Encounter Data Research Articles

Cost Impact of Telehealth: A National Analysis of COVID-19 Data.

Background: The exponential growth in the use of telehealth during the pandemic underscored the need to quantify how telehealth impacts overall health care costs. While the pandemic inhibited access to in-person care for all Americans, access to care will remain challenging for some populations. Objective: We sought to assess the cost-benefit of telehealth by reviewing a data set of 1.4 million telehealth encounters across the United States performed between February and September 2020. Methods: A retrospective analysis used data from six large health systems and one state Medicaid agency. The economic model considered both direct and indirect costs. Results: Building upon a report published in 2021 by the Centers for Telehealth and eHealth Law, this article presents an analysis of the six states with the highest telehealth encounters within the data set. The study revealed significant cost savings. Telehealth was associated with a reduction in costs ranging from $445,000 to $33 million for Medicare and $155,000-$181 million for Medicaid, except for one metropolitan area. Cost savings were based on the most frequent diagnoses: behavioral health, cancer, heart disease, pulmonary conditions, and endocrine disorders. Limitations: The use of encounter data prohibited the analysis of a patient's longitudinal use of telehealth. Each encounter was treated as a unique observation. While the data set represented telehealth use across the nation, some states were over-represented while others were under-represented, based on available data. Finally, for the six health systems, data was restricted to the regions covered by the health system. As such, in some states, most encounters take place in metropolitan areas. Conclusion: Telehealth can generate significant cost savings, particularly within the Medicaid program, by increasing access to health care452244 services, especially for conditions directly impacted by provider shortages within geographic proximity to the patient.

Formation and Stability of the Propionitrile:Acetylene Co-Crystal Under Titan-Relevant Conditions.

Propionitrile (also known as ethyl cyanide, CH3CH2CN) and acetylene (C2H2) are two organic molecules that have been detected in Titan's atmosphere. Over time, they may interact with each other as they are transported to Titan's surface. We sought to determine if any reactions or associations such as co-crystal formation might occur between the two molecules. Using micro-Raman spectroscopy, we characterized band shifts, new bands, and morphological changes, which are characteristic of co-crystal formation. We found that the propionitrile:acetylene co-crystal forms within minutes at 90 K and is stable from 90 to 160 K. A cryogenic powder X-ray diffraction study confirms co-crystal formation at 90 K and indexes to a monoclinic unit cell, P21/a. A thermal expansion study between 90 and 140 K indicates that the co-crystal exhibits anisotropic thermal expansion, with a limited change in the b axis over the temperature range. This information gives insight into the preferred form of propionitrile:acetylene and the nature of these molecular interactions under Titan-relevant conditions. We discuss broader implications of the propionitrile:acetylene co-crystal's participation in forming Titan's geologic features such as the karstic, labyrinth terrain. Additionally, co-crystals that include acetylene as a coformer may provide a source of energy for acetylenotrophs to harness, should putative life exist on Titan's surface or in the subsurface. The Dragonfly mission to Titan will explore the nature and distribution of Titan's organics at the surface; thus, characterizing these organics in the laboratory before surface operations will inform the likely phases Dragonfly may encounter and support data analysis and interpretation of this exciting mission.

Pregnancy-Related Mortality in California Due to Obstetric Hemorrhage.

To identify underlying causes, contributing factors, and quality-improvement opportunities of pregnancy-related hemorrhage deaths. The California Pregnancy-Associated Mortality Review examined pregnancy-related hemorrhage deaths in California that occurred in 2014-2018. Data were abstracted from multiple sources (vital records, hospital encounter data, medical records, and coroner or autopsy reports). A multidisciplinary expert panel reviewed all case summaries. Data from reviews were aggregated to determine underlying causes of death, preventability, contributing factors, and quality-improvement opportunities at the patient, clinician, facility, and system levels. During the study period, there were 2,409,732 live births and 49 pregnancy-related hemorrhage deaths. Placenta accreta spectrum accounted for 16 (32.7%) of deaths; intra-abdominal bleeding and uterine atony each accounted for 10 deaths (20.4%). Compared with the California birth population, a significantly higher proportion of women who died were born in China (14.3% vs 3.9%); were 35 years of age or older (49.0% vs 21.9%); had two or more prior births (57.4% vs 29.1%); had cesarean deliveries (74.4% vs 31.8%); or delivered at hospitals with fewer than 1,200 births per year (33.3% vs 12.2%) (all P<.05). The committee determined that 63.3% of all hemorrhage deaths were highly preventable with substantial variation by cause. Clinician-, facility-, and system-level contributing factors were noted in 88.9% of cases and included delayed response or escalation (77.8%), delayed recognition (72.2%), and insufficient quantities of blood products used (52.8%). Corresponding quality-improvement opportunities included timely hemorrhage risk assessment; increased vigilance for identifying signs and symptoms of hemorrhage; escalation of care and aggressive management; preparation for hemorrhage complications and ongoing training for all hospitals, particularly low-resource facilities; and adherence to severe hemorrhage protocols. Obstetric hemorrhage remains a leading cause of pregnancy-related mortality and has multiple causes with various levels of preventability. Optimizing system-based approaches for hemorrhage preparedness, detection, and clinical management is critical to reduce preventable deaths from hemorrhage, especially among patients who do not respond to first-line treatment.

Outcomes for Dual-Eligible Beneficiaries With Dementia in Special Needs Plans and Other Medicare Advantage Plans

Alzheimer disease and related dementias (ADRD) are especially prevalent among Medicare-Medicaid dual-eligible beneficiaries-the clinical complexity of ADRD amplifies the challenges of managing chronic conditions and accessing care for dual-eligible beneficiaries, and the need to navigate the fragmented Medicare-Medicaid benefits adds to patients' burdens. Little is known about how enrollment in dual-eligible special needs plans (D-SNPs) that coordinate Medicare and Medicaid coverage is associated with health outcomes for dual-eligible beneficiaries with ADRD. To examine the associations between Medicare Advantage (MA) plan type and adverse medical events among dual-eligible beneficiaries with ADRD. This cross-sectional analysis used MA encounter data from 2016 to 2019. Participants included dual-eligible, community-dwelling Medicare beneficiaries aged 65 years and older with ADRD who enrolled in MA plans in 50 US states and Washington, DC. Data were analyzed from January to November 2024. Enrollment in non-D-SNP Medicare Advantage plans and D-SNPs. The exposure variable for additional analyses included enrollment in fully integrated special needs plans (FIDE SNPs). Preventable hospitalizations, 30-day all-cause readmissions, and avoidable emergency department (ED) visits. Analysis included a total of 121 145 patients in non-D-SNP plans with an enrollment of 173 662 patient-years (mean [SD] age, 81.8 [7.8] years; 122 565 female [70.6%]; 6078 Asian [3.5%], 34 150 Black [19.7%], 37 580 Hispanic [21.6%], 95 854 White [55.2%]) and 78 166 patients in D-SNP plans with an enrollment of 122 681 patient-years (mean [SD] age, 80.2 [8.0] years; 87 329 female [71.2%]; 10 530 Asian [8.6%], 33 280 Black [27.1%], 43 294 Hispanic [35.3%], 35 577 White [29.0%]). Dual-eligible enrollees with ADRD had a preventable hospitalization rate of 10.8% (95% CI, 10.3%-11.4%), a 30-day readmission rate of 22.3% (95% CI, 21.6%-22.9%), and an avoidable ED visit rate of 21.1% (95% CI, 20.3-21.9) in D-SNPs. These rates were 11.1% (95% CI, 10.7%-11.5%), 23.6% (95% CI, 22.9%-24.3%), and 20.8% (95% CI, 20.1%-21.6%) in non-D-SNP MA plans. There were no statistical differences in rates of preventable hospitalizations or avoidable ED visits between dual-eligible enrollees with ADRD in D-SNPs and those in non-D-SNP MA plans. Compared with non-D-SNPs, enrollees in FIDE SNPs had lower probabilities of preventable hospitalizations by 1.2 percentage points (95% CI, -2.7 to -0.2 percentage points) and 30-day readmissions by 7.2 percentage points (95% CI, -9.3 to -5.1 percentage points). Dual-eligible beneficiaries with ADRD enrolled in D-SNPs and non-D-SNP MA plans had similar rates of adverse events. Dual-eligible beneficiaries with ADRD may benefit from enrollment in more coordinated MA plans, such as FIDE SNPs, by lowering unnecessary hospitalizations.

Time-space characteristics of emergency medical service attendance and layperson naloxone administration during non-fatal opioid overdoses in Rhode Island: A retrospective, event-level analysis.

Time-space characteristics of emergency medical service attendance and layperson naloxone administration during non-fatal opioid overdoses in Rhode Island: A retrospective, event-level analysis.

Dealing with data gaps for TianQin with massive black hole binary signal

Space-borne gravitational wave detectors like TianQin might encounter data gaps due to factors like micro-meteoroid collisions or hardware failures. Such events will cause discontinuity in the data, presenting challenges to the data analysis for TianQin, especially for massive black hole binary mergers. Since the signal-to-noise ratio (SNR) accumulates in a non-linear way, a gap near the merger could lead to a significant loss of SNR. It could introduce bias in the estimate of noise properties, and the results of the parameter estimation. In this work, using simulated TianQin data with injected a massive black hole binary merger, we study the window function method, and for the first time, the inpainting method to cope with the data gap, and an iterative estimate scheme is designed to properly estimate the noise spectrum. We find that both methods can properly estimate noise and signal parameters. The easy-to-implement window function method can already perform well, except that it will sacrifice some SNR due to the adoption of the window. The inpainting method is slower, but it can minimize the impact of the data gap.

P-1710. Prescribing Patterns for Clostridioides difficile Treatment in Outpatient Setting Using the Collaboration to Harmonize Antimicrobial Registry Measures (CHARM)

Abstract Background Clostridioides difficile infection (CDI) is a form of infectious diarrhea associated with antibiotic use. In 2021, the IDSA released guidelines for treatment of CDI, which recommended fidaxomicin for 10 days as the first line treatment and vancomycin as an acceptable alternate. It is unclear to what extent prescribers have adopted this recommendation. This study aimed to examine patients’ antibiotic exposure before developing CDI and describe the prescribing patterns for CDI treatment in outpatient settings.Table 1:Frequency and Duration of Initial Clostridioides difficile Infection (CDI) Therapy Methods This observational study used the CHARM database, which contains outpatient encounter data extracted from the medical records of nine health systems. Patients with CDI were identified using ICD-10 codes and medications commonly used for CDI. The data period was between July 2019 and June 2023. The frequency and duration of antibiotics used for CDI treatment and the percentage of patients receiving subsequent therapy were estimated. Antibiotics prescribed within 180 days prior to a diagnosis of CDI visit were captured.Figure 1:Duration Distribution of Initial Clostridioides difficile Infection (CDI) Therapy Results A total of 551 patients with CDI were identified. Of those, 439 (80%) received vancomycin, 80 (15%) received fidaxomicin, and 52 (9%) received metronidazole. The average duration of therapy in days for vancomycin, fidaxomicin, and metronidazole was 12, 8, and 10, respectively (Table 1). The most common duration of therapy was 7-days for vancomycin (46%), fidaxomicin (41%), and metronidazole (50%) (Figure 1). After the initial treatment, 4% received a subsequent treatment within 3 weeks. Fluoroquinolone prescriptions had the highest prevalence of CDI (3.6 cases per 10,000 prescriptions). Of patients with an identified antibiotic 30 days prior to CDI, 38% had multiple courses of antibiotics. Conclusion Receiving multiple courses of antibiotics is associated with developing CDI. The majority of patients with CDI received vancomycin treatment (the alternative recommended therapy). The average duration of therapy was longer than recommended. Metronidazole use is still common. Disclosures Minji Sohn, PhD, Emergent BioSolutions, Inc.: Grant/Research Support

Health and Health Care Utilization Outcomes for Individuals With Traumatic Brain Injury: A 1-Year Longitudinal Study.

Traumatic brain injury (TBI) can result in new onset of comorbidities and limited studies suggest health care utilization following TBI may be high. Setting, Participants, Mean Measures, and Design: This study used 2018 and 2019 MarketScan Commercial Claims and Encounters data to examine differences in longitudinal health outcomes (health care utilization and new diagnoses) by various demographic factors (age, sex, U.S. region, intent/mechanism of injury, urbanicity, and insurance status) among individuals with and without a TBI in the year following an index health care encounter. Results show that within 1 year of the initial encounter, a higher percentage of patients with TBI versus without TBI had at least one outpatient visit (96.7% vs 86.1%), emergency department (ED) visit (28.5% vs 13.1%), or hospital admission (6.4% vs 2.6%). Both children (33.8% vs 23.4%) and adults (43.8% vs 31.4%) who sustained a TBI had a higher percentage of new diagnoses within 1 year compared to the non-TBI group. Additionally, individuals with a TBI had greater health care utilization across all types of health care settings (outpatient and inpatient), visits (ED visits and hospital admissions), and across all demographic factors (P <.001). These results may inform future research around the development of systems of care to improve longer-term outcomes in individuals with TBI.

Medicare Risk Arrangement and Use and Outcomes Among Physician Groups

Many physician groups are in 2-sided risk payment arrangements with Medicare Advantage plans (at-risk MA). Analysis of quality and health resource use under such arrangements may inform ongoing Medicare policy concerning payment and service delivery. To compare quality and efficiency measures under 2 payment models: at-risk MA and fee-for-service (FFS) MA. This cross-sectional study used Medicare encounter and enrollment data from 2016 to 2019 covering 17 physician groups, 15 488 physicians, and 35 health insurers to compare quality and health resource use for Medicare beneficiaries within the same physician groups. The data were analyzed between August 4 and October 30, 2024. Care delivered under at-risk MA and FFS MA payment arrangements by the same physicians and medical groups. Twenty quality and efficiency measures across 4 domains of patient care (hospital care, avoidance of the emergency department [ED], avoidance of disease-specific admissions, and outpatient care) were examined using logistic regression analysis. The overall sample comprised 5 278 717 person-years (37.7% at-risk MA and 62.3% FFS MA). The mean (SD) age of beneficiaries was 73.6 (9.2) years in the at-risk MA group (56.8% women) and 71.8 (10.4) years in the FFS MA group (57.4% women). For at-risk MA compared with FFS MA, inpatient admissions and 30-day readmissions per 1000 were 10.03 (95% CI, -10.61 to -9.44) and 1.95 (95% CI, -2.18 to -1.73) lower. ED use measures per 1000 ranged from 2.95 (95% CI, -3.28 to -2.63) lower for avoidable ED visits to 26.02 (95% CI, -26.92 to -25.12) lower for overall ED visits. Avoidance of disease-specific admissions per 1000 ranged from 0.24 (95% CI, -0.35 to -0.13) lower for composite diabetes-related admissions to 2.18 (95% CI, -2.43 to -1.94) lower for the composite of chronic disease-related admissions. High-risk drug use per 1000 was 14.26 (95% CI, -14.85 to -13.67) lower. Overall, compared with FFS MA, at-risk MA was associated with higher quality and efficiency in 18 of 20 measures after adjusting for differences in demographics, Hierarchical Condition Categories Risk Adjustment Factor scores, and other health characteristics. In this cross-sectional study, at-risk MA payment arrangements managed by physician groups were associated with higher quality and efficiency compared with FFS MA managed by the same groups. The population and methods used provide robust evidence that at-risk payment arrangements in MA may improve health care delivery for the MA population.

Success of the German Cystic Fibrosis Registry.

The German Cystic Fibrosis (CF) Registry (GCFR) is a national General Data Protection Regulation-compliant centralised database sponsored by the German Cystic Fibrosis Association (Mukoviszidose e.V.) and based on informed consent for each participating patient, ethical approval, and data protection votes. The aims of the GCFR are to optimise quality of care for CF at the centres, generate epidemiologic overviews, address research questions related to improved CF care, and inform caregivers, patients (aimed at patient empowerment), and health authorities and industry (aimed at care planning and pharmacovigilance). Established in 1995, the Registry has captured data on > 9600 individuals with a combined total of more than 140 000 annual assessments with an estimated coverage rate of > 90%. Patient data are collected after informed consent and confirmed diagnosis of CF, or a CFTR-related disorder, or a screening-positive inconclusive diagnosis of CF (i.e., CFSPID). The registry collects core, encounter, and annual health data. Data include demographics, anthropometrics, lung function, microbiology, CF-specific complications and chronic medications, hospitalisations, demand-oriented antibiotic therapies, and outcomes (death and transplants). Real world and pharmacovigilance studies have been published and additional research underway; there is a formal process for requesting access to the GCFR.

The Effect of Visual Aids on Reading Numeric Data Tables.

Data tables are one of the most common ways in which people encounter data. Although mostly built with text and numbers, data tables have a spatial layout and often exhibit visual elements meant to facilitate their reading. Surprisingly, there is an empirical knowledge gap on how people read tables and how different visual aids affect people's reading of tables. In this work, we seek to address this vacuum through a controlled study. We asked participants to repeatedly perform four different tasks with four table representation conditions (plain tables, tables with zebra striping, tables with cell background color encoding cell value, and tables with in-cell bars with lengths encoding cell value). We analyzed completion time, error rate, gaze-tracking data, mouse movement and participant preferences. We found that color and bar encodings help for finding maximum values. For a more complex task (comparison of proportional differences) color and bar helped less than zebra striping. We also characterize typical human behavior for the four tasks. These findings inform the design of tables and research directions for improving presentation of data in tabular form.

EXAMINING THE COMPLETENESS OF MEDICARE ADVANTAGE ENCOUNTER DATA FOR MEASURING POST-ACUTE CARE UTILIZATION

Abstract Given the rapid growth of Medicare Advantage (MA) program, the degree to which the newly-released MA encounter data reliably capture care utilization has serious implications for the ability to evaluate MA-related policies accurately and conduct rigorous academic research. However, little is known about the quality of MA encounter data outside of the acute care setting. We assessed how well the encounter data captured post-acute skilled nursing facility (SNF) and home health (HH) utilization overall and across MA contracts. We identified 2016-2019 Minimum Data Set (MDS) and the Outcome and Assessment Information Set (OASIS) admission assessments preceded by inpatient claims and calculated the proportion of assessments matched to a SNF or HH encounter record within 7 days of the assessment’s admission date. In 2019, there were 871,101 MDS assessments and 812,002 OASIS assessments following an MA inpatient stay. About 82% of MDS assessments could be matched to a SNF encounter records (up from 75% in 2016) while 63% of OASIS assessments matched to a HH encounter record (52% in 2016). There was substantial contract-level variation in match rates and a lack of correlation across services. Only 21% of contracts that had high SNF encounter completeness (match rates of 90% and above) also had high HH completeness, and 68% of contracts with high HH completeness also had high SNF completeness. Efforts to improve the quality of MA encounter data are needed as CMS prioritizes this data as a source for program oversight and payment.

HOME HEALTH USE BY OLDER ADULTS WITH DEMENTIA: COMPARING MEDICARE ADVANTAGE AND TRADITIONAL MEDICARE

Abstract Skilled home health care (HHC) is a critical service for community-dwelling older adults with dementia, but the majority of evidence about its use and quality is based on Traditional Medicare (TM) beneficiaries. Medicare Advantage (MA) plans - which now enroll over half of Medicare beneficiaries - have flexibility in financing and managing HHC, potentially affecting access and utilization. Given the growth in MA, increasing dementia prevalence, and delivery shifts to community settings, understanding how HHC use differs between MA and TM among persons with dementia is needed. This study compared HHC utilization in a nationally representative sample of persons with dementia in MA and TM. We used Medicare enrollment files linked to FY 2018-2019 MA encounter and TM claims data to identify persons 65+ years with dementia and at least one HHC visit in 2019. Our study sample included 316,407 persons with dementia (66% TM vs 34% MA). MA enrollees were more likely to identify as non-Hispanic, Black (13% vs. 10%), or Hispanic (12% vs. 6%) than TM. Greater proportion of TM beneficiaries were dual eligible (37% vs. 32%). The groups were similar in age, and 34% were male. Overall, MA enrollees were less likely to use HHC services than TM beneficiaries (26.2% vs 29.8%). This presentation will discuss variation in home health visit type/intensity and findings stratified by MA plan type, carriers, and geographic distribution. We will share novel approaches and best practices for measuring HHC utilization among people with dementia using newly available MA encounter data.

Influenza vaccine effectiveness against hospitalizations and emergency department or urgent care encounters for children, adolescents, and adults during the 2023-2024 season, United States.

The 2023-2024 influenza season had predominant influenza A(H1N1)pdm09 virus activity, but A(H3N2) and B viruses co-circulated. Seasonal influenza vaccine strains were well-matched to these viruses. Using health care encounters data from health systems in 8 states, we evaluated influenza vaccine effectiveness (VE) against influenza-associated medical encounters from October 2023-April 2024. Using a test-negative design, we compared the odds of vaccination between patients with an acute respiratory illness (ARI) who tested positive (cases) versus negative (controls) for influenza by molecular assay, adjusting for confounders. VE was stratified by age group, influenza type (overall, influenza A, influenza B), and care setting (hospitalization, emergency department or urgent care [ED/UC] encounter). Overall, 74,000 encounters in children and adolescents aged 6 months - 17 years (3,479 hospitalizations, 70,521 ED/UC encounters) and 267,606 in adults aged ≥18 years (66,828 hospitalizations, 200,778 ED/UC encounters) were included. Across care settings, among children and adolescents 15% (2,758/17,833) of cases versus 32% (18,240/56,167) of controls had received vaccination. Among adults, 25% (11,632/46,614) of cases versus 44% (97,811/220,992) of controls across care settings had received vaccination. VE was 58% (95% confidence interval [95% CI]: 44-69%) against hospitalization and 58% (95% CI: 56-60%) against ED/UC encounters for children and adolescents, and 39% (95% CI: 35-43) against hospitalization and 47% (95% CI: 46-49%) against ED/UC encounters for adults. Across age groups, VE was higher against influenza B than influenza A. Influenza vaccines provided protection against influenza-associated illness across health care settings and age groups during the 2023-2024 influenza season.

Lack Of Persistent Coding In Traditional Medicare May Widen The Risk-Score Gap With Medicare Advantage.

Payments to Medicare Advantage (MA) plans are adjusted by a risk-score model that is calibrated on diagnostic and demographic data from traditional Medicare beneficiaries and then applied to MA beneficiaries. If MA plans capture more diagnostic codes than traditional Medicare, they receive payment that is higher than the amount that would be spent in traditional Medicare. Although most previous research has focused on the coding practices of MA plans, less attention has been paid to the completeness of coding in traditional Medicare. We analyzed 2017-19 traditional Medicare claims data and MA encounter data to compare the persistence of diagnostic coding for sixteen chronic conditions. Our primary analysis found that the lack of persistent coding of these conditions in traditional Medicare accounted for 2.85percentage points, or 22.3percent, of the 2020 traditional Medicare/MA risk-score gap, translating to $8.1billion in Medicare spending. In our most conservative sensitivity analysis, this discrepancy accounted for 9.8percent of the total gap, although this was likely an underestimate, as it excluded acute conditions and incident chronic conditions. To resolve this discrepancy, a comprehensive approach addressing coding practices in both MA and traditional Medicare may be required.

Abstract 4136805: Type 2 Myocardial Infarction Patients Have Significantly More Days Not at Home

Background: A Type 2 (T2) myocardial infarction (MI) occurs “secondary to ischemia due to either increased oxygen demand or decreased supply,” while a Type 1 MI (T1) is atherothrombotic. Treatment includes correction of the underlying cause and not catheterization. The current study's aim is to assess the patient-centered outcome of days not at home (DNAH) within a year of discharge among older adults hospitalized with T1 and T2 MI, and to evaluate the distribution of non-home days. Methods: Data for this analysis came from a prospective cohort study of adults ≥75 years old hospitalized with MI at 94 U.S. hospitals and linked to Medicare claims and encounter data. MI type was adjudicated according to the Fourth Universal Definition of MI. Patient characteristics were identified via chart review or self-report. DNAH was defined as the number of days dead or in a hospital, skilled nursing facility (SNF), rehab facility, or hospice. Multivariable-adjusted negative binomial regression was used to evaluate the association between MI type and DNAH in the year after discharge. Results: Of the 375 participants evaluated in this interim analysis, 264 (70.4%) had T1 MI and 111 (29.6%) had T2 MI. There was no difference in distribution of age, gender, or race. T2 patients were more likely to have heart failure (HF), coronary artery disease (CAD), COPD, and arrythmias. Patients with T2 MI had a median [interquartile range] of 5 [0-71] DNAH in the year after discharge, compared with 2 [0-10] DNAH among patients with T1 MI (p = 0.008). After adjusting for age and comorbidities, T2 patients had 137% more DNAH (IRR = 2.37, 95% CI = 1.43, 3.94, p &lt; 0.001) than T1 patients. The number of days dead or in SNF was significantly higher among patients with T2 MI compared with T1 MI, whereas the association between MI type and increase in days readmitted was borderline (p = 0.06). In the multivariable model, age, HF, and CAD were significantly associated with more DNAH, but COPD and arrhythmias were not. Conclusion: Our findings demonstrate that older patients with T2 MI have more days not at home, attributable to death, SNF stays, and to a lesser extent, rehospitalization. Interestingly, accounting for comorbidities did not significantly attenuate this association. Further studies are needed to develop guidelines for medical teams, including evaluating how receipt of cardiac interventions impacts home days in older patients with T1 and T2 MI.

Abstract 4137587: Need for Testing Standardization and Improved Treatment of Elevated Lipoprotein(a) at a Large Urban Academic Medical Center

Background: Lipoprotein(a) [Lp(a)] is causally linked to ASCVD events and aortic stenosis. Some guidelines now recommend screening of Lp(a) at least once in an adult’s lifetime. Currently, there is inconsistency in measurement modality (mg/dL vs. nmol/L), but most guidelines recommending testing in nmol/L due to less variability and improved standardization. We sought to determine the Lp(a) measurement practices, including testing modality and downstream interventions, at a large academic medical institution. Methods: We evaluated all patient encounter data at UT Southwestern Medical Center (UTSW) between January 1, 2017 to December 31, 2021 for any Lp(a) measurement. High Lp(a) was defined as &gt;50mg/dL or &gt;125 nmol/L. Aggregate data were used to summarize patient demographics, relevant ASCVD co-morbidities, and lipid lowering prescriptions. Chart-review was conducted on patients with high Lp(a) to assess referrals to specialty clinics. Results: From 2017 to 2021, there were 1,065 Lp(a) measurements among 938 patients, representing fewer than 0.1% of all patients with labs at UTSW. Most were ordered by cardiologists (71%). Lp(a) tests ordered by cardiologists increased 69% annually but remained stagnant for other specialties (figure 1, lines). Median Lp(a) levels across all tests were 17mg/dL and 43nmol/L. Lp(a) was high in 30% of all initial tests. A higher proportion of tests ordered in 2021 by cardiologists (84%) were in nmol/L, the recommended standard, compared with other specialties (55%) (figure 1, bars). Patients with high Lp(a) found by a non-cardiologist were infrequently referred to cardiology (16%), and 53% of patients with high Lp(a) were prescribed lipid lowering therapy within 3 months. Conclusion: Lp(a) testing at a major academic medical center was rare and only marginally increased during the 5-year study period. Measurement frequency and assay varied widely between specialties, and there were potential opportunities for downstream interventions. In addition to improving awareness of Lp(a), there is an opportunity to standardize practice patterns regarding its measurement and implications.

Leveraging the Electronic Health Record to Measure Resident Clinical Experiences and Identify Training Gaps: Development and Usability Study.

Competence-based medical education requires robust data to link competence with clinical experiences. The SARS-CoV-2 (COVID-19) pandemic abruptly altered the standard trajectory of clinical exposure in medical training programs. Residency program directors were tasked with identifying and addressing the resultant gaps in each trainee's experiences using existing tools. This study aims to demonstrate a feasible and efficient method to capture electronic health record (EHR) data that measure the volume and variety of pediatric resident clinical experiences from a continuity clinic; generate individual-, class-, and graduate-level benchmark data; and create a visualization for learners to quickly identify gaps in clinical experiences. This pilot was conducted in a large, urban pediatric residency program from 2016 to 2022. Through consensus, 5 pediatric faculty identified diagnostic groups that pediatric residents should see to be competent in outpatient pediatrics. Information technology consultants used International Classification of Diseases, Tenth Revision (ICD-10) codes corresponding with each diagnostic group to extract EHR patient encounter data as an indicator of exposure to the specific diagnosis. The frequency (volume) and diagnosis types (variety) seen by active residents (classes of 2020-2022) were compared with class and graduated resident (classes of 2016-2019) averages. These data were converted to percentages and translated to a radar chart visualization for residents to quickly compare their current clinical experiences with peers and graduates. Residents were surveyed on the use of these data and the visualization to identify training gaps. Patient encounter data about clinical experiences for 102 residents (N=52 graduates) were extracted. Active residents (n=50) received data reports with radar graphs biannually: 3 for the classes of 2020 and 2021 and 2 for the class of 2022. Radar charts distinctly demonstrated gaps in diagnoses exposure compared with classmates and graduates. Residents found the visualization useful in setting clinical and learning goals. This pilot describes an innovative method of capturing and presenting data about resident clinical experiences, compared with peer and graduate benchmarks, to identify learning gaps that may result from disruptions or modifications in medical training. This methodology can be aggregated across specialties and institutions and potentially inform competence-based medical education.

Financial burden within first year of diagnosis for privately-insured patients with early-onset breast or colorectal cancer.

9 Background: Rising incidence of early-onset (E-O) cancers has been observed globally. E-O breast cancer (BC) are patients (pts) diagnosed ages 18 to 44 and E-O colorectal cancer (CRC) are aged 18 to 49. Because many E-O cancers are among pts who do not meet screening eligibility criteria by age, they are often diagnosed at advanced stage, which is also more expensive to treat. Younger pts may also have lower incomes and fewer assets, increasing risk of financial burden for pts with E-O cancers. We estimated the financial burden for pts and private payors for E-O BC and CRC, compared to non-elderly pts with BC and CRC diagnosed between the age of 45 to 64 and 50 to 64 (older-onset), respectively. Methods: We applied a claims-based algorithm to identify pts with incident BC and CRC diagnosed between 2014 and 2021 from MarketScan Commercial Claims and Encounters Data and required 12-month continuous enrollment before and after the index diagnosis for completeness of claims. Financial burden was quantified as total and out-of-pocket (OOP) payments, calculated as the sum of deductibles, copayments, and coinsurance. We used generalized linear models and quantile regressions to compare differences in mean and median costs, respectively, between pts with E-O vs. older onset cancer, adjusting for comorbidity, region, insurance plan type, sex (for CRC) and year. Results: Study cohort included 58,419 pts with BC and 11,251 pts with CRC. The proportion of E-O increased from 15% in 2014 to 17% in 2022 (Ptrend&lt;0.01) in BC and from 23% to 30% (Ptrend&lt;0.01) in CRC. Higher percentage of E-O pts were enrolled in high-deductible plans (BC: 25% v22%; CRC: 24% vs. 21%) and received systemic therapy (BC: 61% v 49%; CRC: 57% vs. 43%). Higher percent of surgery (93% v 89%) was observed in E-O BC and radiation (21% v 16%) in E-O CRC. Pts with E-O BC and CRC had significantly higher adjusted mean and median total and OOP payments (Table). Conclusions: E-O BC and CRC result in substantial costs to payors and moderately higher OOP payments. OOP maximums in private insurance may offer some financial protection for pts. E-O Older onset Difference 95% CIBC: BC: Mean total pay $182,770 $128,640 $54,130 $50445, $57817 Median total pay 143,351 93,317 50,034 47691, 52377 Mean OOP 6,014 5,063 951 817, 1085 Median OOP 5,142 4,258 884 791, 978 CRC: Mean total pay $153,446 $123,449 $29,998 $24244, $35752 Median total pay 119,747 89,340 30,406 25216, 35597 Mean OOP 5,429 4,791 638 428, 848 Median OOP 4,452 4,015 437 266, 607

البرمجة الضبابية وتحسين أداء الخوارزميات في بيئة متعددة المتغيرات الرتيبة

In many situations of daily life, when we start statistical analysis, we encounter data that we suffer from inaccuracy in its measurement, either due to observation or measurement errors or the lack of appropriate conditions for collecting this data, such as failure times of machines, equipment, electrical devices, medical, engineering and economic data. In many medical studies, the researcher may have a strong conviction that the regression function used to describe the relationship between two variables has a certain form or formula that can be characterized by certain ordering restrictions such as monotonicity; monotonic regression has important applications in statistics, operations research, and signal processing, and these applications are often characterized by a very large value of n. For such large-scale problems, it is of great practical importance to develop algorithms whose complexity does not increase rapidly with increasing n. It is a nonparametric regression technique that preserves order. In this thesis, the proposed fuzzy autoregressive monotonic method, fuzzy autoregressive monotonic least squares (FILSR), fuzzy autoregressive M estimator (FIM), and fuzzy autoregressive maximum likelihood estimator (FIML) were proposed. The best method for estimating the autoregressive function is the fuzzy autoregressive maximum likelihood method with a mean square error of (0.51455).