Health Care Resources Research Articles

A New Natural Language Processing-Inspired Methodology (Detection, Initial Characterization, and Semantic Characterization) to Investigate Temporal Shifts (Drifts) in Health Care Data: Quantitative Study.

Proper analysis and interpretation of health care data can significantly improve patient outcomes by enhancing services and revealing the impacts of new technologies and treatments. Understanding the substantial impact of temporal shifts in these data is crucial. For example, COVID-19 vaccination initially lowered the mean age of at-risk patients and later changed the characteristics of those who died. This highlights the importance of understanding these shifts for assessing factors that affect patient outcomes. This study aims to propose detection, initial characterization, and semantic characterization (DIS), a new methodology for analyzingchanges in health outcomes and variables over time while discovering contextual changes for outcomes in large volumes of data. The DIS methodology involves 3 steps: detection, initial characterization, and semantic characterization. Detection uses metrics such as Jensen-Shannon divergence to identify significant data drifts. Initial characterization offers a global analysis of changes in data distribution and predictive feature significance over time. Semantic characterization uses natural language processing-inspired techniques to understand the local context of these changes, helping identify factors driving changes in patient outcomes. By integrating the outcomes from these 3 steps, our results can identify specific factors (eg, interventions and modifications in health care practices) that drive changes in patient outcomes. DIS was applied to the Brazilian COVID-19 Registry and the Medical Information Mart for Intensive Care, version IV (MIMIC-IV) data sets. Our approach allowed us to (1) identify drifts effectively, especially using metrics such as the Jensen-Shannon divergence, and (2) uncover reasons for the decline in overall mortality in both the COVID-19 and MIMIC-IV data sets, as well as changes in the cooccurrence between different diseases and this particular outcome. Factors such as vaccination during the COVID-19 pandemic and reduced iatrogenic events and cancer-related deaths in MIMIC-IV were highlighted. The methodology also pinpointed shifts in patient demographics and disease patterns, providing insights into the evolving health care landscape during the study period. We developed a novel methodology combining machine learningand natural language processing techniques to detect, characterize, and understand temporal shifts in health care data. This understanding can enhance predictive algorithms, improve patient outcomes, and optimize health care resource allocation, ultimatelyimproving the effectiveness of machine learning predictive algorithms applied to health care data. Our methodology can be applied to a variety of scenarios beyond those discussed in this paper.

Assessing Quality of Referrals to a Community-Based Chronic Pain Clinic

ABSTRACT Introduction Because patients with chronic pain are complex, with significant medical and psychiatric comorbidities, referrals to specialty pain clinics are often necessary. The present study explores the quality of information submitted and the profile of referring physicians associated with rejected patient referrals by a community pain clinic. Methods A retrospective cross-sectional study was conducted on a series of consecutive new patient referrals rejected by a noninterventional community pain clinic (November 2021–June 2022). Data were collected on the reasons for rejected referrals and physicians responsible for these referrals using the public database of the College of Physicians and Surgeons of Ontario. Results During the study period, 120 new referrals made by 99 physicians (88% primary care providers, or PCPs; male : female ratio 1:1.2; 53% Canadian university graduates) were rejected because of inadequate information (62%) or because they were inappropriate (38%). Only 46% of the rejected referrals were resubmitted within a median of 7 days (range 0–96 days) and accepted. Half of the non-resubmitted referrals could have been accepted if the referring provider had sent in the missing information. Conclusion A significant number of referrals to our pain clinic (primarily from PCPs) are rejected for mainly avoidable reasons. The process of rejected referrals and resubmissions requires 92 to 126 h of additional staff time/year. Without additional health care resources, our study highlights simple but effective improvements in the referral process that could facilitate patient care, avoid unnecessary delays, and decrease possible sources of patient complaints.

Characterizing disease burden and health care resource utilization in patients with hypertrophic cardiomyopathy: a nationwide real-world study in Finland

Abstract Background Hypertrophic cardiomyopathy (HCM) is an often hereditary myocardial disease with an estimated prevalence of 1:500 in the general population. Purpose This study aimed to investigate healthcare resource utilization (HCRU) and associated costs in patients diagnosed with HCM (and the associated subtypes: obstructive or non-obstructive) in a nationwide cohort in Finland. Methods This retrospective, registry-based cohort study included all Finnish patients diagnosed with HCM between 2000 and 2021, who were 12+ years old at the time of diagnosis, as identified from the national care registers for healthcare. HCRU data were collected between 2014 and 2021 from the Finnish national care registers for health care and the social insurance institution. Data pertaining to New York Heart Association (NYHA) classification were collected from three Finnish university hospitals. Results The study cohort comprised 5,834 patients with an HCM diagnosis; obstructive HCM accounted for 34% of cases. Mean per patient-year costs were €6638, 95% confidence interval (CI) €6472-€7415, and €6112, 95% CI €5957-€6560 for those with obstructive and non-obstructive HCM respectively. All-cause hospitalizations at specialized care were the most prominent cost associated with patients with obstructive and non-obstructive HCM equating to 46.3% and 46.1% of the total cost respectively (Fig 1.). Comorbidity burden, as measured by Charlson comorbidity index (CCI) score, was greater in patients with the obstructive than non-obstructive phenotype of the disease (CCI ≥4: 2.2 and 1.8, p<0.01, respectively). The highest utilization of invasive procedures was found for patients with NYHA class III-IV. Conclusion This population-based study, utilizing real-world data, provides novel insights into HCRU and related costs among Finnish patients with HCM (and associated subtypes). HCRU appears to be primarily driven by hospitalizations at specialized care. Furthermore, the data indicate that patients with obstructive HCM are likely to have a more severe disease, with higher comorbidity burden and requiring more invasive procedures than patients with the non-obstructive form of the disease. However, there were no statistically significant differences in health care costs between those with obstructive and non-obstructive HCM.

Ferric derisomaltose versus usual care in patients with heart failure, reduced ejection fraction, and iron deficiency: a short-term UK cost-utility analysis based on the IRONMAN RCT

Abstract Background In the IRONMAN trial, patients with heart failure (HF), a reduced ejection fraction and iron deficiency who were randomly assigned to ferric derisomaltose (FDI), rather than usual care, had a lower rate of the composite of hospitalization for heart failure (HHF) and cardiovascular (CV) death (rate ratio, RR, 0.82; 95% CI 0.66 to 1.02; p=0.07). A COVID-19 sensitivity analysis, censoring data at 1 year of follow-up showed a greater magnitude of treatment effect (RR 0.66; 95% CI 0.48 to 0.91; p=0.011). Purpose Patient-level data from IRONMAN were used to evaluate the effectiveness and cost-utility of FDI compared to usual care for patients with a current or recent HHF, or raised plasma natriuretic peptide concentrations, from a UK National Health Service (NHS) perspective. Methods A cost-utility analysis (CUA) was conducted covering the first year after randomization. Numbers-needed-to-treat (NNTs) were calculated for the primary endpoint censored at 1 year. In the CUA model, patient survival and rates of (re)hospitalization due to HF, other CV events, infections, respiratory conditions, and other non-CV events were modeled based directly on data from the IRONMAN RCT. UK-specific costs were obtained from the national schedule of NHS costs. Quality of life was estimated based on EQ-5D-5L data collected from patients included in the IRONMAN RCT. Results were undiscounted and reported as absolute and incremental costs in 2023 pounds sterling, and quality-adjusted life expectancy in quality-adjusted life years (QALYs). A willingness-to-pay threshold of £20,000 per QALY was adopted to allow calculation of a net monetary benefit (NMB), a summary measure of the overall value of FDI in monetary terms, capturing changes in both cost and QALY outcomes. Results The NNT analysis showed that 9 patients would need to be treated with FDI to avoid one composite primary endpoint event (CV death and HHF) over 1 year. Relative to usual care, FDI was associated with an improvement of 0.01 QALYs per patient over 1 year (0.58 versus 0.57 QALYs). Total average costs per-patient were £1,672 for FDI, versus £1,975 for usual care, leading to a saving of £302 per patient with FDI. The cost of iron procurement was more than offset by reductions in costs of (re)hospitalizations (Figure). FDI was therefore dominant over usual care, yielding an NMB of £483 over 1 year. Conclusions This short-term, within-trial CUA suggests that FDI both improves QALYs and reduces healthcare expenditure versus usual care when administered to patients with HF and iron deficiency in the UK. Iron repletion with FDI may be a prudent allocation of healthcare resources in this patient population.Breakdown of costs

Regional disparities and socio-demographic factors associated with eight or more antenatal care visits in Ghana

BackgroundAntenatal care is vital for maternal health and wellbeing, with the World Health Organization recommending a minimum of eight visits during pregnancy. In this study, we examined the regional disparities and factors associated with eight or more antenatal care visits in Ghana.MethodsWe performed a cross-sectional analysis of data from the 2022 Ghana Demographic and Health Survey. Our study comprised 3,893 women of reproductive age with birth history in the last two years before the survey. Regional disparities in the proportion of eight or more antenatal care visits were visualised using a spatial map. A mixed-effect multilevel binary logistic regression analysis was conducted to determine the factors associated with eight or more antenatal care visits using a four-modeled approach. The results were presented as adjusted odds ratios (aOR) with a 95% confidence interval (CI).ResultsThe prevalence of eight or more antenatal care visits in Ghana was 38.4% [95% CI = 36.0–41.0]. The regions with the highest prevalence were Eastern, Greater Accra, Western, and Volta. Those with the lowest prevalence were Northern, North East, Savannah, and Oti. The odds of eight or more antenatal care visits were lower among women aged 40–49 [aOR = 0.42, 95% CI = 0.18–0.96], women with four or more children [aOR = 0.57, 95% CI = 0.36–0.93], women who wanted pregnancy later [aOR = 0.63, 95% CI = 0.46–0.85], and women in five regions: Western North [aOR = 0.43, 95% CI = 0.19–0.94], Bono [aOR = 0.33, 95% CI = 0.14–0.76], Northern [aOR = 0.29, 95% CI = 0.13–0.66], Savannah [aOR = 0.30, 95% CI = 0.14–0.65] and North East [aOR = 0.33, 95% CI = 0.14–0.75]. Women in the richer [aOR = 1.99, 95% CI = 1.19–3.33] and richest [aOR = 4.82, 95% CI = 2.45–9.51] wealth index showed a higher likelihood of completing eight or more antenatal care visits relative to women in the poorest wealth index.ConclusionA significant proportion of women in Ghana fall short of the recommended eight or more antenatal care visits. Age, parity, desired pregnancy timing, wealth status, and region of residence are associated with the number of antenatal care visits. Women in five regions (Bono, Northern, North East, Savannah, and Western North) are significantly less likely to have eight or more antenatal care visits than those in the Western region. The government and policymakers should design programs to address the needs of older women, those with high parity, and women who want to delay pregnancy. Increased healthcare resources, educational campaigns, and addressing regional barriers to antenatal care access are crucial. Promoting public health initiatives to emphasise the importance of completing the recommended number of antenatal care visits for a healthy pregnancy is essential.

Exploring Stakeholder Perspectives on the Implementation of WHO iSupport for Dementia Program: A Qualitative Study.

To explore the stakeholders' perspectives and develop a conceptual framework for promotion strategies to implement the iSupport-based intervention for family caregivers of people with dementia. A descriptive qualitative design was adopted. Semi-structured interviews were conducted with 49 stakeholders of people with dementia from July to December 2023. The Consolidated Framework for Implementation Research was applied to guide the development of the interview guide, data collection and analysis. Directed content analysis was employed to identify facilitators and barriers, with data analysed based on the framework and the established its codebook. These findings were then summarised into a conceptual framework of critical components. The identified 16 barriers and 28 facilitators were distributed across all Consolidated Framework for Implementation Research domains. All facilitators and barriers were integrated into a conceptual framework guiding the implementation of iSupport. This four-tier, eight-component conceptual framework guides the global promotion of the web-based dementia care model, covering state, society, hospitals, individuals and strategies. The components included comprehensive and balanced national medical guidelines, a friendly social culture, adequate hospital collaboration, cooperative healthcare workers, responsible family caregivers, a comprehensive intervention system, appropriate learning content and digital health support. The 'iSupport for Dementia' program is seen positively for its potential to improve dementia care by providing mental and technical support to family caregivers. Successful implementation requires addressing barriers, enhancing facilitators and adapting to China's conditions and policies. Mobilising local healthcare resources and gaining stakeholder recognition is crucial. This approach may help develop a localised version of iSupport that suits the needs and habits of Chinese family caregivers, with the potential for broader dissemination. The 'iSupport for Dementia' program could greatly improve dementia care in China by addressing barriers and utilising facilitators. This study offers critical insights for future policy development and effective implementation strategies. Adherence to the COREQ guidelines for reporting qualitative research was maintained. No patient or public contribution.

Sex-specific clinical outcomes and healthcare resource utilization in the 5 years following hospitalization for heart failure

Abstract Background Heart failure (HF) a leading cause of hospitalization, and sex differences in care have been described. Purpose We assessed sex-specific clinical outcomes and healthcare resource utilization following hospitalization for HF. Methods This was an exploratory analysis of patients hospitalized for HF across 10 Canadian hospitals enrolled in the Patient-Centred Care Transitions in HF pragmatic cluster-randomized trial. Primary outcome was all-cause mortality. Secondary outcomes included all-cause readmissions, HF readmissions, emergency department (ED) visits, and healthcare resource utilization. Outcomes were obtained via linkages with administrative datasets. Results The 4441 patients (50.7% female) had high event rates. At 5 years of follow-up, 63.6% male and 65.5% of male and female patients, respectively, had died (p=0.19); 85.4% and 84.4% of male and female patients, respectively, were readmitted with no sex differences in mean [SD] all-cause readmissions (males, 2.8 [7.8] and females, 3.0 [8.4], p=0.54) or HF readmissions (males, 0.9 [3.6] and females, 0.9 [4.5], p=0.80) per person. The mean (SD) annual total healthcare costs per patient was $80334 (116762) for males and $81010 (112625) for females, with no sex difference (p=0.90); however, there were sex differences in cost breakdown: males incurred greater costs from specialist, hemodialysis, and day surgical care, and females incurred greater costs from home visits and long-term care. Conclusions Males and females were at similarly high risk of mortality and readmissions, and had similar total healthcare costs following hospitalized for HF. Notwithstanding similar risks, males received relatively more specialist and invasive care, and females received relatively more supportive care.

Costs of Potential Medication Wastage Due to Switching Treatment Among People With Multiple Sclerosis

Background: Unused medications negatively impact healthcare resource utilization and environmental safety, contribute substantially to annual healthcare expenditures, and may ultimately affect patient health outcomes. People with multiple sclerosis (PwMS) commonly switch disease-modifying therapies (DMTs), leading to medication wastage and substantial costs for insurers and patients. Objectives: To estimate the cost associated with potential medication wastage (PMW) in a subcohort of PwMS receiving oral or self-injectable US Food and Drug Administration–approved DMTs who switched DMTs in a calendar year in the United States. Methods: This retrospective cohort study included adults with MS and used PharMetrics® Plus claims data from 2017 to 2021. PwMS were required to have 12 months of continuous eligibility for the entire year and a claim for at least 2 unique DMTs during the same calendar year. The PMW cohort was defined as those who had an aggregate overlap in days’ supply across DMT switches within the year; those in the non-PMW cohort did not. The cost of PMW for insurers and PwMS due to overlap was calculated only at the point of switch to the new DMT and defined as the cost of the remaining days’ supply of the prior DMT. Results: The number of PwMS meeting the inclusion criteria was 1762 in 2017, 1947 in 2018, 1679 in 2019, 1461 in 2020, and 1782 in 2021. Approximately 95% of PwMS switched DMTs once within single calendar years, and 25% (n = 381-464) contributed to PMW. For those who had overlapping DMT supply, it was estimated that 34% to 38% of the DMT being switched from was potentially wasted. The total cost of PMW paid by the insurer and PwMS ranged from $1 200 866 to $1 489 859. While most of the total cost ($1 172 140-$1 450 328) was paid by the insurer, PwMS still owed substantial amounts ($28 726-$74 578). Across all PwMS, the per person per year cost ranged from $716 to $846. The estimated wastage and associated costs were consistent across all study years. Conclusions: DMT switching is common among PwMS, resulting in PMW and high costs to patients and insurers.

Quality of life measures with etripamil self-administration for acute episodes of paroxysmal supraventricular tachycardia in a medically unsupervised setting: patient-reported outcomes from NODE-303

Abstract Background Etripamil nasal spray (NS) is a fast-acting, self-administered calcium-channel blocker in development for the conversion of AV-nodal dependent paroxysmal supraventricular tachycardia (PSVT) in a medically unsupervised setting. Prior studies show favorable safety and efficacy in converting single episodes of PSVT to sinus rhythm (SR). Purpose In NODE-303, patient-reported outcome (PRO) instruments assessed quality of life (QoL) over multiple etripamil-treated episodes of PSVT. Methods NODE-303 was an event-driven, multi-center, open-label Phase 3 study in North and South American patients with documented PSVT that evaluated the safety and efficacy of etripamil in PSVT termination, over multiple episodes and without the need for prior test dosing. Enrolled patients who perceived PSVT symptoms applied an ambulatory ECG cardiac monitoring system (CMS), performed a pre-trained vagal maneuver and, if symptoms persisted, self-administered etripamil NS 70 mg. A study amendment allowed a repeat dose (etripamil NS, 70 mg) if symptoms persisted 10 min after the first dose. Each patient could self-treat up to 4 episodes. Safety was assessed through adverse events, clinical data, and ECG CMS recordings. The Treatment Satisfaction Questionnaire for Medication (TSQM; validated for acute episodic assessments) and other PROs were administered, and healthcare utilization data were acquired. Patients completed PROs at baseline (BL), monthly, and per PSVT episode, which collected information on symptoms, episode characteristics, rescue medications, and emergency room visits. Additional PROs were the Brief Illness Perception Questionnaire (BIPQ), Cardiac Anxiety Questionnaire (CAQ), and 36-Item Short Form Health Survey (SF-36). Results There were higher proportions of patients reporting mild, minimal or no disease severity, every 6 months, than at BL; extremely severe, severe, and moderate disease severity was reported by smaller proportions of patients than at BL, though incomplete surveys at later visits may limit this analysis. Anxiety and stress about future PSVT episodes were consistently reduced from BL. Measures of treatment satisfaction, effectiveness, and convenience were consistent across multiple episodes, and were at levels considered favorable for the TSQM instrument (Table 1). Rates of emergency-room visits and hospital admissions across multiple, treated PSVT episodes were similar to those observed in trials assessing single episodes (Table 2). The BIPQ, CAQ or SF-36 had no notable changes from BL. Conclusions Etripamil self-administration was associated with patient-reported improvements in degree of disease severity, decreased anxiety and stress over future PSVT episodes, and levels of treatment satisfaction, effectiveness, and convenience considered favorable for respective PRO instrument. Using a symptom-prompted, self-administered treatment for PSVT could potentially improve QoL measures and reduce healthcare resource utilization.

Cost-effectiveness of respiratory syncytial virus adjuvanted vaccine in Portuguese aged ≥ 60 years

Abstract Background Respiratory syncytial virus (RSV) infections are one of the leading causes of lower respiratory tract disease among adults aged ≥60 years in Europe. This study aims to assess the potential public health impact of the RSVPreF3 OA adjuvanted vaccine, the first approved preventive intervention for the older adult population in Portugal. Methods A monthly-cycle static Markov model was developed to assess RSVPreF3 OA adjuvanted vaccine impact on adults aged 60 years and older in Portugal. A single dose of RSVPreF3 OA adjuvanted vaccine was compared to no-vaccination over a three-year time-horizon. The model captures lower respiratory tract disease (LRTD) RSV cases, hospitalizations, deaths, and healthcare resource utilization. Data inputs were based on local published literature, supplemented by the best available data when local information was lacking. Results Based on preliminary analysis considering 75% vaccine coverage, model outputs estimate that RSVPreF3 OA adjuvanted vaccine can prevent 71,433 LRTD cases requiring medical attendance, 11,067 hospitalizations, 1,793 intensive care unit admissions and 1,003 deaths. The model estimates that 32 adults need to be vaccinated to avoid one RSV LRTD case, 207 adults need to be vaccinated to avoid one hospitalization and 2,283 adults need to be vaccinated to avoid one death. The incremental cost-effectiveness ratio was estimated at 9,541€, hence the RSVPreF3 OA adjuvanted vaccine is cost-effective compared to no vaccination. Conclusions The results demonstrate a strong preventive impact of the RSVPreF3 OA adjuvanted vaccine on health outcomes and healthcare resource utilization in adults ≥60 years, leading to a significant public health benefit. This result emphasizes the importance of preventing RSV to preserve the health and well-being of Portugal’s older adults. In addition, data from ongoing studies may enhance precision and extensive sensitivity analyses validate the robustness of the model’s input assumptions. Key messages • This study shows the robust evidence of RSVPreF3 OA adjuvanted vaccine to improve public health by preventing thousands of hospitalizations and deaths among ≥60 years, in Portugal. • Vaccinating adults aged ≥ 60 years with RSVPreF3 OA adjuvanted vaccine in Portugal is a cost-effective strategy.

Burden of vaso-occlusive crisis, its management and impact on quality of life of Indian sickle cell disease patients.

Sickle cell disease (SCD) with vaso-occlusive pain crisis (VOC) significantly impacts patient well-being and often results in extensive healthcare resource utilization. This study assessed the VOC burden, its management and its impact on patients' quality of life (QoL). A cross-sectional observational study was conducted between November 2021 and June 2022, including 1000 SCD patients from high-prevalence states in India. Data on demographics, clinical characteristics, VOC severity, management and QoL were collected. The study revealed that 33.5% of patients reported at least one VOC episode during the study period. In the year prior to their enrolment, 836 (83.60%) patients reported at least one VOC episode, with an equal proportion of 407/487 (83.6%) adults and 429/513 (83.6%) paediatric patients, reducing their QoL across all domains compared to patients without VOC. Of these, 469/1000 patients (46.9%) experienced ≥3 VOC episodes. Additionally, 764/1000 (76.40%) patients managed their VOCs at healthcare facilities, with 501/1000 (50.1%) requiring inpatient admissions. Further, 71.80% of patients received Hydroxyurea (HU) therapy. The study depicts the severity of the Arab-Indian haplotype in Indian SCD patients visiting healthcare settings based on high VOC burden. This highlights the urgent need for better management strategies and resource allocation for these patients.

Digital devices for heart rhythm monitoring in atrial fibrillation patients scheduled for elective electrical cardioversion. Kardiover study

Abstract Introduction the management of patients with recent-onset atrial fibrillation (AF) is to achieve sinus rhythm (SR) by electrical or pharmacological cardioversion (CV). However, frequently SR is spontaneously restored, making scheduled admission and/or transesophageal echocardiogram (TEE) unnecessary and therefore causing misutilization of healthcare resources. Emerging medical technology has allowed for accurate heart rhythm monitoring. Objective to evaluate the diagnostic ability of a smart device ECG monitor to detect spontaneous conversion to SR in AF patients, preventing unnecessary admission and providing an earlier management. Methods A prospective multicenter study (Kardiover study) was designed including patients with paroxysmal, persistent or first diagnosed AF scheduled for elective electrical CV in cardiology departments of 7 hospitals in Spain. Patients were asked to submit ECG recordings to a central Corelab daily, twice a day and whenever they present symptoms, until CV (spontaneous or scheduled) and a week afterwards. Whenever a spontaneous conversion to SR was detected, investigators were contacted to confirm SR and abort admission, likewise when AF recurrence after CV was detected. Patients’ satisfaction was evaluated using a test for perceived utility and value, convenience, and accessibility. Results A total of 74 patients were enrolled (age 62 ± 10 years). Twenty-two patients (30%) showed spontaneous conversion to SR correctly detected by the devices. 86% of the spontaneous CV occurred during the first week. Among 52 patients admitted for CV, 45 (88%) were discharged in SR. During follow up after conversion to SR (spontaneous or electrical), recurrences of AF occurred in 24 patients (34%). At the end of the follow-up 51 patients (69%) remained in SR. Due to the early detection of spontaneous conversion to SR, a total of 22 admissions and 16 TEE were prevented and these resources used for other patients. Patients’ adherence to the protocol in regard to ECG recording transmissions was high, the CoreLab received 93% of the expected transmissions. Patient’s overall satisfaction was also high with a punctuation of 9.1 over 10 in the feedback test. Conclusion Digital devices for heart rhythm monitoring can optimize the management of AF patients scheduled for CV, preventing unnecessary admissions and providing a more rational use of healthcare resources.Baseline characteristicsStudy design and results

Integrating international lifestyle management of acute coronary syndrome and type 2 diabetes mellitus: a rapid review of guidelines

Abstract Background The rising prevalence of comorbidity has been described as an international health priority. There has been a dramatic increase in the levels of Type 2 Diabetes Mellitus (T2DM) among those with Acute Coronary Syndrome (ACS), with approximately 25-40% of patients admitted to hospital for ACS, also having diabetes. Comorbid ACS-T2DM provides a more complex set of symptoms for patients and clinicians to manage, and health policy makers to plan for. Those living with comorbid ACS-T2DM are at increased risk of death, another heart attack, re-hospitalisation, heart failure, reduced physical and psychological health, increased health service use and poorer quality of life. Due to shared disease determinants such as obesity, low physical activity levels and poorer dietary habits; individuals with ACS are more likely to have a comorbid T2DM. Care for patients with comorbidities is fragmented, siloed and poorly organised as it reflects a tradition of single disease management meaning comorbidity is rarely considered. Robust evidence is required to shape provision and guidance for those with comorbid ACS-T2DM and the clinicians involved in their care; with an emphasis on redesigning service provision and practice to address the needs of this growing population. Purpose To identify opportunities in existing clinical guidance to improve integrated care strategies and streamline management for those with comorbid ACS-T2DM. Methods Following Cochrane rapid review recommendations, a Population, Concept, and Context (PCC) framework guided eligibility. Guidelines for adults with ACS, T2DM, or both conditions in high-income countries were considered. Nineteen guidelines from the UK, Australia, Canada, Europe, Ireland, New Zealand, and the USA were compared, covering ACS (n = 10), T2DM (n = 6), and comorbid ACS-T2DM (n = 3). Lifestyle factors examined included diet/nutrition, physical activity, weight management, clinical and psychological aspects. Results The review identified consistent lifestyle recommendations for both ACS and T2DM, with overlaps in guidance for diet, physical activity, weight management, clinical, and psychological factors. The findings offer opportunity for integrated care strategies, potentially reducing duplicated lifestyle management efforts. The results lay the groundwork for more cohesive management of comorbid ACS-T2DM. Conclusions This research is relevant for healthcare providers, policymakers, and patients living with comorbid ACS-T2DM. Understanding the shared lifestyle factors provides valuable insights into the potential for integrated care. Recognising the overlap in existing clinical guidelines points to opportunity for a more streamlined and effective approach to managing comorbid ACS-T2DM. This knowledge can contribute to improved patient outcomes and seek to optimise healthcare resources.

Burden of systemic inflammation and associated health outcomes in adults with atherosclerotic cardiovascular disease managed in routine care

Abstract Background The burden and outcomes of inflammation in people with atherosclerotic cardiovascular disease (ASCVD) are poorly defined, particularly beyond the controlled settings of trials and research cohorts. Methods We conducted a longitudinal observational study of adults with ASCVD undergoing C-reactive-protein (CRP) testing in routine healthcare in Stockholm, Sweden. After excluding CRP tests associated with acute illness and patients with medications/conditions that bias CRP interpretation, the systemic inflammation of participants was defined over a 3-month ascertainment window. Baseline determinants of CRP≥2 mg/L were explored with logistic regression, and baseline CRP categories were compared via Poisson and Cox regression for subsequent healthcare resource utilization and occurrence of major adverse cardiovascular events (MACE), heart failure hospitalization, and all-cause death. Result After applying inclusion/exclusion criteria, we identified 84,399 adults with ASCVD with a mean age of 71 years and of which 54% were men. In total, 60% had CRP≥2 mg/L. At baseline, female sex, older age, lower kidney function, albuminuria, diabetes, hypertension, and recent anemia, were associated with CRP≥2 mg/L. Conversely, the use of RASi, antiplatelets, and lipid-lowering therapy were associated with lower odds. Over a median follow-up of 6.4 years and compared to people with CRP <2 mg/L, those with CRP≥2 mg/L had a higher rate of hospitalizations, days spent in hospital, outpatient consultations, and dispensed medications during follow-up (P<0.05 for all). They also had a higher rate of MACE [adjusted hazard ratio (HR), 1.30; 95% CI, 1.27–1.33], heart failure hospitalization [1.24; 1.20–1.39], and all-cause death [1.35; 1.20–1.30]. Results were consistent across subgroups and more granular CRP categories, and robust to the exclusion of extreme CRP values or early events. Conclusions Two in three adults with ASCVD have systemic inflammation. A CRP≥2 mg/L is associated with excess healthcare resource utilization as well as increased rates of MACE, heart failure, and death.

Health care utilisation in patients with mild pulmonary hypertension - EVIDENCE-PAH UK study

Abstract Background ESC/ERS 2022 guidelines1, redefined precapillary pulmonary hypertension (PH) as patients with a mPAP>20mmHg,PVR>2WU and PAWP<15mmHg1.We and others identified patients with mildly elevated pulmonary artery(PA) pressures demonstrates a higher mortality2-4. It is important to understand healthcare resource utilisation(HRCU) in this newly defined group who now meet the thresholds for diagnosis, however, treatment options are limited. Purpose The EVIDENCE-PAH aims to describe mortality and hospitalisation outcomes, baseline demographics in mild elevations in PA pressure in a national cohort. We report preliminary analysis of HRCU from data obtained from NHS Hospital Episode Statistics(HES); inpatient admissions, outpatient(OP) and emergency attendances(AE). Method Retrospective analysis of all patients with a mPAP<25mmHg and a sample of patients with a mPAP≥25mmHg at index-right heart catheterisation(RHC), across all UK PH tertiary centres between 2009-2017 with hospitalisation data captured 24-months pre and post index-RHC. For analysis patients were categorised into 3 groups; normal haemodynamics(mPAP<21mmHg & PVR≤2WU), mild elevation in haemodynamics(mPAP<21mmHg & PVR>2WU, mPAP21-24mmHg with all PVR groups, mPAP>25mmHg & PVR≤3WU) and abnormal haemodynamics(mPAP>25mmHg & PVR>3WU). Results A total of 2413(82.3%) patients had complete records 24-months pre and post index-RHC; 561(23.2%), 1228(50.9%) and 624(25.9%) in the normal haemodynamic, mildly elevated haemodynamic and abnormal haemodynamic groups respectively. Figure 1, demonstrates HRCU; Unscheduled admissions are significantly higher in the abnormal haemodynamic group 24-months pre index-RHC compared to the normal/mild elevations in haemodynamic groups (p-value<0.05). There was reduction in unscheduled encounters 24-months post index-RHC in the normal/abnormal haemodynamic group. No significant difference identified in AE attendance and OP 24-months post across all haemodynamic groups. Total HRCU demonstrates a lower attendance 24-months post RHC in normal versus abnormal haemodynamic group (p-value<0.05). Multivariate analysis demonstrates unscheduled admissions 24-months pre/post index RHC, as an independent predictor of survival, adjusted for age, sex and haemodynamics (Figure 2;p-value<0.05). Conclusion Unscheduled admissions may act as a discriminator identifying advanced PH (abnormal haemodynamics), but not normal versus mild elevations in haemodynamics. Meanwhile AE and OP attendances fails to discriminate between normal and mild elevation in haemodynamics. Unscheduled admissions 24-months pre/post index RHC is an independent predictor of survival which may lend as a useful surrogate marker for mortality in the PH population as a whole. Although total HRCU appears high across haemodynamics groups referred to PH centre, in the 24-months post RHC HRCU increases in the mild/abnormal haemodynamic groups, this may represent ongoing unmet need in this group.

Mortality, Clinical Complications, and Healthcare Resource Utilization Associated with Managing Transfusion-Dependent β-Thalassemia and Sickle Cell Disease with Recurrent Vaso-occlusive Crises in Italy.

To examine the clinical burden and healthcare resource utilization (HCRU) among patients with transfusion-dependent β-thalassemia (TDT) and patients with sickle cell disease (SCD) with recurrent vaso-occlusive crises (VOCs) in Italy. Eligible patients were identified from an administrative claims database from 1 January 2010 and 1 February 2019. Patients with TDT had ≥ 1 iron chelation treatment, ≥ 8 red blood cell transfusions (RBCTs) during any 12-month period, and ≥ 12 months of available data pre- and post-index (i.e., first RBCT claim). Patients with SCD with recurrent VOCs had ≥ 2 VOCs/year in ≥ 2 consecutive years and ≥ 12 months of available data pre- and post-index (second VOC claim in the second of 2 consecutive years). Patients were propensity score matched to five controls by age, sex, geographic area, and index year. Clinical and HCRU outcomes were evaluated post-index. In total, 214 patients with TDT and 111 patients with SCD with recurrent VOCs were matched to 1070 and 555 controls, respectively. Both patient groups had substantially higher mortality rates than controls (TDT: 4.8 versus 0.8 deaths per 100 person-years; SCD: 1.6 versus 0.4 deaths per 100 person-years). Clinical complications were prevalent in both patient groups. Compared with controls, both patient groups had significantly higher mean rates of all-cause hospitalizations (TDT: 1.4 versus 0.1; SCD: 2.0 versus 0.1) and outpatient services (TDT: 21.9 versus 1.6; SCD: 6.2 versus 1.0) per patient per year (all: p < 0.05). Management of TDT and SCD in Italy is associated with significant clinical and health system burden, highlighting the need for new treatments that eliminate RBCTs and VOCs.

Inequalities in Primary Care Provision in Gwangju Metropolitan City, South Korea

Abstract Background Primary care clinics play a crucial role in community health promotion by facilitating early disease detection and management. The number of these clinics in Gwangju Metropolitan City increased from 931 in 2000 to 2,400 in 2022, but this growth was not evenly distributed within the city. This study aims to examine the spatial inequalities in the distribution of clinics in Gwangju Metropolitan City. Methods This study utilized local administrative licensing data on medical institutions classified as clinics. To estimate healthcare resource imbalances, Lorenz curves and Gini indices for the number of clinics per 100,000 individuals and per square kilometer were calculated by district. Results The number of primary care clinics per 1,000 individuals or per square kilometer was highest in Dong-gu and Seo-gu, while Gwangsan-gu had relatively fewer facilities. In particular, Buk-gu, Seo-gu, and Nam-gu had more than 40% of areas with a high number of healthcare facilities relative to population or area, whereas less than 50% of Gwangsan-gu fell into the lower tier in these categories. The Gini index, used to measure the geographical inequality of healthcare facility distribution, showed a slight improvement from 2000 to 2023. However, Seo-gu and Buk-gu exhibited different trends compared to other districts. Conclusions Geographical disparities in the distribution of primary care clinics in Gwangju Metropolitan City have slightly improved since 2000, but show different patterns by district. Addressing healthcare imbalances is essential for enhancing health equity, requiring multifaceted efforts to mitigate disparities and improve medical service accessibility in underserved areas. Key messages • Significant disparities exist in the distribution of primary care clinics across Gwangju, with higher densities in Dong-gu and Seo-gu, and fewer facilities in Gwangsan-gu. • The Gini index for clinic distribution has improved since 2000, but disparities remain, particularly in Seo-gu and Buk-gu. Continued efforts are essential to reduce healthcare inequalities further.

Cardiovascular emergency in indonesian primary health care (PUSKESMAS): a national multicentre service evaluation study based on ESC guidelines adherence

Abstract Background Early diagnosis and prompt treatment are crucial in reducing cardiovascular (CVD) burden in the global level, especially in Indonesia with more than a half million CVD death annually. As frontliner, more than 10,000 primary healthcare (PUSKESMAS) spreading around Indonesia are pivotal in delivering CVD emergency care. However, due to the scarcity of healthcare resources, significant disparities exist between guideline recommendations and their implementation in Indonesian primary health care. Purpose Our study aims to describe current cardiovascular emergency care, assess guideline adherence, and identify key factors influencing the trend. Methods This multicentre study was conducted in 40 PUSKESMAS across Indonesia from October to December 2023. Data related to cardiovascular emergencies diagnosis, work-ups, treatment, and outcomes were gathered and then evaluated according to the ESC Guidelines. Recommendations, particularly Class I, were converted into points with respect to diagnostic and treatment domains. Guideline adherence scores were then calculated based on the percentage of accomplished points. Linear regression analysis was employed to identify factors that could explain variations in guideline adherence across all PUSKESMAS. Results 215 CVD emergency patients were reported. The most prevalent diagnosis was hypertensive crisis (n=137; 64%) with ECG done in only 26% of cases and none underwent imaging. Oral amlodipine (59%) and captopril (55%) were mostly used as antihypertensive, with none receiving intravenous. The second most common diagnosis was ACS (n=42; 20%), with ECG performed in only 71% of cases. Among 13 patients with STEMI, 69% only received aspirin, and 46% were given DAPT. Malignant arrhythmia occurred in 26 patients, with none receiving cardioversion. The most used anti-arrhythmic are bisoprolol, propranolol, and atropine. Among 23 cases of acute HF, only 39% received oxygen, while IV furosemide was used in only one case. Cardiac arrest occurred in two patients, both received CPR and epinephrine. In terms of guideline adherence, mean diagnostic score (%) was demonstrated highest in Cardiac Arrest at 100 and the lowest in Hypertensive Crisis and Acute HF at 53, while mean treatment score (%) was highest in Hypertensive Crisis at 86 and lowest in arrhythmia at 25. Linear regression suggests that human resources have a positive and significant association with diagnostic adherence scores (R2: 0.3485, p-value: 0.0450), whereas essential medicine has a strong but non-significant correlation with treatment adherence score (R2: 1.0768, p-value: 0.460). Conclusion This study has demonstrated a huge disparity between the current CVD emergency practices and guidelines in Indonesian primary healthcare. These gaps emphasised the need for improved human resources and essential medicine for primary healthcare along with the implementation of data-driven policy making concerning cardiovascular disease in Indonesia.Cardiovascular Emergency Diagnosis in InCardiovascular Emergency Work-up and Tre

Trends in Regional Disparities of Cardiovascular Surgery and Mortality in South Korea

Abstract Objectives Regional disparities in cardiovascular care in South Korea have led to uneven patient outcomes. Although procedure access and needs are increasing, few studies have linked regional service availability to mortality rates. This study analyzed variation in utilization of major cardiovascular procedures by region and association with short-term mortality to provide better evidence on links between healthcare resources distribution and patient survival. Methods A cross-sectional study was conducted using nationwide claims data on patients who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), stent insertion, or aortic aneurysm resection in 2022. Regional variation was assessed by a Relevance Index (RI). The associations between regional RI and 30-day mortality were analyzed. Results The RI was lowest for aortic aneurysm resection (mean, 26.2; standard deviation, 26.1), indicating the most uneven regional distribution among the surgical procedures. Patients undergoing this procedure in regions with higher RIs showed significantly lower 30-day mortality (adjusted odds ratio [aOR], 0.73; 95% confidence interval, 0.55 to 0.96; p = 0.026) versus those with lower RIs. This suggests that cardiovascular surgery regional availability, as measured by RI, has an impact on mortality rates for certain complex surgical procedures. The RI was not associated with significant mortality differences for more widely available procedures like CABG (aOR, 0.96), PCI (aOR, 1.00), or stent insertion (aOR, 0.91). Conclusions Significant regional variation and underutilization of cardiovascular surgery were found, with reduced access linked to worse mortality for complex surgeries. Addressing disparities through cooperation among hospitals and policy efforts is warranted to improve outcomes. Key messages • This study analyzed regional variations in major cardiovascular procedures using the Relevance Index and investigated their impact on mortality rates within 30 days of admission. • Addressing regional disparities requires improved healthcare infrastructure and comprehensive networks of specialists to ensure timely and high-quality cardiovascular care across South Korea.

Economic Burden of Treatment-Resistant Depression: Insights from Real-World Data

Background: Treatment-resistant depression (TRD) is a highly prevalent condition. It is generally referred to as the failure of at least two or more prior treatments with antidepressants or augmentation therapy with adequate dose and duration. TRD affects the individual's overall health and social life, in addition to the economic impact associated with the illness. Therefore, this review is focused on examining the financial burden of illness among patients with TRD across different countries and identifying the key drivers for the incremental costs and healthcare resource utilization (HRU). Methods: A literature search was carried out in the PubMed database using relevant MeSH terms. This review included relevant studies published between 2019 &amp; 2024. Results: Overall, 22 studies were included in this review, with the majority based in the United States (n=15). The majority of the patients were females, ranging from 53.1% to 77%, and the mean age of patients with TRD ranged from 37.7±14.4 to 73.1±6.5 years. The mean annual all-cause healthcare cost per patient ranged from $3,190 to $40,040. The mean annual all-cause indirect costs per patient ranged from $4,199 to $6,342. Outpatient visits were the frequently utilized healthcare services, especially psychiatric visits and visits to general practitioners or family physicians. The incremental costs were primarily driven by worsening symptom severity, the presence of comorbidities, advancing age, and frequent visits to specialists. Conclusion: Regardless of the factors influencing the cost burden, TRD generally accounts for higher healthcare use and costs compared to individuals with major depressive disorder or without any mental illness. This underscores the need for fostering newer interventions and implementation of multidisciplinary approaches to lessen the cost burden of this condition, in addition to managing it effectively.