Including Emergency Department Research Articles

(358) Improved Healthcare Utilization Among Men with Depression Undergoing Inflatable Penile Prosthesis in a United States Commercial Population

Abstract Introduction Inflatable penile prosthesis (IPP) is widely considered medically necessary and a definitive treatment to restore erectile function, yet employer benefit exclusion and lack of insurer coverage of IPP implantation among non-Medicare men may limit their access to the treatment that can negatively impact quality of life. While previous research examined the impact of penile implants among men with depressive symptoms, limited evidence is available to quantify the impact of IPP on depression-related healthcare utilization including emergency department, inpatient, outpatient, and office visits among this patient population. Objective To evaluate the real-world healthcare utilization associated with depression among men undergoing IPP in a US commercial population. Methods A retrospective claims-based analysis was conducted using the 85% Merative™ MarketScan® commercial database to identify men aged ≥18 undergoing IPP (CPT 54405) between 2007 and 2020. Male patients were included if they had at least one claim of depression as a primary diagnosis one-year pre-index IPP and did not have any IPP during this period. Patients were required to have one-year continuous enrollment pre- and post-index IPP. Healthcare utilization associated with a primary diagnosis of depression including number of emergency department visits, inpatient visits, outpatient visits, office visits, and total healthcare visits were measured one-year pre- and post-index IPP. The total healthcare visits included all sites of service for depression. A paired t-test was conducted to evaluate the differences pre- and post-index IPP among patients using the Instant Health Data software (Panalgo, Boston MA, USA) and R, version 3.2.1 (R Foundation for Statistical Computing, Vienna, Austria). Results Among 11,177 patients identified with an IPP during the index period, 808 patients had depression. Average age was 55.26 (±6.83) and average Charlson comorbidity score was 1.63 (±1.67). A statistically significant reduction in the mean number of total healthcare visits, inpatient visits, and office visits were observed pre- and post-index IPP. The mean number of total healthcare visits in the pre-IPP period was 4.88 ± 7.71 compared to 3.82 ± 8.48 in the post-index IPP period (P<0.0001). Among these, the mean number of inpatient visits in the pre-index IPP period was 0.07 ±0.57 compared to 0.03 ±0.22 in the post-index IPP period (P=0.02) and the mean number of office visits in the pre-index IPP period was 4.25 ±7.17 compared to 3.29 ±7.84 in the post-index IPP period (P<0.0001). Conclusions The study provides evidence highlighting the benefits of IPP in alleviating the healthcare resource utilization associated with depression among men undergoing an IPP. For these benefits to be fully realized, it is critical to ensure comprehensive coverage of medically necessary IPP among commercially insured patients with depression. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Clearing the Air: Understanding the Impact of Wildfire Smoke on Asthma and COPD

Wildfires are a global natural phenomenon. In North America, wildfires have not only become more frequent, but also more severe and longer in duration, a trend ascribed to climate change combined with large fuel stores left from modern fire suppression. The intensification of wildfire activity has significant implications for planetary health and public health, as exposure to fine particulate matter (PM2.5) in wildfire smoke is linked to adverse health effects. This review focuses on respiratory morbidity from wildfire smoke exposure. Inhalation of wildfire PM2.5 causes lung injury via oxidative stress, local and systemic inflammation, airway epithelium compromise, and increased vulnerability to infection. Wildfire PM2.5 exposure results in exacerbations of pre-existing asthma and chronic obstructive pulmonary disease, with an escalation in healthcare utilization, including emergency department visits and hospitalizations. Wildfire smoke exposure may be associated with asthma onset, long-term impairment of lung function, and increased all-cause mortality. Children, older adults, occupationally-exposed groups, and possibly women are the most at risk from wildfire smoke. Future research is needed to clarify best practices for risk mitigation and wildfire management.

Acute care disruptions due to information technology failures in the Netherlands from 2000 to 2020

Background and aimHealthcare organizations are becoming increasingly dependent on Information technology (IT) for the provision of routine services. IT failures within hospital systems can impact acute patient care, including emergency department (ED) closure operating room (OR) stops.. The aim of this study is to gain insight into the impact of hospital IT failures in the Netherlands on acute care delivery and to provide recommendations for improved IT failure preparedness and hospital resilience during such an event. MethodsThis is a systematic scoping review of major acute care disruptions in Dutch hospitals between 2000 and 2020. Incidence of etiology, duration, ED diversion, and closure of multiple locations was evaluated. IT failures were included when associated with the closure of hospital departments and/or evacuations. ResultsThirty-nine IT failures resulting in acute care disruption were identified. The majority occurred between 2010 and 2020 (n = 37, 95 %). Of the 39 events, 33 (85 %) were primary IT failures and were mainly caused by computer network and/or hospital software failure. Secondary events predominantly resulted from power failure. Most events (n = 36, 92 %) were resolved within minutes to hours. All events were associated with an ED closure, 27 (69 %) with an operating room (OR) stop and two (5 %) with external hospital evacuation of one or more patients. Furthermore, 17 incidents (44 %) involved multiple hospital locations, and seven (41 %) of these involved closure of multiple locations with an ED. ConclusionThe impact of IT failures on acute care disruptions in the Netherlands has considerably increased since 2010. This stresses the urge to improve IT security and business continuity in today's hospitals.

Number and nature of psychiatric emergency department visits in a tertiary hospital before, during, and after coronavirus pandemic.

The COVID-19 pandemic has significantly impacted mental health globally, leading to a deterioration in the overall mental health of the population and changes across all healthcare levels, including emergency departments (ED). However, the evolution of the quantity and nature of psychiatric ED visits in the post-pandemic period remains uncertain. To examine changes in the number and nature of psychiatric emergencies at a general hospital before, during, and after the COVID-19 pandemic. Psychiatric ED visits from a tertiary hospital in the Basque Country (Spain) between January 2019 and November 2023 were investigated. Electronical health registers detailing the number and nature of psychiatric care consultations were analyzed for the study timeframe. Three periods were then compared: pre-pandemic (from January 2019 to February 2020), pandemic (from March 2020 to January 2022), and post-pandemic (from February 2022 onwards). 16,969 psychiatric ED visits were recorded for the study period. The number of psychiatric ED visits remained stable from pre-pandemic (269.93 visits/month) to pandemic (264.48 visits/month) periods but experienced a significant rise during the post-pandemic period (330.00 visits/month; t=-6.42; p<0.001), which was not reflected in medical and traumatological visits. The proportion of visits for anxiety (Z=-2.97; p=0.003), suicidal ideation (Z=-5.48; p<0.001), and administrative and social consultations (Z=-5.69; p<0.001) increased over the course of the pandemic. In contrast, visits for schizophrenia and other psychotic disorders (Z=4.85; p<0.001), as well as unspecified behavioral alterations (Z=2.51; p=0.012), significantly decreased. The COVID-19 pandemic and its aftermath have altered the patterns of urgent psychiatric care, characterized by a sharp increase of average monthly number of consultations and a shift in their nature. Future efforts should focus on characterizing this surge in demand and enhancing both emergency services and outpatient settings.

Same-Day Discharge is Safe, Feasible Following Vaginal Hysterectomy with Apical Suspension.

Studies involving minimally invasive hysterectomy and robotic sacrocolpopexy have demonstrated safety and feasibility of same-day discharge. There are limited data, however, on same-day discharge outcomes for vaginal hysterectomy and pelvic reconstruction. This study aimed to compare 30 and 90-day surgical outcomes between same-day discharge versus overnight stay following vaginal hysterectomy and apical suspension. This retrospective study evaluated surgeries performed over two time periods. Overnight stay was standard between December 2018 and February 2020. Same-day discharge was standard from December 2020 to February 2022. All patients who underwent vaginal hysterectomy with apical suspension were included. The primary outcome was to determine if there was an increase in 30-day readmission rates. Secondary outcomes included emergency department visits and reoperations within 30 days, the previous variables at 90 days, and the rate for successful same-day discharge. A total of 324 patients were analyzed over the 30 months: 149 (46%) in the overnight stay group and 175 (54%) in the same-day discharge group. At 30 days, no difference was found between groups for readmissions (2.7% vs 4.0%, p = 0.56), emergency department visits (14.8% vs 14.9%, p = 1.0), or reoperations (2.0% vs.1.7%, p = 1.0). At 90 days, outcomes were also similar. Same-day discharge as standard practice was successful in 80% of patients. In this retrospective two cohort study, the safety of same-day discharge following vaginal hysterectomy with apical suspension was demonstrated with no increased risk of 30 or 90-day readmissions, emergency visits, or reoperation rates. The majority (80%) of patients were discharged on the day of surgery, suggesting feasibility of this model.

First-episode psychosis intervention programme versus standard care for the clinical management of early phases of psychosis: cost analysis.

Early intervention programmes (EIPs) in psychosis have gained attention as specialised interventions to improve health-related and societal impacts for people with psychotic disorders. Previous studies have presented evidence in favour of EIPs over the first year of intervention, despite none considering the critical period before psychosis onset (5 years). To compare the associated costs of the First Episode Psychosis Intervention Program (CRUPEP) and treatment as usual (TAU) in a real-world cohort in a non-specialised psychiatric community setting. Direct and indirect mental health-related costs were calculated over 1 year and up to 7 years. Healthcare and societal costs were calculated from economic data related to the consumption of all healthcare resources, including emergency department attendances, hospital admissions, psychotropic medication prescriptions and societal costs. From a healthcare perspective, the intervention (CRUPEP) group initially showed a marginally higher cost per patient than the TAU group (€7621 TAU group v. €11 904 CRUPEP group) over the first year of follow-up. However, this difference was reversed between the groups on considering the entire follow-up, with the TAU group showing considerably higher associated costs per patient (€77 026 TAU v. €25 247 CRUPEP). The EIP (CRUPEP) showed clinical benefits and minimised the direct and indirect health-related costs of the management of psychosis. Although the CRUPEP intervention initially reported increased costs over 1 year, TAU surpassed the global costs over the entire follow-up.

Linking Toxic Leadership With Work Satisfaction and Psychological Distress in Emergency Nurses: The Mediating Role of Work-Family Conflict

IntroductionToxic leadership is a prevalent issue within health care organizations, including emergency departments. No studies have been found specifically examining these issues among emergency nurses. This study examined the mediating effects of work-family conflict on the relationship between toxic leadership behaviors of nurse managers and psychological distress and work satisfaction among emergency nurses. MethodsA cross-sectional survey was used to gather data from 285 Filipino emergency nurses, using 4 validated measures. Mediation analyses were conducted using the PROCESS Macro with Model 4. ResultsToxic leadership had a direct negative effect on work satisfaction (β = −0.3313, P < .001) and a direct positive effect on psychological distress (β = 0.0945, P = .0491). Work-family conflict partially mediated the relationship between toxic leadership and both psychological distress (β = 0.0217, SE = .0141, 95% CI = 0.0002-0.0538) and work satisfaction (β = −0.0438, SE = 0.0216, 95% CI = −0.0884 to −0.0049). DiscussionThe study findings highlighted the negative influence of toxic leadership behaviors on the overall work satisfaction and psychological well-being of emergency nurses. In addition, this study identified work-family conflict as a mechanism that explained how the toxic leadership behaviors of nurse managers influenced the psychological well-being and job satisfaction of emergency nurses. The results of this study underscore the need for interventions and strategies to address toxic leadership and mitigate the negative consequences it poses to emergency nurses’ well-being.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware

BackgroundThe Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware.MethodsThe study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization.ResultsIn total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03–1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86–0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01).ConclusionThere was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study

Approximately 1800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020, allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls. Retrospective observational cohort study across 9 OTPs, geographically dispersed, in the National Institute of Drug Abuse (NIDA) Clinical Trials Network. Newly enrolled patients between April 15 and October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, control period) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and adverse events including emergency department visits, hospitalizations, and overdose. 821 individuals were newly admitted in the post-COVID and year-ago control periods, average age of 38.3 (SD 11.1), 58.9% male. The only difference across pre- and post-reform groups was the prevalence of psychostimulant use disorder (25.7% vs 32.9%, p=0.02). Retention was non-inferior (60.0% vs 60.1%) as were hazards of adverse events in the aggregate (X2 (1)=0.55, p=0.46) in the post-COVID period. However, rates of month-level opioid use were higher among post-COVID intakes compared to pre-COVID controls (64.8% vs 51.1%, p<0.001). Moderator analyses accounting for stimulant use and site-level variation in take-home schedules did not change findings. Policies allowing for extended take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use while in care. Relaxed guidelines were not associated with measurable increased harms and findings could inform future studies with prospective trials. USDHHSNIDACTNUG1DA013035-15.

Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes

Discharge from the hospital to the community has been associated with serious patient risks and excess service costs. To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community. CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022. Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified. At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake. Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits. These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.

Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study

ObjectiveInterhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. MethodsThis was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. ResultsA total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. ConclusionGeographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

Social Deprivation and End-of-Life Care Use Among Adults With Cancer.

Socioeconomic differences are partially responsible for racial inequities in cancer outcomes, yet the association of area-level socioeconomic disadvantage and race with end-of-life (EOL) cancer care quality is poorly understood. This retrospective study used electronic medical records from an academic health system to identify 33,635 adults with cancer who died between 2013 and 2019. Using multivariable logistic regression, we examined associations between decedent characteristics and EOL care, including emergency department (ED) visits, intensive care unit (ICU) stays, palliative care consultation (PCC), hospice order, and in-hospital deaths. Social deprivation index was used to measure socioeconomic disadvantages. Racially minoritized decedents had higher odds of ICU stay than the least deprived White decedents (eg, other race Q3: aOR, 2.06 [99% CI, 1.26 to 0.3.39]). White and Black decedents from more deprived areas had lower odds of ED visit (White Q3: aOR, 0.382 [99% CI, 0.263 to 0.556]; Black Q3: aOR, 0.566 [99% CI, 0.373 to 0.858]) than least deprived White decedents. Compared with White decedents living in least deprived areas, racially minoritized decedents had higher odds of receiving PCC and hospice order, whereas White decedents in most deprived areas had lower odds of PCC (aOR, 0.727 [99% CI, 0.592 to 0.893]) and hospice order (aOR, 0.845 [99% CI, 0.724 to 0.986]). Greater deprivation was associated with greater odds of hospital death relative to least deprived White decedents, but only among minoritized decedents (eg, Black Q4: aOR, 2.16 [99% CI, 1.82 to 2.56]). Area-level socioeconomic disadvantage is not uniformly associated with poorer EOL cancer care, with differences among decedents of different racial groups.

Presentation Rates for Acute Pharyngitis in the Emergency Room Are Influenced by Extreme Weather Events.

Extreme weather events are becoming more prevalent with the increasing pace of climate change. These events negatively impact human health and put considerable strain on health care resources, including emergency departments. Within otolaryngology, acute pharyngitis is a common reason for emergency room visits (ERV). Therefore, we aimed to investigate the impact of extreme meteorological conditions on ERV rates related to acute pharyngitis. Retrospective time-series study. ERVs related to acute pharyngitis (n = 1511) were identified at a tertiary care hospital in Vienna, Austria, between 2015 and 2018. The effects of single-day and prolonged (3-day) extreme weather events on ERVs were analyzed using a distributed lag nonlinear model. Relative risk (RR) and cumulative relative risk (cRR) were calculated over a lag period of 14 days. RR refers to the risk for pharyngitis-related ERV at extreme conditions (1st, 5th, 95th, or 99th percentile) compared to the risk at median conditions. Same-day RR (lag0) was elevated more than 3-fold after prolonged extremely low mean temperatures (P = .028). Furthermore, same-day RR after single-day and prolonged extremely high relative humidity was elevated by 51% (P = .024) and 46% (P = .036), respectively. Significant delayed effects on cRR were observed for extreme mean temperatures, relative humidity, and mean wind speeds within 8 days and for extreme atmospheric pressure within 14 days. Extreme weather events impact ERV rates for acute pharyngitis. Extremely low temperatures, high relative humidity, high atmospheric pressure, and low and high wind speeds were risk-promoting factors.

Association Between Same-Day Discharge Shoulder Arthroplasty and Risk of Adverse Events in Patients with American Society of Anesthesiologists Classification ≥ 3: A Cohort Study.

Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature, however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge versus inpatient SA in a cohort of patients considered higher-risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. Data from a US-based healthcare system's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018-2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge versus ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism (VTE), and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. The cohort included a total of 1,814 SA patients, of whom 1,005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR]=0.64, one-sided 95% upper bound [UB]=0.89) and overall complications (OR=0.67, 95% UB=1.00). We lacked evidence in support of non-inferiority for 90-day ED visit (OR=0.96, 95% UB=1.18), cardiac event (OR=0.68, 95% UB=1.11), or VTE (OR=0.91, 95% UB=2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. In a cohort of over 1,800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.

Organ Dysfunction in Children With Blood Culture-Proven Sepsis: Comparative Performance of Four Scores in a National Cohort Study.

Previous studies applying Sepsis-3 criteria to children were based on retrospective analyses of PICU cohorts. We aimed to compare organ dysfunction criteria in children with blood culture-proven sepsis, including emergency department, PICU, and ward patients, and to assess relevance of organ dysfunctions for mortality prediction. We have carried out a nonprespecified, secondary analysis of a prospective dataset collected from September 2011 to December 2015. Emergency departments, wards, and PICUs in 10 tertiary children's hospitals in Switzerland. Children younger than 17 years old with blood culture-proven sepsis. We excluded preterm infants and term infants younger than 7 days old. None. We compared the 2005 International Pediatric Sepsis Consensus Conference (IPSCC), Pediatric Logistic Organ Dysfunction-2 (PELOD-2), pediatric Sequential Organ Failure Assessment (pSOFA), and Pediatric Organ Dysfunction Information Update Mandate (PODIUM) scores, measured at blood culture sampling, to predict 30-day mortality. We analyzed 877 sepsis episodes in 807 children, with a 30-day mortality of 4.3%. Percentage with organ dysfunction ranged from 32.7% (IPSCC) to 55.3% (pSOFA). In adjusted analyses, the accuracy for identification of 30-day mortality was area under the curve (AUC) 0.87 (95% CI, 0.82-0.92) for IPSCC, 0.83 (0.76-0.89) for PELOD-2, 0.85 (0.78-0.92) for pSOFA, and 0.85 (0.78-0.91) for PODIUM. When restricting scores to neurologic, respiratory, and cardiovascular dysfunction, the adjusted AUC was 0.89 (0.84-0.94) for IPSCC, 0.85 (0.79-0.91) for PELOD-2, 0.87 (0.81-0.93) for pSOFA, and 0.88 (0.83-0.93) for PODIUM. IPSCC, PELOD-2, pSOFA, and PODIUM performed similarly to predict 30-day mortality. Simplified scores restricted to neurologic, respiratory, and cardiovascular dysfunction yielded comparable performance.

Development and validation of a community-level social determinants of health index for drug overdose deaths in the HEALing Communities Study

IntroductionSocial determinants of health (SDoH), such as socioeconomic status, education level, and food insecurity, are believed to influence the opioid crisis. While global SDoH indices such as the CDC's Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) combine the explanatory power of multiple social factors for understanding health outcomes, they may be less applicable to the specific challenges of opioid misuse and associated outcomes. This study develops a novel index tailored to opioid misuse outcomes, tests the efficacy of this index in predicting drug overdose deaths across contexts, and compares the explanatory power of this index to other SDoH indices. MethodsFocusing on four HEALing Communities Study (HCS) states (Kentucky, Massachusetts, New York and Ohio; encompassing 4269 ZIP codes), we identified multilevel SDoH potentially associated with opioid misuse and aggregated publicly available data for each measure. We then leveraged a random forest model to develop a composite measure that predicts age-adjusted drug overdose mortality rates based on SDoH. We used this composite measure to understand HCS and non-HCS communities in terms of overdose risk across areas of varying racial composition. Finally, we compared variance in drug overdose deaths explained by this index to variance explained by the SVI and ADI. ResultsOur composite measure included 28 SDoH measures and explained approximately 89 % percent of variance in age-adjusted drug overdose mortality across HCS states. Health care measures, including emergency department visits and primary care provider availability, were top predictors within the index. Index accuracy was robust within and outside of HCS communities and states. This measure identified high levels of overdose mortality risk in segregated communities. ConclusionsExisting SDoH indices fail to explain much variation in area-level overdose mortality rates. Having tailored composite indices can help us to identify places in which residents are at highest risk based on their composite contexts. A comprehensive index can also help to develop effective community interventions for programs such as HCS by considering the context in which people live.

Differences in personal characteristics and health outcomes between ambulatory and non-ambulatory adults with traumatic spinal cord injury

Objective To identify differences in personal characteristics, health outcomes, and hospital utilization as a function of ambulatory status among adults with chronic SCI. Design Prospective cohort study linked to state administrative billing data. Setting Population-based SCI Registry from the Southeastern United States. Participants 1,051 adults (>18 years old) with chronic (>1-year), traumatic SCI. Outcome Measures The self-report assessment (SRA) included demographic, injury and disability characteristics, health status, psychological and behavioral factors, and participation and quality of life (QOL) variables. We linked cases to administrative billing data to assess hospital utilization, including Emergency Department (ED) visits and inpatient (IP) admissions (through the ED and direct IP) in non-federal state hospitals within the year following the SRA. Results There were 706 ambulatory and 345 non-ambulatory participants. We found significant differences across all sets of factors and significant differences in hospital utilization metrics. Ambulatory adults had fewer ED visits (36% vs 44%), IP admissions through the ED (11% vs 25%) and IP only admissions (9% vs 19%) and spent fewer days in the hospital for both admissions through the ED (0.9 vs 4.6 days) and IP only admissions (0.7 vs 3.1 days). They also reported having fewer past year ED visits (44% vs 62%) and IP admissions (34% vs 52%). Conclusions We identified differences in personal characteristics, ED visits and IP admissions between ambulatory and non-ambulatory adults with SCI, providing a better understanding of the characteristics of those with SCI. The findings suggest the need for separate analyses based on ambulatory status when assessing long-term health outcomes including hospital utilization.

Epilepsy hospitalizations and mental disorders: A Portuguese population-based observational retrospective study (2008–2015)

BackgroundPsychiatric comorbidities are highly frequent in people with epilepsy and were found to be markers of poorer prognosis. These comorbidities increase the use of healthcare resources, including emergency department visits and inpatient care. Despite this, there is little information on healthcare utilization associated with a wide range of comorbid mental disorders in people with epilepsy (PWE). ObjectiveTo characterize registered mental disorders among all hospitalizations with a primary diagnosis of epilepsy and to analyze their association with crucial hospitalization outcomes. MethodsAn observational retrospective study was performed using administrative data from hospitalization episodes with epilepsy as the primary diagnosis discharged between 2008 and 2015. Mental disorder categories 650 to 670 from Clinical Classification Software were selected as secondary diagnoses. Mann-Whitney U, Kruskall-Wallis, and Chi-squared tests were used to establish comparisons. For each episode, data regarding hospitalization outcomes was retrieved, including length of stay (LoS), in-hospital mortality (IHM), 8-year period readmissions, and total estimated charges. ResultsOverall, 27,785 hospitalizations were analyzed and 33.9% had registered mental disorders, with alcohol-related disorders being the most prevalent (11.7%). For episodes with a concomitant register of a mental disorder, LoS was significantly longer (5.0 vs. 4.0 days, P <0.001), and IHM was higher (2.8% vs. 2.2%, P <0.001), as were readmissions (25.5% vs. 23.7%, P <0.001), and median episodes’ charges (1,578.7 vs. 1,324.4 euros, P <0.001). ConclusionEpilepsy-related hospitalizations with registered mental disorders heightened the utilization of healthcare resources, stressing the importance of diagnosing and treating mental disorders in PWE.

Safety and Health Care Utilization following COVID-19 Vaccination among Adults with Rheumatoid Arthritis - A population-based self-controlled case series analysis.

To determine if COVID-19 vaccines were associated with adverse events of special interest (AESIs) and health care use among adults with rheumatoid arthritis (RA). Among adults with RA who received at least 1 COVID-19 vaccine, a self-controlled case series (SCCS) analysis was conducted to evaluate relative incidence (RI) rates of AESIs (Bell's Palsy, Idiopathic Thrombocytopenia, Acute Disseminated Encephalomyelitis, Pericarditis/Myocarditis, Guillain-Barre syndrome, Transverse Myelitis, Myocardial Infarction, Anaphylaxis, Stroke, Deep Vein Thrombosis, Pulmonary Embolism, Narcolepsy, Appendicitis, and Disseminated Intravascular Coagulation) in any 21-day period following vaccination compared to control periods. Secondary outcomes included emergency department (ED) visits, hospitalizations, and rheumatology visits. A matched non-RA comparator group was created and a separate SCCS analysis was conducted. Relative incidence ratios (RIR) were used to compare between RA and non-RA groups. Among 123,466 RA patients and 493,864 comparators, the majority received mRNA vaccines. For RA patients, relative to control periods, AESIs were not increased. ED visits increased after dose 2 [RI:1.06 (95%CI:1.03-1.10)] and decreased after dose 3 [RI:0.93 (95%CI:0.89-0.96)]. Hospitalizations were lower after the first [RI:0.83 (95%CI:0.78-0.88)], second [RI:0.86 (95%CI:0.81-0.92)], and third [RI:0.89 (95%CI:0.83-0.95)] doses. Rheumatology visits increased after dose 1 [RI:1.08 (95%CI:1.07-1.10)], and decreased after doses 2 and 3. Relative to comparators, RA patients had a higher AESI risk after dose 3 [RIR:1.28 (95%CI:1.1- 1.6)]. RA patients experienced fewer ED visits [RIR:0.73 (95%CI:0.58-0.90)] and hospitalizations [RIR:0.52 (95%CI:0.36-0.75)] after dose 4. COVID-19 vaccines in RA patients was not associated with an increase in AESI risk or health care utilization after every dose.

A-256 Clinical Performance of Presepsin for Sepsis in the Emergency Department Patients in a Tertiary Hospital in Korea

Abstract Background Sepsis is a life-threatening condition that requires prompt recognition and treatment. Presepsin is a new diagnostic biomarker of sepsis that has been implemented as a selective reimbursement in Korea and was introduced in our hospital in October 2022. This study aimed to evaluate the clinical performance of the Presepsin Assay (Sysmex, Kobe, Japan) on the Sysmex HISCL-5000 system in the southeast population in Korea. Methods The study is a retrospective study that included emergency department (ED) and ED-based intensive care unit (EICU) patients tested for presepsin from August 18, 2022, to February 11, 2023. We calculated the patients’ sepsis-related organ failure assessment (SOFA) score at the time of blood collection for presepsin from the electronic medical record. Presepsin, procalcitonin, and high-sensitivity C-reactive protein (hsCRP) were also investigated. The sepsis markers for sepsis prediction were evaluated using receiver operating characteristic (ROC) curve analysis and area under the curve (AUC). Results A total of 81 patients, including 66 ED and 15 EICU patients, were tested for presepsin. The presepsin results ranged from 101 to 8788 pg/mL (Mean 1,005.9 pg/mL, Standard deviation 1,509.4). In ROC curve analysis, three biomarkers—presepsin, procalcitonin, and hsCRP generated an area under the curve (AUC) value of 0.698, 0.670, and 0.694 for predicting sepsis, respectively, for the threshold ≥7 of SOFA score to screen the risk of sepsis. Conclusion The clinical performance of presepsin in the ED-based setting in Korea was found to be comparable in detecting the risk of sepsis. Further research is needed to determine the optimal use of presepsin in the other clinical areas of the hospital, such as intensive care units, and to assess its impact on patient outcomes.