Higher Healthcare Utilization Research Articles

Cross-sectional study evaluating the association of haemophilia-related distress and clinically relevant outcomes.

In chronic diseases, disease-related distress can impact disease outcomes. Distress and haemophilia-related distress has been demonstrated in people with haemophilia (PwH). The association of haemophilia-related distress on disease outcomes among PwH is unknown. To study the association of haemophilia-related distress with haemophilia specific outcomes, including adherence to prophylactic therapy, the presence of a target joint, healthcare utilization and work-impairment. In a cross-sectional study, adults with haemophilia A or B were enrolled in a study to validate the haemophilia-related distress questionnaire (HRDq). In this planned analysis, univariate and multivariate associations between the HRDq total score and disease outcomes were explored. The 114 participants in this analysis were male, mostly with haemophilia A (92%) and severe disease (52%) with a median age of 31.9 years. On univariate analysis, HRDq total score (5-point change) was associated with the presence of a target joint (P=.002), high healthcare utilization (P=.011), poor adherence (P=.033) and work-impairment (P≤.001). After adjustment for age, race, severity and other potential confounders, adherence (aβ0.33, 95% CI .17, .49) and work-impairment (aβ4.69, 95% CI 3.27-6.1) remained statistically significantly associated with HRDq total score. Haemophilia-related distress is associated with poor adherence to factor prophylaxis and work-impairment. The direction of the association (causation) is yet to be determined and requires future study.

Acute-on-chronic liver failure: Controversies and consensus.

Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.

Prematurity, birth weight, and access to a medical home among school-aged children in the US: A cross-sectional survey

Introduction Prematurity and low birth weight (LBW) are associated with higher health care needs and higher health care utilization in the first few years of life. The aim of this cross-sectional study was to determine how prematurity and LBW were correlated with access to a medical home later in childhood, at ages 6–17 years. Methods Data were analyzed from the 2016–2018 National Survey of Children's Health. Non-institutionalized US children 6–17 years of age who had been born preterm were classified as very low birth weight (VLBW, <1500 g), LBW (1500–2500 g), and normal weight (NBW, >2500 g). Term-born NBW children were included as a reference group. Medical home access was determined according to caregiver report. Results The analysis included 64,597 infants (preterm VLBW n = 737; preterm LBW n = 2869; preterm NBW n = 3942; and term NBW n = 57,049). Based on this sample, 44% of children ages 6–17 years were estimated to receive care meeting the criteria of a medical home. On multivariable analysis, none of the preterm groups had higher likelihood of receiving care in a medical home compared to children born at term and NBW (odds ratios ranging from 0.75 to 0.95). Conclusions School-aged children born preterm and LBW were equally or less likely to receive care meeting the criteria of a medical home than children born at term and NBW. Although prematurity and LBW are associated with increased health care use early in the life course, this does not appear sufficient to help children establish and maintain access to a medical home.

Ceftolozane/tazobactam for the treatment of Pseudomonas aeruginosa infections: A multicenter case series analysis

IntroductionPseudomonas aeruginosa displays resistance to several available antibiotics. Infections caused by this pathogen are associated with a high mortality, morbidity, and considerable healthcare resource utilization and costs. This study was aimed at describing the use of ceftolozane/tazobactam (C/T) for the treatment of patients with P. aeruginosa infections. MethodsCase series analysis of hospitalized patients treated with C/T for P. aeruginosa infections in five public Portuguese hospitals. Patients presenting with infections caused by this pathogen and receiving C/T for at least 72h during hospitalization were eligible. ResultsSixty-four hospitalized patients with P. aeruginosa infections treated with C/T were evaluated between December 2016 and July 2019. Most patients were aged between 60 and 79 years (53.9%). Patients presented a total of 68 P. aeruginosa infections, with respiratory infections being the most common (28.1%, 18 out of 64). Most P. aeruginosa strains (85.9%, 55 out of 64) were extensively drug-resistant (XDR). C/T was mostly used as targeted therapy (98.4%, 63 out of 64 patients) and as monotherapy (72.7%, 47 out of 64 patients). Combination therapy was used in 47.4% (9 out of 19) of patients with bacteriemia. Most patients had successful microbiological (79.2%, 42 out of 53) and clinical (78.7%, 48 out of 61) outcomes. All-cause in-hospital mortality rate was 34.4%. ConclusionThe present case series contributes to the body of evidence suggesting that C/T is an effective and safe option for treating P. aeruginosa infections, namely those caused by XDR strains, both when used as mono- or combination therapy.

Opioid Dependence and Associated Health Care Utilization and Cost in Traumatic Spinal Cord Injury Population: Analysis Using Marketscan Database.

Postinjury pain is a well-known debilitating complication of spinal cord injury (SCI), often resulting in long-term, high-dose opioid use with the potential for dependence. There is a gap in knowledge about the risk of opioid dependence and the associated health care utilization and cost in SCI. To evaluate the association of SCI with postinjury opioid use and dependence and evaluate the effect of this opioid dependence on postinjury health care utilization. Using the MarketScan Database, health care utilization claims data were queried to extract 7187 adults with traumatic SCI from 2000 to 2019. Factors associated with post-SCI opioid use and dependence, postinjury health care utilization, and payments were analyzed with generalized linear regression models. After SCI, individuals were more likely to become opioid users or transition from nondependent to dependent users (negative change: 31%) than become nonusers or transition from dependent to nondependent users (positive change: 14%, p < .0001). Individuals who were opioid-dependent users pre-SCI had more than 30 times greater odds of becoming dependent after versus not (OR 34; 95% CI, 26-43). Dependent users after injury (regardless of prior use status) had 2 times higher utilization payments and 1.2 to 6 times more health care utilization than nonusers. Opioid use and dependence were associated with high health care utilization and cost after SCI. Pre-SCI opioid users were more likely to remain users post-SCI and were heavier consumers of health care. Pre- and postopioid use history should be considered for treatment decision-making in all individuals with SCI.

Developing a specialty transition clinic: Inaugural clinical and financial operations

PurposeFew examples of hospital-wide transition programs have been presented in the literature and to date, we have no data on the clinical and financial operations of such services. Design and methodsA transition clinic, guided by Got Transition’s Six Core Elements, was created for youth with moderate-to-high medical and psychosocial complexity (per Bob’s Levels of Social Support scale). The clinic visit and transition readiness assessment (UNC TRxANSITION Index) were billed fee-for-service or under a bundled payment managed care model. We present data on patient characteristics, clinic operations, finances, and patient/parent satisfaction (online survey) in the clinic’s first year of operation (March 2021-February 2022). ResultsIn Year 1, the clinic completed 115 appointments (113 unique patients). Most patients were older adolescents/young adults (M = 19.7 ± 1.8 years) and nearly half were Latinx. Patients presented with several complex medical needs including coordination of care across multiple subspecialties, high health care utilization, decision-making determinations, behavioral and mental health concerns, and resource needs. Implementation of the Six Core elements was high (range 99.1%−100%). The average billed per patient was $498 (in 2021–2022 USD). Considering paid and unpaid office visits, we collected an average of 31.6 cents on the dollar. Almost 80% of office visit claims and 21.9–33.3% of transition readiness assessments were paid by insurers. Patient/parent satisfaction was high, with over 90% of families reporting that they learned something, knew one thing they could do to improve transition readiness, and were able to get their questions asked and answered. ConclusionsTransition clinics may never be fully self-sustainable given low collection rates and inability to capture extra charge codes related to chronic care management and transitional care. However, our collection rate was on-par with the collection rate for our hospital’s subspecialty clinics and we show it is possible to receive some funding from insurers.

Associations Between Physical Activity Vital Sign in Patients and Health Care Utilization in a Health Care System, 2018-2020.

Physical inactivity is a risk factor for many chronic conditions. This retrospective cohort study examined associations between physical activity (PA) with health care utilization (HU). A PA vital sign was recorded in clinicsfrom January 2018 to December 2020. Patients were categorized as inactive, insufficiently active, or sufficiently active by US PA aerobic guidelines. Associations between PA vital sign and visits (inpatient admissions, emergency department, urgent care, and primary care) were estimated using population average regression by visit type. 23,721 patients had at least one PA vital sign recorded, with a mean age of 47.3 years and mean body mass index (BMI) of 28; 52% were female and 63% were White. Sufficiently active patients were younger, male, White, and had lower BMI than insufficiently active patients. Achieving 150 minutes per week of moderate to vigorous PA per 1000 patient years was associated with 34 fewer emergency department visits (P < .001), 19 fewer inpatient admissions (P < .001), and 38 fewer primary care visits (P < .001) compared with inactive patients. Stronger associations betweenlower PA and higher HU were present among those who were older or had a higher comorbidity. BMI, sex, ethnicity, and race did not modify the association between PA and HU. Meeting aerobic guidelines was associated with reduced HU for inpatient, primary care, and emergency department visits.

Immunotherapy in combination with chemotherapy vs. immunotherapy alone for advanced non-small cell lung cancer and programmed death ligand 1 score

IntroductionLittle is known about the effectiveness of immunotherapy alone or with chemotherapy for patients with non-small cell lung cancer (NSCLC) and programmed death ligand 1 (PD-L1) expression <50 %. We examined the outcomes of PD-L1 therapy vs. PD-L1 therapy in combination with chemotherapy as first-line treatment among NSCLC patients with PD-L1 score <50 %. MethodsWe used administrative claims and prior authorization data of a national insurer from November 2015 to July 2021. We selected patients with Stage IIIb/IV NSCLC and PD-L1 expression <50 %. Each patient was required to have ≥1 claim of a PD-L1 or PD-1 inhibitor. Treatment groups were propensity-score matched 1:1 on baseline characteristics. We measured PD-L1 therapy duration, incident immune-related adverse events (irAEs), healthcare utilization, costs, and overall survival (OS). ResultsIn the matched sample totaling 176 patients, mean duration of PD-L1 therapy was similar (4.1 [SD 3.3] months combination vs. 4.0 [SD 4.9] months monotherapy, p = 0.800). IrAEs were similar, both for FDA-recognized irAEs (48.9 % combination, 48.9 % monotherapy, p = 0.710) and other types (34.1 % combination, 39.8 % monotherapy, p = 0.473). The combination group had more all-cause inpatient stays, ER visits, and outpatient visits (all p < 0.001). Total adjusted all-cause medical cost was $112,833 (95 % CI $5,548-$251,973) higher for combination therapy. We saw no difference in OS (adjusted hazard ratio 1.09 [95 % CI 0.72–1.65]). ConclusionThis study found no difference in adverse drug effects or survival between PD-L1 monotherapy compared to combination therapy for patients with Stage IIIb/IV NSCLC and PD-L1 expression <50 %, though the combination therapy cohort had higher healthcare utilization and costs. MicroAbstractUse of immunotherapy alone or combined with chemotherapy for patients with non-small cell lung cancer and programmed death ligand 1 expression <50 % is understudied. Our observational study using claims and authorization data from a matched sample of 176 patients found no difference in survival or the rate of adverse drug effects between groups, although the chemo-immunotherapy cohort generated higher overall healthcare costs.

Health disparity and healthcare utilization inequity among older adults living in poverty in South Korea: a cross-sectional study

BackgroundKorea has a two-tiered universal health security system: the wage-based National Health Insurance (NHI) program and government-subsidized Medical Aid (MA) program. Beneficiaries of the MA program belong to the lowest economic class. This study aims to investigate the association between economic status—defined as NHI or MA enrollment—and health disparity of older people aged ≥ 65 years in South Korea.MethodsThe claims records of 672,525 older age population from the 2017 Health Insurance Review and Assessment Service-Adult Patient Sample were used to estimate adjusted odds ratios (aORs) of MA vs. NHI beneficiaries for prevalence for common geriatric diseases. Logistic regression and negative binomial regression were used to investigate the association between economic status and prevalence or healthcare utilization for each disease.ResultsMA beneficiaries showed significantly higher prevalence than NHI beneficiaries for seven out of nine diseases (aORs ranging from 1.18 to 1.95). The discrepancy in the prevalence between the two groups was highest among those aged 65–69 years (aORs: 1.34–2.94), and diminished as they got older (aORs: 1.05–1.67). MA beneficiaries had significantly more outpatient visits to treat six diseases (aORs: 1.07–1.28), and more hospitalization to treat seven diseases (aORs:1.08–1.73) than NHI beneficiaries.ConclusionThe higher prevalence of common geriatric diseases among MA than NHI beneficiaries confirms unfavorable health disparity in the elderly living in extreme poverty. Similar or higher healthcare utilization in treating the same conditions among MA beneficiaries suggests a low possibility of inequity for access to healthcare resources covered by the universal health security system due to poor economic status. Greater excess use of inpatient than outpatient care by MA beneficiaries implies that the condition of poor older adults might be more severe when diagnosed with the same disease.

A real-world analysis of factors associated with high healthcare resource utilization and costs in patients with myasthenia gravis receiving second-line treatment

Despite current treatments, patients with myasthenia gravis (MG) experience unpredictable and inadequately controlled symptoms, lending to variability in the clinical and economic burden of disease. However, limited data are available on MG healthcare costs, and specifically, no data on patients initiating second-line therapy. Using claims data from the IBM® MarketScan® database, we assessed patient characteristics, healthcare resource utilization, and costs among MG patients initiating second-line therapy, and identified potential factors associated with high healthcare costs over a two-year follow-up period. We identified 1498 patients, of whom 49% and 31% received chronic steroids and non-steroidal immunosuppressants (NSISTs) as their second-line therapy, respectively. During follow-up, 49% experienced ≥1 MG exacerbation. Among all patients, mean all-cause total healthcare cost was $106,821 per patient during follow-up, with $88,040 and $18,780 attributed to medical and pharmacy costs, respectively. In a multivariable analysis, variables significantly associated with high cost included use of high-dose steroids, chronic intravenous immunoglobulin (IVIg, ≥6 cycles), and 1 and ≥ 4 (but not 2–3) MG exacerbations in the first year after second-line therapy initiation. Any number of exacerbations were associated with high cost in a univariable analysis. A stratified cost analysis showed that patients with >1 exacerbation, ≥1 treatment switch, and high-dose steroid use in this first year experienced $198,487, $114,037, and $79,752 mean MG-related total healthcare spend during follow-up, respectively. These data suggest that patients receiving chronic IVIg or NSISTs for MG experience significant economic burden. Disease characteristics including exacerbation and treatment history may be an indicator of future high costs.

Real-World Evidence on Disease Burden and Economic Impact of Sickle Cell Disease in Italy.

A real-world analysis was conducted in Italy among sickle cell disease (SCD) patients to evaluate the epidemiology of SCD, describe patients' characteristics and the therapeutic and economic burden. A retrospective analysis of administrative databases of various Italian entities was carried out. All patients with ≥1 hospitalization with SCD diagnosis were included from 01/2010-12/2017 (up to 12/2018 for epidemiologic analysis). The index date corresponded to the first SCD diagnosis. In 2018, SCD incidence rate was 0.93/100,000, the prevalence was estimated at 13.1/100,000. Overall, 1816 patients were included. During the 1st year of follow-up, 50.7% of patients had one all-cause hospitalization, 27.8% had 2, 10.4% had 3, and 11.1% had ≥4. Over follow-up, 6.1-7.2% of patients were treated with SCD-specific, 58.4-69.4% with SCD-related, 60.7-71.3% with SCD-complications-related drugs. Mean annual number per patient of overall treatments was 14.9 ± 13.9, hospitalizations 1.1 ± 1.1, and out-patient services 5.3 ± 7.6. The total mean direct cost per patient was EUR 7918/year (EUR 2201 drugs, EUR 3320 hospitalizations, and EUR 2397 out-patient services). The results from this real-world analysis showed a high disease burden for SCD patients with multiple hospitalizations during the follow-up. High healthcare resource utilization and costs were associated with patient' management and were most likely underestimated since indirect costs and Emergency Room admissions were not included.

THE PRESCRIPTION DRUG LANDSCAPE OF ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Abstract Alzheimer’s Disease and Related Dementias (ADRDs) are debilitating conditions that impact cognition and function of nearly 5 million adults in the U.S. This study describes the landscape of prescription drugs to treat cognitive and behavioral symptoms of ADRD among Medicare Advantage Part D enrollees with ADRD (Dementia, Alzheimer’s Disease, Parkinson’s, Frontotemporal Dementia, Lewy Body, Vascular Dementia, or Mild Cognitive Impairment). We assessed prevalence of prescription fills in the years pre- and post-ADRD diagnosis. Prescription fills to manage cognitive symptoms, were assessed by acetylcholinesterase inhibitors and NMDA receptor antagonists. Prescription fills to manage behavioral and psychological symptoms of dementia were assessed by antipsychotics, mood stabilizers and anticonvulsants, antidepressants, sedative-hypnotic z-drugs, and benzodiazepines. The final sample (N=161,368) consisted of 79.2% white, 62.2% female with median age 83 (IQR 77-89). Most drug fills increased from pre-diagnosis year to post diagnosis year including Acetylcholinesterase inhibitor (15.3% to 35.5%), NMDA Receptor Antagonists (5.8% to 16.6%), mood stabilizers and anticonvulsants (15.8% to 18.2%), and antidepressants (19.4% to 24.2%). Benzodiazepine use remained stable (13.0% to 13.6%) as did Sedative hypnotic z- drugs (1.9% 1.8%). Results reveal polypharmacy (median of 11 prescriptions post-ADRD diagnosis) and high healthcare utilization (median of 10 specialty types visited post-ADRD diagnosis). This study shows discrepancies between real-world pharmacologic ADRD management and evidence-based practices. This work highlights the need for innovative care models that simultaneously address polypharmacy and optimally coordinated care for people with ADRD.

Comorbidity and healthcare utilization in patients with treatment resistant depression: A large-scale retrospective cohort analysis using electronic health records

BackgroundMedical comorbidity and healthcare utilization in patients with treatment resistant depression (TRD) is usually reported in convenience samples, making estimates unreliable. There is only limited large-scale clinical research on comorbidities and healthcare utilization in TRD patients. MethodsElectronic Health Record data from over 3.3 million patients from the INSIGHT Clinical Research Network in New York City was used to define TRD as initiation of a third antidepressant regimen in a 12-month period among patients diagnosed with major depressive disorder (MDD). Age and sex matched TRD and non-TRD MDD patients were compared for anxiety disorder, 27 comorbid medical conditions, and healthcare utilization. ResultsOut of 30,218 individuals diagnosed with MDD, 15.2 % of patients met the criteria for TRD (n = 4605). Compared to MDD patients without TRD, the TRD patients had higher rates of anxiety disorder and physical comorbidities. They also had higher odds of ischemic heart disease (OR = 1.38), stroke/transient ischemic attack (OR = 1.57), chronic kidney diseases (OR = 1.53), arthritis (OR = 1.52), hip/pelvic fractures (OR = 2.14), and cancers (OR = 1.41). As compared to non-TRD MDD, TRD patients had higher rates of emergency room visits, and inpatient stays. In relation to patients without MDD, both TRD and non-TRD MDD patients had significantly higher levels of anxiety disorder and physical comorbidities. LimitationsThe INSIGHT-CRN data lack information on depression severity and medication adherence. ConclusionsTRD patients compared to non-TRD MDD patients have a substantially higher prevalence of various psychiatric and medical comorbidities and higher health care utilization. These findings highlight the challenges of developing interventions and care coordination strategies to meet the complex clinical needs of TRD patients.

Primary Care and Behavioral Health Services Use Differ Among Medicaid-Enrolled Children by Initial Foster Care Entry Status

Most children in foster care have poor health outcomes and high health care utilization. Health complexity influences health care utilization as well foster care placement. Health care utilization studies among children in foster care have not accounted for health complexity status and foster placement. A 7-year retrospective study linked Colorado child welfare and Medicaid administrative data for 30,164 Medicaid-enrolled children, up to 23 years old, who differed by initial foster care entry, to examine primary care and behavioral health (BH) utilization patterns from 2014 to 2021. Children entering care were matched with replacement to non-foster peers by age, sex, Medicaid enrollment patterns, managed care status, family income, and health complexity. We calculated weighted monthly average percentages of children with primary care and BH utilization by foster care entry, health complexity, sex, and age over 25 months relative to the month of foster care entry for the foster cohort or the reference month for non-foster peers. Children in the foster cohort had lower primary care but higher BH utilization relative to non-foster peers prior to the reference month. Primary care and BH use increased among children in foster care during and 12 months after the reference month, unlike matched comparisons. Primary care and BH utilization increased by health complexity but differed by foster care status and time. Foster care entry and health complexity produced distinct patterns of primary care and BH utilization. Given higher utilization among children in foster care, future investigation should explore health care quality and delivery factors.

Socioeconomic Disparities Associated With Healthcare Utilization Among Adults With Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a chronic and debilitating disease associated with negative health outcomes and high healthcare utilization. Little is known about the role of demographic and socioeconomic factors associated with healthcare utilization in RA. The purpose of this study was to explore the relationships between demographic and socioeconomic characteristics, insurance status, general health perception, and healthcare utilization among adults with RA. In this cross-sectional analysis of data from 537 participants with a self-reported diagnosis of RA from the 2017-2020 National Health and Nutrition Examination Survey, multivariate logistic regression analyses were used to explore the relationships between demographic and socioeconomic factors, insurance status, general health perception, and healthcare utilization (i.e., whether an individual saw a provider, had a routine place to go for healthcare, and stayed overnight in the hospital). The mean age of participants was 57 years; 50% were female, 57.9% were non-Hispanic White, 17.9% were Black, and 15.2% were Mexican or other Hispanic. Individuals without health insurance were less likely than insured individuals with RA to have seen a provider, have a routine place to go for healthcare, and have stayed overnight in the hospital. Adults with RA who rated their health as very good or excellent were more likely to have a routine place for healthcare and less likely to stay overnight in the hospital than those who rated their health as fair or poor. Lack of health insurance significantly correlates with decreased healthcare utilization in adults with RA in the United States. Our findings underscore the need for more frequent assessment of insurance status in adults with RA to identify individuals at an increased risk for reduced healthcare utilization and who are more likely to experience poorly perceived general health.

Developing a Model to Predict High Health Care Utilization Among Patients in a New York City Safety Net System.

Health care facilities use predictive models to identify patients at risk of high future health care utilization who may benefit from tailored interventions. Previous predictive models that have focused solely on inpatient readmission risk, relied on commercial insurance claims data, or failed to incorporate social determinants of health may not be generalizable to safety net hospital populations. To address these limitations, we developed a payer-agnostic risk model for patients receiving care at the largest US safety net hospital system. We transformed electronic health record and administrative data from 833,969 adult patients who received care during July 2016-July 2017 into demographic, utilization, diagnosis, medication, and social determinant variables (including homelessness and incarceration history) to predict health care utilization during the following year.We selected the final model by developing and validating multiple classification and regression models predicting 10+ acute days, 5+ acute days, or continuous acute days. We compared a portfolio of performance metrics while prioritizing positive predictive value for patients whose predicted utilization was among the top 1% to maximize clinical utility. The final model predicted continuous number of acute days and included 17 variables. For the top 1% of high acute care utilizers, the model had a positive predictive value of 47.6% and sensitivity of 17.3%. Previous health care utilization and psychosocial factors were the strongest predictors of future high acute care utilization. We demonstrated a feasible approach to predictive high acute care utilization in a safety net hospital using electronic health record data while incorporating social risk factors.

The Use of Telemedicine in Older-Adults During the COVID-19 Pandemic: a Weekly Cross-Sectional Analysis in Ontario, Canada.

The COVID-19 pandemic led to rapid adoption of telemedicine for health-care service delivery. There are concerns that older adults, the highest users of the health-care system, would be left behind because of this shift. It remains unclear how the pandemic impacted telemedicine and other health-care service use in this group. We conducted a population-based, weekly cross-sectional study using administrative data from Ontario, Canada. Telemedicine use was measured for the overall older-adult population aged 65+ and across sociodemographic groups from January 2018 to March 2021. We also assessed the use of key health-care services between high and low patient users of telemedicine who were diagnosed with dementia. We found that telemedicine visits outnumbered in-person visits in older adults during the pandemic (average of 74 vs. 62 visits per 1000 per week). Of all specialties, psychiatrists delivered the most telemedicine visits, reaching 90% of visits in a week. Higher rates of telemedicine use during COVID-19 were found for patients who resided in urban regions (84 visits per 1000 per week), but no differences were found across income quintiles. Among dementia patients, high telemedicine users had higher health-care utilization than low telemedicine users (i.e., 21,108 vs. 3,276 outpatient visits per week) during the pandemic. Findings suggest that telemedicine was crucial in helping older adults, a group most vulnerable to COVID-19, maintain access to care during the pandemic. Telemedicine presents an important opportunity for older adults; however, future research should focus on barriers to equitable access and quality of care provided through telemedicine.

Predictive Analysis of Healthcare Resource Utilization after Elective Spine Surgery.

The management of degenerative spine pathology continues to be a significant source of costs to the US healthcare system. Besides surgery, utilization of healthcare resources after spine surgery drives costs. The responsibility of managing costs is gradually shifting to patients and providers. Patient-centered predictors of healthcare utilization after elective spine surgery may identify targets for cost reduction and value creation. Therefore, our study aims to quantify patterns of healthcare utilization and identify risk factors that predict high healthcare utilization after elective spine surgery. A total of 623 patients who underwent elective spine surgery at a tertiary academic medical center by one of three fellowship-trained orthopedic spine surgeons between 2013 and 2018 were identified in this retrospective cohort study. Healthcare utilization was quantified including advanced spine imaging, emergency and urgent care visits, hospital readmission, reoperation, PT/OT referrals, opioid prescriptions, epidural steroid injections, and pain management referrals. Patient variables, namely, the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification system, were assessed as potential predictors for healthcare utilization. Among all patients, a wide range of health utilization was identified. Age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiology class were identified as positive predictors of postoperative healthcare utilization including emergency department visits, spine imaging studies, opioid and nerve blocker prescriptions, inpatient rehabilitation, any referrals, and pain management referrals. Markers of patient health-such as CCI and ASA class-may be used to predict healthcare utilization following elective spine surgery. Identifying at-risk patients and addressing these challenges prior to surgery is an important step to deliver efficient postoperative care. 3.

Impact of Social Determinants of Health on Disease-Related Outcomes in Pediatric Sickle Cell Patients

Background: Social Determinants of Health (SDoH) are socioeconomic factors that influence health and well-being and are largely responsible for health inequities. Research has shown that economic, housing, food and medical insecurities are associated with lower quality of life, poor mental health, and worse outcomes for people living with chronic illness. Individuals with Sickle Cell Disease (SCD) are at increased risk of mortality, poor health-related quality of life, functional disability and high health care utilization. Furthermore, SCD primarily affects populations of African descent, who also tend to be disproportionately burdened by poverty and systemic racism. Prior studies have shown that children with SCD from lower income families have worse health-related quality of life, and higher healthcare utilization rates. However, there is paucity of data investigating links between SDoHs with quality of life and disease-related outcomes in this population. Thus, it is important to gain a better understanding of how these factors affect the well-being of children living with SCD. In this study, we attempt to identify the unmet social needs of patients in one pediatric sickle cell clinic and their association with self-reported health care utilization and disease complications. Methods: We approached pediatric patients (aged 1-18 years) and their guardians attending routine visits at the Children's Hospital of Richmond Comprehensive Sickle Cell Clinic. Those coming for a newborn visit or having acute crises were excluded. After consenting, parents completed a demographic and patient-reported outcome questionnaire followed by the Boston Medical Center's WECARE survey that screens for SDoH, such as housing, food, utility, transportation and medical insecurities. We defined an unmet social need as any positive answer to the WECARE survey. Counts, percentages and exact tests were used to examine the relationship between unmet needs and demographic factors and disease outcome variables. Results: To date, 50 children with SCD aged 1-17 years and their parents were screened, consented, assented (children >7) and completed the surveys. There was incomplete data on social needs from 5 subjects, thus 45 total are included here. 53% of subjects indicated an unmet need in at least one of the categories in the WECARE survey: 41% had food insecurity, 4% had housing insecurity, 13% had problems paying for medication, 11% had problems with transportation, 24% had trouble paying utility bills, 9% had difficulty taking care of family members and 13% were unemployed. Children with at least one unmet social need were more likely (p<0.05) to have a lower household income (Table 1), report one or more hospitalizations in the past six months and report missing a scheduled activity or school in the previous month compared to children without an unmet need (Table 2). Those with an unmet need also reported higher Emergency Department visits, acute SCD complications, and lower grades than those without an unmet need, but these findings were not statistically significant. Conclusion: This preliminary data demonstrates that SDoH, represented by unmet social needs, have an association with increased healthcare utilization and disease-related complications for children with SCD. A larger sample size is needed to characterize these relationships more fully. Ongoing research includes investigating the relationships between SDoH with Quality of Life and disease indicators gathered from medical charts of children with SCD. By identifying which unmet socioeconomic needs exist in our clinics, we can provide more equitable and holistic care to children with SCD and ultimately improve their health outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Novel Electronic Consultation for Sickle Cell Disease Inpatient Management

Sickle cell disease (SCD) is an inherited blood disorder that affects 100,000 persons in the US. Despite affecting a small percentage of the US population, health care costs for SCD are approximately 1.7 million for total lifetime cost mostly due to high healthcare utilization. Though outpatient comprehensive SCD centers reduce healthcare costs by decreasing acute visits, there has been little in the literature on optimizing inpatient SCD care and facilitating a successful transition back to outpatient care. Improving the transition between inpatient care and the outpatient provider may also reduce health care expenses. Current inpatient models of care for adults with SCD vary among hospital centers, but are generally a combination of hematology and oncology providers, internists, and/or SCD specialists. Similar to most hospital systems, our internal medicine resident teams and hospitalists provide most of the care for adults with SCD. The hematology consult team is only consulted for a small number of adults with SCD who have severe complications due to limited capacity. Prior to 2020, the discharge planning, transfusion guidance, and pain management for adults with SCD in the hospital was highly variable. To improve continuity of care, we developed a new inpatient model of care using electronic communication (e-consult) notes that encompass the important aspects of management (i.e. individualized care plan, etc.) for every patient admitted with SCD. At the time of admission, the SCD team receives an EMR-alert to initiate the consultation and does not require an order from the inpatient team. This inpatient model of care was also helpful during the COVID-19 pandemic when the hospital experienced a shortage of staff making it more difficult for the hematology consult services to participate in SCD care. We hypothesized that the e-consult service would increase the inpatient medical teams’ satisfaction level with care and improve discharge planning for adults admitted with SCD. Methods: We analyzed 1,282 inpatient visits during January 2019 to July 2021. The e-consult notes, written by a SCD specialist, provided recommendations on the following: electronic medical record review (hospital course, vital signs, and laboratories), outpatient treatment plans, best-practices from the national SCD guidelines, and discharge planning. E-consult notes were written beginning in April 2020. Inpatient provider teams were asked to complete surveys measuring satisfaction of the SCD management before (Jan 2019-Mar 2020) and after (Apr 2020-Jul 2021) the implementation of e-consults. Time to first discharge appointment, length of stay, and hospital readmission were obtained using the electronic medical record. We used ANOVA test to compare mean values between the two time periods. Results: There were a total of 106 providers who participated in the satisfaction survey, but three entries were incomplete. The majority of inpatient provider teams who responded were internal medicine (76%; 80/106). Only 61% (62/103) of the providers were familiar with the e-consult service. Among those familiar with the e-consult service, 79.6% (45/62) of the providers followed the recommendations of the e-consult service. Over 80% of the providers reported that e-consults were valuable to SCD care, promoted good quality of care, and resulted in an overall improvement in the care of SCD. Furthermore, provider satisfaction were significantly improved. The mean number of days between hospital discharge and outpatient follow up were also significantly lower than before the implementation of this service. The length of hospital stay was statistically higher for the post implementation period, however remained under the national average of hospitalizations for SCD. The hospital readmission rate was unchanged. Limitations: We are unable to capture hospital follow up that occurred at another institution due to patients being under another provider's care. Conclusion: Improving inpatient care for people with SCD is important. Due to insufficient SCD staff, new models of inpatient care are needed. The e-consult program initiated at UAB can significantly improve inpatient team satisfaction, inpatient SCD guidance, and facilitate timely discharge with an outpatient SCD provider. E-consult notes can be an acceptable tool to help optimize inpatient care when a formal inpatient SCD service does not exist due to limited SCD staff. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal