Health Care Resources Research Articles

EDI&S SO06 Do All Patients with Biliary Problems Need Surgery? Applying C-Gall Study Results to Long Waiters for Laparoscopic Cholecystectomy

Abstract Background The recent C-GALL study, a multi-centre randomised trial, found no significant difference in quality of life at two years between operative and non-operative management of uncomplicated gallstone disease. This suggests some patients may not benefit from elective laparoscopic cholecystectomy (LC), potentially leading to over-listing for surgery. By identifying patients who may no longer need surgery, we could reduce waiting lists and improve resource allocation. This study aims to reassess patients with an enforced period of observation on an elective waiting list for LC, to determine if they wish to make a different decision about proceeding with surgery. Method Patients listed for an elective LC who had been waiting longer than 11 months from referral were reviewed. Patients were contacted through telephone clinics by a surgeon. Data was collected on type of gallstone disease, history of abdominal surgery, biliary pain since last seen by a clinician, pain radiation to the back, pain reduction with simple analgesia, nausea, and heartburn. Identified patients were contacted and, if exhibiting minimal or no symptoms, were offered the option to be removed from the waiting list with 12 months of patient-initiated follow-up and high priority relisting if their clinical condition worsened. Results We contacted 59 patients awaiting elective LC Most were female (49, 83%), had biliary colic (43, 73%), and were under 60 years old (38, 64%). Seventeen patients (29%) were happy to opt out due to lack of symptoms. Of these, 13 (76%) were female, 11 (65%) had biliary colic, and 7 (41%) were under 60. Chi-squared analysis identified age as the only predictive factor, with those under 60 being less likely to opt out (p=0.038). We will continue to monitor representation and the need for reoperation to ensure safety and the findings remain consistent overtime. Conclusion The study demonstrates that a significant proportion of patients awaiting elective LC can be safely managed without planned cholecystectomy, potentially reducing waiting lists, cost and utilisation of healthcare resources. We would advise considering review of long waiters to re-evaluate their clinical need for cholecystectomy in order to improve sustainability within surgery. These findings support a more personalised approach to managing biliary pain, prioritising patients for surgery based on symptom severity.

Machine Learning in Health Anylitics and Patient Monitoring Solomon Kavuta and Mr Joel Mulepa Dmi St John The Baptist University, Lilongwe, Malawi

The integration of machine learning techniques in healthcare has revolutionized the way predictive analytics and patient monitoring are conducted. This transformation is reshaping traditional healthcare practices by harnessing the power of advanced computational methods to analyze vast amounts of patient data. Machine learning algorithms, which excel at detecting patterns and making predictions, leverage this data to forecast disease onset, progression, and treatment outcomes. This capability enables healthcare providers to adopt proactive measures, facilitating early intervention and the development of personalized treatment plans tailored to individual patients' needs. The potential of machine learning in healthcare is vast and multifaceted. By continuously analyzing real-time patient data streams from various sources such as electronic health records (EHRs), medical imaging, genomic information, and data from wearable devices, these algorithms can identify subtle changes in a patient's condition that may indicate the early stages of a disease or the risk of an adverse event. This continuous monitoring allows for timely interventions that can prevent complications, reduce the severity of diseases, and improve overall patient outcomes. For example, machine learning can help predict the likelihood of a patient developing conditions like diabetes or heart disease, allowing for lifestyle changes and medical interventions that can mitigate these risks before they become severe health issues. Moreover, machine learning facilitates remote patient monitoring, which has become increasingly important in the context of modern healthcare. With the advent of wearable devices and Internet of Things (IoT) sensors, it is now possible to collect and analyze health data outside of traditional clinical settings. These technologies enable healthcare providers to monitor patients in real-time, regardless of their location, ensuring continuous care and oversight. This is particularly beneficial for managing chronic diseases, where regular monitoring can significantly improve patient management and outcomes. For instance, remote monitoring of patients with heart conditions can detect early signs of arrhythmias or other issues, prompting immediate medical responses that can prevent more serious complications. The transformative impact of machine learning on healthcare delivery extends beyond patient monitoring and predictive analytics. It also includes enhancing diagnostic accuracy, optimizing treatment protocols, and streamlining administrative processes. By reducing the need for frequent hospital visits and enabling more efficient use of healthcare resources, machine learning can help lower healthcare costs while improving the quality of care provided to patients. Additionally, the ability to analyze large datasets quickly and accurately can aid in medical research, uncovering new insights into disease mechanisms and potential treatments.

Abstract A061: A cost-effective two-step approach for multi-cancer early detection in general population

Abstract In population-wide cancer screening, three key issues need to be focused on: number of cancer cases identified, the issue of false positives, and cost. A high false positive rate can result in a significant waste of healthcare resources. Large-scale screening inevitably leads to significant financial burdens on the healthcare system which is a key factor constraining nationwide screening. OncoSeek is a multi-cancer early detection (MCED) test using a panel of seven plasma protein tumor markers (PTMs) and artificial intelligence (AI). SeekInCare is a MCED test that integrates the seven PTMs and four cancer genomic features (aneuploidy, fragment size, end motifs, and oncogenic viruses) from cell-free DNA (cfDNA) by shallow whole-genome sequencing (sWGS). In a two-step approach, the initial screening is conducted using OncoSeek and SeekInCare is then used as the secondary test for those individuals who tested positive by OncoSeek. In a case-control study (n = 1197) including both OncoSeek and SeekInCare testing results, OncoSeek showed 49.9% sensitivity at 91.0% specificity, while SeekInCare demonstrated 60.0% sensitivity at 98.3% specificity. In the two-step process, specificity significantly increased from 91.0% to 99.3%, while sensitivity decreased from 49.9% to 39.9%. We modeled a screening in five million adults aged ≥ 50 years with a cancer incidence rate of 1.9%. The simulated real-world sensitivities of OncoSeek and two-step were adjusted downward proportionally to 28.0% and 22.4% based on the sensitivity differences observed between GRAIL’s CCGA study (case-control, 51.5%) and PATHFINDER study (prospective, 28.9%). While at 91.0% specificity OncoSeek had 441,450 cases of false positives, using the two-step approach significantly reduced false positives to 34,335 (0.7%). Although Galleri ($949 per test) identified more cancer cases than the two-step MCED, with 27,455 and 21,280 cases respectively, its total cost for the former reached $4,745 million. As the positive predictive value (PPV) of two-step (38.3%) was the same as Galleri (38.3%), it reduced cost 6.6-fold, amounting to a total cost of $713.6 million and a cost of $143 per individual screened. The cost of per cancer case detected using Galleri is $172,828 compared to $33,534 using the two-step MCED, which represents a 5.2-fold difference. In conclusion, the two-step approach not only significantly reduces false positives, but also cuts the screening cost down substantially, making it a cost-effective strategy for population-wide cancer screening. Citation Format: Mao Mao, Geng shuai peng, Li shi yong, Wu Wei, Chang Yin Yin. A cost-effective two-step approach for multi-cancer early detection in general population [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr A061.

Abstract 4122677: Reduced Costs and Readmissions With Outpatient Versus Inpatient Diuresis in Heart Failure Patients at UNC Hospital

Background: Heart failure (HF) remains a leading cause of hospital admissions, with high morbidity, mortality, and projected healthcare costs of $70 billion by 2030. Effective management of the patient’s volume status is crucial in managing symptom burden, preventing rehospitalization, and thus reducing healthcare expenses. In 2017, UNC Hospital opened an ambulatory diuresis clinic to address this issue. Aim: This retrospective cohort study evaluates the cost and rehospitalization rates of HF patients treated in the ambulatory diuresis clinic versus those receiving inpatient diuresis at the hospital. Methods: We retrospectively analyzed 2,950 unique HF patients from August 2017 to September 2023, treated with IV diuresis at UNC Hospital or its outpatient clinic. Patients were classified into a clinic cohort, who visited the diuresis clinic at least once, and a non-clinic cohort, who never visited and were defined by a primary HF diagnosis with an ED/observation visit or inpatient stay ≤ two days. The primary outcome measured was average readmissions per cohort; the secondary outcome included total charges from billing records. Rehospitalization and mortality rates were tracked via EHR. Statistical analyses, including descriptive and inferential statistics, were conducted to compare costs and outcomes between the two groups. Results: This study compared 996 patients in the clinic group with 1,954 in the non-clinic group, noting similar baseline characteristics of average ages of 66.80 and 67.24 years, BMIs of 33.95 and 33.73 kg/m^2, and one-year all-cause mortality rates of 21.18% and 22.77%, respectively. Average admissions per cohort were higher for the clinic group one year prior to the index visit—0.159 vs. 0.127—but decreased post-index visit: by six months, admissions were 0.094 for the clinic and 0.161 for the non-clinic; at one year, they were 0.133 and 0.210, respectively. Financially, the clinic group incurred $7,895 less in charges during the index visit and had lower total costs one-year post-index, at $17,785 compared to $23,982 for the non-clinic group. Conclusions: The study demonstrates that outpatient diuresis at UNC Hospital is more cost-effective than inpatient diuresis for HF patients and reduces rehospitalization rates at six months and one-year post-index visit. These results suggest that outpatient diuresis is cost-effective, may enhance patient outcomes, and could alleviate the strain on healthcare resources.

Abstract 4146306: Rural Urban Disparities in Inpatient Outcomes of Chronic Limb-Threatening Ischemia in the United States

Background: Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease characterized by chronic ischemic rest pain, non-healing wounds, or gangrene in one or both legs. With prevalence rates of 1-2% in the United States (increasing with age, with over 20% of adults over 70 diagnosed with CLTI) and 1-year mortality rates approaching 20-25%, CLTI is a critical public health issue due to its significant impact on patient morbidity, mortality, and healthcare resources. Aims: To understand if disparities exist between rural and urban inpatient outcomes for patients with CTLI. Methods: A retrospective analysis of the National Inpatient Sample database from 2016 to 2021 was conducted to identify patients admitted with CLTI according to ICD-10 codes. Patients were stratified by rural and urban status, followed by propensity-matched analysis to compare inpatient outcomes between these groups. Results: A total of 2,667,279 patients with CLTI, with 445255 (16.7%) categorized as rural status and the remaining 83.3% categorized as urban status, were included in this study. Patients belonging to rural status had an increased odds of in-hospital mortality (aOR)=1.35; 95% CI 1.26-1.45; p<0.001), in-patient sudden cardiac arrest (aOR=1.27; 95% CI=1.13-1.43; p<0.001), cerebrovascular accidents (aOR=1.31; 95% CI=1.19-1.45; p<0.001), venous thromboembolism (aOR=1.18; 95% CI=1.09-1.27; p<0.001), surgical site infection (aOR=1.25; 95% CI=1.16-1.35; p<0.001), requirement for vasopressors (aOR=2.02; 95% CI=1.76-2.32; p<0.001), invasive (aOR=1.18; 95% CI=1.10-1.26; p<0.001) and non-invasive (aOR=1.37; 95% CI=1.25-1.50; p<0.001) mechanical ventilation, hemodialysis (aOR=1.11; 95% CI=1.06-1.15; p<0.001), major amputation (aOR=1.38; 95% CI=1.32-1.43; p<0.001), surgical revascularization (aOR=1.53; 95% CI=1.46-1.60; p<0.001), endovascular revascularization (aOR=1.53; 95% CI=1.46-1.60; p<0.001), and blood transfusion (aOR=0.92; 95% CI=0.88-0.97; p=0.001). No difference was observed in the odds of acute myocardial infarction (aOR=1.06; 95% CI=0.99-1.14; p=0.082) and risk of acute kidney injury (aOR=0.99; 95% CI=0.96-1.02; p=0.485). Conclusions: Disparities in CLTI outcomes are evident, with patients from rural areas experiencing worse outcomes than their urban counterparts. Future research should focus on understanding the underlying causes of these disparities and developing targeted interventions to bridge the gap between rural and urban health care outcomes.

Differences in Time of Birth between Spontaneous and Operative Vaginal Births.

Previous studies have identified an association between obstetric interventions and the time of day in which they are performed; however, they do not account for granular variations in the temporality of delivery interventions, which is influenced by both health care providers and resource availability. We sought to assess differences in time of birth among spontaneous vaginal births (SVBs) versus operative (forceps- and vacuum-assisted) vaginal births (OVBs). This cross-sectional study used birth certificate data from the National Vital Statistics System from 2016 to 2021, which includes the time of birth and delivery method for recorded U.S. births. The number of SVBs and OVBs at each minute was normalized relative to the total births within each delivery group to facilitate balanced comparisons between groups. Logistic regression analysis assessed the odds of OVBs per time of day. A total of 15,412,129 subjects who underwent vaginal birth were included in this analysis, 690,905 (4.5%) of whom underwent OVBs. Compared to births at other time intervals, those between 4:30 and 7:30 p.m. were more likely to be OVBs (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.12-1.14). Conversely, births between 3:00 and 6:00 a.m. were less likely to be OVBs (OR = 0.87, 95% CI: 0.86-0.88). After adjusting for adjusting for maternal age, gestational age, and induction of labor, births between 4:30 and 7:30 p.m. remained more likely to be OVBs (adjusted odds ratio [aOR] = 1.09, 95% CI: 1.08-1.10) and births between 3:00 and 6:00 a.m. remained less likely to be OVBs (aOR = 0.91, 95% CI: 0.90-0.92). In this population-based study, we identified temporal differences between SVBs and OVBs with increased use of instrumentation during the late afternoon and reduced use in the early morning. These findings prompt further investigation into the indications for OVBs and root causes of these temporal variations, which are likely multifactorial and involve provider and resource availability. · This study identifies temporal differences between SVBs and OVBs.. · Compared to SVBs, operative births are more likely in the late afternoon.. · OVBs are also less likely in the early morning.. · These temporal trends suggest the influence of provider and resource availability..

Abstract 4118777: Outcomes Of Patients With Hypertrophic Cardiomyopathy In Academic Versus Non-Academic Centers: Analysis from the National Inpatient Sample Database 2012-2020

Introduction: Hypertrophic Cardiomyopathy (HCM) is an uncommon heart condition associated with serious complications. Advances in medicine have improved its prognosis. Despite this, such potentially life-saving improvements concerning the implementation of best practices are not ubiquitous; guidelines recommend management at specialized centers. Unfortunately, not all hospitals have specialized HCM centers. However, given that a sizeable portion of these specialists are also in academic centers (ACs), we hypothesize that ACs may be better positioned than non-academic centers to provide the highest quality care for HCM patients. Purpose: Our study aimed to assess in-hospital outcomes and healthcare burdens among patient admissions with HCM diagnoses, comparing those treated at academic centers with those receiving care at non-academic centers. We examine all-cause in-hospital mortality, length of stay (LOS), hospital costs, and investigate ethnic differences in patients with HCM. Methods: The National Inpatient Sample database was utilized to obtain HCM patient hospitalizations from 2012 through 2020 in the United States. Patient hospitalizations for which adult patients had a primary diagnosis of HCM were identified. Outcomes included all-cause in-hospital death, LOS, and hospital costs. All-cause in-hospital mortality was evaluated using multivariable logistic regression analysis. Multivariable lognormal regression models were used to estimate LOS and inflation adjusted cost outcomes. Results: All-cause mortality unadjusted rates were 2.2% in non-teaching hospitals compared with 1.7% at teaching hospitals; however, this difference was not statistically significant ( p =.235). Both unadjusted and adjusted hospital LOS were 32% shorter for non-teaching hospitals ( p <.001). Both unadjusted and adjusted hospital costs were 46% lower for non-teaching hospitals compared to teaching hospitals ( p <.001; $37,829 vs $70,216). For both LOS and cost, the overall interaction between race and teaching status was statistically significant ( p < .001.) Conclusion: Our study shows variations in hospital outcomes and costs between teaching and non-teaching hospitals. Non-teaching hospitals displayed shorter stays and lower costs. Additionally, the interaction of race and teaching status significantly impacted length of stay and costs. These results underscore the necessity of tailored interventions to address healthcare delivery and resource inequities, especially in teaching hospitals.

Identifying and prioritizing inefficiency causes in Iran's health system.

Enhancing efficiency is crucial in addressing the escalating scarcity of healthcare resources. It plays a pivotal role in achieving Universal Health Coverage (UHC), with the ultimate goal of ensuring health equity for all. A fundamental strategy to bolster efficiency involves pinpointing the underlying causes of inefficiency within the healthcare system through empirical research. This study aimed to determine and prioritize the causes of inefficiency in Iran's health system. This mixed-method study comprised three phases. The initial phase involved identifying the causes of inefficiency through a comprehensive literature review of relevant studies published between January 1, 2010, to January 1, 2021. The causes were then aligned and prioritized using criteria derived from the literature and expert opinion. Finally, the identified causes were ranked based on their significance using Multiple-Criteria Decision Analysis (MCDA). From an initial pool of 307 causes of inefficiency, they were reduced to 121 causes in the first round of screening which were categorized into 13 thematic topics. The second screening process further narrowed the list to 48 causes. Among these, the leading causes of inefficiency included the inadequate supply and unequal distribution of hospital beds, the overuse of health services, and the mismanagement of the health workforce. In contrast, the use of traditional treatment methods was determined to be the least significant factor contributing to inefficiency. This study identified key inefficiencies in Iran's health system, such as resource misallocation, overuse of services, and workforce mismanagement. Addressing these issues is essential for optimizing resource utilization, enhancing service delivery, and achieving UHC. The findings suggest that policymakers should prioritize reforms in hospital bed distribution, implement strategies to reduce unnecessary health service use, and strengthen human resource management. Additionally, targeted policies that focus on decentralizing healthcare decision-making and enhancing primary care could significantly improve system-wide efficiency. Future research should evaluate the effectiveness of these interventions and explore the role of digital health solutions in mitigating identified inefficiencies.

Clinical Benefits of Sustained Oral Nirmatrelvir/Ritonavir Use for the Outpatient Treatment of COVID-19: Findings from the Taiwanese Health Authority Perspective Using a Decision Tree Modeling Approach

Despite the observed clinical benefits of nirmatrelvir/ritonavir (NMV/r), it is uncertain whether Taiwan will continue covering NMV/r for high-risk individuals with mild-to-moderate coronavirus disease 2019 (COVID-19). This analysis assessed the impact of sustained utilization of NMV/r on COVID-19-associated healthcare resource utilization (HCRU) and mortality from the Taiwanese health authority perspective (THAP). A decision tree model estimated the incremental number of clinical events associated with NMV/r utilization over a 30-day period. Model results compared (1) a base case using current rates of NMV/r from the THAP, and (2) a hypothetical scenario assuming the current supply of NMV/r is not extended in Taiwan. NMV/r utilization rates included 80% and 0% in the base case and hypothetical scenario, respectively. Outcomes included the number of hospitalizations involving a general ward (GW) stay, intensive care unit (ICU) stay, and mechanical ventilation (MV) use, as well as the number of bed days, symptom days, and hospitalization deaths. Based on epidemiologic data, 150,255 patients with COVID-19 were eligible for treatment from the THAP. In the hypothetical scenario, HCRU increased by 175% compared to the base case, including increases in hospitalizations involving GW, ICU, and MV use (differences: 2067; 623; 591, respectively), bed days (difference: 51,521), symptom days (difference: 51,714), and deaths (difference: 480). Findings indicate that sustained utilization of NMV/r from the THAP reduces the clinical burden of mild-to-moderate COVID-19 through the reduced incidence of COVID-19-related HCRU and deaths.

Abstract 4134851: Demographic and regional disparities in cerebrovascular disease mortality among adult patients with pre-existing atherosclerosis in the United States from 1999-2020

Introduction: Atherosclerosis (ATH) is a major risk factor for cerebrovascular disease (CEVD), with persistent mortality disparities. Our study aims to identify vulnerable regions and demographics in the US adult population with pre-existing ATH at risk of CEVD. Methods: CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to access National Vital Statistics System data from 1999 to 2020. ATH-related CEVD was identified using CEVD as the underlying cause of death and ATH as a contributing cause of death. Results were presented as age-adjusted mortality rates (AAMR) per 100,000 population. Joinpoint regression was used to examine changes in trend and annual percentage change (APC). Results: A total of 325,408 CEVD occurred in patients with ATH from 1999 to 2020 (AAMR = 6.9, 95% CI: 6.8-7). Increased mortality rates were observed in males (AAMR = 6.3) as compared to females (AAMR = 5.1) (Figure, Panel A). AAMRs were highest in Non-Hispanic Whites [NHW] (5.7, 95% CI: 5.7 - 5.8), followed by non-Hispanic blacks [NHB] (5.5, 95% CI: 5.4 - 5.5), Hispanics (4.1, 95% CI: 4.0 - 4.1) and non-Hispanic American Indian/Alaska Native [NH-AIAN] (3.6, 95% CI: 3.4 - 3.8). Non-Hispanic Asian/Pacific Islander [NH-API] had the lowest mortality rates (3.4, 95% CI: 3.4 - 3.5). Region-wise analysis revealed that mortality rates were highest in the West (6.4, 95% CI: 6.3-6.4) and Midwest (6.2, 95% CI: 6.1-6.2). The South reported the rate of 5.5 (95% CI: 5.5-5.6), while the Northeast had the lowest rate (4.4, 95% CI: 4.3-4.4). Mortality rates were consistently higher in rural areas (6.1, 95% CI: 6.0-6.1) compared to urban areas (5.3, 95% CI: 5.3-5.4) throughout the study period. Overall AAMR rose from 9.0 in 1999 to 10.4 in 2001, then steadily declined before increasing to 3.6 from 2016 to 2020 (APC: 0.41). After an initial decline, AAMR increased in men (APC: 1.09) from 2016 and in women (APC: 5.09) from 2018. AAMR also increased among NH-API (APC: 8.9) and NHB (APC: 8.3) from 2018 onwards, and NHW (APC: 0.1) from 2016 (Figure, Panel B). Conclusions: Our study reveals significant mortality disparities from CEVD in patients with ATH, identifying males, NHW, and residents in the West and Midwest as particularly at increased risk. Rural areas consistently show higher mortality rates than urban areas. These findings highlight the need for targeted interventions and strategic provision of healthcare resources to improve outcomes for vulnerable populations.

Abstract 4137461: Elevated Lipoprotein(a) Increases Cardiovascular-Related Healthcare Resources Utilization and Costs among US Medicare, Medicaid, and Commercial Enrollees with ASCVD

Background: Elevated lipoprotein(a) [Lp(a)] is a recognized genetic, independent, and causal risk driver for atherosclerotic cardiovascular disease (ASCVD). Less is known about how elevated Lp(a) affects downstream cardiovascular (CV)-related healthcare resource utilization (HCRU) and costs in patients with ASCVD. Objective: To assess the association of Lp(a) levels with CV-related HCRU (hospitalizations, outpatient and emergency department [ED) visits), and CV-related costs for patients with ASCVD in a national-scale multi-insurance cohort. Methods: Patients with ASCVD were pooled from US Medicare, commercial, and Medicaid health plans from 2017 to 2022. Lp(a) levels (mg/dL and nmol/L) were linked at the patient level with HealthVerity Lab Data. Elevated Lp(a) was defined as Lp(a)≥70mg/dL (≥ 175 nmol/L) and normal Lp(a) was defined as Lp(a)<30mg/dL (<75 nmol/L). Generalized linear models with log link negative binomial distribution (HCRU) and log link gamma distribution (costs) adjusted for age, sex, race, insurance type, comorbidities, statin use, and prior hospitalizations, measured the association of Lp(a) levels with the annualized rate of CV-related hospitalizations, ED visits, and outpatient visits (incidence rate ratio [IRR]) and CV-related costs (annualized cost ratio). Results: A total of 180,240 ASCVD patients were identified with Lp(a) values. Median (IQR) Lp(a) was 14 mg/dL (4 mg/dL – 48 mg/dL) or 35 nmol/L (12 nmol/L – 114 nmol/L). Mean (SD) age was 68.6 (12.0) years with 49.9% being female; 72.8% of patients were from Medicare, followed by commercial (21.8%) and Medicaid (5.4%). Fully adjusted CV-related HCRU was significantly higher in those with elevated Lp(a) compared to normal Lp(a): inpatient hospitalizations (IRR=1.11), outpatient visits (IRR=1.11) and ED visits (IRR=1.06), all p <0.001 (IRR and 95% CI reported in Table 1). Patients with elevated Lp(a) had 14% higher CV-related annualized healthcare costs than patients with normal Lp(a) (p <0.001) with significantly higher CV-related HCRU beginning with Lp(a) levels >30 mg/dL (>75 nmol/L). Conclusion: Elevated Lp(a) was significantly associated with greater CV-related HCRU and costs in patients with ASCVD.

Abstract 4132212: Trends in Atrial Fibrillation or Flutter Related Mortality Among Adults in the United States: Insights from CDC WONDER Database from 1999-2020

Background: Atrial fibrillation or flutter (Afib/AFL) incidence rates continue to rise and are linked to significant mortality, particularly in older populations. Our analysis examines Afib/AFL mortality trends across different demographics and regions in the U.S. from 1999 to 2020, highlighting the importance of understanding these patterns. Aim: To guide preventive measures that alleviate the impact of Afib/AFL and identify high-risk populations and regions, we sought to quantify trends associated with Afib/AFL related mortality in the U.S. Methods: We conducted a comprehensive search of death certificates from 1999-2020 using Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) database focusing on Afib/AFL mortality in adults with ICD-10 codes I48. Gender, race, geographical and urban-rural parameters were investigated by calculating annual percent change (APC) and age-adjusted mortality rates (AAMRs) per 100,000 persons using the Joinpoint Regression Program (Joinpoint V 4.9.0.0, National Cancer Institute). Results: A total of 2,581,488 deaths occurred in patients with Afib/AFL from 1999 to 2020. The AAMR displayed an abrupt rise from 2018 to 2020 (APC: 8.51; 95% CI: 4.84-10.47). Men consistently exhibited a higher AAMR (overall AAMR male: 79.4, 95% CI 79.3-79.6; female: 60.8, 95% CI 60.7-60.9). Non-metropolitan areas showed higher AAMRs than metropolitan areas (overall AAMR non-metropolitan areas: 74.9, 95% CI 74.7-75.1; metropolitan: 67.2, 95% CI 67.1-67.2). Disparities were also observed in AAMRs by region with the West region showing the highest mortality rate with a notable rise between 2010 and 2020 (APC: 3.70, 95% CI 3.30-5.37). Non-hispanic (NH) White population showed the highest mortality (overall AAMR: 74.2, 95% CI 74.1-74.3), followed by NH American Indian (AAMR: 50.3), NH Black (AAMR: 45.8), NH Asian (AAMR: 35.0) and Hispanic (AAMR: 37.9) populations. Conclusion: Mortality from Afib/AFL has risen from 1999 to 2020. Men, NH white populations, and residents in non-metropolitan areas and Western U.S. are at higher risk. Targeted interventions and strategic healthcare resource allocation are needed to address these disparities and improve outcomes.

Healthcare resource utilization and costs associated with first versus subsequent use of cariprazine for bipolar I disorder

Aims To evaluate the healthcare resource utilization (HRU) and costs of patients who initiated cariprazine as their first versus subsequent atypical antipsychotic (AA) following a bipolar I disorder (BP-I) diagnosis. Methods Adults with a BP-I diagnosis (first claim = index), commercial, Medicare Supplemental, or Medicaid insurance, and ≥1 outpatient cariprazine dispensing were identified from Merative MarketScan database. Cohorts included patients who initiated cariprazine as either their first or subsequent AA after initial BP-I diagnosis. Characteristics were balanced between cohorts using inverse probability of treatment weighting (IPTW). Outcomes evaluated post-index included all-cause and mental health (MH)–related HRU (hospitalizations, emergency department [ED] visits, outpatient visits), total healthcare costs (medical + pharmacy), and treatment patterns. HRU and healthcare costs were reported per patient-year (PPY) and compared between cohorts using rate ratios and 95% CIs estimated using nonparametric bootstrap procedures. Treatment patterns were analyzed descriptively, with standardized differences ≥10% considered important. Results After IPTW, cohorts included 1,409 patients who initiated cariprazine first and 1,621 patients who initiated cariprazine subsequently; the average (standard deviation, SD) observation period was 678 (373) and 758 (389) days for first and subsequent initiators, respectively. Patients who initiated cariprazine first had 23% fewer all-cause hospitalizations and 28% fewer MH-related hospitalizations PPY (each comparison, p < 0.001). Rates of all-cause and MH-related outpatient visits were significantly lower in patients who initiated cariprazine first versus subsequently (each comparison, p < 0.001), while rates of ED visits were similar. Relative to subsequent initiators, first initiators incurred $2,587 and $2,130 lower all-cause and MH-related total healthcare costs PPY, respectively (each comparison, p < 0.05). Before starting cariprazine, first initiators used fewer BP-I–related medications on average than subsequent initiators (2.6 vs 3.9; standardized difference = 23.9%). Limitations Potential coding inaccuracies and residual confounding. Conclusions In this real-world database analysis, patients with BP-I who initiated cariprazine as their first AA had lower rates of HRU and incurred lower costs than patients who initiated cariprazine as a subsequent AA.

Abstract 4138475: Comparative Outcomes of Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement in Patients with Right Heart Failure: Insights from Nationwide Readmission Database

Background: The annual number of transcatheter aortic valve implantation (TAVI) performed has surpassed that of surgical aortic valve replacement (SAVR) as its use expands to patient populations not included in initial clinical trials. However, in patients with Right Heart Failure (RHF), the outcomes of TAVI and SAVR remain unclear. Methods: We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2021. Using ICD-10 codes, we identified all adult admissions for TAVI and SAVR with the presence of RHF. The primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, 30-day readmission rate, length of stay, and total hospitalization charges. Results: The study included 3,712 adult patients with RHF, of which 1,386 (37.3%) underwent TAVI and 2,326 (62.7%) underwent SAVR. Compared to SAVR patients, TAVI patients were older (63 years vs. 76 years, p&lt;0.01) and had a higher burden of peripheral vascular disease, chronic liver disease, and coagulopathy, while SAVR patients had a higher burden of hypertension, diabetes mellitus, coronary artery disease, left heart failure, chronic lung disease, smoking, malignancy, and anemia. On multivariable analysis, compared to TAVI, SAVR was associated with higher odds of mortality (26.6% vs. 9.3%, p&lt;0.01), mechanical circulatory support use (41.5% vs. 9.22%, p&lt;0.01), respiratory failure (34.2% vs. 10.2%, p&lt;0.01), acute kidney injury (58.1% vs. 37.7%, p&lt;0.01), and need for blood transfusion (31.4% vs. 11.0%, p&lt;0.01). There was no difference in 30-day readmission (13.8% vs. 14.3%, p=0.51) and permanent pacemaker implantation (7.0% vs. 8.7%, p=0.33). SAVR was associated with a longer median hospital stay (14 days vs. 8 days, p&lt;0.01) and higher hospitalization charges ($406,826 vs $265,303, p&lt;0.01). When compared to patients wihout RHF, the presence of RHF predicted higher in-hospital mortality for both TAVI (9.3% vs. 1.2%, p&lt;0.01) as well as SAVR (26.6% vs. 3.7%, p&lt;0.01). Conclusions: From 2018 to 2021, more RHF patients underwent SAVR (62.7%) than TAVI (37.3%), but SAVR was associated with worse short-term outcomes, including higher in-hospital mortality, in-hospital complications, and healthcare resource utilization.

Abstract 4117180: Hyperkalemia-Related Hospitalization Associated with Short-Term vs. Long-Term Outpatient SZC Therapy Among RAASi Users: The GALVANIZE Outcome study

Introduction: Patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi) are at increased risk of developing hyperkalemia (HK). Sodium zirconium cyclosilicate (SZC) is used to treat HK, but the impact of duration of SZC on healthcare resource utilization (HRU) in RAASi users is unknown. The GALVANIZE Outcome study compared HK-related HRU among RAASi users between long-term and short-term SZC users. Methods: Adults with ≥1 outpatient prescription for SZC (index date) and ≥1 RAASi prescription spanning the index date were identified from a large US insurance claims database (7/2018-12/2022) and were stratified based on duration of SZC use. Long-term SZC users (&gt;90 days) and short-term SZC users (≤30 days) were exactly and propensity score matched on key baseline characteristics. Rates of HK-related hospitalizations or emergency department (ED) visits, HK-related ED visits, and HK-related hospitalizations were compared during follow-up from index to the earliest of 6 months post-index, end of data availability, other potassium binder use, or re-initiation of SZC post-discontinuation. Results: Among 1,586 matched pairs, the mean age was 65.5 years, 41.0% of patients were female, and most patients had any stage chronic kidney disease (91.9%), hypertension (90.8%), and diabetes (73.4%). Also, 30.0% of patients had heart failure. The most used RAASi therapies at index were angiotensin-converting enzyme inhibitors (57.3%) and angiotensin-receptor blockers (56.3%). Patients with long-term SZC use had a 44% lower rate of HK-related hospitalizations or ED visits, a 41% lower rate of HK-related hospitalizations and a 52% lower rate of HK-related ED visits than patients with short-term SZC use during follow-up (all p&lt;0.01; Figure 1). Conclusions: Among patients with RAASi and SZC therapy use, long-term SZC use was associated with significantly lower rates of HK-related HRU compared to matched patients with short-term SZC use. Funding: AstraZeneca

From Clinical to Non-clinical Outcomes in the Treatment of HIV: An Economic and Organizational Impact Assessment.

The aim of this study was to define the economic and organizational impacts related to a broader utilization of bictegravir/emtricitabine/alafenamide (BIC/FTC/TAF) in Italian clinical practice. A budget impact analysis-representing the evolution of the Italian National Healthcare Service (NHS) healthcare expenditure over 3years-was developed, considering the overall Italian population treated for human immunodeficiency virus (HIV). Model input variables were treatment history, therapeutic regimen, development of adverse events, achievement of an undetectable viral load and total direct healthcare costs. Besides the BIA, an organizational impact assessment was conducted to determine the impact on the use of healthcare resources, assessing the release of organizational hospital assets, focusing on the management of drug-related adverse events. Data were collected from scientific evidence, Italian national and regional legislations and healthcare professionals' reports. To verify the robustness of the economic and organizational impact assessment, sensitivity analyses were performed. Results demonstrate economic savings of about 26million euros in total health spending, assuming a higher penetration rate for BIC/FTC/TAF. This change in the current case mix would lead to a reduction in the specific costs related to adverse event management (0.9million euros; -2.09%) and in the medical management of patients (38million euros; -7.79%), with a positive impact on the achievement of virological control. From an organizational perspective, a wider use of BIC/FTC/TAF generates a reduction in the utilization of healthcare resources due to a decrease in adverse events and complications. The model estimated a 19.64% reduction in HIV-related inpatient days, which freed up healthcare professional time. Capable of improving both economic and organizational sustainability for the entire HIV care continuum, BIC/FTC/TAF is an efficient therapeutic strategy for people with HIV.

A systematic literature review on public health and healthcare resources for pandemic preparedness planning.

Generating insights into resource demands during outbreaks is an important aspect of pandemic preparedness. The EU PANDEM-2 project used resource modelling to explore the demand profile for key resources during pandemic scenarios. This review aimed to identify public health and healthcare resources needed to respond to pandemic threats and the ranges of parameter values on the use of these resources for pandemic influenza (including the novel influenza A(H1N1)pdm09 pandemic) and the COVID-19 pandemic, to support modelling activities. We conducted a systematic literature review and searched Embase and Medline databases (1995 - June 2023) for articles that included a model, scenario, or simulation of pandemic resources and/or describe resource parameters, for example personal protective equipment (PPE) usage, length of stay (LoS) in intensive care unit (ICU), or vaccine efficacy. Papers with data on resource parameters from all countries were included. We identified 2754 articles of which 147 were included in the final review. Forty-six different resource parameters with values related to non-ICU beds (n = 43 articles), ICU beds (n = 57), mechanical ventilation (n = 39), healthcare workers (n = 12), pharmaceuticals (n = 21), PPE (n = 8), vaccines (n = 26), and testing and tracing (n = 19). Differences between resource types related to pandemic influenza and COVID-19 were observed, for example on mechanical ventilation (mostly for COVID-19) and testing & tracing (all for COVID-19). This review provides an overview of public health and healthcare resources with associated parameters in the context of pandemic influenza and the COVID-19 pandemic. Providing insight into the ranges of plausible parameter values on the use of public health and healthcare resources improves the accuracy of results of modelling different scenarios, and thus decision-making by policy makers and hospital planners. This review also highlights a scarcity of published data on important public health resources.

Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021.

The COVID-19 pandemic overwhelmed health systems, resulting in a surge in excess deaths. This study clustered countries based on excess mortality to understand their response to the pandemic and the influence of various factors on excess mortality within each cluster. This ecological study is part of the COVID-19 MORtality (C-MOR) Consortium. Mortality data were gathered from 21 countries and were previously used to calculate weekly all-cause excess mortality. Thirty exposure variables were considered in five categories as factors potentially associated with excess mortality: population factors, health care resources, socioeconomic factors, air pollution, and COVID-19 policy. Estimation of Latent Class Linear Mixed Model (LCMM) was used to cluster countries based on response trajectory and Generalized Linear Mixture Model (GLMM) for each cluster was run separately. Using LCMM, two clusters were reached. Among 21 countries, Brazil, the USA, Georgia, and Poland were assigned to a separate cluster, with the mean of excess mortality z-score in 2020 and 2021 around 4.4, compared to 1.5 for all other countries assigned to the second cluster. In both clusters the population incidence of COVID-19 had the greatest positive relationship with excess mortality while interactions between the incidence of COVID-19, fully vaccinated people, and stringency index were negatively associated with excess mortality. Moreover, governmental variables (government revenue and government effectiveness) were the most protective against excess mortality. This study highlighted that clustering countries based on excess mortality can provide insights to gain a broader understanding of countries' responses to the pandemic and their effectiveness.

Promising strategies for the prevention of alcohol-related brain damage through optimised management of acute alcohol withdrawal: A focussed literature review.

There is an increasing awareness of the link between chronic alcohol consumption and the development of cognitive, behavioural and functional deficits. Currently, preventative strategies are limited and require engagement in dedicated long-term rehabilitation and sobriety services, the availability of which is low. The acute alcohol withdrawal syndrome is an episode of neurochemical imbalance leading to autonomic dysregulation, increased seizure risk and cognitive disorientation. In addition to harm from symptoms of alcohol withdrawal (e.g. seizures), the underpinning neurochemical changes may also lead to cytotoxicity through various cellular mechanisms, which long-term, may translate to some of the cognitive impairments observed in Alcohol-Related Brain Damage (ARBD). Here we review some of the pharmacological and neurochemical mechanisms underpinning alcohol withdrawal. We discuss the cellular and pharmacological basis of various potential neuroprotective strategies that warrant further exploration in clinical populations with a view to preventing the development of ARBD. Such strategies, when integrated into the clinical management of acute alcohol withdrawal, may impact large populations of individuals, who currently face limited dedicated service delivery and healthcare resource.

Alleviation of COVID-19 Symptoms and Reduction in Healthcare Utilization Among High-Risk Patients Treated With Nirmatrelvir/Ritonavir (NMV/R): A phase 3 randomized trial.

Nirmatrelvir/ritonavir (NMV/r) is an oral antiviral treatment for mild to moderate COVID-19. This phase 2/3, double-blind, randomized (1:1) study assessed oral NMV/r 300 mg/100 mg versus placebo every 12 hours for 5 days in high-risk, unvaccinated, nonhospitalized, symptomatic adults with COVID-19 from 343 sites across 21 countries. In testing the primary endpoint of COVID-19‒related hospitalization and all-cause deaths and key secondary endpoints including symptom duration and COVID-19‒related medical visits, Type I error was controlled with prespecified sequential testing and the Hochberg procedure. Among 2113 randomized patients enrolled from July 2021 through December 2021, 1966 (NMV/r, n=977; placebo, n=989) were included in the prespecified analysis population (symptom onset ≤5 days, did not receive monoclonal antibodies). NMV/r significantly reduced times to sustained alleviation (median, 13 vs 15 days; hazard ratio [HR]=1.27, p<0.0001) and resolution (16 vs 19 days; HR=1.20, p=0.0022) through Day 28 and significantly reduced the number of COVID-19‒related medical visits and the proportion of patients with such visits. Hospitalized patients treated with NMV/r had shorter stays, none required ICU admission or mechanical ventilation, and all were discharged to home/self-care. Fewer NMV/r-treated patients required additional treatment for COVID-19. No NMV/r-treated patients died through Week 24 compared with 15 placebo-treated patients. In addition to reducing COVID-19‒related hospitalization or death from any cause through Day 28, NMV/r was found to also reduce duration of COVID-19 symptoms and utilization of healthcare resources versus placebo in patients at high risk of progressing to severe disease. ClinicalTrials.gov, NCT04960202, https://clinicaltrials.gov/study/NCT04960202.