High Utilization Group Research Articles

인공지능 학습기 기반 멘토링이 취약계층 초등학생의 학습격차 해소에 미치는 효과

This study examines the impact of artificial intelligence (AI) learning devices and community-based mentoring on underprivileged elementary students to alleviate post COVID 19 pandemic educational disparities. 104 school-aged students engaged in self directed learning with AI devices and received mentoring for 8 months. Data included device usage, attendance, pre-and post-assessment scores in Korean language and math, and self-reported learning efficacy. Results showed significant improvements in Korean language and math scores for students in the mentoring program. A ‘high-utilization group’ displayed notable gains in math scores and learning efficacy. This study underscores the potential of EdTech and community-based mentoring in bridging educational gaps for underprivileged students, suggesting a viable alternative to traditional schooling.

1082 Creation of a Spine Healthcare Resource Utilization Grouping (SHRUG) to Complement Patient-reported Outcome Measurements in Assessing Surgical Success

INTRODUCTION: Patient-reported outcome measures (PROs) are increasingly utilized to assess surgical success. However, when taken as the sole measure of surgical success they have limitations due to the requirement of collection time and infrastructure, response bias, and inherently subjective nature. The large volume of digital data generated by modern health systems may instead offer a method to track healthcare utilization and surgical outcome. METHODS: We retrospectively reviewed a consecutive patients undergoing elective surgery to the cervical and lumbar spine for degenerative pathologies at our institution. Pre- and post-operative 12-month change in PROMIS Global Health was collected. Post-operative measures of healthcare utilization included clinic visits, inpatient encounters, telephone encounters, opioid use, physical therapy, injections, and imaging. A SHRUG metric was then constructed through latent profile analysis. RESULTS: A total of 8039 surgeries were included in our analysis. Four utilization groups were identified: 1) low utilizer group, representing 53.9% of all patients; 2) moderate utilizer group (13.2%); 3) heterogenous utilizer group (25.2%); and 4) high utilizer group (7.7%). Patients were placed into one of four groups with high average probability (97%, 92%, 95%, 93% respectively). CONCLUSIONS: Our study developed a novel method for defining surgical outcomes based on healthcare utilization. These groupings have the potential to add an objective measure of operative success to supplement the use of PROs clinically. SHRUG can approximates PROMIS, nonbiased, provides new insight on outcome and healthcare utilization, and finally clinically feasible to implement.

Integrating Fall Prevention Strategies into EMS Services to Reduce Falls and Associated Healthcare Costs for Older Adults.

The purpose of this study is to detail the implementation of fall prevention initiatives through emergency medical services (EMS) and associated outcomes. Paramedics with MedStar Mobile Healthcare utilized the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention model to screen and direct intervention through 9-1-1 emergency response, High Utilization Group (HUG), and 30-day Hospital Readmission Avoidance (HRA) programs. Outcomes from 9-1-1 calls measured the number of older adults screened for falls and identified risk factors. The HUG and HRA programs measured change in quality of life with EuroQol-5D, referral service utilization, falls, emergent healthcare utilization, and hospital readmission data. Analysis included costs associated with reduced healthcare usage. Emergency paramedics provided fall risk screening for 50.5% (n=45,090) of adults aged 65 and older and 59.3% were at risk of falls, with 48.1% taking medications known to increase the risk of falls. Services provided through the HUG and HRA programs, along with additional needed referral services, resulted in a 37.2% reduction in fall-related 9-1-1 calls and a 29.5% increase in overall health status related to quality of life. Analysis of the HUG program revealed potential savings of over $1 million with a per-patient enrolled savings of $19,053. The HRA program demonstrated a 16.4% hospital readmission rate, in comparison to a regional average of 30.2%, and a cost-savings of $4.95 million or $15,618 per enrolled patient. Implementation of the STEADI model into EMS services provides an effective and cost-saving model for addressing fall prevention for older adults, provides meaningful and impactful improvement for older adults, and could serve as a model for other EMS programs.

결혼이주여성의 디지털 조력자 활용에 따른 잠재 유형 분류와 특성 비교

The purpose of this study is to classify latent classes according to the use of digital assistants by married migrant women, identify the influencing factors of each latent class, and compare the level of social capital and digital informatization for each class. As a result of LPA, it was classified into three types: 'high-utilization group', 'middle-utilization group', and 'low-utilization group'. In addition, as factors affecting the latent classes using R3STEP, age, education level, regional size, duration of residence, and country of origin variables were affected. As a result of examining whether there was a difference in the level of social capital and digital informatization between each type through DU3STEP, there was a significant difference in social capital in all three groups, and the level of digital informatization was different between the low-utilization group and the rest of the groups. This study is significant in that it provides a basis for clearly recognizing the factors affecting the digital information gap of marriage migrant women and establishing appropriate policies.

A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial

BackgroundChildren with medical complexity (CMC) often rely upon the use of multiple medications to sustain quality of life and control substantial symptom burden. Pediatric polypharmacy (≥ 5 concurrent medications) is prevalent and increases the risk of medication-related problems (MRPs). Although MRPs are associated with pediatric morbidity and healthcare utilization, polypharmacy is infrequently assessed during routine clinical care for CMC. The aim of this randomized controlled trial is to determine if a structured pharmacist-led Pediatric Medication Therapy Management (pMTM) intervention reduces MRP counts, as well as the secondary outcomes of symptom burden and acute healthcare utilization.MethodsThis is a hybrid type 2 randomized controlled trial assessing the effectiveness of pMTM compared to usual care in a large, patient-centered medical home for CMC. Eligible patients include all children ages 2–18 years old, with ≥ 1 complex chronic condition, and with ≥ 5 active medications, as well as their English-speaking primary caregivers. Child participants and their primary parental caregivers will be randomized to pMTM or usual care before a non-acute primary care visit and followed for 90 days. Using generalized linear models, the overall effectiveness of the intervention will be evaluated using total MRP counts at 90 days following pMTM intervention or usual care visit. Following attrition, a total of 296 CMC will contribute measurements at 90 days, which provides > 90% power to detect a clinically significant 1.0 reduction in total MRPs with an alpha level of 0.05. Secondary outcomes include Parent-Reported Outcomes of Symptoms (PRO-Sx) symptom burden scores and acute healthcare visit counts. Program replication costs will be assessed using time-driven activity-based scoring.DiscussionThis pMTM trial aims to test hypotheses that a patient-centered medication optimization intervention delivered by pediatric pharmacists will result in lower MRP counts, stable or improved symptom burdens, and fewer cumulative acute healthcare encounters at 90 days following pMTM compared to usual care. The results of this trial will be used to quantify medication-related outcomes, safety, and value for a high-utilization group of CMC, and outcomes may elucidate the role of integrated pharmacist services as a key component of outpatient complex care programs for this priority pediatric population.Trial RegistrationThis trial was prospectively registered at clinicaltrials.gov (NCT05761847) on Feb 25, 2023.

Factors Associated With Increased Laboratory Use in the Pediatric Cardiac Intensive Care Unit.

Laboratory testing is frequently used to guide postoperative management and contributes to hospital resource utilization; however, there is little evidence identifying patient or clinical factors to inform the appropriate frequency of laboratory testing in the pediatric cardiac intensive care unit. To examine the factors associated with increased laboratory utilization following pediatric congenital heart surgery. For each patient, the total number of tests and types of laboratory tests were recorded. Patients whose number of tests was greater than the 90th percentile were categorized as increased laboratory use. A sample of 250 unique patients and 909 nursing shifts were obtained for patient- and shift-level analyses. The top 10% of patients identified as the high laboratory utilization group (>128 laboratory tests). High-use group reported significantly younger patients and longer bypass time (P < .001). Patients in the highest Risk Adjustment for Congenital Heart Surgery 1 risk category were 34.7 times more likely to be in high laboratory utilization group (P = .006), independent of age at time of surgery and time on bypass (receiver operating characteristic curve = 0.855). At the shift level, time on bypass (P = .002), age younger than 30 days at surgery (P < .001), 3 to 5 years' registered nurse experience (P < .001), staff precepting (P = .03), and weekday shift status (P = .03) were all independently associated with high laboratory utilization. There are multiple factors associated with increased laboratory utilization. Recognition of specific patient and nursing factors can be used to impact patient management.

Characteristics of sickle cell patients with frequent emergency department visits and hospitalizations

Vaso-occlusive episodes (VOEs) are a hallmark of sickle cell disease (SCD), and account for >90% of health care encounters for this patient population. The Cooperative Study of Sickle Cell Disease, a large study enrolling >3000 patients, showed that the majority of SCD patients (80%) experienced 0-3 major pain crises/year. Only a small minority (~5%) experienced ≥6 VOEs/year. Our study sought to further understand this difference in VOE frequency between SCD patients. We analyzed 25 patients (13M/12F, mean age of 28.8) with ≥6 ED visits or hospitalizations/year (high utilizers), and compared these with 9 patients (6M/3F, mean age of 37.6) who had ≤2 ED visits or hospitalizations/year (low utilizers). All subjects were given a demographic survey along with questionnaires for depression, anxiety, and Health Locus of Control. Each subject then underwent quantitative sensory testing (QST) with three different modalities: pressure pain sensitivity, heat and cold sensitivity, and Von Frey monofilament testing. Laboratory and clinical data were collected through subjects' medical records. CBC and chemistry analysis showed high utilizers had higher WBC (p<0.01), ANC (p<0.01), total bilirubin (p = 0.02), and lower MCV (p = 0.03). Opioid use (morphine equivalents) over the past 6 months was significantly higher in the high utilizer group (12125.7 mg vs 2423.1 mg, p = 0.005). QST results showed lower pressure pain threshold at the ulna (224.4 KPa vs 338.9 KPa, p = 0.04) in the high utilizer group. High utilizers also had higher anxiety (9.0 vs 4.6, p = 0.04) and depression scores (10.0 vs 6.0, p = 0.051). While the low utilizer group had higher education levels with more associate and bachelor degrees (p = 0.009), there was no difference in income or employment. These data show that many biological and psychosocial factors contribute to high health care utilization in SCD. A multi-disciplinary and multi-faceted approach will be required to address this complex problem.

Health Care Utilization, Transition Readiness, and Quality of Life: A Latent Class Analysis.

To identify possible subgroups of health care utilization (HCU) patterns among adolescents and young adults (AYAs) with a chronic medical condition (CMC), and examine how these patterns relate to transition readiness and health-related quality of life (HRQoL). Undergraduates (N = 359; Mage=19.51 years, SD = 1.31) with a self-reported CMC (e.g., asthma, allergies, irritable bowel syndrome) completed measures of demographics, HCU (e.g., presence of specialty or adult providers, recent medical visits), transition readiness, and mental HRQoL (MHC) and physical HRQoL (PHC). Latent class analysis identified four distinct patterns of HCU. The BCH procedure evaluated how these patterns related to transition readiness and HRQoL outcomes. Based on seven indicators of HCU, a four-class model was found to have optimal fit. Classes were termed High Utilization (n = 95), Adult Primary Care Physician (PCP)-Moderate Utilization (n = 107), Family PCP-Moderate Utilization (n = 81), and Low Utilization (n = 76). Age, family income, and illness controllability predicted class membership. Class membership predicted transition readiness and PHC, but not MHC. The High Utilization group reported the highest transition readiness and the lowest HRQoL, while the Low Utilization group reported the lowest transition readiness and highest HRQoL. The present study characterizes the varying degrees to which AYAs with CMCs utilize health care. Our findings suggest poorer PHC may result in higher HCU, and that greater skills and health care engagement may not be sufficient for optimizing HRQoL. Future research should examine the High Utilization subgroup and their risk for poorer HRQoL.

Pediatric asthma hospitalization: individual and environmental characteristics of high utilizers in South Texas

Objective: Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma from a low-income community with a high number of hospitalizations. Methods: The study population included 902 children admitted at least once to a children’s hospital in South Texas because of asthma from 2010 to 2016. The population was divided into three groups by utilization frequency (high: ≥4 times, medium: 2–3 times, or low: 1 time). Individual-level factors at index admission and environmental factors were included for the analysis. Unadjusted and adjusted multivariate ordered logistic regression models were applied to identify significant characteristics of high hospital utilizers. Results: The high utilization group comprised 2.4% of total patients and accounted for substantial hospital resource utilization: 10.8% of all admissions and 13.5% of days stayed in the hospital. Patients in the high utilization group showed longer length of stay (LOS) and shorter time between admissions on average than the other two groups. The multivariate ordered logistic regression models revealed that age of 5–11 years (OR = 0.57, 95%CI = 0.35–0.93), longer LOS (2 days: OR = 1.80, 95%CI = 1.15–2.84; ≥3 days: OR = 3.38, 95%CI = 2.10–5.46), warm season at index admission (OR = 1.49, 95%CI = 1.01–2.20), and higher average ozone level in children’s residential neighborhoods (OR = 1.78, 95%CI = 1.01–3.14) were significantly associated with a higher number of asthma hospitalizations. Conclusions: The findings suggest the importance of monitoring high hospital utilizers and establishing strategies for such patients based on their characteristics to reduce repeated hospitalizations and to increase optimal use of hospital resources.

Trajectories of prescription opioids filled over time.

We performed a retrospective cohort study that aimed to identify one or more groups that followed a pattern of chronic, high prescription use and quantify individuals’ time-dependent probabilities of belonging to a high-utilizer group. We analyzed data from 52,456 adults age 18–45 who enrolled in Medicaid from 2009–2017 in Allegheny County, Pennsylvania who filled at least one prescription for an opioid analgesic. We used group-based trajectory modeling to identify groups of individuals with distinct patterns of prescription opioid use over time. We found the population to be comprised of three distinct trajectory groups. The first group comprised 83% of the population and filled few, if any, opioid prescriptions after their index prescription. The second group (12%) initially filled an average of one prescription per month, but declined over two years to near-zero. The third group (6%) demonstrated sustained high opioid prescriptions utilization. Using individual patients’ posterior probability of membership in the high utilization group, which can be updated iteratively over time as new information become available, we defined a sensitive threshold predictive of sustained future opioid utilization. We conclude that individuals at risk of sustained opioid utilization can be identified early in their clinical course from limited observational data.

Reduction in Hospital Days Using a Multidisciplinary Approach for Pediatric Patients with Sickle Cell Disease

Background: Pain crisis is the most frequent reason for admission in children with sickle cell disease (SCD). Frequent hospitalizations are associated with school absenteeism, emotional distress, and financial hardships. There is limited literature on initiatives to decrease admissions and hospital days in SCD pain crises. Prior studies have shown that individualized pain plans in emergency rooms can decrease admission rates and that a multidisciplinary approach with provider and patient education and close follow up can decrease 30-day readmission rates. Our goal was to decrease hospital days for pain crisis admissions by 40% over a 5-year period using a multidisciplinary approach.Methods: From September 2011 to August 2016 a multidisciplinary quality improvement project was conducted. A Plan-Do-Study-Act methodology was used. Five key drivers were identified and nine interventions were implemented. Interventions for the entire cohort included individualized home pain plans, emergency room and inpatient order sets, inpatient daily schedules, and a psychoeducation and biofeedback program. High utilizers, defined as ≥ 4 admissions per year, had an individualized SCD plan and were assigned a mental health provider. The high utilizer group was expanded to include at risk patients (3 admissions per year). Data was analyzed for all patients age 0-21 years admitted for SCD pain crises. The primary measure was hospital days, with 30-day readmission rate as a balancing measure.Results: 216 SCD patients were followed in 2011, with a 14% increase over the five year study period. From this cohort, a total of 122 patients were admitted for pain crises during this time. 48% of admitted patients were male, with a mean age of 10.68±5.65 years, and 72% had hemoglobin SS disease (16% SC, 5% Sβ0, 7% Sβ+). As shown in Table 1, the number of patients admitted decreased from 55 patients (25.4% of total SCD patients) in the pre-intervention period to 33 patients (13.3% of total SCD patients) in the final year of the intervention (p = 0.0014). The number of admissions decreased from 148 admissions in the pre-intervention period to 86 admissions in the final year of the intervention (54.7% decrease). The number of hospital days decreased by 61% from 59.6 days per month in the pre-intervention period to 23.2 days per month in the final year of the intervention (p < 0.0001). Number of high utilizers decreased from 13 patients in the pre-intervention period to 7 patients in the final year of the intervention. There was a 66% reduction in the number of hospital days in the high utilizer group compared to a 47% reduction in the low utilizer group. The 30-day readmission rate decreased from 33.9% pre-intervention to 19.4% in the final year of intervention. Special cause variation was first achieved in April 2014, 18 months after the start of all interventions, with a shift of the centerline from 59.6 days/month to 38.3 days/month and again in February 2016 with a decrease to 23.2 days/month (Figure 1). There was special cause variation in 30-day readmissions in April 2014 with a centerline shift in the 30-day readmission rate from 33.9% to 19.4%. The baseline direct hospital cost for SCD admissions was $909,000 per year. In the final year of the project, the average cost was $353,880 per year, with an overall annual savings of $555,120 in direct hospital costs.Conclusion: In this single center study, the multidisciplinary approach of effective home, emergency room, and inpatient pain management combined with increased mental health services for higher risk individuals proved to be effective in decreasing SCD pain crisis admissions and hospital days. A dedicated team effort with simple interventions had a significant impact on the well-being of the entire SCD population, but especially those who were more frequent utilizers of the healthcare system, while decreasing hospital costs, and can serve as a model for other institutions. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Implementation of an interdisciplinary care team to create individualized care plans for high risk oncology patients: A model to decrease aggressiveness of care at the end of life and improve cost effectiveness of care.

171 Background: Due to complexity of disease and treatments, oncology patients have among the highest hospitalization rate, especially towards End of Life (EOL). In our cancer institute, just 6% of all discharged patients accounted for &gt;40% of unplanned readmissions, and continue to be highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and under use of hospice care. We hypothesized that developing individualized care plans (ICP) for this high-utilization group will provide guidance in the complex care they require to reduce unnecessary and aggressive medical services. Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, and nurses. On a bimonthly basis, patients with at least two unplanned hospital readmissions over the last 60 days were identified. ICPs were created using a team-based approach with parallel input from patient’s primary outpatient providers. Results: A total of 36 patients, 226 hospitalizations, and 163 ED visits were evaluated over a 6-month period, with an average number of hospitalizations of 1.08 per patient month (ppm). After implementation of ICP, hospitalizations decreased to 0.23 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days. Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay. A dedicated focus from a team of experts, beyond disease biology, on a unique patient situation may result in improved patient experience with decreased aggressiveness of care at EOL and overall resource utilization.

77 Patterns of Emergency Department High Utilizers at Grady Memorial Hospital

High utilizers of emergency care represent an area of unmet need and can be a financial burden on the health care system. We aimed to identify emergency department (ED) high utilizers at Grady and determine the relationship between high utilizer patients and total visits. Previous studies have identified predictive factors associated with ED high utilizers at a specific setting. The demographics and clinical features of Grady high utilizers are also described. This retrospective study examined the electronic medical records of 216,522 patients with a total of 492,766 (ED) visits at Grady Hospital from November 2010 to March 2015. High utilizers were defined as patients with at least six ED visits in one year during the study period. Patient characteristics, diagnostic information, and ED operational measures were also examined. Data analysis was performed using descriptive statistics, chi-square tests, and independent samples t-tests. In this study, 2.6% of patients were high utilizers accounting for 25% of all visits. Of high utilizers, 69% were only high utilizers during one of the six calendar years included in the study period. High utilizers were more likely to be male (67% vs. 53%, p<.0001) and older than non-high utilizers (48.0 vs. 41.5, p<.0001). Sickle cell disease, substance abuse, chronic disease and mental health conditions were more frequent diagnoses in high-utilizer ED visits. The rate of leaving without being seen was significantly higher in the high utilizer group (21.3% vs. 11.2%, p<.0001). A small percentage (2.6%) of high utilizers made up one quarter of ED visits at Grady during the study period. These patients have a higher frequency of certain diagnoses than their non-high utilizer counterparts and tend to have transient patterns of high utilization. Further study is warranted to better understand and meet the unique needs of these patients.

Characteristics of Sickle Cell Patients with Frequent ED Visits and Hospitalizations: Demographic, Clinical, Laboratory and Psycho-Social Aspects

Vaso-occlusive episodes (VOE), are considered a hallmark of sickle cell disease (SCD), and account for >90% of health care encounters for this patient population. Although an orphan disease (total number of patients in the US ~110,000), SCD has a huge medical-economic impact, with annual hospitalization costs of nearly $ 0.5 billion by 2004 figures, mostly for VOEs. The Cooperative Study of Sickle Cell Disease (CSSCD) was a large natural history study, carried in 23 Centers in the US, enrolling >3000 patients between 1977-93. An analysis of the frequency of VOEs in CSSCD showed that the majority of patients (80%) experienced 0-3 major pain crises/year; this was similar across all genotypes of the disease (SS, SC, Sβ0 thalassemia, Sβ+ thalassemia). Only a small minority (~5%) experienced ≥6 VOEs/year. Similar findings have been reported in subsequent, smaller studies, with 5-10% of SCD patients with frequent ED visits and hospitalizations. Hydroxyurea (HU), the only disease modifying agent approved for adults with SCD, results in a ~50% reduction in the frequency of VOEs and hospitalizations. Despite this, HU is underutilized in SCD. Recent NIH evidence based guidelines includes strong recommendations for HU therapy in the majority of SCD patients. Although 230 of the 650 adult SCD patients at our Center are prescribed HU, in a recent study we found that ~40% of these patients were non-adherent, based upon their own admission, and/or the lack of anticipated change in several laboratory parameters (Hb F, MCV, Hb, WBC, reticulocyte and platelet count). A minority of SCD patients followed at our Center have frequent ED visits and hospitalizations. We conducted a study analyzing demographic, clinical, laboratory and psycho-social characteristics of 25 patients with ≥6 ED visits and hospitalizations per year (high utilizers), and compared these with 9 patients (controls) who experienced ≤2 ED visits/hospitalizations (low utilizers). Data on gender, age, genotype, number of ED visits and hospitalizations, CBC, chemistry panel, Hb F, HU usage, opioid use (morphine equivalents), education level, employment, annual income and marital status were collected. All subjects were also administered a depression, anxiety and Health Locus of Control Questionnaire, and underwent quantitative sensory testing (QST) with three different modalities: pressure pain sensitivity with a hand held, computerized algometer (AlgoMed, Medoc, Israel), heat and cold sensitivity (Q-Sense, Medoc, Israel) and Von Frey monofilament testing for neuropathic pain.Of the 25 patients (13M, 12F), 19 were SS, 4 SC, 1 SD-Los Angeles and 1 Sdβ-thalassemia. The median age was 28 (range 21-49). In the low utilizer group (6M, 3F) all were SS with a median age of 39 (range 23-46). The average number of hospitalizations in the high utilizer group was 15.6/year (range 6-33), while in the low utilizer group it was 0.44/year. Annual opioid usage as mg morphine equivalents was significantly higher in the high utilizers (12125.7 mg vs 2423.1 mg, p=0.0048). 19/25 (76%) of high utilizers, and 7/9 (78%) of low utilizers were on HU. Laboratory data on both groups are shown in Table 1. High utilizers had significantly higher WBC, ANC, total bilirubin and lower MCV. Hb F was also lower in the high utilizers (11.8% vs 17.5%) although this did not reach significance. QST results showed significantly lower pressure pain threshold at ulna (224.4 KPa vs 338.9 KPa, p=0.04), and higher baseline sensitivity with von Frey monofilament (0.92 vs 0.33, p=0.056) in the high utilizer group. High utilizers also had a higher anxiety score (9.0 vs 4.6, p=0.039) and depression score (10.0 vs 6.0, p=0.051). While the low utilizers had higher education levels with more associate and bachelor degrees (p=0.009), there was no difference in household income. These data show that multiple factors contribute to high health care utilization in SCD; these include biologic (younger age, disease severity as indicated by higher WBC and ANC, bilirubin, opioid induced hyperalgesia, and poor adherence to HU) as well as psycho-social factors (higher anxiety and depression scores, lower educational status). A multi-disciplinary and multi-faceted approach, including a sound patient education and transition program, a concerted effort to increase adherence to HU therapy, and psycho-social as well as pharmacologic approaches to anxiety and depression will be required to address this complex problem. [Display omitted] DisclosuresKutlar:Novartis Pharmaceuticals: Research Funding.

Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes.

ObjectiveTo investigate the association between the number of prenatal visits (PNV) and pregnancy outcomes in women with gestational diabetes (GDM) and Type 2 diabetes (DM).Study DesignA 4-year prospective cohort study of women with GDM and DM and was conducted. Patients ≥ 75th percentile for number of PNV were compared to those ≤ 25th percentile. The primary outcomes were large for gestational age (LGA) with birthweight > 90% and NICU admission for more than 24 hours. Secondary neonatal outcomes included severe LGA (>95%), shoulder dystocia, hyperbilirubinemia requiring phototherapy, neonatal hypoglycemia, low 5 minute APGAR score (<7) and preterm birth (prior to 37 weeks). Secondary maternal outcomes included mean 3rd trimester fasting blood glucose, hemoglobin A1c in labor, preeclampsia, gestational weight gain over Institute of Medicine recommendations, mode of delivery and maternal readmission within 30 days. Logistic regression was used to adjust for maternal race, nulliparity and BMI.ResultsOf 305 women, 4 were excluded for unknown number of PNV. Among the 301 included, the average number of visits was 12. Rates of LGA were similar between the high (28%) compared to low (18%) utilization groups (adjusted odds ratio [aOR] 1.69; 95% confidence interval [CI] 0.81–3.54). The high utilization group was 85% less likely to deliver an infant requiring NICU admission (aOR 0.15; 95% CI 0.04–0.53) and 59% less likely to have a preterm birth (aOR 0.41; 95% CI 0.21–0.80). A time-to-event analysis to account for the fact that patients who delivered earlier had fewer weeks to experience prenatal visits showed the risk for NICU admission was still significantly lower in the high prenatal visit utilization group (HR 0.15; 95% CI 0.04–0.51) after adjusting for confounders in a Cox proportional hazard model. The mean Hgb A1c at the time of delivery was significantly better in the high (6.4%) compared to low (6.9%) utilization groups (p=0.01). There were no differences in other maternal outcomes based on prenatal care utilization.ConclusionDiabetic women with high PNV utilization have better glycemic control in the 3 months prior to delivery and are significantly less likely to deliver preterm infants or infants requiring NICU admission. There may be innovative ways to provide prenatal care for GDM and DM to optimize maternal and neonatal outcomes.

Borderline Personality Disorder and High Utilization of Inpatient Psychiatric Hospitalization: Concordance Between Research and Clinical Diagnosis.

The goals of this study were to (1) assess prevalence rates of borderline personality disorder (BPD) in public mental health patients and (2) compare research assessment rates to clinical record rates in those with and without a history of high utilization of inpatient psychiatric hospitalization. One hundred and sixty participants randomly selected from county mental health centers were fully assessed. Among the non-high utilizers, 10% met criteria for BPD on research diagnosis, 4.5% on clinical record diagnosis, and 1.5% on both. Among high utilizers, 42% met criteria for BPD on research diagnosis, 19% on clinical record diagnosis, and 19% on both. For the non-high utilizers, the sensitivity of the clinical record diagnosis (compared to the gold standard of the research diagnosis) was 15% and the specificity was 97%. For the high utilizer group, the sensitivity of the clinical record diagnosis was 45% and specificity was 100% indicating that there was never an incorrect clinical diagnosis of BPD among the high utilizers. Thus, while the specificity of the clinical record was high, the sensitivity of the clinical record diagnosis was quite low, and the clinical record greatly underestimated the prevalence of BPD in this sample. Further, since effective outpatient treatment has been developed for these expensive high utilizers with BPD, the under-recognition of BPD has significant implications for the planning of outpatient mental health services in public sector settings.

High Resource Utilizers From The Multicenter Compact Study Of Complications In Patients With Sickle Cell Disease and Utilization Of Iron Chelation Therapy

IntroductionWhile treating patients (pts) with sickle cell disease (SCD) can be costly, costs are not evenly distributed across pts; rather, a minority of pts accounts for a majority of costs. Identifying those pts who consume a disproportionately large share of healthcare resources can assist payers and providers in directing appropriate and targeted interventions to deliver better pt care with lower costs. The objective of this study was to understand characteristics of pts who have increased utilization of inpatient (IP) and emergency department (ED) resources in a population of SCD pts ≥16 years old. MethodMedical records of 254 SCD pts ≥16 years old were retrospectively reviewed between 8/2011 and 7/2012 at three US tertiary care centers. The high utilization threshold was derived from the literature and defined as pts with ≥ 5 days of IP+ED care (assuming 1 day/ED visit) for SCD-related complications per year (high utilizer group). Pts were also classified into cohorts based on cumulative blood transfusion units and use iron chelation therapy (ICT): <15 units, no ICT (Cohort 1 [C1]), ≥15 units, no ICT (Cohort 2 [C2]), and ≥15 units, with ICT (Cohort 3 [C3]). SCD complication rates were expressed as the number of SCD complications per pt per year (PPPY); rate ratios (RRs) were used for cohort comparisons. A logistic regression was used to identify risk factors associated with high utilization of IP+ED care. ResultsOf the 254 pts (C1: 69, C2: 91, C3: 94), 30% (n =76) were classified as high utilizers (C1: 14 [18.4%], C2: 37 [48.7%], C3: 25 [32.9%]). Patients in the high utilizer group were younger (median [range] (21 years old [16-65], vs. 23 years old [16-59]) and had shorter follow-up (4.2 years [0.6-23.9], vs. 5.4 years [0.5-33.3]) compared to the rest of the sample. Those in the high utilizer group accounted for 68% of all SCD-related complications and over 88% of all IP+ED days for treatment of these complications. Similar to the rest of the sample, pain (81%) and infection (7%) were the two key complications seen in this high utilizer group. The rate of IP +ED days was significantly higher among the high utilizer group with 16.63 [16.28-16.99] IP+ED days PPPY compared to 0.89 [0.84-0.94] PPPY for other pts. Similarly, the high utilizer group had 4.58 [95% CI: 4.39-4.76] IP+ED visits PPPY, compared to 0.34 [0.31-0.37] visits PPPY for other pts (Table). Among regularly transfused pts (C2+C3) in the high utilizer group, those who received ICT had lower rates of IP+ED visits (C2 vs. C3 rate ratio [RR] [95% CI]: 1.31[1.20-1.44]), IP+ED days (C2 vs. C3 RR: 1.30 [1.24-1.36]), and readmission to IP+ED settings within 30 days (1.70 [1.49-1.93]) compared with those who did not (Table). History of infections (odds ratio: 7.45, p<0.0001) was associated with an increased risk of high utilization of IP+ED care. [Display omitted] ConclusionResults from this study show that a relatively small fraction of SCD pts account for the majority of IP+ED visits. Moreover, among regularly transfused pts identified as high utilizers, those who received ICT had lower rates of IP+ED utilization than those who did not. Pts receiving ICT may also receive closer monitoring, which may help with early identification and intervention to delay or prevent the development of complications and improve outcomes. Closer management of pts with SCD, especially those at risk of becoming high utilizers, is critical to lowering IP+ED utilization and reducing the overall costs of care. Disclosures:Jordan:Novartis Pharmaceuticals Corporation: Consultancy. Adams-Graves:Analysis Group, Inc.: Research Funding. Kanter-Washko:Analysis Group, Inc.: Research Funding. Oneal:Novartis Pharmaceuticals Corporation: Honoraria; Analysis Group, Inc.: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Vekeman:Novartis Pharmaceuticals: Research Funding. Bieri:Novartis Pharmaceuticals Corporation: Research Funding. Marcellari:Novartis Pharmaceuticals Corporation: Employment. Magestro:Novartis Pharmaceuticals: Employment. Adams:Novartis Pharmaceuticals Corporation: Research Funding. Duh:Novartis Pharmaceuticals: Research Funding.

Acute Care Visits in Sickle Cell Disease: a Population-Based Multi- State Study

Background: The number of times a patient will seek acute care in the emergency department or require hospitalization for sickle cell related illness has not been described in a population-based manner. Twenty years ago, rates of acute care visits for 3,578 patients who were part of the Cooperative Study of Sickle Cell Disease were reported, eloquently describing patterns of acute care utilization for people followed at select centers. In that study, only 1% of patients had more than six visits per year and 5% of the population (who made three to 10 visits per year) accounted for almost one-third of all visits. The objective of this study is to describe the emergency department and hospital utilization for patients with sickle cell related conditions over a two- year period. This study will be the first to provide a complete assessment of the utilization patterns of patients with sickle cell disease, one that is multi-state, inclusive of all ages, all insurance types, and includes patients that are followed at community, academic and tertiary care centers.Methods: We conducted a retrospective cohort study using 2005 and 2006 State Emergency Department and State Inpatient Databases that include encrypted personlevel identifiers to allow linkage of record level information. The data are from the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. Data for all sickle cell related emergency department visits and hospitalizations within the following seven states (Arizona, California, Florida, Missouri, South Carolina, Tennessee, and New York) were extracted for each patient. To be eligible, a patient had at least one sickle cell specific visit, defined as a visit with a principal diagnosis of sickle cell crisis or a secondary diagnosis of sickle cell disease with a principal diagnosis that was sickle cell related (e.g. pneumonia, stroke, fever). All sickle cell related visits were linked by unique personal identifiers, thus clustering visits by patient and allowing population-based statewide assessments of utilization. An emergency department visit on the same day as an inpatient hospitalization was counted only as an inpatient hospitalization to avoid over counting care-seeking visits. The distribution of acute care visits for each patient (presented as numbers of emergency department visits and hospitalizations over the two-year period) was determined for the entire cohort, then stratified as child versus adult.Results: A total of 24,668 patients with sickle cell disease made 86,535 acute care visits during the two-year study period, 33,520 (38.7%) were emergency department visits and 53,015 (61.3%) were inpatient visits. Of the 24,668 patients, 8,895 (36.1%) were less than 18 years of age; 15,773 were adults. 52.8% of the entire cohort made one visit in the two year period. 1,320 (5.4%) patients had more than 12 visits over the two-year time period; 3,210 (13.0%) made 6–20 visits over two years, and accounted for 31,752 (36.7%) acute care visits. An additional 579 (2.4%) patients had more than 20 visits over two years, accumulating 18,701 (21.6%) acute care visits. Children were less likely to have more than 12 visits over the two years (1.9%) compared to adults aged 18–45 (8.1%) and were also less likely to be in the high utilization group of 6–20 visits over two years (9.9% of children compared to 15.8% of those 18–45 years old).Conclusions: A significant proportion of patients with sickle cell disease seek acute care multiple times in an emergency department setting or through hospitalization. Our population-based study demonstrates an increased proportion of high utilizers compared to previous work, especially among adult patients. Our findings likely reflect the difference in healthcare utilization in the broader community as compared to that within a cooperative study in academic settings. It suggests that some patients, adults in particular, may have limited access to urgent care in a primary care setting and would benefit from better access and more aggressive preventive care. Further work on patterns of and reasons for utilization, especially emergency department care, in this high-utilizer group, would be helpful in targeting and improving overall care for these patients.

Predictors of physical therapy clinic performance in the treatment of patients with low back pain syndromes.

Little is known about organizational and service delivery factors related to quality of care in physical therapy. This study sought to identify characteristics related to differences in practice outcomes and service utilization. The sample comprised 114 outpatient clinics and 1,058 therapists who treated 16,281 patients with low back pain syndromes during the period 2000-2001. Clinics participated with the Focus on Therapeutic Outcomes, Inc (FOTO) database. Hierarchical linear models were used to risk adjust treatment outcomes and number of visits per treatment episode. Aggregated residual scores from these models were used to classify each clinic into 1 of 3 categories in each of 3 types of performance groups: (1) effectiveness, (2) utilization, and (3) overall performance (ie, composite measure of effectiveness and utilization). Relationships between clinic classification and the following independent variables were examined by multinomial logistic regression: years of therapist experience, number of physical therapists, ratio of physical therapists to physical therapist assistants, proportion of patients with low back pain syndromes, number of new patients per physical therapist per month, utilization of physical therapist assistants, and setting. Clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified in the low utilization group compared with the high utilization group, and 12.4 times more likely to be classified in the best performance group compared with the worst performance group. Serving a higher proportion of patients with low back pain syndromes was associated with an increased likelihood of being classified in the lowest or middle group. Years of physical therapist experience was inversely associated with being classified in the middle utilization group compared with the highest utilization group. These findings suggest that, in the treatment of patients with low back pain syndromes, clinics that are low utilizers of physical therapist assistants are more likely to provide superior care (ie, better patient outcomes and lower service use).

Grating writing model for materials with nonlinear photosensitive response

Presents a model for the growth of grating devices in materials with a nonlinear photosensitive response to incident radiation. We derive an expression for the written refractive index modulation in the material in terms of this photosensitive response and the incident fluence profile along the device. We investigate the validity of the model experimentally using gratings written in two optical fibers with very different photosensitivity response functions. These gratings are characterized both spatially and spectrally, through direct measurements of the refractive index modulation and the analysis of the spectral filter response. The results show good agreement with the model. We extend the analysis to show how to compensate for the nonlinear material response in order to achieve a desired grating design in a given material. This compensation method is used to improve the performance of a dispersion flattened grating device to display both high bandwidth utilization and low group delay ripple over the reflection band.