Higher Healthcare Utilization Research Articles

Impact of an automatic palliative care consultation trigger on healthcare use in patients with relapsed/refractory acute myeloid leukemia.

224 Background: Patients with relapsed/refractory acute myeloid leukemia (AML) have poor outcomes and high levels of healthcare use at end of life. Palliative care remains underused in hematology and questions remain on how best to integrate palliative care for high-risk patients. We conducted a prospective cohort study evaluating palliative care consultation triggers for patients admitted to a tertiary academic center with advanced AML. Methods: Criteria were developed for all hospitalized patients with hematologic malignancy on the inpatient hematology floors and included: 1) persistent disease after ≥ 2 lines of therapy, 2) length of stay (LOS) > 7 days for symptom management, 3) ECOG performance status > 2, and 4) refractory GVHD ≥ 3 lines of therapy. Patients with relapsed/refractory AML were included if they met criteria 1. A nurse coordinator performed chart review of admitted patients 1-2 times/week from June to December 2020 on the inpatient hematology floor at Smilow Cancer Hospital and contacted the primary team when patients met eligibility. Patient characteristics and healthcare outcomes were compared with patients with AML meeting criteria 1 admitted pre-intervention (June to December 2019) using Fisher t-tests. Results: A total 110 admitted patients were eligible (64 pre-intervention and 46 post-intervention). Baseline patient and disease characteristics were similar, including mean age at admission (60.4 vs 60.9 years, p = 0.848), gender (64% vs 59% male, p = 0.691), prior transplant (56% vs 52%, p = 0.702), and AML risk stratification (67% vs 78% adverse risk, p = 0.283). In the post-intervention group, 61% of eligible patients were screened. Of the screened patients, 54% received a palliative care consult, 18% were declined by the primary team, 14% were marked as not eligible, and 14% did not have consult with reason unspecified. Overall, palliative care consults increased in the post-intervention group (22% vs 43%, p = 0.021). There was a significant increase in advance care planning and/or advanced directive documentation post-intervention (13% vs 28%, p = 0.049). There was no differences in pre- and post-intervention groups in LOS (12.13 vs 12.33 days, p = 0.941), 30-day readmissions (52% vs 39%, p = 0.557), critical/intermediate care escalation (22% vs 13%, p = 0.318) and non-palliative chemotherapy post-discharge (48% vs 39%, p = 0.246). Conclusions: A triggered palliative care referral intervention is feasible and doubled palliative care use in patients with relapsed/refractory AML, a group with high mortality and high healthcare utilization. Our intervention improved documentation of advance care planning. Although there were directional reductions in other healthcare use measures, the differences were not statistically significant, likely from the small sample sizes leading to the study being underpowered.

Health care utilization of individuals with Rome IV irritable bowel syndrome in the general population.

BackgroundIrritable bowel syndrome (IBS) is highly prevalent worldwide but mechanisms for healthcare seeking behaviours in this patient group are poorly understood.ObjectiveTo describe healthcare utilization and identify factors associated with seeking healthcare amongst IBS subjects in the general population.MethodsAn internet survey was completed by 6,300 individuals equally distributed between United States, United Kingdom and Canada. The Rome IV diagnostic questionnaire was used to identify subjects with IBS. Data on demographics, medical history, gastrointestinal (GI) and non‐GI symptoms, quality of life and health care consumption was collected.ResultsA total of 5,931 subjects were included; 274 (4.6%) IBS subjects and 5657 (95.3%) non‐IBS controls. IBS subjects reported more doctor consultations for both GI and other health problems as well as increased use of medication and rate of abdominal surgery (appendectomy excluded). Having healthcare insurance or access to free public healthcare (adjusted odds ratio (AOR) 4.49, 95% confidence interval (CI) 1.31–15.44), followed by high frequency of bloating (AOR 2.65, 95% CI 1.42–4.93) and increasing age (AOR 1.02, 95% CI 1.01–1.05) were found to be independently associated with being an IBS consulter while doctor‐diagnosed IBS subjects were more likely to be female and to report abdominal pain as their most bothersome GI symptom than other consulters with IBS.ConclusionIBS subjects have higher healthcare utilization than non‐IBS controls, medication use and abdominal surgery included. Furthermore, consulters with and without an IBS diagnosis differ in sex distribution and symptom profiles. Hence, awareness of the possibility of unnecessary medical and surgical treatment in IBS subjects and a sex‐related diagnostic bias by doctors is warranted.

S198 Gender-Based Differences in Microscopic Colitis: Analysis of Demographics, Outcomes and Healthcare Utilization From a National Database

Introduction: Microscopic colitis (MC) is a chronic inflammatory bowel disease diagnosed histologically with a macroscopically normal large bowel. It is 2.4 times more common in women with over 75% patients >50 years old (Gastroenterol Hepatol 2017;13(11):671-5). Most MC studies are small with scarce data about its effects on healthcare utilization. The aim of our study was to evaluate gender-based differences in demographics, outcomes and healthcare utilization in MC from a national database Methods: The US Healthcare Cost and Utilization Project’s National Inpatient Sample (HCUP-NIS) 2016-2018 was queried to identify patients with MC using ICD-10 codes. We studied men and women for differences in patient and hospital demographics, comorbidities, complications, mean length of stay (LOS), mean Total Hospital Charges (THC), adjusted all-cause mortality. Statistical analysis utilized chi-square test, univariate and multinomial logistic regression Results: A total 7,145 MC admissions were identified with 1,965 men and 5,180 women (M:F ratio of 1:2.6). Overall, 90.5% were >50 years old (91.5% women and 88% men). Compared to men, women were non-significantly older (mean age 71.2 vs 69.2, P = 0.054), white (90.8% vs 86.7%, P = 0.2), less Hispanic (3.7% vs 7.2%, P = 0.2). Treating Hospital size, teaching status, region, income quartile zip codes where patients hailed from and insurance types were similar between groups. Men had significantly higher rates of diabetes, coronary artery disease, heart failure, chronic kidney disease and smoking (all P < 0.001) while women had higher rates of hypertension (P = 0.002). Dyslipidemia, obesity, COPD were similar between groups. Celiac disease and rheumatoid arthritis prevalence (known to increase risk of MC) was also similar. LOS was higher for men (5.3 vs 4.8 days, P = 0.023), non-significant when adjusted for patient and hospital demographics. THC were similar between the groups ($51,642 men vs $48,103 women, P = 0.14). There were 60 total deaths (0.8%) with no difference between the groups Conclusion: MC is more common with age with much higher proportion (>90%) of patients >50 years old than previously reported. Women had higher prevalence (M:F ratio 1:2.6). Women with MC were more likely to be white and less likely Hispanic. While men had significantly higher rates of medical co-morbidities than women, it did not translate into higher healthcare utilization, indicating the need to explore why women with MC are utilizing healthcare as much as men despite less medical problems.

Loss to Follow-Up and Health Care Utilization After Initial Diagnosis of Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic disease, but the extent of patient loss to follow-up (LTFU) and health care utilization has not been fully investigated. To determine frequency and predictors of LTFU and health care utilization in EoE patients. In this retrospective cohort study, we extracted data from patients with a new diagnosis of EoE. Follow-up time for each patient was calculated as the time from the first diagnostic endoscopy to the last GI-related contact date in the medical record. Patients with and without LTFU were compared, and the volume of EoE-related health care interactions was recorded. Of 944 EoE cases, 249 (26%) met the definition for LTFU. Major reasons for LTFU were never being scheduled (45%) and inability to contact patients (40%). Factors independently associated with regular follow-up were having insurance (aOR 2.89; 95% CI 1.85-4.50), white race (aOR 2.16; 95% CI 1.37-3.41), and longer symptom length (aOR 1.04 per year; 95% CI 1.01-1.08). At the time of last contact, patients with follow-up had better symptom response (55% vs. 12%; p < 0.001), improved esophageal caliber (14.3 vs. 12.4mm; p = 0.005), and more histologic response (45% vs. 4% at 15 eos/hpf; p < 0.001). Health care utilization was high, with an average of 4.6 endoscopies and 4.0 clinic visits over the follow-up period. LTFU of newly diagnosed EoE cases was common and associated with lack of insurance, non-white race, and shorter symptom duration. Those who followed up had high health care utilization but improved response rates. Strategies are needed to help decrease LTFU in EoE.

Co-Occurring Depression and Associated Healthcare Utilization and Expenditure in Individuals with Respiratory Condition: A Population-Based Study.

The existing literature is limited on the prevalence of depression among people with respiratory conditions and person-level factors that are associated with increased healthcare utilization and expenditures. The aim of this study was to explore the prevalence, pattern of healthcare use, and expenditures in noninstitutionalized individuals having co-occurring depression with respiratory conditions. The Medical Expenditure Panel Survey (MEPS) data from 2011 to 2017 was used in this study. Our sample included individuals having respiratory conditions (asthma, emphysema, and chronic bronchitis) with and without depression. Healthcare use and expenditure data were analyzed using a chi-square test, t-tests, and multiple linear regression analyses. There were 8848 individuals in the study. The prevalence of comorbid depression was 20%. Individuals with co-occurring depression with respiratory conditions differed significantly from individuals without co-occurring depression for age ≥ 45 years, white, and with ≤2 chronic disease conditions. Depressed individuals with respiratory conditions had higher healthcare utilization and expenditures. The presence of co-occurring depression with respiratory conditions increases the treatment complexity, healthcare utilization, and expenditure. Better treatment and management of these patients may reduce healthcare use and expenditures in the future.

Treatment of Gastric Antral Vascular Ectasia With Radiofrequency Ablation Does Not Improve Patient Outcomes

Gastric antral vascular ectasia (GAVE) affects between 4% and 30% of patients with cirrhosis and leads to high healthcare utilization.1,2 Some patients experience gastrointestinal bleeding, which is typically treated with argon plasma coagulation (APC).3-6 Radiofrequency ablation (RFA) is a promising intervention for GAVE which recurs despite APC treatment.6 We hypothesized that primary treatment with RFA would reduce hospital admissions, frequency of transfusions and time to repeat endoscopy when compared to APC treatment.

The Effect of Back Pain on Health Care Utilization and Costs

Introduction: We assessed the effect of self-reported back pain on health care utilization and costs in a population-based sample of Ontario adults.&#x0D; Methods: We conducted a population-based matched cohort study of Ontarian respondents aged ≥18 years of Canadian Community Health Survey (CCHS) from 2003-2012. CCHS data were individually linked to health administrative data to measure health care utilization and costs up to 2018. We propensity-score matched (hard-matched on sex) adults with self-reported back pain to those without back pain, accounting for sociodemographic, health-related, and behavioural factors. We evaluated back pain-specific and all-cause health care utilization and costs from healthcare payer perspective adjusted to 2018 Canadian dollars. Poisson and linear (log-transformed) models were used to assess healthcare utilization rates and costs. &#x0D; Results: After propensity-score matching, we identified 36,806 pairs (21,054 for women, 15,752 for men) of CCHS respondents with and without back pain (mean age 51 years; SD=18). Compared to propensity-score matched adults without back pain, adults with back pain had two times the rate of back pain-specific visits (women: rate ratio [RR] 2.06, 95% CI 1.88-2.25; men: RR 2.32, 95% CI 2.04-2.64), 1.1 times the rate of all-cause physician visits (women: RR 1.12, 95% CI 1.09-1.16; men: RR 1.10, 95% CI 1.05-1.14), and 1.2 times the costs (women: 1.21, 95% CI 1.16-1.27; men: 1.16, 95% CI 1.09-1.23). Incremental annual per-person costs were higher in adults with back pain versus those without (women: $395, 95% CI $281-$509; men: $196, 95% CI $94-$300), corresponding to $532 million for women and $227 million CAD for men annually in Ontario.&#x0D; Conclusions: Adults with back pain had considerably higher health care utilization and costs compared to adults without back pain. These findings provide the most recent, comprehensive, and high-quality estimates of the health system burden of back pain to inform healthcare policy and decision-making. New strategies to reduce the substantial burden of back pain are warranted.

Heavy clinical and economic burden of osteoporotic fracture among elderly female Medicare beneficiaries.

Postmenopausal women with osteoporosis are stratified to high and very-high fracture risk categories, and this categorization drives algorithms for osteoporosis management in osteoporosis treatment guidelines. This study comprehensively describes a very-high-risk cohort. This retrospective cohort study used the Medicare 20% database; elderly women with an outpatient visit in 2011 and fracture within 2 years before the visit were included. Outcomes included fracture risk, all-cause and fracture-related healthcare resource utilization and cost, and osteoporosis medication use in the 5 years after the visit. Overall, 43,193 patients were included. The 5-year probability was 0.36 for major fracture and 0.11 and 0.17 for hip fracture and vertebral fracture, respectively, much higher than the guidelines' 10-year probability thresholds for very-high-risk (0.3 for major fracture, 0.045 for hip fracture). Rates of hospitalizations, emergency department visits or observation stays, and skilled nursing facility stays in year 1 were 53.7, 57.0, and 18.8 per 100 patient-years, respectively, decreasing slightly in subsequent years. Mean healthcare cost was $23,700 in year 1, decreasing to $18,500 in year 5. About 29.1% of patients received osteoporosis medications in year 1, decreasing to 16.9% by year 5. Rates for all outcomes, especially fractures, were much higher among vertebral and multiple fracture cohorts. Elderly women with a fracture within last 2 years were at very-high-risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low. More effort is needed to identify and treat patients at very-high-risk for fracture.

Healthcare Utilization Among Justice‐Involved Individuals Enrolled in Medicaid: Lessons from a Midwestern State

Research ObjectiveJustice‐involved individuals have historically faced numerous barriers to accessing timely healthcare, especially after release from incarceration. This population disproportionately needs behavioral health services, for which continuity of care is crucial to prevent poor outcomes. To address this need, several states including Indiana have implemented policies to facilitate Medicaid enrollment for justice‐involved adults. Specifically, Indiana implemented policies and procedures, including Medicaid eligibility expansion through an 1115 waiver, the ability of the Indiana Department of Corrections (IDOC) to submit applications for coverage on behalf of the individuals prior to release, and allowing for coverage to be suspended rather than terminated during incarceration. Increased Medicaid coverage after release followed, but healthcare utilization patterns after release are not yet well understood. The purpose of this study is to describe healthcare utilization for individuals released from state prisons and enrolled in the Healthy Indiana Plan, Indiana's Medicaid coverage for adults.Study DesignIn this retrospective, observational study, we linked IDOC release data to Medicaid enrollment, claims data, and other state program data. We described trends in healthcare utilization in the four months following Medicaid coverage and further explore trends by time between release and Medicaid coverage.Population StudiedJustice‐involved adults released from IDOC state correctional facilities and subsequently enrolled in Medicaid between 2013‐2018 (n=19,636).Principal FindingsApproximately 80% of individuals received some sort of healthcare within the first 4 months of becoming enrolled in Medicaid, with the highest utilization occurring in the emergency department (ED, 44.1%) and office visits (41.2%). The average time to first service was approximately 55 days (SD: 37.4). The ED was the most common first setting for care (30.8%) and 20.3% of first encounters were for mental health and substance use‐related services. Those who were enrolled in Medicaid shortly after their release (within 7 days) were more likely to utilize any care compared to those who were enrolled later (89.5% vs 77.0%, p &lt;0.0001) and received care an average of 27 days quicker (p&lt;0.0001). In addition, those who were enrolled quickly were more likely to receive any care in almost all settings, receive substance use and mental health services, and seek care faster than those who were enrolled later.ConclusionsWe identify high healthcare utilization in this population after release from prison, largely higher than among the general population. In addition, we find that individuals who receive Medicaid coverage shortly after release are more likely to seek care in most settings and faster. While this may be indicative of better access to care, this may also be driven by selection or individuals becoming enrolled presumptively at the time of an acute encounter.Implications for Policy or PracticeThe transition that occurs when individuals are released from prison represents an important opportunity to fill gaps in coverage and facilitate continuous access to needed services. Findings from this study provide a better understanding of the patterns of healthcare utilized after release from prison, including the settings and types of care received. Further research is needed to understand of the extent to which Medicaid coverage improves behavioral health outcomes and chronic disease management.Primary Funding SourceState of Indiana

Epidemiology, Time Trends, and Outcomes of Serious Infections in Patients With Vasculitis: A Nineteen-Year National Study.

To examine the epidemiology, time trends, and outcomes and types of serious infections in people with vasculitis in the US. We identified people with vasculitis who were hospitalized with a primary diagnosis of pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections, or opportunistic infections in the 1998-2016 US National Inpatient Sample. We used adjusted logistic regression to examine the predictors of a hospital stay >3 days, total hospital charges greater than the median, discharge to a non-home setting, and in-hospital mortality. We noted 111,345 serious infections in patients with vasculitis (14% of all vasculitis hospitalizations). Among the patients, the mean age was 67.3 years, the Deyo-Charlson comorbidity index score was ≥2 in 54%, 37% were male, and 67% were White. The serious infection hospitalization rate per 100,000 US National Inpatient Sample claims in 1998-2000 versus 2015-2016 (and rates of increase) in patients with vasculitis was as follows: overall, 12.14 versus 25.15 (2.1-fold); opportunistic infections, 0.78 versus 0.83 (1.1-fold); skin and soft tissue infections, 1.38 versus 2.52 (1.8-fold); UTI, 0.35 versus 1.48 (4.2-fold); pneumonia, 7.10 versus 6.23 (0.9-fold); and sepsis, 2.53 versus 14.10 (5.6-fold). Pneumonia was the most common serious infection in 1998-2000 (58%) versus sepsis in 2015-2016 (56%). Sepsis, older age, Deyo-Charlson comorbidity index score of ≥2, urban hospital, or medium/large hospital (by number of beds) were associated with higher health care utilization and in-hospital mortality rates; Northeast region and Medicare and Medicaid payer type were associated with higher rates of health care utilization. Serious infection hospitalization rates are increasing in patients with vasculitis except among those with pneumonia. Sepsis was the most common serious infection in 2015-2016. Several patient and hospital factors are associated with health care utilization and mortality in serious infection hospitalization in vasculitis.

The Edmonton Symptom Assessment Scale in Heart Failure: A Systematic Review.

Heart failure is a troublesome condition with high healthcare utilization and cost. Most individuals with heart failure experience multiple symptoms including breathlessness, pain, depression, and anxiety. The aim of this study was to review the literature describing the use of the Edmonton Symptom Assessment Scale to assess the burden of symptoms and the impact of symptoms on heart failure outcomes including quality of life and functional outcomes. The search engines PubMed, Scopus, CINAHL, and Web of Science were searched from January 2001 to March 2020. A review of literature was undertaken using key terms "heart failure," "CHF," "cardiac failure," "heart decompensation," "myocardial failure," "Edmonton Symptom Assessment Scale". Hand searching of articles was also undertaken. The search resulted in 33 relevant articles, which were imported into Rayyan, a Web-based systematic review software program. We present synthesis of results of studies (1) using the Edmonton Symptom Assessment Scale as an assessment of symptom burden and (2) evaluating the impact of symptom burden on quality of life and functional status. This review highlighted the Edmonton Symptom Assessment Scale as a predictive instrument to identify symptom burden, symptom clusters, and symptom changes for patients living with heart failure. The clinical use of the Edmonton Symptom Assessment Scale may identify treatment priorities, promote self-management, inform the treatment plan, and advance effective therapeutic adjustments. The symptom burden in heart failure is high, and improving the symptom experience is an important focus of future healthcare interventions. The Edmonton Symptom Assessment Scale has utility in heart failure management due to psychometric properties and ease of administration. The Edmonton Symptom Assessment Scale may be useful in measuring patient-reported symptom burden in patients with heart failure in the clinical setting because it correlates well with other heart failure measures on quality of life and functional outcomes and provides useful information on symptom burden.

Influenza vaccination and mortality among adults with heart failure in an integrated healthcare delivery system, 2009-2018.

Influenza infection can result in decompensation or exacerbation of heart failure (HF) symptoms, hospitalization, and death. To examine the association of influenza vaccination with mortality and hospitalization during influenza and non-influenza seasons between 2009 and 2018. In this prospective, observational cohort study, we included Kaiser Permanente Southern California members with a HF diagnosis prior to September 1 each year from 2009 to 2017. The first influenza vaccination in each season (September 1 to May 31) was recorded. Vaccinated/unvaccinated patients were matched 1:1 on age, sex, and ejection fraction at the vaccination date (n-total = 74,870). Patients were followed through the end of each influenza season for all-cause mortality. Secondary outcomes included cardiovascular mortality and all-cause hospitalization. In a sensitivity analysis, we examined mortality in the non-influenza season. Influenza vaccinated vs unvaccinated patients had more comorbidities and higher healthcare utilization. After multivariable adjustment for utilization, sociodemographics, comorbidities, and medications, influenza vaccinated vs unvaccinated patients had a lower risk of all-cause mortality and cardiovascular mortality during the influenza season (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.63, 0.70 and HR 0.68, 95% CI 0.63, 0.74, respectively) but a higher risk of all-cause hospitalization (HR 1.27, 95% CI 1.21, 1.31). There was no association between influenza vaccination and all-cause or cardiovascular mortality during the non-influenza season (HR 0.99, 95% CI 0.89, 1.09 and HR 1.00, 95% CI 0.84, 1.21, respectively). Influenza vaccination in HF patients was associated with a lower risk of mortality during the influenza season. Our findings provide support for recommendations of universal influenza vaccination in patients with HF.

Geography as a Determinant of Health: Health Services Utilization of Pediatric Respiratory Illness in a Canadian Province.

Respiratory diseases contribute to high healthcare utilization rates among children. Although social inequalities play a major role in these conditions, little is known about the impact of geography as a determinant of health, particularly with regard to the difference between rural and urban centers. A regional geographic analysis was conducted using health repository data on singleton births between 2005 and 2010 in Alberta, Canada. Data were aggregated according to regional health sub-zones in the province and standardized prevalence ratios (SPRs) were determined for eight respiratory diseases (asthma, influenza, bronchitis, bronchiolitis, croup, pneumonia, and other upper and other lower respiratory tract infections). The results indicate that there are higher rates of healthcare utilization in northern compared to southern regions and in rural and remote regions compared to urban ones, after accounting for both material and social deprivation. Geography plays a role in discrepancies of healthcare utilization for pediatric respiratory diseases, and this can be used to inform the provision of health services and resource allocation across various regions.

Factors associated with persistent high health care utilization in managed Medicaid.

Prior studies have had difficulty predicting which patients will have persistent high utilization past 1year within the Medicaid population. The objective of this study was to examine the medical diagnoses at the time of enrollment of patients with persistent high health care utilization over 24 months following enrollment in Medicaid managed care in a large integrated care setting. Retrospective cohort study in a large integrated managed health care system. We identified a cohort of high utilizers (top 5% of health care costs in 2014) and extracted their electronic health record data (2014-2016). Differences in baseline characteristics of high utilizers and the general Medicaid population were determined using bivariate analysis. We used multivariable regression to determine the independent association between medical comorbidities and demographics with persistent high health care utilization over the 2 years following enrollment. Compared with the general Medicaid managed care enrollee population, schizophrenia was the only mental health diagnosis at the time of enrollment associated with persistent high health care utilization (risk ratio [RR], 1.50; 95% CI, 1.20-1.86). Additional characteristics associated with persistent high utilization included age between 31and 50 years (RR, 1.20; 95% CI, 1.02-1.41), dual enrollment in Medicaid and Medicare (RR, 1.26; 95% CI, 1.09-1.45), chronic pain diagnoses (RR, 1.26; 95% CI, 1.04-1.53), and multimorbidity (RR, 1.43; 95% CI, 1.25-1.63). Among adults newly enrolled in Medicaid managed care, certain diagnoses noted at the time of enrollment into the plan are associated with persistent high health care utilization over the first 2 years, suggesting that targeting early supportive case management to these individuals could optimize care and reduce health care costs.

The Role of Pediatric Health-care Providers in Promoting Students' Asthma Health.

The Role of Pediatric Health-care Providers in Promoting Students' Asthma Health.

Should children with asthma simply be treated as little adults?

Asthma is the most common chronic disease in children, affecting approximately 8.3% of children in the United States with considerable impact including school absenteeism, loss of parental workdays, and high health care utilization. Asthma remains common in adulthood, affecting approximately 7.7% of adults in the United States with continued mortality, morbidity, and financial implications. Asthma is a heterogenous disease that warrants distinct approaches between children and adults. First, we will discuss age-variant asthma phenotypes that drive the varying clinical presentations of asthma.

A systematic review of engagement in care and health care utilization among older adults living with HIV and non-communicable diseases

ABSTRACT It is critical to understand health care engagement and utilization among older persons living with HIV (OPWH) who may have greater burden for non-communicable diseases. Following the PRISMA guidelines, a systematic review using 5 electronic databases was conducted to appraise and synthesize the current literature on the relationship of non-communicable diseases on engagement in care and health care utilization among OPWH. Original studies published in English between 2009 and 2019 were included, yielding 16 relevant articles. Overall, having co-morbid non-communicable diseases was associated with a decreased likelihood of initiating and adhering to ART. Being on ART and viral suppression were associated with better engagement in non-communicable disease care. Findings also suggest that an increasing number of co-morbidities is associated with higher health care utilization and financial burden. This review underscores the need for preventing and managing co-morbidities to enhance engagement in HIV care and that health care practitioners need to ensure that OPWH are engaged in care for both HIV and their co-morbid conditions by providing coordinated and integrated care.

Health profiles of adults with autism spectrum disorder: Differences between women and men.

The purpose of the present study was to investigate the hypothesis that women with autism have poorer health compared with men with autism, and compared with women without autism. Utilizing electronic health records drawn from a single health care system serving over 2 million individuals, 2119 adults with diagnosed autism spectrum disorders were compared with age- and sex-matched controls. When considering health care utilization, we found evidence of multiplicative risk for conditions within some domains (i.e., nutrition conditions, neurologic disease, psychiatric conditions, and sleep disorders) such that women with autism spectrum disorder (ASD) experienced double jeopardy-meaning they had greater rates of health care utilization within a domain than what would separately be expected by virtue of being a woman and having ASD. For other domains (i.e., endocrine disorders, gastrointestinal disorders), the risk was additive such that being a female and having ASD were both associated with higher health care utilization, but there were no significant interaction effects. It was only with respect to one domain (cardiovascular) that rates of health care utilization were reflective of neither ASD diagnosis nor sex. Overall, our findings suggest that women with ASD are a vulnerable subgroup with high levels of health care utilization. LAY SUMMARY: This study asked whether women with autism have poorer health compared with men with autism, and compared with women without autism. To answer this question, we used data from electronic health records. We found that women with autism spectrum disorder (ASD) were at the greatest risk for health problems such as nutrition conditions, neurologic disease, psychiatric conditions, and sleep disorders. More research on health of women with ASD is needed.

Replicated Risk Index of Patient Functional Status Prior to Allogeneic Hematopoietic Cell Transplantation Predicts Healthcare Utilization and Survival

Poor physical functioning is associated with adverse outcomes after allogeneic hematopoietic cell transplantation (alloHCT). Analytic tools to predict mortality in alloHCT recipients include the HCT Comorbidity Index (HCT-CI) based on comorbidities and the Disease Risk Index (DRI) based on disease and disease status. We developed and replicated a risk model for overall survival (OS), early mortality (ie, death from any cause at or before day +100), initial hospital length of stay (LOS), and percentage of inpatient days within the first year post-alloHCT. In this study, we incorporated a physical therapy (PT) assessment with the HCT-CI and DRI to improve outcome predictions. The well-defined and feasible measure of functional status for assessing risk includes (1) the number of sit-to-stands performed in 30 seconds, (2) performance of 25 step-ups on the right/left side with (3) oxygen saturation recovery and (4) heart rate recovery, (5) weight-bearing ability, (6) assistance with ambulation, (7) motor and grip strength, (8) sensory and coordination impairment (eg, self-reported peripheral neuropathy, imbalance), (9) self-reported pain, and (10) limited endurance (ie, inability to complete step-ups and/or sit-to-stands). Our training cohort (TC) included 349 consecutive alloHCT recipients at Roswell Park treated between 2010 and 2016 and a subsequent replication cohort (RC; n=163) treated between 2016 and 2019. Four of the 10 metrics-self-reported pain, limited endurance, self-reported neuropathy, and <10 sit-to-stands in 30 seconds-were identified as significant predictors and were included in the multivariable models with the HCT-CI and DRI to create a new risk index (HCT-PCDRI: HCT-physical, comorbidity, and DRI) for outcomes. Models were tested in the RC. Shorter OS was associated with self-reported pain, limited endurance, higher HCT-CI, and higher DRI. At a median follow-up of 34 months, the 3-year OS based on the HCT-PCDRI was 30% for the very-high-risk group, 54% for the high-risk group, 49% for the intermediate-risk group, and 80% for the low-risk group. The number of patients identified as very high risk increased from 55 using HCT-CI alone to 120 with the new HCT-PCDRI, whereas the number in the low-risk group decreased from 91 to 45. Early mortality and a higher percentage of inpatient days within the first year post-alloHCT (a proxy for poor quality of life and high healthcare utilization) were associated with self-reported pain, higher HCT-CI, and higher DRI. A shorter initial LOS (ie, initial low healthcare utilization) was associated with performance of >10 sit-to-stands in 30 seconds, no self-reported neuropathy, and lower HCT-CI. These PT metrics combined with the HCT-CI and DRI created the HCT-PCDRI, which resulted in more patients being categorized accurately as high risk versus low risk. The HCT-PCDRI results were replicated in an independent cohort. Pre-alloHCT PT metrics with self-reported symptoms (pain and neuropathy) were associated with survival post-alloHCT and prolonged hospital LOS. The HCT-PCDRI scoring system for risk stratification of alloHCT recipients more accurately identifies patients at potential risk of poor outcomes. The HCT-PCDRI can be tested in <15 minutes to identify patients for intervention before or during treatment to potentially improve outcomes.

Healthcare Resource Utilization and Costs Associated with Different Treatment Modalities of Relapsed/Refractory Multiple Myeloma Patients in the US: Findings from Preamble

Introduction: Proteasome inhibitors (PIs), immunomodulatory drugs (IMiDs), and treatments involving both a PI and an IMiD (PI+IMiD) are the principal therapies for treating relapsed/refractory multiple myeloma (RRMM). The immuno-oncology (I-O) agents elotuzumab (elo) and daratumumab (dara) may bring new and promising solutions to patients (pts). The adoption of these treatments may come with high healthcare resource utilization (HCRU) and costs. It is important to further understand HCRU by different treatment modalities in real-world practice settings. Here we evaluate HCRU and costs in pts receiving different treatment modalities for RRMM.Methods: PREAMBLE is an ongoing, prospective, multinational, noninterventional observational study (NCT01838512). Pts ≥18 y of age with RRMM, ≥1 prior therapy, and who initiated treatment (index therapy) with a PI (including carfilzomib [carf], bortezomib [bort], and ixazomib), an IMiD (including lenalidomide [len], pomalidomide [pom], and thalidomide), an IMiD+PI combination, or I-O agents within 90 d before or 30 d after study consent were identified. Pt data were collected at each healthcare provider (HCP) visit, over 3 y or until the end of pt follow-up, including clinic/physician office visits, emergency room (ER) visits, hospital outpatient visits, hospitalizations, and home healthcare/other visits. Demographic and baseline characteristics were analyzed using descriptive statistics. The median duration of treatment (mDoT) was estimated using Kaplan-Meier (K-M) methods. HCRU was estimated using the mean number of incidents, per-1000-patients-per-month (1000 PPM) metric in a period up to 12 mo from start of index therapy (index date).Results: 341 pts (median age 67 y; 59% male) were enrolled in the US. At the time of data cut-off (May 27, 2017), 187 (55%) had withdrawn from the study; 117 (63%) of the withdrawn pts had died. Median (range) follow-up was 11.8 mo (<0.1, 41.2). At study entry, 30 pts were receiving I-O agent-based index therapy (dara, n=26; elo, n=4). Pts were divided into 4 cohorts based on index therapy: dara (26/337, 8%), PI (n=174, 52%; carf 92/174; bort 80/174), IMiD (n=75, 22%; pom 31/75), and IMiD+PI (n=62, 18%; bort+len 35/62). The 4 treatment cohorts were similar in sex, race, disease status, International Staging System stage, and comorbidities, although pts on dara received significantly more prior therapies than those on other treatments (Table). Of the 26 pts on dara, 31% (n=8) were still on treatment at the time of data cut-off, and of those who discontinued index therapy (n=18, 69%), 61% (n=11) were due to disease progression, which was higher than for other treatments (p=0.0468). The K-M estimate of mDoT for pts on dara was 4.2 mo, similar to that for PI (4.1 mo) but shorter than for other treatments (p=0.0305). In the PI cohort, carf had a shorter mDoT than bort (3.4 vs 5.2 mo). Of 3093 HCP visits overall, the most common type was clinic/physician office visits (n=2649, 86%), followed by ER visits/hospitalizations (n=233, 8%), and hospital outpatients (n=164, 5%). Per 1000 pts treated, pts receiving PI+IMiD had the most HCRU visits in a 1-mo period, vs least for dara (mean 1000 PPM: 1619 vs 1013 visits). This was also true for clinic/physician office visits and hospital outpatients (Table). Notably, mean 1000 PPM ER visits/hospitalizations were higher for pts receiving dara than for any other treatment (n=181, 18%). Among pts receiving a PI, those on carf had higher mean 1000 PPM total visits (n=1001) than those on bort (n=710); this remained true for each of the healthcare resource categories investigated in this study.Conclusions: Routine management of RRMM and treatment-related events drive HCRU, which may differ by treatment. This preliminary analysis suggests that pts on dara appear to have shorter mDoT and fewer outpatient visits, but more ER visits and hospitalizations, compared with pts on other treatments. Receiving carf appears to be associated with more HCRU visits overall, and for each of the healthcare resource categories compared with bort. The study is ongoing and further analysis will be necessary to better understand HCRU patterns observed with these new treatment modalities in clinical practice settings.Study support: Bristol-Myers Squibb. [Display omitted] DisclosuresKuter:Fujifilm: Consultancy; Dova: Consultancy, Membership on an entity's Board of Directors or advisory committees; ONO: Consultancy; 3SBIO: Consultancy; Protalex: Consultancy, Research Funding; Incyte: Consultancy, Research Funding; Rigel: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Merck: Consultancy; Syntimmune: Consultancy, Research Funding; Pfizer: Consultancy; Novartis: Consultancy; Zafgen: Consultancy; Genzyme: Consultancy; Shire: Consultancy, Research Funding; Amgen: Consultancy; Alexion: Consultancy, Research Funding; Argenx: Consultancy. Chen:Bristol-Myers Squibb: Employment. Popov:Parexel: Employment. Davis:Bristol-Myers Squibb: Employment. Vij:Takeda, Onyx: Research Funding; Celgene, Onyx, Takeda, Novartis, BMS, Sanofi, Janssen, Merck: Consultancy.