Ambulatory Day Research Articles

Efficacy and safety of ambulatory, weekly, high-intensity intravenous diuretic strategy for congestion-refractory heart failure patients: insights from the DEA-HF prospective randomized clinical trial

Abstract Background Congestion and volume overload are strongly associated with low quality of life and pose a significant risk for both rehospitalization and mortality in heart failure (HF) patients. Despite the widespread use of diuretics in HF, the use of weekly, intravenous (IV), high-intensity diuretic treatment has not been prospectively studied in the setting of ambulatory congestion-refractory patients. Purpose To assess the efficacy and safety of weekly high-intensity diuresis regimens in a practical setting of ambulatory day care for chronically congested HF patients. Methods We performed a sub-analysis on data from a prospective, randomized, cross-over controlled study (DEA-HF) originally designed to compare diuresis regimens in the setting of an HF ambulatory daycare unit who had signs of congestion or volume overload despite adherence to guideline-directed medical therapy. Each patient received three different IV diuretic regimens, in one of six randomized sequences: IV furosemide 250mg; IV furosemide 250mg + oral metolazone 5mg; and IV furosemide 250mg + IV acetazolamide 500mg. All regimens given on the same chronological week were pooled, and diuresis efficacy was assessed by measuring excreted urine volume and sodium weight 6 hours post treatment initiation. Additional assessment at one week post each treatment included serum levels of NT-ProBNP, body weight and creatinine as well as congestion score based on the presence of ascites, pleural effusion and pedal edema. Statistical analysis was based on linear mixed models while accounting for the random effect of patient identity. Results A total of 42 patients were recruited. The mean age was 72±9 years, twenty-one subjects (50%) had LVEF ≥ 50%. 74% of patients were NYHA III class. All patients were on contemporary guidelines-directed HF therapy. Analysis of excreted sodium weight and urine volume revealed values of 4202.1±180.1 mg (Mean±SEM) and 1.77±0.07 liter per visit, respectively. No significant differences in efficacy were detected among treatments given in consecutive weeks (P= 0.80 and 0.69 for differences in sodium weight and urine volume, respectively). After 4 weeks, log(NT-ProBNP) was significantly decreased (P=0.044), accompanied by a significant decrease of 2.4±0.62 kg in body weight (P=0.0004) and of 0.92±0.44 points in congestion score (P=0.037). Serum creatinine level was only slightly increased by 0.19±0.04 mg/dl (P=0.0001), demonstrating the overall safety of the high-intensity diuresis strategy. Conclusions In ambulatory, congestion refractory HF patients a strategy based on high-intensity, weekly diuresis therapy was safe and effective for three consecutive weeks. The natriuresis response to the treatments was maintained, NT-ProBNP levels and congestion score were decreased. The strategy may be instrumental for ambulatory HF patients that require diuretic therapy intensification and may allow to prevent hospitalization.

Counting the days: Exploring healthcare contact days during episodes of cancer care.

233 Background: Cancer diagnosis and treatment brings about not only emotional upheavals but also logistical hurdles of navigating a fragmented healthcare system. Little is known about the frequency of healthcare contact for cancer patients and its implications. Healthcare contact days, defined as the number of days a patient spends in direct contact with healthcare professionals outside of home, measures the patient’s interaction with the healthcare system. Methods: Using historical claims data (Part A institutional and Part B ambulatory claims) from the Enhancing Oncology Model (EOM) for 12 practices in The US Oncology Network covering the period between January 2019 to June 2022, we derived healthcare contact days per episode (6-month care periods initiating with the administration of chemotherapy), counting each unique date once. When patients encountered multiple care settings on a single date, the following hierarchy was used: inpatient (IP) > emergency room (ER) > skilled nursing facility (SNF)> hospice > ambulatory care. We further counted contact days for different services conducted during the ambulatory visits. Results: For the 75,246 episodes, an average of 31.9 days per episode (1 in every 6 days) were spent in healthcare contact. Cancer patients’ healthcare contact was predominantly within ambulatory care, and visits with oncology providers exceeded that with all other specialties. ER and IP visits, generally a representation of acute care events, accounted for <10% of the contact days. Conclusions: During cancer treatment, patients spend approximately one-sixth of their time in healthcare contact. The optimal frequency of contact, pattern of primary care support, care of comorbidities, and the interrelationship between acute care and clinician visits are apt for further exploration. Healthcare contact days can reflect different care delivery approaches between providers and may be a metric to assess both healthcare efficiency and accessibility. Understanding caregiver burden and social disparities associated with high contact days offers an opportunity to improve care coordination and streamline healthcare encounters while balancing patients’ care needs. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Healthcare contact days. Mean Percentiles 5 th -95 th Per Episode Healthcare Contact Days 31.9 10-65 Ambulatory Visits* 8-55 Chemotherapy 6.6 0-18 Imaging 2.7 0-7 Procedure 1.8 0-7 Radiation 2.4 0-23 Testing 11.8 3-25 Clinician Oncology 6 1-14 Other Specialties 3.4 0-10 Primary Care 2.8 0-8 Facility Visits ER 0.4 0-2 Hospice (Facility) 0.1 0-0 IP 2.7 0-16 SNF 0.8 0-0 *Ambulatory visits days are not mutually exclusive.

Establishment of Registered Advanced Nurse Practitioners (RANP) Gerontology Clinics in Two Ambulatory Day Units

Abstract Background Ireland is experiencing substantial growth in the older population. Data from The Irish Longitudinal Study on Ageing (TILDA) suggests that up to 25% of older people in Ireland are living with frailty while a further 45% are at risk of being pre-frail (Roe L et al, 2017). Frailty in older adults can be a predictor to adverse health outcomes including hospitalization, falls, and increased mortality risk. Ambulatory day units proactively identify older adults at risk of frailty living in the community using a comprehensive geriatric assessment (CGA), potentially reducing adverse outcomes. Methods Plan-Do- Study-Act (PDSA) cycle was used. Waiting lists were reviewed with Consultant Geriatricians for the ambulatory units. Referral pathways for RANP Gerontology Clinics with inclusion and exclusion criteria were developed. RANP clinics were established in 2023 in the ambulatory day units utilising Slaíntecare’s strategy. Referrals were triaged by Consultants Geriatricians resulting in the RANP clinic caseload. Results During 2023, 844 older adults were reviewed in the RANP clinics. This contributed to a reduction in Consultant Geriatricians’ waiting lists and allowed reduced wait times for new Consultant Geriatricians’ referrals. This service also enhanced communication pathways between primary and secondary care settings and became a point of contact for families in crisis, with rapid access review and care planning to avoid unnecessary Emergency Department attendances. Patients attending the RANP clinics, if admitted to hospital, were seen by the RANP during their admission, ensuring continuity of care. Conclusion Overall, establishment of RANP Gerontology clinics resulted in a better streamlined service for the older adult. This service ensures continuity of patient care through a working knowledge of patient cohort and rapid access for those known to the service, potentially avoiding an Emergency Department attendance.

Bridging The Gap: Between an Older Adult Attending The Ambulatory Day Unit and An Acute Hospital Presentation

Abstract Background Older adults attending the ambulatory day units within the hospital group have a comprehensive geriatric assessment (CGA) completed. This identifies the older adult’s functional, physical, social, environmental and psychological baseline, in order to develop and implement a coordinated plan of care and follow up. The CGA is the gold standard in caring for older adults who are frail or at risk of frailty (HSE, 2016). The units are off site from the main hospital, therefore valuable information may not be available to the acute hospital. Valuable information from the CGA can provide the older adult’s functional and cognitive baseline and prevent unnecessary duplication of assessments and increased length of stay. Methods Plan-Do- Study-Act (PDSA) cycle was used. A questionnaire was produced to ascertain acute care staff’s understanding of; whether an older adult is attending the ambulatory unit? Would this information and a review by the RANP Gerontology be beneficial? A Registered Advanced Nurse Practitioner (RANP) Gerontology Pathway was developed. Education was provided to nursing, and the wider multidisciplinary team. An alert sheet was introduced and provided to older adult attending the ambulatory day units. The alert was for the older adult to produce, if attending or admitted to the acute hospital. This initiates the RANP pathway. Older adults are then seen by the RANP at source of admission. Clinic letters with baseline is documented in the Healthcare record, including advice plan and follow-up. Post-implementation questionnaire and verbal feedback were obtained. Results Positive feedback from older adults, family and staff. Avoidance of unnecessary duplication of assessments, data sharing, optimization of plan of care, treatment and rehabilitation potential. Effective discharge planning, reduction of unnecessary transfer to residential care. Conclusion Bridging the gap promotes positive outcomes: Reducing length of stay, positive impact on overall wellbeing, and an organizational cost containment.

Advances in HoLEP technology and technique – Current state of play

Background: Until recently, Holmium laser enucleation of the prostate (HoLEP) utilisation has been limited despite its perceived benefits over alternative surgical and minimally invasive benign prostatic hyperplasia (BPH) treatments. Objective: The purpose of this review is to highlight our experience with recent advances in laser and morcellator technologies that have made it easier for urologists to consistently offer HoLEP as a safe, efficient, and effective in an ambulatory (day surgery) setting. Methods: Our narrative review focused on contemporary studies published within the last five years. Conclusions: Technological advances coupled with increasing availability of training opportunities has and will continue to improve patients’ accessibility to the gold standard in BPH surgical treatment. Furthermore, we will describe refinements in laser enucleation techniques that have improved procedural efficiencies, rates of temporary post-operative urinary incontinence, and preservation of sexual function. The effects of technical modifications on functional and durability outcomes are to be seen in further prospective studies. Level of Evidence: Level 7 (Expert Opinion)

Health Care Contact Days Among Older Cancer Survivors.

Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care. We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days. We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad." Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.

Healthcare contact days among older adults living with dementia.

For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population. We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days. In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days. Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.

Health Care Contact Days Among Older Adults in Traditional Medicare : A Cross-Sectional Study.

Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. To assess composition of, variation and patterns in, and factors associated with contact days among older adults. Cross-sectional study. Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. Community-dwelling adults aged 65 years and older in traditional Medicare. Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). Study population limited to those in traditional Medicare. On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. National Institute on Aging.

PS-C30-11: EFFECTS OF SGLT-2 INHIBITORS ON 24 H AMBP IN PATIENTS WITH TYPE 2 DIABETIC AND HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: To analyze the effects of different types of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on 24-hour ambulatory blood pressure in patients with type 2 diabetes mellitus and hypertension. Method: In the meta-analysis, The PubMed, Web of science, and Cochrane Library were searched for relevant literature, and the references obtained from these sources were retrieved from inception till December 2020, Using sodium-glucose cotransporter 2 inhibito, hypertension and randomized controlled trial as keywords. The inclusion and exclusion criteria were formulated in accordance with the requirements of Cochrane systematic review. A total of 1354 articles were retrieved, 592 duplicate articles were excluded, 372 articles were excluded after reading the title and abstract, 87 articles were excluded from non-randomized control and irrelevant outcome indicators, and 7 studies with 2343 patients were finally included. Use RevMan5.3 software to compare the changes in 24-hour ambulatory blood pressure, day and night blood pressure of patients with type 2 diabetes and hypertension before and after treatment with different types and doses of SGLT2i. Results: A total of four types of SGLT-2i (Empagliflozin, Canagliflozin, Dapagliflozin, Ertugliflozin) were evaluated in the application of patients with type 2 diabetes and hypertension. The result showed that compared with placebo, SGLT2i could reduce the 24-hour systolic blood pressure of patients with type 2 diabetes and hypertension by 4.36mmHg, among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -4.59mmHg, -3.74mmHg, -5.06mmHg, -3.64mmHg, respectively; similarly, the 24-hour dynamic diastolic blood pressure decreased by 2.20mmHg, among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -2.38mmHg, -1.22mmHg, -2.00mmHg,- 2.69mmHg, respectively. At the same time, the systolic and diastolic blood pressure during the day and night decreased significantly. Conclusions: This meta-analysis shows that SGLT2i can have beneficial effects on the cardiovascular system by reducing 24-hour ambulatory blood pressure in patients with type 2 diabetes and hypertension, other than reducing blood sugar. Therefore, for patients with type 2 diabetes and hypertension, SGLT2i may be the best hypoglycemic choice.

Retrospective Analysis of Spinal Anesthesia for Daycare Surgery during the COVID-19 Pandemic

Introduction: We preferred general anesthesia over spinal anesthesia for day care surgeries in our center. During COVID-19 pandemic, we planned subarachnoid blocks for daycare surgeries, to minimize aerosol generation and to reduce virus transmission risk to health care professions.
 Objectives: This study intended to compare time of discharge after subarachnoid block with general anesthesia in day care surgeries. We compare time to achieve post-anesthetic discharge score (PADS) equal to or more than nine; need for overnight hospitalization; and complications.
 Methodology: A retrospective analysis of cases posted for elective daycare surgery in our institute during COVID-19 pandemic from April 2020 to July 2020 were identified. We compared time to discharge home in patients who received general anesthesia and spinal anesthesia. Normality of distribution was determined using Two sample Kolmogorov-Smirnov Tes. Student t test was used for normally distributed data, Mann-Whitney U test was used for non-normal distributed data. Categorical variables were analyzed using a chi-squared or Fisher’s exact test. 
 Results: A total of 2214 patients were included in this study.181 patients remained for analysis; 70 in the general anesthesia group and 91 in the spinal anesthesia group. Mean time (+SD) to achieve PADS score in group GA is 263.47(+75.06) whereas in group SAB was 339.55(+156.903). Mean time (+SD) taken to discharge home in group GA was 296.08(+74.76) whereas in group SAB was 365.66(+158.68) minutes respectively. Post hoc power of the study was 95.8.
 Conclusion: With low dose bupivacaine, spinal anesthesia is a safe alternative for ambulatory day care surgeries.

Association of Childhood Blood Pressure with Left Atrial Size and Function: Study of High Blood Pressure in Pediatrics–Adult Hypertension in Youth (SHIP AHOY)

To evaluate the cross-sectional association of cardiovascular disease risk factors with left atrial (LA) size and function among healthy youth, aged 11-18years, with a wide range of blood pressures (BPs). Echocardiographic images of youth enrolled in the Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth study were analyzed for LA measurements. The association of casual BP, ambulatory BP, and other cardiovascular disease risk factors with LA size and function were determined using descriptive statistics and multivariable regression. Regression models adjusting for age, sex, race, and body mass index z score determined the independent association between ambulatory systolic BP indices (mean systolic BP/50th %ile systolic BP) and BP phenotypes with LA outcomes while exploratory analyses investigated for additional predictors of LA outcomes. The study population consisted of 347 youth: median age 15.7years, 60% male and 40% non-White. Greater-risk casual systolic BP groups had worse cardiometabolic profiles but no differences in LA size and function. Each 0.1 increase in ambulatory systolic BP day or night index was associated with a 9.9mL/m2 increase in LA volume/body surface area (LAV/BSA; 95th% CI 2.8-17.0, P=.006) and a 6.8mL/m2 increase in LAV/BSA (95th% CI 0.8-12.8, P=.03), respectively. Ambulatory hypertension was associated with greater odds of abnormal LAV/BSA, defined as >75th %ile (2014 ambulatory BP monitoring criteria: OR 3.2 [95th% CI 1.4-7.2; P=.002]; 2022 ambulatory BP monitoring criteria: OR 2.1 [95th% CI 1.0-4.1; P=.008]). Increasing ambulatory systolic BP and ambulatory hypertension are independently associated with LAV/BSA.

Investigating the self-perceived educational priorities among oncology nurses

AimTo understand the self-perceived educational priorities among oncology nurses. BackgroundOncology nurses are the main providers of care to people affected by cancer. However, little is known about the educational needs and priorities of oncology nurses when providing care to people living with cancer. DesignA national online survey. SettingThe Cancer Nurses Society of Australia (CNSA) is an Australian wide professional body for cancer nurses. At the time of conducting the research, there were approximately 1300 members. All members were invited to participate in the survey. CNSA provided access to nurses working in all areas of cancer care, including inpatient wards, outpatient centres, ambulatory day oncology units, radiation oncology, bone marrow transplant units, educational, and research units. ParticipantsRegistered nurses involved in direct care of people affected by cancer who were members of CNSA, and ability to communicate in English. MethodsThe instrument consisted of a 15-item online questionnaire which included demographic and professional questions related to the self-perceived oncology educational needs which were free-text. This survey was hosted using an online electronic data capture system (i.e., SurveyMonkey®), and the electronic link was sent to the CNSA who then sent an email invitation to the 1300 members. Results610 educational needs were identified and ranked. These individual answers were grouped into seven overarching categories with various sub-categories within each group. The oncology nurses identified important educational topics which included: a) cancer biology, b) treatments, c) direct patient care, d) age-specific cancer care, e) leadership and research, and f) law and ethics. ConclusionAs the number of people affected by cancer continue to rise, addressing the educational needs and priorities of oncology nurses has never been so important. Higher educational institutions and healthcare institutions should consider these findings in addressing the learning needs for the current oncology nursing workforce.

Hospital service utilisation of people previously hospitalised with different subtypes of psychotic disorder: A record linkage study.

Little research has examined the physical and mental comorbidities, and health service use patterns, of people diagnosed with psychotic disorder subtypes other than schizophrenia spectrum disorders. This study aims to examine the physical and mental comorbidities, and subsequent hospital service use patterns, of individuals previously hospitalised with various psychotic disorder subtypes using linked health service data. We included individuals hospitalised with a psychotic disorder in New South Wales, Australia, between 1 July 2002 and 31 December 2014 (N = 63,110). We examined the demographic profile of the cohort and rates of subsequent acute hospital care and ambulatory mental health service use. We compared the rates of subsequent hospital admissions, emergency department presentations and ambulatory mental health treatment days of people hospitalised with different psychotic disorder subtypes to people hospitalised with schizophrenia spectrum disorders using Poisson regression. People most recently hospitalised with mood/affective disorders and psychotic symptoms had a higher rate of subsequent hospital admissions than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratio = 1.06; 95% confidence interval = [1.02, 1.10]), while people most recently hospitalised with drug-induced and other organic (adjusted incident rate ratio = 1.19; 95% confidence interval = [1.12, 1.27]) and acute psychotic disorders (adjusted incident rate ratio = 1.10; 95% confidence interval = [1.03, 1.18]) had more subsequent emergency department presentations than those most recently hospitalised with schizophrenia spectrum and delusional disorders. All three groups had fewer subsequent mental health ambulatory days than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratios = 0.85-0.91). The health profiles and subsequent hospital service use patterns of people previously hospitalised with different psychotic disorder subtypes are heterogeneous, and research is needed to develop targeted health policies to meet their specific health needs.

893-P: Incremental Health Care Utilizations and Medical Expenditures Associated with Cognitive Impairment among Older Adults with Diabetes

Cognitive impairment (CI) poses a large economic burden on the US health care system, but little is known about how CI impacts health care (HC) utilization and medical expenditures among people with diabetes. Using data from the 2016-20Medical Expenditure Panel Survey, we quantified the incremental HC utilization and medical expenditures associated with CI among adults aged ≥ 60 years with diabetes. Diabetes status was based on self-report. Participants who reported having difficulty concentrating, remembering, or making decisions were defined as having CI. We used negative binomial regressions to model the number of ambulatory visits, prescriptions, and home health care days; logistic regressions to model the probabilities of ER visits and hospital admissions; and gamma regressions to model medical expenditures in total and by category. All models were adjusted for age, sex, race and ethnicity, income, education, and comorbidities. We included 6,714 adults ≥ 60 years with diabetes, of which 1,025 (15.27%) had CI. CI was associated with additional ambulatory visits (+4.7 [95% CI, 3.5-5.8]) , drug prescriptions (+10.6 [8.1-13.1]) , and home health care days (+32.6 [19.2-52.2]) ; and higher odds of ER visits (Odds Ratio (OR) : 1.55 [95% CI, 1.27-1.89]) and hospital admissions (OR: 1.27 [1.02-1.58]) . CI was also associated with additional expenditures for outpatient care (+$12[$731-$1720], or 28% higher than those without CI [17%-40%]) , prescription drugs (+$17[$1103-$2372], or 31% higher [20%-43%]) , and home health care (+$25[$445-$7060], or 197% higher [35%-555%]) . Overall, those with CI spent $70[$5168-$8835], or 42% [31%-53%] more than those without CI. All p < 0.05. CI is associated with higher HC utilization and medical expenditures among older adults with diabetes. Early detection of CI and additional assistance to those with CI may lower CI-related HC utilization and expenditure in this population. Disclosure D.Guan: None. P.Zhang: None. S.Tang: None. J.D.Brown: None. R.R.Fang: None. J.Guo: None. Y.Zhang: None. H.Shao: Board Member; BRAVO4HEALTH, LLC.

EFFECTS OF SGLT-2 INHIBITORS ON 24H AMBULATORY BLOOD PRESSURE IN PATIENTS WITH TYPE 2 DIABETIC AND HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: To analyze the effects of different types of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on 24-hour ambulatory blood pressure in patients with type 2 diabetes mellitus and hypertension. Design and method: In the meta-analysis, The PubMed, Web of science, and Cochrane Library were searched for relevant literature, and the references obtained from these sources were retrieved from inception till December 2020. The inclusion and exclusion criteria were formulated in accordance with the requirements of Cochrane systematic review. A total of 1354 articles were retrieved, 592 duplicate articles were excluded, 372 articles were excluded after reading the title and abstract, 87 articles were excluded from non-randomized control and irrelevant outcome indicators, and 7 studies with 2343 patients were finally included. Use RevMan5.3 software to compare the changes in 24-hour ambulatory blood pressure, day and night blood pressure of patients with type 2 diabetes and hypertension before and after treatment with different types and doses of SGLT2i. Results: A total of four types of SGLT-2i were evaluated in the application of patients with type 2 diabetes and hypertension. The result showed that compared with placebo,SGLT2i could reduce the 24-hour systolic blood pressure of patients with type 2 diabetes and hypertension by 4.36mmHg (95%CI -5.92--2.79,p < 0.001),among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -4.59mmHg, -3.74mmHg, -5.06mmHg, -3.64mmHg, respectively; similarly, the 24-hour dynamic diastolic blood pressure decreased by 2.20mmHg (95%CI -2.74, -1.65,p < 0.001), among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -2.38mmHg, -1.22mmHg, -2.00mmHg,- 2.69mmHg, respectively. At the same time, the systolic and diastolic blood pressure during the day and night decreased significantly. Conclusions: his meta-analysis shows that SGLT2i can have beneficial effects on the cardiovascular system by reducing 24-hour ambulatory blood pressure in patients with type 2 diabetes and hypertension, other than reducing blood sugar. Therefore, for patients with type 2 diabetes and hypertension, SGLT2i may be the best hypoglycemic choice.

Establishment of a clinical nurse specialist-led, virtual aneurysm surveillance clinic.

The COVID-19 pandemic has necessitated significant changes to the manner in which healthcare is delivered. Chief among these has been the need to rapidly adopt virtual, or telephone clinics as a means of reducing unnecessary patient exposure to hospitals and clinical care settings. We were greatly aided in our adoption of virtual clinics by our experience in the establishment and maintenance of a Clinical Nurse Specialist-led, virtual clinic for both abdominal aortic (AAA) and extra-aortic aneurysm (EAA) surveillance within our department since 2016. Patients undergoing surveillance for abdominal aortic aneurysm (AAA) require frequent and lifelong clinical review. Previous studies have shown that post-operative surveillance in particular is critical in prolonging survival in AAA patients and in the early detection of late complications particularly following endovascular repair (EVAR). Poor compliance with EVAR surveillance has been shown to result in worse outcomes. The aim of this study was to evaluate the success of a nurse-led virtual clinic programme in terms of the safe management of patients undergoing AAA surveillance in a nurse-led virtual clinic. Over the course of the 4-year period from 2016 to 2019, 1352 patients were enrolled in the virtual aneurysm surveillance clinic. The majority of patients each year were male, ranging from 78.2% in 2016 to 85.2% in 2017. The majority of patients encountered the service owing to pre-operative surveillance of an AAA, with this group comprising at least 65% of the total cohort of patients each year.Over the course of the 4-year period of the virtual clinic there were 1466 patient encounters. Each ambulatory day care centre (ADCC) attendance normally costs the hospital €149. Therefore, a total saving of €218,434 resulted from this initiative alone. No patient presented as an emergency with a ruptured aneurysm during the time period studied. Patients with AAA can be safely kept under surveillance in a nurse-led virtual clinic. Our experience with this model of care proved to be particularly advantageous during the period of the early COVID-19 pandemic.

Healthcare workers’ experiences of transitioning natalizumab infusions from hospital services to an in-home setting: a qualitative study

Objective: This study explored healthcare workers’ experiences of transitioning infusions of natalizumab from hospital to a patient-centred model of home care. Background: Hospital in the home is one of the fastest growing healthcare delivery models. In Australia, intravenous infusions are rarely available at home for chronic disease patients, such as those with multiple sclerosis. A recent trial of natalizumab infusions at home for patients with multiple sclerosis required both the hospital and hospital in the home staff to consider the logistics of how this transition could be achieved safely. Study design and methods: This was a qualitative study using an exploratory-descriptive approach. Twelve participants from two main groups of healthcare workers participated in delivering natalizumab infusions during the six-month trial period and were subsequently interviewed about their experience. Participants were recruited from a hospital ambulatory care day unit and a Home Infusion Team from a private provider of home nursing care located in South Australia. The data was analysed thematically. Results: Three main themes were identified from the interviews: ‘preparing for change’, ‘focussing on the patient’, and ‘enhancing professional support and relationships’. These findings demonstrated the importance of understanding healthcare workers’ experiences of transitioning to a patient-centred model of care, from hospital to home infusion of natalizumab. Discussion: Flexibility and good management of logistics is necessary to maintain the standards of the health services, which highlights the need for training and professional support to facilitate quality home care. This may enhance workers’ sense of professional confidence and trust and reduce stress when delivering the home model of care. Conclusion: Healthcare workers and patients worked to support one another, not only therapeutically but also logistically within collegial relationship and interdependent communications. Being flexible, communicating clearly and being willing to work together within the team, especially between the hospital in the home staff and the hospital staff, was demonstrated to be an important factor for the safe delivery of infusions at home. Managing the logistics of delivering a flexible and safe home therapy service was an important part of this model of care. Implications for research, policy, and practice: The results of this study will be used to inform healthcare teams about the key logistical components that are important for healthcare services, when considering transitioning to a home-based model of care for treating people with relapsing-remitting multiple sclerosis.

Epidemiology and outcome of occult bacteremia in patients discharged from emergency departments or ambulatory units: one-year study.

Microbiological diagnosis of bloodstream infection (BSI) is made several hours after blood culture sampling. This delay could be critical in ambulatory clinics, emergency departments, and hospital day care units, as the patient may be discharged prior to blood culture positivity. Our aim was to evaluate the clinical outcome (including the number of readmissions) of patients diagnosed with BSI after discharge. We prospectively included all adult patients with positive blood culture for BSI that was confirmed after discharge from our center (Grenoble-Alpes University Hospital) in 2016. Patients were contacted about their blood culture results, and their clinical status was controlled via an external consultation or their family physician, with hospital readmission if necessary. Clinical outcome, accuracy of initial diagnosis, microbiological epidemiology, and antibiotic prescription were assessed. In 2016, 1433 episodes of positive blood culture were detected in our hospital, with 50 (3.5%) occurring after patient discharge. Clinically relevant bacteria were determined in 32/50 cases (64%), while other positive blood culture results were considered to be contaminants. Clinical reevaluation was performed in 45 patients (90%). The diagnosis was changed during the clinical reassessment of 24/49 patients (49%). Antibiotics were prescribed prior to discharge for 24/50 patients (48%), modified during follow-up for 15/45 (33%), and initiated for 13/45 (29%) at the reevaluation. Overall, 24/45 (53%) patients were readmitted to hospital units after reevaluation. The clinical follow-up of patients with positive blood culture after discharge led to diagnostic changes and hospital readmission in around half of patients.

Experiences and priorities of older adults during the COVID-19 pandemic.

BackgroundThroughout the COVID-19 pandemic, older adults have been prioritized in public health campaigns to limit social interactions and ‘cocoon’ in their homes. This limits the autonomy of older people and may have unintended adverse consequences.AimsTo ascertain the self-reported physical and psychological effects of ‘cocooning’ and the expressed priorities of older adults themselves during the pandemic.MethodsThis is a cross-sectional, survey-based study involving 93 patients aged 65 and older, attending geriatric medicine out-patient and ambulatory day hospital services or our in-patient rehabilitation units. Demographic data was obtained from the medical records. Frailty level was calculated using the Clinical Frailty Scale (CFS), and disease burden was calculated with the Charlson Comorbidity Index.ResultsMean age was 79.1 (range 66–96), 24% had dementia, and most were mildly frail (CFS < 5). One-third reported new feelings of depression, decreased mobility, and loss of enjoyment as a consequence ‘cocooning’. Loneliness was more prevalent amongst in-patients (38% vs 9%, p > 0.001). Respondents worried more about the risks of COVID-19 to their family than themselves. Expressed priorities varied from ‘enjoying life as much as possible’ to ‘protecting the development of children’.ConclusionsAdverse consequences of ‘cocooning’ were commonly expressed amongst older adults. Public health policy should take into account the heterogeneity of this population and be sensitive to their self-expressed wishes and priorities.Supplementary informationThe online version contains supplementary material available at 10.1007/s11845-021-02804-y.

The impact of WALANT anesthesia and office-based settings on patient satisfaction after carpal tunnel release: A patient reported outcome study

HypothesisWide awake local anesthesia with no tourniquet (WALANT) and office-based procedures are used in hand surgery. There are limited literature data on patient satisfaction when comparing methods of anesthesia and location of surgery. MethodsWe conducted a retrospective single-surgeon study with patient reported satisfaction in three groups. We compared patient impressions of anesthesia type; WALANT vs locoregional anesthesia plus sedation. We also compared satisfaction in three surgery settings; office surgery vs hospital ambulatory minor procedure room vs main operating room. Group 1 office surgery patients had ultrasound guided surgery with WALANT. Group 2 main operating room surgery patients also had ultrasound guided surgery with WALANT. Group 3 main operating room patients had endoscopic surgery with sedation and a tourniquet. Each group had 30 patients with a minimum follow up of 2 months. We measured overall satisfaction, satisfaction with the organization of care, satisfaction with the administration of anesthesia, and satisfaction with the quality of anesthesia. We also collected secondary data on the resolution of the neuropathic symptoms. ResultsProcedures performed in an office-based setting showed higher rates of patient satisfaction when compared to the ambulatory day surgery setting. WALANT anesthesia also showed significantly higher rates of patient satisfaction on a numerical analog scale when compared to sedation based on, irrespective of the surgical setting. All patients had resolution of their neuropathic symptoms regardless of the technique performed. ConclusionWe found that carpal tunnel releases performed in an office-based setting produces superior patient satisfaction. WALANT anesthesia also provides improved patient satisfaction when compared to sedation and monitoring techniques, irrespective of the surgical setting and location. Carpal tunnel release with WALANT in an office-based setting is better for patient comfort and satisfaction, with no evidence of lesser clinical outcomes at a short term follow-up. Level of evidenceIII.