity-based Duke Endo-Oncology Electronic Consultative Service, which has since done consults for more than 300 patients. The biggest gain has been the cost-saving impact as Shariff reduced both the time to appointment and hospitalizations from 61 days to 39 days and from 11% to 2%, respectively.  (See New Endo-Oncology Program is Reducing Wait Times and Hospital Admissions.)  

“We have been able to provide value-based, high-impact service that saves lives, patients time and it turns out we also save the system hundreds of thousands of dollars with admissions we have been able to prevent,” said Shariff, an endocrinologist with expertise in endocrine disease in cancer patients. “This has been a win-win situation for everyone, oncologists, us and most importantly our patients, who deserve to continue effective cancer treatments while worrying less about how side effects will be managed.”  

“Dr. Shariff’s recognition that endocrinopathies arising in modern cancer therapy are a common and important problem is timely and prescient, and her rapid and effective development of a program to treat these is a boon to the Cancer Center and Duke Health generally,” said Dave D’Alessio, MD, chair of the division of Endocrinology, Metabolism and Nutrition.  “This will allow more directed specialty care that improves patient outcomes, and offers people being treated at Duke a layer of expertise that they cannot get elsewhere. Dr Shariff is a remarkable young physician and I expect that she will continue to make bold advances in this new area of endocrinology.” 

Dr. Shariff is the director of the Duke Endo-Oncology Program and an associate director for the Cancer Therapy Toxicity Program at Duke Cancer Institute’s Center for Cancer Immunotherapy. Dr. Shariff completed her medical school at the Deccan College of Medical Sciences in India and did her internal medicine training at East Carolina University Brody School of Medicine followed by an endocrinology fellowship at Duke.  

Innovative Patient Care 

The service, simply put Shariff said, means the right patient gets the right treatment at the right time by the right experts while the access bottleneck that exists between oncology and sub-specialty practices is reduced. It has been embraced by the oncology services at Duke with open arms. After the notable success of the program and experiences gained, she has helped experts in rheumatology and dermatology create similar platforms that support cancer patients at Duke. 

This is how it works, Shariff explains: When an oncologist at Duke sees a cancer patient with a suspected endocrine side effect, they place an electronic consult in the electronic health records just like any order. This reaches Shariff’s team of three clinicians, who review the cases for acuity and place instructions for labs, medications and most importantly when the first appointment should be done. Appointments can be made as soon as the next day or six to eight weeks later, depending on the acuity and intervention recommended.  

“A good example would be new onset type 1 diabetes,” Shariff added. “The chart would be reviewed in 24 to 48 hours, recommendations made and patient would be seen in days compared to drug-induced hypothyroidism where recommendations are made on dose of thyroid replacement and patient can be seen in six to eight weeks.”  

The Endo-Oncology e-consult is unique in that it is a specialty-to-specialty consultative service rather than the typical primary care provider to specialist model, which works well with value-based care and payment models—where providers are paid when their patients avoid hospitalization—including the system currently being implemented by Duke oncologists. 

As value systems gain traction, Shariff noted, such cost savings are likely to be substantial. About two million new patients are expected to be diagnosed with cancer in 2023, and about 1.2 million qualify for treatments like checkpoint inhibitors. Among those patients, about 15% can develop an endocrine side effect with 12% (about 21,000) of them admitted to the hospital.  

An Early-Warning System: The Predictive Model 

Shariff is moving forward with another cancer patient and toxicity management project with Duke Institute for Health Innovation that is an outgrowth of her e-consult work on reducing hospital admissions from toxicities. It is a machine-learning model she calls the Adverse Event – Early Warning system that performs like a clinical decision tool that helps predict hospital admissions related to checkpoint inhibitors.  

Shariff hopes to tie these two projects together where Duke Cancer will have access to an end-to-end toxicity management model that lets her predict hospitalizations and act swiftly through the e-consultative service to get patients evaluated and treated in a timely manner, mitigating the need for a hospitalization in some cases.  She is actively working toward clinical implementation of the Predictive Model at the Duke Cancer Center Acute Care Clinic (ACC) in collaboration with oncologist, Dr. Hope Uronis, MD, MHS.   

Using a machine learning algorithm with data from about 5,000 Duke patients, Shariff trained the model to predict which patients over the coming two to three weeks are more likely to get a hospital admission resulting from immune checkpoint inhibitor related side effect. If successful, the predictive model could allow Shariff and others at DCI to pivot from a reactive to a more proactive stance in managing toxicities. She hopes eventually that the data may be applied on a more granular level to help pinpoint the specific toxicity.  

Patients are selected who are moderate to high risk from patients receiving checkpoint inhibitors daily at Duke, and put at the front of the line with an assigned advanced practice provider (APP), who reviews the chart and contacts the patient. If the patient does not seem sick enough, care is de-escalated. If the patient is sick or has newer complaints, they are directed to the ACC and the oncology team is informed.  

The burden is taken off busy oncology practices and moved to the ACC, which is equipped with cancer-focused APPs who are highly familiar with side effects, rather than the emergency department.  

“We are preventing hospital admissions, loss of lives and money, and also difficult treatment decisions that occur after patients get to the hospital because of a side effect,” Shariff said. “We're making decision-making for the patient much easier because we're taking ownership of the side effects in a comprehensive way, and taking the process from prediction to actual outcomes.” 

See Dr. Shariff's ACCC interview on the Duke Endo-Oncology Program.