Cleveland Clinic Health System Research Articles

Healthcare utilization and clinical characteristics of genetic epilepsy in electronic health records.

Understanding the clinical characteristics and medical treatment of individuals affected by genetic epilepsies is instrumental in guiding selection for genetic testing, defining the phenotype range of these rare disorders, optimizing patient care pathways and pinpointing unaddressed medical need by quantifying healthcare resource utilization. To date, a matched longitudinal cohort study encompassing the entire spectrum of clinical characteristics and medical treatment from childhood through adolescence has not been performed. We identified individuals with genetic and non-genetic epilepsies and onset at ages 0-5 years by linkage across the Cleveland Clinic Health System. We used natural language processing to extract medical terms and procedures from longitudinal electronic health records and tested for cross-sectional and temporal associations with genetic epilepsy. We implemented a two-stage design: in the discovery cohort, individuals were stratified as being 'likely genetic' or 'non-genetic' by a natural language processing algorithm, and controls did not receive genetic testing. The validation cohort consisted of cases with genetic epilepsy confirmed by manual chart review and an independent set of controls who received negative genetic testing. The discovery and validation cohorts consisted of 503 and 344 individuals with genetic epilepsy and matched controls, respectively. The median age at the first encounter was 0.1 years and 7.9 years at the last encounter, and the mean duration of follow-up was 8.2 years. We extracted 188,295 Unified Medical Language System annotations for statistical analysis across 9659 encounters. Individuals with genetic epilepsy received an earlier epilepsy diagnosis and had more frequent and complex encounters with the healthcare system. Notably, the highest enrichment of encounters compared with the non-genetic groups was found during the transition from paediatric to adult care. Our computational approach could validate established comorbidities of genetic epilepsies, such as behavioural abnormality and intellectual disability. We also revealed novel associations for genitourinary abnormalities (odds ratio 1.91, 95% confidence interval: 1.66-2.20, P = 6.16 × 10-19) linked to a spectrum of underrecognized epilepsy-associated genetic disorders. This case-control study leveraged real-world data to identify novel features associated with the likelihood of a genetic aetiology and quantified the healthcare utilization of genetic epilepsies compared with matched controls. Our results strongly recommend early genetic testing to stratify individuals into specialized care paths, thus improving the clinical management of people with genetic epilepsies.

Clinician use of the Statin Choice Shared Decision-making Encounter Tool in a Major Health System.

Effective shared decision-making (SDM) tools for use during clinical encounters are available, but, outside of study settings, little is known about clinician use of these tools in practice. To describe real-world use of an SDM encounter tool for statin prescribing, Statin Choice, embedded into the workflow of an electronic health record. Cross-sectional study. Clinicians and their statin-eligible patients who had outpatient encounters between January 2020 and June 2021 in Cleveland Clinic Health System. Clinician use of Statin Choice was recorded within the Epic record system. We categorized each patient's 10-year atherosclerotic cardiovascular disease risk into low (< 5%), borderline (5-7.5%), intermediate (7.5-20%), and high (≥ 20%). Other patient factors included age, sex, insurance, and race. We used mixed effects logistic regression to assess the odds of using Statin Choice for statin-eligible patients, accounting for clustering by clinician and site. We generated a residual intraclass correlation coefficient (ICC) to characterize the impact of the clinician on Statin Choice use. Statin Choice was used in 7% of 68,505 eligible patients. Of 1047 clinicians, 48% used Statin Choice with ≥ 1 patient, and these clinicians used it with a median 9% of their patients (interquartile range: 3-22%). In the mixed effects logistic regression model, patient age (adjusted OR per year: 1.04; 95%CI 1.03-1.04) and 10-year ASVCD risk (aOR for 5-7.5% versus < 5% risk: 1.28; 95%CI: 1.14-1.44) were associated with use of Statin Choice. Black versus White race was associated with a lower odds of Statin Choice use (aOR: 0.83; 95%CI: 0.73-0.95), as was female versus male sex (aOR: 0.83; 95%CI: 0.76-0.90). The model ICC demonstrated that 53% of the variation in use of Statin Choice was clinician-driven. Patient factors, including race and sex, were associated with clinician use of Statin Choice; half the variation in use was attributable to individual clinicians.

2740. Letermovir for the Prevention and Treatment of Cytomegalovirus Infection in Solid Organ Transplant Recipients

Abstract Background Cytomegalovirus (CMV) is a common infection that can lead to end-organ damage and graft rejection in solid organ transplant (SOT) recipients. Due to the increase in drug-resistant CMV and unfavorable side effect profile of available CMV-active agents, there is a need for additional prophylactic and treatment strategies in this patient population. The goal of this study is to evaluate SOT recipients prescribed letermovir for prophylaxis and/or treatment of CMV. Methods This study was a retrospective review of adult SOT recipients in the Cleveland Clinic Health System prescribed letermovir from 11/8/2017 to 8/1/2022. The primary objective was to describe the utilization of letermovir in SOT recipients. Secondary objectives included: proportion of SOT recipients that experienced CMV breakthrough on letermovir prophylaxis, proportion of SOT recipients that experienced refractory CMV infection on letermovir treatment, prevalence of letermovir resistance, and letermovir-induced adverse effects. Results A total of 45 patients were included in the study, with 52 letermovir courses. Lung was the most commonly transplanted organ (35%), followed by kidney (22%). 78% of patients were high-risk CMV and the most common immunosuppression regimen consisted of a calcineurin inhibitor in combination with a corticosteroid (82%). 11 patients received letermovir for primary CMV prophylaxis, with only one patient experiencing new/worsening viremia while on the agent. Of the 34 patients who received letermovir for secondary CMV prophylaxis, 11 experienced new/worsening viremia. 7 patients received letermovir for CMV treatment, at a median viral load of 991 IU/mL (IQR 603-2,738) on initiation and peak viral load of 3,892 IU/mL (IQR 1,407-10,209) while on therapy. No patients in the treatment group experienced refractory infection. 7/52 (13.5%) letermovir courses were discontinued due to new/worsening viremia, with no letermovir resistance identified. No letermovir-related adverse effects were documented. Conclusion Our study shows that letermovir appears to be effective in suppressing CMV viremia. Letermovir may be an alternative option for SOT recipients who are unable to tolerate or have resistance to traditional CMV therapeutics. Disclosures All Authors: No reported disclosures

Reducing antimicrobial overuse through targeted therapy for patients with community-acquired pneumonia: a study protocol for a cluster-randomized factorial controlled trial (CARE-CAP)

BackgroundCommunity-acquired pneumonia (CAP) is a significant public health concern and a leading cause of hospitalization and inpatient antimicrobial use in the USA. However, determining the etiologic pathogen is challenging because traditional culture methods are slow and insensitive, leading to prolonged empiric therapy with extended-spectrum antibiotics (ESA) that contributes to increased hospital length of stay, and antimicrobial resistance. Two potential ways to reduce the exposure to ESA are (a) rapid diagnostic assays that can provide accurate results within hours, obviating the need for empiric therapy, and (b) de-escalation following negative bacterial cultures in clinically stable patients.MethodsWe will conduct a large pragmatic 2 × 2 factorial cluster-randomized controlled trial across 12 hospitals in the Cleveland Clinic Health System that will test these two approaches to reducing the use of ESA in adult patients (age ≥ 18 years) with CAP. We will enroll over 12,000 patients and evaluate the independent and combined effects of routine use of rapid diagnostic testing at admission and pharmacist-led de-escalation after 48 h for clinically stable patients with negative cultures vs usual care. We hypothesize that both approaches will reduce days on ESA. Our primary outcome is the duration of exposure to ESA therapy, a key driver of antimicrobial resistance. Secondary outcomes include detection of respiratory viruses, treatment with anti-viral medications, positive pneumococcal urinary antigen test, de-escalation by 72 h from admission, re-escalation to ESA after de-escalation, total duration of any antibiotic, 14-day in-hospital mortality, intensive care unit transfer after admission, healthcare-associated C. difficile infection, acute kidney injury, total inpatient cost, and hospital length-of-stay.DiscussionOur study aims to determine whether identifying an etiological agent early and pharmacist-led de-escalation (calling attention to negative cultures) can safely reduce the use of ESA in patients with CAP. If successful, our findings should lead to better antimicrobial stewardship, as well as improved patient outcomes and reduced healthcare costs. Our findings may also inform clinical guidelines on the optimal management of CAP.Trial registrationClinicalTrials.gov NCT05568654. Registered on October 4, 2022.

Predictors of Major Adverse Cardiovascular Events in Patients With Moderate Aortic Stenosis: Implications for Aortic Valve Replacement.

Although the prognosis and management of severe aortic stenosis has been extensively studied, the risk stratification and outcomes of patients with moderate aortic stenosis remain elusive. This study included 674 patients from the Cleveland Clinic Health System with moderate aortic stenosis (aortic valve area, 1-1.5 cm2; mean gradient, 20-40 mm Hg; and peak velocity <4 m/s) and an NT-proBNP (N-terminal pro-B-type natriuretic peptide) level within 3 months of index diagnosis. The primary outcome of major adverse cardiovascular events (defined as the composite outcome of progression to severe aortic stenosis requiring aortic valve replacement, heart failure hospitalization, or death) was extracted from the electronic medical record. The mean age was 75.3±12 years, and 57% were men. During a median follow-up of 316 days, the composite end point occurred in 305 patients. There were 132 (19.6%) deaths, 144 (21.4%) heart failure hospitalizations, and 114 (16.9%) patients underwent aortic valve replacement. Elevated NT-proBNP (1.41 [95% CI, 1.01-1.95]; P=0.048), diabetes (1.46 [95% CI, 1.08-1.96]; P=0.01), elevated averaged mitral valve E/e' ratio (hazard ratio, 1.57 [95% CI, 1.18-2.10]; P<0.01), and presence atrial fibrillation at the time of index echocardiogram (hazard ratio, 1.83 [95% CI, 1.15-2.91]; P=0.01) were each independently associated with an increased hazard for the composite outcome and when taken collectively, each of these factors incrementally increased risk. These results further elucidate the relatively poor short-medium term outcomes and risk stratification of patients with moderate aortic stenosis, supporting randomized trials assessing the efficacy of transcatheter aortic valve replacement in this population.

Emergency Department Co-testing for Human Immunodeficiency Virus When Testing for Gonorrhea and Chlamydia: A Readily Available, Missed Opportunity for Targeted HIV Testing in Emergency Departments.

Conducting human immunodeficiency virus (HIV) testing in emergency departments (EDs) can be an effective approach to testing and reaching populations at highest risk of contracting HIV. All gonorrhea and chlamydia (G/C) and HIV tests ordered in the Cleveland Clinic Health System's 14 EDs were included in the analysis. Data were collected from electronic health records. Descriptive statistics, with medians and means, were computed. From January 1, 2019, to December 31, 2021, we reviewed ED visits for the purpose of sexually transmitted infection (STI) screening, with an emphasis on G/C screening. In October 2019, both HIV rapid testing and G/C testing began across all 14 Cleveland Clinic EDs. The overall rate of co-testing for HIV when obtaining a G/C test for STI evaluation increased overall to around 30% for our health system EDs, with some individual EDs approaching 60%. The approach the Cleveland Clinic implemented is an effective way to test for HIV in the ED. Local health departments and stakeholders in HIV communities should support and collaborate with EDs in their jurisdictions to accelerate HIV testing initiatives by using an HIV plus G/C co-testing metric.

Patient, Operator, and Procedural Characteristics of Guidewire Retention as a Complication of Vascular Catheter Insertion.

Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015. Ten hospitals within the Cleveland Clinic Health System in Ohio, United States. Consecutive all-comers who experienced guidewire retention after vascular catheter insertion. None. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention, stratified into patient, operator, and procedural characteristics. A total of 24 events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m2. A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, three (12%) were performed by first-year trainees, seven (29%) by residents, three (12%) by fellows, and four (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8 amto 5 pm). In total, 22 (92%) guidewires were inserted nonemergently, with two (8%) during a cardiac arrest. Ultrasound guidance was used in all but one case. Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Self-reported factors contributing to delay in ALS diagnosis among primary care providers in a large Ohio-based US healthcare network

ObjectiveThis study's primary objective is to identify self-reported factors that contribute to diagnostic delay in ALS among Primary Care Providers (PCPs). MethodsA de novo email-based survey was deployed to Ohio-based PCPs in the Cleveland Clinic Health System. ResultsOf the 77 PCP participants [including 30 Advance Practice Providers (APPs)] only: (a) 18% of physicians, and 3% of APPs were very confident or confident with recognizing signs and symptoms of ALS, (b) 13% of physicians, and 21% of APP s felt very confident or confident with distinguishing between a neurologic cause of dysfunction from other possible causes, and (c) 23% of physicians, and 11% of APPs felt very confident or confident with distinguishing between upper and lower motor neuron signs. If presented with a weak patient without a specific diagnosis, PCPs most frequently ordered electrodiagnostic testing, brain MRI, cervical or thoracic spine MRI, and serum creatine kinase. PCPs identified top reasons for delayed ALS diagnosis as: (a) patient's delay in seeking medical help, (b) diagnostic uncertainty (c) waiting time for neurology/neuromuscular medicine (NM) consultation. The most desired strategies to shorten diagnostic delay involved: (a) educating PCPs and other non-neurologist “gatekeeper” providers, (b) improving access to specialist neurology care, and (c) developing a reliable diagnostic test for ALS. DiscussionSelf-reported factors that increase ALS diagnostic delay among PCPs primarily comprise gaps in clinical knowledge and skills required to detect key symptoms and signs, and suboptimal referral access to a neurology/NM provider. These areas represent important opportunities for targeted improvement efforts.

Multidisciplinary Approach to Improve Human Immunodeficiency Virus and Syphilis Testing Rates in Emergency Departments.

Best practice guidelines recommend that patients at risk for sexually transmitted infections (STIs), such as gonorrhea (GC) and chlamydia, should also be tested for human immunodeficiency virus (HIV) and syphilis. This prospective quality assurance study aimed to increase HIV and syphilis testing rates in emergency departments (EDs) across the Cleveland Clinic Health System from January 1, 2020 through January 1, 2022. A multidisciplinary team of emergency medicine, infectious diseases, pharmacy, and microbiology personnel convened to identify barriers to HIV and syphilis testing during ED encounters at which GC/chlamydia were tested. The following interventions were implemented in response: rapid HIV testing with new a workflow for results follow-up, a standardized STI-screening order panel, and feedback to clinicians about ordering patterns. There were 57 797 ED visits with GC/chlamydia testing completed during the study period. Human immunodeficiency virus testing was ordered at 5% of these encounters before the interventions were implemented and increased to 8%, 23%, and 36% after each successive intervention. Syphilis testing increased from 9% before the interventions to 12%, 28%, and 39% after each successive intervention. In multivariable analyses adjusted for age, gender, and location, the odds ratio for HIV and syphilis testing after all interventions was 11.72 (95% confidence interval [CI], 10.82-12.71; P ≤.001) and 6.79 (95% CI, 6.34-7.27; P ≤.001), respectively. The multidisciplinary intervention resulted in improved testing rates for HIV and syphilis.

Sustained weight loss may reduce cancer risk.

Although it is widely accepted that obesity is a cancer risk factor, there has been little research showing that losing weight and maintaining that loss reduce the risk of developing and possibly dying of certain cancers. A new study by Cleveland Clinic Health System (CCHS) researchers, published in the Journal of the American Medical Association (doi:10.1001/jama.2022.9009), does just that by focusing on patients who underwent bariatric surgery. Although the biological mechanisms are still incompletely understood, it is believed by many that obesity can affect cancer development and growth by causing increased inflammation, by altering microbiota, by causing insulin resistance, and by increasing the levels of circulating insulin-like growth factor, estrogens, and adipokines. Lead study author Ali Aminian, MD, professor of surgery at the Lerner College of Medicine and director of Cleveland Clinic’s Bariatric & Metabolic Institute, says that the researchers focused on bariatric surgery because it is an effective and long-lasting way for patients with obesity to lose weight. The risk of developing 13 different types of cancers that account for 40% of all annual cancer diagnoses in the United States increases with obesity. Bariatric surgery patients had a 32% lower incidence of obesity-associated cancer and a 48% lower risk of death from cancer than patients in a nonsurgical control group. The primary composite end point of this retrospective, observational, matched cohort study was the time to first incidence of one of 13 obesity-associated cancers: esophageal adenocarcinoma; renal cell carcinoma; postmenopausal breast cancer; cancer of the gastric cardia, colon, rectum, liver, gallbladder, pancreas, ovary, corpus uteri, or thyroid; and multiple myeloma. The secondary end point was cancer-related mortality. The SPLENDID study included 5053 adult patients with obesity who underwent either Roux-en-Y gastric bypass or sleeve gastrectomy at Cleveland Clinic hospitals between 2004 and 2017. Each surgical patient was matched with five patients who did not undergo bariatric surgery. These 25,265 nonsurgical control patients were selected via a logistic regression model based on 10 potential self-reported potential confounders, including the following: race (Black, White, or other), body mass index (35–39.9, 40–44.9, 45–49.9, 50–54.9, 55–59.9, or 60–80 kg/m2), smoking history (never, former, or current), presence of type 2 diabetes, Elixhauser Comorbidity Index, Charlson Comorbidity Index, and state of residence (classified as Florida or as Ohio [because many patients were treated at CCHS facilities in those states] or as other US states combined). The median age of the patients was 46 years. Most were female (77%), and 73% were White. The median follow-up interval was 5.8 years for the bariatric surgery group and 6.1 years for patients in the nonsurgical control group. The CCHS researchers found rather dramatic results: The bariatric surgery patients had a 32% lower incidence of obesity-associated cancer and a 48% lower risk of death from cancer than the patients in the nonsurgical control group. At the 10-year mark, the bariatric surgery group lost 19.2% more body weight than the control group did; this corresponded to a 54.7pound difference in weight loss. The researchers also found that 96 patients in the bariatric surgery group and 780 patients in the nonsurgical control group developed an obesity-related cancer by 2021 during the 17-year follow-up period; this yielded a 10-year cumulative incidence of this primary end point of 2.9% in the bariatric surgery group and 4.9% in the nonsurgical control group. Also, 21 patients in the bariatric surgery group (0.41%) and 205 patients in the control group (0.81%) died of cancer-related causes; these rates corresponded to 0.6 and 1.2 cancer-related deaths, respectively, per 1000 person-years of follow-up. “What we found is striking,” said Dr Aminian in an official release from the Cleveland Clinic. “The greater the weight loss, the lower the risk of cancer.” Dr Nissen adds, “Our findings also showed that losing weight with bariatric surgery could decrease the risk of developing precancerous lesions, such as endometrial hyperplasia, ductal carcinoma in situ of breast, colorectal polyps, and Barret’s esophagus.” Marji McCullough, ScD, RD, senior scientific director of epidemiology research at the American Cancer Society (ACS) in Kennesaw, Georgia, who was not involved in this study, points out that it supports a growing body of literature showing that weight loss among those with morbid obesity may reduce the risk of developing cancer, especially obesity-related cancers. “Many questions remain, however,” she says. “Is this association causal? What are the mechanisms? Should certain patients be prioritized for bariatric surgery? How much weight loss is required to see an effect?” Dr McCullough also notes that although long-term weight loss without surgery typically does not result in as dramatic of a weight loss, other observational studies suggest that more modest weight loss may also lower the risk of certain obesity-related cancers. Lauren R. Teras, PhD, Dr McCullough’s colleague at the ACS and a senior scientific director of epidemiology in the ACS’s Department of Population Science, notes that the study did not find a lower risk of breast cancer with bariatric surgery. “This may be due to the young age of the participants, who were age 46 on average at study entry, with a median follow-up of about six years. The increased risk of breast cancer for obesity is restricted to postmenopausal breast cancer only.” Thus, a study that enrolled older patients or one with much longer follow-up might have shown even more favorable results, including a reduction in breast cancer incidence and mortality rates. “When considering the broader implications of the study, it’s important to note that results from bariatric surgery studies may not be applicable to the general population,” Dr Teras adds. “Bariatric surgery patients undergo preoperative health screening, have an extremely high body weight before surgery, lose extremely large amounts of weight in a short period of time, and undergo hormonal and metabolic changes from the surgery that induce more pronounced biological responses.” Dr McCullough notes that criteria for evaluating who is a good candidate for bariatric surgery exist from many sources, including the American Society for Metabolic and Bariatric Surgery and the National Institute of Diabetes and Digestive and Kidney Diseases: “For general guidance on cancer prevention, clinicians can refer to the American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention [https://www.cancer.org/healthy/eat-healthy-get-active/acs-guidelines-nutrition-physical-activity-cancer-prevention/guidelines.html].”

An age-friendly population health dashboard geolocating by clinical and social determinant needs.

The call for age friendliness has been championed by numerous organizations. The World Health Organization, John A. Hartford Foundation, Institute for Healthcare Improvement (HI), American Hospital Association, and numerous others have envisioned age friendly cities, communities and health systems.1-3 This call has resonated in a variety of interdisciplinary contexts including education,4 nursing,5 pharmacy,6 audiology7 and oncology.8, 9 Age-friendly health care has also spanned the continuum of care in ambulatory,10 emergency department,11 hospital,12 “minute clinic”,13 and even rural settings.14 The success of the age friendly movement has led to an endeavor to create an age friendly ecosystem including age friendly public health systems with a focus on population health, and social determinants of health (SDH).15, 16 Age-friendly public health initiatives have ranged from homelessness and elder abuse,17 poverty,18 to teaching kitchens19 and public transportation.20-22 Despite these, knowledge regarding specifics of the “4 M's” (“mentation”, “mobility”, “medications”, and “matters most”) of Age-Friendly Health systems amongst clinicians has remained limited.23 One reason for this paradox may be lack of clinician awareness regarding baseline levels of “4 M" clinical quality care gaps in their community settings. In our own local community, around the Cleveland Clinic Health System (CCHS), while surveys of age friendliness have been performed in neighboring cities,24 these have not been through the 4 M lens. Technology may help to efficiently and accurately identify 4 M care gaps. However, age friendly technologies have hitherto been focused on patient portals,25, 26 mobility27 or hospital based electronic medical records (EMR's) where adoption of structured 4 M frameworks has remained low.28 The Area Deprivation Index (ADI) ranks neighborhoods by socioeconomic disadvantage at state and national levels. It includes domains of income, education, employment and housing quality.29 Correlations between ADI and function,30 multi-morbidity31-35 including COVID 1936 as well as utilization37, 38 are well established. To our knowledge, only very novel 4 M based age friendly technology efforts have harnessed ADI to establish social determinant of health (SDH) needs, in addition to clinical, for community older adults. In this commentary, we describe the development of an electronic population health dashboard that identifies baseline demographic and clinical 4 M characteristics for an older adult community in Ohio served by CCHS, and geo-locates patients to zip codes with the highest ADI. An electronic Age Friendly 4 M population health dashboard (“AF4MD”) was designed as follows: The target population consisted of community dwelling older adults with primary residence in Ohio, completion of an office or virtual visit between 2016 and 2021 at the CCHS and age range between 61 and 110. Patients were categorized by gender, race, age bands with 10 year ranges and using the 4 M framework. The AF4MD was constructed via aggregation of demographic, geospatial, and clinical data sourced from the EPIC EMR (Figure 1). Connections were built between population health and proprietary risk management metrics using Teradata (relational database management system) and Tableau (visual analytic software). The 4 M categories were defined as follows; “Mentation” by ICD-10 codes F03.90 and F03.91 on EMR problem lists; “Mobility” by EMR documentation of either two or more falls or one or more fall with injury in the last 12 months, or patients utilizing ambulatory assistive devices; “Medication” defined as any patient with 10 or more currently active medications in the EMR; “Matters Most” as completion of an Advance Care Planning (ACP) discussion between 2019 and 2021 using Current Procedural Terminology (CPT) codes 1123F and 1124F and Healthcare Common Procedure Coding System (HCPCS) codes of 99,497 and 99,498. Populations were mapped geographically by zip codes of primary residence including by highest ADI (highest average decile for the state) as a marker for elevated SDH needs. This enabled the creation of a geospatial heat map, identifying population densities within different zip codes (please see Figure 2). Reported variables included demographics; by age band deciles, gender, race, residence in “highest ADI” and “non-highest ADI” zip codes and by “M” domain. All aforementioned variables were also reported for within “highest ADI” and “non-highest ADI” zip codes. All patient populations were de-identified and descriptive statistics from cross sectional analysis reported in aggregated form. The AF4MD had a total of 438,146 patients meeting inclusion criteria with the following age band distribution: 161,481 patients (36.85%) ages 61 through 70: 186, 424 (42.54%) of ages 71 through 80; 74,590 (17.02%) of ages 81 through 90; 15,309 patients (3.49%) ages 91 through 100; 342 patients above age 100 (0.08%). Gender distribution of overall dashboard population was 192,669 female (43.97%) and 245, 452 male (56.02%) and 35 other (0.01%). Race distribution was 36,271 White (83.82%), 43,931 African American (10.03%) (Who constitute 12.41% of the Ohio population), 4298 Asian (0.98%), 20,024 other (4.57%). The target population satisfied conditions for single M domains as follows: 84,596 (19.31%) of patients only met conditions for Mobility; 52,094 (11.89%) only met conditions for Medication; 956 (0.22%) only met conditions for Mentation; 749 (0.17%) only met conditions for Matters Most (Figure 3 depicts the distribution of single “M” domain populations as well as selected combination M domains). The impact of the low percentages of Mentation and Matters Most on combination M descriptions was significant. As shown in Figure 3, an example is the Medication and Mobility combination of 14.07% which decreased to 0.33% when Mentation alone was added and 0.29% when Matters Most alone was added. Similar impact of Mentation and Matters Most domains was seen for all 12 permutations of the Age Friendly 4 Ms. An overall 131 (0.03%) of patients met conditions for all 4 M's and 232,025 (52.96%) of patients met conditions for none of the 4 M categories. By geospatial location, 38,520 patients (8.79%) were residents of highest ADI zip codes and 399,626 patients (91.21%) were residents of non-highest ADI zip codes. Of the total A4MD population, 94% had never seen the Geriatrics team. Table 1 shows the percentage distribution of patients residing in highest ADI and non-highest ADI sub-populations by “M” domains, gender and race (as opposed to for the total dashboard population). Race distribution of the highest ADI and non-highest ADI sub populations was as follows: 20, 843 (54.11%) of highest ADI and 23,373 (5.85%) of non-highest ADI were African American; 15,564 (40.4%) of highest ADI and 354,020 (88.59%) of non-highest ADI were White. Asian, Hispanic and “Other” populations were similar between highest ADI and non-highest ADI zip codes. It is not possible with our electronic dashboard to establish any association. However, this observation of co-occurrence of highest ADI zip codes with a greater African American population should inform health care policy and population health research. Similar trends linking ADI with African American race and even COVID 19 outcomes have been observed.39 To our knowledge this is the first use of technology to identify baseline characteristics for community dwelling older adults based on a combination of “4 M”, demographic and SDH variables via an electronic dashboard. To date, use of technology for age friendly initiatives has spanned EMR based 4 M documentation in the hospital and long-term care settings,28 clinician to clinician videoconferencing around Mentation in the long term care setting in ECHO-Age40, 41 and patient portal technologies.25, 26 Therefore it is not possible to compare our AF4MD with other studies. There is however a compelling contrast between the “4 M" baselines characteristics by individual “M” domains generated for AF4MD compared to both Ohio and national metrics illustrating actionable 4 M clinical gaps. As regards Mentation, 11.2% of Ohio residents above age 65 were reported in 2019 as having cognitive decline42 compared with the AF4MD 0.22%. This importantly underscores that AF4MD dementia identification rates are significantly lower than the state averages despite the prevalent challenges of poor dementia identification and documentation being common to both populations. This difference will be the impetus for active patient outreach to connect AF4MD patients to Cleveland Clinic Geriatrics for closing the Mentation (and other 4 M) clinical identification gaps. Per the Center for Disease Control (CDC), 36 million older adults had a fall in 2018 resulting in injury in 8 million cases. The prevalence of annual falls for Ohio is 25.7% with a national fall average of 28%.43 This is in alignment with our dashboard Mobility M of 19.31%. Polypharmacy in the elderly has been extensively described as being related to falls and increased hospital utilization.44, 45 There is significant heterogeneity in the literature re: polypharmacy's definition ranging from a count of two to eleven medications with one systematic review describing 46.4% of included studies using a definition of five or more medications.44 Our dashboard used a definition of 10 or more medications to identify those older patients at highest risk of “hyper-polypharmacy” (> 10 medications) which is significantly increasing over time.46, 47 The heterogeneity of polypharmacy definitions also leads to significant variability in the literature for estimated polypharmacy prevalence rates. It is challenging therefore to compare the 11.89% of AF4MD patients meeting our definition of polypharmacy with other studies. Patient outreach to evaluate how much of this polypharmacy is inappropriate per the Beers criteria48 and warrants “deprescribing” efforts will be important. To our knowledge, there are no polypharmacy prevalence statistics for the state of Ohio. The AF4MD may help address this research gap. Every patient should be asked “What Matters Most” to them. The “Matters most” dashboard percentage of 0.17% is significantly less than the ideal of “Matters most” conversations for every patient. It is also much lower than the reported ACP conversation and billing percentages in the literature varying from 13% to 74%.49, 50 Our low “Matters Most” results may be secondary to poor documentation, patient and clinician discomfort or lack of awareness regarding the value of ACP which itself has been questioned recently.51, 52 Limitations included 4 M definition heterogeneity in the literature as described. This calls for standardization of 4 M definitions across Age Friendly Health Systems. Our AF4MD was dependent upon the completeness and quality of EMR 4 M documentation. Specifically, Mentation and Matters Most evidenced very low documentation. The Mobility definition does not account for specific number of falls per year nor mobility promoting interventions (A4MD was designed to capture community baselines not interventions). The Medications “M” did not allow confirmation that EMR medication lists were necessarily all being actively filled. Matters most definition included ACP billing which has been found to be low nationally, with only 15% of 53,926 practices being found to be billing for ACP.53 Our dashboard design was cross sectional, so establishing causation was precluded. Only older residents of Ohio were included, thereby limiting the generalizability to other geographical settings. Access is a top priority for CCHS leadership with a “Patients First” creed. The Cleveland Clinic Community Care (4C) Institute in which our Center for Geriatric Medicine is based, is exclusively focused on population health and the “Quintuple Aim".54 This commitment to access can be seen in the creation of multiple patient family advisory councils proposing themes of access, team based care and patient centric communication.55 The thematic response has been multi-dimensional: Public health focused shared medical appointment programs for underserved communities56; telemedicine programs promoting mental health57; linkage of thousands to supplies and community resources during the pandemic and federally qualified health center partnerships58; building brand new grocery stores in “food deserts”; internet connectivity in impoverished local neighborhoods. All testament to the continued CCHS focus on access for our most underserved communities. The CCHS Age Friendly 4 M Population Health Electronic Dashboard (AF4MD) has both strategic and quality improvement implications for the future. Our health system has had the vision to support the creation of this AF4MD so that the 4 M clinical and social determinant gaps identified can be the first step towards geospatial targeted outreach to those in most need. This outreach in turn will connect vulnerable older populations living in zip codes with greatest 4 M and SDH needs to our Cleveland Clinic Successful Aging platform. This program provides access to both “4 M” clinical care delivered by Geriatrics in combination with SDH services offered by community allies. As an example, females aged greater than 85 had the highest number of Alzheimer's disease related deaths in Ohio, and increased cognitive impairment was seen in lower income households.42 Currently, females constitute 43.97% of the AF4MD population and 8.79% of the total population were residents of the highest ADI zip codes. This should inform the targeting of future active engagement efforts to hone in on those demographics most affected by dementia. This may additionally guide research on cognitive screening in primary care, addressing concerns by the US Preventive Services Task Force (USPSTF) for current lack of sufficient related evidence.59 So while the dashboard cannot practically be an intervention in and of itself, it is designed as a springboard for action: Similarly for Geriatrics Falls Clinic referrals (for Mobility gaps); for Deprescribing efforts to counter polypharmacy; and ACP outreach (for the Matters Most “M”). Furthermore, A4MD presents a call to action and blueprint for increasingly reaching out to those patient demographics not currently as actively engaged with our health system that is, additional engagement with African American, Lesbian, Gay, Bisexual and Transgender (LGBQT); female and oldest old (above age 80 and 90) populations. The AF4MD could also optimize 4 M community baseline awareness for clinicians as well as catalyze integration of 4 M screening at the point of care. Incidentally, the Mobility and Medication “M”s, the M domains most identified by our dashboard with percentages respectively equaling and surpassing national prevalence statistics, are also the M domains that have existent screening processes currently imbedded into clinical practice across CCHS. Emulating this for Mentation and Matters Most will be key. The dashboard also highlights the immense role that Geriatricians could potentially play in addressing current 4 M clinical and SDH care gaps. Of the total 438,146 AF4MD population, 94% had never seen the Geriatrics team. This can be done via direct clinical care as well as in an advisory capacity to diffuse 4 M principles across CCHS, as inspired by the call to define the true mainstream identity of Geriatrics.60 At the national level, the AF4MD can be adopted by other health systems as a “live” data warehouse which redefines geriatrics quality metrics in the 4 M framework. It can also establish a 4 M paradigm for population health research promoting inclusivity of “4 M care gap” older populations who have historically been excluded from research trials and hence been unable to inform age friendly clinical guidelines. Moreover, the AF4MD can longitudinally track progress of Age Friendly initiatives both locally and nationally. The clinical practice, educational, research and policy implications of the AF4MD are manifold. We hope that the AF4MD will guide the futuristic operationalization of Age Friendly Health system strategies, employing an aggregated data analytics approach towards optimizing health care delivery via geolocation. None. No Funding was received.

S658 Risk Factors Associated With Upper Gastrointestinal Bleeding in Cancer Patients Exposed to Immune Checkpoint Inhibitors

Introduction: Immune checkpoint inhibitors (ICIs) have emerged as effective treatment options for many advanced malignancies. These agents have been associated with several immune related adverse events (irAEs) that may lead to discontinuation of therapy. Gastrointestinal (GI) side effects are amongst the most commonly reported irAEs. Currently, limited data exists on upper GI bleed (UGIB) in patients exposed to ICIs. The aim of this study was to evaluate the characteristics and risk factors associated with UGIB among cancer patients treated with ICIs. Methods: We performed a retrospective study on all cancer patients from Cleveland Clinic health system who received treatment with ICI’s till June 2021. Only the patients with clinical and endoscopic evidence of upper GI bleed were included in the study. The study group (GI Bleed) was matched with control group (non-Bleeders) in 1:3. We compared characteristics of both groups (Bleeders and Non-Bleeders) using univariate and multivariate analysis. Results: Of the 6820 patients that received ICIs over the study period, 401 patients developed GI bleed. 30 patients had clinical and endoscopic evidence of upper GI Bleed. The most common endoscopic findings were gastric and duodenal ulcers (63%). Compared with the non-bleeding cohort, patients who developed UGIB bleeding had lower BMI (p= 0.0203). Non-small cell lung cancer was the most frequently treated malignancy in the bleeding group. Patients in the bleeding group had higher exposure to pembrolizumab compared to the non-bleeding group (80% vs. 45.6%, p= 0.001). The incidence of ICI induced colitis and hepatotoxicity were more frequent in the bleeding group compared to the non-bleeding cohort (53.5% vs. 27.8%, p= 0.0106). The presence of cirrhosis, diabetes and chronic kidney disease were similar in both groups. On the multivariant analysis, exposure to pembrolizumab (OR=3.62, p=0.0211), aspirin (OR= 10.55, p=0.0002) and with history of ICI induced colitis and hepatotoxicity (OR=3.66 p=0.0108) were predictive factors in development of bleeding. (Table) Conclusion: This is a novel study that evaluates the risk of UGIB in cancer patients treated with ICIs. In this univariate and multivariate analysis, exposure to aspirin, pembrolizumab and overall incidence of IrAEs were associated with increased risk of bleeding. Although UGIB is a relatively rare irAE, more studies are needed for risk stratification of patients exposed to ICIs. Table 1. - Baseline Clinical Characteristics Of Cancer Patients Exposed To ICIs Variable Non-Bleeding (n=90) Bleeding (n=30) p-value Age, mean ± SD 70.6 ± 11.0 69.6 ± 11.3 0.6854 Gender (Male), n (%) 56 (62.2) 19 (63.3) 0.9133 Race (White), n (%) 76 (84.4) 23 (76.7) 0.3316 Hispanic, n (%) 1 (1.1) 2 (6.7) 0.1539 Medication Type, n (%) PembrolizumabOther 41 (45.6)49 (54.4) 24 (80.0)6 (20.0) 0.0010 BMI, n (%)< 26≥ 26 38 (42.2)52 (57.8) 20 (66.7)10 (33.3) 0.0203 History of Upper GI Bleed, n (%) 7 (7.8) 0 (0.0) 0.1902 On Aspirin prior to procedure, n (%) 5 (5.6) 12 (40.0) < 0.0001 On Plavix prior to procedure, n (%) 1 (1.1) 1 (3.3) 0.4391 On Warfarin prior to procedure, n (%) 0 (0.0) 1 (3.3) 0.2500 Chronic kidney disease, n (%) 34 (37.8) 13 (43.3) 0.5893 Diabetes, n (%) 33 (36.7) 9 (30.0) 0.5073 Cirrhosis, n (%) 4 (4.4) 1 (3.3) 1.0000 Type of cancer treated, n (%)Non-small cell lung cancerOther 25 (27.8)65 (72.2) 15 (50.0)15 (50.0) 0.0253 Evidence of metastasis to the GI Tract, n (%) 4 (4.4) 0 (0.0) 0.5710 ICPI induced side effect, n (%) 25 (27.8) 16 (53.3) 0.0106 Treatment with steroids, n (%) 21 (23.3) 11 (36.7) 0.1527 Treatment with Infliximab or Entyvio, n (%) 1 (1.1) 1 (3.3) 0.4391 Current alive, n (%) 29 (32.2) 8 (26.7) 0.5682 PPI, n (%)NoYes 53 (58.9)37 (41.1) 17 (56.7)13 (43.3) 0.8307 Footnote: PPI (protein pump inhibitor).

A risk model to identify Legionella among patients admitted with community-acquired pneumonia: A retrospective cohort study.

Background:Guidelines recommend testing hospitalized patients with community-acquired pneumonia (CAP) for Legionella pneumophila only if the infection is severe or risk factors are present. There are no validated models for predicting Legionella.Objective:To derive and externally validate a model to predict a positive Legionella test.Design, Setting and Participants:Diagnostic study of adult inpatients with pneumonia using data from 177 US hospitals in the Premier Healthcare Database (training and hold-out validation sets) and 12 Cleveland Clinic Health System (CCHS) hospitals (external validation set). We used multiple logistic regression to predict positive Legionella tests in the training set, and evaluated performance in both validation sets.Main Outcome and Measures:The outcome was a positive Legionella test. Potential predictors included demographics and co-morbidities, disease severity indicators, season, region, and presence of a local outbreak.Results:Of 166,689 patients hospitalized for pneumonia, 43,070 were tested for Legionella and 642 (1.5%) tested positive. The strongest predictors of a positive test were a local outbreak (odds ratio [OR], 3.4), June–October occurrence (OR, 3.4), hyponatremia (OR, 3.3), smoking (OR, 2.4), and diarrhea (OR, 2.0); prior admission within 6 months (OR, 0.27) and chronic pulmonary disease (OR, 0.49) were associated with a negative test. Model c-statistics were 0.79 in the Premier and 0.77 in the CCHS validation samples. High-risk patients were only slightly more likely to have been tested than lower-risk patients. Compared to actual practice, the model-based testing strategy detected twice as many cases.Conclusions:Although Legionella is an uncommon cause of pneumonia, patient characteristics can identify individuals at high risk, allowing for more efficient testing.

Primary care physician referral practices regarding BRCA1/2 genetic counseling in a major health system.

The United States Preventive Services Task Force recommends primary care physicians refer patients at high risk for BRCA1/2 mutations to genetic testing when appropriate. The objective of our study was to describe referrals for BRCA1/2 testing in a large integrated health system and to assess factors associated with referral. This retrospective cohort study includes female patients between 18 and 50years who had a primary care visitin the Cleveland Clinic Health System between 2010 and 2019. We used multivariable logistic regression to estimate differences in the odds of a woman being referred for BRCA1/2 testing by patient factors and referring physician specialty. We also assessed variation in referrals by physicians. Among 279,568 women, 5% were high risk. Of those, 22% were referred for testing. Black patients were significantly less likely to be referred than white patients (aOR 0.87; 95% CI 0.77, 0.98) and Jewish patients were more likely to be referred than non-Jewish patients (aOR 2.13; 95% CI 1.68, 2.70). Patients primarily managed by OB/GYN were significantly more likely to be referred than those cared for via Internal/Family Medicine (aOR 1.45; 95% CI 1.30, 1.61). Less than a quarter of primary care physicians ever referred a patient for testing. The majority of primary care patients at high risk for a BRCA1/2 mutation were not referred for testing, and over a decade, most physicians never referred a single patient. Internal/Family Medicine physicians, in particular, need support in identifying and referring women who could benefit from testing.

Abstract 231: Patient, Operator, And Procedural Characteristics Of Guidewire Retention As A Complication Of Vascular Catheter Insertion

Introduction: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. Methods: All consecutive incidents of guidewire retention across 10 hospitals within the Cleveland Clinic Health System in Ohio from August 2007 to October 2015 were prospectively identified and retrospectively analyzed. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention including patient, operator, and procedural characteristics. Results: A total of 24 guidewire retention events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m 2 . A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, 3 (12%) were performed by first-year trainees, 7 (29%) by residents, 3 (12%) by fellows, and 4 (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8AM - 5PM). In total, 22 (92%) guidewires were inserted non-emergently, with 2 (8%) during a cardiac arrest. Ultrasound guidance was used in all but 1 case. Conclusion: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality.

Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.

Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study.

BackgroundDriven by quality outcomes and economic incentives, predicting 30-day hospital readmissions remains important for healthcare systems. The Cleveland Clinic Health System (CCHS) implemented an internally validated readmission risk score in the electronic medical record (EMR).ObjectiveWe evaluated the predictive accuracy of the readmission risk score across CCHS hospitals, across primary discharge diagnosis categories, between surgical/medical specialties, and by race and ethnicity.DesignRetrospective cohort study.ParticipantsAdult patients discharged from a CCHS hospital April 2017–September 2020.Main MeasuresData was obtained from the CCHS EMR and billing databases. All patients discharged from a CCHS hospital were included except those from Oncology and Labor/Delivery, patients with hospice orders, or patients who died during admission. Discharges were categorized as surgical if from a surgical department or surgery was performed. Primary discharge diagnoses were classified per Agency for Healthcare Research and Quality Clinical Classifications Software Level 1 categories. Discrimination performance predicting 30-day readmission is reported using the c-statistic.ResultsThe final cohort included 600,872 discharges from 11 Northeast Ohio and Florida CCHS hospitals. The readmission risk score for the cohort had a c-statistic of 0.6875 with consistent yearly performance. The c-statistic for hospital sites ranged from 0.6762, CI [0.6634, 0.6876], to 0.7023, CI [0.6903, 0.7132]. Medical and surgical discharges showed consistent performance with c-statistics of 0.6923, CI [0.6807, 0.7045], and 0.6802, CI [0.6681, 0.6925], respectively. Primary discharge diagnosis showed variation, with lower performance for congenital anomalies and neoplasms. COVID-19 had a c-statistic of 0.6387. Subgroup analyses showed c-statistics of > 0.65 across race and ethnicity categories.ConclusionsThe CCHS readmission risk score showed good performance across diverse hospitals, across diagnosis categories, between surgical/medical specialties, and by patient race and ethnicity categories for 3 years after implementation, including during COVID-19. Evaluating clinical decision-making tools post-implementation is crucial to determine their continued relevance, identify opportunities to improve performance, and guide their appropriate use.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07277-4.

Association of Weight Loss Achieved Through Metabolic Surgery With Risk and Severity of COVID-19 Infection

Obesity is an established risk factor for severe COVID-19 infection. However, it is not known whether losing weight is associated with reduced adverse outcomes of COVID-19 infection. To investigate the association between a successful weight loss intervention and improved risk and severity of COVID-19 infection in patients with obesity. This cohort study involved adult patients with a body mass index of 35 or higher (calculated as weight in kilograms divided by height in meters squared) who underwent weight loss surgery between January 1, 2004, and December 31, 2017, at the Cleveland Clinic Health System (CCHS). Patients in the surgical group were matched 1:3 to patients who did not have surgical intervention for their obesity (control group). The source of data was the CCHS electronic health record. Follow-up was conducted through March 1, 2021. Weight loss surgery including Roux-en-Y gastric bypass and sleeve gastrectomy. Distinct outcomes were examined before and after COVID-19 outbreak on March 1, 2020. Weight loss and all-cause mortality were assessed between the enrollment date and March 1, 2020. Four COVID-19-related outcomes were analyzed in patients with COVID-19 diagnosis between March 1, 2020, and March 1, 2021: positive SARS-CoV-2 test result, hospitalization, need for supplemental oxygen, and severe COVID-19 infection (a composite of intensive care unit admission, need for mechanical ventilation, or death). A total of 20 212 patients (median [IQR] age, 46 [35-57] years; 77.6% female individuals [15 690]) with a median (IQR) body mass index of 45 (41-51) were enrolled. The overall median (IQR) follow-up duration was 6.1 (3.8-9.0) years. Before the COVID-19 outbreak, patients in the surgical group compared with control patients lost more weight (mean difference at 10 years from baseline: 18.6 [95% CI, 18.4-18.7] percentage points; P < .001) and had a 53% lower 10-year cumulative incidence of all-cause non-COVID-19 mortality (4.7% [95% CI, 3.7%-5.7%] vs 9.4% [95% CI, 8.7%-10.1%]; P < .001). Of the 20 212 enrolled patients, 11 809 were available on March 1, 2020, for an assessment of COVID-19-related outcomes. The rates of positive SARS-CoV-2 test results were comparable in the surgical and control groups (9.1% [95% CI, 7.9%-10.3%] vs 8.7% [95% CI, 8.0%-9.3%]; P = .71). However, undergoing weight loss surgery was associated with a lower risk of hospitalization (adjusted hazard ratio [HR], 0.51; 95% CI, 0.35-0.76; P < .001), need for supplemental oxygen (adjusted HR, 0.37; 95% CI, 0.23-0.61; P < .001), and severe COVID-19 infection (adjusted HR, 0.40; 95% CI, 0.18-0.86; P = .02). This cohort study found that, among patients with obesity, substantial weight loss achieved with surgery was associated with improved outcomes of COVID-19 infection. The findings suggest that obesity can be a modifiable risk factor for the severity of COVID-19 infection.

IsoPSA® Reduces Provider Recommendations for Biopsy and Magnetic Resonance Imaging in Men with Total Prostate Specific Antigen ≥4 ng/ml: A Real-World Observational Clinical Utility Study.

We assessed the impact of the IsoPSA® test for prostate cancer risk assessment on provider patient management decisions in a real-world clinical setting. A total of 38 providers, including advanced practice providers, fellowship trained oncologists and general urologists in the Cleveland Clinic health system including both community-based practices and academic locations, enrolled 900 men being evaluated for prostate cancer; 734 met inclusion criteria (age ≥50 years, total serum prostate specific antigen [PSA] ≥4 and <100 ng/ml and no history of prostate cancer) and IsoPSA indication for use. A standard template was used to document biopsy recommendation prior to and after receiving IsoPSA results. The primary outcome was the number of biopsy and magnetic resonance imaging recommendation changes occurring after IsoPSA testing. IsoPSA testing resulted in a 55% (284 vs 638) net reduction in recommendations for prostate biopsy for men with total PSA ≥4 ng/ml. Additionally, a 9% reduction in recommendations for magnetic resonance imaging was observed. There was strong concordance between IsoPSA results and provider recommendations for prostate biopsy, with 87% of patients with an IsoPSA index above the threshold recommended for biopsy and 92% of patients with an IsoPSA index below the threshold not recommended for biopsy. In a real-world clinical setting, providers from diverse training backgrounds and practice settings readily adopted IsoPSA with substantial reductions in the rate of recommended prostate biopsies in patients with elevated PSA values (≥4 ng/ml). There was a high concordance between recommendation for or against prostate biopsy and the IsoPSA result.

Abstract 12933: Myocardial Dysfunction After In-Hospital Cardiac Arrest in COVID-19 Patients

Introduction: Post resuscitation myocardial dysfunction (PRMD) is common after out-of-hospital cardiac arrest. While PRMD is a known cause of post-resuscitation circulatory failure, few studies have reported associations between PRMD and neurologic outcome or survival. Further, little is known about PRMD after in-hospital cardiac arrest (IHCA) nor on the incidence and prognosis of PRMD in COVID-19 IHCA. We sought to evaluate the incidence of PRMD in a multicenter cohort of resuscitated COVID-19 IHCA patients. Study Population and Methods: We included adult patients (≥18 y) admitted to multiple hospitals of Cleveland Clinic Health System. Patients who attained ROSC with an initial echocardiogram (EC) in the 72 hours post-arrest were included. Data were extracted from a data registry and electronic medical records. Results: From 03/2020-10/2020, 58 patients with COVID-19 had IHCA. ROSC was noted in 35 patients (60.3%), 27 (46.6%) were alive at 24 h and 13 patients (22.4%) survived to hospital discharge. Of the 35 patients who had ROSC, 14 patients (40%) had an EC within 72 h. The median age of this cohort was 67 y (IQR 47 - 73); 71% were male, and median BMI of 28 (IQR 27 - 34), and admission APACHE II score was 13 (IQR 11 - 19). One third of the patients (36%) were mechanically ventilated before arrest and 43% were on vasopressors. Initial arrest rhythms were: PEA/Asystole, 79%; and VF/VT, 21%. Most patients (93%) received manual chest compression with median CPR duration of 5 min (IQR 2 - 10). The median time of obtaining first EC post-ROSC in these 14 patients was 22 hours (IQR 6 - 62). 7/14 (50%) of the patient had systolic dysfunction on initial EC (6 had global dysfunction, 1 with regional wall motion abnormality, and 4/7 had combined LV and RV systolic dysfunction). 5/14 patients had a follow up EC with a median time of 43 days. 2/5 had normal initial EC and 3 out of these 5 patients who initially had PMRD showed complete recovery in their LV and RV systolic function. Conclusion: We report a case series of PRMD in COVID-19 patients who experienced IHCA. We found that PMRD is seen in half of the patients. Most patients with PMRD recovered to normal RV and LV function, consistent with prior studies of non-COVID-19 arrest EC.