Identify Patient Characteristics Research Articles

The effect of cardiac resynchronization without a defibrillator on morbidity and mortality: an individual patient data meta-analysis of COMPANION and CARE-HF.

AimsCardiac resynchronization therapy (CRT) reduces morbidity and mortality for patients with heart failure, reduced left ventricular ejection fraction, QRS duration >130 ms and in sinus rhythm. The aim of this study was to identify patient characteristics that predict the effect, specifically, of CRT pacemakers (CRT‐P) on all‐cause mortality or the composite of hospitalization for heart failure or all‐cause mortality.Methods and resultsWe conducted an individual patient data meta‐analysis of the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) and Cardiac Resynchronization‐Heart Failure (CARE‐HF) trials. Only patients assigned to CRT‐P or control (n = 1738) were included in order to avoid confounding from concomitant defibrillator therapy. The influence of baseline characteristics on treatment effects was investigated. Median age was 67 (59–73) years, most patients were men (70%), 68% had a QRS duration of 150–199 ms and 80% had left bundle branch block. Patients assigned to CRT‐P had lower rates for all‐cause mortality (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.56–0.81; p < 0.0001) and the composite outcome (HR 0.67, 95% CI 0.58–0.78; p < 0.0001). No pre‐specified characteristic, including sex, aetiology of ventricular dysfunction, QRS duration (within the studied range) or morphology or PR interval significantly influenced the effect of CRT‐P on all‐cause mortality or the composite outcome. However, CRT‐P had a greater effect on the composite outcome for patients with lower body surface area and those prescribed beta‐blockers.ConclusionsCardiac resynchronization therapy‐pacemaker reduces morbidity and mortality in appropriately selected patients with heart failure. Benefits may be greater in smaller patients and in those receiving beta‐blockers. Neither QRS duration nor morphology independently predicted the benefit of CRT‐P.Clinical Trial Registration: COMPANION, NCT00180258; CARE‐HF, NCT00170300.

Cardiac Monitoring and Heart Failure in Advanced Breast Cancer Patients Treated With Trastuzumab in Ontario, Canada.

BackgroundTrastuzumab has improved patient outcomes in HER2 + breast cancer (BC) but carries a risk of cardiotoxicity. Routine cardiac imaging is recommended for advanced breast cancer (aBC) patients during trastuzumab treatment despite a lack of evidence that this improves patient outcomes. This study was conducted to understand predictive factors for cardiac events and determine the impact of cardiovascular monitoring in aBC.MethodsThis retrospective population-based cohort study included aBC patients treated with trastuzumab (all lines), in Ontario, Canada from 2007 to 2017. The overall cohort was divided into two groups; those who developed a cardiac event (CE) vs. those who did not. Patients with pre-existing heart disease were excluded. Logistic regression was performed to identify patient characteristics associated with an increased risk of CE.ResultsOf 2,284 patients with HER2 + aBC treated with trastuzumab, 167 (7.3%) developed a CE. Median age at first dose of trastuzumab was 57 (IQR 49–66); 61 (IQR 51–70) for patients with a CE. Median number of cycles was 16 (IQR 7–32); 21 (IQR 8–45) for patients with a CE (p < 0.01). Twelve (0.5%) patients died of cardiac causes; all had a prior CE. Increased risk of CEs was associated with age > 60 (OR 5.21, 95% CI 1.83–14.84, p = 0.05) and higher number cycles of trastuzumab (OR 1.01; 95% CI 1–101, p = 0.028).ConclusionThis is the first population-based study to report on CEs and cardiac monitoring in HER2 + aBC patients during trastuzumab-based therapy. Older age and longer treatment with trastuzumab were associated with an increased risk of a CE.

Mapping the risk of infections in patients with multiple sclerosis: A multi-database study in the United Kingdom Clinical Practice Research Datalink GOLD and Aurum

Background: People with multiple sclerosis (pwMS) have an increased risk of infections; risk factors include underlying disease, physical impairment and use of some disease-modifying treatments. Objective: To quantify changes in population-level infection rates among pwMS and compare these to the general population and people with rheumatoid arthritis (pwRA), and identify patient characteristics predictive of infections after MS diagnosis. Methods: We conducted a multi-database study using data on 23,226 people with MS diagnosis from the UK Clinical Practice Research Datalink Aurum and GOLD (January 2000–December 2020). PwMS were matched to MS-free controls and pwRA. We calculated infection rates, and estimated incidence rate ratios (IRR) and 95% confidence intervals (CI) of predictors for infections ⩽ 5 years after MS diagnosis using Poisson regression. Results: Among pwMS, overall infection rates remained stable – 1.51-fold (1.49–1.52) that in MS-free controls and 0.87-fold (0.86–0.88) that in pwRA – although urinary tract infection rate per 1000 person-years increased from 98.7 (96.1–101) (2000–2010) to 136 (134–138) (2011–2020). Recent infection before MS diagnosis was most predictive of infections (1 infection: IRR 1.92 (1.86–1.97); ⩾2 infections: IRR 3.00 (2.89–3.10)). Conclusion: The population-level elevated risk of infection among pwMS has remained stable despite the introduction of disease-modifying treatments.

Treatment effect modifiers for individuals with acute low back pain: secondary analysis of the TARGET trial.

Treatment effect modifiers identify patient characteristics associated with treatment responses. The purpose of this secondary analysis was to identify potential treatment effect modifiers for disability from the TARGET trial that compared usual care (control) with usual care + psychologically informed physical therapy (PIPT). The sample consisted of a STarT Back tool identified high-risk patients with acute low back pain that completed Oswestry Disability Index (ODI) data at index visit and 6 months later (n = 1250). Candidate treatment effect modifiers were identified a priori and informed by the literature. Linear mixed models tested for treatment effect modification through tests of statistical interaction. All statistical interactions ( P ≤ 0.20) were stratified by modifier to inspect for specific effects ( P ≤ 0.05). Smoking was identified as a potential effect modifier (treatment * smoking interaction, P = 0.08). In participants who were smokers, the effect of PIPT was (ODI = 5.5; 95% CI: 0.6-10.4; P = 0.03) compared with usual care. In participants who were nonsmokers, the effect of PIPT was (ODI = 1.5; 95% CI: -1.4 to 4.4; P = 0.31) compared with usual care. Pain medication was also identified as a potential effect modifier (treatment × pain medication interaction, P = 0.10). In participants prescribed ≥3 pain medications, the effect of PIPT was (ODI = 7.1; 95% CI: -0.1 to 14.2; P = 0.05) compared with usual care. The PIPT effect for participants prescribed no pain medication was (ODI = 3.5; 95% CI: -0.4 to 7.4; P = 0.08) and for participants prescribed 1 to 2 pain medications was (ODI = 0.6; 95% CI: -2.5 to 3.7; P = 0.70) when compared with usual care. These findings may be used for generating hypotheses and planning future clinical trials investigating the effectiveness of tailored application of PIPT.

PO-710-04 CONTEMPORARY PREVALENCE AND PREDICTORS OF INTACT PULMONARY VEIN ISOLATION IN PATIENTS UNDERGOING REPEAT ATRIAL FIBRILLATION ABLATION

Pulmonary vein isolation (PVI) is the primary goal of atrial fibrillation (AF) ablation. Prior studies have noted a 50-95% prevalence of pulmonary vein (PV) reconnection at the time of repeat ablation. However, the prevalence of PV reconnection with contemporary AF ablation techniques, including high frequency jet ventilation, is unknown. Furthermore, there is an incomplete understanding of predictors of intact PVI at the time of repeat ablation. To assess the prevalence of PV reconnection in a contemporary cohort utilizing jet ventilation, contact force catheters, and adenosine testing for dormant conduction, and identify patient characteristics and ablation techniques that predict PVI at time of repeat ablation. We reviewed 615 consecutive radiofrequency AF ablations from 2013-2019 at an academic medical center performed by a single operator. There were 121 unique patients who underwent a de novo AF ablation followed by a repeat AF ablation. We evaluated clinical and previous procedural characteristics to identify predictors of PVI at the time of repeat ablation, using logistic regression models. Of the 121 patients, 42.1% were female, average age was 64.5 years, and BMI 31. At the time of repeat ablation, 57% (n=69) had intact prior PVI. Baseline characteristics of patients with intact PVI and reconnected PVI were similar, including age (64 years and 65 years; p=0.75), left atrial diameter (4.13 cm and 4.39 cm; p=0.09), left ventricular ejection fraction (54.5 % and 55.4%; p = 0.38), and time to first atrial fibrillation recurrence (237 days v. 344 days, p=0.28). The only significant clinical predictor of intact PVI was the pre-procedure diagnosis of atypical atrial flutter (20.3 % v. 3.8%, p=0.02) (Figure 1). In multivariate analysis, prior mitral line ablation (OR 8.93, 95%CI [3.65, 21.87]: p <0.01) and first pass isolation of right pulmonary vein during the index AF ablation (OR 2.59, 95% CI [1.09, 6.12]: p = 0.03) strongly predicted intact PVI at the time of repeat AF ablation. With contemporary techniques, PVI reconnection is seen in 43% of patients at the time of repeat AF ablation. History of atypical flutter, prior mitral line ablation, and first pass isolation of the right PVs were significant predictors for intact PVI.

77P A real-world population study in early breast cancer to identify patient characteristics, treatment and outcomes in Scotland

Despite adjuvant endocrine treatment (AET) advances, hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2−), node-positive early breast cancer (EBC) is associated with a considerable (∼20%) risk of recurrence. We conducted a retrospective study to describe demographic/clinical characteristics and outcomes alongside treatment patterns in patients (pts) with HR+, HER2− node-positive EBC in the region of Scotland served by the Edinburgh Cancer Centre, a specialist referral centre.

MP16-20 PREDICTORS OF DISCHARGE TO HOME FOLLOWING MAJOR SURGERY FOR UROLOGIC MALIGNANCIES

You have accessJournal of UrologyCME1 May 2022MP16-20 PREDICTORS OF DISCHARGE TO HOME FOLLOWING MAJOR SURGERY FOR UROLOGIC MALIGNANCIES Nehizena Aihie, Deukwoo Kwon, Matthew Mason, Helen Yang Hougen, Dimple Chananmolu, Sanoj Punnen, Bruno Nahar, Dipen Parekh, Mark Gonzalgo, and Chad Ritch Nehizena AihieNehizena Aihie More articles by this author , Deukwoo KwonDeukwoo Kwon More articles by this author , Matthew MasonMatthew Mason More articles by this author , Helen Yang HougenHelen Yang Hougen More articles by this author , Dimple ChananmoluDimple Chananmolu More articles by this author , Sanoj PunnenSanoj Punnen More articles by this author , Bruno NaharBruno Nahar More articles by this author , Dipen ParekhDipen Parekh More articles by this author , Mark GonzalgoMark Gonzalgo More articles by this author , and Chad RitchChad Ritch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Discharge to home is a measurable patient outcome used to assess quality of care for hospitals. The 2021 US news and world report (USNWR) uses this metric to rate patient outcomes when calculating Urology hospital rankings. Our objective was to identify patient risk factors that predict non-home discharge after surgery for urologic malignancies. METHODS: The ACS-NSQIP database was queried using urology specific Current Procedural Terminology (CPT) codes to retrospectively identify patients who had undergone open, laparoscopic, or robotic surgery for urologic malignancies including prostate, bladder, kidney, or upper tract urothelial cancer from 2011-2019. Descriptive statistics were used to compare patients who were discharged to home versus non-home discharges. Univariable and multivariable logistic regression analysis were performed to identify patient characteristics that were associated with non-home discharges. All tests were two-sided and statistical significance was considered when p<0.05. RESULTS: Non-home discharge occurred in 3.03% of the 103,244 patients in our study. In our study population 91.7% were male while 8.3% were female. Women were more likely to have non-home discharges (male:female OR 0.62 p<0.0001). As expected, non-home discharge was more common in patients who underwent cystectomy when compared to nephrectomy (OR 1.51 p=0.016) or prostatectomy (OR 1.56 p=0.002). Those with elevated BMI were less likely to experience non-home discharge (OR 0.85 p=0.002) while patients who were identified as underweight and those with unexpected weight loss prior to surgery were more likely to have non-home discharges (OR 1.90 p<0.0001, OR 2.02, p<0.0001). Comorbidities including diabetes and cardiopulmonary disease were also found to be significant independent predictors of non-home discharges. CONCLUSIONS: Patient factors including age, gender, weight, comorbidities, and site of procedure were found to be independent predictors of non-home discharge following surgery for urologic malignancies. Patients with these risk factors should be counseled pre-operatively on the likelihood of requiring a non-home discharge to help manage expectations and create a standardized transition of care pathway following surgery. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e283 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nehizena Aihie More articles by this author Deukwoo Kwon More articles by this author Matthew Mason More articles by this author Helen Yang Hougen More articles by this author Dimple Chananmolu More articles by this author Sanoj Punnen More articles by this author Bruno Nahar More articles by this author Dipen Parekh More articles by this author Mark Gonzalgo More articles by this author Chad Ritch More articles by this author Expand All Advertisement PDF DownloadLoading ...

Introduction to Topical Issue on mHealth for Brain Injury Rehabilitation.

Introduction to Topical Issue on mHealth for Brain Injury Rehabilitation.

PD17-02 COST IMPLICATIONS OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSIES IN THE UNITED STATES

You have accessJournal of UrologyCME1 May 2022PD17-02 COST IMPLICATIONS OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSIES IN THE UNITED STATES Sharon White, Eric Ballon-Landa, Michael Bronsert, Boris Gershman, Peter Clark, Granville Lloyd, Jeffrey Morrison, Rodrigo Rodrigues-Pessoa, Marc Smaldone, Anessa Sax-Bolder, and Simon Kim Sharon WhiteSharon White More articles by this author , Eric Ballon-LandaEric Ballon-Landa More articles by this author , Michael BronsertMichael Bronsert More articles by this author , Boris GershmanBoris Gershman More articles by this author , Peter ClarkPeter Clark More articles by this author , Granville LloydGranville Lloyd More articles by this author , Jeffrey MorrisonJeffrey Morrison More articles by this author , Rodrigo Rodrigues-PessoaRodrigo Rodrigues-Pessoa More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Anessa Sax-BolderAnessa Sax-Bolder More articles by this author , and Simon KimSimon Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002555.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Infectious complications following transrectal ultrasound prostate biopsies (TRUS-PB) represent a growing burden in the U.S. Understanding the health care costs attributable to these adverse outcomes following this common urologic procedure is essential but remains largely unknown. Herein, we describe the economic burden attributable to post TRUS-PB infectious complications from a population-based cohort of privately-insured patients. METHODS: From 2010 to 2015, we identified all patients who underwent an incident TRUS PB from MarketScan. Health care costs and patient out-of-pocket costs due to infectious complications requiring hospital admission and emergency room (ER) visits within 30 days of the TRUS-PB represented the primary outcome. Multivariable analyses were used to identify patient characteristics associated with higher health care and out-of-pocket costs. RESULTS: Overall, 193,490 patients underwent TRUS-PB and the mean age was 57.6 years (SD: 5.0). The rates of infectious complications requiring ER visits and hospital admissions were 0.4 and 1.2 per 100 prostate biopsies. Compared to patients who did not experience any infectious complications, patient admitted to hospital within 30 days had higher health care costs ($14,057 vs. $625; p < 0.001) and out-of-pocket costs ($80 vs. $9; p<.0001). Similarly, patients who required ER visits also had higher total health care costs compared to those who did not experience infectious complications ($141 vs. $4; p<.0001). Higher aggregate health care costs ($14,198 vs. $629; p<.0001) and out-of-pockets costs ($89 vs. $18; p<.0001) were observed for patients who sustained infectious complications. The total health care cost for infections was $38,234,689 On multivariable analyses, patients who had Elixhauser index defined comorbidities had total health care costs (p<0.001). CONCLUSIONS: Infectious complications following TRUS-PB are associated with significant economic burden to the health care system and patients. Efforts to reduce post TRUS-PB infectious complications can significantly improve value-based health care delivery. Source of Funding: This study was supported by the Schramm Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e336 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sharon White More articles by this author Eric Ballon-Landa More articles by this author Michael Bronsert More articles by this author Boris Gershman More articles by this author Peter Clark More articles by this author Granville Lloyd More articles by this author Jeffrey Morrison More articles by this author Rodrigo Rodrigues-Pessoa More articles by this author Marc Smaldone More articles by this author Anessa Sax-Bolder More articles by this author Simon Kim More articles by this author Expand All Advertisement PDF DownloadLoading ...

Individualized Assessment of Risk of Complications after Benign Hysterectomy

The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. Retrospective cohort. The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Home Health Nursing Care Time for Patients with Parkinson's Disease.

There is an urgent need to provide personalized care more efficiently to patients with Parkinson’s disease (PD) who live at home. To understand the impact of patient attributes and features on nursing care time, we assessed the amount of time required to perform home visits to patients with PD and identified patient characteristics related to differences in nursing care time. Twenty patient (median age 78.0 years) visits were video-recorded. Nursing care activities were categorized, while time spent on them was measured to identify differences in care time by patient. Correlations between patient characteristics and care times were calculated. The median time per visit was 49 min and 7 s. Time was mostly spent on daily living assistance (76.0%), followed by medical care assistance (10.0%) and record keeping and administration (14.0%). Results suggested that patient care was characterized by longer time spent on patient comfort, physical therapy, and patient consultation or education. In general, time per visit increased with patients’ age. The variation in care implementation time tended to be large in daily living assistance and small in medical care assistance. These data may be useful for providing and managing personalized care for patients. These data can also contribute to making nurse care more specialized.

Lessons learned: Telemedicine patterns and clinical application in patients with gynecologic cancers during COVID-19

ObjectiveTo describe the use of telemedicine in gynecologic oncology and identify patient characteristics associated with telemedicine use during COVID-19. MethodsSingle-institution retrospective chart review of patients with gynecologic cancer who participated in in-person and telemedicine visits (video and telephone) from January 2019 to November 2020. Patient characteristics, visit and treatment characteristics were collected. Comparisons between 2019 and 2020 and between in-person and telemedicine visits were performed. Cancer-specific visit details were described. ResultsFrom January to November 2020, 2,039 patients attended 5240 ambulatory visits in our gynecologic oncology outpatient clinics with 4,304 (82.1%) in-person visits, 512 (9.8%) video telemedicine visits, and 424 (8.1%) telephone visits. In 2020, 936 (45.9%) patients participated in a telemedicine visit. Demographic characteristics did not differ between those who participated in any telemedicine versus in-person visits (p > 0.05). Black patients represented a larger share of telephone visits but this was not significant. Patients aged > 65 years were more likely to use the telephone for a visit and less likely to use video visits compared to their younger counterparts. The majority of patients who attended a telemedicine visit also attended a visit in-person (88.0%). The most common purpose of the telemedicine visits was to discuss results and/or treatment plans (46%) with other appointments occurring for treatment check-ins and clinical trials. ConclusionsThe use of telemedicine drastically increased in 2020. Patient demographics were not different between in-person and telemedicine visits except that older patients were more likely to use telephone visits over video visits. Telemedicine can be used for a variety of care needs in gynecologic oncology but further work needs to be done to optimize implementation, assess cost-effectiveness and patient outcomes.

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study.

BackgroundBlended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes.ObjectiveA multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes.MethodsA total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities.ResultsParticipants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions.ConclusionsA blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming.

Quality of Care and Outcomes for Patients with Acute Ischemic Stroke and Transient Ischemic Attack During the COVID-19 Pandemic

Background and PurposeHospitalizations for acute ischemic stroke (AIS) and transient ischemic attack (TIA) decreased during the COVID-19 pandemic. We compared the quality of care and outcomes for patients with AIS/TIA before vs. during the COVID-19 pandemic across the United States Department of Veterans Affairs healthcare system. MethodsThis retrospective cohort study compared AIS/TIA care quality before (March–September 2019) vs. during (March-September 2020) the pandemic. Electronic health record data were used to identify patient characteristics, quality of care and outcomes. The without-fail rate was a composite measure summarizing whether an individual patient received all of the seven processes for which they were eligible. Mixed effects logistic regression modeling was used to assess differences between the two periods. ResultsA decrease in presentations occurred during the pandemic (N = 4360 vs. N = 5636 patients; p = 0.003) and was greater for patients with TIA (-30.4%) than for AIS (-18.7%). The without-fail rate improved during the pandemic (56.2 vs. before 50.1%). The use of high/moderate potency statins increased among AIS patients (OR 1.26 [1.06–1.48]) and remained unchanged among those with TIA (OR 1.04 [0.83,1.29]). Blood pressure measurement within 90-days of discharge was less frequent during the pandemic (57.8 vs. 89.2%, p < 0.001). Hypertension control decreased among patients with AIS (OR 0.73 [0.60–0.90]) and TIA (OR 0.72 [0.54-0.96]). The average systolic and diastolic blood pressure was 1.9/1.4 mmHg higher during the pandemic than before (p < 0.001). Compared to before, during the pandemic fewer AIS patients had a primary care visit (52.5% vs. 79.8%; p = 0.0001) or a neurology visit (27.9 vs. 41.1%; p = 0.085). Both 30- and 90-day unadjusted all-cause mortality rates were higher in 2020 (3.6% and 6.7%) vs. 2019 (2.9, 5.4%; p = 0.041 and p = 0.006); but these differences were not statistically significant after risk adjustment. ConclusionsOverall quality of care for patients with AIS/TIA did not decline during the COVID-19 pandemic.

52. THE EFFECT OF PREOPERATIVE PATIENT CHARACTERISTICS ON POSTOPERATIVE OUTCOMES OF CLEFT PALATE REPAIR: AN ANALYSIS OF GLOBAL SMILE TRAIN DATA

PURPOSE: The aim of this study was to identify patient characteristics that contribute to fistula and postoperative speech outcomes using global Smile Train data. METHODS: Analysis of palatoplasty outcomes was performed for 1,110 Smile Train partner hospitals. Patient factors following palatoplasty, including age, weight, and region, were correlated with fistula occurrence and speech outcomes. RESULTS: 2,560 patients were analyzed. The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 + 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased VPD and fistula surgery compared to Asian patients. Central/South American patients were also more likely to require VPD assessment. CONCLUSION: In the largest global cleft outcomes study to date, age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train’s continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

Using machine learning to predict heavy drinking during outpatient alcohol treatment.

Accurate clinical prediction supports the effective treatment of alcohol use disorder (AUD) and other psychiatric disorders. Traditional statistical techniques have identified patient characteristics associated with treatment outcomes. However, less work has focused on systematically leveraging these associations to create optimal predictive models. The current study demonstrates how machine learning can be used to predict clinical outcomes in people completing outpatient AUD treatment. We used data from the COMBINE multisite clinical trial (n=1383) to develop and test predictive models. We identified three priority prediction targets, including (1) heavy drinking during the first month of treatment, (2) heavy drinking during the last month of treatment, and (3) heavy drinking between weekly/bi-weekly sessions. Models were generated using the random forest algorithm. We used "leave sites out" partitioning to externally validate the models in trial sites that were not included in the model training. Stratified model development was used to test for sex differences in the relative importance of predictive features. Models predicting heavy alcohol use during the first and last months of treatment showed internal cross-validation area under the curve (AUC) scores ranging from 0.67 to 0.74. AUC was comparable in the external validation using data from held-out sites (AUC range=0.69 to 0.72). The model predicting between-session heavy drinking showed strong classification accuracy in internal cross-validation (AUC=0.89) and external test samples (AUC range=0.80 to 0.87). Stratified analyses showed substantial sex differences in optimal feature sets. Machine learning techniques can predict alcohol treatment outcomes using routinely collected clinical data. This technique has the potential to greatly improve clinical prediction accuracy without requiring expensive or invasive assessment methods. More research is needed to understand how best to deploy these models.

Stigma, Intrusiveness, and Distress in Parents of Children with a Disorder/Difference of Sex Development.

The impact of parent-reported stigma due to their child's disorder/difference of sex development (DSD) on parent psychosocial adjustment is poorly understood. In other pediatric populations, perceived interference of medical conditions into daily activities (i.e., illness intrusiveness ) mediates the relationship of stigma to adjustment. This study assessed relationships between parent-focused and child-focused stigma → illness intrusiveness → depressive and anxious symptoms . Exploratory analyses sought to identify patient characteristics associated with stigma. Caregivers (59 women and 43 men) of 63 children diagnosed with a DSD up to age 4 years completed measures of demographics, parent-focused and child-focused stigma, illness intrusiveness, and depressive and anxious symptoms. Increased parent-focused and child-focused stigma were associated with increased illness intrusiveness, which, in turn, was associated with increased depressive and anxious symptoms for parents nested within dyads. Among children with DSD family histories, parents reported greater child-focused stigma. Parents who experience DSD-related stigma report greater interference of their child's DSD into their daily activities, which is associated with poorer psychosocial adjustment. Findings support developing clinical interventions related to parents' perceptions of stigma and illness intrusiveness to improve parent adjustment.

Patient Characteristics Associated With Missed Appointments in Pediatric Subspecialty Clinics.

Missed appointments negatively affect patients, providers, and health systems. This study aimed to (1) quantify the percentage of missed appointments across 14 pediatric subspecialties in a tertiary-care children's hospital and (2) identify patient characteristics associated with missed appointments in those subspecialties. We extracted patient characteristics from 267,151 outpatient appointments, between January 1, 2013, and December 31, 2018, across 14 subspecialty clinics. Medical complexity was categorized using the Pediatric Medical Complexity Algorithm. The primary outcome was appointment nonattendance. Cancellations, imaging/laboratory visits, patients older than 18 years, and duplicate visits were excluded. Characteristics associated with nonattendance were analyzed with chi-square tests and included in the multivariable model if p < .1. Missing data were addressed using random forest imputation, and assuming data were "missing at random." Variables were considered statistically significant if p < .05. Of the 128,117 scheduled appointments analyzed, 23,204 (18.1%) were missed. In the multivariable model, clinical nutrition had the greatest subspecialty odds of missed appointments, whereas cardiology had the lowest. Patient characteristics most strongly associated with missed appointments were public insurance, history of >2 missed appointments, appointment lead time, lesser medical complexity, Black race/ethnicity, and fewer medications. Clinical characteristics including lesser medical complexity and fewer medications are associated with missed appointments in pediatric subspecialties.

Use of Polysomnography and CPAP in Children Who Received Adenotonsillectomy, US 2004 to 2018.

1) To determine the prevalence polysomnogram (PSG) and continuous positive airway pressure (CPAP) therapy use in children who received adenotonsillectomy (AT) for sleep symptoms. 2) To identify health care disparities in these regards. Retrospective database analysis. This study used data from Optum (Health Services Innovation Company) to identify 92,490 children who received AT for sleep symptoms between 2004 and 2018. Prevalence of preoperative PSG and postoperative PSG and CPAP were described. Clinical and demographic characteristics were compared between children who had preoperative PSG and those who did not. Characteristics of children with trisomy 21 (T21) were compared to assess PSG and CPAP use in a high-risk cohort. Predictive modeling was used to identify patient characteristics associated with postoperative PSG and CPAP use. Preoperative PSG was obtained in 5.5% of children overall and 33.2% of children with T21. Male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with preoperative PSG. Fewer than 3% of children received postoperative PSGs and approximately 3% went on to receive CPAP therapy postoperatively. Multiple logistic regression showed that age at surgery, male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with postoperative PSG and CPAP use. This study described the prevalence pre-AT PSG use and post-AT PSG and CPAP use for persistent symptoms and identified sleep health care disparities in these regards. These results show that increased, equitable access to PSG is needed in children, particularly in the workup and treatment persistent symptoms after AT. 4 Laryngoscope, 133:184-188, 2023.

Exposure based cognitive behavioral group therapy for IBS at a gastroenterological clinic – a clinical effectiveness study

Background Patients with irritable bowel syndrome (IBS) may benefit from psychological treatment when diet changes and medications do not sufficiently reduce symptoms. Our research team has developed an exposure based cognitive behavioral therapy protocol (ECBT), which has been shown to be effective in several randomized controlled trials. Aim To investigate the effectiveness of ECBT in clinical routine care at a gastroenterological clinic in Stockholm and to find predictors for treatment outcome. Method A ten session ECBT based on our protocol was given face to face by licensed psychologists in groups of 4–6 patients. A total of 129 patients provided information regarding IBS symptoms, quality of life, gastrointestinal symptom-specific anxiety (GSA), and depression pre and post-treatment. We used linear regression analyses to identify patient characteristics that predicted treatment outcome. Results The primary outcome was symptom severity measured with The Gastrointestinal Symptom Rating Scale for IBS (GSRS-IBS). Average pre-and post-treatment GSRS-IBS scores were 49.24 (SD = 11.54) and 37.03 (SD = 10.03), corresponding to a 34.0% reduction in symptom severity (p < .001). Reductions were also found in GSA, 43.9% (p < .001) and depression, 38.6% (p < .001). IBS-related quality of life was on average increased by 68.2% (p < .001). The effect sizes were large and varied between (Cohen’s d) 0.95 and 1.84. None of the patients’ pre-treatment characteristics predicted outcome. Conclusion We conclude that ECBT for IBS delivered face-to-face in a group-format is very effective, also in a routine care setting. We did not find any reliable predictors for treatment outcome. The trial was registered at Clinicaltrials.gov with ID: NCT04756414.