30-day ED Visit Research Articles

Associations Between Implementation of the Caregiver Advise Record Enable (CARE) Act and Health Service Utilization for Older Adults with Diabetes: Retrospective Observational Study.

BackgroundThe Caregiver Advise Record Enable (CARE) Act is a state level law that requires hospitals to identify and educate caregivers (“family members or friends”) upon discharge.ObjectiveThis study examined the association between the implementation of the CARE Act in a Pennsylvania health system and health service utilization (ie, reducing hospital readmission, emergency department [ED] visits, and mortality) for older adults with diabetes.MethodsThe key elements of the CARE Act were implemented and applied to the patients discharged to home. The data between May and October 2017 were pulled from inpatient electronic health records. Likelihood-ratio chi-square tests and multivariate logistic regression models were used for statistical analysis.ResultsThe sample consisted of 2591 older inpatients with diabetes with a mean age of 74.6 (SD 7.1) years. Of the 2591 patients, 46.1% (n=1194) were female, 86.9% (n=2251) were White, 97.4% (n=2523) had type 2 diabetes, and 69.5% (n=1801) identified a caregiver. Of the 1801 caregivers identified, 399 (22.2%) received discharge education and training. We compared the differences in health service utilization between pre- and postimplementation of the CARE Act; however, no significance was found. No significant differences were detected from the bivariate analyses in any outcomes between individuals who identified a caregiver and those who declined to identify a caregiver. After adjusting for risk factors (multivariate analysis), those who identified a caregiver (12.2%, 219/1801) was associated with higher rates of 30-day hospital readmission than those who declined to identify a caregiver (9.9%, 78/790; odds ratio [OR] 1.38, 95% CI 1.04-1.87; P=.02). Significantly lower rates were detected in 7-day readmission (P=.02), as well as 7-day (P=.03) and 30-day (P=.01) ED visits, among patients with diabetes whose identified caregiver received education and training than those whose identified caregiver did not receive education and training in the bivariate analyses. However, after adjusting for risk factors, no significance was found in 7-day readmission (OR 0.53, 95% CI 0.27-1.05; P=.07), 7-day ED visit (OR 0.63, 95% CI 0.38-1.03; P=.07), and 30-day ED visit (OR 0.73, 95% CI 0.52-1.02; P=.07). No significant associations were found for other outcomes (ie, 30-day readmission and 7-day and 30-day mortality) in both the bivariate and multivariate analyses.ConclusionsOur study found that the implementation of the CARE Act was associated with certain health service utilization. The identification of caregivers was associated with higher rates of 30-day hospital readmission in the multivariate analysis, whereas having identified caregivers who received discharge education was associated with lower rates of readmission and ED visit in the bivariate analysis.

Racial disparities in surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing pancreas surgery.

e16255 Background: Previous studies have suggested disparity in PDAC survival in African American (AA) compared to non-AA patients. Pancreas surgery is associated with significant morbidity, and technical outcomes are known to impact survival; however, there is little reported data on surgical outcomes by race. We sought to evaluate the effect of race on surgical outcomes and survival in an urban tertiary care center for patients with PDAC undergoing pancreas surgery. Methods: A retrospective single-center analysis of PDAC patients undergoing pancreas resection between January 2013 and September 2021 was performed. Patient demographics, Clavien-Dindo (CD) complications, readmission, and mortality in the 30- and 90- day period were collected and stratified by race. Univariate and multivariate analyses were performed. Results: Among 180 patients, 145 (81%) were non-AA and 35 (19%) were AA. Demographic and pre-operative characteristics were found to be similar between the two groups. 30-day ED visits, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and intra-abdominal abscess (IAA) were found to be significant on univariate analysis in the AA cohort. On multivariate analysis, 30-day ED visit (OR 4.5; 95% CI 1.3-15.8; p = 0.02), POPF (OR 4.5; 95% CI 1.3-14.8; p = 0.015), and IAA (OR 4.4; 95% CI 1.12-17.3; p = 0.033) were still significantly higher in the AA cohort while DGE lost its significance. Median overall survival and disease-free survival showed no significant difference on Kaplan-Meier curves. There was no statistical difference in local, regional, or metastatic recurrence patterns between the two groups (distant metastasis 36% in non-AA and 37% in AA). Conclusions: AA undergoing pancreas surgery for PDAC were noted to have higher incidence of POPF and IAA as well as ED visits compared to non-AA patients. However, no significant difference was seen in reoperation rates, major CD complications, recurrences, or survival. Exploring tumor biology, and preoperative treatment algorithms may shed additional insight on the differences in surgical outcomes in this patient cohort.[Table: see text]

Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit.

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.

The Diabetes Transition of Hospital Care (DiaTOHC) Pilot Study: A Randomized Controlled Trial of an Intervention Designed to Reduce Readmission Risk of Adults with Diabetes.

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 16 October 2017 and 30 May 2019, 93 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission, while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit. The Intervention–UC cost ratio was 0.33 (0.13–0.79) 95%CI. At least 93% of subjects were satisfied with key intervention components. Among the 69 subjects with baseline HbA1c >7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC) and composite 30-day readmission/ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC). In this subgroup, the Intervention–UC cost ratio was 0.21 (0.08–0.58) 95%CI. The DiaTOHC Program may be feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with HbA1c levels >7.0% (53 mmol/mol).

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

For patients with super obesity (BMI > 50kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18years of age, BMI > 50kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

The Impact of Surgical Scheduling on Outcomes in Lumbar Laminectomy.

ObjectiveThe purpose of this study was to determine whether surgical scheduling affected patient outcomes following lumbar laminectomy. Physician fatigue caused by prolonged work hours has been shown to worsen outcomes. Previous research has also established a relationship between surgical scheduling and outcomes.MethodsThis was a retrospective chart review of single-level lumbar laminectomy patients at the Penn State Milton S. Hershey Medical Center between 1992 and 2019. Patients who underwent a one-level laminectomy between 1992 and 2019 were included in the study. Patients with procedures defined as complex (>1 level, tumor or abscess removal, discectomy, implant removal) were excluded. The surgical complication rate [cerebrospinal fluid (CSF) leak, 30-day redo, 30-day ED visit, weakness, sensation loss, infection, urinary retention] was compared across surgical start times, day of the week, proximity to a holiday, and procedure length.ResultsProcedures that started between 9:01-11:00 were more likely to have a complication than those between 7:01-9:00 (p=0.04). For every 60-min increase in surgery length, odds of having a complication increased by 2.01 times (p=0.0041). Surgeries that started between 11:01-13:00 had a significantly longer median surgery length than those between 7:01-9:00.ConclusionThe time of the day when the procedure was started was predictive of worse outcomes following laminectomy. This may be attributed to several factors, including fatigue and staff turnover. Additionally, increased surgical length was predictive of more complications. It remains unclear whether increased surgical time results from correction of noticed errors or a fatigue-related decline in speed and performance. These findings on one-level laminectomy warrant further investigations since they have implications for reducing systemic failures that impact patient outcomes.

Risk factors for ED visits and admissions during outpatient chemotherapy in head and neck cancer.

223 Background: Despite the recent introduction of the CMS metric, OP-35, which tracks 30-day inpatient admissions and ED visits after outpatient chemotherapy administration, the risk factors driving acute care utilization (ACU) in the head and neck cancer treatment setting are not yet well understood. Further characterization of these risk factors could allow for improved care quality and reduce preventable inpatient and ED admissions. Methods: This was a retrospective cohort study utilizing the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked cancer registry-claims database. The study cohort consisted of patients aged 66 years or older diagnosed with head and neck cancer between 2004-2015 who received outpatient chemotherapy within the first two years after diagnosis. Multivariable logistic regression modeling was utilized to characterize the risk factors associated with an inpatient or ED admission within 30 days after receiving chemotherapy. Results: Of the 2,236 eligible patients, 735 (32.9%) had at least one inpatient or ED admission within 30 days of receiving outpatient chemotherapy. On multivariable analysis, cancer of the oral cavity [odds ratio (OR) 1.43; 95% confidence interval (CI) 1.04-1.96] and oropharynx/hypopharynx [OR 1.34; 95% CI 1.06-1.70] were associated with an increased odds of ACU. Other factors associated with ACU included NCI comorbidity index [OR 1.10; 95% CI 1.03-1.18], prior ACU [OR 1.06; 95% CI 1.02-1.09], second cycle of chemotherapy relative to the first cycle [OR 0.38, 95% CI 0.29-0.50], and third or greater cycle of chemotherapy [OR 0.17; 95% CI 0.13-0.21]. Certain chemotherapeutic agents also modified risk: use of an angiogenesis inhibitor [OR 0.18; 95% CI 0.06-0.45], alkylating agent [OR 1.24; 95% 1.01-1.53], plant alkaloid [OR 1.63; 95% CI 1.25-2.10], or antimetabolite [OR 2.69; 95% CI 1.78-4.09]. The most common admission diagnosis was pain (n = 243; 33.1%) followed by dehydration (n = 167; 22.7%). Conclusions: Multiple clinical variables modify risk of acute care utilization after outpatient chemotherapy in the head and neck cancer setting, providing several potential avenues of intervention for providers.

P79. The COVID-19 pandemic significantly impacted hospital length of stay and discharge patterns for ASD surgery

BACKGROUND CONTEXTDuring the COVID-19 pandemic, surgeons found ways to provide appropriate care while conserving inpatient resources and limiting potential exposure. For patients with adult spinal deformity (ASD), spine surgery often requires extended LOS and non-routine discharge. Given resource limitations during the COVID-19 pandemic and caution regarding hospital stays, surgeons have modified standard postoperative protocols to minimize patient exposure.PURPOSEThe primary aim of this study was to compare LOS and discharge disposition of ASD patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, readmissions, and ED visits.STUDY DESIGN/SETTINGRetrospective review of an institutional surgical registry.PATIENT SAMPLEA total of 117 patients with adult thoracolumbar deformity.OUTCOME MEASURESOutcome measures included LOS and discharge disposition (home vs non-home), as well as 30-day major complications, reoperations, readmissions and ED visits.METHODSWe identified all patients who underwent elective thoracolumbar ASD surgery with ≥5 levels fusion at a tertiary care center during two distinct time intervals: Jul-Dec 2019 (Pre-COVID, N=60) and Jul-Dec 2020 (During-COVID, N=57). Outcome measures included LOS and discharge disposition (home vs non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors.RESULTSPatients who underwent ASD surgery during the pandemic were younger (61 vs 67 years) and had longer fusion constructs (9 vs 8 levels) compared to before pandemic (p<0.05 for both). On bivariate analysis, patients undergoing surgery during the pandemic had significantly lower LOS (6 vs 8 days) and were more likely to be discharged home (70% vs 28%) (p<0.05 for both). After controlling for age and levels fused on multivariable regression, patients who had surgery during the pandemic continued to demonstrate a significantly lower LOS (IRR=0.83, p=0.015) and greater odds of home discharge (OR=7.2, p<0.001). Notably, there were no significant differences in reoperations, readmissions, ED visits, or major complications between the two groups (p>0.05 for all).CONCLUSIONSDuring the COVID-19 pandemic, the LOS for patients undergoing thoracolumbar ASD surgery decreased, and more patients were discharged home without adversely affecting complication or readmission rates. Lessons learned during the pandemic may help improve resource utilization without negatively influencing outcomes.FDA DEVICE/DRUG STATUSThis abstract does not discuss or include any applicable devices or drugs.

Chief Resident Indirect Supervision in Training Safety Study: Is a Chief Resident General Surgery Service Safe for Patients?

There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs. A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services. A single institution associated with a community based-university associated hybrid general surgery residency was included in this study. Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service. A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p < 0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p < 0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p < 0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p < 0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p < 0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group. This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

Same-day discharge across FPMRS surgical cases is safe and feasible: A 10-year single-surgeon experience.

Enhanced recovery after surgery protocols and increased attention to value-based care have led to the reconsideration of routine postoperative admission in female pelvic medicine and reconstructive surgery (FPMRS) cases. We aimed to assess trends in same-day discharge (SDD) and associated readmissions and emergency room visits in a single-surgeon 10-year experience. The electronic medical record was queried for 30-day outcomes (readmission and emergency department visits with associated indications) for all cases performed between June 2010 and August 2020 by a single FPMRS surgeon. Non-FPMRS specialty cases were excluded. Patient characteristics and 30-day outcomes were compared based on SDD status for the overall cohort as well as the subset of cases traditionally involving an overnight stay (i.e., robotic transabdominal, apical prolapse repair). 1793 surgeries were identified and analyzed, including 357 apical prolapse repairs, 370 slings, 392 neuromodulation and 114 complex mesh excisions. The majority (79.1%) had SDD. For admitted patients, mean length of stay was 1.5 (1.3) days. Among cases traditionally involving overnight stay, rates of SDD were significantly higher in 2020 than 2010 (84% vs. 32%, p < 0.001), and increased over time. Overall rates of 30-day readmission and ED visits were low (1.9% and 2.6%, respectively) and did not differ based on SDD status (p = 0.76). Readmissions occurred at mean 11.6 (7.0) days, most commonly for urinary tract infection (13/34). SDD is not associated with increased 30-day readmission or ED visits across a wide breadth of FPMRS cases. SDD is safe and feasible in the majority of FPMRS cases.

211 ERAS protocol for cesarean section does not lead to decreased length of stay (LOS)

The objective of this study was to determine if the implementation of an Enhanced Recovery After Surgery (ERAS) protocol for Cesarean section would lead to a decreased length of stay, defined as a difference of 6 hours of greater, in a patient cohort including those of all gestational ages, anesthesia types (neuraxial and general), and acuity levels (emergent, urgent, scheduled). This project is a prospective cohort study comparing surgical outcomes for cesarean section patients before and after the implementation of an ERAs protocol. This study was powered for the primary outcome (LOS) to detect a 6-hour difference in length of stay with a target sample size of 336 patients, 168 pre-intervention and 168 post-intervention. Secondary outcomes included opioid use, NSAID use, and 30-day re-admission and ED visit rates. On analysis of descriptive variables there were no significant differences between groups. For the primary outcome the mean LOS pre-intervention was 80.5 hours and post-intervention was 82.3 hours, P=0.5146. This association remained non-significant when controlled for several potential confounders (hypertensive disorders, gestational diabetes, acuity of procedure, anesthesia type, etc). There was a trend towards fewer re-admissions and ED visits in the post-intervention cohort, however neither of these findings were statistically significant. The ERAS protocol did lead to significantly more NSAID use (p=0.044) but did not have a significant impact on opioid consumption (p=0.53). Implementation of an ERAS protocol for Cesarean Section did not lead to a clinically or statistically significant reduction in length of stay. This outcome suggests that there are other variables at the institutional level that may be contributing to the length of stay such as patient expectations/preferences, neonatal care, and provider counseling prior to delivery, which warrant further exploration.

Quality outcomes, healthcare resource utilization and costs in Medicare patients with chronic heart failure with reduced ejection fraction with and without a worsening event

Aims The study compared quality outcomes, resource utilization, and costs in Medicare beneficiaries with chronic heart failure with reduced ejection fraction (HFrEF) with and without a worsening heart failure event (WHFE). Methods This retrospective observational study evaluated claims data for two cohorts of Medicare beneficiaries with chronic HFrEF who were enrolled in Medicare fee-for-service (FFS) or Medicare advantage (MA) plans. The index date was the first claim of HFrEF between October 2015 and September 2017. Patients with WHFE were identified if they had IV diuretic use or hospitalization for HF during 12 months after index date; with remaining patients classified as non-WHFE. During follow-up, starting from the 13th month after HFrEF index date to end of follow-up, generalized linear models were used to adjust for patient characteristics to compare mean per patient per year (PPPY) quality outcomes, resource utilization, and costs between HFrEF patients with and without WHFE Results Of the 1,182,509 FFS and 28,645 MA patients with HFrEF, 34.2% and 32.5% developed WHFE, respectively. Compared to patients without WHFE, patients with WHFE had higher rates of all-cause 30-day readmissions (FFS: 42% vs. 31%; MA: 41% vs. 31%), hospitalizations (FFS: 2.27 vs. 1.36; MA: 1.47 vs. 0.78 PPPY) and ED visits (FFS: 1.82 vs. 1.25; MA: 1.43 vs. 0.96 PPPY); all comparisons p < .05. Mortality rates in FFS patients were higher among patients with WHFE (34.3%) compared to those without (23.4%). All-cause total PPPY costs were higher for patients with WHFE compared to those without by $20,825 in FFS and $15,974 in MA. Similar trends were observed for HF-related outcomes. Conclusion Medicare patients with chronic HFrEF experiencing a WHFE had worse quality outcomes as well as higher resource utilization and costs compared to those without WHFE, thus, suggesting the need for better treatments and interventions to manage these patients.

Looking across health and healthcare outcomes for people with intellectual and developmental disabilities and psychiatric disorders: population-based longitudinal study.

Intellectual and developmental disabilities (IDDs) and psychiatric disorders frequently co-occur. Although each has been associated with negative outcomes, their combined effect has rarely been studied. To examine the likelihood of five negative health and healthcare outcomes for adults with IDD and mental health/addiction disorders (MHAs), both separately and together. For each outcome, demographic, clinical and system-level factors were also examined. Linked administrative data-sets were used to identify adults in Ontario, Canada, with IDD and MHA (n = 29 476), IDD-only (n = 35 223) and MHA-only (n = 727 591). Five outcomes (30-day readmission, 30-day repeat ED visit, delayed discharge, long-term care admission and premature mortality) were examined by logistic regression models with generalised estimating equation or survival analyses. For each outcome, crude (disorder groups only) and complete (adding biosocial covariates) models were run using a general population reference group. The IDD and MHA group had the highest proportions across outcomes for both crude and complete models. They had the highest adjusted ratios for readmissions (aOR 1.93, 95%CI 1.88-1.99), repeat ED visit (aOR 2.00, 95%CI 1.98-2.02) and long-term care admission (aHR 12.19, 95%CI 10.84-13.71). For delayed discharge, the IDD and MHA and IDD-only groups had similar results (aOR 2.00 (95%CI 1.90-2.11) and 2.21 (95%CI 2.07-2.36). For premature mortality, the adjusted ratios were similar for all groups. Poorer outcomes for adults with IDD, particularly those with MHA, suggest a need for a comprehensive, system-wide approach spanning health, disability and social support.

Functional Status and Therapy for Older Patients with Diffuse Large B-Cell Lymphoma (DLBCL): A Population-Based Study

Background: DLBCL is a potentially curable lymphoma, yet up to 25% of older Medicare beneficiaries with DLBCL do not receive any therapy (Hamlin et al, Oncologist, 2014). Older adults with DLBCL may have vulnerabilities and require care from home health agencies. Functional impairment may compromise DLBCL therapy, but data are lacking about treatment and outcomes of home health services (HHS) recipients. There is ongoing need for accurate and efficient tools to assess function and guide therapy in geriatric patients with DLBCL, as inaccurate assessment may lead to under- and over-treatment with suboptimal outcomes. Medicare beneficiaries who receive HHS periodically undergo functional assessments using the standardized Outcome and Assessment Information Set (OASIS). OASIS scores have been recently linked to SEER-Medicare data, and can offer insights into the role of functional status in DLBCL treatment. We examined the association of functional status, measured in OASIS, and treatments and outcomes in DLBCL. Methods: From SEER-Medicare, we selected beneficiaries diagnosed with DLBCL in 2011-2015, and identified HHS recipients who had OASIS assessments within 3 months before diagnosis or treatment. OASIS instrument measures functional status as a linear score ranging from 0 to 40; higher scores represent worse functioning. We classified the scores as mild (OASIS 0-9), moderate (10-16), and severe (17-40) impairment by tertiles of the population distribution. We examined the following outcomes: receipt of therapy (including standard [RCHOP-like] and non-standard [bendamustine, rituximab monotherapy, etc.] regimens), and among treated patients: mortality, ED visit, hospitalization, and ICU admission within 30 days from first chemotherapy. We used logistic models, reporting odds ratios (OR) with 95% confidence intervals (CI). We additionally compared overall survival (OS) between groups receiving standard and non-standard regimens in each functional category using adjusted hazard ratios (aHR) derived from Cox models. All models were adjusted for age, sex, race, DLBCL stage, and comorbidity index. Results: Among 8,914 beneficiaries with DLBCL, 1,317 had OASIS assessments. Their characteristics included: median age 80 years, 46% men, 83% White, 53% stage 3/4 DLBCL. Median OASIS score was 13 (interquartile range, 7-18). Chemotherapy was administered to 63% of HHS recipients, compared with 75% of other beneficiaries (OR, 0.66; 95%CI, 0.57-0.76). HHS recipients were significantly more likely to experience 30-day ED visit, hospitalization, ICU admission, and mortality after chemotherapy (OR 1.24-1.52), and have shorter OS compared with other beneficiaries with DLBCL (7 vs 40 months, aHR, 1.55, 95% CI, 1.44-1.67; Fig. A). Severe functional impairment was associated with lower odds of receiving any therapy, as well as higher rates of acute mortality, hospitalization, and ICU admission. Patients with moderate impairment had an increased risk of 30-day ED visit and ICU admission after chemotherapy (Table). OS was worse with severe functional impairment, even after adjusting for other clinical factors (aHR, 1.64, 95% CI, 1.24-2.17; Fig. B). Functional status was not significantly associated with the use of standard or non-standard regimen, and OS was better with RCHOP-like therapy in all functional groups (aHR, 0.50-0.56, P for interaction: 0.85; Fig. C). Conclusions: In this novel population-based study using OASIS assessments to examine function as a predictor of cancer therapy, functional impairment was an independent predictor of treatment and outcomes in geriatric patients with DLBCL. We observed that a substantial proportion of patients on HHS did not receive any therapy, and worse survival in those who received attenuated regimens, independent of their functioning. Our results highlight the need for novel, less toxic strategies in this population, supporting research on emerging chemotherapy-free approaches. Clinicians should consider a dedicated functional assessment (such as a comprehensive geriatric assessment) to optimize treatment selection in DLBCL. OASIS assessments for HHS recipients are easily available to clinicians and could be incorporated into pre-chemotherapy evaluation to improve patient selection for intensive therapies, potentially avoiding under-treatment with attenuated regimens Disclosures Panagiotou: International Consulting Associates, Inc: Other: personal fees from International Consulting Associates, Inc. outside the scope of the submitted work. Olszewski:TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding; Spectrum Pharmaceuticals: Research Funding; Genentech, Inc.: Research Funding.

Use of the MMPI-2 personality profile in predicting 30-day ED-visits and readmissions following primary bariatric surgery

Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is used for psychological screening of bariatric surgery (BS) candidates. To date, no studies have analyzed the relationship between MMPI-2 and early returns to hospital. The aim of this study was to determine whether high T scores on the MMPI-2 clinical scales were associated with early return to hospital after primary bariatric surgery. Patients who completed an MMPI-2 evaluation, undergoing primary BS from 2014 to 2016 were evaluated. T score for the tested scales were collected and stratified into a high T score (T>65) vs not (T<65). The optimal 'cut-point' (specific number of high T scores predicting likelihood for 30-day ED-visit/hospital readmission) was calculated using Youden's Index (J)=Max(c) [sensitivity (c)+specificity (c)-1], where c=number of scales with a T score>65. Patients were stratified based on the optimal cut-point which was determined to be≥4 high T scores. Univariate and multivariate logistic regression analyses were used to identify differences between groups and predictors for early ED-visits and hospital readmissions. 375 patients had psychological evaluations available for review. Patients were divided into those with≥4 high T scores (Scr(≥4); n=86) versus not (Scr (<4); n=289). Multivariate analysis showed Scr(≥ 4) (aOR 2.99, CI 1.20-7.47; p=0.019), bipolar disorder (aOR 4.82, CI 1.25-18.83; p=0.022), and urgent hospital complications (aOR6.81, CI 2.02-22.91; p=0.002), were significant independent predictors of 30-day readmissions. Early ED-visits were significantly predicted by public insurance (aOR 3.30, CI 1.22-8.91; p=0.019), but the effect of the Scr(≥4) profile (aOR 2.42, CI 0.97-6.09; p=0.06), while influential, did not reach significance. Differences in personality traits may be associated increased 30-day readmissions following primary bariatric surgery. Our study represents a novel application of the MMPI-2.

Factors associated with admission after implementation of a same-day discharge pathway in patients undergoing peroral endoscopic myotomy (POEM).

Although peroral endoscopic myotomy (POEM) has emerged as a highly efficacious procedure in the treatment of a variety of esophageal motility disorders, currently no standard pathway for postprocedural care exists. Our study aims to report institutional outcomes in performing POEM as an outpatient procedure with same-day discharge. Additionally, we seek to determine factors associated with admission. Demographic, perioperative, and postoperative outcome data of 115 patients who underwent POEM between June 2014 and January 2020 on a same-day discharge pathway were analyzed. Cohorts were compared using the t test, Wilcoxon rank-sum, or chi-square test. Multivariable logistic regression with a manual backward selection method was used to identify factors associated with admission. Fifty-five patients (48%) were successfully discharged same-day. The most common primary reasons for admission were delay in obtaining an esophagram (25%), intraoperative complication (13.3%), and pain (10%). There were no differences in 30-day ED visit rate (12.7% vs 15.0%, p = 0.725) or 30-day readmission rate (9.1% vs 16.7%, p = 0.373) between patients who were discharged same-day versus patients who were admitted. Patients discharged same-day had fewer intraoperative complications (1 vs 9, p = 0.017), shorter OR time (69 vs 100min, p < 0.001), and earlier cessation of narcotic use (day 0 vs day 1, p = 0.001). On multivariable analysis, intraoperative complication (p = 0.048) was associated with overnight admission. Patients did not experience additional morbidity with same-day discharge after POEM. A delay in obtaining an esophagram was the most common reason that patients were admitted and those who suffered an intraoperative complication are more likely to require admission.

Quality assessment of weekend discharge: a systematic review and meta-analysis

Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges. PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019. Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies. Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate. There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity. In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.

Abstract 309: Outcomes of Depressed Patients With and Without Antidepressant Prescription

Background: Many studies have shown a relationship between depression and an increased risk of rehospitalization, suggesting assessment and management, potentially including antidepressants, should remain an important part of inpatient treatment. However, studies analyzing the outcomes associated with antidepressant use among cardiac patients have shown mixed results. This study aims to describe the long-term outcomes (ED visits, readmissions, and death) of a cohort of cardiac patients with concomitant depression treated with antidepressants. Methods: A total of 151 patients with a medical history of depression were randomly selected between 2008-2017 from a cardiac transitional care clinic registry. A retrospective chart review was conducted to determine the frequency of antidepressant prescription at discharge following a cardiac hospital admission. Demographics and outcomes were compared between those prescribed and those not prescribed antidepressants at discharge. Results: Of 4,298 patients, 1,067 (24.8%) had a diagnosis of depression recorded in their medical record. Of the 151 randomly selected depression patients, 106 (70.2%) were on at least one antidepressant at discharge. Significantly more females were prescribed antidepressants at discharge than males (78.0% v. 58.3%, p=0.010). No significant differences were seen in race, socioeconomic status, or outcomes at 30, 60, 90, or 180 days post-discharge between those prescribed and those not prescribed antidepressants at discharge. However, when compared to patients without depression (n=3,231), those on at least one antidepressant had significantly more 30-day ED visits (25.5% vs 17%, p=0.026), 180-day ED visits (52.9% vs 38.1%, p=0.002), and 180-day readmissions (55.8% vs 40.1%, p=0.001). Conclusions: Patients with depression had worse outcomes than those without depression, despite the majority (70.2%) being treated with antidepressants. These results suggest efforts should be made post-discharge to closely monitor patients with depression, even if they are prescribed antidepressants, and additional treatment modalities should be researched.

Implementation and Effect of a Pharmacist-to-Pharmacist Transitions of Care Initiative on Ambulatory Care Sensitive Conditions.

One of the most vulnerable times in a patient's encounter with a health care system is during transitions of care (TOC), defined by the Joint Commission as the movement of a patient from one health care provider or setting to another. The use of a clinical pharmacist as a member of the care transitions team has received focused attention and shown improved benefit. To determine the effect of a large-scale pharmacist-to-pharmacist TOC model where inpatient clinical pharmacists identify patients during a hospital stay, provide evidence-based care and education, and then coordinate follow-up with an outpatient clinical pharmacist who provided comprehensive medication management (CMM) under a scope of practice. This was a multisite, single health care system, quasi-experimental, matched interrupted time series design study conducted at an integrated Veterans Affairs (VA) health care system. Patients admitted with a primary or secondary diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and heart failure (HF) were included for enrollment. Clinical pharmacists rounding on inpatient medical teams provided evidence-based recommendations to optimize medications while coordinating follow-up by an outpatient clinical pharmacy specialist within 10 days of discharge for CMM. The primary endpoint of this study was to determine the effect on the composite all-cause 30-day acute care utilization rate (emergency department [ED] visit or hospital readmission) for patients discharged with a primary or secondary diagnosis of diabetes, hypertension, COPD, and HF compared with a comparator group of patients with similar discharge diagnosis before implementation of the TOC program. 484 patients (242 in each group, with 366 heart failure, 66 COPD, 10 hypertension, and 42 diabetes) were included for analysis. For the primary outcome of composite 30-day, all-cause acute care utilization rates, no statistically significant difference was identified, with 26.9% of patients in the intervention group and 28.9% in the historical group readmitted or seen in the ED within 30 days of discharge (P = 0.6852). Outcomes for the HF index acute care utilization rate (i.e., admission for the same disease state discharged with), including 30-day index readmissions (P = 0.0014), 30-day index ED visits (P = 0.0047), and 90-day index readmissions for HF (P < 0.0001) were significantly reduced. Our study is one of the first to identify at-risk patients using rounding clinical pharmacists in the acute care arena and coordination of care systematically with a clinical pharmacy specialist practicing under a scope of practice targeted for CMM. Although the overall primary endpoint was not met, a reduction in acute care utilization rates for HF at 30 and 90 days can be achieved. No outside funding supported this research. The authors report no conflicts of interest.

Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates

PurposeThe factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients. MethodsA retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed. Results1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients. ConclusionsSocioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients. Type of studyRetrospective review. Level of evidenceLevel III.