Overtreatment Research Articles

Outcomes, unmet needs, and challenges in the management of patients who withdraw from anti-CGRP monoclonal antibodies: A prospective cohort study.

The anti-calcitonin gene-related peptide (CGRP), or its receptor (CGRP/R) monoclonal antibodies (mAbs), offer targeted, effective, and tolerated drugs for migraine. However, about 25% of patients fail to achieve a clinically meaningful response, usually leading to discontinuation. These patients often have a lengthy migraine history and multiple prior preventive treatment failures, resulting in limited therapeutic options. Herein, we describe the cause for and outcome of withdrawal of anti-CGRP/R mAb and evaluate the treatment course until discontinuation. We conducted a prospective analysis on migraine patients attending the Florence Headache Center in Italy, who discontinued treatment with anti-CGRP/R mAbs. The primary objectives were to describe the reasons for anti-CGRP mAbs discontinuation and the treatment course. Secondary objectives were the evaluation of the absolute change from baseline in monthly headache days, response rates, persistence in medication overuse, absolute change from baseline of the overall number and days of analgesics use per month, change of MIDAS and HIT-6 at three, six, and 12 months, and the last month of treatment. Among 472 patients, 136 (28.8%) discontinued mAb treatment after an average of 9.0 ± 6.1 (mean ± SD) months. The majority (96/136, 70.6%) discontinued due to ineffectiveness, followed by lost to follow-up during treatment (18/136, 13.1%) and adverse events (10/136, 7.3%). In total, 77.9% of the 136 patients ceased treatment within the first year. Following discontinuation, 48.5% initiated new pharmacological treatment, 39.7% were lost to follow-up, and 11.8% opted not to start another treatment. The majority of patients that started a new pharmacology treatment switched to another anti-CGRP/R (46/68, 67.6%). The second most-used treatment was onabotulinumtoxinA (7/68, 10.2%; all patients in this subgroup were naïve to this treatment), followed by an anticonvulsive medication (7/68, 10.2%). The response status (≥50% reduction in monthly headache days) was achieved by 30.5%, 34.6%, and 40.0% of patients at month 3, 6, and 12 of treatment, respectively. Considering only the comprehensive last month of treatment before withdrawn the percentage of responders was 16.9%. Although anti-CGRP/R mAbs have provided a substantial amelioration of migraine management, a relevant proportion of patients remains unresponsive and requires additional therapeutic support. Further research is required to identify non-responder features and address unmet needs in migraine treatment.

The Basis of Cognitive and Behavioral Dysfunction in Amyotrophic Lateral Sclerosis.

To summarize and evaluate evidence pertaining to the clinical, genetic, histopathological, and neuroimaging correlates of cognitive and behavioral dysfunction in amyotrophic lateral sclerosis (ALS). We comprehensively reviewed the literature on cognitive and behavioral manifestations of ALS, narrating findings from both cross-sectional and longitudinal studies. We discussed knowledge gaps in the evidence base and key limitations affecting studies to date, before formulating a framework for future research paradigms aimed at investigating clinicopathological correlates of neuropsychological dysfunction in ALS. Studies have demonstrated clinical associations with cognitive dysfunction in ALS e.g., bulbar-onset of symptoms, pathological associations (extramotor TDP-43 deposition), and imaging associations (frontotemporal involvement). The most common behavioral deficit, apathy, is highly associated with verbal fluency, but longitudinal studies assessing behavioral dysfunction in ALS are comparatively lacking. Longitudinal studies have been helpful in identifying several potential correlates of cognitive and behavioral dysfunction but have frequently been confounded by selection bias and inappropriate testing platforms. This review provides a framework for more robust assessment of clinicopathological associations of neuropsychological abnormalities in ALS in the future, advocating for greater utilization of pre-symptomatic C9orf72 repeat expansion-carrying cohorts.

The Rise in Glucagon-Like Peptide-1 Receptor Agonist Related Calls to United States Poison Centers

Abstract Background In 2005, the United States (U.S.) Food and Drug Administration (FDA) approved the first Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) as adjunctive therapy to improve glycemic control in type 2 diabetes. In 2021, the FDA approved semaglutide for chronic weight management. We aim to characterize GLP-1RAs related calls to all U.S poison centers (PCs). Methods We conducted a retrospective review of the U.S. National Poison Data System (NPDS) between 2005 and 2023 for all GLP-1RA exposures. All 55 PCs covering the entire U.S. population submit, in near real-time, de-identified case data to NPDS after providing poison exposure management to callers from the general public and health care providers. Results During the study period, U.S. PCs handled 13,692 GLP-1RAs related calls, of which 12,451 were a GLP-1RA single substance exposures. In 2023, PCs received 4,414 GLP-1RA related calls, compared to 234 in 2014 (a twenty-fold increase over 10 years). Seventy three percent of exposures involved females (n = 10,017). The main reasons for exposure were therapeutic errors (n = 10,213; 75%), adverse drug reactions (n = 1,222; 9%) and suspected suicide (n = 557; 4%). Gastrointestinal symptoms, such as nausea (n = 2,913; 23%), vomiting (n = 2,515; 20%), and abdominal pain (n = 593; 5%), and neurological symptoms, including central nervous system depression (n = 191; 1.5%), dizziness (n = 563; 5%) and headache (n = 495; 4%) were the most commonly reported clinical effects in single substance exposures. Hypoglycemia was reported in 431 cases (3.5%), Most single substance exposures were managed outside a healthcare facility (n = 8.573; 69%), and hospital admission was reported in 5% of exposures (n = 601). Conclusions PCs are well positioned to monitor trends in GLP-1RAs human exposures and associated adverse events and therapeutic errors. Based on available data, PCs can manage specific cases-types without referral to the hospital, preventing unnecessary healthcare utilization. Key messages • Poison centers are well positioned to monitor trends in GLP-1RAs adverse events. • Poison centers can prevent unnecessary healthcare utilization.

An Innovative Public Health Solution with European Features for an American Problem

Abstract Problem The Eastern Shore of Maryland is a beautiful region that boasts a multicultural community of 455,000 year-round residents. Despite its rural location, the coastal lifestyle attracts retirees, making it the state’s oldest population. Unfortunately, the region also has the highest socioeconomic disparities in the state, which creates difficulties in accessing healthcare. This is a significant public health issue that results in costly barriers to preventive care and timely, accounting for $320 billion in unnecessary healthcare spending. Description of the problem Maryland’s healthcare funding formulas favor larger health systems in urban areas, leading to health inequities. To address this, we propose an innovative scenario analysis model partially based on European public health approaches. This model will adjust funding formulas based on each region’s specific needs and challenges, promoting fairness and equity in healthcare funding. Results Adopting this population health management approach would have built-in efficiencies: In the United States, healthcare spending tends to be higher among underserved populations due to delayed care, access challenges, missed diagnoses, and limited access to the latest scientific advances as well as proper preventive services. Lessons The proposed scenario-based public health funding approach targeting the needs of the underserved population on the Eastern Shore of Maryland could yield significant positive health outcomes and health savings generating a ripple effect across the state, and perhaps even the country. The lessons learned in how other countries handle public health funding could lead to global collaboration. Key messages • Our approach aims to provide a practical solution to unnecessary healthcare spending. • We must adapt to the changing tides to stay on course.

Guidelines for the prescription of standard hematology and biochemistry clinical laboratory tests in the intensive care unit: A scoping review protocol.

This scoping review protocol describes the strategy for a scoping review that aims to provide a comprehensive overview of published guidelines for the prescription of standard laboratory tests performed in intensive care unit (ICU) patients. The use of clinical laboratories is constantly increasing. However, there is evidence of inappropriate use. Inappropriate laboratory testing has the potential to harm patients, increase costs, burden staff, and has an environmental impact. Effective management can be achieved through demand managing strategies, such as providing guidelines on performing the appropriate test, for the right patient, at the right time. Although national and international guidelines exist for individual tests, a comprehensive summary of available recommendations for laboratory testing in the ICU is currently unavailable. This scoping review will incorporate documents that provide explicit advice on which test to perform in ICU patients. We selected 34 tests routinely ordered in the ICU. This review will consider any document type that matches our concept and context. We will consider gray literature with appropriate adherence to guidelines methodology. We will not limit the review by geographical location, but will only include articles published in English. Our scoping review will follow the Joanna Brigg Institute (JBI) methodology. We will search Medline (PubMed), Embase, Scopus, Google Scholar, and Google. Our search strategy adheres to the JBI 3-step construction approach for systematic reviews. We will search for keywords related to guidelines, laboratory testing, and the 34 selected tests. We will report our study using the S1 Checklist. Review registration number: osf.io/yfs9z.

One-Year and Five-Year Outcomes in Medication Overuse Headache: A Real-World Study.

Medication overuse headache (MOH) is one of the global health-related problems that imposes significant morbidity. Effective management requires the abrupt cessation of the overused medications, transition therapy in the initial days, and initiation of preventive treatment. The objective of this study is to provide one-year and five-year follow-ups of study participants diagnosed with chronic migraine and MOH. The study will examine the efficacy of withdrawal therapy, the use of conventional preventive medication, and the use of anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies. We conducted a single-center, prospective, and descriptive study at a tertiary center in Brazil. The population was included by convenience sampling of consecutive subjects diagnosed with chronic migraine and MOH. Demographics and clinical data at baseline and one-year and five-year follow-ups were collected in the clinical records. Among 142 subjects, 116 were females and 26 were males, with a mean age of 42.1±14.3. They were followed for five years. The diagnosis was performed at the mean age of 24.9±14.7 years after the headache onset, and the time with headache ≥15 days per month was 6.3±7.6 years. On baseline, the average number of headache days per month (HDM) was 25.2±5.9. There was a reduction in HDM. At one-year and five-year follow-ups, a ≥75% reduction in HDM was observed, respectively, in 51.4% and 70.4% of the sample. The five-year follow-up of chronic migraine and MOH treated with the discontinuation of excessive medication, the use of preventative pharmacological agents, and the optional inclusion of anti-CGRP pathway monoclonal antibody led to a significant decrease in the initial occurrence of HDM.

Psychotropic Polypharmacy Leading to Reversible Dementia: A Case Report.

Psychotropic polypharmacy presents a diagnostic challenge that may be further complicated by inadequate medication history and underappreciation of the cognitive effects of such polypharmacy. Here we present the case of a 57-year-old man who presented to our memory clinic with progressive cognitive decline and a prior neuropsychological evaluation supporting the diagnosis of a neurodegenerative disorder. He was taking multiple psychotropic medications at the time, but the exact dosages were unclear due to a lack of collateral history. He was also taking prescribed opioids and a combination of buprenorphine and naloxone for pain relief, again with unclear dosages at the time of presentation. Brain imaging and cerebrospinal spinal fluid biomarker testing were negative for Alzheimer pathophysiologic processes. Months later, the patient was taken to the emergency room after an overdose caused by overuse of opioid medications. Once he was taken off all psychoactive medications, the patient's cognitive impairment completely reversed, and he became independent in activities of daily living. Psychotropic polypharmacy can have a myriad of cognitive manifestations which need to be better recognized by clinicians. Deprescription of such medications should be attempted whenever clinically appropriate.

Diagnosis of chronic migraine and comorbid neurological disorders in real-life clinical practice

Chronic migraine (CM) is a neurological disorder whose diagnosis requires not only knowledge of its diagnostic criteria, but also the physician's ability to differentiate between various forms of primary and secondary headache (HA), as well as to recognize comorbid neurological disorders that aggravate the course of CM. Timely and correct diagnosis of CM and comorbid disorders allows to prescribe effective treatment to a patient and convert the migraine from a chronic to an episodic form. The diagnostics of CM and comorbid neurological disorders has not been sufficiently investigated in our country, which formed the basis for this study.Objective: to evaluate the quality of diagnostics of CM and comorbid neurological disorders in real-life neurological practice.Material and methods. The study included 200 patients with CM (63 men and 137 women, mean age 33.1±7.1 years) admitted to A.Ya. Kozhevnikov Clinic of Nervous Diseases (CND) of Sechenov University, complaining of frequent headaches. They had previously been examined and treated by neurologists in other medical institutions on an outpatient and/or inpatient basis. A clinical interview was conducted with all patients to establish a diagnosis and analyze their previous treatment, and a psychometric test was performed to assess symptoms of anxiety and depression.Results. Only 6% of patients had been previously diagnosed with CM, the remaining 94% were incorrectly diagnosed with secondary HA. All patients had previously been prescribed additional examinations, mainly neuroimaging of the brain and ultrasound of the cerebral vessels, although there were no "red flags". None of the patients had been previously assessed for their emotional state, while almost all patients had high situational anxiety (n=190; 95%) and high personal anxiety (n = 180; 90%), there were symptoms of depression (n=190; 95%) of varying severity. Comorbid neurological disorders (medication overuse HA), insomnia, musculoskeletal pain etc.) were diagnosed in 91.5% of patients in CND and in only in 8% of patients in other medical centers.Conclusion. In real-life clinical practice, CM and comorbid neurological disorders are inadequately diagnosed and excessive and unjustified additional examinations are prescribed.

Economics of risk stratification for skin cancer screening in solid organ transplant recipients

Background: Solid organ transplant recipients (SOTRs) have different risks of developing skin cancer depending on patient characteristics. However, there is currently no widely used tool to stratify skin cancer risk in these patients. The Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) is an attempt to stratify skin cancer risk in SOTRs and guide screening recommendations for those patients. Materials and methods: It was assumed that the 2022 solid organ transplant population in the United States would follow the same distribution of skin cancer risk as the population in the study that led to the development of the SUNTRAC. The total number of skin cancer screening visits and the total cost of those visits over 10 years were determined utilizing the screening recommendations in the SUNTRAC. Results: If all SOTRs received yearly skin cancer screens, 428,870 office visits would be conducted over 10 years for a total cost of $94,780,270. If the SUNTRAC were utilized, 336,666 office visits would be conducted for a 10-year cost of $74,403,186. Conclusions: Utilizing the SUNTRAC to guide skin cancer screening recommendations in SOTRs has the potential to minimize over-screening and lower the total cost of skin cancer screening visits for SOTRs. Initial studies into the applicability of the SUNTRAC have found similar risk distribution in different populations of SOTRs. Utilizing this model to guide skin cancer screening recommendations will better allocate resources to the highest risk patients while also avoiding unnecessary health care costs.

A real-world adverse events study of rimegepant from the FAERS database

ABSTRACT Background The primary objective of this research is to conduct an exhaustive evaluation of rimegepant with the Food and Drug Administration Adverse Event Reporting System (FAERS) repository. Research design and methods This study downloaded the reporting files related to rimegepant from the second quarter of 2020 to the first quarter of 2024. Disproportionality analysis was utilized to explore the relationship between rimegepant and adverse drug events (ADEs). Results This study analyzed 6659 ADE reports associated with rimegepant as the primary suspected (PS) drug. In the disproportionate analysis of system organ classes (SOCs), the significant signal for rimegepant was general disorders and administration site conditions. On the preferred terms level, 35 ADEs were identified following the exclusion. The top 5 ADEs with high signal strengths were medication overuse headache, nasal edema, tension headache, performance status decreased, and motion sickness. The most frequent ADEs were nausea, feeling abnormal, abdominal pain upper, somnolence, and hypersensitivity. In addition, we need to pay attention to the ADEs not mentioned in the instruction and clinically significant: vertigo, hyperacusis, somnolence, Raynaud’s phenomenon, motion sickness, panic attack, and fear. Conclusions This study highlights previously unrecognized safety concerns associated with the use of rimegepant. These novel safety aspects suggest that while these treatments can be effective, additional risks may need further exploration.

Ordering and Utilization of Peripheral Blood Flow Cytometry in an Academic Medical Center

Abstract Introduction/Objective The American Society for Clinical Pathology and the American Board of Internal Medicine’s Choosing Wisely campaign have developed best practice utilization guidelines for laboratory testing. Wisconsin Diagnostic Laboratories and Medical College of Wisconsin leadership noticed an increase in inappropriate peripheral blood flow cytometry testing in the last two years. An intervention was developed to help reduce inappropriate testing requests. Methods/Case Report The laboratory implemented a clinical decision support tool in the electronic medical record system that looked at patient diagnosis, history of stem cell transplant, and recommendations from pathology to help improve utilization of peripheral blood flow cytometry testing. Based on patient history, flow cytometry testing would move forward, or an alternative order of a peripheral blood pathology smear review with reflex to flow cytometry was offered. Pathologists would reflex flow cytometry if abnormalities were present by light microscopy or predetermined reflexing criteria were met. Results (if a Case Study enter NA) 314 cases were included for analysis. The intervention reduced volumes of peripheral blood flow cytometry in patients without a history of hematologic malignancy by 49.1% (p=<0.001). Appropriate utilization increased from 47.0% in the pre-intervention period to 80.4% in the post intervention period (p=<0.001). Significant diagnosis rate increased from 42.5% to 50.0% (p=.261). This resulted in a cost savings of $12,232 for the health system during the intervention period. Conclusion Clinical decision support based utilization efforts provide strong and consistent interventions to reduce the unnecessary and inappropriate ordering of peripheral blood flow cytometry.

Association between lifetime criminal legal involvement and acute healthcare utilization in middle-aged and older US adults, 2015-2019.

Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015-2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06-1.31) but not older adults (IRR 0.99, 95% CI 0.85-1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08-1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization.

Evaluation of rimegepant utilization patterns and patient characteristics among new users: a United States administrative claims-based study

Objective To assess tablet utilization patterns and describe pre-treatment characteristics among new users of rimegepant. Background Rimegepant is the only oral calcitonin gene-related peptide antagonist approved in the United States for both the acute and preventive treatment of migraine. Methods We conducted a retrospective cohort study of people with migraine who initiated treatment with rimegepant using two US commercial claims databases (MarketScan and Optum). Patients (≥18 years old) with migraine who newly initiated rimegepant were included. Patients were stratified into two groups representing acute (quantity = 8) and prevention (quantity = 15 or 16) use cohorts. Baseline characteristics and medication use history were assessed on index and during the 365-day pre-index period. Rimegepant utilization periods were calculated based on days supplied and varying approaches to define use periods. Tablet quantity per 30 days was reported separately for both acute and prevention cohorts. Results In MarketScan, a total of 14,037 rimegepant users were identified; 11,195 (79.8%) in the acute group and 1,880 (13.4%) in the prevention group. Rimegepant utilization for acute use was 4.9 ± 2.1 tablets per 30 days and for preventive use was 13.1 ± 7.7 tablets per 30 days. There was high baseline prevalence of triptan contraindications, warnings, and high cardiovascular risk, with a combined 46.2% meeting one or more of these criteria. Acute medication overuse was also common (25.1%) prior to rimegepant initiation. Results were consistent in the Optum database. Conclusion Our analysis provides the first real-world data available on tablet utilization and characteristics of new users of rimegepant.

Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes.

The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges. This review explores the complex interplay between patient safety, economic, and environmental factors-known as the "triple bottom line" or "3Ps" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety. The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.

A-184 Evidence-based Test Utilization: Test Ordering Patterns in Functional Medicine and Community Clinics, and Implications for Laboratory Stewardship

Abstract Background Functional Medicine Physicians (FMPs) use a holistic approach to identify and address “the root cause of a disease”. These physicians routinely order laboratory tests that are not supported by clinical suspicion and practice guidelines (i.e., Centers for Disease Control and Prevention Laboratory Medicine Best Practices, and local diagnostic algorithms) and are unnecessarily duplicative, with inappropriate testing patterns. Ordering unnecessary tests does not improve diagnosis; indeed, 5% of disease-free patients falsely test positive for a given diagnostic test. Test overutilization increases the rate of false positives, leading to unnecessary medical follow-ups, compromised patient care, and financial constraints on the healthcare system. The objective of this study is to: 1) Compare test ordering patterns between FMPs and General Practitioners (GPs) to identify disparities and opportunities for laboratory stewardship improvements. 2) Analyze the potential factors impacting test utilization in areas served by FMPs, 3) investigate the proper approach to improve test utilization. Methods Using our laboratory’s information system, we conducted a retrospective study spanning from January 2022 to December 2022 to assess testing patterns by 15 FMPs in Southern Alberta, comparing them to those of randomly selected community GPs within the same geographical region. A query was executed to retrieve data on the top 50 chemistry tests ordered by functional medicine clinics and community clinics. These tests were further categorized into six groups: general chemistry, endocrinology, immunology, trace elements, toxic metals, and vitamins. Data analysis included determining the geographical locations of functional medicine clinics and assessing the socioeconomic status of their patient populations. Additionally, the percentage of abnormal test results were calculated for both functional medicine clinic and community clinics. Furthermore, the average cost of tests per patient, per physician, and per clinic was computed to evaluate the financial implications of testing practices. Results Our preliminary results showed significant variability in test ordering practices among FMPs, with potential implications for patient care and healthcare costs. Most tests ordered by FMPs were normal (94%), suggesting a need for further scrutiny regarding the necessity and appropriateness of these tests. A notable trend observed was the disproportionate preference of FMPs for expensive tests, including hormones, vitamins, and toxic metals. Our analysis reveals that the cost per reportable test from FMPs was four times higher compared to the tests ordered by GPs. Furthermore, on average, functional medicine clinics in urban areas ordered around 60% more tests annually compared to their rural counterparts. Conclusions Our preliminary findings clearly show a need to monitor the testing behavior more carefully by the functional medicine clinics. The data from this study will be shared with the physicians practicing functional medicine in Alberta. Strategies to improve the test utilization and patient care include educating the functional medicine doctors and provincial healthcare authorities about the appropriate test utilization and the impact of inappropriate use of lab on patient care. In addition, using algorithms for test ordering will be used if the pattern of inappropriate testing continues.

B-330 Reducing Inappropriate Fecal Immunochemical Test

Abstract Background Colorectal cancer is the third most common cancer worldwide. The risk of colorectal cancer increases with age and predominantly affects individuals over the age of 50. Regular screening is crucial for early detection and prevention of colorectal cancer. Pre-cancerous polyps and colorectal cancers can bleed into the gastrointestinal tract. While the presence of blood in the stool cannot always be seen visually, it can be detected by the Fecal Immunochemical Test (FIT), currently the most sensitive method for directly measuring hemoglobin in this specimen type. In our province, FIT is recommended for testing average-risk asymptomatic patients aged 50 to 74 every 1-2 years. Patients aged 40 to 49 or 75 to 84 can be tested if they meet specific criteria. Like many other tests in the lab, FIT can be used inappropriately. The focus of this study was to examine the utilization of FIT in our institution. Methods Data were collected from our institution's laboratory information system for the FIT performed on-site from July to December 2023. Results We performed 91,545 FIT tests during the 6-month period with an overall positive rate of 6.8%. Of the total tests performed, 87.9% were for patients aged 50-74 years, 10.6% for patients aged 40-49 or 75-84 years, and 1.2% for patients outside the approved age range. Each year, we performed over 2,000 FIT tests for patients outside the accepted screening age, with an estimated cost of over 30,000 CAD. Conclusions Our results showed a significant number of FITs were ordered inappropriately by healthcare providers. Considering the relatively high cost of FIT kits, labor, reagents, etc., the overall cost per reportable is significant. Thus, we have started engaging healthcare providers involved in FIT testing to strategize approaches to improve utilization.

B-116 Cost Estimation of Laboratory Test Overuse in 14 Ordered Parameters: Experience From 6 hospitals and 65 Primary Care Centers

Abstract Background Inappropriate retesting and test request are considered causes of laboratory overutilization. The former can be managed through minimum retesting intervals (MRI) and the latter with expert rules in the laboratory information system (LIS). The aim of this study was to assess the effectiveness of both tools. Methods We performed a retrospective analysis of 14 laboratory routine tests subject to MRI or expert rules among 6 hospitals and 65 primary care centers from March 2018 through December 2023. Both tools were gradually implemented in the LIS (Servolab4®, Siemens, Berlin, Germany). Data from an export software was used for analysis (Health Analytics, Siemens Healthineers, Madrid, Spain). Results During the observation period, a total of 493.640 tests requests were analyzed and 60.151 violations were counted (Table 1). All violations represented an economic saving of 494.603€ (8.760€ per month). The most popular rejected test was 1,25-DihydroxyvitaminD (34,5%), followed by thyroid peroxidase antibodies (20,3%) and 25-HydroxyVitaminD (19%). These three tests were responsible for 73,8% of the total cost savings. Conclusions The real cost estimation of inappropriateness is difficult to assess, but the generated costs for the health system are certainly high and not negligible. Moreover, addressing overutilization would ensure standardization and high-quality care.

Community paramedicine program and outcomes of referred coronary artery bypass grafting patients.

Community paramedicine is a field in its infancy. The use of community paramedics has expanded in recent years as an alternative or adjunct to home health in the continued drive to decrease health disparities and complications. In current practice, they function in a position like a home healthcare nurse with an expanded scope of practice, such as providing specialized follow-up care, for example with postoperative care for patients who have undergone major surgery or recent hospitalization. This study assesses if community paramedics are a valid option in reducing rehospitalization of patients who underwent a coronary artery bypass grafting (CABG) procedure. A retrospective chart review between 2021 and 2022 was performed on all patients who underwent CABG in Bismarck, North Dakota, along with obtaining a referral for the community paramedics spanning urban and rural areas. A comparison was made between individuals who saw the community paramedics in their post-care versus those who continued with the standard of care. There were 80 participants and 38 location-matched controls. All variables were found to be statistically insignificant except for the number of walk-in visits (urgent care), in which 7 out of 38 sought medical attention in the controls and 4 out of 80 sought medical attention in the participants. The proportions of inpatient readmission rates and emergency department (ED) visits were similar. Given that paramedicine is in its infancy, the emergence of other variations of the community paramedic certification has brought a discussion of their scope of practice. While walk-in visits, even with the limitations, showed significant improvement with the addition of community paramedics, more research is still needed to show their effectiveness in reducing readmission to hospital. Additionally, the patients who sought help from community paramedics may be more likely than the controls to seek help from medical professionals. This study provided a novel look into the effect that community paramedics can have on patients in urban and rural areas in regard to reducing postoperative complications and minimizing unnecessary advanced healthcare utilization.

Urgent palliative care: An effective intervention to improve end-of-life experience and outcomes for patients with advanced cancer.

203 Background: Early integration of palliative care services for advanced oncology patients has a well-documented benefit on quality-of-life measures including symptom management, quality-of-death measures, cost-effectiveness, care-giver burden, and patient satisfaction metrics. However many barriers exist, including delayed referrals and negative perceptions of hospice/palliative care by patients and families. Furthermore, wait times from referral to visit can vary from weeks to months. For patients with late-stage disease, rapidly advancing disease or symptoms, this delay can lead to unnecessary acute care utilization, impoverished quality-of-life, and discordant end-of-life care. Methods: The CU Cancer Center CARE clinic provides advanced symptom management and urgent care services to oncology patients, often seeing patients with high symptom burden and advanced disease. A recent unpublished case-based analysis demonstrated that patients seen in CARE clinic 4 times or more in a month have a high risk of inpatient mortality within 3 months. In response, the CARE clinic created an urgent palliative care program wherein patients have the ability to see a palliative care provider within 1 week of referral who could provide ongoing advanced symptom management/medication titration and facilitate conversations around goal-concordant care in late-stage illness. A 1-year feasibility pilot took place from 2022-2023. Referrals required patients to meet the following criteria: 1) Not already being seen by an ambulatory palliative care professional; and 2) any of the following: prognosis of weeks without an end-of-life care plan; symptoms likely to require hospitalization if not addressed within a week; or seen in CARE clinic 4 or more times in the last month From 09/2022-08/2023, 55 patients were seen. Outcomes were followed for 3 months following final CARE clinic visit and were compared to patients who had received palliative care referrals from the CARE clinic in the preceding year (9/2021-9/2022). Results: In-hospital deaths, hospital days in the last 30 days of life, and palliative care/hospice involvement were all positively affected in our initial pilot. Notably, in-hospital deaths were reduced by 50%. There was also a 14% increase in deaths with hospice care in the pilot group compared to the control group. Conclusions: Data from this feasibility pilot suggest that urgent palliative care can improve key metrics in oncology quality-of-care, and improve cost effectiveness. Further delineation of the outcomes compared in a rigorously controlled population will further define the relative clinical benefit and fiscal implications of such interventions. Urgent palliative care outcomes. Historical Control (2021-2022) Pilot (2022-2023) N 44 55 Hospitalizations 101 52 Deaths 30 (68%) 40 (72%) Deaths in the Hospital 8 (18%) 5 (9%) Deaths With Hospice Care 21 (47%) 34 (61%)

Real-world analysis of neuroendocrine tumor misdiagnosis and associated costs

PurposeConditions for which neuroendocrine tumor (NET) is commonly misdiagnosed were compared among patients with and without NET, and the associated healthcare costs were described. MethodsAdults with a NET diagnosis were selected retrospectively from the IBM MarketScan claims databases during 1/1/2015-12/31/2018 (earliest = index), comprising the NET cases. Non-NET controls included age/gender matched patients without any cancer diagnoses. Patients were followed for a five year look back period when conditions for which NET is commonly misdiagnosed (gastrointestinal, respiratory, metabolic [i.e. liver disease], dermatologic) were measured and compared between cases and matched controls using odds ratios. Misdiagnosis-related costs were reported per patient per month (PPPM) from the earliest misdiagnosis to NET diagnosis. Patients with pancreatic adenocarcinoma misdiagnoses and related costs were reported separately. ResultsThis analysis included 3,460 NET cases and 10,370 non-NET controls (mean age 61 years). Compared to non-NET controls, 70% of NET cases had a diagnosis of a gastrointestinal, respiratory, metabolic, or dermatologic condition, with 2.07 higher odds (95% CI 1.91-2.25). Median time from earliest potential misdiagnosis to NET was 3.4 years. Overall mean (standard deviation) healthcare costs related to misdiagnoses were $2,858 ($6,495) PPPM. Costs were highest for gastrointestinal misdiagnoses ($3,350 [$7,108]). Among NET cases, 69 (2%) patients had a pancreatic adenocarcinoma misdiagnosis; related PPPM costs were substantial ($29,321 [$62,385]) and driven by outpatient services including treatment administration. ConclusionThe increased odds of common misdiagnosis conditions among NET cases compared with non-NET controls, contributing to unnecessary healthcare costs, supports the need for accurate identification of NET. SynopsisThe majority of patients with NET (70%) were previously misdiagnosed, occurring a median of 3.4 years before correct diagnosis. Total mean healthcare costs related to misdiagnoses were $2,858 PPPM and costs related to pancreatic adenocarcinoma misdiagnoses were substantial ($29,321 PPPM).