Health System Encounters Research Articles

Real-world evidence study on the impact of SPECT MPI, PET MPI, cCTA and stress echocardiography on downstream healthcare utilisation in patients with coronary artery disease in the US.

Coronary artery disease (CAD) is associated with a large clinical and economic burden. However, consensus on the optimal approach to CAD diagnosis is lacking. This study sought to compare downstream healthcare resource utilisation following different cardiac imaging modalities, to inform test selection for CAD diagnosis. Claims and electronic health records data from the Decision Resources Group Real-World Evidence US Data Repository were analysed for 2.5 million US patients who underwent single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI), positron emission tomography myocardial perfusion imaging (PET MPI), coronary computed tomography angiography (cCTA), or stress echocardiography between January 2016 and March 2018. Patients were stratified into nine cohorts based on suspected or existing CAD diagnosis, pre-test risk, and prior events or interventions. Downstream healthcare utilisation, including additional diagnostic imaging, coronary angiography, and cardiac-related health system encounters, was compared by cohort and index imaging modality. Among patients with suspected CAD diagnosed within 3 months of the index test, PET MPI was associated with lower downstream utilisation; 25-37% of patients who underwent PET MPI required additional downstream healthcare resources compared with 40-49% of patients who received SPECT MPI, 35-41% of patients who underwent cCTA, and 44-47% of patients who received stress echocardiography. Patients who underwent PET MPI experienced fewer acute cardiac events (5.3-9.4%) and generally had lower rates of healthcare encounters (0.8-4.1%) and invasive coronary angiography (ICA, 15.4-24.2%) than those who underwent other modalities. SPECT MPI was associated with more downstream ICA (31.3-38.2%) and a higher rate of cardiac events (9.5-13.2%) compared with PET MPI (5.3-9.4%) and cCTA (6.9-9.9%). Across all cohorts, additional diagnostic imaging was 1.6 to 4.7 times more frequent with cCTA compared with PET MPI. Choice of imaging modality for CAD diagnosis impacts downstream healthcare utilisation. PET MPI was associated with lower utilisation across multiple metrics compared with other imaging modalities studied.

Patient characteristics and health system encounters of decedents not marked deceased in the electronic health record.

Health systems are increasingly accountable for patients and require accurate electronic health record (EHR) vital status. We recently demonstrated that 19% of seriously ill primary care patients in one system were not marked dead in the EHR and 80% of these decedents had an encounter or appointment outstanding after death. Herein we describe the mechanism of identifying decedents whose death is not captured at the level of the EHR, characterize these decedents, and describe medications refilled after death. Description of multistep process to identify deceased patients not marked dead in the EHR among a cohort of seriously ill primary care patients including public death file matching, utilization analysis, and chart abstraction. We compared decedents not marked dead in the EHR to known decedents and described pharmacy requests and refills. Nearly 90% of encounters and appointments occurred because the health system EHR did not record the death although 11% of these encounters contained condolences or death notifications. Decedents not marked dead in the EHR were older and lived in more vulnerable areas than those marked dead. Of 146 refill requests after death, 88 medications were authorized. Matching with a limited public death file is an inadequate solution to inaccurate vital status. Better workflows are needed to capture deaths about which clinicians and staff are aware, but will identify only a fraction of the decedents inaccurately listed as alive. Efforts are needed to connect EHRs with more specific sources of linkable decedent information.

Health System Encounters after Loss to Cardiology Follow-Up among Patients with Congenital Heart Disease

To analyze receipt of care at other locations within a single rural academic health system after loss to follow-up in a cardiology clinic. Patients with congenital heart defects seen in the clinic during 2018 and subsequently lost to cardiology follow-up were included in the study. We defined loss to follow-up as not being seen in the clinic for at least 6months past the most recently recommended follow-up visit. Subsequent visits to other locations, including other subspecialty clinics, primary care clinics, the emergency department, and the hospital, were tracked through2020. Of 235 patients (median age 7years, 136/99 female/male), 96 (41%) were seen elsewhere in the health system. Of 96 patients with any follow-up, 40 were seen by a primary care provider and 46 by another specialist; 44 were seen in the emergency department and 12 more were hospitalized. Patients with medical comorbidities or Medicaid insurance and those living closer to the clinic were more likely to continue receiving care within the same health system. Patients with congenital heart defect are frequently lost to cardiology follow-up. Our study supports collaboration across specialties and between cardiology clinics and affiliated emergency departments to identify patients with congenital heart defect who have been lost to cardiology follow-up but remain within the health system. A combination of in-person and remote outreach to these patients may help them continue cardiology care.

Telehealth utilization in gynecologic oncology clinical trials

ObjectivePrior to the COVID-19 pandemic, telehealth visits and remote clinical trial operations (such as local collection of laboratory tests or imaging studies) were underutilized in gynecologic oncology clinical trials. Current literature on these operational changes provides anecdotal experience and expert opinion with few studies describing patient-level safety data. We aimed to evaluate the safety and feasibility of telehealth and remote clinical trial operations during the COVID-19 Pandemic. MethodsGynecologic oncology patients enrolled and actively receiving treatment on a clinical trial at a single, academic institution during the designated pre-Telehealth and Telehealth periods were identified. Patients with at least 1 provider or research coordinator telehealth visit were included. Patient demographics, health system encounters, adverse events, and protocol deviations were collected. Pairwise comparisons were performed between the pre-Telehealth and Telehealth period with each patient serving as their own control. ResultsThirty-one patients met inclusion criteria. Virtual provider visits and off-site laboratory testing increased during the Telehealth period. Delays in provider visits, imaging, and laboratory testing did not differ between time periods. Total and minor protocol deviations increased in incidence during the Telehealth period and were due to documentation of telehealth and deferment of non-therapeutic testing. Major protocol deviations, emergency department visits, admissions, and severe adverse events were of low incidence and did not differ between time periods. ConclusionsTelehealth and remote clinical trial operations appeared safe and did not compromise clinical trial protocols in a small, single institutional study. Larger scale evaluations of such trial adaptations should be performed to determine continued utility following the Pandemic.

Meaningful engagement through critical reflexivity: Engaging people with lived experience in continuing mental health professional development.

Engaging people with lived experience of mental health system encounters in the design and actualization of continuing professional development initiatives for mental health professionals can have transformative systemic impacts. Yet, despite evidence that involving people with lived experience benefits mental health professional education, far less focus has been placed on how to engage people with lived experience in continuing professional development initiatives. Tensions persist regarding the role of lived experience perspectives in continuing professional development, as well as how to establish people with lived experience as partners, educators and leaders in a thoughtful way. We propose that meaningful and equitable partnerships with people with lived experience can be realized by engaging in critical reflexivity and by systematically challenging assumptions. This paper explores three topics: (1) the current state of engagement with people with lived experience in continuing professional development initiatives; (2) barriers to meaningful engagement and (3) recommendations for using critical reflexivity to support the involvement and leadership of people with lived experience in continuing professional development for mental health professionals. PATIENT OR PUBLIC INVOLVEMENT: This viewpoint manuscript was co-designed and co-written by people with diverse lived and learned experiences. Each author's professional roles involve meaningfully and equitably partnering with and centring the perspectives of those with lived experience of mental health system encounters. In addition, approximately half of the authorship team identifies as having lived experience of accessing the psychiatric system and/or supporting family members who are navigating challenges related to mental health. These lived and learned experiences informed the conception and writing of this article.

A182 PREDICTING HIGH DIRECT HEALTHCARE COSTS IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN THE FIRST YEAR FOLLOWING DIAGNOSIS

Abstract Background The incidence of inflammatory bowel disease (IBD) continues to rise rapidly among Canadian children. The care of children results in higher direct healthcare costs than adults with IBD. It is imperative that we identify individuals who will become the highest-cost users of the health system in order to intervene early and decrease the individual- and system-level burden of IBD. Purpose To develop a predictive-model for high-cost health system users and (2) identify factors associated with high-cost healthcare use. Method Incident cases of IBD diagnosed ≤17y residing in Ontario and enrolled in the Canadian Children IBD Network (CIDsCaNN) between Dec 31 2013 and Jan 31 2019 were linked deterministically using health card number to health administrative data. Using a validated algorithm, direct healthcare costs accumulated between the 31st and 365th day after diagnosis were calculated using data from CIDsCaNN (medications) and health administrative data (health system encounters, including surgery). A predictive model was created to determine high-cost (≤25th percentile) and medium-cost (26th to 75th) users, compared to low-cost users (>75th) using ordinal logistic regression. Potential predictive variables were determined a priori based on clinical significance and magnitude of univariable association, based on sample size-informed degrees of freedom. Variables from CIDsCaNN data included: IBD type, age at diagnosis, sex, first line of therapy (steroids, aminosalicylates, exclusive enteral nutrition; yes or no, not mutually exclusive), disease activity (severe vs. moderate vs. none/mild based on PUCAI [UC] or wPCDAI [Crohn’s]). Predictive variables from the health administrative data included: rural/urban residence, hospitalization at diagnosis, intestinal resection or colectomy within 3 months of diagnosis, emergency department visit ±1 month of diagnosis, and a mental health encounter within the first year following diagnosis. Anti-TNF treatment was excluded from models due to the strong correlation with the outcome (direct costs). Overall model fit was estimated with a c-statistic. Result(s) Among the 487 (57% Crohn’s) children included in the study, the mean (sd) direct costs accumulated between the 31st and 365th days following IBD diagnosis was $14,451 (14,665). The mean cost among high-cost users was $33,533 (16,530); medium-cost users, $11,038 (5322); low-cost users, $2530 (831). The predictive model identified high-cost users of the health system with acceptable model fit (c-statistic 0.69). The relative contribution of individual variables, as measured by odds ratio (OR), is reported in the Table. Image Conclusion(s) The direct healthcare costs of pediatric IBD are substantial. Children with IBD who become high-cost users of the health system were identifiable using characteristics at diagnosis (e.g., need for mental health care, emergency visits, older age). Further research should assess whether interventions in patients at-risk for becoming high-cost users may help to reduce costs. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; Ontario Academic Health Sciences Centres Alternate Funding Plan Innovation Fund Disclosure of Interest E. Kuenzig: None Declared, R. Duchen: None Declared, T. Walters Grant / Research support from: Janssen, Abbvie, Psfizer, Ferring, Amgen, Consultant of: Janssen, Abbvie, Psfizer, Ferring, Amgen, D. Mack: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, C. Bernstein Grant / Research support from: Research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, Takeda, Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, W. Yu: None Declared, X. Wang: None Declared, J. Guan: None Declared, S. Fung: None Declared, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

Use Of Implantable Pulmonary Artery Pressure Monitoring To Guide Care Of Patients With Ambulatory Heart Failure; The First Three Years In A Real World, Single Center Experience

Introduction Use of implantable pulmonary artery pressure monitoring in select patients with heart failure (HF) has been associated with reduction in HF-related admissions and improved HF-specific health status. We sought to analyze real world data from a large tertiary referral center after three years of implants, to inform future patient selection and management. Methods Using retrospective chart abstraction, we collected data on baseline demographics and outcomes of interest for all patients implanted from 1/1/2017 through 12/31/2019 at a single center. Using paired t-tests, we compared frequency of relevant health system encounters in the year before and the year after implant. Results The study cohort (n=63) was comprised of 33% (n=21) females, mean (±SD) age of 72.7 (±10.7) yrs, 49% HFpEF (EF>50%; n=31), 5% HFmrEF (EF=40-50%; n=3), and 46% HFrEF (EF<40%, n=29). Mean (±SD) eGFR at implant was 45.7 (±16.9) ml/min: 16% CKD Stage 2 (eGFR 60-89 ml/min; n=10), 71% Stage 3 (eGFR 30-59 ml/min; n=45), and 13% Stage 4 (eGFR 15-30 ml/min; n=8). HF readmission within 30 dys after implant occurred in 8% of patients (n=5). In comparison of the year before vs the year after implant, patients experienced significant reductions in the frequency of nearly all health system encounters. (Table) In the first year post-implant, 3% of patients (n=2) underwent LVAD implant, 3% (n=2) had progression of CKD requiring initiation of dialysis, 8% (n=5) required device recalibration due to discordant pressure readings, and 20% (n=13) did not survive to one year post-implant. In sensitivity analysis with these 13 patients removed, results remained similar. Among the subset of patients with no HF ED visits/admissions in the year before implant who lived at least one year post-implant (n=11), frequency of HF clinic visits decreased significantly (mean [±SD] visits pre = 6.1 [±3.0] vs post = 2.6 [±1.4]; p=0.0054). Conclusion In this three-year, single-center experience using implantable pulmonary artery pressure monitoring to guide treatment of patients with HF, the study population experienced significant reductions in encounters with the health system, even in the absence of HF admissions in the year before implant, and despite event rates in the year post-implant implying a high acuity, highly morbid population. Use of implantable pulmonary artery pressure monitoring in select patients with heart failure (HF) has been associated with reduction in HF-related admissions and improved HF-specific health status. We sought to analyze real world data from a large tertiary referral center after three years of implants, to inform future patient selection and management. Using retrospective chart abstraction, we collected data on baseline demographics and outcomes of interest for all patients implanted from 1/1/2017 through 12/31/2019 at a single center. Using paired t-tests, we compared frequency of relevant health system encounters in the year before and the year after implant. The study cohort (n=63) was comprised of 33% (n=21) females, mean (±SD) age of 72.7 (±10.7) yrs, 49% HFpEF (EF>50%; n=31), 5% HFmrEF (EF=40-50%; n=3), and 46% HFrEF (EF<40%, n=29). Mean (±SD) eGFR at implant was 45.7 (±16.9) ml/min: 16% CKD Stage 2 (eGFR 60-89 ml/min; n=10), 71% Stage 3 (eGFR 30-59 ml/min; n=45), and 13% Stage 4 (eGFR 15-30 ml/min; n=8). HF readmission within 30 dys after implant occurred in 8% of patients (n=5). In comparison of the year before vs the year after implant, patients experienced significant reductions in the frequency of nearly all health system encounters. (Table) In the first year post-implant, 3% of patients (n=2) underwent LVAD implant, 3% (n=2) had progression of CKD requiring initiation of dialysis, 8% (n=5) required device recalibration due to discordant pressure readings, and 20% (n=13) did not survive to one year post-implant. In sensitivity analysis with these 13 patients removed, results remained similar. Among the subset of patients with no HF ED visits/admissions in the year before implant who lived at least one year post-implant (n=11), frequency of HF clinic visits decreased significantly (mean [±SD] visits pre = 6.1 [±3.0] vs post = 2.6 [±1.4]; p=0.0054). In this three-year, single-center experience using implantable pulmonary artery pressure monitoring to guide treatment of patients with HF, the study population experienced significant reductions in encounters with the health system, even in the absence of HF admissions in the year before implant, and despite event rates in the year post-implant implying a high acuity, highly morbid population.

Study protocol for the Innovative Support for Patients with SARS-COV-2 Infections Registry (INSPIRE): A longitudinal study of the medium and long-term sequelae of SARS-CoV-2 infection.

Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection. INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses. Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing. This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection.

B-PO03-006 PATIENT EXPERIENCE OF AN IMPLANTED CARDIAC MONITOR FOR HYPERTROPHIC CARDIOMYOPATHY

Hypertrophic cardiomyopathy (HCM) is considered the most common inherited heart disease affecting 1 in 500 individuals. Those with HCM are at increased risk of non-sustained ventricular tachycardia (NSVT) and sudden cardiac death. Guidelines recommend HCM patients undergo arrhythmia monitoring every 1-2 years to determine candidacy for primary prevention implantable cardioverter defibrillators (ICD). A variety of implantable cardiac monitors (ICMs) are currently approved for use with varying technology and interface platforms. Unlike other ICMs, the Abbott Confirm Rx™ ICM has the capability of connecting directly to the individual’s smart phone via Bluetooth technology. This enables real-time transmission of cardiac events, patient-reported symptoms and the potential for two-way communication with care providers enabling direct feedback of alert severity to the patient. The purpose of this study was to explore individuals’ experiences and understand the psychosocial effects of patients with HCM who underwent implantation of the Confirm Rx™ ICM and participated in a prospective trial looking at a novel two-way communication alert system. Using an exploratory qualitative approach, semi-structured interviews were conducted by telephone with 10 participants who received a Confirm Rx™ ICM. Analysis revealed three key themes 1) psychological impact 2) educational needs and 3) technology expectations. Participants reported that receiving feedback from real-time transmissions resulted in improved understanding of symptoms and reduced patient anxiety. Over time, this led to fewer health system encounters. Some participants reported uncertainty regarding when to send manual transmissions, identifying a possible gap in educational needs. Lastly, participants reported the smart phone app interface did not meet expectations with regards to the amount of data displayed to patients, with patients expecting more data available to them. Overall, participants report psychological benefit utilizing a smart phone app to facilitate two-way communication of ICM transmissions. Future directions include addressing gaps in educational needs and technology expectations and deliverables.

An Evaluation of Linked Administrative Data for Cancer Clinical Trial Economic Analysis

IntroductionEconomic analyses of well-conducted clinical trials are critical to rational health policy that informs value-based decision making. Trial economic analyses, such as cost-effectiveness analysis, often rely on trial-collected data, which are burdensome and expensive to collect. In contrast, administrative databases systematically collect health system encounters and are available at low cost for nearly all patients with cancer in Ontario, Canada, and many other jurisdictions.&#x0D; Objectives and ApproachWe investigated whether administrative data could improve the performance of trial economic analysis. Health administrative data were probabilistically linked to 148 Ontario patients from the Canadian Cancer Trials Group CO.17 trial (n=572), which evaluated cetuximab plus best supportive care (n=75) versus best supportive care alone (n=73) in previously treated metastatic colorectal cancer. Trial-collected resource utilization data and vital status were compared with administrative data. Cost-effectiveness in 2007 Canadian dollars according to administrative data was determined with bootstrap incremental cost-effectiveness ratio (ICER) confidence intervals (CIs).&#x0D; ResultsUp to trial date of last contact, administrative data vital status was concordant in &gt;96%. Twenty-nine subsequent deaths occurred. Up to trial last contact, there were 50 net additional hospitalizations and 33 net additional emergency department visits in administrative data. Total costs were $3,023,034 for the cetuximab group and $1,191,118 for the control group up to trial last contact. ICER was $211,128 per life-year gained (90% CI: $101,396 to $694,950) up to trial last contact and $164,378 (90% CI: -$138,260 to $644,555) up to administrative data last contact. ICER estimates were similar to analyses using trial-collected data.&#x0D; Conclusion/ImplicationsAdministrative data were more complete than trial data for hospital encounters, a key cost driver in economic analysis and there was longer follow-up. This study demonstrates the potential of administrative data to relieve the burden of collecting key data in cancer trials, which represents considerable effort and expense.

Health System Encounters in Kidney Transplant Recipients Converted from Immediate-Release Tacrolimus Capsules to Extended-Release Tacrolimus Tablets

Health System Encounters in Kidney Transplant Recipients Converted from Immediate-Release Tacrolimus Capsules to Extended-Release Tacrolimus Tablets

Clinical features of COVID-19 mortality: development and validation of a clinical prediction model

BackgroundThe COVID-19 pandemic has affected millions of individuals and caused hundreds of thousands of deaths worldwide. Predicting mortality among patients with COVID-19 who present with a spectrum of complications is very difficult, hindering the prognostication and management of the disease. We aimed to develop an accurate prediction model of COVID-19 mortality using unbiased computational methods, and identify the clinical features most predictive of this outcome.MethodsIn this prediction model development and validation study, we applied machine learning techniques to clinical data from a large cohort of patients with COVID-19 treated at the Mount Sinai Health System in New York City, NY, USA, to predict mortality. We analysed patient-level data captured in the Mount Sinai Data Warehouse database for individuals with a confirmed diagnosis of COVID-19 who had a health system encounter between March 9 and April 6, 2020. For initial analyses, we used patient data from March 9 to April 5, and randomly assigned (80:20) the patients to the development dataset or test dataset 1 (retrospective). Patient data for those with encounters on April 6, 2020, were used in test dataset 2 (prospective). We designed prediction models based on clinical features and patient characteristics during health system encounters to predict mortality using the development dataset. We assessed the resultant models in terms of the area under the receiver operating characteristic curve (AUC) score in the test datasets.FindingsUsing the development dataset (n=3841) and a systematic machine learning framework, we developed a COVID-19 mortality prediction model that showed high accuracy (AUC=0·91) when applied to test datasets of retrospective (n=961) and prospective (n=249) patients. This model was based on three clinical features: patient's age, minimum oxygen saturation over the course of their medical encounter, and type of patient encounter (inpatient vs outpatient and telehealth visits).InterpretationAn accurate and parsimonious COVID-19 mortality prediction model based on three features might have utility in clinical settings to guide the management and prognostication of patients affected by this disease. External validation of this prediction model in other populations is needed.FundingNational Institutes of Health.

Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation

Objective Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk. Methods We retrospectively identified patients age 2–17 years seen in our rural ED for asthma exacerbation during 2016–2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits. Results The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114). Conclusions A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Factors associated with appropriate and low-value PSA testing

BackgroundProstate-specific antigen (PSA) testing for early detection of prostate cancer is low-value when it is not indicated by guidelines and the harms outweigh the benefits. In this retrospective cohort study, we identify provider and patient factors associated with PSA testing, particularly in situations where testing would be low-value. MethodsWe used electronic health record data from 2011 to 2018 representing 1,738,021 health system encounters in the United States. Using logistic generalized estimating equation models, we examined patient factors (age, comorbid illness, family history, race and prior PSA results), provider factors (gender, specialty, graduation year and medical school rank), and overall time trends associated with PSA testing in low-value and appropriate settings. ResultsComorbid illness (odds ratio (OR) 0.0 for 3+ conditions vs none) and no prior PSA testing (OR 0.2) were associated with a lower likelihood of PSA testing in low-value situations, while family history of prostate cancer (OR 1.6) and high prior PSA test results (OR 2.2 for PSA > 6 vs 0–1) were associated with a greater likelihood. Men aged 55–65 years were at greatest risk for PSA testing in low-value situations.The provider factor associated with PSA testing in low-value situations was specialty, with urologists being most likely (OR 2.3 versus advanced practice providers). Internal medicine physicians were more likely to perform PSA testing during low-value situations (OR 1.3 versus advanced practice providers) but much more likely to order a PSA test where appropriate (OR 2.2). All PSA testing decreased since 2011. ConclusionWe identified several patient and provider factors associated with PSA testing in low-value settings. Some aspects suggest attention to relevant factors for PSA testing in low-value settings (e.g. comorbid illness), while others may encourage PSA testing in low-value settings (e.g. family history). The greatest likelihood of PSA testing in low-value settings is among men within the age range most commonly recommended by guidelines.

Can Administrative Data Improve the Performance of Cancer Clinical Trial Economic Analyses?

Trial economic analyses, such as cost-effectiveness analysis, often rely on trial-collected data, which are burdensome and expensive to collect and may be incomplete. In contrast, administrative databases systematically collect health system encounters. We investigated whether administrative data could improve the performance of cancer trial economic analysis. Health administrative data were probabilistically linked to Ontario patient data from the Canadian Cancer Trials Group CO.17 trial (n = 572), which evaluated cetuximab plus best supportive care (75 linked Ontario patients) versus best supportive care alone (73 patients) in previously treated metastatic colorectal cancer. Trial-collected resource utilization data and vital status were compared with administrative data. Cost effectiveness in 2007 Canadian dollars was determined with bootstrap incremental cost-effectiveness ratio (ICER) CIs. Up to trial date of last contact, administrative data vital status was concordant in more than 96%. Twenty-nine subsequent deaths occurred. Up to trial last contact, there were 50 net additional hospitalizations in administrative data and 33 net additional emergency department visits. Total costs were $3,023,034 for the cetuximab group and $1,191,118 for the control group up to trial last contact. The ICER was $211,128 per life-year gained (90% CI, $101,396 to $694,950) up to trial last contact and $164,378 (90% CI, -$138,260 to $644,555) up to administrative data last contact. ICER estimates were similar to the analysis using trial-collected data. Administrative data were more complete than trial data for hospital encounters, a key cost driver in economic analysis. There was a longer follow-up. This demonstrates the potential of administrative data to relieve the burden of collecting key data in cancer trials, which represents a considerable effort and expense.

Yield and bias in defining a cohort study baseline from electronic health record data

AimsDespite growing interest in using electronic health records (EHR) to create longitudinal cohort studies, the distribution and missingness of EHR data might introduce selection bias and information bias to such analyses. We aimed to examine the yield and potential for these healthcare process biases in defining a study baseline using EHR data, using the example of cholesterol and blood pressure (BP) measurements. MethodsWe created a virtual cohort study of cardiovascular disease (CVD) from patients with eligible cholesterol profiles in the New England (NE) and Southeast (SE) networks of the Veterans Health Administration in the United States. Using clinical data from the EHR, we plotted the yield of patients with BP measurements within an expanding timeframe around an index date of cholesterol testing. We compared three groups: (1) patients with BP from the exact index date; (2) patients with BP not on the index date but within the network-specific 90th percentile around the index date; and (3) patients with no BP within the network-specific 90th percentile. ResultsAmong 589,361 total patients in the two networks, 146,636 (61.0%) of 240,479 patients from NE and 289,906 (83.1%) of 348,882 patients from SE had BP measurements on the index date. Ninety percent had BP measured within 11 days of the index date in NE and within 5 days of the index date in SE. Group 3 in both networks had fewer available race data, fewer comorbidities and CVD medications, and fewer health system encounters. ConclusionsRequiring same-day risk factor measurement in the creation of a virtual CVD cohort study from EHR data might exclude 40% of eligible patients, but including patients with infrequent visits might introduce bias. Data visualization can inform study-specific strategies to address these challenges for the research use of EHR data.

Impact of a Cleft and Craniofacial Center on an Academic Health System.

The contributions of all physician specialties and ancillary services involved in cleft and craniofacial center care must be evaluated to fairly assess the financial impact of a cleft and craniofacial center. The authors hypothesized that the cleft and craniofacial center generates profitable downstream productivity for the academic health system. This was a retrospective cohort study of all patients who presented to a cleft and craniofacial center in the first quarter of 2011. Analysis included all health system encounters for each patient over a 2-year period using the electronic medical record and health system financial database. Sixty-two patients were seen (mean age, 11.4 years; 38 boys and 24 girls; 18 new and 44 established patients). Over 2 years, there were 618 health system encounters (599 outpatient and 19 inpatient encounters), 68 hospital days, and 110 procedures. The most common physician specialty was plastic surgery [312 encounters (50.5 percent)] and the most common ancillary service was speech therapy [256 encounters (41.4 percent)]. The overall reimbursement rate was 39.9 percent, with a majority payor-mix of government payors (62.1 percent). The total profit margin percentage from all encounters was 13.7 percent, which was greater for managed care compared with government payor (38.9 percent versus -10.8 percent; p = 0.022), inpatient compared to outpatient (24.5 percent versus -2.8 percent; p < 0.001), and plastic surgery compared to other specialty encounters (19.7 percent versus 8.7 percent; p = 0.003). The cleft and craniofacial center generated profitable downstream productivity for the academic health system with referrals to 39 different physician and nonphysician specialties. Health system providers and the business team should align to analyze the center, enhance patient outcomes, and improve specialty care access for patients.

P.3.d.027 - Food craving evolution in schizophrenic patients starting treatment with clozapine

This study sought to identify patient characteristics and care processes related to reengagement in VA psychotherapy.Using national VA data, a retrospective cohort was constructed (N = 24,492) of veterans who received a new PTSD diagnosis in FY08/FY09 and attended only one to five PTSD psychotherapy sessions. A nested case-control study was conducted comparing veterans who reengaged in psychotherapy (n = 9649) in a 1:5 ratio with those who did not reengage by the end of FY12. Conditional logistic regression models were run to examine differences in sociodemographic, mental health, and service utilization factors between cases and controls.Among veterans in the study cohort, 39.4% reengaged in psychotherapy. In adjusted analyses, all measured types of health system encounters (primary care [OR = 1.61], primary care mental health [OR = 1.61], non-PTSD psychotherapy [OR = 1.76], other non-PTSD mental health care [OR = 1.43], other non-psychotherapy PTSD care [OR = 3.31], emergency room [OR = 1.14], and psychiatric hospitalization [OR = 1.56]) were related to greater odds of reengagement in PTSD psychotherapy.Veterans' receipt of a broad range of care services may play an important role in reengagement in PCT psychotherapy, suggesting providers across care settings should be knowledgeable in how to support a Veteran's return to psychotherapy for PTSD.

Reengagement in PTSD psychotherapy: A case-control study.

This study sought to identify patient characteristics and care processes related to reengagement in VA psychotherapy. Using national VA data, a retrospective cohort was constructed (N=24,492) of veterans who received a new PTSD diagnosis in FY08/FY09 and attended only one to five PTSD psychotherapy sessions. A nested case-control study was conducted comparing veterans who reengaged in psychotherapy (n=9649) in a 1:5 ratio with those who did not reengage by the end of FY12. Conditional logistic regression models were run to examine differences in sociodemographic, mental health, and service utilization factors between cases and controls. Among veterans in the study cohort, 39.4% reengaged in psychotherapy. In adjusted analyses, all measured types of health system encounters (primary care [OR=1.61], primary care mental health [OR=1.61], non-PTSD psychotherapy [OR=1.76], other non-PTSD mental health care [OR=1.43], other non-psychotherapy PTSD care [OR=3.31], emergency room [OR=1.14], and psychiatric hospitalization [OR=1.56]) were related to greater odds of reengagement in PTSD psychotherapy. Veterans' receipt of a broad range of care services may play an important role in reengagement in PCT psychotherapy, suggesting providers across care settings should be knowledgeable in how to support a Veteran's return to psychotherapy for PTSD.

Telemedicine to Promote Patient Safety: Use of Phone-Based Interactive Voice-Response System to Reduce Adverse Safety Events in Pre-dialysis CKD.

CKD patients have several features conferring on them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired kidney function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated kidney function loss, acute kidney injury, ESRD, and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations that hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review, we summarize previous assessments of the pre-dialysis CKD populations' proficiency in using telemedicine modalities and describe the use of interactive voice-response system to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded interactive voice-response system use in CKD to address the safety threats inherent to this population.