Differences In Emergency Department Visits Research Articles

Postoperative Complications and Readmission Rates in Robotic-Assisted and Manual Total Hip Arthroplasty

Objective: This study aims to compare 90-day postoperative complications, readmissions, and emergency department (ED) visits between robotic-assisted (RA-THA) and manual (M-THA) total hip arthroplasty. Methods: A retrospective review of a multi-hospital database identified primary total hip arthroplasty patients between January 2016 and December 2021. The cohorts were 1-to-1 matched based on patient sex, age, and body mass index resulting in 8033 patients in each cohort (N = 16,066). Odds of 90-day revisits, readmission with >23 hours of observation, and ED visits were compared between cohorts. Complications reported during revisits and readmission were classified according to the Clinical Classification Software schema, using the International Classification of Diseases, 10th Revision codes, and compared using mixed-effect models. Results: This study found an overall 90-day revisit rate of 8.3%. RA-THA was associated with significantly reduced odds of revisit within 90 days [odds ratio (OR): 0.71, 95% CI: 0.58–0.89, P = 0.002] and readmissions with >23 hours of observation (OR: 0.61, 95% CI: 0.48–0.77, P < 0.001). RA-THA patients had fewer readmissions with >23 hours of observation due to dislocations (RA-THA: 0.09%; M-THA: 0.39%, P < 0.001), surgical site infections (RA-THA: 0.04%; M-THA: 0.20%, P = 0.004), and wound infections/cellulitis (RA-THA: 0.01%; M-THA: 0.11%, P = 0.021). No difference in ED visits was observed between cohorts (OR: 0.92, 95% CI: 0.77–1.09, P = 0.3). RA-THA patients had more ED visits for dyspnea without pulmonary embolism (RA-THA: 0.20%; M-THA: 0.06%, P = 0.03). Conclusion: RA-THA showed significantly lower odds of overall 90-day revisit rates and readmissions with >23 hours of observation, most notably for readmissions due to dislocation and surgical site infection/wound infections. There was no significant difference in the odds of ED visits between cohorts.

The impact of a mobile geriatric acute team on healthcare consumption.

This study describes the effects of a mobile geriatric acute team (GAT) treating acutely ill geriatric patients in their homes. GAT offered more advanced diagnostic and treatment options than are normally available to primary-care led mobile teams. The aim of this study was to evaluate if interventions by GAT had effect on the number of emergency department (ED) visits, hospitalisations, and length of stay in hospital. This is a before-after study, with outcomes recorded for each participant during the 3months prior to the first visit by GAT and compared to the same outcomes for each participant during the 3months after the first visit. The participant's mean age was 84.6years, 56% were women. There was no observed difference in ED visits, hospitalisations, and length of stay in hospital for all participants (n = 102). However, for the 27 participants living in nursing homes; ED-visits reduced on average by 0.5/participant (p = 0.002), the number of hospitalisations reduced by 0.3/participant (p = 0.018) and length of stay in hospital reduced by 4.3days/participant (p = 0.045). For the 13 participants referred by ambulance, the number of hospitalisations reduced by 0.7/participant (p = 0.044) and length of stay in hospital reduced by 4.1days/participant (p = 0.028). The participants who got intravenous antibiotics also had less hospital care. This geriatric acute mobile team did not cause reduced hospital care among the participants overall. However, it might have reduced hospitalization in some subgroups, such as patients living in nursing homes or those who got intravenous antibiotics.

Is Next-day Discharge Safe After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

While the implementation of enhanced recovery after surgery protocols and improvements in pain control have decreased the length of stay (LOS) after scoliosis surgery, adolescents are typically hospitalized for several days after posterior spinal instrumented fusion (PSF). The purpose of this study was to determine whether next-day discharge after PSF for adolescent idiopathic scoliosis (AIS) had an equivalent safety profile compared with longer LOS. The secondary purpose was to examine perioperative factors associated with next-day discharge. We performed a retrospective study of all patients who underwent PSF for AIS at a single institution from 2017 to 2022. We compared patients based on postoperative LOS with an early discharge group consisting of those who were discharged on the first postoperative day 1 (POD1; n = 40) and a standard discharge group consisting of those who were discharged after POD1 (n = 71). We documented preoperative variables, including patient demographics and curve characteristics, intraoperative variables, including levels fused, implant density, operative time, and blood loss, and postoperative variables, including emergency department (ED) visits within 30 days and hospital readmissions within 90 days. One hundred eleven patients were included with a mean curve magnitude of 67 degrees. Forty patients (36%) were discharged on POD1. There were one (3%) ED visit and 2 (5%) readmissions in the early discharge group and 3 (4%) ED visits and 2 (3%) readmissions in the standard discharge group (P = 0.64 and 0.55, respectively). Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1 (P = 0.02). There were no other significant differences in perioperative variables between the two groups including: BMI, distance from home to hospital, magnitude of main curve, curve flexibility, number of levels fused, estimated blood loss, implant density, operative time, or postoperative pain scores. Next-day discharge after PSF for AIS has an equivalent safety profile compared with longer LOS. Over one-third of patients were discharged on POD1, and there was no statistically significant difference in ED visits or hospital readmissions between the groups. Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1. In a retrospective study of posterior spinal fusions for AIS, we found no increase in ED visits or hospital readmissions for those discharged the next day. Level III.

Comparing The Effectiveness Of Mentalization-Based Therapy And Dialectical Behavior Therapy In An Adult Population With Cluster B Personality Disorders To Reduce Hospital Service Use

IntroductionMentalization-based therapy (MBT) and dialectical behavior therapy (DBT) are two treatments known to be effective for borderline personality disorder (BPD). However, head-to-head comparisons between those two treatments are scarce and their effectiveness in naturalistic clinical services, where BPD is often comorbid with other cluster B personality disorders (PD), needs to be further explored.ObjectivesThe study’s goal was to answer the following question: Is there a difference in emergency department visits, hospitalizations and dropout rates after one year of treatment in MBT compared to DBT for a clinical adult population with cluster B PD?MethodsWe compared the effectiveness of MBT and DBT in 288 patients between 2015 and 2019 with at least one cluster B PD by measuring their emergency services use and hospitalizations one year before and one year after beginning therapy. Drop-out rates for those two treatment modalities are also compared. Image 1 illustrates the patient distribution for the study.ResultsIn terms of reducing emergency room use, patients in each treatment group experienced a significant decrease with medium effect sizes (p < .001 for both, d=.768 for MBT and d=.640 for DBT).In terms of reducing hospitalizations, the MBT group had a significant decrease (p < .05) with a medium effect size (d=.568) whereas the DBT group had a non-significant decrease (p = .595) with a negligible effect size (d=.140).When we compare both therapies, no significant differences were found between them in terms of reductions in emergency room use (p = .358) and hospitalizations (p =.195), as well as dropout rates (p = .743). Image 2 further illustrates the dropout trends in the first year of treatment for both groups in intervals of 3 months.Hospitalizations were rare in our population, which may hinder the validity of results containing this variable. In absolute numbers, total emergency room visits decreased from 119 to 37, whereas hospitalizations were reduced from 24 to 12. Drop-out rates before entering treatment were high (20.6%), as it was during treatment for both therapies (around 30% in the first year of treatment).Image:Image 2:ConclusionsThis study emphasizes that both DBT and MBT are linked to a reduction in service use over time. Dropout rates in both treatments are also similar to other studies. Therefore, future research should investigate the factors that can help clinicians guide individuals with PDs towards the type of therapy that is most suitable for them.Disclosure of InterestNone Declared

Effect of a Co-Located Bridging Recovery Initiative on Hospital Length of Stay Among Patients With Opioid Use Disorder

Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and postdischarge outcomes remains unclear. To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD. This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic. The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD. The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis. Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio [AOR], 0.94 [95% CI, 0.65-1.37]; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 [95% CI, 0.32-0.92]), more readmissions (AOR, 2.17 [95% CI, 1.25-3.76]), and higher care costs (AOR, 2.25 [95% CI, 1.51-3.35]), with no differences in ED visits (AOR, 1.15 [95% CI, 0.68-1.94]) or deaths (AOR, 0.48 [95% CI, 0.08-2.72]) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 [95% CI, 1.32-4.26]) and have more MOUD refills (AOR, 6.17 [95% CI, 3.69-10.30]) and less likely to experience an overdose (AOR, 0.11 [95% CI, 0.03-0.41]). This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships. ClinicalTrials.gov Identifier: NCT04084392.

A Pragmatic Rethinking of Glucose Monitoring for the Incarcerated.

Using continuous glucose monitoring (CGM) improves diabetes-related outcomes in the community, yet the fingerstick blood glucose monitoring (BGM) method is the norm in prisons. The purpose of this study was to investigate the safety and patient perceptions of CGM in the carceral environment, quantify changes in A1C after initiating CGM, and investigate rates of emergency department (ED) visits for diabetes-related complications comparing CGM users to patients using BGM. This pragmatic longitudinal analysis was conducted in two parts. A pilot program was carried out at a single women's prison. A CGM program was initiated at men's facilities within a single U.S. state, where A1C change and ED visit rates were investigated. Interested patients at an appropriate security level were invited to use CGM. Pre- and post-CGM surveys of glucose monitoring perceptions were administered during the pilot program. Security and perceptions were analyzed descriptively. A1C change was assessed using a t test. Fisher exact test, Barnard exact test, and post hoc power analysis were applied to ED visits. Security was not disrupted. Patient perceptions of glucose monitoring improved with CGM use (n = 6). A1C declined by 0.60% with a medium effect size (Cohen d -0.45, n = 42). Power to detect a difference in ED visits was low; however, no CGM patients had an ED visit (n = 758). It is safe and efficacious to replace BGM with CGM in prisons when patients are engaged in their care and are at a security level allowing CGM devices in their cells.

Rural-Urban Differences in Hospital and Patient-Reported Outcomes Following Total Hip Arthroplasty.

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care. A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural. Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P= .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P= .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P= .05), Hip Disability and Osteoarthritis Outcome Score interval (P= .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference. There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

Early postoperative telehealth visit protocol implementation reduces emergency department utilization following benign foregut procedures.

Emergency department (ED) visits and readmissions following benign foregut surgery (BFS) represent a burden on patients and the health care system. The objective of this study was to identify differences in ED visits and readmissions before and after implementation of an early postoperative telehealth visit protocol for BFS. We hypothesized that utilization of telehealth visits would be associated with reduced post-operative ED and hospital utilization. An early postoperative telehealth protocol was initiated in 2020 at an academic medical center to provide a video conference within the first postoperative week. Consecutive elective BFS including fundoplication, Linx, paraesophageal hernia repair, and Heller myotomy performed between 2018 and 2022 were included. Outcomes included ED visits and 30-day readmission. Bivariate analyses were performed using Chi-squared testing for categorical variables. The association between telehealth visits and outcomes were evaluated using multivariable logistic regression. 616 patients underwent BFS during the study period. 310 (50.3%) were performed prior to the implementation of telehealth visits and 306 (49.7%) were after. 241 patients in the telehealth visit group (78.8%) completed their telehealth visit. A total of 34 patients (5.5%) had ED visits without readmission while 38 patients (6.2%) were readmitted within the first 30days. The most common cause of ED visits and readmissions included pain (n = 18, 25%) and nausea/vomiting (n = 12, 16%). There was a significant reduction in ED visits without admission following telehealth visit implementation (7.4% vs 3.6%; OR 2.20, 95% CI 1.04-4.65, p = 0.04). There was no difference in readmission rates (6.1% versus 6.5%; OR 0.89, 95% CI 0.46-1.73, p = 0.73). The telehealth cohort had significantly lower ED visits for pain (31% vs 16.7%, p = 0.04) and nausea/vomiting (23.8% vs 6.7%, p = 0.02). Early telehealth follow-up was associated with a significant decrease in ED visits following BFS. The majority of this was attributable to a reduction in ED visits for pain, nausea, and vomiting. These results provide a possible avenue for improving quality and cost-effectiveness within this patient population.

(246) Risk for Prolonged Opioid Usage after Inflatable Penile Prosthesis, A Global Analysis

Abstract Introduction Urologists are not immune from the opioid epidemic. While narcotics still have a role to play in postoperative pain management, examining individual surgeries, such as inflatable penile prosthesis placement (IPP), to identify opportunities to limit opioid use should be a priority. Objective By querying a large, global research network, we sought to evaluate the impact of a narcotic prescription on short term patient outcomes and long-term opioid use following IPP placement. Methods TriNetX is a collaborative research enterprise which collects real-time data from almost 89 million patients located in 58 healthcare organizations across the globe and analyzes patient data from 20 years back to present (2002-2022). We queried TriNetX for all adult patients undergoing IPP. The index event was surgery. Cohorts included patients prescribed oxycodone within 2 days of surgery, tramadol within 2 days of surgery, or one of many frequently prescribed oral opioids (oxycodone, hydrocodone, hydromorphone, oxymorphone or tramadol) within 2 days of surgery. The control cohorts were patients not prescribed a narcotic in the same timeframe. TrinetX identifies prescriptions using RxNorm Concept Unique Identifier, part of the Unified Medical Language System. We also compared patients taking opioids within 6 months to 1 day prior to surgery against “opioid naive” patients. Our short-term outcome was the rate of return visits to the Emergency Department (ED) within 90 days of the index event. Our long-term outcomes were a diagnosis of opioid abuse (ICD-10 F11.1) or dependence (ICD-10 F11.2) disorder 6 months or later after surgery, and we also evaluated persistent opioid use 9 to 15 months after surgery, consistent with previous literature. Propensity score matching (PSM) was performed on potential cofounders: age, race, mental and behavioral disorders, pain disorders, and prior opioid use. The analyses were performed on June 28th, 2022. Results There were 9702 patients who received an IPP (Table 1). Patients considered opioid- or oxycodone naive were less likely to have a diagnosis of opioid dependence or abuse (Relative Risk (RR)=0.51 and RR=0.42) at 6 months. Patients prescribed an opioid postoperatively, or oxycodone or tramadol specifically, were more likely have persistent opioid, oxycodone, or tramadol use (all p&amp;lt;0.05) at 9 to 15 months, except for patients prescribed postoperative tramadol for the outcome of any oral opioid prescription (p=0.75). Patients prescribed any opioid or oxycodone specifically were more likely to have an ED visit (RR=1.5 and 1.3) while patients prescribed tramadol postoperatively showed no difference in ED visits (RR=1.2). There was no significant difference in ED visits based on opioid naivety, while all patients taking preoperative opioids were more likely to continue taking an opioid at 9 to 15 months (all p&amp;lt;0.01). Conclusions The prescription of opioids after IPP has risks of long-term opioid use and prescribing opioids in general may increase healthcare utilization in the short term. Prescribing a partial agonist, such as tramadol, may reduce persistent opioid use while being non-inferior in need to return to the emergency department when compared to oxycodone; however, a non-opioid regimen is preferred to maximally reduce risk. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast

An Increase in Same Day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: a Retrospective Cohort Analysis.

The COVID-19 pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip (THA) and total knee arthroplasty (TKA). This retrospective study split patients into cohorts; TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following resumption of elective surgery (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index (BMI), ASA score and pertinent comorbidities were analyzed, and length-of-stay (LOS), 30-day emergency department (ED) visit rates, readmissions and reoperations were compared. 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (IQR 63-76) and the post-COVID group had a median age of 68 years (IQR 61-75) (P=0.024). SDD increased from 0.1% to 28.9% (P<0.001) and LOS decreased from 1.3 days to 0.89 days (P<0.001). There was no change in 30-day ED visits, readmissions, or reoperations (P=0.817, P=0.470, P=0.643 respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P<0.001, OR=0.94), BMI (P=0.006, OR=0.95), male sex (P<0.001, OR=1.83), and history of tobacco use (P<0.001, OR=1.87). At our institution, the COVID-19 pandemic accelerated utilization of SDD pathways without increasing ED visits, readmissions or reoperations.

Low health literacy is associated with worse postoperative outcomes following hepato-pancreato-biliary cancer surgery.

Low health literacy (HL) can lead to worse health outcomes for patients with chronic diseases and could also lead to worse postoperative outcomes. This retrospective cohort study investigates the association between HL and postoperative textbook outcome (TO) after hepato-pancreato-biliary (HPB) cancer surgery. Patients that consented and underwent surgery for a premalignant andmalignant HPB tumor were included. Preoperatively, HL was measured by the brief health literacy screen (BHLS). Patients were categorized as having low or adequate HL. Primary outcome was TO (length of hospital stay (LOS)≤75th percentile; and no severe complication; and no readmission and mortality within 30 days after discharge). Secondary outcomes were LOS and emergency department (ED) visits within 30 days after discharge. In total, 137 patients were included, of whom thirty-six patients had low HL. In patients with low HL (vs. adequate HL), rate of TO was lower (55.6% vs. 72.3%; p=0.095), LOS was significantly longer (13.5 vs. 9 days; p=0.007) and there was only a slight difference in ED visits (14.3% vs. 11.0%; p=0.560). Patients with low HL had a significant lower chance of achieving TO (OR 0.400, 95%-CI 0.169-0.948; p=0.037). Low HL leads to worse postoperative outcome after HPB cancer surgery. Better preoperative education and guidance of patients with low HL could lead to better postoperative outcomes. Therefore, HL could be the next modifiable risk factor before major surgery.

Prospective Comparison of Opioid vs Nonopioid Pain Regimen After Ureteroscopy.

Objective: We wanted to evaluate two new treatment phases within our practice, including a nonopioid pathway, to determine the effect on opioid usage, health care utilization, and pain following ureteroscopy. Methods: Patients undergoing ureteroscopic lithotripsy were enrolled in a study utilizing text messaging to evaluate postoperative pain and opioid usage. Our historical postoperative pain regimen included #30 oxycodone. Patients in the N15 cohort were given improved counseling, preanesthesia acetaminophen, and #15 oxycodone. With further experience, narcotics were removed entirely from our postoperative care plan (N0) and replaced with a nonopioid multimodal regimen. Results: There were 61 and 58 patients in cohorts N15 and N0, respectively, with no difference in demographics, stone, or procedure details between each cohort. No difference in pain scores was detected between the N15 and N0 cohorts (p = 0.14). The median time to pain resolution was postoperative day (POD) 4 for cohort N15 and POD 3 for cohort N0 (p = 0.06). In the N0 cohort, nine patients required postoperative narcotics (15.5%; average of 2.4 pills/patient). There was no significant difference in emergency department visits, phone calls, or clinic visits (p = 0.17) between each cohort. Conclusions: Patients undergoing ureteroscopy have adequate postoperative pain control with a nonopioid treatment regimen, although some patients will still ultimately require narcotics.

“I Had Never Felt More Alone in My Life as I Did Those Eight Days.” Impact of COVID-19 Visitation Restrictions on Patients and Caregivers

Outcomes1. Determine the impact of visitation restriction on caregivers and patients2. Describe ways to improve communication and caregiver involvement to families during times of caregiver separationOriginal Research BackgroundThe impact of restricting hospital visitation during the COVID-19 pandemic on patients and caregivers has not been described.Research ObjectivesWe explored how hospital visitation restrictions affected the health and experience of hospitalized patients and their caregivers.MethodsWe conducted a multimethod cohort study, matching adult patients (N = 100) hospitalized before the pandemic with 100 patients hospitalized after the pandemic. Matching was based on age, gender, and primary diagnosis. Based on chart abstractions, we conducted t tests estimating whether patient outcomes and medical teams’ communication with caregiver varied by status of visitor restrictions. We then conducted and analyzed semistructured interviews with a subset of patients hospitalized under visitor restrictions and their caregivers (N = 13) to understand the impact of visitation restrictions on patient and caregiver experience.ResultsOur chart abstraction revealed that caregivers of patients hospitalized during visitation restriction were more likely to receive no contact from medical teams (36.1% vs 16.5%; P < 0.001) and less likely to receive discharge counseling compared to those hospitalized before visitation restriction (36.5% vs 51.6%; P = 0.04). There were no significant differences in emergency department visits, rehospitalization, or death. Our qualitative analysis revealed that caregivers and patients experienced negative emotional consequences of the separation, such as anxiety, confusion, fear, and conflict with the medical team. Caregivers struggled with a lack of information about their loved ones’ overall psychological state. Although video visits were helpful, many caregivers either were not offered this option or did not have the technological literacy necessary to benefit.ConclusionVisitation restrictions during COVID were associated with lack of communication with caregivers but no significant differences in hospitalizations or ER visits. Interviews indicate that patients’ and caregivers’ unmet information needs due to lack of communication caused negative emotional consequences.Implications for Research, Policy, or PracticeFuture research should explore how to mediate the negative emotional sequelae of caregiver physical separation.

Mifepristone and Misoprostol for Undesired Pregnancy of Unknown Location.

To compare immediate initiation with delayed initiation of medication abortion among patients with an undesired pregnancy of unknown location. This retrospective cohort study used electronic medical record data from the Planned Parenthood League of Massachusetts (2014-2019) for patients who requested medication abortion with a last menstrual period (LMP) of 42 days or less and pregnancy of unknown location (no gestational sac) on initial ultrasonogram. Clinicians could initiate medication abortion with mifepristone followed by misoprostol while simultaneously excluding ectopic pregnancy with serial serum human chorionic gonadotropin (hCG) testing (same-day-start group) or establish a diagnosis with serial hCG tests and repeat ultrasonogram before initiating treatment (delay-for-diagnosis group). We compared primary safety outcomes (time to diagnosis of pregnancy location [rule out ectopic], emergency department visits, adverse events, and nonadherence with follow-up) between groups. We also reported secondary efficacy outcomes: time to complete abortion, successful medication abortion (no uterine aspiration), and ongoing pregnancy. Of 5,619 medication abortion visits for patients with an LMP of 42 days or less, 452 patients had pregnancy of unknown location (8.0%). Three patients underwent immediate uterine aspiration, 55 had same-day start, and 394 had delay for diagnosis. Thirty-one patients (7.9%), all in the delay-for-diagnosis group, were treated for ectopic pregnancy, including four that were ruptured. Among patients with no major ectopic pregnancy risk factors (n=432), same-day start had shorter time to diagnosis (median 5.0 days vs 9.0 days; P=.005), with no significant difference in emergency department visits (adjusted odds ratio [aOR] 0.90, 95% CI 0.43-1.88) or nonadherence with follow-up (aOR 0.92, 95% CI 0.39-2.15). Among patients who proceeded with abortion (n=270), same-day start had shorter time to complete abortion (median 5.0 days vs 19.0 days; P<.001). Of those who had medication abortion with known outcome (n=170), the rate of successful medication abortion was lower (85.4% vs 96.7%; P=.013) and the rate of ongoing pregnancy was higher (10.4% vs 2.5%; P=.041) among patients in the same-day-start group. In patients with undesired pregnancy of unknown location, immediate initiation of medication abortion is associated with more rapid exclusion of ectopic pregnancy and pregnancy termination but lower abortion efficacy.

Interactive Inpatient Asthma Education: A Randomized Controlled Trial.

Inpatient asthma education interventions provide benefit compared with usual care, but evaluation of the most effective educational model is needed. We compared the impact of interactive versus didactic inpatient pediatric asthma education on subsequent emergency department (ED) visits and hospitalizations. Children (aged 2‒16) with asthma admitted to a tertiary care children's hospital with an asthma exacerbation between October 2016 and June 2017 were randomly assigned to interactive or didactic (control) asthma education. The primary outcome was asthma ED visits at 6 and 12 months; secondary outcomes included hospitalizations (6 and 12 months), inhaler technique, asthma knowledge, symptoms, quality of life, and parental management skills at baseline, discharge, and/or 12 months. One hundred forty participants (69 interactive, 71 control) completed the study. There were no differences in ED visits at 6 or 12 months. Compared to controls, the interactive group had fewer hospitalizations (10.1% vs 22.5%; P = .04) at 6 months. Inhaler technique in the interactive group improved at discharge (mean change 4.07 [95% confidence interval (CI): 3.21-4.94]) and remained increased at 12 months (P = .03). Patient-reported asthma symptoms and quality of life were similar in both groups at baseline (19.9 vs 20.62, best possible score 8) and significantly improved in the interactive group at 12 months (least square mean change, 3.52 vs -1.75; P < .01). There were no differences in ED visits; however, the interactive education reduced asthma hospitalizations over a 6-month period. These findings demonstrate that educational delivery methods can play a role in improving clinical outcomes for asthma.

Pediatric Hospital Medicine Needs More Randomized Controlled Trials.

Pediatric Hospital Medicine Needs More Randomized Controlled Trials.

Impact of race/ethnicity and socioeconomic status on emergency department visits in patients with hepatocellular carcinoma.

385 Background: Despite advances in diagnosis and treatment of hepatocellular carcinoma (HCC), disparities in care utilization and health outcomes persist. Few studies have evaluated the impact of race/ethnicity and socioeconomic status (SES) on incidence of emergency department (ED) visits, which may reflect access to and quality of cancer care. We investigated this relationship among patients (pts) with HCC. Methods: Using 100% Medicare Fee-for-Service claims and a commercial multi-payor claims database, pts diagnosed with HCC between 2014-2018 were identified. Using 9-digit ZIP code from enrollment records, pts were matched to near-neighborhood social determinants of health (SDOH) characteristics, including income, education, English language ability, living alone, vehicle ownership, rurality, and primary care shortages. We defined SES according to income level: low (≤2 times [x] federal poverty level [FPL]), middle (2-3x FPL), and high (&gt;3x FPL). We used generalized linear regressions to evaluate the effect of race/ethnicity on incidence rate ratios (IRR) of ED visits, adjusting for SDOH variables and demographic and clinical characteristics. We further stratified ED IRR by income level to examine how racial/ethnic differences in ED visits differ by SES. Results: 22,247 pts with HCC were identified (median age 69; 63% male; 69% White, 14% Black, 7% Hispanic, 6% Asian, 4% Other). The table summarizes adjusted IRR of ED visits for each racial/ethnic group compared with whites, overall and by income level. Overall, ED visits were higher for Blacks (IRR 1.27) and Hispanics (IRR 1.17) and lower for Asians (IRR 0.67). When stratified by income, Blacks and Hispanics had larger incidence of ED visits compared with Whites at higher income levels; these differences became insignificant at low income level. Asians had lower rate of ED visits regardless of income. Conclusions: Black and Hispanic pts with HCC demonstrated higher rates of ED visits compared with Whites. These differences were more pronounced at higher income levels, particularly for Blacks, suggesting racial disparities may differ by SES. Further research is needed to understand the intersectionality between race/ethnicity, SES and other SDOH, to guide structural-level interventions to address these disparities. [Table: see text]

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty.

To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits. We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits. A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD. Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.

A Tertiary Care-based Complex Care Program: Improving Care for Children With Medical Complexity.

Children with medical complexity (CMC) have significant health care costs, but they also experience substantial unmet health care needs, hospitalizations, and medical errors. Their parents often report psychosocial stressors and poor care satisfaction. Complex care programs can improve the care for CMC. At our tertiary care institution, we developed a consultative complex care program to improve the quality and cost of care for CMC and to improve the experience of care for patients and families. To address the needs of CMC at our institution, we developed the Compass Care Program, a consultative complex care program across inpatient and outpatient settings. Utilization data [hospital admissions per patient month; length of stay per admission; hospital days per patient month; emergency department (ED) visits per patient month; and institutional charges per patient month] and caregiver satisfaction data (obtained via paper survey at outpatient visits) were tracked over the period of participation in the program and compared preenrollment and postenrollment for program participants. Participants had significant decreases in hospital admissions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enrollment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains. Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.

Transitioning a Practice to Robotic Total Knee Arthroplasty Is Correlated with Favorable Short-Term Clinical Outcomes-A Single Surgeon Experience.

This study sought to evaluate the patient experience and short-term clinical outcomes associated with the hospital stay of patients who underwent robotic arm-assisted total knee arthroplasty (TKA). These results were compared with a cohort of patients who underwent TKA without robotic assistance performed by the same surgeon prior to the introduction of this technology. A cohort of consecutive patients undergoing primary TKA for the diagnosis of osteoarthritis by a single fellowship trained orthopaedic surgeon over a 39-month period was identified. Patients who underwent TKA during the year that this surgeon transitioned his entire knee arthroplasty practice to robotic assistance were excluded to eliminate selection bias and control for the learning curve. All patients received the same prosthesis and postoperative pain protocol. Patients that required intubation for failed spinal anesthetic were excluded. A final population of 492 TKAs was identified. Of these, 290 underwent TKA without robotic assistance and 202 underwent robotic arm-assisted TKA. Patient demographic characteristics and short-term clinical data were analyzed. Robotic arm-assisted TKA was associated with shorter length of stay (2.3 vs. 2.6 days, p < 0.001), a 50% reduction in morphine milligram equivalent utilization (from 214 to 103, p < 0.001), and a mean increase in procedure time of 9.3 minutes (p < 0.001). There was one superficial infection in the nonrobotic cohort and there were no deep postoperative infections in either cohort. There were no manipulations under anesthesia in the robotic cohort while there were six in the nonrobotic cohort. Additionally, there were no significant differences in emergency department visits, readmissions, or return to the operating room. This analysis corroborates existing literature suggesting that robotic arm-assisted TKA can be correlated with improved short-term clinical outcomes. This study reports on a single surgeon's experience with regard to analgesic requirements, length of stay, pain scores, and procedure time following a complete transition to robotic arm-assisted TKA. These results underscore the importance of continued evaluation of clinical outcomes as robotic arthroplasty technology continues to grow.