Hospital Emergency Room Visits Research Articles

Early detection of pediatric health risks using maternal and child health data

Machine learning (ML)-driven diagnosis systems are particularly relevant in pediatrics given the well-documented impact of early-life health conditions on later-life outcomes. Yet, early identification of diseases and their subsequent impact on length of hospital stay for this age group has so far remained uncharacterized, likely because access to relevant health data is severely limited. Thanks to a confidential data use agreement with the California Department of Health Care Access and Information, we introduce Ped-BERT: a state-of-the-art deep learning model that accurately predicts the likelihood of 100+ conditions and the length of stay in a pediatric patient’s next medical visit. We link mother-specific pre- and postnatal period health information to pediatric patient hospital discharge and emergency room visits. Our data set comprises 513.9K mother–baby pairs and contains medical diagnosis codes, length of stay, as well as temporal and spatial pediatric patient characteristics, such as age and residency zip code at the time of visit. Following the popular bidirectional encoder representations from the transformers (BERT) approach, we pre-train Ped-BERT via the masked language modeling objective to learn embedding features for the diagnosis codes contained in our data. We then continue to fine-tune our model to accurately predict primary diagnosis outcomes and length of stay for a pediatric patient’s next visit, given the history of previous visits and, optionally, the mother’s pre- and postnatal health information. We find that Ped-BERT generally outperforms contemporary and state-of-the-art classifiers when trained with minimum features. We also find that incorporating mother health attributes leads to significant improvements in model performance overall and across all patient subgroups in our data. Our most successful Ped-BERT model configuration achieves an area under the receiver operator curve (ROC AUC) of 0.927 and an average precision score (APS) of 0.408 for the diagnosis prediction task, and a ROC AUC of 0.855 and APS of 0.815 for the length of hospital stay task. Further, we examine Ped-BERT’s fairness by determining whether prediction errors are evenly distributed across various subgroups of mother–baby demographics and health characteristics, or if certain subgroups exhibit a higher susceptibility to prediction errors.

Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study.

Obstructive sleep apnea (OSA) is a highly prevalent, yet under-diagnosed condition. Due to its adverse impact on risk for cardiopulmonary disorders, there is interest in pro-active screening of OSA in hospitalized patients. We studied the long-term outcome of such screened patients who were initiated on positive airway pressure (PAP) therapy. Hospitalized patients who screened positive for OSA and were confirmed with post-discharge polysomnography (PSG) were dichotomized by PAP adherence and followed for a period of 12 months to evaluate for the composite endpoint of hospital readmissions and emergency room (ED) visits for cardiopulmonary reasons. Cost analysis between the two groups was also conducted. 2042 hospitalized patients were assessed for OSA as part of a hospital sleep medicine program from August 2019 to June 2023. Of these, 293 patients were diagnosed with OSA and prescribed PAP therapy. Of these 293 patients, 108 were adherent to therapy and 185 were non-adherent. The overall characteristics of the groups included a mean (SD) age: 58 years (12.82), mean BMI (kg/m2): 39.72 (10.71), male sex: 57%, and apnea-hypopnea index (AHI): 25.49 (26). 78%, 41% and 43% had hypertension, congestive heart failure, and diabetes mellitus, respectively. Hospitalized patients diagnosed with OSA and adherent to therapy have reduced readmissions and ED visits for cardiopulmonary reasons 12 months after discharge. Adherent patients have reduced cost of health care and length of stay during hospitalizations.

Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery.

Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit. Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit. Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical proceduresthat had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)]. Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.

New concentration-response functions for seven morbidity endpoints associated with short-term PM2.5 exposure and their implications for health impact assessment

BackgroundMorbidity burdens from ambient air pollution are associated with market and non-market costs and are therefore important for policymaking. The estimation of morbidity burdens is based on concentration–response functions (CRFs). Most existing CRFs for short-term exposures to PM2.5 assume a fixed risk estimate as a log-linear function over an extrapolated exposure range, based on evidence primarily from Europe and North America. ObjectivesWe revisit these CRFs by performing a systematic review for seven morbidity endpoints previously assessed by the World Health Organization, including data from all available regions. These endpoints include all cardiovascular hospital admission, all respiratory hospital admission, asthma hospital admission and emergency room visit, along with the outcomes that stem from morbidity, such as lost work days, respiratory restricted activity days, and child bronchitis symptom days. MethodsWe estimate CRFs for each endpoint, using both a log-linear model and a nonlinear model that includes additional parameters to better fit evidence from high-exposure regions. We quantify uncertainties associated with these CRFs through randomization and Monte Carlo simulations. ResultsThe CRFs in this study show reduced model uncertainty compared with previous CRFs in all endpoints. The nonlinear CRFs produce more than doubled global estimates on average, depending on the endpoint. Overall, we assess that our CRFs can be used to provide policy analysis of air pollution impacts at the global scale. It is however important to note that improvement of CRFs requires observations over a wide range of conditions, and current available literature is still limited. DiscussionThe higher estimates produced by the nonlinear CRFs indicates the possibility of a large underestimation in current assessments of the morbidity impacts attributable to air pollution. Further studies should be pursued to better constrain the CRFs studied here, and to better characterize the causal relationship between exposures to PM2.5 and morbidity outcomes.

Higher risk of future events, mortality and greater healthcare use among patients with increasingly recurrent atherosclerotic cardiovascular disease events in Taiwan: a retrospective cohort study

ObjectivesTo describe the occurrence of recurrent atherosclerotic cardiovascular disease (ASCVD) events within 3 years after a new-onset event, the associated disease burden and statin prescribing in patients with ASCVD in...

Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists.

existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists. articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test. a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.

Utilization of Health Resources During the Coronavirus Pandemic in Israel: Meuhedet Health Services’ Real Data Analysis and Future Conclusions

Aim: This study aimed to examine the utilization of health resources during the first year of the COVID-19 pandemic in Israel through the analysis of Meuhedet Health Services’ real-world database. Background: The history of COVID-19 in Israel comprises three waves: from February to May 2020, from May to November 2020, and from November 2020 to April 2021. Restrictions imposed on the Israeli population included travel limitations and even lockdowns. Meuhedet Health Services, the third largest health management organization in Israel, manages all its medical data through computerized electronic files and has collected various types of health services data from 2018 to 2020. This paper compared the consumption of Meuhedet Health Services over two consecutive years of the pandemic using a real-world database. Methods: Electronic medical records from primary care physicians, laboratory tests, hospitalization medical histories, treatments in hospitals and institutes, visits to and treatments by community physicians, and prescriptions and medical equipment consumption were collected from 2018 to 2020. This research used aggregated, non-personalized, and decoded data from a cohort of insured individuals, and the research was approved by all the relevant institutional Helsinki Committees. The data analysis compared the corresponding data in a chosen month of the year with the data in the same month of the previous year. The differences were then scaled by the data corresponding to the month of the previous year, and the result was multiplied by 100 and plotted. To analyze drug consumption, we used the fixed price of every drug in a year multiplied by the difference in consumption of the drug in question between the month of the current year and the same month of the previous year, multiplied by 100. Results: A significant decrease was noted in hospitalization days, general hospital outpatient clinic visits, general hospital emergency room visits, and total numbers of visits to community physicians during the first lockdown in the first wave of the pandemic in comparison to 2019. At the end of the lockdown, however, a compensatory increase was noted in all services. In terms of drug consumption, the data showed no differences in the effects of the different waves. Our findings revealed that the first wave of COVID-19 was a shock, with a significant reduction in the consumption of health services, but this decrease attenuated with the second wave due to immediate management interventions and safety rules implemented in hospitals and clinics. Conclusion: People shun medical services during a fast-spreading epidemic that causes significant mortality. Since new variants of COVID-19 could be part of our lives for the next few years, we should learn how to continue living with the pandemic and develop alternative medical services to maintain healthy states. Digitization, remote services, telemedicine, and home care, including home hospitalization, should be part of the health services to cope with pandemic situations.

Efficacy of paliperidone palmitate 3-month formulation in preventing hospital admissions and emergency room visits. 66 months of follow-up

IntroductionPaliperidone Palmitate 3-month formulation (PP3M) has shown a significantly longer time to relapse compared to placebo, with similar efficacy and safety to Paliperidone Palmitate 1-month (PP1M) (Carpiniello et al. Drug Des. Devel. Ther. 2016; 10 1731–1742).ObjectivesThe main objective of this study was to determine the effectiveness of PP3M in preventing hospital admissions and emergency room visits, in people with non-acute schizophrenia in a naturalistic psychiatric outpatient settingMethodsSample: 30 people with diagnosis of schizophrenia (DSM 5 criteria), who had started treatment with PP3M, after being stabilized with PP1M (the dose was not modified in the four months prior to inclusion in the study)Quarterly basis, the following evaluations were performed during a follow-up period of 66 months:The Clinical Global Impression-Schizophrenia scale (CGI-SCH)Treatment adherence, concomitant medication and the number of hospitalizations and emergency visitsEfficacy values: Percentage of patients who remained free of admissions at the end of 66 months of follow-up.Other evaluation criteria: Percentage of patients who never visited the emergency department at the end of 66 months of follow-up. Average change from baseline visit to the final evaluation as assessed by score obtained on the following scale: GSI-SCH, percentage of patients on antipsychotic monotherapy and treatment adherence rate.ResultsThe mean dose of PP3M was 401. 55 mgThe percentage of patients who remained free of admissions at the end of the 66 months was 83.25% and the percentage of patients who never visited the emergency department at the end of 66 months was 79.92%Mean variations from baseline scores at 66 months were: (-0.36 ±0-37) on the GCI-SCH.The percentage of patients on antipsychotic monotherapy at the end of the 66 months was 76.56%The rate of adherence was 86.58%.ConclusionsIn our study, we found that paliperidone palmitate 3-month formulation was effective in reducing the number of admissions and visits to the emergency department, under conditions of daily clinical practice.Disclosure of InterestNone Declared

Utilization of Health Resources during the Coronavirus Pandemic in Israel: Meuhedet Health Services’ Real Data Analysis and Future Conclusions

Aim To examine the utilization of health resources during the first year of the COVID-19 pandemic in Israel through the analysis of Meuhedet Health Services’ real-world database. Background The history of COVID-19 in Israel comprises three waves: from February to May 2020, from May to November 2020, and from November 2020 to April 2021. Restrictions imposed on the Israeli population included travel limitations and even lockdowns. Meuhedet Health Services, the third largest health management organization in Israel, manages all its medical data through computerized electronic files and has collected various types of health services data from 2018 to 2020. This paper compares the consumption of its services between two consecutive years. pandemic for Meuhedet Health Services using a real-world database. Method Electronic medical records from primary care physicians, laboratory tests, hospitalization medical histories, treatments in hospitals and institutes, visits to and treatments by community physicians, and prescriptions and medical equipment consumption were collected from 2018 to 2020. This research used aggregated, non-personalized, and decoded data from a cohort of insured persons, and the research was approved by all the relevant institutional Helsinki Committees. The data analysis compares the corresponding data in a chosen month of a year with the data in the same month of the previous year. The differences are then scaled by the data corresponding to the month of the previous year and the result multiplied by 100 and plotted. To analyze drug consumption, we use the fixed price of every drug in a year multiplied by the difference in consumption of the drug in question between the month of the current year and the same month of the previous year, multiplied by 100. Result A significant decrease was noted in hospitalization days, general hospital outpatient clinic visits, general hospital emergency room visits, and total numbers of visits to community physicians during the first lockdown in the first wave of the pandemic in comparison to 2019. At the end of the lockdown, however, a compensatory increase was noted in all services. In terms of drug consumption, the data show no differences in the effects of the different waves. Our findings reveal that the first wave of COVID-19 was a shock, with a significant reduction in the consumption of health services, but this decrease attenuated with the second wave, due to immediate management interventions and safety rules implemented in hospitals and clinics. Conclusion People shun medical services during a fast-spreading epidemic that causes significant mortality. Since new variants of COVID-19 could be part of our lives for the next few years, we should learn how to continue living with the pandemic and develop alternative medical services to maintain health states. Digitization, remote services, telemedicine, and home care, including home hospitalization, should be part of the health services to cope with pandemic situations.

Does an eHealth Intervention Reduce Complications and Healthcare Resources? A mHeart Single-Center Randomized-Controlled Trial

(1) Background: In the mHeart trial, we showed that an eHealth intervention, mHeart, improved heart transplant (HTx) recipients' adherence to immunosuppressive therapy compared with the standard of care. Herein, we present the analysis assessing whether mHeart reduces complication frequency and healthcare resource use, and whether this reduction depends on patients' adherence. (2) Methods: The mHeart was a single-center randomized-controlled trial (IIBSP-MHE-2014-55) in 134 adult HTx recipients (n = 71 intervention; n = 63 controls). The endpoints were mortality, complications, and resource use during follow-up (mean 1.6 ± 0.6 years). (3) Results: A significantly lower proportion of HTx recipients in mHeart had echocardiographic alteration (2.8% vs. 13.8%; p = 0.02), cardiovascular events (0.35% vs. 2.4%; p = 0.006), infections (17.2% vs. 56%; p = 0.03), and uncontrolled Hba1c (40.8% vs. 59.6%; p = 0.03) than controls. In addition, a significantly lower proportion of patients in the intervention needed hospital (32.4% vs. 56.9%; p = 0.004) or urgent admissions (16.9% vs. 41.4%; p = 0.002) and emergency room visits (50.7% vs. 69.0%; p = 0.03). Adherence status (measured by the self-reported SMAQ) influenced only controls regarding hospitalizations and emergency room visits. Differences were not significant on deaths (intervention 4.2% vs. control 9.5%; p = 0.4) (4) Conclusions: the mHeart strategy significantly reduced the occurrence of the studied post-transplant complications and the need for medical attention in HTx recipients. Adherence status influenced controls in their need for medical care.

Influencia del índice de privación social en resultados durante la pandemia de COVID-19

ObjectiveTo see the relationship between the population deprivation index and the use of the health services, adverse evolution and mortality during the COVID-19 pandemic. MethodRetrospective cohort study of patients with SARS-CoV-2 infection from March 1, 2020 to January 9, 2022. The data collected included sociodemographic data, comorbidities and prescribed baseline treatments, other baseline data and the deprivation index, estimated by census section. Multivariable multilevel logistic regression models were performed for each outcome variable: death, poor outcome (defined as death or intensive care unit), hospital admission, and emergency room visits. ResultsThe cohort consists of 371,237 people with SARS-CoV-2 infection. In the multivariable models, a higher risk of death or poor evolution or hospital admission or emergency room visit was observed within the quintiles with the greatest deprivation compared to the quintile with the least. For the risk of being hospitalized or going to the emergency room, there were differences between most quintiles. It has also been observed that these differences occurred in the first and third periods of the pandemic for mortality and poor outcome, and in all due for the risk of being admitted or going to the emergency room. ConclusionsThe groups with the highest level of deprivation have had worse outcomes compared to the groups with lower deprivation rates. It is necessary to carry out interventions that minimize these inequalities.

The clinical burden of extremely preterm birth in a large medical records database in the United States: complications, medication use, and healthcare resource utilization

Introduction Approximately 5% of global preterm births are extremely premature (EP), defined as occurring at less than 28 weeks gestational age. Advances in care have led to an increase in the survival of EP infants during the neonatal period. However, EP infants have a higher risk of developing complications such as bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). BPD and other respiratory morbidities are particularly prevalent among this population. To understand the healthcare resource utilization (HRU) of EP infants in the United States, the clinical and economic burden of extreme prematurity was examined in this retrospective study of data extracted from electronic medical records in the Kaiser Permanente Northern California (KPNC) health system. Methods The analysis included data from EP infants live-born between January 1997 and December 2016, and focused on complications and HRU up to 3 years corrected age (CA), covering the period up to December 2018. Stillbirths, infants born at <22 weeks gestational age, and infants with major congenital malformations were excluded. Complications of interest (BPD, IVH, and ROP) and medication use were compared by age group (≤1 year, >1 year and ≤2 years, and >2 years and ≤3 years CA). Analysis of HRU included hospital readmissions, ambulatory visits, and emergency room (ER) visits. Results A total of 2154 EP births (0.32% of total live births and 4.0% of preterm births that met the inclusion/exclusion criteria) were analyzed. The prevalence of EP birth showed a declining trend over time. ROP was the most commonly recorded complication during the birth hospitalization (37.1% any stage; 2.9% Stages 3 and 4). BPD was recorded in 34.3% of EP infants. IVH (any grade) was recorded in 22.7% of EP infants (6.4% Grades III and IV). A majority (78.7%) of EP infants were diagnosed with at least one respiratory condition during the first year CA, the most common being pneumonia (68.9%); the prevalence of respiratory conditions decreased over the second and third years CA. During the first 3 years CA, the most common medications prescribed to children born EP were inhaled bronchodilators (approximately 30% of children); at least 15% of children received systemic corticosteroids and inhaled steroids during this period. During the first 3 years CA, at least one hospital readmission was recorded for 16.4% of children born EP; 57.1% of these readmissions were related to respiratory conditions. At least one ER visit was recorded for 33.8% of children born EP, for which 53.1% were due to a respiratory condition. Ambulatory visits were recorded for 54.2% of EP children, for which 82.9% were due to a respiratory condition. Conclusions The short- and long-term clinical burden of EP birth was high. The onset of BPD, IVH, and ROP was common during the birth hospitalization for EP infants. Medication use, hospital readmission, and clinic visits (ER and ambulatory) occurred frequently in these children during the first 3 years CA, and were commonly due to respiratory conditions. Strategies prioritizing the reduction of risk and severity of respiratory conditions may alleviate the clinical burden of EP birth over the long term.

Prevalence and mortality of infective endocarditis among community acquired and healthcare acquired staphylococcus aureus bacteremia: a nationwide study

Abstract Background Staphylococcus aureus bacteremia (SAB) may be community acquired or healthcare acquired, and prior small studies have suggested that the place of acquisition impacts the subsequent prevalence of infective endocarditis (IE) and also patient outcomes. However, data on this relationship is sparse and this may influence optimal work-up and treatment of these patients. Purpose To examine the prevalence of IE among patients with community acquired and healthcare acquired SAB. Further, to investigate one-year mortality among patients with SAB-IE stratified by place of acquisition. Methods Patients with first-time SAB from 2010–2018 were identified using Danish nationwide registries and categorized into either community acquired (no health care contact within 30 days) or healthcare acquired (either a. hospital admission or emergency room visit within 30 days, b. SAB &amp;gt;48 hours after hospital admission, or c. out-patient dialysis). SAB was then related to IE and compared between the two study groups using multivariable adjusted logistic regression analysis. The one-year mortality was compared using multivariable adjusted Cox proportional hazard analysis for patients with SAB-IE stratified by place of bacteremia acquisition. The proportional hazard assumption was violated, and a landmark analysis was conducted comparing mortality between groups with a) 0–40 days of follow-up, and b) 40–365 days of follow-up. Results We identified 13,040 patients with SAB; 5,512 (62.3% male, median age 71.0 years) were community acquired and 7,528 (63.1% male, median age 69.0 years) were healthcare acquired. The prevalence of IE was 12.0% among patients with community acquired SAB and 6.6% among patients with healthcare acquired SAB, Figure. After accounting for patient characteristics, community acquired SAB was associated with a higher odds of IE as compared with healthcare acquired SAB, adjusted OR=2.12 (95% CI: 1.86–2.41). Sex- and age groups did not modify this association. The one-year mortality was 37.3% for community acquired SAB-IE and 47.3% for healthcare acquired SAB-IE, Figure. With up to 40 days after IE admission, no difference in associated mortality was seen between groups in adjusted analysis, HR=1.07 (95% CI: 0.83–1.37) with healthcare acquired SAB-IE as reference group. Beyond 40 days of follow-up patients with community acquired SAB-IE was associated with a lower mortality as compared with healthcare acquired SAB-IE, HR=0.71 (95% CI: 0.53–0.95). Conclusion Community acquired SAB was associated with twice the odds of IE as compared with healthcare acquired SAB. SAB-IE was associated with high mortality rates, with no difference between groups at short-term follow-up, however long-term follow-up revealed an associated lower mortality in patients with community acquired SAB-IE. These findings indicate a need for an intensified work-up strategy for IE in patients with community acquired SAB. Funding Acknowledgement Type of funding sources: None.

Patient-reported outcome measurement (PROM) program in patients with lymphoma receiving intravenous therapy: Preliminary results of a prospective study using PRO-CTCAE to individualize healthcate and to reduce unscheduled appointments.

e18670 Background: PROMs have been included in cancer clinical trials but it is yet to come in daily clinical practice. Their implications in healthcare management have not been well stablished yet. We hypothesize that patients subscribed to these programs may benefit from a better self-perception of health status and might require fewer hospital admissions and emergency room visits, which could allow a reduction in the costs of treatment. Methods: “E-Res Salud” is a value-based healthcare program implemented in patients with hematological malignancies in our institution. Patients (pts) with diagnosis of any type of lymphoma in the need of treatment between 1st Jan 2019 and 31st Dec 2020 were included in our research. Inclusion in PROMs program was offered to every patient starting intravenous treatment in 2020. Pts who started treatment in 2019 and those who rejected inclusion in 2020 were considered the control arm of our study. The principal endpoint was to compare physician and patient-reported adverse events through a standardized questionnaire such as PRO-CTCAE. Secondary endpoints included association between inclusion in PROMs program and reduction of hospital admissions and emergency room visits. Results: A total of 142 pts were included in our study; 76 of them (53.5%) were included in a PROMs program. There were no differences in pts characteristics with regards of age or sex. Most frequent diagnoses were diffuse large B-cell, follicular and Hodgkin lymphoma. Adverse events (AEs) most frequently reported by physicians were hematological complications (76.1%), general (73.9%), gastrointestinal symptoms (59.9%) and infections (43.7%). When patients were asked to report AEs of higher intensity, the most frequently reported were general (31.6%), genitourinary (26.3%), gastrointestinal (23.7%), neurological (15.8%) and cutaneous (13.2%) symptoms. Patients included in PROMs program experienced reported fewer general (64.5% vs. 84.8%; p &lt; 0.05) and infectious (30.3% vs. 59.1%; p &lt; 0.05) AEs than those in the control arm. Moreover, inclusion in the PROMs program was associated with fewer number of visits to Emergencies, with 34.2% of pts vs 60% of pts not enrolled in the PROM program (p = 0.003). None of the different types of AEs were associated to an increase in the number of admissions or outpatient consultations. With such a short follow-up we have not found association between any type of AE and survival. Conclusions: This program can help to increase awareness among hematologists about patients’ perception of symptoms and what really matters to them. Our study establishes the association of PROMs with health care utilization among patients with different types of lymphoma. A longer follow-up and changes in PROMs during the treatment will be further analyzed.

The impact of an oncology-specific shared savings agreement.

1536 Background: In response to rising healthcare costs, several innovative payment strategies have emerged to improve the value and efficiency of healthcare spending. One of these strategies is a shift from volume-based to value-based care (VBC), resulting in the introduction of alternative payment models, innovative provider contracting and new value frameworks. The purpose of this study is to evaluate the impact of a VBC arrangement on total cost of care for chemotherapy patients, specifically cancer-related drug costs, daily hospital inpatient admissions and emergency room visits. Methods: This is a cohort study of chemotherapy patients, in a single state, enrolled in a large national insurer from January 18, 2021, to September 30, 2021. Oncology patients were divided into two groups; the study group consisted of chemotherapy patients receiving care in a VBC arrangement; the control group consisted of chemotherapy patients receiving care at oncology practices not engaged with the insurer in a VBC agreement. The following levers were employed to improve value: digital symptom tracking, biosimilar or lower-cost drug options and NCCN regimen concordance. We defined cancer-related drug costs as the sum of allowed costs paid for medical and pharmacy claims during the study period. Additionally, we averaged the cost per hospital inpatient day and emergency room visit and compared these by group. Results: This study included 1,574 patients, 733 patients in the study group and 841 in the control group. A reduction of 5.1% (a difference of $441) in cancer-related drug costs per member per treatment month (PMPTM) was observed among patients in the study group. Patients in the study group reported 27.8% fewer inpatient days resulting in a savings of $194 PMPTM. Similarly, patients in the study group reported 70.0% fewer emergency room visits resulting in a savings of $59 PMPTM. Conclusions: In this study, chemotherapy patients participating in a shared savings VBC spent less on cancer-related drug costs, hospital inpatient days and emergency room visits through three value levers. Further studies are needed to assess if these results are similar all types of healthcare coverage and to what degree additional value levers further reduce costs. Additionally, the long-term health outcomes of these patients should be assessed.

Abstract 207: Quality Improvement Project: Urgent Heart Failure Clinic Reduces Admissions And Emergency Department Visits In Heart Failure Patients.

Currently, 6 million Americans suffer from congestive heart failure (CHF). The economic burden of the disease continues to rise with an estimated cost of $70 billion by 2030. Providing high value care to CHF patients continues to be a challenge and a priority nationwide. We aim to evaluate the efficacy of the multicenter telemedicine Urgent Heart Failure Clinic (UHFC) in the reduction of hospital admission and emergency room visit rates and health care costs. UHFC care team consists of a primary cardiologist to review the patient’s overall care plan, care coordination by cardiology CHF nurse navigator, CHF nurse practitioners, community-based resources, and intensive medication management and monitoring. Enrolled patients are offered complex care coordination and frequent nursing follow up to reinforce compliance, provide education, and identify additional resources for patients. A retrospective chart review of patients deemed high-risk for heart failure readmission and enrolled into UHFC was conducted. Primary endpoint was the evaluation of admission and emergency room utilization 90-day prior and post enrollment in UHFC. Of the 132 patients enrolled: 80% (106 of 132) hypertensive, 71% (94 of 132) had hyperlipidemia, 55% (73 of 132) diabetic, 61% (81 of 132) had chronic renal disease, 54% (71 of 132) had coronary artery disease, 31% (41 of 132) had valvular disease, 22% (29 of 132) had pulmonary hypertension, and 60.6% (80 of 132) had arrhythmias. 44% (58 of 132) ejection fraction (EF) &lt; 50% and 56% (74 of 132) EF ≥ 50%. There was a 47.2% (103 vs 195) reduction in hospitalizations and a 24% (19 vs 25) reduction in emergency room visits post enrollment. Prior to enrollment 79% (105 of 132) of patients had hospitalizations compared to the 54.5% (72 of 132) of patients that had hospitalizations post enrollment. An individual decrease in the number of admissions was seen in 56.8% (75 of 132) of patients post enrollment. Overall, 92 admissions were saved equating to a cost savings of $1,487,124.50. In conclusion, utilization of UHFC had a significant reduction in admission rates within 90-day post enrollment. Implementation successfully led to a decrease in hospital utilization and thus a substantial reduction in cost of care.

Abstract WP207: Switching Antiplatelets In Breakthrough Ischemic Stroke: Long Term Outcomes And Safety

Introduction: Previous studies have shown that switching antiplatelets after having an ischemic stroke on aspirin may have better outcomes. However, these studies included patients who were switched to dual antiplatelets, which have an established benefit in the immediate post-stroke period. The purpose of this study is to assess outcomes in patients who continue aspirin versus switch to clopidogrel after having a cerebrovascular event on aspirin. Methods: We retrospectively identified patients within 14 Southern California hospitals using ICD-9 and ICD-10 codes who had a diagnosis of ischemic stroke on aspirin from January 2017-December 2019. Outcomes included recurrent hospital admission or emergency room visit for ischemic stroke, TIA, or intracranial hemorrhage up to two years post index event. Patients were grouped by which antiplatelet was prescribed at discharge. Those prescribed dual antiplatelets or an anticoagulant were excluded. Cox regression analysis was used to estimate risk of readmission. Results: Of the 580 patients who met the inclusion criteria, 372 (64%) continued aspirin and 208 (36%) switched to clopidogrel. Those with coronary artery disease (55.0% versus 45.0%, p = 0.015), dyslipidemia (61.4% versus 38.6%, p = 0.001), diabetes (59.5% versus 40.5%, p = 0.007), and a higher NIHSS score (mean 6.06 +/- 6.96 SD versus 4.08 +/- 4.32 SD, p = 0.001) were more likely to be discharged on aspirin. There were no differences in recurrent ischemic stroke {18.8% versus 15.4%, HR 1.12 (95% CI, 0.74-1.72), p = 0.587}, ischemic stroke plus TIA {19.9% versus 18.3%, HR (95% CI, 0.84-1.86), p = 0.253}, systemic embolism {25.5% versus 21.6%, HR 1.16 (95% CI, 0.82-1.66), p = 0.413} or intracranial hemorrhage {3.2% versus 2.4%, HR 0.94 (95% CI, 0.34-2.70), p = 0.919} between those discharged on aspirin versus clopidogrel, respectively. Conclusion: This study suggests that switching antiplatelets after having an ischemic stroke on aspirin may not be warranted.

Impact of Pharmacist-Driven Transitions of Care Interventions on Post-hospital Outcomes Among Patients With Coronary Artery Disease: A Systematic Review

Background: Transitions of care (ToC) aim to provide continuity while preventing loss of information that may result in poor outcomes such as hospital readmission. Readmissions not only burden patients, they also increase costs. Given the high prevalence of coronary artery diseases (CAD) in the United States (US), patients with CAD often make up a significant portion of hospital readmissions. Objective: To conduct a systematic review evaluating the impact of pharmacist-driven ToC interventions on post-hospital outcomes for patients with CAD. Methods: MEDLINE, Scopus, and CINAHL were searched from database inception through 03/2020 using key words for CAD and pharmacists. Studies were included if they: (1) identified adults with CAD at US hospitals, (2) evaluated pharmacist-driven ToC interventions, and (3) assessed post-discharge outcomes. Outcomes were summarized qualitatively. Results: Of the 1612 citations identified, 11 met criteria for inclusion. Pharmacist-driven ToC interventions were multifaceted and frequently included medication reconciliation, medication counseling, post-discharge follow-up and initiatives to improve medication adherence. Hospital readmission and emergency room visits were numerically lower among patients receiving vs not receiving pharmacist-driven interventions, with statistically significant differences observed in 1 study. Secondary prevention measures and adherence tended to be more favorable in the pharmacist-driven intervention groups. Conclusion: Eleven studies of multifaceted, ToC interventions led by pharmacists were identified. Readmissions were numerically lower and secondary prevention measures and adherence were more favorable among patients receiving pharmacist-driven interventions. However, sufficiently powered studies are still required to confirm these benefits.

Amiodarone, Verapamil, or Diltiazem Use With Direct Oral Anticoagulants and the Risk of Hemorrhage in Older Adults

BackgroundRoutinely used cardiac medications, based on pharmacokinetics, are hypothesized to increase drug levels of direct oral anticoagulants (DOACs), with the potential to increase the risk of hemorrhage. We set out to compare the risk for hemorrhage following initiation of amiodarone, verapamil, or diltiazem (moderate cytochrome P450 3A4 and/or P-glycoprotein activity) vs metoprolol or amlodipine (weak or no activity), among older adults prescribed DOACs. MethodsWe conducted a population-based, retrospective cohort study of all adults (aged ≥ 66 years) on a DOAC (dabigatran, apixaban, rivaroxaban; n = 295,038) who were newly prescribed amiodarone (n = 4872), verapamil (n = 1284), or diltiazem (n = 14,638), compared with metoprolol or amlodipine, from Ontario, Canada (2009-2016). The outcome was hospital admission or emergency room visit with a major hemorrhage (upper or lower gastrointestinal tract, intracranial), examined using weighted models. ResultsA total of 1737 hemorrhage events occurred (amiodarone, 80 [1.6%] vs metoprolol 503 [2.3%]; verapamil, 32 [2.5%] vs amlodipine, 406 [1.6%]; diltiazem, 312 [2.1%] vs amlodipine, 404 [1.5%]). The weighted risk of major hemorrhage was not elevated with amiodarone, verapamil, or diltiazem initiation in DOAC users, compared to metoprolol or amlodipine, during the full follow-up period (hazard ratio [HR; 95% confidence interval]: amiodarone HR 0.77 [0.61-0.97]; verapamil HR 1.32 [0.88-1.98]; diltiazem HR 0.99 [0.85-1.15]). This finding was consistent with a broader definition of bleeding, adjusting for kidney function, by DOAC type or dosage. ConclusionsHemorrhage risk with amiodarone, verapamil, and diltiazem was similar to that with comparators, among DOAC users aged > 66 years.

Early follow-up in the cardiological day hospital after heart surgery. Impact on hospital readmissions and emergency room visits

Abstract Introduction In the first few months after heart surgery, readmissions and emergency visits are common. In order to reduce these events, we developed an early follow-up protocol after discharge based on attention in our cardiological day hospital (CDH), which allows clinical and analytical assessment, monitoring and intravenous treatment at successive visits. The objective of the study is to assess the effectiveness of the protocol after its implementation. Methods Patients in our area discharged after heart surgery between 2013 and 2017 were included. They were divided into two groups, one with conventional follow-up and one with initial follow-up in CDH. Baseline clinical characteristics, type of surgery and surgical risk were compared. The primary endpoint was the time to the first readmission or emergency visit. The follow-up time was 200 days from discharge. Quantitative variables were compared using Student's t test and categorical variables using chi-square test. Cox proportional hazards model was used for multivariate analysis. Results 321 patients, 160 with conventional and 161 with CDH follow-up, were included. There were no differences in baseline characteristics (age, type of surgery, comorbidities, risk and hospital stay) except for sex (44.7% women in conventional group vs 33.8% in HDC, p=0.04). The results of readmissions and the composite endpoint (readmission or emergency visit) at 30, 90 and 200 days are shown in the table. We found a trend of decreasing events in the CDH group, although statistical significance was not achieved. In multivariate analysis, the variables independently associated (p&amp;lt;0.05) with an increase in the combined endpoint at 200 days were: female sex, prior atrial fibrillation, hypertension and an Euroscore surgical risk index greater than 3. The time to a first cardiological assessment after discharge decreased significantly in the CDH group (58 vs 18 days, p&amp;lt;0.001). Conclusions In patients followed in CDH after heart surgery, there is a trend towards less readmissions and emergency visits in the first six months after discharge. Some baseline characteristics have been shown to be independently associated with the risk of events, which will help us to identify the most at-risk patients, on which an intervention could have a greater magnitude of benefit. Funding Acknowledgement Type of funding sources: None. Table 1. ResultsFigure 1. Hazard of composite end-point