Higher Rates Of Emergency Department Visits Research Articles

Preoperative Antidepressant Prescriptions Are Associated With Increased Opioid Prescriptions and Health Care Use but Similar Rates of Secondary Surgery Following Primary Anterior Cruciate Ligament Reconstruction in a Young Adult Population

The purpose of this study was to compare adverse events, postoperative opioid prescribing patterns, healthcare utilization, and secondary ACLR surgery rates of patients undergoing primary ACLR with a preoperative antidepressant prescription (ADP) against a propensity matched group with no preoperative antidepressant prescription (NADP) using TriNetX Diamond Network. Patients undergoing primary ACLR between ages 18 and 35 were queried from the database using ICD-10/CPT codes. ADP patients were propensity matched in a 1:1 ratio to NADP patients based on 11 patient characteristics. Post-operative rates of adverse events, emergency department (ED) visits, in-patient hospitalizations, out-patient services, physical therapy evaluations, postoperative opioid prescriptions, and secondary ACLR were compared at various time points. 3736 ADP patients with an average age of 21.4 +/- 4.5 years undergoing primary ACLR were propensity matched to NADP patients. A significantly greater percentage of ADP patients received opioid prescriptions at 2 weeks (ADP: 21%, NADP 11.3%, OR: 2.08), 6 weeks (ADP: 25.5%, NADP 13.9%, OR: 2.13), 3 months (ADP: 27.6%, NADP: 15.6%, OR: 2.07), 6 months (ADP: 30.5%, NADP 17.2%, OR: 2.1), and 1 year (ADP: 35.3%, NADP: 20.2%, OR: 2.16) postoperatively (P < 0.0001 for each time point). ADP patients had higher rates of ED visits (ADP: 9.7%, NADP: 7.1%, P<.0001, OR: 1.39) and outpatient appointments (ADP: 28.3%, NADP: 21.8%) P<.0001, OR: 1.42) at 3 months postoperatively. Secondary surgery rates at 1 and 2 years were non-significant (P = 0.381 and P = 0.062, respectively). Following ACLR, ADP patients had a significant increase in post-operative opioid prescriptions at all time points, and utilized more ED resources and outpatient services compared with NADP patients at 3 months post-operatively. 30-day post-operative adverse events and both 1- and 2-year secondary ACL surgery rates demonstrated no significant differences between the groups. Level III, cohort study.

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use.

International Classification of Diseases, 10th revision Z codes capture social needs related to health care encounters and may identify elevated risk of acute care use. To examine associations between Z code assignment and subsequent acute care use and explore associations between social need category and acute care use. Retrospective cohort study. Adults continuously enrolled in a commercial or Medicare Advantage plan for ≥15 months (12-month baseline, 3-48 month follow-up). All-cause emergency department (ED) visits and inpatient admissions during study follow-up. There were 352,280 patients with any assigned Z codes and 704,560 sampled controls with no Z codes. Among patients with commercial plans, Z code assignment was associated with a 26% higher rate of ED visits [adjusted incidence rate ratio (aIRR) 1.26, 95% CI: 1.25-1.27] and 42% higher rate of inpatient admissions (aIRR 1.42, 95% CI: 1.39-1.44) during follow-up. Among patients with Medicare Advantage plans, Z code assignment was associated with 42% (aIRR 1.42, 95% CI: 1.40-1.43) and 28% (aIRR 1.28, 95% CI: 1.26-1.30) higher rates of ED visits and inpatient admissions, respectively. Within the Z code group, relative to community/social codes, socioeconomic Z codes were associated with higher rates of inpatient admissions (commercial: aIRR 1.10, 95% CI: 1.06-1.14; Medicare Advantage: aIRR 1.24, 95% CI 1.20-1.27), and environmental Z codes were associated with lower rates of both primary outcomes. Z code assignment was independently associated with higher subsequent emergency and inpatient utilization. Findings suggest Z codes' potential utility for risk prediction and efforts targeting avoidable utilization.

Early Systemic Anti-neoplastic Treatment Post SARS-CoV-2 Infection in Patients with Breast Cancer.

It is unclear how soon after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection it is safe to resume systemic anti-neoplastic treatment in patients with cancer. We assessed the risk of admissions or postponed treatment cycle in vaccinated patients with breast cancer receiving early systemic anti-neoplastic treatment following SARS-CoV-2 infection. This was a retrospective cohort study conducted during Omicron SARS-CoV-2 outbreak in Israel, January-July 2022. SARS-CoV-2 cohort included 30 vaccinated patients with breast cancer with SARS-CoV-2 infection 7-14days prior to systemic treatment. All patients had resolved symptoms and a negative antigen detection test on the day of treatment. The pre-coronavirus disease 2019 (COVID-19) pandemic cohort consisted of 49 matched patients with breast cancer treated with systemic anti-neoplastic agents during 2019. In 30 vaccinated patients with breast cancer who received systemic anti-neoplastic treatment 7-14days following SARS-CoV-2 infection, compared with 49 matched patients treated in 2019, the rates of emergency department (ED) visits (13% versus 6%, respectively), hospitalizations (3% versus 4%), next cycle of treatment given per protocol (90% versus 88%), and death (0% versus 0%) were similar. In a cohort of vaccinated patients with breast cancer who received systemic anti-neoplastic treatment 7-14days after SARS-CoV-2 infection, we did not observe substantially higher rates of ED visits, hospitalizations, or deaths compared with a similar cohort of pre-COVID-19 patients with breast cancer. Most patients received the next planned cycle on time. Early resumption of systemic anti-neoplastic treatment following SARS-CoV-2 infection in vaccinated patients with breast cancer with a negative antigen test at the day of treatment appeared to be safe. Additional data on larger cohorts and other malignancies are needed to support clinical guidelines.

Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia.

To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT). A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed. Studies were considered if they were available in English and conducted in humans. PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT. This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations. With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).

The role of social connections and support in the use of emergency care among older adults

ObjectivesLimited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. MethodsThis is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. ResultsMedium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. ConclusionsED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.

Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia.

Infants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for morbidity/mortality arising from life-threatening adrenal crisis. Management of acute illnesses in CAH requires an understanding of factors leading to emergency department (ED) visits and hospitalizations in the first few years of life. We, therefore, examined adrenal crisis at prehospital and ED stages of illness in young children with CAH as they related to medical outcomes. Retrospective cohort study of 39 children with CAH due to 21-hydroxylase deficiency (0-4 years of age) and 27 age-matched controls. ED visit, acute illness symptoms (fever, vomiting, diarrhoea) and other characteristics (hospitalizations, administration of stress-dose hydrocortisone, electrolyte abnormalities). CAH infants and toddlers had significantly higher rates of ED visits (0.50 [0.25-0.88] per person-year) than controls (0 [0-0] per person-year; p < .001). Moreover, CAH children under 6 months old had significantly higher rates of ED visits compared with older ages. Only 50% (51/102) of illness-related ED visits in CAH children were preceded by the administration of either oral (46/51) or intramuscular (11/51) stress dosing by parents. A total of 10.8% of ED visits resulted in hospital admission. Controlling for age and 17-hydroxyprogesterone at diagnosis, electrolyte abnormalities and administration of parenteral hydrocortisone in the ED significantly predicted hospital admission. Receiving a hydrocortisone injection before the ED was a significant predictor of having electrolyte abnormalities. Infants and toddlers with classical CAH are at high risk for acute illness and hospitalizations and often do not receive adequate stress dosing before the ED.

Associations between recreational cannabis legalization and cannabis-related emergency department visits by age, gender, and geographic status in Ontario, Canada: An interrupted time series study.

Legalization of recreational cannabis in Ontario included the legalization of flower and herbs (Phase 1, October 2018), and was followed by the deregulation of cannabis retailers and sales of edibles (Phase 2, February 2020). Research on the impact of cannabis legalization on acute care utilization is nascet; no research has investigated potential age, gender, and geographically vulnerable subgroup effects. Residents living in Northern Ontario not only have higher levels of substance use problems, but also have inadequate access to primary healthcare. Our study investigated the impact of Ontario's recreational cannabis policy (including Phase 1 and 2) on cannabis-attributable emergency department (ED) visits, and estimated the impact separately for different age and gender groups, with additional analyses focused on Northern Ontarians. We created a cohort of adults (18 and over) eligible for provincial universal health insurance with continuous coverage from 2015-2021 (n = 14,900,820). An interrupted time series was used to examine the immediate impact and month-to-month changes in cannabis-related ED visits associated with Phase 1 & 2 for each subgroup. While Northern Ontario has higher rates of cannabis-related ED visits, both Northern and Southern Ontario show similar patterns of changes. Phase 1 was associated with significant increases in adults 25-64, with the strongest increases seen in women 45-64. Month-to-month trends were flattened in most groups compared to pre-legalization. Phase 2 was associated with significant immediate increases for adults aged 18-44 in both genders, but the increases were larger in women than men. No significant month-to-month changes were detected in this period. While current preventive efforts are largely focused on reducing cannabis-related harms in youths and younger adults, our results show that adults 25-64, particularly women, have been significantly impacted by cannabis policies. Further research on gender-specific cannabis dosage and targeted interventions for adult women should be investigated. Legalization did not appear to have a differential impact on Northern versus Southern Ontario, but higher rates of ED visits in the North should be addressed.

Increased Emergency Department Utilization and Costs for Medicare Cancer Patients with Malnutrition Diagnoses.

Malnutrition or its risk affects up to 70% of cancer patients. Compared to adequately nourished oncology patients, those with malnutrition experience more complications and have poorer prognoses, thus higher needs for healthcare. We compared utilization of emergency department (ED) services and costs for Medicare-covered cancer patients with or without a malnutrition diagnosis. We used the Centers for Medicare and Medicaid Services (CMS) Standard Analytic File to identify fee-for-service beneficiaries who had a cancer diagnosis, and had one or more outpatient claims in 2018. We totaled individual claims and costs for ED visits per beneficiary, then calculated mean per-person claims and costs for malnourished vs non-malnourished patients. Using data from over 2.8 million claims of patients with cancer diagnoses, the prevalence of diagnosed malnutrition was 2.5%. The most common cancer types were genitourinary, hematologic/blood, and breast. Cancer patients with a malnutrition diagnosis, compared to those without, had a significantly higher annual total number of outpatient claims (21.4 vs. 11.5, P<.0001), including a 2.5-fold higher rate of ED visits (1.43 vs. 0.56, p<.0001). As result, such patients incurred more than 2-fold higher mean ED claim costs than did their adequately nourished counterparts ($10,724 vs. $4,935, P<.0001). Our results suggest that malnutrition in cancer patients imposes a high outpatient burden on resource utilization and costs of care in terms of ED use. We propose that nutritional interventions can be used to improve health outcomes for people with cancer and to improve economic outcomes for patients and providers.

Healthcare utilization and costs associated with acute lymphoblastic leukemia in children with and without Down syndrome.

Children with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) are at increased risk of treatment-related morbidity and mortality compared to non-DS-ALL, requiring increased supportive care. We examined the healthcare utilization and costs in DS-ALL patients to inform future evaluations of novel therapies. A provincial registry identified all children (1-17years) diagnosed with B-lineage ALL in Ontario, Canada between 2002 and 2012. Detailed demographic, disease, treatment, and outcome data were abstracted. Linkage to population-based health services databases identified all outpatient and emergency department (ED) visits, hospitalizations, and physician billings. Healthcare utilization costs were available for patients diagnosed during 2006-2012 using validated algorithms (2018 Canadian dollars). Healthcare utilization rates and costs were compared between DS and non-DS patients using regression models, adjusting for all covariates. Of 711 patients, 28 (3.9%) had DS. Adjusting for all covariates, children with DS-ALL experienced substantially higher rates of ED visits (rate ratio [RR] 1.5, 95% confidence interval [95% CI]: 1.2-2.0; p=.001) and inpatient days (RR 2.5, 95% CI: 1.4-4.5; p=.002) compared to non-DS children. Outpatient visit rates were similar (RR 1.1, 95% CI: 0.9-1.3; p=.41). Among patients with available cost data (N=533, DS=19), median 5-year healthcare utilization cost was $247,700 among DS patients (interquartile range [IQR]: 200,900-354,500) and $196,200 among non-DS patients (IQR: 148,900-280,300; p=.02). In adjusted analyses, DS-associated costs were 50% higher (RR 1.5, 95% CI: 1.2-1.9; p<.002). Healthcare utilization and treatment costs of DS-ALL patients are substantially higher than those of non-DS-ALL. Our data provide a baseline for future DS-specific cost-effectiveness studies.

Ambulatory Percutaneous Nephrolithotomy May Be Cost-Effective Compared to Standard Percutaneous Nephrolithotomy.

Background: Coronavirus disease 2019 (COVID-19) changed the practice of medicine in America. During the March 2020 lockdown, elective cases were canceled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing aPCNL against standard PCNL (sPCNL). Materials and Methods: Ninty-eight patients underwent PCNL at Indiana University Methodist Hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of emergency department (ED) visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included cost analysis and stone-free rates (SFRs). Propensity score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results: Ninety-eight patients underwent PCNL during the study period (sPCNL = 75 and aPCNL = 23). After propensity score matching, 42 patients were available for comparison (sPCNL = 19 and aPCNL = 23). We found no difference in 30-day ED visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327 ± 442 per case. SFRs were higher for aPCNL compared with sPCNL. Conclusions: aPCNL appears safe to perform and does not have a higher rate of ED visits or readmissions compared with sPCNL. aPCNL may also be cost-effective compared with sPCNL.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

MP17-15 FREQUENCY AND TIMING OF EMERGENCY DEPARTMENT VISITS AND HOSPITAL ADMISSIONS FOLLOWING COMMON STONE PROCEDURES

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures I (MP17)1 Sep 2021MP17-15 FREQUENCY AND TIMING OF EMERGENCY DEPARTMENT VISITS AND HOSPITAL ADMISSIONS FOLLOWING COMMON STONE PROCEDURES Rohail Rashid Kazi, Molly Jung, Yan Xiong, Timothy Kelly, and Andrew Harris Rohail Rashid KaziRohail Rashid Kazi More articles by this author , Molly JungMolly Jung More articles by this author , Yan XiongYan Xiong More articles by this author , Timothy KellyTimothy Kelly More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002002.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Emergency department (ED) visits and hospital admissions (HA) following urologic procedures are a concern for payors, providers, and patients. We seek to quantify ED visits and HA after urologic stone procedures. METHODS: A retrospective analysis was conducted using claims data from IBM MarketScan Commercial and Medicare Supplement databases. Adults with urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), or shockwave lithotripsy (SWL) and had ureteral stent codes during the index procedure between 2012 and 2017 were analyzed. All cause vs GU-specific ED visits and HA were evaluated during 30, 60, 90, and 120-day periods. RESULTS: 88,047 patients with mean age of 52.6 years and 44% female gender were identified that met inclusion criteria. Of these patients, 8,924 (10%) had their index procedure as an inpatient and 79,123 (90%) as an outpatient. For inpatients, rate of all cause vs GU-specific ED visits was 10% vs 9% at 30 days, 14% vs 12% at 60 days, 16% vs 14% at 90 days, and 19% vs 15% at 120 days. For outpatients, rate of all cause vs GU-specific ED visits was 9% vs 8% at 30 days, 11% vs 10% at 60 days, 13% vs 11% at 90 days, and 15% vs 12% at 120 days. A similar trend was found when examining rate of all-cause vs GU-specific HA. Younger patients (18-44 years old) tended to have higher rates of ED visits than older patients (>65 years old) following inpatient index stone procedure (13.4% vs 9.6% at 30 days, p ≤0.01). Patients with CCI ≥2 had higher rates of unplanned ED visits following stone procedures compared with those with CCI = 0 (11.3% vs 9.7%, p <0.01). CONCLUSIONS: Nearly one-fifth of patients have an unplanned hospital visit up to 120 days after having stone procedure, regardless of site of treatment. The majority of these visits involve GU-related diagnoses. Younger patients and patients with higher number of comorbidities have unplanned hospital visits in greater proportion than older patients and patients with fewer comorbidities. Further studies need to determine causation of these unplanned visits in order to guide appropriate intervention. Source of Funding: IBM Marketscan Database information provided by BD © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e314-e314 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rohail Rashid Kazi More articles by this author Molly Jung More articles by this author Yan Xiong More articles by this author Timothy Kelly More articles by this author Andrew Harris More articles by this author Expand All Advertisement Loading ...

Emergency Department Visits, Related Hospitalizations, and Reasons for Emergency Department Utilization After Traumatic Spinal Cord Injury

ObjectiveTo identify the self-reported frequency of emergency department (ED) visits, ED-related hospitalizations, and reasons for ED visits among people with traumatic spinal cord injury (SCI) and compare them with general population data from the same geographic area. DesignCross-sectional. SettingA specialty hospital in the Southeastern United States. ParticipantsThe participants (N=648) were community-dwelling adults (18 years and older) with a traumatic SCI, who were at least 1 year postinjury. A comparison group of 9728 individuals from the general population was retrieved from the 2017 National Health Interview Survey (NHIS). InterventionsNot applicable. Main Outcome MeasuresParticipants completed self-report assessments on ED visits, ED hospitalizations, and reasons for ED visits in the past 12 months using items from the NHIS. ResultsA total of 37% of participants with SCI reported at least 1 ED visit, and 18% reported at least 1 ED hospitalization in the past 12 months. Among those having at least 1 ED visit, 49% were admitted to hospitals. After controlling for sex, age, and race/ethnicity, participants with SCI were 151% more likely to visit the ED (odds ratio [OR], 2.51) and 249% more likely to have at least 1 ED hospitalization than the NHIS sample (OR, 3.49). Persons with SCI had a higher percentage of ED visits because of severe health conditions, reported an ED was the closest provider, and were more likely to arrive by ambulance. NHIS participants were more likely to visit the ED because no other option was available. ConclusionsCompared with those in the general population, individuals with SCI have substantially higher rates of ED visits, yet ED visits are not regularly assessed within the SCI Model Systems. ED visits may indicate the need for intervention beyond the acute condition leading directly to the ED visits and an opportunity to link individuals with resources needed to maintain function in the community.

Phase-specific risks of outpatient visits, emergency visits, and hospitalizations during Children's Oncology Group-based treatment for childhood acute lymphoblastic leukemia: A population-based study.

Therapy for childhood acute lymphoblastic leukemia (ALL) is associated with substantial health care utilization and burden on families. Little is known about health care utilization during specific treatment phases. We identified children with ALL diagnosed during 2002-2012 in Ontario, Canada and treated according to Children's Oncology Group (COG) protocols. Disease and treatment data were chart abstracted. Population-based health care databases identified all outpatient visits, emergency department (ED) visits, and hospitalizations. In addition to comparing standard and intensified versions of treatment phases, we compared patients receiving different steroids (dexamethasone vs. prednisone) and different versions of interim maintenance (IM) (Capizzi vs. high-dose methotrexate [HD-MTX]). Six hundred thirty-seven children met inclusion criteria. During intensified consolidation, 76.2% of patients were hospitalized at least once, compared to only 32.3% of patients receiving standard consolidation (p<.0001). Similarly, 72.9% of patients receiving intensified delayed intensification (DI) were hospitalized during this phase compared to 50.3% of patients receiving standard DI (p<.0001). Among patients receiving a four-drug induction, those receiving dexamethasone had an 85% higher rate of ED visits (adjusted rate ratio [aRR] 1.85, 95th confidence interval [95CI] 1.14-3.00; p=.01) and a 44% higher rate of hospitalization (aRR 1.44, 95CI 1.24-1.68) compared to those receiving prednisone. Among high-risk B-ALL and T-ALL patients in IM, Capizzi MTX was not associated with an increased rate of ED visits versus HD-MTX. These results can be used to inform anticipatory guidance for families, particularly those undergoing intensified therapy. Our results also suggest that increased toxicity rates associated with dexamethasone during Induction seen in clinical trials reflect real-world practice.

Health care utilisation and costs associated with different treatment protocols for newly diagnosed childhood acute lymphoblastic leukaemia: A population-based study in Ontario, Canada

BackgroundAlthough different treatment protocols for childhood acute lymphoblastic leukaemia (ALL) all achieve high cure rates, their health care utilisation and costs have not been rigorously compared. MethodsDisease, treatment, and outcome data were chart abstracted for all children with ALL in Ontario, Canada, diagnosed 2002–2012. Linkage to population-based databases identified health care utilisation. Utilisation-associated costs were determined through validated algorithms. Chemotherapy-associated costs were calculated separately. Health care utilisation and costs were compared between patients receiving Children's Oncology Group (COG) versus Dana-Farber Cancer Institute (DFCI)-based treatment. FindingsOf 802 patients, 146 (18.2%) were treated on DFCI-based protocols. COG patients experienced significantly higher rates of emergency department (ED) visits (adjusted rate ratio [aRR]: 1.3, 95% confidence interval [CI]: 1.1–1.5; p = 0·01), whereas outpatient visit rates were 60% higher among DFCI patients (aRR: 1.6, 95% CI: 1.5–1.7, p < 0.0001). In adjusted analyses, DFCI-associated cost intensity was 70% higher (aRR: 1.7, 95% CI: 1.5–1.9; p < 0.0001), mainly attributable to outpatient visit costs. Total chemotherapy costs were higher among COG-treated patients ($39,400 ± $1100 versus $33,400 ± $2800; p = 0.02). Among PEG-ASNase–treated patients, total chemotherapy costs were highest among DFCI patients (median $54,200 ± $7400; p = 0.003 versus COG patients). InterpretationCOG and DFCI treatments were associated with higher ED visit rates and higher outpatient visit rates, respectively. Overall utilisation-associated costs were increased in DFCI-treated patients. Administration of some intravenous chemotherapy at home and decreases in PEG-ASNase cost would decrease health care utilisation and costs for all patients and mitigate differences between COG and DFCI protocols. FundingC17 Research Network.

Emergency Department Utilization and Readmissions Following Major Surgery: A Retrospective Study of Medicare Data

Reliable strategies for reducing postoperative readmissions remain elusive. As the emergency department (ED) is a frequent source of post-operative admissions, we investigated whether hospitals with high readmission rates also have high rates of post-discharge ED visits and high rates of readmission once an ED visit occurs. We conducted a retrospective analysis of 1,947,621 Medicare beneficiaries undergoing 1 of 5 common procedures in 2,894 hospitals between 2008 and 2011. We stratified hospitals into quintiles based on risk-standardized, 30-day post-discharge readmission rates (RSRR) and then compared rates of post-discharge ED visits, proportion readmitted from the ED, and readmissions within 7 days of ED discharge across these quintiles. RSRR varied widely across extremes of hospital quintiles (3.9% to 17.5%). Hospitals with either very low or very high RSRR had modest differences in rates of ED visits (12.4% versus 14.6%). In contrast, the proportion readmitted from the ED was nearly 3 times greater in Hospitals with very high RSRR compared with those with very low RSRR (12% versus 32.2%). These findings were consistent across all procedures. Importantly, hospitals with a low proportion readmitted from the ED did not exhibit an increased rate of readmission within 7 days of ED discharge. Although hospitals experience similar rates of ED visits following major surgery, some EDs and their affiliated surgeons and health system may deliver care preventing readmissions without an increased short-term risk of readmission following ED discharge. Reducing 30-day readmissions requires greater attention to the coordination of care delivered in the ED.

Clinician Care Team Composition and Health Care Utilization.

ObjectiveTo test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization.Patients and MethodsWe retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions.ResultsThe proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = –0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians.ConclusionCare team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Patterns of respiratory health services utilization from birth to 5 years of children who experienced adverse birth outcomes.

Adverse birth outcomes have important consequences for future lung health. We evaluated patterns of respiratory health services utilization in early childhood among children born preterm (PTB), small and large for gestational age at term (SGA and LGA, respectively), and appropriate-for-gestational age at term. We conducted a population-based retrospective cohort study using administrative health data of all singleton live births in Alberta, Canada between 2005-2010. Data on hospitalizations and emergency department (ED) visits from birth to 5 years were collected for asthma, bronchitis, bronchiolitis, croup, influenza, pneumonia, and other acute upper and lower respiratory tract infections (other URTI and other LRTI, respectively). Adjusted rate ratios were estimated for respiratory ED visits and hospitalizations for adverse birth outcomes using the appropriate-for-gestational age at term group as reference. Age-specific trajectories of total respiratory health services utilization rates for each group were estimated in Poisson models. A total of 293,764 episodes of respiratory care from 206,994 children were analyzed. Very PTB children had the highest rates of health services use for all respiratory conditions, particularly for asthma, pneumonia, and bronchiolitis hospitalizations. Moderate/late PTB children also had elevated ED visits and hospitalizations for all respiratory conditions. Children born SGA showed high rates of ED visits for other LRTI, and of hospitalizations for bronchitis, bronchiolitis, and other URTI. Children born LGA had high rates of croup and other URTI ED visits, and of bronchiolitis and bronchiolitis hospitalizations. Age-specific trajectories showed a decreasing trend in the rates of total respiratory health service utilization from birth to five years of age for all groups studied. Children born PTB and LGA at term significantly required more respiratory health services over time compared to the reference group. Patterns of paediatric respiratory health services utilization vary according to gestational age and fetal growth.

Enhanced Recovery After Surgery Protocols. Does Frailty Play a Role?

The 5-modified frailty index (mFI) is a valid predictor of 30-day mortality after surgery. With the wide implementation of enhanced recovery after surgery (ERAS) protocols in colorectal patients, the predictive power of frailty and its contribution to morbidity and length of stay (LOS) can be underestimated. We reviewed all colectomy patients undergoing ERAS protocol at a single, tertiary care institution from January 2016-January 2019. The 5-mFI score was calculated based on the presence of 5 comorbidities: Congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease, functional status, and hypertension (HTN). Multivariate analysis was used to assess the impact of 5-mFI score on morbidity, emergency department (ED) visits, readmissions, and LOS. 360 patients were evaluated including 163 elderly patients. Frailer patients had a higher rate of ED visits (P = .024), readmissions (P = .029), and LOS (P < .001). Patients with CHF had a higher chance of prolonged LOS, whereas patients with HTN had a higher chance of ED. Elderly patients with an mFI score of 3 and 4 were likely to have longer LOS (P = .01, P = .07, respectively). Elderly patients with an mFI score of 4 were 15 times more likely to visit ED and 22 times more likely to be readmitted than patients with an mFI score of 0. An increase in 5-mFI for elderly patients undergoing colorectal procedures increases ED visits or readmissions, and it correlates to a higher LOS, especially in elderly patients. This instrument should be used in the assessment of frail, elderly patients undergoing colorectal procedures.

The relation between regular outpatient follow-up and frequency of emergency department visits in sickle cell pediatric patients.

Objectives:To evaluate the relationship between the frequency of ED visits and outpatient department (OPD) follow-up in sickle cell disease (SCD) pediatric patients.Methods:A retrospective cohort study included 247 SCD pediatric patients between January 2016 and December 2018 at the Maternity and Children Hospital, Department of Pediatrics, Al Medinah Al Munawarah, Saudi Arabia. Data were extracted from electronic medical record system; patient demographics, medications, frequency of emergency department (ED) and OPD visits. Pearson correlation coefficient, linear regression and independent sample t-test were applied.Results:There was no significant correlation (95% CI [-0.013- 0.233]; p=0.07) between the frequency of ED and OPD visits. However, a significant correlation was found between ED visits and missed OPD appointments. Thus, linear regression was applied and indicated that one missed OPD appointment is associated with 1.92 ED visits, (95% CI: 0.19-0.42; p<0.001). Also, a higher rate of ED visits was observed when compared with other studies, with a high ED reliance of 43%.Conclusion:This study found that regular OPD visits could improve SCD management, as a directly proportional relationship between the frequency of ED visits and missed OPD appointments were found, along with high ED reliance.