First Year Of Care Research Articles

The Use of Precision Epigenetic Methods for the Diagnosis and Care of Stable Coronary Heart Disease Reduces Healthcare Costs.

The cost of secondary prevention of coronary heart disease (CHD) is continuing to increase, with a substantial portion of this acceleration being driven by the expense of confirmatory diagnostic testing. Conceivably, newly developed precision epigenetic technologies could drive down these costs. However, at the current time, their impact on overall expense for CHD care is poorly understood. We hypothesized that the use of a newly developed, highly sensitive, and specific epigenetic test, PrecisionCHD, could decrease the costs of secondary prevention. To test this hypothesis, we constructed a budget impact analysis using a cost calculation model that examined the effects of substituting PrecisionCHD for conventional CHD diagnostic tests on the expenses of the initial evaluation and first year of care of stable CHD using a 1-year time horizon with no discounting. The model projected that for a commercial insurer with onemillion members, full adoption of PrecisionCHD as the primary method of initial CHD assessment would save approximately $113.6million dollars in the initial year. These analyses support the use of precision epigenetic methods as part of the initial diagnosis and care of stable CHD and can meaningfully reduce cost. Real-world pilots to test the reliability of these analyses are indicated.

Improving diabetes outcomes using an intensive structured education programme during first year of care after diagnosis

Improving diabetes outcomes using an intensive structured education programme during first year of care after diagnosis

Racial/ethnic disparities in HIV care outcomes among insured patients at a large urban sexual health clinic.

Prior studies demonstrate that non-White patients are less likely to achieve human immunodeficiency virus (HIV) suppression compared to White patients due to lack of health insurance. This study aims to determine whether racial disparities in the HIV care cascade persist among a cohort of privately and publicly insured patients. This retrospective analysis evaluated HIV care outcomes during the first year of care. Eligible patients were aged 18-65 years, treatment-naïve, and seen between 2016 and 2019. Demographic and clinical variables were extracted from the medical record. Differences in the proportion of patients achieving each HIV care cascade stage by race were evaluated using unadjusted chi-square testing. Risk factors for viral non-suppression at 52 weeks were analyzed using multivariate logistic regression. We included 285 patients; ninety-nine were White, 101 were Black, and 85 identified as Hispanic/LatinX ethnicity. Significant differences in retention in care for Hispanic/LatinX patients (odds ratio (OR): 0.214, 95% confidence interval (CI): 0.067-0.676) and viral suppression for both Black (OR: 0.348, 95% CI: 0.178, 0.682) and Hispanic/LatinX patients (OR: 0.392, 95% CI: 0.195, 0.791) compared to White patients were observed. In multivariate analyses, Black patients were less likely to achieve viral suppression compared to White patients (OR: 0.464, 95% CI: 0.236, 0.902). This study showed that non-White patients were less likely to achieve viral suppression after 1 year despite insurance and suggests that other unmeasured factors may disproportionately affect viral suppression in these patients. Interventions to identify and address these factors are needed to improve HIV care outcomes for non-White populations.

Secondary data analysis of social care records to examine theprovision of mental health support for young people in care.

Young people in care are much more likely to experience mental health difficulties than the general population, yet little is known about the provision of mental health support for this group in the United Kingdom. Using routinely collected social care data, we explored the provision of mental health support for 112 young people in care in the UK. We identified young people experiencing elevated internalising or externalising difficulties in their first year in care (based on strengths and difficulties questionnaire scores) and extracted data on mental health referrals and provision. We generated descriptive statistics relating to provision of mental health support and used regressions to examine predictors of mental health provision, and associations between support and mental health outcomes one and 2years later. Eighty-one percent of the children (n=79) were referred to mental health services in their first year of being in care. Referrals were usually for emotional or conduct problems. Those with higher externalising symptoms were more likely to be referred than those with higher internalising symptoms (OR=1.2, (95% confidence interval (CI): 1.01, 1.38)). Females were more likely to access support than males (OR=3.82 (95% CI: 1.2, 13.3)). Sixty-eight percent of children (n=66) accessed mental health services in their first year of being in care. Of those who accessed services, support ended prematurely for 29 (44%) of them, often due to placement instability or disengagement. Accessing support in the first year of care was not associated with changes in mental health 1year (OR: 2.14 (95% CI: 0.62,7.29)), or 2years after entering care (OR: 0.72-8.57, (95% CI: 0.72, 8.57)), although methodological limitations are noted. Mental health difficulties for children in care are recognised quickly, but mental health support may be difficult to access, with issues evident in retention and engagement.

Examination of risk factors for discontinuation of follow-up care in patients with head and neck cancer.

Little research has examined discontinuation of follow-up care in patients with head and neck cancer. This exploratory study sought to examine key demographic, disease, and behavioral factors as possible correlates of discontinuation (N=512). Cross-sectional study examined correlates of discontinuation of follow-up care within 1 year. The primary outcome was defined as a disease-free survivor not returning to cancer clinic for two consecutive follow-up appointments within the first year of care and not reentering oncologic care at any point thereafter. Demographic, disease, and behavioral factors were examined using multivariable logistic regression. One hundred twenty-six (24.6%) patients discontinued by 12-month follow-up. Being unmarried (OR=1.28, 95% CI=1.01-1.63, p=0.041) and having elevated depressive symptomatology (OR=1.04, 95% CI=1.01-1.07, p=0.034) were significantly associated with discontinuation. Receipt of a single (vs. multimodal) treatment approached significance (OR=1.71, 95% CI=0.96-3.07, p=0.071). Approximately one quarter of patients disengaged from important follow-up care within 1 year. Lack of social support, depressive symptomatology, and single treatment modality may be important correlates of discontinuation of care in patients with head and neck cancer. Additional studies of this outcome are needed. Improved understanding of correlates associated with discontinuation could facilitate the identification of at-risk patients and further development of interventions to keep patients engaged at a crucial time in the survivorship care trajectory.

Children's and young People's diabetes services: What works well and what doesn't?

ObjectivesThe first year of care, post diagnosis, is pivotal for children and young people diagnosed with type 1 diabetes. This study evaluated a paediatric type 1 diabetes intervention, the ‘First Year of Care’, designed to maximise the care that newly diagnosed children and young people received. Study designAn observational mixed methods approach, underpinned by the Influencer Framework. MethodsA purposeful, non-probability sample of children and young people with type 1 diabetes and their families, and healthcare professionals were invited to take part. Data were collected through medical records of thirty-two newly diagnosed children and young people, plus thirty seven semi-structured interviews and exposure to six concurrent sources of influence through a questionnaire. ResultsFor many participants, HbA1c levels were within the optimal range by the time of their first clinic visit post-diagnosis and continued to stay within this range throughout the first year of care. Healthcare professionals prioritised the ‘First Year of Care’ intervention. Positive practices included: a cohesive and collaborative approach; patient-centred care; latest health technology and embedded structured education. Unusually, different multidisciplinary team members were located in one place.Data indicated statistically significant differences in total sources of influence score (t [35] = 2.331, p = 0.026); healthcare professionals’ scores were higher compared to children. This suggests that children and young people have less social capital to self-manage their diabetes effectively. Greater encouragement and assistance from healthcare professionals and social networks may be needed. ConclusionsThis paper identifies contemporary issues in practice and highlights the strengths and challenges for a paediatric diabetes intervention. The findings confirm the potential of layered approaches to behaviour change in managing type 1 diabetes across multiple domains of influence. Our study strongly suggests enhancing social motivation among children, young people and families to support successful long-term engagement in a paediatric diabetes intervention. Findings demonstrate healthcare professionals are key in delivering the intervention, along with opportunities to improve patient care, experience and outcomes.

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic.

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6months (aOR = 0.866, p = 0.038) and 12months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6months (aOR = 1.232, p = 0.037) and 12months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

Immunomodulatory Medication Use in Newly Diagnosed Youth With Systemic Lupus Erythematosus.

To examine glucocorticoid-sparing immunomodulatory medication use in youth with systemic lupus erythematosus (SLE) during their first year of care. We conducted a retrospective cohort study using administrative claims for 2000 to 2013 from Clinformatics DataMart for youth ages 10-24 years with an incident diagnosis of SLE (≥3 International Classification of Diseases, Ninth Revision codes for SLE [710.0], each >30 days apart). We determined the proportion of subjects filling a prescription for immunomodulatory medications within 12 months of the first SLE code (index date). We used multivariable regression to examine associations between demographic/disease factors and time to prescription fill in the first year, and also between prescription fill at any time after the index date. We identified 532 youth with an incident SLE diagnosis, of which 413 (78%) had a glucocorticoid-sparing immunomodulatory prescription fill in the first year. Prescriptions for hydroxychloroquine and immunosuppressants were filled in the first year by 366 youth (69%) and by 182 (34%), respectively. Those with adult-onset (versus childhood-onset) disease were less likely to fill animmunomodulatorymedication by 12 months. No other statistically significant associations were found, although there was increasing likelihood of immunomodulatory medication fills with each subsequent calendar year. Among youth with newly diagnosed SLE, hydroxychloroquine use is prevalent although not universal, and prescription immunosuppressant use is notably low during the first year of care. Further research is needed to identify factors contributing to suboptimal immunomodulatory medication use during the first year of care.

Cost‐effectiveness of prenatal screening methods for congenital heart defects in pregnancies conceived by in‐vitro fertilization

To determine if a policy of universal fetal echocardiography (echo) in pregnancies conceived by in-vitro fertilization (IVF) is cost-effective as a screening strategy for congenital heart defects (CHDs) and to examine the cost-effectiveness of various other CHD screening strategies in IVF pregnancies. A decision-analysis model was designed from a societal perspective with respect to the obstetric patient, to compare the cost-effectiveness of three screening strategies: (1) anatomic ultrasound (US): selective fetal echo following abnormal cardiac findings on detailed anatomic survey; (2) intracytoplasmic sperm injection (ICSI) only: fetal echo for all pregnancies following IVF with ICSI; (3) all IVF: fetal echo for all IVF pregnancies. The model initiated at conception and had a time horizon of 1 year post-delivery. The sensitivities and specificities for each strategy, the probabilities of major and minor CHDs and all other clinical estimates were derived from the literature. Costs, including imaging, consults, surgeries and caregiver productivity losses, were derived from the literature and Medicare databases, and are expressed in USA dollars ($). Effectiveness was quantified as quality-adjusted life years (QALYs), based on how the strategies would affect the quality of life of the obstetric patient. Secondary effectiveness was quantified as number of cases of CHD and, specifically, cases of major CHD, detected. The average base-case cost of each strategy was as follows: anatomic US, $8119; ICSI only, $8408; and all IVF, $8560. The effectiveness of each strategy was as follows: anatomic US, 1.74487 QALYs; ICSI only, 1.74497 QALYs; and all IVF, 1.74499 QALYs. The ICSI-only strategy had an incremental cost-effectiveness ratio (ICER) of $2 840 494 per additional QALY gained when compared to the anatomic-US strategy, and the all-IVF strategy had an ICER of $5 692 457 per additional QALY when compared with the ICSI-only strategy. Both ICERs exceeded considerably the standard willingness-to-pay threshold of $50 000-$100 000 per QALY. In a secondary analysis, the ICSI-only strategy had an ICER of $527 562 per additional case of major CHD detected when compared to the anatomic-US strategy. All IVF had an ICER of $790 510 per case of major CHD detected when compared with ICSI only. It was determined that it would cost society five times more to detect one additional major CHD through intensive screening of all IVF pregnancies than it would cost to pay for the neonate's first year of care. The most cost-effective method of screening for CHDs in pregnancies following IVF, either with or without ICSI, is to perform a fetal echo only when abnormal cardiac findings are noted on the detailed anatomy scan. Performing routine fetal echo for all IVF pregnancies is not cost-effective. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study.

IntroductionPresence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics.MethodsThe study sample is a post-9–11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012–2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access.ResultsThe proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women).ConclusionNatural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

Évaluation clinique des pratiques intégratives dans les troubles du spectre autistique (EPIGRAM) : méthodologie, population à l’inclusion et satisfaction des familles à 12 mois

BackgroundIntegrative care practices (ICPs) in the management of autism spectrum disorders (ASDs) do not currently receive sufficient rigorous evaluation. Moreover, they lack formalisation despite their important place in clinical practice, particularly in France, where they are implemented in day care hospital structures. We present here the methodology of the EPIGRAM study financed by the French General Directorate of Healthcare Organisations (PREPS 2013), the profile of the inclusive population (M0), and the experience of families after 12 months of care. MethodIn order to homogenise practices, a manual has been formalised following the methodology of the clinical pathway and the recommendations of the High Authority of health. We then conducted an open, multi-centre, observational study in a natural environment in routine care evaluating ICPs in ASDs for children aged 3 to 6 years. The main inclusion criteria were the diagnosis (typical or atypical autism, according to the ICD10) and the duration of care (2 to 4 half-days per week) during the first year of care. The children were clinically assessed using several instruments including the PEP-3 (Psychoeducational Profile-3) and the CARS (Children Autism Rating Scale). In order to maintain a blind assessment for the main variable, randomly assigned videos of the PEP-3 were rated by two independent psychologists. A questionnaire, completed separately by the families and the professionals at inclusion and at one year, complemented the study. ResultsWe included 89 children demonstrated to have severe autism through the CARS (mean=44; SD=6.51) and moderate autism through he PEP-3 maladaptive behaviour category (CAT MB) (mean=30; SD=29.89). The children were all diagnosed before the age of 3 years 6 months. Most of the children had severe language impairments. With PEP-3, the impairment is more pronounced in gross motor skills and characteristic verbal behaviours. Thirty percent of the families had a low socioeconomic status and 56 % were first generation immigrants. Seventy-seven percent of the children were enrolled in kindergarten with school life support. Children of immigrant parents have more severe autism (CARS : mean=45.8 (±6.51) vs. 41.2 (±5.58), t-test, P=0.001) in addition to a more marked cognitive deficit (CVP : median=24.5 [min–max: 9.75–45.5] vs. 52 [min–max: 26–76], Wilcoxon, P=0.001). At entry, the collection of the signs at the structured clinical observation met the signs noted by the families as being the object of their concern. With standardised tools, these observations constituted an efficient functional and multidimensional analysis for the integrative care project. At 12 months, the families’ level of satisfaction was high and consistent with that of the practitioners. ConclusionOur results show that the day units take care of a population of children with predominantly severe and complex ASDs, for the most part, from families with low socioeconomic status and first-generation immigration. The relevance of the multidimensional observation and the care project of the ISPs were confirmed by the families at entry and after 12 months of care.

The Delay and Costs of Diagnosing Systemic Vasculitis in a Tertiary-Level Clinic.

IntroductionThe diagnosis of systemic vasculitis is a challenge because of the heterogeneity of clinical manifestations. The aim of this study is to analyze the diagnostic delay in systemic vasculitis, the total costs during the first year of care, and how the diagnostic delay affects the costs in a tertiary health care facility.MethodsPatients with a new diagnosis of systemic vasculitis between 2010 and 2018 were identified from hospital records. The diagnostic delay and health care costs were evaluated during the diagnostic period and within 12 months after the first contact with tertiary health care. Vasculitis-related costs were recorded as true costs charged. A total of 317 patients fulfilled the study criteria. The diagnoses were grouped into three clinically relevant groups: IgA vasculitis and other small-vessel vasculitis (n = 64), ANCA-associated vasculitis (AAV) (n = 112), and large-vessel vasculitis (LVV) (n = 141).ResultsThe diagnostic delay from the first referral to tertiary-level clinic was shortest in the LVV group and longest in the AAV group. Total costs during the diagnostic period were the highest in the AAV group (median = €6754 [IQR €8812]) and lowest in the LVV group (median = €3123 [IQR €4517]), p < 0.001. There was a significant positive correlation between the diagnostic delay and total costs during the diagnostic period and 12 months (rs = 0.38, p < 0.001 and rs = 0.34, p < 0.001, respectively). In a linear model, the inpatient days and the number of laboratory tests were the strongest predictors (p < 0.001) of a higher treatment cost during the diagnostic period.ConclusionsThere is a substantial diagnostic delay that correlates significantly with the costs in tertiary-level health care when diagnosing systemic vasculitis.Electronic supplementary materialThe online version of this article (10.1007/s40744-020-00266-9) contains supplementary material, which is available to authorized users.

Hematologic alterations and early mortality in a cohort of HIV positive African patients.

IntroductionInfection with Human Immunodeficiency Virus (HIV) is highly prevalent worldwide, especially in Sub-Saharan Africa, where anaemia is also widespread. HIV infection is known to be associated with anaemia and various other haematologic alterations, but little data on correlation with immunological and virologic conditions in treatment-naïve patients and impact on mortality are available. Our study aims to investigate hematologic features in HIV-infected individuals in Malawi and Mozambique and assesses possible correlations with early morality.Material and methodsWe conducted a retrospective analysis of baseline data (general details, nutritional status, full blood count and HIV infection progress data) and 12 months follow-up status for HIV+ adult patients in 22 health facilities in Malawi (11 sites) and Mozambique (11 sites) run by DREAM program. Anagraphic details, anthropometric characteristics, full blood count, CD4+ count and Viral Load data were collected from electronical medical records (EMR) for all the HIV-positive, treatment-naïve patients starting care in the sites in the period January 2007 –December 2016. Follow-up status after one year since enrolment in care was also considered. All the data extracted from the EMR were included in a dataset and then analysed. Univariate and multivariate analysis were conducted through logistical regression to investigate associations, and survival analysis analysed in a Cox regression model.ResultsOn the whole, 22.657 patients were included; severe and moderate anaemia were observed in 1.174 (8,2%) and 4.703 (21,9%) patients respectively. Gender, nutritional status, CD4+ count, and viral load (VL) were associated with anaemia, leukopenia, and thrombocytopenia. Among 21.166 fully evaluable patients, 8.494 (40,1%) had at least one cytopenia. Any cytopenia was present in 1/3 of patients with normal nutritional status and less advanced HIV infection, and it wouldn’t be diagnosed in a basic HIV care setting. During the first year of treatment, 1.725 subjects (7,6% of the entire sample) died. Anaemia, lower Red blood cells and platelets counts correlated with mortality in the first year of care, independently by body mass index, haemoglobin, CD4+ count and VL.ConclusionsNotwithstanding anaemia is known to be associated with HIV infection at diagnosis, full blood count is not routinely performed in many African countries. Our results emphasize that including the study of a broader set of parameters in the routine HIV care services in Sub-Saharan Africa would provide significant clinical information able to predict other alterations and poor outcomes.

Mood Disorders and Increased Risk of Noncommunicable Disease in Adults With HIV.

People living with HIV (PLWH) experience high rates of mood disorders (major depression and bipolar affective disorder) which in the general population have been associated with noncommunicable disease (NCD) risk. We examined whether prevalent mood disorders are associated with incident NCDs and multimorbidity (accumulation of ≥2 NCDs) in PLWH. Adult HIV clinic cohort in Nashville, Tennessee, between 1998 and 2015. PLWH with ≥1 year of follow-up in the clinic were assessed for cardiovascular disease, metabolic syndrome (any 3 of hypertension, hyperlipidemia, diabetes, or obesity), chronic kidney and liver disease, non-AIDS-defining cancers, and dementia. Only mood disorders documented during the first year of care were included. Cumulative incidence and adjusted subhazard ratios (aSHRs) were calculated for risk of NCDs and multimorbidity with death as a competing risk. Multivariable Cox models estimated mortality risk after multimorbidity. Of 4140 adults, 24% had a mood disorder diagnosed in the first year of care, 51% had ≥1 NCD at baseline, and there were 2588 incident NCDs during the study period. Mood disorders were associated with increased risk of first NCD (aSHR = 1.29, 95% confidence interval: 1.06 to 1.57), incident multimorbidity (aSHR ranging from 1.04 to 1.42), and metabolic syndrome (aSHR = 1.29, 95% confidence interval: 1.02 to 1.64). Mood disorders were not conclusively associated with mortality risk after multimorbidity. PLWH with mood disorders were at increased risk of incident NCDs and multimorbidity, particularly metabolic syndrome. Focused prevention and treatment of NCDs may reduce the burden of multimorbidity in this high-risk group.

Patients' Experiences with Refilling their HIV Medicines: Facilitators and Barriers to On-Time Refills.

Adherence to antiretroviral therapy (ART) is particularly important for patients with HIV. Prior research on ART adherence has focused primarily on behavioral interventions targeting patients and providers. No study has focused on the pharmacy refill experience as a potential target for improving adherence to HIV medicines. Informed by patients' experiences, this study aimed to assess patients' experiences with refilling their HIV medicines and to explore facilitators and barriers to refilling medicines on time. We interviewed patients at three time points during their first year of care at an HIV clinic in Houston, TX. We analyzed interviews using directed and conventional content analysis. Analyses revealed individual, interpersonal, and system-level barriers that affect patients' ability to pick up their HIV medicines on time. Many patients perceived the refill process as being difficult. For some patients, picking up their HIV medicines each month triggered anxiety. Positive interactions with pharmacists and pharmacy staff, as well as clear and consistent messaging, played a key role in augmenting patients' refill experience. Self-efficacy, social support, and workarounds to resolve issues were also key facilitators. Many patients said changing ART-dispensing protocols from 30- to 90-day refills could mitigate the anxiety experienced with picking up HIV medicines and decrease opportunities for missing a refill. Offering 90-day refills for HIV medicines may decrease anxiety concerning missed doses and improve medication adherence. Providing pharmacy staff with communication skills training is another strategy that may improve the patients' refill experience.

1240-P: Differences in Initial Care and Outcomes Comparing Adults with Early vs. Usual Onset Type 2 Diabetes

The prevalence of newly diagnosed type 2 diabetes (T2D) among American adults under age 45 is increasing. Given the lasting benefits conferred by early glycemic control, we examined initial diabetes care and subsequent glycemic control at one year following diagnosis, comparing adults with early onset (21-&amp;lt;45 years old) vs. usual onset (45-&amp;lt;65 years old) T2D. Using data from a large, integrated care delivery system, we identified adults who had a first diabetes-defining Hemoglobin A1c value (≥6.5% “index A1c”) between Jan. 2010 and Dec. 2016, followed by clinical diagnosis of T2D (visit with T2D ICD code or T2D on problem list) within 3 months of the index A1c. We excluded anyone with evidence of prior T2D, gestational diabetes or T1D. We compared baseline characteristics by onset age using t- or chi-2 tests. Adjusting for index A1c and other patient characteristics, we used logistic regression to examine initial management and GEE models to examine glycemic control (goal A1c &amp;lt;7%) at one-year following diagnosis, comparing early vs. usual age onset status. We identified 32,137 adults with new T2D, including 8,496 with early onset (26.4%, age 37.6 ± 5.3 years) and 23,641 with usual onset (73.6%, age 54.4 ± 5.5 years). Adults with early onset had a higher index A1c (A1c 8.9% vs. 8.4% for usual onset, p&amp;lt;0.001). Compared to usual onset, adults with early onset were more likely to initiate metformin (adjusted odds ratio [aOR] 1.20, 95% CI [1.12-1.27]), but less likely to receive a retinal exam (aOR 0.80, 95% CI [0.76-0.85]) or diabetes-related education (aOR 0.84, 95% CI [0.80-0.89]) during the first year of care. Adults with early onset were less likely to achieve goal glycemic control at one year following diagnosis (aOR 0.85, 95% CI [0.79-0.91]). In conclusion, individuals with early onset T2D were less likely to achieve goal A1c (&amp;lt;7%) at one year following diagnosis. This suggests a need for tailored strategies to improve early T2D care for this high-risk population of adults presenting with T2D at younger ages. Disclosure M.A. Blatchins: None. P. Mishra: None. R.W. Grant: None. A. Gopalan: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Pilot Study of the Impact of Giant Cell Arteritis and Its Treatment on the Autonomy of the Elderly in the First Year of Care

Pilot Study of the Impact of Giant Cell Arteritis and Its Treatment on the Autonomy of the Elderly in the First Year of Care

What patient involvement means to new patients at two HIV clinics: A longitudinal, qualitative study

ObjectivesThis study 1) defines patient involvement from the perspective of patients new to a provider, 2) describes provider communication that patients perceive as promoting involvement, and 3) examines changes in patient definitions of involvement over time. MethodsWe enrolled 56 patients at two HIV clinics in Houston, Texas, from August 2013 until March 2015. We interviewed patients three times during the first year of care and analyzed interviews using content analysis. ResultsThe mean age was 45 years; 54% were men. Patient definitions of involvement ranged from adherence- to decision-oriented. Analysis revealed three provider communication behaviors that patients perceive as promoting involvement: 1) soliciting patient feedback, 2) discussing treatment options and trade-offs, 3) narrating the decision-making process. Definitions of involvement can change over time as providers reframe the patient's illness as manageable and through perceived partnerships with the provider. ConclusionProvider communication plays a critical role in shaping new patients' perception of involvement and can make patients feel involved even when patients do not actively make medical decisions. Practical implicationsFinding strategies to make patients feel involved in their care is important, particularly for new patients, even if those strategies do not necessarily promote more talk from the patient.

Abstract PD6-08: Medicare costs for women after breast cancer: Preparing for survivorship

Abstract BACKGROUND Improvements in breast cancer survival and increasing population life expectancy have resulted in a growing number of women receiving subsequent health care after breast cancer diagnosis and treatment. We sought to determine the magnitude of increases in healthcare costs related to breast cancer survivorship, in anticipation of predicted increases in enrollment, higher intensity utilization, and greater healthcare spending among Medicare beneficiaries. METHODS Women age 65+ diagnosed with stage 0-III breast cancer in 1998, 2003 or 2008, were identified from the SEER database linked to Medicare records. After restrictions they were propensity score matched to a comparable group of non-breast-cancer women on demographic characteristics and co-morbidities at time of diagnosis based on the Elixhauser co-morbidity index. Line payments to care providers were then calculated for the first year of care after diagnosis (cases only) as well as years 2-6, 8-11 and 12-16 post-diagnosis (cases and controls). Direct Medicare costs were adjusted for inflation using the experimental Medicare costs Price Index and compared under real world and alternative survival scenarios. RESULTS Overall, the costs of care were progressively higher in later cohorts across all time periods. Differences in survivorship were the primary driver of differences in costs between breast cancer cases and controls. All-stage costs in years 2-6 were higher in the cancer group ($2,499, $10,261 and $12,029 higher per-person in 1998, 2003 and 2008 respectively), however, higher mortality in the cancer group reduced the costs and quantity of care received in later years [years 7-11 ($2,183 lower per-person in 1998) and 12-16 ($2,431 lower per-person in 1998)]. In pairs with identical survival, costs in the cancer group were significantly higher than in matched non-breast-cancer controls across all time periods (years 2-6: $4,799, $9,545 and $12,245 higher in 1998/2003/2008; years 7-11: $2,922 and $5,597 higher in 1998/2003). Stratification by stage changed the magnitude but not the general pattern of our results. The first year of care in 2003 was on average $4,933 dollars higher than in 1998; in 2008 costs again increased by $4,223 per-person. In years 2-6 the cost of cancer care increased by $12,440 (2003 vs 1998) and $3,456 (2008 vs 2003) per-person; Finally, cancer care for years 7-11 in 2003 $3,964 higher than in 1998 per-person. CONCLUSION Improved breast cancer survival and increased overall life expectancy among women in the United States will contribute to higher Medicare expenditures. Future risk-based capitation schemes should account for these advancements when preparing for healthcare delivery after cancer. Citation Format: Greenup RA, Yashkin A, Gorbunova G, Akusevich I, Hwang ES. Medicare costs for women after breast cancer: Preparing for survivorship [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-08.

Retention in care and mortality trends among patients receiving comprehensive care for HIV infection: a retrospective cohort study.

Studies examining the relation between comprehensive care and health outcomes associated with comorbidities unrelated to HIV infection have focused mainly on the health outcomes of HIV-infected people and comorbid substance use disorders. We aimed to assess the impact of retention in comprehensive HIV infection care on overall, AIDS-related and non-AIDS-related mortality. Using a retrospective cohort design, we collected data for HIV-infected patients aged 19 years or more who first visited a comprehensive HIV infection clinic in Vancouver between Jan. 1, 2004, and Dec. 31, 2014. We defined retention in care as visit constancy (whether the patient attended the clinic at least once per given period) of 75% or greater. We used Poisson regression modelling to examine mortality trends. We performed Cox proportional hazards modelling to assess survival by retention during the first year of follow-up and identify factors associated with death. A total of 2101 patients were included in the study. Of the 2101, 1340 (63.8%) were retained in the first year of care, and 271 (12.9%) died during the study period. Among the 264 cases in which the cause of death was known, although the primary underlying cause of death (74 [28.0%]) was AIDS-related, half of all AIDS-related deaths (37/74 [50%]) occurred early in the study (2004-2007). In later years, most deaths (147/184 [79.9%]) were non-AIDS-related. Overall mortality was significantly reduced among patients with higher retention in care during the first year of follow-up (per 20% increase in visit constancy; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.96). Higher retention was also associated with reduced risk of AIDS-related death (adjusted HR 0.79, 95% CI 0.64-0.97). Although there was an overall trend toward decreased AIDS-related mortality over time, retention in care markedly decreased the likelihood of death. Maintaining patient engagement in comprehensive ancillary care is a patient-centred way of decreasing mortality rates among HIV-infected people.