Emergency Inpatient Admissions Research Articles

Who dies from venous thromboembolism after hospitalisation for other reasons in England?: a national retrospective cohort study

ObjectivesVenous thromboembolism (VTE) is a major cause of morbidity and mortality globally, with hospital-associated thrombosis (HAT) accounting for at least half of VTE. We set out to understand more about...

Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma.

Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.

INNOVATING HOME HEALTH DELIVERY TO IMPROVE VETERANS’ ACCESS TO CARE AND CARE COORDINATION

Abstract Nearly 350,000 Veterans receive home health services through the Veterans Health Administration (VA) annually. Historically, VA has purchased most home health services from contract agencies in the community. VA leaders have expressed growing concerns about Veterans’ access to home health, especially in rural areas. Coordinating care between VA and contract agencies is an ongoing challenge. To address these challenges, the VA Midwest Health Care Network (VISN 23) developed the VA Home Health (VAHH) pilot program. The program launched at the Iowa City VA and is currently operating at 4 sites in Iowa and South Dakota. Through VAHH, local VA Medical Centers hire home health staff directly (nurses, aides, physical and occupational therapists), rather than purchase these services through contract agencies. In this presentation, we describe program development, challenges, and early evaluation findings. In fiscal year (FY) 2022, 200 Veterans received VAHH. So far in FY2023, over 700 Veterans have been served. Pre/post comparisons involving Veterans receiving VAHH show modest reductions in emergency room visits (727 vs. 664 visits) and inpatient admissions (227 vs. 192 admissions). Overall hospital lengths of stay have reduced more dramatically (2132 vs. 1390 total days). VAHH staff note close communication with Veterans’ primary care teams, and Veterans describe being highly satisfied with the program. Interest in VAHH is growing nationally, particularly as access to home health in many regions is limited. Early lessons from the VAHH pilot program could inform VA decisions about home health delivery and assist other sites in improving care for Veterans.

LINKING HEALTH ATTRIBUTES TO ACUTE-CARE USAGE IN SOUTH FLORIDA VETERANS, A PILOT SURVEY STUDY

Abstract “High-Need, High-Risk” (HNHR) Veteran patients are identified quarterly by the Department of Veterans Affairs (VA) as having the top 5% predicted probability of hospitalization or mortality. We fielded a pilot survey to 2,543 older “HNHR” Veterans receiving care at the Miami VA Medical Center between October 2017 and September 2018, where 634 replied; mean age 70.61, standard deviation, 8.98, racially/ethnically White (403, 61.24%), Black (240, 36.47%), Hispanic (537, 81.61%) and nineteen women (3%). The survey contained 42 self-reported questions covering physical, mental, and social determinants of health, and access/use of healthcare resources. Two measured prior 6-month acute-care utilization outcomes: emergency room visits (ERV) and inpatient hospital admissions (IHA). Logistic regression was used to find health attributes associated with both outcomes, and latent class analysis was used to group Veterans into clinically relevant latent classes, analyzing health attributes endorsed by each. We found that transportation access issues to receiving healthcare were associated with both outcomes (OR = 2.980, p = 0.014), underscoring the role of social determinants of health. Self-perceptions of general health (OR = 0.806, p = 0.04), and a Veteran attending the Miami VA frailty clinic (OR = 0.435, p < 0.001), were associated with ERV and IHA, respectively. We identified four latent classes distinctly grouping patients by endorsing 1) depression; 2) not having a caregiver and being unmarried; 3) functional issues, and 4) being homebound and receiving home healthcare. These latent classes will help better inform clinical recommendations and program development to better meet needs for “HNHR” Veterans.

Prior Diagnosis of Opioid Related Disorder is Associated with Higher Medical Resource Utilization Following Primary Hip Arthroscopy: A National Database Study

To compare adverse events, medical resource utilization, prescribing patterns, and revision surgery rates of patients with opioid-related disorders (ORDs) undergoing primary hip arthroscopy against a propensity-matched group with no opioid-related disorders (NORDs). The TriNetX database was queried between January 2015 and December 2020 using International Classification of Diseases, 10th Revision and Current Procedural Terminology codes to identify patients undergoing primary hip arthroscopy between ages 18 and 70 years. The ORD cohort was propensity matched in a 1:1 ratio to NORD patients based on age, sex, alcohol-related disorders, heart disease, hypertension, metabolic disorders, anxiety disorders, major depressive disorder, diabetes mellitus, and antidepressant prescriptions. Postoperative rates of adverse events and medical resources were compared within 90 days of procedure, prescriptions were compared within 1 year, and revision surgery was compared within 2 years. A total of 809 ORD patients were propensity matched in a 1:1 ratio to NORD patients. Postoperative adverse events were similar between groups (P= .693). Rates of revision arthroscopy were also similar for both ORD (9.3%) and NORD (8.0%) cohorts (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.83-1.66; P= .377). ORD patients received care from the emergency department, inpatient admission, outpatient visit, and physical therapy evaluations at higher rates. The ORD cohort received a greater amount of new opioid (OR, 2.66; 95% CI, 2.17-3.26; P < .0001) and antidepressant prescriptions (OR, 1.58; 95% CI, 1.26-1.97; P < .0001) compared to NORD patients within 1 year of surgery. ORD patients demonstrated similar rates of adverse events and revision surgery when compared to a propensity-matched group of NORD patients undergoing primary hip arthroscopy. However, ORD patients experienced increased rates of emergency department visits and hospitalizations and were prescribed higher rates of opioid and antidepressant prescriptions. Level III, cohort study.

Routine history and physical examinations prior to cataract surgery are not beneficial

ObjectiveTo determine the safety of a policy change eliminating the requirement for preoperative history and physical examination before cataract surgery. DesignA retrospective population-based study. MethodsBecause preoperative history and physical examination were no longer required in Alberta after April 1, 2017, a retrospective review of provincial health claims data was conducted to determine the safety of removing this requirement. Data from Albertans who underwent cataract surgery and had a preoperative medical examination between April 2014 and March 2017 were compared with data from those who underwent surgery between April 2017 and May 2020 without one. The primary outcome was adverse medical events, defined as an emergency room visit, inpatient admission, or death within 30 days of cataract surgery. ResultsA total of 236,046 cataract surgeries were performed over the study period. The likelihood of a postoperative emergency room visit was higher (odds ratio [OR] = 1.04; 95% CI, 1.01–1.08) in the preoperative examination group (n = 112,806 eyes), occurring in 4.8% of patients, compared with 4.7% in the no preoperative examination group (n = 123,240 eyes; p = 0.03). Inpatient admissions also were more likely to occur in the preoperative examination group (OR = 1.26; 95% CI, 1.18–1.34) at 1.8% in comparison with 1.5% in the no preoperative examination group (p < 0.0001). The death rate in both groups was 0.09% (p = 0.992). ConclusionsThe rate of postoperative emergency room visits and inpatient admissions within 30 days of cataract surgery was negligibly different, indicating that preoperative examinations, which have been traditionally performed to reduce postoperative morbidity and mortality, offer little value to patients.

Education, wealth, and survival after dementia diagnosis

AbstractBackgroundThe relationship between socio‐economic status (SES) and length of life after dementia diagnosis may vary by specific aspects of SES. Education and wealth, two widely used measures of SES, may extend life expectancy via greater efficiency of health investment and better access to care. However, according to the cognitive reserve hypothesis, education protects against dementia pathology and thus when dementia symptoms manifest, individuals with higher education have more advanced atrophy, likely shortening their post‐dementia life expectancy. This paper examined education and wealth disparities in 1) timing of dementia diagnosis, 2) length of life after diagnosis, and 3) use of healthcare after diagnosis as a potential mechanism through which education and wealth differentially influence survival.MethodData was extracted from the Health and Retirement Study (HRS) linked to Medicare claims. From claims we identified 2,377 individuals with incident dementia diagnosis between 2000 and 2016 and followed them for up to 18 years. Using Cox proportional hazard models, we estimated relationships between education, household wealth, and mortality, adjusting for demographics, comorbidity, function, and cognition at the time of dementia diagnosis. To test whether SES disparities were driven by healthcare utilization, we ran linear regressions on the number of emergency room (ER) visits, inpatient admissions, and office visits after diagnosis with the same set of predictors.ResultIndividuals with higher education and wealth exhibited less functional and cognitive impairment at dementia diagnosis. The protective effect of higher education on mortality was absorbed by controlling for wealth. In the fully adjusted model, ranking in the top quartile of wealth was associated with a 17% reduction in mortality risk (HR = 0.83, 95% CI: 0.72‐0.96), relative to the bottom quartile. Wealth was not associated with ER visits, hospitalization, or office visits.ConclusionMore intact function and cognition at incident diagnosis did not confer longer survival for the highly educated. In contrast, the most affluent experienced a lower mortality risk, which was unrelated to healthcare utilization. While more research is warranted to understand pathways, these disparities inform opportunities for achieving health equities among persons living with dementia, by targeting at those with limited financial resources.

Advancing Suicide Intervention Strategies for Teens (ASSIST): study protocol for a multisite randomised controlled trial

IntroductionBrief interventions that reduce suicide risk following youth’s experience with acute care due to suicidality are needed.Methods and analysisThe study will use a three-arm randomised controlled trial designed to test...

A Sticky Situation: Diagnosing Post-Transfusion Purpura in the Setting of Longstanding, Transfusion-Dependent AML

Background Post-transfusion purpura (PTP), a commonly underreported adverse transfusion event. It is defined as severe thrombocytopenia with related sequelae occurring 5-10 days of transfusion where both transfused and autologous platelets are destroyed. Low cell counts may be masked by other conditions (i.e. AML) and there is a paucity of literature on cases of PTP especially in concurrent pancytopenia. Swift diagnosis is critical for management. This case presents a unique opportunity to examine PTP in a patient with a complex hematopathologic malignancy history. Methods Relevant clinical data was obtained through examination of available medical records, concurrent ancillary diagnostic testing, and serological send-out testing was performed. Appropriate investigation and evaluation of repeated transfusion reactions with clinical symptomatology in accordance with available bio-vigilance surveillance guidelines aided in the diagnosis. Findings A 73-year-old female patient presented to the emergency department with acute, worsening fatigue, lethargy, pallor, and shortness of breath. She was found at home by emergency medical services with bright red blood covering her legs, originating from the rectum, several longstanding pressure ulcers, and an oxygen saturation in the 80s. The initial physical exam revealed a cachectic, ill-appearing woman who was tachypneic, wheezing, with new and old blood at anus, generalized weakness, fatigue, shortness of breath, cough, myalgias, and diffuse bruising of various sizes. There was no loss of consciousness or history of anticoagulant therapy. The patient had a complex medical history which included acute myeloid leukemia with concurrent chemotherapy complicated by longstanding, transfusion-dependent pancytopenia, lung adenocarcinoma status-post radiation therapy now in remission, congestive heart failure, chronic obstructive pulmonary disease on continuous home oxygen, chronic intermittent bilateral lower extremity rashes secondary to adult-onset Still's disease, and multiple visits to the emergency department, inpatient admissions, and numerous outpatient infusions for the management of pancytopenia. The patient's initial laboratory workup in the emergency room setting demonstrated clear, previously known, pancytopenia along with severe acidosis, marked anemia, and derangements of coagulation testing. With numerous visits to both the emergency department and outpatient infusion centers, the patient had previous transfusion reactions which ranged from mild allergic to repeating patterns of fulminant weakness, lethargy, and confusion relating to the timing of transfusions. With increasing skin manifestations of purpuric skin lesions, severely acute thrombocytopenia regardless of HLA matched or compatible platelet units, and results of send-out serology demonstrating 100% reactivity to all platelets and specific HPA antibodies, the diagnosis of post-transfusion purpura was made. Conclusion Despite this patient succumbing to diffuse hypoxic anemia and suffering a fatal cardiac dysrhythmia, the results of reference laboratory send-out serology revealed positivity in 100% of platelets crossmatched and the presence of antibodies to HLA Class I and HPA-2b, which satisfy the clinical and serologic criteria for post-transfusion purpura and represent a rare diagnostic finding.

Utilization of Pharmacologic and Non-Pharmacologic Therapies for Pain in Sickle Cell Disease: A Cross-Sectional Study

Background: The sickling deformity of red blood cells in sickle cell disease (SCD) results in multisystem sequelae, including severe, acute pain from vaso-occlusive crises (VOCs) and chronic pain from central sensitization. Pain is the main cause of poor quality of life and hospital admissions among patients with SCD. While opioid therapy is an important component of treatment for acute SCD pain, it can be complicated by side effects and toxicities. In contrast, chronic SCD pain is best managed with non-pharmacologic therapies. A multimodal, multidisciplinary approach to pain management that promotes non-pharmacologic therapies can improve the quality of care for patients with SCD by addressing biopsychosocial components of the pain experience and is recommended by the American Society of Hematology (ASH). This study examines current usage of pharmacologic and non-pharmacologic therapies among Adolescents and Young Adults (AYAs) with SCD receiving care at our institution. Methods: The electronic medical record and Sickle Cell Knowledgebase, a customized data visualization platform unique to our institution, were utilized to conduct a retrospective chart review of AYAs, ages 13-21 years of age, with SCD from 2016-2021. Data collected included demographic information, diagnosis of chronic pain, emergency department (ED) visits and inpatient admissions for VOCs, as well as pharmacologic and non-pharmacologic therapies utilized in the ED, inpatient setting, and, for patients with chronic pain, in the outpatient setting. Results: The cohort included 90 AYAs with SCD (73% were 13-17 years old). The most common SCD genotypes were HbSS (n=47, 52%) and HbSC (n=32, 36%). The majority were female (n=53, 49%), Black (n=85, 94%), and non-Hispanic (n=86, 96%). There were 95 ED visits for VOC, where the patient was subsequently discharged home, and 246 admissions for VOC during the study period. There was a high frequency of opioid interventions for VOCs during the 95 extracted ED visits (81.8% in 2016, 91.7% in 2021). During VOC admissions, there was consistent use of opioids in 100% of admissions from 2016-2021 with increasing utilization of patient-controlled analgesia (7.7% in 2016, 45.1% in 2021) and subanesthetic ketamine (0% in 2016, 18.3% in 2021) each year during the study period. Compared to pharmacologic measures, non-pharmacologic therapies (i.e., healing touch, massage, art therapy, child life, music therapy, occupational therapy, physical therapy, psychology) were less utilized during VOC admissions. While healing touch and child life therapy were ordered during approximately 85% of VOC admissions, they occurred &amp;lt;50% of the time. All other integrative therapies were ordered between 5-55% of admissions each year and occurred &amp;lt;50% of the time. There was no correlation between length of hospital stay and use of integrative therapies. Seven patients with a diagnosis of chronic pain were identified. All 7 received non-pharmacologic therapies in the outpatient setting, including cognitive behavioral therapy, guided imagery, and psychology consultation. Six received either a gabapentinoid, serotonin and norepinephrine reuptake inhibitor (SNRI), or tricyclic antidepressant (TCA). Conclusion: Per the ASH SCD guidelines, non-pharmacologic therapies are recommended for SCD-related pain. In our cohort, we found that non-pharmacologic therapies occurred in &amp;lt;50% of VOC admissions and were underutilized for SCD-related pain in AYAs when compared to pharmacologic therapies at our institution. Though we speculate that healing touch and child life were frequently ordered as a default within our admission order set, utilization rates were still low. To better understand barriers to non-pharmacologic therapies in SCD, we are conducting qualitative interviews of patients, caregivers, and healthcare providers using the Consolidated Framework for Implementation Research (CFIR) as a theoretical model. Understanding barriers to the use of non-pharmacologic therapies will be essential to maximizing their implementation and hence maximizing pain control, improving quality of life, and increasing self-efficacy.

535. Risk Factors for Seeking Medical Care Following Monoclonal Antibody Treatment For COVID-19

Abstract Background The FDA issued emergency use authorization for neutralizing monoclonal antibodies (mAb) for the treatment of mild-moderate coronavirus disease 2019 (COVID-19) in patients who were at high risk of disease progression. Methods In this case-control study, we assessed risk factors for patients with mild-moderate COVID-19 infection treated with mAb on the composite outcome of subsequent evaluation in the Emergency Department (ED) or inpatient admission through December 1, 2020, through May 30, 2022. Cases were patients who failed MAB and visited the ED or were hospitalized within four weeks of their MAB treatment; controls received MAB but did not visit the ED or were not hospitalized within four weeks of MAB treatment. Cases were matched to controls in 1:1 ratio for the patient age ± 5 years. and for the calendar month of positive COVID tests. Data were analyzed using Student’s t-test, the chi-squared test, the Mann-Whitney U test and logistic regression using SPSS v. 29.0. The study was approved by the Ascension IRB. Results Of 212 patients who received mAb treatment, the mean (SD) age was 61.3 (±18) years; 51.8 % (99) were female, and 84.8% (162) white. The mean body mass index of the cohort was 32.6 ± 8.5 kg/m2. Following mAb infusion, 106 cases had a positive composite outcome of interest. Patients with peptic ulcer disease (PUD) (64.4% vs 35.6%; p=0.029), asthma (72.7% vs 27.3%; p=0.024), and chronic lung diseases (12.5% vs 35.5%; p=0.001) were more likely to seek medical care in the ED or hospital post mAb infusion. Alcohol users were less likely to seek medical care following mAb infusion (41.7% vs 58.3%; p=0.013). The number of reported days of symptoms prior to mAb infusion were 5.81 days in cases versus 5.79 days in controls (p=0.98). There were no differences in sex, BMI, tobacco use or vaccinations rates between the two groups. In multivariable logistic regression, factors associated with seeking medical care post mAb infusion were Black race (OR 3.1; 95% CI 1.1-9.2), peptic ulcer disease (OR 3.3; 95% CI 1.1-9.7) and alcohol use at the time of mAb treatments (OR 0.5; 95% CI 0.3-0.97) Conclusion Independent risk factors for seeking medical care following mAb treatment for COVID-19 were Black race and peptic ulcer disease while alcohol users were less likely to seek medical care following the mAb infusion. Disclosures All Authors: No reported disclosures

511. Risk Factors for Seeking Medical Care Following Nirmatrelvir-Ritonavir (Paxlovid) Treatment For COVID-19

Abstract Background In December 2021, the FDA issued an emergency use authorization (EUA) for nirmatrelvir-ritonavir (Paxlovid). This was based on the randomized placebo-controlled trial data from the EPIC-HR study which showed that high-risk non-hospitalized patients given Paxlovid had an 88.9% reduction in the relative risk of progression to hospitalization or death by Day 28 in coronavirus disease 2019 (COVID-19). We aimed to study the risk factors for seeking medical care following Paxlovid treatment. Methods In this historical cohort study, we assessed risk factors for high-risk non-hospitalized patients treated with Paxlovid from January 1, 2022, to December 31, 2022, at outpatient facilities associated with Ascension St. John Hospital. Our outcome variable was the composite of subsequent evaluation in the Emergency Department (ED) or inpatient admission within four weeks of their Paxlovid treatment. Data were analyzed using SPSS v. 29.0. The study was approved by the IRB. Results Of 371 patients who received Paxlovid treatment, the mean (SD) age was 59.4 (±13.8) years; 63.9 % (237) were female, and 77.7% (282) white. The mean body mass index (BMI) of the cohort was 31.3 ± 7.8 kg/m2. The incidence of the composite event was 6.7% (25/371). The risk of the composite event was higher in patients with a history of myocardial infarction (MI) (28 % vs 9.3%), congestive heart failure (CHF) (12 % vs 2.3%), chronic lung diseases (CLD) (48 % vs 26.4%) and diabetes mellitus (DM) with complication (24% vs 4.1%), respectively. Alcohol users were less likely to seek medical care following Paxlovid (40 % vs 63.7%, respectively). There were no differences in BMI, tobacco use or vaccination rates between the groups. In multivariable logistic regression, factors associated with seeking medical care post-Paxlovid were female sex (OR 4.6; 95% CI 1.4-15.3; p= 0.013), alcohol use (OR 0.4; 95% CI 0.2-0.9; p= 0.039), MI (OR 4.0; 95% CI 1.4-11.8; p=0.011), DM with complications (OR 6.9; 95% CI 2.0-23.3; p= 0.002), CLD (OR=3.9, 95% CI 1.1-13.5; p=0.03), at the time of Paxlovid treatments. Conclusion Independent risk factors for seeking medical care following Paxlovid treatment for COVID-19 were MI, CHF, CLD, and DM with complications while alcohol users were less likely to seek medical care following the Paxlovid treatment. Disclosures All Authors: No reported disclosures

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use.

International Classification of Diseases, 10th revision Z codes capture social needs related to health care encounters and may identify elevated risk of acute care use. To examine associations between Z code assignment and subsequent acute care use and explore associations between social need category and acute care use. Retrospective cohort study. Adults continuously enrolled in a commercial or Medicare Advantage plan for ≥15 months (12-month baseline, 3-48 month follow-up). All-cause emergency department (ED) visits and inpatient admissions during study follow-up. There were 352,280 patients with any assigned Z codes and 704,560 sampled controls with no Z codes. Among patients with commercial plans, Z code assignment was associated with a 26% higher rate of ED visits [adjusted incidence rate ratio (aIRR) 1.26, 95% CI: 1.25-1.27] and 42% higher rate of inpatient admissions (aIRR 1.42, 95% CI: 1.39-1.44) during follow-up. Among patients with Medicare Advantage plans, Z code assignment was associated with 42% (aIRR 1.42, 95% CI: 1.40-1.43) and 28% (aIRR 1.28, 95% CI: 1.26-1.30) higher rates of ED visits and inpatient admissions, respectively. Within the Z code group, relative to community/social codes, socioeconomic Z codes were associated with higher rates of inpatient admissions (commercial: aIRR 1.10, 95% CI: 1.06-1.14; Medicare Advantage: aIRR 1.24, 95% CI 1.20-1.27), and environmental Z codes were associated with lower rates of both primary outcomes. Z code assignment was independently associated with higher subsequent emergency and inpatient utilization. Findings suggest Z codes' potential utility for risk prediction and efforts targeting avoidable utilization.

Association between social determinants of health and cancer treatment delay in an urban population.

167 Background: Delay in time to treatment initiation (TTI) has been shown to independently and adversely affect disease-specific mortality in patients with different cancers. Social Determinants of Health (SDoH) are increasingly recognized as significant contributors to patients’ disease management and health outcomes. Our academic center has developed and validated a 10-item SDoH screener that has been in place since 2018. We evaluated which self-reported social needs may be predictive of delayed TTI. Methods: This is a retrospective cohort study at an urban community-based academic center of patients diagnosed with breast, colorectal, endocrine and neuroendocrine, gastrointestinal, genitourinary, gynecologic, head and neck, hematologic, hepatobiliary, lung, and pancreatic cancer from August 2018 to September 2022. We identified patients who had completed an SDoH screening and had diagnosis and treatment data in the hospital’s cancer registry. Variables of interest included median household income (based on home zip code and US Census data), area deprivation index (ADI) (based on the Neighborhood Atlas from the University of Wisconsin), Charlson Comorbidity Index (CCI) score, marital status, smoking history, insurance status, tumor stage, and emergency department (ED) or inpatient admission 30 days before diagnosis. Factors associated with TTI delay, defined as TTI ≥ 45 days, were assessed using multivariable logistic regression. Results: Among 2,328 patients (66.6% female, 43.4% Hispanic, 35.7% Black, and 9.4% White), the median age was 65 (IQR, 56-73) and the median TTI was 25 days (IQR, 0-51 days). The multivariable models showed that patients with one or more self-reported unmet social needs experienced a statistically significant delay in TTI (odds ratio [OR], 1.68; 95% CI, 1.54-1.82). The disparities most strongly associated with delay were legal help, healthcare transportation, housing stability, and the need to provide care for others. Additionally, patients identified as non-Hispanic Black (OR, 1.44; 95% CI, 1.32-1.57) or Hispanic (OR, 1.47; 95% CI, 1.19-1.50) were more likely to have a delay compared to non-Hispanic White patients. A decreased likelihood for delayed TTI was found in those with ED (OR, 0.49; 95% CI, 0.44-0.54) or inpatient (OR, 0.54; 95% CI, 0.50-0.58) admission 30 days before diagnosis. Conclusions: Our data show that delays over 45 days are independently associated with unmet social needs. Additionally, ED or inpatient admissions within 30 days before diagnosis help increase care coordination and compliance, leading to improved TTI. These findings suggest that cancer patients who have unmet social needs are at higher risk of treatment delay and may benefit from interventions to mitigate needs, especially legal, transportation, and housing assistance.

Differences in personal characteristics and health outcomes between ambulatory and non-ambulatory adults with traumatic spinal cord injury

Objective To identify differences in personal characteristics, health outcomes, and hospital utilization as a function of ambulatory status among adults with chronic SCI. Design Prospective cohort study linked to state administrative billing data. Setting Population-based SCI Registry from the Southeastern United States. Participants 1,051 adults (>18 years old) with chronic (>1-year), traumatic SCI. Outcome Measures The self-report assessment (SRA) included demographic, injury and disability characteristics, health status, psychological and behavioral factors, and participation and quality of life (QOL) variables. We linked cases to administrative billing data to assess hospital utilization, including Emergency Department (ED) visits and inpatient (IP) admissions (through the ED and direct IP) in non-federal state hospitals within the year following the SRA. Results There were 706 ambulatory and 345 non-ambulatory participants. We found significant differences across all sets of factors and significant differences in hospital utilization metrics. Ambulatory adults had fewer ED visits (36% vs 44%), IP admissions through the ED (11% vs 25%) and IP only admissions (9% vs 19%) and spent fewer days in the hospital for both admissions through the ED (0.9 vs 4.6 days) and IP only admissions (0.7 vs 3.1 days). They also reported having fewer past year ED visits (44% vs 62%) and IP admissions (34% vs 52%). Conclusions We identified differences in personal characteristics, ED visits and IP admissions between ambulatory and non-ambulatory adults with SCI, providing a better understanding of the characteristics of those with SCI. The findings suggest the need for separate analyses based on ambulatory status when assessing long-term health outcomes including hospital utilization.

2051P E-PRO within comprehensive companion program for patients undergoing systemic cancer treatment to reduce emergency visits and inpatient admission in a Peruvian institution

2051P E-PRO within comprehensive companion program for patients undergoing systemic cancer treatment to reduce emergency visits and inpatient admission in a Peruvian institution

Clinical and economic impact of oncology-trained pharmacist integration in an ambulatory cancer clinic.

Outpatient oncology practice is a growing area of opportunity for pharmacists to provide clinical services and evidence-based care. This single-center, retrospective chart review analyzed the clinical and economic benefits of a board-certified oncology pharmacist after integration into the ambulatory oncology clinic setting. Primary outcomes were total cost avoidance for pharmacist interventions and impact on Centers for Medicare and Medicaid Services (CMS) OP-35 measures. Pharmacist interventions were characterized into distinct types which were then assigned a cost avoidance value. Cost avoidance was calculated per hour and then extrapolated to a yearly estimate based on a 40-h work week for one year for one full-time equivalent pharmacist. Data collection for the primary clinical outcome was performed by compiling provider-specific emergency department (ED) and inpatient admission rates for diagnoses specified in CMS OP-35 measures within 30 days after receiving outpatient chemotherapy. The rates for the data collection period were compared to the rates six months prior to pharmacist integration to assess pharmacist impact. In six months, 516 total interventions were made by the oncology pharmacist. The incidence of ED visits was 3.34% and 1.72% during the pre- and post-pharmacist intervention periods, respectively. The incidence of inpatient admissions was 2.43% and 0.34% pre- and post-pharmacist intervention, respectively. Total cost avoidance was estimated to be US$375,795 and when accounted for the median pharmacist salary at our institution, total cost savings was US$204,437. The presence of an oncology pharmacist specialist in the ambulatory cancer clinic provided clinical and economic benefits to the cancer clinic.

Ambient Temperature and Emergency Hospital Admissions in People Experiencing Homelessness: London, United Kingdom, 2011-2019.

Objectives. To assess the impacts of ambient temperature on hospitalizations of people experiencing homelessness. Methods. We used daily time-series regression analysis employing distributed lag nonlinear models of 148 177 emergency inpatient admissions with "no fixed abode" and 20 804 admissions with a diagnosis of homelessness in London, United Kingdom, in 2011 through 2019. Results. There was a significantly increased risk of hospitalization associated with high temperature; at 25°C versus the minimum morbidity temperature (MMT), relative risks were 1.359 (95% confidence interval [CI] = 1.216, 1.580) and 1.351 (95% CI = 1.039, 1.757) for admissions with "no fixed abode" and admissions with a homelessness diagnosis, respectively. Between 14.5% and 18.9% of admissions were attributable to temperatures above the MMT. No significant associations were observed with cold. Conclusions. There is an elevated risk of hospitalization associated with even moderately high temperatures in individuals experiencing homelessness. Risks are larger than those reported in the general population. Public Health Implications. Greater emphasis should be placed on addressing homeless vulnerabilities during hot weather rather than cold. Activation thresholds for interventions such as the Severe Weather Emergency Protocol (SWEP) could be better aligned with health risks. Given elevated risks at even moderate temperatures, our findings support prioritization of prevention-oriented measures, rather than crisis response, to address homelessness. (Am J Public Health. 2023;113(9):981-984. https://doi.org/10.2105/AJPH.2023.307351).

Key causes and long-term trends related to emergency department and inpatient hospital admissions of homeless persons in England

BackgroundIt is estimated that approximately 300,000 people are experiencing homelessness in England. The aim of this study was to evaluate key causes and long-term trends of emergency departments (EDs) and in hospital inpatient admissions of persons experiencing homelessness in England.MethodsED and hospital inpatient admissions data were obtained from Hospital Episode Statistics (HES) covering all National Health Service (NHS) England hospitals. Anyone identified or declared to be experiencing homelessness during the service usage are recorded in HES datasets. Data were extracted for the 10-year study period and compared to the general population, which includes all patients attending the ED or admitted to inpatient care in England.ResultsDrug- and alcohol-related causes contribute to the most frequent reasons for attendance and admissions of persons experiencing homelessness in the ED and inpatient respectively. A total of 30,406 ED attendances were recorded for persons experiencing homelessness in the year 2018/2019 (+ 44.9% rise vs 2009/10) of which injuries and poisoning respectively represented 21.8% and 17.9% of all persons experiencing homelessness presentations to the ED. Poisoning (including drug overdose) represented only 1.9% of all attendances by the general population during the same study year (rate ratio vs general populations 9.2 95% CI 9.0–9.4). High mortality rates were observed in relation to presentations attributed to drug- and alcohol-related causes. A total of 14,858 persons experiencing homelessness inpatient admissions were recorded in 2018/2019 (+ 68.6% vs 2009/2010). Psychoactive substance use constituted 12.7% of all admissions in 2018/2019 compared to 0.4% of in the general populations (rate ratio: 33.3, 95% CI: 31.9–34.7). There was a 44.3% rise in the number of admissions related to poisoning in the study period amongst persons experiencing homelessness in England (vs 14.2% in general population).ConclusionMarked disparities around primary causes of ED and inpatient admissions were identified between persons experiencing homelessness and the general population. There is a continued need for prevention measures to reduce the prevalence of drug and alcohol, injury and poisoning-related admissions to the ED, enhanced service provision at the community level, and multisector collaborations. These initiatives should maximise opportunities for early interventions and improve outcomes for persons experiencing homelessness, including increased accessibility of healthcare and mental health services, particularly in areas that demonstrate increasing ED and inpatient attendance rates over time.

Building an inpatient addiction medicine consult service in Sudbury, Canada: preliminary data and lessons learned in the era of COVID-19

ObjectiveThe goal of this study was to (1) Describe the patient population of a newly implemented addiction medicine consult service (AMCS); (2) Evaluate referrals to community-based addiction support services and acute health service use, over time; (3) Provide lessons learned.MethodsA retrospective observational analysis was conducted at Health Sciences North in Sudbury, Ontario, Canada, with a newly implemented AMCS from November 2018 and July 2021. Data were collected using the hospital’s electronic medical records. The outcomes measured included the number of emergency department visits, inpatient admissions, and re-visits over time. An interrupted time-series analysis was performed to measure the effect of AMCS implementation on acute health service use at Health Sciences North.ResultsA total of 833 unique patients were assessed through the AMCS. A total of 1,294 referrals were made to community-based addiction support services, with the highest proportion of referrals between August and October 2020. The post-intervention trend for ED visits, ED re-visits, ED length of stay, inpatient visits, re-visits, and inpatient length of stay did not significantly differ from the pre-intervention period.ConclusionImplementation of an AMCS provides a focused service for patients using with substance use disorders. The service resulted in a high referral rate to community-based addiction support services and limited changes in health service usage.