Ambulatory Services Research Articles

EGS SO02 - The undifferentiated general surgical take over 10 years: Admissions

Abstract Background Hospital admissions in England and Wales have been increasing over time. This increase has occurred across many specialties, including across the surgical specialties. The aim of this study is to review the undifferentiated emergency general surgical take, with regards to admissions in July 2013 and July 2023, at a District General Hospital to understand the specific pressures on the department and to identify areas in which we could adapt to facilitate these demands. Method Retrospective data regarding admission and re-admission on all patients treated by the emergency general surgical team in July 2013 and July 2023 was collected from electronic notes. If insufficient information was available, patients were excluded from analysis. Results Patient numbers increased by 50% from 2013 to 2023, from 395 to 594. Average length of stay in 2013 was 3.26 days (+/-0.2, p = 0.03), reducing to 2.58 days (+/-0.2, p = 0.03) in 2023. Number of patients admitted overnight has decreased from 74% (n=291/395) in 2013, to 54% (n=324/594) in 2023. Proportion of referrals from ED increased from 48% in 2013, to 69% in 2023. Planned reviews and patients ambulated for surgery the following day has increased from 4% of all patients seen in 2013, to 16% in 2023. Conclusion Volume of patients has increased significantly over this 10-year period. Simultaneously, duration and number of overnight admissions have decreased, alongside increasing use of ambulatory services. This reflects the aims of the Government, and the Royal College of Surgeons, with increasing investment in day-case and ambulatory services. However, without an increase in hospital bed numbers, the rising volume of patients may become difficult to manage.

Capacity Planning in Paediatric Palliative and Hospice Care: An Italian Case

Although the growing demand for healthcare services has enhanced the occurrence of inefficiencies in care provision, healthcare systems should ensure safe, timely and equitable access to care. In particular, the long waiting lists, the lack of beds, and the shortage of healthcare workforce have highlighted the necessity to effectively manage and strategically plan the available resources. Capacity Planning (CP) contributes to determine what, when, where and how much product or service to deliver, with the goal of analysing and optimizing the use and allocation of human and material resources (e.g., physical spaces, equipment, beds, workforce) based on the demand. CP demonstrates to be extremely relevant for hospital units to schedule appointments, diagnostics, surgeries and admissions. Complex contexts and broader healthcare networks could benefit even more from this approach, helping to coordinate multiple care providers and aligning the available resources with the demand pace. The current research presents the implementation of CP in the context of Paediatric Palliative and Hospice Care (PPHC), delivered in an Italian facility. PPHC provides long-term, interdisciplinary and coordinated care between territorial, ambulatory and hospice services. It encompasses follow-up activities, parental training, end-of-life and respite care. In the Italian case analysed, the shortage of beds affects the quality of care delivered to these patients, in terms of accessibility to the service, effectiveness and timeliness of care. Hence, a CP analysis has been performed to pursue a twofold objective: a) to understand if the current capacity of the facility meets the demand for care; b) to improve productivity through an optimized allocation of resources, particularly the available beds and the healthcare workforce. The expected results involve a more effective use of resources, an increased bed occupancy rate and a reduction in rescheduled admissions due to inadequate planning. Optimizing capacity in this specific setting can serve as a pilot project for other similar contexts, aiming to improve patients’ access to healthcare services, their quality of life and supporting the workforce involved in PPHC. This research offers new insights from both the academic and managerial point of view, providing evidence about the implementation of CP in complex healthcare settings.

Abstract 4138516: Effects of Serious Mental Illness on Transcatheter Aortic Valve Replacement (TAVR) Outcomes and Access

Introduction: Serious mental illness (SMI) is associated with higher risk of immediate procedural complications after transcatheter aortic valve replacement (TAVR), including myocardial infarction, major bleeding, and acute renal failure. There is limited data on the impact of SMI on in-hospital mortality and 30-day readmissions. We aimed to evaluate access to and outcomes after TAVR for patients with SMI compared to those without SMI. Methods: We performed a retrospective cohort study of adults aged ≥18 years who received TAVR with a primary diagnosis of aortic stenosis using the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database in FL, MD, VT, UT, and WI (2016-2019). SMI was defined using ICD-10 codes for schizophrenia spectrum, mood, or anxiety disorders. Primary outcomes include in-hospital mortality, 30-day readmission, length of stay, and routine discharge. The secondary outcome was access type (elective vs. urgent/emergent). Multivariable logistic and negative binomial regression models with adjustment for patient demographics, co-morbidities, and hospital characteristics were used to examine outcomes. Results: Of 21,905 patients who underwent TAVR for aortic stenosis, 2,954 (13.5%) patients had SMI. Overall, 16,762 (76.5%) of patients had elective procedures. Patients with SMI were more likely to be female (59% vs. 41%, p<0.001) and have 3+ co-morbidities (91% vs. 77%, p<0.001) but had similar income quartile distribution (p=0.18), home-to-hospital distance (p=0.09), and clinically similar hospital TAVR volume over the study period (435 vs. 430, p=0.01). After adjustment for potential confounders, access to and outcomes of TAVR differed significantly by SMI status (See Table). Conclusions: SMI patients had increased odds of emergent access to TAVR. After TAVR, SMI patients had longer length of stay and were less likely to be discharged to home. These findings suggest increased discharge planning may be required for patients with SMI after TAVR and highlight the need for additional investigation into barriers to elective TAVR in this vulnerable population.

Abstract 4124457: Socioeconomic Deprivation is Associated with Readmission Within One Year After Atrial Fibrillation Ablation

Introduction: Gender and race have been shown to impact access and outcomes regarding rhythm control management such as atrial fibrillation (AF) ablation. We aimed to evaluate the role of the Area Deprivation Index (ADI), a validated metric that represents the social disadvantage of communities, to determine if socioeconomic disadvantage (SED) increases the risk of readmission within one year after AF ablation. Methods: Patients ages ≥18 were identified in the Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases in New York and Florida from 2016-2019 with follow-up into 2020 into the inpatient setting. These states were chosen due to availability for linkage of the 2020 ADI. International Classification of Diseases 10 and Current Procedural Terminology codes for AF and AF ablation were used. The risk of readmission was assessed using multivariable Cox proportional hazards with covariates age, sex, race, insurance, Charlson Comorbidity Index (0 vs ≥ 1 comorbidity), and ADI quartiles. ADI is scored 1-100 with higher scores representing more disadvantage. Results: 14,078 patients met inclusion criteria. The readmission rate at one, three, and twelve months was 6.1%, 9.9%, and 20.9% respectively. The most common readmission diagnoses at twelve months were AF (22.8%), followed by symptoms such as chest pain, dyspnea, palpitations, and syncope (13%). In the adjusted model, older age, female sex, federal insurance, ≥ 1 Charlson comorbidity, and higher ADI had higher one-, three-, and twelve-month risks of readmission. Hispanic ethnicity had a higher risk of one month readmission. Conclusion: Readmission for AF after ablation is common at twelve months. Higher risk of readmission after AF ablation was observed with SED. Enhanced awareness and additional research regarding SED as a risk factor for readmission may help improve post-ablation AF outcomes and equitable access to cardiovascular care.

Implementing palliative care in hepatocellular carcinoma ambulatory clinics—study protocol for Accelerated translational research in PRImary liver CAncer (APRICA) randomised controlled palliative care trial

BackgroundIntegration of symptom and palliative care for people with advanced cancer is established in many tumour types, but its role in people with hepatocellular carcinoma (HCC) has not been clearly defined. This study aims to evaluate the clinical and cost effectiveness of an intervention involving a suite of strategies designed to assess and treat palliative care symptoms and needs in adult outpatients with HCC attending four New South Wales (NSW) metropolitan tertiary hospitals.MethodsThis trial will use a pragmatic cluster-based randomised-controlled design, with ambulatory HCC services as the clusters. HCC patients will be recruited if they have Barcelona Clinical Liver Cancer (BCLC) stage A disease with active tumour or a current or prior diagnosis of BCLC stage B or C disease regardless of tumour activity. Patients with BCLC stage D disease will be excluded as palliative care is the standard of care (SOC) in this group. Cluster sites will be randomised to the study intervention or control where patients are managed according to SOC. All participants will complete the liver-specific Edmonton Symptom Assessment Scale (ESAS) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire at regular ambulatory clinic appointments. At intervention sites, patients scoring ≥ 5 on any liver-specific ESAS symptom will be referred to palliative care physicians for consultation. The primary clinical outcome will be improvement in all symptoms scored ≥ 5 on the liver-specific ESAS by 50% within 3 months and the primary implementation outcome will recording the liver-specific ESAS in ≥ 80% of all participants attending clinic appointments. Caregivers of patients enrolled in the trial will be invited to perform Carer Support Needs Assessment Tool at each appointment.DiscussionThis trial will inform if earlier palliative care involvement significantly reduces the symptom burden associated with HCC. If found to be effective, earlier implementation of palliative care consultation should be included in HCC treatment guidelines.Trial registrationACTRN12623000010695. Registered on September 1, 2023.

Australian community and inpatient general public sector mental health services between 2017-18 and 2021-22: Relative stasis in bed capacity, increasing outpatient demand, and stunted expenditure.

To descriptively analyse Australian public sector General Mental Health Services (GMHS) expenditure, ambulatory, and inpatient services, including key performance indicators (KPIs) in comparison with other subspeciality mental health services (MHS). We descriptively analysed data published by the Australian Institute of Health and Welfare (AIHW), including inpatient, ambulatory services, expenditure, and KPIs. From 2017-18 to 2021-22, per capita expenditure for Australian GMHS (18-64) rose by an average annual inflation-adjusted change of 2%. Overall bed numbers remained static, with non-acute beds declining, and commensurate expansion of acute beds. Community GMHS had high outpatient utilisation, with high rates of schizophrenia, schizoaffective disorder, and bipolar affective disorders as primary diagnoses in mid-life. From 2017-18 to 2021-22, GMHS inpatient and ambulatory episodes had decreasing rates of significant improvement and increasing rates of significant deterioration. Although GMHS has the highest overall population and service utilisation, there has been static bed availability and relatively small increases in expenditure which are occurring concurrently with worsening clinical outcomes. Evidence-based modelling of GMHS and outcomes is required to inform future service improvement.

Exploring the suitability of a ward-based clinical pharmacy activity collection tool for ambulatory care practice: a mixed-methods study.

At a London-based hospital, a validated ward-based clinical pharmacy activity collection tool has been used to monitor activities of clinical pharmacy teams across all settings, including ambulatory care services. No data confirm its representativeness for the full range of ambulatory clinical pharmacy services, and pharmacists share this concern. This study aimed to identify the range of clinical pharmacy activities in ambulatory care, assess the suitability of the existing ward-based tool for capturing these activities, and recommend modifications. Non-participant direct observations were conducted to record pharmacists' clinical activities in ambulatory clinics and multidisciplinary meetings. These observations were compared to the existing ward-based tool to identify discrepancies. Semi-structured interviews with eight ambulatory pharmacists were transcribed verbatim and thematically analysed inductively to explore the tool's representativeness of their routine clinical activities. Twenty-nine clinical pharmacy activities were observed in ambulatory services. Only fifteen were captured by the existing tool, with therapy monitoring and recommending therapeutic changes not accurately captured. Pharmacists agreed that the tool was not fully representative and included irrelevant activities. Four common uncaptured activities were multidisciplinary meeting-specific activities, arranging laboratory tests, monitoring patient outcomes, and liaising with community healthcare professionals. This study identified 33 candidate ambulatory clinical pharmacy activities. The existing ward-based tool does not fully capture the full range of ambulatory care clinical pharmacy activities, highlighting the need for an improved tool. Pharmacists recommended including the uncaptured activities. The candidate activities provide a foundation for standardised measurement of relevant ambulatory care activities to enable effective workforce deployment and improve patient outcomes.

REDUCE-HF: a stronger heart go a long way

Abstract Introduction/Purpose Heart failure (HF) is a serious cardiovascular condition with a significant global health concern. The risk of heart failure rehospitalisation is high globally and locally, the 30-day HF readmission was about 32% from a local study (1). The study aims to adopt an intensive treatment strategy similar to Strong-HF trial (2) and evaluate rapid up-titration of guideline directed medical therapy (GDMT) and close follow-up will improve patients' outcomes after acute heart failure (AHF). Objectives The Reduction of Decompensation and Unnecessary Cardiac failure Emergency admissions: ambulatory Heart Failure service model (REDUCE-HF) is a non-randomised prospective study evaluating clinical outcome of patients discharged from AHF. Exclusion criteria included primary valvular disorders, end-stage renal failure and metastatic cancer. After HF discharge, eligible patients were recruited into our REDUCE-HF program irrespective of LVEF. They were subsequently managed in our ambulatory HF centre within two weeks, where intensive up-titration of GDMT and close follow-up would be proceeded. The data of our service model will be compared with our 5-year historical cohort. Primary outcome comprised of all-cause mortality and heart failure hospitalisation. Secondary outcome will be comparison of clinical and functional status at baseline and 3-month on follow up. Results Between October 2022, and December 2023, 245 patients were successfully recruited into our REDUCE-HF service model. Historical cohort of 6867 patients with primary diagnosis of acute heart failure were served as control (usual care pathway), data extracted from 2018 to 2022. Their mean age was 67.8+/-12.2 and 72.2%were male. 60% of them were HFrEF (EF<=40%) and 28% were ischaemic cardiomyopathy. The mean follow up period was 3 months. At 90 days, REDUCE-HF cohort group has shown much lower all-cause mortality than usual care group (2.5% vs 9.3%, HR 0.26, 95% CI 0.18-0.41, p<0.001). There was a much lower incidence of heart failure hospitalisation in REDUCE-HF group as compared to control (8.6% vs 13.1%, HR 0.65; 95% CI 0.55 to 0.74, p<0.01). In secondary outcome, there was significant reduction of NT-ProBNP of 45.2% (from 4229 to 2319pg/m, p<0.001), tremendous increment of 6-minute walk test (from 211 to 250m, p<0.001) and remarkable improvement of KCCQ score from 55.1 to 86.7, p<0.001. The overall LVEF was significantly increased from 39% to 44%, p<0.05. The positive outcome were attributed to good adherence to GDMT: ACEi/ARB/ARNI 91%, Betablocker 90.3%, MRA 72.4% and SGLT2i 95.5%. Conclusion The REDUCE-HF ambulatory service model has been proven effective in reducing mortality, decompensation and preventing unnecessary heart failure hospitalisation in this prospective study. By intervening proactively, this model not only enhances the quality of life but also hold promise in alleviating the burden of in-patient services on heart failure.

Direct annual healthcare costs in survivors of acute pulmonary embolism: estimates based on a prospective multicentre cohort study

Abstract Background Patients surviving acute pulmonary embolism (PE) necessitate long-term care and follow-up. However, the economic impact of PE on healthcare systems after the acute event remains largely unknown. Purpose To estimate the direct cost of PE during the first year after discharge from hospital for the index event, focusing on rehospitalizations, anticoagulant medication, and outpatient follow-up. Methods We analyzed the data from a multicentre cohort study of 1017 unselected patients with confirmed acute symptomatic PE in Germany. After the index episode, the costs of which were not considered, patients prospectively followed an outpatient visit plan at 3, 12 and 24 months. All rehospitalisations were documented with the main and accompanying diagnoses; hospital costs were calculated based on current reimbursement in the German Diagnosis Research Groups (G-DRG) system. The duration and type (central unique drug identifier) of anticoagulant treatment was documented at each visit. Per-patient costs of ambulatory follow-up visits and tests were calculated by multiplying (i) the costs of each visit/test (German ambulatory healthcare services reimbursement catalogue) by (ii) the probability π (0.0≤π≤1.0) of needing that specific service, based on the PE follow-up algorithm of the ESC Guidelines which we populated with the actual results per step in the present study (Figure). The primary analysis was conducted in all patients with ≥3-month follow-up. An additional sensitivity analysis included only the patients completing ≥12-month follow-up. We additionally identified the baseline predictors for the number of rehospitalizations and costs using multivariable zero-inflated Poisson and hurdle regression and accounting for censored data. Results Of 1017 enrolled patients, 958 (94%) were included in the primary analysis. Of them, 24% were rehospitalized, for a marginal mean of 0.34 (bootstrapped 95% CI: 0.30-0.39) readmissions per PE survivor. Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis) cancer, emerged as independent cost predictors by multivariable hurdle gamma regression (Table). Estimated overall rehospitalisation costs were €1138 (95% CI 896-1420) per patient (€1171 [908-1479] in the sensitivity analysis). Mean anticoagulation duration was 330 days, with estimated per-patient costs of €1050 (€1190 in the sensitivity analysis). Per-patient costs of ambulatory follow-up visits and tests were estimated at €182, yielding a total cost of illness per PE survivor of €2370-2543. For the entire country, the annual direct costs after acute PE would thus amount to €202-217 million. Conclusions By estimating per-patient costs and identifying major cost drivers of post-PE care, the present study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved overall cardiovascular prevention.TableFigure

The Role of the Hemostasis and Thrombosis Unit in the Management of the Patients with Acquired Hemophilia.

Acquired hemophilia A (AHA) is a rare autoimmune disease characterised by the presence of autoantibodies against coagulation factor VIII (FVIII), leading to spontaneous haemorrhage in patients without a prior family or personal history of bleeding. This study describes the demographics, diagnosis, underlying disorders, bleeding characteristics, treatment, and outcomes of 41 AHA patients, along with specific case reports. Diagnosis and treatment occurred between 2005 and 2023. The median age at diagnosis was 67.8 years (range 15-93). Among the 41 patients, 10 (24%) were idiopathic, 4 (10%) were postpartum, 18 (44%) had autoimmune diseases, and 9 were diagnosed with cancer. Diagnostic delay exceeded 30 days in 15 out of the 41 cases (36.5%). A total of 38 out of the 41 (93%) patients presented with spontaneous bleeding, with mucocutaneous bleeding being the most common presentation (23/41, 56%). Four patients experienced postpartum bleeding. Clinical remission was achieved in 100% of patients, and no patient died. Haemostatic and Immunosuppressive therapy is essential in AHA, and it should be started as soon as possible in patients with bleeding. However, a significant delay in diagnosis was observed. The absence of mortality is likely attributable to the management of the disease within a specialised Haemostasis and Thrombosis Unit, which offers a clinical ward, a specialised laboratory, and a dedicated ambulatory service. The Italian Society for the Study of Haemostasis and Thrombosis (SISET) is working to secure recognition for this essential role in every hospital.

Increased spending on low-value care during the COVID-19 pandemic in Virginia.

Characterizing the value and equity of care delivered during the COVID-19 pandemic is crucial to uncovering health system vulnerabilities and informing postpandemic recovery. We used insurance claims to evaluate low-value (no clinical benefit, potentially harmful) and clinically indicated utilization of a subset of 11 ambulatory services within a cohort of ∼2 million Virginia adults during the first 2 years of the pandemic (March 1, 2020-December 31, 2021). In 2020, low-value and clinically indicated utilization decreased similarly, while in 2021, low-value and clinically indicated utilization were 7% higher and 4% lower, respectively, than prepandemic rates. Extrapolated to Virginia's population of insured adults, ∼$1.3 billion in spending was associated with low-value utilization of the 11 services during the study period, with 2021 spending rates 6% higher than prepandemic rates. During March 1, 2020-December 31, 2021, low-value and clinically indicated utilization were 15% and 16% lower, respectively, than pre-pandemic rates among patients with the greatest socioeconomic deprivation but similar to prepandemic rates among patients with the least socioeconomic deprivation. These results highlight widening healthcare disparities and underscore the need for policy-level efforts to address the complex drivers of low-value care and equitably redistribute expenditures to services that enhance health.

Impact on ambulatory palliative appointment lead times by standardizing scheduling protocols based on cognitive computing models.

62 Background: Although palliative care is available across the United States, access continues to remain variable. In Texas, only 52% of hospital systems have palliative services. As a result, optimizing existing systems is critical to providing timely services to this vulnerable population. The Supportive Care Services Clinic at University Health in San Antonio, TX provides ambulatory palliative services to patients including physical and psychosocial symptom management and care coordination. For the period April 1, 2023 to June 30, 2023 average lead times for new palliative patient visits (NPPV) and hospital consult discharge visits (HCDV) was 53 days and 39 days respectively. The aim of this project was to decrease the lead times for NPPV and HCDV through standardization of scheduling criteria. We hypothesized that by applying a scheduling protocol utilizing cognitive computing models (CCM) calculating readmission risk scores to prioritize referrals, we could reduce appointment lead times. Methods: During the implementation phase, we developed referral triage criteria to prioritize patients on a scheduling wait list, including patients who were at higher risk of hospitalization or rapid decline based on CCM readmission risk scores calculated within the electronic medical record. Patients were assigned to next available in template. If a cancelation occurred, patients were pulled forward and vacancy was filled based on priority score. Results: For the initial post-implementation period between September 1, 2023 and November 30, 2023 NPPV average lead time was 47 days which was a reduction of 11% from baseline. The average lead time for HCDV was 33 days which was a reduction of 15% from baseline. In a second follow-up period from February 1, 2024 to April 30, 2024, the average lead time of NPPV was 22 days, a 58% decrease from baseline. The average lead time for HCSV was 24 days which was a significant reduction (p-value = 0.011) of 38% from the pre-implementation baseline. Conclusions: Utilization of CCM risk scores to triage NPPV and HCDV significantly reduced the lead times and resulted in more timely services for critical patients. We also noted increased template utilization. Future projects aim to study the effects of scheduling protocols on template utilization, cancellation rates, no-show rates, readmission rates and other health care utilization. Palliative appointment lead times. April-June 2023 Sept-Nov 2023 Feb-Apr 2024 Total Pt Seen 292 364 534 Avg Lead Time (d) 41 38 29 New Patient New Patient New Patient Completed 66 82 74 Avg Lead Time (d) 53 47 22 Hospital Discharge Hospital Discharge Hospital Discharge Completed 27 28 25 Avg Lead Time (d) 39 33 24

Patient Experience in Older Adults Ambulatory Care services in a large Irish teaching hospital

Abstract Background Ambulatory care pathways aim to reduce hospital overcrowding, provide multidisciplinary, speciality outpatient care, in a timely and cost-effective manner to older people with complex care needs. The delivery of care is centred on the needs of the patient; obtaining and implementing personalized feedback is essential to upholding the highest standards of care. Methods All Patients attending ambulatory care services, at a large teaching hospital in 2023–2024 were offered a 30-question survey covering demographics, hospital access, facility usage, and care delivery, with yes/no responses, 5-point Likert scale and free text comments. Results This cohort represents 3.5% of overall service users (n=642). Of the group in question, 55% were between 65 and 85, and 10% were over 85, a quarter were under 65. A quarter of people were seen within a month, a further 38% within four months of referral. 63% of respondents travelled by car, 31% took public transportation, 5% walked, and 1% rode a bike. 68% of older adults commuted by car (12% by taxi). Taxi use was due to inability to conveniently access onsite parking. Over three quarters were accompanied to their appointment. A delay was reported by 24% of respondents, two thirds cited a parking issue on campus, with almost 20% identifying a traffic issue. 4% found the distance from the car park to the department challenging. The majority of concerns related to campus traffic and delays getting parking onsite. When asked to rate communication, the environment, and multidisciplinary care delivery, 99%-100% responded positively. Conclusion Care delivery was positively represented in this sample. This patient feedback highlights the need for accessible parking in hospital infrastructure planning. Vulnerable older adults requiring supportive care should be protected from the cost implications of hospital attendance, costly taxi use is indicated in this group. There is a need for national action on this.

Everyday Ageism experienced by Community-Dwelling Older People with Frailty

Abstract Background Ageism encapsulates stereotypes, prejudice and discrimination towards others or oneself based on age. While identified as the most frequent form of discrimination, relatively little work has captured the problem of day-to-day ageism faced by older people with frailty in community settings. The aim of this study therefore was to examine the prevalence of everyday ageism experienced by older people attending hospital-based ambulatory care services, and to clarify its association with measures of quality of life (QOL) and frailty. Methods A consecutive series (n=100) of patients aged ≥70 years attending ambulatory care completed focused interviews. Day-to-day experience of ageism was measured with the Everyday Ageism Scale, QOL was measured with the Control Autonomy Self-Realisation Pleasure Scale (CASP-19). Results Just over half of participants reported exposure to ageist messages; over 5/6 reported experiencing ageism in interpersonal interactions and 2/3 held some ageist beliefs themselves. Logistic regression demonstrated that experiencing ageism in interpersonal interactions was associated with a higher likelihood of internalised ageism (Adjusted Odds Ratio 6.02 (95% CI 1.70, 21.34); p=0.005)). Both ageism in interpersonal interactions (β= -5.22 (95% CI -9.52, -0.91); p=0.018) and internalised ageism (β= -5.36 (95% CI -8.75, -1.97); p=0.002) were associated with significantly lower QOL. Conclusion This study highlights the striking prevalence of everyday ageism experienced by a cohort of community-dwelling older people with frailty and multimorbidity. In the context of further projected demographic changes in coming decades, with increasingly higher proportions of older people worldwide, these findings highlight an important societal issue that needs to be addressed.

Language-Based Disparities in Route of Hysterectomy for Benign Disease

Study ObjectiveTo assess the association between patient primary language and route of hysterectomy. DesignA retrospective cohort study was conducted using the Healthcare Cost and Utilization Project's State Inpatient Database (SID) and State Ambulatory Surgery and Services Database (SASD). SettingAll inpatient and outpatient hysterectomies from the most recent year of available data (2020–2021) from the six states that record patient primary language in the SID and SASD (Indiana, Iowa, Maryland, Michigan, Minnesota, and New Jersey) were queried. Patients or ParticipantsPatients aged 18 and over undergoing an inpatient or ambulatory hysterectomy for benign indication. InterventionsMinimally invasive hysterectomy compared to abdominal hysterectomy. Measurement and Main ResultsThe association between patient primary language (English vs. non-English) and route of hysterectomy (abdominal vs minimally invasive) was evaluated. The cohort included 52,226 patients who met inclusion criteria. The majority of patients were non-Hispanic White (71%), with a median age of 46 years (IQR 40.0–53.0). 91.4% of patients spoke English as their primary language, 3.6% spoke Spanish, and 5.0% spoke another non-English language. Patients with a non-English primary language were significantly less likely to undergo minimally invasive hysterectomy compared to patients who spoke English (OR 0.60, 95% CI 0.56–0.64, p <.001). This association remained significant following adjustments for age, race, insurance, median income, state, and fibroid, abnormal uterine bleeding, prolapse or endometriosis diagnosis (aOR 0.77, 95% CI 0.71–0.84). In a sensitivity analysis of English vs Spanish vs other non-English language, the association remained significant for other non-English languages (aOR 0.67, 95% CI 0.60–0.75) but not for Spanish (aOR 0.95, 95% CI 0.83–1.09). ConclusionPatients who are non-English speaking are significantly less likely to receive a minimally invasive hysterectomy. Addressing language disparities may improve access to a minimally invasive route of surgery, a possible surrogate for improved surgical outcomes, for our gynecologic patients.

Premorbid Incidence of Mental Health and Substance Abuse Disorders in Facial Trauma Patients.

A retrospective study. Facial trauma is a prevalent cause of morbidity and mortality with increasing incidence over recent decades. Few studies have examined the prevalence of mental health and substance abuse disorders at the time of diagnosis. Herein we investigate the psychosocial demographics associated with facial trauma. The 2016 State Inpatient Database (SID) was used to identify patients with facial trauma from all hospitals in New York, Florida, and Maryland. A non-trauma control group undergoing elective same-day surgeries at ambulatory surgical centers in Florida, Kentucky, Nevada, North Carolina, New York, and Maryland was identified using the State Ambulatory Surgery and Services Database (SASD) from the Healthcare Cost and Utilization Project (HCUP). 777 patients were identified with facial trauma and compared to 500 patients without facial fractures. Patients with facial fractures were statistically significantly more likely to have a substance abuse disorder (OR 34.78, P < .001) or mental health disorder (OR 2.75, P < .001) compared to controls. Patients with facial fractures were significantly more likely to be black than white (OR 4.80, P < .001). Patients with facial fractures were significantly more likely to have Medicaid compared to Medicare (OR 2.12, P = .005). Patients with facial fractures are more likely to have premorbid substance abuse and mental health disorders as compared to controls.

WP5.19 - The undifferentiated general surgical take over 10 years: admissions

Abstract Aims The aim of this study is to review the undifferentiated emergency general surgical take, with regards to admissions in July 2013 and July 2023, at a District General Hospital in order to understand the specific pressures on the department and to identify areas in which we could adapt to facilitate these demands. Methods Retrospective data regarding admission and re-admission on all patients treated by the emergency general surgical team in July 2013 and July 2023 was collected from electronic notes. If insufficient information was available, patients were excluded from analysis. Results Patient numbers increased by 50% from 2013 to 2023, from 395 to 594. Average length of stay in 2013 was 3.26 days (+/-0.2, p = 0.03), reducing to 2.58 days (+/-0.2, p = 0.03) in 2023. Number of patients admitted overnight has decreased from 74% (n=291/395) in 2013, to 54% (n=324/594) in 2023. Proportion of referrals from ED increased from 48% in 2013, to 69% in 2023. Planned reviews and patients ambulated for surgery the following day has increased from 4% of all patients seen in 2013, to 16% in 2023. Conclusions Volume of patients has increased significantly over this 10-year period. Simultaneously, duration and number of overnight admissions have decreased, alongside increasing use of ambulatory services. This reflects the aims of the Government, and the Royal College of Surgeons, with increasing investment in day-case and ambulatory services. However, without an increase in hospital bed numbers, the rising volume of patients may become difficult to manage.

WP3.14 - A Single Unit Service Review in Northern Ireland: The Ever-increasing Acute Surgical Take and the Need for Service Adaptation

Abstract Aims Referrals to the on-call general surgeons in the unit has increased significantly over the past year. Staff levels and hospital resources have not changed to reflect this increasing demand on the service. Our aim is to evaluate the increase in numbers and develop a strategic plan for resolution. Methods A database of referrals to the on-call surgical team was developed using the daily handover records. Two periods of data collection were undertaken, each lasting a duration of 30 days, taking place approximately one year apart. Patient demographics and clinical information was gathered using our electronic care record and electronic notes record. Data gathered included diagnosis, treatment, investigations, interventions, length of stay, suitability for ambulation and follow up. Results The total number of patients referred to the on-call team during cycle one was 233, compared with 405 in cycle two; this is a 74% increase in referrals. During the windows of data collection, 75% of patients with an unscheduled admission did not undergo any intervention and 80% were deemed suitable for ambulation. Conclusion Increasing demands on the NHS require a forward-thinking approach to how we provide an acute surgical service. This study demonstrates that a large proportion of patients are suitable for an ambulatory model of care and development of this service would be a valuable adjunct to the unit. To propose an ambulatory service providing urgent surgical assessment would be an asset to the Trust; potential outcomes would include improving the patient experience, reducing inpatient admissions and bed days, with the associated cost-saving.

Mortality in people living with dementia who self-harmed: An Australian data linkage study.

This study aimed to examine mortality for people living with dementia/mild cognitive impairment who self-harmed. We conducted a retrospective cohort study in New South Wales, Australia, using data ranging from 2001 to 2015. From people who accessed hospital services in the study period, we identified 154,811 people living with dementia/mild cognitive impairment, 28,972 who self-harmed and 1511 who had a record of both dementia/mild cognitive impairment and self-harm. We examined rates, causes and predictors of death for people with dementia/mild cognitive impairment and/or self-harm diagnoses using flexible parametric survival analyses. We explored rates of repeat self-harm in people living with dementia who self-harmed. Circulatory disorders accounted for 32.0% of deaths in people with a living with dementia who self-harmed, followed by neoplasms (14.7%), and mental and behavioural disorders (9.6%). Death was more likely for someone who had self-harmed if they developed dementia/mild cognitive impairment. Predictors of death included male sex, greater physical comorbidity, a history of delirium, more previous emergency department presentations and fewer previous mental health ambulatory service days. Greater engagement with outpatient mental health services predicted a decreased likelihood of repeat self-harm. We found that mortality increases when people who self-harm develop dementia. We argue post-diagnosis support offers a potential opportunity to reduce mortality rates in people with both dementia and self-harm diagnoses.

Everyday ageism experienced by community-dwelling older people with frailty.

Ageism encapsulates stereotypes, prejudice and discrimination towards others or oneself based on age. While identified as the most frequent form of discrimination, relatively little work has captured the problem of day-to-day ageism faced by older people with frailty in community settings. The aim of this study therefore was to examine the prevalence of everyday ageism experienced by older people attending hospital-based ambulatory care services, and to clarify its association with measures of quality of life (QOL) and frailty. A consecutive series (n = 100) of patients aged ≥ 70years attending ambulatory care completed focused interviews. Day-to-day experience of ageism was measured with the everyday ageism scale, QOL was measured with the control autonomy self-realisation pleasure scale. Just over half of participants reported exposure to ageist messages; over 5/6 reported experiencing ageism in interpersonal interactions and 2/3 held some ageist beliefs themselves. Logistic regression demonstrated that experiencing ageism in interpersonal interactions was associated with a higher likelihood of internalised ageism [Adjusted Odds Ratio 6.02 (95% CI 1.70, 21.34); p = 0.005)]. Both ageism in interpersonal interactions [β = -5.22 (95% CI -9.52, -0.91); p = 0.018] and internalised ageism [β = -5.36 (95% CI -8.75, -1.97); p = 0.002] were associated with significantly lower QOL. This study highlights the striking prevalence of everyday ageism experienced by a cohort of community-dwelling older people with frailty and multimorbidity. In the context of further projected demographic changes in coming decades, with increasingly higher proportions of older people worldwide, these findings highlight an important societal issue that needs to be addressed.