Emergency Department Visit Rates Research Articles

Real-world effectiveness of benralizumab in US subspecialist-treated adults with severe asthma: Findings from CHRONICLE

BackgroundPatients with eosinophilic severe asthma (SA) have an increased risk of asthma exacerbations. Benralizumab is approved for eosinophilic SA, and there is great value in understanding real-world effectiveness. ObjectiveThe aim of this analysis was to examine the effectiveness of benralizumab in a real-world cohort of subspecialist-treated US patients with eosinophilic SA. MethodsCHRONICLE is an ongoing, noninterventional study of subspecialist-treated US adults with SA receiving biologics, maintenance systemic corticosteroids, or those persistently uncontrolled by high-dose inhaled corticosteroids with additional controllers. For this analysis, eligible patients enrolled from February 2018 to February 2021, had received ≥ 1 dose of benralizumab, and had study data for ≥ 3 months before and after benralizumab initiation. The primary analysis included patients with prior exacerbations reported and 12 months of outcomes data before and after initiation. Patient outcomes occurring 6–12 months before and after initiation were also evaluated. ResultsA total of 317 patients had ≥ 3 months of follow-up before and after first benralizumab dose. For patients with 12 months (n = 107) and 6–12 months (n = 166) of data, significant reductions were observed in annualized rates of exacerbations (62%; P < 0.001 and 65%; P < 0.001, respectively), with similar reductions in the rates of hospitalizations and emergency department visits. Benralizumab recipients with blood eosinophil counts (BEC) of ≥ 300/ μL and < 300/ μL at baseline and 12 months of data also had significant reductions in exacerbations (68%; P < 0.001, 61%; P < 0.001). ConclusionThis real-world, noninterventional analysis reinforces the clinical value of benralizumab in the management of patients with eosinophilic SA.

Bloodstream infection burden among cancer clinic patients with PICC Lines: A prospective, observational study

Background: Oncology patients are at high risk for bloodstream infection (BSI) due to immunosuppression and frequent use of central venous catheters. Surveillance in this population is largely relegated to inpatient settings and limited data are available describing community burden. We evaluated rates of BSI, clinic or emergency department (ED) visits, and hospitalizations in a large cohort of oncology outpatients with peripherally inserted central catheters (PICCs). Methods: In this prospective, observational study, we followed a convenience sample of adults (age&gt;18) with PICCs at a large academic outpatient oncology clinic for 35 months between July 2015 and November 2018. We assessed demographics, malignancy type, PICC insertion and removal dates, history of prior PICC, and line duration. Outcomes included BSI events (defined as &gt;1 positive blood cultures or &gt;2 positive blood cultures if coagulase-negative Staphylococcus), ED visits (without hospitalization), and unplanned hospitalizations (excluding scheduled chemotherapy hospitalizations). We used χ2 analyses to compare the frequency of categorical outcomes, and we used unpaired t tests to assess differences in means of continuous variable in hematologic versus solid-tumor malignancy patients. We used generalized linear mixed-effects models to assess differences in BSI (clustered by patient) separately for gram-positive and gram-negative BSI outcomes. Results: Among 478 patients with 658 unique PICC lines and 64,190 line days, 271 patients (413 lines) had hematologic malignancy and 207 patients (232 lines) had solid-tumor malignancy. Cohort characteristics and outcomes stratified by malignancy type are shown in Table 1. Compared to those with hematologic malignancy, solid-tumor patients were older, had 47% fewer clinic visits, and had 32% lower frequency of prior PICC lines. Overall, there were 75 BSI events (12%; 1.2 per 1,000 catheter days). We detected no significant difference in BSI rates when comparing solid-tumor versus hematologic malignancies (P = 0.20); BSIs with gram-positive pathogen were 69% higher in patients with solid tumors. Gram-negative BSIs were 41% higher in patients with hematologic malignancy. Solid-tumor malignancy was associated with 4.5-fold higher odds of developing BSI with gram-positive pathogen (OR, 4.48; 95% CI, 1.60–12.60; P = .005) compared to those with hematologic malignancy, after adjusting for age, sex, history of prior PICC, and line duration. Differences in gram-negative BSI were not significant on multivariate analysis. Conclusions: The burden of all-cause BSIs in cancer clinic adults with PICC lines was 12% or 1.2 per 1,000 catheter days, as high as nationally reported inpatient BSI rates. Higher risk of gram-positive BSIs in solid-tumor patients suggests the need for targeted infection prevention activities in this population, such as improvements in central-line monitoring, outpatient care, and maintenance of lines and/or dressings, as well as chlorhexidine bathing to reduce skin bioburden.Disclosures: None

Physical distancing and emergency medical services utilization after self-harm in Korea during the early COVID-19 pandemic: A nationwide quantitative study.

People experienced various stress and psychological responses to the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to examine the changes in emergency medical services (EMSs) utilization by self-harm patients in early pandemic and the impacts of physical distancing measures on the EMSs utilization by self-harm patients. Data for all patients presenting to emergency departments (EDs) after self-harm injuries including self-poisoning were collected from the National ED Information System (NEDIS). Characteristics of patients in two study regions (urban versus rural) were compared. Weekly and annual ED visit rates after self-harm (VRSH) per 100,000 population were calculated. Mobile phone mobility index (MPMI) was calculated by dividing a region's aggregated mobile phone mobility by mid-year population. Joinpoint regression analysis was conducted to assess changes in 2020 over pre-pandemic years. Test for presence of joinpoint at the end of 2019 was performed. A cross-correlation function was used to estimate the maximal morphological similarity and lag time between changes in MPMI and VRSH. In 2020, in early phases of the pandemic, there was a moderate decline in self-harm-related ED visits to 30,797 from a continuously increasing trend seen in previous years. However, proportions of young people (50.1%) and females (62.3%) increased over previous years. VRSHs among women and young people aged 15-34 years showed higher levels in 2020 than in previous five years. There was a significant decrease in the proportion of patients transported directly from the scene. In addition, there was a polarization of mental state upon ED arrival from alert and unresponsive. The median correlation coefficient between MPMI values and VRSH values was 0.601 (interquartile range [IQR]: 0.539-0.619) in urban regions and 0.531 (IQR: 0.454-0.595) in rural regions, showing no statistically significant difference between the two. Physical distancing measures adopted to prevent the spread of transmittable diseases following the pandemic had the effect of decreasing ED visits due to self-harm. When the pandemic has ended, and daily life has been restored, it will be particularly important to pay attention to the increased numbers of self-harm patients expected to visit EDs compared to during the pandemic.

Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study.

Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.

Extracorporeal veno-venous ultrafiltration in congestive heart failure: What's the state of the art? A mini-review.

Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.

The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study

BackgroundOlder adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU.MethodsThis is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes.ResultsA total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08–2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03–5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00–5.31, p = 0.049). The association lost significance after adjustment.ConclusionsThe increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.

Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study.

The global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada. We conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018. The age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (p<0.0001) and was 459 per 100,000 in 2018 (n = 33,479), with a lower prevalence in rural compared to urban residents (401 vs. 467 per 100,000). Rates of hospitalizations and family physician visits declined over time in both men and women with PD in rural and urban areas, while rates of emergency department, neurologist, and other specialist visits increased. Adjusted rates of hospitalizations were similar between rural and urban residents (RR = 1.04, 95% CI [0.96, 1.12]), while rates of emergency department visits were higher among rural residents (RR = 1.35, 95% CI [1.27, 1.42]). Rural residents had lower rates of family physician (adjusted RR = 0.82, (95% CI [0.79, 0.84]) and neurologist visits (RR = 0.74, 95% CI [0.72, 0.77]). Lower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed.

Outpatient Total Knee Arthroplasty From a Stand-Alone Surgery Center: Safe as the Hospital?

BackgroundLiterature suggests that outpatient arthroplasty may result in low rates of complications and readmissions. There is, however, a dearth of information on the relative safety of total knee arthroplasty (TKA) performed at stand-alone ambulatory surgery centers (ASCs) versus hospital outpatient (HOP) settings. We aimed to compare safety profiles and 90-day adverse events of these 2 cohorts. MethodsProspectively collected data were reviewed on all patients who underwent outpatient TKA from 2015 to 2022. The ASC and HOP groups were compared, and differences in demographics, complications, reoperations, revisions, readmissions, and emergency department (ED) visits within 90 days of surgery were analyzed. There were 4 surgeons who performed 4,307 TKAs during the study period, including 740 outpatient cases (ASC = 157; HOP = 583). The ASC patients were younger than HOP patients (ASC = 61 versus HOP = 65; P < .001). Body mass index and sex did not differ significantly between groups. ResultsWithin 90 days, 44 (6%) complications occurred. No differences were observed between groups in rates of 90-day complications (ASC = 9 of 157, 5.7% versus HOP = 35 of 583, 6.0%; P = .899), reoperations (ASC = 2 of 157, 1.3% versus HOP = 3 of 583, 0.5%; P = .303), revisions (ASC = 0 of 157 versus HOP = 3 of 583, 0.5%; P = 1), readmissions (ASC = 3 of 157, 1.9% versus HOP = 8 of 583, 1.4%; P = .625), and ED visits (ASC = 1 of 157, 0.6% versus HOP = 3 of 583, 0.5%; P = .853). ConclusionThese results suggest that in appropriately selected patients, outpatient TKA can be safely performed in both ASC and HOP settings with similar low rates of 90-day complications, reoperations, revisions, readmissions, and ED visits.

Medicaid expansion associated with no change in emergency department use across racial and ethnic groups.

To estimate changes in the emergency department (ED) visit rate, hospitalization share of ED visits, and ED visit volumes associated with Medicaid expansion among Hispanic, Black, and White adults. For the population of adults aged 26-64 with no insurance or Medicaid coverage, we obtained census population and ED visit counts during 2010-2018 in nine expansion and five nonexpansion states. The primary outcome was the annual number of ED visits per 100 adults ("ED rate"). The secondary outcomes were the share of ED visits leading to hospitalization, total number ("volumes") of all ED visits, ED visits leading to discharge ("treat-and-release") and ED visits leading to hospitalization ("transfer-to-inpatient"), and the share of the study population with Medicaid ("Medicaid share"). An event-study difference in differences design that contrasts pre- versus post-expansion changes in outcomes in Medicaid expansion and nonexpansion states. In 2013, the ED rate was 92.6, 34.4, and 59.2 ED visits among Black, Hispanic, and White adults, respectively. The expansion was associated with no change in ED rate in all three groups in each of the five post-expansion years. We found that expansion was associated with no change in the hospitalization share of ED visits and the volume of all ED visits, treat-and-release ED visits, and transfer-to-inpatient ED visits. The expansion was associated with an 11.7% annual increase (95% CI, 2.7%-21.2%) in the Medicaid share of Hispanic adults, but no significant change among Black adults (3.8%; 95% CI, -0.04% to 7.7%). ACA Medicaid expansion was associated with no changes in the rate of ED visits among Black, Hispanic, and White adults. Expanding Medicaid eligibility may not change ED use, including among Black and Hispanic subgroups.

The outcomes of same-day discharge following holmium laser enucleation of the prostate (HoLEP) surgeries: our experience during the COVID-19 pandemic.

To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic. A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD. A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9ng/dL, P < 0.001), prostate volume (152.3 vs 100.6mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01). Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only.

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada.

It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Effects of Opioid-Limiting Legislation and Increased Provider Awareness on Postoperative Opioid Use and Complications After Hip Arthroscopy.

On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures. (1) To determine if the opioid prescription-limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing. Cohort study; Level of evidence, 3. This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting-adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts. A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = -280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01). Opioid prescription-limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Tacking upwind: reducing spending among high-risk commercially insured patients.

The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates. Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019. Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected. Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Improving the Quality of Upper Urinary Tract Stone Surgery: External Validation of a Statewide Collaborative's Efforts to Reduce Emergency Department Visits After Ureteroscopy.

The ROCKS (Reducing Operative Complications from Kidney Stones) program in MUSIC (Michigan Urological Surgery Improvement Collaborative) was created to optimize ureteroscopy outcomes. Through data collection, distribution of reports, patient education, and standardization of medication, post-ureteroscopy emergency department visits in Michigan have declined. It is unclear whether this is because of statewide quality efforts or due to national trends. We therefore sought to understand emergency department visit rates in Michigan compared to a national data set. We compared the MUSIC ROCKS clinical registry in Michigan against a national cohort, Optum's de-identified Clinformatics Data Mart, from 2016-2021 (excluding Michigan). We identified patients who underwent ureteroscopy and the proportion who had a postoperative emergency department visit within 30 days. Emergency department rates were modeled over time, adjusting for age, gender, comorbidity, and ureteral stenting. We identified 24,688 patients in MUSIC ROCKS and 99,340 in the Clinformatics Data Mart database who underwent ureteroscopy. The risk-adjusted emergency department visit rate in MUSIC ROCKS significantly declined over the study period (10.5% in 2016 to 6.9% in 2021, P < 0.001) while the mean emergency department visit rate in the Clinformatics Data Mart cohort was 9.9% and did not change over time (9.6% in 2016 to 10% in 2021). Comparing emergency department visits between the cohorts, the MUSIC ROCKS rate significantly declined relative to the Clinformatics Data Mart (P < 0.001) over the study period. Postoperative emergency department visit rates in Michigan have declined significantly after ureteroscopy since the establishment of MUSIC ROCKS. This decline outpaced national rates, providing evidence that systematic quality initiatives can improve urological care.

Virtual Care and Emergency Department Use During the COVID-19 Pandemic Among Patients of Family Physicians in Ontario, Canada

The COVID-19 pandemic has played a role in increased use of virtual care in primary care. However, few studies have examined the association between virtual primary care visits and other health care use. To evaluate the association between the percentage of virtual visits in primary care and the rate of emergency department (ED) visits. This cross-sectional study used routinely collected administrative data and was conducted in Ontario, Canada. The sample comprised family physicians with at least 1 primary care visit claim between February 1 and October 31, 2021, and permanent Ontario residents who were alive as of March 31, 2021. All residents were assigned to physicians according to enrollment and billing data. Family physicians' virtual visit rate was the exposure. Physicians were stratified by the percentage of total visits that they delivered virtually (via telephone or video) during the study period (0% [100% in person], >0%-20%, >20%-40%, >40%-60%, >60%-80%, >80% to <100%, or 100%). Population-level ED visit rate was calculated for each stratum of virtual care use. Multivariable regression models were used to understand the relative rate of patient ED use after adjusting for rurality of practice, patient characteristics, and 2019 ED visit rates. Data were analyzed for a total of 13 820 family physicians (7114 males [51.5%]; mean [SD] age, 50 [13.1] years) with 12 951 063 patients (6 714 150 females [51.8%]; mean [SD] age, 42.6 [22.9] years) who were attached to these physicians. Most physicians provided between 40% and 80% of care virtually. A higher percentage of the physicians who provided more than 80% of care virtually were 65 years or older, female individuals, and practiced in big cities. Patient comorbidity and morbidity were similar across strata of virtual care use. The mean (SD) number of ED visits was highest among patients whose physicians provided only in-person care (470.3 [1918.8] per 1000 patients) and was lowest among patients of physicians who provided more than 80% to less than 100% of care virtually (242.0 [800.3] per 1000 patients). After adjustment for patient characteristics, patients of physicians with more than 20% of visits delivered virtually had lower rates of ED visits compared with patients of physicians who provided more than 0% to 20% of care virtually (eg, >80% to <100% vs >0%-20% virtual visits in big cities: relative rate, 0.77%; 95% CI, 0.74%-0.81%). This pattern was unchanged across all rurality of practice strata and after adjustment for 2019 ED visit rates. In urban areas, there was a gradient whereby patients of physicians providing the highest level of virtual care had the lowest ED visit rates. Findings of this study show that patients of physicians who provided a higher percentage of virtual care did not have higher ED visit rates compared with patients of physicians who provided the lowest levels of virtual care. The findings refute the hypothesis that family physicians providing more care virtually during the pandemic resulted in higher ED use.

Effect of Celiac Disease on Outcomes After Posterior Lumbar Fusion: A Matched Cohort Study

The purpose of this study was to analyze if celiac disease (CD) is associated with increased postoperative complications following single-level posterior lumbar fusion (PLF). A retrospective database review was performed using the PearlDiver dataset. The study population included all patients older than 18years who underwent elective PLF with diagnosis of CD using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. Study patients were compared with controls for 90-day medical complications and 2-year surgical complications including 5-year reoperation rates. A multivariate logistic regression was used to determine the independent effect of CD on the postoperative outcomes. A total of 909 patients with CD and 4483 patients in the matched control group who underwent primary single-level PLF were included in this study. CD patients had a significantly increased risk of 90-day emergency department (ED) visit (OR 1.28; P=0.020). CD patients also demonstrated higher rates of 2-year pseudarthrosis and instrument failure, but they were statistically comparable (P>0.05). There was no difference in 5-year reoperation rate. There were also no significant differences in 90-day medical complication rate and 2-year surgical complication rate between the two groups. In addition, there were no differences in procedure cost and 90-day cost. For CD patients undergoing PLF, the current study demonstrated increased rate of 90-day ED visit. Our findings may be useful for patient counseling and surgical planning for those with this condition.

The effect of recreational cannabis legalization on rates of traffic injury in Canada.

To measure the impact of Canada's recreational cannabis legalization (RCL) in October 2018 and the subsequent impact of the COVID-19 lockdowns from March 2020 on rates of emergency department (ED) visits and hospitalizations for traffic injury. An interrupted time series analysis of rates of ED visits and hospitalizations in Canada recorded in population-based databases from January/April 2010 to March 2021. ED visits in Ontario and Alberta and hospitalizations in Ontario, Alberta, British Columbia, Prairies [Manitoba, Saskatchewan], and Maritimes [Nova Scotia, New Brunswick, Newfoundland, Prince Edward Island]. Cases Monthly counts of presentations to the ED or hospital for motor vehicle injury or pedestrian/cyclist injury, used to calculate monthly rates per 100,000 population. An occurrence of one or more International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) code for motor vehicle injury (V20-V29, V40-V79, V30-39, V86) and pedestrian/cyclist injury (V01-V09, V10-V19) within the National Ambulatory Care Reporting System and Discharge Abstract Database. There were no statistically significant changes in rates of ED visits and hospitalizations for motor vehicle or pedestrian/cyclist injury after RCL after accounting for multiple testing. After COVID-19, there was an immediate decrease in the rate of ED visits for motor vehicle injury that was statistically significant only in Ontario (level change ß = -16.07 in Ontario, 95% confidence interval [CI] -20.55 to -11.60, p=0.000; ß = -10.34 in Alberta, 95% CI -17.80 to -2.89, p=0.008; alpha of 0.004) and no changes in rates of hospitalizations. Canada's recreational cannabis legalization (RCL) did not notably impact motor vehicle and pedestrian/cyclist injury. The rate of emergency department visits for motor vehicle injury decreased immediately after COVID-19, resulting in rates below post-RCL levels in the year after COVID-19.

MP06-03 EXTERNAL VALIDATION OF DECREASED ED VISITS AFTER URETEROSCOPY DUE TO QUALITY IMPROVEMENT INITIATIVES OF A STATEWIDE COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023MP06-03 EXTERNAL VALIDATION OF DECREASED ED VISITS AFTER URETEROSCOPY DUE TO QUALITY IMPROVEMENT INITIATIVES OF A STATEWIDE COLLABORATIVE Andrew Higgins, Stephanie Daignault-Newton, Russell Becker, Golena Fernandez Moncaleano, Bronson Conrado, John Hollingsworth, Khurshid Ghani, and Casey Dauw Andrew HigginsAndrew Higgins More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Russell BeckerRussell Becker More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Bronson ConradoBronson Conrado More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , and Casey DauwCasey Dauw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Michigan Urological Surgery Improvement Collaborative Reducing Operative Complications from Kidney Stones (ROCKS) was created to optimize outcomes after ureteroscopy (URS). Through outcomes data collection, distribution of performance reports, patient educational efforts, and standardization of an opioid-free postoperative pain regimen, emergency department (ED) visits in Michigan have declined. It is unclear, whether this trend is unique to Michigan and thus a reflection of these quality efforts or is similar to national data. We thus sought to understand ED visit rates in Michigan compared to a large national dataset. METHODS: We used data from two sources for this study to understand 30-day ED visits after URS. In Michigan, the ROCKS database, a prospectively maintained registry including more than 90% of participating urologic practices in the state was utilized, capturing patients from 2016-2021. To serve as comparison, we used Optum claims data from 2011 to 2021 (excluding Michigan), which includes commercially insured adults and dependents. We identified patients who underwent URS defined by CPT codes and calculated the proportion who had an ED visit within 30 days of URS. Cohort age and gender were compared with rank and chi-square tests, respectively. ED rates were modeled (logistic) adjusting for age and gender to compare cohorts over time. RESULTS: Overall, we identified 24,163 patients in ROCKS who underwent URS and 162,642 patients in Optum. Significant differences were seen with regards to gender (51% vs 44% female, p<0.01) and median age (58 vs 62 years, p<0.01) between ROCKS and Optum cohorts. The mean ED rate in ROCKS was 7.9% (range 6.3 to 10.5%) with a significant decline over time (p<0.01, Figure 1). The ED rate in Optum was 9.9% (range 9.1 to 10.5%) with an increase over time (p<0.01). Comparing ED visits between the two cohorts after adjusting for observed demographic differences, the ROCKS ED visit rate declined significantly relative to national Optum rates (p<0.01). CONCLUSIONS: ED visit rates in Michigan have declined significantly after URS since establishment of the ROCKS initiative. This decline outpaces national ED rates, which have gradually increased over the past 10 years. This lends credence to systematic quality initiatives seeking to improve urologic care. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e53 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Higgins More articles by this author Stephanie Daignault-Newton More articles by this author Russell Becker More articles by this author Golena Fernandez Moncaleano More articles by this author Bronson Conrado More articles by this author John Hollingsworth More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author Expand All Advertisement PDF downloadLoading ...

PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS Samantha Wilder, Ji Qi, Mahin Mirza, Adam Gadzinski, Thomas Maatman, Brian Lane, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Samantha WilderSamantha Wilder More articles by this author , Ji QiJi Qi More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Adam GadzinskiAdam Gadzinski More articles by this author , Thomas MaatmanThomas Maatman More articles by this author , Brian LaneBrian Lane More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003231.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The prescription of opioids following surgery has played a role in the current opioid epidemic, both by increasing the risk of persistent opioid use and through diversion of unused pills into the community. We evaluated practice-level variation in opioid prescribing following surgery for cT1 renal masses (T1RM) and examined the relationships between opioid-free discharge and postoperative emergency department (ED) visits and readmissions. METHODS: We retrospectively examined all T1RM patients with data regarding prescription of postoperative opioids within the MUSIC-KIDNEY registry from April 2021 to August 2022. Patients were stratified into those who received opioids at discharge and those who had opioid-free discharge, and associations with patient, tumor, and surgical factors were evaluated. Practice-level variation was assessed. Rates of postoperative ED visits and readmissions within 30 days were compared between cohorts. RESULTS: Of 248 patients who underwent surgery for T1RM across 11 practices in MUSIC-KIDNEY, 24.2% underwent opioid-free discharge. Practice level variation in rates of opioid-free discharge ranged from 0% to 72.7% (Figure 1). For patients prescribed opioids, the median number of pills was 12 (IQR 8-12). Patients prescribed opioids at discharge had a higher median BMI than those with opioid-free discharge (31.7 vs 28.7, p=0.003). Other patient comorbidities, tumor factors, surgical approach (minimally invasive vs. open), and surgery type (partial vs. radical nephrectomy) did not differ between cohorts (p>0.05). The opioid-free group had at least comparable rates of 30 day ED visits (0% vs. 3.2%) and readmission (1.7% vs. 5.3%), although this did not reach statistical significance (P>0.05). CONCLUSIONS: MUSIC-KIDNEY data suggests that opioid-free discharge is not associated with increased rates of postoperative ED visits or readmissions. There exists wide practice-level variation in the prescription of opioids following surgery for T1RM in the state of Michigan. Further investigation into additional factors driving this variation is warranted. There is potential to learn from practices that are safely limiting the number of pills entering the community, and future QI initiatives may focus on this metric. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e161 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha Wilder More articles by this author Ji Qi More articles by this author Mahin Mirza More articles by this author Adam Gadzinski More articles by this author Thomas Maatman More articles by this author Brian Lane More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Acute Effects of Ambient Air Pollution on Asthma Emergency Department Visits in Ten U.S. States.

Previous studies of short-term ambient air pollution exposure and asthma morbidity in the United States have been limited to a small number of cities and/or pollutants and with limited consideration of effects across ages. To estimate acute age group-specific effects of fine and coarse particulate matter (PM), major PM components, and gaseous pollutants on emergency department (ED) visits for asthma during 2005-2014 across the United States. We acquired ED visit and air quality data in regions surrounding 53 speciation sites in 10 states. We used quasi-Poisson log-linear time-series models with unconstrained distributed exposure lags to estimate site-specific acute effects of air pollution on asthma ED visits overall and by age group (1-4, 5-17, 18-49, 50-64, and y), controlling for meteorology, time trends, and influenza activity. We then used a Bayesian hierarchical model to estimate pooled associations from site-specific associations. Our analysis included asthma ED visits. We observed positive associations for multiday cumulative exposure to all air pollutants examined [e.g., 8-d exposure to : rate ratio of 1.016 with 95% credible interval (CI) of (1.008, 1.025) per increase, : 1.014 (95% CI: 1.007, 1.020) per increase, organic carbon: 1.016 (95% CI: 1.009, 1.024) per increase, and ozone: 1.008 (95% CI: 0.995, 1.022) per increase]. and ozone showed stronger effects at shorter lags, whereas associations of traffic-related pollutants (e.g., elemental carbon and oxides of nitrogen) were generally stronger at longer lags. Most pollutants had more pronounced effects on children ( y old) than adults; had strong effects on both children and the elderly ( y old); and ozone had stronger effects on adults than children. We reported positive associations between short-term air pollution exposure and increased rates of asthma ED visits. We found that air pollution exposure posed a higher risk for children and older populations. https://doi.org/10.1289/EHP11661.