All-cause Hospital Admissions Research Articles

Comparison of safety and efficacy between Nirmatrelvir-ritonavir and molnupiravir in the treatment of COVID-19 infection in patients with advanced kidney disease: a retrospective observational study

Nirmatrelvir-ritonavir is used in patients with coronavirus disease 2019 (COVID-19) with normal or mild renal impairment (eGFR ≥30ml/min per 1.73m2). There is limited data regarding its use in advanced kidney disease (eGFR <30ml/min per 1.73m2). We performed a retrospective territory-wide observational study evaluating the safety and efficacy of nirmatrelvir-ritonavir when compared with molnupiravir in the treatment of patients with COVID-19 with advanced kidney disease. We adopted target trial emulation using data from a territory-wide electronic health record database on eligible patients aged ≥18 years with advanced kidney disease (history of eGFR <30ml/min per 1.73m2) who were infected with COVID-19 and were prescribed with either molnupiravir or nirmatrelvir-ritonavir within five days of infection during the period from 16 March 2022 to 31 December 2022. A sequence trial approach and 1:4 propensity score matching was applied based on the baseline covariates including age, sex, number of COVID-19 vaccine doses received, Charlson comorbidity index (CCI), hospitalisation, eGFR, renal replacement therapy, comorbidities (cancer, respiratory disease, myocardial infarction, ischaemic stroke, diabetes, hypertension), and drug use (renin-angiotensin-system agents, beta blockers, calcium channel blockers, diuretics, nitrates, lipid lowering agents, insulins, oral antidiabetic drugs, antiplatelets, immuno-suppressants, corticosteroids, proton pump inhibitors, histamine H2 receptor antagonists, monoclonal antibody infusion) within past 90 days. Individuals were followed up from the index date until the earliest outcome occurrence, death, 90 days from index date or the end of data availability. Stratified Cox proportional hazards regression adjusted with baseline covariates was used to compare the risk of outcomes between nirmatrelvir-ritonavir recipients and molnupiravir recipients which include (i) all-cause mortality, (ii) intensive care unit (ICU) admission, (iii) ventilatory support, (iv) hospitalisation, (v) hepatic impairment, (vi) ischaemic stroke, and (vii) myocardial infarction. Subgroup analyses included age (<70; ≥70 years); sex, Charlson comorbidity index (≤5; >5), and number of COVID-19 vaccine doses received (0-1; ≥2 doses). A total of 4886 patients were included (nirmatrelvir-ritonavir: 1462; molnupiravir: 3424). There were 347 events of all-cause mortality (nirmatrelvir-ritonavir: 74, 5.06%; molnupiravir: 273, 7.97%), 10 events of ICU admission (nirmatrelvir-ritonavir: 4, 0.27%; molnupiravir: 6, 0.18%), 48 events of ventilatory support (nirmatrelvir-ritonavir: 13, 0.89%; molnupiravir: 35, 1.02%), 836 events of hospitalisation (nirmatrelvir-ritonavir: 218, 23.98%; molnupiravir: 618, 28.14%), 1 event of hepatic impairment (nirmatrelvir-ritonavir: 0, 0%; molnupiravir: 1, 0.03%), 8 events of ischaemic stroke (nirmatrelvir-ritonavir: 3, 0.22%; molnupiravir: 5, 0.16%) and 9 events of myocardial infarction (nirmatrelvir-ritonavir: 2, 0.15%; molnupiravir: 7, 0.22%). Nirmatrelvir-ritonavir users had lower rates of all-cause mortality (absolute risk reduction (ARR) at 90 days 2.91%, 95% CI: 1.47-4.36%) and hospitalisation (ARR at 90 days 4.16%, 95% CI: 0.81-7.51%) as compared with molnupiravir users. Similar rates of ICU admission (ARR at 90 days-0.09%, 95% CI:-0.4 to 0.2%), ventilatory support (ARR at 90 days 0.13%, 95% CI:-0.45 to 0.72%), hepatic impairment (ARR at 90 days 0.03%, 95% CI:-0.03 to 0.09%), ischaemic stroke (ARR at 90 days-0.06%, 95% CI:-0.35 to 0.22%), and myocardial infarction (ARR at 90 days 0.07%, 95% CI:-0.19 to 0.33%) were found between nirmatrelvir-ritonavir and molnupiravir users. Consistent results were observed in relative risk adjusted with baseline characteristics. Nirmatrelvir-ritonavir was associated with significantly reduced risk of all-cause mortality (HR: 0.624, 95% CI: 0.455-0.857) and hospitalisation (HR: 0.782, 95% CI: 0.64-0.954). Patients with COVID-19 with advanced kidney disease receiving nirmatrelvir-ritonavir had a lower rate of all-cause mortality and hospital admission when compared with molnupiravir. Other adverse clinical outcomes were similar in both treatment groups. Health and Medical Research Fund (COVID1903010), Health Bureau, The Government of the Hong Kong Special Administrative Region, China.

Early Access to First-Seizure Clinics, Subsequent Outcomes, and Factors Associated With Attendance

First-seizure clinics (FSCs) aim to deliver prompt specialist care to patients with new-onset undifferentiated seizure events. To determine whether FSC attendance and time to FSC are associated with subsequent health care utilization and mortality and to investigate factors associated with FSC nonattendance. This was a record-linkage, retrospective, cohort study of patients who booked appointments at 2 FSCs between 2007 and 2018. Patients' records were linked to state-wide administrative databases between 2000 and 2021. The setting comprised the FSCs of 2 major metropolitan public hospitals in Melbourne, Australia, providing national inpatient and outpatient adult epilepsy services. Of patients who booked appointments at the FSCs, those who were successfully linked for analysis were included in the study. Patients who recorded only canceled appointments were excluded from analysis of outcomes. Study data were analyzed from January 2000 to December 2021. FSC attendance. Subsequent all-cause and seizure-related emergency department (ED) presentations and hospital admissions. Of 10 162 patients with appointments at FSCs, 9392 were linked for analysis, with mean (SD) follow-up time 6.9 (2.8) years after FSC referral. A total of 703 patients were excluded. Among 9392 linked patients, 5398 were male (57.5%; mean [SD] age, 59.7 [11.2] years). FSC attendance was associated with reduced subsequent all-cause emergency presentations (adjusted incidence rate ratio [aIRR], 0.72; 95% CI, 0.66-0.79) and all-cause hospitalization (aIRR, 0.81; 95% CI, 0.75-0.88). Those who attended at the first-scheduled appointment, compared with those who attended only a rescheduled, delayed appointment, had reduced subsequent all-cause emergency presentations (aIRR, 0.83; 95% CI, 0.76-0.91), all-cause hospitalization (aIRR, 0.71; 95% CI, 0.65-0.79), seizure-related presentations (aIRR, 0.40; 95% CI, 0.33-0.49), and mortality (hazard ratio, 0.82; 95% CI, 0.69-0.98). Male sex was associated with nonattendance (adjusted relative risk [aRR], 1.12; 95% CI, 1.03-1.22), as were injury at emergency presentation (aRR, 1.12; 95% CI, 1.01-1.24), psychiatric comorbidity (aRR, 1.68; 95% CI, 1.55-1.81), previous seizure-related presentations (aRR, 1.35; 95% CI, 1.22-1.49), and delays (>14 days) between FSC referral and appointment (aRR, 1.35; 95% CI, 1.18-1.54). Hospitalization at referral was associated with reduced nonattendance (aRR, 0.80; 95% CI, 0.72-0.90), as were non-English language preference (aRR, 0.81; 95% CI, 0.69-0.94), distance greater than 6 mi from home to clinic (aRR, 0.85; 95% CI, 0.76-0.95), and physical comorbidity (aRR, 0.80; 95% CI, 0.72-0.89). Results of this cohort study suggest that FSC attendance, particularly early attendance, was associated with reduced rates of subsequent hospital utilization. This knowledge may support adequately resourcing FSCs to improve equitable, timely access. Future study directions include assessing interventions that may support FSC attendance for at-risk groups.

Enhancing patient outcomes: Integrating electronic cardiology consultation in primary care for cancer patients.

The prevalence of cancer patients with concomitant cardiovascular (CV) disease is on the rise due to improved cancer prognoses. The aim of this study is to evaluate the long-term outcomes of cancer patients referred to a cardiology department (CD) via primary care using e-consultation. We analysed data from cancer patients with prior referrals to a CD between 2010 and 2021 (n = 6889) and compared two care models: traditional in-person consultations and e-consultations. In e-consultation model, cardiologists reviewed electronic health records (e-consultation) to determine whether the demand could be addressed remotely or necessitated an in-person consultation. We used an interrupted time series regression model to assess outcomes during the two periods: (1) time to cardiology consultation, (2) rates of all-cause and CV related hospital admissions and (3) rates of all-cause and CV-related mortality within the first year after the initial consultation or e-consultation at the CD. Introduction of e-consultation for cancer patients referred to cardiology care led to a 51.8% reduction (95%CI: 51.7%-51.9%) in waiting times. Furthermore, we observed decreased 1-year incidence rates, with incidence rate ratios (iRRs) [IC95%] of .75 [.73-.77] for CV-related hospitalizations, .43 [.42-.44] for all-cause hospitalizations, and .87 [.86-.88] for all-cause mortality. Compared to traditional in-person consultations, an outpatient care program incorporating e-consultation for cancer patients significantly reduced waiting times for cardiology care and demonstrated safety, associated with lower rates of hospital admissions.

Exercise-based cardiac rehabilitation for adults with heart failure.

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting. To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure. We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers. We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF. We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence. We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes. This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Age- and sex-specific associations of frailty with mortality and healthcare utilization in community-dwelling adults from ontario, Canada

BackgroundUnderstanding how health trajectories are related to the likelihood of adverse outcomes and healthcare utilization is key to planning effective strategies for improving health span and the delivery of care to older adults. Frailty measures are useful tools for risk stratification in community-based and primary care settings, although their effectiveness in adults younger than 60 is not well described.MethodsWe performed a 10-year retrospective analysis of secondary data from the Ontario Health Study, which included 161,149 adults aged ≥ 18. Outcomes including all-cause mortality and hospital admissions were obtained through linkage to ICES administrative databases with a median follow-up of 7.1-years. Frailty was characterized using a 30-item frailty index.ResultsFrailty increased linearly with age and was higher for women at all ages. A 0.1-increase in frailty was significantly associated with mortality (HR = 1.47), the total number of outpatient (IRR = 1.35) and inpatient (IRR = 1.60) admissions over time, and length of stay (IRR = 1.12). However, with exception to length of stay, these estimates differed depending on age and sex. The hazard of death associated with frailty was greater at younger ages, particularly in women. Associations with admissions also decreased with age, similarly between sexes for outpatient visits and more so in men for inpatient.ConclusionsThese findings suggest that frailty is an important health construct for both younger and older adults. Hence targeted interventions to reduce the impact of frailty before the age of 60 would likely have important economic and social implications in both the short- and long-term.

Comparison of Acute Health Care Utilization Between Patients Receiving In-Center Hemodialysis and the General Population: A Population-Based Matched Cohort Study From Ontario, Canada.

Patients receiving maintenance hemodialysis have multiple comorbidities and are at high risk of presenting to the hospital. However, the incidence and cost of acute health care utilization in the in-center hemodialysis population and how this compares with other populations is poorly understood. To determine the rate, pattern, and cost of emergency department visits and hospitalizations in patients receiving in-center hemodialysis compared with a matched general population. Population-based matched cohort study. We used linked administrative health care databases from Ontario, Canada. We included 25 379 patients (incident and prevalent) receiving in-center hemodialysis between January 1, 2010, and December 31, 2018. Patients were matched on birth date (±2 years), sex, and cohort entry date using a 1:4 ratio to 101 516 individuals from the general population. Our primary outcomes were emergency department visits (allowing for multiple visits per individual) and hospital admissions from the emergency department. We also assessed all-cause hospitalizations, all-cause readmissions within 30 days of discharge from the original hospitalization, length of stay for hospital admissions (including multiple visits per individual), and the financial cost of these admissions. We presented the rate, percentage, median (25th, 75th percentiles), and incidence rate per 1000 person-years for emergency department visits and hospitalizations. Individual-level health care costs for emergency department visits and all-cause hospitalization were estimated using resource intensity weights multiplied by the cost per weighted case. Patients receiving in-center hemodialysis had substantially more comorbidities (eg, diabetes) than the matched general population. Eighty percent (n = 20 309) of patients receiving in-center hemodialysis had at least 1 emergency department visit compared with 56% (n = 56 452) of individuals in the matched general population, over a median follow-up of 1.8 years (25th, 75th percentiles: 0.7, 3.6) and 5.2 (2.5, 8.4) years, respectively. The incidence rate of emergency department visits, allowing for multiple visits per individual, was 2274 per 1000 person-years (95% confidence interval [CI]: 2263, 2286) for patients receiving in-center hemodialysis, which was almost 5 times as high as the matched general population (471 per 1000 person-years; 95% CI: 469, 473). The rate of hospital admissions from the emergency department and the rate of all-cause hospital admissions in the in-center hemodialysis population was more than 7 times as high as the matched general population (hospital admissions from the emergency department: 786 vs 101 per 1000 person-years; all-cause hospital admissions: 1056 vs 139 per 1000 person-years). The median number of all-cause hospitalization days per patient year was 4.0 (0, 16.5) in the in-center hemodialysis population compared with 0 (0, 0.5) in the matched general population. The cost per patient-year for emergency department visits in the in-center hemodialysis population was approximately 5.5 times as high as the matched general population while the cost of hospitalizations in the in-center hemodialysis population was approximately 11 times as high as the matched general population (emergency department visits: CAN$ 1153 vs CAN$ 209; hospitalizations: CAN$ 21 151 vs CAN$ 1873 [all costs in 2023 CAN$]). External generalizability and we could not determine whether emergency department visits and hospitalizations were preventable. Patients receiving in-center hemodialysis have high acute health care utilization. These results improve our understanding of the burden of disease and the associated costs in the in-center hemodialysis population, highlight the need to improve acute outcomes, and can aid health care capacity planning. Additional research is needed to address the risk of hospitalization after controlling for patient comorbidities. This is not applicable as this is a population-based matched cohort study and not a clinical trial.

Temperature change between neighboring days and hospital admissions in China

The short-term temperature fluctuation caused by global climate change is one of the risk factors affecting public health. Exploring the association between temperature fluctuation and diseases, which has received relatively limited research attention, can contribute to enhancing awareness of health risks and taking timely measures for health risk alert and management. Therefore, this study aims to investigate the relationship between temperature change between neighboring days (TCN) and hospitalizations, identify diseases sensitive to extreme TCN, and evaluate the related disease burden. We collected meteorological and hospitalization data from 2014 to 2019 in 23 sites of China to explore the impact of TCN on hospitalizations. We first quantified site-specific associations between TCN and hospitalizations and then conducted meta-analysis to pool the results, to assess the relative risk of extreme TCN for susceptible diseases, and to estimate the related disease burden attributed to TCN. Stratified analyses were undertaken by age, sex, and disease type. Results showed that all-cause hospital admission was significantly linked to TCN. A negative TCN (below −1.9 °C) in the cool season and a positive TCN (above 1.0 °C) in the warm season increased the risk of hospitalization. People aged 15–64 years, men, and patients with musculoskeletal system or connective tissue diseases were more sensitive to extremely negative TCN during the cool season. People aged over 65 years, men, and patients with respiratory diseases were more sensitive to extremely positive TCN during the warm season. The attributable fraction to all-cause hospitalization from negative TCN in the cool season was 2.05% (95% CI: −0.90%, 4.53%) and from positive TCN in the warm season was 5.79% (95% CI: 2.98%, 8.31%). Circulatory diseases in the cool season and respiratory diseases in the warm season had the highest disease burden. Our findings indicate that awareness of TCN and its health risks should be promoted and evidence-informed policies are needed to reduce the risk of TCN.

Strong and graded associations between level of asthma severity and all-cause hospital care use and costs in the UK

BackgroundHospital admissions account for a large share of the healthcare costs incurred by people with asthma. We assessed the hospital care use and costs associated with asthma severity using the...

Maintaining or increasing cardiorespiratory fitness is associated with reduced hospital admission rate.

The aim of this study was to investigate the association between change in cardiorespiratory fitness (CRF) and cardiovascular disease (CVD)-related and all-cause hospital admission and explore if the association varies dependently on prior admission, baseline CRF, sex, and age. A total of 91 140 adult participants (41.5% women) with two examinations from occupational health profile assessments between 1986 and 2019 were included (mean of 3.2 years between examinations). Cardiorespiratory fitness was assessed as maximal oxygen consumption and estimated through a submaximal cycle test. Cardiorespiratory fitness change was defined as annual percentage change in relative CRF (mL/min/kg) and further divided into 'decliners' (≤1%), 'maintainers' (-1% to 1%), and 'increasers' (>1%). Hospital admissions were followed over a mean of 7 years. Natural cubic splines and Cox proportional hazards model were applied. Additionally, prevented fraction for the population was calculated. Increase in CRF was associated with a lower risk of CVD [hazard ratio (HR) = 0.99] and all-cause hospital admission (HR = 0.99), after multilevel adjustment for confounders and change in smoking, diet, and stress. Compared with a decline, maintenance of CRF was associated with 9% and 7% lower risk of CVD and all-cause admission, respectively. Increase in CRF reduced the risk by 13% and 11% and, for individuals with prior admission, by 20% and 14%. The burden of CVD and all-cause admission was 6% and 5% lower than if the whole cohort had declined CRF, with large potential cost savings. Efforts to maintain or improve CRF should be included in disease-preventive strategies, regardless of change in other lifestyle-related risk factors. Preventing the age-associated decline in CRF can lessen healthcare utilization and costs.

1771. A Novel Approach to Distributing COVID-19 Oral Antivirals During a Public Health Emergency Using a Pharmacy Home Delivery Model in New York City, 2022

Abstract Background In December 2021, the oral antivirals (OAVs) nirmatrelvir/ritonavir and molnupiravir were authorized for the treatment of COVID-19 in high-risk patients. Initial supplies were limited and states designated pharmacies to receive OAVs from a weekly federal allocation. New York City (NYC) has nearly 3,000 pharmacies serving a diverse population across a large urban area. To ensure fair access to OAVs, the NYC Health Department partnered with an online pharmacy to provide rapid delivery to any NYC address. Here we describe characteristics of patients served and metrics used to evaluate the program as the pandemic and OAV access evolved in 2022. Methods The NYC partner pharmacy provided data on OAV prescriptions including patient age, sex, delivery zip code, and dates of prescription and delivery. These data were matched with the NYC Health Department’s COVID-19 surveillance data including positive lab reported cases, Citywide Immunization Registry, deaths, all-cause emergency department (ED) visits and hospital admissions. Descriptive statistics were calculated using R Statistical Software. Results A total of 48,947 OAV prescriptions were delivered in 2022, reaching 99.5% of residential zip codes, accounting for 17.5% of the OAVs dispensed in NYC. The median time from prescription receipt to delivery was 17 hours (IQR 6-24) with half (49%) of deliveries going to high social vulnerability zip codes. Of OAV recipients, most (58%) were female, with a median age of 56 years (IQR 39, 68) with 32% aged 65 years or older; 78% had received at least a primary vaccination series; 36% matched with a lab reported COVID-19 case; 5.5% had an ED visit and 0.8% were hospitalized in NYC for any cause within 30 days of prescription date. Conclusion The NYC antiviral delivery program provided broad and timely access to COVID OAVs, serving a significant proportion of patients in high social vulnerability neighborhoods and older adults at higher risk for severe outcomes. Of note, an increasing proportion of people receiving OAVs were not reported as cases to public health, which likely reflects the increasing use of home tests in 2022. Limitations include the lack of data on race/ethnicity, underlying medical conditions and for patients receiving OAVs through other pharmacies. Disclosures All Authors: No reported disclosures

Use of real-world data to assess the effectiveness of ustekinumab in treating IBD patients: a retrospective linked database study in northwest London

ABSTRACT Background Data on the optimum positioning of biologics in the treatment of inflammatory bowel disease (IBD) are limited. Research design and methods This was a longitudinal retrospective study of linked health-care data from northwest London, UK, for adults who started ustekinumab for IBD from 1 April 20161 April 2016 to 1 April 20211 April 2021. We compared outcomes by line of therapy (1 vs. 2 or 3+) and age group (18‒59 years or ≥ 60 years). In an analysis of CD patients, we calculated risks of IBD-related hospitalization, IBD-related abdominal surgery, ustekinumab persistence, and switching by line of therapy. Results Of 163 patients screened, 149 were eligible. Age had no effect on outcomes. Elective all-cause hospital admissions were significantly higher when ustekinumab was used as second-line or third-line therapy compared with first-line treatment (p = 0.0048 and p = 0.001, respectively). In CD patients the numbers of hospital admissions were also higher with second-line or third-line therapy (p = 0.040 and p = 0.018, respectively). Use of ustekinumab as third-line therapy significantly increased the risk of IBD-related hospitalization (hazard ratio 2.5, 95% CI 1.1‒5.6, p = 0.029), IBD-related abdominal surgery (9.45, 1.2‒75.7, p = 0.03), and switching (14.6, 1.6‒131.0, p = 0.02). Drug persistence risks did not differ. Conclusions These findings support the use of ustekinumab as first-line therapy.

Associated adverse health outcomes of polypharmacy and potentially inappropriate medications in community-dwelling older adults with diabetes.

Aim: This study aimed to identify the association of chronic polypharmacy and potentially inappropriate medications (PIMs) with adverse health outcomes (AHOs) in community-dwelling older adults with diabetes in China. Methods: A 2-year retrospective cohort study was conducted using 11,829 community-followed older adults with diabetes and medical records from 83 hospitals and 702 primary care centers in Shenzhen, China. Chronic polypharmacy and PIMs were identified from prescription records using Beers' criteria, and their associated AHO was analyzed using multivariable logistic regression analysis. Results: The prevalence of chronic polypharmacy and at least one PIM exposure was 46.37% and 55.09%, respectively. The top five PIMs were diuretics, benzodiazepines, first-generation antihistamines, sulfonylureas, and insulin (sliding scale). Chronic polypharmacy was positively associated with all-cause hospital admission, admission for coronary heart disease, admission for stroke, admission for dementia, and emergency department visits. Exposure to PIMs was positively associated with all-cause hospital admission, admission for heart failure (PIMs ≥2), admission for stroke (PIMs ≥3), emergency department visits, bone fracture, constipation, and diarrhea. Conclusion: Chronic polypharmacy and PIMs were prevalent in older adults with diabetes in Chinese communities. Iatrogenic exposure to chronic polypharmacy and PIMs is associated with a higher incidence of different AHOs. This observational evidence highlights the necessity of patient-centered medication reviews for chronic polypharmacy and PIMs use in older patients with diabetes in primary care facilities in China and draws attention to the caution of polypharmacy, especially PIM use in older adults with diabetes in clinical practice.

Predictors of clinical outcome in adults with repaired tetralogy of Fallot and the prognostic value of surrogate markers of right ventricular dyssynchrony

Abstract Introduction Sequelae or residual lesions after surgical repair of tetralogy of Fallot (rTOF) are inevitable and have an impact on long-term outcome. So far, most of our attention was directed to negative consequences of residual pulmonary regurgitation. Less attention has been paid to the impact of right bundle branch block and intraventricular dyssynchrony on biventricular function, exercise capacity and clinical outcome. Purpose Using the Swiss Adult Congenital HEart disease Registry we aimed to investigate the 5-year clinical course of adults with rTOF late after surgical repair. We used echocardiography strain analysis as surrogate to quantify right and left ventricular dyssynchrony and correlated our findings with routine clinical measures from cardiopulmonary exercise testing, neurohumoral blood work and cardiac magnetic resonance imaging with the aim to identify patients at increased risk for an adverse clinical event. Methods 2D speckle-tracking strain analysis of the right and left ventricle was performed with dedicated software (Tomtec, Germany). RV dyssynchrony index was measured as the standard deviation of time to peak shortening (TTP) in six RV segments. Interventricular shortening delay (IVSD) was defined as the maximal delay of TTP between ventricular segments. We constructed a multivariate model with NT-proBNP, ECG, clinical, imaging and exercise testing variables to predict the composite outcome of all-cause mortality, relevant arrhythmias and hospital admission for decompensated heart failure. Results A total of 285 patients were included. During a mean follow-up of 48±21 months, 33 patient (12 %) suffered an adverse event with a mean time to event of 30 ± 21 months after the baseline visit. RV dyssynchrony index and IVSD did not differ statistically between the groups with and without events (49±31ms vs 41±18ms, p-value 0.21, 130±65ms vs. 103±50ms, p-value 0.9). In the multivariate Cox-regression model, NT-proBNP, right atrial area and peak heart rate at exercise testing were independent predictors of outcome. An integrated risk score with the median values of these 3 variables as cut-off was highly accurate in separating patients at low risk (score 0; n=39) and high risk (score 3; n=38) for an adverse event. After 6 years of follow-up, no patient at low risk (score 0) had an adverse event, while in 62% of patients at high risk (score 3) an adverse event occurred (p&amp;lt;0.001). Conclusion In our cohort of rTOF patients, echocardiographic surrogates of RV dyssynchrony did not correlate with clinical events. An integrated multimodality approach proved to be effective in predicting outcomes.

Abstract 14025: Health Status Profiles in Patients With New or Worsening Peripheral Artery Disease Symptoms and 12-month Hospitalization Risk From the Portrait Registry

Introduction: Risk stratification for healthcare utilization in PAD is critical given rising costs. The association between health status measures and hospitalization is unknown. We examined the association between a disease-specific patient-reported outcome measure and risk of hospitalization at 12 months. Methods: Patients with new or worsened lower extremity claudication enrolled at US sites in the PORTRAIT registry from 2011 to 2015 were included. The Peripheral Artery Questionnaire, a PAD-specific patient-reported outcome measure, was used to measure health status. PAQ summary scores range from 0 to 100 (better health status). Kaplan-Meier failure curves and adjusted Cox proportional hazards models assessed the association between baseline PAQ summary score and (1) the combined endpoint of all-cause hospital admission and ED visit (AD-ED) and (2) all-cause hospital admission (AD) at 12 months. Results: Of the 796 patients (mean age 69 ± 10 years, 42% female, 72% white, mean baseline PAQ summary score 46.8 ± 22.0) included, 349 (44%) had a hospital admission or ED visit at 12 months, with a total of 661 visits. Patients in the lowest PAQ quartile had higher rates of AD-ED at 30 days (16.1% vs. 4.3%), 90 days (29.8% vs. 12.8%), and 12 months (53.3% vs. 22.4%). In the fully adjusted model, lower PAQ score was associated with higher risk for AD-ED (HR per 10-point decrease, 1.12, 95% CI, 1.06-1.19, P&lt;0.001) and AD (HR per 10-point decrease, 1.14, 95% CI, 1.06-1.22, P&lt;0.001). Conclusion: Lower PAD-specific health status is associated with an increased risk in the combined endpoint of hospital admission or ED visits and all-cause hospital admission. These results support the use of baseline health status as a strong predictor for healthcare utilization in a high-risk population and may help to offset costs.

Abstract 13338: Intravenous Iron for Patients With Iron Deficiency and Acute or Chronic Heart Failure, a Meta Analysis

Iron deficiency is very common in heart failure (HF), both with preserved and reduced ejection fraction (HFp/rEF); and has significant impact on both symptoms and prognosis. This review highlights the effect of use of intravenous iron (IVI) therapy in patients with HFrEF Several databases were searched to identify RCTs that investigate the efficacy and safety of IVI therapy in patients with acute or chronic HF. A meta-analysis was performed using RevMan using random effect model. We used the odds ratio (OR) and mean difference (MD) for dichotomous and continuous outcomes, respectively presented with the corresponding 95% confidence interval (CI). A total of 18 studies were included with 3,436 patients with mean age of 68 years old. There was no statistically significant difference between IVI and placebo in terms of cardiovascular death or all-cause hospital admission. However, IVI was associated with statistically significant lower risk for hospitalization for any cardiovascular disorder and all cause death with OR 0.42 [95% CI 0.28, 0.64, p&lt;0.0001] and 0.61 [95% CI 0.39, 0.96, p=0.03], respectively. Additionally, there was statistically significant variation in serum ferritin and serum transferrin from baseline favoring intravenous iron with MD -189.62 [95%CI -236.55, -142.69, p=0.01], and -7.65 [95% CI -13.43, -1.87, p=0.009], respectively. Furthermore, IVI was associated with a significant improvement in HF patients’ functional status, evaluated by both Kansas City Cardiomyopathy Questionnaire (KCCQ), and changes from baseline in left ventricular ejection fraction (LVEF) with MD -7.14 [95% CI -10.52, -3.76, p&lt;0.0001], and 3.76 [95% CI 2.32, 5.21, p&lt;0.00001], respectively. Our meta-analysis demonstrated the capability of IVI to improve clinically meaningful outcomes as HF-related cardiovascular-related hospitalization as well as functional status; however, intravenous iron showed no difference in term of mortality.

Impact of a clinician-to-clinician electronic consultation in heart failure patients with previous hospital admissions.

To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4851 were attended in e-consult, and 2230 had previous HFH. Using an interrupted time series regression model, we analysed the impact of incorporating e-consult into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P < 0.001). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840-0.833]), 0.900 [0.862-0.949] for CV and 0.699 [0.678-0.726] for all-cause hospitalizations. There was also lower mortality (iRR [95%CI]: 0.715 [0.657-0.798] due to HF, 0.737 [0.764-0.706] for CV and 0.687 [0.652-0.718] for all-cause). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. In patients with HFH, an outpatient care programme that includes an e-consult significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.

Abstract 16380: Does Non-Alcoholic Fatty Liver Disease Increase the Risk of Ventricular Arrhythmias in Patients With Heart Failure?

Background: Non-alcoholic fatty liver disease (NAFLD), including non-alcoholic fatty liver and non-alcoholic fatty steatohepatitis, is associated with increased incidence of heart failure (HF). Previous studies have shown an association of NAFLD with increased incidence of ventricular arrhythmias (VAs). however, it is unknown if the increased rate of VA is related to increased HF or if from an independent NAFLD-related mechanism. Therefore, this study aimed to investigate the effect of NAFLD on VA in patients with HF. Methods: A retrospective cohort study of electronic heath records using the TriNetX Research Network was performed. Patients at least 18 years old with diagnosis of cardiomyopathy (CM) or HF were identified by ICD-10-CM codes from January 1, 2014 to December, 31, 2019. Patients were separated based on the diagnosis of NAFLD. Patients who had HF and NAFLD were propensity-score matched (PSM) using age, sex, race, hypertension, hyperlipidemia, ischemic heart disease, cerebrovascular disease, atherosclerosis, diabetes mellitus, acute or chronic kidney disease, acute or chronic respiratory failure, anemia, atrial fibrillation/atrial flutter, body mass index, corrected QT interval, presence of implantable cardioverter-defibrillator, and medications with patients with HF alone. The primary outcomes were 3-year all-cause mortality, hospital admission, and incident VAs. Results: After PSM, 50,969 pairs were analyzed. NAFLD diagnosis was associated with significantly higher odds of VA (odds ratio [OR] 2.75, 95% confidence interval [CI] 2.54-2.98, p &lt;0.0001) and hospital admission (OR 1.05, CI 1.03-1.08, p &lt;0.0001) at 3-years. No significant difference was observed in mortality (OR 0.98, 95% CI 0.95-1.01, p =0.10). Conclusion: Patients with HF diagnosed with NAFLD had significantly higher odds of VA and hospital admission but not mortality at 3-years. Future studies are needed to evaluate mechanisms of VA in NAFLD patients.

Air pollution, mortality, and hospital admissions in Scotland: A 16 years register-based study

Abstract Background Air pollution is associated with poor health and higher mortality. However, studies that link high spatial resolution air pollution data for several pollutants to individual-level data over prolonged period (&amp;gt;10 years) and assess multiple health outcomes are limited. In this study, we investigated the association between 16-years exposure to air pollution and all-cause and cause-specific (cardiovascular, respiratory, cancer, infectious, and mental/behavioural disorders) mortality and hospital admissions in Scotland. Methods Individual-level data from the “Scottish Longitudinal Study” for 202,237 individuals (2002-2017) were linked to yearly concentrations of NO2, SO2, PM10, and PM2.5 pollutants at 1-Km2 spatial resolution using the individual's residential postcode. The association between air pollution and mortality and hospital admissions was examined using Cox Proportional-Hazards and multilevel mixed-effects negative binomial models, respectively. Results Increasing concentrations of PM2.5, PM10, and NO2 pollutants were associated with higher rates of all-cause, cardiovascular, respiratory, cancer, and infectious mortality and hospital admissions. Mortality from respiratory diseases increased by 6.2% (95%CI=2.8%−9.6%), 2.5% (95%CI=0.5%−4.5%), and 1.2% (95%CI=0.5%−1.9%) per 1 µg/m3 increase in PM2.5, PM10 and NO2 pollutants, respectively. Exposure to SO2 was mainly linked to mental/behavioural disorders mortality (HR = 1.05; 95%CI=1.02-1.07) and respiratory hospital admissions (IRR=1.02; 95%CI=1.01-1.03). Conclusions This study revealed a positive association between air pollution and mortality and hospital admissions in Scotland. Interventions on air pollution through stricter environmental regulations could help ease the mortality and hospital admission burden, for both physical and mental illness. Key messages • Air pollution is associated with a higher risk of mortality and hospital admissions for both physical and mental health-related outcomes. • Policymakers are urged to provide incentives for the usage of greener energy sources to reduce air pollution emissions.

Population vulnerability to heat: A case-crossover analysis of heat health alerts and hospital morbidity data in Victoria, Australia

ObjectiveFrom 2010 to 2022, the Victorian Department of Health operated a heat health alert system. We explored whether changes to morbidity occurred during or directly after these alerts, and how this differed for certain population groups. MethodsWe used a space-time-stratified case-crossover design and conditional logistic regression to examine the associations between heat health alerts and heat-related and all-cause emergency department (ED) presentations and hospital admissions at the state-wide level, with models created for the whole population and subgroups. Data were included for the warm season (November-March) from 2014 to 2021. ResultsIncreases occurred in heat-related ED presentations (OR 1.73, 95% CI: 1.53-1.96) and heat-related hospital admissions (OR 1.23, 95% CI: 1.16-1.30) on days on or after heat health alerts. Effect sizes were largest for those 65 years and older, Aboriginal and Torres Strait Islander people, and those living in the most disadvantaged areas. ConclusionsWe confirm that increases in morbidity occurred in Victoria during heat health alerts and describe which population groups are more likely to require healthcare in a hospital. Implications for Public HealthThese findings can inform responses before and during periods of extreme heat, data-driven adaptation strategies, and the development of heat health surveillance systems.

The association of long-term exposure to outdoor air pollution with all-cause GP visits and hospital admissions by ethnicity and country of birth in the United Kingdom.

Air pollution is associated with poor health. Yet, more research is needed to reveal the association of long-term exposure to outdoor air pollution with less studied health outcomes like hospital admissions and general-practitioner (GP) visits and whether this association is stronger for ethnic minorities compared to the rest of population. This study investigates the association between air pollution and all-cause GP visits and hospital admissions by ethnicity in the United-Kingdom (UK). We used individual-level longitudinal data from the "UK Household Longitudinal Study" including 46,442 adult individuals who provided 140,466 responses across five years (2015-2019). This data was linked to yearly concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) outdoor pollution using the Lower Super Output Area (LSOA) of residence for each individual. Multilevel mixed-effects ordered logistic models were used to assess the association between air pollution and all-cause GP visits and hospital admissions. We found higher odds of hospital admissions per 1 μg/m3 increase in annual concentrations of NO2 (OR = 1.008; 95%CI = 1.004-1.012), SO2 (OR = 1.048; 95%CI = 1.014-1.083), PM10 (OR = 1.011; 95%CI = 1.003-1.018), and PM2.5 (OR = 1.018; 95%CI = 1.007-1.029) pollutants. Higher odds of GP visits were also observed with increased exposure to NO2 (OR = 1.010; 95%CI = 1.006-1.014) and SO2 (OR = 1.114; 95%CI = 1.077-1.152) pollutants. The observed associations did not differ across ethnic groups, but by country of birth, they were more pronounced in individuals born outside UK than those born in UK. This study supports an association between higher exposure to outdoor air pollution and increased all-cause hospital admissions and GP visits. Further longitudinal studies with longer follow-up time periods may be able to reveal more definite conclusions on the influence of ethnicity on the association between long-term outdoor air pollution and both hospital admissions and GP visits.