Hospital Discharge Research Articles

Abstract 4135846: Cardiovascular Effectiveness of Glucagon-like Peptide-1 Receptor Agonists and Empagliflozin Combination Therapy in Adults with Type 2 Diabetes

Introduction/Background: Both empagliflozin and glucagon-like peptide-1 receptor agonists (GLP-1RA) have demonstrated cardiovascular (CV) benefits in clinical trials. However, few trials examined the combination of both therapies and evidence is scarce on whether the addition of empagliflozin to GLP-1RA has further CV benefits. Aim/Goal: We evaluated the risk of CV outcomes in patients with type 2 diabetes (T2D) initiating baseline GLP-1RA therapy that added empagliflozin compared to those that added sulfonylureas (SU). Methods: Using Medicare, Optum, and Marketscan data (2014-22), we identified patients with T2D aged ≥18 years initiating GLP-1RA that subsequently added either empagliflozin or SU. Follow-up began on the date of additional therapy and continued until discontinuation of either drug, a gap in insurance coverage, death, or study end. After propensity score standardized mortality ratio weighting adjusting for 98 covariates, we estimated hazard ratios (HR) and rate differences (RD) per 1,000 person-years evaluating a composite of myocardial infarction (MI) or stroke, hospitalization for heart failure (HHF), or all-cause death in the overall population and in patients with history of CV disease. Results: We identified 27,962 patients initiating GLP-1RA + empagliflozin vs 25,137 patients initiating GLP-1RA + SU. After weighting, relative to patients initiating GLP-1RA + SU, those initiating GLP-1RA + empagliflozin had lower risks of MI-stroke [HR 0.70 (0.55, 0.90); RD: -4.3 (-6.6, -2.0)], HHF in the primary hospital discharge position [HR: 0.59 (0.43, 0.81); RD: -3.9 (-5.8, -2.1)]; HHF in any discharge positions [HR: 0.84 (0.72, 0.98); RD: -7.6 (-11.6, -3.6)], and all-cause death [HR: 0.83 (0.62, 1.11); RD: -1.3 (-3.2, 0.56)]. Findings were similar but with larger RDs in patients with baseline CV disease ( Table ). Conclusion: In US clinical practice, patients with T2D initiating GLP-1RA that added empagliflozin had lower risks of MI-stroke, HHF, and death compared to adding SU, which suggests an additive CV benefit when combining GLP-1RA and empagliflozin therapies.

Abstract 4136267: Racial and ethnic disparities in-hospital outcomes after out-of-hospital cardiac arrest: Insight from the United States national inpatient sample

Background: Out-of-hospital cardiac arrest (OHCA) continues to have a high mortality with an overall survivability to hospital discharge of less than 10%. Increased bystander cardiopulmonary resuscitation has resulted in better survival after OHCA. Some studies have tackled sociodemographic characteristics and rates of survival, but these are mostly localized studies with varied results. We investigated racial disparities in in-hospital mortality and mechanical circulatory support (MCS) use in OHCA. Methods: Retrospective cohort study based on the 2019-2020 National Inpatient Sample database of the Healthcare Utilization Project. Our population included patients 18 years or older with out-of-hospital cardiac arrest (OHCA) identified using ICD-10 codes. The primary risk factors examined were race/ethnicity categorized into White, Black, and Hispanic. The primary outcome was in-hospital mortality among patients with OHCA. The secondary outcome was mechanical circulatory support (MCS) use. Left ventricular assist device (LVAD), extracorporeal membrane oxygenation (ECMO), and intra-aortic balloon pump (IABP) were identified as MCS. Multivariate regression analysis was used to estimate the odds ratio. Results: During the study period, 26,640 hospitalizations with OHCA were identified, of whom 67,4% were White, 22,9% were Black, and 9,7% were Hispanic. The mean (SD) age of patients with OHCA was 65.2 (16) years old, and Black patients well as Hispanic patients had lower mean age compared to White patients (63.1 vs 63 vs 66.3 years old, p<0.001). A total of 19,425 died (72.9%) and 0.9% needed MCS. Notably, more Hispanics needed MCS, compared to White and Black patients (1.7% vs 0.9% vs 0.4%, p=0.049). In the multivariate analysis, we did not find statistical significance among racial/ethnic groups regarding in-hospital mortality. However, Hispanic patients had higher odds of MCS (OR=2.4; CI 95% 1.05-5.55, p=0.039) compared to White patients. No statistical significance was found regarding the use of IABP or LVAD. Conclusion: Overall, in-hospital mortality was elevated. Moreover, our findings highlight significant racial disparities after OHCA regarding MCS use. More research is needed to identify factors of racial disparities to improve outcomes.

Abstract 4137878: Trends in Survival After Out-of-Hospital Cardiac Arrest Across Community Demographics Since the COVID-19 Pandemic

Background: The COVID-19 pandemic in 2020 was marked by a sharp decrease in out-of-hospital cardiac arrest (OHCA) survival. Whether OHCA survival has recovered to pre-pandemic levels, and whether changes in OHCA survival are similar across communities of different racial and ethnic composition, is unknown. Methods: We included adult patients with non-traumatic OHCA from 2015-2022 in the Cardiac Arrest Registry to Enhance Survival registry. Using hierarchical multivariable regression, we calculated risk-adjusted rates of survival to hospital discharge during 2015-2019 (reference period) and compared this to survival rates during 2020, 2021, and 2022. We also examined whether the trajectory of survival over this period differed based on the racial/ethnic composition of the community served by the emergency medical service (EMS) agency, defined as predominantly White (>80% White residents), majority Black or Hispanic (>50% Black or Hispanic residents), or integrated (neither). Results: Of 485,079 patients with OHCA, mean age was 61.9 years; 64% were male, and 22% were of Black race with 7% of Hispanic ethnicity. Overall, risk-adjusted survival rates to hospital discharge for OHCA decreased from 10.1% in 2015-2019 to 8.4% in 2020 (P<0.0001). The relative decrease was similar at EMS agencies serving predominantly Black and Hispanic communities (-17.2%) as compared to predominantly White (-17.5%) or integrated communities (-16.8%). Risk-adjusted survival rates recovered partially in 2021 (8.7%) and 2022 (8.9%) but remained below the pre-pandemic period. As of 2022, OHCA survival in majority Black and Hispanic communities was still 9.7% lower, as compared to pre-pandemic years, whereas it was 10.9% lower in integrated communities and 13.6% lower in predominately White communities. Moreover, the survival disparity for OHCAs in Black/Hispanic vs. White communities narrowed to 0.4% (8.4% vs. 8.8%) in 2022, as compared to 1.0% (9.3% vs. 10.3%) prior to the pandemic. Conclusions: OHCA survival has improved in the U.S. since the initial pandemic year of 2020, but remains lower than the pre-pandemic years. The survival disparity for OHCAs occurring in majority Black and Hispanic relative to predominately White communities decreased since 2020, although absolute survival remained lower in majority Black and Hispanic communities throughout the study period.

Abstract 4137065: Efficacy and Safety of Extracorporeal CPR in Out-of-Hospital Cardiac Arrest Survival and Neurological Integrity: a Meta-Analysis of Randomized Controlled Trials

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a significant public health challenge, with conventional cardiopulmonary resuscitation (CPR) often yielding limited success. Extracorporeal CPR (eCPR) has emerged as a potential adjunctive therapy to improve outcomes in OHCA patients. Purpose: To evaluate the efficacy and safety of eCPR compared to conventional CPR in OHCA. Methods: A comprehensive search of Cochrane CENTRAL, PubMed, Ovid Medline, and Web of Science databases was conducted independently until November 10, 2023. Randomized controlled trials (RCTs) comparing eCPR with conventional CPR in OHCA were included. Primary efficacy outcome was defined as survival to hospital discharge, while primary safety outcome was assessed for bleeding events. Summary effect measures of the primary outcomes were obtained by pooling the data with an inverse variance–weighted random-effects model. A sensitivity analysis was performed regarding whether the conclusions reached might differ substantially if a single study was omitted. Statistical analyses were performed with “meta” package in R (version 4.3.2) and Revman 5.4. Results: Four unique RCTs involving 435 patients were included in the analysis. ECCPR was associated with a significantly higher rate of survival at 1 month with good neurological outcome (Risk Ratio [RR] 1.55, 95% Confidence Interval (CI) 1.06 to 2.27, I 2 : 0%) but comparable at survival to hospital discharge (RR 1.10, 95% CI 0.16 to 7.30, I 2 : 47%) compared to conventional CPR. Furthermore, no significant differences were observed between eCPR and conventional CPR groups in survival rates at 3 months (RR 1,33, 95% CI 0.92 to 1.94, I 2 : 64%), survival at 6 months with good neurological outcome (RR 1.39, 95% CI 0.97 to 1.99, I 2 : 0%), and survival at 6 months (RR 2.79, 95% CI 0.33 to 23.28, I 2 : 63%). eCPR demonstrated a statistically significant elevation in bleeding events compared to conventional CPR (RR 4.25, 95% CI 2.37 to 7.64, I 2 : 0%). Sensitivity analysis revealed that none of the studies significantly influenced the pooled risk estimate to any great extent. Conclusion: eCPR shows beneficial results in improving short-term survival and neurological outcomes at 1-month post-OHCA. However, it is associated with an elevated risk of bleeding when compared to conventional CPR. Further investigations are imperative to delineate the specific patient populations that stand to gain the most benefit from ECPR intervention.

A Scientific Approach for Optimizing Patient Bed Occupancy in an Overcrowded Teaching Hospital in Sri Lanka

Background: In Sri Lanka, the healthcare system predominantly relies on the public sector, which delivers nearly 95% of inpatient care and approximately 50% of outpatient care. Effective monitoring of bed occupancy rates is crucial for optimizing resource allocation amidst limited hospital resources and fluctuating patient demands.Objectives: This study aims to develop a scientific approach to enhance patient bed utilization at Colombo South Teaching Hospital (CSTH) in Sri Lanka.Methodology: A mixed-method approach was employed, integrating quantitative analysis of historical patient data from CSTH's medical record room with qualitative insights from key stakeholders, including hospital administrators, consultants, medical officers, and nursing staff.Results and Discussion: In 2023, CSTH reported an overall bed occupancy rate of 80%, surpassing both national and global averages, indicating strain on healthcare delivery. The study identifies disparities in occupancy rates across different wards, highlighting overcrowding in medical and surgical units alongside underutilization in other specialities.Recommendations and Conclusions: Revising the consultant-based ward allocation system, implementing patient-centric ward clustering based on occupancy rates, appointing bed managers, and expanding facilities in high-demand units like Medical, Accident Service Unit, Emergency Treatment Unit, and Nephrology. Implementing these strategies could mitigate overcrowding, improve bed availability, and enhance the quality and safety of patient care services at CSTH.

Abstract 4119908: Outcomes for heart failure patients with reduced ejection fraction attending emergency department and discharged within 24 hours versus those admitted patients in heart failure unit.

Introduction: Heart failure (HF) is a clinical syndrome with increasing prevalence. Currently, there are extensive evidence-based therapies targeted at managing patients with heart failure and reduced ejection fraction (HFrEF) to improve outcomes. The National Heart Failure Audit shows the quality of inpatient care (specialist review, discharge medication etc) is related to outcome. This study aimed to evaluate the current practice at a London tertiary centre hospital in managing patients with heart failure and compared outcomes in patients who had a short course of admission (less than 1 day) with those who had a more prolonged course of admission. Method: Retrospective data was collected from a London tertiary centre hospital database for consecutive patients from Sep/2022 till Sep/2023. Statistical analysis was performed using Chi-Square test. The eligibility criteria included a new or previous diagnosis of HF with left ventricular ejection fraction (LVEF) < 40%. Patients were divided into two groups: Group A included 40 eligible patients who were admitted and discharged from the emergency department (ED) within 24 hours. Group B included 37 eligible patients who were admitted and discharged from the dedicated heart failure unit after 10-15 days of hospital admission. Results: In Group A, prescribing guideline-directed medical therapy (GDMT) was lower compared to Group B; Renin-Angiotensin-Aldosterone Inhibitors (47.50% vs. 94.59%), beta blockers (55% vs. 91.89%), mineralocorticoid receptor antagonists (12.50 %vs. 94.59%), and sodium-glucose co-transporter 2 inhibitors (15% vs. 89.19%). More patients in Group B received all four pillars of GDMT (86.49%) compared to Group A (5%). At 6-month follow-up,18.75% were on 4 GDMT in Group A versus 92% in group Group B. Re-admission within 6 months was higher in Group A (30%) compared to Group B (16.22%); however, the difference was not statistically significant (P value: 0.153). Higher mortality rates were observed in Group A (mortality rate: 20%) compared to Group B (mortality rate: 2.70%), with statistical significance (P value: 0.018). Conclusion: This study showed that HFrEF patients admitted to a specialist heart failure unit achieve higher rates of GDMT and have significantly improved outcomes compared to those who had a shorter inpatient stay and discharged from the emergency department. These findings underscore the high risks associated with rapid discharge from hospital on incomplete medical therapy.

Abstract 4140198: Impact of Non-ST-segment elevation Myocardial Infarction on outcomes of Diabetic Ketoacidosis in Hospitalized Patients: A National Inpatient Sample Analysis

Introduction: Diabetes Mellitus (DM) has a broad spectrum of complications and is one of the leading 5 causes of hospital admissions in the US. Decompensated DM is associated with high mortality in hospitalized patients. Cardiac ischemia and related events are proposed to be increasingly prevalent in hospitalized patients with decompensated diabetes. Numerous studies and reports have suggested that elevation in troponin levels is associated with high mortality in such patients. Notably, there have only been a few studies that assessed the prevalence of NSTEMI (Non-ST segment elevation myocardial infarction) and its effect on outcomes in patients hospitalized with Diabetes ketoacidosis (DKA). Methods: We aimed to compare the outcomes of DKA in hospitalized adults (age >18 years) with NSTMI with those without NSTEMI using the National Inpatient Sample (NIS) database from 2018 to 2020. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays. Results: There were a total of 1113295 hospitalizations identified with a diagnosis of DKA. Of these, 9860 (0.88%) patients had NSTEMI. The mean age of this subpopulation was 38.71 years. Among these patients, 48.59% were female, and 58.40% were male. We attempted to assess the impact of NSTEMI on the occurrence of complications such as cardiac arrest, acute renal failure (ARF), Acute liver failure (ALF), Acute heart failure (Acute HF), and acute respiratory failure in patients admitted with DKA. The results of this analysis are depicted in the table below. The cost of hospitalization for DKA with NSTEMI was $35878 higher and the length of stay was 50% longer compared to the patients with DKA without NSTEMI. The Odds ratio for mortality was 2.84 for patients with NSTEMI. Conclusions: Our analysis suggests that the occurrence of NSTEMI negatively impacts outcomes in DKA patients. The occurrence of primary outcomes assessed in this study (Cardiac arrest, ARF, ALF, Acute HF, and Acute respiratory failure) was significantly higher in DKA patients with concomitant diagnosis of NSTEMI. NSTEMI also increased the cost burden on hospitalizations for DKA.

End-of-Life Health Care Service Use and Cost Among Medicare Decedents With Neurodegenerative Diseases.

Although neurodegenerative diseases are a leading cause of death, little is known about health care utilization and cost during the end-of-life (EoL) period or how it compares with that of other life-limiting conditions. We aimed to describe and compare resource utilization among US Medicare decedents with neurodegenerative diseases with decedents with cancer. We conducted a retrospective study of Medicare Part A and B beneficiaries with Alzheimer disease (AD), Parkinson disease (PD), or amyotrophic lateral sclerosis (ALS) who died in 2018. Decedents diagnosed with malignant brain tumors or pancreatic cancer served as non-neurodegenerative comparators. Descriptive analyses examined demographic and clinical characteristics in the last year of life. The probabilities and associated costs of emergency department (ED), inpatient, skilled nursing facility (SNF), and hospice utilization during the last 12 and 6 months of life were also compared between persons with neurodegenerative diseases and cancer, adjusting for sociodemographic factors and comorbidity burden. A total of 1,126,799 Medicare beneficiaries died in 2018, of which 357,926 had a qualifying diagnosis. Persons with neurodegenerative diseases were older and more frequently received Medicaid assistance than persons with brain or pancreatic cancer. In all groups, health care service utilization increased over the last year of life, and total costs were predominantly attributable to inpatient care. In the last 6 months of life, neurologist care was infrequent among patients with neurodegenerative disease (AD: 1.5%; PD: 8.6%; ALS: 32.0%). Persons with neurodegenerative diseases as compared to persons with malignant brain tumors also had greater odds of ED use (AD: adjusted odds ratio [aOR] 1.17, 95% CI 1.11-1.23; PD: aOR 1.18, 95% CI 1.11-1.25; ALS: aOR 1.11, 95% CI 1.01-1.23), lower odds of hospitalization (AD: aOR 0.64, 95% CI 0.60-0.68; PD: aOR 0.65, 95% CI 0.61-0.69; ALS: aOR 0.33, 95% CI 0.30-0.37), and lower odds of hospice enrollment (AD: aOR 0.33, 95% CI 0.31-0.36; PD: aOR 0.33, 95% CI 0.31-0.36; ALS: aOR 0.41, 95% CI 0.36-0.46). The findings were similar in pancreatic cancer. Persons with neurodegenerative diseases in the United States are more likely to visit the ED and less likely to use inpatient and hospice services at EoL than persons with brain or pancreatic cancer. These group differences may stem from prognostic uncertainty and reflect inadequate EoL care practices, requiring further investigation to ensure more timely palliative care and hospice referrals.

BIOS-01. MACHINE LEARNING-BASED PREDICTION OF INPATIENT CARE COSTS FOR PATIENTS WITH BRAIN METASTASES: A REAL-WORLD ANALYSIS

Abstract INTRODUCTION Brain metastases (BMs) are increasingly a cause of significant cancer-related morbidity, mortality, and economic burden. While BM-related healthcare costs have been previously described, predictive analytics based on contemporary cohorts, particularly for inpatient care, remain unavailable. This study sought to evaluate inpatient care costs (IPCC) and associated reimbursements for patients with BMs and perform predictive modeling through supervised machine learning (sML) using a contemporary, commercial US claims database. METHODS This retrospective study, reported following STROBE and TRIPOD+AI reporting guidelines, included adult patients (aged 18-65 years) in the United States (US) with BMs included in the MarketScan Commercial Claims and Encounters Database who received inpatient care during January 2016 to December 2021. Eligible patients were identified using ICD-10 codes. IPCC measures were adjusted using the Medical Care component of the 2023 Consumer Price Index. The primary study outcome was total IPCC, represented by adjusted gross total payments. After log-transformation performed due to data skew, sML was carried out using Random Forest algorithm with 1000 iterations with a 70:30 training-test data split, followed by residual analysis and evaluation of predictive performance using root-mean-squared error (RMSE), out-of-bag error (OOBE), and calibration curve. Multivariable linear regression was carried out for sensitivity analyses. RESULTS A total of 25117 unique inpatient admissions across 13477 BM patients were included, with median (IQR) age of 57 years (51-61). Gross median (IQR) CPI-medical-care-adjusted values per admission were: total payments $28,119.51 (16847.45-55111.67); hospital payments $24,678.74 (14601.66-47864.84); and payments to principal physician $884.80 (441.07-2434.15), being 3.6% (IQR 1.9-6.8) of total payment. Median inpatient length of stay was 4 days (IQR 2-8). ML model had an OOBE of 0.61 and, using test data, RMSE of 0.85, indicating robust performance. No major deviations were found on residual analysis. CONCLUSIONS Contemporary IPCCs for BM patients in US are substantial but driven minimally by payments to principal physician. sML may be utilized to successfully predict IPCC for BM patients.

EPID-15. INPATIENT CARE COSTS AND ASSOCIATED REIMBURSEMENTS FOR PATIENTS WITH LEPTOMENINGEAL DISEASE: A REAL-WORLD ANALYSIS

Abstract INTRODUCTION Leptomeningeal disease (LMD) is an increasingly significant cause of cancer-related morbidity, mortality, and economic burden. While healthcare costs associated with brain metastases (BMs) have been well-described, minimal economic literature exists for LMD. This study sought to evaluate inpatient care costs (IPCCs) and reimbursements for LMD patients using a contemporary US claims database. METHODS This retrospective study, reported following STROBE guidelines, included adult LMD patients (aged 18-65 years) receiving inpatient care during January 2016 to December 2021 in TruvenHealth MarketScan Commercial Claims and Encounters Database, currently the largest US commercial insurance database. Patient selection using ICD-10 codes, data management, and statistical analyses were performed in Stata/SE18.0. Demographic, clinical, and financial attributes were summarized through descriptive statistics. IPCC measures were adjusted using 2023 Consumer Price Index Medical Care component. Primary study outcome was adjusted gross total payments (total IPCC). Given skewness in IPCC, log-transformation was carried out, followed by multivariable linear regression using socio-demographic, clinical and insurance-related characteristics to identify significant covariates. RESULTS A total of 1047 inpatient admissions across 1010 LMD patients were included. 43.8% (N=442) had brain metastases (BM) concomitantly present while 56.2% (N=568) did not. Primary tumor associated with LMD comprised of: lung and/or lower respiratory tract cancer (18%), breast cancer (6.6%), and melanoma (6.1%). 54.8% (N=554) did not have any bone metastases and 78.6% (N=794) did not have any liver metastases. Per inpatient admission, median adjusted values of gross total payments were $32603.6 (IQR $19967-64960) and gross payments to principal physician $1119.26 (IQR $532.41-2919.78), being 3.4% of total payments. Covariates associated with significantly higher total IPCC included age, male sex, length -of-stay, whole brain radiotherapy, and admission year, while cancer from lung and melanoma, medical and psychiatric admission (versus surgical), and drug claims capture were associated with significantly lower IPCC. CONCLUSIONS Contemporary IPCCs for LMD patients in US are substantial but driven minimally by payments to principal physician for services rendered.

‘I just don’t want them to be my patient again’: an exploratory mixed-methods study examining provider home safety concerns for adolescents with acquired brain injuries in the US Midwest

ObjectiveAdolescents with acquired brain injuries are at risk for additional injuries after hospital discharge. We asked healthcare providers to identify and prioritise urgent hazards in the home setting for this...

Psychological distress in heart failure patients: Implications for healthcare utilization and expenditure.

Psychological distress is prevalent among heart failure (HF) patients, yet its impact on healthcare expenditure and utilization remains understudied. The aim of this study was to investigate the prevalence of psychological distress in HF patients and its impact on healthcare expenditure and utilization. We analysed data from the Medical Expenditure Panel Survey from January 2016 to December 2021, focusing on adults diagnosed with HF. We assessed the prevalence of psychological distress using the Kessler 6 (K6) questionnaire and examined its association with healthcare utilization and expenditures through multivariate regression models, adjusting for relevant covariates. Among 10 681 886 HF patients, 6.8% experienced psychological distress. The mean age was 69.9 years, and 50% were female. Multivariable analysis revealed significant associations between psychological distress and smoking (adjusted odds ratio [aOR] 2.87), Charlson comorbidity index ≥3 (aOR 3.05), and sleep disorders (aOR 2.82). Protective factors included exercise (aOR 0.40), higher education (aOR 0.89) and higher income levels (middle-income: aOR 0.19, high-income: aOR 0.20). HF patients with psychological distress incurred significantly higher annual total expenses ($14 709, p < 0.01), with inpatient costs ($6014, p = 0.02) and office-based expenses ($3993, p = 0.04) being notably elevated. Additionally, these patients exhibited more frequent annual emergency room visits (0.07 visits, p < 0.01), hospital discharges (0.2 discharges, p = 0.01), and nights spent in the hospital (1.4 nights, p < 0.01). Psychological distress in HF patients is associated with significantly higher medical expenditure and healthcare utilization. These findings underscore the need for integrated care approaches and present possible areas for intervention to address this significant healthcare burden.

My patients can go home in the evening after pulmonary vein isolation : Pros and cons

Given the background of optimizing financial and personnel resources while aligning with patient needs, the concept of same-day discharge following pulmonary vein isolation (PVI) appears attractive. However, a non-selective approach to different strategies is inappropriate, as is often the case in medicine. A "one size fits all" approach is therefore not advisable for outpatient PVI. Instead, the primary focus should be on identifying which patients can safely and effectively undergo PVI in an outpatient setting and which patients would benefit from inpatient care. Both procedural and patient-specific criteria should be considered in this context. In addition, structural prerequisites must also be met. Ultimately, the decision as to whether outpatient PVI is feasible should remain with the treating physician and the patient.

Excess costs of depression among a population-based older adults with chronic diseases in Singapore.

There is limited evidence on the economic burden of depression among the older population in Singapore. We aim to evaluate the impact of depression on healthcare expenditure and productivity loss among older adults with chronic diseases in Singapore. Using the data from the Well-being of the Singapore Elderly study (WiSE), a 2011 national representative survey of older adults aged 60 years and above, 2510 respondents were included in this study. The sample comprised 44% male and 56% female respondents with 75% respondents aged between 60 and 74 years old. Healthcare utilisation data was obtained from respondents and healthcare cost was tabulated by multiplying each service unit by the unit cost price. These services include care from polyclinic doctors, private general practitioners (GP), outpatient specialists and inpatient care. We modelled the relationship of healthcare cost and depression using two-part models (probit & generalised linear model - loglink and gamma distribution). For total healthcare expenditure, older adults with both depression and chronic diseases were associated with an average annual incremental cost of $7940 (95% CI 1490-14400; p = 0.016), compared to those without these conditions. They were also associated with an average incremental cost of $257 (95% CI 38.7-475; p = 0.021) for primary care. Likewise, in the case of specialist outpatient clinics, they had an average incremental cost of $970 (95% CI 163-1780; p = 0.018). However, for inpatient setting, the average incremental cost of $6180 (95% CI 418-12800; p = 0.066) was not significant. Additionally, older adults with depression and chronic diseases contribute to an annual productivity loss of $676 (95% CI 346-1010; p < 0.001). This study provides evidence that there are significant incremental costs associated with depression amongst the older adults with chronic diseases in Singapore's primary healthcare setting. The increased somatic presentations among the depressed older adults and the underdiagnosis of depression in primary care may contribute to higher utilisation of healthcare resources which entail higher expenditure. This is one of the first studies to look at the cost of depression using a representative sample of Singaporean older adults and taking into account the multi-ethnic nature of the population. Analyses were restricted to a cross-sectional design, and data relied heavily on the accuracy of self-report utilisation on health care services which was subjected to recall bias. Depression was found to inflate the total healthcare expenditure among older adults with chronic disease by two-fold. This study provides evidence that there are significant incremental costs associated with depression among the older adults with chronic diseases, demonstrating a need for more resources to improve systematic and clinical care for depressed older adults with chronic diseases.

EPID-30. THE COST OF HOSPITAL-BASED CARE AMONG CANADIAN PATIENTS WITH MALIGNANT CENTRAL NERVOUS SYSTEM TUMOURS IN COMPARISON TO THOSE WITH LUNG AND COLORECTAL CANCERS IN THE YEAR PRECEDING THEIR CANCER DIAGNOSIS

Abstract BACKGROUND Approximately 12% of the Canadian GDP was spent on healthcare in 2023. While hospital-based care (HC) constitutes a significant portion of this expenditure, the costs may vary depending on the cancer type. We investigate the HC cost of patients with malignant central nervous system tumours (CNS cancer) and compare it to patients with common cancers in Canadian provinces. METHODS We obtained data between 2010 and 2014 from the Canadian Institute for Health Information’s in-patient and ambulatory care datasets. HC cost was estimated using a 12-month look back period prior to diagnosis date for each patient, including cost related to cancer diagnosis and general healthcare. Choosing colorectal (CRC) and lung (LC) cancers to be the common cancers, patients who were 15 years of age or older and had a diagnosis of one of these cancers were included. We used quantile regression to investigate the factors associated with HC cost. RESULTS A total of 4,498 (CNS), 41,028 (CRC) and 29,747 (LC) patients were included from Alberta and Ontario, Canada. Encounter type (in-patient/out-patient), province (AB/ON), and comorbidities (Yes/No) were the top three factors contributing to HC cost. Adjusting for encounter type, comorbidities and age, the HC costs for CNS patients were $0.7k and $2.4k higher than CRC patients at 50th and 90th percentile, respectively, and $1.0k higher than LC patients at 90th percentile in Ontario. While in Alberta, HC costs for CNS patients were $0.2k and $0.8k higher than CRC patients at 50th and 90th percentile, respectively, and $1.0k lower than LC patients at both 50th and 90th percentiles. CONCLUSIONS We compared HC cost among Canadian patients with different cancer types; significant HC cost differences between patients with CNS and common cancer were observed. Further investigations are warranted to understand drivers of the cost differences.

QLTI-19. PEDIATRIC NEURO-ONCOLOGISTS NAVIGATING AN ADULT WORLD: A TALE OF TWO CENTERS

Abstract BACKGROUND Adolescent and Young Adult Neuro-Oncology(AYA-NO) patients are a distinct cohort with an overlap of tumors found in childhood and adulthood. For adult patients with pediatric-type Central Nervous System tumors, optimal work-flow to manage these patients is unclear. METHODS We examine the work-flow of pediatric neuro-oncologists starting AYA-NO clinics within two high volume adult institutions: the University of Miami(Florida, USA) and the Princess Margaret Cancer Centre(Toronto, Canada). RESULTS Over 18 months, the AYA-NO clinics managed 167 patients total with several key differences emerging in both institutions between the pediatric and adult work-flows. Adult providers commonly have neurology backgrounds, while pediatric providers mostly have hematology/oncology backgrounds. In pediatrics, providers typically meet the patient inpatient before pathology results, adult providers meet their patients in outpatient settings once histopathology results are available. Outpatient management in pediatric oncology centers typically includes labs, infusion centers, provider rooms, and social workers in one area while adults, due to the larger volume, have these services on separate units. Chemotherapy related differences included the primary provider for inpatient admissions and the emphasis of adult institutions on outpatient administration when feasible. Psychosocial factors such as the variety of caregivers, increased opportunity for patient autonomy in decision-making, and the increased fragmentation in care magnifies the importance of providers forming a strong rapport with AYA-NO patients. End of life care is vastly different including the inability for adult patients to receive palliative treatment in hospice care and the availability medically-assisted death. CONCLUSION Pediatric neuro-oncologists building AYA-NO workflows within adult settings can provide unique expertise for AYA-NO patients with pediatric-type tumors. Growing AYA-NO clinics can benefit from allocating AYA CNS specific resources such as chemotherapy/targeted therapy provider education, a dedicated hospital/clinic space, chemotherapy nursing, a care coordinator, and a social worker with experience treating this patient population.

Postoperative Exercise Training in Patients with Colorectal Liver Metastases A Randomized Controlled Trial.

Postoperative morbidity can reduce quality of life, physical performance, and tolerability of postoperative chemotherapy in patients with colorectal liver metastases (CRLM). Exercise can improve these outcomes in some cancer populations. However, it remains unknown whether exercise can be delivered in the early postoperative period following surgery for CRLM without increasing the risk of harms. The primary objective was to compare the number of serious adverse events (SAEs) with exercise intervention versus control. The secondary objectives were to compare non-SAEs, chemotherapy dose modifications, patient-reported outcomes, cardiorespiratory fitness, and physical performance. Patients with CRLM scheduled to open surgery with or without postoperative chemotherapy were randomized 2:1 to intervention or control. The intervention group performed 30-50 min low-to-high intensity exercise 5 times/week for 8 weeks, initiated one day after postoperative hospital discharge. The primary outcome was SAEs. The secondary outcomes were SAEs; chemotherapy dose modifications; patient-reported outcomes; cardiorespiratory fitness; and physical performance. Fifty-five participants were randomized. The number of SAEs was similar between the groups (between-group difference [95% CI]: -0.07 [-0.59; 0.43] events), whereas the number of non-SAEs was lower in intervention (between-group difference [95% CI]: -4.65 [-9.14; -0.17] events). We found between-group differences in time to postoperative chemotherapy (intervention: 25 days, control; 42 days) and chemotherapy dose modifications (RR [95%CI]: 0.55 [0.35; 0.88]). Additionally, we found between-group differences in quality of life, cardiorespiratory fitness, and physical performance, in favor of intervention. Early-onset postoperative exercise exhibit a favorable harms-benefit profile in patients with CRLM. This warrants further investigation in larger randomized controlled trials. Prospectively registered at clinicaltrials.gov (NCT04751773).

“It’s an Extra Twist That’s a Bit Tricky to Solve”: Staff Balancing Parental Involvement When Supporting the Participation of Adolescents in a Family-Oriented Practice

This study explores staff balancing parental involvement when performing recovery-oriented work via Patient-Initiated Brief Admission (PIBA) for adolescents. Data from focus group interviews with employees in Swedish Child and Adolescent Psychiatry (CAP) is discussed and analyzed using ecological systems theory. Findings suggest dualistic views on participation and parental involvement, where safety and security have to be considered supporting adolescents’ participation in psychiatric inpatient care. Staff has the potential to involve parents during PIBA without automatically diminishing adolescents’ participation, and this has to be legitimized if PIBA is to become an integrated tool to promote recovery-oriented care in CAP.

Alteplase in COVID-19 severe hypoxemic respiratory failure: the TRISTARDS multicenter randomized trial

BackgroundPulmonary intravascular thrombus formation has been widely observed in patients with respiratory failure, for example, in patients with SARS-CoV-2 infection (COVID-19). The aim of this study was to evaluate the efficacy/safety of alteplase thrombolysis in COVID-19 severe hypoxemic respiratory failure. In this multicenter, open-label study, patients were randomized to receive alteplase (low- or high-dose) over 5 days plus standard of care (SOC), or SOC alone. The primary endpoint was time to clinical improvement (≥ 2-point decrease on WHO Clinical Progression Scale, or hospital discharge) up to Day 28. Secondary endpoints included all-cause mortality at Day 28, treatment failure at Day 28 and change in arterial oxygen partial pressure/fractional inspired oxygen (PaO2/FiO2) ratio at Day 6 versus baseline.ResultsSixty-nine patients were randomized to alteplase (low- or high-dose) and 35 to SOC; 65% were on high-flow oxygen or non-invasive ventilation at baseline. Median time to clinical improvement was 25 days in the alteplase group and > 28 days (median not reached) in the SOC group. All-cause mortality was 8/69 (12%) versus 10/35 (29%) in the alteplase versus SOC groups, respectively (unadjusted risk difference [RD], − 17% [95% confidence interval (CI) − 34 to 0], p = 0.047; adjusted RD, − 16% [95% CI − 31 to 1], p = 0.058). The PaO2/FiO2 ratio (mean [standard deviation]) increased by + 30 (84) mmHg in the alteplase group and decreased by − 12 (59) mmHg in the SOC group (adjusted mean difference vs. SOC, p = 0.052). Differences were greater in patients receiving high-dose alteplase, and in those not receiving invasive ventilation. Eighteen patients (26.1%) in the alteplase group discontinued treatment due to adverse events. Major bleeding was more frequent with alteplase than with SOC (9 vs. 0 patients); no bleeding was fatal. The study closed early due to insufficient patient recruitment.ConclusionAlteplase was not associated with faster clinical recovery from COVID-19 severe hypoxemic respiratory failure. A numerical difference in survival and PaO2/FiO2 ratio was observed, particularly in patients not receiving invasive ventilation. These exploratory findings merit further investigation in larger patient cohorts that are adequately powered to confirm the hypotheses generated in this study regarding the impact of alteplase on treatment outcomes.Trial registration ClinicalTrials.gov: NCT04640194 (November 23, 2020); https://clinicaltrials.gov/study/NCT04640194 (early discontinuation due to insufficient patient recruitment).

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan–Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients’ characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p &lt; 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p &lt; 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09–0.72; p = 0.02) but not the need for re-intervention. A Kaplan–Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14–0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.