Ambulatory Services Research Articles

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications

IntroductionAn increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database. MethodsPatients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities. ResultsArthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30–3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23–3.64, p = 0.007) were independent risk factors for total complications following TJA. ConclusionArthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.

Pharmacist ambulatory pain services for a chronic non‐cancer pain clinic: a descriptive study

AbstractBackgroundPatients presenting to specialist pain clinics are often prescribed complex and high‐risk analgesic regimens. In this setting, pharmacists can help identify at risk patients and provide valuable clinical input to improve patient outcomes.AimTo evaluate the role of a clinical pharmacist in improving the triage, assessment and management of patients presenting to ambulatory pain clinics.MethodThis descriptive study enrolled patients from two chronic noncancer pain clinics from July to December 2021. A new clinical pharmacist service was devised, which operated as telehealth one day per week. The pharmacist was responsible for accepting referrals, triaging based on clinic criteria and updating them with prescription risk factors, in line with SafeScript's traffic light system. Pharmacist clinical services included completion of medication histories, drug dose interventions and patient education. This project received departmental ethical approval from the Eastern Health Office of Research and Ethics prior to commencement (Approval No: QA21‐068).ResultsThe pharmacist assessed 253 patients and identified prescription risk factors for 68 patients; of which 11 (16%) had received opioids from ≥4 prescribers, 10 (15%) were issued a monitored prescription from ≥4 pharmacies, seven (10%) were on high‐risk drug combinations, 25 (37%) had an Oral Morphine Equivalent Daily Dose (OMEDD) of 50–100 mg, and 26 (38%) with OMEDD &gt;100 mg. The pharmacist completed 67 medication histories and provided 22 accepted drug intervention recommendations to clinic physicians, including seven recommendations for dose adjustments, six to cease a medicine and nine to start a new medicine.ConclusionThe pharmacist incorporated SafeScript in the clinics' triage processes and provided valuable clinical interventions complementing the care provided by the pain physicians and the allied health staff.

Quality assuring an outsourced ambulatory electrocardiogram pathway

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The rising demand for arrhythmia care has led to the use of outsourced ambulatory electrocardiogram (ECG) pathways to maintain timely service delivery and meet diagnostic targets. Since COVID-19, our ambulatory ECG service operates primarily through external third-party providers, using the remote (postal) model, where monitors are dispatched to patients for self-application. This pathway was activated to comply with social distancing restrictions and has now been integrated into our diagnostic model of care. A quality assurance (QA) process was introduced to ensure compliance with our internal ECG reporting practice and escalation protocols. Purpose To quality assure our outsourced ambulatory ECG reports and pathways against internal practices and protocols. Methods We audited our QA records on outsourced services from 1st January 2022 - 31st December 2022. During this period, a total of 4317 patients were provided with an ambulatory ECG monitor via the remote service. We conducted regular (~every 2-3 months) retrospective random sampling of ambulatory ECG reports (~10%) for inclusion in QA. Our QA framework consists of a series of quality and consistency checks related to clinical information, report content, and adherence to escalation protocols (table 1). QA reports are fed back to our providers at quarterly meetings to ensure improved service quality. To obtain the requisite data, a variety of sources were cross-referenced. These included our QA reports, outsourced databases, third-party provider platforms, and our patient information system. Results Over a 12-month period, a total of 459 reports were quality assured. Ambulatory ECG reports were checked for clinical information, report content, supporting ECG evidence and amendment requests (table 1). A compliance rate of 99% was achieved. There were few cases (1%) where a request was made to the provider to amend the report or include additional information, namely ECG strips to clarify the findings. We also quality checked compliance to our escalation protocols: appropriate RAG (red, amber, green) rating and action, timely notification to clinicians, and adequate documentation. The reviewed ambulatory ECG reports were RAG rated as: Red 23 (5%), Amber 189 (40%), Green-Amber 142 (30%), Green 117 (25%). These were carried out with 99% accuracy. Activation of the appropriate escalation protocols and timely clinician notification achieved 100% compliance, including 23 red-flagged reports requiring immediate action. Conclusion The outsourced ambulatory ECG pathway had a very high rate of compliance with internal ECG reporting practice and escalation protocols. Our QA framework ensures we work in collaboration with our external partners to continually provide high-quality ECG diagnostics. We believe undertaking internal quality checks is a vital part of using outsourced service providers.

Ambulatory Orbital Fracture Repair: An Analysis of ER Visits After Surgery From a Multistate Study.

To determine the 30-day postoperative emergency room (ER) visit rate following ambulatory orbital fracture repair with same-day discharge, and the causes and risk factors associated with ER visit. Database study. State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) for California, New York, and Florida for 2011. We identified orbital fracture repair procedures among adults from the SASD, which was linked to the SEDD to identify the incidence and causes of ER visits within 30 days. Univariate and multivariable logistic regression models were used to determine the factors associated with ER visit. Among 762 patients, the 30-day postoperative ER visit rate was 4.5%. Most ER visits (58.9%) occurred during the first week after surgery. The most common reasons for ER visits were related to pain, swelling, headache, dizziness, and fatigue (29.4%), followed by ophthalmologic etiologies including visual disturbances and infection of the eye (14.7%). There was no case of retrobulbar hematoma. In the multivariate analysis, patients living in Florida were at a significantly higher risk for ER visit compared to those in California (odds ratio: 4.48 [1.43-14.10], p = .010). Ambulatory orbital fracture repair appears to be safe. Common reasons for ER visit included pain, swelling, and ophthalmic symptoms. An increased risk for ER visit was seen with certain geographic regions but not with medical comorbidities or concurrent facial fractures or procedures.

Using the National Mental Health Service Planning Framework to inform integrated regional planning: a case study in Tasmania, Australia

BackgroundThe aim of this study was to demonstrate the application of a needs-based mental health service planning model in Tasmania, Australia to identify indicative directions for future service development that ensure the equitable provision of mental health services across the State.MethodsThe activity and capacity of Tasmania’s 2018–19 mental health services were compared to estimates of required care by: (1) generating estimates of required care using the National Mental Health Service Planning Framework (NMHSPF); (2) collating administrative mental health services data; (3) aligning administrative data to the NMHSPF; and (4) comparing aligned administrative data and NMHSPF estimates to identify priority areas for service development. Findings were contextualised using information about service location, population demographics, and upcoming service development.ResultsBed-based services capacity reached 85% of the NMHSPF estimate. However, access to certain bed types was inequitable across regional areas. Access to jurisdictional clinical ambulatory team-based services was lowest in the South, while overall full-time equivalent staff capacity reached 58% of the NMHSPF estimate. Access to Primary Health Tasmania (PHT) primary care services was highest in the North West; access to Medicare services was highest in the South. Collectively, activity across primary care (PHT, headspace and Medicare) reached 43% of the NMHSPF estimate. Over half of Community Managed Mental Health Support Services were state-wide services.ConclusionsThis study demonstrates the application of a needs-based planning model for mental health services. Findings revealed service priority areas across Tasmania and highlight considerations for needs-based planning.

Retrospective evaluation of the causes and distribution of lameness in beef and dairy cattle evaluated by ambulatory and in-house clinical services at a North American veterinary teaching hospital.

To describe the causes and distribution of lameness in beef and dairy cattle presenting to either a primary care ambulatory or in-house clinical service at a veterinary teaching hospital. This retrospective clinical case study was conducted by reviewing hospital admissions of beef and dairy cattle seen by in-house or ambulatory clinicians at a veterinary teaching hospital from 2001 to 2021. Final diagnosis was recorded and, when available, the affected limb, whether a lesion was localized to the digit, and the affected claw were also recorded. Data were stratified by location of initial evaluation (ambulatory vs in hospital), period of presentation, production class, age, sex, and whether the final diagnosis was infectious or noninfectious. Overall, 2,220 animals met criteria for inclusion in the study. The most common diagnoses were noninfectious in nature and affected a hind limb more often than a forelimb. More than 82% of all cattle had lameness localized to the digit, with the lateral claw being affected more than 80% of the time. Lameness is an important concern from both a humane and economic standpoint. The results of this study will help with the diagnosis and prevention of lameness in beef and dairy cattle of different ages and production classes.

Poster 362: Identifying Racial Disparity in Utilization and Outcomes of Hip Arthroscopy using Machine Learning

Objectives: Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has been increasingly used in the past thirty years with interventions resulting in improved hip function and ultimate delay of hip arthroplasty in a minimally invasive manner. Unfortunately, previous investigations have observed decreased rates of access, utilization of, and outcomes following orthopedic interventions such as hip arthroplasty in underrepresented patients. The purpose of this study is to examine racial differences in procedural rates, outcomes, and complications in patients undergoing hip arthroscopy. Methods: The State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) of New York were queried for patients undergoing hip arthroscopy from 2011 to 2017. The primary outcomes investigated were utilization over time, total charges billed per encounter, 90-day emergency department visits, and revision hip arthroscopy. Patients were stratified into White and non-White race, and intergroup differences were evaluated with descriptive statistics. Subgroup analysis was performed with linear mixed-effects models to identify significant interactions between race and individual variables that contributed to any differences in the outcomes of interest. Temporal trends in utilization of hip arthroscopy and concomitant procedures between the two groups were analyzed with Poisson regression modeling. Finally, targeted maximum likelihood estimation (TMLE) was performed to provide nonparametric estimates of the specific differences in the outcomes studied using machine learning ensembles while controlling for patient risk factors. Results: A total of 9,745 patients underwent hip arthroscopy during the study period, with 1,081 patients of non-White race (11.9%). Results of Poisson regression demonstrated an annual increase of 1.11 in the incidence rate of hip arthroscopy among White patients, compared to 1.03 for non-White patients (p&lt;0.001), with this disparity projected to increase by 2040. Based on TMLE utilizing an ensemble of machine learning models, non-White patients were significantly more likely to incur higher costs (OR: 1.30, 95% CI: 1.24-1.37, p&lt;0.001) and visit the emergency department within 90-days (OR: 1.09, 95% CI: 1.01, 1.18, p=0.05), but had negligible differences in reoperation rates at 90 days to 2 years (OR: 1.13, 95% CI: 0.78-1.63, p=0.53). Subgroup analysis identified higher likelihood for 90-day emergency department admissions among non-White patients compared to White patients, which were significantly compounded by Medicare insurance (OR: 2.95, 95% CI 1.46-5.95, p=0.002), median income in the lowest quartile (OR: 1.84, 95% CI: 1.2-2.61, p=0.012), and residence in low-income neighborhoods (OR: 2.05, 95% CI: 1.31-3.2, p=0.006). Subgroup analysis for charges billed and reoperation did not identify significant findings. Conclusions: Hip arthroscopy remains an increasingly utilized surgical technique for the treatment of a myriad of hip disorders. Unfortunately, racial disparities exist and are worsening over time. Irrespective of insurance status, non-white patients undergo hip arthroscopy at a lower rate, incur higher costs, and more frequently experience unexpected returns to the emergency department. Improved initiatives to improve the disparity in access to and outcomes following hip arthroscopy must be addressed to further its utility for all patients.

An evaluation of outpatient pediatric asthma prescribing patterns in the United States

Pediatric asthma is often under-diagnosed and under-treated, resulting in a lack of concentration, difficulty sleeping, and tiredness. The Global Initiative for Asthma (GINA) guidelines recommended that children should be prescribed maintenance inhalers along with rescue inhalers. Concurrent use of rescue and maintenance inhalers were considered appropriate use for this study. The aim of the study was to determine the prevalence of inappropriate prescribing patterns against various patient and prescriber demographic factors. A total of 2,264 patients meeting the inclusion criteria for ICD 10 codes, J45.20 - J45.52 and age less than 18 were extracted from the 2018 National Ambulatory Medical Care Survey (NAMCS), which captures ambulatory services offered in physicians’ offices directly engaged in patient care. This data is collected by the National Center of Health Statistics (NCHS), a division of the CDC. The data were analyzed using descriptive analysis, two-tailed t-tests, and ANOVA with an alpha significance level at 0.05. The majority of the pediatric patient population was in the age range of 17-18 years old. Overall, more patients were prescribed inappropriately (68.3%) as compared to appropriate prescribing (31.7%). Inappropriate prescribing was seen more for patients with Medicaid (24.8%) and self-payment (38.2%) as compared to other types of payment (p= 0.052). General practice/ family physicians (35.1%) and nurse practitioners (20.9%) prescribed more inappropriately as compared to other prescribers. (p= 0.001). Patients from the Southern region of the U.S. were prescribed more inappropriately compared to the other regions in the U.S. (p= 0.205). This study concluded that a significant number of pediatric asthma patients across all demographics were not appropriately prescribed inhalers, thus not adhering to GINA guidelines. Appropriate prescribing and adhering to guidelines would prevent morbidity, mortality and improve the patient's quality of life, thereby saving healthcare costs.

Practice Patterns in the Operative Management of Pediatric Thyroid Disease Across Surgical Specializations

BackgroundMultiple surgical specializations are involved in the operative management of pediatric thyroid disease, but current practice patterns remain unknown. The objective of this study was to examine current practice patterns in the operative management of pediatric thyroid disease, specifically comparing practices across different surgical specializations including pediatric surgery, pediatric otolaryngology, general surgery, adult otolaryngology, and endocrine-focused general surgery. MethodsChildren 0-18 years-old undergoing thyroid surgery from 2015 to 2019 were identified using the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases across 6 states. Surgeon specialization was determined for all included surgeons. Patient and hospital characteristics were compared across surgical specializations. Clinical outcomes including hypocalcemia/hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, and wound infection were assessed. ResultsA total of 1241 pediatric thyroidectomies performed by 363 surgeons were included. Procedures were most frequently performed by pediatric surgeons (34.9%). Only 7.2% of procedures were performed by adult general surgeons. There were statistically significant differences in patient age, sociodemographics, surgical indications, and type of procedure performed between specializations (p < 0.05). Endocrine-focused general surgeons had the highest average annual thyroid procedure volume with 78.2 cases/year, and pediatric surgeons and pediatric otolaryngologists had the lowest volumes with 0.7 and 0.6 cases/year, respectively. Overall complication rates were low. ConclusionsOperative management of pediatric thyroid disease was most frequently performed by pediatric surgery. Pediatric specializations are more likely to operate on low-income, minority children with public insurance and patients with Graves’ disease. Overall complications were low. Level of EvidenceIII.

Clinical effectiveness of rehabilitation in ambulatory care for patients with persisting symptoms after COVID-19: a systematic review

BackgroundLingering symptoms after acute COVID-19 present a major challenge to ambulatory care services. Since there are reservations regarding their optimal management, we aimed to collate all available evidence on the effects of rehabilitation treatments applicable in ambulatory care for these patients.MethodsOn 9 May 2022, we systematically searched articles in COVID-19 collections, Embase, MEDLINE, Cochrane Library, Web of Science, CINAHL, PsycArticles, PEDro, and EuropePMC. References were eligible if they reported on the clinical effectiveness of a rehabilitation therapy applicable in ambulatory care for adult patients with persisting symptoms continuing 4 weeks after the onset of COVID-19. The quality of the studies was evaluated using the CASP cohort study checklist and the Cochrane Risk of Bias Assessment Tool. Summary of Findings tables were constructed and the certainty of evidence was assessed using the GRADE framework.ResultsWe included 38 studies comprising 2,790 participants. Physical training and breathing exercises may reduce fatigue, dyspnoea, and chest pain and may improve physical capacity and quality of life, but the evidence is very weak (based on 6 RCTs and 12 cohort studies). The evidence underpinning the effect of nutritional supplements on fatigue, dyspnoea, muscle pain, sensory function, psychological well-being, quality of life, and functional capacity is very poor (based on 4 RCTs). Also, the evidence-base is very weak about the effect of olfactory training on sensory function and quality of life (based on 4 RCTs and 3 cohort studies). Multidisciplinary treatment may have beneficial effects on fatigue, dyspnoea, physical capacity, pulmonary function, quality of life, return to daily life activities, and functional capacity, but the evidence is very weak (based on 5 cohort studies). The certainty of evidence is very low due to study limitations, inconsistency, indirectness, and imprecision.ConclusionsPhysical training, breathing exercises, olfactory training and multidisciplinary treatment can be effective rehabilitation therapies for patients with persisting symptoms after COVID-19, still with high uncertainty regarding these effects. These findings can guide ambulatory care practitioners to treat these patients and should be incorporated in clinical practice guidelines. High-quality studies are needed to confirm our hypotheses and should report on adverse events.

A study analyzing outcomes after bariatric surgery by primary language.

Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language. This retrospective, observational cohort study of bariatric surgery patients age ≥ 18years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race. Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (-0.02days, p = 0.677), nor significantly different mean healthcare costs (-$265, p = 0.309). There were no significant conditional effects of race seen among outcomes. Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Quality of pain management in patients with cancer in the outpatient setting.

12106 Background: Pain represents a common health issue among patients with cancer. Uncontrolled pain significantly impairs the quality of life, resulting in increased healthcare utilization and costs. We examined the patterns of pain medication prescriptions among patients with cancer pain in the outpatient setting. Methods: We used the National Ambulatory Medical Care Survey (NAMCS), an annually administered survey designed to collect data regarding the use of ambulatory medical services from office-based physicians in the United States. We analyzed NAMCS data from 2005 to 2019 for all types of cancers visits. The primary outcome was prescription of pain medications among patients with cancer pain. We performed multivariate logistic regression to identify factors associated with opioid and non-opioid prescription among patients with cancer pain. Results: We captured a total of 520.8 million outpatient visits from 2005-2019. Breast cancer (18.7%) followed by cancer of the male genital tract (11.0%) represented the highest proportion of patient visits. 4.8% of cancer patients reported pain. Majority (60%) complaining of pain did not receive any pain medications. 14.9% received opioids and 25.1% received nonsteroidal anti-inflammatory drugs, acetaminophen, or adjuvant pain medications. The odds of receiving opioids were 3.4 times higher among 45-65 years vs patients over 75 years. African-Americans had 84% higher odds of receiving opioid prescription compared to white patients. The odds of receiving opioids were 61% lower for privately insured vs patients on Medicare. Patients visiting oncologic care had 2.1 times higher odds of receiving opioids compared to primary care (Table). Conclusions: This is one of the largest drug utilization studies among patients with cancer in outpatient setting, covering half a billion patient visits. A significant proportion of outpatients with cancer who reported pain did not receive a prescription for analgesics suggesting a possibility of undertreatment of pain. Within the limitation of this dataset, undertreatment of pain in outpatients with cancer remains a major unmet patient need. [Table: see text]

Assessment of National Trauma Trends for Motor Vehicle Accidents

Background: The aim of this study was to determine if emergency department (ED) visits due to motor vehicle accidents (MVA) are affected by patient demographics, national holidays, and days of the week. Methodology: This was a retrospective, secondary database analysis research exploring the motor vehicle accident patterns in 2018 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is a secondary database of the utilization of ambulatory care services in hospital EDs. The incidence of ED visits due to MVA were assessed as it relates to various patient demographics, which included age, sex, race, in addition to geographic region, national holidays, and days of the week. Results: The study found that the incidence of MVA varies significantly by the time of the year, the days of the week, patient characteristics, and various holidays. Christmas (31.8%), Fridays (30.5%), Sundays (24.8%), Northeast region (36.2%), and the White population (48.9%) had the greatest number of MVA versus their comparable demographics. Males were affected in the majority of the cases (52.2%). One-third (34%) of the MVA were fatal. Conclusions: Strict enforcement of roadside checks for impairment and speeding must be enforced during the periods and days of the week as identified in this study. MVA can be reduced by law enforcement during holidays that have high-risk of crashes. High-risk groups identified in this study should be encouraged to take defensive driving training. There should be more signs, lighting and enforcement during bad weather to enforce road safety. Adherence to driving rules, and promoting awareness amongst the vulnerable groups would reduce the MVA significantly resulting in reduced morbidity, mortality, and societal cost.

Non-English Primary Language: A Growing Population's Access to Cholecystectomy.

To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients. The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy. We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes. Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken. Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied.

Analysing outpatient care access for planning purposes: The Basilicata Region experience

The delivery of healthcare services at regional level should be modeled on population needs, stemming from patients’ consumption pattern and trying to include unexpressed needs and exclude excesses of demand due to both moral hazard behaviors and inducements from the supply side. We propose a model able to estimate the frequency of access in outpatient care (OC) based on the characteristics of the population. According to empirical evidence, among the determinants of outpatient access we include variables addressing health, socioeconomic status and place of residence, plus variables related to the supply of services. We run generalized linear models for counting data of the Poisson family with the aim of both identifying the determinants of OC utilization and quantifying the related effects. We use the regional administrative database of Basilicata region, year 2019. Results are consistent with literature findings and provide new insights into the analysis of OC, suggesting that our model could easily be implemented by regional policymakers to plan the supply of ambulatory services on population needs.

Unplanned 30-Day ER Visit Rate and Factors Associated With ER Visits After Ambulatory Sinus Surgery.

Emergency room (ER) visits after surgery can be inconvenient and costly to the patient and the healthcare system. Estimates of the 30-day ER visit rate following ambulatory sinus procedures and their risk factors are largely unknown in the literature. To determine the 30-day postoperative ER visit rate following ambulatory sinus procedures and the causes and risk factors associated with ER visits. This is a retrospective, cohort study using data from the State Ambulatory Surgery and Services Databases (SASD) and the State Emergency Department Databases (SEDD) for California, New York, and Florida in 2019. We identified adult (18 years old) patients with chronic rhinosinusitis who underwent ambulatory sinus procedures from the SASD. Cases were linked to the SEDD to identify ER visits occurring within 30 days after the procedure. Logistic regression models were used to identify patient- and procedure-related risk factors associated with the 30-day postoperative ER visit. Among the 23 239 patients, the 30-day postoperative ER visit rate was 3.9%. The most common reason for ER visit was bleeding (32.7%). A total of 56.9% of the ER visits occurred within the first week. In the multivariate analysis, factors associated with ER visits included Medicare (odds ratio [OR] 1.29 [1.09-1.52], P = .003), Medicaid (OR 2.06 [1.69-2.51], P < .001), self-pay/no insurance (OR 1.44 [1.03-2.00], P = .031), chronic kidney disease/end-stage renal disease (OR 1.63 [1.06-2.51], P = .027), chronic pain/opioid use (OR 2.70 [1.02-7.11], P = .045), and a disposition other than home (OR 12.61 [8.34-19.06], P < .001). The most common reason for ER visit after ambulatory sinus procedures was bleeding. An increased ER visit rate was associated with certain demographic factors and medical comorbidities but not with procedure characteristics. This information can help us identify the patient populations who are at higher risk for ER visits to improve their postoperative recovery.

Impact, healthcare utilization and costs of travel-associated mosquito-borne diseases in international travellers: a prospective study.

International travellers frequently acquire infectious diseases whilst travelling, yet relatively little is known about the impact and economic burden of these illnesses on travellers. We conducted a prospective exploratory costing study on adult returning travellers with falciparum malaria, dengue, chikungunya or Zika virus. Patients were recruited in eight Travel and Tropical Medicine clinics between June 2016 and March 2020 upon travellers' first contact with the health system in their country of residence. The patients were presented with a structured 52-question self-administered questionnaire after full recovery to collect information on patients' healthcare utilization and out-of-pocket costs both in the destination and home country, and about income and other financial losses due to the illness. A total of 134 patients participated in the study (malaria, 66; dengue, 51; chikungunya, 8; Zika virus, 9; all fully recovered; median age 40; range 18-72years). Prior to travelling, 42% of patients reported procuring medical evacuation insurance. Across the four illnesses, only 7% of patients were hospitalized abroad compared with 61% at home. Similarly, 15% sought ambulatory services whilst abroad compared with 61% at home. The average direct out-of-pocket hospitalization cost in the destination country (USD $2236; range: $108-$5160) was higher than the direct out-of-pocket ambulatory cost in the destination country (USD $327; range: $0-$1560), the direct out-of-pocket hospitalization cost at home (USD $35; range: $0-$120) and the direct out-of-pocket ambulatory costs at home (US$45; range: $0-$192). Respondents with dengue or malaria lost a median of USD $570 (Interquartile range [IQR] 240-1140) and USD $240 (IQR 0-600), respectively, due to their illness, whilst those with chikungunya and Zika virus lost a median of USD $2400 (IQR 1200-3600) and USD $1500 (IQR 510-2625), respectively. Travellers often incur significant costs due to travel-acquired diseases. Further research into the economic impact of these diseases on travellers should be conducted.

The early use of Antibiotics for At-risk children with InfluEnza in Primary Care (the ARCHIE programme)

The early use of Antibiotics for At-risk children with InfluEnza in Primary Care (the ARCHIE programme)

Healthcare Resources Utilization throughout the Last Year of Life after Acute Myocardial Infarction.

Healthcare resource utilization (HRU) peaks in the last year-of-life, and accounts for a substantial share of healthcare expenditure. We evaluated changes in HRU and costs throughout the last year-of-life among AMI survivors and investigated whether such changes can predict imminent mortality. This retrospective analysis included patients who survived at least one year following an AMI. Mortality and HRU data during the 10-year follow-up period were collected. Analyses were performed according to follow-up years that were classified into mortality years (one year prior to death) and survival years. Overall, 10,992 patients (44,099 patients-years) were investigated. Throughout the follow-up period, 2,885 (26.3%) patients died. The HRU parameters and total costs were strong independent predictors of mortality during a subsequent year. While a direct association between mortality and hospital services (length of in-hospital stay and emergency department visits) was observed, the association with ambulatory services utilization was reversed. The discriminative ability (c-statistics) of a multivariable model including the HRU parameters for predicting the mortality in the subsequent year, was 0.88. In conclusion, throughout the last year of life, hospital-centered HRU and costs of AMI survivors increase while utilization of ambulatory services decrease. HRUs are strong and independent predictors of an imminent mortality year among these patients.

MP62-17 THE EVALUATION OF THREE VALIDATED COMORBIDITY INDICES TO PREDICT POSTOPERATIVE OUTCOMES AFTER INFLATABLE PENILE PROSTHESIS AND ARTIFICIAL URINARY SPHINCTER PLACEMENT: WHICH IS BEST?

You have accessJournal of UrologyCME1 Apr 2023MP62-17 THE EVALUATION OF THREE VALIDATED COMORBIDITY INDICES TO PREDICT POSTOPERATIVE OUTCOMES AFTER INFLATABLE PENILE PROSTHESIS AND ARTIFICIAL URINARY SPHINCTER PLACEMENT: WHICH IS BEST? Michael Tram, Nikolas Moring, Paul Feustel, Charles Welliver, and Brian Inouye Michael TramMichael Tram More articles by this author , Nikolas MoringNikolas Moring More articles by this author , Paul FeustelPaul Feustel More articles by this author , Charles WelliverCharles Welliver More articles by this author , and Brian InouyeBrian Inouye More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with increasing comorbidities are at risk of poor postoperative outcomes. Comorbidity indices have been developed to identify high-risk patients; the most common include the Charlson Comorbidity Index (CCI), Elixhauser/Van Walraven Index (VWI), and modified frailty index (mFI). This study compares the ability of these indices to predict adverse events after inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) placement. METHODS: Using the State Inpatient Database (SID) and State Ambulatory Surgery and Services Database (SASD) for Florida (FL) from 2010-2015 and for California (CA) from 2010-2011, we identified patients who underwent IPP or AUS placement. CCI, VWI, and mFI were calculated for each patient. We extracted 30-day ER services, 30-day inpatient readmissions, 90-day postoperative complications, and 90-day device complications. We constructed receiver operating characteristic curves and compared area under the curve (AUC) between the comorbidity indices. RESULTS: We identified 4242 IPP patients (3060 from FL and 1181 from CA) and 1190 AUS patients (705 from FL and 485 from CA). 4.4% of IPP patients and 7.6% of AUS patients had a device complication. All three comorbidity indices had poor performance in predicting postoperative outcomes. All AUCs and their 95% CIs were less than 0.70. The CCI was the weakest predictor of 30-day ER services (AUC=0.56, 95% CI [0.51-0.60] for IPP) while the VWI was weakest for 30-day readmissions (AUC=0.57, 95% CI [0.53-0.61] for IPP) (Figure 1). All indices had better performance for IPP patients compared to AUS patients (Figure 2). These findings were consistent when analyzing each state individually. CONCLUSIONS: All three commonly used comorbidity indices had poor predictive ability of adverse outcomes following IPP or AUS implantation. Our results support the need for further research and development of a urology-specific comorbidity index to better identify high-risk patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e868 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Tram More articles by this author Nikolas Moring More articles by this author Paul Feustel More articles by this author Charles Welliver More articles by this author Brian Inouye More articles by this author Expand All Advertisement PDF downloadLoading ...