Adjustment For Patient Demographics Research Articles

Patient Care Technician Staffing and Outcomes Among US Patients Receiving In-Center Hemodialysis

Dialysis patient care technicians (PCTs) play a critical role in US in-center hemodialysis (HD) care, but little is known about the association of PCT staffing with patient outcomes at US HD facilities. To estimate the associations of in-center HD patient outcomes with facility-level PCT staffing. This was a retrospective cohort study, with data analysis performed from March 2023 to January 2024. Data on US patients with end-stage kidney disease and their treatment facilities were obtained from the US Renal Data System. Participants included patients (aged 18-100 years) initiating in-center HD between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for 90 days or more and had data on PCT staffing at their initial treating HD facility. Facility-level patient-to-PCT ratios (number of HD patients divided by the number of PCTs reported by the treating facility in the prior year), categorized into quartiles (highest quartile denotes the highest PCT burden). Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. Associations of outcomes with quartile of patient-to-PCT ratio were estimated using incidence rate ratios (IRRs) from mixed-effects Poisson regression, with adjustment for patient demographics and clinical and facility factors. A total of 236 126 patients (mean [SD] age, 63.1 [14.4] years; 135 952 [57.6%] male; 65 945 [27.9%] Black; 37 777 [16.0%] Hispanic; 153 637 [65.1%] White; 16 544 [7.0%] other race; 146 107 [61.9%] with diabetes) were included. After full adjustment, the highest vs lowest quartile of facility-level patient-to-PCT ratio was associated with a 7% higher rate of patient mortality (IRR, 1.07; 95% CI, 1.02-1.12), a 5% higher rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91). The highest vs lowest quartile of patient-to-PCT ratio was also associated with an 8% higher rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% higher rate of vascular access-related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28). These findings suggest that initiation of treatment in facilities with the highest patient-to-PCT ratios may be associated with worse early mortality, hospitalization, and transplantation outcomes. These results support further investigation of the impact of US PCT staffing on patient safety and quality of US in-center HD care.

Does diabetes affect breast cancer survival?

The objective of this study is to investigate the influence of diabetes on breast cancer-specific survival among women with breast cancer in Aotearoa/New Zealand. This study included women diagnosed with invasive breast cancer between 2005 and 2020, with their information documented in the Te Rēhita Mate Ūtaetae-Breast Cancer Foundation National Register. Breast cancer survival curves for women with diabetes and those without diabetes were generated using the Kaplan-Meier method. The hazard ratio (HR) of breast cancer-specific mortality for women with diabetes compared to women without diabetes was estimated using the Cox proportional hazards model. For women with diabetes, the 5-year and 10-year of cancer-specific survival were 87% (95% CI: 85%-88%) and 79% (95% CI: 76%-81%) compared to 89% (95% CI: 89%-90%) and 84% (95% CI: 83%-85%) for women without diabetes. The HR of cancer-specific mortality for patients with diabetes compared to those without diabetes was 0.99 (95% CI: 0.89-1.11) after adjustment for patient demographics, tumor characteristics, and treatments. Age at cancer diagnosis and cancer stage had the biggest impact on the survival difference between the two groups. When stratified by cancer stage, the cancer-specific mortality between the two groups was similar. While differences in survival have been identified for women with diabetes when compared to women without diabetes, these are attributable to age and the finding that women with diabetes tend to present with more advanced disease at diagnosis. We did not find any difference in survival between the two groups due to differences in treatment.

Real-world primary nonadherence to antiobesity medications.

BACKGROUND: Primary nonadherence (PNA), when a medication is newly prescribed but not filled, has been identified as a major research gap potentially impacting the optimal treatment of patients with overweight and obesity who are newly prescribed antiobesity medications (AOMs). OBJECTIVES: To assess PNA among patients with newly prescribed AOMs and to examine factors associated with PNA to AOMs. METHODS: This was a retrospective study that used the Optum Integrated Clinical plus Claims database to identify individuals who had at least 1 prescription order for an AOM the US Food and Drug Administration approved for long-term use. Individuals with prescription orders between January 1, 2012, and February 28, 2019, were identified, and patient demographics, clinical characteristics, medication prescribed, baseline health care utilization, and obesity-related complications were described by PNA status. PNA was defined as no pharmacy claim for the AOM within 60 days of the date of the new prescription order as identified in electronic health record data. A multivariable logistic regression model was used to examine factors associated with PNA. RESULTS: The study sample included a total of 1,563 patients. The mean body mass index was 38.4 kg/m2; 10.7% were prescribed liraglutide 3.0 mg, 26.0% were prescribed lorcaserin, 36.3% of patients were prescribed naltrexone-bupropion, 5.4% were prescribed orlistat, and 21.6% were prescribed phentermine-topiramate. Most patients (91.1%) exhibited PNA, with only 8.9% filling their newly prescribed AOM within 60 days. Both the adherent and nonadherent groups were predominately female sex, White, and covered by commercial insurance. The mean age was similar between the 2 groups. Most obesity-related complications were less prevalent in the adherent group, although the Charlson comorbidity index score was similar between the 2 groups. After adjustment for patient demographics and clinical characteristics, there was not a statistically significant association between the specific AOM and PNA (P = 0.299). Patients with depression or living in the Midwest or South regions were at significantly increased risk of PNA. CONCLUSIONS: The rate of PNA to AOMs was very high, suggesting barriers in effective medical management of patients with overweight and obesity. Future research is warranted to understand reasons for PNA to AOMs and how to address these barriers. DISCLOSURES: Dr Kan, Dr Bae, Dr Dunn, and Dr Ahmad are employees of Eli Lilly and Company. Ms Buysman and Dr Gronroos are employees of Optum. Dr Swindle was an employee of Optum at the time the study was conducted and is currently employed at Evidera. Dr Bengtson is employed at Boehringer Ingelheim Pharmaceuticals, Inc. (Boehringer Ingelheim has no connection to this study), and during the conduct of this study was employed at Optum.

Comparative effectiveness of pain control between opioids and gabapentinoids in older patients with chronic pain.

Gabapentinoid (GABA) prescribing has substantially increased while opioid prescribing has decreased since the 2016 Centers for Disease Control and Prevention Guidelines restricted opioid prescribing for chronic pain. The shift to GABA assumes equal analgesic effectiveness to opioids, but no comparative analgesic effectiveness data exist to support this assumption. We compared GABA to opioids by assessing changes in pain interfering with activities (activity-limiting pain) over time in patients with chronic pain. We used 2017 to 2019 data from a 20% national sample of Medicare beneficiaries diagnosed with chronic pain who initiated a GABA or opioid prescription for ≥30 continuous days and received home health care in the study year. The main outcome was the difference in reduction in pain score from pre- to post-prescription assessments between the 2 groups. Within a 60-day window before-and-after drug initiation, our sample comprised 3208 GABA users and 2846 opioid users. Reduction in post-prescription scores of pain-related interference with activities to less-than-daily pain was 48.1% in the GABA group and 41.7% in the opioid group; this remained significant (odds ratio = 1.29, 95% confidence interval: 1.17-1.43, P < 0.0001) after adjustment for patient demographics and comorbidities. The adjusted difference in reduced pain-related interference score between the 2 groups was -0.10 points on a 0 to 4 scale ( P = 0.01). Gabapentinoid use had greater odds of less-than-daily pain post-prescription, in a dose-dependent manner. Thus, GABA use was associated with a larger reduction in chronic pain than opioids, with a larger effect at higher GABA dosage. Future research is needed on functional outcomes in patients with chronic pain prescribed GABA or opioids.

Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis

Neighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health. To investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK. This was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record. Individual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics. A total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40. Findings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

HIGHER RETURN TO SPORT WITH PATELLAR TENDON AUTOGRAFT VERSUS HAMSTRING TENDON AUTOGRAFT FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

The bone-patellar tendon-bone (BTB) autograft has a lower rate of graft failure but a higher rate of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Subsequent contralateral injury may be a marker of success of the BTB graft, but it is unclear whether the type of graft influences the rate of return to sport. This study aimed to compare the rates of return to weekly sport and return to preinjury activity levels between the BTB and hamstring tendon autografts following primary ACL reconstruction.Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014-November 2019 were analyzed. The primary outcome was return to weekly sport, defined as a Marx activity score of 8, at 2-year follow-up. The secondary outcome was return to preinjury activity level, defined as a post-operative Marx activity score that was equal or greater to the patient's preinjury Marx score. Return to sport was compared between the BTB and hamstring tendon autografts via multivariate binary logistic regression with adjustment for patient demographics.4259 patients were analyzed, of which 50.3% were playing weekly sport (n = 2144) and 28.4% had returned to their preinjury activity level (n = 1211) at 2-year follow-up. A higher rate of return to weekly sport was observed with the BTB autograft compared to the hamstring tendon autograft (58.7% versus 47.9%, adjusted odds ratio = 1.23, p = 0.009). Furthermore, the BTB autograft had a higher rate of return to preinjury activity levels (31.5% versus 27.5%, adjusted odds ratio = 1.21, p = 0.025).The BTB autograft is associated with a higher return to sport and may explain the higher rate of contralateral ACL injury following primary ACL reconstruction.

PATELLAR TENDON AUTOGRAFT IS ASSOCIATED WITH DIFFICULTY KNEELING BUT DOES NOT RESULT IN A MORE PAINFUL OR SYMPTOMATIC KNEE COMPARED WITH HAMSTRING TENDON AUTOGRAFT AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

The bone-patellar tendon-bone (BTB) autograft is associated with difficulty kneeling following anterior cruciate ligament (ACL) reconstruction, however it is unclear whether it results in a more painful or symptomatic knee when compared to the hamstring tendon autograft. This study aimed to identify the rate of significant knee pain and difficulty kneeling following primary ACL reconstruction and clarify whether graft type influences the risk of these complications.Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and November 2019 were analyzed. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was analyzed to identify patients who reported significant knee pain, defined as a KOOS Pain subscale score of ≤72 points, and kneeling difficulty, defined as a patient who reported “severe” or “extreme” difficulty when they kneel. The rate of knee pain and kneeling difficulty was compared between graft types via univariate Chi-square test and multivariate binary logistic regression with adjustment for patient demographics.4492 primary ACL reconstructions were analyzed. At 2-year follow-up, 9.3% of patients reported significant knee pain (420/4492) and 12.0% reported difficulty with kneeling (537/4492). Patients with a BTB autograft reported a higher rate of kneeling difficulty compared to patients with a hamstring tendon autograft (21.3% versus 9.4%, adjusted odds ratio = 3.12, p&lt;0.001). There was no difference between graft types in the rate of significant knee pain (9.9% versus 9.2%, p = 0.49) or when comparing absolute values of the KOOS Pain (mean score for BTB = 88.7 versus 89.0, p = 0.37) and KOOS Symptoms subscales (mean score for BTB = 82.5 versus 82.1, p = 0.49).The BTB autograft is a risk factor for post-operative kneeling difficulty, but it does not result in a more painful or symptomatic knee when compared to the hamstring tendon autograft.

ED point-of-care ultrasonography is associated with earlier drainage of pericardial effusion: A retrospective cohort study

ObjectivesTo determine the association between emergency department point-of-care cardiac ultrasonography (POCUS) utilization and time to pericardial effusion drainage during an 8-year period when the emergency ultrasound program was established at our institution. MethodsWe performed a single-center retrospective cohort study in patients undergoing pericardiocentesis or other procedure for evacuation of pericardial effusion. Data was collected using both direct queries to the electronic health record database and two-examiner chart review. The primary outcome was time to intervention for pericardial effusion drainage. Multivariable Cox regression, with and without inverse probability weighting for likelihood to receive POCUS, was used to determine the association between POCUS and time to intervention. Secondary outcomes included 28-day mortality. Results257 patient encounters were included with 137 receiving POCUS and 120 who did not. The proportion of patients receiving POCUS increased from 18.5% to 69.5% during the early to late periods of the study. POCUS was associated with an earlier median time to intervention of 21.6 h (95% CI 17.2, 24.2) compared to 34.6 h (27.0, 50.5) in the No POCUS group. After adjustment for patient demographics, anticoagulation, time of presentation and hemodynamic instability, POCUS was associated with earlier intervention (HR 2.08 [95% CI 1.56, 2.77]). POCUS use was not associated with a difference in 28-day mortality, which was evaluated as a secondary outcome. However, diagnosis of pericardial effusion by the ED physician using any means (POCUS or other imaging) was associated with decreased 28-day mortality (9.7% vs. 26.0%, −16.3% for POCUS [95% CI −29.1, −3.5]). ConclusionPOCUS was associated with an earlier time to intervention for pericardial effusions after adjustment for multiple confounding factors. Failure to diagnose pericardial effusion in the ED using any diagnostic testing including POCUS, was associated with increased 28-day mortality.

Is seizure disorder a risk factor for complications following surgical treatment of hip dysplasia in the pediatric population?

The impact of seizure disorders on pediatric patients who undergo hip dysplasia surgery has yet to be elucidated. This study focused on identifying the effect of seizure disorders on the incidence of complications following surgical management of hip dysplasia. Pediatric patients undergoing surgical treatment for hip dysplasia from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were divided into two cohorts: patients with and patients without a seizure disorder. Patient demographics, comorbidities and postoperative outcomes were compared between the two groups. Bivariate and multivariate analyses were performed. Of 10 853 pediatric patients who underwent hip dysplasia surgery, 8117 patients (74.8%) did not have a seizure disorder whereas 2736 (25.2%) had a seizure disorder. Bivariate analyses revealed that compared to patients without a seizure disorder, patients with a seizure disorder were at increased risk of developing surgical site infections, pneumonia, unplanned reintubation, urinary tract infection, postoperative transfusion, sepsis, extended operation time and length of stay and readmission ( P < 0.05 for all). Following adjustment for patient demographics and comorbidities on multivariate analysis, there were no differences in any postoperative complications between pediatric patients with and without a seizure disorder. There were no differences in 30-day postoperative complications in patients with and without a seizure disorder. Due to potential decreased bone mineral density as an effect of antiepileptic drugs and the risk of femur fracture during surgery for hip dysplasia, pediatric patients with a seizure disorder should be closely monitored as they may be more susceptible to injury. Level of Evidence: III.

MO899: The Clinical frailty Scale is Useful for ICU Triage in Dialysis Patients With COVID-19–An Eracoda Analysis

BACKGROUND AND AIMSduring the COVID-19 pandemic, several guidelines have recommended the use of the Clinical Frailty Scale (CFS) for triage of critically ill patients with COVID-19 in case of shortage in ICU resources. However, no data on using CFS assessment for ICU triage for dialysis patients is yet available. This study evaluates whether CFS is associated with mortality rates in a cohort of hospitalized dialysis patients with COVID-19.METHODthe analyses are based on data of the European Renal Association COVID-19 Database (ERACODA). Dialysis patients who presented with COVID-19 between 1 February 2020 and 30 April 2021 and with complete information on CFS and vital status at 3 months were included. Study outcomes were hospital and ICU admission rates and hospital and ICU mortality at 3 months after hospital admission. Cox regression analyses were performed to assess the association of CFS category (≤5 versus ≥ 6) and study outcomes in line with Dutch ICU triage guidelines for COVID-19. Furthermore, additional subgroup analyses were performed to assess the association between CFS and 3-month mortality by age category (<65, 65–75 and >75 years).RESULTSamong a total of 2206 dialysis patients (mean age = 67.2 (14.1) years, male sex = 61%), 1694 (77%) had CFS ≤ 5 and 514 (23%) had CFS ≥ 6. Hospitalization rate was comparable in patients with CFS ≤ 5 and in patients with CFS ≥ 6 (67 and 71%, respectively), whereas the rate of ICU admission was higher in patients with CFS ≤ 5 than in patients with CFS ≥ 6 (16 versus 9%, p = 0.001). Among 1501 hospitalized patients, 3-month mortality was 26% of patients with CFS ≤ 5 and 59% in patients with CFS ≥ 6 (P < 0.001). Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with hospital mortality [aHR 2.27 (1.88–2.74) versus CFS ≤ 5; P < 0.001) with a significant interaction for age (P = 0.029). aHR was 4.00 (2.56–6.37; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients < 65 years, aHR was 1.87 (1.33–2.64; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients 65–75 years and aHR was 2.12 (1.64–2.75; CFS ≥ 6 versus CFS ≤ 5; P < 0.001) in patients >75 years. Among 219 ICU admitted patients, 3-month mortality was 60% of the patients with CFS ≤ 5 and 91% in the patients with CFS ≥ 6, respectively. Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with ICU mortality [aHR 1.80 (1.17–2.77); CFS ≥ 6 versus CFS ≤ 5; P = 0.002].CONCLUSIONmore frail dialysis patients with CFS ≥ 6 who are hospitalized for COVID-19 were less often admitted to the ICU, but in case they were admitted to the ICU they have a very high mortality of 91% in this cohort study. In fit to mildly frail dialysis, patients who were admitted to the ICU, mortality rates are lower. The association between frailty and hospital mortality is interacted by age with the strongest association in patients younger than 65 years. These findings suggest that CFS may be a useful complementary triage tool for ICU admission of dialysis patients during the ongoing COVID-19 pandemic.

Association of fluoroquinolones or cephalosporin plus macrolide with Clostridioides difficile infection (CDI) after treatment for community-acquired pneumonia.

Clostridioides difficile infection (CDI) is the most common cause of gastroenteritis, and community-acquired pneumonia (CAP) is the most common infection treated in hospitals. American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) CAP guidelines recommend empiric therapy with a respiratory fluoroquinolone or cephalosporin plus macrolide combination, but the CDI risk of these regimens is unknown. We examined the association between each antibiotic regimen and the development of hospital-onset CDI. We conducted a retrospective cohort study using data from 638 US hospitals contributing administrative including 177 also contributing microbiologic data to Premier, Inc. We included adults admitted with pneumonia and discharged from July 2010 through June 2015 with a pneumonia diagnosis code who received ≥3 days of either empiric regimen. Hospital-onset CDI was defined by a diagnosis code not present on admission and positive laboratory test on day 4 or later or readmission for CDI. Mixed propensity-weighted multiple logistic regression was used to estimate the associations of CDI with antibiotic regimens. Our sample included 58,060 patients treated with either cephalosporin plus macrolide (36,796 patients) or a fluoroquinolone alone (21,264 patients) and with microbiological data; 127 (0.35%) patients who received cephalosporin plus macrolide and 65 (0.31%) who received a fluoroquinolone developed CDI. After adjustment for patient demographics, comorbidities, risk factors for antimicrobial resistance, and hospital characteristics, CDI risks were similar for fluoroquinolones versus cephalosporin plus macrolide (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.70-1.38). Among patients with CAP at US hospitals, CDI was uncommon, occurring in ∼0.33% of patients. We did not detect a significant association between the choice of empiric guideline recommended antibiotic therapy and the development of CDI.

Advance Care Planning for Emergency Department Patients with COVID-19 Infection: An Assessment of a Physician Training Program (QI411)

Outcomes1. Describe the components of an educational toolkit to improve advance care planning in the emergency department for patients with COVID-192. Appraise the effectiveness of an educational toolkit to improve advance care planning in the emergency department for patients with COVID-19BackgroundThe sudden emergence of coronavirus disease 2019 (COVID-19) heightened the importance of advance care planning (ACP) conversations, particularly in the emergency department (ED). The objective of this quality improvement project was to determine the effect of an educational training program (“toolkit”) for emergency providers on ACP conversations in the ED during the COVID-19 pandemic.Aim StatementWe sought to examine the efficacy of an emergency provider–facing educational intervention, led by palliative care physicians, on the initiation of ED-based ACP for patients with COVID-19.MethodsThis was an evaluation of a quality improvement project at an academic ED using observational pre-/post-interventional data. Palliative care physicians delivered a 60-minute ACP educational intervention for emergency medicine providers in conjunction with release of reference documents as part of an educational toolkit. Initial training occurred on April 1, 2020. Measured outcomes for each patient included identification of a healthcare decision maker (HCDM), an order for a code status, or a documented goals-of-care (GOC) conversation.ResultsIn total, 143 charts of patients with confirmed COVID-19 presenting for ED care between March 26 and May 25, 2020 were reviewed. There was exceptional representation in gender, race, and ethnicity, with 58% of participants being female, 29% Black, and 49% Hispanic/Latino. There was a 25.4% (95% CI, 7.0-43.9) increase in ED-based ACP, as measured by documentation of at least an HCDM, code status, or GOC conversation. Even after adjustment for patient demographics, a trend toward increased ACP activity was observed (OR = 2.71, 95% CI, 0.93-8.64).Conclusions and ImplicationsIn response to a pandemic threat, we found that a rapid and simple provider-facing educational toolkit was associated with increased ED-based ACP activities for patients with COVID-19.

Contemporary Costs Associated With Transcatheter Versus Surgical Aortic Valve Replacement in Medicare Beneficiaries.

In patients with severe aortic stenosis, treatment with transcatheter aortic valve replacement (TAVR) has been shown to be cost-effective in the high-risk surgical population and cost-saving in the intermediate-risk population when compared with surgical aortic valve replacement (SAVR) in early pivotal clinical trials. Whether TAVR is associated with comparable or lower costs when compared with SAVR in contemporary clinical practice is unknown. Using data from the Medicare Dataset Standard Analytic Files 5% Fee for Service database, patients receiving either TAVR or SAVR between 2016 and 2018 were identified. Patients were categorized as low, intermediate, or high mortality risk based on 2 validated indices-the Hospital Frailty Risk Score and the logEuroScore. Health care costs out to 1 year were compared between TAVR and SAVR among the low, intermediate, and high-risk groups, after adjustment for patient demographics. Nine thousand seven hundred forty-six patients were identified (4834 TAVR; 3760 SAVR) and included in the analysis. Patients receiving TAVR were older and more likely to be female. Index hospitalization costs were significantly lower with TAVR compared with SAVR across all risk strata (logEuroScore: low: $61 845 versus $68 986; intermediate: $64 658 versus $76 965; high: $65 594 versus $91 005; P<0.001 for all). Follow-up costs through 1 year were generally lower with TAVR and this difference was more pronounced in the low risk groups (logEuroScore: $9763 versus $14 073; Hospital Frailty Risk Score: $10 116 versus $12 880). Accordingly, cumulative 1-year costs were substantially lower with TAVR compared with SAVR. At 1 year, TAVR is associated with lower health care costs across all risk strata when compared with SAVR in contemporary practice. If long-term data continue to demonstrate similar clinical outcomes and valve durability with TAVR and SAVR, these findings suggest that TAVR may be the preferred treatment strategy for patients with aortic stenosis from an economic standpoint.

Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program.

Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. This was an observational pre-/post-interventional study. This study was conducted at a Southeastern U.S. academic ED. 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.

Clinical characteristics and treatments in patients with chronic kidney disease and dementia

AbstractBackgroundThere is limited information on clinical features and treatments of patients with chronic kidney disease (CKD)–associated dementia. In this study, we assessed the difference in dementia diagnoses, cognitive function, and dementia treatment among patients with and without CKD.MethodWe included 20,032 patients with newly diagnosed dementia from the Swedish Dementia Registry (SveDem) within the region of Stockholm during 2006‐2018. Patient baseline kidney function was extracted from the Stockholm CREAtinine Measurements (SCREAM) project, and categorized by estimated glomerular filtration rate (eGFR) as ≥60, 30‐59, 15‐29, and &lt;15 ml/min/1.73m2 or dialysis. Dialysis patients were identified via linkage with Swedish Renal Registry. The difference in dementia diagnosis, cognitive function, dementia treatment among patients with different eGFR strata were examined. Confounders included demographics, living conditions, comorbidities, and therapies.ResultAmong the dementia patients 70% had GFR≥60ml/min, 27% GFR 30‐59ml/min, 2% GFR 15‐29ml/min and 1% &lt;15 % ml/min or with dialysis. The proportion of vascular dementia increased across lower eGFR categories, while Alzheimer’s and mixed dementia, dementia with Lewy Bodies and Parkinson's disease dementia decreased. Patient diagnosis in nursing home, the use of renin‐angiotensin‐system‐inhibitors, calcium‐channel‐blockers, and statins increased while antipsychotics and antidepressants decreased. Compared with eGFR ≥60 ml/min, lower eGFR strata were associated with worse cognitive function (MMSE unit, adjusted β coefficient, ‐0.69, 95% confidence interval [‐1.22,‐0.17] for eGFR 15‐29ml/min and ‐1.50, (‐2.66,‐0.34) for eGFR&lt;15ml/min or dialysis). After adjustment for patient demographics, living conditions, comorbidities, MMSE and therapies, lower eGFR strata were significantly associated with less prescription of acetylcholinesterase inhibitors (aChEIs) and memantines [Odds ratio 0.91(0.84‐0.99) in eGFR 30‐59ml/min and 0.20 (0.09‐0.46), in eGFR&lt;15ml/min or dialysis for aChEIs; 0.91(0.83‐0.99) in eGFR 30‐59ml/min, 0.37 (0.25‐0.55) in eGFR 15‐29ml/min and 0.14(0.03‐0.58), in eGFR&lt;15ml/min or dialysis for memantine use].ConclusionPatients with advanced chronic kidney disease had worse cognitive function and less prescribed anti‐dementia drugs. Since we have previously shown that aChEI treatment is associated with lower mortality, the relationship between anti‐dementia medication, renal function and cognition must be further investigated.

Association of antibiotic use and acute kidney injury in patients hospitalized with community-acquired pneumonia

Background Acute kidney injury (AKI) is common among hospitalized patients with community-acquired pneumonia (CAP). We aimed to estimate and compare the risk of AKI for various antibiotic combinations in adults hospitalized for CAP. Methods We conducted a retrospective cohort study of the Premier Healthcare Database containing all admissions for 660 US hospitals from 2010 to 2015. We included adults aged ≥18 years hospitalized with CAP and considered 6 different antibiotic combinations based on continuous use in the first 3 hospital days. The primary outcome was incident AKI, defined by ICD-9 codes 584.5-584-9. We evaluated associations of AKI with in-hospital mortality and length-of-stay. We excluded patients who were admitted directly to the intensive care unit, had AKI codes present on admission or had dialysis in the first 2 days. We used generalized linear mixed models with the hospital as a random effect and covariate adjustment for patient demographics, comorbidities, other treatments on day 0/1, and hospital characteristics. Results The total sample included 449,535 patients, 3.15% of whom developed AKI. All other regimens but fluoroquinolones exhibited higher AKI odds than 3rd generation cephalosporin with or without macrolide. The combination of piperacillin/tazobactam and vancomycin with or without other antibiotics was associated with the highest AKI odds (OR = 1.89; 95% CI: 1.73–2.06). Patients with incident AKI had an increased odds of hospital mortality (OR = 6.37; 95% CI: 6.07–6.69) and longer length-of-stay (mean multiplier = 1.84; 95% CI: 1.82, 1.86). Conclusion Compared to 3rd generation cephalosporin with or without macrolide, piperacillin/tazobactam, vancomycin, and their combination were associated with higher odds of developing AKI, which in turn were associated with worse clinical outcomes.

Two-Tier Lyme Disease Serology in Children with Previous Lyme Disease

Background: A history of Lyme disease can complicate the interpretation of Lyme disease serology in acutely symptomatic patients. Materials and Methods: We prospectively enrolled children undergoing evaluation for Lyme disease in the emergency department of one of eight participating Pedi Lyme Net centers. We selected symptomatic children with a Lyme disease history (definite, probable, or none) as well as an available research biosample. We defined a Lyme disease case with either an erythema migrans (EM) lesion or positive two-tier serology with compatible symptoms. Using a generalized estimating equation, we examined the relationship between time from previous Lyme disease diagnosis and current Lyme disease after adjustment for patient demographics and symptoms as well as clustering by center. Results: Of 2501 prospectively enrolled study patients, 126 (5.0%) reported a history of definite or probable Lyme disease. Of these children with previous Lyme disease, 47 met diagnostic criteria for Lyme disease at the time of enrollment (37.3%; 95% confidence interval [CI] 29.1-45.7%); 2 had an EM lesion, and 45 had positive two-tier Lyme disease serology. Over time from the previous Lyme disease diagnosis, the less likely the patient met diagnostic criteria for Lyme disease (adjusted odds ratio 0.62 per time period; 95% CI 0.46-0.84). Conclusions: For children with a history of Lyme disease before enrollment, one-third met the diagnostic criteria for acute Lyme disease with a declining rate over time from previous Lyme disease diagnosis. Novel Lyme disease diagnostics are needed to help distinguish acute from previous Lyme disease.

Proton pump inhibitor therapy is associated with reduced survival following first-time transarterial chemoembolization in patients with hepatocellular carcinoma.

Several studies have reported associations of proton pump inhibitor (PPI) treatment with the incidence of complications and even increased mortality in patients with liver cirrhosis. Up to now, there are no studies on the impact of PPI treatment in patients with hepatocellular carcinoma (HCC). Therefore, the aim of our study was to investigate the prognostic effects of PPI treatment in a cohort of patients with HCC treated by transarterial chemoembolization (TACE). Three hundred fifty-eight patients with HCC that received first-time TACE were included in a retrospective analysis. We explored effects of PPI treatment using uni- and multivariable regression models. One hundred sixty-seven of the 358 patients (46.6%) received PPI treatment. Median transplant-free survival after TACE was significantly lower in patients treated with PPIs compared to patients without PPI treatment [16.0 (10.7-21.3) months vs. 26 (22.2-29.8) months, P = 0.006]. Importantly, PPI treatment remained a significant prognostic factor for reduced survival after adjustment for patient demographics, tumor stadium and liver function [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.09-1.78, P = 0.005]. We observed a dose-dependent association of PPI treatment with survival: A higher daily PPI dose was an independent prognostic factor for reduced survival (HR 1.32, 95% CI 1.14-1.54, P < 0.001). Notably, 58.1% of patients receiving PPIs had no clear indication therefor. PPI treatment is associated with reduced survival in patients with HCC in a dose-dependent manner. Thus, indication for PPI treatment should be evaluated attentively in these patients. Further, prospective studies are needed to validate the findings of this study.

A Retrospective Study of Low-Risk Cesarean Delivery by Midwife Versus Obstetrician Service [02P

INTRODUCTION: To evaluate the variation in low risk cesarean delivery rate between the midwife and obstetrician-led services at a rural tertiary care center. METHODS: A retrospective cohort study of 1787 term, singleton, and vertex (TSV) deliveries without a history of cesarean delivery at a rural academic tertiary care center was performed. The primary outcome was rate of cesarean delivery among midwife and obstetrician-led services. Statistical comparisons were performed using student t-tests, chi-square tests, and multivariable logistic regression. RESULTS: Between January 2015 and December 2017, 1787 deliveries were analyzed with 956 (53%) managed by the midwife service and 831 (47%) managed by the obstetrician-led service. Midwife patients had significantly lower odds of having a cesarean delivery after adjustment for all maternal and delivery characteristics (aOR 0.56, 95% CI 0.30–0.82). Other factors favoring cesarean delivery include older maternal age, higher body mass index at delivery, and nulliparity. Midwife patients had higher odds of presenting in spontaneous labor (63.0% vs 53.3%, P&lt;.001), while obstetrician patients had increased odds of receiving neuraxial anesthesia (72.3% vs 56.1%, P&lt;.001) and were more likely to be nulliparous (56.4% vs. 50.3%, P=.01). There were no differences in frequency of APGAR scores less than 7 at five minutes between the two groups (2.5% for obstetrician vs. 1.7% for midwife, P=.204). CONCLUSION: In this rural academic tertiary care center, patients cared for by the midwife service have significantly lower odds of cesarean delivery than patients cared for by the physician-led service after adjustment for patient demographics and maternal medical conditions.

Relationship between early follow-up and readmission within 30 and 90 days after ischemic stroke.

To examine whether early follow-up with primary care or neurology is associated with lower all-cause readmissions within 30 and 90 days after acute ischemic stroke admission. We performed a retrospective cohort study of patients who were discharged home after acute ischemic stroke, identified by ICD-9 and ICD-10 codes, using PharMetrics, a nationally representative claims database of insured Americans from 2009 to 2015. The primary predictor was outpatient primary care or neurology follow-up within 30 and 90 days of discharge, and the primary outcome was all-cause 30- and 90-day readmissions. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, with adjustment for patient demographics, comorbid conditions, and stroke severity measures. The cohort included 14,630 patients. Readmissions within 30 days occurred in 7.3% of patients, and readmissions within 90 days occurred in 13.7% of patients. By 30 days, 59.3% had a primary care visit, and 24.4% had a neurology visit. Primary care follow-up was associated with reduced 30-day readmissions (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.72-0.98). Primary care follow-up before 90 days did not reach significance (HR 0.92, 95% CI 0.83-1.03). Neurology follow-up was not associated with reduced readmissions within 30 or 90 days (HR 1.05, 95% CI; HR 1.00, 95% CI, respectively). Early outpatient follow-up with primary care is associated with a reduction in 30-day hospital readmissions. Early outpatient follow-up may represent an important opportunity for intervention after acute stroke admissions.