30-day Emergency Department Research Articles

Clinical and cost-effectiveness of earlier discharge from acute hospital after total joint arthroplasty.

Reducing length of stay has been proposed as a key component of policies that aim to meet demand and minimize costs associated with total joint arthroplasty. However, few studies explore shifting of healthcare utilization when length of stay is shortened. This retrospective cohort study examined patients undergoing primary, total hip and knee arthroplasty for osteoarthritis to simulate a policy-level institutional reduction in acute hospital stay by 1 day. Costs, quality of life, and rates of complications, readmission and discharge to inpatient rehabilitation were compared in patients with a three- and four-day length of acute stay. Balance was achieved using overlap-propensity weighting. In total, 2023 patients were included. Earlier discharge from acute hospital was not associated with a change in odds of 90-day complications (OR: 0.85 [95% CI, 0.58 to 1.27]; P = 0.447), readmissions (OR: 1.11 [95% CI, 0.67 to 1.82]; P = 0.691), and emergency department presentations (OR: 1.07 [95% CI, 0.66 to 1.73]; P = 0.774). Earlier discharge from acute hospital was associated with an increase in odds of discharge to inpatient rehabilitation (OR: 2.16 [95% CI, 1.45 to 3.20]; P < 0.001). No significant differences in costs and quality adjusted life years were observed at one-year. Cost savings during index admission were shifted onto increased costs associated with inpatient rehabilitation. Earlier discharge was not associated with changes in 90-day complications, readmission, or ED presentations. However, an increase in utilization of inpatient rehabilitation was observed, offsetting early cost savings. Patients who were discharged from acute care on day three had no difference in costs compared to those discharged on day four.

Virtual Home Care for Patients With Acute Illness

Recent evolutions in clinical care and remote monitoring suggest that some acute illnesses no longer require intravenous therapy and inpatient hospitalization. To describe outcomes of patients receiving care in a new, outpatient, virtual, home-based acute care model called Safer@Home. This retrospective cohort analysis, conducted from September 1, 2022, through August 31, 2023, included 2466 patients treated at a safety net hospital in Los Angeles County for 10 core illnesses and 24 other acute illnesses for which patients are commonly hospitalized. Outpatient, home-based, acute care with virtual monitoring and clinic visits in lieu of inpatient or in-home care. The primary measure was hospital length of stay. Secondary measures included all-cause mortality, 30-day readmission, return urgent care visit rates, and return emergency department (ED) visit rates. Safer@Home provided care to 876 patients (mean [SD] age, 54.0 [14.5] years; 541 men [61.8%]) during the study period, compared with a cohort of 1590 patients (mean [SD] age, 52.3 [19.6] years; 901 men [56.7%]) with matching diagnoses who received standard, hospital-based care. Safer@Home patients had significantly shorter mean (SD) lengths of inpatient stay than the comparison cohort (1.3 [2.0] vs 5.3 [10.4] days; P < .001), totaling 3505 bed-days avoided (mean [SD], 4.0 [10.6] bed-days saved per patient), with no significant difference in all-cause mortality at last follow-up (2.6% [23 of 876] vs 4.0% [64 of 1590]; P = .07). Safer@Home patients and control patients also had no significant difference in the proportion experiencing 30-day hospital readmission (19.9% [174 of 876] vs 16.7% [266 of 1590]; P = .06). As intended, more Safer@Home than control patients had at least one 30-day return urgent care visit (37.3% [327 of 876] vs 5.2% [82 of 1590]; P < .001). In contrast, the Safer@Home and control cohorts did not significantly differ in experiencing at least one 30-day return ED visit (15.2% [133 of 876] vs 12.5% [199 of 1590]; P = .06). Safer@Home patients had significantly fewer mean (SD) total 30-day return ED visits per patient than control patients (0.19 [0.50] vs 0.21 [0.85]; P < .001). In this cohort study, patients receiving acute, virtual, home care with remote monitoring and as-needed return urgent care visits had markedly shorter hospital stays than patients receiving standard inpatient hospital care, with no significant increase in mortality, ED revisits, or return hospitalizations. This new care model is promising for systems that cannot staff Medicare-compliant hospital-at-home visits.

Outpatient Physical Therapy Attendance by Older Adults After Emergency Department Discharge was a Predictor for Lower 30-Day Revisits-But Demographic Factors Affected Attendance.

Given the high risk of functional loss and revisits among older adults presenting to the emergency department (ED), there is a need to understand how post-ED discharge outpatient physical therapy affects outcomes. This study sought to examine patient demographics and their association with outpatient physical therapy utilization after ED discharge and physical therapy attendance with 30-day ED revisits among older adults discharged to home. In this retrospective cohort study, we analyzed data from 1395 older adults (65years old and older) who had a referral to outpatient physical therapy upon discharge from 15 EDs between January 2021 and December 2022. Descriptive statistics and multivariate logistic regression were used to evaluate the likelihood of attending outpatient physical therapy and the odds of a 30-day ED revisit. Of the sample, 39.3% attended outpatient physical therapy. Older adults in the first and second neighborhood income quintile had a 51% lower odds of attending outpatient physical therapy than those in the fourth quintile. Patients with a diagnosis of vertigo had a 67% higher odds of attending outpatient physical therapy (OR = 1.67; 95% CI = 1.21-2.29) than those with back pain. Older adults who did not attend outpatient physical therapy within 30days of ED visit had a 88% higher odds of returning to the ED than those who did attend (OR = 1.88; 95% CI = 1.34-2.64). Older adults in the first and second income quintile had a 66% higher odds of revisiting the ED than those in the fourth quintile. Outpatient physical therapy attendance after ED discharge was a predictor of revisit within 30days. Patient diagnosis of vertigo and higher median household income were predictors of higher outpatient physical therapy attendance. However, a diagnosis of falls or mobility concerns and a lower household income status were associated with lower attendance. Physical therapy after ED discharge has the potential to reduce 30-day ED revisit but requires strategies to improve access equity across diagnostic groups and household income levels.

Outcomes of ED chest pain visits: the prognostic value of negative but measurable high-sensitivity cardiac troponin (hs-cTn) levels.

Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of "negative but measurable" hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels. This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3-50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality. Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p < 0.001), and 30-day mortality (0.3% vs. 0.01%, p < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L. Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

Outpatient Total Joint Arthroplasty at an Ambulatory Surgical Center: An Analysis of Failure to Launch

There has been a tremendous increase in same-day discharge (SDD) following primary total joint arthroplasty (TJA). While the concept of failure to launch (FTL) has been recently investigated in hospital settings, there is a paucity of data in the ambulatory surgical center (ASC) context. This study aimed to examine the incidence and underlying causes of FTL within an ASC at a major academic medical center. A retrospective review from 2021 to 2024 was performed on all patients who underwent same-day surgery at our ASC after intentional selection and medical optimization per institutional protocols. The demographic information, incidence and source of FTL, 90-day readmissions, and reoperations/revisions were recorded. There were 1,974 patients who underwent primary TJA at the ASC during the study. There were nine patients who required direct hospital admission from the ASC (0.45%). This patient population had a significantly increased American Society of Anesthesiologists (ASA) score compared to patients who were discharged home. Additionally, these patients had a significantly higher number of 90-day emergency department visits. Syncopal episodes were the most common reason for hospital admission from the ASC (66.7%), followed by nausea, seizures, and pain (all 11.1%). After review by attending orthopaedic surgeons and anesthesiologists, only two patients had potentially preventable medical causes for admission. Approximately 99.55% of patients had successful SDD at our ASC, underscoring the importance of proper preoperative screening. Only 0.45% of patients required hospital admission, primarily attributed to hypotension and syncopal events. Interestingly, only two patients in our cohort experienced a potentially preventable instance of FTL. It is crucial that additional efforts be aimed at identifying patients at risk and implementing treatment strategies to prevent postoperative hypotension and syncopal events that may further improve SDD and outcomes in outpatient TJA in the ASC setting.

Reasons for 90-day emergency department visits after primary knee arthroplasty.

Postoperative visits to the emergency department (ED) generate additional costs on health care systems and consume already limited resources. We sought to determine the rate and reasons why patients who underwent primary knee arthroplasty returned to the ED within 90 days of postoperative discharge, which could guide the development of preventative measures. We identified patients who underwent primary knee arthroplasty at 2 hospitals in Nova Scotia, Canada, between April 2021 and March 2022 and who had an ED visit within 90 days of postoperative discharge. We reviewed data for timing and reason for ED visits. Of 687 patients who had primary knee arthroplasty surgeries, 145 (21.1%) patients visited the ED within 90 days of postoperative discharge. Most visits occurred in the early postoperative period, predominantly for surgical reasons (94.7% within 7 days) and shifting toward medical reasons over time. Pain was the most common surgical reason for ED visits (15.9%), followed by swelling (9.7%), and hematoma drainage (9.7%). Understanding the reasons for postoperative ED visits after knee arthroplasty is important in developing strategies to reduce ED overcrowding and improve patient outcomes. Implementing targeted interventions, such as enhanced pain management and patient education, may help alleviate the burden on EDs, reduce costs, and improve overall health care delivery for patients undergoing knee arthroplasty.

A comparison study of 90-day readmission and emergency department visitation after outpatient versus inpatient pediatric pollicization surgery

IntroductionTransition to outpatient surgery has grown with an emphasis on delivery of safe, high-quality medical care. The purpose of this study is to compare 90-day emergency department (ED) visits, readmissions, and complications between patients undergoing outpatient versus inpatient pollicization surgery. MethodsA single institution database was queried for primary thumb pollicization from 2010 to 2022 in patients under 18 years of age. Standard demographic data, comorbidities, surgical information, and discharge disposition were collected. Primary outcome measures were complications including ED visits, unplanned reoperations and hospital readmissions within 90-days of index procedure. ResultsTwenty-seven patients underwent pollicization surgery. Twenty patients were outpatient surgery while 7 had postoperative hospital admission, defined as an overnight hospital stay. The outpatient cohort had no major postoperative complications including no ED visits, reoperations or readmissions within 90 days of index procedure. One outpatient experienced swelling around bilateral thumb pin sites without infection or vascular compromise. One inpatient represented to the ED within 90 days of surgery for bilateral hand cellulitis.All patients with ASA I classification were performed outpatient. Three of 7 inpatients (43 %) had congenital heart disease versus 5 of the 20 (25 %) outpatients. There was a trend that inpatients were younger than the outpatient cohort (19 vs. 33 months). The average length of procedure in the inpatient cohort was significantly longer than the outpatient cohort (237 vs. 173 min). Pollicizations performed between 2017 and 2022 were more likely to be outpatient than those performed between 2010 and 2016. ConclusionOn properly selected patients, outpatient pollicization appears to be a safe option. Patients with longer operative times were more likely to require postoperative hospital admission. Over the study years evaluated at our institution, pollicization procedures were more likely to be performed outpatient, reflecting an evolution of our practice. Level of evidenceLevel III, retrospective cohort study.

Is Tranexamic Acid Safe for Patients Who Have End-Stage Renal Disease Undergoing Total Joint Arthroplasty?

BackgroundTranexamic acid (TXA) is a renally-excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty. MethodsThrough a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or hemiarthroplasty (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; nonelective/hemiarthroplasty: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (ROA; intravenous, topical), were extracted. Pre- and postoperative (≤ 7 days) creatinine, perioperative transfusions, revisions, and 90-day emergency department (ED) visits, readmissions, and mortalities were recorded and compared between TXA groups. ResultsIn the total sample and all cohorts, change in pre- to postoperative creatinine and incidence of postoperative acute kidney injury (AKI), per Kidney Disease Improving Global Outcomes (KDIGO) guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or ROA (P values ≥ 0.256). There were no statistically significant differences in 90-day ED visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA, three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA, one no TXA, P = 0.882) in the nonelective/hemiarthroplasty cohort, with none in the elective cohorts. ConclusionsThe administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or hemiarthroplasty for fracture, suggesting TXA should not be contraindicated in this population.

Smokeless tobacco use is associated with a lower risk of perioperative complications and revision surgery after anatomic and reverse total shoulder arthroplasty compared to cigarette smokers

BackgroundNo prior study has separated the effects of smokeless tobacco from traditional cigarettes in patients undergoing anatomic total shoulder (aTSA) and reverse total shoulder arthroplasty (rTSA). Therefore, the purpose of this study was to evaluate the effects of smokeless tobacco on postoperative outcomes after aTSA and rTSA. MethodsA retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary TSA with a minimum two-year follow-up were included. Smokeless tobacco only users, cigarette only users, and nontobacco users were propensity score matched based on demographic variables and comorbidities. Postoperative medical complications and surgery-specific complications were compared among groups. Patient groups were further stratified by surgical technique: aTSA or rTSA. Multivariable logistic regressions were employed to account for confounding variables. ResultsSmokeless tobacco use was not associated with increased risk of complications after TSA compared to nonusers. Cigarette use was associated with an increased risk of pneumonia (OR: 1.20), wound dehiscence (OR: 1.39), emergency department (ED) visits (OR: 1.40), and readmissions (OR: 1.12) within 90 days as well as infection (OR: 1.21), aseptic loosening (OR: 1.28), dislocation (OR: 1.27), fracture (OR: 1.30), and revision surgery (OR: 1.19) within 2 years compared to nonusers. After separating by surgical technique, smokeless tobacco use, after aTSA was associated with fewer 90-day ED visits (OR: 0.52), while cigarette only use was associated with increased risk of rotator cuff tear (OR: 1.17) and fracture (OR: 1.88) within two years compared to nonusers. Compared to cigarette smokers, smokeless tobacco users had significantly decreased risk of ED visits (OR: 0.40) within 90 days and implant removal (OR: 0.13) within two years of surgery. For rTSA, smokeless tobacco use was not associated with increased risk of complications compared to nonuser controls; however, cigarette use was associated with an increased risk of ED utilization (OR: 1.33) within 90 days as well as aseptic loosening (OR: 1.32) and irrigation and debridement (OR: 1.37) within two years. Smokeless tobacco use, when compared to cigarette users, was associated with significantly fewer shoulder dislocations (OR: 0.27) within two years. ConclusionSmokeless tobacco use was associated with a lower risk of complications compared to cigarette users and no difference compared to nonusers after aTSA and rTSA. These findings suggest that while all tobacco use, including smokeless tobacco and cigarettes, is best avoided prior to surgery, the risks associated with smokeless tobacco use may be less severe than those linked to cigarette smoking after aTSA and rTSA.

Machine Learning For Risk Prediction After Heart Failure Emergency Department Visit or Hospital Admission Using Administrative Health Data.

Patients visiting the emergency department (ED) or hospitalized for heart failure (HF) are at increased risk for subsequent adverse outcomes, however effective risk stratification remains challenging. We utilized a machine-learning (ML)-based approach to identify HF patients at risk of adverse outcomes after an ED visit or hospitalization using a large regional administrative healthcare data system. Patients visiting the ED or hospitalized with HF between 2002-2016 in Alberta, Canada were included. Outcomes of interest were 30-day and 1-year HF-related ED visits, HF hospital readmission or all-cause mortality. We applied a feature extraction method using deep feature synthesis from multiple sources of health data and compared performance of a gradient boosting algorithm (CatBoost) with logistic regression modelling. The area under receiver operating characteristic curve (AUC-ROC) was used to assess model performance. We included 50,630 patients with 93,552 HF ED visits/hospitalizations. At 30-day follow-up in the holdout validation cohort, the AUC-ROC for the combined endpoint of HF ED visit, HF hospital readmission or death for the Catboost and logistic regression models was 74.16 (73.18-75.11) versus 62.25 (61.25-63.18), respectively. At 1-year follow-up corresponding values were 76.80 (76.1-77.47) versus 69.52 (68.77-70.26), respectively. AUC-ROC values for the endpoint of all-cause death alone at 30-days and 1-year follow-up were 83.21 (81.83-84.41) versus 69.53 (67.98-71.18), and 85.73 (85.14-86.29) versus 69.40 (68.57-70.26), for the CatBoost and logistic regression models, respectively. ML-based modelling with deep feature synthesis provided superior risk stratification for HF patients at 30-days and 1-year follow-up after an ED visit or hospitalization using data from a large administrative regional healthcare system.

Postoperative Complications and Readmission Rates in Robotic-Assisted and Manual Total Hip Arthroplasty

Objective: This study aims to compare 90-day postoperative complications, readmissions, and emergency department (ED) visits between robotic-assisted (RA-THA) and manual (M-THA) total hip arthroplasty. Methods: A retrospective review of a multi-hospital database identified primary total hip arthroplasty patients between January 2016 and December 2021. The cohorts were 1-to-1 matched based on patient sex, age, and body mass index resulting in 8033 patients in each cohort (N = 16,066). Odds of 90-day revisits, readmission with &gt;23 hours of observation, and ED visits were compared between cohorts. Complications reported during revisits and readmission were classified according to the Clinical Classification Software schema, using the International Classification of Diseases, 10th Revision codes, and compared using mixed-effect models. Results: This study found an overall 90-day revisit rate of 8.3%. RA-THA was associated with significantly reduced odds of revisit within 90 days [odds ratio (OR): 0.71, 95% CI: 0.58–0.89, P = 0.002] and readmissions with &gt;23 hours of observation (OR: 0.61, 95% CI: 0.48–0.77, P &lt; 0.001). RA-THA patients had fewer readmissions with &gt;23 hours of observation due to dislocations (RA-THA: 0.09%; M-THA: 0.39%, P &lt; 0.001), surgical site infections (RA-THA: 0.04%; M-THA: 0.20%, P = 0.004), and wound infections/cellulitis (RA-THA: 0.01%; M-THA: 0.11%, P = 0.021). No difference in ED visits was observed between cohorts (OR: 0.92, 95% CI: 0.77–1.09, P = 0.3). RA-THA patients had more ED visits for dyspnea without pulmonary embolism (RA-THA: 0.20%; M-THA: 0.06%, P = 0.03). Conclusion: RA-THA showed significantly lower odds of overall 90-day revisit rates and readmissions with &gt;23 hours of observation, most notably for readmissions due to dislocation and surgical site infection/wound infections. There was no significant difference in the odds of ED visits between cohorts.

Youth suicidality risk relative to ambient temperature and heatwaves across climate zones: A time series analysis of emergency department presentations in New South Wales, Australia.

Youth suicidality prevalence continues to rise alongside hot weather severity. Links between these two variables are underexplored. We examined associations between daily temperature and emergency department suicidality presentations by young people. We assessed these associations for five regions covering New South Wales as determined by 'climate zone' and analysed for heatwave effects as well as based on demographic subgroups. Daily emergency department presentations for suicidality by people aged 12-24 years across New South Wales, Australia, during warmer months (November to March) from 2012 to 2019 were examined in relation to daily mean temperature and heatwaves (⩾3 consecutive days ⩾ 95th percentile of long-term daily mean temperature) and by climate zone, using a generalised additive model with negative binomial distribution. Risks for age- and sex-based subgroups were also calculated. New South Wales youth suicidality presentation rates were significantly higher on hotter days. For every 1°C rise above average daily mean temperature, youth suicidality presentations to New South Wales emergency departments increased by 1.3%. Heatwaves did not increase presentation rates beyond single-day daily mean temperature effects. These findings were predominantly replicated across climate zones and demographic subgroups, though the association between suicidality and ambient temperature was weaker in coastal regions including Eastern Sydney. There is a positive linear association between ambient temperature and youth suicidality presentations to emergency departments. Risks are increased on single hot days, not only during heatwaves. Public health, broader societal approaches to heat and health system planning should consider impacts on youth suicidality of predicted increases in hot weather severity and frequency.

The association between fracture and short-term adverse health outcomes among children with cerebral palsy

BackgroundChildren with cerebral palsy (CP) have a high risk of fracture; yet, little is known about their post-fracture health outcomes. A fracture is an unplanned event in contrast to surgeries or procedures where there is a pre-operative period to optimize body composition and health and planned post-operative follow-up care. Fractures may be associated with significant outcomes due to the unplannable nature and reactionary care. The objective of this study was to determine if fractures were associated with an increased rate of short-term adverse health outcomes among children with CP, and if these associations were dependent on age. MethodsThis retrospective cohort study used commercial claims from 01/01/2001–12/31/2018. The primary cohort was children 2–18 years old with CP and an incident fracture (CP + Fx). Comparison cohorts were propensity score matched 1:1 to CP + Fx on demographic and health-related indicators: CP without fractures (CPw/oFx); without CP with (w/oCP + Fx) or without (w/oCPw/oFx) a fracture. The incidence rate (IR) and IR ratios (IRR) of 30-day and 31–90-day pneumonia and 90-day emergency department (ED) visit were estimated. Cox regression tested for effect modification by age and sex. ResultsThe CP + Fx cohort (n = 1670) had higher IRs of 30-day pneumonia (IRR range, 1.53–4.54) and 90-day ED visit (IRR range, 1.45–2.37) (all P < 0.05), and higher IRs of 31–90-day pneumonia but this did not reach statistical significance (IRR, 1.41 to 2.32, all P > 0.05). Notably, there was evidence of effect modification by age. The rate of 30-day pneumonia became more problematic for CP + Fx with older age relative to comparison cohorts and for 90-day ED visit compared to CPw/oFx. The rate of 90-day ED visit for CP + Fx was more problematic at younger ages compared to w/oCP + Fx. ConclusionsFractures among children with CP were associated with an increased rate of short-term pneumonia and ED visit, which was more problematic with older age.

A Higher Area Deprivation Index is Associated with Increased Medical Complications and Emergency Department Utilizations after Total Hip Arthroplasty

IntroductionThe Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. The purpose of this study was to determine whether patients undergoing total hip arthroplasty (THA) in areas of high ADI (greater disadvantage) were associated with differences in 90-day: 1) medical complications; 2) emergency department (ED) utilizations; and 3) readmissions. MethodsA nationwide database was queried for primary THA patients from 2010 to 2020. The ADI is reported on a scale of 0 to 100, with higher numbers indicating greater disadvantage. Patients undergoing primary THA in regions associated with high ADI (90%+) were compared to those of lower ADI (0 to 89%). A total of 138,670 patients were evenly matched between the two cohorts following 1:1 propensity score matching by age, sex, and Elixhauser Comorbidity Index (ECI). Primary endpoints were 90-day medical complications, ED utilizations, and readmissions. Multivariable logistic regression models calculated the odds ratios (OR) and 95% confidence intervals (95% CI). P-values less than 0.01 were statistically significant. ResultsPatients undergoing THA from high ADI had significantly higher rates and odds of developing any medical complications (13.00 versus 11.91%; OR: 1.09, P < 0.0001), including acute kidney injuries (1.83 versus 1.52%; OR: 1.20, P < 0.0001), myocardial infarctions (0.35 versus 0.24%; OR: 1.45, P = 0.0003), and surgical site infections (0.94 versus 0.76%; OR: 1.23, P = 0.0004). High ADI patients had significantly higher rates and odds of ED visits within 90 days (3.94 versus 3.67%; OR: 1.08, P = 0.008). There was no significant difference in readmissions (5.44 versus 5.69%; OR: 0.95, P = 0.034). ConclusionsSocioeconomically disadvantaged patients have increased odds of 90-day medical complications and ED utilizations, despite comparable 90-day readmission rates. Measures of neighborhood disadvantage may be valuable metrics to inform healthcare policy and improve post-discharge care.

General versus disease-specific medical oncology consults and impact on inpatient quality of care.

321 Background: Hospitalization is a time of crisis for patients and caregivers. Subspeciality oncologists may bring more timely, effective support compared to a general oncologists. Attendings, fellows and advance practice providers (APPs) may benefit from focused expertise for consultative care and education. Methods: Subspeciality oncology consults launched July 2023, with consults staffed by 4 oncologists from: 1) breast 2) head and neck/thoracic 3) gastrointestinal and 4) genitourinary/melanoma. Previously, 3 oncologists staffed all patients, regardless of primary malignancy. Throughout the study period, oncologists were supported by at least 1 fellow or 1 APP. Using Epic and Tableau, we collected LOS, time to consult (TTC), ICU rate, hospice referral rate, 30-day readmission, 30-day emergency department (ED) visit data. Using Qualtrics, we collected fellow, attending, and APP satisfaction feedback pre- and post-intervention. Data was analyzed using R-4.40. Oncologists, fellows, and APPs completed Qualtrics surveys pre- and post-intervention regarding their experience. Results: Subspeciality oncology consults were associated with a significant decrease in LOS, TTC, and ICU rate. Median LOS decreased by 2.0 days (P&lt;0.001), with median TTC decreasing by 1.0 hour (P=0.003). ICU rate decreased from 27.5% to 16.4% (P&lt;0.001). There was no difference in hospice referrals or 30-day ED visits. A significant increase in 30-day readmission during post-intervention was observed (Table). Oncologists reported a high level of satisfaction with the program. Oncologist, fellow, and APP overall experience and educational rankings increased after the introduction of subspeciality consults. Inpatient productivity measured by wRVU increased by 30% following the intervention, without associated changes to outpatient productivity. Conclusions: Transition to a subspeciality oncology consult model improved inpatient quality of care, as well as clinician experience. Additionally, inpatient productivity increased without decrease in outpatient metrics. Subspeciality medical oncology consultation can improve inpatient quality of care, education, clinician satisfaction and productivity. Subspeciality oncology consult outcomes. General Consults (Baseline)* Subspeciality Consults (Intervention) P-value Median TTC (Hours) 4.0 (1.5-6.0)** 3.0 (0-5.0)** P=0.003 Median LOS (Days) 7.0 (4.0-13.0)** 5.0 (3.0-10.0)** P&lt;0.001 ICU Rate 148 (27.5%) 161 (16.4%) P&lt;0.001 Hospice Referral Rate 56 (10.4%) 95 (9.7%) 0.655 30-Day Readmission Rate 136 (25.3%) 301 (30.7%) 0.028 30-Day ED Rate 157 (29.2%) 315 (32.1%) 0.247 *Baseline data reflects outcomes for general oncology consult staffing, prior to initiation of subspeciality consult model (pre-intervention). **Interquartile Range (IQR).

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and longer-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. MethodsPatients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology (CPT) codes. Exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI).Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. One-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. ResultsIn total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354 respectively.Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (p<0.0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (p<0.0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and ConclusionFibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in one-year revisions.

Outcomes After Total Knee Arthroplasty in Patients With a History of Patella Fracture: A Propensity Score-Matched Analysis.

Posttraumatic osteoarthritis is a common indication for total knee arthroplasty (TKA). The purpose of this study was to evaluate the association between a history of patella fracture and postoperative complication rates after TKA. Patients diagnosed with a patella fracture before undergoing TKA were identified from a large national database and matched to a control cohort using propensity scoring. Rates of medical complications occurring within 90 days of TKA and surgery-related complications occurring within 1 year of TKA were compared using odds ratios. Healthcare utilization outcomes including 90-day emergency department (ED) presentation, hospital readmission, and total cost were also compared. Compared with a propensity-matched control cohort, TKA patients with a history of patella fracture had a lower incidence of pulmonary embolism (OR 0.74, P = 0.0442) and higher incidences of periprosthetic joint infection (OR 1.68, P < 0.0001), revision surgery (OR 1.84, P < 0.0001), dislocation (OR 1.61, P = 0.026), lysis of adhesions (OR 2.21, P = 0.0082), and wound disruption (OR 1.52, P < 0.0001). A history of patella fracture was also associated with an increased rate of ED presentation (OR 1.08, P = 0.0454) and increased total cost ($14,359 vs. $12,786, P = 0.0003). A history of patella fracture is associated with early surgery-related complications after TKA including periprosthetic joint infection, revision surgery, dislocation, lysis of adhesions, and wound disruption. Healthcare utilization is increased among these patients with higher rates of ED presentation and increased total cost. These findings allow for more accurate risk stratification and counseling of patients. III, Retrospective review.

Downstream Emergency Department and Hospital Utilization Comparably Low Following In-Person Versus Telemedicine Primary Care for High-Risk Conditions.

Telemedicine use expanded greatly during the COVID-19 pandemic. More data is needed to understand how this shift may impact other venues of acute care delivery. We evaluate the association of visit modality (telephone, video, or office) and downstream emergency department (ED) and hospital visits among primary care visits for acute, time-sensitive conditions. Observational study of patient-scheduled primary care telemedicine and office visits for acute conditions (cardiac, gastrointestinal, neurologic, musculoskeletal, and head and neck) in a large, integrated healthcare delivery system. Adults with a new self-booked primary care appointment for an eligible acute condition from January 1, 2022, to December 31, 2022 (with no primary care, ED, or hospital visits in prior 30 days). Visit modality, including office, video, or telephone. Seven-day ED and hospital utilization, adjusted for patient and visit characteristics. Among 258,958 primary care visits by 239,240 adult patients, 57.7% were telemedicine visits; of these, 72.4% were telephone and 27.6% were video. Telephone visits were the timeliest, with over 70% of visits scheduled within 1 day of booking. Rates of 7-day ED utilization were low, and varied by condition group, with cardiac visits having the highest rates (4.8%) and musculoskeletal visits having the lowest (0.8%). There was less than a 1% absolute difference in ED use by visit modality for all condition types; however, telephone visits were associated with slightly higher rates than video visits. The 7-day hospitalization rate was less than 1% and observed between visit type differences varied by clinical condition. Among office, telephone, and video visits in primary care for potentially high-risk, time-sensitive conditions, downstream ED and hospital use were uncommon. ED utilization was lower for video visits than telephone visits, although telephone visits were timelier and may offer a safe and accessible option for acute care.

Orthopaedic patients' emergency department attendance behavior in relation to weather conditions: temperature, rain, day and time, and regional thursday effect.

Great variation was noticed in emergency department (ED) afflux in relation to daily weather conditions, including difficulties in arranging the correct number of orthopaedic on-calls on the floor. This study aimed to quantify the association between the number of patients referred to the orthopaedic team from the ED and weather conditions, particularly daily temperature and rain. Data were obtained from a large state research hospital's ED attendance. Weather information for the local area for the year was obtained from the regional meteorological office. Data were evaluated using descriptive statistics, with one-way analysis of variance for the relationship between the day of the week and patient numbers, the Pearson test for correlations between daily ED patient flow and daily temperature and the Spearman correlation test for correlations between daily patient flow and daily rain status. A positive and meaningful correlation existed between daily patient influx and daily temperature, along with a negative correlation between daily patient flow and daily rain. Throughout the year, significantly more patients were referred to the orthopaedic team on Thursdays than on any other day of the week. Patients tended to visit the ED more on warm days and days without rain. These results may help in organising daily, monthly or seasonal on-call orthopaedic team requirements despite the challenges. Incorporating climate forecasts into planning the on-call service might help alleviate the stress on the team.

A pilot study testing a new transition of care model from hospital to the community for Hispanic/Latino adults with diabetes to reduce emergency department visits and hospital re-admissions

BackgroundHispanic/Latino populations have the second highest prevalence of diabetes (12.5%) among ethnic minority groups in the USA. They also have higher rates of uncontrolled diabetes and diabetes-related complications. Approximately 29% of diabetes care costs are attributed to inpatient hospital care. To reduce hospital length of stay and re-admission rates for diabetes, the American Diabetes Association (ADA) recommends a “structured discharge plan tailored to the individual patient with diabetes.” However, limited research exists on the feasibility and applicability of a transition of care model specifically tailored for the Hispanic/Latino population.MethodsWe conducted a 2-year pilot study to develop a practical, patient-centered, and culturally competent transition of care (TOC) model for Hispanic/Latino adults with diabetes discharged from the hospital to the community. Feasibility outcomes included recruitment rates, questionnaire completion rates, adherence to a 30-day post-discharge phone call, and resource needs and utilization for study implementation. Participant-centered outcomes included 30-day post-discharge emergency department (ED) visits, 30-day post-discharge unplanned re-admissions, follow-up visits within 2 weeks of discharge, and patient satisfaction with the TOC model.ResultsTwelve participants were enrolled over the study period, with weekly enrollment ranging from 0 to 4 participants. Participants’ average age in years was 47 (± 11.6); the majority were male (85%), and 75% had type 2 diabetes. Recruitment involved the support of 4 bilingual staff. The estimated time to review the chart, approach participants, obtain informed consent, complete questionnaires, and provide discharge instructions was approximately 2.5 h. Of the 10 participants who completed the 30-day post-discharge phone call, none had ED visits or unplanned hospital re-admissions within 30 days post-discharge, and all had a follow-up with a medical provider within 2 weeks.ConclusionsImplementing a patient-centered and culturally competent TOC model for Hispanic/Latino adults with diabetes discharged from the hospital to the community is feasible when considering key resources for success. These include a bilingual team with dedicated and funded time, alignment with existing discharge process and integration into the Electronic Medical Record (EMR) systems.